The Essential cTBNA Bronchoscopist

Question I.19 A patient is referred for EBUS-TBNA from the subcarinal lymph node. The CT
scan is shown below. Your EBUS scope is out for repair and expected to be returned in several
days. The patient and his referring doctor would like to proceed with a diagnostic intervention
as soon as possible. What is the most appropriate next step?
A. Wait until the EBUS scope is available and then proceed with EBUS-TBNA.
B. Refer the patient to your gastroenterologist colleague for EUS-FNA.
C. Refer the patient to your thoracic surgery colleague for mediastinoscopy.
D. Proceed with cTBNA with rapid on-site examination.
Answer: D
One could argue that waiting for the EBUS scope is appropriate. If diagnosed with lung cancer,
this would be a stage IIIA (with bulky lymphadenopathy) and the patient will likely initiate
multimodality treatment rather than undergo primary surgical resection. Delaying diagnosis for
several days will not impact management. Both the patient and the referring physician,
however, wish to obtain a diagnosis as soon as possible. EUS-FNA and mediastinoscopy have a
high diagnostic yield for subcarinal lymph nodes, but might delay the diagnosis because
necessary specialist consultations may not always be readily available; furthermore,
mediastinoscopy is more invasive and with higher complication rates than needle aspiration
techniques (if one excludes possible false-negative EBUS-TBNA as a complication). cTBNA with
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