Banner image courtesy of Intuitive
University of Rochester Medical Center (URMC) pulmonologists are adopting new technology to enhance their capabilities in performing lung biopsies. Using traditional methods, high yields on smaller lesions remained elusive, but the use of robotic technology significantly increases the ability to biopsy more difficult-to-reach places, and increases the accuracy needed to target extremely small nodules or lesions.
Associate professor of Medicine and interventional pulmonologist Michael Nead, M.D., Ph.D., uses the Ion Endoluminal System by Intuitive, drawing patients from throughout the state to Rochester. After completing more than 100 cases with the new robot, Nead and his team are applying lessons learned to better adapt teams and workflow, improving the level of care provided to patients.
What are the advantages of this robot compared to traditional biopsy methods or other bronchoscopy robots?
Nead: The Ion uses shape-sensing technology to navigate and then stabilize the catheter even as tools are deployed, which enhances accuracy. The scope is smaller than others, so we can access smaller airways, which is a tremendous benefit in sampling peripheral lesions. The ultra-thin and maneuverable catheter permits us to reach even difficult-to-navigate to airways, and even go around tight bends to reach all areas of the lung.
Very early on, we had one case where a patient had multiple nodules we wanted to biopsy. The most concerning nodule was quite a distance from the airway in the upper right lobe, adjacent to the pleura, requiring a hard turn to get to it, plus it was only one centimeter in diameter, but we successfully sampled the nodule and secured a diagnosis for our patient. There was no way we could have confidently sampled that lesion with our previous system.
Another big advantage is that this robot does not rely on electromagnetic fields to navigate. Other systems, even other bronchoscopy robots, use electromagnetic fields for navigation, meaning you need to worry about interference: Where are cell phones and pagers? Does the patient have a pacemaker? With the Ion, we don't have to worry about that.
Lastly, we do our own scope processing. With other robots, you have to ship the robotic arms back to the manufacturer after every use. We can do ours in-house, which my team preferred, and I fully trust our people to do a great job.
What have you learned between your first few cases and now, past your 100th case?
Early on, we were perfecting our workflow as well as learning the capabilities and nuances of the Ion robot. Now with over 100 cases under our belts, we have a stronger sense of what we can do, and which cases are going to be more of a challenge. Our workflow has generally stayed the same, but we're more efficient now. That wisdom of knowing what we’re able to do is significant.
Another pulmonary colleague, Aaron Lampkin, D.O.,and I did our first 20 cases together to optimize both of our experience. Now that we both fully understand the process, we each perform them as solo attendings, but with a pulmonary fellow assisting. The fellow doesn’t drive the robot, but they work some of the tools that go with it. We have also trained another colleague, Christina Dony, M.D. Each case is a huge team effort, and we have procedure nurses and patient care techs who assist us. We could not do this without our anesthesiologists who come to the bronchoscopy suite to support these procedures. How they manage patients in the OR differs from patients in the bronch suite undergoing robotic bronchoscopy, and we have appreciated the support and collaboration.
Has the Ion changed how you practice medicine?
It hasn’t changed the way I practice medicine, but I am more optimistic about what I can successfully biopsy. I have a higher degree of confidence in sampling smaller lesions; there’s a higher yield than what we were getting before, and that’s significant for our patients. It may have changed how the thoracic oncology team practices. As a group I believe we are more willing to try and biopsy a smaller lesion, rather than order a follow-up CT scan. Looking at some of our early data, the average lesion diameter size was 17 millimeters, with our smallest one yet at 3.3 millimeters. We’ve also been able to diagnose some interesting illnesses, like aspergillosis and amyloidosis.
Are there other potential uses for this robotic technology beyond lung biopsies?
We haven’t begun to perform anything other than lung biopsies yet, but I’ve started some initial conversations with the hope of collaborating with other departments in the future. The system can be used for dye marking for lung resections by thoracic surgery. There is also potential use for procedures like tumor ablation or immunotherapy injections. Those would require a partnership with radiology, and the use of cone beam CT scans or similar technology to ensure we’re in the right place for these procedures. It’s been done at other academic centers, but is considered an investigational or “off-label” use of the robot. We’re still interested in exploring its capabilities.
What is important for all physicians to know about the bronchoscopy robot?
We understand that not every nodule needs to be biopsied, but the Ion robot makes necessary biopsies more feasible. Nodules are very common and determining who does and does not need a biopsy remains that critical first step. As more and more at-risk patients get lung cancer screening CT scans, technology like the Ion robot can help our multidisciplinary thoracic oncology group diagnose and manage cancers at an earlier stage. If you’ve got a small, concerning nodule in the lung, just chalking it up to a three- or six-month follow-up scan might not be appropriate if it meets guidelines for a biopsy. This is a very safe and accurate procedure. It can only benefit patients and physicians alike.