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Correspondence |

Complete Mediastinal and Hilar Lymph Node Staging of Primary Lung Cancer by Endobronchial Ultrasound: Moderate Sedation or General Anesthesia? FREE TO VIEW

Marcus P. Kennedy, MD; Yousef Shweihat, MD; Mona Sarkiss, MD; Georgie A. Eapen, MD
Author and Funding Information

Affiliations: University of Arkansas for Medical Sciences Little Rock, AR,  University of Texas MD Anderson Cancer Center Houston, TX

Correspondence to: Marcus P. Kennedy, MD, Assistant Professor, Pulmonary and Critical Care Medicine, 4301 W Markham St, #555, Little Rock, AR 72205-7199; e-mail: marcus.kennedy1@hse.ie


The authors have no conflicts of interest to disclose.

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(6):1350-1351. doi:10.1378/chest.08-1300
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To the Editor:

Herth et al1 have reemphasized the superiority of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) in staging non-small cell lung cancer in comparison to CT and positron emission tomography and pushed the boundary to stage I patients. In this group of patients, under general anesthesia, complete mediastinal and hilar node screening was performed with biopsy of lymph nodes (mean, 1.6 per patient) between 5 mm and 10 mm (mean, 7.9 ± 0.7 mm). In reference to their previous report,2 the authors comment that “there is no known difference in yield or patient tolerance if the procedure is performed under moderate sedation or general anesthesia.” However, the patient population studied in this previous report is different. These were patients with adenopathy not limited by size (mean size of lymph nodes sampled, 16 ± 3.6 mm; range, 8 to 32 mm), complete mediastinal and hilar lymph node screening was not performed, and fewer nodes were sampled (mean, 1.14 per patient). These three differences would lead to reduced time and increased simplicity of the procedure, making it more amenable to moderate sedation.

As more and more centers begin EBUS-TBNA programs, it is important that the procedure is performed in the correct environment and with realistic expectations of patients, operators, and equipment performance characteristics. If a consensus is reached that complete nodal staging is feasible and accurate with EBUS-TBNA, it may be more optimally performed under general anesthesia until the bronchoscopist feels comfortable in targeting these smaller lymph nodes in multiple stations in a conscious patient. We have recently described a safe option using propofol sedation with a laryngeal mask airway ventilation in the bronchoscopy suite that allows full access to the mediastinal lymph node stations.3 In contrast, EBUS-TBNA may be safely performed under conscious sedation in those patients with larger nodes without the requirement for complete lymph node staging.

Herth FJ, 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] [CrossRef]
 
Herth FJ, Eberhardt R, Vilmann P, et al. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax. 2006;61:795-798. [PubMed]
 
Sarkiss M, Kennedy M, Riedel B, et al. Anesthesia technique for endobronchial ultrasound guided fine needle aspiration of mediastinal lymph node. J Cardiothorac Vasc Anesth. 2007;21:892-896. [PubMed]
 

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References

Herth FJ, 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] [CrossRef]
 
Herth FJ, Eberhardt R, Vilmann P, et al. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax. 2006;61:795-798. [PubMed]
 
Sarkiss M, Kennedy M, Riedel B, et al. Anesthesia technique for endobronchial ultrasound guided fine needle aspiration of mediastinal lymph node. J Cardiothorac Vasc Anesth. 2007;21:892-896. [PubMed]
 
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