Digital tomosynthesis for navigational bronchoscopy: a clinical practice review

Pulmonary nodules, defined as single opacities up to 30 mm within normal lung tissue, are more frequently detected as a result of enhanced lung cancer screening methods utilizing low-dose computed tomography (LDCT), which has significantly reduced the mortality rate of lung cancer. The National Lung Screening Trial (NLST) highlighted that 39% of participants exhibited nodules, with a substantial proportion requiring further evaluation. The United States Preventive Services Task Force (USPSTF) has since recommended routine LDCT screening for high-risk individuals. Traditionally, lung nodule evaluation relied on risk prediction calculators, guiding management through serial imaging or biopsies. Computed tomography (CT)-guided transthoracic needle biopsy (TTNB) has been the gold standard for minimally invasive biopsy. However, its limitations include higher complication rates, especially for smaller and more central nodules. Navigational bronchoscopy (NB) offers a safer alternative, enabling the assessment of multiple nodules in one session along with concomitant mediastinal and hilar lymph node evaluation utilizing endobronchial ultrasound (EBUS). One of the challenges of bronchoscopic biopsy of lung nodules has been CT-body divergence, limiting diagnostic yield and accuracy. In order to combat this challenge, recent advancements in NB technology, particularly the integration of digital tomosynthesis (DT), enhance procedural visualization and has been shown to improve diagnostic yield. This clinical practice review emphasizes the significance of optimizing intraoperative ventilator techniques as well as integrating enhanced imaging modalities like DT and cone beam CT (CBCT) in order to overcome CT-body divergence and subsequently improving localization and biopsy outcomes. Preliminary studies indicate promising diagnostic yields by integrating these advanced imaging technologies. Ongoing research is essential to refine these approaches and improve patient outcomes in lung nodule management.