Endoluminal visualization of distal airway abnormalities within a ground-glass opacity during robotic-assisted bronchoscopy

A 62-year-old never-smoking woman was referred for robotic-assisted bronchoscopy to evaluate a 2.9-cm pure ground-glass opacity (GGO) in the left upper lobe, incidentally detected on chest radiography and confirmed by high-resolution computed tomography (HRCT). Follow-up HRCT performed 4 months later showed no interval change in lesion size or attenuation.

Robotic-assisted bronchoscopy was performed using the iON platform (Intuitive Surgical). A high-definition, miniaturized 1.3-mm video probe (Iriscope; Lys Medical) was advanced toward the target through its dedicated 2.0-mm outer diameter delivery catheter, which incorporates a port for saline or air instillation to maintain lens visualization. Following navigation to the target segment with the robotic bronchoscope, the probe-catheter assembly was advanced distally toward the target lesion, with positioning within the GGO confirmed using cone-beam CT (Artis Pheno; Siemens) (Figure 1A-D). Endoluminal imaging revealed diffuse abnormal mucosal irregularities of the distal airways within the target region (Figure 1E-F; Video E1 in the online supplement). The probe was withdrawn, and multiple forceps biopsy were obtained through the guide sheath under fluoroscopic guidance. Histopathological examination of bronchoscopic specimens demonstrated adenocarcinoma with predominant lepidic growth. The patient subsequently underwent left upper trisegmentectomy, which confirmed minimally invasive adenocarcinoma, defined by a predominantly lepidic pattern with an invasive component measuring ≤ 5 mm (Figure 2).

Figure 1.

Cone-beam computed tomography images confirming correct positioning of the Iriscope video probe within the ground-glass opacity in sagittal (A), axial (B), and coronal (C-D) planes. High-definition endoluminal images obtained with the Iriscope demonstrate diffuse mucosal ­irregularities of the distal airways within the target region (E-F).

Figure 2.

(A) Low-power photomicrograph of the left upper trisegmentectomy specimen showing a minimally invasive adenocarcinoma with a predominant lepidic growth pattern (star) and a focal invasive component (center). A hemorrhagic area with surrounding fibrosis, consistent with the prior biopsy site, is also visible (arrowhead). Hematoxylin and eosin (H&E) stain; original magnification × 4. (B) Higher-power inset showing nonmucinous acinar adenocarcinoma glands infiltrating a sclero-elastotic stroma. H&E stain; original magnification × 80.

This case illustrates the endoscopic evaluation of a large pure GGO and demonstrates that distal airway abnormalities within GGOs can be directly visualized in vivo using high-definition endoscopic video probes.^1,2

Author contributions

Conception and design: R.T. Acquisition of the data: R.T., E.A., A.C. Drafting of the manuscript: R.T., E.A. Revision of the manuscript: E.A., F.L., A.C., S.L.

Supplementary material

Supplementary material is available at American Journal of Respiratory and Critical Care Medicine online.

Conflicts of interest

Edoardo Amante, Alessandra Cancellieri, Qianqian Zhang have no conflicts of interest to declare. Filippo Lococo received honoraria for lectures or advisory board participation from Roche, AstraZeneca, Pfizer, and Merck. Samy Lachkar received honoraria for lectures or advisory board participation from Olympus, Lys Medical, Bronchus, Fujifilm, and Ambu. Rocco Trisolini received honoraria for lectures, consultation or advisory board participation from Olympus, Pentax, Mediglobe, Lys Medical, Erbe, Eli Lilly, AstraZeneca, Merck, and Amgen.

Funding

The present manuscript did not have any source of support, and the images have not been previously published.

Data availability

This article has an online data supplement, which is accessible from this issue’s table of content online at www.atsjournals.org.