Advanced Bronchoscopic Approaches to Peripheral Pulmonary Lesions: a Narrative Review of Current and Emerging Techniques

Abstract

Peripheral pulmonary lesions (PPLs), defined by their location in the outer one-third of the lung, are expected to be identified with increasing frequency following the widespread adoption of lung cancer screening. The majority of PPLs will have a benign aetiology; however, obtaining tissue to exclude malignancy can be challenging, leading to high rates of benign surgical resections or prolonged surveillance imaging. Over the last two decades, there has been rapid advancement in bronchoscopic technologies, with the adoption of radial probe endobronchial ultrasound (RP-EBUS), ultrathin bronchoscopes, electromagnetic navigation bronchoscopy (ENB), virtual bronchoscopic navigation (VBN) and robotic assisted bronchoscopy (RAB). These technologies provide access to lesions that are inaccessible by conventional bronchoscopic approaches, with diagnostic yields comparable to those of CT-guided transthoracic needle biopsy (TTNB). Whilst these advanced technologies offer a lower risk of complications than CT-guided TTNB, they are significantly more expensive. In addition, advances in biopsy techniques, such as transbronchial cryobiopsy, have further enhanced the diagnostic yield for PPLs.

Recent data supports the potential for a one-stop ‘diagnose and treat’ approach, where advanced bronchoscopic platforms are combined with thoracic surgery and rapid onsite evaluation. This offers the potential to locate and diagnose nodules prior to potential resection, thereby reducing benign resections and shortening the diagnostic pathway. The therapeutic potential of these advanced bronchoscopic platforms is an active area of research, with the potential to deliver thermal ablation therapies and intralesional brachytherapy and chemotherapy agents. This narrative review summarises the current evidence base of this rapidly evolving field.

Key Summary Points

The last two decades have seen rapid technological advances in the ability to access peripheral pulmonary lesions (PPLs)

Multiple advanced bronchoscopic platforms including electromagnetic navigation bronchoscopy, virtual bronchoscopic navigation and robotic assisted bronchoscopy are able to access PPLs with a comparable yield and lower complication rate compared to CT-guided transthoracic needle biopsy

Advances in sampling techniques, such as cryobiopsy, have further improved the ability to diagnose PPLs

Advanced bronchoscopic platforms can be combined with thoracic surgery to provide a ‘one-stop’ diagnose and treat approach

The therapeutic potential of advanced bronchoscopic platforms is an active area of research

Introduction

Lung cancer is the most commonly diagnosed cancer worldwide, with an overall age-standardised incidence of 23.6 cases per 100,000 individuals, with an even higher incidence in the UK and USA of 30.1 and 31.9 per 100,000 respectively [1]. It remains the largest cause of cancer-related mortality in the UK with 33,100 deaths each year, representing 20% of all cancer related deaths [2].

Targeted lung cancer screening programmes utilising low-dose computed tomography (CT) imaging have transformed the diagnostic pathway, with significant reductions in lung cancer mortality [3–5]. The widespread uptake of screening has led to an increased burden of incidental findings, with an incidence of 2–3% for pulmonary nodules. More than 60% of these nodules are in the outer one-third of the lung [6, 7]. Around 1.5% of incidentally detected pulmonary nodules are malignant, and whilst the use of Brock and Herder models can risk stratify nodules to guide management decisions, there remains a 12–15% rate of benign resection [8, 9]. Furthermore, real-world data suggests around one-third of patients do not undergo biopsy prior to surgical resection of suspected lung cancer with small, peripheral lesions making histological diagnosis challenging [10, 11]. For those amenable to biopsy, CT-guided transthoracic needle biopsy (TTNB) is the most widely utilised diagnostic test [12].

Modern interventional pulmonology has undergone a paradigm shift, transitioning from a discipline primarily focused on central airway visualisation to one capable of precise mediastinal staging and accessing peripheral pulmonary lesions (PPLs) with a high diagnostic yield, comparable to that of CT-guided TTNB [13]. This has been possible by a number of technological advances, as summarised in Fig. 1. This narrative review aims to provide clinicians with an up-to-date overview of the current evidence base to support clinical decision-making and technology selection for the diagnosis of peripheral pulmonary lesions. Although much of the evidence for this field has been generated for pulmonary nodules (defined as discrete lesions ≤ 30 mm in diameter), this review will use the broader term ‘peripheral pulmonary lesions’ which encompass a range of peripheral lung abnormalities, including pulmonary nodules, masses, focal consolidation and cavitary lesions present in the outer one-third of the lung.

Fig. 1.

A timeline of technological advances in bronchoscopic platforms

Methods

We conducted a non-systematic literature search in PubMed/MEDLINE for English-language articles published between 2000 and 2026 using terms related to advanced bronchoscopic techniques for peripheral pulmonary lesions, including navigation bronchoscopy, robotic assisted bronchoscopy, radial probe endobronchial ultrasound, ultrathin bronchoscopy and cryobiopsy. Additional relevant articles were identified through manual review of reference lists from selected publications. Original research articles, systematic reviews, meta-analyses, clinical guidelines, and landmark studies were considered. Articles were selected based on clinical relevance, methodological quality, and their contribution to the current understanding of the field, with preference given to the highest quality evidence available for each topic.

This review is based solely on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Endobronchial Ultrasound (EBUS) and Radial Probe Endobronchial Ultrasound (RP-EBUS)

The introduction of linear (or convex probe) EBUS has been one of the most significant advancements in thoracic oncology over the last two decades. By incorporating a curvilinear ultrasound transducer at the distal tip of the bronchoscope, this allows direct, ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of hilar and mediastinal lymph nodes and centrally located lesions [14].

With a diagnostic yield of close to 90%, EBUS-TBNA has largely replaced surgical mediastinoscopy as the preferred first-line invasive test for lung cancer staging in patients with suspected N2 or N3 involvement [15–18]. Linear-EBUS bronchoscopes typically have an outer diameter of less than 7 mm, with 2.0- to 2.2-mm working channels. Although the recent introduction of thinner linear-EBUS bronchoscopes with outer diameters < 6 mm facilitates sampling of lesions in subsegmental bronchi [19, 20], they cannot reach small PPLs.

While linear-EBUS excels at central staging, the limitations in accessing PPLs led to the development of RP-EBUS. The concept of RP-EBUS was first described in 1992 by Hürter and Hanrath [21]; however, its utility in accessing PPLs was described a decade later [22]. RP-EBUS probes are miniaturised ultrasound catheters (1.4–1.7 mm diameter) that are passed through the working channel of a standard, thin, or ultrathin bronchoscope, providing a 360° circumferential ultrasound image of the surrounding structures [14]. The ultrasound image allows the clinician to distinguish between different ultrasound patterns: the snowstorm-like appearance of normal aerated lung compared with the dark, homogeneous appearance of a solid lesion, with a specific positional pattern: concentric, eccentric, or adjacent [23]. In fact, the diagnostic yield is highly dependent on the probe’s position relative to the lesion. Chen et al. demonstrated that when the probe is positioned within a target lesion, the diagnostic yield reaches approximately 84%, compared with only 48% when the probe is adjacent [24]. Meta-analyses have established a sensitivity of approximately 73% for RP-EBUS in PPLs for lung cancer detection [25]. A significant limitation of RP-EBUS, however, is that it does not provide real-time visualisation during biopsy; the probe must be retracted before sampling tools can be utilised. To improve accuracy, RP-EBUS is frequently combined with navigation technologies [26].

Ultrathin Bronchoscopy

Ultrathin bronchoscopes typically have an outer diameter of 3.0 mm or less. These instruments were designed to overcome the physical constraints of conventional bronchoscopes, which generally reach only the third to fifth generations of bronchi.

Ultrathin bronchoscopes were first described in 1984 by Tanaka et al., who reported the use of a 1.8-mm fibre-optic device designed to pass through the working channel of a conventional bronchoscope [27]. In 1985, the first report emerged of a 3.5-mm paediatric bronchoscope being utilised in adults to access PPLs [28]. Modern ultrathin bronchoscopes feature 1.2- to 1.7-mm working channels, while allowing the exploration of the 9th- to 12th-generation bronchi [29].

In the context of PPLs, typically those < 20 mm, randomised controlled trials (RCTs) and prospective multicentre studies have demonstrated the superior diagnostic yield of ultrathin scopes compared with conventional bronchoscopes [30, 31]. The pooled diagnostic yield from one meta-analysis was 65%, though lesion size, distance from the hilum and presence of a bronchus sign (defined as an airway leading into the target lesion) influenced the yield [29, 32].

Operating an ultrathin scope presents unique challenges: the instruments are fragile, suction capability is limited, and the peripheral airway may collapse. To counter this, selective mechanical ventilation protocols and lateral or prone decubitus have been investigated to maintain bronchial lumen patency and improve visualization [33, 34].

Navigation Bronchoscopy

Navigation bronchoscopy refers to image-guided bronchoscopic techniques, which are used to access PPLs with greater accuracy. This includes both electromagnetic navigation bronchoscopy (ENB) and virtual bronchoscopic navigation (VBN).

Electromagnetic Navigation Bronchoscopy

ENB systems utilise a 3D reconstruction of the bronchial tree, combined with an electromagnetic field to track the location of the bronchoscope and provide a real-time virtual road map to access a peripheral lesion. These systems require a recent high-resolution CT thorax which is loaded onto proprietary software for reconstruction.

The superDimension™ navigation system (Medtronic, Minneapolis, USA) was the first navigational system to obtain US Food and Drug Administration (FDA) approval in 2004 [35]. There have been numerous published datasets for this system, including the NAVIGATE study. This was a prospective multicentre cohort study which evaluated 1157 ENB procedures. The diagnostic yield was 73%, with a median nodule size of 20 mm and median distance from pleura of 9 mm [36].

The superDimension™ has now been superseded by the ILLUMISITE™ Fluoroscopic Navigation Platform (Medtronic, Minneapolis, USA), which obtained FDA approval in 2019 and is currently the only commercially available ENB platform [37]. This system incorporates digital tomosynthesis, which creates a 3D image of the target area from a standard C-arm. This provides a solution to CT to body divergence, with studies demonstrating a higher diagnostic yield when utilised [38]. A diagnostic yield of 75–79% has been reported with the ILLUMISITE™ system, from two randomised studies [39, 40].

The SPiN Thoracic Navigation System™ (Veran Medical Technologies, St Louis, USA) was an alternative ENB system; however, it was discontinued in 2023 [41], with patient safety and quality control issues cited by the company. This system additionally used inspiratory and expiratory phase CT imaging alongside catheter tracking technology, offering a ‘4D’ view during the procedure. Whilst high-quality studies were lacking, the reported diagnostic yields ranged between 55% and 82% [42, 43].

Overall, complication rates from ENB systems are low with a 3.1% incidence of pneumothorax and 1.6% of cases requiring chest drain insertion [44].

Virtual Bronchoscopic Navigation

VBN similarly utilises a 3D reconstruction from thoracic CT imaging to provide a virtual route to a peripheral nodule. These systems display the reconstructed CT images alongside the endoscopic view to guide the clinician. However, VBN does not utilise an electromagnetic field and therefore has a significant cost advantage, with the ability to utilise pre-existing flexible or ultra-thin bronchoscopes. Multiple platforms are commercially available including DirectPath™ (Olympus, Tokyo, Japan), Archimedes™ (Broncus Medical, San Jose, USA), Synapse 3D™ (Fujifilm, Tokyo, Japan) and Ziostation2™ (Ziosoft, Tokyo, Japan), with the first system released in 2008 [45]. Given the lack of electromagnetic navigation, these systems are generally combined with r-EBUS or fluoroscopy. A visual representation of the Archimedes™ platform is shown in Fig. 2.

Fig. 2.

Archimedes virtual bronchoscopic navigation platform. Image demonstrating identification of the target nodule with confirmation by fused fluoroscopy. Reprinted with permission from Broncus Medical

Several randomised studies have compared VBN to non-guided bronchoscopy, with yields between 67% and 84% reported when utilised alongside RP-EBUS or fluoroscopy [46–48]. Whilst the advantage over conventional methods is not consistent across all groups, there is a clear improvement in the diagnostic yield when utilising VBN for PPLs < 20 mm.

The absence of a bronchus sign can impact the diagnostic yield, particularly when advanced imaging modalities such as cone-beam CT or digital tomosynthesis are not utilised. To address this, the Archimedes™ system allows vessel mapping to facilitate bronchoscopic trans-parenchymal nodule access (BTPNA), by puncturing airway walls to access lesions. This has been shown to be safe and effective in small single-arm studies with comparable diagnostic yields [49, 50].

Robotic Assisted Bronchoscopy (RAB)

The first RAB platform entered the market in 2018, with three now commercially available, and others still in the testing and market entry phase [51]. The Monarch™ (Johnson & Johnson, Redwood City, USA) and Galaxy™ systems (Noah Medical, San Carlos, USA) utilise electromagnetic navigation whilst the Ion™ platform (Fig. 3) (Intuitive Surgical, Sunnyvale, USA) is unique in its use of shape-sensing technology which measures the catheter’s form, to accurately determine the shape and location of the catheter tip [52–54]. Compared with manually operated ENB systems, RAB provides better stabilisation of the bronchoscope, with a robotic controlled interface operated by the clinician. The advantages include precise, micromillimetre movements, the ability to lock the catheter in place and the potential to reach more peripheral lesions [55].

Fig. 3.

Ion endoluminal system (Intuitive Surgical). Images reproduced in accordance with the Intuitive Surgical Press Resources terms of use

Like other navigational platforms, RAB also requires a recent CT thorax to create a roadmap for navigation to the lesion. The Ion™ and the Monarch™ systems are compatible with cone-beam CT (CBCT), whilst the Galaxy™ system has its own propriety digital tomosynthesis technology known as Tool in Lesion Technology (TiLT+ Technology™), which utilises a standard fluoroscopy C-arm to confirm accurate placement of the catheter at the lesion [53]. These technologies allow correction of CT-to-body divergence, which if not addressed can lead to inaccurate placement of the catheter tip. All three systems use a working channel of at least 2 mm which allows for adjunct tools including RP-EBUS and cryobiopsy [55]. The technologies are summarised in Table 1.

Table 1.

Comparison of commercially available robotic assisted bronchoscopy platforms

	Monarch™	Galaxy™	Ion™
Navigation technology	Electromagnetic	Electromagnetic	Fibre-optic shape sensing
Outer catheter diameter	4.4 mm	4.0 mm	3.5 mm
Working channel diameter	2.1 mm	2.1 mm	2.0 mm
Imaging integration capability	CBCT	Proprietary digital tomosynthesis (TiLT+ Technology™)	CBCT
Continuous vision	Yes	Yes	No probe removed for biopsy

The evidence base for RAB has evolved rapidly, with large multicentre trials and meta-analysis confirming a favourable yield for PPLs. Results from multicentre prospective studies have demonstrated a lesion reach rate of 99% with RAB [56, 57]. Whilst the TARGET study reported a relatively low diagnostic yield of 61.6%, this was reported according to strict American Thoracic Society/American College of Chest Physicians reporting guidelines, whereas investigator-reported diagnostic yield was 83.2%. The median nodule size was 20.9 mm with a 5-mm median distance from the pleural surface. One limitation of this study was the low utilisation of CBCT (16.6%) [56]. The importance of advanced imaging modalities to maximise diagnostic yield with RAB was demonstrated in the CONFIRM study. This reported a diagnostic yield of 89% when CBCT was utilised, for lesions with a median size of 14 mm and a median distance of 8.2 mm from the pleural surface [57]. Complication rates were very low with an incidence of pneumothorax requiring chest tube of 0–2.2% and grade 2 bleeding rates of 0.9–1.3% [56, 57].

Sampling Techniques

Once PPLs are located using these advanced platforms, numerous biopsy techniques are deployed. Conventional methods include transbronchial forceps biopsy, needle aspiration and brush biopsy, though more recently transbronchial lung cryobiopsy (TBLC) has emerged as an alternative technique [58].

Cryobiopsy technology is based on the Joule–Thomson effect, in which the rapid expansion of a compressed gas (carbon dioxide) generates extremely low temperatures, approximately − 80 °C, at the tip of the cryoprobe [59]. This process allows for the instantaneous freezing of the surrounding lung tissue, which adheres to the tip and is removed en bloc. Technological advances have led to the development of miniaturized cryoprobes with diameters of 1.1–2.4 mm, enabling greater precision in the most distal airways [60].

The main advantage of cryobiopsy over conventional forceps biopsy lies in the significantly larger sample size and being free of crush artefact, preserving the lung architecture [58]. Recent data indicate that TBLC combined with RAB can achieve a diagnostic yield consistently above 80%, providing sufficient material for molecular genotyping. Numerous studies and meta-analysis data confirm the superiority of cryobiopsy over forceps biopsy and needle aspiration techniques in obtaining a tissue diagnosis, even when utilising this via conventional flexible bronchoscopy [61–65]. Whilst TBLC is not associated with an increased pneumothorax risk for PPL sampling, meta-analysis data suggests a 2.17 odds ratio of moderate to severe bleeding events, compared with forceps biopsy [64].

Comparison of Technologies

Whilst there is an evolving body of evidence supporting the use of advanced bronchoscopic techniques to reliably access and diagnosis PPLs, it is more important to understand how they perform compared with the current standard of practice, and how they fit into the diagnostic pathway. Results from a pairwise and network meta-analysis suggest the diagnostic yield from RAB (84.8%) is comparable to CT-guided TTNB (88.9%), with data from 363 studies included [12]. The authors also assessed the diagnostic yields of ENB (72.7%), VBN (75.1%) and RP-EBUS (72%), with RP-EBUS the only modality found to reach statistical significance for inferiority compared with CT-guided TTNB, which has been consistently demonstrated across three other meta-analyses [66–68]. The overall incidence of pneumothorax (16.8%) and clinically significant bleeding (5.2%) was significantly higher with CT-guided TTNB compared with all other technologies, the lowest incidence was with RAB (2.2% and 0.3% respectively) [12]. Despite the extensive coverage of this meta-analysis, it remains limited by the high proportion of small single-centre, non-comparative studies with only 18 RCTs included. Following this meta-analysis further RCT data has emerged to support the role of ENB. VERITAS was a multicentre, randomised, noninferiority trial which included 234 patients with 10–30 mm peripheral pulmonary nodules, comparing ENB and CT-guided TTNB. The diagnostic accuracy of ENB was 79%, compared with 73.6% for CT-guided TTNB, with a vastly lower rate of complications in the ENB group [13]. A further large retrospective comparative cohort study of 2258 patients found no statistically significant difference in the diagnostic yields for bronchus sign-positive PPLs [40].

Multicentre RCTs to compare the efficacy of ENB, VBN and RAB platforms are lacking, which is perhaps not surprising given the associated expense and logistical challenges. To date, the highest quality evidence is from the RELIANT study which was a single-centre, cluster-randomised noninferiority trial of 411 patients. The diagnostic yield was 77.8% in the RAB group versus 75.5% in the ENB group, with a comparatively low rate of complications in both groups [39]. A retrospective comparative cohort study of 303 patients also found comparable yields when comparing shape-sensing RAB and digital tomosynthesis-corrected ENB platforms, with a < 1.8% pneumothorax risk in both groups [69]. Further randomised data comparing ENB and RAB will be obtained from the ARTICULAtE trial, which is currently in the recruitment stage [70].

There is a notable absence of cost analysis in these studies, which fail to recognise the limitations of adopting expensive technologies in universal and value-based healthcare systems. Whilst comparative cost data are limited, one study estimated that ENB cost an additional USD 3719 per case compared with CT-guided TTNB [71]. Therefore, healthcare policies need to carefully balance the provision of advanced technologies to improve patient outcomes with the need to provide value for money. There are several additional factors that should be considered when planning a biopsy of PPLs, as summarised in Table 2.

Table 2.

Overview of capabilities and procedural elements of CT-guided transthoracic needle biopsy versus advanced bronchoscopic platforms

	CT-guided lung biopsy	Advanced bronchoscopy (RAB, ENB, virtual)
Diagnostic yield	Comparable	Comparable
Sufficient tissue for molecular analysis	Comparable	Comparable
Overall complications	Higher	Lower
Pneumothorax risk	High 10–25%	Low 1–5%
Bleeding risk	Variable	Low
Procedure time	Shorter approx. 30–45 min	Longer approx. 60 min
Anaesthesia	Local anaesthetic	General anaesthetic (conscious/deep sedation possible for ENB/virtual)
Nodule reach	Better closer to chest wall, difficult to sample apical and juxta-diaphragmatic lesions	Most regions (though requires favourable airway geometry)
Staging & additional procedures	Not possible—often single lesion	EBUS/ biopsy multiple nodules/ fiducial/ dye marking
Availability	Widely available	Limited—specialised centres
Cost	Low	High
Tactile feedback	Present via needle	Limited

Combining Advanced Technologies with Thoracic Surgery

Localising small, peripheral lesions during surgery is a frequent challenge for thoracic surgeons, particularly in the era of minimally invasive surgical techniques. Preoperative localisation of lung nodules has been described for over 30 years with CT-guided procedures the current standard of practice [72]. Precise localisation can facilitate minimally invasive surgical approaches and the potential for sparing of healthy lung parenchyma.

The evidence for combining advanced bronchoscopic localisation of PPLs with thoracic surgery largely comprises of small, single-centre studies, with no randomised clinical trial data available. Yanagiya et al. conducted a meta-analysis assessing the use of bronchoscopic marking (either dye, barium or coil marking) for pulmonary nodules, prior to planned thoracic surgery. The overall pooled successful marking rate was 97% with a subsequent resection rate of 98%. The complication rate was very low. The studies included a range of technologies including ENB, VBN and RAB, however, the analysis was largely based on small, non-comparative studies [72]. A number of small retrospective comparative studies have demonstrated the high success rate of both CT-guided and advanced bronchoscopic techniques in localising small nodules prior to surgery, with a successful intraoperative localisation rate of over 94% in all groups [73–75]. Whilst localisation rates do not appear to differ significantly between groups, two studies demonstrated around a 15% rate of pneumothorax in the CT-guided group whilst none occurred in the ENB/VBN groups [73, 74].

A combined approach offers the potential for a one-stop ‘diagnose and treat’ procedure under a single anaesthetic event, with rapid on-site evaluation (ROSE) of biopsy specimens prior to surgical resection. This has been shown to reduce down time between procedures, reduce overall procedural times and the time from diagnosis to treatment [75–77]. Further benefits include reduced costs and the potential to reduce benign resections and further surgical procedures [77–81]. Perez et al. demonstrated a reduction from 21.9% to 7.6% in benign resection rates when using RAB and ROSE prior to resection, with all benign diagnoses true negatives [78]. Furthermore, Dolan et al. demonstrated a reduction in intraoperative repeat resections from 18% to 0% when localising PPLs with RAB [79]. Whilst these results are encouraging, other single-centre studies have shown a high frequency of lobectomies performed regardless of the RAB/ENB results, suggesting the need for careful case selection [76, 82].

Future Directions

The therapeutic potential of advanced bronchoscopic technologies is a focus of current research. Whilst percutaneous thermal ablation therapies are established treatments for peripheral lung tumours [83], emerging evidence supports the potential for bronchoscopic delivery. One study of 20 patients showed a local control rate of 82.6% following radiofrequency ablation (RFA) delivered via CT-guided bronchoscopy [84]. Transbronchial delivery of microwave ablation has also been assessed with ENB guidance, with a 100% technical success achieved at 1 month in a cohort of 30 patients who were unsuitable for surgery or stereotactic radiotherapy [85]. To date, the available evidence for these interventions is limited to small, non-comparative datasets, limiting broader generalisation. However, advanced bronchoscopic delivery may have a role where lesions are inaccessible via CT guidance and patients are unsuitable for surgical resection.

There is evidence to support the feasibility of bronchoscopic intralesional delivery of chemotherapy agents from small-scale studies [86, 87]. There was anticipation of a future role of utilising advanced systems such as RAB and ENB to deliver these to smaller peripheral lesions [88]; however, this is yet to be demonstrated.

The feasibility of ENB-guided brachytherapy placement has been demonstrated in two small studies [89, 90]; however, the small cohorts and lack of comparator group limit the interpretability of the data. Given the resource intensive nature of these treatments and the absence of data to demonstrate superiority over established treatments of peripheral lung lesions, this remains confined to a research setting.

Direct visualisation of small peripheral lesions could offer the potential to improve the accuracy of diagnostic and therapeutic bronchoscopic interventions. A commercially available 1.3-mm video-endoscopic probe has shown promise, with over 70% of malignant PPLs visualised in one study, with a high positive predictive value [91]. Even smaller video-endoscopes may be on the horizon, with a 0.97-mm probe in development [92].

Conclusion

In expert hands, the diagnostic yields from advanced bronchoscopic procedures are comparable to CT-guided approaches for peripheral pulmonary lesions, with lower complication rates. However, these newer technologies should be viewed as complementary to traditional CT-guided approaches, given the high associated costs. The absence of robust health economic evaluation of these technologies should be acknowledged and necessitates careful case selection, particularly in resource-constrained healthcare systems. For lesions easily accessible by CT-guided biopsy, this is likely to remain the investigation of choice, with advanced bronchoscopic approaches reserved for difficult to reach locations, sampling of multiple lesions or where mediastinal staging is required. A combined ‘diagnose and treat’ approach combining advanced bronchoscopic technologies with thoracic surgery may provide benefit from a reduced number of interventions and a shortened diagnostic pathway. Whilst these conclusions have been drawn from the available literature, the limitations of this review must be acknowledged. A non-systemic methodology was utilised with the inclusion of many small-scale and non-comparative studies, with inconsistent definitions of diagnostic yields used across studies. In addition, a large proportion of studies were industry sponsored raising the possibility of reporting bias.

Further large-scale, independently funded RCTs incorporating health economic evaluation are required to provide a more robust evidence base in this field. Such studies are crucial to enable objective evaluation of emerging technologies and support their appropriate integration into routine clinical practice.

Author contributions

Richard Westley, Alberto Fantin, Ernesto Crisafulli and Rakesh Panchal contributed to the study conception, design, material preparation, literature review and critical appraisal. The first draft of the manuscript was written by Richard Westley and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

No funding or sponsorship was received for this study or publication of this article.

Data availability

Data sharing is not applicable to this article as no datasets were generated or analysed.

Declarations

Conflict of Interest

Richard Westley, Alberto Fantin, Ernesto Crisafulli and Rakesh Panchal declare that they have no competing interests.

Ethical Approval

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.