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Correspondence |

Please Lead, But Don't Mislead FREE TO VIEW

Frank C. Detterbeck, MD
Author and Funding Information

Yale University New Haven, CT

Correspondence to: Frank C. Detterbeck, MD, Yale University, FMB 128, Department of Thoracic Surgery, 330 Cedar St, New Haven, CT 06520-8062; e-mail: frank.detterbeck@yale.edu


The author has no significant conflicts of interest with any companies/organizations whose products or services are relevant to this article.

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. doi:10.1378/chest.08-0973
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To the Editor:

Herth and colleagues deserve much credit for leading the way in carefully establishing the role of endobronchial ultrasound (EBUS) in the staging of lung cancer. They have been part of developing the technology and clearly have established the value of this procedure in a broader group of patients, most of which had enlarged lymph nodes.1 In a recent article,2 they have continued to lead the way in studying the role of EBUS in another cohort, those with small nodes (ie, ≤ 1 cm and negative positron emission tomography scan findings). This was an important article that further established the value of this procedure in experienced hands.

Unfortunately, some details of the study are vague and potentially misleading. Although the techniques are described in detail, the analyses are not. It is unclear whether the analysis was calculated per patient or per node. A per-node calculation would artificially elevate all of the test performance measures, and would be inappropriate because we care for patients and not individual nodes. The article implies that it addresses the value of EBUS in staging the mediastinum, but the analysis lumps stage N1 and N2 nodes together. This is not appropriate, and is not consistent with how we have approached preoperative staging for lung cancer. If I have added up the numbers correctly, the results of EBUS for mediastinal staging are even better: sensitivity, 100%; specificity, 100%; and false-negative and false-positive result rates of 0. It is not clear why the authors would choose to report on stage N1 and N2,3 nodes combined.

The incidence of positive stage N2 nodes (6%) is a little higher than has been reported in other series (average, 3%) of patients with negative CT and positron emission tomography scan findings.3 Nevertheless, it is fairly low. Whether 6% is high enough to justify performing this test on all patients is a matter of judgment, particularly since all of the patients went on to undergo surgical procedures. I would argue that the rate of mediastinal node involvement is low enough that invasive staging of any sort is hard to justify in this patient cohort.

There clearly are some advantages to EBUS over mediastinoscopy. However, modern mediastinoscopy, using a videomediastinoscope, provides excellent access to posterior subcarinal nodes, and in fact allows a complete lymphadenectomy to be performed.4 It is also not clear that EBUS performed under general anesthesia is any less costly than mediastinoscopy, which is also routinely performed on an outpatient basis, at least in North America. The advantage that EBUS allows “additional pulmonary procedures” to be performed is rather vague. What additional procedures? Are they really of value in these patients, or is this just a theoretical statement?

These issues are raised not to diminish the value of this article; in fact, I wish to enhance it. However, the authors should be careful to be fair in their assessment of EBUS and not overplay the benefits. The simple facts speak well enough.

Detterbeck F, Jantz M, Wallace M, et al. Invasive mediastinal staging of lung cancer: an ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132suppl:202S-220S. [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]
 
Meyers BF, Haddad F, Siegel BA, et al. Cost-effectiveness of routine mediastinoscopy in computed tomography- and positron emission tomography-screened patients with stage I lung cancer. J Thorac Cardiovasc Surg. 2006;131:822-829. [PubMed]
 
Detterbeck F. Integration of mediastinal staging techniques for lung cancer. Semin Thorac Cardiovasc Surg. 2007;19:217-224. [PubMed]
 

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References

Detterbeck F, Jantz M, Wallace M, et al. Invasive mediastinal staging of lung cancer: an ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132suppl:202S-220S. [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]
 
Meyers BF, Haddad F, Siegel BA, et al. Cost-effectiveness of routine mediastinoscopy in computed tomography- and positron emission tomography-screened patients with stage I lung cancer. J Thorac Cardiovasc Surg. 2006;131:822-829. [PubMed]
 
Detterbeck F. Integration of mediastinal staging techniques for lung cancer. Semin Thorac Cardiovasc Surg. 2007;19:217-224. [PubMed]
 
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