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Objectives We proposed a new virtual bronchoscopy tool to improve the accuracy of traditional transbronchial needle aspiration for mediastinal staging. Methods Chest-computed tomographic images (1 mm thickness) were reconstructed with Osirix software to produce a virtual bronchoscopic simulation. The target adenopathy was identified by measuring its distance from the carina on multiplanar reconstruction images. The static images were uploaded in iMovie Software, which produced a virtual bronchoscopic movie from the images; the movie was then transferred to a tablet computer to provide real-time guidance during a biopsy. To test the validity of our tool, we divided all consecutive patients undergoing transbronchial needle aspiration retrospectively in two groups based on whether the biopsy was guided by virtual bronchoscopy (virtual bronchoscopy group) or not (traditional group). The intergroup diagnostic yields were statistically compared. Results Our analysis included 53 patients in the traditional and 53 in the virtual bronchoscopy group. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for the traditional group were 66.6%, 100%, 100%, 10.53% and 67.92%, respectively, and for the virtual bronchoscopy group were 84.31%, 100%, 100%, 20% and 84.91%, respectively. The sensitivity ( P = 0.011) and diagnostic accuracy ( P = 0.011) of sampling the paratracheal station were better for the virtual bronchoscopy group than for the traditional group; no significant differences were found for the subcarinal lymph node. Conclusions Our tool is simple, economic and available in all centres. It guided in real time the needle insertion, thereby improving the accuracy of traditional transbronchial needle aspiration, especially when target lesions are located in a difficult site like the paratracheal station.

Lung cancer still represents the leading cause of cancer-related death, and the long-term survival rate remains low. Computed tomography (CT) is currently the most common imaging modality for lung diseases recognition. The purpose of this work was to develop a simple and easily accessible virtual bronchoscopy system to be coupled with a customized electromagnetic (EM) tracking system for navigation in the lung and which requires as little user interaction as possible, while maintaining high usability. The proposed method has been implemented as an extension to the open-source platform, 3D Slicer. It creates a virtual reconstruction of the airways starting from CT images for virtual navigation. It provides tools for pre-procedural planning and virtual navigation, and it has been optimized for use in combination with a $$5^{\circ }$$ of freedom EM tracking sensor. Performance of the algorithm has been evaluated in ex vivo and in vivo testing. During ex vivo testing, nine volunteer physicians tested the implemented algorithm to navigate three separate targets placed inside a breathing pig lung model. In general, the system proved easy to use and accurate in replicating the clinical setting and seemed to help choose the correct path without any previous experience or image analysis. Two separate animal studies confirmed technical feasibility and usability of the system. This work describes an easily accessible virtual bronchoscopy system for navigation in the lung. The system provides the user with a complete set of tools that facilitate navigation towards user-selected regions of interest. Results from ex vivo and in vivo studies showed that the system opens the way for potential future work with virtual navigation for safe and reliable airway disease diagnosis.

This thesis describes the development of an open-source system for virtual bronchoscopy used in combination with electromagnetic instrument tracking. The end application is virtual navigation of the lung for biopsy of early stage cancer nodules. The open-source platform 3D Slicer was used for creating freely available algorithms for virtual bronchscopy. Firstly, the development of an open-source semi-automatic algorithm for prediction of solitary pulmonary nodule malignancy is presented. This approach may help the physician decide whether to proceed with biopsy of the nodule. The user-selected nodule is segmented in order to extract radiological characteristics (i.e., size, location, edge smoothness, calcification presence, cavity wall thickness) which are combined with patient information to calculate likelihood of malignancy. The overall accuracy of the algorithm is shown to be high compared to independent experts' assessment of malignancy. The algorithm is also compared with two different predictors, and our approach is shown to provide the best overall prediction accuracy. The development of an airway segmentation algorithm which extracts the airway tree from surrounding structures on chest Computed Tomography (CT) images is then described. This represents the first fundamental step toward the creation of a virtual bronchoscopy system. Clinical and ex-vivo images are used to evaluate performance of the algorithm. Different CT scan parameters are investigated and parameters for successful airway segmentation are optimized. Slice thickness is the most affecting parameter, while variation of reconstruction kernel and radiation dose is shown to be less critical. Airway segmentation is used to create a 3D rendered model of the airway tree for virtual navigation. Finally, the first open-source virtual bronchoscopy system was combined with electromagnetic tracking of the bronchoscope for the development of a GPS-like system for navigating within the lungs. Tools for pre-procedural planning and for helping with navigation are provided. Registration between the lungs of the patient and the virtually reconstructed airway tree is achieved using a landmark-based approach. In an attempt to reduce difficulties with registration errors, we also implemented a landmark-free registration method based on a balanced airway survey. In-vitro and in-vivo testing showed good accuracy for this registration approach. The centreline of the 3D airway model is extracted and used to compensate for possible registration errors. Tools are provided to select a target for biopsy on the patient CT image, and pathways from the trachea towards the selected targets are automatically created. The pathways guide the physician during navigation, while distance to target information is updated in real-time and presented to the user. During navigation, video from the bronchoscope is streamed and presented to the physician next to the 3D rendered image. The electromagnetic tracking is implemented with 5 DOF sensing that does not provide roll rotation information. An intensity-based image registration approach is implemented to rotate the virtual image according to the bronchoscope's rotations. The virtual bronchoscopy system is shown to be easy to use and accurate in replicating the clinical setting, as demonstrated in the pre-clinical environment of a breathing lung method. Animal studies were performed to evaluate the overall system performance.

Objective : The aim of this study was to compare the results of virtual bronchoscopy (VB) images in defining tracheobronchial pathologies with those of fiber-optic bronchoscopy (FOB) in patients with clinical indication for bronchoscopy. Methods : Twenty-two patients with bronchoscopy indication were evaluated with FOB and VB. The VB results were evaluated blindly, independent of the FOB results. Results : In 19 of the 22 patients, tracheobronchial abnormalities were present on FOB, whereas 3 patients had normal findings on FOB. In 17 of 19 patients, VB demonstrated the FOB diagnosis of tracheobronchial abnormality. While FOB detected 11 endoluminal lesions, VB detected 6. While FOB detected 20 obstructive lesions, VB detected 26. In evaluating external compression, FOB detected 2 lesions and VB detected 15. Conclusions : VB is a non-invasive, uncomplicated, and reproducible examination method in patients with an indication for thorax examination. Virtual bronchoscopy could find a clinically broader field of application in the future.

Occasionally, we have difficulty in diagnosing small peripheral pulmonary nodules. However, efforts have been made to resolve this problem. For instance, computed-tomography (CT), positron emission tomography (PET), flexible bronchoscopy examination (BF), and videoassisted thoracic surgery (VATS) have been performed to investigate such nodules. We have used endobronchial ultrasonography with a guide-sheath (EBUS-GS) for BF examination, and recently applied the virtual reality technique "virtual bronchoscopy (VB)". Here, we present a case in which a combined technique with VB and EBUS-GS was useful. The patient was a 54-year-old man with a persistent cough and chest pain. Small nodules were seen in the bilateral lungs on the chest CT taken at the local hospital. A slight increase in the CEA level (6.1 ng/ml; normal level< 5.0 ng/ml) was shown as well as an uptake in the latter term on PET. As a result, he was referred to our hospital for a detailed work-up. We applied VB to confirm the location of the tumor, which allowed us to approach the lesion easily. Furthermore, we precisely localized the lesion using EBUS-GS. Then a biopsy was performed, which demonstrated bronchiolitis obliterans organizing pneumonia (BOOP). As seen in this case, combining VB and EBUS-GS seems beneficial for diagnosing peripheral pulmonary nodules.

Virtual bronchoscopy is a new method for viewing helical/spiral computed tomography (CT) images of the tracheobronchial trees. Using commercially available software to process the CT data, the tracheobronchial trees can be inspected through a series of three-dimensional images. Recently, this technique has been increasingly used to detect benign and malignant airway stenosis. We report the findings of virtual bronchoscopy in a 41-year-old man with recurrent respiratory papillomatosis (RRP). Several tiny nodules were evident in the lower trachea. Fiberoptic bronchoscopy was performed 1 month later during a planned surgery for laryngeal papillomas, and the findings were in agreement with virtual bronchoscopy. Detection of intrabronchial spreading in RRP is important since peripheral seeding of RRP can cause complications, including recurrent pneumonia, obstructive atelectasis, hemoptysis, and, rarely, may degenerate to squamous cell carcinoma. Virtual bronchoscopy is an alternative method for inspecting the tracheobronchial trees in patients with RRP when laryngeal papillomas impede fiberoptic bronchoscopy.

Cushing syndrome (CS) is certainly one of the most challenging endocrine disorders. The greatest problem involves the differentiation between Cushing disease and ectopic ACTH syndrome. We report a patient with ACTH-dependent CS who elsewhere underwent unsuccessful transsphenoidal surgery for a pituitary microadenoma. In our institution, high resolution CT didn't show any chest tumor but laboratory data were consistent with ectopic ACTH secretion.Only In-111 Octreoscan, integrated with SPECT-CT and virtual bronchoscopy, allowed the diagnosis of ectopic Cushing syndrome due to occult bronchial carcinoid. Successful surgery was then performed. © 2009 by Lippincott Williams & Wilkins.

No abstract available. Article truncated after the first page. A 59 year-old woman with a 40 pack-year smoking history was referred to our practice with a 2.5 cm spiculated right upper lobe lung nodule for a diagnostic bronchoscopy. We performed electromagnetic navigation bronchoscopy under general anesthesia in the operating room. After successfully navigating to the lesion and obtaining 3 needle biopsy samples and two cytology brush samples we lost target alignment. After attempting to rotate and reposition the catheter several times it was decided to re-navigate from the trachea. Two images comparing virtual navigation to real anatomy during the first and second navigation attempts are provided bellow (Figures 1 and 2). Why are the virtual images different? 1. It is an artifact from respiratory movements; 2. The locatable guide is outside the sensing volume; 3. You should suspect a pneumothorax; 4. Your registration procedure was suboptimal, you should repeat it. ...

BACKGROUND: Since introduction of multislice CT scanners into clinical practice, virtual brochoscopy has gained a lot of quality and diagnostic potential. Nevertheless it does not have established place in diagnostics of tracheal and bronchi disorders and its potential has not been examined enough. Nowadays a majority of bronchial tree variants and lesions are revealed by bronchofiberoscopy, which is an objective and a relatively safe method, but has side effects, especially in higher-risk subjects. Therefore noninvasive techniques enabling evaluation of airways should be consistently developed and updated. MATERIALMETHODS: Material consisted of 100 adults (45 female, 55 male) aged between 18 and 65 years (mean 40 years, median 40.5 years, SD 14.02), who underwent chest CT examination by means of a 16-slice scanner. Every patient had normal appearance of chest organs, with the exception of minor abnormalities that did not alter airways route. Divisions of bronchial tree to segmental level were evaluated and assigned to particular types by means of virtual bronchoscopy projection. In case of difficulties MPR or MinIP projection was used. RESULTS: THE FREQUENCY OF LOBAR BRONCHI DIVISIONS OTHER THAN THE TYPICAL ONES WAS IN: right upper lobar bronchi 45%, left 55%; middle lobar bronchi 21%, lingula 26%; right lower lobar bronchi 28%, left 29%. Subsuperior bronchus or bronchi were found on the right side in 44% and on the left side in 37%. No dependency between types of bronchial divisions on different levels was found.

A case of severe COPD patient complicated by pneumomediastinum due to spontaneous tracheal perforation related to post-influenza vaccination is presented. The virtual bronchoscopy was superior to fiberoptic bronchoscopy and classic multi-slice CT in diagnosing the tracheal perforation. The use of virtual bronchoscopy should be considered as a reliable diagnostic tool in cases of pneumomediastinum especially due to the ability to explore the airways in both antegrade and retrograde navigation.

In diagnosing the aspiration of the foreign body (AFB) in children most important are: medical history, clinical signs and positive radiography of the lungs. Common dilemmas in the diff erential diagnosis are life-threatening asthma attacks or difficult pneumonia. Conventional rigid bronchoscopy (RB) is not recommended as a routine method. Virtual bronchoscopy (VB) can be a diagnostic tool for solving dilemmas. Fiber-optic bronchoscopy (FOB) has a therapeutic stake in severe cases. Herein, we describe a girl, at the age of 6, who was hospitalized due to rapid bronchoconstriction and based on the anamnesis, clinical symptoms and physical fi ndings the suspicion was that she aspirated the foreign body. Due to the poor general condition and possible sequel, the idea of RB was dropped out. Multidetector computed tomography of the chest and VB was performed and AFB was not found. Due to positive epidemiological situation, virus H1N1 was excluded. FOB established that the foreign body does not exist in the airways. During bronchoscopy numerous castings are aspirated from the peripheral airways which lead to faster final recovery. With additional procedures, the diagnosis of asthma was confirmed and for girl that was the first attack. Along with inhaled corticosteroids as prevention she feels well. Virtual bronchoscopy can be successfully used as a valid diagnostic procedure in suspected foreign body in the children’s lungs, but fiber-optic bronchoscopy remains most important diagnostic and therapeutic method.

Introduction: Virtual bronchoscopy (VB) is a new, noninvasive diagnostic technique that allows visualization of trachea and bronchi. Virtual images are created based on scans from helical multidetector computed tomography (CT) scans using a special protocol. The obtained reconstructed virtual image of the bronchial tree reflects pictures seen under conventional fibre-optic bronchoscopy (FOB). The aim of the study was to compare VB images of the bronchial tree with findings from FOB and to evaluate the diagnostic value of VB in the examination of central lung tumours. Material and methods: The studied group consisted of 40 patients with suspected central lung tumours, detected first on chest X-ray. Each patient underwent routine CT and FOB, followed by VB. Physicians performing FOB were blinded to VB results and vice versa. The presence of tumour, bronchial stenosis, and widening of the carina were the analysed features. Lung cancer was confirmed by histopathological examination in all patients, including 32 cases of non-small cell lung cancer (80%), 2 cases of small cell lung cancer (5%), 5 cases of squamous cell carcinoma (12.5%), and one case of carcinoid (2.5%). Results: Virtual bronchoscopy for bronchial tumour detection had a sensitivity of 79.5% and specificity of 95.5%. When bronchial stenosis was assessed, sensitivity was 58.6% and specificity was 98.1%, whereas detection of widening of carina had a sensitivity of 60.7% and specificity of 97.7%. Conclusions: The results indicate that virtual bronchoscopy is a highly sensitive and specific diagnostic method, of high clinical importance in the evaluation of lung tumours with central location.

Propósito. Conocer tipos y prevalencia de las variantes anatómicas de la segmentación bronquial, en pacientes a quienes se les realizó TC de Tórax Multidetector 64 (TCMD 64). Evaluar la capacidad de este método para el diagnóstico de las mismas. Material y métodos. Se estudiaron en forma retrospectiva los estudios tomográficos que incluyeron el tórax, en 156 pacientes adultos, con tomógrafo Toshiba Aquilion 64, con adquisiciones volumétricas del tórax, cortes de 0.5 mm, obteniendo imágenes que permitieron reconstrucciones MPR, 3D y visualización endoscópica virtual traqueobronquial, en el período entre mayo de 2007 y mayo de 2011, independientemente del motivo por el cual fueron solicitados. Resultados. De los 156 estudios examinados, 89 (57%) fueron de sexo masculino y 67 (43%) femenino. En su análisis se encontraron 52 variantes, en 47 pacientes, ya que en cinco de ellos se observaron dos variantes. Entre las más frecuentes fueron: de número (28 variantes-53%), de las cuales: 15 (28%) con bronquio sub-superior; 6 (11%) bronquio accesorio en lóbulo inferior izquierdo; 5 (10%) isomerismo de lóbulos inferiores; y 2 (4%) bronquio accesorio en lóbulo superior derecho. Entre las variantes de origen (24 variantes-47%) encontramos 17 variantes (33%) con bifurcación del lóbulo superior derecho; 6 (12%) trifurcación del bronquio del lóbulo superior izquierdo; y 1 (2%) bronquio traqueal accesorio. Conclusión.Las variantes anatómicas en el árbol traqueobronquial presentaron una prevalencia en nuestra población de estudio del 33%, hallándose 52 en 47 pacientes, siendo las más frecuentes la bifurcación del lóbulo superior derecho y el bronquio subsuperior. Su estudio y el de la anatomía total del árbol traqueo-bronquial mediante TCMD 64, independientemente del protocolo de estudio empleado, puede aportar información de utilidad previo a la realización de procedimientos más invasivos como la broncoscopía convencional. Purpose. A) To determine types and prevalence of anatomical variants of bronchial segmentation in patients who underwent 64-section Multidetector CT (MDCT) of the chest. B) To evaluate the ability of this method as a diagnostic tool. Material and methods. We conducted a retrospective review of chest computed tomography studies of 156 adult patients, performed with Toshiba, Aquilion 64 CFX, CT Scanner Equipment, with chest volumetric acquisitions, and cuts of 0.5 mm. Images obtained allowed MPR and 3D reconstructions, along with virtual endoscopic visualization of the tracheobronchial tree, in the study period from may 2007 to may 2011, irrespective of reasons to request those examinations. Results. Eighty-nine (57%) of the 156 cases corresponded to male patients and 67 (43%) to female.patients. Fifty-two variants were found in 47 patients, since in five of them two variants were observed. The most commonly encountered variants were: variant of number (28 variants, 53%), of which 15 (28%) showed sub-superior lobar bronchus, 6 (11%) accessory bronchus in the left lower lobe; 5 (10%) isomerism of lower lobes, and 2 (4%) accessory bronchus in the right upper lobe. Among variations of origin (24 variants, 47%) we found 17 variants (33%) with right upper lobe bifurcation; 6 (12%) exhibited trifurcation of the left upper lobe bronchus, and 1 (2%) showed accessory tracheal bronchus. Conclusion. Anatomical variants in the tracheobronchial tree exhibited a prevalence of 33% in our study population. We found 52 variants in 47 patients, the most common being bifurcation of the right upper lobe bronchus, and subsuperior lobar bronchus. The study of anatomical variants, along with total anatomy of the tracheobronchial tree by 64 MDCT, irrespective of study protocol applied, can provide useful information prior to performing more invasive procedures, such as conventional bronchoscopy.

Multislice helical CT generated virtual bronchoscopy (VB) represents one of the most recent developments in three-dimensional computer aided visualisation techniques. VB allows non-invasive and relatively accurate 3D evaluation of tracheobronchal tree. We performed virtual bronchoscopy and in-space 3D volume analysis on CT-data set acquired from sixty-four-year old male with bronchial cancer in order to demonstrate advantages and disadvantages of these methods in diagnostics and preoperative management of metastatic bronchial cancer. Siemens Somatom Emotion 16 helical CT scanner was used for data acquisition. Data post-processing was done with 3D Syngo 2006G software package from Siemens medical systems. CT scanning of the thorax was performed in heavy smoker with an expansive T4N1M1 malignant process in a superior lobe of the right lung accompanied with large metastatic lesion attached on the right lateral chest wall. Metastatic lesions were also found in vertebral column. In-space 3D analysis followed with virtual bronchoscopy had revealed obstruction of apical branch of superior lobe segmental bronchus. External compression done by tumor to the superior segmental and right main bronchus was found. We concluded that multi-slice CT in connection with VB became a possible non-invasive alternative to bronchoscopy, if tissue samples are not required.

Background: Progress in multislice computer tomography and computer software is making is possible to achieve high quality images of the trachea and bronchial tree. This new technique, called virtual bronchoscopy (VB), enables non-invasive, painless evaluation of the bronchial tree and trachea in a 3D presentation, which can be applied especially in pediatric diagnostics. Case report: This paper presents the value of VB in trachea and bronchial tree diagnostics in a five-year-old boy admitted to surgery for an operation on the humeral bone. The presence of a tracheal and bronchial tree defect was determined on the basis of the interview and previous examinations. Diagnosis of the upper airways was necessary due to the anesthetic planned for surgery. Virtual bronchoscopy was chosen as a safer, less risky method without general anesthesia. Results: Bronchofiberoscopy and virtual bronchoscopy are valuable and complementary methods for the imaging diagnostics of the trachea and bronchial tree. Virtual bronchoscopy can be a reference examination in many cases, especially in children.

Esophageal cancer may spread by direct extension to the tracheobronchial tree, aorta, pericardium, lungs, and diaphragm. The aim of the study is to present the CT images of esophageal carcinoma with invasion of surrounding structures. CT criteria of tracheobronchial invasion include the presence of an esophageal mass that displaces the trachea or bronchus from the spine or discrete indentation on the posterior wall of the trachea or bronchus on CT images. Bronchial stenosis or occlusion may be clearly seen in virtual bronchoscopy. An area of contact between the aorta and esophageal tumor greater than 90o is diagnostic for aortic invasion. Another criterion for predicting aortic invasion is obliteration of the triangular fat space between the esophagus, the aorta, and the spine. CT detection of pericardial invasion is based on the obliteration of fat planes and the presence of a mass effect or the presence of a mass effect with a concave deformity in this region. A fat plane separating the esophageal mass from the surrounding structures at all CT sections excludes an invasion.

PURPOSE: To describe an original protocol for single slice spiral Computed Tomography (CT) virtual bronchoscopy in the evaluation of patients with central airway stenoses and compare the results with fibreoptic bronchoscopy. MATERIALS AND METHODS: Ten patients (4 female and 6 male; age range 22-60 years; mean age 44 years) with endobronchial disease diagnosed by fibreoptic bronchoscopy (8 malignant tumours, 1 benign tumour and 1 fibroid stenosis) underwent virtual bronchoscopy with single slice spiral CT. A panoramic spiral CT scan of the whole chest was first obtained. Once the area of interest had been identified, a new contrast enhanced scan was performed, from bottom to top, with the following parameters: 2 mm slice thickness, 1 mm reconstruction index, 1.3 pitch, 120 Kvp, 80 mAs. Virtual bronchoscopy was generated with an upper threshold of -500 HU from the cross-sectional images of the second scan on a dedicated workstation. Axial, multiplanar reformations (MPR), and virtual endoscopy simulation were simultaneously visualised. Virtual CT bronchoscopy findings were compared with those of fibreoptic bronchoscopy. RESULTS: The protocol we used to perform single slice spiral CT virtual bronchoscopy enabled us to obtain virtual bronchoscopy images that correlated well with fibreoptic bronchoscopy findings in all cases, as well as allowing the visualization of the airways beyond the stenoses. Information about tissues surrounding the tracheobronchial tree was also available from axial and MPR images. Only in 1 case were motion artefacts observed. CONCLUSIONS: The set of the most appropriate parameters for performing virtual bronchoscopy by single slice spiral CT has not yet been standardized. In our opinion the appropriate selection of the protocol to adequately realize virtual bronchoscopic images is crucial when using CT devices such as the above, so as to achieve the correct balance between the quality of image definition and exposure dose.

PURPOSE: To describe an original protocol for single slice spiral Computed Tomography (CT) virtual bronchoscopy in the evaluation of patients with central airway stenoses and compare the results with fibreoptic bronchoscopy. MATERIALS AND METHODS: Ten patients (4 female and 6 male; age range 22-60 years; mean age 44 years) with endobronchial disease diagnosed by fibreoptic bronchoscopy (8 malignant tumours, 1 benign tumour and 1 fibroid stenosis) underwent virtual bronchoscopy with single slice spiral CT. A panoramic spiral CT scan of the whole chest was first obtained. Once the area of interest had been identified, a new contrast enhanced scan was performed, from bottom to top, with the following parameters: 2 mm slice thickness, 1 mm reconstruction index, 1.3 pitch, 120 Kvp, 80 mAs. Virtual bronchoscopy was generated with an upper threshold of -500 HU from the cross-sectional images of the second scan on a dedicated workstation. Axial, multiplanar reformations (MPR), and virtual endoscopy simulation were simultaneously visualised. Virtual CT bronchoscopy findings were compared with those of fibreoptic bronchoscopy. RESULTS: The protocol we used to perform single slice spiral CT virtual bronchoscopy enabled us to obtain virtual bronchoscopy images that correlated well with fibreoptic bronchoscopy findings in all cases, as well as allowing the visualization of the airways beyond the stenoses. Information about tissues surrounding the tracheobronchial tree was also available from axial and MPR images. Only in 1 case were motion artefacts observed. CONCLUSIONS: The set of the most appropriate parameters for performing virtual bronchoscopy by single slice spiral CT has not yet been standardized. In our opinion the appropriate selection of the protocol to adequately realize virtual bronchoscopic images is crucial when using CT devices such as the above, so as to achieve the correct balance between the quality of image definition and exposure dose.

This paper describes a method for the automated anatomical labeling of the bronchial branch extracted from a three-dimensional (3-D) chest X-ray CT image and its application to a virtual bronchoscopy system (VBS). Automated anatomical labeling is necessary for implementing an advanced computer-aided diagnosis system of 3-D medical images. This method performs the anatomical labeling of the bronchial branch using the knowledge base of the bronchial branch name. The knowledge base holds information on the bronchial branch as a set of rules for its anatomical labeling. A bronchus region is automatically extracted from a given 3-D CT image. A tree structure representing the essential structure of the extracted bronchus is recognized from the bronchus region. Anatomical labeling is performed by comparing this tree structure of the bronchus with the knowledge base. As an application, the authors implemented the function to automatically present the anatomical names of the branches that are shown in the currently rendered image in real time on the VBS. The result showed that the method could segment about 57% of the branches from CT images and extracted a tree structure of about 91% in branches in the segmented bronchus. The anatomical labeling method could assign the correct branch name to about 93% of the branches in the extracted tree structure. Anatomical names were appropriately displayed in the endoscopic view.