The Front Line of Lung Cancer Diagnosis: How Interventional Pulmonology Drives Early Detection, Staging, and Treatment Planning

From selecting the safest and most informative biopsy approach to coordinating with thoracic surgeons and oncologists, interventional pulmonology is integral to the lung cancer care pathway. Advances in technologies such as endobronchial ultrasound (EBUS), real-time cytopathology assessment, and minimally invasive techniques are enabling diagnosis and staging to occur in a single procedure while preserving tissue for molecular testing, according to Jasleen Pannu, MBBS.^1,2

“Our goals are threefold: we want to get the diagnosis, [determine] the stage, and [take] steps toward therapy, which includes getting enough tissue or marking the spot for the surgeon to resect,” Pannu said.

In an interview with OncLive®, Pannu, an associate professor at The Ohio State University Wexner Medical Center in Columbus, discussed the evolving responsibilities of interventional pulmonologists in lung cancer diagnosis and management, the importance of multidisciplinary collaboration, and how emerging diagnostic and therapeutic technologies are reshaping lung cancer care.

OncLive: As a pulmonologist, what is your ultimate role within the lung cancer diagnostic paradigm?

Pannu: As an interventional pulmonologist, I’m usually the first person that a patient sees [if they] have a spot on their lung or a finding that is concerning for cancer. I will discuss the different possibilities and then take further steps toward diagnosis. If the patient is confirmed to have cancer, then we send them for treatment.

What are the key steps in making the right diagnosis and determining the correct staging?

It can be a very intricate, sometimes challenging, methodical process, because we try to accomplish staging and diagnosis together. We don’t want to do multiple procedures. We want to do the simplest, safest procedure first that gives the maximum information, so the patient can get treatment by the time we’re done. And now, in the world of molecular testing and markers, we need more tissue. Therefore, not only is it just about diagnosis and staging, it’s also about getting adequate tissue. The process is different for everybody. It depends on where the spot is and how big the spot is. If it’s a small lung nodule, we try to team up with the surgeons very early on [to determine] plans for resection [if] it’s looking like stage I disease. [We’d ask whether] we need to do a biopsy or place a marker for the surgeons, because if it’s stage I disease, maybe the patient will get a wedge resection very early on.

Of course, getting PET scans and MRIs [is done in conjunction with taking a] biopsy. For any mass, which is a spot measuring more than 3 cm and located near the inner two-thirds of the lung, or if there are multiple spots, it’s a mandatory to do EBUS. [For that], in the same procedure, we will look at all the lymph nodes through an EBUS, stage the disease, and perform the biopsy for the nodule.

There is now usually in a lot of centers, a cytotechnologist that is available, or some kind of equipment at bedside while we are doing the procedure, that would enable us to gauge if we are getting a positive result or result that is adequate to make a diagnosis. For example, if a person has a right upper lobe mass and maybe some hilar adenopathy or some PET activity, or if the mass is central enough, we will first proceed with EBUS. We will look at the lymph node starting from the opposite side of the lung, [then] progress toward the same side of the lung. As we biopsy the lymph nodes, the cytotechnologist will look at our samples, tell us if we’re getting good enough samples, and if they find cancer in the lymph nodes, it’ll indicate that we have enough cancer tissue so we can stop. We don’t always need to go through long procedures and put patients through aggressive biopsies, as well as the risks that come with doing multiple site biopsies. [That] makes the procedures efficient as well as high quality, because we get the yield that we need, and then we focus on getting as much tissue as we can.

How do you determine whether patients have actionable alterations that could inform therapy?

That may be variable at different institutions, according to the coverage that is offered to patients. At our institution, if we have a preliminary suspicion or an indication by our cytotechnologist that this could be [cancer], especially if it’s non–small cell–like disease, we may order [testing for] these markers at the time of diagnosis. We want to stay ahead as much as possible, because the results do take some time to come back, which can lead to an appointment in which there’s not enough information for the oncologist, [causing them] to wait [for the findings]. We try to expedite [the process] as much as possible by making it an integral part of our workflow, especially for patients with stage II and above disease.

We also have a very multidisciplinary practice. There are weekly tumor boards, and we sit in the same clinic as the thoracic oncologists and the thoracic surgeons, so we are always fully interacting [with each other]. If somebody has a patient with disease progression, and they wondered whether a site could be biopsied or they needed more tissue from an insufficient collection and wondered what the most appropriate procedure would be to do, there’s a free-flowing exchange of information, which ends up teaching the whole team about what’s going on in each other’s field. Having that multidisciplinary environment is key, as is working ahead of time so that we don’t waste time between ordering and starting treatment. When these tests are not ordered on time, patients may end up getting started on treatments that may not have been the most ideal first choice. Having these tests done on time and the results readily available early on for the patient means the world for their outcome, and we take that very seriously.

How do you stay up to date on scientific advances and ensure team alignment?

Because we are so multidisciplinary, we actively collaborate during conferences or at teaching sessions or seminars. There’s a lung cancer symposium in which we’ll involve all the specialties. And now larger organizations like the American College of Chest Physicians, the American Association of Bronchoscopy and Interventional Pulmonology, and WCLC IASLC are recognizing how multidisciplinary and integral these practices are.

When the literature and research grow, it grows with all the specialties. In each of these arenas, there will be a dedicated group of interventionists that will participate and surgeons that will give talks to stay updated on the literature, because it is a focused field. Approximately 80% of the patients we see may have cancer, so we have to intricately understand how one field connects to the other. The field is growing, and it will get more intricately involved, towards more minimally invasive options and earlier, more efficient treatment.

What is the importance of ensuring collaboration across all thoracic subspecialties?

Since 2018 when I started working [at Ohio State], there has been so much growth in being able to identify suspicious spots in the lung. When I joined, we would mostly biopsy areas around 2 cm. Now with our equipment we can reach lesions that are less than 1 cm, and couple that not only with diagnosis and staging, but also therapeutics. Now we can deliver therapeutic options while performing biopsies. The field is growing, and there will be more development towards endobronchial treatments and therapies, ablations and cryoablations, and whatnot.

A lot of lot of research and growth is happening, but I would stress that to engage in cutting-edge, multidisciplinary practice, [we may have to engage in] what may not be listed in the guidelines today. The [practices] that may be there in 5 or 10 years are currently active now. Whether one is at a large center or a small community center [it’s important] to be aware of what would make a difference in getting the patient their best possible treatment at the end, so make referrals early. Don’t wait until the lesions grow. If you are in a large center, please make a referral to your thoracic oncology groups and interventional pulmonology groups. If you are at a smaller community center, look for your nearest collaborative center for these kinds of referrals, because this field is not what it was 5 years ago, and it will not be the same 5 years later. It’s growing immensely and openly collaborating within your own hospital as well as the ones closer to you is key. Lung cancer is a rapidly evolving disease, but so are the treatments, and it’s very important to stay on top of them.

References

1. Fielding D, Kurimoto N. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Diagnosis and Staging of Lung Cancer. Clin Chest Med. 2018;39(1):111-123. doi:10.1016/j.ccm.2017.11.012
2. The evolving role of next-generation sequencing in NSCLC management. OncLive.com. Updated February 24, 2026. Accessed March 6, 2026. https://www.onclive.com/publications/supplements/the-evolving-role-of-next-generation-sequencing-in-nsclc-management