INTRODUCTION Transbronchial needle aspiration (TBNA) is a technique that has revolutionized the diagnosis of mediastinal pathology by enabling intrathoracic nodal sampling in a minimally invasive manner. The sampling of paratracheal masses using an esophageal varix needle passed through a rigid bronchoscope was initially described by Ko-Pen Wang in 1978. The following year Oho and colleagues created a needle that could be passed through a flexible bronchoscope, thus ushering in a novel modality for sampling intrathoracic lymph nodes without surgical intervention. Over the last 30 years, the technique of TBNA has been relatively unchanged, although the indications for TBNA have expanded to include sampling of hilar lymph nodes, submucosal disease, visible endobronchial lesions, as well as peripheral nodules. The recent development of advanced imaging such as computed tomography (CT) fluoroscopy, electromagnetic navigation, and endobronchial ultrasound (EBUS) now allows real-time visualization of lymph node sampling. Because of these advances, TBNA has emerged as the first line of intrathoracic lymph node sampling for the diagnosis, staging, and prognosis of bronchogenic carcinoma, sarcoidosis, and even infectious diseases. Bronchogenic carcinoma is the leading cause of cancer death in both men and women in the United States as well as in several other countries. Therapeutic options and prognoses are heavily dependent on accurate staging, and nodal staging is a key component of determining overall clinical stage (Figure 11.1). Non-invasive radiologic staging is suboptimal with sensitivities ranging from 51% to 74%.
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