The authors want to thank the interventional pulmonology team, endoscopy staff, anesthesia team, cytopathology team, and hybrid operating room radiology technicians at UT Southwestern Medical Center.

The protocol described in this article outlines standard clinical practice. The University of Texas Southwestern Medical Center Institutional Review Board approved the prospective data collection of patients undergoing standard-of-care bronchoscopy with ssRAB (STU-2021-0346), and individual consent is waived for inclusion in our database. Routine procedure consent is obtained from the patient prior to the procedure. Patients who have DPLD radiographically and are acceptable candidates for bronchoscopic biopsy are referred for this procedure5,27. Patients over 18 years of age are deemed able to undergo the procedure by the referring and performing physicians. Exclusion criteria include bleeding disorders (elevated INR &#62;1.3, thrombocytopenia &#60;100,000/&#181;L), hypoxia with pulse oximetry &#60;90% on 2 L/min supplemental oxygen, pulmonary hypertension (echocardiographically measured systemic pulmonary artery pressure &#62;50 mmHg), or severe cardiac disease. The details of the equipment used in this study are listed in the Table of Materials.
1. Pre-procedural planning
<ol>
	<li>Upload the patient&#8217;s thin slice CT chest to the planning software. The software will automatically create a 3-dimensional reconstruction of the airways and lungs.</li>
	<li>Select targets in the lungs for proposed sampling approximately 10 mm from the pleural border. NOTE: This may be an area of ground glass, infiltrate, nodularity, or fibrosis after discussion with the referring physician, radiologist, or clinical judgment. Prior reported literature for peripheral lung lesions shows an increased diagnostic yield if the targeted area is&#160; &#62;2 cm28.</li>
	<li>Plan a pathway to each target site. 
	NOTE: In the event that the pathway is not feasible during the procedure, consider planning a secondary pathway.</li>
	<li>Review the plan in all three CT views (axial, coronal, and sagittal) and virtual bronchoscopy (Figure 1).</li>
	<li>Export the plan to the controller console.&#160;</li>
</ol>
2. Patient preparation
<ol>
	<li>Induce and maintain the patient under general anesthesia with a minimum size 8.0 single-lumen endotracheal tube. Use neuromuscular blockade and total intravenous anesthesia with ventilator protocols to reduce the development of atelectasis29. 
	NOTE: Monitoring of paralysis is performed using a train-of-four test with a peripheral nerve stimulator29.</li>
	<li>Tuck the patient&#8217;s arms to allow for full rotation of the c-arm during CBCT spin.</li>
	<li>Position the patient and c-arm so that the targeted area for TBLC is isocentered on fluoroscopy.</li>
</ol>
3. Conventional bronchoscopy
<ol>
	<li>Insert the diagnostic or therapeutic bronchoscope via a bronchoscope adapter into the endotracheal tube.</li>
	<li>Perform an airway examination and minimize suction to reduce the development of atelectasis30.</li>
	<li>Remove the bronchoscope.</li>
</ol>
4. Robotic-assisted bronchoscopy
<ol>
	<li>Docking
	<ol>
		<li>Move the robotic bronchoscope to a position adjacent to the patient.</li>
		<li>Dock the robotic arm with the magnetic bronchoscope adapter. Insert the catheter and vision probe into the endotracheal tube.</li>
	</ol>
	</li>
	<li>Registration
	<ol>
		<li>Position the catheter so that direct vision matches the virtual bronchoscope image at the carina.</li>
		<li>Maneuver the robotic catheter via a scroll wheel and track ball on the controller console into both mainstem airways, then bilateral upper and lower airways to collect airway data.</li>
		<li>Compare virtual versus actual bronchoscope images after registration is complete. If significant mismatching or divergence is noted, perform re-registration; otherwise, accept the registration.</li>
	</ol>
	</li>
	<li>Navigation
	<ol>
		<li>Maneuver the catheter using the scroll wheel and track ball on the controller console through the airways to the target lesion following the planned pathway.</li>
		<li>Use the &#8220;Preview Path&#8221; feature to follow images of the airways if divergence (discrepancy between the virtual and actual airways) is noted.</li>
	</ol>
	</li>
	<li>Use fluoroscopy, r-EBUS, and CBCT to confirm location.
	<ol>
		<li>Remove the vision probe when the catheter is within 5&#8211;10 mm of the target lesion.</li>
		<li>Advance the r-EBUS probe with probe rotation under fluoroscopy. Advance to the pleural border (Figure 2A).</li>
		<li>Retract the r-EBUS probe under fluoroscopy approximately 10 mm from the pleural border to the anticipated biopsy target site. Use the r-EBUS probe to visualize the target area and assess the surrounding parenchyma and any vasculature in the potential biopsy area. Remove the r-EBUS probe.</li>
		<li>Insert the 1.1 mm touch cryoprobe via the catheter and extend under fluoroscopy to the pre-determined target area for biopsy (Figure 2B).</li>
		<li>Perform cone beam CT spin per system-specific protocol. The ventilation may be continued or held per provider preference using an end-inspiratory breath hold with the ventilator&#8217;s adjustable pressure-limiting valve set to match the positive end-expiratory pressure (PEEP) or vital capacity maneuver. 
		NOTE: The CBCT spin may be performed with the extension of the r-EBUS probe without rotation or 1.1 mm cryoprobe in the anticipated biopsy site.</li>
		<li>Interpret and compare the intra-procedure imaging to the pre-procedure CT chest and plan to ensure the catheter is at the target. If augmented fluoroscopy is available on the CBCT, segment the target for visualization with 2-D fluoroscopy during biopsy (Figure 3).</li>
		<li>Adjust the catheter based on fluoroscopy, CBCT, and r-EBUS to ensure that sampling occurs in the appropriate location.</li>
		<li>Repeat CBCT after the catheter is adjusted if necessary.</li>
	</ol>
	</li>
	<li>Tissue sampling
	<ol>
		<li>Ensure the 1.1 mm touch cryoprobe is in the appropriate biopsy position.</li>
		<li>Press the pedal to activate the freeze cycle from 4 s to 6 s, then retract the probe in one motion while continuing to depress the pedal.</li>
		<li>Release the pedal while placing the probe tip with tissue biopsy in sodium chloride 0.9% or fixative to release the biopsy from the tip.</li>
		<li>Repeat steps 4.5.1&#8211;4.5.3 to perform TBLC. 
		NOTE: The authors typically perform 1&#8211;4 biopsies at each site. During the biopsy process, the catheter may be adjusted slightly prior to each biopsy to ensure adequate tissue procurement; this may require repeating CBCT spins or using r-EBUS to confirm position in step 4.4.</li>
		<li>After the final biopsy, inject 1&#8211;2 mL of normal saline and air in a 10 mL Leuer lock syringe into the catheter to clear any blood or secretions.</li>
		<li>Insert the vision probe to view the sampling site and retract the catheter slowly. If there is evidence of bleeding via direct vision or blushing on fluoroscopy, then instill topical 1:10,000 epinephrine 1 mL, additional cold saline, or 50&#8211;100mg of tranexamic acid via Leuer lock syringe. Then, leave the catheter in place for 3&#8211;5 min for additional tamponade.</li>
		<li>Repeat step 4.5.6. If there is no evidence of bleeding, retract the catheter to the trachea.</li>
		<li>If significant bleeding is noted, then remove the robotic bronchoscope and follow protocols for the management of iatrogenic bleeding after flexible bronchoscopy31.</li>
	</ol>
	</li>
	<li>Additional target sites: If additional target sites are planned for biopsy, then repeat steps 4.3&#8211;4.5.</li>
	<li>After the conclusion of robotic-assisted bronchoscopy, retract the catheter, undock the robotic system, and move out of position.</li>
</ol>
5. Conventional bronchoscopy&#160;
<ol>
	<li>Reinsert the diagnostic or therapeutic bronchoscope through the bronchoscope adapter into the airways for airway examination and suctioning.</li>
	<li>If bronchoalveolar lavage is indicated, advance the bronchoscope into a subsegmental airway where TBLC was not performed to create a wedge. Instill serial aliquots of normal saline and then return via hand suction.&#160;</li>
</ol>
6. Procedure conclusion
<ol>
	<li>Remove the bronchoscope.</li>
	<li>Perform fluoroscopy or focused ultrasound5 to assess for pneumothorax. If pneumothorax is identified, consider the placement of a chest tube versus conservative management with serial observation depending on size and patient&#8217;s clinical status.</li>
	<li>If necessary, transfer the TBLC specimens to the container with a fixative if initially placed in 0.9% sodium chloride.</li>
	<li>Reverse anesthesia, extubate, and awaken the patient.</li>
	<li>Transfer the patient to the post-anesthesia care unit.</li>
	<li>Perform and review post-procedure chest radiograph (Figure 4).</li>
</ol>
7. Follow-up post procedure
<ol>
	<li>Review results from the bronchoscopy at a multi-disciplinary discussion attended by pulmonologists who are experts in interstitial lung disease, thoracic radiologists, and thoracic pathologists to determine an ILD subtype.</li>
	<li>Discuss the results of the bronchoscopy and MDD conference with the patient, as well as plans for further management and follow-up.&#160;</li>
</ol>

Advancements in Pulmonary Lesion Biopsy Through Robotic Bronchoscopy

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A., Annema, J., Bonta, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Advances+in+optical+coherence+tomography+and+confocal+laser+endomicroscopy+in+pulmonary+diseases.">Advances in optical coherence tomography and confocal laser endomicroscopy in pulmonary diseases.</a> Respiration. 99 (3), 190-205 (2020).</li><li>Kheir, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+bronchoscopic+lung+cryobiopsy+and+a+genomic+classifier+in+the+multidisciplinary+diagnosis+of+diffuse+interstitial+lung+diseases.">Using bronchoscopic lung cryobiopsy and a genomic classifier in the multidisciplinary diagnosis of diffuse interstitial lung diseases.</a> Chest. 158 (5), 2015-2025 (2020).</li><li>Chaudhary, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interstitial+lung+disease+progression+after+genomic+usual+interstitial+pneumonia+testing.">Interstitial lung disease progression after genomic usual interstitial pneumonia testing.</a> Eur Respir J. 61 (4), (2023).</li><li>Tian, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+confocal+laser+endomicroscopy+in+pulmonary+medicine.">The role of confocal laser endomicroscopy in pulmonary medicine.</a> Eur Respir Rev. 32 (167), 2201245 (2023).</li></ol>

DP has no conflicts of interest to declare. KS reports a relationship with Intuitive Surgical Inc. that includes travel reimbursement.

This manuscript provides a stepwise approach for performing RAB with fluoroscopy, r-EBUS, and cone beam CT to obtain targeted TBLC.&#160;
There are several critical steps in this protocol. First, patient selection is imperative to ensure patients are both appropriate candidates (the biopsy procedure may have a direct impact on diagnosis and further care) and medically able to undergo the procedure5,6. Pre-procedure preparation includes...

Flexible bronchoscopy with transbronchial lung biopsy (TBBX) is a diagnostic modality used for the evaluation of abnormal chest imaging, including masses, nodules, non-resolving infiltrates, or parenchymal lung diseases1. Diffuse parenchymal lung diseases (DPLD) can often be characterized by fibrosis and/or inflammation. While some patients can be diagnosed noninvasively with a thorough history, physical examination, relevant serologies, high-resolution computed tomography (HRCT) findings, and multi-disciplinary discussion (MDD), many patients need an invasive procedure to establish a diagnosis2. Conventional transbronchial lung biopsies with forceps are limited due to small biopsy size and crush artifacts; as a result, surgical lung&#160;biopsy has been considered the gold standard, although it has significant morbidity and mortality3,4.
Transbronchial lung cryobiopsy (TBLC) is a technique that can be used to diagnose interstitial lung disease (ILD) or diffuse parenchymal lung disease (DPLD) and might serve as an alternative to surgical lung biopsy (SLB)5. According to the European Respiratory Society guidelines, TBLC is recommended as a substitute for SLB in eligible patients6. Similarly, the American Thoracic Society guidelines offer a conditional recommendation for TBLC as an alternative to SLB in medical centers with the necessary expertise in performing and interpreting TBLC results7. TBLC has historically provided good accuracy in diagnosis compared to SLB but is limited by complications, including bleeding and pneumothorax8. A recent meta-analysis showed an overall diagnostic yield of 77% that improved to 80.7% with MDD, and reported a pneumothorax rate of 9.2% and bleeding rate of 9.9%9. TBLC is also used in the evaluation of PPLs10.&#160;
The development of robotic-assisted bronchoscopy (RAB) allows for targeted sampling in the lung by navigating through the airways under direct vision with easy catheter maneuverability, precise catheter tip articulation, stability, and the ability to maintain a bronchoscopic wedge in distal airways with the catheter using a robotic arm. The Ion endoluminal system utilizes shape-sensing technology for navigation to access specific targeted areas in the lung. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profile, primarily for PPLs suspicious of malignancy11,12,13,14. A 1.1 mm cryoprobe for TBLC combined with ssRAB has been shown to be safe and effective for the diagnosis of pulmonary nodules compared to transbronchial biopsy with forceps15. This technique can be used to obtain targeted lung biopsies larger than conventional transbronchial biopsies using forceps that are relatively free of crush artifacts.&#160;
Radial endobronchial ultrasound (r-EBUS) and cone beam computed tomography are used in conjunction with conventional bronchoscopy, electromagnetic, or robotic navigational systems for real-time confirmation prior to sampling PPLs16,17,18,19,20,21,22. R-EBUS has also been utilized during TBLC for DPLD to increase the pathologic confidence of lung specimens, decrease bleeding, and have a shorter procedure time23. The addition of CBCT has improved the safety profile of TBLC for DPLD by confirming the probe tip is in a safe zone for biopsy, allowing objective measurement of the distance from the pleura with the ability to visualize and avoid vasculature24,25,26.&#160;
This protocol will describe a procedure to obtain targeted TBLC in the setting of parenchymal lung disease for patients who are able to tolerate and benefit from the procedure using the Ion endoluminal system in conjunction with fluoroscopy, r-EBUS, and CBCT in a clinical setting under general anesthesia. This multimodal approach allows for precise sampling of targeted areas of interest.&#160;

<table><tbody><tr><td>0.9% normal saline, 1000 mL</td><td>Any make</td><td></td><td></td></tr><tr><td>10 mL Leuer lock syringes</td><td>Any make</td><td></td><td></td></tr><tr><td>20 mL slip tip syringes</td><td>Any make</td><td></td><td></td></tr><tr><td>Bronchoscope</td><td>Intuitive</td><td></td><td></td></tr><tr><td>Bronchoscope processor and video screens</td><td>Intuitive</td><td></td><td></td></tr><tr><td>Carbon dioxide gas tank</td><td></td><td></td><td></td></tr><tr><td>Cone beam computed tomography system with c-arm and controller console</td><td></td><td></td><td></td></tr><tr><td>Disposable valve for biopsy channel</td><td></td><td></td><td></td></tr><tr><td>Disposable valve for suction</td><td></td><td></td><td></td></tr><tr><td>ERBECRYO 2 1-pedal footswitch AP &amp;amp; IP X8 Equipment US</td><td>Erbe</td><td>20402-201</td><td></td></tr><tr><td>ERBECRYO 2 Cart</td><td>Erbe</td><td>20402-300</td><td></td></tr><tr><td>ERBECRYO 2 Cryosurgical unit</td><td>Erbe</td><td>10402-000</td><td></td></tr><tr><td>ERBECRYO 2 System</td><td>Erbe</td><td></td><td></td></tr><tr><td>Flexible Cryoprobe, OD 1.1 mm, L1.15 m with oversheath, OD 2.6 mm, L817 mm</td><td>Erbe</td><td>20402-401</td><td></td></tr><tr><td>Flexible gas hose; L 1m for Erbokryo CA/AE/ERBECRYO 2</td><td>Erbe</td><td>20410-004</td><td></td></tr><tr><td>Gas bottle adapter H; CO2; Pin index</td><td>Erbe</td><td>20410-011</td><td></td></tr><tr><td>Ion endoluminal system with robotic arm, controller console</td><td>Intuitive</td><td></td><td></td></tr><tr><td>Ion fully articulating catheter</td><td>Intuitive</td><td>490105</td><td></td></tr><tr><td>Ion instruments and accessories</td><td></td><td></td><td></td></tr><tr><td>Ion peripheral vision probe</td><td>Intuitive</td><td>490106</td><td></td></tr><tr><td>Laptop with PlanPoint planning software</td><td>Intuitive</td><td></td><td></td></tr><tr><td>Probe driving unit</td><td>Olympus</td><td>MAJ-1720</td><td></td></tr><tr><td>Radial EBUS Probe</td><td>Olympus</td><td>UM-S20-17S or UM-S20-20R-3</td><td></td></tr><tr><td>Radial endobronchial ultrasound system</td><td></td><td></td><td></td></tr><tr><td>Specimen containers with fixative per institution standards</td><td></td><td></td><td></td></tr><tr><td>Sterile disposable cups</td><td></td><td></td><td></td></tr><tr><td>Suction tubing</td><td></td><td></td><td></td></tr><tr><td>Topical 1:10,000 epinephrine, 10 mL</td><td></td><td></td><td></td></tr><tr><td>Topical tranexamic acid 1000mg, 10 mL</td><td></td><td></td><td></td></tr><tr><td>Universal ultrasound processor&amp;nbsp;</td><td>Olympus</td><td>EU-ME2</td><td></td></tr><tr><td>Wire basket; 339 x 205 x 155 / 100 mm</td><td>Erbe</td><td>20180-010</td><td></td></tr></tbody></table>

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).

The described technique allows for targeted transbronchial lung cryobiopsies via RAB with fluoroscopy, r-EBUS, and CBCT guidance. Compared to conventional bronchoscopy with random TBLC, this technique allows for targeting specific areas of DPLD or PPLs of interest while assessing surrounding structures prior to biopsy. This technique can be used with r-EBUS and fluoroscopy only or with a combination of CBCT. While this technique had been devised for PPLs, it can be utilized in benign and diffuse parenchymal lung...

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 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 ...

robotic-assisted-bronchoscopy-combined-with-multimodal-imaging-for

Research

JoVE Journal

Medicine

498 Views.  University of Texas Southwestern Medical Center. 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. 

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

In vivo Near Infrared Fluorescence (NIRF) Intravascular Molecular Imaging of Inflammatory Plaque, a Multimodal Approach to Imaging of Atherosclerosis

The vascular response to injury is a well-orchestrated inflammatory response triggered by the accumulation of macrophages within the vessel wall leading to an accumulation of lipid-laden intra-luminal plaque, smooth muscle cell proliferation and progressive narrowing of the vessel lumen. The formation of such vulnerable plaques prone to rupture underlies the majority of cases of acute myocardial infarction. The complex molecular and cellular inflammatory cascade is orchestrated by the recruitment of T lymphocytes and macrophages and their paracrine effects on endothelial and smooth muscle cells.1
Molecular imaging in atherosclerosis has evolved into an important clinical and research tool that allows in vivo visualization of inflammation and other biological processes. Several recent examples demonstrate the ability to detect high-risk plaques in patients, and assess the effects of pharmacotherapeutics in atherosclerosis.4 While a number of molecular imaging approaches (in particular MRI and PET) can image biological aspects of large vessels such as the carotid arteries, scant options exist for imaging of coronary arteries.2 The advent of high-resolution optical imaging strategies, in particular near-infrared fluorescence (NIRF), coupled with activatable fluorescent probes, have enhanced sensitivity and led to the development of new intravascular strategies to improve biological imaging of human coronary atherosclerosis.
Near infrared fluorescence (NIRF) molecular imaging utilizes excitation light with a defined band width (650-900 nm) as a source of photons that, when delivered to an optical contrast agent or fluorescent probe, emits fluorescence in the NIR window that can be detected using an appropriate emission filter and a high sensitivity charge-coupled camera. As opposed to visible light, NIR light penetrates deeply into tissue, is markedly less attenuated by endogenous photon absorbers such as hemoglobin, lipid and water, and enables high target-to-background ratios due to reduced autofluorescence in the NIR window. Imaging within the NIR 'window' can substantially improve the potential for in vivo imaging.2,5
Inflammatory cysteine proteases have been well studied using activatable NIRF probes10, and play important roles in atherogenesis. Via degradation of the extracellular matrix, cysteine proteases contribute importantly to the progression and complications of atherosclerosis8. In particular, the cysteine protease, cathepsin B, is highly expressed and colocalizes with macrophages in experimental murine, rabbit, and human atheromata.3,6,7 In addition, cathepsin B activity in plaques can be sensed in vivo utilizing a previously described 1-D intravascular near-infrared fluorescence technology6, in conjunction with an injectable nanosensor agent that consists of a poly-lysine polymer backbone derivatized with multiple NIR fluorochromes (VM110/Prosense750, ex/em 750/780nm, VisEn Medical, Woburn, MA) that results in strong intramolecular quenching at baseline.10 Following targeted enzymatic cleavage by cysteine proteases such as cathepsin B (known to colocalize with plaque macrophages), the fluorochromes separate, resulting in substantial amplification of the NIRF signal. Intravascular detection of NIR fluorescence signal by the utilized novel 2D intravascular NIRF catheter now enables high-resolution, geometrically accurate in vivo detection of cathepsin B activity in inflamed plaque.
In vivo molecular imaging of atherosclerosis using catheter-based 2D NIRF imaging, as opposed to a prior 1-D spectroscopic approach,6 is a novel and promising tool that utilizes augmented protease activity in macrophage-rich plaque to detect vascular inflammation.11,12 The following research protocol describes the use of an intravascular 2-dimensional NIRF catheter to image and characterize plaque structure utilizing key aspects of plaque biology. It is a translatable platform that when integrated with existing clinical imaging technologies including angiography and intravascular ultrasound (IVUS), offers a unique and novel integrated multimodal molecular imaging technique that distinguishes inflammatory atheromata, and allows detection of intravascular NIRF signals in human-sized coronary arteries.

In vivo Near Infrared Fluorescence NIRF Intravascular Molecular Imaging of Inflammatory Plaque, a Multimodal Approach to Imaging of Atherosclerosis

We detail a new near-infrared fluorescence (NIRF) catheter for 2-dimensional intravascular molecular imaging of plaque biology in vivo. The NIRF catheter can visualize key biological processes such as inflammation by reporting on the presence of plaque-avid activatable and targeted NIR fluorochromes. The catheter utilizes clinical engineering and power requirements and is targeted for application in human coronary arteries. The following research study describes a multimodal imaging strategy that utilizes a novel in vivo intravascular NIRF catheter to image and quantify inflammatory plaque in proteolytically active inflamed rabbit atheromata.

The vascular response to injury is a well-orchestrated inflammatory response triggered by the accumulation of macrophages within the vessel wall leading ...

Improved Visualization of Lung Metastases at Single Cell Resolution in Mice by Combined In-situ Perfusion of Lung Tissue and X-Gal Staining of lacZ-Tagged Tumor Cells

Metastasis is the main cause of death in the majority of cancer types and consequently a main focus in cancer research. However, the detection of micrometastases by radiologic imaging and the success in their therapeutic eradication remain limited.
While animal models have proven to be invaluable tools for cancer research1, the monitoring/visualization of micrometastases remains a challenge and inaccurate evaluation of metastatic spread in preclinical studies potentially leads to disappointing results in clinical trials2. Consequently, there is great interest in refining the methods to finally allow reproducible and reliable detection of metastases down to the single cell level in normal tissue. The main focus therefore is on techniques, which allow the detection of tumor cells in vivo, like micro-computer tomography (micro-CT), positron emission tomography (PET), bioluminescence or fluorescence imaging3,4. We are currently optimizing these techniques for in vivo monitoring of primary tumor growth and metastasis in different osteosarcoma models. Some of these techniques can also be used for ex vivo analysis of metastasis beside classical methods like qPCR5, FACS6 or different types of histological staining. As a benchmark, we have established in the present study the stable transfection or transduction of tumor cells with the lacZ gene encoding the bacterial enzyme &beta;-galactosidase that metabolizes the chromogenic substrate 5-bromo-4-chloro-3-indolyl-beta-D-galactopyranoside (X-Gal) to an insoluble indigo blue dye7 and allows highly sensitive and selective histochemical blue staining of tumor cells in mouse tissue ex vivo down to the single cell level as shown here. This is a low-cost and not equipment-intensive tool, which allows precise validation of metastasis8 in studies assessing new anticancer therapies9-11. A limiting factor of X-gal staining is the low contrast to e.g. blood-related red staining of well vascularized tissues. In lung tissue this problem can be solved by in-situ lung perfusion, a technique that was recently established by Borsig et al.12 who perfused the lungs of mice under anesthesia to clear them from blood and to fix and embed them in-situ under inflation through the trachea. This method prevents also the collapse of the lung and thereby maintains the morphology of functional lung alveoli, which improves the quality of the tissue for histological analysis. In the present study, we describe a new protocol, which takes advantage of a combination of X-gal staining of lacZ-expressing tumor cells and in-situ perfusion and fixation of lung tissue. This refined protocol allows high-sensitivity detection of single metastatic cells in the lung and enabled us in a recent study to detect "dormant" lung micrometastases in a mouse model13, which was originally described to be non-metastatic14.

Improved Visualization of Lung Metastases at Single Cell Resolution in Mice by Combined In-situ Perfusion of Lung Tissue and X-Gal Staining of lacZ-Tagged Tumor Cells

The novel protocol reported in the present study allows selective detection of lung metastases at single cell resolution in mice by combined in-situ lung perfusion and fixation and X-Gal staining of lacZ-tagged tumor cells.

Metastasis is the main cause of death in the majority of cancer types and consequently a main focus in cancer research. However, the detection of ...

MR Molecular Imaging of Prostate Cancer with a Small Molecular CLT1 Peptide Targeted Contrast Agent

Tumor extracellular matrix has abundance of cancer related proteins that can be used as biomarkers for cancer molecular imaging. In this work, we demonstrated effective MR cancer molecular imaging with a small molecular peptide targeted Gd-DOTA monoamide complex as a targeted MRI contrast agent specific to clotted plasma proteins in tumor stroma. We performed the experiment of evaluating the effectiveness of the agent for non-invasive detection of prostate tumor with MRI in a mouse orthotopic PC-3 prostate cancer model. The targeted contrast agent was effective to produce significant tumor contrast enhancement at a low dose of 0.03 mmol Gd/kg. The peptide targeted MRI contrast agent is promising for MR molecular imaging of prostate tumor.

To demonstrate MR cancer molecular imaging with a small peptide targeted MRI contrast agent specific to clotted plasma proteins in tumor stroma in a mouse prostate cancer model.

Tumor extracellular  matrix has abundance of cancer related proteins that can be used as biomarkers  for cancer molecular imaging. In this work,  we ...

The Bovine Lung in Biomedical Research: Visually Guided Bronchoscopy, Intrabronchial Inoculation and In Vivo Sampling Techniques

There is an ongoing search for alternative animal models in research of respiratory medicine. Depending on the goal of the research, large animals as models of pulmonary disease often resemble the situation of the human lung much better than mice do. Working with large animals also offers the opportunity to sample the same animal repeatedly over a certain course of time, which allows long-term studies without sacrificing the animals.
The aim was to establish in vivo sampling methods for the use in a bovine model of a respiratory Chlamydia psittaci infection. Sampling should be performed at various time points in each animal during the study, and the samples should be suitable to study the host response, as well as the pathogen under experimental conditions.
Bronchoscopy is a valuable diagnostic tool in human and veterinary medicine. It is a safe and minimally invasive procedure. This article describes the intrabronchial inoculation of calves as well as sampling methods for the lower respiratory tract. Videoendoscopic, intrabronchial inoculation leads to very consistent clinical and pathological findings in all inoculated animals and is, therefore, well-suited for use in models of infectious lung disease. The sampling methods described are bronchoalveolar lavage, bronchial brushing and transbronchial lung biopsy. All of these are valuable diagnostic tools in human medicine and could be adapted for experimental purposes to calves aged 6-8 weeks. The samples obtained were suitable for both pathogen detection and characterization of the severity of lung inflammation in the host.

The Bovine Lung in Biomedical Research: Visually Guided Bronchoscopy, Intrabronchial Inoculation and In Vivo Sampling Techniques

This article describes bronchoscopic techniques in the bovine lung under experimental conditions, i.e. bronchoscopically guided inoculation, bronchoalveolar lavage, bronchial brushing, and transbronchial lung biopsy.

There is an ongoing search for alternative animal models in research of respiratory medicine. Depending on the goal of the research, large animals as ...

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.

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 ...

Murine Endoscopy for In Vivo Multimodal Imaging of Carcinogenesis and Assessment of Intestinal Wound Healing and Inflammation

Mouse models are widely used to study pathogenesis of human diseases and to evaluate diagnostic procedures as well as therapeutic interventions preclinically. However, valid assessment of pathological alterations often requires histological analysis, and when performed ex vivo, necessitates death of the animal. Therefore in conventional experimental settings, intra-individual follow-up examinations are rarely possible. Thus, development of murine endoscopy in live mice enables investigators for the first time to both directly visualize the gastrointestinal mucosa and also repeat the procedure to monitor for alterations. Numerous applications for in vivo murine endoscopy exist, including studying intestinal inflammation or wound healing, obtaining mucosal biopsies repeatedly, and to locally administer diagnostic or therapeutic agents using miniature injection catheters. Most recently, molecular imaging has extended diagnostic imaging modalities allowing specific detection of distinct target molecules using specific photoprobes. In conclusion, murine endoscopy has emerged as a novel cutting-edge technology for diagnostic experimental in vivo imaging and may significantly impact on preclinical research in various fields.

Murine Endoscopy for In Vivo Multimodal Imaging of Carcinogenesis and Assessment of Intestinal Wound Healing and Inflammation

Small animal imaging techniques allow serial diagnostic examinations and therapeutic interventions in vivo. Recently, the scope of applications has significantly widened and currently includes assessment of colonic tumor development, wound healing and monitoring of inflammation. This protocol illustrates these diverse potential applications of murine endoscopy.

Mouse models are widely used to study pathogenesis of human diseases and to evaluate diagnostic procedures as well as therapeutic interventions ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

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 ...

Removal of Subcostal Specimen After Complete Portal Robotic Lobectomy

Subcostal Specimen Removal in Completely Portal Robotic Lobectomy

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional robot-assisted lobectomy (RAL). CPRL-4 integrates a fourth robotic arm and CO2 insufflation, resulting in superior visualization within the intrathoracic cavity owing to enhanced lung deflation. While CPRL-4 effectively achieves pulmonary resection, extracting specimens typically necessitates an intercostal utility thoracotomy, which may pose risks. To address potential damage associated with this method, we introduced a subcostal trans-diaphragmatic access port during resection, later enlarging it for specimen removal post-lobectomy. This study evaluated the efficacy and feasibility of this subcostal trans-diaphragmatic specimen removal approach following CPRL-4 procedures for pulmonary malignancies, all performed by a single surgical team. The findings suggest that subcostal specimen removal post-CPRL-4 offers several advantages, including reduced risk of thoracotomy-related complications, making it a practical, feasible, and safe method. This innovation has the potential to improve outcomes and patient care in pulmonary malignancy surgeries significantly.

This protocol describes the removal of lung specimens following a completely portal robotic lobectomy. Determining the optimal location for specimen extraction is a pertinent question, as both intercostal and subcostal routes can serve as potential extraction paths following robotic or video-thoracoscopic lobectomy. We choose subcostal lung specimen removal over intercostal removal.

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional ...

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

Summary

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