Advanced Bronchoscopic Approaches to Peripheral Pulmonary Lesions: a Narrative Review of Current and Emerging Techniques.

Peripheral pulmonary lesions (PPLs), defined by their location in the outer one-third of the lung, are expected to be identified with increasing frequency following the widespread adoption of lung cancer screening. The majority of PPLs will have a benign aetiology; however, obtaining tissue to exclude malignancy can be challenging, leading to high rates of benign surgical resections or prolonged surveillance imaging. Over the last two decades, there has been rapid advancement in bronchoscopic technologies, with the adoption of radial probe endobronchial ultrasound (RP-EBUS), ultrathin bronchoscopes, electromagnetic navigation bronchoscopy (ENB), virtual bronchoscopic navigation (VBN) and robotic assisted bronchoscopy (RAB). These technologies provide access to lesions that are inaccessible by conventional bronchoscopic approaches, with diagnostic yields comparable to those of CT-guided transthoracic needle biopsy (TTNB). Whilst these advanced technologies offer a lower risk of complications than CT-guided TTNB, they are significantly more expensive. In addition, advances in biopsy techniques, such as transbronchial cryobiopsy, have further enhanced the diagnostic yield for PPLs.Recent data supports the potential for a one-stop 'diagnose and treat' approach, where advanced bronchoscopic platforms are combined with thoracic surgery and rapid onsite evaluation. This offers the potential to locate and diagnose nodules prior to potential resection, thereby reducing benign resections and shortening the diagnostic pathway. The therapeutic potential of these advanced bronchoscopic platforms is an active area of research, with the potential to deliver thermal ablation therapies and intralesional brachytherapy and chemotherapy agents. This narrative review summarises the current evidence base of this rapidly evolving field.