Annual progress in transbronchial diagnosis and treatment of pulmonary malignant tumors [2025]: a narrative review

Introduction

Pulmonary malignant tumors remain one of the most prevalent and deadly malignancies, posing a significant threat to global health. The incidence rate of lung cancer in China reached 75.13 per 100,000 people in 2022, ranking first among all major cancers, while the mortality rate stood at 51.94 per 100,000 (1). Traditional diagnostic and therapeutic approaches for pulmonary malignant tumors—such as percutaneous needle biopsy and surgical resection—are limited by factors including patient tolerance, tumor staging, and anatomical location, leaving some patients unable to benefit from these methods.

In recent years, with the rapid advancement of interventional pulmonology, guided bronchoscopy techniques have emerged as minimally invasive and precise alternatives for the diagnosis and treatment of pulmonary malignant tumors. Since its inception in the late 19th century, transbronchial endoscopic intervention has evolved from rigid bronchoscopy to flexible fiberoptic bronchoscopy, and further to modern electronic bronchoscopy, endobronchial ultrasound (EBUS), electromagnetic navigation bronchoscopy (ENB), and robotic-assisted bronchoscopy (RAB). Modern bronchoscopy not only enables diagnostic and therapeutic procedures in the central airways but also, with the aid of various navigation techniques, allows for precise access to PPLs, facilitating accurate biopsy and even ablation therapy. Today, it has become an important component of pulmonary malignant tumors management.

Building upon the rapid progress in related techniques, this review aims to summarize the latest advances in transbronchial diagnosis and treatment of pulmonary malignant tumors in 2025, including the precision diagnosis of PPLs, biopsy strategies, and ablation therapies, providing valuable insights for clinical practice and future research. We present this article in accordance with the Narrative Review reporting checklist (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0281/rc).

Methods

A literature search was conducted in PubMed using medical subject headings (MeSH) terms including “Bronchoscopy”, “Lung Neoplasms”, “Solitary Pulmonary Nodule”, “Multiple Pulmonary Nodules”, “Airway Obstruction”, “Bronchial Neoplasms”, and related free words. All retrieved records were screened by title and abstract according to predefined inclusion and exclusion criteria: we included English-language publications comprising original studies, meta-analyses, and case reports, while excluding articles with low relevance to the topic (reasons include: studies on benign diseases, review articles, preprints, clinical trial protocols, and animal experiments). Full texts of potentially eligible articles were obtained and further evaluated for literature quality and clinical significance through panel discussions to determine final inclusion. Additionally, we selectively retrieved references related to the technical background from the included literature and performed supplementary searches for epidemiological studies on pulmonary malignant tumors. The complete search process is detailed in Table 1.

Diagnosis of peripheral pulmonary lesions (PPLs)

With the widespread adoption of early pulmonary malignant tumor screening, the demand for diagnosing pulmonary nodules has surged. However, the limited navigation accuracy and accessibility of conventional guided bronchoscopy techniques have constrained the application of bronchoscopy in the diagnosis and treatment of PPLs. In recent years, guided bronchoscopy techniques such as RAB, ENB, and cone-beam computed tomography (CBCT) have experienced rapid development, driving transbronchial endoscopic intervention into an era of precision medicine.

RAB

RAB is a novel minimally invasive diagnostic and therapeutic platform that integrates ultra-thin flexible bronchoscopes, advanced navigation systems, and robotic manipulation technology, significantly improving handleability, stability, and accessibility to PPLs. Currently, the mainstream robotic systems include the Ion system, Monarch system, and Galaxy system. The Ion system utilizes shape-sensing technology, providing accurate positional information at every point along the catheter through embedded fiber optics along its entire length. The Monarch system and Galaxy system primarily rely on electromagnetic navigation technology for localization (2). RAB is increasingly being recognized as a safe and reliable guidance tool for the diagnosis and even treatment of PPLs. In 2025, a new wave of high-quality clinical studies provided further evidence. A retrospective study by Zhang et al. analyzed diagnostic data from 59 cases of solid or partially solid PPLs with bronchus sign, ranging 8–30 mm in diameter. The study demonstrated that shape-sensing RAB (ssRAB) achieved significantly higher overall diagnostic yield for PPLs compared to virtual bronchoscopic navigation (VBN)-guided transbronchial lung biopsy (90.0% vs. 69.0%, P=0.045) (3).

A large-scale multicenter prospective study by Murgu et al. utilized RAB to perform biopsy on 679 patients with lesions measuring 8–50 mm in diameter, among which 87.5% of lesions were located in the outer two-thirds of the lung. The results demonstrated a diagnostic yield of 61.6% for RAB, with a sensitivity of 78.8% for malignant tumors. Among all participants, only 15 cases developed pneumothorax requiring chest tube placement, six cases experienced bleeding requiring local bronchoscopic treatment, and only one case presented with life-threatening hemorrhage requiring emergency intervention. These findings suggest that RAB exhibits both high diagnostic yield and favorable safety profile (4). In a single-center, cluster-randomized noninferiority trial, Paez et al. allocated 411 patients requiring pathological confirmation of PPLs into two groups for either ENB or RAB. Bronchus sign was present in 58.4% of the lesions. The study confirmed that RAB demonstrated non-inferior diagnostic yield compared to ENB (77.8% vs. 75.5%, P=0.007), with only a 5-minute prolongation in median bronchoscopy procedure time. However, RAB showed advantages in aspects such as learning curve, catheter stability, and the ability to adjust the probe connected to the catheter as needed (5).

RAB enables precise targeting of challenging pulmonary nodules. Conventional biopsy of pulmonary nodules that contact the pleura has been limited by high pneumothorax risk. A retrospective study by Fernandez-Bussy et al. analyzed 182 nodules ≤30 mm which contact with pleura, demonstrating that ssRAB combined with CBCT and cryobiopsy achieved a diagnostic yield of 80.2%, with 83.2% sensitivity for malignancy and only 2.8% pneumothorax rate (6). This success is attributed to the submillimeter-level positioning accuracy of robotic systems combined with real-time three-dimensional (3D) verification by CBCT, offering a potential solution for biopsy of pleural-adjacent nodules. For subsolid nodules (SSNs) that are crucial in early pulmonary malignant tumor screening, RAB demonstrates excellent diagnostic performance. A multicenter prospective study by Gomes et al. enrolled 78 patients with part-solid nodules and 13 with ground-glass nodules (GGNs), with 89.0% located in the outer two-thirds of the lung. The localization rates were 81.4% for SSN and 61.5% for GGN, with a sensitivity of 77.8% and 75.0% for malignant tumors, and a diagnostic yield of 50.0% and 61.5%, respectively (7).

The diagnostic utility for multiple pulmonary nodules has also achieved substantial improvement through robotic technology. A single-center study by Chrissian et al. analyzed diagnostic data from 503 peripheral pulmonary nodules in 341 patients. Sampling secondary PPNs impacted the final diagnosis in 38% of the cases. Notably, 56% of patients diagnosed with pulmonary malignant tumors through multiple nodule biopsies obtained more comprehensive disease characterization and staging information (8). Another retrospective study by Fernandez-Bussy et al. analyzed the diagnostic data of 393 nodules from 189 patients. Each patient underwent biopsy of multiple nodules during a single ssRAB procedure. The results showed that ssRAB achieved an overall diagnostic yield of 86.2%, with 42.3% of patients diagnosed with malignant tumors through this technique. Only seven patients developed pneumothorax requiring chest tube placement, and one patient experienced severe bleeding requiring endotracheal intubation or balloon blocker (9).

The outstanding diagnostic efficiency and safety of RAB make it an important diagnostic tool for PPLs, and its relatively gentle learning curve facilitates rapid operator proficiency. However, the high cost of robotic bronchoscopy platforms may limit their widespread implementation in primary and secondary hospitals.

Other guided bronchoscopy techniques

The thin convex probe EBUS (TCP-EBUS) demonstrates superior instrument accessibility compared to conventional convex probe EBUS (CP-EBUS). The outer diameter of the tip of TCP-EBUS measures only 5.9–6.6 mm (vs. 6.9 mm for CP-EBUS). Additionally, while CP-EBUS has an upward articulation of 120°, TCP-EBUS achieves 160–170°, enabling access to more peripheral and tortuous bronchi, thereby reaching lesions inaccessible to CP-EBUS. In a single-center prospective study by Pastis et al., patients initially underwent CP-EBUS for biopsy of lesions located in the inner two-thirds of the lung. When CP-EBUS failed, TCP-EBUS was employed. Results showed that among 44 lesions where CP-EBUS failed, 27 were successfully biopsied using TCP-EBUS. Furthermore, TCP-EBUS could reach lesions up to 120 mm from the carina—20 mm farther than CP-EBUS (10). Another single-center prospective study by Chen et al. utilized a 6.6 mm outer diameter TCP-EBUS (Olympus BF-UC290F, Tokyo, Japan) to perform EBUS-guided transbronchial needle aspiration (EBUS-TBNA) in 30 patients with PPLs. The average lesion size was 25.7 mm, with 25 lesions located in subsegmental bronchi and 5 in sub-subsegmental bronchi. TCP-EBUS obtained adequate biopsy specimens in all cases, achieving a diagnostic yield of 90% (11).

Iriscope is an ultra-thin, miniaturized video probe with a diameter of only 1.3 mm. This new probe can directly visualize PPLs that conventional bronchoscopes cannot reach. The combination of radial EBUS (R-EBUS) and Iriscope achieves dual-modality (“ultrasound + direct visualization”) localization of target lesions. In a randomized controlled trial (RCT) by Taton et al., 81 patients requiring pathological diagnosis of PPLs were randomly divided into two groups: one group underwent R-EBUS-guided bronchoscopy, while the other group underwent combined Iriscope and R-EBUS examination. The procedure involved: first inserting the Iriscope through the bronchoscope working channel to the approximate lesion location; confirming the probe’s arrival at the lesion site based on bronchial mucosal images transmitted by Iriscope combined with intraoperative fluoroscopy; then withdrawing the Iriscope probe and inserting the R-EBUS probe to the same location; and performing biopsy after dual confirmation of the lesion. The results showed that the diagnostic yield of R-EBUS combined with Iriscope was significantly higher than R-EBUS alone (80% vs. 55%, P=0.036), regardless of lesion size or bronchus sign presence (12). Features observed under Iriscope, such as white plaques, bronchial obstruction, and extrinsic compression, had positive predictive values (PPVs) for malignancy of 94%, 90%, and 100%, respectively, providing intuitive diagnostic criteria for malignant lesions (13). Additionally, the application of Iriscope in EBUS-TBNA procedures enabled direct visualization of lymph node internal structures. A case series of four cases showed that this technique could safely achieve real-time internal lymph node imaging, assisting in assessing tissue texture and structure, thereby supplementing traditional cytological examination (14).

Some novel guided bronchoscopy techniques enhance the ability of bronchoscopes or biopsy tools to reach target lesions, potentially improving diagnostic yield. Pulmonary nodules without bronchus sign typically cannot be directly accessed by bronchoscopy. The bronchoscopic transparenchymal nodule access (BTPNA) technique overcomes this limitation by creating an artificial pathway through lung parenchyma. This technique requires identifying a safe point of entry (POE) that avoids critical structures like blood vessels, then drilling toward the lesion and placing a guide sheath for subsequent diagnostic or therapeutic procedures. However, the size, flexibility, maneuverability, and angulation of the guide sheath reduce its utility in bronchoscopy. The modified BTPNA (mBTPNA) technique eliminates the need for a guide sheath. Using the Archimedes system, it plans a vascular-free pathway from the POE to the lesion. Under guidance from virtual imaging of this pathway and real-time R-EBUS confirmation, either an 18-gauge Flexneedle (Broncus Medical Inc., San Jose, CA, USA) or a 21-gauge Periview needle (Olympus) is selected based on the type of bronchoscope to create the access channel. An ultrathin bronchoscope (UTB) is then inserted through this channel for subsequent procedures, providing a novel solution for diagnosing lesions without bronchus sign. A single-center retrospective study by Büscher et al. analyzed 37 lesions with an average size of 18.6 mm and a mean distance to the pleura of 34.4 mm. The success rate for pathway creation was 97.3%. After channel establishment, most lesions showed improved ultrasound visualization patterns (central or good eccentric pattern increased from 19.4% to 61.3%). Final diagnostic accuracy was comparable to that of bronchus-sign-positive lesions (66.7% vs. 72.9%, P=0.58) (15).

A single-center retrospective study by Onyancha et al. described a novel “dual bronchoscope kissing technique”: this technique uses a standard-sized bronchoscope carrying a radial probe EBUS (RP-EBUS) to locate the lesion, followed by insertion of a second UTB carrying a cryoprobe through the same endotracheal tube or rigid bronchoscope to the precise location for sampling. The advantages of this technique include: not only does the operator obtain direct physical feedback during the dual bronchoscope kissing maneuver to ensure precise lesion localization, but also the presence of another bronchoscope at the biopsy site allows for immediate treatment of bleeding, thereby improving safety. The study enrolled 43 PPLs with an average size of 24.6 mm. Through real-time coordination between R-EBUS and the cryoprobe, tool-contact confirmation was achieved in 81% of cases, with an overall diagnostic yield of 83.7%. No pneumothorax or severe bleeding occurred in any patient (16).

Miyake et al. attempted to diagnose PPLs in a porcine model by balloon-dilating normal bronchi to facilitate bronchoscopic access to more peripheral bronchi (17). This technique achieved its first clinical application in 2025 and successfully diagnosed one case of a peripheral upper lobe lesion that was difficult to biopsy using conventional methods (18). Miyake et al. subsequently published the first clinical study of this technique in 22 patients. The results demonstrated that this method allowed UTBs to advance an average of 2.3 bronchial generations further, with successful advancement to the lesion site for direct visualization and biopsy in 17 patients. The technique ultimately achieved a sensitivity of 77.8% for malignant lesions (19).

The UTB now has a working channel that can reach 1.7 mm, allowing the insertion of an R-EBUS probe and 1.5 mm biopsy forceps. A retrospective study by Kawakita et al. analyzed diagnostic data from 157 peripheral pulmonary nodules ≤30 mm with bronchus sign, marking the first comparison of diagnostic performance between two types of UTBs [small channel UTB (SC-UTB), outer diameter 2.8/3.1 mm, working channel 1.2 mm; large channel UTB (LC-UTB), outer diameter 3.0 mm, working channel 1.7 mm]. In the SC-UTB group, after guiding to the lesion using VBN and fluoroscopy, biopsy forceps were inserted through the working channel of the bronchoscope, followed by CBCT scanning for confirmation before biopsy. In the LC-UTB group, in addition to VBN and fluoroscopy, R-EBUS was used to confirm arrival, followed by CBCT scanning to verify the position before withdrawing the R-EBUS probe and replacing it with biopsy forceps for tissue sampling. Results showed that the diagnostic yield using LC-UTB combined with R-EBUS under CBCT guidance (79.4%) was significantly higher than that using SC-UTB under CBCT guidance (64.0%). The proportion of biopsy forceps tips located within the lesion during the first CBCT scan increased from 31.5% to 50.0% (P=0.019), while the need for repositioning after the first CBCT scan decreased from 47.5% to 20.6% (P=0.001) (20). This difference may be attributed to having a larger working channel that accommodates biopsy forceps with a greater diameter, as well as its R-EBUS-assisted localization capability. The multimodal guidance strategy used in LC-UTB group provides a superior solution for precise biopsy of PPLs.

In summary, advancements in guided bronchoscopy techniques have provided novel diagnostic methods for PPLs, offering new hope for improving diagnostic yield. However, further studies are needed to validate these emerging technologies and clarify their optimal application scenarios and limitations.

Innovation in biopsy strategies

With the advancement toward precision diagnostics and treatment of pulmonary malignant tumors, transbronchial lymph node biopsy has achieved higher diagnostic performance through the cryobiopsy technique. The transbronchial biopsy technique for PPLs is undergoing a paradigm shift from reliance on single tools to combined utilization of multiple tools. Artificial intelligence (AI)-assisted diagnosis systems and rapid on-site evaluation (ROSE) further enhance the ability to differentiate between benign and malignant lesions, assisting operators in adjusting biopsy strategies.

Transbronchial mediastinal lymph node cryobiopsy

Cryobiopsy can obtain larger and more intact tissue specimens compared to forceps biopsy, demonstrating higher diagnostic performance (21). In recent years, researchers have attempted to create a pathway into mediastinal lymph nodes either through the needle tract formed by puncture biopsy or by using high-frequency needle knife to establish an access channel, followed by inserting a cryoprobe into the mediastinal lymph node to perform cryobiopsy under EBUS guidance—a technique termed EBUS-guided transbronchial mediastinal cryobiopsy (EBUS-TBMC) (22). New evidence demonstrates that cryobiopsy offers significant advantages over conventional TBNA and lymph node forceps biopsy. A multicenter RCT by Deng et al. showed that, benefiting from more intact tissue samples with less crush artifacts, EBUS-TBMC achieved significantly higher granuloma detection rates and better histologic sample quality for patients with sarcoidosis compared to EBUS-TBNA (23). A prospective study by Lin et al. further confirmed that EBUS-TBMC had a significantly higher diagnostic accuracy than EBUS-guided intranodal forceps biopsy (EBUS-IFB) (95.4% vs. 84.9%, P<0.001), while yielding substantially larger tissue samples (16.3 vs. 3.1 mm², P<0.001) (24). A single-center study by Beattie et al. indicated that cryobiopsy provided a significantly higher diagnostic yield (82%) compared to Franseen needle biopsy (73%) and TBNA (50%), with cryobiopsy specimens being more suitable for special staining and immunohistochemical testing requirements (61% vs. 33%) (25).

Combined utilization of multiple biopsy tools

R-EBUS-guided bronchoscopic brushing and forceps biopsy remain widely used in clinical practice due to their lower cost. However, biopsy tools often fail to reach lesions without bronchus sign, making it difficult to diagnose the target. Peripheral TBNA (pTBNA) can directly access lesions through needle puncture, partially overcoming anatomical limit of the bronchus, but its clinical application remains limited due to yielding only cytological samples. Emerging evidence demonstrates that combining R-EBUS-guided bronchoscopic brushing and forceps biopsy with pTBNA improves diagnostic yield. A prospective study by Olive et al. involved 101 PPLs (76% with bronchus sign), with pTBNA performed first in 61 cases and last in 40 cases. The result shows that adding pTBNA during UTB increased diagnostic yield by 11.9%, with greater benefits for lesions <20 mm or those displaying eccentric R-EBUS images (26). The advantage of combined utilization of multiple biopsy tools has also been validated under the circumstances of ENB. A RCT by Kim et al. enrolled 142 participants requiring biopsy for PPLs, of which 64.1% showed bronchus sign. For each patient, both ENB-TBNA and forceps biopsy were performed in randomized sequences. The study demonstrated that combined needle aspiration and forceps biopsy increased diagnostic yield by 15.5% (66.9% vs. 51.4%, P<0.001) and 22.5% (66.9% vs. 44.4%, P<0.001) compared to using needle aspiration or forceps biopsy alone, respectively (27). Enhancing diagnostic yield for PPL remains challenging in transbronchial endoscopic intervention. A meta-analysis indicates conventional biopsy methods achieve approximately 70% diagnostic yield for PPLs (28). Cryobiopsy, providing larger tissue samples with less crush artifacts than needle aspiration/forceps biopsy, represents a key strategy for enhancing diagnostic yield (29). A prospective observational study by Seong et al. enrolled 50 patients with peripheral pulmonary nodules requiring pathological confirmation by biopsy, among which 66% exhibited bronchus sign. Under R-EBUS guidance to target lesions, sequential procedures were performed: two cryobiopsies, one forceps biopsy, and one pTBNA, achieving diagnostic yield of 78.7%, 66.7%, and 54.2%, respectively. The complementary advantages of cryobiopsy obtaining more intact tissue samples with less crush artifacts and forceps biopsy capable of passing through sharply angulated bronchi increased overall diagnostic yield from 74% to 78%, with sensitivity for malignant lesions improving from 84.6% to 89.7% (30).

The combined utilization of multiple biopsy tools, with cryobiopsy serving as the cornerstone, improved diagnostic yield for PPLs. However, we should be alert to the diminishing marginal benefits brought by the combined application of too many biopsy tools.

Distinguishing benign from malignant lesions

EBUS assists operators in determining the nature of target lesions (benign vs. malignant), thereby facilitating optimal biopsy method selection and appropriate inspection items (31). Traditional CP-EBUS image analysis heavily relies on physician expertise, whereas a deep learning-assisted diagnostic system (AI-CEMA) can differentiate benign from malignant lesions by processing dynamic CP-EBUS images. Chen et al. trained AI-CEMA using a dataset of 1,006 lymph nodes from a single center and validated it through a prospective multicenter study of 267 patients. The results demonstrated that AI-CEMA achieved diagnostic performance comparable to that of experienced experts in distinguishing benign from malignant lymph nodes (32).

ROSE is a reliable method for distinguishing benign from malignant pulmonary lesions. The combination of ROSE during bronchoscopy can promptly confirm adequate tissue acquisition to reduce procedure time and help operators adjust the biopsy strategy for negative results. A meta-analysis of 32 studies involving 8,243 pulmonary lesions showed that ROSE had a sensitivity of 91.8% and specificity of 94.9% for diagnosing pulmonary lesions (33). A retrospective study by Yan et al. comparing ROSE results with final pathological diagnoses in 510 patients reported an overall concordance rate of 93.92%. For central lesions, ROSE achieved 89.05% accuracy in differentiating benign from malignant lesions, while for peripheral lesions the accuracy reached 95.66% (34). These newly published studies in 2025 indicate that ROSE results have high reliability and provide more evidence for operators to optimize the biopsy strategy.

AI-assisted diagnostic systems and ROSE reliably distinguished benign from malignant lesions to optimize biopsy strategies. In the future, large-scale, multi-center studies are needed to evaluate the diagnostic performance of AI-CEMA for intrapulmonary lesions.

Innovation in transbronchial therapy

Ablation of periphery pulmonary malignant tumors

In recent years, bronchoscopic technology has evolved into a comprehensive platform integrating both diagnosis and local ablation for pulmonary malignant tumors. The application of ablation in the treatment of pulmonary malignant tumors has a history of over two decades. Currently, radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation represent the three primary modalities of transbronchial ablation. With technological and experiential advancements, guided bronchoscopy ablation techniques have provided effective treatment options for patients with early-stage peripheral pulmonary malignant tumors who are not surgical candidates, as well as those with pulmonary oligometastases or local recurrences. The primary challenge in transbronchial ablation remains the efficient and accurate guidance of ablation tools to target lesions. To address this, multiple studies have explored combining various guided bronchoscopy techniques. A retrospective study by Huang et al. analyzing 49 ablation cases of pulmonary nodules ≤30 mm demonstrated that the application of CBCT in ENB-guided transbronchial MWA significantly improved technical success rates (97.0% vs. 91.5%, P=0.034) and ablation success rates (90.9% vs. 81.5%, P=0.018) without increasing complication rates (35). Although the combination of ENB and CBCT has shown good accuracy (36), repeated CBCT scans increase patient radiation exposure. Xu et al. employed a combined approach using ENB with enhanced fluoroscopy for intraoperative guidance, supplemented by CBCT for confirmation. This technique aimed to improve navigation efficiency while reducing repeated CBCT scans during the procedure. The study involved 39 patients with malignant pulmonary nodules ≤30 mm who were not surgical candidates. This approach achieved a MWA success rate of 92.2%, with a median navigation time of only 12 minutes, a median total procedure time of 85 minutes, and an average of merely three CBCT scans per procedure (37).

Cryoablation provides a safe and effective alternative treatment for patients with peripheral pulmonary malignant tumors who are unsuitable for or unwilling to undergo surgery. Zhang et al. successfully performed transbronchial cryoablation using ssRAB combined with CBCT guidance, providing precise treatment for six patients. The six patients included in the study exhibited variations in both size and characteristics of their ablated lesions: three were GGNs (two pathologically confirmed malignant), and three were solid nodules pathologically confirmed as malignant (including two metastatic lesions), with the largest lesion measuring 25 mm × 14 mm. All patients successfully completed the ablation procedure with complete coverage of target lesions and no procedure-related complications. Follow-up showed no local recurrence or progression within 3 months in any patient, with imaging demonstrating gradual shrinkage or disappearance of lesions (38).

RFA is one of the commonly used energy forms for pulmonary lesion ablation. During RFA, tissue carbonization near the ablation probe increases impedance, affecting current conduction and consequently limiting the ablation range and efficacy, especially when ablating GGNs that have higher air content. A retrospective cohort study by Hong et al. summarized data from 46 patients with 55 lesions averaging 16.4 mm in size, showing 1-, 2-, and 3-year local control progression-free survival (PFS) rates of 87.5%, 73.4%, and 69.8%, respectively, after transbronchial RFA (39). The novel ablation system can continuously inject saline near the ablation probe during RFA to reduce impedance and improve ablation efficiency and range. Additionally, the system can adjust saline perfusion volume and ablation energy output in real-time based on bronchus temperature to ensure the lesion remains within a stable temperature range throughout the ablation procedure. Using the same ablation system, a multicenter prospective study by Zhong et al. enrolled 126 patients with lesions smaller than 30mm that had bronchus sign, most of whom had stage I peripheral lung cancer but were unsuitable for surgery due to other conditions. The study revealed an ablation success rate of 99.35% with this method. The complete ablation rate and intrapulmonary PFS rate at 12-month follow-up were 90.48% and 88.89%, respectively. This method achieved a 12-month complete ablation rate of 100% for GGNs by reducing impedance (solid vs. pure GGN vs. mixed GGN: 82.14% vs. 100% vs. 96.08%, P=0.007) (40).

Percutaneous ablation is easier to perform than transbronchial ablation but has higher procedure-related complications (41). Emerging evidence demonstrates that transbronchial MWA can achieve comparable efficacy and superior safety to percutaneous MWA. A retrospective study by Wang et al. analyzed clinical data from 126 stage I non-small cell lung cancer (NSCLC) patients who were not surgical candidates, showing similar 6-month local control rates (LCRs) between the CT-guided bronchoscopic transbronchial MWA (BTMA) group and percutaneous transthoracic MWA (PTMA) group (95.5% vs. 96.7%). The 12-month LCR and PFS rates were also nearly identical (LCR: 95.5% vs. 95.0%; PFS: 90.9% vs. 91.7%). However, the BTMA group had significantly lower incidences of chest pain (10.0% vs. 66.7%, P<0.001) and pneumothorax requiring thoracentesis (3.3% vs. 18.8%, P=0.006) (42).

Although precise and efficient ablation systems have shown promising short-term survival benefits for patients with peripheral pulmonary malignant tumors, long-term (≥3-year) outcome data are still being accumulated due to the relatively recent introduction of these techniques in clinical practice.

Central airway therapy

Patients with central airway obstruction often present with life-threatening respiratory distress requiring immediate evaluation and intervention. With the rapid development of interventional pulmonology, therapeutic bronchoscopy has been proven to be an effective treatment for central airway obstruction. A novel balloon cryoablation system utilizes an airway cryoablation catheter to increase the cryoablation working area and improve cryoablation efficacy: when the catheter reaches the lesion, the balloon is inflated to ensure close contact with the lesion, followed by rapid delivery of liquid nitrogen to achieve cryoablation. For malignant central airway obstruction treatment, this system demonstrated a 41% reduction in procedural time compared with conventional CO₂-driven cryoablation system (378 vs. 625 seconds, P<0.001) and improved 6-week airway patency rate by 17.6% (78.5% vs. 60.9%, P<0.001) (43).

Hybrid-argon plasma coagulation (APC) is a novel transbronchial ablation technique. This technique creates a protective submucosal saline cushion through needle-free high-pressure saline injection to reduce thermal damage, followed by APC for mucosal ablation. A prospective single-arm study by Zheng et al. enrolled 14 patients diagnosed with early-stage central airway superficial mucosal lung cancer, all with lesions ≤20 mm exhibiting flat, nodular, or polypoid growth patterns. Results showed that after hybrid-APC treatment, the 3-month complete remission rate of pathological biopsy reached 90%, 3-year PFS rate reached 70%, and an estimated overall survival rate was 90%. This technique provides a new non-surgical treatment option for patients unsuitable for or refusing surgery (44).

The development of novel ablation techniques provided promising treatment options for patients with central airway malignant tumors. We look forward to the establishment of standardized operation protocols, which will facilitate broader clinical adoption.

Conclusions

In 2025, transbronchial diagnosis and treatment of pulmonary malignant tumors achieved significant advancements. RAB and novel guided bronchoscopy techniques significantly improved diagnostic yield through enhanced probe flexibility, lesion accessibility, and confirmation capability. Transbronchial lymph node biopsy achieved higher diagnostic performance using cryobiopsy technique. The combined utilization of multiple biopsy tools, with cryobiopsy serving as the cornerstone, improved diagnostic yield for PPLs. AI-assisted diagnostic systems and ROSE reliably distinguished benign from malignant lesions to optimize biopsy strategies. Precise and efficient ablation systems effectively destroyed lesion tissue while minimizing damage to normal lung tissue, providing significant survival benefits for patients with peripheral pulmonary malignant tumors. The development of novel ablation techniques provided new non-surgical interventional treatment options for patients with central airway malignant tumors. With future development of thinner and more flexible bronchoscopes combined with more advanced bronchoscopy guidance techniques, the diagnostic and therapeutic efficacy for various pulmonary lesions will be further improved.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0281/rc

Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0281/prf

Funding: The work was supported by the Science and Technology Commission of Shanghai Municipality (No. 25SF1907400).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2026-0281/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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