A robotic arm guides physicians in performing a lung biopsy — and might be key in diagnosing lung cancer earlier

In a surgical suite at Barnes-Jewish Hospital, a robotic arm snakes an ultra-thin, ultra-flexible tube through a patient’s airway. Once the tube reaches the lungs, the surgeon operating the device remotely uses a tiny camera to search the area for an abnormal growth, or nodule, that might be cancerous. Once located, a needle pierces the nodule for biopsy. 

“It looks very futuristic,” says Emily Thomson, clinical program manager for robotic surgery at Barnes-Jewish Hospital. The giant C-shaped device uses a robotic arm to view the inside of a patient’s airway and lungs, a procedure known as a bronchoscopy. This new technology is helping interventional pulmonology and radiology teams reach further than they ever have before in the fight against lung cancer. On May 1, Barnes-Jewish Hospital became the first hospital in the St. Louis region to use robotic technology to aid lung biopsies, allowing physicians to improve precision and efficiency in collecting lung tissue samples from patients. 

Fighting a deadly disease

Lung cancer is one of the deadliest cancers in the world, with an overall five-year survival rate of just 25%. The reason, according to Nathaniel Moulton, MD, a Washington University pulmonologist at Barnes-Jewish Hospital, is delayed diagnosis. Lung cancer symptoms include coughing, chest pain and shortness of breath, but patients often don’t present with them in the disease’s early stages. 

Providers are working to increase regular screenings for those most at risk of lung cancer: The American Lung Association recommends an annual low-dose CT scan for people ages 50-80 who smoke, or who have quit within the past 15 years, and who have smoked the equivalent of one pack of cigarettes per day over the past 20 years, or two packs per day over the past 10 years. But screening rates are still low, and potential malignancies seen during scans are often too small or too far into the periphery of the lung to be reached by a traditional biopsy. Many patients are left waiting until the nodule becomes large enough to sample and diagnose—and by that time, it might have spread beyond the lung. 

“Most patients are diagnosed with lung cancer after it’s advanced, meaning there’s lymph node involvement or it’s spread to other parts of the body,” Moulton says. “Even as lung cancer screenings increase, we’re talking about very small nodules. And not every nodule represents cancer. You need a sample, and that’s the challenge we’ve had in the past.”

A team effort

Typically, bronchoscopies are done using a camera inserted through the mouth via a breathing tube and into the lung, where physicians work to get a view of a nodule and then sample it using a small needle. This procedure, if done without robotic assistance, relies entirely on the coordination and experience of the physician. During robotic-assisted procedures, the robotic arm anchors the scope, enabling more precise images of the lungs to be captured so the team has more detailed information to help find and sample nodules in the lung’s periphery. 

“The physicians upload the map of the lung to the system,” says Susan Morrison, operating room registered nurse. “If the preferred route is not possible, the system can calculate alternate paths to get to the target.” 

This planned procedure requires multidisciplinary collaboration from a small army of health care professionals. A dedicated chest CT scan performed by radiologists provides imaging, which is then uploaded by the bronchoscopist to plan the procedure. Nurses and respiratory therapists assist with setup and handle needed instruments and are the primary providers of care before and after the procedure. Additionally, anesthesiologists sedate and monitor the patient, pulmonologists and surgeons guide the arm, and lab technicians process biopsied tissues. The procedure typically lasts 40-50 minutes. It is done on an outpatient basis; patients are under general anesthesia during the procedure and usually go home the same day. 

The procedure is expanding throughout BJC and is now also available at Barnes-Jewish St. Peters Hospital.

New hope through earlier diagnosis 

Moulton says the device may be a good option for some patients who have nodules that are very small or hard to reach without robotic assistance. Smaller nodules, if cancerous, are often an earlier stage lung cancer and easier to treat.  

“If we can diagnose patients at stage 1 lung cancer, the survival rate with treatment is excellent,” Moulton said. 

Alexander Chen, MD, a Washington University pulmonologist at Barnes-Jewish Hospital and director of the interventional pulmonology center, said that Barnes-Jewish Hospital was able to become the first in the region to offer this procedure because its large and multidisciplinary team has the expertise and focus on patient’s individual needs. 

“We’ve done clinical trials into utilization of this technology,” he says. “We have more experience than anyone, and we are continuing clinical investigations so we use this in the right way and every patient has an experience that’s tailored to them.” 

Thomson says the robot used in the bronchoscopy has additional applications, including dye marking to tag nodules for easier removal. 

In the meantime, Moulton encourages anyone who may be at risk for lung cancer to get screened, knowing that Barnes-Jewish has the resources to help them through any next steps.

Lung cancer screening eligibility

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