A comprehensive evidence review by 24 experts from the American Association of Bronchology and Interventional Pulmonology and the International Association for the Study of Lung Cancer has established endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as the preferred method for lung tissue sampling, offering superior safety while providing adequate samples for comprehensive biomarker testing.
The expert panel's findings, published in the Journal of Thoracic Oncology, represent a significant shift from traditional approaches to lung cancer diagnosis and staging. "As we've increased lung cancer screening, one of the questions that has come to us is how do we diagnose these patients early, but also how to obtain tissue not just for diagnosis, but also for adequate biomarker testing, and do that in the safest manner," said Abhinav Agrawal, MD, system director of interventional pulmonology at Northwell Health in New York and one of the report's authors.
Safety Profile Shows Clear Advantage
The evidence review analyzed 67 studies, including one randomized controlled trial and three retrospective trials that directly compared safety outcomes between bronchoscopic and percutaneous approaches. The results demonstrated a compelling safety advantage for EBUS-TBNA, with 70.8% of panelists strongly agreeing that guided bronchoscopy was safer than percutaneous approaches for sampling parenchymal lung lesions.
The most striking evidence came from a 2011 randomized controlled trial, which showed a dramatic difference in complication rates: 27% with CT-guided percutaneous needle biopsy versus just 3% with EBUS technique. The expert panel cited significantly lower risks of post-procedural pneumothorax and bleeding with bronchoscopy compared to percutaneous sampling, which has complication rates of up to 25%, primarily due to pneumothorax.
For lymph node sampling, the safety advantage was even more pronounced, with 79.2% of panelists strongly agreeing that guided bronchoscopy was safer than percutaneous approaches. The panel noted that multiple lymph nodes can be sampled in a single EBUS-TBNA procedure, and transesophageal bronchoscopic ultrasound can access lymph nodes not reachable by EBUS-TBNA alone.
Sample Adequacy Meets Clinical Needs
While safety advantages were clear, the question of sample adequacy for comprehensive biomarker testing required more nuanced analysis. For parenchymal lung lesions, 41.7% of panelists strongly agreed and 50% agreed that guided bronchoscopy provided greater adequacy than percutaneous approaches. For lymph nodes, 37.5% strongly agreed and 54.2% agreed with the adequacy advantage.
The review concluded that current evidence "largely suggests no difference between guided bronchoscopy and percutaneous approaches to obtain adequate material for comprehensive biomarker testing." However, the panel acknowledged that only prospective trials could definitively answer this question. Supporting data included sample adequacy for EGFR, ALK, and PD-L1 testing, though data remain limited for comprehensive next-generation sequencing adequacy.
Technological Advances Enhance Outcomes
The evolution from traditional mediastinoscopy to EBUS-guided approaches represents more than just a procedural change. "The traditional way about 20 years ago was mediastinoscopy, when EBUS was not available. The community has seen a shift to doing EBUS-guided lymph node biopsy given the high sensitivity, as well as the high positive predictive value and negative predictive value," Agrawal explained.
Advanced endoscopic tools are further improving outcomes. Cryoprobes, which can freeze and extract larger samples, have enhanced sample adequacy and reduced the need for repeat biopsies. The panel also highlighted the importance of rapid on-site evaluation (ROSE) to assess target tissue cellularity and improve diagnostic yields. Forceps and cryoprobe procedures can additionally improve sample adequacy.
Recent validation came from the VERITAS trial, which supported the noninferiority of diagnostic accuracy for EBUS-based navigational bronchoscopy versus transthoracic needle biopsy, further strengthening the evidence base for bronchoscopic approaches.
Clinical Practice Implications
The expert panel's recommendations provide clear guidance for clinicians managing patients with suspected lung cancer. In the absence of comparative data for comprehensive biomarker testing, they recommended using EBUS-TBNA as a first-line modality due to its superior safety profile and ability to access multiple lymph nodes.
"EBUS-guided lymph node biopsy has become the standard of care, both from the diagnostic standpoint and safety standpoint. With this guideline, [it has] also from the molecular yield standpoint [become] the first-line approach for patients with suspected lung cancer," Agrawal noted.
The recommendations are particularly relevant as biomarker testing becomes increasingly important for treatment decisions in lung cancer. The ability to obtain adequate tissue samples safely while avoiding the complications associated with more invasive procedures represents a significant advancement in patient care.
While questions remain about the application of these findings to comprehensive biomarker testing, the expert panel's recommendations provide a framework for future clinical trial designs that could further improve accuracy in this critical area of lung cancer management.
