Citations

ABSTRACT Background Shape‐sensing robotic‐assisted bronchoscopy (ssRAB) is a navigation platform for biopsy of indeterminate pulmonary lesions. Large‐scale, real‐world evidence confirming the safety profile of ssRAB compared to transthoracic needle biopsy (TTNB) is needed. Study Design and Methods A retrospective cohort study was performed using the PINC AI healthcare database among patients who underwent ssRAB or TTNB lung lesion biopsy at participating hospitals between April 2019 and March 2023. Outcomes were rates of pneumothorax and pneumothorax requiring chest‐tube intervention within 3 days, and rates of in‐hospital bleeding or all‐cause death. Quasi‐binomial logistic regression analysis was performed after one‐to‐five propensity score matching (PSM) accounting for patient‐ and hospital‐related characteristics. Results A total of 119 424 patients (5121 ssRAB, 114 303 TTNB) were identified with 4554 ssRAB and 14 319 TTNB patients after PSM. Relative to ssRAB, TTNB had significantly higher risk of pneumothorax (18.4% vs. 2.6%, OR = 7.10, p < 0.001) and pneumothorax requiring chest‐tube (10.8% vs. 1.4%, OR = 7.62, p < 0.001). TTNB was associated with a higher risk for bleeding (1.5% vs. 0.6%, OR = 2.20, p < 0.001) and all‐cause death (0.48% vs. 0.15%, OR = 2.47, p = 0.023); however, rates for both outcomes were relatively low. Interpretation In this large‐scale, real‐world database analysis with diverse patient populations, physician experience, and health care settings, ssRAB demonstrated a better safety profile compared to TTNB. Superior safety combined with a potentially comparable performance profile and known advantages of bronchoscopy, including concurrent staging, support ssRAB as an optimal choice for non‐surgical biopsies for suspicious pulmonary lesions.

ABSTRACT Airway perforation is a potentially lethal complication from tracheal or mediastinal malignancies that require complex management. Advanced thyroid cancer is known to have high morbidity, and patients with tracheal metastatic lesions are vulnerable to injury. Therapeutic management typically comprises a combination of surgical and nonoperative treatment modalities, whose adverse effects can lead to significant airway injury. We present the case of a 67‐year‐old man with papillary thyroid carcinoma who developed a tracheocutaneous fistula following proton beam therapy and chemotherapy for metastatic disease. Airway repair and recanalization were successfully achieved through a combined surgical and bronchoscopic approach.

Abstract Introduction Multiple pulmonary nodules (MPNs) are commonly encountered in patients at elevated risk for thoracic malignancy and represent a spectrum of disease states and stages. We evaluated the safety, and procedural outcomes of a combined robotic assisted bronchoscopy (RaB) and linear endobronchial ultrasound (EBUS) approach to patients with MPNs during a single bronchoscopic procedure. Methods This multicenter observational registry included patients who underwent RaB for evaluation of MPNs. Data were prospectively collected from six centers between 2019 and 2025. Demographics, imaging characteristics, safety events, and procedural outcomes were analyzed and associated with final diagnosis. Results A total of 191 patients underwent RaB with biopsy of MPN during a single procedure; 167 patients also underwent linear EBUS lymph node sampling. The strict per nodule diagnostic yield was 71.5% overall (first nodule 70.7%, second 74.3%, third 71.4%). At least one malignant nodule was identified in 127 patients (66.8%), and 85 patients (44.5%) had two or more malignant nodules; 15 patients (17.6%) demonstrated heterogeneous histopathology between malignant nodules. Among patients with non–small cell lung cancer, adequate cellularity for next generation sequencing was achieved in 82.6% of nodules. Malignant lymph nodes were identified in 10.8% (18/167). No patients with two pure ground glass nodules (0/8) had malignant nodal involvement. Pneumothorax occurred in 7.3% of cases, with 2.1% requiring chest tube placement; unplanned admissions occurred in 3.7%. Conclusion This study provides a large multisite registry evaluation of performance of simultaneous bronchoscopic sampling of multiple pulmonary nodules with EBUS staging during a single anesthesia event demonstrating an acceptable safety profile and adequacy for molecular profiling.

ABSTRACT Pulmonary vein thrombosis (PVT) is an uncommon but potentially fatal condition that is often underdiagnosed due to nonspecific clinical presentation. We report a case of a 47‐year‐old woman with a thrombus in the right inferior pulmonary vein incidentally found during a robotic‐assisted bronchoscopy biopsy (RAB) and endobronchial ultrasound (EBUS) performed for mediastinal evaluation and lymph node sampling. PVT was confirmed with computed tomography pulmonary angiography, and the patient was successfully treated with anticoagulation therapy. A review of the literature revealed that reports of PVT detected via EBUS are exceedingly rare and usually malignant in nature. To our knowledge, this is the first peer‐reviewed case report describing PVT identified incidentally during EBUS, underscoring the potential of this technique to reveal clinically significant vascular abnormalities.

8049 Background: Multiple pulmonary nodules (MPN) pose significant challenges for accurate staging of non-small cell lung cancer (NSCLC). As next generation sequencing (NGS) technologies have become more widely available on smaller amounts of tissue, the prevalence and clinical implications of heterogeneity between MPNs are poorly understood. This study retrospectively evaluates the histopathological and NGS findings after MPN biopsy in a single robotic-assisted bronchoscopy (RaB) procedure. Methods: 191 patients were retrospectively enrolled at 6 geographically diverse centers in the US. All patients had 2+ pulmonary nodules biopsied and staging EBUS in the same procedure. An expert molecular pathologist reviewed NGS data between nodule pairs to determine if they were discordant, concordant, or indeterminate. Results: Of 191 patients, 85 patients had 2 malignant nodules with 15 of those demonstrating histopathologic heterogeneity (e.g., one adenocarcinoma, one squamous cell carcinoma). 26 patients with 2 malignant nodules of similar histopathology demonstrated molecular heterogeneity between nodules. These cases were reviewed by an expert molecular pathologist who determined the following breakdown: -15 discordant pairs (57.7%) -3 concordant pairs (11.5) -8 indeterminate pairs (30.8%) Breakdown by nodule density: -Discordant: 7 same density, 8 different density -Concordant: 3 same density -Indeterminate: 5 same density, 3 different density Breakdown by nodule laterality: -Discordant: 7 ipsilateral, 8 contralateral -Concordant: 2 ipsilateral, 1 contralateral -Indeterminate: 4 ipsilateral, 4 contralateral Staging EBUS was performed in all 26 cases with malignancy identified in 2 cases. NGS sufficiency for NSCLC from three sites with standardized NGS reporting was as follows: 1 st nodule biopsied: 42/54 (77.8%), 2 nd nodule biopsied: 37/51 (72.5%), 3 rd nodule biopsied: 2/4 (50%). In total, 90/109 (82.6%) NSCLC samples had adequate tissue for NGS. In 85 cases with 2 malignant nodules, 35 (41.2%) had all nodules Stage IIB or lower. Notably, 25 (29.4%) of the cases did not have NGS available on one or more of the nodules, thus precluding staging. Conclusions: This study highlights the frequency and clinical relevance of histopathologic and molecular heterogeneity among synchronous MPNs. Importantly, heterogeneity was not limited to contralateral or anatomically distant lesions, challenging the assumption that spatial proximity implies clonal relatedness. Further, this study shows that relying solely on density or radiographic features of a nodule is an incomplete discriminator between separate primary lung cancers and intrapulmonary metastasis. Our findings support the need for an integrated diagnostic paradigm in which sampling of multiple lesions is used to inform clonality, refine staging, and guide precision therapy.

Abstract Introduction VACTERL is an uncommon association of congenital anomalies that stands for vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities. In addition to these classical features, patients may present with airway abnormalities such as bronchial stenosis or bronchomalacia, which can lead to significant respiratory compromise. Severe bronchial stenosis is usually treated with open airway reconstruction or lung transplantation; however, this is associated with substantial risks, especially in patients with complicated congenital conditions. Interventional bronchoscopic techniques, such as paclitaxel-coated balloon dilatation, allow a less invasive alternative for restoring airway patency and reducing restenosis. We describe the case of a patient with VACTERL association and severe bronchial stenosis successfully treated with serial paclitaxel-coated balloon dilatations, avoiding the need for lung transplantation. Case description A 27-year-old male with VACTERL association presented with symptomatic left mainstem bronchial stenosis and complete right lung collapse. Bronchoscopic intervention was performed over lung transplantation because of the patient’s young age and high surgical risk. It revealed complete fibrotic obstruction of the right main bronchus and proximal stenosis of the left mainstem bronchus, measuring approximately 5-6 mm in diameter. Performing paclitaxel-coated balloon dilation showed progressive airway enlargement and clinical improvement. Under bronchoscopic guidance using a drug-coated balloon (diameter 8-10 mm, length 40 mm), which was placed in the narrowed segment and inflated for 2 minutes to expand the airway and deliver paclitaxel locally, thereby inhibiting cell proliferation and scar tissue formation. Subsequent follow-ups showed that the left mainstem bronchus diameter increased to 8-9 mm, with improvement in the airway patency and respiratory function, without any significant complications. Discussion Although the use of paclitaxel-coated balloon dilation for bronchial stenosis is still limited, this case illustrates its potential benefits as an adjunctive interventional therapy in patients with VACTERL association. The serial dilatations resulted in a progressive, sustained increase in airway diameter, from an initial 5-6 mm to approximately 8-9 mm at final follow-up in our patient (Figure 1). Compared with lung transplant, this intervention offers lower complication rates and the avoidance of chronic graft rejection and immunological complications, which are particularly relevant for young patients. This case report shows the potential of paclitaxel-coated balloon dilation as a safe, effective, and minimally invasive therapeutic option for managing bronchial stenosis in patients with complicated congenital disorders. This abstract is funded by: None

Abstract Introduction Pulsed Electric Field (PEF) Ablation has been used as an adjunct therapy for cancer. Robotic-Assisted Bronchoscopy (RAB) enables precise access to pulmonary lesions for biopsy and ablative therapy. However, anatomic obstructions within the airway may prohibit access to peripheral targets. We report a case in which robotic bronchoscopy navigation for the delivery of PEF was not initially possible due to a new anatomic airway obstruction secondary to radiation fibrosis. We were able to utilize therapeutic bronchoscopy to re-cannulate the airway and deliver the PEF via the robotic bronchoscope. Case Report A 68-year-old man with a history of left lung adenocarcinoma was treated with surgery, chemoradiation and durvalumab consolidation therapy. Surveillance imaging 4 years later revealed consolidation in the right upper mediastinum. A bronchoscopy brush biopsy confirmed adenocarcinoma and received systemic chemotherapy. Later a PET-CT showed a non FDG avid enlarged right paratracheal lesion. Follow-up CT revealed complete obstruction of the right middle lobar bronchus with associated middle lobe collapse likely secondary to radiation. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the right paratracheal lesion confirmed malignancy on onsite cytopathology. Subsequently, we performed two PEF ablations targeting the involved lesion. Repeat PET-CT demonstrated two hypermetabolic foci in the right hilum and right supraclavicular region. However, the previously PEF treated paratracheal lesion was not PET avid. We used a RAB to navigate into the right upper lobe and identified the anterior segment to be obstructed in addition to the previously noted right middle lobe. Due to this, the robotic bronchoscope couldn’t be advanced to the right hilar PET avid lesion. Utilizing guidewires, balloon dilatation and fluoroscopy we re-cannulated the obstructed right upper lobe segment and subsequently advance the robotic bronchoscope to the target in the right upper lobe. Under cone-beam guidance, multiple biopsies were obtained and confirmed as malignant. Following this, the INUMI PEF needle was deployed. We delivered two PEF activations to the right hilar PET-avid lesion. Subsequent systemic staging using linear EBUS identified station 4R lymph node involvement, positive for malignancy on rapid onsite cytopathologic evaluation. The 4R lymph node was superior to the previously treated paratracheal lesion. We then deployed the INUMI PEF needle, and PEF ablation was performed successfully. Discussion To our knowledge, this is the first reported instance of combining robotic and therapeutic bronchoscopy to overcome airway obstruction to facilitate the distal treatment of peripheral target with PEF. This abstract is funded by: None

Abstract Introduction The diagnosis of fungal lung infections remains challenging as standard tests, such as bronchoalveolar lavage (BAL) antigen testing, often yield variable or inconclusive results. These limitations can delay appropriate therapy and may require additional tissue sampling for definitive diagnosis. Robotic-assisted bronchoscopy (RAB) biopsy has been primarily used as a minimally invasive technique for assessing suspicious peripheral pulmonary lesions (PPL). This case series highlights the diagnostic utility of RAB for identifying fungal infections within PPL when conventional BAL antigen analysis is non-diagnostic. Case Description Four patients with suspected infectious or malignant PPL underwent RAB-guided biopsy for diagnostic clarification, all yielding histopathologic confirmation of fungal disease. The first, a 73-year-old bilateral lung-transplant recipient with hemoptysis, had a negative BAL Aspergillus antigen despite RAB biopsy confirming Aspergillus infection. Similarly, a second 73-year-old man with chronic obstructive pulmonary disease (COPD) and esophageal adenocarcinoma had a negative BAL antigen, while RAB biopsy of bilateral cavitary lesions confirmed Aspergillus. Additionally, a 39-year-old woman with a nodule being evaluated for malignancy, had negative BAL Histoplasma antigen and PCR, whereas RAB biopsy confirmed Histoplasma capsulatum. In contrast, a 56-year-old woman with a right-lower-lobe nodule had a positive BAL Aspergillus antigen that aligned with the histopathologic biopsy findings. Discussion BAL-based antigen testing demonstrates variable diagnostic accuracy in fungal lung disease. Reported sensitivities for Aspergillus detection are typically high in meta-analysis, approximately 80%-90%, but clinical performance in the immunocompromised or high-risk patients is often substantially lower. Similarly, while BAL antigen testing for Histoplasma performs well in disseminated infections, it often fails to detect localized pulmonary disease. In this series, three out of four patients had negative BAL results in the presence of histopathologic confirmation of fungal infection. While current guidelines consider BAL positivity supportive of a “probable” diagnosis, tissue histopathology remains the gold standard for a “proven” infection. These findings emphasize the value and capability of RAB in obtaining direct tissue confirmation when conventional testing, such as BAL antigen analysis, is non-diagnostic. Conclusion RAB-guided biopsy of PPLs offers the opportunity for histopathologic confirmation of fungal infection when BAL testing is non-diagnostic. This approach can enhance upfront diagnostic yield in patients with suspected fungal pulmonary infections, avoiding delays in diagnosis and treatment initiation. This abstract is funded by: None

Abstract Rationale Endobronchial valve (EBV) placement is an established bronchoscopic lung volume reduction (BLVR) therapy for advanced emphysema. Although randomized trials have shown improvements in lung function, real-world data on predictors of response and complications remain limited. This study evaluated physiological and clinical outcomes after EBV placement and explored predictors of treatment response and adverse events. Methods We retrospectively analyzed 75 patients who underwent EBV placement for severe emphysema at Mayo Clinic Florida between 2018 and 2023. Demographics, comorbidities, pulmonary function test and complications data were collected before and after procedure. Responders were defined as those achieving a ≥ 15% relative increase in forced expiratory volume in one second (FEV1), ≥10% reduction in residual volume (RV), ≥25-meter increase in six-minute walk distance (6MWD), or ≥ 1-point decrease in modified Medical Research Council (mMRC) dyspnea score. Results The mean age was 70.4 ± 7.1 years, 59% were female, and the mean Body Mass Index was 25.6 ± 4.9 kg/m². Most patients were non-Hispanic White (96%) and ever-smokers (97%, median 40 pack-years). Following EBV placement, FEV1 increased by + 0.10 L (p &lt; 0.001), forced vital capacity by + 0.17 L (p = 0.001), RV decreased by -0.69 L (p &lt; 0.001), while total lung capacity decreased by -0.35 L (p &lt; 0.001). Diffusing capacity, 6MWD, and mMRC did not significantly change. Responder analysis showed FEV1 improvement in 52% (34/65), RV reduction in 65% (42/65), 6MWD gain in 33% (18/55), and mMRC improvement in 33% (21/63). Complete lobar atelectasis occurred in 59% (44/75) and was significantly associated with FEV1 improvement (p &lt; 0.01). 30-day follow up complications included pneumothorax (26.7%), COPD exacerbation (21%), and pneumonia (20%). 15% pneumothoraces were managed conservatively, 55% required chest tube, 30% needed valve removal due to persistent air leak. Valve migration and replacement occurred in 2.6% each, and valve removal in 26.6% patients. Median hospital stay was longer in patients with complications (5 vs 4 days, p = 0.003). In-hospital mortality was 5.3% but no procedure-related deaths were identified. Conclusions EBV placement is a safe and effective BLVR approach yielding significant improvements in FEV1 and reductions in hyperinflation. Pneumothorax and valve-related events were the most frequent complications. Complete lobar atelectasis strongly correlated with functional improvement, suggesting that early reassessment should be considered when collapse is not achieved to prevent complications and unnecessary valve retention. This abstract is funded by: None

Abstract Rationale Advances in bronchoscopic technology, including robotic-assisted bronchoscopy (RaB) and cone-beam CT (CBCT), have enabled biopsy of multiple nodules in a single procedure. Here we present the procedural characteristics, safety, diagnostic yield, and use of linear endobronchial ultrasound (EBUS) staging in patients with multifocal pulmonary nodules biopsied under a single anesthesia event. Methods This multi-center, retrospective observational study included adults undergoing RaB biopsy of multifocal peripheral pulmonary lesions and lymph node assessment under a single anesthesia event at six U.S. centers from 11/2019 - 8/2025. Procedures utilized either the Ion (Intuitive) or Monarch (Ethicon) systems under general anesthesia. De-identified demographic, radiologic, procedural, pathologic, and safety data were collected in a secure centralized database. Safety outcomes included pneumothorax and its sequelae, hypoxia, and infectious complications. Diagnostic yield was determined using the 2024 ATS/ACCP consensus statement. NGS adequacy was reported from two health systems with well-defined criteria for sufficiency and standard institutional practices for sending NGS testing on both nodules. Statistical analyses utilized included descriptive statistics, t-tests, chi-squared/Fisher’s tests where appropriate, and logistic regression. Results Among 191 patients, 177 underwent biopsy of two and 14 of three nodules. Lymph nodes were sampled in 167 (87.4%), with 18 (10.8%) positive for malignancy; notably, 17 of 18 (94%) patients with nodal metastases had at least one fully solid nodule. Complications occurred in 20 patients (10.5%), including pneumothorax in 14 (7.3%), with 4 (2.1%) requiring tube thoracostomy. There were no cases of bilateral pneumothorax. Transient hypoxia occurred in 3 patients (1.6%) and 3 developed outpatient-managed bronchitis. Seven patients (3.7%) required unplanned admission. Overall diagnostic yield was 72.2%, with 122 (63.9%) patients having two diagnostic nodules and 33 (17.4%) having two non-diagnostic nodules. Bronchus sign (OR 2.9, p = 0.003), radial EBUS use (OR 2.6, p = 0.025), and CBCT use (OR 2.4, p = 0.021) were associated with procedures having two diagnostic nodules. At sites with standardized NGS adequacy reporting, 74 of 81 malignant nodules (91%) provided sufficient tissue for NGS. Conclusions •Single-procedure biopsy of multifocal pulmonary nodules is feasible, safe, and achieves industry-standard strict diagnostic yield. •Complications are slightly higher than single-nodule procedures. Serious events were rare. •17 of 18 patients with malignant nodal disease had at least one fully solid nodule; no patients with two pure ground glass nodules had nodal metastasis. •NGS testing was feasible and adequate on the majority of samples, aiding clinicians in staging multifocal nodules. This abstract is funded by: None