Diagnostic Value Of Virtual Bronchoscopic Navigation Versus Non-Virtual Bronchoscopic Navigation Assisted Bronchoscopy For Peripheral Pulmonary Lesions

Background Lung cancer is by far the second most common cancer diagnosed and the leading cause of cancer death worldwide.Adoption of low-dose computed tomography(CT)for lung cancer screening has increased the incidence of peripheral pulmonary lesions(PPLs)in clinical practice.Early detection of peripheral pulmonary lesions and early treatment is paramount for lesions that are at high risk of malignancy,while avoiding unnecessary procedures for benign lesions.CT-guided transthoracic needle aspiration(CT-TTNA)which can obtain peripheral tissue samples from the lung is widely used in the histological diagnosis of PPLs,however there is a risk of pneumothorax.Despite technologic advancements in guided bronchoscopy such as ultrathin bronchoscopy,and radial probe endobronchial ultrasound(REBUS),the diagnostic yield of bronchoscopic approaches for peripheral nodules has been inconsistent across studies.Image-guided bronchoscopy techniques such as virtual bronchoscopic navigation(VBN)has emerged as a means of assisting in the biopsy of peripheral pulmonary lesions.Virtual bronchoscopic navigation is a promising technology that requires no specific training,incorporates a low overall complication rate and doesn’t directly induce or cause severe complications.However,the role of VBNassisted(VBNA)bronchoscopy in the diagnosing of peripheral pulmonary lesions has not been well established.Recent randomized clinical trials(RCTs)of VBN-versus non-VBN-assisted techniques compared diagnostic yield and safety of peripheral pulmonary lesions.The results of randomized controlled trials have been heterogeneous in their conclusions.This systematic review and meta-analysis was conducted to assess i)the overall diagnostic yield and safety profile of VBN-assisted group versus non-VBN-assisted(NVBNA)bronchoscopy for the PPLs.ii)in addition,we further adopted subgroup analysis to investigate diagnostic yield of VBNA and NVBNA group according to the lesion size,nature of lesion,lesion location,distance from the hilum,and bronchus sign.Materials and MethodsComprehensive search of Pub Med,Embase,Cochrane library,and Web of Sciences databases were systematically conducted thru August 2020 to identify randomized controlled trials(RCTs)evaluating the performance of VBNA compared with NVBNA group.Reference lists of relevant articles were also reviewed.Data about first author,year of publication,study design,patient demographics,setting,bronchoscopy,navigation system,biopsy instruments and other auxiliaries were recorded.Total diagnostic yield,total examination time and diagnostic yield by the lesion size(≤20mm or > 20 mm),location of lesion in the lobe,distance from the hilum(central,intermediate and peripheral third),bronchus sign(presence or absence of bronchus sign),and nature of the lesion(malignant or benign),and complications were also collected.All meta-analyses were performed using Review Manager,Version 5.3.Dichotomous outcomes were analyzed using Mantel-Haenszel risk ratios(RR).Continuous outcomes were pooled using the inverse-variance mean difference(MD).Heterogeneity between studies was evaluated with I2 estimation and the Cochran Q test based on Chi-squared statistics.ResultsA total of six randomized trials with 1626 patients were included in this study.The overall diagnostic rate was similar in the VBNA(74.17 %)and NVBNA(69.51 %)groups,with risk ratio of 1.07(95% CI: 0.98 to 1.17;P=0.13).However,in the VBNA group,the total examination time was significantly shorter(MD=-3.94 minutes,95% CI:-6.57 to-1.36;P =0.003)than NVBNA group.VBNA had superior diagnostic yield than NVBNA for PPLs ≤ 20 mm(RR = 1.18,95% CI: 1.05 to 1.32;P = 0.005).In addition,diagnostic yield according to nature of lesion(RR= 1.06,95%CI: 0.97 to 1.17;P=0.21),lesion location in the lung lobe(RR= 1.06,95%CI: 0.99 to 1.14;P=0.10),distance from the hilum(RR= 1.05,95% CI:0.91 to 1.21;P=0.50),bronchus sign(RR= 1.07,95% CI: 0.93 to 1.24;P=0.33),and complications(RR= 0.42,95% CI: 0.42 to 1.67;P=0.62)were similar between VBNA and NVBNA groups.ConclusionVBNA bronchoscopy did not increase overall diagnostic yield in patients with PPLs compared with NVBNA bronchoscopy.The superiority of VBNA over NVBNA was evident among patients with PPLs ≤ 20 mm.No significant difference was seen in the incidence of complications between VBNA and NVBNA group.Future multicenter randomized controlled trials are needed for further investigation.