Originally Broadcast Wednesday, July 14th
As the first to bring this technology to patients in New York State in July 2020, Dr. Ivanick has now performed more than 100 bronchoscopies using the platform, more than any other provider in New York State.
Robotic navigational bronchoscopy allows for access to remote nodules and lesions and biopsy with greater accuracy and precision, avoiding risks of delayed treatment or surgical complications. Presenter:
Nathaniel Ivanick, MD, FCCP
Assistant Professor of Oncology
Roswell Park Comprehensive Cancer Center
Hi, I'm Nathaniel ivanic. I'm an interventional pulmonologist and part of the Department of thoracic surgery at Roswell Park Comprehensive Cancer Center. And today I'm excited to be bringing you a demonstration of the monarch robotic Bronx scope. So let's get started by taking a look at the images on the patient that will be treating today. So the first part of planning any robotic bronchoscopy is to first take the cat, scan images from a recently obtained high resolution cT and use that to generate a virtual bronchus ka pic procedure, which allows us to know precisely where in the airways we're going to go. So we've got this cat scan on our gentlemen and now we're going to take a look to see what the nodule of interest is that we'll be going after. What we have here is an axial CT view um which shows the airways, including the tricky here, a soft Ghous front and back of the patient as we go down. We're going to be seeing precisely the areas where we'll want to go. So this gentleman has severe pain, lobular emphysema from Alpha one. Anti trips and efficiency. Um And so we'll need to be extremely careful as we go forward with taking our biopsies. And that's one reason that we're using the monarch robot today. As we go through, we see this very rounded and somewhat speculated nodule sitting in the left upper lobe, which is very concerning for a malignancy. However, in a gentleman like this, we couldn't jump right to a surgical resection because his risk of complications and the amount of remaining lung tissue that he'd have would be too little. So we need some other way to identify it. And that's where the robot comes in is a number of other smaller modules that we won't be going after Today. As this was the primary nodule of interest. The robotic technology allows us to build out the major airways that sit in a person's chest and help us to map out to these various areas to find where precisely we're going to go. So after we have decided on our nodule of interest, we can go and identify it added as a target and build a pathway out to it in this instance. Mhm. Because it's it's fairly close to a main airway. Were able to get a very good sense of its air wave properties in this three D. Reconstruction of the airways. So we know that we'll be driving down the trachea into the left main stem, into the left upper lobe and then from there into the anterior sub segment of the left upper lobe to find our target. Even with the nodule this close to a main airway, it's still helpful to use a navigational platform because it allows us to angle our our bronco scope in such a way that we can ensure accurate and safe biopsies. So this is the first part of a successful navigational bronchus copy we've identified on a computer image where precisely we need to go. We've identified in the operator's brain where precisely will need to go just in case there is a malfunction with the equipment. And we're gonna going to take this and combine this with electromagnetic navigation to make the most accurate uh procedure possible to minimize risk in this patient. So we've completed our planning for the robotic procedure. And now what we always do is follow that with an inspection bronchoscopy. This allows us to ensure that the patient doesn't have any tumour visible within the airway, which would mean that we could avoid uh the more detailed uh procedure, you can see this gentleman has some antique Asus and a little bit of extra because in the airways. But aside from that visible tumor heading to the left side, the left main stem, left upper lobe branch point to the lingua, the interior segment, which is where we will be looking for this nodule and the april and posterior segments, not only the basilar segments also look good. So with this in mind, we're going to get started with setting up the robotic Baraka scope to move forward with the procedure. So preparation for the monarch robot is extremely important because the operator doesn't have the same haptic feedback on their hands as they would. For a traditional bronchoscopy, we have to set everything up so that we can anticipate exactly um what we'll be seeing in the airway and um and ensure that the scope is properly set up so that I can navigate through the airways without too much difficulty. Got an A plus team which works to basically set this up, coordinate the electromagnetic field the um the endotracheal tube at the right length as well as setting up these, which basically serve as uh kind of stabilizers to allow the Bronx scope to go in. This is the monarch cart, it functions as the driver of the robotic bronchoscopes. And on the tower is where we have uh all the ah information with the navigation, the cat scan that we previously planned is now loaded into the tower. And what we're doing is we're merging the virtual bronchus coptic images of the airways with what we know of um ah where the Bronx scope is in space, using an electromagnetic field generator to do so. So once we've got our entire ah field set up will now load the bronchoscopes. The cart is designed to have a number of small actuators on it which allow the Bronx scope to turn with four different angles and these basically attached to uh police that are inside of both the bronchoscopes as well as the sheath. Both of these together allow for the articulation that's so important. Although this first one on this lighter ah this lighter bit that you see is the she that has the same actu waiting properties as the Bronx scope, which is the darker blue. And now we'll insert this in. So rather than driving this by hand like a traditional bronchus scope, we actually use um a remote control shaped like a playstation. Ah Sony playstation two ah basically drive out to the ah location an act and we are set to go. And so with this we begin, that's what we're doing now, is just driving down the airway into the endotracheal tube and then we perform a series of small registration steps that essentially aligns what the robot understands of where we are in space with what's present here in the electromagnetic field with the virtual bronchus coptic image that we got from the cat scan on syria. We adjust our role. Once we're registered, it's off to the races. They're driving down the left main stem. And what I'm seeing as I'm doing this as a virtual bronchus coptic image as well as where I'm going to my target as well as the actual visual image from the camera that's embedded within the Bronx scope. So as we get out a little further, we try to slow down to ensure that we going to get to our destination. Then what we can do is toggle from the first of these, which is the, which is the sheep over to this. And this is really interesting. This is a uh this is actually what I'm expecting here is that I'm seeing tumor within the airway as part of this lesion. So to recap Within about 30 seconds, we were able to drive our bronchoscopes out to the side of the lesion, which was not visible with conventional bronchoscopy. And we were actually able to see a view of what I expect to be tumor directly within a more distal airway segment. Now, to confirm, we're going to confirm with our radio, lead us to ensure that we have an accurate idea of what precisely we are looking at. And then after that we'll we'll measure it up with Flora Skopje and start taking biopsies. Now, we're working to see if we can match up our floral image with our ultrasound image with our visual image from the monarch camera. Quick shot. Please. Can I get a quick shot, please adjusting my position slightly. We're getting a view that has a portion of the target in it. Um You can pause it there and get a picture of that please. So this is really helpful in that. Even though we're able to see this, we can see on the screen and get a sense that this is not the most ideal position to get the ah biopsy in. So we're going to adjust our position slightly, trying to get a slightly better ultrasound view. Um Before we start our biopsy, I'm expecting this to give us what we call an E century few meaning just to the side of the target because that's how it lines up on the cat scan. Quick shot. All right, let's start this off here and can we freeze that please? So, what we're seeing right here on the edge is that our probe is directly next to a solid dense nodule. We measured it on the cat scan to be about 18 mm. This is 3.3 cm in total vertical or horizontal distance, so that roughly corresponds to about half of the screen. And I think that's what we're seeing here as the target lesion. So this corresponds with what we're seeing on the cat scan. And it's now time for us to start taking our biopsies. Actually, before I do that go Floral on, please. And floor off. And a quick shot there, it really is just at the entrance. So another hopeful part about tying this in with Flora Skopje. To minimize risk to this guy with advanced emphysema is to ensure that our scope will be positioned in such a way that we can take a biopsy without creating an injury right now I don't have a long length of space before I hit the nodule. But if I moved to a slightly different position, I should have it much more in line knowing where the ah instruments are coming out of. Also gives me a sense for where I'll get that s centric positioning on the cat scan or on ultrasound? Quick shot please. Quick shot. And ultrasound on please. Mhm. We're on please. And there we have it and looks down off. Could we get one more ah ultrasound picture of that please? Great. But and that actually corresponds. We can see on the we can see on the X ray what we're seeing looks to be the nodule in question. Alright with all this information in place, we're just gonna do one final test which is floral on please. And floor off. Can you mark there with the wax pen? For where? Where the edge of that is? It's only it's only on your screen. Okay now looks down off there. Quick shot there. So basically from here and we have our target. So with this in mind we'll start our biopsies. Yeah Let's do a 21 gauge please. So most studies demonstrate the highest diagnostic yield using a fine needle aspiration. So that's generally what we start with for our biopsies yep and floor on please. Let's go a needle out. Okay suction on getting good resistance not great. Great and needle back exhale. See what we get back screw probably yeah left upper lobe nodule. Clinical history is a pet avid nodule in an elderly gentleman with long smoking history and Off one Anti trips and efficiency and floor on please. And needle out. Okay. Election on should have better election this time. So one important thing is that we coordinate with our endoscopy staff. They can let us know. Yes it seems like we're bypassing into something more solid or something more airfield that can give us a sense. So even though things look good on the ultrasound image actually all and needle back we can ensure on this that we're not seeing straight up in airway which only gives us bronchial cells. Okay does it look like grabs him? Okay so generally our first slides we send uh we send immediately to the psychologist to take a look at and review while additional slides get put together in a pooled sample that we call a cell block. And this way even if there is too much blood to see on the initial biopsies were able to get it on subsequent biopsies and floor on please and needle out and section on this is okay an X ray off and needle back. One thing that's really nice about the monarch robot is that we're able to make micro adjustments so that if any given position that we're in doesn't yield good tissue. We can make very small angular adjustments which allow us to take tissue from a more advantageous area. So in this way even large modules or masses can be sampled from a number of different number of different areas. Right now we're getting great tissue back so we're not going to change our position and floral on and needle out and now we can see on our screen actually the needle penetrating into the lesion actually off. Please can actually instead of using X ray just follow that quick shot dr Okay. And needle back. So to recap where we are right now we've driven the scope into the left upper lobe and we spent a little bit of time adjusting our position to ensure that we had the most ideal position to both safely and accurately collect sample. We did that by looking with the radio Libous with the camera view with Flora Skopje all together uh to ensure that we had a view that had us directly adjacent to the target. Now we've been taking samples with the fine needle to essentially collect uh for slides as well as the cellblock. And following this, we're going to be taking samples in other ways while we wait for a call from our psychologist. All right and floor on please. And needle out section on ever this slow that. Okay. Yeah, I see it up there now. X ray off and needle back. That's she. Let me know when you think our cell block is completely. It looks good. Okay so we're gonna move on now to ah uh uh to biopsy with forceps. So if we go the pediatric gi please forceps biopsy has several advantages. First you can get a bigger swath of tissue. Second you can collect slides that reviewed with the psychologist in a touch prep as well as with the um as well as with his still pathology and gives two different opinions on the same tissue to ensure that you have the greatest amount of accuracy. Yes please. Once we collect samples for those, we often will then also collect for permanent pathology so that additional uh stains can be made and floor on please. And open slow close type we're off so hopefully you can see with this we're able to get really sizable chunks of tissue still and hopefully a safe manner floor on please. And open slow close, take quick shot there floor on please. And open slow close. Right. We often use a check somewhere during the course of the biopsy just to ensure that we're still in a advantageous position and we find that we still are. Yeah we're jumping and open low close. Okay. Usually psychology takes about 10 minutes or so to give us our first calls and by that time we built usually enough sample to be collecting also surgical pathology floor on please. And open slow close thanks. How's our frozen looking good. Okay, one more for frozen and then we'll send that ah floor on please. And open slow close. Right. The tissue sample that we're able to get were able to run for the various targeted mutations that medical oncologists will want to know about as well as immunology studies such as the PDO one status would like any of this chance to go. Let's take a look at what we've got so far. So I think that looks good. Let's send that to frozen. Will collect a few more. Right. No. Okay. Excellent. Thanks very much. That's it for us then. So we just got a call back from psychology. It is positive for what we're anticipating to be non small cell lung cancer which fits with the clinical picture in a gentleman with a heavy smoking history. So that's it for the navigation portions of the procedure. I think the highlights are that we were able to ah able to plan this case, navigate out to the lesion in the lesion. We couldn't see with traditional bronchus bronchoscopy. And once we were there we confirmed our position so that we could take uh samples safely and accurately um to be able to ah to be able to get this gentleman a diagnosis. We're now going to move on to a non televised portion which is going to be Eavis bronchoscopy to ah collect additional samples. Thanks very much for tuning in for this. Uh We'll jump now into a live question and answer session. Thank you for tuning in to our demonstration of the monarch robotic bronchoscopy program. I'm delighted to be here tonight to take your questions live and share with you my experience using this technology over the last year, please feel free to submit your questions at any time using the submission form that you see on your screen before we jump into the questions. I wanted to provide a little more information about the patient that you just saw the received the procedure. So this gentleman, as I mentioned during the bronchoscopy video was a gentleman with advanced central lobular and pen lobular emphysema in part due to Alpha one anti trips and efficiency. He had been followed in the thoracic surgery clinic for some time because of waxing and waiting uh lung modules, many of which were suspected to be infectious in nature. In fact, he had previously had procedures including a biopsy of a super oclock, vehicular lymph nodes, as well as a needless biopsy, which had looked to find evidence of malignancy, but it found non cash creating granulomas. This procedure that we did was what I believe to be the only safe procedure that could have gotten to that uh to that location to take the biopsy of the nodule. And as you saw in the video, were able to get a positive diagnosis on the first pass. Um and uh ibis bronchoscopy immediately following that, again demonstrated non castigating granulomas of the media, sino, lymph nodes. He's doing very well after the procedure without any complications and is looking forward to starting therapy on the screen. During the video recording, there was a poll question asking about whether the robot can also help to diagnose noncancerous conditions. Let's take a look at those responses so it looks like everyone answered the correct answer, which is yes, that the robotic bronchoscopes can be used to diagnose other conditions such as infection and inflammation. In fact, we sometimes use this when we're evaluating for the possibility of fungal infections, looking for abscesses in the lungs or answering the questions about cava, terry lesions on top of that. We're able to diagnose sarcoidosis and other inflammatory granulomas conditions with this technology. Now, we're going to put up our second poll question, You'll see that on your screen shortly if you haven't already. While you take a look at that question and log your answers, let's take some of your questions. And we have our first question coming across, which is how is the monarch robot? Different from how doctors previously sampled peripheral modules? And that's a great question. Um And it has uh it has several answers. So previously we had a couple of options as we looked at peripheral modules. First, there's conventional bronchoscopy, conventional bronchoscopy does have the ability to access a number of modules, but our diagnostic accuracy is unfortunately not the best With that. We're looking at diagnostic yields of somewhere around the 30 to 40% range And that even continues on recent studies where in 2018 they looked at um how well conventional bronchoscopy with a with Floral guidance was able to identify lesions and that was that about 39%. Um We also had radio Abbas used through a conventional or even thin bronchoscopes and that is a really effective tool for being able to identify these lesions. We were able to improve our diagnostic build from that, Depending on the literature that you read somewhere in the 50-60% range with that, but still by no means at a high enough percentage that we can confidently believe the answer of a negative bronchoscopy. Finally, there is navigational bronchoscopy in its traditional and standard sense using um one of the older platforms, including medtronic or um or the various systems uh and depending on the literature that's read, for instance, they acquire registry, had the diagnostic accuracy of those um More original technologies at somewhere in the 40% range. So clearly another technology is absolutely crucial if we're going to be able to get to these modules and have a chance at really believing, um either positive or negative answers. So robotic Bronchoscopy has a number of benefits first it has reached. So it's been demonstrated in studies that it is able to peripherally navigate between 1-6 more airway branch points than um than traditional bronchoscopes, including bronchoscopes of the same outer diameter with. So the reach assessment, they basically assessed whether or not a bronchoscopes that that had a four millimeter outer diameter compared to a four millimeter outer diameter robotic bronchoscopes could get to the same distance. And in fact, as it turned out, the robotic bronchoscopes was able to navigate much further out into the periphery. Obviously as we look at peripheral lung lesions, that's crucial. Uh So we think that the reason is because for anyone who's ever held the bronchoscopes recognized that only the distal tip is able to flex back and forth. Everything else is floppy um with the robotic scope, because of the actuators that basically allow for tension within the scope, it's able to maintain tension and that offers a support and offers the ability to get out into more difficult to reach areas including the bilateral upper loads, which are obviously certainly a challenge when it comes to uh diagnostic bronchoscopy. Um I would also add that the robotic bronchoscopes can be used with traditional systems such as the radio Libous. And in fact, as you saw in the video, I was using it to good effect to identify the lesion in an e centric position. I would also add that e centric position is less of a problem for a robotic bronchoscopy because of its ability to maintain stability. We are actually able to go uh we're actually able to um maintain a high degree of diagnostic accuracy um with uh with an e centric position somewhere around the 70% range is what's quoted in literature as compared to uh slim bronchoscopes. Plus radio Leavis really only has a diagnostic accuracy of the 30 to 40% range if they identify an e centric position as compared to a concentric or right in the center position. So thank you for that question. That is a great question. Next question that we have is your biopsy specimens were a pretty good size. What's the risk of pneumothorax with this technology? So that's a great question. Obviously the larger the biopsy specimens, the greater the chance that a pneumothorax may uh may result. Um And so we always have to be cognizant, not just of the biopsy size but also of the location of the biopsy. So for instance, even taking needle biopsies at a position that's very much adjacent to a a major fisher uh increases the risk. Some people think that the middle lobe taking biopsies, they're increases the risk and obviously being directly adjacent to the pleura also adds to adds to the risk. So the risk of pneumothorax with this procedure is anywhere in the range of what's quoted in literature as low as about 2% to as high as about 10%,, And while the 10% does sound high, I would say that um that that does still compare favorably to other techniques, such as CT guided biopsies, where the risk can be somewhere in the 20 to as high as 60% range. Again, depending on the study that you're looking at. Um And so, so yes, new authorities do happen, luckily, luckily though they're easily managed with chest tubes and frequently discharged the next day and not even chest tubes in every single patient. Uh One uh interventional pulmonologist famously said, I don't fear numa authorities, but I do fear lack of diagnosis and I I kind of take that to heart when I'm taking my biopsies to make sure that we don't have the latter, which is not a complication, but obviously not a great thing. The next question that we have is, can fiduciaries be placed with this system? Yes, So financial markers for those of you who are unfamiliar are tiny little uh metal uh metal markers that can be used um and we can provide radiation um that is directed at the area around that financial marker. We use those frequently with certain types of radiation oncology platforms to be able to direct the radiation using respiratory gating. What does that mean? Basically as the lung moves up and down and may even move side to side, we know that modules can move anywhere from 1-6 cm from their original location. We know that from the time of biopsy and that probably holds true to a similar degree, especially for lower lobe modules. Obviously you don't want to provide radiation to areas that should not receive it. And thus uh financial markers can be placed to localize around that that system. And yes, I have placed financial markers um in a number of these patients, especially those that were anticipating, are likely going to um likely going to receive radiation as their as their primary treatment. Thank you. Great question. The next question is, have you used the system to localize these modules for robotic resection such as I. C. G. Or methylene blue? That's a great question. Um No I haven't. Uh And uh that uh comes into merely just a matter of feasibility um to give some background to those unfamiliar, basically methylene blue can be used to identify precisely the area where where the lesion is. Uh So that a surgeon could then go in and use a reception techniques such as a wedge wedge resection to spare as much lung tissue as possible. Um It is more the matter of logistics that has limited me from doing this more than anything else. I think it's entirely feasible to do. But just with the procedural schedule and the surgical schedule, the two together um sometimes might make this challenging. And since we want to go directly from methylene blue right to the operating room to treat in those instances. No, I have not yet. Although I'd be excited to try at some point in the future. Okay, so another great question. Ct guided biopsy is an excellent and accurate way for diagnosing peripheral modules. Why not just use this technique? So great question. Um I would say a few things. So first, cT guided biopsy is absolutely um a very high diagnostic accuracy depending on on the central that you're looking at, it can be as high as 95%. So wow, fantastic way of diagnosing it. We have excellent interventional radiologists here who are able to accomplish that without difficulty. Um sometimes the reason that I would recommend robotic bronchoscopy would be instead because of patient preference. Some patients are very nervous with the idea of being awake and having to hold their breath as they are about to receive a biopsy in a given area. Um some people like the idea instead of being fully asleep for the duration of the procedure. The second is that when we consider the possibility of how to take uh how to stage the media steinem afterward, obviously with cT guided biopsy, once you get the answer at a peripheral nodule, that's all you can do at that moment. You're not going to then go and do ct guided biopsies of the media spinal lymph nodes. That's one thing that I can offer with robotic bronchoscopy. I can first start with robotic bronchoscopy and then regardless of the answer that I get, I can then proceed with staging the media steinem. There have been instances where um the initial calls on the table are negative for malignancy and then a day or two later it pops up that yes, in fact there was a cancer and um and because of that, I have I have moved more now toward um staging the media steinem entirely unless there's a really good reason not to. So that's an added benefit over the over the ct guided biopsies. The third would be complication rate as I alluded to already. So, um the rate of 2 to 10% for pneumothorax as compared to the potential risk of hemothorax or pneumothorax with a ct guided biopsy that could be as high as 20 to 60% and 10% or so for uh for major bleeding. All those things I think are important considerations, especially as we consider um patient for lT as as as we do this again though. See, take out a biopsy is an excellent way to proceed and speaking to the pneumothorax question just a little bit more. So if you consider that for this gentleman that we just treated, for instance, he had large blobs really surrounding many portions of his chest and that lung nodule, a needle inserted into that area would almost be guaranteed to cause a pneumothorax, you might say, well, okay, he gets a pneumothorax, he gets the chest tube, he's okay. But as he gets a pneumothorax, sometimes the lung collapses down and away from the chest wall, and so they're stuck, kind of chasing after the nodule as long as collapsing away, and that can create additional risks and additional challenges. So for instances like this, um proceeding with something like a robotic bronchoscopy, were able to stabilize our position and take biopsies in that way is really the most ideal thing that we can do. Um And so I think we'll be demonstrated that in our procedure. Um So let's go to the poll question here. Um So again, the poll question was, what's the historical yield of conventional bronchoscopy? When used with Flora Skopje? If the nodule is not central? So 50% 58% of you answered. Uh 30% which is the correct answer. Yeah, so less than a coin flip. Um you know, if we're using conventional bronchoscopy and what I take that to mean as well as the more recent studies um from Nicole tanner at all, um where they compared to conventional bronchoscopy and and thin broncos go plus radio Libous is um if you can't see the lesion uh with a regular bronchus scope, um it's probably reasonable to take a couple of experimental biopsies, but I wouldn't expect to get your answer there. And so if you're studying the CT scan and trying to determine, should I should I maybe make a referral or take a crack at it myself? Um You know, just consider that even at high volume centers, they were having numbers that were not ideal. 30% is really not an ideal percentage to be able to say, Well, I subjected this patient to a bronchoscopy and I gave it a shot. Um so as as a point of consideration, it's um 30-40% is a range where it's probably reasonable to consider other options if if that's um what it's looking like. So I'd say if when you go in with the Bronx scope of what you're seeing is an airway that looks largely normal and we know that we can get out to about four branch points and nothing past that. I would stop there. I would say, okay, let's call dr ivanic, let's try to get some additional techniques to take this biopsy. So next question is, what is your typical time frame for seeing a person in clinic until the patient can receive a robotic broncos, bronchoscopy procedure at your institution? Uh so I'm proud to say very quickly. So I routinely get patients in within 1-2 weeks after after hearing about them, either through an email or otherwise, you reach out to me in another way, especially with concerns and the need to move quickly. We can generally accommodate getting them in within that one or two week time frame. Um And uh and we make an extra effort to do that because these patients are frightened. They've got these modules, they're not certain about what to do about them, and so we really make an effort to as much as possible, get them in quickly. Okay, so we've got another question. What are the possible complications of robotic bronchoscopy? Uh so another great question. I would say. There are a few that I think are the most notable first pneumothorax and again somewhere in the range of 2-10%. That risk is um probably highest if you're looking at the middle lobe or in areas of significant emphysema. Um Sometimes that's sometimes the upper lobe turns out to be the safest surprisingly. Um so to to 10% about I would say in my experience thus far um my range is probably in the six or 7% range. Um if you're uh considering that um and again I would say I don't fear pneumothorax, I fear um if you're non diagnostic um bleeding is really not a significant issue. So thankfully we really have not had any major bleeds in the 100 robotic bronchoscopy is that we've done we'll have some amount of blood coming out but really really even less than you would expect for like a radio Libous. Um Sometimes people are concerned with various procedures about the risk of bleeding. Again haven't really seen that to be a significant risk. Risk of infection would be the other one that I would consider and that's probably under reported. But somewhere in the 1% range for a significant infection, obviously for many of these were going in to try to find the source of a nodule which may be an infection. Um but I would say that the risk of causing an infection during this procedure is fairly low. Um and then the risk of non diagnosis, so diagnostic yields is another way of saying that how likely are we to get an answer for these patients? So if you look at the literature, um we're looking somewhere in the range of 70-85%,, part of that is going to depend on the patient's nodule size. So if this is a nodule that's up to 15 millimeters in size, it's going to be a little bit harder to identify and take accurate biopsies as compared to na jewels that are in the 15 to 30 or even greater than 30 centimeters, 30 millimeter size. Um Another thing is what I see on my radio, Eavis. So if I go out with radio Libous and I'm able to see a concentric position, I really feel like I can believe pretty much anything that my pathologist or my psychologist is calling me back with because I'm in the center of it and I might change my position slightly to make sure I'm sampling it completely. But I really feel like that gives a really good estimate of everything. Um The I would say those would be the big ones for for non diagnosis. So I'd say somewhere in the 70 to 85% range I mentioned uh e centric view on radio Libous ground glass modules might be another thing that you're considering. So um in various studies, surprisingly, actually they haven't shown a decadent in diagnostic accuracy with ground glass modules as compared to solid nodules. That's interesting because that really speaks to the power of the navigational technology. Because when you extend a radio ibis, looking for a ground glass nodule, you might come up with this blizzard pattern, which is sometimes described, but past that you really don't see much and I can tell you it's a lot more comforting to put a radio Libous out and see that you're in the center of a lesion as compared to this uh this blizzard pattern. But despite that, we also have biopsied, we have biopsied ground glass modules with good effect. So um so and we're often looking for Lepic adenocarcinoma and other things of that nature with that. Um So those would be the major complications I'd I'd think about. Um Okay, next question, is it possible to watch this live stream again or the program available in some format to watch a second time? It was an excellent program. Well, thank you. Um and thank you to the entire team who helped put this together. Yes, it will be possible. It will be up in a few days on the, on the broadcast website and we will give some information on that at the, at the end of this. Uh another question, would it be feasible or advantageous to perform media spinal staging with the monarch system? That is an interesting question. Um So, so probably not. And the reason is that um that at the end of the day, what you want at any given time is you want to be able to see your needle go into a lesion or go into a lymph node, for instance. Um While it's probably feasible to do, I have to just be honest and say that the linear ibis, the way that we typically stage the media steinem right now, it just can't be beat. It's basically more reliable than surgical. Media stone, Oscar p. You can watch a needle penetrate into a lymph node and as I like to say, the area in the center of the chest. The media steinem is an area of high priced real estate. You've got your aorta, you've got your pulmonary artery, you have your heart lower down at the sub criminal. Um, I wouldn't want to use an old image, like a CT guidance sort of image that had been collected the day before to trust that I knew where my to know where my Bronx scope was. As I inserted. Well, someone do it at some point in time and probably write a small case report on it. Probably so, but it won't be me. I think I'm going to go with what is recommended by the professional societies but an interesting question and it does bring up what do you do for na jewels that are just a little bit too far to get to from the with a conventional even scope but are still pretty approximately. I'd say that is an area where the monarch can shine because once you position yourself in the correct location, you can actually, you can actually puncture through the wall of an airway with a little bit greater success with needles, um a varying sizes. So there are some uh navigational platforms out there right now that actually use a very systematic sequence of puncturing through an airway wall and then actually dilating it slightly and going in through that to take biopsies. Um I think we accomplish that by and large with the monarch robot already. If I'm looking at a peripheral or I'm sorry, somewhat central lesion, I can get to that spot and I can put a needle through it with a pretty high degree of accuracy because the the positioning remained so stable with the actuators that are basically holding the robotic scope in place. Um So that's an area where I think the robot really really can shine and help to take biopsies. But thanks. That's a interesting and thought provoking question. Um Okay, next question is, what type of lung lesions are you more confident using, going more confident going after and diagnosing with the robotic broncos, bronchoscopy system compared to legacy navigational bronchoscopy equipment? So that's a great question. Um I would say I would say that I'm I'm more comfortable with almost any lesion going after than than with what what we had before. Now, Please don't get me wrong. The technology that we were using previously and sometimes still do use um uh was was excellent and it served its function. Um But in these instances now that I have the robotic uh broadcast uh Bronx scope available, um I really don't see a need to go back to those those older technologies. They don't have the stability, they don't have the reach, they don't have the visualization to take me all the way to the peripheral um edge of the airways, be able to really see with great effect what I'm, what I'm seeing and what I'm going to biopsy. Um And so for those reasons um there's something that I I probably won't won't really use anymore. So the backward answer to your question is I would feel more comfortable with any sort of lung nodule going after with the robotic scope than with the more traditional Super de Baron systems. Um Let's see if we've got any more. Okay uh So that looks like uh most of our most of our questions there. Um Thank you guys so much. Thank you for tuning in. It was a pleasure to be able to share some of my experiences and expertise with you and here are your perspectives and questions. Um The recording of this event will be available within a few days on our physician resources website so please feel free to reference back and share it with colleagues. You'll find it at physician resources dot Roswell Park dot org. Also more than happy to field questions after tonight or connect with you about a particular patient case. Please feel free to reach me by calling our physician line at 1 800 rpm D. And they'll be sure to connect me with you have a great evening everyone, be safe. Thanks very much. Yeah.