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Rocco Trisolini, MD, FCCP; Alessandra Cancellieri, MD; Marco Patelli, MD, FCCP
Author and Funding Information

From the Thoracic Endoscopy and Pulmonology Unit (Drs Trisolini and Patelli) and Pathology Unit (Dr Cancellieri), Maggiore Hospital.

Correspondence to: Rocco Trisolini, MD, FCCP, Thoracic Endoscopy and Pulmonology Unit, Maggiore Hospital, Largo B. Nigrisoli 2, 40133 Bologna, Italy; e-mail: rocco.trisolini@ausl.bologna.it


Financial/nonfinancial disclosures: The authors have 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):560. doi:10.1378/chest.11-0747
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To the Editor:

We thank Dr Medford for his interest in our study on the role of rapid on-site evaluation (ROSE) in patients undergoing transbronchial needle aspiration (TBNA) for lymphadenopathy.1 Unlike Dr Medford, we are not particularly surprised by the fact that ROSE did not result in an increased diagnostic yield for TBNA in the setting of lymphadenopathy. Trials suggesting that ROSE increases the yield and specimen accuracy of TBNA pooled the results from patients evaluated for very different indications, such as lymphadenopathy, peripheral pulmonary lesions, or both. Remarkably, ROSE was not associated with an increase in the diagnostic yield or accuracy of TBNA specimens in the only previous study where a subgroup analysis was performed for patients studied for lymphadenopathy alone.2

The thoughtful comment by Dr Medford on the needle types used in each arm of our study gives us the opportunity to clarify that the 19-gauge needle was used in a minority of patients (20 of 168 [12%]) and in similar proportions in the ROSE arm as in the TBNA arm (12 vs eight patients, P = .313). These data rule out the possibility that the needle type influenced in any way the study results.

We completely share Dr Medford’s view that the long-term experience of bronchoscopists and pathologists involved in our study may have contributed to the high yield of TBNA, thus preventing, to some degree, a significant increase in diagnostic success of TBNA in patients undergoing on-site review. However, the ability of ROSE to increase yield of TBNA in a less expert setting is all but certain and should be demonstrated in a randomized controlled trial to control the many variables (eg, size and position of the lymph nodes, underlying disease, needle type used), besides the examiner’s experience, that may influence the yield of TBNA.

In conclusion, we believe that judging the value of ROSE based exclusively on its capacity to increase the diagnostic yield is against the very interests of on-site review. The ongoing diffusion of endobronchial ultrasound-guided TBNA, which enables real-time visualization and sampling of lymph nodes, will likely reduce, in the near future, the use of ROSE to increase specimen accuracy and yield for TBNA. On the contrary, advantages such as the reduction of the complication rate of bronchoscopy without loss in diagnostic yield, the possible modification of the sampling strategy based on the on-site information, and the possible identification of the site where diagnostic material can be found and retrieved in sufficient amounts to enable molecular characterization of malignant diseases in the era of targeted treatments3 will likely be the stimuli for its continued and successful future use.

Trisolini R, Cancellieri A, Tinelli C, et al. Rapid on-site evaluation of transbronchial aspirates in the diagnosis of hilar and mediastinal adenopathy: a randomized trial. Chest. 2011;1392:395-401. [CrossRef] [PubMed]
 
Baram D, Garcia RB, Richman PS. Impact of rapid on-site cytologic evaluation during transbronchial needle aspiration. Chest. 2005;1282:869-875. [CrossRef] [PubMed]
 
Nakajima T, Yasufuku K. How I do it—optimal methodology for multidirectional analysis of endobronchial ultrasound-guided transbronchial needle aspiration samples. J Thorac Oncol. 2011;61:203-206. [CrossRef] [PubMed]
 

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Trisolini R, Cancellieri A, Tinelli C, et al. Rapid on-site evaluation of transbronchial aspirates in the diagnosis of hilar and mediastinal adenopathy: a randomized trial. Chest. 2011;1392:395-401. [CrossRef] [PubMed]
 
Baram D, Garcia RB, Richman PS. Impact of rapid on-site cytologic evaluation during transbronchial needle aspiration. Chest. 2005;1282:869-875. [CrossRef] [PubMed]
 
Nakajima T, Yasufuku K. How I do it—optimal methodology for multidirectional analysis of endobronchial ultrasound-guided transbronchial needle aspiration samples. J Thorac Oncol. 2011;61:203-206. [CrossRef] [PubMed]
 
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