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Home > Cancer Services > Lung Cancer Center > Diagnosis/Staging/Endobronchial Ultrasound (EBUS)

Diagnosis/Staging/Endobronchial Ultrasound (EBUS)

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Although x-ray studies and scans may suggest that a patient has lung cancer, the actual diagnosis of lung cancer can only be made using a biopsy (tissue samples) reviewed by a pathologist. At The Lung Cancer Center at The Valley Hospital, biopsy samples may be gathered through a variety of minimally invasive procedures including the following:


A procedure in which our doctors insert a flexible, lighted tube called a bronchoscope through the nose down into the lungs. If the mass or abnormal area can be accessed by the bronchoscope then a small piece can be obtained as a biopsy. This procedure is usually performed with sedation.

Transthoracic Needle Biopsy
Image during a Transthoracic Needle Biopsy of a small lung nodule about the size of a pea. The arrow shows the nodule with the biopsy needle entering it.

Transthoracic Needle Biopsy

Our interventional radiologists are specially trained to perform this type of biopsy. With the patient in the CT scanner (called CT guidance), the interventional radiologist identifies the abnormality on the scan and inserts a skinny needle into it through the skin under local anesthesia. Cells are then sucked out of the needle and evaluated by the pathologist. Patients go home on the same day as the biopsy and the results are usually available in 48 hours. Our doctors can even obtain adequate biopsies using this technique on nodules smaller than the size of a dime.

Tip of an EBUS scope
Tip of an EBUS scope

Endobronchial Ultrasound (EBUS) Guided Biopsy

A type of bronchoscopy that uses a flexible bronchoscope with a tiny ultrasound device on the tip. The ultrasound guides the physician to see through the airway walls to locate enlarged lymph nodes or masses. A thin needle can be passed through the scope to obtain a biopsy sample. For more information on EBUS, see the section below on lung cancer staging.

VATS (Video-Assisted Thoracic Surgery) Biopsy

A surgical procedure where one or two small incisions are made on the side of the chest allowing the surgeon to insert a camera and long instruments to locate and take a sample of or actually remove the mass or abnormal area in the lung.

In addition to noninvasive studies such as CT scans and PET scans, the lymph nodes in the center of the chest may need to be biopsied (sampled) to determine if the cancer has spread to this area. This is because, in many instances, the noninvasive CT and PET scans are not completely accurate in determining if spread to the lymph nodes has occurred. In many institutions, lymph nodes are biopsied using a procedure called Mediastinoscopy, where an incision is made in the neck area to expose the lymph nodes for biopsy.

At the Lung Cancer Center at The Valley Hospital, however, these same lymph node biopsies can be performed using an incision-free approach called Endobronchial Ultrasound (EBUS). EBUS allows our doctors to see lymph nodes and sample them using a small scope which is passed through the mouth – not requiring any incisions whatsoever.

At The Lung Cancer Center, the use of EBUS to perform lymph node biopsies has replaced the use of the more invasive Mediastinoscopy procedure in about 90% of patients. Even very small lymph nodes less than one centimeter (about half an inch) are able to be sampled using EBUS at Valley. EBUS is also very useful in diagnosing conditions in the chest other than lung cancer including lymphoma, metastases from other malignancies, and benign inflammatory conditions such as sarcoidosis.

Lung Cancer Staging

Once the diagnosis of lung cancer is confirmed through biopsy, the next important step in creating an appropriate treatment plan is to determine the stage of the lung cancer. Staging involves determining how far the cancer has spread, if at all. As with most types of solid, malignant tumors, lung cancers are assigned one of four stages, and the appropriate treatment depends on the stage. It is important to know that adequate staging is necessary prior to treatment:

Stage Characteristics Treatment
Stage I Tumors that are small (less than about an inch) and do not have lymph node involvement Surgical removal
Stage II Tumors that have spread to local lymph nodes in the lung or larger tumors involving the chest wall without lymph node involvement Surgical removal, followed by chemotherapy
Stage III Tumors that are “locally advanced” in multiple lymph nodes in the chest, but do not appear to have spread (metastasized) to other organs Chemotherapy and radiation, and sometimes surgical removal
Stage IV Tumors that have spread to other organs outside the chest Chemotherapy, sometimes “targeted” therapy

As the table above demonstrates, treatment of lung cancer depends on the stage of disease, underlining the need for adequate staging prior to treatment. The above table is relevant for patients with the most common type of lung cancer, called non-small cell lung cancer. If biopsy results show an uncommon type of lung cancer called small cell lung cancer, treatment may differ, and it is less likely that your doctor will recommend removal using surgery.

Outcomes at The Valley Hospital using EBUS
The pie chart above shows our outcomes at The Valley Hospital using EBUS for patients whose lymph nodes in the chest need to be biopsied (sampled). The most likely reason is for a patient with lung cancer, although other diseases, both benign (non cancerous) and malignant (cancerous) are also diagnosed.

In addition to lymph node biopsies, our doctors at The Lung Cancer Center are also performing EBUS to biopsy lung nodules, or masses in patients that are difficult to biopsy using other techniques. Abnormalities which are best sampled using EBUS are located near the center of the chest, which tend to be out of reach for Transthoracic Needle Biopsy, as described above.

Patients with lung nodules successfully biopsied
CT scan images from two patients with lung nodules successfully biopsied (sampled) with EBUS. The arrows point to the nodules which were both diagnosed as lung cancer by EBUS. These nodules are located near the center of the chest, making Transthoracic Needle Biopsy more difficult, and EBUS as the biopsy technique of choice.

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