This is an investigator-initiated, multicenter, non inferiority, cluster randomized controlled trial. The primary objective is to compare the diagnostic yield of the electromagnetic robotic assisted bronchoscopy with digital tomosynthesis (Galaxy system by Noah Medical) to the shape sensing robotic assisted bronchoscopy with integrated cone beam CT (Ion™ Endoluminal System by Intuitive) in patients undergoing bronchoscopy for peripheral pulmonary lesion (PPL) evaluation.

Millions of nodules are detected every year in the United States. The majority are benign, but some represent early lung cancer and biopsy is often needed to establish the diagnosis. Advanced imaging and navigational guidance systems are routinely used to sample these small peripheral lesions bronchoscopically.

A variety of navigational technologies are currently available, including non-robotic electromagnetic navigational bronchoscopy (ENB) and robotic assisted bronchoscopy (RAB), both cleared by the FDA via the 510(k) pathway. Since market release in 2019, few studies, mostly retrospective and observational studies have reported on the diagnostic yield of RAB which is estimated to be approximately 75-80%. Most of these procedures were performed using conventional fluoroscopy which provides a two-dimensional image to assist with location of the bronchoscope within the chest and with biopsy. However, pulmonary nodules are frequently not visible with conventional fluoroscopy, particularly subsolid or ground glass nodules, which may contribute to non-diagnostic procedures. Thus, the combination of RAB with CBCT, a three-dimensional cross-sectional imaging modality, has been widely adopted by the interventional pulmonology and advanced bronchoscopy community. Cone beam CT produces a near real-time intraprocedural CT image that allows the proceduralist to reposition the robotic bronchoscope based on the location of the bronchoscope relative to that of the nodule and minimize CT to body divergence (CT2BD). Preliminary data suggest that addition of CBCT improves the diagnostic yield. One of the RAB platforms (ssRAB by Intuitive) is now integrated with CBCT, which allows the proceduralist to update the position of the nodule in the navigation system itself. This upgrade is believed to increase the diagnostic yield of ssRAB.

The Galaxy System (Noah Medical) is the latest robotic bronchoscopy platform that integrates its digital tomosynthesis (DT) technology with electromagnetic navigation (EMN) robotic platform with continuous vision. DT is an imaging modality whereby a series of fluoroscopic digital images taken during a partial rotational sweep of a C-arm are superimposed and computationally processed to provide a final three-dimensional image in which the lesion of interest can be far more readily seen than by standard fluoroscopic screening whilst minimizing radiation exposure compared, for example, to CBCT. This new generation Image-Integrated Robotic Assisted Bronchoscopy (ii-RAB) utilizes the advantages of the stability of a robotic bronchoscopy and mitigates CT2BD with imaging confirmation that demonstrates the biopsy tool inside the lesion.

The current assumed pros of using the Galaxy system compared to ssRAB with integrated CBCT is that the procedure may be shorter in time with less use of radiation to the patient and staffs. While the potential downside of the use of DT only without CBCT is that it may be less accurate.

As there are no randomized or retrospective comparative data comparing the two robotic bronchoscopy platforms despite being commercially available and widely utilized, the investigators propose to compare the diagnostic yield of the newest electromagnetic RAB (E-RAB) with integrated digital tomosynthesis (DT) to that of ssRAB with integrated CBCT. Cleveland Clinic and RUSH University currently utilizes both E-RAB with DT and ssRAB with integrated CBCT and they are used interchangeably. Patients are typically assigned arbitrarily to procedures using either platform based on operating room availability.

Thus, the investigator proposes a randomized controlled study to test the hypothesis that the diagnostic yield of E-RAB with DT is not inferior to ssRAB with integrated CBCT in patients undergoing bronchoscopy to biopsy a PPL.

Inclusion Criteria:

1. ≥ 18 years of age at time of bronchoscopy
2. Scheduled for navigational bronchoscopy for the evaluation of pulmonary lesion

Exclusion Criteria:

1. Inability to provide informed consent

Individual participant data that underlie the results reported will be made available (including data dictionaries) after de-identification.

The data will become available 3 months following publication of outcomes and will remain available for at least 5 years.

Data will be made available to researchers who provide a methodologically sound proposal that has been approved by the Cleveland Clinic Institutional Review Board and the study executive committee.

It is not possible to blind the bronchoscopist or the patient to the platform used for each procedure, as they are both large distinctive-appearing pieces of equipment.

However, thoracic pathologists (the outcomes assessor) and bronchoscopy schedulers (the care provider team) will remain blinded, such that allocations should be unable to influence their histopathological interpretation or scheduling of procedures in a given bronchoscopy suite, respectively.