Efficacy and Safety of Cone-Beam CT Augmented Electromagnetic Navigation Guided Bronchoscopic Biopsies of Indeterminate Pulmonary Nodules

Round 1

Reviewer 1 Report

In this study, the authors used electromagnetic navigation (ENB), endobronchial ultrasound (REBUS) and cone-beam CT (CBCT) to improve the diagnostic yield for peripheral pulmonary nodules. I think their result (diagnostic yield=76%) was good even though small-sized, showing only 24% concentric REBUS pattern and representing only 35% bronchus sign. I can agree that the combined use of various modality could generally improve the diagnostic yield. I have some comments listed below.

1. Of these 3 modalities, which is the most important? I guess CBCT is important. Because these 17 nodules are small-sized, showing only 24% concentric REBUS pattern and representing only 35% bronchus sign, indicating difficult cases to diagnose. Nevertheless, the diagnostic yield was relative good. this is because CBCT could work well for second confirmation. Therefore, I suggest they should represent a typical case including CBCT image as a new figure, and add the CBCT findings which show relationship between locatable guide (LG) and nodule before biopsy in all cases in table 4. Within? or Adjacent to? or Not? In addition, they should discuss more about the importance of CBCT to improve the diagnostic yield in the Discussion part although new information such as robotic-assisted bronchoscopy is also important.

2. Page 3, line 114-115; the number of CBCT spins was 3.5. I think this is quite many. Why? I think radiation exposure is a big problem when using CBCT. The authors should address in the Discussion part. And they calculated the effective dose. How did they calculate? They also should mention the detail in the Methods part.

3. Page 4, line 167-168; The diagnostic yield 76% is thought to be good. The author mentioned‘ efforts to improve the diagnostic yield’. However, do they have any idea to archive this? They should address in the limitation part.

Author Response

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Reviewer 2 Report

Materials and methods:

-        Please more background on the cone beam CT and the electromagnetic navigation. These are not discussed in details.

-        Please provide a pictorial demonstration of the proposed method.

 

Procedure description:

-        Can you please provide the imaging resolution of the bronchoscope.

 

Results:

-        The authors mentioned that the proposed method had better efficacy. Can you please compare the efficiency with other reported methods.

 

Discussion:

-        Can the authors please add few biopsy real images? This would increase interest in the paper.

 

References:

-        Some references are more than 10 years old, and most of the references are at least 5 years old. Please use more recent articles.

Author Response

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Reviewer 3 Report

Thank you for the privilege of reviewing your interesting article on efficacy and safety of Cone-Beam Augmented Electromagnetic Needle Guided Bronchoscopic Biopsies. I enjoyed reading your article.

Please correct 2 sentences:line 108: replace: "17" by "In total, 17"

line 120: replace "67%" by "Overall, 67%"

 

Author Response

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Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The authors revised correctly according to the reviewer's comment.