In this blog, Body Vision Medical sits down with Dr. Kyle Hogarth, Professor of Medicine and Director of Bronchoscopy at the University of Chicago Medical Center, a high-volume bronchoscopy center that always strives to be on the leading edge of technology. Today, Dr. Hogarth is pioneering new possibilities in bronchoscopy by combining the accuracy of Body Vision’s intraoperative real-time imaging with the precision of a robotics bronchoscopy platform.

Body Vision: How did you hear about Body Vision Medical and what was your motivation to ultimately adopt the LungVision™ system?

Dr. Kyle Hogarth: We were using another navigation platform prior to Body Vision but it became obvious to me the limitations in that particular technology. After a meeting with Dorian Averbuch, [Founder and CEO of Body Vision Medical] at the American Thoracic Society [ATS] Annual Meeting in 2014, I immediately got what he was trying to accomplish, what problem he was striving to solve for bronchoscopists like myself, and I was hoping he was going to be able to pull it off because it sounded almost impossible to do when he first described it to me.

What got me immediately interested in LungVision was that every form of peripheral navigation bronchoscopy that I've used, and I've used most of them, have all revealed severe limitations in knowing exactly where your target is because of the perpetual issue of CT-to-body-divergence and never having the true knowledge of where the lesion is right then and there when you're doing bronchoscopy. The power of tomosynthesis is what Dorian promised me, and it's what he's actually delivered.

I remember seven years ago, the very first time I saw the use of bronchoscopy with cone beam CT and the amazing three-dimensional and augmented fluoro images. It was incredible. And then, of course, you learn how expensive it is and how cumbersome it is and how unlikely it is for you to get access, etc.

And so, along came Dorian, and he showed me something that looked just like cone-beam CT, but I was doing it right there in my bronchoscopy suite with a good old-fashioned C-arm. It integrates perfectly with my other devices so I can do it right there with my robot or my bronchoscope and get real-time confirmation exactly where the lesion is, tool-in-lesion, and 3D reconstructions to see that my tool is in the lesion in the 3D space. It looks exactly like cone-beam CT to me, but at a lower price and a lot easier to use.

That's been my evolution into LungVision and Body Vision’s C-Arm Based Tomography [(CABT)] technology. Dorian and the team have delivered what they promised, have evolved, and they continue to evolve. The company has never been static. They listen, they keep adapting and making it better. The University of Chicago owns the Body Vision system precisely for this reason.

It’s a tool that we use now with just about every single robotic bronchoscopy case. It very much adds to our outcomes and our accuracy because it allows us to compensate for the CT-to-body divergence that happens. I don't want to put words in others’ mouths, but colleagues of mine who are using the competing robotic platform have had the same experience where they have CT-to-body divergence and the LungVision system clearly shows the lesion in a location different from where the robot did. Same thing that happens with electromagnetic navigation bronchoscopy [(ENB)] platforms. Physicians can only correct for it when they know where the lesion is, and they can only do that using Body Vision’s LungVision technology.

Why is CT-to-body divergence not more talked about and why aren't, in your opinion, more of your colleagues looking for solutions to address it?

Well, there are a lot of different potential reasons, I suppose. CT-to-body divergence is not as bad in certain areas of the lung versus others. So, depending on what you’re biopsying, it may not be as much of an issue. Two, there are certain ways you can manipulate the ventilator to further expand the lung to compensate for some of that. Three, if you're going after 2cm or larger regions, you know you're likely going to hit it even if there's some divergence because you're in the general area.

And then, the divergence, in my opinion, gets worse when you're in your outer third of the lung. There are just obviously issues with CT quality and so forth and inherently atelectasis can develop as the scopes are pushing through these airways. Before I had the robot, I knew what lesions I would have extreme difficulty in getting to and honestly didn't go after them. When we acquired the Monarch, we obviously started going after smaller lesions and more peripheral lesions.

As we're out further and going after smaller lesions, divergence becomes a bigger issue for us. If you have 1cm of divergence on an 8mm nodule, that's a big deal. The other problem is that you can talk about CT-to-body divergence all you want, but what is your plan to fix it? Are you going to go get a cone beam [CT]? Do you have a million dollars just lying around? Are you going to go get access to cone-beam every other Saturday? So even if you knew you had a problem, until Body Vision developed LungVision, there was no real solution for it. 

What I like about LungVision is I can move my robot in any direction I want and can, across multiple planes, see that I'm perfectly aligned with the lesion. And that lesion is visually represented in real-time because I did a CABT spin around it and can confirm that I’m targeting it, pass my needle, and can see across two different planes that I'm in the lesion. If I need to, I can do another CABT for added confidence that I'm indeed there. That’s real-time tomographic imaging combined with real-time augmented fluoro overlay. That's what people really like about cone beam CT, and that's what you get with LungVision.

I hear you saying that the real value is the ability to image in real-time and confirm in real-time that your tool is actually in the lesion. Expound on that a bit. Why do you see this as the true value of the LungVision system?

I think about it like I got to know where I'm at right? If I’m bronching, I need to make a diagnosis. I need to be able to confirm that my tools are definitively in the lesion. On the diagnostic side, I absolutely need this. So diagnostically, LungVision helps me dramatically. Maybe some people targeting large lesions can live without you, but they are still going to have a longer, messier procedure.

But let’s talk about therapeutics. That's where, precision is a must have. I need to know that my needle that's going to inject some biologic agent, for example, is in the tumor. That means that I don't have the liberty to take multiple passes into the lesion. I need to be able to get my needle in there, first try, confirm that it's embedded in there, inject that delivery vehicle, be able to plug it and get out. I absolutely need what LungVision gives me in order to do that.

I understand that in some clinical trials for therapeutic delivery, you are using LungVision. Is there a specific case that comes to mind that illustrates the true value of LungVision?

Our Oncology Department is in several clinical trials. There are various independent companies that have technologies they believe will help either directly target one tumor or create an abscopal type effect or act as a checkpoint inhibitor.

One case we did was that we were going to be injecting a biological agent into a tumor that had recurred along the patient's suture line of their prior resection. There was no airway to the lesion. The lung anatomy was very distorted because it had been operated on and irradiated prior. We needed to get into the tumor, prove we are in the tumor, and then be able to inject the agent. So we navigated as well as we could to the limits of the airways until we felt like we were fairly lined up. We knew we'd have to penetrate the wall with a needle and be able to reliably push the needle roughly about 2cm to get to the target.

When we did the CABT with LungVision, it was clear that the target was further away than where we first thought using the targeting part of the Monarch.

So, we made some adjustments, moved the robot to line up to where the fluoro images showed the target to be across multiple planes, passed the needle, and penetrated the wall with confidence. Then again, under fluoro, we could see the augmented image. We then rotated the C-arm to image the lesion from a couple of different angles and saw that we were dead center. We took our sample, got ROSE confirmation that it was the malignancy, passed the needle right back to the same hole, injected the biological delivery vehicle that was part of the study, and then got out. 

So would you have been able to perform the procedure with just the robot without LungVision?

Absolutely not. The ability to be accurate is what matters., It’s what’s most important for the patient. The worst thing I can imagine would be for us to say it didn't work at all because we never actually put it where it belongs.

Tell us more about your use of LungVision with the Auris Monarch robot. How do these two technologies fit into your armamentarium and what role do each of them play?

We use LungVision in every navigation case, including robotic bronchoscopy cases. The reason we do is because I want anything that's going to add to my accuracy. The key here in diagnostic bronchoscopy is not about hoping to maybe get a diagnosis. This is not what my patient wants to hear.

So, from my perspective, I want any tool that's going to make it possible for me to walk out of that bronch suite and go to the patient's room and say, ‘I made a diagnosis,’ because that's the only thing my patient cares about. Bottom line is my patient could care less if I use 30 pieces of technology or one piece of technology. If you're a bronchoscopist that can biopsy every single thing in the lung using just a regular C-arm and your knowledge of the CT scan, and you can get everything every single time, then good for you. That's great. I'm not that guy. I need tools. And so, I'm going to use all the tools I have. And because the integration with LungVision is so seamless, I would use it every single case.

What would you say to a colleague that says, “Hey, I’ve already invested in a robot? Why should I look at LungVision?”

The robot gives you a lot of thing but it's lacking external confirmation of targeting. And that's exactly what tomography and augmented fluoro give you. With LungVision you’re going to have a harder time missing. You’re going to curse less. It gives you the confidence to go after the most difficult lesions. You have that much more confidence that you are there, because for the first time ever, you can see the real lesion. And the thing is, it's not some virtual representation of the lesion, it’s real. 

What percent of the time would you say that there's a disagreement between where the robot says the target is and where LungVision says it is?

I will say a majority of the time.

What do you think about the approach that Body Vision Medical took to address the problems pulmonologists are facing?

The approach is very novel. The beauty of it is that at the core of it is the software. The essential thing about this software is that because it’s powered by artificial intelligence and machine learning, it's only going to keep getting better.

This product has the potential to never truly be static and that as advances come, everyone who's using it will get it. And I think that's really key, that advances in the technology will be able to be immediately utilized and that’s very exciting. 

The gold standard for seeing a lesion intraprocedurally has been cone-beam [CT]. But it requires a ridiculous amount of radiation and is ridiculously expensive. Body Vision’s CABT gives you everything you get out of cone-beam using a regular C-arm.

And it’s not surprising that the idea for this technology came from Dorian. He has been in the lung space for 20+ years and was part of the original group that gave us ENB. Yes, this is a completely different technology from electromagnetics, but this is what happens when you listen to bronchoscopists regarding what we want and understand the problems we face. You have the insight needed to come up with a novel, clean-slate, game-changing approach to a longstanding problem. That's why I like working with the people at Body Vision. They have the ability to provide a solution, they just need to understand what the clinical problem is. They are legitimately trying to change how we approach the lung and you can feel that motivation.