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Correspondence |

Endobronchial Ultrasound and Esophageal UltrasoundEndobronchial and Esophageal Ultrasounds: Just Because We Can, Does Not Necessarily Mean We Should FREE TO VIEW

Ko Pen Wang, MD, FCCP; David Feller-Kopman, MD, FCCP; Atul Mehta, MD, FCCP; Malay Sharma, MD; Lonny Yarmus, MD, FCCP
Author and Funding Information

From the Department of Interventional Pulmonology (Drs Wang, Feller-Kopman, and Yarmus), The Johns Hopkins Hospital; the Department of Pulmonology (Dr Mehta), Cleveland Clinic; and the Department of Gastroenterology (Dr Sharma), Jaswant Rai Speciality Hospital.

Correspondence to: Ko Pen Wang, MD, FCCP, Department of Interventional Pulmonology, Johns Hopkins Hospital, 1830 E Monument St, 5th Floor, Baltimore, MD 21205; e-mail: kopenwang@yahoo.com


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Feller-Kopman has received consulting fees from Olympus America, Inc. The remaining authors have reported that no conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(1):271-272. doi:10.1378/chest.11-0171
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To the Editor:

In the excellent studies by Herth et al1 and Hwangbo et al2 and the editorial by Annema et al3 in a recent issue of CHEST (October 2010), the authors, who are leading experts and pioneers in the development of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed that a combined approach yields better results in the staging of lung cancer. Because the esophagus is a long, tubular structure without clearly identifiable endoscopic landmarks, lymph nodes adjacent to it may be difficult to locate during transesophageal ultrasound needle aspiration (TENA). Fluoroscopy-guided TENA has been used to sample lymph node stations 4L, 5, 7, and 8, and when combined with conventional transbronchial needle aspiration (TBNA), reports indicate no increase in diagnostic yield.4

Using the International Association for the Study of Lung Cancer staging system, station 8 is bordered by the right lower lobe bronchus all the way down to the diaphragm. The portion medial to the right lower lobe bronchus can be reached by TBNA. According to the International Association for the Study of Lung Cancer, 4L is lateral to the left tracheal wall starting from the upper border of the aortic arch end to the upper rim of the left pulmonary artery, and the station 5 aorta-pulmonary window node is found between the lower border of the aortic arch and upper rim of the left pulmonary artery but lateral to the ligamentum arteriosum.5 Both 4L and 5 are frequently involved together and are difficult to separate, so 4L/5 nodes are often used synonymously. Strictly the aorta-pulmonary window lymph node is the portion of the lymph node far lateral to the pulmonary ligamentum arteriosum beyond the subaortic area (station 5/6), which traditionally is not accessible by TBNA.6

In the article by Herth et al,1 only three exclusively positive cases are obtained by TENA from station 2L, 10L, and 7, which all could be sampled by TBNA. In the second article, by Hwangbo et al,2 all three exclusive positive cases determined by TENA were from station 5. No station 8 or 9 nodes contributed to an increase in diagnostic yield by TENA. In the future we will likely be required to justify the cost of TBNA and to provide the best value to the patient and health-care system for procedures such as TBNA. Nothing can replace the training and the skill. The authors performed EBUS-TBNA and TENA under IV sedation, without an on-site cytologic evaluation and outside the operating room, which is a giant step. A similar study to compare standard TBNA with EBUS-TBNA by those skillful experts is encouraged.7

As interventional pulmonologists, we must use our skills with judgment for the patient’s benefit. Both EBUS-TBNA and EUS-TENA have been promoted as a first-line procedure for the staging of lung cancer. The medical literature has shown both procedures have a yield equal to mediastinoscopy. Mediastinoscopy and EUS-FNA are complementary procedures. EBUS-TBNA and EUS-FNA are potentially competitive procedures. Each can accomplish the intended goal. EUS-FNA is a much more tolerable procedure for patients. EBUS-TBNA has the most accessibility to the mediastinum and hilar lymph nodes.

We agree that EBUS-TENA should be used only in circumstances when the lymph node stations are difficult or are not accessible by TBNA. If these groups of lymph nodes are the only lymph nodes involved, there is no need for EBUS-TBNA, and the patient can go through EBUS-TENA or EUS-FNA directly.

The value of these two studies is not only about combining EBUS-TBNA and TENA; they have also given us a valuable guide among the many alternative procedures for the staging of lung cancer. For that we are grateful for their contribution.

Herth FJF, Krasnik M, Kahn N, Eberhardt R, Ernst A. Combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest. 2010;1384:790-794. [CrossRef] [PubMed]
 
Hwangbo B, Lee G-K, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;1384:795-802. [CrossRef] [PubMed]
 
Annema JT, Rabe KF. Endosonography for lung cancer staging: one scope fits all? Chest. 2010;1384:765-767. [CrossRef] [PubMed]
 
Wang KP, Turner JF. TBNA versus TENA in the diagnosis and staging of bronchogenic carcinoma: a comparative study. J Bronchol. 2007;144:246-250. [CrossRef]
 
Sharma M, Arya CL, Somasundaram A, Rameshbabu CS. Techniques of linear endobronchial ultrasound imaging. J Bronchol Intervent Pulmonol. 2010;172:177-187. [CrossRef]
 
Kim D, Browning RF, Wang KP. Transbronchial needle aspiration (TBNA) using and extended length needle under fluoroscopic guidance for accessing the lateral aortopulmonary window (A-P Window). CHEST Web site.http://meeting.chestjournal.org/cgi/content/abstract/134/4/c25002.Accessed February 8, 2011.
 
Wang KP, Browning RF. Transbronchial needle aspiration with or without endobronchial ultrasound. Thoracic Cancer. 2010;12:87-93. [CrossRef]
 

Figures

Tables

References

Herth FJF, Krasnik M, Kahn N, Eberhardt R, Ernst A. Combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest. 2010;1384:790-794. [CrossRef] [PubMed]
 
Hwangbo B, Lee G-K, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;1384:795-802. [CrossRef] [PubMed]
 
Annema JT, Rabe KF. Endosonography for lung cancer staging: one scope fits all? Chest. 2010;1384:765-767. [CrossRef] [PubMed]
 
Wang KP, Turner JF. TBNA versus TENA in the diagnosis and staging of bronchogenic carcinoma: a comparative study. J Bronchol. 2007;144:246-250. [CrossRef]
 
Sharma M, Arya CL, Somasundaram A, Rameshbabu CS. Techniques of linear endobronchial ultrasound imaging. J Bronchol Intervent Pulmonol. 2010;172:177-187. [CrossRef]
 
Kim D, Browning RF, Wang KP. Transbronchial needle aspiration (TBNA) using and extended length needle under fluoroscopic guidance for accessing the lateral aortopulmonary window (A-P Window). CHEST Web site.http://meeting.chestjournal.org/cgi/content/abstract/134/4/c25002.Accessed February 8, 2011.
 
Wang KP, Browning RF. Transbronchial needle aspiration with or without endobronchial ultrasound. Thoracic Cancer. 2010;12:87-93. [CrossRef]
 
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