Real-world Comparative Analysis of Transbronchial Versus Transthoracic Biopsy for Middle Lung Zone Pulmonary Lesions in the Preadvanced Bronchoscopy Era

<a href="https://journals.lww.com/bronchology/fulltext/2026/04010/real_world_comparative_analysis_of_transbronchial.6.aspx"><img src="https://images.journals.lww.com/bronchology/SmallThumb.01436970-202604010-00006.F1.jpeg" border="0" align ="left" alt="image"/></a>Background: The optimal diagnostic approach for indeterminate pulmonary lesions in the middle lung zone remains unclear, particularly in settings without advanced bronchoscopic technologies. This study explores factors influencing diagnostic approach selection and differences in diagnostic flow in facilities operating without such advanced technologies, aiming to clarify practice patterns that may help bridge the technological gap in current clinical guidance. Methods: We retrospectively analyzed patients referred to a tertiary thoracic oncology program for middle lung zone lesion diagnosis between January 2015 and June 2016. Patients were grouped by the initial diagnostic approach: transbronchial-first (TBF) or transthoracic-first (TTF). We compared diagnostic yield, complications, diagnostic workup duration, and costs. Results: The study included 108 TBF and 99 TTF patients. TBF had larger lesions (P = 0.0087) and more pulmonary lesions with a positive bronchus sign (P < 0.0001). TBF had a lower initial diagnostic yield (77.8% vs 89.9%, P = 0.0238), but a lower pneumothorax rate (P < 0.0001) and shorter workup duration (P = 0.0001). Overall costs were similar (P = 0.6773), but TBF was more cost-effective for cases requiring pathologic nodal staging (P = 0.0002). Conclusion: Experienced clinician-driven triage of middle lung zone lesions, based on lesion characteristics, effectively guided initial diagnostic approaches. When appropriately triaged, an initial transbronchial approach resulted in fewer complications, shorter workup duration, and lower costs for pathologic nodal staging, even in an era predating advanced bronchoscopy. Although limited by its retrospective and historical design, these findings provide descriptive insights and underscore the continued value of established diagnostic practices in settings without universal access to newer technologies.