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Armin Ernst, MD, FCCP; Felix J. F. Herth, MD, FCCP; Raplf Eberhardt, MD; Mark Krasnik, MD
Author and Funding Information

Affiliations: Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA,  Thoraxklinik am Universitätsklinikum Heidelberg, Germany,  Gentofte University Hospital Copenhagen, Denmark

Correspondence to: Armin Ernst, MD, FCCP, BIDMC/ Harvard Medical School, PCCM, Interventional Pulmonology, Beth Israel Deaconess Med Center, 330 Brookline Ave, Boston, MA 02215; e-mail: aernst@bidmc.harvard.edu


The authors have received equipment on loan from Olympus Corporation. The Harvard University Continuing Medical Education office has received unrestricted grants from Olympus America for course activities.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2008;134(3):672-673. doi:10.1378/chest.08-1404
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To the Editor:

We wish to thank Dr. Detterbeck for his thoughtful comments and compliments.1 We obviously do agree that endobronchial ultrasound (EBUS)-guided transbronchial needle aspirations (TBNAs) have become a most valuable tool in the diagnosis and staging of lung cancer patients, especially in patients with enlarged lymph nodes.

Dr. Detterbeck's criticisms and questions of our study that was recently published in CHEST (April 2008)2 addressing the usefulness of EBUS-guided TBNA in cancer patients with a radiologically normal mediastinum are as follows: (1) how the analysis was performed (ie, per patient or per node); (2) the issue of the inclusion of N1 nodes in our study; (3) whether invasive staging in our patients was required; (4) the role of EBUS-guided TBNA in the context of emerging video mediastinoscopy; and (5) what additional bronchoscopic procedures could be of value when performing EBUS. We will address these issues in order.

  1. The analysis was conducted on a per-patient basis and was clearly reported as such.

  2. We agree that there may be some confusion about why we included N1 nodes. The title of the article could suggest that only mediastinal nodes were biopsied, but it is clearly stated that the mediastinum had to be radiologically negative and that nodal biopsies were not specifically limited to those stations. It was stated in the “Material and Methods” section that N1 nodes were biopsied. We did not feel it was ethical to perform endoscopic staging without including the N1 stations with a procedure that made them easily accessible. Considering the impending changes in the TNM classification and the realization that patients with bulky N1 stage tumors have outcomes comparable to those of patients with N2 tumors may in fact make it very important to include hilar staging in the future.

  3. Whether staging is required is a valid discussion, and we respect Dr. Detterbeck's opinion. If, on the other hand, with the help of a minimally invasive low-risk procedure these patients with positive nodes can be identified, then we think it is eminently justified and is what we would want for our family members. To quote Dr. Detterbeck: “We take care of individuals, not nodes” (or cohorts for that matter).

  4. The advent of video mediastinoscopy is exciting. We are surprised, however, that Dr. Detterbeck, who cautioned readers to use restraint in technology assessment, was so quick to endorse this technology. The literature about its added benefit is very limited and has come from very few centers. Blanket statements or recommendations cannot yet be made due to a lack of good evidence. The quoted study3 is not an original investigation, and we would refer to an original study, such as, for example, the article by Witte et al.4

  5. Additional procedures can certainly be indicated and beneficial, such as, for example, an attempt at biopsy of a peripheral lesion, be it a primary or secondary one. A malignancy is not always the leading potential diagnosis, and transbronchial biopsies as well as endobronchial biopsies may be performed to rule out other diseases, such as, for example, sarcoidosis.

Again, we thank Dr. Detterbeck for his thoughtful comments. It is through this kind of scientific discussion that data and opinions can be discussed and clarified.

Detterbeck FC. Please lead, but don't mislead. Chest. 2008;134:672. [PubMed] [CrossRef]
 
Herth FJF, Eberhardt R, Krasnik M, et al. Endobronchial ultrasound guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography normal mediastinum in patients with lung cancer. Chest. 2008;133:887-891. [PubMed]
 
Detterbeck F. Integration of mediastinal staging techniques for lung cancer. Semin Thorac Cardiovasc Surg. 2006;131:822-829
 
Witte B, Wolf M, Huertgen M, et al. Video-assisted mediastinoscopic surgery: clinical feasibility and accuracy of mediastinal lymph node staging. Ann Thorac Surg. 2006;82:1821-1827. [PubMed]
 

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References

Detterbeck FC. Please lead, but don't mislead. Chest. 2008;134:672. [PubMed] [CrossRef]
 
Herth FJF, Eberhardt R, Krasnik M, et al. Endobronchial ultrasound guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography normal mediastinum in patients with lung cancer. Chest. 2008;133:887-891. [PubMed]
 
Detterbeck F. Integration of mediastinal staging techniques for lung cancer. Semin Thorac Cardiovasc Surg. 2006;131:822-829
 
Witte B, Wolf M, Huertgen M, et al. Video-assisted mediastinoscopic surgery: clinical feasibility and accuracy of mediastinal lymph node staging. Ann Thorac Surg. 2006;82:1821-1827. [PubMed]
 
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