title: Improved targeting accuracy of lung tumor biopsies with scanning-beam digital x-ray tomosynthesis image guidance.
abstract: OBJECTIVE
  Electromagnetic navigation bronchoscopy (ENB) provides improved targeting accuracy during transbronchial biopsies of suspicious nodules. The greatest weakness of ENB-based guidance is the registration divergence that exists between the planning CT, acquired days or weeks before the intervention, and the patient on the table on the day of the intervention. Augmenting ENB guidance with real-time tomosynthesis imaging during the intervention could mitigate the divergence and further improve the yield of ENB-guided transbronchial biopsies. The real-time tomosynthesis prototype, the scanning-beam digital x-ray (SBDX) system, does not currently display images reconstructed by the iterative algorithm that was developed for this lung imaging application. A protocol using fiducial markers was therefore implemented to permit evaluation of potential improvements that would be provided by the SBDX system in a clinical setting.
  
  
  METHODS
  Ten 7 mm lesions (5 per side) were injected into the periphery of each of four preserved pig lungs. The lungs were then placed in a vacuum chamber that permitted simulation of realistic motion and deformation due to breathing. Standard clinical CT scans of the pig lung phantoms were acquired and reconstructed with isotropic resolution of 0.625 mm. Standard ENB-guided biopsy procedures including target identification, path planning, CT-to-lung registration and navigation to the lesion were carried out, and a fiducial marker was placed at the location at which a biopsy would have been acquired. The channel-to-target distance provided by the ENB system prior to fiducial placement was noted. The lung phantoms were then imaged using the SBDX system, and using high-resolution conebeam CT. The distance between the fiducial marker tip and the lesion was measured in SBDX images and in the gold-standard conebeam-CT images. The channel-to-target divergence predicted by the ENB system and measured in the SBDX images was compared to the gold standard to determine if improved targeting accuracy could be achieved using SBDX image guidance.
  
  
  RESULTS
  As expected, the ENB system showed poorer targeting accuracy for small peripheral nodules. Only 20 nodules of the 40 injected could be adequately reached using ENB guidance alone. The SBDX system was capable of visualizing these small lesions, and measured fiducial-to-target distances on SBDX agreed well with measurements in gold-standard conebeam-CT images (p = 0.0001). The correlation between gold-standard conebeam-CT distances and predicted fiducial-to-target distances provided by the ENB system was poor (p = 0.72), primarily due to inaccurate ENB CT-to-body registration and movement due to breathing.
  
  
  CONCLUSIONS
  The SBDX system permits visualization of small lung nodules, as well as accurate measurement of channel-to-target distances. Combined use of ENB with SBDX real-time image guidance could improve accuracy and yield of biopsies, particularly of those lesions located in the periphery of the lung.
authors.affiliation: Department of Radiology, Stanford University, Stanford, California 94305.
authors.forename: Geoff
authors.initials: G
authors.lastname: Nelson
authors.affiliation: Department of Radiology, Stanford University, Stanford, California 94305.
authors.forename: Meng
authors.initials: M
authors.lastname: Wu
authors.affiliation: Department of Radiology, Stanford University, Stanford, California 94305.
authors.forename: Cameron
authors.initials: C
authors.lastname: Hinkel
authors.affiliation: Palo Alto Medical Foundation, Department of Medicine, University of California San Francisco, San Francisco, California 94143.
authors.forename: Ganesh
authors.initials: G
authors.lastname: Krishna
authors.affiliation: Triple Ring Technologies, Inc., Newark, California 94560.
authors.forename: Tobias
authors.initials: T
authors.lastname: Funk
authors.affiliation: Department of Radiology, Stanford University, Stanford, California 94305.
authors.forename: Jarrett
authors.initials: J
authors.lastname: Rosenberg
authors.affiliation: Department of Radiology, Stanford University, Stanford, California 94305.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Fahrig
mesh_terms: D000818:Animals; D006801:Humans; D007091:Image Processing, Computer-Assisted; D061705:Image-Guided Biopsy / Q000379:methods*; D008175:Lung Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology*; D019047:Phantoms, Imaging; D011856:Radiographic Image Enhancement; D013552:Swine