When Dan Hannon, 72, received guidance to have part of a lung taken out whether nodules were cancerous or not, he wanted a second opinion to see if he would indeed live the rest of his life without a full set of lungs.

After incidentally learning of a suspicious spot in his lungs while getting imaging to diagnose a kidney stone in 2025, he was advised to get his lungs checked. Several months later, he had a diagnostic PET scan under the care of a Georgia pulmonologist near his home in Buford, Georgia.

Some spots “lit up,” indicating metabolic activity, which often means cancer but may be due to infection or inflammation. He went on to get a bronchoscopy, a minimally invasive procedure using a camera on a thin tube to examine his lungs and obtain biopsy tissue.

He and his wife, Janice, learned the areas that were successfully biopsied were benign, but there were two additional areas the physician couldn’t reach.

Thus came the recommendation for an open surgery to remove the undefined tissue for biopsy. It was also advised that Hannon have a sizeable portion of his affected lung removed while still under anesthesia, regardless of the biopsy results.

That didn’t sit well with the couple, so they drove four hours to Vanderbilt Health in Nashville. Their son had been successfully treated for cancer there in the past.

“The prior lack of knowledge of whether I had cancer or not, and being told I should have surgery and get part of my lung cut out — whether it was cancer or not — was very bothersome,” Hannon said. “I decided to get a second opinion. I wanted all the information I could get to make a good decision, and that’s exactly what’s happened.”

At Vanderbilt Health, a new approach to a difficult diagnosis

The Hannons met with Fabien Maldonado, MD, MSc, professor of Medicine and Thoracic Surgery and director of Interventional Pulmonology at the Vanderbilt Lung Institute. Maldonado told them he was pretty confident he could reach those areas for biopsy using robotic bronchoscopy, the standard of care at Vanderbilt University Hospital.

“Robotic bronchoscopy, combined with cone-beam CT, has transformed the way we do things,” said Maldonado, who holds the Pierre Massion Directorship in Lung Cancer Research. “Ninety-five percent of people with lung nodules don’t have cancer, but for the 5% that do, they need to receive a diagnosis and get treatment as soon as possible.

Inside the robotic bronchoscopy advancing lung care

During a robotic bronchoscopy, physicians use a controller to precisely guide a bronchoscopy tube, which is typically smaller and more flexible than traditional tubes. The additional agility allows access into the lung’s harder-to-reach peripheral structures so biopsy tissue can be obtained. A 3D, high-resolution image of the lung obtained through cone-beam computed tomography (CBCT) is displayed on a monitor to guide the interventional pulmonologist’s progress.

At Vanderbilt Health, the four board-certified interventional pulmonologists who do the robotic bronchoscopies have all completed a fellowship and an additional year of interventional pulmonology training before receiving board certification from the American Association for Bronchology and Interventional Pulmonology.

Oncologist Mohamed Shanshal, MBChB, assistant professor of Medicine, said robotic bronchoscopy significantly improves getting patients the appropriate treatment as soon as possible, reducing their anxiety and improving care.

To expand access to the diagnostic procedure, the Vanderbilt Health Interventional Pulmonology program recently bought two additional robot and CBCT systems, making it one of the largest interventional pulmonology programs in the South. Four state-of-the-art bronchoscopy suites are slated to open later this year.

“This reduces diagnostic uncertainty and helps us move more quickly from suspicion to confirmed diagnosis,” Shanshal said. “Earlier and more accurate tissue diagnosis allows us to initiate treatment sooner, including surgery, targeted therapy, immunotherapy or clinical trials. In lung cancer, timing and adequate tissue for molecular testing are critical to optimizing outcomes.”

Maldonado explained that the Interventional Pulmonology program is a national leader in testing new technologies for safety and results.

“Many new technologies related to lung nodule biopsies have come on the market without any data to prove their benefit,” Maldonado said. “We are doing the randomized controlled trials here to prove whether something new is better than what we’re already doing. We study these technologies carefully and quickly, and within six months to a year, we know if the new is more beneficial and needs to be adopted.”

From uncertainty to action: What Hannon’s biopsy uncovered

For the Hannons, having the assurance that the robotic bronchoscopy would reach the spots in his lung and offer clearer details about their makeup was important.

“With the help of the robot, Dr. Maldonado was able to get what he needed, and it came back as adenocarcinoma,” Hannon said. “He was awesome when he explained his findings and everything we needed to do.”

Hannon has mucinous adenocarcinoma, a rare, non-small cell lung cancer that accounts for 2-10% of all lung adenocarcinomas and is most often found in the outer regions of the lung.

During a return visit to Nashville in late February, Hannon had a pulmonary function test, and met with Konrad Hoetzenecker, MD, PhD, professor of Thoracic Surgery, who will soon surgically remove the cancerous spots, and with Shanshal, his new oncologist.

“We’ve had a fantastic experience at Vanderbilt, and we’ve got a fantastic team of medical professionals we’re working with,” Hannon said. “We’re prepared for surgery and any future treatment because of the consultations we’ve had with Dr. Maldonado, Dr. Hoetzenecker and Dr. Shanshal. This has given me confidence in what has to happen.”

And as the Hannons move with hope toward healing, they’re looking forward to future cruises and travels to visit family.

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Navigational bronchoscopy is as effective as the traditionally used transthoracic needle biopsy for diagnosing lung nodules, but with significantly fewer complications, per a new study published May 18 in the New England Journal of Medicine. This development may shift medical practice and reduce hospitalizations for patients undergoing lung nodule biopsies, said researchers.  

Each year, millions of lung nodules are detected during routine X-rays or CT scans. While most nodules are benign, some are cancerous and when found at this stage they are the earliest and most curable stage of lung cancer.   

Accurate biopsy of lung nodules is often required to tell benign nodules from malignant ones. To date, the most commonly used method, CT-guided transthoracic needle biopsy, carries a high complication rate — including pneumothorax, or partial lung collapse, affecting about 25% of patients. Treatment of the partially collapsed lung often requires a chest tube during a multiple day inpatient stay.  

This study is the first to directly compare these biopsy techniques and the results are compelling, said first author Robert Lentz, MD, associate professor of Medicine and Thoracic Surgery in the Division of Allergy, Pulmonary and Critical Care Medicine at Vanderbilt University Medical Center. The study, conducted across seven centers in the United States, compared the two techniques in a multicenter, randomized trial involving 234 patients with lung nodules between 10-30 mm.  

Navigational bronchoscopy uses a sophisticated targeting system and 3D imaging to guide biopsy tools through small peripheral airways directly to a lung nodule.   

The comparison revealed a diagnostic accuracy of 79% using navigational technology, closely matching the 74% accuracy of transthoracic biopsy. More importantly, the risk of pneumothorax was significantly lower, occurring in only 3% of bronchoscopy patients compared to 35% in those undergoing transthoracic biopsy. Severe cases requiring hospital admission or chest tube insertion were less than 1% with bronchoscopy, as opposed to 14% with the traditional method.  

“With approximately 300,000 lung nodule biopsies performed annually in the U.S., shifting to navigational bronchoscopy could greatly reduce complications and hospital stays. This study confirms its diagnostic efficacy and superior safety profile, making it the preferred choice for lung nodule diagnosis,” said senior author Fabien Maldonado, MD, MSc, professor of Medicine and Thoracic Surgery and director of Interventional Pulmonology.  

The research team plans to continue exploring optimal biopsy techniques, comparing different navigational and robotic bronchoscopy systems, and studying novel biopsy tools, said Maldonado, Pierre Massion Director in Lung Cancer Research.  

They are also involved in research on bronchoscopic ablation of lung cancer, advancing the field of interventional pulmonology.  

“As a relatively new medical subspecialty, we are quite proud and excited to have matured our research infrastructure to the point of being able to produce high quality multicenter trials like this, and hope that publication of this trial will serve as an introduction of sorts for interventional pulmonology to the larger general medical audience,” said Lentz.   

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