Robotic bronchoscopy in early lung cancer: a biomarker-driven platform for genomic profiling and immunotherapy-oriented decision-making

Robotic bronchoscopy is increasingly used to sample peripheral pulmonary lesions as lung cancer screening detects more small, distal, subsolid and ground-glass nodules. Most evidence has assessed the technology by diagnostic yield and safety, but these endpoints only partly capture clinical value. In early lung cancer care, the relevant question is whether bronchoscopy provides information that is sufficient for diagnosis, staging, molecular profiling and treatment-ready decision-making. This state-of-the-art review examines robotic bronchoscopy as a potential diagnosis-to-treatment platform rather than an isolated navigation device. We summarise evidence on distal airway access, procedural stability, CT-to-body divergence, tool-in-lesion confirmation, cone-beam CT, mobile cone-beam CT and radial endobronchial ultrasound. We also discuss tissue stewardship, rapid on-site evaluation, cell block preparation, next-generation sequencing, PD-L1 testing and same-session endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and, when appropriate, endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) as determinants of molecular adequacy and clinical actionability. We propose clinically actionable yield as a pragmatic, complementary, and currently unvalidated reporting construct linking lesion access, confirmed targeting, pathological diagnosis, molecular adequacy, staging completeness, and management decisions. For prospective evaluation, Level 5 (treatment decision informed or changed) should be assessed within 30 days after the index bronchoscopic procedure or before definitive therapy, whichever occurs first. Bronchoscopic ablation is considered as a future therapeutic extension, but current evidence remains early and does not establish equivalence with surgery, stereotactic body radiotherapy or percutaneous ablation. Future studies should evaluate decision-centred and patient-centred endpoints, including molecular-testing success, repeat biopsy avoidance, time to treatment, local control, pulmonary function, quality of life and cost-effectiveness.