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Korean J Intern Med > Volume 28(6); 2013 > Article
Rhee: Is there enough support for endobronchial ultrasound-guided transbronchial needle aspiration as an initial diagnostic tool?
See Article on Page 660-667
The main purpose of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is in the staging workup of patients with lung cancer. However, the indications for EBUS-TBNA have widened to include the diagnosis of mediastinal lymphadenopathy. A biopsy via mediastinoscopy has been the standard diagnostic procedure for mediastinal lymphadenopathy of unknown etiology. However, mediastinoscopy is invasive and has associated morbidity.
For isolated mediastinal lymphadenopathy, EBUS-TBNA has shown promising diagnostic results. EBUS-TBNA prevented the need for 87% of mediastinoscopies, and its sensitivity is 92% [1]. In a previous study on 101 patients with mediastinal and hilar lymphadenopathy or suspected lung cancer seen prospectively, EBUS-TBNA had a sensitivity of 95.1% for the correct diagnosis [2]. Choi et al. [3] studied 56 patients who underwent EBUS-TBNA as an initial diagnostic tool for enlarged lymph nodes. All diagnostic accuracy of EBUS-TBNA regardless of procedure purpose was calculated to be 83.9%. Overall, that study's diagnostic yield was comparable to other previous studies, although the diagnostic yield of benign disease was much lower than in previous studies.
Recent studies have suggested that EBUS-TBNA is useful for the diagnosis not only malignant lymphadenopathy but also benign lesions, such as sarcoidosis or tuberculosis lymphadenopathy. Of 65 patients with suspected sarcoidosis, Wong et al. [4] diagnosed sarcoidosis in 61 (93.8%) using EBUS-TBNA. Garwood et al. [5] found that EBUS-TBNA had a sensitivity of 85% for the primary diagnosis of sarcoidosis. Navani et al. [6] found that EBUS-TBNA was diagnostic in 94% of 156 patients with tuberculous intrathoracic lymphadenopathy. Moreover, EBUS-TBNA provided a positive culture in 47% and identified eight cases of drug-resistant tuberculosis. In contrast, in Choi et al. [3], the diagnostic yield of EBUS-TBNA was 50% for tuberculosis and 60% for sarcoidosis; the reason for the low diagnostic yield remains obscure, and needs further study.
We should be cautious when using EBUS-TBNA as the initial diagnostic tool in patients with lymphoma because of the relatively low diagnostic yield. Steinfort et al. [7] reviewed a prospectively recorded database of consecutive patients with suspected lymphoma who underwent EBUS-TBNA. The sensitivity of EBUS-TBNA for detecting lymphoma was 76%, and that for a definitive diagnosis of lymphoma was 57%. One possible explanation for this low diagnostic yield for lymphoma was the relatively small volume of the EBUS-TBNA samples [6]. Some subtypes of lymphoma, such as marginal zone and follicular lymphomas, are difficult to diagnose definitively from small secimens.
In conclusion, EBUS-TBNA can be an initial diagnostic tool for mediastinal lymphadenopathy. If does not provide a diagnosis, mediastinoscopy can be considered the next step.

Conflict of interest

No potential conflict of interest relevant to this article is reported.


1. Navani N, Lawrence DR, Kolvekar S, et al. Endobronchial ultrasound-guided transbronchial needle aspiration prevents mediastinoscopies in the diagnosis of isolated mediastinal lymphadenopathy: a prospective trial. Am J Respir Crit Care Med 2012;186:255–260PMID : 22652031.
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2. Ye T, Hu H, Luo X, Chen H. The role of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) for qualitative diagnosis of mediastinal and hilar lymphadenopathy: a prospective analysis. BMC Cancer 2011;11:100. PMID : 21418631.
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3. Choi YR, An JY, Kim MK, et al. The diagnostic efficacy and safety of endobronchial ultrasound-guided transbronchial needle aspiration as an initial diagnostic tool. Korean J Intern Med 2013;28:660–667.
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4. Wong M, Yasufuku K, Nakajima T, et al. Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis. Eur Respir J 2007;29:1182–1186PMID : 17331972.
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5. Garwood S, Judson MA, Silvestri G, Hoda R, Fraig M, Doelken P. Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis. Chest 2007;132:1298–1304PMID : 17890467.
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6. Navani N, Molyneaux PL, Breen RA, et al. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: a multicentre study. Thorax 2011;66:889–893PMID : 21813622.
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7. Steinfort DP, Conron M, Tsui A, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for the evaluation of suspected lymphoma. J Thorac Oncol 2010;5:804–809PMID : 20521347.
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