The Essential cTBNA Bronchoscopist

Question I.29 A 69 year old smoker female presented with cough, fever and weight loss. CT
scan showed a left hilar mass with PET positive nodes at stations 10L and 4L. Flexible
bronchoscopy is requested for diagnosis. You choose to:
A. Send the patient to another hospital because it is mandatory to sample multiple lymph
nodes under EBUS guidance.
B. Initially perform cTBNA with ROSE on station 4R nodes because results will change the
treatment approach.
C. Biopsy the tumor for diagnosis, then perform cTBNA of station 4L only because results
will affect the treatment strategy.
D. Biopsy the central tumor using ROSE (rapid on site examination) because PET shows it
to be unresectable. Lymph node sampling is not necessary.
Answer: B
This patient likely has bronchogenic carcinoma. Although taking a direct biopsy of the leftsided
tumor will make a diagnosis and likely assure adequate tissue for molecular testing,
optimal patient management requires staging and thus a systematic lymph node sampling of
possible N2 and N3 nodal stations is warranted. PET-CT suggests stage IIIA disease, but the
presence of N1 nodes and of a central mass increases the likelihood of occult mediastinal
involvement to as high as 20-25%. Furthermore, lung cancer patients with single N2 zone
positivity have a significantly higher survival rate than patients with multiple N2 involvement
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