Pioneering endobronchial ultrasound-guided transbronchial needle aspiration in North Africa: Results from a prospective Moroccan case series.

BACKGROUND: Mediastinal and hilar lymphadenopathy pose a diagnostic challenge, especially in regions with a high prevalence of tuberculosis (TB) and lung cancer. OBJECTIVES: To evaluate the feasibility, safety and diagnostic performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in a Moroccan centre. METHODS: This prospective observational study evaluated patients undergoing EBUS-TBNA from December 2021 to March 2025. Samples were analysed using rapid on-site cytology, cell block histology, and additional tests including GeneXpert and molecular profiling when indicated. Final diagnoses were established using a composite reference standard based on surgical pathology or clinical follow-up. RESULTS: A total of 180 patients were included, of whom 104 were men and 76 women (sex ratio 1.37), with a mean age of 61 years. EBUS TBNA was performed for primary lung cancer diagnosis or staging in 57.2% of cases, for evaluation of suspected mediastinal metastases in 24.4%, and for investigation of unexplained mediastinal lymphadenopathy in 18.3%. The procedure provided a diagnosis in 91.5% of patients, yielding 151 true positives and 12 true negatives (17 false negatives), corresponding to a sensitivity of 91% and a specificity of 100%, with no complications reported. Final diagnoses included 103 lung cancers, 39 metastatic carcinomas, 5 lymphomas, 5 cases of sarcoidosis and 3 cases of TB, with only 9 patients subsequently requiring mediastinoscopy. CONCLUSION: In TB-endemic regions, EBUS-TBNA is safe and effective for mediastinal evaluation, providing reliable diagnoses for both malignant and granulomatous diseases. Its implementation is justified as a first-line modality in resource-limited settings. STUDY SYNOPSIS: What the study adds. This prospective case series reports one of the first and largest North African experiences with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in a tuberculosis-endemic setting. Among 180 patients evaluated for mediastinal and hilar lymphadenopathy, EBUS-TBNA demonstrated high diagnostic performance and excellent safety, while enabling molecular and microbiological analyses when required.Implications of the findings. These findings support the use of EBUS-TBNA as a first-line minimally invasive diagnostic modality in resource-limited settings, with the potential to reduce the need for surgical mediastinoscopy and facilitate earlier diagnosis and management of both malignant and granulomatous diseases.