We thank Dr. Gerard Silvestri and &#8220;Proceedings of The American Thoracic Society&#8221; for their permission to reproduce their schematic diagram of the Convex-Probe Endobronchial Ultrasound (Figure 2; Proc Am Thorac Soc Vol 6. pp 180&#8211;186, 2009). We thank &#8220;American College of Chest Physicians&#8221; for their permission to reproduce the image of the substernal thyroid biopsy (Figure 4; CHEST Journal 137.6 (2010): 1435-1436). We thank Kelly Watson, RN, for her help in preparation of the procedure video.

The protocol outlined below follows the guidelines of the institution (Roswell Park Cancer Institute, State University of New York at Buffalo, NY).
1. Initial Preparation
<ol>
	<li>Perform Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) under moderate sedation, monitored anesthesia care (MAC), or deep sedation and general anesthesia. 
	NOTE: Patient surveys show favorable satisfaction scores with moderate sedation19, but recent data shows higher diagnostic yield using general anesthesia20.</li>
	<li>Optionally, perform the procedure without an airway device under moderate sedation. Use a laryngeal mask airway (LMA; size 4) for procedures involving deep sedation or general anesthesia. 
	NOTE: Use LMA for lesions that are higher in the trachea. Because of the high tracheal location of substernal thyroid gland, endotracheal intubation should not be used in these cases</li>
	<li>During the procedure, use the lowest effective dose of 1% or 2% lidocaine (cumulative maximum dose of &#8804;7 mg/kg; maximum serum level &#8804;5 mg/L) for topical airway anesthesia through the bronchoscope&#8217;s working channel 21.</li>
</ol>
2. Pre-procedure Surveillance Bronchoscopy
<ol>
	<li>Introduce a conventional flexible bronchoscope into the airway through the oral cavity, or the LMA. Perform a sequential inspection of each sub-segment of both the left and right tracheobronchial tree for obvious endobronchial abnormalities and ensure adequate airway patency. Clean the airway of any secretion or mucus by suctioning. Remove bronchoscope from the airway when done.</li>
</ol>
3. Localizing the Lesion of Interest
<ol>
	<li>Introduce Convex Probe-Endobronchial Ultrasound (CP-EBUS) bronchoscope with a 35&#176; forward oblique angle view. Observe the anterior airway wall and a small portion of the adjacent lumen while advancing the bronchoscope centrally in the airway. When passing through the vocal cords, ensure that only the anterior angle of the glottic opening is visible. When in trachea, visualize the entire lumen with 35&#176; backward flexion as needed.</li>
	<li>Observe the display-screen while using the white-light bronchoscopy. Advance the bronchoscope to the estimated level of the lesion. Always, ensure that the lumen is not fully visible when advancing the bronchoscope. Full view of the lumen indicates that the tip of the CP-EBUS probe is in backward flexion, and poses the risk of traumatic scraping against the posterior airway wall.</li>
	<li>After reaching the desired site of interest, inflate the balloon using about 2 ml of normal saline. Flex the tip of the CP-EBUS forward to bring it in contact with the airway.</li>
	<li>Turn on the ultrasound view using the dedicated ultrasound processor. Use the two-screen display (or split-screen display) to see both the endoscopic view of the lumen, and the corresponding ultrasound image together on the screen.</li>
	<li>Ensure that the EBUS bronchoscope is in flexion position. Move the CP-EBUS both clockwise and counterclockwise in small angles at the same level to identify the substernal thyroid gland. Identify the lesion. Adjust the CP-EBUS probe by moving it up-and-down so that the largest diameter of the lesion is seen.</li>
	<li>Using the Doppler mode, identify the adjacent vascular structures to determine lesion&#8217;s accurate station22, and avoid accidental puncture of the blood vessels.</li>
	<li>At the level of the lesion, flex the tip of the EBUS bronchoscope forward so its ultrasound probe comes in contact with the airway to obtain an ultrasound view of the lesion. When needed, flex the tip backward for full endoscopic view. Repeat the manoeuver and identify a point of entry for the TBNA needle between two tracheal rings.</li>
</ol>
4. Obtaining Endobronchial Ultrasound-guided Transbronchial Needle Biopsy
<ol>
	<li>With the CP-EBUS tip in neutral (non-flexed) position, introduce the dedicated the 22 or 21 G&#160;TBNA needles into the working channel of the EBUS bronchoscope. Fasten the needle assembly onto the working channel using the locking mechanism.</li>
	<li>Loosen the sheath adjuster knob and advance the sheath so that the tip can be barely visualized on the endoscopic image. Fasten the sheath adjuster knob now.</li>
	<li>Flex the CP-EBUS probe forward to bring it in contact with the airway wall. On the ultrasound image, reconfirm that the longest diameter of the lesion is aligned with the projected path of the needle. Ensure that the needle exits the working channel at an angle of 20&#176;.</li>
	<li>Loosen the needle adjuster knob, and puncture through the airway wall into the lesion under real-time ultrasound guidance. With the EBUS needle inside the lesion, shake the internal stylet to clean out the needle tip.</li>
	<li>Remove the internal stylet and attach the 20 ml vacuum-generating syringe to apply negative pressure.</li>
	<li>Move the needle back-and-forth (&#8220;passes&#8221;) inside the lesion, with &#8211; 20 ml negative pressure applied by a special vacuum-generating syringe. A total of 3-7 passes is suggested based on the current literature10,11.</li>
	<li>After making sufficient number of passes, negative pressure knob is turned off, and needle is retrieved out of the working channel.</li>
	<li>Push out the histological core using the internal sheath. Obtain both histological core as well as cytological aspirate by this method. Alternatively, use an air-filled 6 or 12 ml syringe to expel the content of the needle onto the slide or in the specimen cup.</li>
	<li>Determine the adequateness of the specimen using on-site cytology services.</li>
</ol>
5. Post-procedure Surveillance Bronchoscopy
<ol>
	<li>Remove the CP-EBUS bronchoscope out after biopsy. Reintroduce a conventional bronchoscope and perform a surveillance bronchoscopy to confirm absence of significant bleeding at the TBNA site. After hemostasis is ensured, remove the bronchoscope out and conclude the procedure.</li>
</ol>

The authors have nothing to disclose.

Substernal goiter was first described in 1749 by Haller23. The reported incidence of substernal or mediastinal goiter varies between 0.2% and 45% of all goiters, depending on the definition used24. More than ten definitions of substernal goiter have been proposed. By the simple clinical definition, a part of the substernal thyroid remains permanently retrosternal on physical exam without neck in hyperextension, as opposed to with neck in hyperextension as per Torre&#8217;s definition25. K...

Substernal thyroid goiter (STG) is a slow growing tumor, eventually causing symptoms in 70-80% of cases. As per literature review, between 2.5-22.6% of STG can have malignant transformation2. Compression of the trachea, esophagus, recurrent laryngeal nerve, and superior vena cava often causes symptoms like dyspnea, stridor, cough, dysphagia, dysphonia, vocal cord paralysis, Horner&#8217;s syndrome, superior vena cava syndrome, and cerebral edema. Occasional cases of overt hyperthyroidism have also been reported. A retrospective study by Shin et al. reported a positive correlation between thyroid size and presence of shortness of breath, globus sensation, and symptoms of hyperthyroidism3. This study, however, did not find a correlation between goiter size and presence of dysphagia, local discomfort, changes in voice, hemoptysis, or symptoms of hypothyroidism. Both substernal and cervical goiters carry similar malignancy risk. However, the retrosternal location makes diagnostic biopsy and treatment of STG very challenging. Most cases eventually require surgical removal using mediastinoscopy or sternotomy.
Endobronchial ultrasound (EBUS) was first described in 1992 by Hurter and Hanrath4. Over the years, EBUS-TBNA has become the procedure of choice for diagnosis and staging of non-small cell lung cancer. The reported sensitivity, specificity, and positive predictive value of EBUS-TBNA for mediastinal and hilar lymphadenopathy is 94%, 100%, and 100% respectively, with a low complication rate making it very safe, effective and superior to conventional TBNA5. However, both conventional and EBUS-guided TBNA were found to have statistically similar results for subcarinal lymph nodes6.
Two types of EBUS probes have been developed so far &#8211; the radial probe (RP-EBUS) and the curvilinear probe (CP-EBUS). RP-EBUS was the first one to become commercially available in 1999. It has a thin ultrasound probe inside a water-inflatable balloon tip. The probe rotates 360&#176;&#160;at an angle perpendicular to the axis of insertion. The inflated balloon provides a circular contact for the probe, enabling it to obtain 360&#176;&#160;view around the airways. It is used for evaluation of the central airways, assessment of airway invasion and obtaining biopsy of peripherally located lesions7,8. After the lesion is localized, radial probe must be taken out of the guide sheath in the bronchoscope&#8217;s working channel to make way for the biopsy tool. Hence, a real-time ultrasound guided biopsy cannot be performed. Three different radial probes are currently available - 20-MHz and 30-MHz miniature probes, and the 20-MHz ultra-miniature probe. The miniature probes can be inserted through the 2.8 mm working channel of a bronchoscope and reach sub-segmental airways; the higher frequency probe provides better image resolution9. With an outer diameter of 1.4 mm, the ultra-miniature probe fits into the 2 mm working channel of the smaller bronchoscope and reaches more peripheral lesions.
CP-EBUS was introduced in 2005. It is a 7.5 MHz convex probe inside a saline-inflatable balloon at the tip of the bronchoscope (Figure&#160;1). The outer diameter of the bronchoscope tube is 6.3&#160;mm, and of the tip is 6.9 mm. The inner diameter of the working channel is 2.2 mm. The scope looks at a 35&#176;&#160;forward oblique angle, with an angle of view of 80&#176;&#160;(Figure&#160;2). The convex probe itself generates a 50&#176;&#160;image, and scans parallel to the insertion axis. Ultrasound images can be obtained by either placing the probe directly over the bronchial wall using forward flexion, or by additionally inflating the balloon with saline. Water is a better conductor than air of ultrasound waves, and improves image quality. Vascular structures can be differentiated from tissues using the color Doppler mode scan. Biopsy is performed using a dedicated 22 or 21 G&#160;TBNA needle with an echogenic-dimpled tip (Figure&#160;3), which comes out at an angle of 20&#176;&#160;to the long axis of the bronchoscope. The needle has a maximum extruding stroke of 40 mm, with a safety mechanism that stops it at 20 mm to prevent excessive protrusion. The internal wire of the needle minimizes sample contamination while the needle passes through the bronchial wall. It is also used to clean up the needle after it has passed through the bronchial wall and into the targeted lesion. The optimal number of aspiration &#8220;passes&#8221; is reported to be 3-7 for a satisfactory sample, but the highest yield is from the first pass10,11. The images are processed in a dedicated ultrasound processor. Both ultrasound and white-light bronchoscopy images are simultaneously visible on the monitor, allowing for easy navigation to the site of the suspected lesion. CP-EBUS has the ability to perform real-time TBNA with direct ultrasound guidance under moderate sedation or general anesthesia. The procedure can be performed in an outpatient setting, eliminating surgery-related morbidity and need for inpatient admission.
The use of EBUS-TBNA for diagnosis of substernal thyroid is new, and has been reported in only a few case reports12-18. Based on the review of the current literature, this paper seeks to elaborate on the procedural requirements and propose EBUS-TBNA as a modality for biopsy of substernal thyroid gland. Please note that the above equipment description is more specific to Olympus Inc. There are other commercially available products as well, and minor variations do exist.

<table><tbody><tr><td>7.5-MHz Convex Probe-EBUS bronchoscope</td><td></td><td></td><td></td></tr><tr><td>Dedicated 22 or 21 G TBNA needle</td><td></td><td></td><td></td></tr><tr><td>Ultrasound processor unit</td><td></td><td></td><td></td></tr><tr><td>On-site cytopathology (optional)</td><td></td><td></td><td></td></tr><tr><td>Moderate sedation drugs - benzodiazepines or fentanyl&amp;nbsp;</td><td></td><td></td><td></td></tr><tr><td>Deep sedation / General anesthesia drugs - propofol or remifentanil</td><td></td><td></td><td></td></tr><tr><td>Local anesthesia (for airways) - 1% or 2% lidocaine</td><td></td><td></td><td></td></tr></tbody></table>

substernal thyroid biopsy using endobronchial ultrasound-guided transbronchial needle aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) biopsy of substernal thyroid has been reported in eight case reports as per literature review12-18. The first case of substernal thyroid biopsy using Endobronchial Ultrasound was reported by Rosario et al. in 200612, wherein a CT chest done for metastatic work-up of prostate adenocarcinoma showed mediastinal lymphadenopathies. EBUS-TBNA of the lesion revealed a previously undiagnosed papillary thyroid carcinoma met...

Watch this Scientific Journal Video about Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration at JoVE.com

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

substernal-thyroid-biopsy-using-endobronchial-ultrasound-guided

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

25.5K Views.  State University of New York, Buffalo. Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

Video: Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Ultrasound-guided Transthoracic Intramyocardial Injection in Mice

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. Experiments involving myocardial injection are currently performed by direct surgical access through a thoracotomy. While convenient when performed at the time of another experimental manipulation such as coronary artery ligation, the need for an invasive procedure for intramyocardial delivery limits potential experimental designs. With ever improving ultrasound resolution and advanced noninvasive imaging modalities, it is now feasible to routinely perform ultrasound-guided, percutaneous intramyocardial injection. This modality efficiently and reliably delivers agents to a targeted region of myocardium. Advantages of this technique include the avoidance of surgical morbidity, the facility to target regions of myocardium selectively under ultrasound guidance, and the opportunity to deliver injectate to the myocardium at multiple, predetermined time intervals. With practiced technique, complications from intramyocardial injection are rare, and mice quickly return to normal activity on recovery from anesthetic. Following the steps outlined in this protocol, the operator with basic echocardiography experience can quickly become competent in this versatile, minimally invasive technique.

Echocardiography-guided percutaneous intramyocardial injection represents an efficient, reliable, and targetable modality for the delivery of gene transfer agents or cells into the murine heart. Following the steps outlined in this protocol, the operator can quickly become competent in this versatile, minimally invasive technique.

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. ...

Femoral Bone Marrow Aspiration in Live Mice

Serial sampling of the cellular composition of bone marrow (BM) is a routine procedure critical to clinical hematology. This protocol describes a detailed step-by-step technical procedure for an analogous procedure in live mice which allows for serial characterization of cells present in the BM. This procedure facilitates studies aimed to detect the presence of exogenously administered cells within the BM of mice as would be done in xenograft studies for instance. Moreover, this procedure allows for the retrieval and characterization of cells enriched in the BM such as hematopoietic stem and progenitor cells (HSPCs) without sacrifice of mice. Given that the cellular composition of peripheral blood is not necessarily reflective of proportions and types of stem and progenitor cells present in the marrow, procedures which provide access to this compartment without requiring termination of the mice are very helpful. The use of femoral bone marrow aspiration is illustrated here for cytological analysis of marrow cells, flow cytometric characterization of the hematopoietic stem/progenitor compartment, and culture of sorted HSPCs obtained by femoral BM aspiration compared with conventional marrow harvest.

This protocol describes a procedure for serial sampling of femoral bone marrow (BM) without requiring the sacrifice of mice. This procedure facilitates longitudinal studies of the BM composition of mice over time and provides serial access to cells within the BM for ex vivo and transplantation studies.

Serial sampling of the cellular composition of bone marrow (BM) is a routine procedure critical to clinical hematology. This protocol describes a detailed ...

Human Skeletal Muscle Biopsy Procedures Using the Modified Bergstr&#246;m Technique

The percutaneous biopsy technique enables researchers and clinicians to collect skeletal muscle tissue samples. The technique is safe and highly effective. This video describes the percutaneous biopsy technique using a modified Bergstr&#246;m needle to obtain skeletal muscle tissue samples from the vastus lateralis of human subjects. The Bergstr&#246;m needle consists of an outer cannula with a small opening (&#8216;window&#8217;) at the side of the tip and an inner trocar with a cutting blade at the distal end. Under local anesthesia and aseptic conditions, the needle is advanced into the skeletal muscle through an incision in the skin, subcutaneous tissue, and fascia. Next, suction is applied to the inner trocar, the outer trocar is pulled back, skeletal muscle tissue is drawn into the window of the outer cannula by the suction, and the inner trocar is rapidly closed, thus cutting or clipping the skeletal muscle tissue sample. The needle is rotated 90&#176;&#160;and another cut is made. This process may be repeated three more times. This multiple cutting technique typically produces a sample of 100-200 mg or more in healthy subjects and can be done immediately before, during, and after a bout of exercise or other intervention. Following post-biopsy dressing of the incision site, subjects typically resume their activities of daily living right away and can fully participate in vigorous physical activity within 48-72 hr. Subjects should avoid heavy resistance exercise for 48 hr to reduce the risk of herniation of the muscle through the incision in the fascia.

The purpose of this video is to present the modified Bergstr&#246;m skeletal muscle biopsy technique on human subjects.

The percutaneous biopsy technique enables researchers and clinicians to collect skeletal muscle tissue samples. The technique is safe and highly ...

Simulation-Based Training of EBUS-TBNA

Systematic Endobronchial Ultrasound - The Six Landmarks Approach

Lung cancer is the leading cause of cancer mortality globally. To ensure the correct diagnosis and staging in relation to treatment options, it is crucial to obtain valid biopsies from suspected tumors and mediastinal lymph nodes and accurate identification of the mediastinal lymph nodes regarding the Tumor-Node-Metastasis (TNM)-classification. Flexible bronchoscopy combined with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is essential in the workup and diagnosis of patients suspected of lung cancer. EBUS-TBNA from mediastinal lymph nodes is a technically difficult procedure and has been identified as one of the most important procedures that should be integrated into a simulation-based training program for invasive pulmonologists. More specific guidelines that govern training in EBUS-TBNA are needed to meet this demand. We hereby propose a systematic, stepwise approach with specific attention to six landmarks that support the endoscopist when navigating through the bronchial maze. The stepwise approach relying on the six landmarks is used in the EBUS-certified training program offered by the European Respiratory Society (ERS).

Author Spotlight: Demonstrating Systematic Endobronchial Ultrasound to New Endoscopists 

Endobronchial ultrasound-guided sampling using transbronchial needle aspiration plays a key role in staging and diagnosing lung cancer. We propose a systematic stepwise approach dividing the procedure into six landmarks that should be taught to new operators.

Lung cancer is the leading cause of cancer mortality globally. To ensure the correct diagnosis and staging in relation to treatment options, it is crucial ...

Cancer Research

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules

We describe the novel use of electromagnetic navigational guided transthoracic needle aspiration for the pathologic assessment of human lung nodules.

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently ...

Transbronchial Lung Cryobiopsy for Diagnosing Interstitial Lung Diseases and Peripheral Pulmonary Lesions - A Stepwise Approach

Transbronchial lung cryobiopsy (TBLC) is an invasive procedure increasingly implemented during the last decade as an alternative to video-assisted thoracic surgery lung biopsy (SLB) for diagnosing interstitial lung diseases (ILDs). The indication for TBLC has primarily been to sub-classify a specific ILD subtype when this cannot be achieved on the basis of a preceding multidisciplinary team discussion. Although SLB is considered the gold standard for establishing a histological diagnosis, TBLC has been gradually suggested as the first-choice histological diagnostic modality in patients with unclassified ILDs due to a comparable diagnostic yield with SLB, but superior to SLB in terms of complications, including mortality. During recent years, radial endobronchial ultrasound (R-EBUS) and electromagnetic navigation bronchoscopy (ENB)-guided TBLC for peripheral pulmonary lesions have also been described as safe procedures, which may improve the diagnostic yield compared to forceps biopsies. Still, the diagnostic properties of TBLC rely on the quality of the procedure&#39;s performance. This article aims to describe the stepwise approach to conducting TBLC with a flexible bronchoscope for the different indications mentioned, which might be helpful for novice bronchoscopists performing TBLC.

Transbronchial lung cryobiopsy (TBLC) for diagnosing interstitial lung disease and peripheral pulmonary lesions is a high-yield diagnostic and safe procedure. We describe a stepwise approach to conduct TBLC for the different indications mentioned with a flexible bronchoscope, which might be helpful for novice bronchoscopists performing TBLC.

Transbronchial lung cryobiopsy (TBLC) is an invasive procedure increasingly implemented during the last decade as an alternative to video-assisted ...

Radial Endobronchial Ultrasound and Electromagnetic Navigation Bronchoscopy with Fluoroscopy for the Diagnosis of Peripheral Lung Lesions

Diagnosing lung cancer using a flexible bronchoscope is a safe procedure with a very low risk of complications. Bronchoscopy has high diagnostic accuracy for endobronchial lesions, but it falls short when sampling peripheral lesions. Therefore, several modalities have been invented to guide the bronchoscope to the lesion and confirm the location of the tumor before tissue sampling. 
Fluoroscopy is used during bronchoscopy to provide a 2D X-ray image of the thorax during the procedure. The bronchoscope and tools will be visible, as well as lesions if larger than 2.0-2.5 cm. Radial endobronchial ultrasound (rEBUS) consists of an ultrasound probe, small enough to be inserted into the working channel of the bronchoscope. The ultrasound probe is used to differentiate between consolidated tissue, such as tumor tissue, and normal air-filled lung parenchyma. Electromagnetic navigation bronchoscopy (ENB) creates a 3D model of the bronchial tree from computed tomography (CT) scans of the patient. Prior to the bronchoscopy, a route from the trachea to the lesion is planned, to create real-time guidance of the bronchoscope to the lesion during the procedure, similar to the Global Positioning System. The aim of this article is to describe a stepwise approach to performing bronchoscopy with rEBUS and fluoroscopy, bronchoscopy with ENB, rEBUS, and fluoroscopy. In the discussion section, the pros and cons of each modality will be discussed.

Diagnosing small lung tumors is quite difficult using a bronchoscope alone. Electromagnetic navigation bronchoscopy is used to locate the lesion, similar to the Global Positioning System. Radial endobronchial ultrasound and fluoroscopy confirm the correct location and monitor the sampling.

Diagnosing lung cancer using a flexible bronchoscope is a safe procedure with a very low risk of complications. Bronchoscopy has high diagnostic accuracy ...

A Stepwise Approach for Performing Ultrasound Guided Transthoracic Lung Biopsy

Diagnosing patients with radiological lung lesions, especially those suspected of having primary lung cancer, is a common and critical clinical scenario. When selecting the most suitable invasive procedure to establish a diagnosis in these cases, a delicate balance must be struck between achieving a high diagnostic yield, providing staging information, minimizing potential complications, enhancing the patient experience, and controlling costs. The integration of thoracic ultrasound as a routine clinical tool in respiratory medicine has led to increased awareness and utilization of ultrasound-guided invasive techniques in chest procedures, including transthoracic biopsies. By following a systematic and stepwise approach, transthoracic ultrasound-guided lung biopsy emerges as a safe, cost-effective procedure with a remarkable diagnostic accuracy. These attributes collectively position it as an ideal invasive technique when technically feasible. Consequently, in patients presenting subpleural lung lesions suspected of malignancy, transthoracic ultrasound-guided lung biopsy has become a standard procedure in the realm of modern invasive pulmonology.

Transthoracic ultrasound-guided lung biopsy represents a safe, cost-effective, and efficient approach for patients presenting with subpleural lung lesions suspected of malignancy. Employing a systematic, step-by-step process is crucial to achieve optimal patient selection, minimize complication risks, and maximize diagnostic accuracy.

Diagnosing patients with radiological lung lesions, especially those suspected of having primary lung cancer, is a common and critical clinical scenario. ...

Integrating Transesophageal Ultrasound with an Echoendobronchoscope

Using the Endoscope for Endobronchial Ultrasound in the Esophagus

EUS-B is a procedure using the echoendobronchoscope in the esophagus and stomach. The procedure is a minimally invasive, safe, and feasible approach that pulmonologists can use to visualize and biopsy structures adjacent to the esophagus and stomach. EUS-B gives access to many structures of which some may also be reached by EBUS (mediastinal lymph nodes, lung or pleural tumors, pericardial fluid) while others cannot be reached such as retroperitoneal lymph nodes, ascites, and lesions in the liver, pancreas or left adrenal gland. The procedure is a pulmonologist- and patient- friendly version of the gastroenterologists' EUS using the thin EBUS endoscope that the pulmonologist already masters. Thus EUS-B training should be easy and a natural continuation of EBUS. With the patient under conscious sedation and in the supine position, the echoendoscope is introduced either through the nostril or mouth into the oropharynx. Then the patient is encouraged to swallow while the endoscope is slowly bent posteriorly and introduced into the esophagus and stomach. Using the ultrasonic image, the operator identifies the six landmarks by EUS-B and EUS: the left liver lobe, abdominal aorta (with the celiac trunk and superior mesenteric artery), left adrenal gland, and mediastinal lymph node stations 7, 4L, and 4R. Biopsies can be taken from suspected lesions under real-time ultrasonographic guidance- fine needle aspiration (EUS-B-FNA) using a technique similar to that used with EBUS-TBNA. The biopsy order is M1b-M1a-N3-N2-N1-T (M = metastasis, N = lymph node, T = tumor) to avoid iatrogenic upstaging. Pre- and post-procedural observation is similar to that of bronchoscopy. EUS-B is safe and feasible in the hands of experienced interventional pulmonologists and provides a significant expansion of the diagnostic possibilities in providing safe, fast, and thorough diagnosis and staging of lung cancer.

Author Spotlight: Advancing Biopsy Techniques with Transesophageal Ultrasound

Transesophageal ultrasound (EUS-B) is a safe and feasible procedure using the echoendobronchoscope (EBUS) in esophagus and stomach. After identifying six anatomical landmarks, additional structures can be identified and biopsied, sparing subsequent diagnostic sessions. Thus, EUS-B is an ideal continuation of bronchoscopy and EBUS in diagnosing lung cancer and other diseases.

EUS-B is a procedure using the echoendobronchoscope in the esophagus and stomach. The procedure is a minimally invasive, safe, and feasible approach that ...

Advancements in Pulmonary Lesion Biopsy Through Robotic Bronchoscopy

Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted Lung Cryobiopsies

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways under direct vision after establishing a pathway to a target lesion based on mapping performed on a 3-dimensional (3D) lung and airway reconstruction obtained from a pre-procedure thin-slice computed tomography chest. RAB has maneuverability to distal airways throughout the lung, precise catheter tip articulation, and stability with the robotic arm. Adjunct imaging tools such as fluoroscopy, radial endobronchial ultrasound (r-EBUS), and cone beam computed tomography (CBCT) can be used with RAB. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profiles in both malignant and non-malignant processes for the biopsy of peripheral pulmonary lesions (PPLs). A 1.1 mm cryoprobe combined with ssRAB has been shown to be safe and effective for the diagnosis of PPLs compared to a traditional bronchoscopy with forceps biopsy. This technique can also be used for targeted lung sampling in benign processes. The aim of this article is to describe a stepwise approach to performing RAB combined with fluoroscopy, r-EBUS, and CBCT to obtain targeted transbronchial lung cryobiopsies (TBLC).

Author Spotlight: Expanding Interventional Pulmonology Research with Robotic-Assisted Bronchoscopy

This article aims to describe a stepwise approach to performing robotic-assisted bronchoscopy combined with fluoroscopy, radial endobronchial ultrasound, and cone beam computed tomography to obtain targeted transbronchial lung cryobiopsies.&#160;

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways ...