This article has been removed: please see Elsevier policy on Article Correction, Retraction and Removal (https://www.elsevier.com/about/policies-and-standards/article-withdrawal). This article has been removed at the request of the Author. This abstract has been removed following communications that it was not presented at the IASLC 2025 Asian Conference on Lung Cancer.

BACKGROUND:The practice of precision medicine has transformed outcomes for patients with advanced non-small cell lung cancer (NSCLC). Precision medicine is increasingly applied to the therapeutic algorithms of early-stage NSCLC both in the neoadjuvant and adjuvant space. Procuring sufficient tumour specimens safely and preparing tissue are key components. Whilst there are guidelines on how to optimise tissue acquisition and handling, real-world practice identifies wide variation in diagnostic yields and procedural complication rates, which underscores the need for a consensus-driven multidisciplinary approach. METHODS:This article reflects the collective consensus of an international expert panel of different specialities from the United States, Europe, and Asia-Pacific regions. Consensus recommendations were developed following a structured virtual working group discussion, during which the group shared recommendations for tissue acquisition and initial handling. The manuscript was finalised through successive rounds of offline review until consensus was achieved. FINDINGS:The site of involvement that denotes the most advanced stage should be chosen for biopsy. The choice of technique should depend on where the tissue is acquired from, e.g., pulmonary nodules, intra-thoracic lymph nodes, tissue in advanced stage disease, or pleural disease. INTERPRETATION:The optimal biopsy technique should support simultaneous diagnosis and staging and be selected based on the patient's clinical presentation, the expected diagnostic yield, the required sample type, and the degree of invasiveness, while maintaining a patient-centred approach. FUNDING:AstraZeneca.

Pulmonologists have contributed significantly to the detection, diagnosis, and management of lung cancer in the past two decades. Improved understanding of lung cancer epidemiology and risk factors has informed screening programs across the world. Refinements in bronchoscopy have allowed the development of minimally invasive techniques for diagnosis and staging of lung cancer. Technological advances in endoluminal treatments for lung cancer coupled with refinements in navigational bronchoscopy raise the possibility of a one-step diagnosis-staging-treatment for early stage lung cancer. Advances in evaluation and management of malignant pleural effusions have led to better clinical outcomes and quality of life. Better understanding of lung cancer pathogenesis has identified biomarkers that inform cancer risk stratification, application of targeted therapies, treatment-related side effects, and likelihood of recurrence. The growing subspecialization of lung cancer care, coupled with rapid technological and clinical developments, has made essential the multidisciplinary team approach for delivering high-quality, evidence-based care. In this article, an international panel of experts will review the major developments in pulmonary diagnostics in lung cancer in the past two decades. Together, these developments have had a transformative effect on lung cancer care and clinical outcomes. The clinical impact of these developments will be explored, along with future potential for research and innovation, and presented in two parts, first for essential standards and second for emerging innovations.

Medical thoracoscopy (MT) is a minimally invasive procedure with a well-established role in the diagnosis and management of malignant pleural disease; however, its therapeutic applications in benign pleural conditions remain variably adopted and inconsistently defined. In response to increasing clinical utilisation and emerging evidence, the World Association for Bronchology and Interventional Pulmonology (WABIP) and the American Association for Bronchology and Interventional Pulmonology (AABIP) convened a multidisciplinary, international expert panel to develop a consensus statement examining the therapeutic role of MT in benign pleural disease. Six clinically relevant PICO (patient, intervention, comparison and outcome) questions were formulated to guide a systematic literature review of PubMed, Scopus and Cochrane databases from 1980 through 2025. Evidence was appraised using standardised risk-of-bias tools and consensus was achieved using a modified Delphi methodology. This consensus statement summarises the available evidence regarding MT across a spectrum of benign pleural conditions, including recurrent benign pleural effusions, primary and secondary spontaneous pneumothorax, empyema, and tuberculous pleural disease. Emphasis is placed on procedural outcomes, complication profiles and comparative effectiveness relative to alternative medical and surgical approaches. The document also highlights key considerations related to patient selection, procedural complexity and the influence of operator expertise and local resources on clinical outcomes. Given the heterogeneity of underlying disease processes and the predominance of observational data, this work is presented as a consensus statement rather than a formal clinical practice guideline. Overall, it aims to consolidate current knowledge, identify gaps in evidence and provide a practical framework to inform multidisciplinary decision-making and future research on the therapeutic use of MT in benign pleural disease.

Abstract Diagnosing tuberculous pleuritis (TBP) is challenging. No consensus currently guides its workup and management in tuberculosis (TB)-endemic regions. An online survey was conducted to assess real-world practices of respiratory physicians when approaching new-onset unilateral pleural effusion and the likelihood of TBP being considered in the diagnostic workup. Responses from 414 respiratory physicians across 15 countries/regions were analyzed, with 98.8% from intermediate-to-high TB burden areas. TBP was frequently considered as a differential diagnosis for new-onset unilateral pleural effusion by 80.4% of respondents. Heterogeneity was observed in the diagnostic and therapeutic approaches among respondents. Initial investigations, including pleural fluid Mycobacterium tuberculosis (MTB) culture, adenosine deaminase and pleural biopsy for histology, were performed variably. Selection of TBP-specific diagnostic tests was correlated with regional TB burden and initial consideration of TBP. Varied perceptions of diagnostic test accuracy were also evident among respondents. A definitive TBP diagnosis, supported by histological or microbiological proof, was required by 60.9% of respondents before anti-TB treatment was initiated. 77.8% of respondents had experienced a revision of the diagnosis of probable TBP cases following empirical anti-TB treatment failure. These findings highlight the need to strengthen the diagnosis and management of TBP in surveyed regions.

Benign central airway obstruction (BCAO) related strictures include post-intubation tracheal stenosis, post-tracheostomy tracheal stenosis, post-surgical or anastomotic stenosis, stenosis related to inflammatory disorders or infectious disorders, chemical injury or post radiotherapy. Techniques and thresholds for airway stenting for each of these unique conditions vary significantly across centres due to lack of guidance. The management of the airway stents once placed due to scarcity of data also has a similar knowledge void. This document aims to address these knowledge gaps by addressing relevant questions related to airway stenting in BCAO. A multidisciplinary, international group of 20 experts from 19 institutions across 12 countries with extensive experience in airway stenting in BCAO was convened as part of this guideline document through the World Association of Bronchology and Interventional Pulmonology (WABIP). A literature search was performed for reports addressing eight clinically relevant PICO questions. Recommendations addressing these questions were formulated using a systematic process involving the evaluation of published evidence, supplemented with expert experience when necessary. The panel participated in the development of the final recommendations using a modified Delphi technique.

BACKGROUND:The ninth edition of the TNM classification (TNM-9) for NSCLC introduces distinct N2 subgroups based on single (N2a) or multiple (N2b) involved stations, impacting prognosis and staging. This survey aimed to assess the impact of these changes on mediastinal staging with EBUS-TBNA, particularly regarding the need for needle change when sampling lymph nodes from different N2 stations. METHODS:A 10-question online questionnaire was distributed from March 4, 2025 to March 16, 2025, to pulmonologists through interventional pulmonology sections of medical societies, online networks, and social media. RESULTS:A total of 605 questionnaires from 66 countries were analyzed. Most respondents were males (58.8%), aged 40 to 49 years, and worked in academic hospitals. Regarding EBUS procedure frequency, 28.9% performed 1 to 2 procedures weekly, and 13.6% performed more than 10. When asked about the need for needle change between different N2 stations, 20.7% saw it as necessary, 33.2% disagreed, and 17.4% considered it necessary in some cases. Although 38.1% considered changing the needle at least sometimes, only 5.5% reported actually doing so. The main barriers were costs (68.3%) and lack of evidence (31.3%). Those against needle change cited the belief that it does not affect results (58.2%), lack of evidence (54.2%), and other factors (4.5%), with many considering flushing the needle sufficient. Free-text responses indicated a lack of knowledge or implementation of TNM-9 in some centers. CONCLUSION:Opinions on implementing TNM-9 are inconsistent, within the IP community, particularly regarding needle change for different N2 stations. Education, reliable data, and consensus guidelines are needed.

PURPOSE OF REVIEW:Peripheral bronchoscopy is increasingly practiced to gain access to peripheral pulmonary lesions (PPLs). Lung cancer screening with low-dose computed tomography (CT) is fuelling the need for superior navigational tools such as robot-assisted bronchoscopy to target screen-detected pulmonary nodules which may be as small as 6 mm. RECENT FINDINGS:It is an opportune moment to return to the basics of performing peripheral bronchoscopy through revising airway mapping with CT imaging. Virtual bronchoscopy, electromagnetic navigation bronchoscopy (ENB) and robot-assisted bronchoscopy (RAB) have yet to supplant the accuracy of manual airway mapping achieved simply by CT reading. The technique of airway mapping should be consistently utilised for airway navigation as it is complementary to technologies such as virtual bronchoscopy, ENB or RAB. In this review, we share the technique of performing airway mapping with a case illustration, and our approach to peripheral bronchoscopy. SUMMARY:Airway mapping is a foundational skill that must be preserved, practiced and perfected in our bronchoscopic approach to a PPL. In the absence of advanced navigational tools, peripheral bronchoscopy can be performed in combination with readily available tools to obtain a high diagnostic yield.

Background: Lung cancer screening with low-dose computed tomography (LDCT) may uncover incidental findings (IFs) unrelated to lung cancer. There may be potential benefits from identifying clinically significant IFs that warrant intervention and potential harms related to identifying IFs that are not clinically significant but may result in additional evaluation, clinician effort, patient anxiety, complications, and excess cost. Objectives: To identify knowledge and research gaps and develop and prioritize research questions to address the approach to and management of IFs. Methods: We convened a multidisciplinary panel to review the available literature on IFs detected in lung cancer screening LDCT examinations, focusing on variability and standardizing reporting, management of IFs, and evaluation of the benefits and harms of IFs, particularly cardiovascular-related IFs. We used a three-round modified Delphi process to prioritize research questions. Results: This statement identifies knowledge gaps in 1) reporting of IFs, 2) management of IFs, and 3) identifying and reporting coronary artery calcification found on lung cancer screening LDCT. Finally, we present the panel's initial 36 research questions and the final 20 prioritized questions. Conclusions: This statement provides a prioritized research agenda to further efforts focused on evaluating, managing, and increasing awareness of IFs in lung cancer screening.

Purpose of review Aerodigestive fistulas (ADFs) cause significant morbidity and mortality, especially in advanced malignancies. This review summarizes current knowledge on etiology, diagnostic, and management strategies. Recent findings Esophageal carcinoma is the predominant cause of malignant ADFs with their development influenced by tumor location, most often involving the upper and middle thirds of the esophagus, and by prior interventions such as radiotherapy or esophageal stenting. Benign acquired ADFs typically result from iatrogenic injuries including pressure necrosis from cuffed tubes, stent erosion, endoscopy, and surgery. Diagnosis often is delayed by nonspecific symptoms, requiring combined imaging and endoscopic evaluation. Benign ADFs are typically amenable to surgical repair, whereas malignant fistulas usually require individualized palliation, notably airway and esophageal stenting. Dual airway-esophageal stenting has advantages over single stenting for malignant ADFs due to superior quality of life and survival outcomes. Emerging minimally invasive techniques include endoscopic clips, occluder devices, and tissue adhesives. Summary Optimal management of ADFs requires high clinical vigilance, timely diagnostic evaluation, and individualized multidisciplinary approaches. Further research into emerging therapies and standardized management algorithms is essential for improving patient outcomes and guiding evidence-based clinical practice.

Background:The diagnostic gold standard for interstitial lung disease (ILD) has evolved from histopathology to multidisciplinary discussion (MDD) consensus. However, physicians' practices remain heterogeneous, impacting upon core data acquisition, interpretation and eventual MDD diagnosis. Our study compared approaches between ILD (fellowship-trained and providing dedicated ILD services) and non-ILD physicians in Singapore. Methods:Between October 2017 and January 2018, non-ILD respiratory physicians from public hospitals in Singapore were invited to participate in a survey designed by a focus group comprising ILD and non-ILD physicians. Responses of local ILD physicians were benchmarked against that of overseas ILD physicians from expert centres and thoracic radiologists. Results:Fifty-nine of ninety-six (61%) local physicians responded. As practices between local and overseas ILD physicians revealed no significant differences, they were pooled together for analysis. ILD physicians diagnosed more cases annually, presented more frequently at MDD, utilised supportive tests more consistently, reported higher confidence levels interpreting high resolution computed tomography (HRCT) and placed higher weightage on physician rather than radiologist or pathologist opinion. In four case-based scenarios, there were higher levels of agreement in diagnoses among ILD than non-ILD physicians. Inter-rater agreement on radiological diagnoses was moderate among ILD physicians (κ=0.55) and between ILD physicians and radiologists (κ=0.56), but fair among non-ILD physicians (κ=0.29) and both physician groups (κ=0.25). Inter-rater agreement on clinical diagnoses was moderate among ILD physicians (κ=0.52), but fair among non-ILD physicians (κ=0.35). Conclusions:Substantial differences between ILD physicians and non-ILD physicians exist. Early referral to appropriate expertise is recommended.

PURPOSE OF REVIEW:The purpose of this review is to elaborate on the role of medical thoracoscopy for various diagnostic and therapeutic parietal pleural interventions. The renewed interest in medical thoracoscopy has been boosted by the growth of the field of interventional pulmonology and, possibly, well tolerated and evolving anesthesia.RECENT FINDINGS:Medical thoracoscopy to obtain pleural biopsies is established largely as a safe and effective diagnostic procedure. Recent data suggest how a pragmatic biopsy-first approach in specific cancer scenarios may be patient-centered. The current scope of medical thoracoscopy for therapeutic interventions other than pleurodesis and indwelling pleural catheter (IPC) placement is limited. In this review, we discuss the available evidence for therapeutic indications and why we must tread with caution in certain scenarios.SUMMARY:This article reviews contemporary published data to highlight the best utility of medical thoracoscopy as a diagnostic procedure for undiagnosed exudative effusions or effusions suspected to be secondary to cancers or tuberculosis. The potentially therapeutic role of medical thoracoscopy in patients with pneumothorax or empyema warrants further research focusing on patient-centered outcomes and comparisons with video-assisted thoracoscopic surgery.