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Respiratory Tracking Vital in GGO Diagnosis

OVER 3CM OF NODULE MOVEMENT DURING RESPIRATORY CYCLE
Author
Dr. Eric Flenaugh

Chief & Director of Pulmonary and Critical Care & Interventional Pulmonary Medicine

Grady Memorial Hospital

Atlanta, Georgia

Patient Information: 86 y/o, F

Scan Protocol: Veran Inspiration/Expiration CT Scan Protocol

Nodule: 14 X 4mm

Target Motion: 33mm

Instruments Used: Always-On Tip Tracked® Forceps & Brush

Biopsy Results: Lepidic Adenocarcinoma

Conclusion: SBRT

Observations

“This was a slow growing ground glass nodule that had been followed over a 2 year period. Given the risk factors for cancer and the patient’s excellent performance status, the decision to pursue a diagnosis was made. Navigation was critical to being able to diagnose this small GGO, as it would not have been visible with fluoroscopy.”

Patient History
The patient is an 86 year-old chronic (30-year) tobacco user that was noted to have an incidental right lower lobe (RLL) ground glass pulmonary nodule measuring 11 x 4mm on a prior CT scan. On follow-up serial CT imaging, the ground glass nodule had increased in size to 14 x 4mm. Diagnostic and treatment options were discussed with the patient. She declined surgical diagnosis and treatment but did agree to navigational bronchoscopy for diagnosis and fiducial placement, to be followed with SBRT if it was determined to be cancer.

Planning
Veran’s SPiN Planning™ software, in addition to a same-day respiratory gated scan was used to target the 14mm ground glass pulmonary nodule for biopsy and fiducial placement. Respiratory gating was key due to the 33mm of movement between inspiration and expiration.

Procedure
With the patient under conscious sedation, Dr. Flenaugh performed an initial inspection of the airways prior to proceeding with ENB. He then used an Always-On Tip Tracked® serrated cup forceps to successfully access and obtain eight biopsies. Once enough biopsies were obtained for ROSE diagnosis by Pathologist, Dr. Flenaugh successfully placed two 0.75 x 5mm Visicoil fiducial markers around the targeted area using an Always-On Tip Tracked® brush. Final diagnosis was Lepidic Adenocarcinoma and the patient was sent for SBRT.

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