Utility and performance of robotic-assisted bronchoscopic fine-needle aspiration compared with robotic-assisted bronchoscopic cryo-biopsy for the evaluation of pulmonary lesions.

INTRODUCTION: Few studies have compared robotic-assisted bronchoscopic (RAB) fine-needle aspiration (FNA) with RAB cryo-biopsy (CB) for the evaluation of peripheral pulmonary lesions. We compared performance between RAB-FNA and RAB-CB in the evaluation of peripheral pulmonary lesions. MATERIALS AND METHODS: From our pathology database, we identified patients who underwent RAB-FNA with rapid on-site evaluation and concurrent RAB-CB between January and December 2024. We recorded patient and lesion characteristics, RAB-CB and RAB-FNA diagnostic categorization (non-diagnostic, benign, atypical, suspicious, malignant), and specimen type used for molecular studies. RAB-FNA and RAB-CB results were compared with those of surgical resection and clinical follow-up as the gold standard. For both procedures, we evaluated diagnostic performance for establishing the diagnosis of the pulmonary lesion. RESULTS: We identified 240 cases including 148 malignant, 1 neoplasm with undetermined malignant potential and 91 benign diagnoses, based on the gold standard. The male-to-female ratio was 23:25; median patient age, 69 years; and median lesion size, 1.8 cm. Touch preparation of RAB-CB was performed in 26 (11%) cases. Compared with RAB-CB, RAB-FNA had lower sensitivity for malignant tumors (89% versus 91%) but higher sensitivity for metastasis (73% versus 70%) and lymphoma (86% versus 71%), and it was used less often for molecular testing (99% versus 1%). The RAB-FNA and RAB-CB diagnoses were discordant in 44 cases (18%). CONCLUSIONS: RAB-CB provided superior diagnostic performance overall compared with RAB-FNA for peripheral pulmonary lesions. However, the use of rapid on-site evaluation to evaluate RAB-FNA tissue yield guided the procurement and preservation of CB without touch preparation. Our findings support an integrated dual-sampling approach combining RAB-FNA and RAB-CB, as FNA aids in real-time confirmation of lesional targeting, thereby optimizing procedural adequacy while preserving cryobiopsy material for downstream studies.