Ion robotic bronchoscopy laser ablation and Da Vinci robotic segmentectomy for bilateral pulmonary nodules: a case report

Introduction

In excess of half of the patients identified with pulmonary ground-glass nodules (GGNs) present with multiple nodules (1). The clinical picture of patients with multiple pulmonary nodules is intricate, and achieving complete tumor excision via surgery often comes at the expense of substantial healthy pulmonary tissue. This approach poses a significant challenge in preserving lung function to the fullest extent, potentially compromising patients’ quality of life, with treatment complexity far surpassing that of solitary nodules (2). While precise surgical resection by thoracic surgery is considered a definitive treatment, it is not the most effective strategy for managing patients with multiple primary lung cancers when employing traditional surgical modalities designed for single pulmonary nodules (2). The emergence of novel techniques, such as navigational bronchoscopy, has paved the way for innovative airway intervention strategies (3). Subsequent studies have highlighted the efficacy of electromagnetic navigation bronchoscopy (ENB)-guided microwave ablation (MWA) in conjunction with video-assisted thoracoscopic surgery (VATS) as an alternative for treating multiple nodules (4). However, the utilization of robot bronchoscopy has demonstrated a marked enhancement in the localization of small GGNs, offering increased stability over ENB (5). Clinical trials in China have corroborated the robust diagnostic capabilities of the Ion robotic system (6). Currently, the Ion system is predominantly applied for biopsy diagnosis and localization, with no international reports documenting the integration of Ion for ablation procedures (7). We present the first case of a hybrid procedure combining Ion bronchoscopic robotic laser ablation with Da Vinci robotic surgery for the treatment of multiple pulmonary nodules, introducing a pioneering approach that integrates airway treatment with surgical intervention. The aim of the study is to provide a reference for experts in the field of pulmonary nodules based on our diagnostic and treatment experience. We present this case in accordance with the CARE reporting checklist (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-922/rc).

Case presentation

A 34-year-old female patient was initially diagnosed with multiple pulmonary nodules in August 2023 and has been undergoing regular follow-up since then (Figure 1A,1B). A chest computed tomography (CT) in September 2024 showed a mixed GGN (mGGN) in the S6 of the left lower lobe, measuring approximately 11 mm × 7 mm, indicating a high risk of malignancy; there was also a ground-glass opacity (GGO) between the S6 and S8 of the right lower lobe, measuring 5 mm × 4 mm. Both nodules had increased in size compared to the previous year (Figure 1C,1D). The multidisciplinary team (MDT) concluded that the left-sided lesion was considered to be a microinvasive adenocarcinoma or invasive adenocarcinoma, while the right-sided lesion was thought to be atypical adenomatous hyperplasia or adenocarcinoma in situ. Traditionally, the left would have been treated with a segmentectomy, and the right side would have been monitored. However, based on our MDT consensus, the right-sided lesion will also require treatment in the future, and it is located between segments S6 and S8, posing a significant challenge in protection of pulmonary function. To avoid the need for further invasive interventions, we collaboratively decided with the patient on this concurrent hybrid treatment approach. Using the ion robotic system to precisely reach the lesion along the B6b bronchus of the right lower lobe, the lung nodule ablated with a laser; subsequently, the Da Vinci robotic system used to assist in the precise resection of the S6.

Figure 1 Preoperative chest CT images of pulmonary nodules. (A) The patient detected the nodules situated between the S6 and S8 of the right lower lobe in August 2023 (as shown by green circle). (B) The patient detected the nodules situated in the S6 of the left lower lobe in August 2023 (as shown by green circle). (C) A chest CT in September 2024 showed a GGO between the S6 and S8 of the right lower lobe, measuring 5 mm × 4 mm (as shown by blue circle). (D) A chest CT in September 2024 showed a mGGN in the S6 of the left lower lobe, measuring approximately 11 mm × 7 mm, indicating a high risk of malignancy (as shown by blue circle). CT, computed tomography; GGO, ground-glass opacity; mGGN, mixed ground-glass nodule.

Preoperative thin-section (1.0 mm) chest CT data were imported into computer software (Ion Plan Manger) for the reconstruction of a three-dimensional (3D) model and designing of the approach to the target (Figure 2A). Under general anesthesia and with a single-lumen endotracheal tube, the patient was placed in a supine position and first underwent a flexible bronchoscopy to assess the patency of the airways, intrabronchial disease, and clear secretions. The shape-sensing robotic-assisted bronchoscopy arm was docked and connected to the endotracheal tube. The surgeon used a joystick controller to guide the robotic catheter towards the B6 bronchus. After reaching the target nodule, a cone-beam computed tomography (CB-CT) (Siemens Artis Zeego, Shanghai, China) scan was performed to confirm the position of the catheter tip in relation to the nodule. The catheter tip was adjusted to point towards the right lower lobe nodule, and a second CB-CT scan was conducted to confirm the positioning (Figure 2B). The fiberscope was removed, and a 23G flexible biopsy needle (Flexision^TM needle, Intuitive Fosun Medical Technology, Shanghai, China) was used to puncture the target through the working channel. The depth of the needle insertion was adjusted based on the CT imaging results to ensure that the biopsy needle was away from blood vessels and located within the inner side of the lesion (Figure 2C). The core of the biopsy needle was withdrawn, and a 0.4-mm laser guide wire (Medex Technology^TM, Jiangxi, China) was placed. Then make sure exposing the tip completely outside the catheter. A CB-CT confirmed that the laser wire tip was positioned above the nodule and away from blood vessels (Figure 2D). Ablation was performed at 3 watts for 30 seconds, and a CB-CT showed a decrease in density at the nodule site, but it was not fully covered. Another ablation at 3 watts for 30 seconds was administered, and a CB-CT revealed tissue vaporization with increased translucency, indicating that the ablation area had fully covered the nodule and exceeded 5 mm (Figure 2E). The patient was then switched to a double-lumen endotracheal tube, positioned in a right lateral decubitus position, and underwent a precise resection of the left lower posterior segment with the assistance of the Da Vinci robotic system. Pathology on the left side revealed adenocarcinoma; a chest CT one week postoperatively showed a 1-cm patch with a cavity at the ablation site (Figure 2F).

Figure 2 Ion robotic tracheoscope positioning laser ablation procedure. (A) Before the operation, plan the path leading to the target; (B) during the operation, scan to confirm the direction; (C) when the needle was inserted, the depth of needle insertion is adjusted according to the CT imaging results to ensure that the biopsy needle is away from blood vessels and located inside the lesion; (D) confirm by CB-CT that the laser wire tip is located above the nodule and away from blood vessels (as shown by red triangle); (E) after the laser ablation, the CB-CT showed that the tissue at the nodule site was gasified, the transmittance increased, and the ablation range completely covered the nodule (as shown by red circle; (F) chest CT at the ablation site one week after surgery (as shown by red circle). CT, computed tomography; CB-CT, cone beam computed tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

In recent years, multiple pulmonary nodules have become increasingly common in clinical practice. Theoretically, the removal of all pulmonary lesions in a single surgical procedure would provide the best oncological prognosis (1). However, to reduce the postoperative risks, medical centers have adopted strategies of first removing the primary lesion, followed by elective removal of secondary lesions at a later date, or monitoring these secondary lesions and performing surgery once they progress (2). Despite this, the downside of the aforementioned treatment approaches is that tumor progression may occur during the wait for further surgery and follow-up periods, leading to increased risk of disease progression in patients. In recent years, with the continuous innovation and development of surgical concepts and equipment, a “one-stop” diagnostic and treatment model for multiple primary early-stage lung cancers has gradually been formed, allowing for the treatment of multiple lesions in a single surgical procedure within a hybrid operating room. Currently, the primary applications of robotic bronchoscopy are focused on biopsy and localization. The exploration of its use in ablation procedures is still in its nascent stages, and it is expected to play a greater role in hybrid treatment models in the future (8).

According to the Fleischner Society guidelines, the management of multiple pulmonary nodules should be based on the most suspicious nodule (9). Consequently, before the advent of navigational bronchoscopy technology, it was preferred to advise conducting surveillance monitoring for the pulmonary nodule located in the right lung of this patient. However, other studies on multiple pulmonary nodules have observed that, in addition to the primary lesion, other nodules should also be treated, which further affects the prognosis (10). Current guidelines recommend that for patients with multiple GGO who cannot achieve complete resection, interventional ablation and other treatment modalities should be considered (11). However, this process usually requires surgeons who have experience in handling multiple nodules and a deep understanding of the complex anatomical localization of these nodules. The introduction of the Ion robotic bronchoscope has significantly shortened the learning curve for surgeons, and with its high stability and motion precision, it is considered easier to master than ENB (12). Therefore, considering the patient’s age, anxiety status, nodule location, follow-up situation, and emerging technologies, it was decided to treat bilateral lung lesions simultaneously: ablating the secondary right-sided nodule and surgically removing the primary left-sided nodule. Due to the deep location of the patient’s nodule, percutaneous puncture would require a longer needle path, increasing the risk of pneumothorax and bleeding. Therefore, endobronchial ablation was chosen to shorten the puncture path and thereby reduce the associated risks. At the same time, considering the nodule’s proximity to blood vessels, to minimize potential damage to the vessels from ablation heat, the planning path selected the upper edge of the nodule, far from the vessels, as the target point, ensuring that the ablation range could completely cover the nodule.

Currently, ablation methods for nodules include cryoablation, MWA, radiofrequency ablation, and laser ablation, among others. However, the current cryoablation, MWA, and radiofrequency ablation tools may not easily and precisely reach the target lesion through robotic bronchoscopy. Therefore, a thinner, more flexible laser guide wire was chosen for ablation to ensure the effectiveness and safety of the treatment. On the other hand, the fiber optic probe, made of quartz material, can be clearly visualized under CB-CT. During the procedure, it was found that the relative position of the puncture tip and the nodule can be affected by mechanical ventilation. Therefore, apnea techniques were used when performing CB-CT to determine the position of the catheter tip and the nodule, when puncturing the nodule with the puncture needle, and when placing the ablation fiber optic. During each CBCT scan, we transitioned from machine-controlled to manual control of the anesthetic device, adjusting the respiratory oxygen flow from 2 to 0.6 L/min, and rapidly oxygenating to maintain airway pressure at 15 cmHg, ensuring consistent lung inflation.

Furthermore, the simultaneous use of Ion ablation combined with Da Vinci allows patients to receive the best treatment under one anesthesia, thereby providing a more minimally invasive treatment plan. The advantages of this combined procedure are as follows: first, when the nodule is located at the junction of lung segments or in a puncture prohibition area, the Ion technology shows significant advantages. Second, the combined use of Ion and CB-CT can achieve rapid and precise localization of small pulmonary nodules. Third, the application of bronchoscopic robotic localization technology in combination with the Da Vinci provides surgeons with a high-precision surgical operation platform, laying the foundation for precise localization, biopsy, ablation, and surgical resection of pulmonary lesions through a hybrid treatment approach. The future exploration of hybrid treatment modalities for multiple pulmonary nodules warrants further investigation. It is essential to delineate the learning curve associated with these treatments, to educate early-career physicians. Due to the unclear long-term prognosis, there is still a need for well-designed clinical studies to assess the efficacy of hybrid surgical methods on patient outcomes.

Conclusions

The ion robotic bronchoscopy-guided laser ablation stands out as an exceedingly promising therapeutic approach for treating multiple pulmonary nodules, with its potential further enhanced when integrated with Da Vinci robotic-assisted surgical interventions.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-922/rc

Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-922/prf

Funding: This study was supported by the Social Development Projects of Key R&D Programs in Xuzhou City (Nos. KC22097 and KC22252), and Postgraduate Research & Practice Innovation Program of Jiangsu Province (No. KYCX22_2882).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-922/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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