Introduction Detection of peripheral pulmonary lesions (PPLs) is on the rise but an accurate means of obtaining a tissue diagnosis without high risk of complications is lacking.¹ Virtual bronchoscopic navigation (VBN) guides the bronchoscope under direct vision and, in combination with radial endobronchial ultrasound (R-EBUS) or ultrathin bronchoscopy, may enhance the diagnostic yield of PPLs with a minimal complication rate.²

Aims To pilot the use of VBN in the diagnosis of PPLs. To identify patient and lesion characteristics that predict successful VBN.

Methods Images from chest CT (slice width 1–1.25 mm) were acquired from patients, and lesion features, including location and presence of a bronchus sign (bronchus contained within PPL), were recorded. CT images were transferred to a portable workstation and Lungpoint Broncus © was used to create a virtual pathway to the PPL. Bronchoscopy was performed with VBN followed by R-EBUS guidance, under conscious sedation, and biopsies obtained. Pre-procedure characteristics, biopsy adequacy, biopsy outcome, 30-day follow up and complications were recorded.

Results The median age of our cohort (n = 7) was 79 and all patients had one or more comorbidities. PPL median size was 28 mm and all were located in sub-segmental bronchi. VBN guided the operator to the correct site in six cases. Adequate biopsies were taken from five patients; four had a positive bronchus sign. Three adequate biopsies received a diagnosis of primary lung cancer; those remaining were negative. One patient with inadequate biopsies underwent transthoracic needle biopsy (TTNB) and was diagnosed with primary lung cancer. No complications occurred in spite of the significant co-morbidity of this patient cohort.

Discussion Our preliminary data suggest that in a selected patient cohort with a bronchus sign, VBN may be a useful and safe adjunct to R-EBUS to obtain a tissue diagnosis from PPLs. In contrast, TTNB has a high diagnostic sensitivity but is tarnished by a high complication rate and is not suitable in patients with significant co-morbidity. Therefore, VBN and R-EBUS are particularly useful where TTNB carries a high risk.

References 1 Kikuchi E, Yamazaki K, Sukoh N, et al. Endobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions. Eur Respir J 2004;24:533–7

2 Ishida T, Asano F, Yamazaki K, et al. Virtual bronchoscopic navigation combined with endobronchial ultrasound to diagnose small peripheral pulmonary lesions: a randomised trial. Thorax 2011;66:1072–7