Robotic Bronchoscopy Across UPMC

By: Omar Awais, DO, Rajeev Dhupar, MD, Ryan Levy, MD, Troy Moritz, DO, and Matthew Schuchert, MD

Over the last three years, thoracic surgeons at multiple hospitals across UPMC have adopted state-of-the-art technology to care for patients with lung nodules. These next-generation robotic bronchoscopy systems feature intuitive controls and direct visualization through an endoscopic camera used in tandem with CT-generated 3D reconstructions. The robotic bronchoscopy systems currently in use at UPMC provide adept tools for lung nodule biopsy and nodule dye marking prior to surgical biopsy or resection.

Thoracic surgeons are often tasked with assessing small lung nodules found either through computed-tomography (CT) lung-cancer screening programs or incidentally on imaging. When these nodules are in the periphery of the lung, biopsy can be particularly challenging. Transthoracic CT-guided biopsy techniques have a high diagnostic accuracy but are associated with a high complication rate, especially in older patients with pulmonary comorbidities, and many peripheral lung lesions cannot be assessed using flexible bronchoscopy.

Robotic bronchoscopy may be an attractive alternative because it offers dramatic improvements over previously employed navigational bronchoscopy systems. Robotic bronchoscopy allows continuous visualization while navigating through the respiratory tree out to the periphery of the lung and precise control of dexterous instrumentation. There are currently two robotic bronchoscopy platforms in use across UPMC: the MONARCH Platform (Auris Health/ Johnson & Johnson) and the Ion endoluminal system (Intuitive Surgical). Both platforms provide our surgeons with adept tools for biopsying lung nodules and dye-marking nodules that are difficult to palpate or visualize for surgical biopsy or resection.

Each system features a flexible bronchoscope manipulated remotely by either a controller with joysticks or a track ball and simple controls. MONARCH has a 6 mm diameter outer shaft and a 4 mm inner bronchoscope with a camera and a 2 mm working channel. The Ion has a bronchoscope with a 3.5 mm outer diameter and a 2 mm working channel.

The MONARCH uses an electromagnetic field to register the location of the bronchoscope during the procedure. In contrast, the Ion uses “shape-sensing” technology to localize the bronchoscope in real time.

At the beginning of a robotic bronchoscopy procedure using either platform, a CT scan is performed, and the data obtained are used to generate a 3D rendering of the patient’s lungs. The robotic bronchoscopy software uses this rendering to evaluate routes through the respiratory tree to reach each lung nodule. The surgeon evaluates the reconstruction and the recommendations given by the software and determines if biopsy with robotic bronchoscopy will likely be successful and diagnostic, and plans the best course of action.

With the patient under general anesthesia, the surgeon begins the endoluminal robotic bronchoscopy and navigates down the trachea, into either mainstem bronchus, and through increasingly smaller bronchi and bronchioles using the 3D reconstructed image of the lungs and the camera on the bronchoscope.

When the surgeon reaches the destination, a lung nodule with an endoluminal component will often be evident. If the lesion is small or outside of the airway, the surgeon can rely solely on the location information provided by CT imaging. The surgeon might also insert a radial ultrasound probe through the working channel to obtain more information about the nodule. We have found ultrasound to be particularly useful for nodules less than 1 cm in diameter. The surgeon can then lock the bronchoscope into position, and the bronchoscope stays stable as tools for biopsy, such as endoscopic needles or forceps, are inserted.

The ability to maintain visualization of the airway while navigating to a nodule is a big improvement over previous electromagnetic navigational bronchoscopy (ENB) systems. Similarly, the ability to guide the bronchoscope to the periphery of the lung without manipulations that require the surgeon to contort their hands, arms, or body and then lock it into a stable position is a game-changing advance in the technology. We know the catheter can be positioned as needed and will stay in position. With these facile tools, we can biopsy further into the periphery of the lung and offer more patients biopsies with navigational bronchoscopy than we did previously.

A low incidence of procedure-related complications, particularly pneumothorax, has been evident during our adoption and continued use of robotic bronchoscopy. It is feasible to biopsy multiple nodules during a robotic bronchoscopy procedure because the risk of encountering procedure-related complications is low. This is very useful in determining nodule etiology in a patient with multiple lesions who was not recommended by previous biopsy techniques due to the high potential for pneumothorax.

Both the MONARCH and Ion platforms are also easy to use as a teaching tool. The primary surgeon can see the same field as the trainee, give verbal guidance, and assume control of the bronchoscope, if necessary, without the risk of inadvertently repositioning it.

Studies of Robotic Bronchoscopy With the MONARCH and Ion Platforms

When we reviewed outcomes in the first 25 patients who underwent robotic bronchoscopy and biopsy using the MONARCH Platform at the VA Pittsburgh Healthcare System, adequate sampling that yielded an actionable diagnosis was achieved in 96% of patients. The nodules selected for robotic bronchoscopy in these patients were 0.8 cm–6.9 cm in diameter (median 1 cm–2 cm) and primarily in the upper lobes of the lungs. We did not encounter any periprocedural complications.

In a retrospective, multicenter study of nodule biopsies using the MONARCH Platform that included patients treated at UPMC Hamot, navigation was successful to 88.6% of nodules and tissue samples were then obtained in 98.8%. Diagnostic yield was 69%–77%, depending on how patients with biopsy-proven inflammation were classified. The average nodule size was 2.5 mm, and 71% were located in the peripheral third of the lungs. Pneumothorax occurred in six patients (3.6%); significant bleeding post-biopsy occurred in 2.4%. A multicenter prospective pilot study of peripheral pulmonary lesions 1 cm–5 cm in diameter was conducted in 54 patients using MONARCH. The nodules were successfully localized in 96.2%, and a diagnosis was made using robotic bronchoscopy in 74.1%. Pneumothorax occurred in two patients (3.7%) and was the only postprocedure complication.

In a multicenter, prospective study of 67 nodule biopsies using the Ion system in 60 patients with 1 cm–3.5 cm nodules identified in CT imaging, biopsy was completed using the robotic bronchoscope in 96.7%. No pneumothorax or airway bleeding was reported.4 A single-center, retrospective study of 159 nodule biopsies attempted in 131 patients using the Ion system had an 81.7% diagnostic yield after navigating successfully to 98.7% of the targeted lesions. A diagnostic procedure was more likely when the nodule was greater than or equal to 1.8 cm. Complications occurred in 3%, with pneumothorax in 1.5%. The sensitivity for primary thoracic malignancies was 79.8% and negative predictive value was 72.4%.

Further carefully designed studies are needed to define the effectiveness of robotic bronchoscopy with day-to-day use by multiple operators, its diagnostic accuracy, and potential complications by lesion anatomic location, lesion size, and lesion type. We currently are performing these analyses at UPMC as we continually monitor the quality of our programs and pursue our mission of advancing academic medicine to improve patient care. Multicenter, prospective, observational trials to assess the clinical utility of the MONARCH and Ion platforms are also currently in progress (NCT04182815, NCT03727425, and NCT03893539).

Robotic Bronchoscopy as Part of the Thoracic Surgeon’s Armamentarium

Surgeons need to be adept at robotic bronchoscopy, but our expertise is perhaps best leveraged when robotic bronchoscopy is one of several options available. Most surgeons are case-selective and consider robotic bronchoscopy in the context of multiple options, including diagnostic resection, while taking tumor location, patient comorbidities, and patient preferences into account. In Pittsburgh, the surgeons in the Department of Cardiothoracic Surgery perform biopsies using robotic bronchoscopy primarily in patients in whom there is a high suspicion of cancer. We can then offer insight into how to treat the patient after a diagnosis is obtained.

Robotic bronchoscopy facilitates doing multiple procedures during a single operative session, which benefits the patient. These procedures might include dye marking the nodule, lymph node staging, or port placement for chemotherapy. If the biopsy is unsuccessful or inconclusive, further diagnostic procedures, such as CT-guided fine-needle aspiration or minimally invasive diagnostic resection, can be performed while the patient is still under general anesthesia.

In the Department of Cardiothoracic Surgery, our patients can access robotic bronchoscopy at multiple sites within UPMC. Robotic bronchoscopy holds promise to become the standard for lung nodule biopsy, and we are moving toward a future where robotic bronchoscopy might be used to administer targeted ablative therapies and chemotherapy. This cutting-edge technology facilitates better care of our patients by promoting definitive diagnosis of lung cancer at an earlier stage, thereby allowing earlier resection and optimized treatments. It is an excellent adjunct to CT-based lung cancer screening programs.

MONARCH at UPMC Mercy

The ability to combine procedures during a single operating-room session that includes robotic bronchoscopy streamlines care for our patients. Our patients can undergo a diagnostic biopsy and clinical staging under a single anesthesia. We can do a diagnostic biopsy using MONARCH followed by lymph node sampling for staging using endobronchial ultrasound (EBUS). We can biopsy and perform dye marking of a nodule too small for visual inspection and palpation and then move immediately to VATS (video-assisted thoracoscopic resection) or robotic resection for a diagnosis.

I started using the super Dimension ENB system in 2013 and upgraded to MONARCH in 2019 at UPMC Mercy and am presently working to bring this technology to UPMC East. I have done more than 300 procedures using MONARCH, approximately 700 navigational bronchoscopy procedures using either system, and have studied the diagnostic yield of ENB biopsies and the efficacy of dye-marking nodules using ENB prior to resection.6,7 Robotic bronchoscopy is a tool that is still being developed. This is not the final technology. The management and treatment of lung cancer is moving toward endobronchial approaches if we can locate lung nodules with more precision. Improved accuracy will increase opportunities to use robotic bronchoscopy as a treatment tool.

MONARCH at UPMC Shadyside

The ability to navigate to the periphery of the lung with robotic bronchoscopy has increased the number of nodules that we can biopsy without resection. For example, I was tasked recently with evaluating a small (8 mm) nodule that was suspected to be cancerous. It was very high in the lung and hard to biopsy by needle. It would have been impossible to reach using ENB, and we would have needed to remove approximately 15% of the lung to biopsy by resection. Using the MONARCH Platform, I was able to navigate easily to the nodule and saw the needle go directly into the mass during the biopsy. The pathologist in the operating room was able to give a diagnosis immediately.

I’m excited for the technology advances that are coming down the pipeline, hopefully in 2023. To administer ablative therapy or chemotherapy using at the bronchoscope (including immunotherapy), you need to be certain of where the end of the bronchoscope is within millimeters; otherwise, you cannot be sure that a small nodule is being targeted. This is essential when treating tumors outside of the airway because you can’t see them through the bronchoscope’s camera. The coming technology, cone-beam CT scans integrated with the MONARCH Platform, will greatly enhance our ability to use robotic bronchoscopy for therapeutics and will also permit injection of advanced localization probes to better identify nodules during surgery.

MONARCH at UPMC Passavant

Robotic bronchoscopy has helped us build the lung cancer screening program at UPMC Passavant, where we serve patients throughout the northern Pittsburgh suburbs and surrounding counties. Our team evaluates lung-screening CT scans in a multidisciplinary conference with a surgeon, a pulmonologist, and a radiologist. We determine which lung nodules require biopsy, as well as deciding on the best method to obtain tissue for diagnosis. It is also important to discuss patient preferences in the clinic. Some patients will elect a diagnostic robotic bronchoscopy first, while others prefer to proceed directly to minimally invasive lung resection. Currently, the biggest advantages of the MONARCH robotic bronchoscopy system are allowing earlier detection of lung cancer and facilitating diagnosis of lesions in anatomic locations that were previously difficult to access. In the future, robotic bronchoscopy will likely provide viable endobronchial treatment options for lung cancer.