Introduction: Robot-assisted navigation bronchoscopy (RANB) has been gaining traction as a new technology for minimally invasive biopsies of peripheral pulmonary lesions (PPLs). Cryobiopsy is an established method of procuring satisfactory lung tissues and can be safely paired with RANB. While some studies have evaluated the diagnostic accuracy and yield of this procedure, there is limited data on the utility of various biopsy tools, the sequence of use and differences in tissue characteristics based on the sampling techniques. Therefore, this study aims to examine the real-life performance of needle, forceps and cryoprobe when utilized in succession with RANB in the biopsy of PPLs, and to evaluate the specific types of tissue samples obtained from each instrument. Methods: In a single-center retrospective study, 50 patients presenting 52 PPLs underwent biopsies sequentially using fine-needle aspiration (FNA), forceps, and cryoprobe. All procedures were performed via cone-beam CT-assisted RANB. Performance metrics, such as diagnostic yield, sensitivity, and specificity, were determined by classifying malignancy as true positives and explicit benign findings as true negatives. Tissue sizes and subtypes were based on pathology description and compared with Student’s t test and χ2, respectively. Results: Cryobiopsy, when performed sequentially after FNA then forceps, was able to retrieve more alveolar tissue (p = 0.0098) among diagnosed lesions and showed higher diagnostic yield (p = 0.001) in PPL biopsy with RANB platform. Cryobiopsy was also able to obtain larger sample size (p = 0.0087). No difference was observed in the diagnosis of malignancy between forceps and cryobiopsy (p = 0.8877). Conclusion: The integration of RANB and sequential biopsies, utilizing FNA, forceps, and cryoprobe, can efficiently diagnose PPLs and procure alveolar tissues. Further research based on histopathological subtypes is required to assess its prognostic significance.

1.
“Cancer,” 7 March 2023. [Online]
. Available from: https://www.who.int/news-room/fact-sheets/detail/cancer.
2.
Kobayashi
Y
,
Ambrogio
C
,
Mitsudomi
T
.
Ground-glass nodules of the lung in never-smokers and smokers: clinical and genetic insights
.
Transl Lung Cancer Res
.
2018
;
7
(
4
):
487
97
.
3.
Fan
X
,
Zhang
X
,
Wang
E
,
Fan
C
.
Alveolar architectures preserved in cancer tissues may be potential pitfalls for diagnosis and histological subtyping of lung cancer: three case reports
.
Medicine
.
2018
;
97
(
39
):
e12613
.
4.
He
J
.
The diagnostic value of electromagnetically guided bronchoscopic lung cryobiopsy for peripheral lung nodules
.
Chin J Endosc
.
2019
;
4
:
54
9
.
5.
Torky
M
,
Elshimy
WS
,
Ragab
MA
,
Attia
GA
,
Lopez
R
,
Mate
JL
.
Endobronchial ultrasound guided transbronchial cryobiopsy versus forceps biopsy in peripheral lung lesions
.
Clin Respir J
.
2021
;
15
(
3
):
320
8
.
6.
Simon
M
,
Simon
I
,
Tent
PA
,
Todea
DA
,
Haranguș
A
.
Cryobiopsy in lung cancer diagnosis-A literature review
.
Medicina
.
2021
;
57
(
4
):
393
.
7.
Griff
S
,
Ammenwerth
W
,
Schönfeld
N
,
Bauer
TT
,
Mairinger
T
,
Blum
TG
.
Morphometrical analysis of transbronchial cryobiopsies
.
Diagn Pathol
.
2011
;
6
(
6
):
53
.
8.
Gasparini
S
.
Conventional biopsy techniques
.
Principles and practice of interventional pulmonology
.
2012
. p.
151
63
.
9.
Benn
BS
,
Romero
AO
,
Lum
M
,
Krishna
G
.
Robotic-assisted navigation bronchoscopy as a paradigm shift in peripheral lung access
.
Lung
.
2021
;
199
(
2
):
177
86
.
10.
Casal
RF
,
Sarkiss
M
,
Jones
AK
,
Stewart
J
,
Tam
A
,
Grosu
HB
.
Cone beam computed tomography-guided thin/ultrathin bronchoscopy for diagnosis of peripheral lung nodules: a prospective pilot study
.
J Thorac Dis
.
2018
;
10
(
12
):
6950
9
.
11.
Lentz
RJ
,
Argento
AC
,
Colby
TV
,
Rickman
OB
,
Maldonado
F
.
Transbronchial cryobiopsy for diffuse parenchymal lung disease: a state-of-the-art review of procedural techniques, current evidence, and future challenges
.
J Thorac Dis
.
2017
;
9
(
7
):
2186
203
.
12.
Babiak
A
,
Hetzel
J
,
Krishna
G
,
Fritz
P
,
Moeller
P
,
Balli
T
.
Transbronchial cryobiopsy: a new tool for lung biopsies
.
Respiration
.
2009
;
78
(
2
):
203
8
.
13.
Nasu
S
,
Okamoto
N
,
Suzuki
H
,
Shiroyama
T
,
Tanaka
A
,
Samejima
Y
.
Comparison of the utilities of cryobiopsy and forceps biopsy for peripheral lung cancer
.
Anticancer Res
.
2019
;
39
(
10
):
5683
8
.
14.
Giri
M
,
Huang
G
,
Puri
A
,
Zhuang
R
,
Li
Y
,
Guo
S
.
Efficacy and safety of cryobiopsy vs. Forceps biopsy for interstitial lung diseases, lung tumors, and peripheral pulmonary lesions: an updated systematic review and meta-analysis
.
Front Med
.
2022
;
10
(
9
):
840702
.
15.
Oberg
CL
,
Lau
RP
,
Folch
EE
,
He
T
,
Ronaghi
R
,
Susanto
I
.
Novel robotic-assisted cryobiopsy for peripheral pulmonary lesions
.
Lung
.
2022
;
200
(
6
):
737
45
.
16.
Arimura
K
,
Tagaya
E
,
Akagawa
H
,
Nagashima
Y
,
Shimizu
S
,
Atsumi
Y
.
Cryobiopsy with endobronchial ultrasonography using a guide sheath for peripheral pulmonary lesions and DNA analysis by next generation sequencing and rapid on-site evaluation
.
Respir Investig
.
2019
;
57
(
2
):
150
6
.
17.
Koslow
M
,
Edell
ES
,
Midthun
DE
,
Mullon
JJ
,
Kern
RM
,
Nelson
DR
.
Bronchoscopic cryobiopsy and forceps biopsy for the diagnostic evaluation of diffuse parenchymal lung disease in clinical practice
.
Mayo Clin Proc Innov Qual Outcomes
.
2020
;
4
(
5
):
565
74
.
18.
Haentschel
M
,
Boeckeler
M
,
Ehab
A
,
Wagner
R
,
Spengler
W
,
Steger
V
.
Cryobiopsy increases the EGFR detection rate in non-small cell lung cancer
.
Lung Cancer
.
2020
;
141
:
56
63
.
19.
Arimura
K
,
Kondo
M
,
Nagashima
Y
,
Kanzaki
M
,
Kobayashi
F
,
Takeyama
K
.
Comparison of tumor cell numbers and 22c3 PD-L1 expression between cryobiopsy and transbronchial biopsy with endobronchial ultrasonography-guide sheath for lung cancer
.
Respir Res
.
2019
;
20
(
1
):
185
.
20.
Ehab
A
,
Khairy El-Badrawy
M
,
Abdelhamed Moawad
A
,
El-Dosouky Abo-Shehata
M
.
Cryobiopsy versus forceps biopsy in endobronchial lesions, diagnostic yield and safety
.
Adv Respir Med
.
2017
;
85
(
6
):
301
6
.
21.
Tang
ER
,
Schreiner
AM
,
Pua
BB
.
Advances in lung adenocarcinoma classification: a summary of the new international multidisciplinary classification system (IASLC/ATS/ERS)
.
J Thorac Dis
.
2014
6
Suppl 5
489
501
.
22.
Girard
N
,
Deshpande
C
,
Lau
C
,
Finley
D
,
Rusch
V
,
Pao
W
.
Comprehensive histologic assessment helps to differentiate multiple lung primary nonsmall cell carcinomas from metastases
.
Am J Surg Pathol
.
2009
;
33
(
12
):
1752
64
.
23.
Miyoshi
T
,
Satoh
Y
,
Okumura
S
,
Nakagawa
K
,
Shirakusa
T
,
Tsuchiya
E
.
Early-stage lung adenocarcinomas with a micropapillary pattern, a distinct pathologic marker for a significantly poor prognosis
.
Am J Surg Pathol
.
2003
;
27
(
1
):
101
9
.
24.
Gildea
TR
,
Folch
EE
,
Khandhar
SJ
,
Pritchett
MA
,
LeMense
GP
,
Linden
PA
.
The impact of biopsy tool choice and rapid on-site evaluation on diagnostic accuracy for malignant lesions in the prospective: multicenter NAVIGATE study
.
J Bronchology Interv Pulmonol
.
2021
;
28
(
3
):
174
83
.
25.
Taton
O
,
Bondue
B
,
Gevenois
PA
,
Remmelink
M
,
Leduc
D
.
Diagnostic yield of combined pulmonary cryobiopsies and electromagnetic navigation in small pulmonary nodules
.
Pulm Med
.
2018
;
2018
:
6032974
.
26.
Tongbai
T
,
McDermott
S
,
Kiranantawat
N
,
Muse
VV
,
Wu
CCC
,
Shepard
JAO
.
Non-diagnostic CT-guided percutaneous needle biopsy of the lung: predictive factors and final diagnoses
.
Korean J Radiol
.
2019
;
20
(
11
):
1515
26
.
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