Lung Nodule Management

An Interventional Pulmonology Perspective

Udit Chaddha, MBBS; Jonathan S. Kurman, MD, MBA; Amit Mahajan, MD, FCCP; D. Kyle Hogarth, MD


Semin Respir Crit Care Med. 2018;39(6):661-666. 

In This Article

Bronchoscopic Transparenchymal Nodule Access

Peripheral pulmonary nodules not immediately adjacent to an airway pose a particular challenge to bronchoscopic sampling. The absence of an airway leading to the nodule has been associated with decreased diagnostic yield.[41] BTPNA was developed to biopsy lesions adjacent to the airways. Using VB planning software, a point-of-entry (POE) through the airway wall is selected.[42] A specific POE is selected based on its proximity to the lesion and its distance from vasculature. Using specialized planning software, an avascular, straight-line path through the lung parenchyma to the target lesion is generated. The POE can be adjusted by the operator within the planning software environment by using a virtual Doppler ultrasound to assess for nearby vessels. A coring needle is used to penetrate the airway wall and create a hole, which is then dilated with a balloon. A sheath with a blunt stylet is then advanced through the dilated hole along the path to the target lesion under fused fluoroscopic guidance. The stylet is then withdrawn, and the sheath serves as a conduit for repeated sampling of the target lesion.

The initial in-human study of 12 patients had a diagnostic yield of 83%.[42] In two patients, the procedure could not be completed because the bronchoscope could not be oriented properly at the POE due to its location in the left upper lobe. The diagnostic yield was 100% in cases where the tunneled pathway was created. No significant bronchoscopy-related adverse events were noted during the case or at 180 days afterward. Another small safety and feasibility study showed a 100% concordance rate between biopsies obtained by BTPNA and final pathology results in resected specimens.[43] However, a pneumothorax was identified in two out of the six patients, one of whom required chest tube insertion. The tunnel length did not correlate with pneumothorax risk. Unlike TTNA, where the number of needle insertions can be correlated with risk of pneumothorax, there was no evidence of increased complication rate with greater number of biopsies with BTPNA.[42–44] The most significant limitation is being able to orient the bronchoscope properly at the POE in order to achieve a straight-line approach to the target.[42]