Endobronchial ultrasound-guided transbronchial needle aspiration: Techniques and challenges

Intrathoracic lymphadenopathy is a common problem encountered in clinical practice and is caused by a wide variety of diseases. Traditionally, the mediastinal lymph nodes were sampled using conventional transbronchial needle aspiration (TBNA), or surgical methods such as mediastinoscopy, and thoracotomy (open or video-assisted thoracoscopy). However, surgical modalities including mediastinoscopy are invasive, expensive, and not universally available. Moreover, they are associated with considerable morbidity and mortality. Conventional TBNA although minimally invasive has a low diagnostic yield. In the last decade, endobronchial ultrasound-guided TBNA (EBUS-TBNA) has emerged as the diagnostic procedure of choice in evaluating undiagnosed intrathoracic lymphadenopathy. EBUS-TBNA is also currently the preferred modality in the mediastinal staging of lung cancer. The procedure is minimally invasive, safe, and can be performed as a day-care procedure. In the era of personalized medicine in lung cancer, optimizing the procedure, sample collection, and processing are crucial, as more tissue is required for performing a wide array of molecular tests. Despite its widespread use and acceptance, the diagnostic sensitivity of EBUS-TBNA is still low. To maximize the yield, cytologists and physicians should be aware of the technical details of the procedure. Herein, we discuss the technique of performing EBUS-TBNA, its indications, contraindications, and the processing of the samples at our bronchoscopy suite. We also highlight the challenges faced by the cytologists and clinicians while processing EBUS aspirates.