Endobronchial Ultrasound Bronchoscopy-Guided Biopsy for Lymphoma

Endobronchial ultrasound bronchoscopy (EBUS) is a minimally invasive and widely utilized endoscopic technique that enables real-time ultrasound visualization of mediastinal and hilar lymph nodes adjacent to the tracheobronchial tree, allowing tissue sampling under direct sonographic guidance. Accessible nodal stations include 1, 2R/L, 3P, 4R/L, 7, 10R/L, and 11R/L; however, stations 5 and 6 are technically more challenging and associated with a higher risk of complications due to their proximity to the aorta and pulmonary vessels.

EBUS can be used for diagnostic, staging, and restaging purposes, particularly in conditions such as lymphoma and sarcoidosis, as demonstrated in the accompanying video. Its diagnostic yield varies according to the underlying pathology and nodal characteristics, and the diagnostic sensitivity for specific diseases is outlined below.

Lymph nodes; lung cancer; biopsy; EBUS; endobronchial ultrasound; EUS; endoscopic ultrasound; transbronchial needle aspiration.

A 70-year-old female patient with a history of sarcoma of her left thigh diagnosed in 2019 status post surgical removal followed by radiation and currently on surveillance program. Her other past medical issues are hypertension, hyperlipidemia, and type 2 diabetes mellitus, well controlled. Her surveillance CT scan of the chest with and without contrast showed enlargement of mediastinal lymph nodes and hilar lymph nodes, and we were consulted for further evaluation.

EBUS was first used in 1992.¹ Since then, EBUS has been commonly used in the last decade, currently considered as the main technique for minimally invasive evaluation of the mediastinum and lung cancer staging.² Before the implementation of EBUS, mediastinal lymph node sampling could be done via rigid bronchoscopy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive and highly specific ( > 99%) modality for evaluating mediastinal lymphadenopathy in suspected lymphoma, offering moderate sensitivity (approximately 67% for de novo and up to 78% for relapsed disease) and enabling cytologic, immunophenotypic, and molecular analyses, although excisional biopsy remains the gold standard when specimens are inadequate—particularly in Hodgkin lymphoma where architectural assessment is essential.

Before the widespread adoption of EBUS, mediastinal sampling was frequently performed with rigid bronchoscopy due to its superior airway control, mechanical stability, and bleeding management, and in selected complex cases—including access to unconventional stations such as subclavicular (station 1) nodes—rigid support combined with laryngeal mask airway ventilation can still provide safe and effective biopsy access when enhanced stability and exposure are required. ^8–11 Current EBUS-TBNA procedure showed a reduction in the procedure risks, including vascular injuries, mediastinal organ injuries, as well as the ability to reach more lymph node stations.³

EBUS-TBNA is a minimally invasive procedure used for sampling mediastinal and hilar lymph nodes as well as centrally located thoracic lesions. It is most commonly used for mediastinal staging in patients with non–small cell lung cancer (NSCLC), including initial staging, restaging after neoadjuvant therapy, and evaluation of PET-positive mediastinal lymph nodes. EBUS-TBNA is also widely used in the diagnostic evaluation of isolated mediastinal and hilar lymphadenopathy, including suspected sarcoidosis, lymphoma, tuberculosis, other granulomatous diseases, and metastatic malignancy of unknown primary. Using real-time ultrasound guidance, lymph node stations such as 2R/L, 4R/L, 7, 10R/L, and 11R/L can be sampled.

The procedure may also be used to evaluate mediastinal masses and cystic lesions, including bronchogenic cysts, although puncture of cystic lesions carries a higher risk of infection. Overall, EBUS-TBNA has a favorable safety profile and a low complication rate, generally reported to be less than 2%, with serious complications and mortality being extremely rare. Compared with surgical mediastinoscopy, EBUS-TBNA offers a less invasive alternative with comparable diagnostic value.

Although complications are uncommon, both infectious and non-infectious events have been reported. Infectious complications may include pneumonia, pleurisy, empyema, mediastinitis, and infection of mediastinal cysts, which may occur due to bacterial inoculation during needle aspiration. Cystic mediastinal lesions appear to carry a higher risk because of their limited vascularity and reduced antibiotic penetration. Non-infectious complications may include minor bleeding, transient hypoxemia, pneumothorax, airway trauma, and extremely rare tumor seeding. Careful patient selection, strict aseptic technique, and consideration of prophylactic antibiotics in selected high-risk cases may help reduce these risks.^12–15

Her physical exam showed an American Society of Anesthesiologist (ASA) score of II, BMI 26, stable vital signs, not on anticoagulation, antiplatelet, as well as medications affecting gastric emptying time, which need to be held temporally prior to the procedure. Her blood test showed a normal range of platelets, BUN, electrolytes, and coagulation factors. Our evaluation concluded that she is clinically stable to undergo bronchoscopy procedure, and her CT scan evaluation showed enlargement of the mediastinal and hilar lymph nodes, and we offered her the EBUS-TBNA procedure under general anesthesia.

Other alternative options would be watchful waiting, traditional transbronchial biopsy, medianoscopy, and lymph nodes removal, which are more invasive and have higher complications risks. After discussing all alternative options, the patient elected to proceed with the procedure.

Absolute contraindications to flexible bronchoscopy include severe hypoxemia, hemodynamic instability, and refractory arrhythmias.⁴ Coagulopathy, recent myocardial infarction, pulmonary hypertension, and increased intracranial pressure are generally considered relative contraindications, though bronchoscopy can generally be performed safely in these scenarios with proper precautions and expertise.⁵

EBUS-TBNA begins with positioning the patient in the supine position. Sedation, either moderate sedation or deep sedation/general anesthesia, has an important role in this procedure as it provides patient comfort as well as increases the diagnostic yield.⁶ In the video, we used general anesthesia.

First, the bronchoscope is inserted and advanced to the vocal cords, and lidocaine is instilled directly to the vocal cords via the working channel. The bronchoscope is then advanced through the vocal cords and into the trachea, at which point additional lidocaine is instilled to the carina and airway exam is performed. We then removed the bronchoscope, and the EBUS scope was introduced to the airway via vocal cords and used to scan throughout the airway for enlarged mediastinal and hilar lymph nodes. To scan the lymph node, the tip of the scope is placed under direct contact in different positions, starting from segmental airway to the main airway on both sides every 5 mm. During scanning through the lymph nodes, the proceduralist identifies the lymph node stations and notes their size, shape, presence or absence of hilum, distant or indistinct margin, homogeneous or non-homogeneous in nature, as well as intranodal vasculature or not. These morphological features are important to predict benign vs malignant.⁷

Once the target lymph node is identified, the tip of the EBUS scope is placed adjacent to the target area. The balloon can be inflated to improve the image quality if needed. Once positioned, the EBUS-TBNA needle is introduced through the working channel and the needle is locked. Then, the guide sheath is adjusted to prevent scope damage and locked. Again, confirm the position and avoid the vessel by scanning with Doppler flow as well as adjusting the position. While maintaining the real-time ultrasound view and stabilization of the position, the needle is pushed out of the catheter in a controlled fashion, passed through the bronchial/tracheal wall and advanced into the targeted lymph node. Once the position is confirmed, the needle stylet is retracted slowly while the needle is passed through the lymph node several times. The EBUS-TBNA needle is retracted and locked, and the whole needle system is removed from the working channel. The sample is collected using a stylet and a small amount of saline. Repeat the procedures until enough samples are collected and move to the next target. Upon completion of lymph nodes sampling, the EBUS scope is withdrawn from the patient and replaced with a flexible bronchoscope for postprocedural airway inspection to confirm hemostasis. If bleeding occurs during the procedure, hemostasis can be achieved by tamponading with the scope, applying iced saline via working channel, as well as diluted iced epinephrine solution. Once hemostasis is confirmed, the scope is withdrawn, and the procedure is concluded.

Patients are typically monitored for a short time postoperatively and discharged home the same day. Significant complications are rare ( < 1% occurrence), but may include respiratory failure, bronchospasm, bleeding and pneumothorax.⁴ Postprocedure chest X-ray is not routinely needed for EBUS-TBNA procedure but can be performed if there are any concerns for complications.

The EBUS scope is the primary tool used for this procedure. As described in the video, the tip consists of a convex probe with 65-degree scanning range using different frequencies from 5 to 12 MHz. In order to increase the contact area between the scope and the bronchial airway, the scope tip is covered by a latex balloon, inflatable with saline. In this video we used the Olympus BF-UC180F EBUS scope. The tip of the scope contains a light source, a video camera, and a working channel. The working channel can be used to instill medications, introduce an EBUS-TBNA needle, or suction airway material. The bronchoscope tip can be flexed and extended via a lever on the handle, and rotation of the handle is used to guide the bronchoscope directionally. EBUS-TBNA needles are designed to be used with the EBUS scope. An easy-to-use, unique safety locking mechanism and sheath is designed to avoid accidental needle protrusion, protecting the personal as well as the scope.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.