, Volume 191, Issue 1, pp 109–115

Linear Probe Endobronchial Ultrasound Bronchoscopy with Guided Transbronchial Needle Aspiration (EBUS–TBNA) in the Evaluation of Mediastinal and Hilar Pathology: Introducing the Procedure to a Teaching Institution

  • Muhanned Abu-Hijleh
  • Yaser El-Sameed
  • Kathleen Eldridge
  • Eduardo Vadia
  • Hsienchang Chiu
  • Zacharay Dreyfuss
  • Lua’i Samir Al Rabadi



Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS–TBNA) is an important tool in the diagnosis of mediastinal and hilar pathology. We describe our experience with EBUS–TBNA performed in a teaching institution primarily under conscious sedation.


Patients who underwent EBUS–TBNA were included in this retrospective review. We focused on the diagnostic yield of EBUS–TBNA in relationship to the nature of the mediastinal or hilar lesions (suspected malignancy vs. benign disease), incremental 25 procedures aliquots, lymph node (LN) station, LN size, and the number of needle aspirations per LN station.


Of the 212 patients who underwent EBUS–TBNA, 200 patients had adequate follow-up information and were included in this analysis. The procedure was performed under conscious sedation in 97 % of patients and 133 patients (67 %) were suspected to have malignancy before the procedure. A total of 690 TBNAs were performed from 294 LN stations. The mean number of LN stations sampled per procedure was 1.47 ± 0.6. The mean number of TBNAs per LN station was 2.35 ± 0.91. The mean number of TBNAs per procedure was 3.45 ± 1.2. The overall sensitivity, specificity, negative predictive value (NPV), and diagnostic accuracy for all procedures were 87.41 % (CI 80.76–91.99), 100 % (CI 93.12–100), 75.36 % (CI 64.04–84.01), and 90.91 % (CI 85.92–94.25), respectively. The NPV increased significantly after the initial 25 procedures and remained high thereafter. EBUS–TBNA was more accurate (96.12 % (CI 91.25–98.33)) with higher NPV (90.74 % (CI 80.09–95.98)) in patients with suspected malignancy compared with patients with suspected benign disease (79.31 % (CI 67.23–87.75), 20 % (7.05–45.19)). Samples from relatively smaller LN (>5 to ≤20 mm) and from all analyzed LN stations were similarly accurate with high sensitivity and NPV.


EBUS–TBNA allows safe real-time sampling of mediastinal and hilar lesions under conscious sedation with high diagnostic accuracy. The NPV is high and increased significantly after the initial 25–50 procedures. This is comparable to available surgical techniques, including mediastinoscopy, when malignancy is suspected. The NPV for specific benign disease remains low in our experience. The diagnostic yield is not affected by the LN station, size, or the number of passes per LN station.


Endobronchial ultrasound (EBUS) Mediastinal lymphadenopathy Hilar lymphadenopathy Diagnostic yield 


  1. 1.
    Krasnik M, Vilmann P, Larsen SS, Jacobsen GK (2003) Preliminary experience with a new method of endoscopic transbronchial real time ultrasound guided biopsy for diagnosis of mediastinal and hilar lesions. Thorax 58(12):1083–1086PubMedCrossRefGoogle Scholar
  2. 2.
    Anantham D, Koh MS, Ernst A (2009) Endobronchial ultrasound. Respir Med 103(10):1406–1414PubMedCrossRefGoogle Scholar
  3. 3.
    Tremblay A, Stather DR, Maceachern P, Khalil M, Field SK (2009) A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest 136(2):340–346PubMedCrossRefGoogle Scholar
  4. 4.
    Unroe MA, Shofer SL, Wahidi MM (2010) Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques. Curr Opin Pulm Med 16(4):295–300PubMedCrossRefGoogle Scholar
  5. 5.
    Yasufuku K, Chiyo M, Sekine Y, Chhajed PN, Shibuya K, Iizasa T, Fujisawa T (2004) Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 126(1):122–128PubMedCrossRefGoogle Scholar
  6. 6.
    Herth FJ, Eberhardt R, Vilmann P, Krasnik M, Ernst A (2006) Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax 61(9):795–798PubMedCrossRefGoogle Scholar
  7. 7.
    Vincent BD, El-Bayoumi E, Hoffman B, Doelken P, DeRosimo J, Reed C, Silvestri GA (2008) Real-time endobronchial ultrasound-guided transbronchial lymph node aspiration. Ann Thorac Surg 85(1):224–230PubMedCrossRefGoogle Scholar
  8. 8.
    Yasufuku K (2010) Current clinical applications of endobronchial ultrasound. Expert Rev Respir Med 4(4):491–498PubMedCrossRefGoogle Scholar
  9. 9.
    Colt HG, Davoudi M, Murgu S (2011) Scientific evidence and principles for the use of endobronchial ultrasound and transbronchial needle aspiration. Expert Rev Med Devices 8(4):493–513PubMedCrossRefGoogle Scholar
  10. 10.
    Alsharif M, Andrade RS, Groth SS, Stelow EB, Pambuccian SE (2008) Endobronchial ultrasound-guided transbronchial fine-needle aspiration: the University of Minnesota experience, with emphasis on usefulness, adequacy assessment, and diagnostic difficulties. Am J Clin Pathol 130(3):434–443PubMedCrossRefGoogle Scholar
  11. 11.
    Harrow EM, Abi-Saleh W, Blum J, Harkin T, Gasparini S, Addrizzo-Harris DJ, Arroliga AC, Wight G, Mehta AC (2000) The utility of transbronchial needle aspiration in the staging of bronchogenic carcinoma. Am J Respir Crit Care Med 161(2 Pt 1):601–607PubMedGoogle Scholar
  12. 12.
    Mazzone P, Jain P, Arroliga AC, Matthay RA (2002) Bronchoscopy and needle biopsy techniques for diagnosis and staging of lung cancer. Clin Chest Med 23(1):137–158PubMedCrossRefGoogle Scholar
  13. 13.
    Holty JE, Kuschner WG, Gould MK (2005) Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis. Thorax 60(11):949–955PubMedCrossRefGoogle Scholar
  14. 14.
    Rintoul RC, Skwarski KM, Murchison JT, Hill A, Walker WS, Penman ID (2004) Endoscopic and endobronchial ultrasound real-time fine-needle aspiration for staging of the mediastinum in lung cancer. Chest 126(6):2020–2022PubMedCrossRefGoogle Scholar
  15. 15.
    Yasufuku K, Chiyo M, Koh E, Moriya Y, Iyoda A, Sekine Y, Shibuya K, Iizasa T, Fujisawa T (2005) Endobronchial ultrasound guided transbronchial needle aspiration for staging of lung cancer. Lung Cancer 50(3):347–354PubMedCrossRefGoogle Scholar
  16. 16.
    Varela-Lema L, Fernández-Villar A, Ruano-Ravina A (2009) Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review. Eur Respir J 33(5):1156–1164PubMedCrossRefGoogle Scholar
  17. 17.
    Adams K, Shah PL, Edmonds L, Lim E (2009) Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis. Thorax 64(9):757–762PubMedCrossRefGoogle Scholar
  18. 18.
    Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH (2009) Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer 45(8):1389–1396PubMedCrossRefGoogle Scholar
  19. 19.
    Wong M, Yasufuku K, Nakajima T, Herth FJ, Sekine Y, Shibuya K, Iizasa T, Hiroshima K, Lam WK, Fujisawa T (2007) Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis. Eur Respir J 29(6):1182–1186PubMedCrossRefGoogle Scholar
  20. 20.
    Nakajima T, Yasufuku K, Kurosu K, Takiguchi Y, Fujiwara T, Chiyo M, Shibuya K, Hiroshima K, Nakatani Y, Yoshino I (2009) The role of EBUS-TBNA for the diagnosis of sarcoidosis—comparisons with other bronchoscopic diagnostic modalities. Respir Med 103(12):1796–1800PubMedCrossRefGoogle Scholar
  21. 21.
    Kennedy MP, Jimenez CA, Bruzzi JF, Mhatre AD, Lei X, Giles FJ, Fanning T, Morice RC, Eapen GA (2008) Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lymphoma. Thorax 63(4):360–365PubMedCrossRefGoogle Scholar
  22. 22.
    Lee HS, Lee GK, Lee HS, Kim MS, Lee JM, Kim HY, Nam BH, Zo JI, Hwangbo B (2008) Real-time endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal staging of non-small cell lung cancer: how many aspirations per target lymph node station? Chest 134(2):368–374PubMedCrossRefGoogle Scholar
  23. 23.
    Groth SS, Whitson BA, D’Cunha J, Maddaus MA, Alsharif M, Andrade RS (2008) Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution’s early learning curve. Ann Thorac Surg 86(4):1104–1109PubMedCrossRefGoogle Scholar
  24. 24.
    Stather DR, Maceachern P, Chee A, Dumoulin E, Tremblay A (2012) Evaluation of clinical endobronchial ultrasound skills following clinical versus simulation training. Respirology 17(2):291–299PubMedCrossRefGoogle Scholar
  25. 25.
    Hoffmann H (2001) Invasive staging of lung cancer by mediastinoscopy and video-assisted thoracoscopy. Lung Cancer 34(Suppl 3):S3–S5PubMedCrossRefGoogle Scholar
  26. 26.
    Rusch VW (2005) Mediastinoscopy: an endangered species? J Clin Oncol 23:8283–8285PubMedCrossRefGoogle Scholar
  27. 27.
    Hammoud ZT, Anderson RC, Meyers BF et al (1999) The current role of mediastinoscopy in the evaluation of thoracic disease. Thorac Cardiovasc Surg 118:894–899CrossRefGoogle Scholar
  28. 28.
    Detterbeck FC, DeCamp MM Jr, Kohman LJ, Silvestri GA (2003) American College of Chest Physicians. Invasive staging: the guidelines. Chest 123(1 Suppl):167S–175SPubMedCrossRefGoogle Scholar
  29. 29.
    Medford AR (2010) Endobronchial ultrasound-guided transbronchial needle aspiration. Pol Arch Med Wewn 120(11):459–466PubMedGoogle Scholar
  30. 30.
    Detterbeck FC, Falen S, Rivera MP, Halle JS, Socinski MA (2004) Seeking a home for a PET, part 2: defining the appropriate place for positron emission tomography imaging in the staging of patients with suspected lung cancer. Chest 125(6):2300–2308PubMedCrossRefGoogle Scholar
  31. 31.
    Yasufuku K, Nakajima T, Motoori K, Sekine Y, Shibuya K, Hiroshima K, Fujisawa T (2006) Comparison of endobronchial ultrasound, positron emission tomography, and CT for lymph node staging of lung cancer. Chest 130(3):710–718PubMedCrossRefGoogle Scholar
  32. 32.
    Hwangbo B, Kim SK, Lee HS, Lee HS, Kim MS, Lee JM, Kim HY, Lee GK, Nam BH, Zo JI (2009) Application of endobronchial ultrasound-guided transbronchial needle aspiration following integrated PET/CT in mediastinal staging of potentially operable non-small cell lung cancer. Chest 135(5):1280–1287PubMedCrossRefGoogle Scholar
  33. 33.
    Herth FJ, Ernst A, Eberhardt R, Vilmann P, Dienemann H, Krasnik M (2006) Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum. Eur Respir J 28(5):910–914PubMedCrossRefGoogle Scholar
  34. 34.
    Herth FJ, Eberhardt R, Krasnik M, Ernst A (2008) Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer. Chest 133(4):887–891PubMedCrossRefGoogle Scholar
  35. 35.
    Kennedy MP, Shweihat Y, Sarkiss M, Eapen GA (2008) Complete mediastinal and hilar lymph node staging of primary lung cancer by endobronchial ultrasound: moderate sedation or general anesthesia? Chest 134(6):1350–1351PubMedCrossRefGoogle Scholar
  36. 36.
    Baram D, Garcia RB, Richman PS (2005) Impact of rapid on-site cytologic evaluation during transbronchial needle aspiration. Chest 128(2):869–875PubMedCrossRefGoogle Scholar
  37. 37.
    Steinfort DP, Irving LB (2010) Patient satisfaction during endobronchial ultrasound-guided transbronchial needle aspiration performed under conscious sedation. Respir Care 55(6):702–706PubMedGoogle Scholar
  38. 38.
    Davenport RD (1990) Rapid on-site evaluation of transbronchial aspirates. Chest 98(1):59–61PubMedCrossRefGoogle Scholar
  39. 39.
    Diacon AH, Schuurmans MM, Theron J, Louw M, Wright CA, Brundyn K, Bolliger CT (2005) Utility of rapid on-site evaluation of transbronchial needle aspirates. Respiration 72(2):182–188PubMedCrossRefGoogle Scholar
  40. 40.
    Griffin AC, Schwartz LE, Baloch ZW (2011) Utility of on-site evaluation of endobronchial ultrasound-guided transbronchial needle aspiration specimens. Cytojournal 8:20PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Muhanned Abu-Hijleh
    • 1
  • Yaser El-Sameed
    • 2
  • Kathleen Eldridge
    • 3
  • Eduardo Vadia
    • 1
  • Hsienchang Chiu
    • 1
  • Zacharay Dreyfuss
    • 1
  • Lua’i Samir Al Rabadi
    • 4
  1. 1.University of Texas Southwestern Medical Center (UTSW)DallasUSA
  2. 2.Respirology Division, Medicine InstituteSheikh Khalifa Medical CityAbu DhabiUnited Arab Emirates
  3. 3.Christiana Care Health SystemLandenbergUSA
  4. 4.Case Western MetroHealth Hospital, The MetroHealth SystemClevelandUSA

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