High Diagnostic Yield From Digital Tomosynthesis-assisted Robotic Bronchoscopic Biopsy of Lung Nodules With Galaxy System™ TiLT+ Technology

Abstract Objectives Transbronchial lung biopsy with electromagnetic navigation (EMN) guidance has been utilized in the past decade with reported diagnostic yield of 60-70%. Newer systems with active robotic control overcome the limitation of older manually controlled systems, but accuracy may still be limited by CT-to-body divergence. The relatively novel Galaxy System (Noah Medical) incorporates Tool-in-Lesion Tomography (TiLT+) technology using C-arm fluoroscopy, enabling real-time lesion location updates, augmented fluoroscopy and tool-in-lesion confirmation, potentially improving diagnostic yield. Methods Between Sep 2023 and Oct 2024, data of 27 lung nodules in 25 patients who underwent robotic bronchoscopic lung biopsy using the Galaxy System in the hybrid operating room were prospectively collected. Patients with moderate risk, small peripheral solid or subsolid lung nodules were enrolled. Robotic bronchoscopy was performed under EMN guidance with TiLT+ using a combination of transbronchial needles, forceps and cryoprobes. Procedure was performed using the robotic system until the deployed needle was determined to be within lesion based on TiLT+ tomography. A cone-beam CT (CBCT) was then used to confirm the actual location of needle tip in relation to lesion. Feasibility, safety, tool-in-lesion percentage, center-strike percentage and diagnostic yield were assessed. Results Baseline characteristics and procedural details were listed in Table 1. 17 out of 27 nodules were solid, the rest being mixed ground glass opacities. Bronchus sign was positive in 66.7%. A mean of 3.1 cycles of TiLT+ tomography (range 2-6 cycles) was required to achieve needle-tip-in-lesion on tomography before CBCT confirmation. Procedural success defined by successful needle deployment using Galaxy System was 96.3%. Tool-in-lesion was confirmed by CBCT in 22 out of 27 nodules, with 16 showing center-strike (needle passing through the central one-third of lesion in any axis). Three cases were found to have needle touching lesion tangentially, and another two to be just off target. In one case, significant atelectasis developed during the second nodule biopsy which precluded visualization of nodule using TiLT+, requiring CBCT to complete the procedure. Diagnostic yield was 85.2% (23 out of 27 nodules), consisting of 16 definitive malignant and 7 benign specific diagnosis. There were no complications, and 88% of patients were discharged within 1 day. Conclusions Digital Tomosynthesis-assisted robotic bronchoscopy with TiLT+ is a safe and feasible method to reduce CT-to-body divergence with superior diagnostic yield. This is useful for clinicians who lack access to in-built CBCT for confirmation, and has potential to reduce total radiation exposure in those who have.