Cone beam CT with integration improves diagnostic yield of bronchoscopic peripheral pulmonary lesion biopsies

Robotic bronchoscopy has improved the ability to biopsy peripheral pulmonary lesions (PPL). Intra-procedure PPL, biopsy tool, and catheter visualization represents another means towards refining procedural outcomes. Recently, the ability to integrate this information in real-time became available through 3D mobile cone beam CT (CBCT) imaging. We analyzed the impact of imaging integration on diagnostic yield of shape sensing robotic assisted bronchoscopy (ssRAB) biopsies compared to procedures done without integration.

Patients undergoing ssRAB (Ion Endoluminal System) with 2D fluoroscopy (03/2023-03/2024) and with 3D CBCT with integration (Cios system) (04/2024-01/2025) were retrospectively identified. The primary outcome was diagnostic yield. Secondary outcomes included diagnostic accuracy and procedural complications.

71 PPLs (67 patients) underwent ssRAB without integration and 102 PPLs (95 patients) were biopsied with integration. While demographics were similar, PPLs in the integration group were smaller (2.11 ± 1.26 cm vs 2.46 ± 1.19 cm, p = 0.010) and more frequently located in the peripheral lung third (n = 82 (80.4 %) vs n = 41 (57.7 %), p = 0.003). Diagnostic yield without integration was 72 % (51/71) and with integration was 86 % (88/102) (p = 0.019). Diagnostic accuracy without integration was 78 % (55/71) and with integration was 89 % (91/102) (p = 0.036). After controlling for other variables, biopsies with integration had a significantly higher diagnostic yield compared to those without integration (OR = 3.34, 95 % CI 1.39-8.44, p = 0.008). Pneumothorax rate (3 without integration vs 1 with integration, p = 0.3) was similar.

The use of 3D CBCT for real time integration of PPL location and biopsy tool and catheter relationship improves diagnostic yield of bronchoscopic biopsies performed via ssRAB.