Francisco Aecio Almeida

Introduction: Lung cancer is a leading cause of cancer-related deaths globally, with approximately 1.5 million new peripheral pulmonary lesions (PPLs) detected annually in the United States. Robotic-assisted bronchoscopy (RAB) has emerged as a promising technology, with two platforms initially approved, the Monarch platform (Auris Health Inc, Redwood City, CA, USA) and the Ion Endoluminal System (Intuitive Surgical, Sunnyvale, CA, USA), offering improved stability and distal airway visualization. As RAB adoption increases, there is a critical need for comparative effectiveness data of these systems to guide clinical decision-making and institutional investments. This study aims to compare the diagnostic yield and safety profiles of the Ion and Monarch RAB platforms after introduction at a single institution. Methods: We conducted a retrospective chart review of patients undergoing RAB in the first six months following the introduction of each platform. Demographic and radiographic data were collected. Diagnostic yield was defined as obtaining a malignant or specific benign diagnosis from bronchoscopy. Results: The study included 56 Ion and 36 Monarch procedures. Diagnostic yield was similar between Ion (75%) and Monarch (72%) groups (p = 0.8), with an adjusted odds ratio 0.89 (95% CI 0.30–2.72). Complications were low, with one pneumothorax occurring in each group. Conclusions: Early adoption and use of both RAB platforms suggests comparable diagnostic yields and safety profiles in our limited sample size. Larger studies including standardized anesthesia protocol and systematic use of real-time imaging are needed for further evaluation and comparative analysis.

The past two decades have witnessed a revolutionary era for peripheral bronchoscopy. Though the initial description of radial endobronchial ultrasound can be traced back to 1992, it was not until the mid-2000s that its utilization became commonplace, primarily due to the introduction of electromagnetic navigation (EMN) bronchoscopy. While the diagnostic yield of EMN-assisted sampling has shown substantial improvement over historical fluoroscopy-assisted bronchoscopic biopsy, its diagnostic yield plateaued at around 70%. Factors contributing to this relatively low diagnostic yield include discrepancies in computed tomography to body divergence, which led to unsuccessful lesion localization and resultant unsuccessful sampling of the lesion. Furthermore, much of peripheral bronchoscopy utilized a plastic extended working channel whose tips were difficult to finely aim at potential targets. However, the recent introduction of robotic-assisted bronchoscopy, and its associated stability within the peripheral lung, has ignited optimism for its potential to significantly enhance the diagnostic performance for peripheral lesions. Moreover, some envision this technology eventually playing a pivotal role in the therapeutic delivery to lung tumors. This review aims to describe the currently available robotic-assisted bronchoscopy technologies and to discuss the existing scientific evidence supporting these.

The treatment of non-small cell lung cancer has dramatically changed over the last decade through the use of targeted therapies and immunotherapies. Implementation of these treatment regimens relies on detailed knowledge regarding each tumor’s specific genomic profile, underscoring the necessity of obtaining superior diagnostic tissue specimens. While these treatment approaches are commonly utilized in the metastatic setting, approval among earlier-stage disease will continue to rise, highlighting the importance of early and comprehensive biomarker testing at the time of diagnosis for all patients. Pulmonologists play an integral role in the diagnosis and staging of non-small cell lung cancer via sophisticated tissue sampling techniques. This multifaceted review will highlight current indications for the use of targeted therapies and immunotherapies in non-small cell lung cancer and will outline the quality of various diagnostic approaches and subsequent success of tissue biomarker testing. Pulmonologist-specific methods, including endobronchial ultrasound and guided bronchoscopy, will be examined as well as other modalities such as CT-guided transthoracic biopsy and more.

Background: Endoscopic therapies are firmly established in the management algorithm of benign subglottic and tracheal stenosis (SGTS). The optimal dilation strategy, however, has yet to be elucidated. The objective of this study was to compare the efficacy and safety of balloon versus rigid bronchoplasty in the treatment of benign SGTS. Methods: De novo cases of benign SGTS at our institution over a 9-year period were retrospectively identified. Patients were divided into 2 groups based on the initial dilation strategy of balloon or rigid bronchoplasty. Demographics, clinical findings, concurrent interventions, lesion characteristics, and complications were analyzed. Two reviewers independently assigned an index and follow-up endoscopic stenosis grade for each case. The mean stenosis grade at follow-up in both groups was then calculated and compared. Results: Sixty-three patients with benign SGTS were included. Most stenoses in the rigid (80%) and balloon (63%) bronchoplasty groups were complex (P=0.174). In addition, 94% (59/63) of index stenoses were classified as Cotton Myer Grade 3. At follow-up, no significant difference was found in the mean stenosis grade between dilation strategies (1.97 vs. 2.2, P=0.287). Furthermore, no procedural-related complications were observed in either group. Conclusion: Balloon and rigid bronchoplasty are safe and effective endoscopic tools in the early management of benign SGTS. A multimodality approach centered around mucosal sparing techniques remains vitally important to the overall and likely long-term success of treating this challenging disease entity.

Purpose of review: Lung cancer is the leading cause of cancer-related deaths worldwide. In the absence of distant metastases, accurate mediastinal nodal staging determines treatment approaches to achieve most favourable outcomes for patients. Mediastinal staging differentiates N0/N1 disease from N2/N3 in surgical candidates. Likewise, presence of nodal involvement in nonsurgical candidates who are being considered for stereotactic body radiation therapy is also critical. This review article seeks to discuss the current options available for mediastinal staging in nonsmall cell lung cancer (NSCLC), particularly the role of bronchoscopy. Recent findings: Although several techniques are available to stage the mediastinum, bronchoscopy with EBUS-TBNA with or without EUS-FNA appears to be superior in most clinical situations based on its ability to concomitantly diagnose and stage at once, safety, accessibility to the widest array of lymph node stations, cost and low risk of complications. However, training and experience are required to achieve consistent diagnostic accuracy with EBUS-TBNA. Summary: EBUS-TBNA with or without EUS-FNA is considered the modality of choice in the diagnosis and staging of NSCLC in both surgical and nonsurgical candidates.

Amyloidosis is a heterogeneous group of diseases characterized by the extracellular deposition of misfolded proteins that can affect either systemically or locally confined to one system. Pulmonary amyloidosis is rare and can be classified into three forms according to the anatomic site of involvement: nodular pulmonary amyloidosis, tracheobronchial amyloidosis and diffuse alveolar-septal amyloidosis. The former two usually represent localized amyloid disease and the latter represents systemic disease. Typically lung parenchymal and tracheobronchial amyloidosis do not present together in localized forms of pulmonary amyloidosis. Here we report a unique case of localized pulmonary immunoglobulin light-chain amyloidosis, manifested as both parenchymal nodules and tracheobronchial amyloid deposition.

The use of convex-probe endobronchial ultrasound (CP-EBUS) has revolutionized bronchoscopy. It has provided the option of a relatively safe, minimally invasive approach for the assessment of various intrathoracic diseases. In current practice, its most dramatic impact has been on the diagnosing and staging of lung cancer. It has served as an invaluable tool that has replaced mediastinoscopy in a variety of clinical scenarios. Many pulmonologists and thoracic surgeons consider CP-EBUS the most significant milestone in bronchoscopy after the development of the flexible bronchoscope itself. In this review, we summarize the historical aspects, current indications, technical approach, and future direction of CP-EBUS.

Background: The value of endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) in the mediastinal staging of lung cancer has been well established. However, data regarding its utility in the diagnosis of intrapulmonary lesions has been sparse. This study assesses the sampling utility of convex probe EBUS-visible intrapulmonary lesions not visualized by the white-light bronchoscopy.Methods: A retrospective analysis of EBUS-TBNA of EBUS-visible intrapulmonary lesions was performed between January 2010 and March 2015. Patients with visible endobronchial lesions by white-light bronchoscopy were excluded from analysis.Results: Among 108 procedures, the diagnostic yield of EBUS-TBNA for EBUS-visible intrapulmonary lesions was 87%. Following diagnoses were established: lung cancer (73/67.6%), lung metastases (10/9.2%), infection (5/4.6%), lymphoma (1/<1%), sarcoma/spindle cell sarcoma or neoplasm (3/2.8%), unspecified malignancy (1<1%), and hamartoma (1/<1%). EBUS-TBNA was nondiagnostic in 14 (13%); among these, 9 turned out to have benign disease based on additional bronchoscopy samples or other testing and/or follow-up imaging. Five were ultimately diagnosed with a malignant condition: lymphoma (1), epithelioid hemangioendothelioma (1), and non–small cell lung cancer (3). The sensitivity and the negative predicted value of EBUS-TBNA for differentiating malignancy from benign disease was 94.7% and 75%, respectively, while the accuracy for diagnosing the neoplastic disease was 95.3%. There was one major bleeding requiring bronchial artery embolization and 1 pneumothorax requiring chest tube drainage.Conclusion: EBUS-TBNA is safe and effective in the diagnosis of EBUS-visible intrapulmonary lesions. It should be considered as the diagnostic test of choice in patients with these lesions undergoing EBUS-TBNA for the staging of suspected lung cancer.