0
Correspondence |

ResponseResponse FREE TO VIEW

Jouke T. Annema, MD, PhD
Author and Funding Information

From the Department of Pulmonology, Leiden University Medical Center.

Correspondence to: Jouke T. Annema, MD, PhD, Department of Pulmonology C3-P, Albinusdreef 2, 2300 RC, Leiden, The Netherlands; e-mail: j.t.annema@lumc.nl


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential 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):272. doi:10.1378/chest.11-0657
Text Size: A A A
Published online

To the Editor:

In their comment, Dr Wang and colleagues raise the point that endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) should not always be performed just because they are available. How endosonography relates to other techniques and how it should be positioned in diagnostic and staging algorithms for patients with lung cancer are very relevant indeed.1 Important issues in that discussion are the ability to detect vs exclude mediastinal nodal spread, complication rate, cost-effectiveness, and patient preference for the various tests.

Ideally, patients with suspected lung cancer on CT imaging (PET scan) are diagnosed and staged in an accurate, safe, minimally invasive, and cost-effective way. Conventional or “blind” transbronchial needle aspiration (TBNA) has variable sensitivity in detecting nodal metastases (39%-78%), depending on the population studied and the experience of the operator.2 TBNA is good for confirming metastases, but not for excluding them, and should, therefore, be performed at initial bronchoscopy. A comparative study between TBNA and radial (not real-time) EBUS-guided TBNA was performed by Herth et al,3 who found that EBUS guidance significantly increased the yield of TBNA in all nodal stations except the subcarinal region.

EBUS and EUS have a similar (lower left paratracheal and subcarinal region) as well as a complementary diagnostic reach (for EBUS, right paratracheal and hilar regions; for EUS, lower mediastinum and aortopulmonary window). With EUS, identification of paraesophageal nodes occurs by relating them to vascular structures such as the aorta, pulmonary artery, and left atrium; fluoroscopy is not indicated.

In a randomized study, EUS and EBUS combined, followed by mediastinoscopy (in the absence of nodal metastases), had higher sensitivity in assessing mediastinal metastases than mediastinoscopy (94% vs 79%). Additionally, unnecessary thoracotomies were reduced by more than one-half.4 Therefore, mediastinal nodal tissue staging (after TBNA) should start with endosonography. Eleven patients needed to undergo mediastinoscopy after negative endosonography to detect one patient with N2 disease. Further studies should focus on predictors for false-negative endosonography findings, to identify which subset of patients should undergo additional staging.

Adequate training in TBNA, EBUS-TBNA, and EUS (with bronchoscope) fine-needle aspiration is essential; dedicated hands-on teaching and simulators may help achieve this goal. Even more important, however, is to assess the proper indication (ie, which technique to use for which patient); this, obviously, also applies to endosonography.

Annema JT, Rabe KF. Endosonography for lung cancer staging: one scope fits all? Chest. 2010;1384:765-767. [CrossRef] [PubMed]
 
Holty JE, Kuschner WG, Gould MK. Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis. Thorax. 2005;6011:949-955. [CrossRef] [PubMed]
 
Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial. Chest. 2004;1251:322-325. [CrossRef] [PubMed]
 
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;30420:2245-2252. [CrossRef] [PubMed]
 

Figures

Tables

References

Annema JT, Rabe KF. Endosonography for lung cancer staging: one scope fits all? Chest. 2010;1384:765-767. [CrossRef] [PubMed]
 
Holty JE, Kuschner WG, Gould MK. Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis. Thorax. 2005;6011:949-955. [CrossRef] [PubMed]
 
Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial. Chest. 2004;1251:322-325. [CrossRef] [PubMed]
 
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;30420:2245-2252. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543