ERS/ESGE/ESTS clinical practice guidelines on endobronchial and oesophageal endosonography for the diagnosis and staging of lung cancer

Background: In lung cancer, adequate treatment selection relies on accurate diagnosis and staging. Tissue sampling is generally indicated. This guideline explores the role of endosonography via the major airways (EBUS-TBNA) and oesophagus (EUS-FNA). EUS-FNA can also be performed using an EBUS-scope (EUS-B-FNA). Methods: Task force members were selected from ERS (European Respiratory Society), ESGE (European Society of Gastrointestinal Endoscopy), and ESTS (European Society of Thoracic Surgeons). Twelve guideline questions were formulated. Systematic literature searches were performed in MEDLINE and Embase (final searches: Apr-2025). GRADE methodology was applied for assessing the certainty of evidence and developing recommendations. Results: In (suspected) non-small cell lung cancer (NSCLC), endosonography is recommended over mediastinoscopy for mediastinal nodal tissue staging. Systematic staging is suggested over targeted staging as the minimal standard. Ideally, combined EBUS-TBNA+EUS(-B)-FNA is performed instead of EBUS-TBNA alone. Add-on mediastinoscopy after a negative endosonography is not recommended. Endosonography is suggested over mediastinoscopy for re-staging after induction therapy. EBUS-TBNA and EUS(-B)-FNA are recommended for centrally located tumours adjacent to the major airways/oesophagus. Both EUS-B-FNA and EUS-FNA are suggested for left adrenal gland analysis. It is suggested that competence is acquired in a simulation-based environment and ensured using valid assessment methods. 21G/22G TBNA needles are considered the standard; there is insufficient evidence to support the structural use of alternative needle sizes/types or cryobiopsy. EBUS-TBNA has high suitability rate for PD-L1 assessment. Conclusions: Endobronchial and oesophageal endosonography provide accurate and minimally invasive tests for the diagnosis and staging of lung cancer.