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Correspondence |

Combined Imaging for Benign Mediastinal LymphadenopathyEndoscopic Ultrasound or Endobronchial Ultrasound: Endoscopic Ultrasonography First or Endobronchial Ultrasonography First? FREE TO VIEW

Malay Sharma, MD, DM
Author and Funding Information

From Gastroenterology, Jaswant Rai Speciality Hospital.

Correspondence to: Malay Sharma, MD, DM, Gastroenterology, Jaswant Rai Speciality Hospital, Opp Sports Stadium, Mawana Rd, Meerut, PIN-250 001, Uttar Pradesh, India; e-mail sharmamalay@hotmail.com


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(2):558-559. doi:10.1378/chest.11-0455
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To the Editor:

I read with interest in a recent issue of CHEST (November 2010) the correspondence by Drs Medford and Agrawal1 about the use of combined endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) in the diagnostic evaluation of benign diseases, such as TB, by an endobronchial ultrasound (EBUS) scope. In their correspondence, the authors discussed the feasibilities of combining the imaging modalities to perform fine needle aspiration (FNA) initially from the respiratory tract (EBUS-FNA) and then, using the same scope, from the esophagus (EBUS-transesophageal-FNA).2,3 The combined approach has potential advantages because it reduces the need for an additional instrument, the operating costs, and the duration of the procedure.

My colleagues and I have defined the standard stations and imaging techniques for fine needle aspiration (FNA) cytology of lymph nodes by endoscopic ultrasound (EUS) from the esophagus and by EBUS from the respiratory tract.4,5 We do not favor the use of EBUS-transesophageal-FNA because the EBUS scope has a limited vision and depth of penetration. Further, it provides a poor-quality ultrasound image because of its limited range of scanning (50°-70° by EBUS scope vs 120°-180° by EUS scope). The availability of an elevator in the EUS scope makes FNA more convenient and enables axis change during multiple passes. Although these experts were able to perform EBUS-transesophageal-FNA, it could be difficult for the newer generation of interventional bronchoscopists to acquire this expertise.

When evaluating benign mediastinal lymphadenopathy (BML), a diagnosis can be made through ultrasound-guided procedures like EBUS and EUS. It could be difficult to select the order of preference if both the techniques are available to the bronchoscopist because no suitable comparison of the results is available in the literature. Once a suitable comparison is made by studies, then only an order of diagnostic FNA (transesophageal first or transbronchial first) can be finalized. The new generation of bronchoscopists needs clear-cut algorithms. Until the algorithms are available, EUS-FNA could be considered the first test for ultrasound-guided evaluation of BML because of the ease and safety of the procedure. The role of EBUS-FNA for BML could be debatable if standard EUS-FNA is easily available. Whatever the order of imaging, the bronchoscopist needs two scopes and must learn the techniques of doing EUS with an EUS scope and EBUS with an EBUS scope. Even if end results are satisfactory, the means may not be justified.

Medford ARL, Agrawal S. Single bronchoscope combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration for tuberculous mediastinal nodes. Chest. 2010;1385:1274. [CrossRef] [PubMed]
 
Hwangbo B, Lee G-K, Lee HS. 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]
 
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]
 
Sharma M, Rameshbabu CS, Pazhanivel M. Standard techniques of imaging of IASLC borders by endoscopic ultrasound. J Bronchol Intervent Pulmonol. 2011;181:99-110. [CrossRef]
 
Sharma M, Arya CL, Somasundaram A, Rameshbabu CS. Techniques of linear endobronchial ultrasound imaging. J Bronchol Intervent Pulmonol. 2010;172:177-187. [CrossRef]
 

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References

Medford ARL, Agrawal S. Single bronchoscope combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration for tuberculous mediastinal nodes. Chest. 2010;1385:1274. [CrossRef] [PubMed]
 
Hwangbo B, Lee G-K, Lee HS. 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]
 
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]
 
Sharma M, Rameshbabu CS, Pazhanivel M. Standard techniques of imaging of IASLC borders by endoscopic ultrasound. J Bronchol Intervent Pulmonol. 2011;181:99-110. [CrossRef]
 
Sharma M, Arya CL, Somasundaram A, Rameshbabu CS. Techniques of linear endobronchial ultrasound imaging. J Bronchol Intervent Pulmonol. 2010;172:177-187. [CrossRef]
 
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