Advancements in Intra-Nodal Forceps Biopsy: A Two-Decade Review of Techniques, Yield, and Future Directions

Abstract

Testing for granulomatous diseases, lymph proliferative disorders, and thoracic cancers requires precise sample of the mediastainal and Hilar lymph nodes. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has long been the accepted minimally invasive procedure; nevertheless, in diseases like lymphoma that need maintained tissue architecture, its reliance on cytological sample reduces the accuracy of the diagnosis. Intra-nodal forceps biopsy (IFB), which allows for the acquisition of histopathological core tissue through a transbronchial tract made under EBUS guidance, has become a useful complement or substitute for TBNA throughout the past 20 years. This review aims to synthesize two decades of clinical and technological advancements in IFB, evaluating its diagnostic performance, safety, and integration into current thoracic diagnostic algorithms. A systematic literature review was conducted using four major databases, identifying relevant studies from 2003 to 2024. The results show that IFB has a low complication rate (<1.5%) and a better diagnostic yield (85-90%) and sample adequacy (90-96%) than TBNA. Notwithstanding its efficacy, its broad adoption is hampered by drawbacks such operator dependence, procedural complexity, equipment variability regulations. Future developments include sensor-integrated forceps for increased precision, robotic bronchoscopy, and AI-assisted targeting. IFB is also anticipated to play a bigger position in technologies. IFB is positioned to develop into a primary diagnostic tool for the assessment of Lymphadenopathy as training programs and regulatory frameworks change. This review underscores IFB’s clinical relevance and potential to reshape the landscape of minimally invasive pulmonary diagnostics.

Introduction

Accurate assessment of mediastinal and hilar lymphadenopathy is essential for diagnosing a range of thoracic diseases, including lung cancer, lymphoma, and granulomatous disorders. The standard minimally invasive approach, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), has good diagnostic performance but is limited by its reliance on cytology, which often fails to provide sufficient tissue architecture for conditions like lymphoma or sarcoidosis.

To address this, intra-nodal forceps biopsy (IFB) was developed as an EBUS-guided technique that retrieves core tissue samples through a tract created by a large-bore needle. Over the past two decades, IFB has demonstrated high sample adequacy (90–96%), diagnostic accuracy (85–90%), and low complication rates (~1.5%), offering a less invasive and more cost-effective alternative to surgical mediastinoscopy. It has proven particularly useful for histology-dependent diagnoses such as lymphoma and granulomatous diseases.

However, IFB’s widespread adoption remains limited by factors such as procedural complexity, operator dependency, lack of standardized equipment, limited training opportunities, and inconsistent regulatory frameworks. Current research focuses on improving technology (e.g., flexible, ultra-slim forceps; Doppler targeting), refining technique, and expanding training.

Future directions include integration of robotic bronchoscopy, AI-assisted targeting, and sensor-equipped forceps to enhance precision and safety. Development of tools that preserve molecular integrity will support personalized medicine, while simulation-based training aims to standardize procedural proficiency.

Conclusion

Intra-nodal forceps biopsy represents a transformative leap in the diagnostic evaluation of mediastainal Lymphadenopathy. Over the past 20 years, the technique has evolved from an adjunct to a near-primary diagnostic tool in selected indications?[31,34]. Its superior yield in diseases demanding histological architecture, low complication rates, and integration with EBUS platforms make it a valuable addition to the bronchoscopes’ toolkit?[36,41]. As technologies converge with robotics, AI, and molecular diagnostics, IFB is poised to further redefine minimally invasive diagnostics in pulmonary medicine?[46,49].

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Copyright © 2025 Kothwala Dr. Deveshkumar Mahendralal, Pathak Vipulkumar, Bhandari Ami Nejas, Kapadia Mahima Pragneshkumar. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.