Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Endobronchial ultrasound in mediastinal lung cancer staging

  Accurate mediastinal staging is central to choosing treatment for patients with suspected or confirmed lung cancer. The presence, location, and extent of lymph node involvement can determine whether surgery, stereotactic radiotherapy, systemic treatment, or a combined approach offers the best chance of disease control.

  Endobronchial ultrasound, commonly abbreviated EBUS, has become a key minimally invasive method for assessing mediastinal and hilar lymph nodes. By combining real-time ultrasound with bronchoscopy, clinicians can identify suspicious nodal stations and obtain tissue during the same procedure.

  For respiratory physicians, thoracic surgeons, oncologists, and trainees attending a medical congress, understanding the strengths and limitations of EBUS-guided sampling supports better multidisciplinary decisions. It also provides a practical framework for comparing this technique with surgical staging and conventional bronchoscopy.

  Why mediastinal staging matters

  Lung cancer staging describes how far a malignancy has spread within the chest and beyond it. Mediastinal lymph node involvement commonly corresponds to N2 or N3 disease, although the exact classification depends on the involved nodal stations and the presence of ipsilateral or contralateral disease.

  Imaging with contrast-enhanced computed tomography and fluorodeoxyglucose positron emission tomography can identify enlarged or metabolically active nodes. However, radiographic suspicion does not equal metastatic disease. Infection, inflammation, granulomatous disorders, and treatment-related changes may produce similar appearances, so pathological confirmation is often necessary before a major treatment decision.

  The result must be interpreted alongside the primary tumor, distant imaging, pulmonary function, comorbidities, and patient preferences. A positive mediastinal biopsy may redirect care away from an operation, while a negative result may still require additional evaluation when imaging and clinical risk remain concerning.

  How EBUS sampling works

  During EBUS-guided transbronchial needle aspiration, a flexible bronchoscope fitted with an ultrasound probe is advanced through the mouth or nose into the airways. Ultrasound displays structures adjacent to the trachea and bronchi, allowing the operator to distinguish vascular structures from lymph nodes and guide a needle through the airway wall.

  The procedure can sample several important nodal stations, including many paratracheal, subcarinal, and hilar locations. Real-time visualization helps target nodes with suspicious morphology, while multiple needle passes can provide material for cytology, histology, immunohistochemistry, and selected molecular tests.

  Adequate tissue is increasingly important because advanced lung cancer management may depend on driver mutation testing, programmed death ligand 1 assessment, and broader genomic profiling. The sampling plan should therefore be discussed with pathology before the procedure, especially when a small specimen must answer several diagnostic and therapeutic questions.

  Selecting patients and preparing safely

  EBUS is particularly valuable when PET-CT or CT shows enlarged, irregular, or hypermetabolic mediastinal or hilar nodes. It is also useful when a central lung lesion is difficult to reach by other means, when invasive surgical staging carries substantial risk, or when tissue is needed to confirm recurrence.

  Before bronchoscopy, the team reviews anticoagulants, antiplatelet medications, allergies, sleep apnea, cardiopulmonary reserve, and prior airway procedures. Fasting and medication instructions vary according to local sedation or anesthesia protocols. The patient should understand that a negative biopsy may be non-diagnostic rather than definitively reassuring if the sampled station does not explain the imaging findings.

  Congress participants traveling for respiratory medicine meetings can also review practical visa information when planning attendance around professional education in bronchoscopy, lung cancer, and thoracic oncology.

  Comparing available staging approaches

  EBUS is often considered alongside endoscopic ultrasound, mediastinoscopy, video-assisted thoracoscopic surgery, and image-guided biopsy. The best route depends on which lymph node stations are abnormal, whether the primary tumor is accessible, the required tissue volume, and the local expertise available.

  Endoscopic ultrasound through the esophagus can reach stations that are less accessible from the airway. In some centers, combining EBUS and esophageal ultrasound during one session improves access to a wider range of mediastinal nodes. Surgical staging remains important when needle-based assessment is negative but the probability of mediastinal disease remains high.

  Approach	Main access or strength	Typical role	Important limitation
  EBUS-TBNA	Airway-side ultrasound-guided needle sampling	Paratracheal, subcarinal, and hilar nodes	Limited access to some stations; tissue volume may be small
  EUS-guided sampling	Esophageal access to posterior mediastinal structures	Complementary assessment of selected nodal stations	Requires appropriate equipment and expertise
  Mediastinoscopy	Direct surgical lymph node biopsy	Confirmation when less invasive tests are inconclusive	General anesthesia and operative morbidity
  PET-CT	Whole-body metabolic imaging	Identifying suspicious nodal or distant sites	Cannot reliably confirm malignancy
  CT-guided biopsy	Percutaneous access to selected lesions	Peripheral masses or accessible targets	Pneumothorax and bleeding risk; not ideal for every node

  Interpreting results in context

  A positive EBUS sample containing malignant cells generally provides definitive evidence that the sampled lymph node is involved. The pathology report should identify the tumor type when possible and preserve material for molecular analysis. Communication between the bronchoscopist, cytopathologist, radiologist, and oncology team helps avoid exhausting a limited specimen.

  A negative result requires more careful interpretation. Its reliability depends on pretest probability, lymph node size and appearance, the station sampled, the number of passes, specimen adequacy, and whether all clinically relevant nodes were assessed. Sampling a benign-appearing node does not exclude cancer in another station.

  Systematic nodal assessment can improve confidence. Operators typically begin with stations that would change management most substantially, often evaluating N3 and N2 regions before the side of the primary tumor. If results remain discordant with imaging, multidisciplinary review should determine whether repeat sampling, combined endosonography, or surgical staging is appropriate.

  Safety, limitations, and quality standards

  EBUS is generally well tolerated and has a favorable safety profile compared with surgical staging. Temporary sore throat, cough, hoarseness, minor bleeding, and sedation-related effects may occur. Serious bleeding, infection, pneumothorax, airway injury, and anesthesia complications are uncommon but should be explained during consent.

  The quality of the examination depends on operator training, ultrasound equipment, specimen handling, and pathology expertise. A technically successful procedure can still be clinically inadequate if too few passes are made, the wrong station is selected, or the sample is not processed for the required tests.

  Useful practice priorities include:

  • Review CT and PET-CT images before bronchoscopy and create a station-specific sampling plan.
  • Sample suspicious nodes systematically rather than relying only on the largest node.
  • Coordinate with pathology when immunostaining or molecular profiling may be required.
  • Document nodal stations, needle passes, specimen adequacy, and complications clearly.
  • Escalate discordant or non-diagnostic cases to a multidisciplinary thoracic team.

  When integrated into a structured diagnostic pathway, EBUS can shorten time to diagnosis, reduce unnecessary surgery, and support more precise lung cancer treatment. Its value is greatest when the procedure is selected thoughtfully and its findings are interpreted with imaging and clinical risk rather than in isolation.

  Respiratory professionals can deepen their understanding of mediastinal staging by reviewing current evidence, observing expert procedural practice, and bringing challenging cases to multidisciplinary discussion. Use congress education and specialist collaboration to make EBUS-guided diagnosis a reliable part of modern lung cancer care.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)