8 Endosonography in bronchopulmonary disease Peter Vilmann, MD, DSci, Head of Endoscopy, Ass. Professor of Surgery a, * , Jouke Annema, MD, DSci, Senior Consultant b , Paul Clementsen, MD, DSci, Senior Consultant c a Endoscopy-unit Z-806, Surgical Department D, Gentofte and Herlev Hospital, University of Copenhagen, Hellerup, Denmark b Department of Pulmonology, Leiden University medical Center, Leiden, The Netherlands c Department of Pulmonary Medicine Y, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark Keywords: endosonography EUS-FNA endosonographically guided biopsy EBUS-TBNA lung cancer staging mediastinal staging NSCLC mediastinal tumours The diagnostic approach to diseases of the mediastinum is divided into two phases: (1) imaging techniques and (2) procedures for obtaining tissue samples for cytologic and histologic examination. The latter has for many years represented a considerable challenge to the clinician. Often invasive procedures in general anaesthesia as mediastinoscopy or thoracoscopy have been necessary. However, the sampling of tissue from the mediastinum has been revolutionized by EBUS and EUS, since they give access to the middle and the posterior compartment via the trachea and the oesophagus, respectively. Both EUS FNA and EBUS-TBNA of medi- astinal nodes and tumors can provide a specimen adequate for interpretation in over 95% of cases with a specificity of close to 100% and a sensitivity ranging between 88% and 96%. A growing number of studies including randomized trails and meta-analyses have demonstrated a major impact of EUSFNA as well as EBUS- TBNA on management of patients with lung cancer as well as in patients with unknown lesions in the mediastinum. The aim of the present review is to discuss the current role of endosonography in bronchopulmonary diseases focusing on endosonographically guided biopsy via the esophagus, trachea and main bronchi. The concept of complete echo-endoscopic staging of lung cancer is postulated as virtually all mediastinal nodes as well as regions relevant to pulmonal medicine (liver and adrenal glands) can be reached by these two methods in combination. Ó 2009 Elsevier Ltd. All rights reserved. * Correspondence to: Tel.: þ45 39 77 79 50; Fax: þ45 39 77 76 29. E-mail addresses: pevi@geh.regionh.dk (P. Vilmann), j.t.annema@lumc.nl (J. Annema), pacl@geh.regionh.dk (P. Clementsen). Contents lists available at ScienceDirect Best Practice & Research Clinical Gastroenterology 1521-6918/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.bpg.2009.05.005 Best Practice & Research Clinical Gastroenterology 23 (2009) 711–728