PMC10130683_01
The target right middle lobe lesion is shown in three axes (sagittal, coronal, axial) upon CBCT spin intra-operatively. CBCT, cone-beam CT; CT, computed tomography.
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It consisted of mostly GGO with a solid centre (Figure 1). Similar to all other ENB cases, bronchoscopic toileting and pre-operative cone-beam CT (CBCT) was performed (Figure 1), followed by registration and navigation by the IllumisiteTM ENB system.
Intraoperative setup during IllumisiteTM lung ablation. (A) shows the set up for ENB ablation using the IllumisiteTM platform. The patient lies supine and is intubated with single lumen endotracheal tube. The bronchoscope is mounted on the head-side of patient and connected to the IllumisiteTM console/screen at patient's right. The mobile C-arm for acquiring fluoroscopic images for tomosynthesis enters at patient's left. (B) Fluoroscopy shows the metallic dots on the electromagnetic board which was placed underneath patient. The dots allow operator to position the C-arm at the most appropriate focal length for best image acquisition in subsequent C-arm spin. ENB, electromagnetic navigation bronchoscopy.
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LG was navigated to a point just within 2.5 cm from the centre of lesion. Local registration by fluoroscopic navigation to correct for CT-body divergence was performed using a mobile C-arm 60-degree spin to generate tomosynthesis images (Figure 2).
Augmented fluoroscopy shows the lesion within an orange circle which is marked by the operator to help the system recognize the target lesion for subsequent tomosynthesis.
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The GGO was not readily seen on fluoroscopy, but the nodule marking was accurate based on the visualized adjacent vessels (Figure 3).
On top right hand corner, local registration was "on" so that the green ball represents the updated nodule position after adjusting CT-to-body divergence. Left hand panel shows real-time fluoroscopy, while right-hand panel shows the tip of the EWC is now directed at the green ball, at 1.9 cm from the centre of lesion. Fine adjustment of the EWC tip allows accurate placement of needle subsequently. EWC, extended working channel; CT, computed tomography.
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After the position of the green ball (representing the target lesion) was adjusted by IllumisiteTM platform, the LG was renavigated to a more distal airway, and with the help of CBCT and fluoroscopy, the LG was directly aligned with the adjusted target (Figure 4).
The CrossCountryTM needle is deployed and shown to be puncturing lesion (green cross) in all 3 axes in CBCT. CBCT, cone-beam CT; CT, computed tomography.
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CrossCountryTM needle (CovidienTM, Plymouth, MN, USA) for transbronchial access was deployed with patient in inspiration, corresponding to the green ball's most bullseye view. CBCT showed the needle puncturing through the GGO (Figure 5), and the dilator and EWC was advanced over the needle to the desired position.
Pre- and Post-ablation cone beam CT findings. (A, left sided panels) and (B, right sided panels) show the pre- and post-ablation images. The original lesion was marked by orange tracings, while the green and blue ovals represent the predicted ablation zone. In (B) ground-glass opacities surrounding the nodule represent the actual ablation zone after 2 ablations at 100 W for 10 minutes. CT, computed tomography.
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Re-ablation at the same position with 100 W for 10 minutes was performed, CBCT showed ablation zone being more consolidated and minimal margin improved to 4 mm, not taking into account tissue contraction from ablation (Figure 6).
Post-ablation CT findings upon follow up. (A,B) Shows the CT scan at 1-month and 4-month post-ablation respectively, which demonstrates a progressive reduction in ablation zone changes, and no evidence of early recurrence or complications. Note that right upper lobectomy has been performed 16 days after ablation for other peripheral lung nodules. CT, computed tomography.
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The post-ablation 1-month and 4-month CT scans show shrinkage of ablation zone (Figure 7) and no short-term complications or early recurrence.