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

Bronchial branch tracing with cone-beam CT tool-in-lesion confirmation for peripheral pulmonary nodules | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bronchial branch tracing with cone-beam CT tool-in-lesion confirmation for peripheral pulmonary nodules Michael V Brown, Arash Badiei, Jelena Solujic, Hubertus Jersmann, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8635328/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 18 You are reading this latest preprint version Abstract 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. Cone-beam computed tomography solitary pulmonary nodule peripheral pulmonary nodule lung cancer bronchoscopy endobronchial ultrasound bronchial branch tracing Figures Figure 1 Main text Peripheral pulmonary nodules (PPNs) are lung parenchymal opacities detected on cross-sectional imaging, not visible on bronchoscopic examination[1]. The American College of Chest Physicians (ACCP) recommends the least invasive diagnostic procedure that permits both diagnosis and staging in suspected lung cancer[2]. With the expansion of lung cancer screening programs and the resulting stage-shift toward smaller, early-stage cancers[3-6], optimising diagnostic yield becomes a priority. Advances in bronchoscopic tools and navigational technologies have improved diagnostic performance. The introduction of radial endobronchial ultrasound (r-EBUS) represented a major step forward[7, 8]. However, diagnostic yield remains limited, attributable to the lack of definitive navigation confirmation of ‘tool-in-lesion’ and real-time visualization of nodule sampling. Various lesion characteristics can also impact diagnostic yield. Small lesions 3cm have a yield approaching 92%[1]. The presence of a bronchus sign on computed tomography (CT) is also a predictor of successful diagnosis correlating with concentric r-EBUS probe positioning within a nodule (yield 83-87%) compared to eccentric probe positioning adjacent to a nodule (yield 42%-61%)[9-11]. Alternatively, CT-guided transthoracic needle biopsy has diagnostic accuracy as high as 92.1%, but is associated with significant morbidity from pneumothorax (20.5-25.9%) and a 6.9% chest drain insertion rate causing hospitalisation and increasing costs[12]. This approach is also associated with malignant pleural seeding and rare systemic arterial air embolism[13, 14]. Advanced navigation platforms have been developed to improve access to peripheral targets, including electromagnetic navigation bronchoscopy (ENB), virtual navigation bronchoscopy (VNB), and robotic-assisted bronchoscopy (RAB)[15-23]. These have demonstrated non-inferiority to transthoracic needle biopsy[24]. However, centres without virtual navigation resourcing rely on bronchial branch tracing[25-27] or targeted sequential examination of airways with r-EBUS due to cost, equipment availability, and training requirements. Within this standard workflow, the remaining gap is tool-in-lesion confirmation , demonstrating the sampling tool positioned within the target lesion at the moment of tissue acquisition. Cone-beam computed tomography (CBCT) integrates a compact CT system with a C-arm or O-arm providing near real-time cross-sectional images that track bronchoscope and biopsy tool position relative to a nodule, facilitating “tool-in-lesion” confirmation. Unlike conventional CT, which uses a fan-shaped x-ray beam to acquire individual axial slices one at a time, CBCT employs a cone-shaped beam capturing a larger volume of data in a single rotation[28]. CBCT can overcome false-positive findings such as intraprocedural atelectasis, a recognised limitation of r-EBUS navigation[29]. Although CBCT is often discussed as part of advanced navigation platforms, it can be applied more narrowly as a confirmation test layered onto conventional navigation (bronchial branch tracing and r-EBUS), rather than serving as the primary navigation modality[30, 31]. 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. Feasibility was determined by navigational success (tool-in-lesion confirmation), with diagnostic yield, procedural time, radiation exposure and safety evaluated as secondary outcomes. We hypothesised that CBCT could be pragmatically implemented in a tertiary Australian setting and improve navigational and diagnostic performance by identifying suboptimal sampling despite apparently adequate r-EBUS positioning. Methods This was a prospective, observational, single-centre study with a control group conducted at a tertiary Australian hospital. The institutional standard-of-care for PPN biopsy is bronchial branch tracing combined with r-EBUS and fluoroscopy. Most procedures are performed under conscious sedation. One weekly general anaesthesia (GA) list is reserved for therapeutic bronchoscopy and complex diagnostic r-EBUS defined by nodule size, location or character as determined by interventional pulmonologists. A mobile O-arm CBCT (O-arm O2 imaging system, MedTronic, Minneapolis, United States of America) is shared between respiratory and surgical disciplines. All diagnostic r-EBUS patients allocated to the more complex general anaesthesia procedure list were sequentially enrolled between July 1 st 2023 and November 30 th 2024. Eligible patients had a PPN (high or low pre-test probability of malignancy), requiring histological diagnosis with transbronchial biopsy. Excluded patients had a lung mass (>30mm in maximal diameter), were unable to consent, pregnant or age <18. All patients provided written consent. Patients on the GA list received standard-of-care (bronchial branch tracing navigation with r-EBUS and fluoroscopy) or CBCT-assisted bronchoscopy (standard workflow plus CBCT confirmation of tool-in-lesion), depending on CBCT availability on the day of the procedure dictated by priority use in orthopaedic and spinal operating theatres(figure 1). Procedures were performed by an interventional pulmonologists and interventional pulmonology fellows, both of whom independently performed bronchial branch tracing[27]. In the CBCT arm, a P-190 flexible fibre-optic bronchoscope (BF-P190, Olympus, Tokyo, Japan) was inserted via an endotracheal tube. The O-arm was positioned around the patient. Lesion localisation was performed using bronchial branch tracing, r-EBUS probe (K-201/K-203, Olympus, Tokyo, Japan), guide-sheath and fluoroscopy from the O-arm. Two proceduralists required consensus of adequacy and accuracy of r-EBUS navigation documented as concentric, eccentric or unsuccessful and navigation videos were stored using a vendor neutral archive as proof of navigation effort. Once navigation was considered satisfactory, forceps were inserted through the guide-sheath into the lesion and the bronchoscope was placed in a scope holder. All staff left the operating room or stood behind acrylic lead shielding during the low-dose CT acquisition. Pre-CBCT navigational accuracy was determined by ‘tool-in-lesion.’ If unsuccessful re-navigation occurred with the EBUS probe and a second CBCT acquisition (post-CBCT navigational accuracy). If tool-in-lesion was confirmed, 2 brushings, 5-7 forceps biopsies and sterile saline washings were taken under fluoroscopy guidance. Transbronchial needle aspiration (PeriView FLEX NA-403D-2021, Olympus, Tokyo, Japan) was used at proceduralist discretion. Cryobiopsy was not used. If navigation was again unsuccessful, further navigation was not attempted. After sampling and assessing for complications, the team performed linear EBUS mediastinal lymph node staging if required. Biopsy samples were placed into formalin and saline for processing by pathology. The patient was then extubated. All standard-of-care control patients received bronchoscopy under GA, using the same bronchoscopic tools, performed by the same team in the same environment. The primary endpoint was navigational yield. Pre-CBCT navigational yield, defined as the presence of tool-in-lesion on first CBCT spin, was recorded as a discrete variable. This was compared to the post-CBCT navigational yield, defined as tool-in-lesion in cases requiring re-navigation. Secondary outcomes included diagnostic yield defined as the number of patients in whom diagnostic samples were obtained divided by the total patients undergoing intervention. A strict diagnostic yield definition was used such that samples demonstrating histopathological evidence of malignancy were diagnostic. Samples demonstrating atypia were non-diagnostic. Benign diagnoses were considered diagnostic if they were positive for a specific benign condition. Non-specific diagnoses such as inflammation were only considered diagnostic if confirmed on transcutaneous CT biopsy and/or demonstrated interval resolution on serial imaging at a minimum of 6-months follow-up. Additional outcomes included time in procedure suite, anaesthesia time and bronchoscopy duration collated from anaesthetic records, and safety defined by mean radiation dose and complications. Significant bleeding was defined as grade 2 or above as stratified in the Delphi consensus statement[32]. Patient demographics, nodule characteristics, procedural data and diagnostic yield were compared to the standard-of-care control group. Radiation data was collated directly from stored data within the fluoroscopy and CBCT devices. Procedural radiation doses were reported as a DAP (dose area product) for 2D-imaging and CTDI/DLP (Computed Tomography Dose Index/Dose Length Product) for CBCT. Retrospective computation of effective doses is unreliable in fluoroscopy due to continuously changing views and exposure settings. However, indicative radiation doses have been calculated to compare risk across modalities. For 2D-imaging on both systems effective doses have been calculated using typical views and the median screening DAP for each group using PCXMC (PCXMC Dose Calculations, Version 2.0 STUK 2008) and 3D doses are quoted from the manufacturer and scaled with DLP. Continuous variables are reported as mean and standard deviation, and dichotomous variables as number and percentage. Baseline characteristics were compared with Student t-tests or Wilcoxon rank-sum tests for continuous variables as per distribution and chi square tests for dichotomous variables. Outcomes in both groups were compared with chi square tests. Analysis was completed with GraphPad Prism 9 (GraphPad, Boston, Massachusetts, USA). Results Fifty sequential patients underwent r-EBUS procedures on the GA procedural list. Ten were excluded due to lesion size >30mm. Twenty patients were enrolled in the CBCT group, dictated by CBCT availability and twenty underwent standard-of-care. Baseline characteristics were comparable between groups, although CBCT patients were older (mean 71 vs 60 years, p=0.004)(Table 1). Mean nodule size was similar (17.55mm (SD 6.74) versus 17.26mm (SD 6.78), p=0.44). In the CBCT arm, most nodules were solid (80%), upper-lobe predominant (70%) and associated with a bronchus sign (90%). There was no significant difference between groups in axial or cranio-caudal dimensions, pleural distance (17.1mm vs 22.5, p=0.14) or outer third location (15/20 vs 11/20, p=0.18). The mean bronchial branches traced were 6.4 vs 5.9 respectively (p=0.07). In the CBCT arm, initial bronchial branch tracing with r-EBUS achieved a navigational yield with confirmed tool-in-lesion in 15/20 cases (75%), including 13 concentric and 2 eccentric r-EBUS views. Five cases demonstrated unsuccessful localisation (2 eccentric without tool-in-lesion and 3 unsuccessful(table 1). Following re-navigation guided by CBCT with bronchial branch tracing and r-EBUS, three additional nodules achieved concentric views with confirmed tool-in-lesion, increasing navigational yield to 18/20 (90%), a 15% absolute improvement. Nodules with persistent eccentric views could not be further optimised. Diagnostic yield in the CBCT arm was 16/20(80%)(table 2). Malignancy was diagnosed in 9 cases (six adenocarcinomas, two squamous cell carcinomas (SCC), one melanoma). Benign diagnoses included 3 tissue culture positive infections with post-treatment radiologic improvement, two anthracotic nodules (supported by exposure history, mediastinal sampling and stability on follow-up), one fibrotic nodule confirmed on CT-biopsy with stability at 12-months and one acute inflammatory nodule with interval resolution on follow-up. Four cases were initially non-diagnostic. Three were subsequently confirmed malignant on CT-guided biopsy and one was treated with SABR based on clinical and radiological suspicion. Among the five cases requiring CBCT-guided re-navigation, diagnostic tissue was obtained in three (SCC, anthracotic nodule, fungal infectious nodule with resolution on follow-up), indicating CBCT enhanced diagnostic yield by 15% (table 3). In the control arm, the diagnostic yield was 13/20(65%). Malignancy accounted for eight cases (four adenocarcinoma, 1 primary lung SCC, one metastatic SCC from skin, 1 germ cell carcinoma and 1 metastatic cystic adenoid carcinoma). Benign diagnoses included 3 tissue culture positive infections responsive to treatment, one sarcoidosis (non-necrotising granulomas) and 1 inflammatory lesions (serial resolution on imaging). Seven cases (35%) were non-diagnostic including one inflammatory lesion, 4 bronchial wall, 1 benign alveolar parenchyma and 1 with non-diagnostic fragments. No complications occurred in the CBCT arm. One moderate bleed occurred in the control arm. Three CBCT and four control patients underwent concurrent linear EBUS contributing to overall procedural time. Mean procedure suite time was longer for CBCT patients (54.95minutes vs 49.65minutes, p=0.03), while anaesthesia time (49.35 vs 45.15minutes, p=0.90) and bronchoscopy time (44.75 vs 41.25minutes, p=0.14) were similar(table 4). The radiation dose was higher in CBCT patients. Although fluoroscopy time was lower in the CBCT arm (74.1 vs 136.5 seconds, p<0.001), the mean effective dose from fluoroscopy was higher (0.35mSv vs 2.7mSv in the CBCT arm). The mean 3D acquisition effective dose was 1.2mSv and hence patients received a mean total exposure of 3.9mSv in the CBCT arm (table 4). All lung cancer cases were discussed at a lung cancer multidisciplinary meeting. In the CBCT arm, 6 (75%) patients had stage I cancer, treated with lobectomy (2/6) or SABR (4/6) based on performance status and comorbidities. Two stage II patients received systemic therapy. At the time of trial recruitment, neo-adjuvant chemo-immunotherapy was not standard-of-care in Australia. In the control arm, one patient had stage I, two stage II and two stage IV disease, one of which had a new nodule representing progression of a prior metastatic lung cancer diagnosis. Three patients underwent surgical resection and two received systemic treatment(table 5). Discussion In many global centres, bronchial branch tracing combined with r-EBUS remains the principal diagnostic approach for PPNs. This approach is supported by existing literature that bronchial branch tracing, even when used as a standalone navigation strategy, is clinically effective for small peripheral lesions , and that r-EBUS without advanced navigational technology remains relevant in the current practice paradigm, providing rapid and safe diagnosis[25, 26]. Within this context, this study demonstrates feasibility that integrating CBCT into a conventional r-EBUS workflow as a tool-in-lesion confirmation modality may enhance bronchial branch tracing navigation and diagnostic yield, rather than replacing an already effective technique. Despite a technically challenging cohort characterised by small nodules (<2 cm), predominantly outer-third lung location (75%), and complex bronchial branch tracing (mean 6.4 branches), navigational yield and diagnostic yield in the CBCT group was high (90% and 80% respectively). The standard-of-care group had comparable lesion complexity and achieved a diagnostic yield consistent with published r-EBUS and bronchial branch tracing series for nodules <20 mm (65%). Although this difference did not reach statistical significance (p=0.29), the observed trend suggests a potentially meaningful reduction in false-negative sampling when CBCT is used to refine an established navigation method. A key difference of this study compared to existing CBCT literature lies in the targeted application of CBCT, layered onto bronchial branch tracing navigation and r-EBUS rather than functioning as a primary navigation platform. Our methodology was similar to Casal et al’s pilot study[33] which demonstrated improvement in navigational yield (80 to 95%) when CBCT was utilised, translating to an 80% diagnostic yield. Our methodology reflects real-world practice in centres without access to virtual navigational platforms, augmented fluoroscopy or robotic systems and highlights the strength of manual bronchial branch tracing approaches. The approach of bronchial branch tracing with r-EBUS has long formed the backbone of PPN navigation due to its relatively low-cost and minimal radiation exposure. Whilst r-EBUS improves nodule identification, it provides no real-time confirmation of target lesion sampling and is limited for lesions lacking a bronchus sign or in part-solid/non-solid nodules, which demonstrate increased ultrasound echogenicity[34, 35]. False-positives can occur in airway bleeding, caused by scope or tool trauma, endobronchial saline, and atelectasis, particularly in posterior lung fields[29]. In this study, CBCT identified suboptimal tool positioning despite apparently satisfactory r-EBUS views, prompting re-navigation in several cases, the majority of which subsequently yielded a diagnosis. The modest increase in procedure suite time (54.95 vs 49.65mins, p=0.03) observed with CBCT was attributable to O-arm positioning and image acquisition, while bronchoscopy duration and anaesthesia time were not significantly different (44.75 vs 41.25mins). CBCT integration did not disrupt procedural workflow once familiarity was established. Safety outcomes were reassuring, with no complications observed in the CBCT group. The International Commission for Radiological Protection (ICRP) Publication 103 estimates a fatal cancer risk of approximately 5% per sievert for adults [30]. While radiation exposure was higher with CBCT than with standard fluoroscopy alone (3.9 mSv vs 0.35 mSv), this corresponds to an absolute risk increase from approximately 1 in 57,000 to 1 in 5,000. Notably, radiation doses in our cohort were lower than those reported in studies where CBCT was used as a primary navigation modality (5.8-14.3mSv) rather than as a targeted confirmation tool[36]. The literature supports an expanding role for navigational bronchoscopy. CBCT bronchoscopy achieves high diagnostic performance, with a pooled diagnostic yield of 78%[31]. When CBCT is combined with r-EBUS, navigation yields range from 75-93%[33, 37, 38] for a pooled diagnostic yield of 80% with acceptable pneumothorax (2.01%) and bleeding (1.08%) rates[30]. This compares favourably with r-EBUS alone which has diagnostic yields of 70%[39], consistent with the historical yield of this technique in our centre, although large prospective registries report lower (57%)[19]. Across navigational platforms (ENB, VNB, RAB), high diagnostic yields are reported with yields similar to this study[24]. RAB currently represents the benchmark for navigation and sampling[40] with a pooled diagnostic yield of ~80%[23, 41]. However, recent randomized data suggests that navigation platform alone is not the primary determinant of diagnostic success, with non-inferior diagnostic yields demonstrated between RAB and ENB[42]. Diagnostic yields are reportedly highest, particularly for small lesions <2cm, when advanced navigation and CBCT are combined[43-45]. In this setting, CBCT overcomes CT-to-body divergence, defined as the difference between pre-procedure CT and nodule position in real-time under GA, by providing real-time tool-in-lesion imaging[46]. Augmented fluoroscopy can also overlay the CBCT image to outline the lesion and create navigation pathways intra-procedurally[29]. We did not have access to AF in our centre. Access to RAB and virtual navigation platforms remains limited in many centres, reinforcing the value of pragmatic workflows that enhance existing bronchoscopic techniques. The major limitations of CBCT are the navigational learning curve particularly for small PPNs, and the radiation dose[36]. Tissue acquisition limitations continue to account for differences between successful tool-in-lesion navigation and diagnostic yield. Forceps and brushings sample predominantly endobronchially and TBNA can facilitate peri-bronchial nodule sampling, however these tools are difficult to manoeuvre in distal airways. Peripheral nodule cryobiopsy, particularly with the small 1.1mm cryoprobes, can facilitate greater tissue acquisition[47, 48]. Multi-modal sampling is critical to ensure adequacy of tissue for Programmed cell-death ligand 1 (PDL1) and molecular analysis, facilitating personalised lung cancer treatment[49]. This study has multiple additional limitations. Patient placement on the GA list was not controlled, as there were no strict criteria defining a challenging nodule (e.g. <2cm, subsolid, no bronchus sign). This was designed to provide real-world evidence of the types of cases CBCT might be used for in our centre. A standard-of-care control arm determined by CBCT availability helped to control for selection bias. Numbers were also small in this feasibility study, reducing the generalisability of results. From a technical perspective, at the time of enrolment our institution did not have access to the MP190 bronchoscope which could have aided in reach. We also did not implement cryobiopsy into the sampling workflow. These two factors could have improved further the already respectable diagnostic yield in both groups. Lastly, formal cost-effectiveness analysis was not conducted, although prior modelling suggests that improving bronchoscopic sensitivity and selective use of advanced imaging may confer downstream economic value[50]. Conclusion In centres where bronchial branch tracing with r-EBUS remains standard practice for peripheral pulmonary nodule diagnosis, CBCT feasibly enhanced navigation by confirming tool-in-lesion and identifying suboptimal positioning not apparent on r-EBUS alone. Used pragmatically for tool-in-lesion confirmation, CBCT enabled targeted re-navigation and was associated with improved navigational and diagnostic yield in a technically challenging cohort, 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. Abbreviations Abbreviation Expansion PPN Peripheral pulmonary nodule CBCT Cone Beam Computed Tomography r-EBUS Radial endobronchial ultrasound ACCP American College of Chest Physicians ENB Electromagnetic navigation bronchoscopy RAB Robotic-assisted bronchoscopy VNB Virtual Navigation Bronchoscopy GA General Anaesthesia CTDI/DLP Computed Tomography Dose Index/Dose Length Product DAP Dose area product SCC Squamous cell carcinoma SABR Stereotactic ablative body radiotherapy TBNA Transbronchial needle aspiration Declarations Acknowledgements The Royal Adelaide Hospital Thoracic Procedure Suite Nursing staff Registrar staff from 2023-2024 inclusive in the Department of Thoracic Medicine, The Royal Adelaide Hospital Statement of ethics The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study obtained Ethics and Governance approval from the Central Adelaide Local Health Network Human Research and Ethics c ommittee (2023/HRE00015 ). Informed consent was obtained from all individual participants for the procedures performed. Conflict of interest statements: All authors have completed the ICMJE uniform disclosure form. Funding sources: This study was not supported by any sponsor or funder Author contribution (I) Conception and design: Michael Brown, Arash Badiei, Phan Nguyen (II) Administrative support: Michael Brown, Phan Nguyen (III) Provision of study materials or patients: Michael Brown, Arash Badiei, Jelena Solujic, Hubertus Jersmann, Chong Ghee Chew, Phan Nguyen (IV) Collection and assembly of data: Michael Brown, Jelena Solujic, Tristan Jones, Kyle Harty, Heidi Barnett (V) Data analysis and interpretation: Michael Brown, Tristan Jones, Kyle Harty, Heidi Barnett, Phan Nguyen (VI) Manuscript writing: All authors (VII) Final approval of manuscript: All authors Availability of data and materials: The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. Further enquiries can be directed to the corresponding author. 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Yu, K.L., et al., Efficacy and Safety of Cone-Beam Computed Tomography-Derived Augmented Fluoroscopy Combined with Endobronchial Ultrasound in Peripheral Pulmonary Lesions. Respiration, 2021. 100 (6): p. 538-546. Ali, M.S., et al., Radial endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis. Respirology, 2017. 22 (3): p. 443-453. Fielding, D.I.K., et al., First Human Use of a New Robotic-Assisted Fiber Optic Sensing Navigation System for Small Peripheral Pulmonary Nodules. Respiration, 2019. 98 (2): p. 142-150. Ali, M.S., et al., Diagnostic Performance and Safety Profile of Robotic-assisted Bronchoscopy: A Systematic Review and Meta-Analysis. Ann Am Thorac Soc, 2023. 20 (12): p. 1801-1812. Paez, R., et al., Robotic Versus Electromagnetic Navigational Bronchoscopy for Pulmonary Lesion Assessment. Results From the RELIANT Randomized Trial. American Journal of Respiratory and Critical Care Medicine, 2025. 211 (Abstracts): p. A5018-A5018. Bashour, S.I., et al., Improving Shape-Sensing Robotic-Assisted Bronchoscopy Outcomes with Mobile Cone-Beam Computed Tomography Guidance. Diagnostics (Basel), 2024. 14 (17). Styrvoky, K., et al., Shape-Sensing Robotic-Assisted Bronchoscopy with Concurrent use of Radial Endobronchial Ultrasound and Cone Beam Computed Tomography in the Evaluation of Pulmonary Lesions. Lung, 2022. 200 (6): p. 755-761. Abia-Trujillo, D., et al., Mobile cone-beam computed tomography complementing shape-sensing robotic-assisted bronchoscopy in the small pulmonary nodule sampling: A multicentre experience. Respirology, 2024. 29 (4): p. 324-332. Fielding, D. and E.H.F.M. van der Heijden, Cone-beam CT imaging for robotic navigation bronchoscopy. Respirology, 2024. 29 (4): p. 274-276. Brown, M., et al., Radial Endobronchial Ultrasound-guided Transbronchial Cryobiopsy versus Forceps Biopsy for the Diagnosis of Solitary Pulmonary Nodules: A Prospective Randomised Trial. Open Respir Med J, 2023. 17 : p. e187430642309190. Sryma, P.B., et al., Efficacy of Radial Endobronchial Ultrasound (R-EBUS) guided transbronchial cryobiopsy for peripheral pulmonary lesions (PPL...s): A systematic review and meta-analysis. Pulmonology, 2023. 29 (1): p. 50-64. Verhoeven, R.L.J., S. Vos, and E. van der Heijden, Multi-modal tissue sampling in cone beam CT guided navigation bronchoscopy: comparative accuracy of different sampling tools and rapid on-site evaluation of cytopathology. J Thorac Dis, 2021. 13 (7): p. 4396-4406. Ost, D.E., et al., Economic Value of Bronchoscopy Technologies that Improves Sensitivity for Malignancy for Peripheral Pulmonary Lesions. Ann Am Thorac Soc, 2024. 21 (12): p. 1759-1769. Tables Characteristics CBCT Control p value Age (years) 71.30±10.21 60.10±12.42 p=0.004 Gender Male 10 (50%) 9 (45%) p=0.75 Female 10 (50%) 11 (55%) p=0.75 ASA Mean 2.80 2.75 p=0.75 Median 3 3 Nodule Location RUL 7 (35%) 6 (30%) p=0.74 RML 1 (5%) 0 NS RLL 3 (15%) 5 (25%) p=0.43 LUL 7 (35%) 7 (35%) p=1 LLL 2 (10%) 2 (10%) p=1 Nodule diameter Mean (mm) 17.55±6.74 17.26±6.78 p=0.44 Median (mm) 15.50 14.67 Nodule size by dimension* Long axis (mm) 19.26±7.90 19.05±7.88 p=0.26 Short axis (mm) 16.40±6.51 14.53±6.12 p=0.18 Cranio-caudal (mm) 15.60±7.01 18.20±8.43 p=0.15 Bronchus sign Yes 18 (90%) 18 (90%) p=1 No 2 (10%) 2 (10%) p=1 Nodule Character Solid 16 (80%) 18 (90%) p=0.38 Part-solid 2 (10%) 0 NS Ground glass 2 (10%) 1 (5%) p=0.55 Cavitating 0 1 (5%) NS Distance from pleura (mm)^ 17.10±15.67 22.50±16.42 p=0.14 Location in the outer third Yes 15 (75%) 11 (55%) p=0.18 No 5 (25%) 9 (45%) p=0.18 Bronchial branches traced # 6.38±1.00 5.94±0.86 p=0.07 Pre-CBCT navigational accuracy Concentric with tool in lesion 13 (65%) Eccentric with tool in lesion 2 (10%) Eccentric without tool in lesion 2 (10%) Unsuccessful 3 (15%) Post-CBCT navigation Concentric with tool in lesion 16 (80%) Eccentric with tool in lesion 2 (5%) Eccentric without tool in lesion 2 (10%) Unsuccessful 0 (0%) Table 1: Patient demographics, baseline nodule characteristics and navigational yield. Data are presented as n(%), mean±SD ASA (American Society of Anaesthesiologists), RUL (Right upper lobe), RML (Right middle lobe), RLL (Right lower lobe), LUL (Left upper lobe), LLL (left lower lobe), SD (Standard Deviation), CBCT (Cone-Beam Computed Tomography), NS (Not significant). *Nodule size as measured in radiology report ^Shortest distance to pleura from nodule #Agreement between two proceduralists Diagnostic yield Subtype CBCT arm: n(%) Control arm: n(%) p value Cancer Total Cancers 9 (45%) 8 (40%) p=0.75 Adenocarcinoma 6 (30%) 4 (20%) SCC 2 (10%) 1 (5%) Metastatic SCC (Skin) 0 1 (5%) Metastatic Melanoma 1 (5%) 0 Metastatic Germ cell tumour 0 1 (5%) Metastatic Cystic adenoid carcinoma 0 1 (5%) Benign Total benign 7 (35%) 5 (25%) p=0.49 Infection with positive tissue culture 3 (15%) 3 (15%) Sarcoidosis 0 1 (5%) Fibrotic nodule^ 1 (5%) 0 Inflammatory nodule* 1 (5%) 1 (5%) Anthracotic nodule 2 (10%) 0 Non-diagnostic 4 (20%) 7 (35%) p=0.29 Total diagnostic yield 16/20 (80%) 13/20 (65%) p=0.29 Table 2: Diagnostic yield. CBCT (Cone beam Computed Tomography), SCC (Squamous Cell carcinoma) *Only if confirmed on alternate biopsy method and/or interval resolution on follow-up imaging. ^confirmed on CT guided biopsy Mean nodule size (mm) Bronchus sign Nodule Character Distance from pleura (mm) Pre-CBCT Navigational yield Bronchoscopy Adjustment Post CBCT Navigational yield Bronchoscopic diagnosis Eventual diagnosis/ management 16 Yes Solid 12 Not Seen Re-navigation Concentric (tool-in-lesion) Squamous cell carcinoma Referred for SABR 11 Yes Solid 0 Not Seen Re-navigation Concentric (tool-in-lesion) Anthrasilicotic nodule^ Anthrasilicotic nodule^ 19.3 Yes Solid 11 Not Seen Re-navigation Concentric (tool-in-lesion) Fungal infectious nodule Fungal infectious nodule 11 No Solid 2 Eccentric (unsuccessful tool-in-lesion) Re-navigation Eccentric (unsuccessful tool-in-lesion) Benign alveolar tissue Referred for SABR 15 Yes Solid 53 Eccentric (unsuccessful tool-in-lesion) Re-navigation Eccentric (unsuccessful tool-in-lesion) Benign bronchial wall tissue Ongoing CT surveillance. No change at 12 months Table 3: Patients with a negative pre-CBCT navigational yield outcomes. CBCT (Cone Beam Computed Tomography), SABR (stereotactic ablative radiotherapy) ^interval follow up CT stability, a history of occupational dust exposure and positive anthracotic mediastinal lymph nodes sampled with linear EBUS Procedural outcomes Subtype CBCT arm Standard of care (C Arm fluoroscopy) p value Radiation Fluoroscopy time (s)(mean) 74.13 136.50 p=0.0001 Indicative effective dose from 2D (mSv)(mean) 2.70 0.35 Effective dose from 1 3D acquisition (mSv)(mean) 1.20 - Total (mSv)(mean) 3.90 0.35 Procedural time Time in procedure suite (mins) 54.95 49.65 p=0.03 Time under anaesthesia (mins) 49.35 45.15 p=0.90 Procedural time (mins) 44.75 41.25 p=0.14 Complications Bleeding (n)(%) 0 1 (5%) Pneumothorax (n) 0 0 Other (n) 0 0 Table 4: Procedural characteristics. CBCT (Cone Beam Computed Tomography), mSv (millisieverts) Lung cancer outcomes Subtype CBCT n=8 (%) Control n=5 (%) Adenocarcinoma IA2 2(25%) 1(20%) IA3 1(13%) 0 IB 2(25%) 0 IIA 0 1(20%) IIB 1(13%) 0 IVA 0 2(40%) Squamous cell carcinoma IA2 1(13%) 0 IIB 1(13%) 1(20%) Management Surgical 2(25%) 3(60%) SABR 4(50%) 0 Systemic treatment 2(25%) 2(40%) Table 5: Eventual staging and management of lung cancer diagnoses. CBCT (Cone Beam Computed tomography, SABR (Stereotactic ablative radiotherapy) Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8635328","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618219412,"identity":"cacb9027-94ef-4bea-be9c-9ec530ed5bc7","order_by":0,"name":"Michael V Brown","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYBACg8MMbEDKIrFBvgHEtyGsxRKiRSKxQeIAiJ9GWIv9AbiWBBD/MGEtZseZnz34USFhzCBx9uFj3h3n7fkb2C8+5mGwS2zApeUwm7lhzxmgFvl2Y2PeM7cTZxzgKTbmYUjGo4WHTYK3DWTLMTbp3LbbCQwHeNIkZzAw49RiANQi+fefhByDRBpIyzl7eYiWerxapHkb4FoOMG44wH5M4gPDYTxa2MykZY5JAJ13jNn4b1ty4sbDPMwGHwyOG+PUcv7wM8k3NTY8/PJtjA9nttnZyx1vf/ggoaJaFpcWOGCDs5h5DIBGEVKPCtgfkKZ+FIyCUTAKhjsAAPn9UdUPXsidAAAAAElFTkSuQmCC","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":true,"prefix":"","firstName":"Michael","middleName":"V","lastName":"Brown","suffix":""},{"id":618219416,"identity":"86a84519-0eaa-417c-810d-2ed49caf1f9a","order_by":1,"name":"Arash Badiei","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Arash","middleName":"","lastName":"Badiei","suffix":""},{"id":618219417,"identity":"2c26fd3c-50d4-4f91-a07a-cd066af72178","order_by":2,"name":"Jelena Solujic","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jelena","middleName":"","lastName":"Solujic","suffix":""},{"id":618219419,"identity":"d978d19f-d2f1-4d89-b6b4-4ffd31e162a8","order_by":3,"name":"Hubertus Jersmann","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hubertus","middleName":"","lastName":"Jersmann","suffix":""},{"id":618219429,"identity":"ee5e3068-b6b9-4384-ab3c-ab5c45d1660f","order_by":4,"name":"Chong Ghee Chew","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chong","middleName":"Ghee","lastName":"Chew","suffix":""},{"id":618219431,"identity":"87b1f5ff-60cb-43ba-a7a9-6647676b1b89","order_by":5,"name":"Tristan Jones","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tristan","middleName":"","lastName":"Jones","suffix":""},{"id":618219434,"identity":"4067a049-4e3f-4da7-b1d2-600ee5a44a08","order_by":6,"name":"Kyle Harty","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kyle","middleName":"","lastName":"Harty","suffix":""},{"id":618219436,"identity":"187b8be7-f1b4-4682-8c59-9e2a9d4dcc38","order_by":7,"name":"Heidi Barnett","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Heidi","middleName":"","lastName":"Barnett","suffix":""},{"id":618219439,"identity":"bec42608-4147-4374-8d08-bb13c05c03ab","order_by":8,"name":"Phan Nguyen","email":"","orcid":"","institution":"Royal Adelaide Hospital","correspondingAuthor":false,"prefix":"","firstName":"Phan","middleName":"","lastName":"Nguyen","suffix":""}],"badges":[],"createdAt":"2026-01-19 05:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8635328/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8635328/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106469185,"identity":"aa827c55-769a-4d41-8603-1674e77decf1","added_by":"auto","created_at":"2026-04-09 00:51:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68628,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design. CBCT (Cone Beam Computed Tomography), R-EBUS (Radial Endobronchial Ultrasound), SOC (standard of Care), GA (General Anaesthetic)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8635328/v1/a9c19e27c123f9fa6be8148c.png"},{"id":106724536,"identity":"ffeada11-d419-46ac-9ff0-a88f5a1e1b7d","added_by":"auto","created_at":"2026-04-12 18:28:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1032558,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8635328/v1/cd40c736-2309-4c1b-9002-042dfabc0ec4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bronchial branch tracing with cone-beam CT tool-in-lesion confirmation for peripheral pulmonary nodules","fulltext":[{"header":"Main text","content":"\u003cp\u003ePeripheral pulmonary nodules (PPNs) are lung parenchymal opacities detected on cross-sectional imaging, not visible on bronchoscopic examination[1]. The American College of Chest Physicians (ACCP) recommends the least invasive diagnostic procedure that permits both diagnosis and staging in suspected lung cancer[2]. With the expansion of lung cancer screening programs and the resulting stage-shift toward smaller, early-stage cancers[3-6], optimising diagnostic yield becomes a priority. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdvances in bronchoscopic tools and navigational technologies have improved diagnostic performance. The introduction of radial endobronchial ultrasound (r-EBUS) represented a major step forward[7, 8]. However, diagnostic yield remains limited, attributable to the lack of definitive navigation confirmation of \u0026lsquo;tool-in-lesion\u0026rsquo; and real-time visualization of nodule sampling. Various lesion characteristics can also impact diagnostic yield. Small lesions \u0026lt;2cm have lower diagnostic yield (11-42%), while larger lesions \u0026gt;3cm have a yield approaching 92%[1]. The presence of a bronchus sign on computed tomography (CT) is also a predictor of successful diagnosis correlating with concentric r-EBUS probe positioning within a nodule (yield 83-87%) compared to eccentric probe positioning adjacent to a nodule (yield 42%-61%)[9-11]. Alternatively, CT-guided transthoracic needle biopsy has diagnostic accuracy as high as 92.1%, but is associated with significant morbidity from pneumothorax (20.5-25.9%) and a 6.9% chest drain insertion rate causing hospitalisation and increasing costs[12]. This approach is also associated with malignant pleural seeding and rare systemic arterial air embolism[13, 14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdvanced navigation platforms have been developed to improve access to peripheral targets, including electromagnetic navigation bronchoscopy (ENB), virtual navigation bronchoscopy (VNB), and robotic-assisted bronchoscopy (RAB)[15-23]. These have demonstrated non-inferiority to transthoracic needle biopsy[24]. However, centres without virtual navigation resourcing rely on bronchial branch tracing[25-27] or targeted sequential examination of airways with r-EBUS due to cost, equipment availability, and training requirements. Within this standard workflow, the remaining gap is tool-in-lesion \u003cstrong\u003econfirmation\u003c/strong\u003e, demonstrating the sampling tool positioned within the target lesion at the moment of tissue acquisition. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCone-beam computed tomography (CBCT) integrates a compact CT system with a C-arm or O-arm providing near real-time cross-sectional images that track bronchoscope and biopsy tool position relative to a nodule, facilitating \u0026ldquo;tool-in-lesion\u0026rdquo; confirmation. Unlike conventional CT, which uses a fan-shaped x-ray beam to acquire individual axial slices one at a time, CBCT employs a cone-shaped beam capturing a larger volume of data in a single rotation[28]. CBCT can overcome false-positive findings such as intraprocedural atelectasis, a recognised limitation of r-EBUS navigation[29]. Although CBCT is often discussed as part of advanced navigation platforms, it can be applied more narrowly as a confirmation test layered onto conventional navigation (bronchial branch tracing and r-EBUS), rather than serving as the primary navigation modality[30, 31]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis 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. Feasibility was determined by navigational success (tool-in-lesion confirmation), with diagnostic yield, procedural time, radiation exposure and safety evaluated as secondary outcomes. We hypothesised that CBCT could be pragmatically implemented in a tertiary Australian setting and improve navigational and diagnostic performance by identifying suboptimal sampling despite apparently adequate r-EBUS positioning.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a prospective, observational, single-centre study with a control group conducted at a tertiary Australian hospital. The institutional standard-of-care for PPN biopsy is bronchial branch tracing combined with r-EBUS and fluoroscopy. Most procedures are performed under conscious sedation. One weekly general anaesthesia (GA) list is reserved for therapeutic bronchoscopy and complex diagnostic r-EBUS defined by nodule size, location or character as determined by interventional pulmonologists. A mobile O-arm CBCT (O-arm O2 imaging system, MedTronic, Minneapolis, United States of America) is shared between respiratory and surgical disciplines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll diagnostic r-EBUS patients allocated to the more complex general anaesthesia procedure list were sequentially enrolled between July 1\u003csup\u003est\u003c/sup\u003e 2023 and November 30\u003csup\u003eth\u003c/sup\u003e 2024. Eligible patients had a PPN (high or low pre-test probability of malignancy), requiring histological diagnosis with transbronchial biopsy. Excluded patients had a lung mass (\u0026gt;30mm in maximal diameter), were unable to consent, pregnant or age \u0026lt;18. All patients provided written consent. Patients on the GA list received standard-of-care (bronchial branch tracing navigation with r-EBUS and fluoroscopy) or CBCT-assisted bronchoscopy (standard workflow plus CBCT confirmation of tool-in-lesion), depending on CBCT availability on the day of the procedure dictated by priority use in orthopaedic and spinal operating theatres(figure 1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProcedures were performed by an interventional pulmonologists and interventional pulmonology fellows, both of whom independently performed bronchial branch tracing[27]. In the CBCT arm, a P-190 flexible fibre-optic bronchoscope (BF-P190, Olympus, Tokyo, Japan) was inserted via an endotracheal tube. The O-arm was positioned around the patient. Lesion localisation was performed using bronchial branch tracing, r-EBUS probe (K-201/K-203, Olympus, Tokyo, Japan), guide-sheath and fluoroscopy from the O-arm. Two proceduralists required consensus of adequacy and accuracy of r-EBUS navigation documented as concentric, eccentric or unsuccessful and navigation videos were stored using a vendor neutral archive as proof of navigation effort. Once navigation was considered satisfactory, forceps were inserted through the guide-sheath into the lesion and the bronchoscope was placed in a scope holder. All staff left the operating room or stood behind acrylic lead shielding during the low-dose CT acquisition. Pre-CBCT navigational accuracy was determined by \u0026lsquo;tool-in-lesion.\u0026rsquo; If unsuccessful re-navigation occurred with the EBUS probe and a second CBCT acquisition (post-CBCT navigational accuracy). If tool-in-lesion was confirmed, 2 brushings, 5-7 forceps biopsies and sterile saline washings were taken under fluoroscopy guidance. Transbronchial needle aspiration (PeriView FLEX NA-403D-2021, Olympus, Tokyo, Japan) was used at proceduralist discretion. Cryobiopsy was not used. If navigation was again unsuccessful, further navigation was not attempted. After sampling and assessing for complications, the team performed linear EBUS mediastinal lymph node staging if required. Biopsy samples were placed into formalin and saline for processing by pathology. The patient was then extubated. All standard-of-care control patients received bronchoscopy under GA, using the same bronchoscopic tools, performed by the same team in the same environment. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe primary endpoint was navigational yield. Pre-CBCT navigational yield, defined as the presence of tool-in-lesion on first CBCT spin, was recorded as a discrete variable. This was compared to the post-CBCT navigational yield, defined as tool-in-lesion in cases requiring re-navigation. Secondary outcomes included diagnostic yield defined as the number of patients in whom diagnostic samples were obtained divided by the total patients undergoing intervention. A strict diagnostic yield definition was used such that samples demonstrating histopathological evidence of malignancy were diagnostic. Samples demonstrating atypia were non-diagnostic. Benign diagnoses were considered diagnostic if they were positive for a specific benign condition. Non-specific diagnoses such as \u0026nbsp;inflammation were only considered diagnostic if confirmed on transcutaneous CT biopsy and/or demonstrated interval resolution on serial imaging at a minimum of 6-months follow-up. Additional outcomes included time in procedure suite, anaesthesia time and bronchoscopy duration collated from anaesthetic records, and safety defined by mean radiation dose and complications. Significant bleeding was defined as grade 2 or above as stratified in the Delphi consensus statement[32]. Patient demographics, nodule characteristics, procedural data and diagnostic yield were compared to the standard-of-care control group. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRadiation data was collated directly from stored data within the fluoroscopy and CBCT devices. Procedural radiation doses were reported as a DAP (dose area product) for 2D-imaging and CTDI/DLP (Computed Tomography Dose Index/Dose Length Product) for CBCT. Retrospective computation of effective doses is unreliable in fluoroscopy due to continuously changing views and exposure settings. However, indicative radiation doses have been calculated to compare risk across modalities. For 2D-imaging on both systems effective doses have been calculated using typical views and the median screening DAP for each group using PCXMC (PCXMC Dose Calculations, Version 2.0 STUK 2008) and 3D doses are quoted from the manufacturer and scaled with DLP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eContinuous variables are reported as mean and standard deviation, and dichotomous variables as number and percentage. Baseline characteristics were compared with Student t-tests or Wilcoxon rank-sum tests for continuous variables as per distribution and chi square tests for dichotomous variables. Outcomes in both groups were compared with chi square tests. Analysis was completed with GraphPad Prism 9 (GraphPad, Boston, Massachusetts, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFifty sequential patients underwent r-EBUS procedures on the GA procedural list. Ten were excluded due to lesion size \u0026gt;30mm. Twenty patients were enrolled in the CBCT group, dictated by CBCT availability and twenty underwent standard-of-care. Baseline characteristics were comparable between groups, although CBCT patients were older (mean 71 vs 60 years, p=0.004)(Table 1). Mean nodule size was similar (17.55mm (SD 6.74) versus 17.26mm (SD 6.78), p=0.44). In the CBCT arm, most nodules were solid (80%), upper-lobe predominant (70%) and associated with a bronchus sign (90%). There was no significant difference between groups in axial or cranio-caudal dimensions, pleural distance (17.1mm vs 22.5, p=0.14) or outer third location (15/20 vs 11/20, p=0.18). The mean bronchial branches traced were 6.4 vs 5.9 respectively (p=0.07). \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the CBCT arm, initial bronchial branch tracing with r-EBUS achieved a navigational yield with confirmed tool-in-lesion in 15/20 cases (75%), including 13 concentric and 2 eccentric r-EBUS views. Five cases demonstrated unsuccessful localisation (2 eccentric without tool-in-lesion and 3 unsuccessful(table 1). Following re-navigation guided by CBCT with bronchial branch tracing and r-EBUS, three additional nodules achieved concentric views with confirmed tool-in-lesion, increasing navigational yield to 18/20 (90%), a 15% absolute improvement. Nodules with persistent eccentric views could not be further optimised. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDiagnostic yield in the CBCT arm was 16/20(80%)(table 2). Malignancy was diagnosed in 9 cases (six adenocarcinomas, two squamous cell carcinomas (SCC), one melanoma). Benign diagnoses included 3 tissue culture positive infections with post-treatment radiologic improvement, two anthracotic nodules (supported by exposure history, mediastinal sampling and stability on follow-up), one fibrotic nodule confirmed on CT-biopsy with stability at 12-months and one acute inflammatory nodule with interval resolution on follow-up. Four cases were initially non-diagnostic. Three were subsequently confirmed malignant on CT-guided biopsy and one was treated with SABR based on clinical and radiological suspicion. Among the five cases requiring CBCT-guided re-navigation, diagnostic tissue was obtained in three (SCC, anthracotic nodule, fungal infectious nodule with resolution on follow-up), indicating CBCT enhanced diagnostic yield by 15% (table 3). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the control arm, the diagnostic yield was 13/20(65%). Malignancy accounted for eight cases (four adenocarcinoma, 1 primary lung SCC, one metastatic SCC from skin, 1 germ cell carcinoma and 1 metastatic cystic adenoid carcinoma). Benign diagnoses included 3 tissue culture positive infections responsive to treatment, one sarcoidosis (non-necrotising granulomas) and 1 inflammatory lesions (serial resolution on imaging). Seven cases (35%) were non-diagnostic including one inflammatory lesion, 4 bronchial wall, 1 benign alveolar parenchyma and 1 with non-diagnostic fragments. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo complications occurred in the CBCT arm. One moderate bleed occurred in the control arm. Three CBCT and four control patients underwent concurrent linear EBUS contributing to overall procedural time. Mean procedure suite time was longer for CBCT patients (54.95minutes vs 49.65minutes, p=0.03), while anaesthesia time (49.35 vs 45.15minutes, p=0.90) and bronchoscopy time (44.75 vs 41.25minutes, p=0.14) were similar(table 4). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe radiation dose was higher in CBCT patients. Although fluoroscopy time was lower in the CBCT arm (74.1 vs 136.5 seconds, p\u0026lt;0.001), the mean effective dose from fluoroscopy was higher (0.35mSv vs 2.7mSv in the CBCT arm). The mean 3D acquisition effective dose was 1.2mSv and hence patients received a mean total exposure of 3.9mSv in the CBCT arm (table 4). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll lung cancer cases were discussed at a lung cancer multidisciplinary meeting. In the CBCT arm, 6 (75%) patients had stage I cancer, treated with lobectomy (2/6) or SABR (4/6) based on performance status and comorbidities. Two stage II patients received systemic therapy. At the time of trial recruitment, neo-adjuvant chemo-immunotherapy was not standard-of-care in Australia. In the control arm, one patient had stage I, two stage II and two stage IV disease, one of which had a new nodule representing progression of a prior metastatic lung cancer diagnosis. Three patients underwent surgical resection and two received systemic treatment(table 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn many global centres, bronchial branch tracing combined with r-EBUS remains the principal diagnostic approach for PPNs. This approach is supported by existing literature that bronchial branch tracing, even when used as a standalone navigation strategy, is \u003cstrong\u003eclinically effective for small peripheral lesions\u003c/strong\u003e, and that r-EBUS without advanced navigational technology remains relevant in the current practice paradigm, providing rapid and safe diagnosis[25, 26]. Within this context, this study demonstrates feasibility that integrating CBCT into a conventional r-EBUS workflow as a tool-in-lesion confirmation modality may enhance bronchial branch tracing navigation and diagnostic yield, rather than replacing an already effective technique.\u003c/p\u003e\n\u003cp\u003eDespite a technically challenging cohort characterised by small nodules (\u0026lt;2 cm), predominantly outer-third lung location (75%), and complex bronchial branch tracing (mean 6.4 branches), navigational yield and diagnostic yield in the CBCT group was high (90% and 80% respectively). The standard-of-care group had comparable lesion complexity and achieved a diagnostic yield consistent with published r-EBUS and bronchial branch tracing series for nodules \u0026lt;20 mm (65%). Although this difference did not reach statistical significance (p=0.29), the observed trend suggests a potentially meaningful reduction in false-negative sampling when CBCT is used to refine an established navigation method.\u003c/p\u003e\n\u003cp\u003eA key difference of this study compared to existing CBCT literature lies in the targeted application of CBCT, layered onto bronchial branch tracing navigation and r-EBUS rather than functioning as a primary navigation platform. Our methodology was similar to Casal et al\u0026rsquo;s pilot study[33] which demonstrated improvement in navigational yield (80 to 95%) when CBCT was utilised, translating to an 80% diagnostic yield. Our methodology reflects real-world practice in centres without access to virtual navigational platforms, augmented fluoroscopy or robotic systems and highlights the strength of manual bronchial branch tracing approaches. The approach of bronchial branch tracing with r-EBUS has long formed the backbone of PPN navigation due to its relatively low-cost and minimal radiation exposure. Whilst r-EBUS improves nodule identification, it provides no real-time confirmation of target lesion sampling and is limited for lesions lacking a bronchus sign or in part-solid/non-solid nodules, which demonstrate increased ultrasound echogenicity[34, 35]. False-positives can occur in airway bleeding, caused by scope or tool trauma, endobronchial saline, and atelectasis, particularly in posterior lung fields[29]. In this study, CBCT identified suboptimal tool positioning despite apparently satisfactory r-EBUS views, prompting re-navigation in several cases, the majority of which subsequently yielded a diagnosis. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe modest increase in procedure suite time (54.95 vs 49.65mins, p=0.03) observed with CBCT was attributable to O-arm positioning and image acquisition, while bronchoscopy duration and anaesthesia time were not significantly different (44.75 vs 41.25mins). CBCT integration did not disrupt procedural workflow once familiarity was established. Safety outcomes were reassuring, with no complications observed in the CBCT group. The International Commission for Radiological Protection (ICRP) Publication 103 estimates a fatal cancer risk of approximately 5% per sievert for adults [30]. While radiation exposure was higher with CBCT than with standard fluoroscopy alone (3.9 mSv vs 0.35 mSv), this corresponds to an absolute risk increase from approximately 1 in 57,000 to 1 in 5,000. Notably, radiation doses in our cohort were lower than those reported in studies where CBCT was used as a primary navigation modality (5.8-14.3mSv) rather than as a targeted confirmation tool[36].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe literature supports an expanding role for navigational bronchoscopy. CBCT bronchoscopy achieves high diagnostic performance, with a pooled diagnostic yield of 78%[31]. When CBCT is combined with r-EBUS, navigation yields range from 75-93%[33, 37, 38] for a pooled diagnostic yield of 80% with acceptable pneumothorax (2.01%) and bleeding (1.08%) rates[30]. This compares favourably with r-EBUS alone which has diagnostic yields of 70%[39], consistent with the historical yield of this technique in our centre, although large prospective registries report lower (57%)[19]. Across navigational platforms (ENB, VNB, RAB), high diagnostic yields are reported with yields similar to this study[24]. RAB currently represents the benchmark for navigation and sampling[40] with a pooled diagnostic yield of ~80%[23, 41]. However, recent randomized data suggests that navigation platform alone is not the primary determinant of diagnostic success, with non-inferior diagnostic yields demonstrated between RAB and ENB[42]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDiagnostic yields are reportedly highest, particularly for small lesions \u0026lt;2cm, when advanced navigation and CBCT are combined[43-45]. In this setting, CBCT overcomes CT-to-body divergence, defined as the difference between pre-procedure CT and nodule position in real-time under GA, by providing real-time tool-in-lesion imaging[46]. Augmented fluoroscopy can also overlay the CBCT image to outline the lesion and create navigation pathways intra-procedurally[29]. We did not have access to AF in our centre. Access to RAB and virtual navigation platforms remains limited in many centres, reinforcing the value of pragmatic workflows that enhance existing bronchoscopic techniques. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe major limitations of CBCT are the navigational learning curve particularly for small PPNs, and the radiation dose[36]. Tissue acquisition limitations continue to account for differences between successful tool-in-lesion navigation and diagnostic yield. Forceps and brushings sample predominantly endobronchially and TBNA can facilitate peri-bronchial nodule sampling, however these tools are difficult to manoeuvre in distal airways. Peripheral nodule cryobiopsy, particularly with the small 1.1mm cryoprobes, can facilitate greater tissue acquisition[47, 48]. Multi-modal sampling is critical to ensure adequacy of tissue for Programmed cell-death ligand 1 (PDL1) and molecular analysis, facilitating personalised lung cancer treatment[49]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has multiple additional limitations. Patient placement on the GA list was not controlled, as there were no strict criteria defining a challenging nodule (e.g. \u0026lt;2cm, subsolid, no bronchus sign). This was designed to provide real-world evidence of the types of cases CBCT might be used for in our centre. A standard-of-care control arm determined by CBCT availability helped to control for selection bias. Numbers were also small in this feasibility study, reducing the generalisability of results. From a technical perspective, at the time of enrolment our institution did not have access to the MP190 bronchoscope which could have aided in reach. We also did not implement cryobiopsy into the sampling workflow. These two factors could have improved further the already respectable diagnostic yield in both groups. Lastly, formal cost-effectiveness analysis was not conducted, although prior modelling suggests that improving bronchoscopic sensitivity and selective use of advanced imaging may confer downstream economic value[50].\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn centres where bronchial branch tracing with r-EBUS remains standard practice for peripheral pulmonary nodule diagnosis, CBCT feasibly enhanced navigation by confirming tool-in-lesion and identifying suboptimal positioning not apparent on r-EBUS alone. Used pragmatically for tool-in-lesion confirmation, CBCT enabled targeted re-navigation and was associated with improved navigational and diagnostic yield in a technically challenging cohort, 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.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbbreviation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eExpansion\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003ePPN\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003ePeripheral pulmonary nodule\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eCBCT\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eCone Beam Computed Tomography\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003er-EBUS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eRadial endobronchial ultrasound\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eACCP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eAmerican College of Chest Physicians\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eENB\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eElectromagnetic navigation bronchoscopy\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eRAB\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eRobotic-assisted bronchoscopy\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eVNB\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eVirtual Navigation Bronchoscopy\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eGA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eGeneral Anaesthesia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eCTDI/DLP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eComputed Tomography Dose Index/Dose Length Product\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eDAP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eDose area product\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eSCC\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eSquamous cell carcinoma\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eSABR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eStereotactic ablative body radiotherapy\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eTBNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cem\u003eTransbronchial needle aspiration\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Royal Adelaide Hospital Thoracic Procedure Suite Nursing staff\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegistrar staff from 2023-2024 inclusive in the Department of Thoracic Medicine, The Royal Adelaide Hospital\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study obtained\u0026nbsp;\u003c/em\u003e\u003cem\u003eEthics and Governance approval from the Central Adelaide Local Health Network Human Research and Ethics c\u003c/em\u003eommittee (2023/HRE00015\u003cem\u003e). Informed consent was obtained from all individual participants for the procedures performed.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statements:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eAll authors have completed the ICMJE uniform disclosure form.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources:\u0026nbsp;\u003c/strong\u003eThis study was not supported by any sponsor or funder\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(I) Conception and design:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Michael Brown, Arash Badiei, Phan Nguyen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(II) Administrative support:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Michael Brown, Phan Nguyen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(III) Provision of study materials or patients:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Michael Brown, Arash Badiei, Jelena Solujic, Hubertus Jersmann, Chong Ghee Chew, Phan Nguyen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(IV) Collection and assembly of data:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Michael Brown, Jelena Solujic, Tristan Jones, Kyle Harty, Heidi Barnett\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(V) Data analysis and interpretation:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Michael Brown, Tristan Jones, Kyle Harty, Heidi Barnett, Phan Nguyen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(VI) Manuscript writing:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(VII) Final approval of manuscript:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. Further enquiries can be directed to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKikuchi, E., et al., \u003cem\u003eEndobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions.\u003c/em\u003e Eur Respir J, 2004. \u003cstrong\u003e24\u003c/strong\u003e(4): p. 533-7.\u003c/li\u003e\n\u003cli\u003eRivera, M.P., A.C. Mehta, and M.M. 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Europe, 2021. \u003cstrong\u003e10\u003c/strong\u003e, 100179 DOI: 10.1016/j.lanepe.2021.100179.\u003c/li\u003e\n\u003cli\u003ePastorino, U., et al., \u003cem\u003eProlonged lung cancer screening reduced 10-year mortality in the MILD trial: new confirmation of lung cancer screening efficacy.\u003c/em\u003e Ann Oncol, 2019. \u003cstrong\u003e30\u003c/strong\u003e(7): p. 1162-1169.\u003c/li\u003e\n\u003cli\u003eZavala, D.C., \u003cem\u003eDiagnostic fiberoptic bronchoscopy: Techniques and results of biopsy in 600 patients.\u003c/em\u003e Chest, 1975. \u003cstrong\u003e68\u003c/strong\u003e(1): p. 12-9.\u003c/li\u003e\n\u003cli\u003ePaone, G., et al., \u003cem\u003eEndobronchial ultrasound-driven biopsy in the diagnosis of peripheral lung lesions.\u003c/em\u003e Chest, 2005. \u003cstrong\u003e128\u003c/strong\u003e(5): p. 3551-7.\u003c/li\u003e\n\u003cli\u003eYamada, N., et al., \u003cem\u003eFactors related to diagnostic yield of transbronchial biopsy using endobronchial ultrasonography with a guide sheath in small peripheral pulmonary lesions.\u003c/em\u003e Chest, 2007. \u003cstrong\u003e132\u003c/strong\u003e(2): p. 603-8.\u003c/li\u003e\n\u003cli\u003eKurimoto, N., et al., \u003cem\u003eEndobronchial ultrasonography using a guide sheath increases the ability to diagnose peripheral pulmonary lesions endoscopically.\u003c/em\u003e Chest, 2004. \u003cstrong\u003e126\u003c/strong\u003e(3): p. 959-65.\u003c/li\u003e\n\u003cli\u003eLee, K.M., et al., \u003cem\u003eClinical outcomes of radial probe endobronchial ultrasound using a guide sheath for diagnosis of peripheral lung lesions in patients with pulmonary emphysema.\u003c/em\u003e Respir Res, 2019. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 177.\u003c/li\u003e\n\u003cli\u003eHuo, Y.R., et al., \u003cem\u003ePneumothorax rates in CT-Guided lung biopsies: a comprehensive systematic review and meta-analysis of risk factors.\u003c/em\u003e Br J Radiol, 2020. \u003cstrong\u003e93\u003c/strong\u003e(1108): p. 20190866.\u003c/li\u003e\n\u003cli\u003eSawabata, N., M. 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Results From the RELIANT Randomized Trial.\u003c/em\u003e American Journal of Respiratory and Critical Care Medicine, 2025. \u003cstrong\u003e211\u003c/strong\u003e(Abstracts): p. A5018-A5018.\u003c/li\u003e\n\u003cli\u003eBashour, S.I., et al., \u003cem\u003eImproving Shape-Sensing Robotic-Assisted Bronchoscopy Outcomes with Mobile Cone-Beam Computed Tomography Guidance.\u003c/em\u003e Diagnostics (Basel), 2024. \u003cstrong\u003e14\u003c/strong\u003e(17).\u003c/li\u003e\n\u003cli\u003eStyrvoky, K., et al., \u003cem\u003eShape-Sensing Robotic-Assisted Bronchoscopy with Concurrent use of Radial Endobronchial Ultrasound and Cone Beam Computed Tomography in the Evaluation of Pulmonary Lesions.\u003c/em\u003e Lung, 2022. \u003cstrong\u003e200\u003c/strong\u003e(6): p. 755-761.\u003c/li\u003e\n\u003cli\u003eAbia-Trujillo, D., et al., \u003cem\u003eMobile cone-beam computed tomography complementing shape-sensing robotic-assisted bronchoscopy in the small pulmonary nodule sampling: A multicentre experience.\u003c/em\u003e Respirology, 2024. \u003cstrong\u003e29\u003c/strong\u003e(4): p. 324-332.\u003c/li\u003e\n\u003cli\u003eFielding, D. and E.H.F.M. van der Heijden, \u003cem\u003eCone-beam CT imaging for robotic navigation bronchoscopy.\u003c/em\u003e Respirology, 2024. \u003cstrong\u003e29\u003c/strong\u003e(4): p. 274-276.\u003c/li\u003e\n\u003cli\u003eBrown, M., et al., \u003cem\u003eRadial Endobronchial Ultrasound-guided Transbronchial Cryobiopsy versus Forceps Biopsy for the Diagnosis of Solitary Pulmonary Nodules: A Prospective Randomised Trial.\u003c/em\u003e Open Respir Med J, 2023. \u003cstrong\u003e17\u003c/strong\u003e: p. e187430642309190.\u003c/li\u003e\n\u003cli\u003eSryma, P.B., et al., \u003cem\u003eEfficacy of Radial Endobronchial Ultrasound (R-EBUS) guided transbronchial cryobiopsy for peripheral pulmonary lesions (PPL...s): A systematic review and meta-analysis.\u003c/em\u003e Pulmonology, 2023. \u003cstrong\u003e29\u003c/strong\u003e(1): p. 50-64.\u003c/li\u003e\n\u003cli\u003eVerhoeven, R.L.J., S. Vos, and E. van der Heijden, \u003cem\u003eMulti-modal tissue sampling in cone beam CT guided navigation bronchoscopy: comparative accuracy of different sampling tools and rapid on-site evaluation of cytopathology.\u003c/em\u003e J Thorac Dis, 2021. \u003cstrong\u003e13\u003c/strong\u003e(7): p. 4396-4406.\u003c/li\u003e\n\u003cli\u003eOst, D.E., et al., \u003cem\u003eEconomic Value of Bronchoscopy Technologies that Improves Sensitivity for Malignancy for Peripheral Pulmonary Lesions.\u003c/em\u003e Ann Am Thorac Soc, 2024. \u003cstrong\u003e21\u003c/strong\u003e(12): p. 1759-1769.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e71.30\u0026plusmn;10.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e60.10\u0026plusmn;12.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Male\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e9 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e11 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eNodule Location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; RUL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; RML\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; RLL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e5 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; LUL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; LLL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eNodule diameter\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e17.55\u0026plusmn;6.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e17.26\u0026plusmn;6.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e15.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e14.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eNodule size by dimension*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Long axis (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e19.26\u0026plusmn;7.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e19.05\u0026plusmn;7.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Short axis (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e16.40\u0026plusmn;6.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e14.53\u0026plusmn;6.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Cranio-caudal (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e15.60\u0026plusmn;7.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e18.20\u0026plusmn;8.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eBronchus sign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e18 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e18 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eNodule Character\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Solid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e16 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e18 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Part-solid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Ground glass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Cavitating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eDistance from pleura (mm)^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e17.10\u0026plusmn;15.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e22.50\u0026plusmn;16.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eLocation in the outer third\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e15 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e11 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e5 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e9 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003eBronchial branches traced\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e6.38\u0026plusmn;1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e5.94\u0026plusmn;0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep=0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePre-CBCT navigational accuracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Concentric with tool in lesion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e13 (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Eccentric with tool in lesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Eccentric without tool in lesion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Unsuccessful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePost-CBCT navigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Concentric with tool in lesion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e16 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Eccentric with tool in lesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Eccentric without tool in lesion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Unsuccessful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1: Patient demographics, baseline nodule characteristics and navigational yield. Data are presented as n(%), mean\u0026plusmn;SD\u003cbr\u003e\u0026nbsp;ASA (American Society of Anaesthesiologists), RUL (Right upper lobe), RML (Right middle lobe), RLL (Right lower lobe), LUL (Left upper lobe), LLL (left lower lobe), SD (Standard Deviation), CBCT (Cone-Beam Computed Tomography), NS (Not significant).\u0026nbsp;\u003cbr\u003e\u0026nbsp;*Nodule size as measured in radiology report\u003cbr\u003e\u0026nbsp;^Shortest distance to pleura from nodule\u003cbr\u003e\u0026nbsp;#Agreement between two proceduralists\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003eDiagnostic yield\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eSubtype\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003eCBCT arm: n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003eControl arm: \u0026nbsp;n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Cancers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9 (45%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 (40%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep=0.75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eAdenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eSCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eMetastatic SCC (Skin)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eMetastatic Melanoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eMetastatic Germ cell tumour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eMetastatic Cystic adenoid carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBenign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal benign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 (35%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 (25%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep=0.49\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eInfection with positive tissue culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eSarcoidosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eFibrotic nodule^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eInflammatory nodule*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003eAnthracotic nodule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-diagnostic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 (20%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 (35%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep=0.29\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal diagnostic yield\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16/20 (80%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13/20 (65%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep=0.29\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2: Diagnostic yield. CBCT (Cone beam Computed Tomography), SCC (Squamous Cell carcinoma)\u003cbr\u003e\u0026nbsp;*Only if confirmed on alternate biopsy method and/or interval resolution on follow-up imaging.\u003cbr\u003e\u0026nbsp;^confirmed on CT guided biopsy\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"742\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003eMean nodule size (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003eBronchus sign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNodule Character\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003eDistance from pleura (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003ePre-CBCT Navigational yield\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eBronchoscopy Adjustment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003ePost CBCT Navigational yield\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eBronchoscopic diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 110px;\"\u003e\n \u003cp\u003eEventual diagnosis/ management\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eSolid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eNot Seen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eRe-navigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eConcentric\u003c/p\u003e\n \u003cp\u003e(tool-in-lesion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 110px;\"\u003e\n \u003cp\u003eReferred for SABR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eSolid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eNot Seen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eRe-navigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eConcentric\u003c/p\u003e\n \u003cp\u003e(tool-in-lesion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eAnthrasilicotic nodule^ \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnthrasilicotic nodule^\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eSolid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eNot Seen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eRe-navigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eConcentric\u003c/p\u003e\n \u003cp\u003e(tool-in-lesion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eFungal infectious nodule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 110px;\"\u003e\n \u003cp\u003eFungal infectious nodule\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eSolid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eEccentric\u003c/p\u003e\n \u003cp\u003e(unsuccessful tool-in-lesion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eRe-navigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eEccentric\u003c/p\u003e\n \u003cp\u003e(unsuccessful tool-in-lesion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eBenign alveolar tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 110px;\"\u003e\n \u003cp\u003eReferred for SABR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eSolid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eEccentric (unsuccessful tool-in-lesion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eRe-navigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003eEccentric\u003c/p\u003e\n \u003cp\u003e(unsuccessful tool-in-lesion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eBenign bronchial wall tissue\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 110px;\"\u003e\n \u003cp\u003eOngoing CT surveillance. No change at 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3: Patients with a negative \u0026nbsp;pre-CBCT navigational yield outcomes. CBCT (Cone Beam Computed Tomography), SABR (stereotactic ablative radiotherapy)\u003cbr\u003e\u0026nbsp;^interval follow up CT stability, a history of occupational dust exposure and positive anthracotic mediastinal lymph nodes sampled with linear EBUS\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"660\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eProcedural outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eSubtype\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCBCT arm\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003eStandard of care (C Arm fluoroscopy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eRadiation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eFluoroscopy time (s)(mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e74.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e136.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ep=0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eIndicative effective dose from 2D (mSv)(mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eEffective dose from 1 3D acquisition (mSv)(mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eTotal (mSv)(mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e3.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eProcedural time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eTime in procedure suite (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e54.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e49.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ep=0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eTime under anaesthesia (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e49.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e45.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ep=0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eProcedural time (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e44.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e41.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ep=0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eBleeding (n)(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003ePneumothorax (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003eOther (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 4: Procedural characteristics. CBCT (Cone Beam Computed Tomography), mSv (millisieverts)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"470\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003eLung cancer outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSubtype\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003eCBCT\u003c/p\u003e\n \u003cp\u003en=8 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003eControl n=5 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003eAdenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIA2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2(25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIA3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2(25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2(40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIA2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003eManagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSurgical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2(25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e3(60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSABR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e4(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSystemic treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2(25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2(40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 5: Eventual staging and management of lung cancer diagnoses. CBCT (Cone Beam\u0026nbsp;\u003cbr\u003eComputed tomography, SABR (Stereotactic ablative radiotherapy)\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cone-beam computed tomography, solitary pulmonary nodule, peripheral pulmonary nodule, lung cancer, bronchoscopy, endobronchial ultrasound, bronchial branch tracing","lastPublishedDoi":"10.21203/rs.3.rs-8635328/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8635328/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePeripheral 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\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eForty 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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelective 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.\u003c/p\u003e","manuscriptTitle":"Bronchial branch tracing with cone-beam CT tool-in-lesion confirmation for peripheral pulmonary nodules","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 00:51:07","doi":"10.21203/rs.3.rs-8635328/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-15T12:55:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-19T04:59:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T20:10:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64687809368260846634575633107582528312","date":"2026-04-14T20:18:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T09:12:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99706547144492448686739951382581230540","date":"2026-04-14T07:30:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-11T10:00:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180127240702592762443833381332236549622","date":"2026-04-11T09:58:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-10T03:13:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273269546893981027292754971548392487628","date":"2026-04-10T03:11:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241462001164081935913284630142823874524","date":"2026-04-10T00:18:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T01:35:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320878033035625367760106462784229638404","date":"2026-04-02T19:01:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T08:41:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-06T12:37:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-20T16:30:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-20T16:28:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2026-01-19T05:25:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"62c63947-f163-4145-8d54-63a39d934d7a","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-15T12:55:28+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T13:10:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 00:51:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8635328","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8635328","identity":"rs-8635328","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}