Invasive mediastinal staging: endobronchial ultrasound, endoscopic ultrasound, and mediastinoscopy.

Accurate mediastinal staging is essential to determining the optimal therapeutic strategy for many patients with lung cancer. Computed tomography and positron emission tomography are first steps, but frequently tissue sampling is recommended to confirm the radiographic findings. Mediastinoscopy has been the gold standard for thirty years, but the new technologies of esophageal endoscopic ultrasound and endobronchial ultrasound provide a less invasive method for biopsy. These techniques enable needle aspiration sampling of nearly all mediastinal and hilar lymph nodes, and experience with them is now sufficiently mature to conclude that they can be equivalent if not preferable to mediastinoscopy. The keys to achieving accurate results are skillful execution combined with sound clinical judgment regarding when to use which techniques. Patients with lung cancer are best served by clinicians experienced with all three methods for invasive mediastinal staging.