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Alberto Fernández-Villar, MD, PhD; Virginia Leiro-Fernández, MD, PhD
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. See online for more details.


© 2012 American College of Chest Physicians


Chest. 2012;141(6):1643-1644. doi:10.1378/chest.12-0684
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To the Editor:

We thank Dr Medford for his interest on our study,1 and we are delighted that he has shown interest in the subject reflecting the importance of establishing the optimal learning curve to perform endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The new British Thoracic Society Interventional Bronchoscopy guidelines indicate that these numbers are arbitrary and that the available evidence indicates that every individual has a different learning curve.2 We agree that the absence of evidence on the number of procedures required to achieve the optimal learning curve is a consequence of the variability of published studies. Differences may be explained not only by the variability in training or learning curve of each bronchoscopy team but also by aspects such as the type of sedation, the possibility of immediate cytologic assessment by a pathologist, the experience of these or the other members of the team who performed the procedure, the size or location of the lymph nodes, and the prevalence of its affectation influencing EBUS-TBNA results.1,3,4 Thus, factors should be taken into account when interpreting the results from all the studies.

The results obtained by Dr Medford are similar to ours, reaching between 90% and 100% diagnostic accuracy from the 140 procedures performed, compared with our numbers of diagnostic accuracy > 95% in 120 procedures.1 As in our study, they also achieve the number of nodes sampled variable, and they included in the analysis other specific etiologies different from lung cancer, such as lymphomas, extrapulmonary carcinoma, and benign pathologies.1 Another important similar issue is that the variable used to assess diagnostic yield, in addition to obtaining adequate samples, was the accuracy of the test rather than sensitivity. This parameter includes not only true positive samples in the numerator but also true negatives, which are especially frequent in series such as ours and include small lymph nodes and benign pathologies. The accuracy does not depend on the prevalence of the involvement of a specific lymph node as much as the sensitivity, as demonstrated in a meta-analysis of conventional transbronchial needle aspiration.5 Thus, in order to compare different groups of consecutive patients or different series, the prevalence of the involvement of a specific lymph node among each group should be similar, which did not occur in our series and is not reflected in the studies of the EBUS-TBNA learning curve published to date.6 Differences between our study and that of Dr Medford are slight, and the similarity in methodology and the results strengthen the consistence of both studies.

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]
 
Kennedy MP, Jimenez C, Mhatre AD, Morice RC, Eapen GA. Factors influencing the diagnosis yield of endobronchial ultrasound-guided transbronchial needle aspiration. Journal of Bronchology and Interventional Pulmonology. 2010;173:202-208. [CrossRef]
 
Navani N, Nankivell M, Nadarajan P, Pereira SP, Kocjan G, Janes SM. The learning curve for EBUS-TBNA. Thorax. 2011;664:352-353. [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]
 
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. [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]
 
Kennedy MP, Jimenez C, Mhatre AD, Morice RC, Eapen GA. Factors influencing the diagnosis yield of endobronchial ultrasound-guided transbronchial needle aspiration. Journal of Bronchology and Interventional Pulmonology. 2010;173:202-208. [CrossRef]
 
Navani N, Nankivell M, Nadarajan P, Pereira SP, Kocjan G, Janes SM. The learning curve for EBUS-TBNA. Thorax. 2011;664:352-353. [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]
 
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. [CrossRef] [PubMed]
 
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