Evidence of the usefulness of EBUS-FNA began to trickle in. Case series5,6 were reported that established several important advantages of this technology over standard TBNA. First, lymph node stations throughout the mediastinum and hilum could be visualized and accessed. Second, real-time visualization of the lymph node while obtaining a specimen was possible. Early efforts7 concentrated on enlarged lymph nodes (mean diameter, 1.6 cm). This led to prospective multicenter trials5 in patients with known or suspected lung cancer. More reports4,6,8 appeared in the literature that confirmed a high sensitivity (approximately 90%) in patients with enlarged mediastinal lymph nodes. Investigators9 began to push the envelope by utilizing EBUS-FNA to assess lymph nodes in patients with lung cancer and a radiographically normal mediastinum (node size range, 5 to 10 mm). The sensitivity, specificity, and negative predictive value remained high (92.3%, 100%, and 96.3%, respectively). Additionally, an unexpected cancer in a normal sized lymph node was diagnosed in one of six patients, thus avoiding a futile thoracotomy. The next logical step was to test this technology in patients with both negative CT scan findings and no detectable PET scan activity in the mediastinum.10 Again the technology stood up to the challenge with a reported sensitivity approaching 90% and an unexpected 9% prevalence of mediastinal metastasis, suggesting that EBUS-FNA is useful as a preoperative staging tool in all patients with lung cancer who are being considered for surgery.