<h2>Lesion Characteristics</h2>Lesion Size (diameter): 10 mmLesion Location: Right upper lobe (RUL) lesionBronchus Sign: NoVisible on Fluoro: YesREBUS Verification: Yes&nbsp;<h2>Case Information</h2>Full Procedure Time: 25 minutesROSE: Sampling was performed and was malignantFinal Pathology Report: Squamous cell lung carcinoma <h2>Patient Background</h2>A 69 year-old female with severe COPD, a lifetime smoking history, scoliosis, rheumatoid arthritis, hypertension and thrombocytosis had a screening CT and subsequent PET that revealed a 10 mm hyper-metabolic nodule in the right upper lobe.&nbsp; <h1>The Procedure</h1>PlanningDuring planning, a preoperative CT is loaded onto the Body Vision system. The lesion is marked and contoured so that Body Vision’s AI-driven intraoperative imaging system has an approximation of the lesion size, shape and location prior to beginning the procedure. The Body Vision system also derives the airways from the preoperative CT and for those who are looking for a complete navigation bronchoscopy system, a virtual bronchoscopy highlighting the preferred pathway to the lesion is provided. In this case, an Ethicon MONARCH(™) robotic bronchoscopy platform was used to navigate out to the lesion.&nbsp; <img src="https://lh5.googleusercontent.com/Q5EpEpiU1uHBm0_cLGd9g1yMSQyoMZ4oPGYVyICGhKLsO9dxXPUac_7Y6xes_NCaEhSIWmb9VP96tv9r7JalswzUqpaVlhg-b2muzXWG0XpVZmnKshThkYkAs2EvAGGrNz9En2vh-xObWX8tGB5uAS7_l2E1-XeIL1VmzaSTYJLh9VUyNdag-k5HwDi5mQ" height="279" width="419"> <h2>Registration</h2>Once the patient is on the table, Body Vision registration consists of two C-arm spins – one iso-centered around the main carina and another iso-centered around the lesion. These spins produce an initial C-Arm Based Computed Tomography (CABT) scan to confirm actual lesion and lesion location on the day of procedure prior to navigation.&nbsp; <img src="https://lh5.googleusercontent.com/UTRxTAQ2ruxNOMgzYSHuSsjNrQ1RKybiuA26LI2fD18SsHZdhuZb3PqczT8e_A5EQdqYXjq4U8hXkxPECKMfmyBp8nvbj7wVOzlnV2kAYwhZULgQvbWYF35F60Kdys67i8PXFNPryuFh8EwzvvhsDkahZIycJ1cqhyW-sdf4GVteb3NEoO5U9J_gJrpvng" height="289" width="433">Marking the main carina on Body Vision’s CABT during registration.&nbsp; <img src="https://lh4.googleusercontent.com/XVRoywVvFl0MtGdNNTuVBI6PllLJT_T18Y503NspQKU9tQmcBhGbWt1Vk1b1URvDcohajiCd9BzdNwCbZ1r-ShSXEio-HcVWw70sEDcta-Gqu6oUbEPhtTlotfzbAvcnoorq6sncyK3ce_t4Yy9bzgFsQrnL_nLkIUaqHbgemr_7_B24lPicK_dW8Yzn4w" height="288" width="431">Marking the lesion on Body Vision’s CABT during registration.&nbsp; Once this is complete, registration of the Body Vision system is finished and registration of the MONARCH robot can now be performed.&nbsp; <h2>Navigation</h2>The MONARCH robotic bronchoscopy platform was used to navigate out to the virtual target. Once at the target location defined by MONARCH, a radial endobronchial ultrasound (r-EBUS) probe was inserted down the working channel of the MONARCH. The r-EBUS returned a signal consistent with the nodule so no additional tool-in-lesion spin was performed. <h2>Biopsy</h2>After the r-EBUS probe returned a positive signal, biopsy samples via needle and forceps were acquired under Body Vision’s real-time, augmented fluoroscopy. A fiducial marker was also placed using guidance from Body Vision’s augmented fluoroscopy. Rapid On-Site Evaluation (ROSE) confirmed that the tissue samples were malignant. The final pathology report stated squamous cell lung carcinoma.&nbsp; <img src="https://lh4.googleusercontent.com/6Khaa8nkvg6oSHuwtiDz8XSGeKdFdx5voQmrROu9X6zD-OnapDrSpzQUknfBXq99obTirftkhAcwobV5R6k_NAdXPCCzuR3UPU6GQ9bGvJC5Cbx8RikhAMfeclkP5EAewAC9SHDWLbp3uKVo-2KFliKufTFullizfGOTSP8NXu_LrSyDfTQJek0vLiP9Xg" height="234" width="415">Needle biopsy performed under Body Vision’s augmented fluoroscopy.&nbsp; <img src="https://lh3.googleusercontent.com/yIYpY0HrEu8O-cLOam4eJONRa-gOCEKyqGazoPqw6uIfL8PaDHc-mQZ8FPHLVNiwIzVe-F6URnKCTU4FAEHw5joXQ_GhQqpmNm18Uiba3WcthvjyaTXJRu57gMi1ljhXXDLM7k0wEGuUB03_CBPlvYtFsqE8xfhomSz-kuSlhVjVoMnnph1ucpuaf-E9EA" height="235" width="417">Another tissue sample acquired via forceps under Body Vision’s augmented fluoroscopy. <img src="https://lh4.googleusercontent.com/WlwejUKJGaOGcopvUGKd-45DtjrpCTIpjPPmP7E5USXNOXj3FXhoTAt3CMleg2-mkj0_y76mRQqAkqVVP3hY1EaDf9BMYhwf74mgpKD7SjpzowRIBuE10lrTDMDC8TqT99bIIuHdXzprXdC8u2qIu28ksTeUiJI8yjktiWo9yM-7v7Q2JjcjTDQMPPRLCw" height="237" width="420">A fiducial marker being placed under Body Vision’s augmented fluoroscopy.&nbsp; <h2>Final Pathology&nbsp;</h2>Following the final pathology report confirming Squamous Cell Lung Carcinoma, this patient was sent for Stereotactic Body Radiation Therapy (SBRT).&nbsp; <img src="/assets/quill-image-1672235513231.jpg" width="540" style="">﻿Final pathology report indicating squamous cell lung carcinoma. <h2>Conclusion</h2>This case demonstrates the ability of Body Vision’s AI-driven, intraoperative imaging system to work seamlessly with the Ethicon MONARCH robotic bronchoscope in a cohesive diagnostic bronchoscopy workflow while adding the missing component of real-time, intraoperative imaging necessary to confirm that tissue samples are taken from within the lesion during biopsy. In this 25-minute case, Body Vision enabled the biopsy, definitive diagnosis of and fiducial marker placement within this small, centimeter lesion.&nbsp; About Dr. Whitlark<img src="https://lh6.googleusercontent.com/M_tJKyYSqF4dCJM4rmgWorBZz6OFxRr8d4geqsFWyqCn25gAqTto9W0uGZVwXmXKicOZ6KSR90hNDBX8XzweuWz9FRHGqqWpcvsYG0yzUuHpUrkoyMoNPLd82Z7YLMea8ORvMXQwOyZyeNzNpGCURnyOB2U9Na4tzhAZwxaZu2hTRyzttDWLpqpBz8JI4Q" height="125" width="125">Joseph D. Whitlark, MDRobotic Thoracic SurgeonCrozer Health

In this case, Dr. Joseph Whitlark was able to biopsy, diagnose and place a fiducial on a 10mm RUL lesion.

Biopsy, Diagnosis and Fiducial Marker Placement of a 10mm RUL Lesion

<h2>Lesion Characteristics</h2>Lesion Size (diameter): 18 mmLesion Location: Right Upper Lobe (RUL) lesionBronchus Sign: NoVisible on Fluoro: YesREBUS Verification: Eccentric Signal <h2>Case Information</h2>Full Procedure Time: 65 minutesROSE: Sampling was performed and was suggestive of NSCLCFinal Pathology Report:&nbsp;Final pathology was&nbsp;lung adenocarcinoma <h2>Patient Background</h2>A 72 year-old man with COPD and a smoking history was sent to the pulmonary clinic on finding a right upper lobe (RUL) lung nodule from a&nbsp;low-dose lung screening CT scan performed by his primary care doctor. No prior history of any lung cancer or malignancy. Found to have PET avidity at the lung nodule sent for tissue diagnosis.&nbsp; <h1>The Procedure</h1><h2>Planning</h2><img src="/assets/quill-image-1661982446213.jpg">During planning, a virtual bronchoscopy (VB) of the preferred pathway to the lesion is provided.&nbsp;This can be recalled at any time during the procedure to be used in conjunction with the augmented fluoroscopy to assist with navigation to the lesion location. During planning, a pre-operative CT is uploaded onto the Body Vision system. The lesion was marked and contoured to inform the Body Vision system of the approximate lesion size, shape and location prior to the procedure. The system also derives the airways from the preoperative CT and, during the planning step, a preferred pathway to the lesion is marked so that the Body Vision system can serve up a virtual bronchoscopy to function as a complete standalone navigational bronchoscopy platform.&nbsp; <h2>Registration</h2>Once the patient is intubated on the table, registration of the Body Vision system begins. Registration consists of two C-arm spins.&nbsp;The first spin produces a scan of the main carina and that is marked so that the Body Vision system can use that as a reference point for instructing how to position the C-arm such that it is iso-centered over the lesion.&nbsp;&nbsp; <img src="/assets/quill-image-1661378265793.jpg">During registration, the main carina is marked on Body Vision’s tomographic 3D scan acquired from the first C-arm spin.The second spin produces an initial C-Arm Based Computed Tomography (CABT) scan in which the clinician can confirm actual lesion and lesion location before navigation. Registration is now complete. <img src="/assets/quill-image-1661378282346.jpg">During registration, the lesion is also marked on Body Vision's C-Arm Based Tomography scan so that the system knows roughly the shape, size and location of the lesion and can provide guidance for how to iso-center the C-arm over the lesion during the procedure. <h2>Navigation</h2>During this case, Body Vision was used as an end-to-end navigational bronchoscopy platform. However, for those using a robotic bronchoscopy platform or EMN system to navigate, Body Vision can be easily integrated into that workflow. Using Body Vision's augmented fluoroscopy, the ability to see the bronchoscope in real-time in conjunction with overlays showing lesion location and airways provided the necessary guidance to successfully navigate to the lesion. Body Vision's augmented fluoroscopy is not based on preoperative CT scans and the overlays of lesion location is updated with each C-arm spin.&nbsp;As a result, none of the imaging provided by the Body Vision system are subject to CT-to-body divergence. <img src="/assets/quill-image-1661378979643.jpg">Body Vision’s fluoroscopy augmented with lesion location as visualized on the most recent C-arm spin as well as preferred pathway guidance for real-time, intraoperative navigation. <h2>Tool-in-Lesion Spin #1</h2>Once near the lesion location as seen on augmented fluoroscopy, a C-Arm spin was performed. This spin showed that the tool was&nbsp;anterior&nbsp;to the lesion meaning a repositioning of the bronchoscope was necessary. <img src="/assets/quill-image-1662072289879.jpg">Body Vision's CABT showing lesion location. <img src="/assets/quill-image-1662072248210.jpg">Body Vision's 3D View confirming that the tool was anterior to the lesion. <h2> </h2><h2>Readjustment</h2>Using Body Vision's augmented fluoroscopy for guidance, the bronchoscope was repositioned such that it was better angled towards&nbsp;the lesion. This was confirmed by using the C-arm to check the relationship between the bronchoscope and lesion in multiple planes.&nbsp; <img src="/assets/quill-image-1664290668493.jpg">Augmented fluoroscopy in multiple 3D views (RAO, LAO, and AP in this case) also confirmed that the bronchoscope was anterior to the lesion. <h2>Tool-in-Lesion Spin #2</h2>Another tool-in-lesion spin was performed after readjustment. The tomographic 3D image provided by Body Vision confirmed that the bronchoscope was better positioned than before, but was now slightly on the posterior edge of the lesion. <img src="/assets/quill-image-1661378298217.jpg">Body Vision's C-Arm Based Tomography providing a tomographic 3D scan of both the lesion and the bronchoscope showing the catheter with biopsy needle extended slightly posterior to the lesion. <img src="/assets/quill-image-1661378308973.jpg">Body Vision's 3D View also confirmed that the bronchoscope was slightly posterior to the lesion. <h2>Tool-in-Lesion Spin #3</h2>A second readjustment was made and a third spin was performed. This spin provided visual confirmation of tool-in-lesion in all three multiple 3D planes. <img src="/assets/quill-image-1661378318207.jpg">Body Vision’s AI-driven imaging providing tool-in-lesion confirmation prior to biopsy. Body Vision's 3D View also confirmed that the biopsy needle was right in the middle of the lesion on the third spin. <img src="/assets/quill-image-1661378325340.jpg">Body Vision's 3D View visually confirming tool-in-lesion. <h2>r-EBUS Confirmation</h2>Once receiving visual, tool-in-lesion confirmation, a r-EBUS probe was inserted down the working channel of Body Vision's procedural kit and returned an eccentric view, further validating that the lesion location shown by Body Vision was the actual lesion location. <h2>Biopsy</h2>Following <a href="https://bodyvisionmedical.com/articles/inside-body-vision-process" target="_blank" style="background-color: transparent; color: rgb(0, 0, 0);">tool-in-lesion confirmation</a>, sampling of the lesion using a biopsy needle commenced. Body Vision's augmented fluoroscopy provided a real-time view of both the biopsy tool and the lesion to guide how far to throw the needle in order to ensure that the tissue acquired was from within the confines of the lesion.&nbsp;While the Rapid On-Site Evaluation (ROSE) assessed that samples collected showed some atypical cells suggestive of adenocarcinoma, the final pathology report later confirmed a diagnosis of adenocarcinoma. Mediastinal staging procedure was done by EBUS showing only N1 disease at 10R lymph node station also showing adenocarcinoma. <img src="/assets/quill-image-1661984065768.jpg">Body Vision's augmented fluoroscopy providing real-time imaging during biopsy. <h2>Conclusion</h2>This case illustrates how Body Vision's AI-driven intraoperative imaging gives physicians the ability to intraoperatively confirm tool-in-lesion prior to and during biopsy. Perhaps even more importantly, since each C-arm spin takes less than a minute and radiation exposure is minimal, if you see that you are not at the lesion, Body Vision’s imaging provides the crucial information needed to reposition the bronchoscope and/or biopsy tools to ensure that biopsy samples are indeed of the suspicious lesion. Because scans are captured during the procedure instead of being reliant on a preoperative CT scan, any <a href="https://bodyvisionmedical.com/articles/overcoming-ct-to-body-divergence" target="_blank" style="background-color: transparent; color: rgb(0, 0, 0);">CT-to-body divergence is eliminated</a>. Patient is now undergoing treatment with neoadjuvant chemotherapy and plans for a right upper lobectomy. About Dr. Mathew<img src="/assets/quill-image-1661983792865.jpg" width="119">Roshen Mathew, MD, DAABIPDirector Interventional Pulmonary / Critical CareCamden Clark Medical Center

Biopsy and diagnosis an 18mm lesion in the Right Upper Lobe

Biopsy and Diagnosis of an 18mm RUL Lesion

<h2>Lesion Characteristics</h2>Lesion Size (diameter): 12 mmLesion Location: Right upper lobe (RUL) lesionBronchus Sign: NoVisible on Fluoro: NoREBUS Verification: Yes, after Body Vision enabled navigation to the lesion <h2>Case Information</h2>Full Procedure Time: 45 minutesROSE: Sampling was performed and was positive for non-small cell lung cancer (NSCLC)Final Pathology Report:&nbsp;Final pathology was adenocarcinoma of the lung <h2>Patient Background</h2>A 69 year-old asymptomatic, current smoker with COPD underwent a routine CT screening where a suspicious nodule was found in the right upper lobe (RUL). A PET scan of the 12 mm RUL nodule confirmed hyper-metabolic activity. A robotic-assisted navigation bronchoscopy procedure using the Auris Monarch platform in conjunction with Body Vision's AI-driven intraoperative imaging was scheduled to biopsy the nodule. <h1>The Procedure&nbsp;</h1><h2>Planning</h2>A pre-operative CT is uploaded onto the Body Vision AI-driven, intraoperative imaging system.&nbsp;The lesion is marked and contoured so that the Body Vision system has an approximation of lesion size, shape, and location prior to the procedure. The Body Vision system also derives the airways from the preoperative CT so for those looking to use the system as an end-to-end navigational bronchoscopy platform, a virtual bronchoscopy with preferred pathway to the lesion is provided.&nbsp;In this case, the Auris Monarch was used for navigation and so this functionality of the Body Vision system was not used. <h2>Registration</h2>Once the patient is on the table, Body Vision registration consists of two C-arm spins: one around the main carina and a second iso-centered on the lesion. This produces an initial C-Arm Based Computed Tomography (CABT) scan to confirm actual lesion and lesion location prior to navigation.&nbsp;Once this is complete, registration of the navigation platform of choice, in this case, the Auris Monarch, is performed.<img src="/assets/quill-image-1661976795561.jpg" width="486">﻿Pre-operative CT in coronal view showing 12mm RUL lesion (left). Body Vision 3D tomographic scan (right) during registration confirming actual size, shape, and location of lesion prior to navigation. <h2>Navigation</h2>The Auris Monarch robotic bronchoscopy platform was navigated to the virtual target as defined by the robotic platform’s electromagnetic navigation (EMN) technology. A radial endobronchial ultrasound (r-EBUS) probe was advanced down the working channel of the Monarch bronchoscope to validate accuracy of the virtual target location. The r-EBUS did not return a signal indicative of a lesion at the virtual target location.&nbsp; A GE OEC 9900 Elite C-arm was brought into position over the patient and a CABT scan with the Body Vision system was performed to determine true lesion location. The intraoperative CT image overlaid onto the Body Vision-generated augmented fluoroscopy enabled repositioning of the robotic bronchoscope. Because Body Vision’s imaging is not based on preoperative CT scans and is captured in real-time intraoperatively, no CT-to-body divergence exists. <img src="/assets/quill-image-1660924889135.jpg">Using Body Vision’s fluoroscopy augmented with lesion location as visualized on the most recent C-arm spin for real-time, intraoperative guidance, the Auris Monarch robotic bronchoscope was repositioned to the actual lesion location. <h2>﻿r-EBUS Confirmation</h2><img src="/assets/quill-image-1660848134903.jpg" width="219">R-EBUS probe confirming tool-in-lesion. The r-EBUS probe was re-inserted down the working channel of the Monarch robotic bronchoscope and extended into the lesion location as shown by Body Vision. At the new bronchoscope location, the r-EBUS probe returned a concentric echo-density, supporting that the lesion location as defined by Body Vision was correct. <h2>Tool-in-Lesion Confirmation</h2>The r-EBUS probe was retracted from the Monarch working channel and replaced with biopsy forceps which were extended into the pulmonary lesion as visualized with Body Vision and verified by r-EBUS. Another C-arm spin was performed with the biopsy forceps extended in order to provide <a href="https://bodyvisionmedical.com/articles/inside-body-vision-process" target="_blank">visual confirmation of tool-in-lesion</a> in multiple 3D planes before biopsy. <img src="https://bodyvisionmedical.com/assets/quill-image-1660780364660.jpg">Body Vision’s AI-driven imaging enabled a C-arm to produce real-time intraoperative scans that visualize the lesion, bronchoscope, and biopsy tools for tool-in-lesion confirmation prior to biopsy. <img src="https://bodyvisionmedical.com/assets/quill-image-1660780471482.jpg">Body Vision's 3D View provided an additional means for visually confirming tool-in-lesion. <h2>Biopsy</h2>After tool-in-lesion confirmation, biopsy commenced under real-time image guidance using Body Vision's augmented fluoroscopy to ensure that tissue sampling occurred from within the lesion. Rapid On-Site Evaluation (ROSE) assessed that samples collected were adequate and consistent with non-small cell lung cancer. This was later confirmed by cytology on the final pathology report which stated adenocarcinoma of the lung. <img src="/assets/quill-image-1662648581003.jpg">Final pathology report indicating adenocarcinoma of the lung. A fiducial marker was placed at this time. Due to poor lung function (FEV1 less than 800 cc's), this patient is not an operative candidate. EBUS performed at the end of bronchoscopy presented no evidence of hilar or mediastinal lymph node involvement. This patient is an excellent candidate for Cyberknife. <img src="/assets/quill-image-1660783888719.jpg">Body Vision's augmented fluoroscopy showing real-time biopsy via forceps. <h2>﻿Conclusion</h2>This case illustrates how Body Vision’s AI-driven, intraoperative imaging can be seamlessly incorporated into the generally-accepted diagnostic bronchoscopy workflow.&nbsp;While robotic assisted bronchoscopy lends added stability and articulation to navigation bronchoscopy, the lack of real-time, intraoperative 3D imaging prevents any potential correction should, as in this case, the virtual target provided by the Monarch’s EMN navigation system prove to be incorrect due to CT-to-body divergence or other factors.&nbsp;&nbsp;Rather than resorting to systematic blind sampling of the lung with r-EBUS to find the lesion, Body Vision enabled visualization of the lesion and lesion location so that the bronchoscope could be repositioned to the actual lesion location.&nbsp;Once the bronchoscope was repositioned, Body Vision’s intraoperative imaging enabled visual tool-in-lesion confirmation to maximize likelihood that tissue samples obtained were from within the lesion.&nbsp;Real-time, intraoperative imaging transformed this case from one in which reliable sampling from within the pulmonary lesion seemed unlikely to one in which a definitive diagnosis of adenocarcinoma of the lung was obtained for this lung patient.&nbsp; About Dr. Whitlark<img src="/assets/quill-image-1656448242426.jpg" width="133">Joseph D. Whitlark, MDRobotic Thoracic SurgeonCrozer Health

Biopsy and Diagnosis of a 12mm Lesion in the Right Upper Lobe

<h2>Lesion Characteristics</h2>Lesion Size (diameter): 13 mmLesion Location: Lower Upper Lobe Lesion (Lingular)Bronchus Sign: YesVisible on Fluoro: YesREBUS Verification: Concentric <h2>Case Information</h2>Full Procedure Time: 55 minutesROSE: Sampling was performed with positive ROSE by cytology.Final Pathology Report: Final pathology was positive for carcinoid. <h2>Background</h2>A 61 year-old female with a history of COPD and tobacco use presented with an inferior lingular nodule. A CT chest scan in January 2021 revealed an 11 mm lingular nodule (Figure 1a). Laboratory analysis demonstrated normal white blood cell count, negative coccidioides antibodies, acid fast cultures, fungal serologies, quantiferon TB test and urine histoplasmosis antigen. Navigational bronchoscopy was initially performed in February 2021. Radial EBUS (r-EBUS) was used intra-procedure and a concentric density was identified. However, rapid on-site evaluation (ROSE) cytology was negative for malignant cells with inconclusive pathology. CT scan in April 2021 showed growth of the lingular nodule to 12 mm. Interventional radiology was consulted and TTNA was performed (Figure 1b). Pathology was again inconclusive. After further discussion with the patient about newer modalities she was still interested in a bronchoscopic method for resection rather than surgery. In October 2021, a robotic-assisted bronchoscopy procedure utilizing the Body Vision system for real-time, intraoperative 3D imaging in conjunction with the Ion by Intuitive system was scheduled.&nbsp;<img src="https://lh4.googleusercontent.com/gVv1_Xmm5VCMaA3tysm6usw-TnnqZ_sYCjF4x9WVWzR1KCHwEe0q10SoVa_VMSVbmNpvfO4CMyTuPWjsgZtHaG2xHol3LPa0hCVoe-1z-l2D4Je9ykFRxbaihEfBsDetVZ0lawB0h9pDgnZJUw" height="248" width="624">&nbsp;&nbsp;&nbsp;&nbsp;(Figures 1a and 1b) The Procedure&nbsp; PlanningA pre-operative CT is uploaded onto the Body Vision system.&nbsp;The lesion is then marked and contoured so that the Body Vision system can approximate the lesion location prior to the procedure. The Body Vision system also derives the airways from the preoperative CT so that if the user were to use the system as an end-to-end navigational bronchoscopy platform, a virtual bronch can be provided.&nbsp; CABT RegistrationRegistration of the Body Vision system consists of two C-arm spins once the patient is on the table: one around the main carina and a second iso-centered around the lesion to produce an initial C-Arm Based Computed Tomography (CABT) scan so that the bronchoscopist can view the actual lesion and lesion location prior to navigation.&nbsp; NavigationThe Ion by Intuitive robotic bronchoscopy platform was registered, the Ion catheter introduced into the airway, and the catheter navigated to the target as defined by the robotic platform’s shape-sensing technology. <img src="https://lh3.googleusercontent.com/IhO6qSf5HvFKalNQ8iPk5yngdd9e9PoexU4puxiK3xX18yqWyIuq1Ub-EloH4iFqo46C92nxO_X1H5wKf3WAVQQonaRsjn7ebFgM5Z2S7FybtwwvBzItGCpiMhyZ-3SxOdFjyb_jh1AKNLwsLQ" height="442" width="362">(Figure 1c) Once the Ion catheter was navigated to within 10mm of the target, the proximity of the bronchoscope to the pleura was enough of a concern that&nbsp;a GE OEC 9900 Elite C-arm was brought into position over the patient and a CABT scan with the Body Vision system performed to determine true lesion location. The intraoperative CT image overlayed onto the Body Vision-generated augmented fluoroscopy shows that the catheter had already been positioned roughly 10mm past the actual lesion. Ion’s shape-sensing technology indicated that the system believed that the proximal edge of the lesion was still 10mm further out, equating to an approximate 20mm (2cm) of <a href="https://bodyvisionmedical.com/articles/overcoming-ct-to-body-divergence" target="_blank" style="color: rgb(0, 0, 0); background-color: rgb(255, 255, 255);">CT-to-body divergence</a>. (Figure 1c). Based on Body Vision’s intraoperative 3D image, the Ion bronchoscope was retracted to the actual lesion location as defined by Body Vision. Because the&nbsp;imaging is not based on preoperative CT scans and is captured in real-time intraoperatively, no CT-to-body divergence exists with Body Vision’s imaging technology. r-EBUS Confirmation<img src="https://lh5.googleusercontent.com/wcHduPNcth4EiYcidlQRNJtLgy-aSUkTCLKxRtcqlWIL1E26Vf1qdLuEg-Z7Fd3Hr_DZYAoloATSGR731dsn_EmTPFFzuBhk1dfB8JyrkKOsB0iWjKv3ZVA3zpEhC0g-l440QoeQQ1CGkfD-Dw" height="242" width="340">(Figure 1d) Once the Ion catheter was repositioned to where Body Vision’s intraoperative imaging showed the lesion to be, the Ion vision probe was retracted from the bronchoscope and replaced with a radial endobronchial ultrasound (r-EBUS) probe.&nbsp;The r-EBUS probe illustrated a concentric echo-density (Figure 1d), verifying that the lesion location as defined by Body Vision was correct and that the repositioned catheter was now at the lesion.&nbsp; Biopsy<img src="/assets/quill-image-1655145121689.jpg" width="405">﻿The r-EBUS probe was retracted from the working channel of the Ion system and replaced by biopsy tools.&nbsp;Under augmented fluoroscopy which showed both lesion boundaries and biopsy tool location in real-time, Dr. Nobari was able to acquire biopsy samples and ensure that those samples were from within the lesion. Rapid On-Site Evaluation (ROSE) assessed that samples collected via needle biopsy were adequate and consistent with a carcinoid (Figure 1e).&nbsp;This was later confirmed by cytology on the final pathology report. <img src="https://lh6.googleusercontent.com/YTK4x-asztIvPF2KVmDlp3cMDf06M7PN-FbSjubqpwliterQSx5kvkGCs2ekN4sgob_Y9IYpaxIN_zmY-YELaOaCAk0f2-Y-Fy9cM8Wivlw7gE0_Nleej3065eeTKLTy_9WrwCvGqPqGAFF3UA" height="230" width="396">(Figure 1e) ConclusionThis case demonstrates the value of Body Vision’s real-time, intraoperative 3D imaging when used in conjunction with the Ion by Intuitive platform during robotic-assisted bronchoscopy. While the benefits of Ion’s robotic catheter – namely stability and articulation – provide very real tangible benefits during navigation bronchoscopy, its reliance on pre-operative CTs for establishing a virtual navigation target makes it susceptible to CT-to-body divergence and does not provide the ability to visually confirm that biopsy samples are acquired from within the lesion.&nbsp;Thus, Body Vision’s intraoperative imaging proved&nbsp;crucial for navigating to the actual lesion location and enabled image-guided sampling of this peripheral pulmonary nodule.&nbsp; About Dr. Nobari<img src="/assets/quill-image-1655144307233.jpg" width="133">Matthew M. Nobari MDPulmonary and Critical CareAssistant Clinical Professor&nbsp;University of California San Diego

Overcoming CT-to-Body Divergence in a 13mm Left Upper Lobe Lesion

<h1>Case Details</h1><h2> </h2><h2>Lesion Characteristics</h2>Lesion Size (diameter): 25 mmLesion Location: Right Upper LobeBronchus Sign: YesVisible on Fluoro: YesREBUS Verification: Concentric <h2>Case Information</h2>Full Procedure Time: 75 minutes (this included biopsy of 25mm nodule in right upper lobe (RUL) as well as a biopsy of a right lower lobe (RLL) nodule and staging of lymph nodes)ROSE: Adenocarcinoma from needle biopsy and touch preps from transbronchial lung biopsy (TBBx)Final Pathology Report: Well-differentiated adenocarcinoma of the lung from needle biopsies and transbronchial lung biopsies <h2>Background</h2>An 88-year-old woman with no smoking history but with a remote history of breast cancer was referred with a solitary pulmonary nodule in the right upper lobe (RUL).&nbsp;The patient had two previous attempts to biopsy from the RUL lesion prior to the referral but both attempts proved non-diagnostic.&nbsp;A Fluorodeoxyglucose (FDG) PET scan of the RUL lesion exhibited a standardized uptake value (SUV) of 4.9.&nbsp;At this point, the patient was referred to Dr. D. Kyle Hogarth at the University of Chicago Medical Center for a second opinion.&nbsp;The patient returned a normal pulmonary function test (PFT).&nbsp;A robotic-assisted navigation bronchoscopy procedure utilizing the Body Vision system for real-time, intraoperative 3D imaging in conjunction with the Auris MONARCH® platform was scheduled. <h1>The Procedure</h1> <h2>Planning</h2><img src="/assets/quill-image-1634652634728.jpg">The Body Vision system derives the airways from the pre-operative CT as well as uses the physician’s marking of the lesion and lesion boundaries to approximate lesion location prior to the procedure.&nbsp;During the procedure, lesion location and positioning of the bronchoscope and tools relative to the lesion is provided by real-time, intraoperative 3D imaging. <h2>CABT™ Registration</h2><img src="/assets/quill-image-1634613070980.jpg">Using any conventional C-arm, Body Vision's C-arm-based computational tomography (CABT) technology provides intraoperative 3D images. Registration of the Body Vision system entails a CABT scan of the main carina and a second CABT scan iso-centered around the lesion which provides visualization of the actual lesion and lesion location, even of radiolucent lesions which are typically not fluoro visible.&nbsp; <h2>Navigation </h2><img src="/assets/quill-image-1649441007414.jpg">The MONARCH® platform was initialized and used to navigate to within close proximity of the virtual target using the robotic platform’s electromagnetic navigation. The C-arm was then brought into position over the patient and a CABT scan with the Body Vision was performed to determine true lesion location (A).&nbsp;The robotic bronchoscope was repositioned based on the new information provided by Body Vision’s intraoperative 3D imaging and lesion’s presence at the location as imaged by Body Vision was confirmed with Radial Endobronchial Ultrasound (REBUS).&nbsp;REBUS returned a concentric view (B).&nbsp;Because Body Vision’s intraoperative 3D imaging is captured in real-time when the patient is on the table and is not reliant on pre-operative CT images, CT-to-body divergence is eliminated and, as in this case, accurate navigation to the actual lesion was enabled. <h2>Tool-In-Lesion Confirmation</h2><img src="/assets/quill-image-1649097333487.jpg">Under Body Vision’s augmented fluoroscopy where the C-arm fluoro image is augmented with actual lesion location provided by the most recent CABT scan, Dr. Hogarth was able to see in real-time as he introduced a Body Vision stylet (no longer needed for robotic bronchoscopy cases) with radiopaque markers down the working channel of the MONARCH and guides it to the lesion. <img src="/assets/quill-image-1649268717249.jpg">With the Body Vision stylet in place, a CABT was performed to provide visual confirmation of tool-in-lesion in multiple 3D planes.&nbsp; <h2>Biopsy</h2><img src="/assets/quill-image-1634652769276.jpg">With tool-in-lesion confirmed under Body Vision’s intraoperative 3D imaging, the Body Vision stylet was retracted and a biopsy needle was introduced down the working channel of the MONARCH.&nbsp;Under augmented fluoroscopy which showed both lesion boundaries and biopsy tool location in real-time, Dr. Hogarth was able to acquire biopsy samples and ensure that those samples were from within the lesion. Rapid On-Site Evaluation (ROSE) assessed that samples collected via needle biopsy and touch preps from transbronchial lung biopsy (TBBx) were adequate and consistent with adenocarcinoma.&nbsp;Endobronchial Ultrasound (EBUS) staging of the mediastinal (station 1) and hilar (station 10) nodes radiographically showed the lymph nodes were of normal size. The diagnosis of well-defined adenocarcinoma was confirmed via the final pathology report.&nbsp;&nbsp;&nbsp; <h2>Conclusion</h2>This use case demonstrates the value of&nbsp;Body Vision’s intraoperative 3D imaging regardless of bronchoscopy platform.&nbsp;The stability and articulation provided by robotic bronchoscopy platforms provide a clear clinical value during navigation bronchoscopy.&nbsp;However, without real-time intraoperative imaging like that provided by Body Vision, the current generation of robotic bronchoscopy platforms cannot account for CT-to-body divergence. Utilizing the Body Vision intraoperative 3D imaging system in concert with the Auris MONARCH robotic bronchoscopy platform, Dr. Hogarth was able to definitively diagnose a peripheral 2.5cm RUL lesion. <h2>About Dr. Hogarth</h2><img src="/assets/quill-image-1634613173893.jpg" width="116">Kyle Hogarth, MD, FCCPProfessor of MedicineDirector of Bronchoscopy, Co-Director of Lung Cancer Screening ProgramUniversity of Chicago Medical Center

Biopsy and Diagnosis of 25mm Right Upper Lobe Lesion

<h1>Case Details</h1><h2> </h2><h2>Lesion Characteristics</h2>Lesion Size (diameter): 9 mmLesion Location: Right Middle LobeBronchus Sign: YesVisible on Fluoro: NoREBUS Verification: Concentric Rebus Confirmation <h2>Case Information</h2>Time to First Biopsy: 13 minutesFull Procedure Time: 30 minutesROSE: No ROSE on-siteDefinitive Diagnosis: Adenocarcinoma <h2>Background</h2>A 67-year-old woman,&nbsp;non-smoker. CT completed due to unexplained weight loss. <h2>Planning</h2><img src="/assets/quill-image-1637006035939.jpg">In Planning, the pre-operative CT was uploaded and the lesion and lesion boundaries were marked. The Body Vision System proposed different pathway options to reach the lesion and Dr. Abramovich chose the appropriate one. <h2>Virtual Navigation</h2><img src="/assets/quill-image-1637005712731.jpg">Dr. Abramovich viewed and verified the virtual pathway via Body Vision's virtual bronchoscopy.<h2> </h2><h2>CABT Registration</h2><img src="/assets/quill-image-1637003491596.jpg">Using only a conventional C-arm, Body Vision produced a tomographic reconstruction of the lesion in 3D, thus enabling Dr. Ambramovich to see the real-time, accurate lesion location and overcome any concerns with CT-to-body divergence. <h2>Tool-in-Lesion CABT</h2><img src="/assets/quill-image-1641926528551.jpg">﻿Here, Dr. Abramovich was able to confirm the tool was inside the lesion using Body Vision's real-time, CABT technology. <h2>Biopsy</h2><h1><img src="/assets/quill-image-1637003920840.jpg"></h1>Dr. Abramovich successfully takes a biopsy sample from within the lesion using forceps. <h2>Conclusion</h2>Small nodules should be diagnosed even if the patient does not have risk factors. The Body Vision system is capable of assisting a definitive diagnosis by creating a reliable augmented fluoroscopy image and providing real-time, CABT tool-in-lesion confirmation in nodules as small as only a few millimeters. <h2>About Dr. Amir Abramovich</h2><img src="/assets/quill-image-1637004139156.jpg" width="200">Director, Interventional PulmonologyCarmel Medical Center

Biopsy and Diagnosis of 9mm Nodule in Right Middle Lobe

<h1>Case Details</h1><h2> </h2><h2>Lesion Characteristics</h2>Lesion Size (diameter): 11 mmLesion Location: Left Upper Lobe, outer 1/3 of the lungBronchus Sign: YesVisible on Fluoro: NoREBUS Verification: Eccentric <h2>Case Information</h2>Time to First Biopsy: 6 minutesFull Procedure Time: 75 minutesROSE: Positive (3 samples)Definitive Diagnosis: Yes, invasive mucinous adenocarcinoma (pT1bN0) <h2>Background</h2>A 59-year-old male with no smoking history underwent a CT scan in January 2021 for evaluation of mid-back pain that revealed an incidental finding of a solitary pulmonary nodule in the left upper lobe (LUL). The patient had previously had a CT chest in August 2012 for the evaluation of dyspnea and chest pain which disclosed a 13mm non-calcified speculated pulmonary nodule at the left upper lobe. Subsequent PET/CT in September 2012 demonstrated no FDG uptake at the LUL nodule. The patient underwent bronchoscopy in December 2012 with endobronchial forceps biopsies that were inconclusive, showing benign respiratory epithelium and scant alveolar parenchyma. The patient had an additional CT chest in October 2013 that demonstrated stability in the size and character of the LUL nodule. There were no further surveillance images. As described above, the patient obtained CT imaging of the c- and t-spine in January 2021 to evaluate back pain. The LUL nodule was re-identified and a dedicated CT chest disclosed that the nodule was 1.6 x 1.6 cm in the axial dimension and 1.6 x 1.1 cm in the coronal plane, increased from the 2012 imaging when it measured 1.5 x 1 cm in axial dimension and 1.1 x 0.9 cm in the coronal plane. There were additional sub-centimeter nodules in the LUL and right upper lobe. The patient was referred to Dr. George Cheng and underwent diagnostic bronchoscopy using LungVision’s advanced imaging navigation technology in March 2021. Dr. Cheng was able to navigate to the lesion in the left upper lobe, confirm the tool was in the lesion using CABTTM, obtain multiple biopsies, and arrive at a successful diagnosis of mucinous adenocarcinoma. The patient was staged as IA2 (T1b, N0, M0) and subsequently referred to Cardiothoracic Surgery where he underwent robotic left upper lobectomy and the diagnosis was confirmed as invasive mucinous adenocarcinoma (pT1bN0).&nbsp; <h1>The Procedure</h1> <h2>Planning</h2><img src="/assets/quill-image-1619707028074.jpg">In this phase, the pre-operative CT was loaded, the lesion and lesion boundaries were marked and the LungVision™ System learned the anatomical structure of the lung and identified potential pathways to the lesion. <h2>CABT™ Registration</h2><img src="/assets/quill-image-1619707317583.jpg">Using a conventional C-arm, a non-fluoro visible lesion became visible to the user, by producing a tomographic reconstruction of the lesion in 3D. This enabled the physician to understand the real-time, accurate location of the lesion and overcome any CT-to-body divergence.&nbsp; <h2>Navigation </h2><img src="/assets/quill-image-1619707528042.jpg">Guided by advanced real-time imaging, the distal tip of the LungVision™&nbsp;sheath, part of the disposable procedural kit, was navigated to the lesion. <h2>CABT™ Tool-In-Lesion Confirmation</h2><img src="/assets/quill-image-1623129732544.jpg">Confirmation that the LungVision tool was inside the lesion occurred here with Body Vision's CABT™ technology. <h2>Biopsy</h2><img src="/assets/quill-image-1619707725644.jpg">Here, biopsy samples were successfully taken from within the lesion. <h2>Conclusion</h2>A peripheral 11mm lesion in the left upper lobe was evaluated via traditional bronchoscopy including endobronchial forceps biopsies. This approach led to inconclusive results. LungVisionTM System enabled true real-time visualization during navigation and tool-in-lesion confirmation, resulting in a definitive cancer diagnosis and treatment.&nbsp; <img src="/assets/quill-image-1629386591370.jpg">Figure 1. A) CT chest of the LUL nodule from August 2012. B) PET imaging from September 2012 with no FDG uptake at the LUL nodule. C, D) Intraoperative radial ultrasound images from bronchoscopy in December 2012.&nbsp; <img src="/assets/quill-image-1629386658342.jpg">Figure 2. A) CT imaging demonstrating LUL nodule in January 2021. B) Dedicated CT chest characterizing the nodule as 1.6 x 1.6 cm in the axial dimension and 1.6 x 1.1 cm in the coronal plane. C, D) Histological slides from navigation bronchoscopy demonstrating samples which were hypercellular with single and sheets of glandular appearing cells with no cilia, abundant intracytoplasmic mucin, increased nuclear to cytoplasmic ratios, prominent nucleoli, and cleared but bland appearing chromatin; findings compatible with mucinous adenocarcinoma of lung origin.&nbsp; <h2>About Dr. Cheng and Dr. Tran</h2> <img src="/assets/quill-image-1626269696304.jpg" width="116">George Z. Cheng, MD, PhDInterventional PulmonologistSan Diego, CA <img src="/assets/quill-image-1632341731007.jpg" width="116">Dr. Brian TranPulmonary Critical Care FellowSan Diego, CA