• Alveolar cell cancer
• asbestos induced lung disease
• bronchoscopy
• lung cancer
• lung cancer chemotherapy
• mesothelioma
• non-small cell lung cancer
• small cell lung cancer
• histology/cytology
• imaging CT/MRI

Solitary pulmonary nodules (SPNs), defined as rounded lesions <3 cm completely surrounded by an aerated lung, are increasingly identified by modern chest radiography and thoracic CT. As CT screening studies report and the debate over the place of national lung cancer screening programmes intensifies, the need for algorithms to efficiently investigate SPNs will become even more important.1

Peripheral pulmonary lesions can be biopsied by various techniques. The most commonly used approach in the UK is transthoracic needle aspiration or core biopsy usually performed under CT guidance. The diagnostic sensitivity for malignancy exceeds 90% in experienced hands but up to 44% of biopsies in benign disease are non-diagnostic.2 While generally safe, it is not without complications; in a large UK-based survey, pneumothorax occurred in 20.5% of cases and intercostal tube drainage was required in 3%.3

Flexible bronchoscopes can be used to approach peripheral lesions but the reported diagnostic sensitivity rates are considerably lower than for CT-guided needle biopsy. Sensitivity has been shown to be dependent upon the size of lesion, the distance from the hilum and the presence of a bronchus leading to the lesion on CT (the CT bronchus sign). A systematic review found that the diagnostic yield was 33% for lesions <2 cm in the outer third of the lung.2 Historically, the approach taken has been to use a thin bronchoscope and perform a combination of bronchial washings, brushings and transbronchial biopsy targeting the appropriate segmental or subsegmental bronchus sometimes with the assistance of fluoroscopy. More recently, several groups have reported their experience of using radial endobronchial ultrasound (EBUS) to guide biopsy of peripheral lesions. Radial EBUS provide 360° images of …