Amanda Wilde (Host): This is Hello Healthy, a Dignity Health Podcast. I'm Amanda Wilde. Early detection is critical in lung cancer treatment and advances in technology have created more and better tools to increase the chances of detecting lung cancer early when it is most treatable. Dr. Sunit Patel explains a minimally invasive robotic-assisted procedure that is a revolutionary advancement in the field of lung nodule evaluation. Dr. Sunit Patel is Medical Director of the Respiratory Therapy Department at Mercy Medical Hospital and the Merced California Sleep Center. Dr. Patel, welcome. So glad you could be here today.

Sunit Patel, MD: Thank you for the introduction.

Host: There have been some really amazing advancements in your field, but let's start by defining what a lung nodule is. Can you define that in simple terms?

Sunit Patel, MD: A lung nodule is a small rounded density or a spot which is detected on a chest x-ray or a CAT scan. It is surrounded by normal lung tissue. It's less than 3 centimeters.

Host: And what does it mean when someone is told they have a lung nodule?

Sunit Patel, MD: A spot in the lung can be cancer or malignant, or it can be a benign nodule. So, cancers can be a primary lung cancer where the origin is from the lung, or it can be metastatic, which means a cancer from somewhere else like breast, prostate, stomach can go to the lung, so it's a metastatic lesion.

There can be other benign conditions, which can be chronic infections like valley fever, which is very common in Central California and Merced. It can be from mycobacterial infections like TB. It can be vascular lesions, which are called AVMs, which is a vascular or a blood vessel malformation, which can mimic a nodule. It can be inflammatory, which is inflammation from autoimmune conditions. It can be sarcoidosis. There are conditions like vasculitis. Even rheumatoid arthritis can give nodules.

Host: So, it could be a number of things. When a lung nodule is discovered, what are the initial steps to evaluate it? What tools do you use to assess a lung nodule?

Sunit Patel, MD: If it's detected on the chest x-ray, the most common imaging modality that we use is a CT of the chest, which gives us more definition about the lesion or the nodule. So, it gives us the characteristics-- how big it is exactly; what the borders, whether they are smooth or rough or spiculated; whether there is calcium in there; whether it's cavitating or breaking down. So, it gives us more information and gives us the exact location.

In addition, there is PET scan. PET scan is a scan where we inject a radionuclide material, a lot, which is tagged onto glucose. Cancer cells multiply, so they need glucose to multiply. So, they hold onto this molecule. And when they take subsequent pictures, it lights up. And we look at the activity, whether it's really lighting up very brightly or very dimly or low light. And there is a score we use of around 2.5. If it's below that, majority of the lesions are benign. If it's higher than that, then 90-95% of the time and more active it is, or the more it lights up, the more chances of cancer. So, it helps us to determine the likelihood of cancer before a biopsy or tissue is obtained.

We then recommend a biopsy, not in all cases, but if our suspicion is high for cancer or certain types of infection, and based on other things that we look at, sometimes we do blood tests also for rheumatoid arthritis. There are blood panels like rheumatoid factor and something called CCP. For vasculitis, there is something called ANCA. For valley fever or coccidioidomycosis, which is the other medical name for that, there are blood tests called cocci serology. And for TB, there is QuantiFERON-TB Gold. If the diagnosis is uncertain and if the chances of cancer are high, then it requires a tissue diagnosis or a biopsy. Then, the other biopsy procedures come in, which can be regular conventional bronchoscopy. It can be CT-guided biopsy, or it can be the newer technique that we are going to talk about.

Host: Are there advantages and disadvantages to each of those approaches?

Sunit Patel, MD: So when we are trying to obtain tissue with a regular or a conventional bronchoscope, it's kind of going through into the lungs. When we go into the lungs, it's called bronchoscopy because you have the trachea and it divides into different smaller tubes. It's like looking at a river with tributaries. So, we go into these. As we go distally, that gets smaller and smaller, but we can't see through the lungs or through the tube.

 For conventional bronchoscopy, only if the lesion is within the bronchial tubes can we look at it directly and biopsy it. So, going to the periphery through those bifurcations or divergence, it can be difficult, because the tip angulation or how it curves is not as much as some of the newer techniques.

So, the other procedure that is commonly used to diagnose a lung nodule is a CT-guided biopsy. So, you do a CAT scan, locate the lesion. And if they are peripheral and a good size, then we would do this procedure where we put a needle between the ribs into the nodule and take a biopsy. The downside of this is at the risk of pneumothorax, which is leakage of air from the lung. A lung is like a balloon. So if you put the needle through the periphery of the lung, it can puncture and leak out air and can collapse that lung. So, incidence of the lung puncture on pneumothorax is high with the CT-guided biopsy. Hence, we prefer to do minimally invasive procedures like the robotic ion bronchoscopy.

Host: Let's talk about the robotic ion bronchoscopy. What exactly is this technology and what makes it revolutionary?

Sunit Patel, MD: It's state-of-the-art robotic technology made by the same company that invented the da Vinci robotic surgical equipment, which has been in use all around the world. It uses a very modern technology called shape-sensing technology in the catheter and is minimally invasive. Using a robotic arm, we can reach the periphery of the airway just like a navigation system in the car. We mark the nodule, and it navigates you to the periphery of the nodule in a safe, shortest time.

Host: And what are the primary benefits of using robotic ion bronchoscopy for patients compared to the traditional bronchoscopies? You were just mentioning the CT-guided needle biopsy, for example?

Sunit Patel, MD: It is safer, it's quicker. The incidence of the leakage of air or pneumothorax, lung collapse is much less. Incidence of bleeding is less. The recovery time is minimal. It's a minimally invasive procedure done using this new technology called the shape-sensing technology where the catheter detects the shape of the whole catheter or tube, almost a hundred times a second. And that way, it creates stability when we approach the lung nodule. And the navigation is done through a robot and its software. So, the biopsy procedure is very safe. The recovery times are minimal. It's a come-and-go procedure. So usually, the patient is in the hospital for maybe three, four hours and they go home.

The other advantage to that is we can, at the same time, do washings to get samples for cultures, which a CT-guided biopsy cannot do. Unlike other surgical procedures for taking a lung nodule out, which is a thoracic surgery where it's under video-assisted thoracoscopy unit, they have to make incisions on the chest wall and then operate. They go under anesthesia, and then usually have to stay in the hospital for at least two to four days.

Host: How do you use the ion system's precision to ensure that tissue for the biopsy is collected from the most relevant areas?

Sunit Patel, MD: First is we load the CAT scan pictures onto the robotic software, mark the nodule that we are going to biopsy, just like a navigation system in the car where we put the address in. And the software then creates a pathway for the bronchoscope to go to the nodule in the safest way, avoiding blood vessels. This software can detect blood vessels and the airway. So, it's overlapping those CAT scan pictures onto the robotic software and creates this pathway.

Once that is done, which is called the planning, then that data is moved on to the robotic driver. And we use an ultrathin catheter, which has the shape-changing technology that will create that path. And through that catheter, we also put a vision scope so that we can have a live view of the bronchial tree as well as the robotic component. And using the robotic component, we go through the trachea, into the peripheral bronchi in a precise way. And the shape-sensing creates a very stable image. And it keeps the catheter tip right at the nodule. Though when we are breathing, the lung is moving, but the catheter remains stable at the periphery of the nodule. It also gives us the distance from the periphery of the lung or the pleura, the lining of the lung. It gives us the proximal end of the nodule as well as the distal end, so we know exactly where to put the biopsy forceps, whether it's one centimeter, two centimeter, half a centimeter, it can go up to three centimeters length with the biopsy, forceps, or needle.

So through this, one is we can do a needle aspiration. It's called transbronchial needle aspiration. Then, we can do a forceps biopsy. It's a biopsy forceps that has the alligator mouth forceps so we can get a small piece. But more importantly, we can also do something called cryobiopsy, where the tip of that biopsy forceps has a cooling component. So, it freezes the tissue, and it gives us a much bigger piece as well as, because it's freezing it, it coagulates the blood vessels, so the chances of bleeding are less. So, this is all that we do when we are performing the robotic ion bronchoscopy.

Host: And all of that increases diagnostic accuracy.

Sunit Patel, MD: Definitely. It not only increases diagnostic accuracy up to 90% almost. And at the same time, it's safer because the incidence of pneumothorax or leakage of air, lung collapse, and bleeding are much less. Any side effects are very minimal. Recovery time is minimal. So, those are the big advantages, and it gives us confidence that we are right within the nodule when we are doing it. It's not a blind procedure.

Host: Mercy Medical Center is leading the way in lung cancer detection with this new technology, and it seems like a giant leap forward. What have you seen this means for patients in terms of access and quality of care?

Sunit Patel, MD: So, Mercy Hospital's fight against lung cancer started with having the Mercy Cancer Center, which has been around for several years and doing a very good job for the community. Then, we have the lung cancer screening program at the hospital as well as in the community, where people who have more than 20 pack years of smoking and are between the ages of 50 and 80 would qualify for this. So, they get yearly CAT scans, and we detect a lot of lung nodules.

So, having a robotic ion system is like a bridge. We screen the patients, we have the nodule, we have the cancer center. But if we can make the diagnosis of these nodules and detect cancer early, it's good for the patients, their families, and the community. The indirect advantage for detecting cancer early is you pick it up in the early stages, like stage I and II simplistically, then they can be operable. If it's more advanced, then they go to the cancer center for the chemotherapy or radiation. So, it creates a continuum of care from screening, diagnosis and treatment.

And if it's done locally without the need of a tertiary care center and we detect cancer early, that improves the quality of care. And also, studies have shown that if lung cancer is diagnosed at a later stage of life, the cost of care is very high. So, detecting cancer early will reduce the cost of care, and that all translates into improving quality of care and making our patients and their families happier.

Host: For our listeners who might have discovered a lung nodule or who have a family history of lung conditions, what advice would you give them regarding understanding their diagnosis and treatment options, especially in light of these new technologies like the robotic ion bronchoscopy?

Sunit Patel, MD: A lung nodule should not be taken lightly. However, they need to understand that majority of lung nodules are benign. A small percentage of them are malignant. But some of these other benign conditions can also be treated like valley fever, TB, rheumatoid arthritis, which can cause nodules or sarcoid.

So, it's not like we are just detecting cancer, but detecting cancer early is important. So if a patient has been told that they have a nodule on their chest x-ray or CAT scan, sometimes the CAT scan can note a lower lung nodule when a CT of the abdomen or CAT scan of the abdomen is done, and then we don't know whether there are any other nodules in the mid and upper lungs. So, talk to your primary care physicians about this. Maybe get a referral to a pulmonologist or any other lung specialist or surgeon so they can then guide the flow of care, whether it needs just observation, whether it needs a PET scan, whether it needs some other blood tests, and finally, a biopsy so we are not delaying care whether it's benign or malignant nodule. And particularly in the case of lung cancer, which among all cancers the U.S., has the highest mortality or death rate. So, the earlier we diagnose, the better it is.

Host: Yeah. The reason lung cancer has the highest cancer death rate in the world, I imagine, is because it's usually discovered quite late, and we're talking about these new techniques to discover it early, so that should make anyone dealing with this feel much more hopeful.

Sunit Patel, MD: That's right. Lung cancer is, you know, a lot of times detected in the latest stages. Most cancers are classified into four grades, stage I, II, III, IV. So, even waiting for a diagnosis delayed by three months can upstage lung cancer. So from stage II, it can go to stage III. If it was stage III at the time it was detected and we delayed by three months or 120 days, it can be upstaged. So, early diagnosis is the key in any cancer, but particularly lung cancer.

Host: Well, I hope you see the mortality rates keep going down with this new technology. Dr. Patel, thank you for your expertise and sharing your insights on detecting lung cancer using the ion bronchoscopy for more successful outcomes.

Sunit Patel, MD: Thank you.

Host: That was Dr. Sunit Patel, Medical Director, Respiratory Therapy Department, Mercy Medical Hospital, and Merced California Sleep Center. For more information, go to dignityhealth.org/mercycancer. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. This is Hello Healthy, a Dignity Health podcast. Thanks for listening.