Bronchial branch tracing with cone-beam CT tool-in-lesion confirmation for peripheral pulmonary nodules

Background Peripheral pulmonary nodules (PPNs) are increasingly detected through lung cancer screening. Conventional navigation techniques like bronchial branch tracing with radial endobronchial ultrasound (r-EBUS), lack ‘tool-in-lesion’ confirmation, limiting diagnostic yield. Cone-beam computed tomography (CBCT) addresses this gap. This study aimed to evaluate the feasibility of integrating CBCT into an established bronchial branch tracing and r-EBUS workflow as a targeted tool-in-lesion confirmation strategy Method This prospective, single-centre observational study compared standard bronchial branch tracing with r-EBUS against the same workflow with CBCT used for tool-in-lesion confirmation. Consecutive patients undergoing bronchoscopy for PPNs under general anaesthesia were enrolled with allocation determined by CBCT availability. Feasibility was determined by the primary endpoint of navigational yield. Secondary outcomes included diagnostic yield, procedural time, radiation exposure and safety. Results Forty patients were analysed (n=20 CBCT, n=20 standard of care). Demographic and nodule characteristics were similar between groups. In the CBCT arm, navigational yield with bronchial branch tracing alone was 75% increasing to 90% with CBCT guided re-navigation. Diagnostic yield was 80% in CBCT compared to 65% in standard of care(p=0.29). Procedure suite time was modestly increased (54.95 vs 49.65minutes, p=0.03) while anaesthesia and bronchoscopy times were similar. No complications occurred in the CBCT arm. Radiation exposure was higher with CBCT (mean total dose 3.9mSv vs 0.35mSv). Conclusion: Selective use of CBCT as a tool-in-lesion confirmation modality is feasible and can enhance navigational yield and diagnostic yield when added to a conventional bronchial branch tracing and r-EBUS workflow with minimal impact on procedural time. Despite an increase in radiation exposure, these findings support CBCT as a practical means of strengthening existing bronchoscopic workflows.