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An elderly man presents with a waxing and waning pulmonary lesion which was biopsy-proven lymphoma. This case highlights the use of robotic-assisted bronchoscopy which was integral in making a definitive diagnosis.CASE PRESENTATION: A 70-year-old man with chronic pancreatitis and a 53 pack-year smoking history presented with waxing and waning nodules seen on CT imaging. A nodule in the right lower lobe (RLL) was identified in 2019 and was followed with serial imaging showing shrinkage in 2020. However, in April 2021, the mass enlarged to 4 x 2 cm with stable mild mediastinal and right hilar adenopathy. PET scan demonstrated an SUV max of 4.28. The lesion was felt to not be amenable to CT-guided biopsy, and the patient was referred for robotic bronchoscopic biopsy.He reported occasional cough that was attributed to his ongoing reflux. He denied dyspnea, fever, and night sweats. He had lost 10 pounds in a month due to decreased appetite. The patient underwent general anesthesia and robotic assisted bronchoscopy. The robotic sheath was navigated to the RLL within millimeters of the lesion located 34 mm away from the pleura. A 23 gauge needle was inserted into the RLL mass, and a cone beam CT spin was performed that verified tool in lesion. Needle aspirations demonstrated atypia but inability for further clarification. Therefore, multiple biopsies were taken with forceps and sent to frozen section with an intraprocedural finding of abnormal lymphoid population of cells consistent with lymphoma of mucosa-associated lymphoid tissue. Additional sampling of stations 4L, 7, and 4R lymph nodes were negative for malignancy.DISCUSSION: Over the last decade, several guided bronchoscopic technologies have been developed to improve the diagnostic yield for sampling. This case highlights how minimally invasive biopsy can be achieved through robotic bronchoscopy when highly-relied on forms of tissue acquisition, like CT-guidance, are not recommended. Real-time 3D planar imaging also verifies needle location and can reduce doubts associated with sampling error when tool in lesion is captured and available to the referring provider. This approach was integral in making a rare diagnosis of primary pulmonary lymphoma (PPL).PPL is defined as clonal lymphoid proliferation in one or both lungs with no detectable extrapulmonary involvement at diagnosis or during the subsequent 3 months. This represents 0.5-1% of primary pulmonary malignancies. The diagnosis is made on histological examination of the tissue, and despite no consensus on treatment, patients typically have a favorable outcome with the median survival of more than 10 years. Treatment typically includes surgical excision for localized disease. CONCLUSIONS:The combination of robotic bronchoscopy, CIOS C spin imaging system, and frozen section was integral in making a rare diagnosis of primary pulmonary lymphoma.