Demet Karnak 1 , Aydın Çiledağ 1 , Koray Ceyhan 2

1. ELECTROMAGNETIC NAVIGATION DIAGNOSTIC BRONCHOSCOPY FOR PERIPHERAL LUNG LESIONS AND MEDIASTINAL LYMPH NODES * Demet Karnak 1, Aydın Çiledağ 1, Koray Ceyhan 2 Çetin Atasoy 3, Serdar Akyar 3, Oya Kayacan 1 Ankara University School of Medicine, Departments of 1Chest Diseases, 2Pathology and 3Radiodiagnostic * This study was supported by TUBITAK (project # 107S156)

2. Lung cancer • Lungcancer is leadingcause of cancerdeath • 173.000/year in USA • 150.000/year SPN in USA • Theincidence in Turkey: 11.5/100.000

3. DIAGNOSIS • Traditionally *Flexiblebronchoscopy: Biopsy, washing, brushing, TBNA *CT guidedneedleaspiration *VATS/Thoracotomy

4. Flexiblebronchoscopy • Lessinvasiveprocedure • Diagnosticyielddepends on size andlocalization • Intheabsence of endobronchialdisease, diagnosticyield 20-80% • <2 cm lesionsandproximal 1/3 of thechest31% • <2 cm lesionsandouther 1/3 of thechest14%

5. DIAGNOSIS *CT guidedneedleaspiration A highpneumothorax risk forcentrallesions (13-38%) *VATS/Thoracotomy (Invasiveprocedures, highmorbitidy rate, especialllyage >65 years)

6. MEDIASTINAL LYMPH NODES • Thediagnosticyield of TBNA withflexiblebronchoscopy15-89% • Thediagnosticyield of TBNA in staginglungcancer50-60% • PET falsepositiveresults, especially in inflammatorylesions • Mediastinoscopy/Mediastinotomy (invasive)

7. New Guided Technique • Theaim is minimal invasiveprocedureandlowmorbitdy *ElectromagneticNavigationBronchoscopy (ENB)

8. ElectromagneticNavigationBronchoscopy • Developedbyadaptation of satellitebaseddirectionmapping of wartechnologytothemedicine

9. Electromagnetic Navigation Bronchoscopy “ROAD MAP” “LUNG MAP”

10. Electromagnetic Navigation Bronchoscopy • Anatomicregistration • Bronchoscop • Three-dimensional CT images • A steerableprobe (LG)

11. Electromagnetic Navigation Bronchoscopy • The procedure requires the patient to have a spiral CT with thin cuts, usually about 1mm • The CT information is uploaded into the navigating computer and a virtual bronchoscopy image is created

12. Electromagnetic Navigation Bronchoscopy

13. Electromagnetic Navigation Bronchoscopy

15. Electromagnetic Navigation Bronchoscopy

16. Electromagnetic Navigation Bronchoscopy

17. Electromagnetic Navigation Bronchoscopy

18. Electromagnetic Navigation Bronchoscopy

21. AIM • To evaluate diagnostic yield and safety of ENB for peripheral lung nodules-mass and mediastinal lymph nodes (LN) when lesions were not good candidates for TTNA (central localization) and in the absence of endobronchial lesion

22. 21 patients *5 patients had onlyperipherallesion (PL) *4 patients had PL+LN *12 patients had only LN On-site cytologicevaluation

23. 9 peripheral lesions • 4 → Right upper lobe • 3 → Left upper lobe • 1 → Lingula • 1 → Left lower lobe The mean size: 25.88 ± 12.24 mm

24. 31 lymph nodes • 11 subcarinal • 7 right hilar • 5 anterior carinal • 4 right paratracheal • 3 left hilar • 1 left paratracheal The mean size:18.16 ± 6.01 mm

25. The mean total procedure time 39.33 ± 9.32 minute

26. RESULTS • The 8 of 9 peripherallesions (88.9%) • The 27 of 31 lymphnodes (87.1%) weresuccesfullysampled

27. RESULTS • ENB wasdiagnostic in 18 of 21 patients • Thediagnosticyield: (85.7%) • Pneumothorax in onepatient

28. RESULTS • 5 nonsmall cell lung cancer • 6 sarcoidosis • 3 tuberculous lymphadenitis • 2 benign pulmonary nodule • 2 reactive lymphadenitis THE DIAGNOSTIC YIELD 18/21x100= 85.7%

29. DISCUSSION • 89 patients (peripherallesion) • Thediagnosticyieldwas 67% • Pneumothorax in twopatients Eberhardt R, Anantham D, Herth F. Et al. Chest 2007;131:1800-1805

30. DISCUSSION • 60 patients (peripherallesionsormediastinallymphnode) • 74% of peripherallesionsand 100% of lymphnodesweresampled • Thediagnosticyield of EBN was 80.3% • Pneumothorax in twopatients Gildea TR, Mazzone PJ, Karnak D, et al. AmJ RespirCritCareMed 2006;174:982-989

31. CONCLUSION • ENB is a safemethodforsamplingperipherallungnodule-massandmediastinallymphnodeswithhighdiagnosticyield