Diagnostic Utility of Sampling Multiple Synchronous Pulmonary Nodules During Same-Session Robotic-Assisted Bronchoscopy

Background: The impact of sampling multiple peripheral pulmonary nodules (mPPNs) during a single robotic-assisted bronchoscopy (RAB) procedure is unknown. Methods: A single-center analysis of 341 consecutive RABs targeting 503 PPNs. The primary outcomes were the proportion of subjects receiving multinodule evaluation that clinically benefited from sampling secondary PPNs during the same RAB, and predictors of benefit. Results: One hundred twenty-five RABs (37% of the total) sampled mPPNs. Among these, 69 (55%) targeted bilateral and 32 (26%) more than 2 PPNs. Sampling secondary PPNs impacted the final diagnosis in 48 cases (38%, 95% CI: 30%-47%). Among 59 multinodule subjects diagnosed with lung cancer, 33 (56%) received meaningful information from sampling mPPNs. Procedural factors predicting benefit included unavailability of rapid on-site cytologic evaluation [adjusted odds ratio (aOR) 5.96, 95% CI: 1.53-23.26; P =0.010], obtaining a concentric radial-probe endobronchial ultrasound image of (aOR: 3.68, 95% CI: 1.17-11.62; P =0.026) and using multiple tools to biopsy (aOR: 3.18, 95% CI: 1.05-9.65; P =0.041) any secondary nodule. Nodule features were not predictive. Compared with single-nodule procedures, multinodule RABs delivered a higher radiation dose [4.6 Gy cm 2 (interquartile range (IQR) 3.5 to 9.5) vs. 2.4 Gy cm 2 (1.3 to 4.3); P <0.001] but had a similar incidence of pneumothorax (2.4% vs. 0.5%; P =0.11). RAB duration increased by 20.8 minutes for every additional targeted nodule (95% CI: 17.5-24.1; P <0.001). Conclusion: Multiple PPNs should be routinely targeted during a single RAB session using established sampling concepts, regardless of nodule characteristics. These findings highlight the versatility of modern bronchoscopy and have implications for managing focal thoracic disease, especially lung cancer.