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Diagnosis of a 17 mm Right Apical Nodule Following Non-Diagnostic CT-Guided TTNA

Dr. Adam Wellikoff

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Fig 1. MONARCH® fused navigation showing REBUS probe deployment
Fig 1. MONARCH® fused navigation showing REBUS probe deployment


An 82-year-old female presented with highly symptomatic chronic obstructive pulmonary disease (COPD) was found to have a 17 mm nodule located in the right upper lobe upon CT examination. The patient previously underwent a CT-guided biopsy which came back with non-diagnostic results. Due to the extent of her disease, she was a poor surgical candidate and was referred for a robotic-assisted navigational bronchoscopy.


The MONARCH® planning software identified a 17 mm nodule located in the apical segment of the right upper lobe that extended medially. Two pathways were planned to the nodule with no definitive bronchus sign leading into the nodule.

Within two minutes of navigation the MONARCH® platform reached the challenging right upper lobe location and REBUS was deployed to confirm positioning for biopsy. (Fig. 1) Initial views showed an eccentric probe position and biopsies were taken which resulted in a non-diagnostic specimen evaluation. Slight adjustments were made with the MONARCH® Platform using the REBUS probe for guidance until a concentric view was identified. (Fig. 2) A 21G FNA needle and biopsy forceps were used for tissue attainment. (Fig. 3) In room pathology results came back as adenocarcinoma on the second pass with the FNA needle. Once all biopsies were taken, a fiducial marker was deployed in the same area for future therapeutics.

The patient was able to begin stereotactic body radiation therapy a week after the procedure within the institution.

The MONARCH Platform instills confidence in a physician’s ability to reach small lesions in the peripheral lung.


The precision and control of the MONARCH® platform allowed for the ability to see the radial probe and make adjustments to biopsy the most accurate location possible. (Fig. 4) Additionally, having the potential to reach challenging locations such as the apical segments after one previous use gives physicians the confidence needed to reach the periphery of the lung. This procedure ultimately led to a quick transition to treatment within the institution even after an unsuccessful previous attempt.

Dr. Adam Wellikoff, M.D.

About Dr. Adam Wellikoff, M.D.

JFK Medical Center, Palm Beach, FL Dr. Adam Wellikoff is a board-certified Interventional Pulmonologist and Critical Care specialist based in Palm Beach, Florida. His clinical interests include advanced diagnostic and therapeutic procedures.

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. Adam Wellikoff is compensated by and writing on behalf of Auris Health and must present information in accordance with applicable FDA requirements.