Photo by Tim Parker
In a surgical suite at Barnes-Jewish Hospital, a robotic arm snakes a 3.5mm, fully articulated catheter through a patient’s airway. When the catheter reaches the lungs, the Washington University surgeon operating the device uses a tiny scope to search the area for an abnormal nodule. Once located, a needle pierces the spot for biopsy.
The giant C-shaped device uses a robotic arm to conduct bronchoscopies and pulmonary biopsies, helping interventional pulmonology and radiology teams to reach further than they ever have before in the fight against lung cancer. On May 1, Barnes-Jewish Hospital became the first and only hospital in the St. Louis region to use robotic technology to aid lung biopsies. The procedure allows physicians to hopefully improve diagnostic yield from smaller and more peripheral nodules.
Fighting a deadly disease
Lung cancer is one of the deadliest cancers in the world with an overall five-year survival rate of just 25%. Delayed diagnosis from low screening rates and limited options for biopsies of smaller and peripheral nodes helps drive this mortality rate.
Through Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, we are working to increase regular screenings for patients recommended to receive them. Taking the “wait and see” approach risks possible cancer metastasis.
Nathaniel Moulton, MD
“Most patients are diagnosed with lung cancer after there’s lymph node involvement or it’s spread to other parts of the body,” says Nathaniel Moulton, MD, a Washington University pulmonologist at Barnes-Jewish Hospital. “Even as lung cancer screenings increase, we’re talking about very small nodules. And not every nodule represents cancer. You need a sample, and that’s the challenge we’ve had in the past.”
A team effort
Bronchoscopies done without robotic assistance rely solely on the coordination and experience of the physician. During robotic-assisted procedures, the robotic arm anchors the scope, and detailed CT images of the lungs uploaded to the system provides the team with additional information to help find and sample nodules in the lung’s periphery.
“The physicians upload the map of the lung to the system,” says Susan Morrison, operating room registered nurse at Barnes-Jewish Hospital. “If the preferred route is not possible, the system can calculate alternate paths to get to the target.”
There is evidence that robotic-assisted bronchoscopy can show a higher diagnostic yield. A multicenter study published this year in Respirology found a robotic pulmonology diagnostic yield of 87.6%. This is in comparison to a meta-analysis of traditional bronchoscopy, which demonstrates a diagnostic yield of 70%. When the lesion size was smaller than 20 mm, the yield dropped to 60%
This planned procedure requires multidisciplinary collaboration from a small army of health care professionals, including radiologists, bronchoscopists, nurses, respiratory therapists, anesthesiologists, attending pulmonologists and surgeons, and lab technicians—many of whom have been specifically trained in the device’s use. The procedure typically lasts 40-50 minutes. It is done on an outpatient basis; patients are under general anesthesia during the procedure and usually go home the same day.
New hope through earlier diagnosis
Moulton says that the device may be a good option for some patients who have nodules that are very small or harder to reach without robotic assistance.
“If we can diagnose patients at stage 1 lung cancer, the survival rate with treatment is excellent,” Moulton said.
Barnes-Jewish Hospital has been able to perform approximately 30 robotic bronchoscopy cases and is continuing clinical investigations to ensure patients have an experience tailored to their specific needs. The robot used in the bronchoscopy has additional applications, including dye marking to tag nodules for easier removal.
Alexander C. Chen, MD
Washington University pulmonologist Alexander Chen, MD, who treats patients at Siteman Cancer Center, said that Barnes-Jewish Hospital was able to become the first in the region to offer this procedure because its large and multidisciplinary team has the experience and focus on patient’s individual needs.
“We have been involved in robotic bronchoscopy technology development since 2017,” he says. “There are several different platforms commercially available, though they all share some common features and aim to do the same thing, which is improve diagnostic yields for lung nodule biopsy. In addition to being a clinical advisor for our industry partners developing robotic bronchoscopy, I have led and participated in multiple clinical trials using these systems, including the first multicenter prospective clinical trial using robotic bronchoscopy in patients with pulmonary nodules.”
Barnes-Jewish Hospital is able to foster partnerships and cross-collaboration between critical institutions needed for the success of this procedure, including Washington University School of Medicine, Siteman Cancer Center, and the Mallinckrodt Institute of Radiology.
“I think that [collaboration] helps us provide not just extraordinary care, but also access to the best technology in the field to give our patients the leading-edge healthcare that they need,” Moulton said.