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Estimating False Multistation N2 Upstaging From Cross-Contamination During EBUS-TBNA Without ROSE: Insights From a

Ala-Eddin S Sagar^1,2, Sami M Bennji³, Ihab Alshelli¹

¹Department of Medicine, King Faisal Specialist Hospital and Research Centre, Madinah.

Journal of Bronchology & Interventional Pulmonology

|May 25, 2026

Summary

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The risk of false N2b upstaging during endoscopic ultrasound (EBUS) staging without ROSE is low but significant, particularly in central tumors. Routine needle changes offer minimal benefit, suggesting selective strategies for EBUS staging without ROSE.

Area of Science:

Pulmonology
Oncology
Medical Imaging

Background:

The 9th TNM edition differentiates single-station (N2a) from multistation (N2b) disease, raising concerns about lymph node cross-contamination during EBUS staging without ROSE.
The clinical significance and probability of this cross-contamination remain uncertain.

Purpose of the Study:

To estimate the theoretical upper bound of false N2b upstaging.
To determine the number of needle changes needed to prevent a single false upstage during EBUS staging without ROSE.

Main Methods:

A Monte Carlo decision model simulated mediastinal staging in 100,000 virtual patients.
Model parameters included occult N2 prevalence, single-station involvement probability, and contamination rates.
Sensitivity analyses explored variations in contamination rate, single-station probability, and sampling order.

Keywords:

EBUS Monte Carlo cross contamination lung cancer staging

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Main Results:

False upstaging in central cN0 disease ranged from approximately 0.5% to 1.4%.
Preventing one false upstage required 250-350 additional needle changes for central cN0 and over 1000 for peripheral cN0.
Contamination rate, single-station probability, and sampling order had comparable influences.

Conclusions:

The risk of spurious upstaging during EBUS staging without ROSE is small but not negligible, especially for central cN0 and cN1 tumors.
Routine needle changes between N2 stations offer minimal benefit when ROSE is unavailable.
Selective strategies targeting high-risk scenarios may optimize accuracy and efficiency in resource-limited settings without ROSE.