EBUS-TBNA, EUS-FNA or EUS-B-FNA for mediastinal staging of lung cancer: A purpose of diagnostic algorithm

To minimize the use of mediastinoscopy in lung cancer staging, EBUS-TBNA and EUS-FNA represent reasonable approaches. Several trials using a combination of both methods showed a higher diagnostic yield than each method alone. EUS complements the anterior mediastinal access of EBUS and most of the mediastinal lymph node stations, as well as the left adrenal gland, can be visualized and biopsied. Indeed, a growing evidence supports the value of a combination of both methods by use of one EBUS bronchoscope (EUS-B-FNA).The combined EBUS/EUS-B-FNA seems to be significantly less time-consuming, cost saving, and as effective and safe as the use of two endoscopes for N staging. Indeed, this approach is associated with less clear US imaging and with some technical issues deriving from the reduced caliper of the EBUS scope and its lesser stiffness compared to the EUS probe, making the biopsy sample more challenging as well as with its limited ability to reach the stomach, to visualize and sample the left adrenal gland.Based on this assumption, we developed a diagnostic algorithm (Figure 1) aiming at planning the choice of the ultrasound device before to proceed with the endoscopic examination. We took into account the best potential approach enabling to correctly perform a complete N and M staging minimizing the risk of endoscopes overuse.A confirmatory case-control study based on our hypothesis is needed.