Diagnostic accuracy and safety of endoscopic ultrasound-guided fine needle biopsy for evaluating mediastinal pathologies

doi:10.4253/wjge.v18.i2.113699

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World Journal of Gastrointestinal Endoscopy

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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World J Gastrointest Endosc. Feb 16, 2026; 18(2): 113699
Published online Feb 16, 2026. doi: 10.4253/wjge.v18.i2.113699

Diagnostic accuracy and safety of endoscopic ultrasound-guided fine needle biopsy for evaluating mediastinal pathologies

Masood Muhammad Karim, Syedda Ayesha, Abdul Hadi Shahid, Muhammad Salman, Danaish Kumar, Zeeshan Uddin, Adeel Ur Rehman

Masood Muhammad Karim, Syedda Ayesha, Adeel Ur Rehman, Section of Gastroenterology, Department of Medicine, Aga Khan University, Karachi 74800, Sindh, Pakistan

Abdul Hadi Shahid, Muhammad Salman, Danaish Kumar, Medical College, Aga Khan University, Karachi 74800, Sindh, Pakistan

Zeeshan Uddin, Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Sindh, Pakistan

Co-first authors: Masood Muhammad Karim and Syedda Ayesha.

Co-corresponding authors: Masood Muhammad Karim and Adeel Ur Rehman.

Author contributions: Karim MM and Rehman AU contribute equally to this study as co-corresponding authors. Karim MM and Ayesha S contribute equally to this study as co-first authors. Karim MM, Salman M, Ayesha S, and Kumar D contributed to structuring the manuscript; Karim MM, Ayesha S, and Shahid AH contributed to the project’s conception and design; Karim MM played a significant role in identifying the topic, providing valuable insights into the data; Ayesha S, Shahid AH, Salman M, and Kumar D contributed to collecting and cleaning data; Shahid AH conducted a literature search and wrote the manuscript; Salman M is interpreting the findings; Kumar D assisted in conducting a literature search; Uddin Z played a substantial role in interpreting the findings of fine-needle biopsy and histological slides, and proofreading the manuscript; Rehman AU supervised the project, provided a critical review, made final edits, and ensured its accuracy and clarity with his expertise.

Institutional review board statement: This study was reviewed and approved as an exemption by the Aga Khan University Hospital-Ethics Review Committee, with ethical code number No. 6874-25427.

Informed consent statement: Informed consent from patients was exempted in this study, as approved by the institutional ethical review committee, because the study did not involve any direct human interaction and utilized data obtained after each patient had provided written consent for treatment. Furthermore, all patient identifiers were removed during data entry, and patient confidentiality was fully maintained.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: The datasets generated and/or analyzed during the current study are not publicly available owing to confidentiality and institutional ethical policies, but can be obtained from the corresponding author upon reasonable request.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Adeel Ur Rehman, Assistant Professor, Section of Gastroenterology, Department of Medicine, Aga Khan University, Karachi 74800, Sindh, Pakistan. adeelur.rehman@aku.edu

Received: September 2, 2025
Revised: October 2, 2025
Accepted: December 17, 2025
Published online: February 16, 2026
Processing time: 155 Days and 19.5 Hours

Abstract

BACKGROUND

The mediastinum comprises vital anatomical structures and can be affected by diverse benign and malignant pathologies. Imaging modalities such as computed tomography, magnetic resonance imaging, and positron emission tomography assist in initial evaluation, but histopathological confirmation remains the diagnostic gold standard. Endoscopic ultrasound (EUS) enables real-time, minimally invasive sampling of mediastinal lesions. EUS-guided fine needle biopsy (FNB) demonstrated high diagnostic accuracy with a favourable safety profile. Despite its established utility in high-income settings, data on the role of EUS in evaluating mediastinal pathologies in low- and middle-income countries, such as Pakistan, remain limited.

AIM

To assess the diagnostic yield of EUS-guided FNB in evaluating mediastinal pathologies and its role in guiding management in low- and middle-income countries.

METHODS

This single-centre retrospective study was conducted at Aga Khan University Hospital, Karachi, from June 2020 to June 2024, involving adults (≥ 18 years) who underwent EUS-guided FNB for mediastinal pathology. Franseen needles with capillary suction were used without rapid on-site evaluation, yielding adequate histopathological samples in all cases. Data included demographics, radiological, procedural, and histopathological details, treatment, and outcomes. Statistical analysis was performed using Statistical Package for the Social Sciences version 23, with receiver operating characteristic curve analysis used to assess the diagnostic performance of EUS-guided FNB.

RESULTS

A total of 77 patients (mean age: 54.4 ± 14.1 years; 55.8% male) underwent EUS-guided FNB for mediastinal pathology. Most (81.8%) were symptomatic, with lymphadenopathy or masses mostly detected on computed tomography (79.2%). Adequate tissue diagnosis was achieved in 94.8%; 41.6% were malignant. EUS-FNB showed 88.9% (95% confidence interval: 74.7-95.6) sensitivity, 100% (95% confidence interval: 91.4-100) specificity, and an area under the curve of 0.94. Malignant cases had significantly larger lymph nodes (2.3 ± 0.9 cm vs 1.57 ± 0.6 cm, P = 0.009) and masses (median 7.8 cm vs 4.2 cm, P = 0.001). Most EUS procedures (96.1%) were performed using a 22G needle. The mean number of needle passes was 2.1 ± 0.8. No post-procedure complications occurred. Common diagnoses included reactive lymphoid tissue (20.8%), tuberculosis (14.3%), and lymphoma (11.7%). Conservative therapy was the most common treatment (28.6%). Overall, 68.8% survived and 13.0% died.

CONCLUSION

EUS-guided FNB is a highly accurate and safe modality for diagnosing mediastinal pathologies, offering excellent diagnostic yield without procedure-related complications and effectively guiding management of both benign and malignant cases.

Keywords: Mediastinal mass; Mediastinal lymphadenopathy; Mediastinal lesion; Endoscopic ultrasound-guided fine needle biopsy; Malignancy; Diagnostic yield; Minimally invasive diagnosis and low- and middle-income countries

Core Tip: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is a minimally invasive technique that enables accurate tissue sampling of mediastinal lesions. In this single-centre study from Pakistan, EUS-FNB demonstrated excellent diagnostic performance, with 94.8% diagnostic yield, 88.9% sensitivity, and 100% specificity, while maintaining a strong safety profile without procedure-related complications. The study highlights the value of EUS-FNB in guiding management of both benign and malignant mediastinal pathologies and addressing a critical evidence gap in low- and middle-income country settings, where data remain limited.