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Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and today we're discussing robotic bronchoscopy at UAB Medicine. Joining me is Dr. Hitesh Batra, he's an Associate Professor of Medicine, the Director of Interventional Pulmonology and Pleural Disease Program. He's also the Director of the Interventional Pulmonology Fellowship in the Division of Pulmonary, Allergy and Critical Care Medicine at UAB Medicine.

Dr. Batra, it's a pleasure to have you join us again. It's been a while since you've been on the podcast with us. So, tell us a little bit about traditional bronchoscopy and this has been the gold standard. Yes? Tell us a little bit about the difference now and what were some of the limitations that you can identify?

Hitesh Batra, MD (Guest): Yes, the robotic bronchoscopy systems are definitely a significant leap forward in improving our diagnostic yields for patients who have lung nodules. Before this, we have had a couple of systems that were being used in the market. And there were more than two, but two had the most market share.

One was made by the Veran Technologies that has been taken over by Olympus now, and another one was Super D System. Both of these use electromagnetic navigation. And the idea was that they used another bronchoscope and then this system was in addition to using a traditional bronchoscope. Now with robotic bronchoscopy system, one big difference, which is obvious somewhat, is the ergonomics. We are no longer holding the bronchoscope in our hand, it's the robotic arm that's driving their bronchoscope back and forth and in different directions. And we are just controlling that on a console. There are a couple of systems in the market. One is made by Intuitive and the other system is called the Monarch System, made my Auris, which has been acquired by Johnson & Johnson now. One big thing, as I was saying, is the ergonomics of this, but really the other big thing is that these systems have improved our ability to reach nodules in the lung and improve our diagnostic yield significantly.

Host: That's so exciting for your field right now, Dr. Batra. And as I understand it, UAB Medicine is the first in the state to use robotic bronchoscopy. So tell us, what you've seen as far as outcomes, how it's changed the landscape for detection of lung nodules and the rationale at UAB for developing new bronchoscopy platforms for this particular procedure.

Dr. Batra: Right. We are the first in the state to use this particular system made by Intuitive called the Ion, Robotic Bronchoscopy System. And I have to say, I have been pleasantly surprised. Like most of my colleagues around the country, I was skeptical before I used it. And I had expected an increase in yield by maybe five to 10%.

But, we are still early in the use of these systems and the data out there is limited. There's only a couple of studies out there reporting what people are seeing in practice in terms of yield. But there's definitely been a considerable improvement in diagnostic yield with these systems. In our own experience, we are more than 90%.

We are only three months into the use of the system at this point. But we are making a diagnosis more than 90% of the time, which is significantly higher than an average of 70 to 75 or 80%, depending on the way we look at the data. So that's one big thing. Why is this important? It's important because we are diagnosing a lot more lung nodules these days and let me backup from that and talk about the big landscape of lung cancer. The survival for lung cancer is slowly improving. It was only about 17% or so a few years ago, and now it has increased to a national average about 23%, the highest being in Connecticut, approaching close to 28%, while Alabama, where we are, our survival actually is the lowest in the country. So, how do we get this better? And why is this improving? The way we get survival for lung cancer better is number one to help people stop smoking. But the other is to find these lung cancers early. If we find these lung cancers early, we can diagnose them and treat them and potentially cure them by doing surgery. So we need to screen more people. We need to screen all the high-risk people. And recently USPTF changed their guidelines for screening and broadened the eligibility criteria, where now people who have smoked 20 pack years and are between the age of 50 to 80, can now get screening. And so as we are broadening the people who are eligible for screening and as we are slowly increasing the screening rates, we are finding more and more of these lung nodules. And when we see a nodule in the lung, it's really hard to really be able to tell right now whether that is cancer or not.

And the way we do, way we can find out, is to biopsy it. So, if we can effectively biopsy these nodules, we can establish whether or not these are cancer or not. And then we can either establish a benign diagnosis or find out it's cancer and then help the patient get curative surgery. So there are a lot of moving parts to improve survival in lung cancer. And this is a small part of it, but this is a very important part that can help improve the overall survival for lung cancer.

Host: Fascinating. So will you tell us a little bit, you mentioned that it's ergonomically better for physicians. Will you tell us a little bit more Dr. Batra about how it works? It combines this built-in visualization capability with its own inter-operative CT scanner, right? With this extremely detailed 3D image of the patient's nodule. That's amazing. Can you tell us a little bit about how it actually works?

Dr. Batra: Yes. The ergonomic part is because in the previously used systems that are still in the market, we have to hold the bronchoscope in our hand. And then put another instrument through the bronchoscope. So, the problem with that is you have to hold it and really twist it around. And it makes it difficult to reach some locations because we have to use our own hands and it has its limit to how much we can rotate it.

And also the bronchoscopes themselves had a limited or less range of motion compared to these catheters that we have now. Because now we just attach this system to the endotracheal tube that is inside the patient and we control the, these systems from a console. So therefore it's ergonomically better.

The way it works is it's very fascinating. The Monarch System actually is still uses electromagnetic fields, similar to the previous systems. The Intuitive System uses a shape sensing fiber. So there is a fiber all along the length of the catheter and in space as we move the catheter, this whole fiber has thousands of sensors all along it.

So as we are moving this catheter inside the patient's lung, based on the spatial relationship between these sensors along the fiber, the system knows exactly where the entire catheter is, what shape it is and exactly where the tip is, where all of it is. So, it's really fascinating technology that has not been used in previous systems.

Now you brought up the question of intraoperative CT, and that's the exciting thing that is about to happen, that we have not done that yet, is to use intra-operative imaging at the same time as we are doing the system. Now we are getting excellent results with this. We are making diagnosis with more than 90% of the time.

And this has really improved our diagnostic yield, but yet there's a small proportion of patients, we still are not able to get the answer. The reason for that is that even though these systems are really good, they are relying upon the information we feed into them, which is based on the CT scan that is done before the procedure.

Now, when we put the patient to sleep, there's a lot of things that happen. There's a lot of motion that can happen. The patients are breathing. There, there can be a little bit of lung collapse because of different way the patients are breathing and this can lead to movement in our target. Now, what we will be able to do very soon at UAB is to do a CT scan during the procedure to know exactly where our instruments are and how we need to adjust them.

And that will be another game changer that will really drive us home. And we will know exactly where we are every time. The other thing, this is very important for, and this would really set the stage for lung cancer ablation, for bronchoscopic ablation. That means when we know exactly where we are, we can put instruments within the bronchoscope to be able to treat these tumors. There are a few that are being studied, microwave ablation, radiofrequency ablation, and we need to be able to know accurately exactly where we are. So once we have the CT imaging, not only can we diagnose the patient, we can also stage. We are already doing that, but now we will also be able to treat at the same time. And that will really change the landscape of treatment options for some of these patients.

Host: That's so cool, Dr. Batra, and I hope that once you get the CT scanner and it's all set, you'll come back on and tell us about some of the outcomes and what you're seeing. Before we get ready to wrap up, you're speaking to other providers. Is this a difficult learning curve? If other providers are looking to use and start to employ robotic bronchoscopy, what do you think is some of the most important information you'd like them to know?

And you would say, you know what if I started at once again, I would do this, or I would look at doing it this way. Any technical considerations that you think would be important for others to know?

Dr. Batra: Yes, Melanie. Great question. There is a learning curve to it, just like any other new procedure. But I would say it's actually much easier than some of the other systems I've used before. The software that they use, the path that it tells you to take to get to the nodule. Those are usually very accurate, perform really well.

The planning software that we use before the procedure to plan, what we are going to do is very easy to use. So I think that, of course there's a learning curve to it and we haven't assessed how many procedures it takes to get competence in it, yet. We will do that at a future point, but I think this is definitely easier to learn than some of the other systems.

The other thing that I feel sometimes, we have seen a similar concern in the surgical world where, some of the physicians who may be older or who may not have experience with video games, feel like, hey, I can't do this. I may not be able to learn it. And we've seen that, that's not necessarily true.

It's less about prior experience and more about your spatial orientation. And you know, if you're a pulmonologist and if you have the skills to do bronchoscopy, learning this is very easy. This is not a hard thing to learn.

Host: I'm so glad that you pointed that out. And as we wrap up, best bit of information, best advice, what you would like other providers to take away, the key message about robotic bronchoscopy at UAB Medicine and why you think it's important to refer to the specialists at UAB.

Dr. Batra: Yeah. So I, I think number one, a key message about this, I would say is we've had a bunch of different technologies over the years and some improvements that have happened and there has been incremental benefit in each of those in the past few years, but this is a big step forward. So, I think the improvement in our ability to reach some of these nodules, to diagnose some of these nodules has significantly increased.

I would say we are only in our first three months and just a month ago I biopsied a very small, six millimeter ground-glass nodule. In fact, I biopsied three nodules in that patient, that were all less than one centimeter and I was able to get a diagnosis in all of them. That's the kind of thing that I was never able to do with the previous systems. So there's definitely an advantage here. I would say that it's important to refer your patients to a center that is a Center of Excellence and has a lot of experience with handling lung cancer patients so that your patients have all of the available options, not just for establishing diagnosis, but also all the available options for treatment, including clinical trials, which I believe are standard of care. I think it's the standard of care to be offering our patients with cancer, all the available clinical trials, which we do a lot of at UAB at our cancer center.

Host: You certainly do. And with an excellent multidisciplinary approach as well. Dr. Batra, thank you so much for joining us today and telling us about robotic bronchoscopy. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST or by visiting our website at UABmedicine.org/physician.

That concludes this episode of UAB Med Cast. Please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.