Global Survey on Current Practices of Endobronchial Ultrasound Approaches to N2 Staging in Non-Small Cell Lung Cancer Following the Ninth Edition of the TNM Classification

BACKGROUND: The ninth edition of the TNM classification (TNM-9) for NSCLC introduces distinct N2 subgroups based on single (N2a) or multiple (N2b) involved stations, impacting prognosis and staging. This survey aimed to assess the impact of these changes on mediastinal staging with EBUS-TBNA, particularly regarding the need for needle change when sampling lymph nodes from different N2 stations. METHODS: A 10-question online questionnaire was distributed from March 4, 2025 to March 16, 2025, to pulmonologists through interventional pulmonology sections of medical societies, online networks, and social media. RESULTS: A total of 605 questionnaires from 66 countries were analyzed. Most respondents were males (58.8%), aged 40 to 49 years, and worked in academic hospitals. Regarding EBUS procedure frequency, 28.9% performed 1 to 2 procedures weekly, and 13.6% performed more than 10. When asked about the need for needle change between different N2 stations, 20.7% saw it as necessary, 33.2% disagreed, and 17.4% considered it necessary in some cases. Although 38.1% considered changing the needle at least sometimes, only 5.5% reported actually doing so. The main barriers were costs (68.3%) and lack of evidence (31.3%). Those against needle change cited the belief that it does not affect results (58.2%), lack of evidence (54.2%), and other factors (4.5%), with many considering flushing the needle sufficient. Free-text responses indicated a lack of knowledge or implementation of TNM-9 in some centers. CONCLUSION: Opinions on implementing TNM-9 are inconsistent, within the IP community, particularly regarding needle change for different N2 stations. Education, reliable data, and consensus guidelines are needed.