Options for non-surgical tissue diagnosis of the peripheral nodule include CT scan-guided TTNA, fluoroscopy-guided bronchoscopy, radial endobronchial ultrasound (EBUS), electromagnetic navigation bronchoscopy (ENB), and virtual bronchoscopy navigation (VBN). For physicians who choose to pursue non-surgical biopsy, the decision to perform CT scan-guided or ultrasound-guided TTNA, conventional bronchoscopy or bronchoscopy guided by EBUS, ENB, or VBN will depend on a number of factors. CT scan-guided TTNA is preferable for nodules located near the chest wall or for deeper lesions, provided that there is no need to go through the fissures and there is no surrounding emphysema. Ultrasound-guided TTNA requires contact between the lesion and the costal pleura. Bronchoscopic techniques are preferable for nodules ≥2 cm located near a patent bronchus, or in individuals at high risk for pneumothorax following TTNA. In most other situations, operator experience should guide the decision. Trainees must possess a perfect knowledge of anatomy and be fully competent in the interpretation of imaging (CT with contrast medium and PET) and have a thorough knowledge of navigation technology in all its complexities. Practical training can be performed on animal, cadaver or plastic models. In the last years, to improve diagnostic yield, navigational bronchoscopy has attracted significant attention.
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