CLINICAL QUESTION: In the evaluation of peripheral lung nodules, how does navigational bronchoscopy compare to transthoracic needle biopsy regarding diagnostic accuracy and procedural complications?
BACKGROUND: Previously, transthoracic needle biopsy, as performed by interventional radiologists, had a higher diagnostic accuracy rate than two-dimensional navigational bronchoscopy. With advancements in navigational bronchoscopy, the accuracy rate of bronchoscopy has greatly improved. Thus, a direct comparison between the two diagnostic methods was warranted to better characterize their accuracy and safety in a head-to-head manner.
STUDY DESIGN: Randomized, parallel group, noninferiority trial
SETTING: Multiple U.S. centers, including both tertiary care academic centers and private community hospitals
SYNOPSIS: Eligible patients included those with a single, peripheral, indeterminate, pulmonary nodule 10 to 30 mm in diameter with a pretest cancer risk of at least 10%. They were randomly assigned to either navigational bronchoscopy or transthoracic needle biopsy. 234 total patients were evaluated. The primary outcome of diagnostic accuracy demonstrated non-inferiority between methods (79% accuracy for navigational bronchoscopy versus 73.6% for transthoracic needle biopsy; P=0.003 for non-inferiority, P=0.17 for superiority). Secondary outcomes of note included higher procedural complications in the transthoracic biopsy group (29.2%, versus 5% for bronchoscopy), with the majority of complications being pneumothorax. Strengths of the study included mitigation of possible expertise bias by the involvement of multiple healthcare sites and proceduralists. Limitations included a higher use of rapid onsite cytologic evaluation in bronchoscopy cases (94.8%) as compared to transthoracic biopsies (7.2%), which may have impacted diagnostic yields.
BOTTOM LINE: For the evaluation of pulmonary nodules, navigational bronchoscopy is noninferior in diagnostic accuracy as compared to transthoracic needle biopsy but with a superior safety profile.
CITATION: Lentz RJ, et al. Navigational bronchoscopy or transthoracic needle biopsy for lung nodules. N Engl J Med. 2025;392(21):2100- 2112. doi: 10.1056/NEJMoa2414059.
Dr. Nohner
Dr. Nohner is a hospitalist at the Nebraska Medical Center and assistant professor in the department of internal medicine at the University of Nebraska Medical Center, both in Omaha, Neb.