Purpose Tissue acquisition in lung cancer is vital for multiple reasons. Primary reasons reported for molecular testing failure in lung cancer biopsy specimens include insufficient amount of tumor cells provided and inadequate tissue quality. Robotic bronchoscopy is a new tool enabling peripheral pulmonary lesion sampling; however, diagnostic yield remains imperfect possibly due to the location of nodules adjacent to or outside of the airway. The 1.1-mm cryoprobe is a novel diagnostic tool and accesses tissue in a 360-degree manner, thus potentially sampling eccentric/adjacent lesions. This study examines the diagnostic yield of the cryoprobe compared to standard needle aspiration and forceps biopsy. It additionally evaluates yield for molecular markers in cases of lung cancer. Methods This is a retrospective analysis of 112 patients with 120 peripheral pulmonary lesions biopsied via robotic bronchoscopy using needle aspirate, forceps, and cryobiopsy. Results The overall diagnostic yield was 90%. Nearly 18% of diagnoses were made exclusively from the cryobiopsy sample. Molecular analysis was adequate on all cryobiopsy samples sent. Digital imaging software confirmed an increase in quantity and quality of samples taken via cryobiopsy compared to needle aspirate and traditional forceps biopsy. Conclusion Using the 1.1-mm cryoprobe to biopsy PPN combined with the Ion robotic bronchoscopy system is safe, feasible, and provides more diagnostic tissue than needle aspirates or traditional forceps biopsies. The combination of cryobiopsy with robotic-assisted bronchoscopy increased diagnostic yield, likely due to its 360-degree tissue acquisition which is beneficial when targeting extraluminal lesions adjacent to the airway.

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<b><i>Background:</i></b> Bronchoscopy for the diagnosis of peripheral pulmonary lesions continues to present clinical challenges, despite increasing experience using newer guided techniques. Robotic bronchoscopic platforms have been developed to potentially improve diagnostic yields. Previous studies in cadaver models have demonstrated increased reach into the lung periphery using robotic systems compared to similarly sized conventional bronchoscopes, although the clinical impact of additional reach is unclear. <b><i>Objectives:</i></b> This study was performed to evaluate the performance of a robotic bronchoscopic system’s ability to reach and access artificial tumor targets simulating peripheral nodules in human cadaveric lungs. <b><i>Methods:</i></b> Artificial tumor targets sized 10–30 mm in axial diameter were implanted into 8 human cadavers. CT scans were performed prior to procedures and all cadavers were intubated and mechanically ventilated. Electromagnetic navigation, radial probe endobronchial ultrasound, and fluoroscopy were used for all procedures. Robotic-assisted bronchoscopy was performed on each cadaver by an individual bronchoscopist to localize and biopsy peripheral lesions. <b><i>Results:</i></b> Sixty-seven nodules were evaluated in 8 cadavers. The mean nodule size was 20.4 mm. The overall diagnostic yield was 65/67 (97%) and there was no statistical difference in diagnostic yield for lesions &#x3c;20 mm compared with lesions measuring 21–30 mm, the presence of a concentric or eccentric radial ultrasound image, or relative distance from the pleura. <b><i>Conclusions:</i></b> The robotic bronchoscopic system was successful at biopsying 97% of peripheral pulmonary lesions 10–30 mm in size in human cadavers. These findings support further exploration of this technology in prospective clinical trials in live human subjects.

Endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) have changed the landscape of pulmonology. Mediastinal structures beyond the confines of airway walls are visualized in real-time with EBUS, leading to improved accuracy of tissue sampling and diagnostic yield. With the development of various needle sizes ranging from 25-G to 19-G, the sampling of lymph nodes is becoming easier and more commonplace. Yet, certain conditions such as sarcoidosis and lymphoma may still be difficult to diagnose via EBUS-TBNA. Furthermore, in the age of targeted therapy, there are more demands on EBUS-TBNA samples for molecular marker testing and next-generation sequencing. Here, we present a complementary methodology, EBUS-guided intranodal forceps biopsy (EBUS-IFB), for tissue acquisition that may help address these deficiencies. Specifically, we aim to propose indications, contraindications, outline approaches in performing IFB, and provide an overview of the data for this complementary technique.

Spontaneous pneumothorax represents air trapped within the pleural space that develops without antecedent trauma. Current understanding regarding the epidemiology of spontaneous pneumothorax has been informed by small studies performed at single medical centers or retrospective reviews of national data registries. 1,2 The overall incidence of spontaneous pneumothorax has been estimated at 17 to 24/100 000 in the male population and 1 to 6/100 000 in the female population. 1-4 Spontaneous pneumothorax recurrence rates have primarily been extrapolated from retrospective case series, with 1-to 6-year recurrence rates ranging from 17% to 54%. 5,6 In this issue of JAMA, Hallifax et al 7 characterize the epidemiology of this condition over 5 decades with an analysis of inpatient-treated spontaneous pneumothorax in England. They report national estimates of incidence and recurrence by age group, sex, and presence or absence of chronic lung disease.The authors used the historical definition of primary spontaneous pneumothorax, which is a spontaneous pneumothorax diagnosed in a patient with no previously identified underlying lung disease or chest trauma. 8 Secondary spontaneous