Improving Lung Cancer Diagnoses with Navigational Bronchoscopy

by John F. Lazar, MD, Thoracic Surgery, Jessica S. Wang Memoli, MD, Pulmonology
November 18, 2020

Editor’s Note: The photo above was taken prior to the COVID-19 pandemic.

In the U.S. and around the world, lung cancer is the leading cause of cancer deaths for both men and women, killing 1.7 million people each year. According to the American Lung Association, the five-year survival rate for lung cancer is lower than many other cancers, at just 18.6 percent. Over half of those diagnosed die within a year. (By comparison, the five-year survival rate for colorectal cancer is 64.5%; breast cancer, 89.6%; and prostate cancer, 98.2%.)

Early detection is key. If this cancer is found while still localized within the lungs, the five-year survival rate jumps to 56%. Unfortunately, only 16% of lung cancers are discovered at that stage.

But MedStar Washington Hospital Center now has the opportunity to improve these grim statistics and save lives by using the Auris MonarchTM Platform, a revolutionary robotic navigational bronchoscopy tool.

Dr. John Lazar: Before robotics became more mainstream in thoracic surgery, we depended on CT-guided biopsy to help us analyze nodules—small, abnormal growths in the lung. The CT guides a radiologist to the target area for a needle biopsy, with the tissue then analyzed outside the body.

Now, using this robotic navigation bronchoscopy technology, we’ve taken a big step toward enhanced accuracy, greater precision, increased safety and the ability to make definitive diagnoses. With the Monarch, CT scan data are loaded into the robot’s computer, giving us the equivalent of turn-by-turn GPS navigation deep into the lungs, where structures are very small and difficult to view via traditional methods. The robot lets us find lesions deeper into the bronchial tree and take tissue samples with unprecedented accuracy.

When cancer is suspected, we are now able to target even tiny lung nodules with greater accuracy and less risk to the patient. Learn more from Drs. Lazar & Wang Memoli. @jflazar @MedStarWHC via https://bit.ly/38E700j.
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Dr. Jessica Wang Memoli: It’s a great addition to our existing tool kit. Pulmonary nodules can be challenging. Early in the disease, they’re often too small to biopsy by traditional means, a lost opportunity for early diagnosis. With Monarch, we can go deeper to target and biopsy the tiniest nodules with a much greater degree of accuracy and less risk to the patient. That improved accuracy helps us better target potentially malignant growths for radiation oncology and other forms of treatment.

Among the First

Dr. Lazar: MedStar Washington Hospital Center was among the first hospitals on the East Coast to acquire this technology. We’ve had the Monarch for over a year and have helped many patients in that time.

Dr. Wang Memoli was doing a great job with traditional bronchoscopy and X-ray before Monarch, but developing our interventional thoracic program requires the most advanced technology. Working as a team to have this technology on-hand has strengthened the partnership between thoracic surgery and interventional pulmonology, benefiting patients who potentially face a lung cancer diagnosis.

Dr. Wang Memoli: We’re doing things we couldn’t have done with traditional methods, like sampling multiple nodules, on both sides of the lung, in one session. This technology has significantly improved interventional pulmonology and our approach to lung nodules.

Robotics for Greater Control

Dr. Lazar: Monarch is an endoscopic robot. For nodules, we first do a high-definition CT scan, with very thin “slices” of the lungs. We load that into the robot’s computer, creating a 3D virtual map of the complete airway pathway. We bring the patient into the bronchoscopy suite and administer anesthesia to put the patient to sleep. We do a traditional bronchoscopy to look for anything larger than a nodule.

Then, we register the patient’s unique anatomy to the robot. We operate the robot with a small console, very similar to a video game controller. We steer a thin tube with a tiny camera, light source and various instruments we use for biopsy directly to the site of the nodule.

Dr. Wang Memoli: Controlling direction is the key. The structure of the lungs is like a tree, with a large trunk dividing into thinner and thinner branches. Monarch reaches into the thin twigs, deep into the airway while still maintaining direct visualization. With other systems, electromagnetic guidance is the only input guiding our pathway. With the new system, we have multiple technologies—from the electromagnetic inputs, to the view of the actual airways, to integrated CT imaging and directional cues—all displayed on the monitor. To have constant visual contact with the target is new and very exciting.

Dr. Lazar: The reach is much broader, and the scope follows some amazing turns and bends to go where it needs to go. It’s real-time vision married to a sort of GPS algorithm.

Dr. Wang Memoli: The other big advantage is stability. The structures we target are very small, only fractions of an inch. Before, we controlled everything manually; when we reached the nodule with traditional bronchoscopy, my assistant and I had to hold the scope steady, which is difficult to maintain in human hands. Meanwhile, the patient is breathing normally, so the lungs are in motion. If either doctor or patient makes the slightest movement, we might lose the target and need to relocate.

But the robot knows where it is at all times. When it’s time to deploy an instrument for a tissue sample, we lock its position and it stays put, rock solid, while we biopsy the nodule.

Reducing Wait Time for Patients

Dr. Lazar: Monarch also supports our commitment to accelerate the whole process. Any potential cancer diagnosis creates a lot of anxiety and a sense of urgency for the patient and family. With traditional methods, we have a delay between biopsy and staging—determining how advanced the disease is. Monarch eliminates that delay: we can examine and stage in the same session. That goes a long way towards relieving the psychological burden on the patient when cancer is suspected.

Dr. Wang Memoli: Plus, we really want to start treatment as soon as possible. Doing biopsy and staging at the same time can eliminate weeks of wait time.

Dr. Lazar: That’s also a key motivation for the unique dynamic between interventional pulmonology and surgery at our hospital. Our collaborative, cooperative relationship also streamlines the process. We both get to know the patient early on and, with the relationship established, we can fast-track diagnosis and treatment as much as possible.

Dr. Wang Memoli: The collaborative approach also improves diagnosis. The whole team works as a unit, gaining experience with each procedure and anticipating each other’s needs. It’s truly a multidisciplinary commitment—the doctors and bronchoscopy tech working together with nursing, anesthesia, radiology and pathology.

Next Step: Treatment

Dr. Lazar: The Holy Grail for cancer is combining diagnosis, staging and treatment. With the Monarch, the first two steps are in place, and we’re heading down the path toward the third. In the future, the Monarch will likely deliver some form of ablation—focused heat or microwave energy to destroy tumors.

It will take some time, as any new procedure must be thoroughly vetted for safety, effectiveness and cost, compared to existing standards of surgery and radiation. But that day will come, maybe in just a few years. Imagine diagnosis, staging and treatment, all in half a day, on an outpatient basis.

Patient Safety in the Age of COVID-19

Dr. Wang Memoli: Cancer doesn’t wait, so we never stopped using the Monarch during the pandemic. Of course, patient safety is the top priority. We take every precaution to protect both patients and team members from infection of any kind, with masks, temperature checks and COVID-19 testing before a procedure.

Dr. Lazar: We’re committed to safety and giving our clinicians access to the best, most advanced tools possible. That’s why MedStar Health is often at the front of the line for new technology—this commitment is organization-wide.

Expanding the Footprint

Dr. Lazar: Although we’re using Monarch only for bronchoscopy, I firmly believe it will become a very valuable tool for other specialty areas, like gastroenterology, and it could possibly be used as an operating room assistant. I see enormous potential for this technology.

But, as important as the new tools are, success also depends on the people performing the procedures. Our team members are exceptionally talented and care deeply about their patients. And they are willing to collaborate at every opportunity for success.


Dr. Lazar and Dr. Wang Memoli discuss lung cancer on Facebook Live.

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Category: Healthy Living, Innovations     Tags: lung cancer diagnosislung cancer stagingnavigational bronchoscopypul-3qths-2q