in an interview with Targeted Oncology<\/a>.<\/strong><\/p>\nAgrawal, director of interventional pulmonology and bronchoscopy\u00a0at Northwell Health in New Hyde Park, New York, said it was vital to address this question because biomarker testing is critical to designing a personalized treatment regimen. The review focused on interpreting data from the past 10 years when comprehensive biomarker testing was starting to see use, to confirm that sufficient tissue for all purposes was being obtained.<\/p>\n
Dietrich agreed that the conclusions drawn by the panel were valuable for oncologists. \u201cThe summary for our clinical practice was that endobronchial approaches are safer and may have a bit of a tendency to be more proficient in procuring enough tissue for our analysis as well. I think this is a practice-changing summary\u2026that helps us to prioritize endobronchial approaches and think of the percutaneous approaches only in a backup setting for most cases.\u201d<\/p>\n
Shortcomings of Tissue Biopsy<\/p>\n
Lack of adequate tissue can have serious impacts on patients with lung cancer. Agrawal noted that a recent comparative study found a 70% to 80% yield in both navigational bronchoscopy and transthoracic needle biopsy,2 although he estimated that newer robotic bronchoscopy techniques may have a diagnostic yield above 90%.<\/p>\n
Dietrich likewise estimated that between 20% and 30% of patients do not have adequate tissue for next-generation sequencing (NGS), which can vary depending on the patient and institution. He described this as a major challenge and a roadblock in making decisions, as lung cancer is a systemic disease that requires tailored systemic therapy in most cases.<\/p>\n
\u201cThe role of tissue biopsy is such a hard stop in the decision-making process of delineating optimal therapy for patients,\u201d Dietrich said. In the past, he had been involved in cases where tissue biopsy had already been done, but now he prefers to get involved as early as possible to guide site selection and tissue requirements.<\/p>\n
\u201cWhen I see a radiographic diagnosis of cancer, I think about the best biomarker evaluation strategy up front, delineating the best approach for endobronchial biopsies, giving me stage and tissue sufficiency for analysis,\u201d he explained.<\/p>\n
With targeted therapy being used not only in the metastatic NSCLC setting but also in earlier stages, the time it takes to get biomarker testing can make a difference. Dietrich said it can sometimes take 6 to 8 weeks to get through the steps of biopsy and processing if a rebiopsy is needed. Particularly in the neoadjuvant perioperative setting, there is a need for a fast approach when coordinating with the surgeon to ensure that delays for biomarker workup and targeted treatment do not interfere with resection.<\/p>\n
Reflex Testing and Liquid Biopsy<\/p>\n
The NCCN guidelines for NSCLC recommend broad-based genomic testing, including EGFR, ALK, ROS1, BRAF, KRAS, MET, RET, HER2 (ERBB2), NTRK1\/2\/3, and PD-L1 in advanced disease, with PD-L1, EGFR, and ALK testing done even in earlier-stage disease.3<\/p>\n
Agrawal said that before performing biopsies, he may bring up cases to a tumor board and ask whether biomarker testing would be indicated. If the findings show locally advanced disease, he can request NGS immediately rather than waiting for the oncologist to order it. Reflex testing has been helpful, but he acknowledged that he works in a tertiary care center where it is easier to do. The traditional workflow would be to find a lesion, wait for a positive biopsy to return, then have the patient see the oncologist, who would order biomarker testing. \u201cIf you can move up the biomarker testing in that algorithm, the time from diagnosis to treatment goes down,\u201d he noted.<\/p>\n
In Dietrich\u2019s experience, reflex testing can be institution-dependent, but ideally any patient with lymph node\u2013positive disease or larger tumors would qualify for testing, and a stage-independent automated reflex protocol should allow NGS to be done as soon as possible. Logistical issues can lead to friction; he gave the example of a patient coming to clinic 7 days after disease histology was determined and only then having NGS testing ordered.<\/p>\n
Dietrich is a proponent of greater use of liquid biopsy to test circulating tumor DNA (ctDNA) to get faster results in virtually all patients, although those with small cell lung cancer may benefit less. Because liquid biopsy lacks invasiveness, there is little risk of harm, and it can complement tissue biopsy, considering the possibility of insufficient tissue. \u201cEspecially the patients [whose disease is] more advanced, where speed is of the essence, the utility of liquid biopsy is enhanced,\u201d he said.<\/p>\n
The NCCN recommends that ctDNA testing should not be used in lieu of a histologic tissue diagnosis for NSCLC, and for stages I to III, tissue-based testing is preferred.3 It also states that metastatic disease confined to the thorax may have a higher yield with tissue-based testing.<\/p>\n
Biomarkers Drive Treatment vs Histology<\/p>\n
The introduction of targeted therapy and immunotherapy to the early-stage setting has changed treatment \u201ctremendously,\u201d according to Dietrich. These patients must be evaluated for potential EGFR- or ALK-targeted adjuvant therapy or neoadjuvant immunotherapy plus chemotherapy.<\/p>\n
The phase 3 CheckMate 816 trial (NCT02998528) reported overall survival benefit for nivolumab (Opdivo) plus chemotherapy at 5 years regardless of PD-L1 status, making most patients with locally advanced disease eligible.4 However, Dietrich says PD-L1 status is still informative in earlier-stage cancer; he may prefer up-front surgery for a patient with PD-L1\u2013negative stage II disease, whereas he would use neoadjuvant immunotherapy in one with PD-L1 of 80% and stage III disease.<\/p>\n
In patients with unresectable locally advanced disease, immunotherapy and targeted therapy can be used in the consolidation setting after chemotherapy and radiation. \u201cThe opportunities are there across stages to translate our learning lessons from biomarker analysis from stage IV into stage III, into stage II, and\u2014to a certain extent\u2014even into stage I high risk,\u201d Dietrich said.<\/p>\n
Molecular characteristics now play a greater role in guiding treatment selection than histology. he traditional approach of first making a histologic diagnosis and then ordering tissue and liquid biopsy may be replaced by a more aggressive approach guided by rapid biomarker testing.<\/p>\n
Communicating the Need for Biomarker Testing<\/p>\n
To Agrawal, it is important to have a discussion between the pulmonologist or thoracic surgeon and the oncologist to evaluate the need for biomarker testing. \u201cWe don\u2019t want the patients with stage I lung cancer to be sent for biomarker testing, but if there is locally advanced disease, then we want the tissue to be sent.\u201d<\/p>\n
Even in patients with smaller lung nodules that are pending diagnosis, a biopsy will be done to identify whether the patient has lung cancer. Then, with biomarker testing, the treatment team can develop a comprehensive treatment plan to guide treatment and assess whether the patient will benefit from targeted therapies for locally advanced disease.<\/p>\n
Many academic institutions have perfected a multidisciplinary approach to tissue analysis, \u201cfrom the interventionalist getting the tissue all the way to the tissue processing and interpretation,\u201d Dietrich said. \u201cThey have made this a very streamlined process.\u201d In the community setting, the process is less seamless, but the availability of liquid biopsy has contributed to making the right treatment decisions.<\/p>\n
Dietrich has also talked to pathologists he works with to make clear his needs for histological staining and to promote awareness of tissue stewardship and conservancy. The recommendation to utilize EBUS-guided approaches is another helpful step for minimizing risk and delays while maximizing tissue proficiency.<\/p>\n
\u201cFor our colleagues in the interventional procedures, we have an open channel of communication,\u201d Dietrich said. \u201cI explain to them, we are seeking this level of information, and the truth is, we\u2019re not getting less in need of tissue, but it\u2019s ever-growing. The number of biomarkers we\u2019re seeking is getting bigger.\u201d<\/p>\n
The expert panel\u2019s report pointed to newer techniques such as forceps and cryoprobe biopsy used in bronchoscopy that can acquire larger tissue samples. Agrawal said new studies should investigate whether these tools make a difference and translate to clinical benefit for patients. However, Dietrich pointed out that these technologies depend on institutional resources and the expertise of the interventionist, and oncologists must rely on their best efforts.<\/p>\n
\u201cWhat we are trying to do as a field of interventional pulmonology through the AABIP, in association with the IASLC, is to make sure that our diagnostics and our diagnostic approach match the advancement that we are seeing in targeted therapy,\u201d Agrawal concluded.<\/p>\n
REFERENCES:<\/strong>1. Chaddha U, Agrawal A, Ghori U, et al. Safety and sample adequacy for comprehensive biomarker testing of bronchoscopic biopsies: an American Association of Bronchology and Interventional Pulmonology and International Association for the Study of Lung Cancer clinical practice guideline. J Thorac Oncol. Published online May 24, 2025. doi:10.1016\/j.jtho.2025.05.0142. Lentz RJ, Frederick-Dyer K, Planz VB, et al; Interventional Pulmonary Outcomes Group. Navigational bronchoscopy or transthoracic needle biopsy for lung nodules. N Engl J Med. 2025;392(21):2100-2112. doi:10.1056\/NEJMoa24140593. Forde PM, Spicer J, Provencio M, et al. Overall survival with neoadjuvant nivolumab (NIVO) + chemotherapy (chemo) in patients with resectable NSCLC in CheckMate 816. J Clin Oncol. 2025;43(suppl 17):LBA8000. doi:10.1200\/JCO.2025.43.17_suppl.LBA80004. NCCN. Clinical Practice Guidelines in Oncology. Non\u2013small cell lung cancer, version 8.2025. Accessed August 19, 2025. https:\/\/www.nccn.org\/professionals\/physician_gls\/pdf\/nscl.pdf<\/p>\n","protected":false},"excerpt":{"rendered":"Illustration of lungs: \u00a9 yodiyim – stock.adobe.com The landscape of lung cancer diagnosis has evolved, with bronchoscopic approaches…\n","protected":false},"author":2,"featured_media":94,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[78],"tags":[110,18,135,19,17,111],"class_list":{"0":"post-27357","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-health","8":"tag-cancer","9":"tag-eire","10":"tag-health","11":"tag-ie","12":"tag-ireland","13":"tag-oncology"},"share_on_mastodon":{"url":"","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/posts\/27357","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/comments?post=27357"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/posts\/27357\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/media\/94"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/media?parent=27357"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/categories?post=27357"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/ie\/wp-json\/wp\/v2\/tags?post=27357"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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