Abstract Introduction The evaluation of pulmonary nodules in patients with prior malignancies poses a diagnostic challenge. Radiographic findings, including PET-CT, may not differentiate between metastasis, new primary, or benign lesions. Lung biopsy remains the gold standard for diagnosis 1. Recent advances in robotic-assisted bronchoscopy (RAB) have improved diagnostic yield, with pooled estimates ranging from 70-87% and sensitivity for malignancy exceeding 85%, while maintaining a low complication rate (∼3%) 2-6. Case presentations Case 1: A 69-year-old man with a history of prostate cancer (diagnosed in 2008, treated with radiation and salvage cryoablation for recurrence in 2019) and a resected anterior mediastinal thymoma (2021). He developed a left upper lobe pulmonary nodule on surveillance CT chest, increasing in size from 3 mm to 13.9 mm. Despite an FDG-negative PET-CT, the nodule remained concerning for primary lung cancer with an extensive smoking history. Patient underwent biopsy of left upper lobe nodule via Robotic-assisted bronchoscopy (RAB) with endobronchial ultrasound and transbronchial needle aspiration (TBNA), which confirmed metastatic thymoma without mediastinal and hilar lymph node involvement. Case 2: An 84-year-old woman with stage IA uterine serous endometrial carcinoma, diagnosed in 2022 s/p hysterectomy and bilateral salpingo-oophorectomy, was under routine surveillance. Chest CT on 7/2025 revealed a right upper lobe nodule that increased from 7 mm to 9 mm compared with prior scans. The multidisciplinary thoracic tumor board recommended a biopsy of the nodule. Robotic-assisted bronchoscopy with transbronchial biopsy confirmed recurrent uterine serous carcinoma. Case 3: A 73-year-old man with prior h/o treated Pulmonary Tuberculosis, right upper lobe aspergilloma, Lewy body dementia, and prostate cancer (diagnosed 2016, status post prostatectomy and radiation). Surveillance imaging revealed a new 3 cm spiculated left upper lobe mass with associated mediastinal and supraclavicular lymphadenopathy. Robotic-assisted bronchoscopy with biopsy of the left upper lobe nodule confirmed metastatic prostatic adenocarcinoma in the lung mass without mediastinal or hilar lymph node involvement. Discussion In all three cases, the radiographic findings and extensive smoking history were suggestive of primary lung cancer without evidence of extra-thoracic metastatic disease from primary cancer. RAB with EBUS-TBNA provided accurate tissue diagnosis, staging, and guided oncologic management. Compared with transthoracic needle biopsy, RAB offers a comparable diagnostic yield with significantly reduced risk of complications 2-6. These cases reinforce the importance of biopsy in patients with complex cancer histories and highlight RAB’s expanding role in multidisciplinary care. This abstract is funded by: NA
Sawalhy et al. (Fri,) studied this question.