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Learning Curve for Endobronchial Ultrasound-Guided Transbronchial Needle AspirationLearning Curve for Endobronchial Ultrasound FREE TO VIEW

Andrew R. L. Medford, MBChB, MD, FCCP
Author and Funding Information

From the North Bristol Lung Centre, Southmead Hospital.

Correspondence to: Andrew R. L. Medford, MBChB, MD, FCCP, North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, England; e-mail: andrewmedford@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. See online for more details.


© 2012 American College of Chest Physicians


Chest. 2012;141(6):1643. doi:10.1378/chest.12-0317
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To the Editor:

The prospective study by Fernández-Villar et al1 in a recent issue of CHEST (January 2012) on the learning curve for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy raises some interesting points on the proposed number of procedures to produce optimal results. They demonstrated improving results up to 120 EBUS-TBNA procedures. Interestingly, no specific numbers have been recommended in UK guideline statement from the British Thoracic Society,2 possibly because the learning curve is perceived to be variable and also because of the lack of consistent evidence on which to base a recommendation.

To look at this question further, we have also conducted a similar prospective analysis in our own institution of the diagnostic accuracy of EBUS-TBNA. This involved one operator only who was previously trained in the technique elsewhere. One hundred sixty consecutive EBUS-TBNA procedures were performed over an 18-month period for a similar unselected cohort of patients with mediastinal or hilar lymph nodes in a UK center receiving tertiary referrals for EBUS-TBNA. Patients were included with lymph nodes >10 mm short axis diameter on CT scan. Two hundred ninety-two nodes were sampled in 160 patients (84 with lung cancer, eight with extrapulmonary carcinoma, three with lymphoma, 37 with positively diagnosed benign pathologies, and a further 28 with reactive nodes stable or regressing on prolonged follow-up). Diagnostic accuracy (in percentages) and number of nodes sampled are as following, in order of consecutive octiles from 1 to 20 until 140 to 160: 85, 85, 90, 90, 90, 95, 90, 100 and 2, 2, 2.2, 1.5, 1.5, 1.6, 1.8, 2, respectively.

Interestingly, the diagnostic accuracy continued to improve up to the 140th to 160th octile (although appearing to peak a little earlier), in keeping with the data from Fernández-Villar et al,1 although the number of nodes sampled did not increase with time. These data and those of Fernández-Villar et al1 suggest the learning curve for EBUS-TBNA may indeed be longer than expected. There is perhaps an argument for all specialist societies to specify a minimum number of at least 100 EBUS-TBNA procedures until this question is further definitely answered.

Fernández-Villar A, Leiro-Fernández V, Botana-Rial M, Represas-Represas C, Núñez-Delgado M. The endobronchial ultrasound-guided transbronchial needle biopsy learning curve for mediastinal and hilar lymph node diagnosis. Chest. 2012;1411:278-279. [CrossRef] [PubMed]
 
Du Rand IA, Barber PV, Goldring J, et al; British Thoracic Society Interventional Bronchoscopy Guideline Group British Thoracic Society Interventional Bronchoscopy Guideline Group British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax. 2011;66suppl 3:iii1-iii21. [CrossRef] [PubMed]
 

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References

Fernández-Villar A, Leiro-Fernández V, Botana-Rial M, Represas-Represas C, Núñez-Delgado M. The endobronchial ultrasound-guided transbronchial needle biopsy learning curve for mediastinal and hilar lymph node diagnosis. Chest. 2012;1411:278-279. [CrossRef] [PubMed]
 
Du Rand IA, Barber PV, Goldring J, et al; British Thoracic Society Interventional Bronchoscopy Guideline Group British Thoracic Society Interventional Bronchoscopy Guideline Group British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax. 2011;66suppl 3:iii1-iii21. [CrossRef] [PubMed]
 
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