Advanced imaging in radial EBUS: Exploring CBCT and ensuring radiation safety

Lin Ching Kai
National Taiwan University Hospital, Taipei, Taiwan

With the increasing implementation of low-dose computed tomography (CT) for lung cancer screening, peripheral pulmonary lesions (PPLs) are being detected more frequently. For suspected malignant PPLs, achieving an accurate diagnosis is crucial for formulating an appropriate treatment plan. Although CT-guided transthoracic biopsy is traditionally favored due to its high diagnostic accuracy, its higher complication rate has led to a growing interest in bronchoscopic alternatives.

Endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) is now widely used in the evaluation of PPLs. However, its standalone diagnostic yield remains moderate, with reported accuracies ranging from 60–70%. Various adjunctive technologies—such as fluoroscopy, virtual bronchoscopic navigation, and rapid on-site cytologic evaluation—have been explored to improve outcomes, but each presents inherent limitations. Therefore, more effective guidance systems are needed to enhance the diagnostic performance of EBUS-TBB.

Cone-beam computed tomography (CBCT) is a novel imaging modality that offers both real-time 2D fluoroscopy and 3D imaging capabilities. When combined with augmented fluoroscopy (AF), which overlays the contoured target lesion onto live fluoroscopic images, CBCT-AF provides real-time navigation and localization during bronchoscopic procedures. This system has been successfully applied in interventional radiology and surgery, and is now gaining attention in pulmonary diagnostics.

Notably, the integration of CBCT-AF into EBUS-TBB significantly improves navigation success rates and enhances diagnostic yield for PPLs. Moreover, CBCT-AF-guided bronchoscopy maintains an acceptable radiation dose and a low rate of procedure-related complications. Given its accuracy, safety, and real-time guidance capabilities, CBCT-AF holds strong potential for widespread adoption in bronchoscopic diagnosis of peripheral lung lesions.