Robotic-assisted bronchoscopy is emerging as the natural successor to endobronchial ultrasonography using a guide sheath (EBUS-GS) to diagnose and localise lung lesions, the Thoracic Oncology Group Australasia ASM has heard.
Dr Shamitha Goonewardene, interventional pulmonary fellow at the Royal Brisbane and Women’s Hospital (RBWH), told the meeting that robotic bronchoscopy was superior to EBUS-GS for sampling pulmonary nodules and had a good safety profile.
He presented data from the hospital comparing use of the Ion robotic bronchoscopy system in 117 patients since 2022 to retrospectively collected data from 77 patients undergoing EBUS-GS sampling from 2018-2020.
In brief, the diagnostic yield for all 8-20mm nodules was 82.9% using the robotic system compared to 54.5% for EBUS-GS. For malignant nodules, the diagnostic yield was 87.5% v 53.4% and for benign nodules 61.9% v 55.9%.
There was a similar pattern but less-marked difference when including larger nodules up to 30mm – 84.0% v 62.5% overall, 90.0% v 63.8% for malignant and 60.0% v 58.5% for benign nodules.
“And this suggests that the superiority of Ion over EBUS-GS is more pronounced in the assessment of smaller nodules measuring less than 20 millimeters,” Dr Goonewardene said.
“Ion performed well across the board, and it retained the diagnostic yield of 77.3% in sampling small nodules located in the peripheral third of the lung compared to only about 43% with EBUS-GS. The yield improved with both techniques in sampling more centrally located pulmonary modules, which would be easier to navigate to.”
He said a significantly lower proportion of robotic bronchoscopy patients required further invasive assessment – either CT guided biopsy or surgery – compared to those who underwent EBUS-GS (9.4% v 22.0%) and for CT follow-up (6.0% v 17.0%).
Associate Professor David Fielding, director of thoracic medicine at the RBWH, told the limbic the hospital had been running the system as a prospective clinical study even before its TGA approval.
There are now two additional sites starting up with Ion and a third in Sydney with a different robotic device.
He predicted total six or seven sites with robotic systems in the next six months and double that in another 12 months after that – a boon in the context of demand coming from the new National Lung Cancer Screening Program.
“It’s critical, because screening detects small nodules, and we find that when using old technologies of biopsy for small nodules, many patients have to come back for a second procedure if you miss it the first time.”
“Because we can get it the first time with robotics, the health economics of that are very positive and in terms of minimising side effects, unexpected admissions, and the need for repeat procedures. In particular, people having to travel long distances for biopsies, don’t have to come back and drive six to seven hours for a second procedure.”
Associate Professor Fielding said the surgeons were very supportive because they don’t like operating on patients without a tissue diagnosis.
“It’s very uncommon for us now to send patients with an unknown tissue diagnosis to a surgeon.
He said oncologists would also appreciate the good quality biopsy enabling tissue biomarkers, especially in the era of neoadjuvant therapy.
“It’s easier getting the tissue diagnosis for the difficult, small nodules, but then getting them to curative therapy with surgery and radiotherapy. And it’s particularly nice to link it to radiation, because so often that we end up referring patients to them without a tissue diagnosis, but now they can be much more certain with a good biopsy.”
He said the learning curve for robotic-assisted bronchoscopy was also minimal.
“In particular, for young trainees coming through, their ability to pick up like a trackball and move a remote device …it is very straightforward and, and I think it’s actually easier to learn than conventional bronchoscopy.”
Associate Professor Fielding said the upfront costs of the system meant robotic bronchoscopy would probably remain in tertiary referral centers.
“It’s not going to be something that a peripheral hospital will have … ultimately it will be in the central facilities, in particular facilities with surgery, because the two are like ‘hand in glove’.”
Mr Kelvin Lau, a thoracic surgeon from St Bartholomew’s Hospital in London, told the meeting that robotic-assisted bronchoscopy avoids the risk of pneumothorax with CT guided biopsy – especially in the population of heavy smokers.
“A bronchoscopic approach also allows you to biopsy multiple lung nodules and also bilaterally, without any concerns about pneumothoraces. For our first 250 cases, we had a pneumothorax rate of less than 1%.”
He said the learning curve was fast and their procedure time was an efficient <30 minutes.