Cone-Beam CT-Assisted Electromagnetic Navigation Bronchoscopy for Challenging Peripheral Pulmonary Lesions

In the context of the growing role of hybrid image-guided bronchoscopic techniques, this study aimed to evaluate the diagnostic value of electromagnetic navigation bronchoscopy (ENB) assisted by cone-beam computed tomography (CBCT) in the assessment of challenging peripheral pulmonary lesions (C-PPLs).

This prospective, single-center study included patients with C-PPLs between September 2023 and May 2025. C-PPLs were defined as pulmonary nodules measuring less than 20mm in diameter and located beyond the 6th bronchial generation, reflecting their proximity to the pleura.

A total of 63 lesions were evaluated, with a mean size of 12.3mm. The diagnostic yield was 65.1% at index bronchoscopy, increasing to 73% after follow-up adjudication. The most prevalent diagnosis was non-small cell lung cancer (50.8%). Diagnostic confirmation was achieved in 58% of lesions in the absence of a bronchus sign. Transbronchial lung cryobiopsy (TBLC) provided a diagnostic yield of 65.6% and was the sole diagnostic modality in 15.2% of confirmed cases. The mean effective radiation dose was 11.2mSv. Pneumothorax occurred in 4.7% of cases, with no major complications observed.

CBCT-assisted ENB is a safe and highly effective approach for diagnosing C-PPLs, even in the absence of a bronchus sign or radial endobronchial ultrasound (rEBUS) confirmation. In addition, TBLC provides high-quality tissue without compromising safety. These findings support a personalized, minimally invasive diagnostic strategy that enables earlier and more accurate detection of pulmonary malignancies.