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In our navigational bronchoscopy ERA

Jonathan Kurman, MD, MBA, FCCP; Irene Riestra Guiance, MD; Cristina Salmon, MD

| Estimated time to read:

3 minutes
Interventional Procedures Section, Thoracic Oncology and Chest Procedures Network
Jonathan Kurman, MD, MBA, FCCP

Lung cancer remains the leading cause of cancer-related death in the United States and worldwide.1,2 Early detection relies on accurate interpretation of abnormal chest imaging and represents a clinical challenge.3 With the rise of CT screening and incidental imaging, more than 1.6 million nodules are detected in the United States per year, and incidence is expected to increase.3 For nodules with an intermediate probability of malignancy, diagnostic biopsy is often the next step.3–5

Irene Riestra Guiance, MD

Since 1965, transthoracic needle aspiration (TTNA) has been considered the gold standard for lung nodule biopsy, with a reported diagnostic accuracy of up to 92% in retrospective and noncomparative studies.6 However, TTNA is also associated with well-known risks, most notably pneumothorax, which can occur in up to 25% of cases. In 2025, it continues to be the standard of care in many community and academic institutions across the United States. 

Cristina Salmon, MD

The evolution of navigational bronchoscopy has created a new frontier in diagnostic bronchoscopy. In the past decade, technological innovation has dramatically improved the reach and precision of bronchoscopy, particularly for peripheral lesions. Electromagnetic navigation, robotic bronchoscopy, augmented fluoroscopy, and cone-beam CT scan integration have all contributed to enhanced accuracy, enabling bronchoscopy to compete with TTNA in terms of yield and safety.

This shift was validated in the Navigation Endoscopy to Reach Indeterminate Lung Nodules Versus Trans-Thoracic Needle Aspiration (VERITAS) trial, a multicenter, randomized controlled study published in the New England Journal of Medicine.7 The trial randomized 258 patients to undergo either navigational bronchoscopy or TTNA and demonstrated that navigational bronchoscopy using electromagnetic navigation with integrated digital tomosynthesis imaging was noninferior to TTNA. The primary outcome of diagnostic accuracy at 12 months for navigational bronchoscopy and TTNA was 79.0% and 73.6%, respectively. Pneumothorax occurred in 5% of cases in the bronchoscopy group with only 0.8% requiring treatment, compared with 29.2% of cases for TTNA with 11.5% requiring further intervention with thoracostomy tube.

VERITAS is a turning point for interventional pulmonology, ushering in an era of high-quality comparative effectiveness trials poised to transform our approach to technology evaluation, implementation, and, ultimately, patient care. The study provides robust, comparative evidence that supports the use of navigational bronchoscopy not just as an alternative but as a first-line diagnostic strategy in appropriately selected patients. Notably, it is the first randomized controlled trial to evaluate the role of TTNA, advancing our understanding of its place within the diagnostic algorithm. It opens the door to safer, integrated pathways that allow for concurrent diagnosis, nodal staging, and future therapeutic interventions achieved in a single, integrated procedure.

References

1. Kratzer TB, Bandi P, Freedman ND, et al. Lung cancer statistics, 2023. Cancer. 2024;130(8):1330-1348. doi:10.1002/cncr.35128

2. Guo L, Zhu C, Cai L, et al. Global burden of lung cancer in 2022 and projected burden in 2050. Chin Med J (Engl). 2024;137(21):2577-2582. doi: 10.1097/CM9.0000000000003268

3. Mazzone PJ, Lam L. Evaluating the patient with a pulmonary nodule: a review. JAMA. 2022;327(3):264-273. PMID: 35040882. doi: 10.1001/jama.2021.24287

4. Radswiki T, Sergev O, Khalighinejad P, et al. Fleischner Society pulmonary nodule recommendations. Radiopaedia. https://doi.org/10.53347/rID-13541. Accessed June 7, 2025.

5. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e93S-e120S. PMID: 23649456; PMCID: PMC3749714. doi: 10.1378/chest.12-2351

6. DiBardino DM, Yarmus LB, Semaan RW. Transthoracic needle biopsy of the lung. J Thorac Dis. 2015;7(Suppl 4):S304-16. PMID: 26807279; PMCID: PMC4700361. doi: 10.3978/j.issn.2072-1439.2015.12.16

7. Lentz RJ, Frederick-Dyer K, Planz VB, et al. Navigational bronchoscopy or transthoracic needle biopsy for lung nodules. N Engl J Med. 2025;392(21):2100-2112. PMID 38045245; PMCID: PMC10690353. doi: 10.1056/NEJMMoa2414059

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