A comprehensive review of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): staging, techniques, and future directions

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered an essential modality for mediastinal and hilar lymph node evaluation in lung cancer and other thoracic diseases. When compared with surgical staging, EBUS-TBNA yields high sensitivity and specificity with a favorable safety profile. It now serves as the first-line approach for invasive mediastinal staging in most guidelines. In this review, we provide a comprehensive overview of EBUS-TBNA, with a focus on mediastinal staging in the era of the 9th edition of the TNM (Tumor, Node, Metastasis) classification, technical considerations, and emerging applications. We outline the limitations of noninvasive imaging and summarize current indications for invasive staging while emphasizing the prognostic importance of accurate nodal assessment in non-small cell lung cancer including the role of N1 and N2 subcategories. Then, we discuss practical aspects of systematic nodal staging such as which stations to sample, the debate around routine evaluation of station 10 and N3 nodes, and the implications of the updated TNM nodal descriptors for decision making. We also review bronchoscope and needle options and examine the role of rapid on-site evaluation (ROSE), needle gauge, needle design, and sampling techniques in optimizing diagnostic yield and tissue adequacy for immunohistochemistry and next-generation sequencing. Finally, we highlight advanced strategies for challenging non-malignant and lymphoproliferative conditions.