Lung Nodule Management

An Interventional Pulmonology Perspective

Udit Chaddha, MBBS; Jonathan S. Kurman, MD, MBA; Amit Mahajan, MD, FCCP; D. Kyle Hogarth, MD


Semin Respir Crit Care Med. 2018;39(6):661-666. 

In This Article

Abstract and Introduction


With the rising number of screening and incidentally detected lung nodules, there is an increasing need for evaluation in the safest and least invasive manner. The last two decades have seen substantial evolution in bronchoscopic approaches to diagnose these nodules. Innovative bronchoscopic techniques, often used in conjunction with each other, have significantly improved our ability to navigate to almost any part of the lung. A comprehensive knowledge of available technologies and the factors affecting diagnostic yield is essential to decide on the best way to approach a particular scenario. This article provides an overview of the technical aspects, yield, and limitations of these modalities.


Lung cancer is currently the leading cause of malignancy-related mortality.[1] This fact is due in large part to the advanced stage at which lung cancer is often diagnosed. Detection of stage I disease followed by timely surgical resection provides a significant increase in 5-year survival compared to those diagnosed at later stages.[2,3] Earlier identification and evaluation are crucial to diagnosing more patients with stage I disease. Lung cancer screening is designed to facilitate this earlier identification and hence has a mortality benefit.[4] With the advent of lung cancer screening and the increased utilization of thoracic imaging, detection of pulmonary nodules has increased dramatically. This trend will continue as screening becomes more widely adopted. Surveillance imaging will be appropriate for most of these nodules, but many will require further diagnostic evaluation.

Minimally invasive diagnostic and therapeutic modalities have supplanted more traditional surgical approaches as the standard of care. Guidelines emphasize gathering the most amount of information in the least invasive manner.[5] Diagnosis and staging of lung cancer are now often completed during a single outpatient procedure using flexible bronchoscopy and endobronchial ultrasound (EBUS).[6] Transbronchial needle aspiration of the mediastinal and hilar lymph nodes frequently provides sufficient information and material, obviating the need for biopsy of the primary site.[7–9] If mediastinal staging is negative for malignancy, a biopsy of the primary site should be performed. Bronchoscopic approaches, even for nodules in the periphery, have become the standard of care when the proper equipment and experience are available.

Techniques and equipment designed to enhance bronchoscopic localization and access of peripheral pulmonary nodules continue to evolve. Innovation in this area has led to the development of radial EBUS (r-EBUS), virtual bronchoscopy (VB), electromagnetic navigation (EMN), fluoroscopy-based navigation, bronchoscopic transparenchymal nodule access (BTPNA), ultrathin bronchoscopes, cone beam computed tomography (CBCT), and robotic bronchoscopy. These technologies are often used in conjunction with one another to augment bronchoscopic access to lesions in the periphery.[10,11] Bronchoscopic approaches have a favorable safety profile compared to transthoracic needle aspiration (TTNA), which carries an increased risk of pneumothorax.[12] Bronchoscopic biopsies are also less invasive than surgical biopsies, even when performed thoracoscopically. The technical aspects, supporting evidence, diagnostic yield rates, and limitations of each advanced bronchoscopic technique listed above will be reviewed here.