ebus  echobronchoscopy is a relatively recent examination method , introduced in clinical practice in 1992 . it is a combination of echography and bronchoscopy , allowing the physician to directly examine the tumors and adenopathies situated next to the airways , both extrabronchial and extratracheal ones , inaccessible to traditional bronchoscopy . a real time , ultrasound guided sampling of cytology and histopathology specimens for diagnostic purposes is also possible with fine needle aspiration . there are 2 types of ebus : - radial probe ebus ( rp - ebus )  for evaluation and bioptic sampling of peripheral tumors - convex probe ebus ( cp - ebus )  for evaluation and sampling of tumors and lymph node stations 2,3,4,7,10,11 outside of the bronchial tree but right next to the bronchial wall . a doctor who wishes to perform ebus should be familiar with mediastinal anatomy , the characteristics of ultrasound , and must have a good bronchoscopy and echography knowledge . main indications of ebus - tbna : - diagnostic and staging of non - small cell lung cancer ( nsclc ) - evaluation of mediastinal tumors ( ex : lymphomas ) - evaluation of mediastinal adenopathies of unknown etiology ( sarcoidosis , lymph node metastasis of a known tumor ) . the contraindications of ebus are similar to the contraindications of bronchoscopy and they include : - myocardial infarction - life threatening arrhythmias - poorly controlled heart insufficiency - uncooperative patient - high risk for hemorrhage : current anticoagulation therapy , coagulopathies , thrombocytopenia , high urea and creatinine levels . the examination can be performed in local anesthesia with 2% xylocaine , under conscious sedation or under general anesthesia with laryngeal mask or endotracheal tube sized at least 8 . the introduction of ebus tbna has brought important changes to the staging and diagnostic strategy of lung cancer . the introduction of ebus has changed this paradigm , ebus being a minimally invasive method with a cost / efficiency value slightly superior to mediastinoscopy . we present the experience of the bronchoscopy department of the pulmonology clinic of cluj - napoca with ebus - tbna as a tool for the diagnosis and staging of tumors in contact with the bronchial wall and mediastinal and hilar adenopathies of unknown etiology . during the period august 2014 january 2016 we examined 152 patients with no direct or indirect signs of lung tumor at traditional bronchoscopy . the examinations were carried out with a fuji echoendoscope , under general anesthesia with laryngeal mask . all patients underwent fine needle aspiration ( tbna ) for diagnosis after rigorous evaluation , measuring and description of the visualized lymph node stations . ebus preoperative staging for non - small tumors has been performed in 4 patients , starting with n3 contralateral to the tumor , followed by n2 , n1 . an experienced cytopathologist was part of the team and she was present in the operation room where she performed the quick - diff rapid coloration and the cytological examination . the real - time examination provided us a direct feedback on the quality of the sampled tissue , it confirmed that the tissue was indeed taken from a lymph node ( > 30% lymphocytes from nucleated cells ) or from the tumor , and identified within 13 minutes the existence of tumoral cells or infirmed the supposition of a malignant disease . these results were confronted with the results of the histopathological examination with immunohistochemical staining , performed by a laboratory of reference . the distribution of the patients according to their presumed diagnostic was as follows : adenopathies of unknown etiology : 25 patients ; suspect of lung tumor : 81 patients ; sarcoidosis : 28 patients ; suspect of lymphoma : 2 patients ; lung or bone metastasis of unknown origin : 6 patients ; unknown adenopathies with a documented tumor ( breast , prostate , cervical , renal ) in personal history : 10 patients . the average age of our patients was 54.43 years and 64% came from urban and 36% from rural background . the results of the onsite examination rose showed a positive diagnostic rate of 59.2% from the total number of the patients from our study , for 62 patients the results were negative , and for 90 patients we could make up a diagnosis on the spot . regarding the diagnostic yield of tumors : in 97 patients suspected of having primary lung tumor or other tumors we could confirm the existence of tumoral cells on site with microscopic examination rose in the case of 79 patients , representing 81% of the patients . ebus - tbna brought the final histological confirmation ( tumors , sarcoidosis , limfoma ) in 82.8% of the cases . a tumor confirmation was obtained in 61.8% of the total number of patients and in 95% in the case of the patients who were suspected of having tumor . the histological profile of the cases was the following : adenocarcinoma : 29 patients ; small cell lung cancer : 19 patients ; squamous cell carcinoma 8 patients ; non - small cell carcinoma : 18 patients ; metastatic carcinoma : 5 patients ( 1 metastases from prostate carcinoma , 2 metastases from renal carcinoma,1 metastasis of melanoma and 1 metastasis of colonic carcinoma ) . we present one of our clinical cases to illustrate a clinical and imaging pattern of ebus indication and to emphasize the importance of this method for the diagnosis in pulmonology . a 38 year old female , non - smoker , with no personal or familiar medical history , with professional exposure to toxic substances ( worker in a factory of car cables ) is admitted for intense precordial pain of a sudden onset , without radiation . electrocardiogram showed sinus rhythm , a heart rate of 90 b / min , intermediate qrs , inferior - lateral t waves . myocardial infarction was excluded by a normal coronarograpy while angio - computed tomography ( angio - ct ) excluded lung embolism ( no evidence of pulmonary emboli ) . however , the angio - ct showed a 2 cm suspicious nodule in the right lower lobe ( rll ) , lower from the bronchial bifurcation towards the basal segments , small bilateral pleural effusions , mainly in the right side , and multiple adenopathies : right interbronchial , subcarinal , barety space , right paratracheal , with dimensions varying up to 2.5 cm . at this moment we performed a traditional bronchoscopy which evidenced the following : no modifications of the trachea , slightly enlarged tracheal bifurcation , hypervascularization of the main bronchus . , we can choose from : mediastinoscopy , open lung biopsy , ebus - tbna . we pick the less invasive procedure available that can bring a rapid result : ebus with on - site cytodiagnostic . the ebus examination showed enlarged mediastinal and hilar lymph nodes , their size varying between 13 cm . the on - site cytological examination brought the following :  lymph node stations 7 , 11r : moderate cellularity , mainly made up of tumor cells , frequent red blood cells , rare eosinophils and polymorphonuclear cells . the tumor cells are medium sized , mononucleated , with excentric nucleus , one macronucleoli / nucleus , cytoplasmatic vacuoles . the conclusions of the cytological examination was of non - small cell carcinoma ( adenocarcinoma ) . the final histopathological examination with immunohistochemical staining concluded that the final diagnosis was ttf-1 positive adenocarcinoma of the lung . the next steps in order to offer our patient a proper staging and pre - therapeutic evaluation would have been a head and abdominal computed tomography ( for evaluation of possible brain / liver / abdominal metastasis ) , followed by referral to medical oncologist for chemotherapy , but an unfortunate complication occurred : bilateral infrapopliteal deep venous thrombosis diagnosed clinically and by echo - doppler . a proper diagnosis and staging of lung cancer is very important , as it is the key to treatment . computer tomography and pet - ct continue to play a key role in the diagnosis and staging of lung cancer . in order to achieve histological confirmation , which allows a modern cancer therapy , twenty years ago tissue samples from tumors localized in the mediastinum was obtained by mediastinoscopy or open lung biopsy with thoracotomy . the introduction of the minimally invasive method ebus has changed the diagnostic and staging methodology of lung cancer . the cost / efficiency rate is high , when compared with surgical procedures . the sensitivity of ct , pet - ct and ebus - tbna for lung cancer diagnosis and staging is 76.9% , 80% and 92.3% respectively according to a study by yasufuku et al . the specificity of the methods was 55.3% , 70.1% and 100% , and the diagnostic accuracy 60.8% , 72.5% and 98% . in our study the sensitivity of the method and diagnostic accuracy in lung cancer was 95 % confirmation from the total number of cancer suspicions . the accp s acquire registry has begun collecting and analyzing data on 1317 patients undergoing ebus at 6 hospitals ( all or nearly all were academic centers training fellows ) . ebus proved to be quite safe , indeed , with the following reported complications occurring within 24 hours : risk of pneumothorax with ebus alone : 0.2% , or 1 in 500 . in comparison the risk of pneumothorax after transbronchial biopsy was of : 2.7% , or 1 in 37 . the study reported seven pneumothorax complications of which 4 required tube thoracostomy and the others resolved without intervention . the risk of bleeding requiring intervention was reported at 0.2% , or 1 in 439 and one patient succumbed from bleeding ( 1 in 1317 or 0.08% ) . the overall 24-hour complication rate was 1.4% , but it was < 1% if transbronchial biopsy was not performed . about 1015% of lung cancers occur in non - smokers of which 2/3 are women . in case of young patients , lung cancer has a few particular characteristics : it appears in a large percent in women , the predominant histological type being adenocarcinoma , it is usually diagnosed in advanced stages and survival rate is similar to the one in case of older patients . the particular features of our case were the young age , lack of smoking history , atypical clinical presentation and the presence of a lung nodule accessible only by ebus , mediastinoscopy or thoracotomy , but not by traditional bronchoscopy . for example : was it a lung embolism , although it was refuted by angio - ct ? the ulterior onset of a deep venous thrombosis , most probably in the context of a paraneoplastic syndrome suggests a possible lung embolism not seen on ct , which can explain the initial symptoms ( sudden onset of severe chest pain ) . the m ( metastasis ) status is also not perfectly clear : the ct - based stage showed mx  but the bilateral pleural effusion of possible malignant origin could have classified it as m1 , stage iv . the influence of environmental factors : the patient was a factory worker , possibly exposed to : chrome , rubber , nickel , cadmium , carbon electrodes . according to the journal of thoracic disease , the exposure to chrome , nickel , cadmium and rubber derivatives has been proved to have carcinogenic effects in humans , and the carbon electrodes are possible to be carcinogens . a review of the literature shows that patients with lung adenocarcinoma have a 20x increased risk to have thrombophlebitis / deep venous thrombosis . young patients with adenocarcinoma of the lung are frequently diagnosed in advanced stages , stadium iv . according to journal of thoracic disease , regarding adenocarcinoma patients , the average time passed from first contact with a doctor until consultation by a respiratory specialist is of 27 days , and 23 more days are generally required to complete the investigations and have a final diagnosis . the unusual presentation form , the quick investigations and the availability of ebus - tbna allowed a very quick diagnosis . the total time from the first manifestation of the tumor ( with severe chest pain ) lead to emergency admission to hospital and start of the diagnostic pathways , leading to a definitive diagnosis of lung adenocarcinoma in just 12 days . the 3rd edition of the accp ( american college of chest physicians ) guidelines regarding lung cancer recommends the minimally invasive technique ebus as a gold standard for the diagnosis and staging of lung cancer with involvement of the n2 , n3 lymph node stations , before mediastinoscopy , thoracotomy or other more invasive techniques . in our case , regarding the cost - effectiveness of ebus compared with mediastinoscopy , gargoum et al . concluded that an ebus based diagnostic pathway results in cost effective patient management compared with traditional mediastinoscopy even in the first year of service . in a 2009 study from the uk , medford et al . also found that ebus can save health community costs , pointing out the need for new , more precise coding procedures for ebus to reflect the true value and difficulty of the procedure . our team has experienced the same problem : lack of proper procedure code for ebus - tbna , the available codes were those of standard bronchoscopy with biopsy or lymph node puncture . endobronchial ultrasound examination combined with fine needle aspiration ebus - tbna is a minimally invasive diagnostic and staging examination tool of the mediastinum . it is also well tolerated by patients , which is a major advantage , and grants ebus a top position among the diagnostic and staging methods of lung cancer . by combining the ebus technique with rose ( rapid on site cytological examination ) we can obtain a cytological confirmation on the examination site , during the examination . it is a valuable and cost efficient tool for the mediastinum and exo - bronchial tumors in contact with the bronchial wall . by examination of the mediastinal and hilar lymph node stations , ebus tbna is a quick staging tool for lung cancer , avoiding thoracotomies and mediastinoscopies , which are more invasive and with more risk for the patient . by the introduction of this method in our country one year ago , we can diagnose patients with lung and mediastinal tumors , which can not be diagnosed by traditional bronchoscopy .