Affiliations: Harbor Hospital Baltimore, MD,
Beth Israel Deaconess Medical Center, Boston, MA,
Thoraxklinik, Heidelberg, Germany
Correspondence to: Ko-Pen Wang, MD, FCCP, Harbor Hospital, Chest Diagnostic Center, 3001 S Hanover St, Baltimore, MD 21225; e-mail: firstname.lastname@example.org
I read the article “Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy in Fluoroscopically Invisible Solitary Pulmonary Nodules” by Herth et al (January 2006)1 with interest.
In consideration of the outcomes of this article, several questions arose, as follows:
With lesion size being 1.4 to 3.3 cm, why were lesions not seen under fluoroscopy in 54 of 138 patients? Were they entirely indiscernible or somewhat visible?
The authors noted that the “suspected area” was approached by a catheter with an ultrasound probe. Was fluoroscopy used in any way during the procedure? Why was the suspected area not investigated initially by obtaining the four to six specimens without endobronchial ultrasound, including cytology?
Six apical lesions from both upper lobes were not found to be abnormal by ultrasound. Was this due to the fact that the catheter and ultrasound probe were not able to reach the suspected area?
The design of this study cannot result in any of the following potential recommendations:
Replace the conventional method. The new method is better, safer, and more accurate. It should be used in all patients.
The new method should be additive to the conventional method. It increased the yield in some circumstances and can be used in selected cases.
This new technique is neither able to replace nor to be added to the conventional method.
The technology for diagnosing these lesions has evolved over the past several decades.2–4 The major determining factor for diagnostic yield is whether the sampling device can reach the lesion or get close to it, confirming whether the lesion is reached or not by any means beyond fluoroscopy before sampling is of great interest.5 At least it might have the “ROSE” (rapid on-site cytologic evaluation) effect with lesser specificity.
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
We thank Dr. Wang for his thoughtful comments1regarding our recent study (January 2006))2 showing the benefit of endobronchial ultrasound guidance for the transbronchial biopsy of solitary pulmonary nodules that are not visible on standard fluoroscopy.
In answer to the questions posed, we offer the following comments: the lesions were not visible at all during the procedure, which is certainly a well-known problem for most bronchoscopists. The suspected area was determined as the most likely lobe and segment from the available static imaging for each patient. Also, the lesions in the upper lobes that Dr. Wang is referring to were not found to be normal but rather could not be identified. This may represent a technical problem, as all of those lesions were in the apical segments.
Our article convincingly showed that in this particular circumstance the addition of endobronchial ultrasound to conventional bronchoscopy (not the replacement) can be very helpful and certainly can be recommended. It avoids aborting an otherwise nonpromising bronchoscopy by providing an acceptable yield, does not expose the patient to unnecessary radiation, and is less invasive than primary surgical procedures.
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