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The Endobronchial Ultrasound-Guided Transbronchial Needle Biopsy Learning Curve for Mediastinal and Hilar Lymph Node DiagnosisEchobronchoscopy Learning Curve FREE TO VIEW

Alberto Fernández-Villar, MD, PhD; Virginia Leiro-Fernández, MD, PhD; Maribel Botana-Rial, MD; Cristina Represas-Represas, MD; Manuel Núñez-Delgado, MD
Author and Funding Information

From the Pulmonology Department, Complexo Hospitalario Universitario de Vigo.

Correspondence to: Alberto Fernández-Villar, MD, PhD, Pulmunology Department, Complexo Hospitalario Universitario Vigo (CHUVI), C/Pizarro 22, 36204 Vigo (Pontevedra), Spain; e-mail: alberto.fernandez.villar@sergas.es


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).


© 2012 American College of Chest Physicians


Chest. 2012;141(1):278-279. doi:10.1378/chest.11-1986
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Published online

To the Editor:

The learning curve required for the endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) of mediastinal or hilar lymph nodes is unclear, and the evidence is scarce and contradictory.1-4 Two of the evidentiary studies2,3 only analyzed the learning curve of EBUS-TBNA for lung cancer diagnosis and staging and did not include the use of this technique in the study of lymph nodes affected by other pathologies. Other factors that might be influenced by learning have also not been examined.2-4

To address these issues, we conducted a prospective study to describe the learning curve of an experienced bronchoscopy team in a unselected sample of patients with mediastinal or hilar lymph nodes. Team performance was analyzed not only in terms of the diagnostic yield of the procedure, but also to evaluate procedure length, number of lymph node passes performed to obtain adequate samples, and number of lymph nodes studied per patient. We included unselected consecutive patients with mediastinal or hilar lymph node >10 mm in the short axis on CT scan or >5 mm in the presence of PET scan-positive uptake. The study involved a team of two bronchoscopists with >10 years experience in diagnostic bronchoscopy, including conventional transbronchial needle biopsy. The bronchoscopists had previously conducted extensive theoretical training and several practical workshops and performed between five and 10 supervised procedures. The learning curve was evaluated by analyzing consecutive groups of 20 patients, the number of adequate samples obtained, and the diagnostic accuracy of the procedure. We also recorded the other variables shown in Table 1. Over a period of 13 months, EBUS-TBNA was performed for 215 lymph nodes in 120 patients (71 with lung cancer, 16 with extrapulmonary carcinomas, seven with lymphomas, and 26 with several nonmalignant pathologies). Table 1 shows these values in groups of 20 consecutive patients. No serious complications were reported.

Table Graphic Jump Location
Table 1 —Lymph Node Characteristics, Procedure Variables, Adequate Samples, and Diagnostic Accuracy of 20 Consecutive Patients

Date are presented as mean (SD) unless otherwise indicated. EBUS = endobronchial ultrasound.

a 

P < .05

The present study demonstrated that the diagnostic effectiveness of EBUS-TBNA clearly improved with an increasing number of procedures performed, allowing for access to a greater number of lymph nodes without increasing the length of the procedure by reducing the number of punctures in each nodal station. Analyzing the studies included in systematic reviews and published meta-analyses,5,6 the diagnostic accuracy of EBUS-TBNA is between 85% and 98%. Accordingly, and based on our findings, we could argue that the minimal diagnostic yield is achieved with procedure 60 but can be improved and even reach optimal results after 100 patients. We hope that this study and others in the same line help scientific societies to establish specific recommendations for learning linear EBUS-TBNA.1,7

Unroe MA, Shofer SL, Wahidi MM. Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques. Curr Opin Pulm Med. 2010;164:295-300 [PubMed] [CrossRef]
 
Groth SS, Whitson BA, D’Cunha J, Maddaus MA, Alsharif M, Andrade RS. Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution’s early learning curve. Ann Thorac Surg. 2008;864:1104-1109 discussion 1109-1110. [PubMed]
 
Kemp SV, El Batrawy SH, Harrison RN, et al. Learning curves for endobronchial ultrasound using cusum analysis [published erratum inThorax. 2010;65(9):844]. Thorax. 2010;656:534-538 [PubMed]
 
Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases performed at an Australian tertiary hospital. Intern Med J. In press. doi:10.1111/j.1445-5994.2009.02142.x.
 
Varela-Lema L, Fernández-Villar A, Ruano-Ravina A. Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review. Eur Respir J. 2009;335:1156-1164 [PubMed]
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;458:1389-1396 [PubMed]
 
Sheski FD, Mathur PN. Endobronchial ultrasound. Chest. 2008;1331:264-270 [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Lymph Node Characteristics, Procedure Variables, Adequate Samples, and Diagnostic Accuracy of 20 Consecutive Patients

Date are presented as mean (SD) unless otherwise indicated. EBUS = endobronchial ultrasound.

a 

P < .05

References

Unroe MA, Shofer SL, Wahidi MM. Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques. Curr Opin Pulm Med. 2010;164:295-300 [PubMed] [CrossRef]
 
Groth SS, Whitson BA, D’Cunha J, Maddaus MA, Alsharif M, Andrade RS. Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution’s early learning curve. Ann Thorac Surg. 2008;864:1104-1109 discussion 1109-1110. [PubMed]
 
Kemp SV, El Batrawy SH, Harrison RN, et al. Learning curves for endobronchial ultrasound using cusum analysis [published erratum inThorax. 2010;65(9):844]. Thorax. 2010;656:534-538 [PubMed]
 
Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases performed at an Australian tertiary hospital. Intern Med J. In press. doi:10.1111/j.1445-5994.2009.02142.x.
 
Varela-Lema L, Fernández-Villar A, Ruano-Ravina A. Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review. Eur Respir J. 2009;335:1156-1164 [PubMed]
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;458:1389-1396 [PubMed]
 
Sheski FD, Mathur PN. Endobronchial ultrasound. Chest. 2008;1331:264-270 [PubMed]
 
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