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Robotic Endoluminal Bronchoscopy Utilizing Cone Beam CT

Wednesday, August 31, 2022


Jett GK, Afolayan O. Robotic Endoluminal Bronchoscopy Utilizing Cone Beam CT. August 2022. doi:10.25373/ctsnet.20735338

Low-dose CT chest screening for patients at high risk for lung cancer has increased the detection of small peripheral nodules (1), but traditional bronchoscopy limits the ability to biopsy these peripheral nodules (2). Shape-sensing robotic-assisted bronchoscopy utilizing the Ion endoluminal system allows airway visualization and navigation to reach and biopsy small peripheral nodules through a stable platform (3, 4). Initial results have demonstrated a high biopsy rate of 96.7% and a diagnostic yield of 79.3% with no pneumothorax or hemorrhage (5). Most reported cases or videos with Ion use radial endobronchial ultrasound and fluoroscopy to aid with the biopsy (6).



This video demonstrates robotic endoluminal bronchoscopy with Ion using cone beam CT. The patient was a sixty-six-year-old current smoker with a history of breast cancer in 1990 and recurrence in 2007. A surveillance PET/CT scan showed a 1.3 cm right upper lobe nodule with SUV 6.1. Repeat imaging after five months demonstrated increased size to 1.9 cm and SUV 23.4.

The patient underwent robotic endoluminal bronchoscopy with Ion in a hybrid room using a stationary Siemens Artis zeego cone beam CT scanner. Fine-needle aspiration, brushing, and biopsy were performed in three separate areas of the right upper lobe nodule. Rapid onsite evaluation (ROSE) showed clusters of atypical cells which, on final pathology, were suspicious for metastatic carcinoma of colorectal origin.

Cone beam CT provides excellent visualization of the nodule with confirmation of the guide and needle location for robotic endoluminal bronchoscopy and biopsy with the Ion endoluminal system.


  1. Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Crit Care Med. 2015; 192(10):1208-14.
  2. Kalanjeri S, Holladay RC, Gildea TR. State-of-the-art modalities for peripheral lung biopsy. Clin Chest Med. 2018; 39:125-38.
  3. Simoff MJ, Pritchett MA, Reisenauer JS, at al. Shape-sensing robotic-assisted bronchoscopy for pulmonary nodules: Initial multicenter experience using the ION endoluminal system. BMC Pul Med. 2021; 21:322.
  4. Reisenauer J, Simoff MJ, Pritchett MA, et al. ION: Technology and techniques for shape-since the robotic-assisted bronchoscopy. Ann Thorac Surg. 2022; 113:308-3155.
  5. Fielding DIK, Bashirzadeh F, Son JH, et al. First human use of a new robotic-assisted fiber optic sensing navigation system for small peripheral pulmonary nodules. Respiration. 2019; 98 (21): 142-50.
  6. Inra ML, Reisenauer JS. Ion Robotic Bronchoscopy and Da Vinci Robotic Resection for a Solitary Pulmonary Nodule. October 2019. doi:10.25373/ctsnet.9955445.


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Strange case management! This video mostly illustrates that a lot of Hi-tech is not a guarantee for good clinical management and even less a guarantee for good outcome. This was a case that looked like a rather straightforward case of (radiotherapy induced) lung cancer, ending up with no clear diagnosis (a colo-rectal metastasis in a patient with no colorectal cancer??). When a CT-guided biopsy would have been easy or a diagnostic wedge would have been a low-cost diagnostic and therapeutic solution this patient finally ended up with SBRT (known to be often poorly efficient on CRC-lung mets). All this after an additional general anesthesia (which might have triggered the subsequent anaphylactic shock), additional irradiation from a supplementary pre-bronchoscopy CT-scan and intra-bronchoscopic radiation of 299mGy, additional costs of 1.5h OR, ROSE and lots of staff required... Considering the result of ROSE, why wasn't the tumor simply resected in the hybrid OR during the same anesthesia as the robotic bronchoscopy? Would be interesting to know what the patient was finally charged for all this? Altogether, despite a technically well performed (easy) procedure, this video does not illustrate any clear benefit of engaging in high-cost hybrid OR robotic bronchoscopy. Side note: Siemens has been spelled Siemens (not Siemans) ever since this German company was created >150 years ago.

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