The Use of MDCT-Based Computer-Aided Pathway Finding for Mediastinal and Perihilar Lymph Node Biopsy: A Randomized Controlled Prospective Trial

Abstract

Background: Mediastinal and perihilar lymph node samples can be acquired safely through the transbronchial approach during a bronchoscopic examination that is usually required as part of the evaluation of suspected lung cancer. Typically, needle aspiration samples are performed and needle cores can be sampled if the operator is confident that the needle is within the lymph node target, partly because of the risk of bleeding if a large blood vessel is sampled during core biopsy, especially in the perihilar region. Many bronchoscopists have difficulty assessing the three-dimensional (3D) positioning for needle sampling during these procedures, especially when relying on multidetector-row computerized tomography (MDCT) images displayed two-dimensionally seen prior to and usually during the procedure. Objective: We have developed and evaluated a process model and associated software for providing interactive 3D displays of the MDCT data for procedure planning and real-time virtual bronchoscopic pathfinding for these procedures. Methods: We undertook a prospective randomized clinical study for evaluating the computer-aided pathfinding assistance in mediastinal lymph node biopsies in 87 consenting subjects. Results: We demonstrate that the addition of this computer-aided pathfinding improved operator performance in perihilar and paratracheal lymph node sampling (100 vs. 69%) but not in subcarinal sampling (82 vs. 85%). Overall success with lymph node sampling is 92% using the computer-aided method and 77% using standard clinical practice. Conclusions: The type of computer-aided pathway assistance described here, using 3D MDCT scanning information obtained before the procedure, but interacting with real-time bronchoscopic images during the bronchoscopic procedure, should improve the confidence of most bronchoscopists in performing these procedures, with improved clinical outcomes, and will add to the personalization of medicine through imaging.

Recent technological and application developments in computed tomography and magnetic resonance imaging for improved pulmonary nodule detection and lung cancer staging

“…Nodule localization, as defined by a biopsy position error ≤5 mm, increased more than 2‐fold from 43% using standard procedure to 94% with the image guided approach (77). McLennan et al (78) investigated the ability of virtual bronchoscopy image guidance in improving lymph node sampling, an important aspect of lung cancer staging, and found an improvement from 66% using standard procedure to 92% with imaging guidance. Building on the success of virtual bronchoscopy guidance, integrated bronchoscopy techniques have been explored in the literature, merging structure from CT with other assistive diagnostic tools such as bronchoscopic color analysis and fluorescence or PET to aid the accurate localization of biopsy targets (79, 80).…”

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“…In an effort to find new guidance systems to improve TBNA sensitivity, in this issue of Respiration , McLennan et al [15] have evaluated the usefulness of a software developed for providing three-dimensional images of the airways and mediastinal structures. The three-dimensional images are reconstructed from multidetector-row CT and used for guiding TBNA of hilar and mediastinal lymph nodes.…”