Comparison of electromagnetic navigation bronchoscopy and transthoracic needle biopsy for diagnosing bronchus sign-positive pulmonary lesions

•This cohort study compared the diagnostic performance and complication rates of ENB and TTNB for diagnosing bronchus sign-positive pulmonary lesions following adjustments for multiple patient and lesion factors.•From multivariable analyses of 1,248 participants who underwent ENB or TTNB for a bronchus sign-positive pulmonary lesion with suspected malignancy, the modality choice (ENB or TTNB) did not significantly affect the diagnostic yield.•A patient-level 1:2 propensity score-matched comparison demonstrated a comparable diagnostic yield (85.0% vs. 89.9%, p = 0.124) and sensitivity (83.0% vs. 88.0%, p = 0.170) for ENB and TTNB following adjustments for multiple pre-procedural lesion factors.•For complications, using TTNB over ENB was associated with a higher risk of pneumothorax and pneumothorax requiring tube drainage. Electromagnetic navigation bronchoscopy (ENB) is an advanced technique for diagnosing peripheral pulmonary lesions, and the bronchus sign is a well-established factor for improving the diagnostic performance. However, ENB is a novel technology compared to the commonly adopted transthoracic needle biopsy (TTNB). There are limited data on the comparison of these techniques for diagnosing bronchus sign-positive lesions. Therefore, we aimed to compare the diagnostic yield and complication rates of ENB and TTNB for diagnosing lung cancer in bronchus sign-positive pulmonary lesions. We assessed 2,258 individuals who underwent either of the techniques for initial biopsy between September 2016 and May 2022 at a tertiary center in South Korea and analyzed 1,248 participants (153 ENB and 1,095 TTNB cases) with a positive bronchus sign. We performed multivariable logistic regression analyses to evaluate the factors associated with the diagnostic yield, sensitivity for malignancy, and procedure-related complications. In addition, the outcomes were compared between the two techniques after a 1:2 propensity score-matching to control for pre-procedural factors. After adjustments for clinical/radiological factors, performing TTNB over ENB was not significantly associated with a higher diagnostic yield but with a higher risk of pneumothorax (OR = 9.69, 95% CI = 4.15–22.59). Propensity score-matching resulted in 459 participants (153 ENB and 306 TTNB cases) with balanced pre-procedural characteristics. The overall diagnostic yield did not differ significantly between ENB and TTNB (85.0% vs. 89.9%, p = 0.124). The diagnostic yield (86.7% vs. 90.3%, p = 0.28