Background: Bronchoscopy is a safe technique for diagnosing peripheral pulmonary lesions (PPLs), and virtual bronchoscopic navigation (VBN) helps guide the bronchoscope to PPLs. Objectives: We aimed to compare the diagnostic yield of VBN-guided and unguided ultrathin bronchoscopy (UTB) and explore clinical and technical factors associated with better results. We developed a diagnostic algorithm for deciding whether to use VBN to reach PPLs or choose an alternative diagnostic approach. Methods: We compared diagnostic yield between VBN-UTB (prospective cases) and unguided UTB (historical controls) and analyzed the VBN-UTB subgroup to identify clinical and technical variables that could predict the success of VBN-UTB. Results: Fifty-five cases and 110 controls were included. The overall diagnostic yield did not differ between the VBN-guided and unguided arms (47 and 40%, respectively; p = 0.354). Although the yield was slightly higher for PPLs ≤20 mm in the VBN-UTB arm, the difference was not significant (p = 0.069). No other clinical characteristics were associated with a higher yield in a subgroup analysis, but an 85% diagnostic yield was observed when segmentation was optimal and the PPL was endobronchial (vs. 30% when segmentation was suboptimal and 20% when segmentation was optimal but the PPL was extrabronchial). Conclusions: VBN-guided UTB is not superior to unguided UTB. A greater impact of VBN-guided over unguided UTB is highly dependent on both segmentation quality and an endobronchial location of the PPL. Segmentation quality should be considered before starting a procedure, when an alternative technique that may improve yield can be chosen, saving time and resources.

1.
Brambilla
E
,
Travis
WD
. World cancer report 2014. In:
Stewart
BW
,
Wild
CP
, editors
.
World cancer report 2014
.
Lyon, France
:
International Agency for Research on Cancer
;
2014
.
2.
Aberle
DR
,
Adams
AM
,
Berg
CD
,
Black
WC
,
Clapp
JD
,
Fagerstrom
RM
, et al.;
National Lung Screening Trial Research Team
.
Reduced lung-cancer mortality with low-dose computed tomographic screening
.
N Engl J Med
.
2011
Aug
;
365
(
5
):
395
409
.
[PubMed]
0028-4793
3.
Black
WC
,
Gareen
IF
,
Soneji
SS
,
Sicks
JD
,
Keeler
EB
,
Aberle
DR
, et al.;
National Lung Screening Trial Research Team
.
Cost-effectiveness of ct screening in the national lung screening trial
.
N Engl J Med
.
2014
Nov
;
371
(
19
):
1793
802
.
[PubMed]
0028-4793
4.
van den Bergh
KA
,
Essink-Bot
ML
,
Borsboom
GJ
,
Th Scholten
E
,
Prokop
M
,
de Koning
HJ
, et al.
Short-term health-related quality of life consequences in a lung cancer CT screening trial (NELSON)
.
Br J Cancer
.
2010
Jan
;
102
(
1
):
27
34
.
[PubMed]
0007-0920
5.
Tammemägi
MC
,
Katki
HA
,
Hocking
WG
,
Church
TR
,
Caporaso
N
,
Kvale
PA
, et al.
Selection criteria for lung-cancer screening
.
N Engl J Med
.
2013
Feb
;
368
(
8
):
728
36
.
[PubMed]
0028-4793
6.
Xu
DM
,
Gietema
H
,
de Koning
H
,
Vernhout
R
,
Nackaerts
K
,
Prokop
M
, et al.
Nodule management protocol of the NELSON randomised lung cancer screening trial
.
Lung Cancer
.
2006
Nov
;
54
(
2
):
177
84
.
[PubMed]
0169-5002
7.
Zhao
Y
,
de Bock
GH
,
Vliegenthart
R
,
van Klaveren
RJ
,
Wang
Y
,
Bogoni
L
, et al.
Performance of computer-aided detection of pulmonary nodules in low-dose CT: comparison with double reading by nodule volume
.
Eur Radiol
.
2012
Oct
;
22
(
10
):
2076
84
.
[PubMed]
0938-7994
8.
Heuvelmans
MA
,
Oudkerk
M
,
de Bock
GH
,
de Koning
HJ
,
Xie
X
,
van Ooijen
PM
, et al.
Optimisation of volume-doubling time cutoff for fast-growing lung nodules in CT lung cancer screening reduces false-positive referrals
.
Eur Radiol
.
2013
Jul
;
23
(
7
):
1836
45
.
[PubMed]
0938-7994
9.
Whitney
DH
,
Elashoff
MR
,
Porta-Smith
K
,
Gower
AC
,
Vachani
A
,
Ferguson
JS
, et al.
Derivation of a bronchial genomic classifier for lung cancer in a prospective study of patients undergoing diagnostic bronchoscopy
.
BMC Med Genomics
.
2015
May
;
8
(
1
):
18
.
[PubMed]
1755-8794
10.
Silvestri
GA
,
Vachani
A
,
Whitney
D
,
Elashoff
M
,
Porta Smith
K
,
Ferguson
JS
, et al.;
AEGIS Study Team
.
A bronchial genomic classifier for the diagnostic evaluation of lung cancer
.
N Engl J Med
.
2015
Jul
;
373
(
3
):
243
51
.
[PubMed]
0028-4793
11.
Chen
CH
,
Cheng
WC
,
Wu
BR
,
Chen
CY
,
Chen
WC
,
Hsia
TC
, et al.
Improved diagnostic yield of bronchoscopy in peripheral pulmonary lesions: combination of radial probe endobronchial ultrasound and rapid on-site evaluation
.
J Thorac Dis
.
2015
Dec
;
7
Suppl 4
:
S418
25
.
[PubMed]
2072-1439
12.
van ’t Westeinde
SC
,
Horeweg
N
,
Vernhout
RM
,
Groen
HJ
,
Lammers
JJ
,
Weenink
C
, et al.
The role of conventional bronchoscopy in the workup of suspicious CT scan screen-detected pulmonary nodules
.
Chest
.
2012
Aug
;
142
(
2
):
377
84
.
[PubMed]
0012-3692
13.
Rivera
MP
,
Mehta
AC
,
Wahidi
MM
. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines. Chest
2013
;143:e142S-165S.
14.
Baaklini
WA
,
Reinoso
MA
,
Gorin
AB
,
Sharafkaneh
A
,
Manian
P
.
Diagnostic yield of fiberoptic bronchoscopy in evaluating solitary pulmonary nodules
.
Chest
.
2000
Apr
;
117
(
4
):
1049
54
.
[PubMed]
0012-3692
15.
Wang Memoli
JS
,
Nietert
PJ
,
Silvestri
GA
.
Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule
.
Chest
.
2012
Aug
;
142
(
2
):
385
93
.
[PubMed]
0012-3692
16.
Asano
F
,
Shinagawa
N
,
Ishida
T
,
Shindoh
J
,
Anzai
M
,
Tsuzuku
A
, et al.
Virtual bronchoscopic navigation combined with ultrathin bronchoscopy. A randomized clinical trial
.
Am J Respir Crit Care Med
.
2013
Aug
;
188
(
3
):
327
33
.
[PubMed]
1073-449X
17.
Oki
M
,
Saka
H
,
Ando
M
,
Asano
F
,
Kurimoto
N
,
Morita
K
, et al.
Ultrathin bronchoscopy with multimodal devices for peripheral pulmonary lesions. A randomized trial
.
Am J Respir Crit Care Med
.
2015
Aug
;
192
(
4
):
468
76
.
[PubMed]
1073-449X
18.
Eberhardt
R
,
Kahn
N
,
Gompelmann
D
,
Schumann
M
,
Heussel
CP
,
Herth
FJ
.
LungPoint—a new approach to peripheral lesions
.
J Thorac Oncol
.
2010
Oct
;
5
(
10
):
1559
63
.
[PubMed]
1556-0864
19.
Botero Zaccour
JA
,
Rosell Gratacos
A
,
Cubero de Frutos
N
,
Lopez Lisbona
R
,
Tazi Mezalek
R
.
Conventional vs ultrathin bronchoscopy in the diagnosis of solitary pulmonary nodules (spn)
.
Eur Respir J
.
2013
;
•••
:
42
.0903-1936
20.
Shinagawa
N
,
Yamazaki
K
,
Onodera
Y
,
Asahina
H
,
Kikuchi
E
,
Asano
F
, et al.
Factors related to diagnostic sensitivity using an ultrathin bronchoscope under CT guidance
.
Chest
.
2007
Feb
;
131
(
2
):
549
53
.
[PubMed]
0012-3692
21.
Naidich
DP
,
Sussman
R
,
Kutcher
WL
,
Aranda
CP
,
Garay
SM
,
Ettenger
NA
.
Solitary pulmonary nodules. CT-bronchoscopic correlation
.
Chest
.
1988
Mar
;
93
(
3
):
595
8
.
[PubMed]
0012-3692
22.
Seijo
LM
,
de Torres
JP
,
Lozano
MD
,
Bastarrika
G
,
Alcaide
AB
,
Lacunza
MM
, et al.
Diagnostic yield of electromagnetic navigation bronchoscopy is highly dependent on the presence of a Bronchus sign on CT imaging: results from a prospective study
.
Chest
.
2010
Dec
;
138
(
6
):
1316
21
.
[PubMed]
0012-3692
23.
Asano
F
,
Matsuno
Y
,
Tsuzuku
A
,
Anzai
M
,
Shinagawa
N
,
Yamazaki
K
, et al.
Diagnosis of peripheral pulmonary lesions using a bronchoscope insertion guidance system combined with endobronchial ultrasonography with a guide sheath
.
Lung Cancer
.
2008
Jun
;
60
(
3
):
366
73
.
[PubMed]
0169-5002
24.
Yasuo
M
,
Kobayashi
T
,
Hama
M
,
Ichiyama
T
,
Horiuchi
T
,
Yamamoto
H
, et al.
Combination of virtual bronchoscopic navigation with conventional transbronchial needle aspiration in the diagnosis of peribronchial pulmonary lesions located in the middle third of the lungs
.
Respir Investig
.
2016
Sep
;
54
(
5
):
355
63
.
[PubMed]
2212-5345
25.
Herth
FJ
,
Eberhardt
R
,
Sterman
D
,
Silvestri
GA
,
Hoffmann
H
,
Shah
PL
.
Bronchoscopic transparenchymal nodule access (BTPNA): first in human trial of a novel procedure for sampling solitary pulmonary nodules
.
Thorax
.
2015
Apr
;
70
(
4
):
326
32
.
[PubMed]
0040-6376
26.
Harzheim
D
,
Sterman
D
,
Shah
PL
,
Eberhardt
R
,
Herth
FJ
.
Bronchoscopic transparenchymal nodule access: feasibility and safety in an endoscopic unit
.
Respiration
.
2016
;
91
(
4
):
302
6
.
[PubMed]
1423-0356
27.
Franke
KJ
,
Linzenbold
W
,
Nuessle
D
,
Enderle
M
,
Boesmueller
H
,
Nilius
G
, et al.
A new tool for transbronchial cryobiopsies in the lung: an experimental feasibility ex vivo study
.
Respiration
.
2016
;
91
(
3
):
228
34
.
[PubMed]
1423-0356
28.
Diez-Ferrer
M
and
Gil
D
,
Tebe
C
,
Sanchez
C
,
Cubero
N
,
Lopez-Lisbona
R
,
Dorca
J
,
Rosell
A.
Positive Airway Pressure to Enhance Computed Tomography Imaging for Airway Segmentation for Virtual Bronchoscopic Navigation.
Accepted for publication in Respiration. doi:
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