Cone beam CT-guided ENB improves detection of pulmonary nodules

Cone beam CT (CBCT) guidance to electromagnetic navigation bronchoscopy (ENB) for the diagnosis of pulmonary nodules significantly increased the diagnostic yield and diagnostic accuracy of transbronchial biopsy for small-size nodules, compared with ENB without CBCT guidance [1].

The diagnostic yield for detecting lung nodules via ‘classical’ forceps transbronchial biopsy is low, with only a 14% success rate if it concerns peripheral nodules less than 2 cm in diameter [1]. ENB increases the diagnostic yield of transbronchial biopsy to 52–72.9% [2–3]. However, this procedure lacks real-time confirmation of the position of the catheter and biopsy tools [4]. “CBCT guidance of ENB allows for real-time control of the position of the catheter, enhanced fluoroscopy, and trans-parenchymal access,” added Prof. Benjamin Bondue (Université Libre de Bruxelles, Belgium) [5]. Therefore, a randomised-controlled trial was designed to evaluate the benefit of CBCT guidance to ENB for the diagnosis of peripheral nodules [5].

The study group randomised 49 patients with pulmonary nodules that were a maximum of 30 mm in diameter to ENB or to CBCT-guided ENB. The primary outcome was the diagnostic yield and the diagnostic accuracy for malignancy.

The CBCT arm outperformed the regular ENB arm with respect to diagnostic yield (80% vs 42%; P=0.023) and diagnostic accuracy (83% vs 52%; P=0.025). The duration of the CBCT procedure was longer than that of the non-guided ENB procedure (80 vs 61 minutes; P=0.001). Pneumothorax occurred in 8% of the participants in the non-guided ENB arm and in 4% of the participants in the CBCT arm (P=0.819). In addition, moderate bleeding occurred in 17% and 4% of the participants in the non-guided ENB arm and the CBCT arm, respectively (P=0.143).

In summary, the use of CBCT guidance during ENB significantly increased the diagnostic yield and accuracy of transbronchial biopsy for small size nodules. Although the analysis did not reveal significant differences with regard to safety due to the limited numbers of participants included in this trial, CBCT may come with additional safety benefits. “This is an issue that should be investigated in the future. Also, subgroup analyses should be performed to examine which patients would benefit from CBCT guidance and which patients would not necessarily need this procedure,” concluded Prof. Bondue.

1. Baaklini WA, et al. Chest. 2000;117(4):1049–1054.
2. Verhoeven RLJ, et al. J Bronchology Interv Pulmonol. 2021;28(1):60–69.
3. Gex G, et al. Respiration. 2014;87(2):165–176.
4. Folch EE, et al. J Thorac Oncol. 2019;14(3):445–458.
5. Bondue B, et al. A randomized controlled trial evaluating the benefit of cone beam CT guidance to electromagnetic navigation bronchoscopy for the diagnosis of pulmonary nodule. ALERT 4, RCT4451, ERS International Congress 2022, Barcelona, Spain, 4–6 September.

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Posted on 30 October 202227 March 2024