Taylor Leddin McMaster (Host): Hello listeners, and thanks for tuning into the Well Within Reach podcast brought to you by Riverside Healthcare. I'm your host, Taylor Leddin McMaster and joining me today is Dr. Raju Abraham, who is a Pulmonologist with Riverside Medical Group.

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Host: Thanks for joining us today.

Raju Abraham, MD: Welcome.

Host: Can you tell us a little bit about your clinical background?

Raju Abraham, MD: Yeah. I've been here in Riverside Medical Center since 1996. And been practicing pulmonary critical care medicine in the community since then.

Host: Fantastic. I know you do a lot of work with the Ion system, so can you tell us what the Ion Endoluminal System is and how it's used in diagnosing or treating lung conditions?

Raju Abraham, MD: There have been a lot of advancements in bronchoscopy over the past few years. Initially, we had only regular bronchoscopy where the access to peripheral lesions was very limited. Then came the electromagnetic navigation bronchoscopy, which we had here, and that was able to improve the outcome in diagnosis by another 20% or so. So we would get an answer in about 60 to 70%, if you choose the case correctly. That was not good enough either. Then came robotic bronchoscopy. The robotic bronchoscopy is a very advanced system for reaching small and peripheral nodules, especially in the lung. So lesions that we would never even think of getting to, now we can get to those lesions. Why is that important? Because you can diagnose early cancers and also we can also find out if there is more than one cancer at the same time. What I have been finding is that we are getting sometimes two diagnosis on the same patient, with two nodules. Doesn't happen all the time, but does happen frequently enough to say that we need to be doing this more often than we ever thought of before.

Host: Yeah, that's really interesting. Can you walk us through what a typical Ion procedure looks like from a patient's perspective and a little bit about what they can expect before, during, and after the procedure?

Raju Abraham, MD: For a Ion Robotic Bronchoscopy, we need to have the CT scan of the chest done in a particular fashion. The cuts are much closer than the usual CAT scans. So at Riverside what we have is the radiology department makes the CT scan according to the Ion protocol. Once we do that, then we put it in a laptop computer, and see about making a pathway to that lesion so we know exactly what the roadmap is before we start the procedure. Ideally, the CT scan, we expect to be within one month of the procedure so that the anatomy hasn't changed or the things have been moved, or that there are no new lesions which have appeared since then. We then proceed to do the Ion bronchoscopy under general anesthesia because the patient should not be moving during the procedure. So they are under general anesthesia. We use a GPS system, which guides us to the lesion. And once we get to the lesion, we confirm the position by using ultrasound, which is a very accurate test to say that we are in the lesion if we see the right picture.

The other way we check it is we use something called a cone beam CT scan, which is a three-dimensional CT, which tells us where the catheter is in relation to the nodule, and then we can adjust the position of the catheter depending on the picture we see on the cone beam CT.

Host: Okay, so with the anesthesia and then also just the accuracy, that's typically the differences between a traditional guided CT?

Raju Abraham, MD: Yes. I think the traditional bronchoscopy used to be what, 40% success. The electromagnetic navigation went to around 60%. And with Ion Robotic Bronchoscopy, we can see is about 80 to 90%.

Host: Wow. Okay. And is this typically done in an outpatient setting?

Raju Abraham, MD: Yes. The usual procedure is done as an outpatient procedure. Patient goes to recovery room after the procedure, and once they're fully awake and alert, they can go home assuming that there are no complications. Complications can occur, such as bleeding or collapse of the lung. So these are very, very rare. So we hardly have to keep the patients after the procedure, they go home. Only if they have any complication, do we have to keep the patient, but that's very rare.

Host: Well, we're going to continue our conversation in a moment. We're going to take brief moment to talk about the importance of primary care. Consistency is being able to count on someone to be there when you need them. At Riverside Healthcare, your primary care provider is dedicated to being in your corner, helping you and your family stay healthy and thrive. Find the right primary care provider for you at myrhc.net/acceptingnew. From annual screenings to well checks and everything in between, having a primary care provider that you can trust makes all the difference. And we're back discussing Ion with Dr. Abraham. First, I'm curious, we talked about being done in an outpatient setting. How soon are they getting the results?

Raju Abraham, MD: The results usually take about anywhere from 24 to 72 hours.

Host: Okay.

Raju Abraham, MD: As long as there's no weekend in between.

Host: Gotcha. Okay. And we talked a little bit about this with the, with talking about CT methods, but what makes the Ion system different from traditional methods like a CT guided biopsy or bronchoscopy?

Raju Abraham, MD: That's a very good question because we used to do a lot of CT guided biopsies in the past because, as I said, before the robotic bronchoscopy, the regular bronchoscopy and the electromagnetic navigation bronchoscopy had a lot of situations where we didn't have an answer. So we did a lot of CT guided biopsy.

Now to talk about CT guided biopsy, the chance of a pneumothorax is about 20%, average. The yield is the same, you know, 80 to 90%, but the complication rate of a pneumothorax is much higher than the Ion robotic bronchoscopy. Now you can have a chest tube put in with a pneumothorax, but you don't really want to get into that situation.

So actually when we started wanting to do this, I was worried how the radiologists would take it. And when I spoke to radiology, because we are probably going to take away a lot of their procedures, and they told me they were very happy about it because that was one biopsy they didn't want to do. The lung. They didn't mind doing any other biopsies, but the lung biopsy put them under a lot of pressure because of potential for pneumothorax, and then having to treat that after that. So actually they went out of the way to help us get this started and going.

Host: So there's also a difference with the Ion procedure, eliminating a step in a process that comes with a CT guided biopsy. Can you tell us a little bit about that?

Raju Abraham, MD: Yes. So when you do a CT guided biopsy, then after that you have to stage the cancer if it's a lung cancer. Now, the old way of doing that would be a PET scan, and the PET scan will show activity and if it's active, then you say that that is tumor. But then subsequently studies showed that you can do endobronchial ultrasound bronchoscopy, which is more accurate than the PET CT in diagnosing small metastatic spread in the mediastinal lymph nodes. So now if the patient is diagnosed on a CT guided biopsy with a lung cancer, the patient will still need to have a PET scan and a endobronchial ultrasound bronchoscopy to stage it correctly. The advantage of the robotic bronchoscopy is that, since the patient is already under anesthesia, we do both at the same time. We do the robotic bronchoscopy and then proceed on to do the endobronchial ultrasound to look at the mediastinal lymph nodes and see if there's malignancy there. So it saves an extra procedure for the patient.

Host: So can you tell me who would be a good candidate for this type of procedure? And is it only for patients with suspected lung cancer? Can it help in other situations?

Raju Abraham, MD: Majority are going to be lung cancers, or it could be from another cancer. Like as I said, you have a patient who could have two disease processes in the same procedure. That is a surprising thing. I think the reason that's happening, this is my interpretation, is that I think we have much better oncology treatment options for patients with cancer. So unlike the situation where they didn't live very much in the past, they're living much longer.

So you're seeing new cancers coming up. Of course, the treatments are getting better, so the new cancers are also getting treated. Like, I had a patient who had been treated for uterine cancer and the patient was responding to that, but also had a history of a renal cell cancer, and there was a nodule in the lung, which was not responding. So that was the only spot that was not responding. So I ended up doing a biopsy on that spot. That turned out to be renal cell carcinoma metastasis.

So that makes a difference because you're treating the patient for one cancer and you have a different cancer. Now the oncologist has to focus on that one too. So that is where it makes a difference to know what you're treating.

Now, you may also have benign lesions. What I mean is infections. So sometimes we go in there, we find an infection rather than a cancer, which is presenting as a nodule. Then you can treat the infection. So it's not all cancer. There could be situations where we know that this is not cancer, but as an infection, such a fungal infection or something like that.

Host: Oh, interesting. Okay. How has technology changed the way that you and your team approach lung nodule evaluation and lung cancer diagnosis?

Raju Abraham, MD: What has changed is now that we can go after these smaller lesions, which we never would think about doing previously. The guidelines used to say that, wait three months for this type of nodule, wait six months for this type of nodule. But now my feeling is that those guidelines will change very soon from the people who make these guidelines nationally, because now with the robotic bronchoscopy, you can access these nodules and we are finding that we can get cancer diagnosed earlier when the prognosis is better than rather later. So I think this is going to open up a lot of new procedures.

So I can tell you I've done more robotic bronchoscopies in one year than I have done in a few years, just because of the fact that we are able to access them better.

Host: Wow, really interesting. For someone listening who might be facing a lung nodule or possible diagnosis, what would you want them to know about this option and when to ask their doctor about it?

Raju Abraham, MD: We have already talked to the oncologists who are very well aware of this. The radiologists are also aware of this, and the primary care physicians have been aware because we presented this at a retreat, so we have told them that the pulmonologists are available. That means everybody in the department is available. They need a robotic bronchoscopy and you just have to send them and then we can take care of it from there.

Host: Well, thank you so much for your time and expertise and thank you to the listeners for tuning into the Well Within Reach podcast brought to you by Riverside Healthcare. To learn more about Riverside, visit riversidehealthcare.org.