Endobronchial ultrasound-guided mediastinal biopsies for the diagnosis of mediastinal diseases: A network meta-analysis

BACKGROUND: Clinical guidelines recommend endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as the initial diagnostic tool for lung cancer staging. However, despite the availability of mediastinal forceps biopsy and cryobiopsy, the optimal diagnostic approaches for other mediastinal conditions remain unclear. METHODS: We searched multiple databases and sources up to February 21, 2025, and employed single-arm, pairwise, and network meta-analytical approaches to comprehensively evaluate EBUS-based biopsies for mediastinal diseases in terms of efficacy and safety. RESULTS: Fifteen prospective studies including 1,316 participants evaluated five EBUS-based mediastinal biopsy strategies (EBUS-TBNA, forceps biopsy, cryobiopsy, and the combinations of EBUS-TBNA with forceps biopsy or cryobiopsy) were involved. Concomitant EBUS-TBNA enhanced the efficacy of both forceps biopsy and cryobiopsy. EBUS-TBNA plus cryobiopsy yielded the best diagnostic outcome, showing significant benefits over EBUS-TBNA (OR 4.01, 95% CrI 3.05-5.33), forceps biopsy (OR 2.75, 95% CrI 1.94-3.92), cryobiopsy (OR 1.80, 95% CrI 1.33-2.45), and EBUS-TBNA plus forceps biopsy (OR 1.81, 95% CrI 1.20-2.72). A similarly favourable safety profile was observed in all EBUS-based biopsy methods. CONCLUSIONS: EBUS-TBNA is the diagnostic cornerstone for mediastinal lesions, with EBUS-TBNA plus cryobiopsy being most effective. All EBUS-guided biopsies demonstrated a favourable safety profile.