Diagnostic accuracy and safety of cone-beam computed tomography-guided percutaneous transthoracic lung biopsy: an updated systematic review and meta-analysis

To update the pooled diagnostic accuracy and safety of cone-beam computed tomography (CBCT)-guided percutaneous transthoracic needle biopsy (PTNB) for pulmonary lesions. METHODSPubMed, Embase, and Cochrane CENTRAL were searched through April 2026 for studies of CBCT-guided PTNB including ≥ 10 patients.Sensitivity and specificity were pooled using a bivariate random-effects model.Complication rates (pneumothorax and pulmonary hemorrhage, encompassing both clinically significant hemoptysis and radiographic perilesional change) were pooled using generalized linear mixed models.Heterogeneity and publication bias were assessed.The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies, used the Quality Assessment of Diagnostic Accuracy Studies 2, and was prospectively registered in PROSPERO (CRD420261370382). RESULTSTwenty-four studies were eligible (k: 22 with extractable 2 × 2 data; n = 3,681; 2010-2026).Pooled sensitivity was 92.2% [95% confidence interval (CI): 90.4-93.7]and pooled specificity was 96.7% (95% CI: 94.3-98.2).The summary receiver operating characteristic area under the curve was 0.974.Pneumothorax incidence was 18.4% [95% CI: 15.5-21.7;prediction interval (PI) 8.3-35.8%].Hemorrhage incidence (k: 19) pooled at 6.1% (95% CI: 3.5-10.6);high heterogeneity (I 2 : 90.9%) reflected variation in outcome definitions. CONCLUSIONCBCT-guided PTNB demonstrates high diagnostic accuracy for pulmonary lesions.The pooled specificity should be interpreted as a plausible upper-bound estimate because of universal differential verification bias across the included studies. CLINICAL SIGNIFICANCEThe wide pneumothorax PI (8-36%) indicates that complication rates may vary substantially across centers despite the precise pooled estimate.