Dr. Susan Garwood
A 60 year-old male with a history of multiple basal cell skin carcinomas now presents with an incidental 8 mm non-calcified left upper lobe nodule. The most recent bout of basal cell carcinoma in 2019 yielded focal squamous cell differentiation of the left arm. A chest CT was ordered and revealed a subcutaneous mass in the left axilla extending into the pectoralis. CT guided biopsy results were also consistent with basal cell carcinoma. The patient was referred to oncology for further evaluation. A follow up PET/CT conveyed hypermetabolic uptake of the axillary mass along with a small sub-centimeter nodule located in the left upper lobe (Fig. 1 & 2). Interventional radiology declined biopsy due to location and size of the nodule. The patient was referred to pulmonary for Robotic-Assisted Bronchoscopy. The patient was a neversmoker with no history of other malignancy.
Examination of CT revealed no discernable bronchus sign but nearby adjacent airway and large vessel suggesting airway may pass close enough to allow successful biopsy. Pre-procedural planning focused on exiting airway away from intervening vasculature.
After initialization, time to target was just under 2 minutes. By maintaining a central position of the MONARCH® scope within the airways, full visualization was maintained out to the target area of interest and the endobronchial nodular component was clearly visible (Fig. 3). Radial EBUS (REBUS) confirmed concentric nature of the probe position (Fig. 4), and was noted under fluoroscopic imaging. Of note, the fluoroscopy image clearly revealed a well-rounded solid structure just apical to the established REBUS location. Visualization confirmed this to be the vessel noted during preprocedural planning which could have easily been mistaken for the nodule (Fig. 5). Onsite pathology evaluation of needle aspirate revealed malignancy on the first pass. Due to the need for multiple immunohistochemical stains to determine site of origin of malignancy, multiple biopsies were performed for large volume tissue acquisition with a 21G flexible biopsy needle, biopsy forceps and bronchoalveolar lavage. Final pathology resulted in basal cell carcinoma (Fig. 6). Time from navigation to the onsite pathology call was just under 10 minutes.
"Navigation was completed within two minutes, highlighting not only the accuracy of the system but the precision and time savings this technology can afford."
Working with interventional radiology partners to establish appropriate referral practices for small, hard to reach nodules is extremely important. Many nodules are high risk for our radiology colleagues, but are often left to watchful waiting due to presumed inability to biopsy by other means.
MONARCH® technology shines when full visualization is maintained throughout navigation and biopsy, allowing proceduralists to diagnose nodules even if they are sub-centimeter and/or have no visible airway on CT (Fig. 7). With greater visualization, greater attention to potential fluoroscopic false positives is an important consideration, especially if the fluoroscopic “nodule” is not in alignment with the navigated target and confirmed with REBUS. As demonstrated in this case, if care is not taken, it may result unwanted complications and an unsuccessful procedure.
Navigation was completed in just under two minutes, highlighting not only the accuracy of the system but the precision and time savings this technology can afford. It is essential to educate referral sources about the benefits of the technology to avoid more invasive techniques and treatment delays.
Dr. Garwood is based in Nashville, TN. She is the Medical Director of Thoracic Oncology for Tristar Health, National Physician Lead of the Pulmonary Service Line for HCA Clinical Service Group, & Co-Chair of the Thoracic Surgery Council for the HCA Clinical Service Group.
Indications for Use: The MONARCH® Platform and its accessories are intended to provide bronchoscopic visualization of and access to patient airways for diagnostic and therapeutic procedures.
Important Safety Statement: Complications from bronchoscopy are rare and most often minor, but if they occur, may include breathing difficulty, vocal cord spasm, hoarseness, slight fever, vomiting, dizziness, bronchial spasm, infection, low blood oxygen, bleeding from biopsied site, or an allergic reaction to medications. It is uncommon for patients to experience other more serious complications (for example, collapsed lung, respiratory failure, heart attack and/or cardiac arrhythmia).
This document reflects the techniques, approaches and opinions of the individual physician. This Auris sponsored document is not intended to be used as a training guide. Other physicians may employ different techniques. The steps demonstrated may not be the complete steps of the procedure. Individual physician preference and experience, as well as patient needs, may dictate variation in procedure steps. Before using any medical device, review all relevant package inserts with particular attention to the indications, contraindications, warnings and precautions, and steps for use of the device(s).
Dr. Susan Garwood is compensated by and writing on behalf of Auris Health and must present information in accordance with applicable FDA requirements.
Complications from bronchoscopy are rare and most often minor, but if they occur, may include breathing difficulty, vocal cord spasm, hoarseness, slight fever, vomiting, dizziness, bronchial spasm, infection, low blood oxygen, bleeding from biopsied site, or an allergic reaction to medications. Only rarely do patients experience other more serious complications (for example, collapsed lung, respiratory failure, heart attack and/or cardiac arrhythmia).
Adverse effects from both Mini-PCNL and Ureteroscopy include pain, urinary tract infection, fever, hematuria (presence of blood in urine), exposure to low levels of radiation, retained or residual stones.
Adverse effects from ureteroscopy may include pain, perforation or injury to the ureter, resulting in extravasation of fluid and urine (urinoma), stricture of the ureter with risk of subsequent obstruction (hydronephrosis needing further repair), rare avulsion of the ureter, urinary blood clots, residual stones.
PCNL access may result in minor and major adverse effects. Minor effects include fever and nephrostomy leak. Major adverse effects may include injuries to pleura, liver, spleen, large vessels with related bleeding, gallbladder, duodenum, jejunum, colon with related cutaneous fistula, fever, pain, ileus, elevated counts.
Major adverse effects related to stone removal may include infection and urosepsis, intravascular fluid overload, extravasation of fluid, and post percutaneous nephrolithotomy bleeding.