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New technologies in diagnostic bronchoscopy – an age of meta-analyses

Last several years were more than dynamic in the field of interventional pulmonology. A variety of new diagnostic tools emerged on the scene, some remained, some were redefined, and some are still waiting in line to be used. The most experienced bronchoscopists would comment: ‘Now we have the technology, what shall we do with it?’ Technological advances influence daily practice in interventional pulmonology in many ways. New techniques make easier identification of pathological sites on the bronchial mucosa. That is more than evident in case of autofluorescence bronchoscopy (AFB) or narrow band imaging (NBI). AFB allows identification of pathological sites even in the absence of radiological signs of disease, such as in cases of positive sputum cytology in radio-occult lung cancers, and it can attribute better definition of submucosal tumor spread. Even with low specificity and high sensitivity, one can never deny high negative predictive value of AFB. On the other hand, NBI could be even more useful, having in mind proposed relationship between NBI vascular pattern and histology of lung cancer. In an era of increased demand for tumor tissue, due to extensive molecular and genetic testing necessary for adequate molecular profiling of lung cancer, this technique might be the additional tool we have been searching for. Proposed five biopsies of tumorous lesion might not be sufficient for all the tests we need. If bronchoscopist finds dotted vascular NBI pattern, having in mind it might be adenocarcinoma of the lung requiring initially immunohistochemistry evaluation followed by further genetic testing (epidermal growth factor [EGFR] mutations, anaplastic lymphoma kinase [ALK] mutations, ROS proto-oncogene 1 [ROS1] mutations, programmed death receptor and ligands [PD/PDL-1/PDL-2], etc.), it is clear why we need more than five biopsies (of viable tissue). If particular NBI pattern appears, some additional risk of taking more biopsies can initially be justified [1,2]. Endobronchial ultrasound revolutionized bronchoscopy in many ways. Linear EBUS with ultrasound probe and camera on tip of the device is useful for evaluation of mediastinal lymph nodes and masses. Even if we know that experienced bronchoscopists, and less experienced but well-trained ones, do know natural positions of mediastinal lymph nodes – some nodes might not be naturally positioned. Linear EBUS provides real-time image of the mediastinal structures, real-time punctures of nodes 5–10 mm in diameter, and insight into relationship with major blood vessels providing extraordinary safety. Radial EBUS, which utilizes ultrasound (US) probe easily protruded through the working channel of standard bronchoscope and connected to the driving unit, provides detection of peripheral lesions. When combined, radial EBUS miniprobes and guiding sheaths demonstrate high diagnostic accuracy for solitary pulmonary nodules and other peripheral lung lesions. Electromagnetic navigation bronchoscopy (EMN), as a new but widely used technique, shows more and more benefit, not only in diagnostic area (for peripheral lesions) but also in therapeutic manner for the placement of fiducial markers for radiotherapy. Major benefit in diagnostics of peripheral lesions EMN shows in combination with other techniques [3,4].