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Accurate Biopsy of a Moving Target

RESPIRATORY GATING KEY TO EARLY DIAGNOSIS
Author
Dr. Nicolas Habib

Hanover Medical Group Pulmonary & Sleep Medicine

Hanover Hospital

Hanover, Pennsylvania

Patient Information: 53 y/o, M

Scan Protocol: Veran’s Inspiration/Expiration CT Scan Protocol

Nodule: RML 11mm

Target Motion: 26mm

Biopsy Results: Carcinoid Tumor

Instruments Used: Always-On Tip Tracked® Forceps, Needle, & SPiN Flex™ 22ga Needle

Conclusion: Stage N0 Carcinoid Tumor—VATS Lobectomy

Observations

“Veran’s respiratory gating was crucial in accurately biopsying this 1.1cm nodule, moving 2.6cm during the respiratory cycle. I was able to confidently biopsy a small target moving with respirations by more than double its diameter. This allowed us to catch the cancer in its early stages and offer the patient a chance for curative surgery.”

Patient History
A 53 year-old male with 25 pack-year smoking history and occupational exposure to granite dust. Initial complaint of abdominal distention and moderate weight loss. He underwent an abdominal CT scan, which found an incidental nodule at the right lung base. Patient was referred for a chest CT with contrast, which showed the nodule to be 1.1cm in the RML medial segment. The patient was then referred to Dr. Habib for pulmonary evaluation of the nodule. Dr. Habib recommended a PET scan due to patient’s smoking history. The PET scan was positive, so Dr. Habib and patient decided to move forward with a Navigated Bronchoscopy for biopsy.

Planning
A vPad™ was placed, and the patient underwent the Veran inspiration/expiration CT scan protocol. This case demonstrated the importance of respiratory gating, with the 11mm RML nodule moving 26mm during respiration. The 11mm nodule was automatically segmented using SPiN Planning™ software.

Procedure
The field generator was positioned over the vPad™, and the patient was automatically registered. Dr. Habib verified registration accuracy and then navigated out to the target. He was able to visualize the target endobronchially and advance his Always-On Tip Tracked® forceps to the nodule. The nodule would only turn green when expiration was matched. At all other points during the respiration cycle, the instrument did not appear to be in the nodule. This scenario explains the importance of respiratory gating and using it to sample at the time patient space matches image space. The patient was diagnosed with a stage N0 carcinoid tumor, referred for surgical resection, and is now cancer free.

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