Tool-in-lesion confirmation and diagnostic yield of digital tomosynthesis-integrated robotic bronchoscopic biopsy of lung nodules

Background: Transbronchial lung biopsy with electromagnetic navigation (EMN) has reported diagnostic yield of 60–70%. Newer systems with active robotic control overcome the limitations of older manually controlled systems, but accuracy may still be limited by computed tomography (CT)-to-body divergence. The novel digital tomosynthesis-integrated Galaxy SystemTM (Noah Medical) incorporating Tool-in-Lesion Tomography (TiLT^+TM) technology enables real-time lesion location updates and tool-in-lesion (TIL) confirmation. The aim of this study is to evaluate the TIL percentage using TiLT^+TM and cone-beam computed tomography (CBCT).

Methods: Between September 2023 and October 2024, data of 27 lung nodules in 25 patients who underwent peripheral lung nodule biopsy using the Galaxy System^TM in the hybrid operating room were prospectively collected. Procedure was performed using the robotic system until the deployed needle was determined to be within lesion based on digital tomosynthesis. A CBCT was then used to confirm the actual location of needle tip in relation to lesion.

Results: Seventeen out of 27 nodules were solid, the rest being mixed ground glass opacities (GGOs). Bronchus sign was positive in 66.7% of the patients. A mean of 3.1 cycles of digital tomosynthesis (range, 2–6 cycles) was required to achieve TIL on tomography before CBCT confirmation. Procedural success, defined as ability to complete biopsy using he robotic system, was 96.3%. TIL/tool-touching-lesion (TTL) was confirmed by CBCT in 25/27 nodules (92.6%), with 16/27 (59.3%) showing center-strike. Conservative diagnostic yield was 84%, consisting of 16 definitive malignant and 5 benign specific diagnoses. There were no complications.

Conclusions: Robotic bronchoscopy with digital tomosynthesis is a safe and feasible method to reduce CT-to-body divergence and provide TIL confirmation, with good diagnostic yield.