Standards & Specifications | Expert consensus on the diagnosis, localization and treatment of pulmonary peripheral nodules under the guidance of augmented reality optical whole lung diagnosis and treatment navigation

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Cite this article:Interventional Group of Respiratory Disease Branch of Chinese Medical Association, Interventional Group of Respiratory Disease Branch of Zhejiang Medical Association. Expert consensus on the diagnosis, localization and treatment of peripheral pulmonary nodules guided by augmented reality optical whole lung diagnosis and treatment navigation [J] . Chinese Medical Journal, 2024, 104(16) : 1371-1380. DOI: 10.3760/cma.j.cn112137-20230804-00166.

Contact: CHEN Enguo, Department of Respiratory and Critical Care Medicine, Sir Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016,Email:[email protected], China 510120,Email:[email protected];

summary

Lung cancer is the second most common malignancy and the highest mortality rate in the world. In recent years, the rapid development of various bronchoscopic navigation technologies has provided a powerful means for early lung cancer screening, and also provided conditions for the minimally invasive diagnosis and treatment of peripheral pulmonary nodules through the airway. Augmented reality optical whole lung diagnosis and treatment navigation is a new technology that integrates augmented reality and optical navigation technology on the basis of virtual navigation bronchoscopy (VBN) to assist bronchoscopy, and is one of the most widely used navigation technologies in clinical practice. There is a lot of clinical evidence that this technology has good safety and efficacy in guiding the diagnosis, localization and treatment of bronchoscopic pulmonary peripheral nodules. In order to standardize the clinical operation of augmented reality optical whole lung diagnosis and treatment navigation technology and guide its application in clinical practice, the interventional group of the Respiratory Disease Branch of the Chinese Medical Association and the interventional group of the Respiratory Disease Branch of Zhejiang Medical Association organized multidisciplinary experts to take the lead in formulating the "Expert Consensus on the Diagnosis, Localization and Treatment of Pulmonary Peripheral Nodules under the Guidance of Augmented Reality Optical Whole Lung Diagnosis and Treatment Navigation", aiming at the indications and contraindications for the diagnosis, localization and treatment of pulmonary peripheral nodules applicable to augmented reality optical whole lung diagnosis and treatment navigation technology. Recommendations and clinical guidance were provided on equipment and instruments, perioperative management, operating procedures, and complication management.

Lung cancer is the second most common malignant tumor with the highest mortality rate in the world [1], ranking first in the incidence and mortality rate of malignant tumors in mainland China [2]. Early screening and early diagnosis of pulmonary nodules is key to reducing mortality from lung cancer [3-8]. The main methods available to obtain pathological specimens from peripheral pulmonary nodules include surgery, transthoracic needle aspiration (TTNA), and transbronchial lung biopsy (TBLB) [9, 10]. In recent years, the rapid development of various bronchoscopic navigation techniques has provided conditions for the minimally invasive diagnosis and treatment of peripheral pulmonary nodules through the airway, greatly improved the positive rate of TBLB [11], and derived a series of emerging diagnostic and treatment methods. Augmented reality optical whole lung diagnosis and treatment navigation is one of the widely used bronchoscopic navigation technologies in clinical practice, but there is still a lack of unified specifications and operation procedures for augmented reality optical whole lung diagnosis and treatment navigation.

The Interventional Group of the Respiratory Disease Branch of the Chinese Medical Association and the Interventional Group of the Respiratory Disease Branch of the Zhejiang Medical Association organized experts in the fields of respiration, imaging, thoracic surgery, medical oncology, interventional radiology and other fields to fully discuss and jointly wrote the "Expert Consensus on the Diagnosis, Localization and Treatment of Peripheral Pulmonary Nodules under the Guidance of Augmented Reality Optical Whole Lung Diagnosis and Treatment Navigation" through 8 rounds of revisions, which provides reference for the work of peers in related fields.

1. The methodology for the development of this consensus

(1) Literature search

在PubMed、Cochrane Library、Embase、中国知网、万方、中国生物医学文献数据库等数据库上检索近10年的临床研究文献，主要自由词和主题词包括肺外周结节（peripheral pulmonary nodules）、增强现实光学导航（augmented reality optical lung navigation）、虚拟导航支气管镜（virtual bronchoscopy navigation）、经支气管镜活检（bronchoscopic biopsy）、经支气管镜定位（bronchoscopic localization）、经支气管镜治疗（bronchoscopic treatment）、经支气管镜消融（bronchoscopic ablation）等。

(2) Literature inclusion and exclusion criteria

(1) Time range and language: January 2013 to October 2023, Chinese and English, (2) Type: systematic review, meta-analysis, cohort study, case-control study, case report, guidelines and consensus, etc. (3) Intervention: methods for diagnosis, localization and treatment of pulmonary peripheral nodules by bronchoscopy.

(3) Quality control

All searches were carried out independently by two staff members. Once the data is aggregated, discuss and resolve disagreements. If views cannot be agreed upon, consult a third staff member and contact study authors if needed.

(4) Methods for forming expert consensus

Through collective discussion and discussion among experts, voting methods will be adopted when necessary to unify the corresponding recommendations.

(5) The level of evidence

In view of the lack of large-scale high-level evidence-based medical evidence for multimodal augmented reality optical navigation bronchoscopy, this consensus does not set the level of evidence and the level of recommendation.

(6) Registration and plan writing

本共识已在国际实践指南注册与透明化平台（http：//www.guidelines-registry.cn）进行注册（注册号：PREPARE-2024CN259），读者可联系指南发起组织索要计划书。

2. Introduction to basic technology and background

电磁导航支气管镜（electromagnetic navigation bronchoscopy，ENB）、虚拟导航支气管镜（virtual bronchoscopy navigation，VBN）、增强现实光学导航，是目前临床广泛应用的支气管镜导航技术［12-15］。

(1) ENB technology

ENB is based on electromagnetic positioning technology to achieve navigation. During the operation, the patient is in a three-dimensional magnetic field, and the bronchoscope function is guided in real time by relying on the electromagnetic probe placed at the front end of the bronchoscope, which has the advantages of high accuracy and strong real-time performance. However, ENB is susceptible to metallic objects, and the presence of cardiac pacemakers and upper body limbs containing metallic substances will interfere with the navigation magnetic field and affect positioning, as well as the dependence on positioning probes and the high cost of related equipment and disposable consumables, which limit its wide application [16, 17].

(2) VBN technology

The principle of VBN is based on the virtual image generated by three-dimensional spiral CT to guide the operator to control the bronchoscope into the target lesion. The VBN product is a preoperative planning software that reconstructs the 3D bronchial tree by using high-resolution chest CT data, which can display the simulated bronchoscope entering the target lesion and the straight-line distance from the "lens" to the lesion at a single frequency, but requires the operator to manually adjust and match the virtual planning path and the real-time path to achieve the role of navigation [18]. VBN cannot achieve automatic matching of real-time images, and the operator needs to manually adjust the matching, which is prone to the wrong airway selection during the entry process, especially when navigating to the peripheral small trachea, the virtual image and the actual bronchial image often have poor agreement, and it needs to be manually corrected by relying on the operator's experience [19].

(3) Augmented reality optical navigation technology

Augmented reality optical navigation technology combines augmented reality and endoscopic image real-time matching optical navigation technology on the basis of VBN, and projects the planned path in real time in the real bronchoscopic image by synchronizing the real bronchoscope and virtual bronchoscopic animation in the form of dual-channel display, without manual adjustment, and can realize the automatic realization of path guidance [20].

Augmented reality optical whole lung diagnosis and treatment navigation is a new generation of optical navigation technology developed on the basis of the previous generation of augmented reality optical navigation, combined with infrared optical tracking navigation technology and perspective fusion function. This navigation technology reconstructs 3D images of tracheobronchial and pulmonary blood vessels, which facilitates the avoidance of blood vessels during needle biopsy. In addition to enabling conventional airway navigation, this navigation technique supports the implementation of bronchoscopic transparenchymal nodule access (BTPNA) [21, 22], that is, navigation can register the patient's CT and X-ray fluoroscopy images through infrared optical tracking technology, and project the reconstructed lesion information onto the real-time X-ray fluoroscopy image to generate a fusion fluoroscopy view, assist the physician to avoid blood vessels, guide the endobronchial fixed-point puncture, and construct a bronchial transmural tunnel to reach the extra-airway lesions. Therefore, augmented reality optical whole-lung diagnosis and treatment navigation has both conventional airway navigation mode and unique out-of-airway navigation mode, which can realize the diagnosis and treatment of whole lung, and can meet most of the clinical requirements for diagnosis and treatment of pulmonary nodules.

3. Indications and contraindications

(1) Indications

1. Diagnosis of pulmonary peripheral nodules: The overall diagnostic rate of navigation-guided intraairway TBLB is 50%~60% [23, 24], and the diagnostic rate can reach more than 85% if it can be combined with auxiliary methods such as CT imaging and radial ultrasound guidance [25-28]. Guided lung biopsy is recommended for specific nodules such as ground-glass pulmonary nodules (especially pure ground-glass nodules), nodules close to the heart or large vessels, nodules with vascular or interlobar fissures on the puncture approach, nodules with abundant blood supply within the lesion, and nodules that are too irregularly shaped (e.g., cord-like nodules, thin nodules with uneven diffuseness), because of the high risk of TTNA. For multiple pulmonary nodules in the periphery of the lungs that need to be collected synchronously, especially if the nodules are not distributed on the same side of the lung, it is recommended to use navigation bronchoscopy-guided lung biopsy, which can reduce the incidence of adverse events such as hemorrhage and pneumothorax. The presence or absence of bronchial signs in pulmonary nodules has an important impact on the diagnostic yield [29, 30], and the diagnostic rate of pulmonary nodules with bronchial signs can be more than twice that of pulmonary nodules without bronchial signs. For lung nodules without bronchial signs, in addition to traditional TTNA, augmented reality optical whole-lung diagnosis and treatment navigation-guided BTPNA has been proven to be a safe and effective biopsy method. In a multicenter, single-arm study [22] using BTPNA and transbronchial needle aspiration (TBNA) to collect samples from peripheral pulmonary nodules, the overall biopsy rate was 75.4%, compared with 86.3% and 67.2% for BTPNA and TBNA, respectively, and the overall diagnostic rate was 75.4%, with a biopsy rate of 70.4% for pulmonary nodules with no bronchial signs and no bronchial signs and 57.1%, with a diagnostic rate of 74.1% and 71.4%, respectively. The biopsy rate in the above study was defined as the number of lesions that could be taken from at least one biopsy in 1 patient that was sufficient for tissue diagnosis divided by the number of lesions sampled using the navigation system.

Recommendation 1: (1) For multiple lesions in the periphery of the lung that cannot be seen directly under ordinary bronchoscopy, especially if the nodules are not distributed on the same side of the lung, it is recommended to choose navigation bronchoscopy-guided lung biopsy;(2) It is recommended that pulmonary nodules with bronchial signs are the first choice to navigate intra-airway TBLB, and for pulmonary nodules without bronchial signs, TTNA or BTPNA is recommended for biopsy collection;(3) Pulmonary peripheral nodules are pure ground-glass, mixed ground-glass, nodules close to the heart or large vessels, If there are vascular or interlobar fissure nodules, nodules with abundant blood supply in the lesion and nodules with too irregular shape, it is recommended to choose lung biopsy guided by navigation bronchoscopy, and for pure ground-glass nodules, it is recommended that relevant departments such as respiratory medicine, thoracic surgery, and imaging department conduct multidisciplinary discussions to evaluate whether biopsy confirmation is needed.

2. Localization of pulmonary peripheral nodules: Bronchoscopic navigation guidance can be applied to preoperative surgery and radiotherapy. Due to the lack of clinical practice and related literature on preoperative positioning of transbronchial radiotherapy, this consensus mainly focuses on the preoperative localization of pulmonary peripheral nodule surgery. Several studies have demonstrated the feasibility of navigating bronchoscopy-guided preoperative nodule calibration [31-35]. Regarding the selection of positioning materials, the most commonly reported in the literature is the localization of liquid dyes injected through navigation bronchoscopy, including methylene blue, medical glue, indocyanine green, iodized oil, etc. [36-39]. Studies on the placement of metal markers via navigation bronchoscopy to localize pulmonary nodules are less common, mainly including spring coils and novel transairway markers. In addition, the use of radioisotopes (e.g., Tc-99m) [40] and intraoperative ultrasound-assisted localization [41] have also been reported. The literature has reported that the localization success rate of VBN-guided transbronchoscopic fluid staining is 85%~96% [32,42, 43]. Indocyanine green was guided by VBN to locate lung nodules preoperatively, with an average lesion size of 9.3 mm and a mean distance from the pleura of 14.0 mm, with a localization success rate of 97.01% [44]. Lachkar et al. [37] reported that VBN combined with radial ultrasound was used to localize peripheral pulmonary nodules by bronchoscopic injection of methylene blue, with a success rate of 96% and 92% lesion size< 10 mm, the average distance between the lesion and the pleura was 10 mm (2~27 mm). Liquid localization material is easy to obtain, and the dye is easy to visualize during intraoperative resection, but easy diffusion after injection may lead to enlargement of the excision area or localization failure. Metal positioning materials can stay in the body for a long time, not easy to displace, and the position can be confirmed by X-ray during or after positioning, so as to increase the positioning accuracy, but metal positioning materials often have requirements for material performance and structural design because they need to meet the needs of intrabronchial expansion and fixation. Toba et al. [31] used VBN-guided transbronchoscopy to calibrate small nodules (lesions ≤ 10 mm) before surgery, with a success rate of 98.4%, multiple lesion localization in 6.9%, and pneumothorax in 1.7%. A prospective, multi-center clinical study of the preoperative localization of pulmonary nodules using a new transairway positioning stent through the bronchi under the guidance of augmented reality optical whole-lung diagnosis and treatment navigation has been completed, but the relevant data have not yet been published (NCT04139408), and the solid component ≤ 10 mm and the distance from the pleura > has been completed5 mm, ground-glass nodules and pulmonary nodules that are difficult to locate intraoperatively. Compared with traditional percutaneous puncture, guided pulmonary nodule calibration can effectively reduce complications such as pneumothorax and hemorrhage [45], and is suitable for marking multiple lesions at a time, and can localize some nodules with blood vessels, important organs, or special locations such as mediastinum, diaphragm, and cardiac margins along the percutaneous puncture path. In addition, the recommended time of surgical surgery after localization has been reported to be mixed, ranging from 1~3 days after localization for metal markers to 5 days after localization for metal markers, and successful surgery after 5 days of localization for the longest time in the literature [31]. Immediate surgery is recommended for liquid dye localization, as the diffusion of liquid dye may lead to positioning failure.

Recommendation 2:

1. Conventional recommendations on the localization of pulmonary peripheral nodules: (1) Pulmonary peripheral nodules that are intended to undergo thoracoscopic pulmonary subsegmental or wedge resection, and the surgeon evaluates the nodules that are difficult to rely on direct vision or touch to locate during the operation, and it is recommended to locate them preoperatively. These include: (1) isolated peripheral pulmonary nodules with a diameter of less than ≤10 mm, (2) deep nodules within 15 mm of the pleural surface ≥, and (3) pure ground-glass or mixed ground-glass nodules on imaging. (2) Ground-glass nodules with pleural changes, such as pulmonary nodules combined with pleural depression, adhesions and other signs of pleural changes, can identify the location of pulmonary nodules under direct vision, and this scheme is not recommended for localization.

2. Recommendations for the localization of pulmonary nodules under the guidance of bronchoscopic navigation: (1) For the distribution of blood vessels and important organs on the percutaneous puncture path, the positioning of multiple pulmonary peripheral nodules that need to be located (especially if the nodules are not distributed on the same side of the lung), or the nodules in special parts such as the diaphragm roof and the edge of the heart, etc., are preferentially recommended for the localization of pulmonary nodules under the guidance of bronchoscopic navigation. (2) The pre-positioning assessment showed that the airway near the arrival point was clear and identifiable, there were bronchial signs, and the angle was suitable for tracheoscopy passers-by, and it was recommended to locate the pulmonary nodule under the guidance of bronchoscopic navigation. (3) The pre-positioning assessment showed that the tracheoscopy navigation path angle was too large, the lumen was distorted and varied, and the airway anatomical variation due to lung surgery/structural lung disease/thoracic adhesion was expected, and it was expected that the tracheoscope would be difficult to reach the positioning point smoothly, and it was recommended to avoid choosing the positioning of lung nodules under the guidance of bronchoscopic navigation, which may lead to arrival failure. (4) For nodules located in the proximal mediastinal surface, apical nodules of the upper lobe and some dorsal nodules of the lower lobe, it is recommended to carefully select the positioning of pulmonary nodules under the guidance of bronchoscopic navigation.

3. Treatment of pulmonary peripheral nodules: In the past, transbronchoscopic treatment methods for central malignancies have been reported, including radiofrequency ablation, microwave ablation, cryoablation, microscopic injection of drugs (eg, cisplatin, iodized oil, transgenic virus vectors), radioactive seed implantation, and photodynamic therapy [46, 47]. With the development of various bronchoscopic navigation techniques and interventional treatment tools, transbronchoscopy has become a hot spot for the treatment of peripheral lung malignant nodules. Several small studies have demonstrated its feasibility and safety [47, 48]. In a study of 25 patients treated with navigation-guided bronchoscopic microwave ablation of 30 pulmonary nodules, the ablation covered 100% of the lesion area, the median hospital stay was only 1.73 days, and postoperative complications included pain (13.30%), pneumothorax (6.67%), postoperative response (6.67%), hemoptysis (3.33%), and pleural effusion (3.33%), with no disease progression after a median follow-up of 12 months [48]. Augmented reality optical whole-lung diagnosis and treatment navigation can quickly and accurately guide the operator to accurately reach the lesion with the front end of the bronchoscope or sheath, and at the same time, with BTPNA technology, the treatment tool can break through the bronchial limitation and reach the lung parenchymal lesion. At present, animal experiments have been reported [49], and the success rate of radiofrequency ablation of simulated lung lesions outside the airway through augmented reality optical whole-lung diagnosis and treatment navigation has been 100%, and no serious adverse events have occurred, which has preliminarily verified the safety and feasibility. This is being further validated by relevant clinical studies (NCT04619472). An exploratory study reported the feasibility and safety of tracheoscopic navigation to guide transbronchoscopic microwave ablation of peripheral lung cancer, including 13 patients with a total of 14 lesions [length and diameter of (20.4±5.7) mm], with a success rate of 100% and a local control rate of 71.4% at two years after surgery [50].

Recommendation 3: Based on the existing evidence and expert consensus, this consensus only applies to the indications for radiofrequency and microwave ablation therapy. At the same time, this consensus encourages the development of clinical trials comparing transbronchoscopic ablation with surgery, radiotherapy, image-guided percutaneous ablation and other treatment regimens to provide more evidence-based medical evidence. (1) Indications for therapeutic ablation for the purpose of radical cure (for patients who cannot tolerate surgery or are unwilling to undergo surgery and cannot tolerate stereotactic ablation radiotherapy or patients who have failed the above treatments) :(1) For a single early-stage lung cancer nodule in the lung, it is recommended to have a diameter of ≤3 cm and be close to the pleura and large blood vessels1 (2) The number of metastatic tumor nodules in the lung is recommended to be 3 in ≤ single lung and 5 in both lungs, and (3) the diameter is recommended to be ≤ 3 cm in the number of metastatic lung tumor nodules in the of both ≤lungs. (2) The indications for palliative ablation can be appropriately relaxed according to the specific situation, and can be considered for patients who have failed or cannot be treated with surgery, radiotherapy, and radiointervention. (3) It is recommended to perform ablation on the basis of pathological confirmation of pulmonary peripheral nodules: (1) pathological confirmation can be performed by biopsy methods such as TBLB, TBNA, TTNA, etc., and can also be interpreted by intraoperative rapid on-site evaluation (ROSE), and the ROSE interpreter must be a professionally trained cytopathologist or a senior respiratory physician with rich experience in ROSE; For patients who are too difficult to biopsy or who refuse biopsy but have typical signs of malignancy on imaging, empiric therapy without pathologic confirmation is considered, a multidisciplinary consultation is recommended, a diagnosis and treatment plan is developed, and the patient and his or her family are adequately informed of the risks and benefits associated with the patient, and the final diagnosis and treatment plan is made with the patient [51].

(2) Contraindications

Recommendation 4: (1) In principle, there are no absolute contraindications to navigating bronchoscopy, and the relative contraindications are similar to those of conventional bronchoscopy, which can be referred to the Guidelines for the Application of Diagnostic Flexible Bronchoscopy in Adults (2019 Edition) [52]. (2) Because navigation-guided bronchoscopic biopsy is completed under non-direct vision of the lesion and is often completed under general anesthesia, some of its contraindications are special compared with conventional bronchoscopy. It mainly includes: (1) lesions with clear vascular envelope or important organs in the biopsy approach shown by contrast-enhanced CT, (2) patients with severe emphysema, alveoli, mediastinal emphysema or pneumothorax shown by CT, (3) those with contraindications to anesthesia or sedative drugs, and (4) those who are not suitable for navigation bronchoscopy, such as mental disorders or psychological disorders. (3) Patients with iodine allergy should not use iodine-containing dyes for navigation bronchoscopic calibration, such as indocyanine green. (4) Patients with pacemakers should not be treated with radiofrequency ablation under navigation bronchoscopy.

4. Equipment and instruments

(1) Equipment

1. Augmented reality optical whole lung diagnosis and treatment navigation: The navigation technology has the functions of preoperative route planning, intraoperative real-time navigation and fluoroscopic guidance, and the principle is to use CT three-dimensional imaging, bronchoscopic optical imaging, fluoroscopy image and other positioning technologies, and realize real-time guidance by combining augmented reality technology to superimpose path information under bronchoscopy and fluoroscopy imaging equipment. Navigation includes a navigation workstation with pre-installed navigation software, a tracking system, and a dedicated instrument cart. Navigation software for CT data transmission, airway/vascular 3D view reconstruction, target definition, path planning and surgical navigation; The tracking system attaches a fluorescence tracking tool to the head of the auxiliary positioning device, and the software reads the pose of the tool in real time, and accurately superimposes the 3D CT information on the real-time fluoroscopy video during patient registration and BTPNA surgery to achieve 3D position tracking. By displaying real-time and reconstructed bronchoscopic images, the system maintains accurate guidance to the intended targets of the lungs. In the case of intra-airway bronchoscopic navigation, the system needs to be connected to the bronchoscope, calibration fixture, related cables and foot pedals, and in the case of fluoroscopic navigation during BTPNA surgery, in addition to the above hardware, auxiliary positioning equipment such as the C-arm and its calibration device need to be connected.

2. Bronchoscope equipment: Augmented reality optical whole lung diagnosis and treatment navigation can match most bronchoscopes on the market, and there are no special requirements for the model. Intraairway TBLB guided by the navigation system is performed without supporting consumables. The ultra-fine bronchoscopy equipment is conducive to getting as close to the lesion as possible during the operation, improving the accuracy of material collection, and has positive significance for improving the positive rate of diagnosis. A bronchoscope with an apical outer diameter of ≤ 4.2 mm and a working aperture of ≥ 2.0 mm is recommended. Conditional units can also be equipped with ultra-fine bronchoscopes with an outer diameter of 3.1~3.7 mm and a working channel of 1.2~1.7 mm, and biopsy tools with an outer diameter of 1.2~1.7 mm are also required. Navigation-guided BTPNA is accompanied by a puncture needle (common size 18 G, outer diameter 1.91 mm), bronchoscopic balloon dilation catheter (common size 1.80 mm outer diameter), and bronchoscopic introducer sheath (common size apical outer diameter 2.2 mm, maximum outer diameter 2.6 mm). During the operation, different types of bronchoscopic equipment can be equipped according to specific needs, or different specifications of puncture needles and balloon dilation catheters can be replaced. If only the needle and balloon are used, a bronchoscope with a working aperture of ≥ 2.0 mm is required, and a therapeutic bronchoscope with a working aperture of ≥.8 mm is required for the use of an introducer sheath.

3. Optional equipment: (1) radial endobronchial ultrasound (R-EBUS): R-EBUS provides a 360° ultrasound view of the small airway and surrounding tissues, which can distinguish lung parenchymal, solid and semi-solid lung lesions, and effectively improve the diagnosis rate of TBLB under bronchoscopic navigation, and is one of the most commonly used TBLB auxiliary positioning devices. The commonly used R-EBUS probe specifications are ≥ tip outer diameter of 1.4 mm and maximum outer diameter ≥ 1.7 mm. (2) Radiological imaging equipment: Radiological imaging equipment can visually display the real-time position relationship between biopsy consumables and target lesions, and is a very effective auxiliary positioning equipment, especially when performing BTPNA, which is indispensable for localization or ablation. Commonly used devices include large cone beam CT (CBCT) and mobile C-arms. (3) ROSE platform: The conventional ROSE platform equipment includes: (1) scientific research grade flat light microscope, (2) wide field scientific research grade high numerical aperture oil-free dry objective lens (×10, × 40, × 100), ;( 3) wide field scientific research grade eyepiece lens (×10, ×15) ;(4) graphic photography system. Hardware upgrades can be carried out by qualified institutions. ROSE is accompanied by the process of specimen collection, and rapid cytology or pathogenic interpretation can be performed during surgery, which can reduce the operation time and improve the diagnosis rate. (4) Confocal laser endomicroscopy (CLE): CLE is a new type of endoscopic examination technology, which combines a miniature confocal laser microscope with a traditional electronic endoscope to perform confocal laser scanning on the mucosa, and converts the obtained real-time images into high-resolution images magnified by 1 000 times, realizing the histological structure at the cellular level, which is helpful for identifying the tissue structure of the bronchial mucosa. cellular and subcellular structures for immediate pathological diagnosis without invasiveness. At present, the data and literature on the application of bronchoscopy are limited, and experienced institutions can be used as one of the devices to assist positioning. Common catheter sizes include probe-based confocal laser endomicroscopy (pCLE) 1.9 mm and needle-based confocal laser endomicroscopy (nCLE) 1.0 mm.

(2) Consumables

1. Biopsy consumables: Conventional biopsy tools include: conventional biopsy forceps (outer diameter 1.5~1.8 mm), fine biopsy forceps (outer diameter 1.0~1.2 mm), puncture needle (18~20 g, outer diameter mostly 1.8~2.0 mm), 18 G puncture needle (outer diameter 1.9 mm) and disposable cell brush are often used for BTPNA. Cryoprobes with different outer diameters can be selected according to the specific nature of the lesion (the current outer diameters of cryoprobes are 1.1, 1.4, 2.0, and 2.6 mm).

2. Positioning consumables or positioning chemicals: There are many types of lung nodule positioning consumables, involving a variety of categories of products. Common metal markers include hooked wires, spring coils, and new airway positioning brackets. Commonly used positioning chemicals are indocyanine green, methylene blue, medical biological glue, iodine oil, etc. It can be selected on a case-by-case basis.

3. Optional guide sheath set: It can be equipped with a guide sheath set according to operational needs or personal habits.

Recommendation 5: (1) Multiple devices can be used to improve the diagnostic yield of navigated pulmonary nodules, such as EBUS combined with CBCT, and (2) fine cryo probe biopsy or standard biopsy forceps (1.8 mm outer diameter) can be selected for pure or mixed ground-glass nodules.

5. Operation process

(1) Preoperative patient assessment and management

Evaluate the general condition of the patient, ask about the medical history in detail (especially whether there is a history of lung surgery or special operations), allergy history, improve the preoperative blood routine, coagulation function, electrocardiogram, imaging examination, etc., and evaluate the cardiopulmonary function. Concern about the risks of anesthesia and discontinuation of anticoagulant and antiplatelet drugs in patients who are going to undergo biopsy before surgery can refer to the Guidelines for the Application of Diagnostic Flexible Bronchoscopy in Adults (2019 Edition) [52], which will not be repeated in this consensus. Before surgery, the high-resolution CT of the chest should be read to grasp the location, size, nature and characteristics of the target lesions, as well as the relationship between the target lesion and the surrounding blood vessels and adjacent tissue structures, and evaluate the surgical risk. Communicate with patients and their families in detail before the operation, inform them of the pros and cons of the current diagnosis and treatment plan, possible risks and coping methods during the operation, fully informed consent and sign written documents.

(2) Preoperative CT collection and path planning

1. Preoperative chest CT collection requirements: (1) The collection time is recommended not to exceed 1 month before surgery, (2) The CT layer thickness is required to be ≤ 1.25 mm, (3) The patient should be educated to hold his breath at the end of deep inspiration before CT acquisition to ensure that the images are stable and clear, (4) It is recommended that the patient cough and produce sputum fully before CT acquisition to avoid the accumulation of secretions in the airway and interfere with the reconstruction of the path.

2. Preoperative path planning: Import the thin-slice CT data of the lung in DICOM format into the navigation system, reconstruct the three-dimensional bronchial tree, complete the vascular labeling and reconstruction of the whole lung blood vessels, label the target to generate the navigation path, and select the optimal path. Focus on the angle of the entry pathway, the diameter of the airway adjacent to the lesion, the blood vessels, whether it is close to the pleura and other details, evaluate the feasibility and safety of the pathway implementation, for the small airway that cannot be automatically reconstructed by the system, manual reconstruction is required; for patients without bronchial signs who need to undergo BTPNA, the virtual Doppler function can be used to turn on the reconstructed blood vessel detection to judge whether the puncture point is appropriate, evaluate the angle and depth of needle insertion, and manually change the position if the puncture point is not suitable. It should be noted that the target of the preoperative positioning of the surgical pathway should be set at the nearest pleural tangent line from the pulmonary nodule to be resected, rather than at the nodule to be resected. Adequate communication with the surgeon is required before surgery to understand the needs.

3. Preparation of instruments and consumables: select the appropriate type of bronchoscope, and complete the preparation according to the situation of the combination of EBUS, ROSE or radiological imaging equipment, as well as the consumables required for positioning and biopsy.

(3) Intraoperative operation

(1) After the patient was removed from the occipital supine position, and after general anesthesia/local anesthesia was ready, routine bronchoscopy was performed to remove residual airway secretions and observe the shape of the airway mucosa and lumen. (2) Observe the matching degree of the real-time bronchoscopic image and the reconstructed bronchial image. When the real-time synchronization is synchronized with the reconstructed bronchial image, the blue path to the target will be displayed on the real-time bronchoscopy image, and if the automatic synchronization fails, the reconstructed bronchial view needs to be rotated or adjusted in time to synchronize the image. (3) According to the preoperative planned path, the bronchoscope is pushed to the airway of the target lesion area under the real-time guidance of navigation, and when the blue path, adjacent blood vessels and target sites are superimposed on the real-time bronchoscopic image, it indicates that the preset range at the end of the path has been reached. (4) According to the location of the nodule, the biopsy can be confirmed by auxiliary positioning equipment such as R-EBUS or CBCT, or the release of the calibrator or ablation treatment can be carried out according to the needs of the operation. (5) In the case of transairway bronchoscopic navigation, auxiliary bronchoscopy such as endobronchial ultrasound system can be used to diagnose, locate and treat intra-airway and adjacent lesions, and BTPNA technology can be used for extra-airway bronchoscopic navigation, which can diagnose, locate and treat pulmonary peripheral nodules without bronchial signs (Fig. 1). First of all, the bronchoscope arrives at the planned puncture point area under the guidance of navigation, the puncture needle punctures the wall and creates a hole at the puncture point through the working channel, and the negative pressure syringe is taken out after confirming that there is negative pressure and no bleeding, and then the sheath is placed to take out the sheath, the balloon is placed and the puncture hole is inflated to expand the puncture hole, the sheath is guided to penetrate the airway to the lung parenchyma, the sheath core is inserted, and finally the blunt sheath is pushed to the lesion through CBCT or X-ray fluoroscopy guidance view under the C-shaped arm to complete the establishment of the channel. Biopsy, localization, or treatment can be performed under fluoroscopic surveillance. It is necessary to pay attention to whether there are complications such as bleeding and pneumothorax.

Fig.1 Diagnosis, localization and treatment of peripheral pulmonary nodules guided by augmented reality optical whole lung diagnosis and treatment

Recommendation 6: (1) Diagnosis: It has an auxiliary role in bronchoscopic forceps, brushing, needle aspiration and other biopsies, taking TBLB as an example, after confirming arrival, the biopsy forceps are inserted through the bronchoscopic working channel, and biopsied at the planned target. If radial ultrasound or fluoroscopy equipment indicates that the biopsy tool is facing the lesion, direct biopsy can be performed according to the estimated depth, and if radial ultrasound or fluoroscopy equipment indicates that the biopsy tool deviates from the lesion and there is a large angle, it is recommended to take turns in multiple directions, or biopsy guided by fluoroscopy equipment. (2) Positioning: The chemical dye positioning method can be injected from the sheath such as methylene blue (0.5~1.0 ml), and then injected with about 20 ml of air, which is withdrawn for about 1 min to observe the reflux of the dye; Depending on the area of dye distribution or the location of metal markers, as well as the extent of the lesion, thoracoscopic wedge and segmentectomy are performed. (3) Treatment: Through the guidance of navigation, radiofrequency, microwave, laser, cryotherapy and other treatment auxiliary probes are sent to the lesion through the working channel for fixed-point precise treatment, drug injection, etc.

6. Complication management and precautions

The common complications of navigation-guided airway TBLB were pneumothorax and hemorrhage, with an incidence of 4.7 and 2.7 percent, respectively (3.2 and 1.7 percent requiring intervention or hospitalization) [53], while the most common complications of BTPNA were pneumothorax and hemorrhage, with an incidence of non-spontaneous complications ranging from 0~16.7%, which improved after symptomatic treatment such as closed chest drainage, oxygen inhalation, and hemostasis [21, 22,54].

Recommendation 7: (1) For patients with pneumothorax, continuous oxygen therapy is required, and no special treatment is required if there are no symptoms or mild symptoms; thoracentesis or thoracostomy should be performed for patients with lung compression exceeding 30 percent, severe clinical symptoms, unstable circulation, and persistent increase in lung compression; bed rest should be ordered, vital signs and oxygen saturation monitoring should be strengthened, and chest x-ray or chest CT should be reviewed in a timely manner [55]. (2) A small amount of bleeding in biopsy does not require special treatment, such as the bleeding point can be identified and the bleeding can be stopped by bronchoscopic compression, and local bleeding can be sprayed locally under the microscope such as epinephrine, thrombin, hemostatic powder, ice normal saline, etc.; continuous bleeding can be intravenously used, such as posterior pituitary, prothrombin, tranexamic acid and other hemostatic drugs; severe massive hemoptysis should be considered to stop the bleeding through interventional vascular embolization or surgery. (3) Navigation, bronchoscopic localization or ablation of pulmonary nodules may also cause some special complications, including postoperative arrhythmias, bronchopleural fistula, massive hemoptysis, and scale detachment or displacement [47,56-58]. Special complications such as bronchopleural fistula need to be combined with the location, shape and size of the fistula to formulate a follow-up treatment plan, small fistula can be promoted by anti-infection, closed drainage and other means to promote its closure; for fistula that is difficult to prognosis on its own, the appropriate occlusion equipment can be selected according to the specific situation for bronchoscopic closure, and difficult cases should be discussed with multidisciplinary consultation and treatment plan.

The augmented reality optical whole lung diagnosis and treatment navigation system is becoming more and more widely used in clinical use, which has expanded the operational scope of pulmonary peripheral lesions and derived emerging diagnosis and treatment methods, and has become one of the important methods for clinical diagnosis and treatment of pulmonary nodules. In the future, it can guide the precise placement of stents, one-way valves, bronchoplugs, etc., and be applied to diseases such as pneumothorax, lung volume reduction, bronchopleural fistula, etc., and can also play an active role in the training of respiratory endoscopists and the teaching of medical students. Therefore, in the period of rapid development of bronchoscopic navigation technology, standardized operation procedures and guidance are of great significance to improve the success rate of diagnosis and treatment and reduce navigation-related adverse events. At the time of the development of this consensus, the clinical evidence for this technique was insufficient compared to traditional bronchoscopy. With the further expansion of the clinical use of this emerging technology and the accumulation of evidence-based medical evidence, this expert consensus will continue to be updated to provide reference for clinicians using this technology. This consensus is not mandatory, is not used as a basis for the identification of medical malpractice and medical liability, and is only for the reference of relevant medical personnel.

Consensus authors (in order of contribution): Zhang Jisong (Department of Respiratory and Critical Care Medicine, Sir Run Shaw Hospital, Zhejiang University School of Medicine); Li Xiaoyan (Department of Medical Oncology, Fifth Medical Center, Chinese People's Liberation Army General Hospital); Jing Lei (Department of Respiratory and Critical Care Medicine, Emergency General Hospital); Xu Shan (Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine); Xu Hangdi (Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine); Dong Liangliang (Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine); Xu Li (Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine)

Experts involved in consensus formulation (in alphabetical order of surname): Chen Enguo (Department of Respiratory and Critical Care Medicine, Sir Run Shaw Hospital, Zhejiang University School of Medicine); Feng Jing (Department of Respiratory and Critical Care Medicine, Tianjin Medical University General Hospital); Gu Ye (Endoscopy Center, Shanghai Pulmonary Hospital, Tongji University); Hu Huihui (Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine); Hu Hongjie (Department of Interventional Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine); Huang Jian'an (Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University); Hu Yi (Department of Oncology, Chinese People's Liberation Army General Hospital) HUANG Yurong (Department of Respiratory and Critical Care Medicine, Xinjiang Production and Construction Corps General Hospital), JIANG Hanliang (Department of Respiratory and Critical Care Medicine, Sir Run Shaw Hospital, Zhejiang University School of Medicine), KONG Delei (Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University), LONG Fa (Department of Respiratory and Critical Care Medicine, Shenzhen Hospital, University of Chinese Academy of Sciences), LI Shiyue (Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University), LI Yaqing (Department of Respiratory and Critical Care Medicine, Hainan Provincial People's Hospital), Meng Jie (Department of Respiratory and Critical Care Medicine, Third Xiangya Hospital, Central South University), SUN Jiayuan (Respiratory Endoscopy Center, Shanghai Chest Hospital) Xiaolian SONG (Department of Respiratory and Critical Care Medicine, Shanghai Tenth People's Hospital), Feng WANG (Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital), Hongcheng WU (Department of Respiratory and Critical Care Medicine, Li Huili Hospital, Ningbo Medical Center), Jiwang WANG (Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University), Limin WANG (Department of Respiratory and Critical Care Medicine, Hangzhou First People's Hospital), Tao WANG (Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology), Xiaoping WANG (Department of Respiratory and Critical Care Medicine, Shandong Provincial Public Health Center), Xiaoqun YE (Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Nanchang University) ZHONG Changhao (Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University);ZHANG Jisong (Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine);ZHANG Quncheng (Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital)

conflict of interest

All authors declare no conflicts of interest

References (scroll down):

[1] SiegelRL, MillerKD, FuchsHE, et al. Cancer statistics, 2022[J]. CA Cancer J Clin, 2022, 72(1):7-33. DOI: 10.3322/caac.21708.

[2] Qin Na, Ma Hongxia, Jin Guangfu, et al. Annual progress in epidemiological research of lung cancer 2022[J]. Chinese Medical Journal, 2023, 103(14):1068-1073. DOI: 10.3760/cma.j.cn112137-20221213-02640.

[3] Wangyun, Fan Li, Zhou Ying, et al. Baseline report of low-dose CT screening for lung cancer in Shanghai[J]. Chinese Journal of Health Management, 2018, 12(1):51-54. DOI: 10.3760/cma.j.issn.1674-0815.2018.01.010.

[4] Zhao Junsong, Cui Li, He Jiangbo, et al. Preliminary analysis of low-dose CT lung cancer screening and follow-up results in 22 351 asymptomatic patients in Shanghai[J]. Diagnostics - Theory & Practice, 2019, (2). DOI: 10.16150/j.1671-2870.2019.02.012.

[5] Gao Zhongsong, Ye Zhaoxiang, Zhang Peng, et al. Preliminary clinical analysis of baseline screening and follow-up of low-dose CT lung cancer in Tianjin[J]. Chinese Journal of Clinical Oncology, 2017, 44(20):1034-1039. DOI: 10.3969/j.issn.1000-8179.2017.20.474.

[6] VeronesiG, BellomiM, MulshineJL, et al. Lung cancer screening with low-dose computed tomography: a non-invasive diagnostic protocol for baseline lung nodules[J]. Lung Cancer, 2008, 61(3):340-349. DOI: 10.1016/j.lungcan.2008.01.001.

[7] NawaT, NakagawaT, KusanoS, et al. Lung cancer screening using low-dose spiral CT: results of baseline and 1-year follow-up studies[J]. Chest, 2002, 122(1):15-20. DOI: 10.1378/chest.122.1.15.

[8] ChongS, LeeKS, ChungMJ, et al. Lung cancer screening with low-dose helical CT in Korea: experiences at the Samsung Medical Center[J]. J Korean Med Sci, 2005, 20(3):402-408. DOI: 10.3346/jkms.2005.20.3.402.

[9] Lung Cancer Group, Chinese Society of Respiratory Diseases, Expert Group of China Alliance for Lung Cancer Prevention and Control. Chinese Expert Consensus on the Diagnosis and Treatment of Pulmonary Nodules (2018 Edition)[J]. Chinese Journal of Tuberculosis and Respiration, 2018, 41(10):763-771. DOI: 10.3760/cma.j.issn.1001-0939.2018.10.004.

[10] Chinese Society of Clinical Oncology (CSCO) Geriatric Cancer Prevention and Treatment Expert Committee. Chinese expert consensus on navigation-guided interventional diagnosis and treatment of transbronchopulmonary nodules[J]. PLA Medical Journal, 2023, (9). DOI: 10.11855/j.issn.0577-7402.0681.2022.0401.

[11] RiveraMP, MehtaAC, WahidiMM. Establishing the diagnosis of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines[J]. Chest, 2013, 143(5Suppl):e142S-e165S. DOI: 10.1378/chest.12-2353.

[12] Fu Yili, Zhang Wenqian, Chen Shuo, et al. Comparison of CT-guided percutaneous and electromagnetic navigation-guided transbronchial microwave ablation in the treatment of pulmonary ground-glass nodules[J]. Chinese Medical Journal, 2021, 101(33):2576-2581. DOI: 10.3760/cma.j.cn112137-20210220-00443.

[13] Wang Gongming, Lin Yongbin, Luo Kongjia, et al. Feasibility of electromagnetic navigation bronchoscopy-guided injection of fluorescent agent in pulmonary nodule localization resection[J]. Chinese Journal of Lung Cancer, 2020, 23(6):503-508. DOI: 10.3779/j.issn.1009-3419.2020.103.01.

[14] KatoA, YasuoM, TokoroY, et al. Virtual bronchoscopic navigation as an aid to CT-guided transbronchial biopsy improves the diagnostic yield for small peripheral pulmonary lesions[J]. Respirology, 2018, 23(11):1049-1054. DOI: 10.1111/resp.13377.

[15] BowlingMR, BrownC, AncianoCJ. Feasibility and Safety of the Transbronchial Access Tool for Peripheral Pulmonary Nodule and Mass[J]. Ann Thorac Surg, 2017, 104(2):443-449. DOI: 10.1016/j.athoracsur.2017.02.035.

[16] Yu Baohua, Zhao Lin, Zheng Yan, et al. Application of electromagnetic navigation bronchoscopy in the diagnosis of pulmonary peripheral nodules[J]. China Medical Device Information, 2018, 24(2):66-67. DOI: 10.3969/j.issn.1006-6586.2018.02.032.

[17] Chen Qiuming, An Zhou, Cheng Jun, et al. Clinical application of electromagnetic navigation bronchoscopy in the diagnosis and treatment of peripheral lung lesions[J]. Chinese Journal of Lung Cancer, 2020, 23(6):440-445. DOI: 10.3779/j.issn.1009-3419.2020.102.04.

[18] AsanoF, EberhardtR, HerthFJ. Virtual bronchoscopic navigation for peripheral pulmonary lesions[J]. Respiration, 2014, 88(5):430-440. DOI: 10.1159/000367900.

[19] KitamuraA, TomishimaY, ImaiR, et al. Findings of virtual bronchoscopic navigation can predict the diagnostic rate of primary lung cancer by bronchoscopy in patients with peripheral lung lesions[J]. BMC Pulm Med, 2022, 22(1):270. DOI: 10.1186/s12890-022-02071-2.

[20] Chen Wenfang, Zhong Zhicheng, Huang Pei, et al. The diagnostic value of bronchoscopic navigation system in peripulmonary lesions[J]. Chinese Journal of Tuberculosis and Respiration, 2017, 40(8):622-625. DOI: 10.3760/cma.j.issn.1001-0939.2017.08.016.

[21] HerthFJ, EberhardtR, StermanD, et al. Bronchoscopic transparenchymal nodule access (BTPNA): first in human trial of a novel procedure for sampling solitary pulmonary nodules[J]. Thorax, 2015, 70(4):326-332. DOI: 10.1136/thoraxjnl-2014-206211.

[22] SunJ, CrinerGJ, DibardinoD, et al. Efficacy and safety of virtual bronchoscopic navigation with fused fluoroscopy and vessel mapping for access of pulmonary lesions[J]. Respirology, 2022, 27(5):357-365. DOI: 10.1111/resp.14224.

[23] ParkS, YoonHY, HanY, et al. Diagnostic yield of additional conventional transbronchial lung biopsy following radial endobronchial ultrasound lung biopsy for peripheral pulmonary lesions[J]. Thorac Cancer, 2020, 11(6):1639-1646. DOI: 10.1111/1759-7714.13446.

[24] ZhouL, WangF, XuX, et al. Is conventional transbronchial lung biopsy out: the evaluation of clinical value in diffuse parenchymal lung disease[J]. Clin Respir J, 2022, 16(9):596-603. DOI: 10.1111/crj.13524.

[25] BiswasA, MehtaHJ, SriramPS. Diagnostic Yield of the Virtual Bronchoscopic Navigation System Guided Sampling of Peripheral Lung Lesions using Ultrathin Bronchoscope and Protected Bronchial Brush[J]. Turk Thorac J, 2019, 20(1):6-11. DOI: 10.5152/TurkThoracJ.2018.18030.

[26] HiddingaBI, SlebosDJ, David KosterT, et al. The additional diagnostic value of virtual bronchoscopy navigation in patients with pulmonary nodules-the NAVIGATOR study[J]. Lung Cancer, 2023, 177:37-43. DOI: 10.1016/j.lungcan.2023.01.012.

[27] XuCH, WangJW, WangW, et al. The diagnosis value of endobronchial ultrasound transbronchial lung biopsy combined with rapid on-site evaluation in peripheral lung cancer[J]. Clin Respir J, 2020, 14(5):447-452. DOI: 10.1111/crj.13151.

[28] ZhengX, XieF, LiY, et al. Ultrathin bronchoscope combined with virtual bronchoscopic navigation and endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions with or without fluoroscopy: a randomized trial[J]. Thorac Cancer, 2021, 12(12):1864-1872. DOI: 10.1111/1759-7714.13995.

[29] MinezawaT, OkamuraT, YatsuyaH, et al. Bronchus sign on thin-section computed tomography is a powerful predictive factor for successful transbronchial biopsy using endobronchial ultrasound with a guide sheath for small peripheral lung lesions: a retrospective observational study[J]. BMC Med Imaging, 2015, 15:21. DOI: 10.1186/s12880-015-0060-5.

[30] AsanoF, ShinagawaN, IshidaT, et al. Virtual bronchoscopic navigation combined with ultrathin bronchoscopy. A randomized clinical trial[J]. Am J Respir Crit Care Med, 2013, 188(3):327-333. DOI: 10.1164/rccm.201211-2104OC.

[31] TobaH, KondoK, MiyoshiT, et al. Fluoroscopy-assisted thoracoscopic resection after computed tomography-guided bronchoscopic metallic coil marking for small peripheral pulmonary lesions[J]. Eur J Cardiothorac Surg, 2013, 44(2):e126-e132. DOI: 10.1093/ejcts/ezt220.

[32] SatoM, OmasaM, ChenF, et al. Use of virtual assisted lung mapping (VAL-MAP), a bronchoscopic multispot dye-marking technique using virtual images, for precise navigation of thoracoscopic sublobar lung resection[J]. J Thorac Cardiovasc Surg, 2014, 147(6):1813-1819. DOI: 10.1016/j.jtcvs.2013.11.046.

[33] AnayamaT, HirohashiK, MiyazakiR, et al. Near-infrared dye marking for thoracoscopic resection of small-sized pulmonary nodules: comparison of percutaneous and bronchoscopic injection techniques[J]. J Cardiothorac Surg, 2018, 13(1):5. DOI: 10.1186/s13019-018-0697-6.

[34] Xu Chunhua, Chi Chuanzhen, Wang Wei, et al. Clinical value of video-assisted thoracoscopic surgery under bronchial ultrasound-guided ultrafine bronchoscopy combined with methylene blue positioning for small pulmonary nodules[J]. Chinese Journal of Thoracic and Cardiovascular Surgery, 2018, 34(5):278-280. DOI: 10.3760/cma.j.issn.1001-4497.2018.05.003.

[35] AbbasA, KadakiaS, AmburV, et al. Intraoperative electromagnetic navigational bronchoscopic localization of small, deep, or subsolid pulmonary nodules[J]. J Thorac Cardiovasc Surg, 2017, 153(6):1581-1590. DOI: 10.1016/j.jtcvs.2016.12.044.

[36] IizukaS, KurodaH, YoshimuraK, et al. Predictors of indocyanine green visualization during fluorescence imaging for segmental plane formation in thoracoscopic anatomical segmentectomy[J]. J Thorac Dis, 2016, 8(5):985-991. DOI: 10.21037/jtd.2016.03.59.

[37] LachkarS, BasteJM, ThibervilleL, et al. Pleural dye marking using radial endobronchial ultrasound and virtual bronchoscopy before sublobar pulmonary resection for small peripheral nodules[J]. Respiration, 2018, 95(5):354-361. DOI: 10.1159/000486205.

[38] BowlingMR, FolchEE, KhandharSJ, et al. Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy[J]. Clin Respir J, 2019, 13(11):700-707. DOI: 10.1111/crj.13077.

[39] YangSM, YuKL, LinJH, et al. Cumulative experience of preoperative real-time augmented fluoroscopy-guided endobronchial dye marking for small pulmonary nodules: an analysis of 30 initial patients[J]. J Formos Med Assoc, 2019, 118(8):1232-1238. DOI: 10.1016/j.jfma.2019.04.017.

[40] ChellaA, LucchiM, AmbrogiMC, et al. A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection[J]. Eur J Cardiothorac Surg, 2000, 18(1):17-21. DOI: 10.1016/s1010-7940(00)00411-5.

[41] ZhouZ, WangZ, ZhengZ, et al. An "alternative finger" in robotic-assisted thoracic surgery: intraoperative ultrasound localization of pulmonary nodules[J]. Med Ultrason, 2017, 19(4):374-379. DOI: 10.11152/mu-1053.

[42] YanagiyaM, SatoM, IjiriN, et al. Virtual-assisted lung mapping using dual staining with indocyanine green and indigo carmine enhanced marking detectability[J]. J Thorac Dis, 2022, 14(4):1061-1069. DOI: 10.21037/jtd-21-1829.

[43] SatoM, KobayashiM, KojimaF, et al. Effect of virtual-assisted lung mapping in acquisition of surgical margins in sublobar lung resection[J]. J Thorac Cardiovasc Surg, 2018, 156(4):1691-1701.e5. DOI: 10.1016/j.jtcvs.2018.05.122.

[44] YangQ, HanK, LvS, et al. Virtual navigation bronchoscopy-guided intraoperative indocyanine green localization in simultaneous surgery for multiple pulmonary nodules[J]. Thorac Cancer, 2022, 13(20):2879-2889. DOI: 10.1111/1759-7714.14633.

[45] Expert consensus on preoperative assisted localization technology for pulmonary nodules (. Expert consensus on preoperative assisted localization technology for pulmonary nodules (2019 edition)[J]. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(2):109-113. DOI: 10.7507/1007-4848.201812072.

[46] PerikleousP, MayerN, FinchJ, et al. Treatment of pulmonary carcinoid tumors with bronchoscopic cryotherapy: a 28-year single-center experience[J]. J Bronchology Interv Pulmonol, 2022, 29(1):71-82. DOI: 10.1097/LBR.0000000000000791.

[47] XieF, ZhengX, XiaoB, et al. Navigation bronchoscopy-guided radiofrequency ablation for nonsurgical peripheral pulmonary tumors[J]. Respiration, 2017, 94(3):293-298. DOI: 10.1159/000477764.

[48] ChanJ, LauR, NgaiJ, et al. Transbronchial microwave ablation of lung nodules with electromagnetic navigation bronchoscopy guidance-a novel technique and initial experience with 30 cases[J]. Transl Lung Cancer Res, 2021, 10(4):1608-1622. DOI: 10.21037/tlcr-20-1231.

[49] ZhongCH, FanMY, XuH, et al. Feasibility and safety of radiofrequency ablation guided by bronchoscopic transparenchymal nodule access in Canines[J]. Respiration, 2021, 100(11):1097-1104. DOI: 10.1159/000516506.

[50] XieF, ChenJ, JiangY, et al. Microwave ablation via a flexible catheter for the treatment of nonsurgical peripheral lung cancer: a pilot study[J]. Thorac Cancer, 2022, 13(7):1014-1020. DOI: 10.1111/1759-7714.14351.

[51] Chinese Society of Clinical Oncology (CSCO) Expert Committee on Tumor Ablation Therapy, Chinese Medical Doctor Association Tumor Ablation Therapy Technical Expert Group, Chinese Anti-Cancer Association Tumor Ablation Therapy Professional Committee, et al. Clinical practice guidelines for image-guided thermal ablation in the treatment of primary and metastatic lung tumors (2021 edition)[J]. Chin J Internal Medicine, 2021, 60(12):1088-1105. DOI: 10.3760/cma.j.cn112138-20210814-00554.

[52] Interventional Respiratory Disease Group, Chinese Society of Respiratory Diseases. Guidelines for the use of diagnostic flexible bronchoscopy in adults (2019 edition)[J]. Chinese Journal of Tuberculosis and Respiration, 2019, 42(8):573-590. DOI: 10.3760/cma.j.issn.1001?0939.2019.08.005.

[53] FolchEE, BowlingMR, PritchettMA, et al. Navigate 24-month results: electromagnetic navigation bronchoscopy for pulmonary lesions at 37 centers in Europe and the United States[J]. J Thorac Oncol, 2022, 17(4):519-531. DOI: 10.1016/j.jtho.2021.12.008.

[54] HarzheimD, StermanD, ShahPL, et al. Bronchoscopic transparenchymal nodule access: feasibility and safety in an endoscopic unit[J]. Respiration, 2016, 91(4):302-306. DOI: 10.1159/000445032.

[55] Expert Group on the Diagnosis, Treatment and Management of Pulmonary Nodules in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. Expert consensus on risk management of pulmonary nodule biopsy[J]. Diagnostics - Theory & Practice, 2022, 21(1):22-31. DOI: 10.16150/j.1671-2870.2022.01.006.

[56] KoizumiT, TsushimaK, TanabeT, et al. Bronchoscopy-guided cooled radiofrequency ablation as a novel intervention therapy for peripheral lung cancer[J]. Respiration, 2015, 90(1):47-55. DOI: 10.1159/000430825.

[57] YanagiyaM, KawaharaT, UedaK, et al. A meta-analysis of preoperative bronchoscopic marking for pulmonary nodules[J]. Eur J Cardiothorac Surg, 2020, 58(1):40-50. DOI: 10.1093/ejcts/ezaa050.

[58] YangYL, LiZZ, HuangWC, et al. Electromagnetic navigation bronchoscopic localization versus percutaneous CT-guided localization for thoracoscopic resection of small pulmonary nodules[J]. Thorac Cancer, 2021, 12(4):468-474. DOI: 10.1111/1759-7714.13775.

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