LAUSR

Interventional pulmonology (IP) is an evolving field with substantial technological progress during the past decade. These advances should be accompanied by efforts to validate their use in different patient populations and improve patient care. An area of significant progress and novel challenges is the diagnosis and management of solitary pulmonary nodules (SPN). The identification of solitary pulmonary nodules in large lung cancer screening studies range from 8% to 51%, with prevalence of malignancy from 1.1% to 12%.1 The National Lung Cancer Screening Trial (NLST) showed that early detection of lung cancer, had a 20% reduction in mortality in the low dose CT (LDCT) arm as compared to CXR.2 Furthermore, a LDCT was positive in 24% of screening studies, requiring further diagnostic procedures.3 Unfortunately, for SPNs of less than 2 cm, the sensitivity of conventional bronchoscopy is low at approximately 34% and the yield is probably influenced by the distance from the hilum, air bronchus sign and the lobe or subsegment where the lesion of interest is located.4 CT-guided transthoracic needle aspiration (CT-TTNA) has a high diagnostic yield for SPNs, particularly in the upper lobe lesions and in close proximity to the pleura. However, this approach is associated with frequent incidence of pneumothorax (20–25%) with approximately 7% of patients requiring insertion of a chest tube. Additionally, in patients with bullous lung disease or lesions that are distant from the pleura, the diagnostic accuracy for TTNA drops to 60% or less when the needle path length exceeded 40 mm.4,5 In an attempt to minimize the risk of the percutaneous approach that traverses the pleura, several bronchoscopy-guided technologies such as: electromagnetic navigation bronchoscopy, virtual bronchoscopy, radial probe endobronchial ultrasound, and ultrathin bronchoscope with guided sheath have been developed to improve the diagnostic yield of transbronchial biopsy for SPNs diagnosis. A meta-analysis of studies published before 2010 showed that the pooled diagnostic yield of guided bronchoscopy using one or a combination of the above modalities was 70% with a pneumothorax rate of 1.5%.6 Nevertheless, the yield was 61% for those lesions <2 cm vs 82% for those