Robotic Bronchoscopy Roundtable, Part 1: The Technical Aspects of Robotic Bronchoscopy

In this video, Jaspal Singh, MD, MHA, MHS, moderates a roundtable discussion with Bradley L. Icard, DO, Brian Shaller, MD, and Dominique Pepper, MD, MBChB, MHSc, on the key issues relating to robotic bronchoscopy. The participants also provide important insights on robotic bronchoscopy, how it helps in the early diagnosis of lung cancer, the differences between CT-guided biopsies and robotically assisted bronchoscopy, and more. This is part one of a three-part series.

For Part 2 of this 3-part series, click here.
For Part 3 of this 3-part series, click here.

Additional Resources: 

  • Agrawal A, Hogarth DK, Murgu S. Robotic bronchoscopy for pulmonary lesions: a review of existing technologies and clinical data. J Thorac Dis. 2020 Jun;12(6):3279-3286. doi: 10.21037/jtd.2020.03.35. PMID: 32642251; PMCID: PMC7330790.
  • Kent AJ, Byrnes KA, Chang SH. State of the Art: Robotic Bronchoscopy. Semin Thorac Cardiovasc Surg. 2020;32(4):1030-1035. doi:10.1053/j.semtcvs.2020.08.008
  • Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j.chest.2020.08.2047


Jaspal Singh, MD, MHA, MHS: Hello, I'm Dr. Jaspal Singh and welcome to Consultant360. Our current roundtable is about robotic bronchoscopy, and with me today are three esteemed guests and we're going to start with our part one of the series. But first let me introduce our guest today Okay, first, Dr. Brad Icard

Bradley L. Icard, DO: Sure, nice to meet everybody. My name's Bradley Icard. I'm a bronchoscopist at Cone Health in Greensboro, North Carolina.

Brian Shaller, MD: Hi everyone, I'm Brian. I'm an interventional pulmonologist at Stanford University in California.

Dr Singh: Right, and Dr. Dominique Pepper.

Dominique Pepper, MD, MBChB, MHSc: Hey, I'm Dominique Pepper. I'm located in in Olympia, Washington, and advanced bronchoscopists.

Dr Singh: Fantastic. It's great to have the three of you to get us all today. And then we're going to have a little bit of a discussion here. So, Dr. Icard, walk me through, sort of we've done navigation on bronchoscopy for a long time, you know, people have done this navigation stuff. A lot of us have done this for a long time. What is this robotic bronchoscopy or robotic-assisted bronchoscopy? Walk us through that a little bit

Dr Icard: So patients that undergo robotic bronchoscopy end up going under general anesthesia and or get put to sleep for the procedure. And then the robotic catheter gets attached to the endotracheal tube, and then we're able to drive that catheter out into the periphery of the lung. It makes access to pretty much anything within the chest safe and easy.

Dr Singh: Got it. So, it's like a sort of fancier tool and to get to sort of lung biopsies. Is that my understanding, Brian? What are your thoughts on this?

Dr Shaller: Yeah, I think that's a perfect summary of it, and what I'd add and to what you've mentioned just while that we've been doing navigational bronchoscopy for quite some time and what robotic bronchoscopy platforms had added on to navigational bronchoscopy and how they've improved the procedures is in a variety of ways, including helping us have greater stability, greater control over our tools, greater precision, and even potentially speeding cases up so that we can get through more cases and see more patients in a timely fashion.

Dr Singh: Got it. So it's pretty fancy stuff and pretty fancy technology, and it seems to work to get to lung biopsies. And Dominique, what are you seeing in your space?

Dr Pepper: Well, I think the question that we want to address is, you know, how do we diagnose lung cancer early? We all know that lung cancer is the number one killer, and the biggest problem is that we're just diagnosing these patients too late. The best-case scenario is that we diagnose them in the lung cancer nodules, a very small, very early-stage lung cancer, and we end up getting a bit of cure rate, 92% if it's Stage 1.

So that's the reason why it's important, and as Brian and Brad mentioned, what we're doing is we're taking these thin catheters driving down to the lung cancer nodule. What's really impressive about the robotic bronchoscopy is that it's stable, it's precise. You're able to get down into these tiny little airways and take really good samples so that you can get an answer as to whether this patient has cancer.

And you can do it a lot earlier than we did before. In our experience, we used to use a legacy platform and we got a yield of 50%. And after starting using robotic bronchoscopy, our yield went up to 80%. So really effective and we've really been excited about the progress that we've made.

Dr Singh: Right. So, I'm just going to summarize a little bit. So just to kind of play off of that a little bit. So basically, what you're seeing is patients in the offices, in the hospitals, they're getting all these CT scans, they're finding nodules in different places. They may go through lung cancer screening programs, for example, they find spots.

And so rather than sort of the old way of doing things where you kind of, you know, biopsy is hard to do, it's hard to get to that lesion, you can either do long aspects of radiologic surveillance, or you can do, which is not a bad option, but for ones that are suspicious, you really want to get to the bottom of that diagnosis, like what you said, Dominique, find out earlier what you're dealing with, rather than waiting 3 months, 6 months, or going through a more aggressive operation to find out what this is. You can find out with a minimally invasive procedure. Yes, it's more technology, but you think it's safer, you think it works better actually, and it seems to be more efficient and effective. Is that about right?

Dr Pepper: Well, definitely. We were able to shorten the time from initial CAT scan to a biopsy from 7 weeks down to 2 to 3 weeks, so really effective technology. We're able to get to stuff that radiology couldn't get to before. Not only can we sample peripheral lung nodules, we can sample those in the mid-third and in the third.

Dr Singh: Great. So you brought up CT-guided biopsies, which is what I think a lot of our audience potentially orders when they see when they were told the lung biopsies needed. They're used to ordering CT-guided lung biopsies. What's different here? Why not just go with that?

Dr Icard: CT-guided lung biopsies are where an interventional radiologist would place a needle through the chest wall or to obtain the specimen. And for biopsies, this way, it increases the patient's risk for the development of a pneumothorax, which is a complication related to also the risk of bleeding that are associated with those. And by switching to the robotic platform after we've launched our program, we've seen almost an 80 % reduction in the number of CT-guided biopsies that are completed.

And that's decreased on that side, but we've also increased our volumes of bronchoscopy by several fold and also effort to save the patient's additional procedures. So by doing the bronchoscopy, robotically, we're also able to stage the patient's mediastinum at the same time. So, we are able to combine two procedures which in certain settings, if patients would receive a CT-guided biopsy, they potentially would still need a bronchoscopy and a mediastinal staging. So we're able to combine that in this situation.

Dr Singh: Got it. So you're going to add additional aspects of the benefit of approaching it bronchoscopically is that you get a staging procedure done at the same time for the majority of lymph nodes that are commonly seen in a lung cancer, in a patient with suspected lung cancer or related disorders. Is that about right?

Dr Icard: Yes.

Dr Singh: Excellent. Brian, you're going to add something?

Dr Shaller: Yeah. I think that both Dominique and Brad hit on something really important here, which is the amount of time that goes by, mentioning that patients who have a CT-guided biopsy need to wait and have a second procedure for staging before they go on to treatment is actually really significant. Dominique talked about going from 7 weeks to 2 weeks for going from a scan to getting a biopsy. There is data suggesting that within a 12 -week period from biopsy to treatment, going beyond that time, patients may actually advance in what their final stage diagnosis is.

So anything we can do to shave time off, whether it's days or weeks, off of that process from detection of a lung nodule to biopsy to definitive treatment could have actually a substantial long lasting impact on mortality and on various other outcomes for these patients.

Dr Singh: Right. That's fantastic. So if I hear you right, just to sort of summarize, robotic bronchoscopy or robotic-assisted bronchoscopy is basically a tool, technique, and technology kind of all integrated using a bronchoscopy approach that seems to be so far superior from a perspective of safety, experience, overall utility in diagnosing, especially as we are asked to do more complicated biopsies on smaller nodules with a greater number of patients coming through with CT scans for various reasons that are finding abnormalities. So we can diagnose them earlier, stage them earlier, get them on a path of way of treatment at a sooner stage with more confidence and safety. Is that about right?

Dr Icard: Yeah, and I think it's really important to put the patient in the center of this because if you think about it, if you're able to find those patients earlier, like Dominique pointed out, there's 92% chance of cure or 5-year survival in Stage 1 disease.

And I think from personal experience, my father-in-law, for example, he quit smoking at the age of 38, and at the age of 57 was diagnosed with Stage 4 lung cancer, you know, and that was before the National Lung Cancer Screening Trial. It was before the Nelson Trial. It was before that we were offering lung cancer screening here regularly in the United States, and so you think back, he would have qualified in today's recommendations for lung cancer screening, you know, most likely at the age of 50, if he would have started with LDCT, he would have been a patient that I could have seen and we would have underwent a single, potentially a single anesthetic event for a bronchoscopy robotic-assisted bronchoscopy and then followed by robotic lobectomy and could have lived out the rest of his life.

But unfortunately, he died from Stage 4 adenocarcinoma. So, when we think about the center focus of the patient care and trying to identify patients early, which is a separate bucket that I think is important for colleagues across the country to understand. And then knowing that we have a minimally invasive opportunity to make a diagnosis with very low risk to the patient, unlike what my father-in-law underwent with an anterior chamberlain for his biopsy. So we've come a long way, and when you think about that, in the past now, what is it, 15 years have come a long way.

Dr Singh: Yeah, well, thanks for sharing that personal story. I'm sorry to hear about your family. I know it's a very personal connection to this, and I think it makes it real, right? The idea that basically there's almost a race, right? Someone gets a CT scan, it's a race to figure out what's wrong with that scan, not just at the old days. I think a lot of us are used to sort of a slower pace of working things up, evaluating it. Now we can kind of, we have some tools, technology and techniques where I think what we're seeing now or witnessing our field is that robotic-assisted bronchoscopy is becoming the first and best choice for many cases of lung biopsies. And I think that's a very interesting thing that I think our audience needs to know that.

Dr Pepper: It's a good one that Jasper, I think what's really great about this technology is that it can be used by community pulmonologists. We're a group of six pulmonologists, not interventional pulmonologists, just four of us, and we were able to use this technology within 6 months, we showed that we could decrease the time to diagnosis, we could expedite the diagnosis, we stage shifted. And for us, what was most encouraging is that more of our patients were alive. So being able to take a technology that can go out into the community and benefit a lot of patients, there's hundreds of thousands of patients diagnosed with lung cancer. And sometimes they just can't get those biopsies done in time.

Robotic bone photography seems to be the way to do it. After the past five years, we've been fortunate to see an internal stage shift of 10% for stage 1 malignancies. So we originally, 5 years ago, or about 26% of our lung cancer diagnoses were Stage 1, which is right at average for the nation.

And we're glad to say that this past year, 36% of our lung cancer or diagnoses or Stage 1s.

Dr Singh: That's fantastic. So we're seeing a difference. And so this is making a difference. And so I think you guys had it really well. I think for an introduction to robotics and bronchoscopy, I think we have some really important points to talk about. And I'm looking forward to our next session pretty soon. So, thank you so much for your time.

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