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Jessica S. Wang Memoli, MD; Gerard A. Silvestri, MD, FCCP
Author and Funding Information

From the Section of Pulmonary, Critical Care, and Respiratory Services (Dr Wang Memoli), MedStar Washington Hospital Center, and Department of Medicine (Dr Silvestri), Medical University of South Carolina.

Correspondence to: Jessica S. Wang Memoli, MD, 110 Irving St NW, 2A-68, Washington, DC 20010; e-mail: Jessica.S.WangMemoli@Medstar.net


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.


Chest. 2012;142(5):1355-1356. doi:10.1378/chest.12-2328
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Published online
To the Editor:

The correspondence from Dr Dieter regarding our article in CHEST1 on endobronchial ultrasound (EBUS) predictors of metastatic malignancy has pointed out an important issue related to all diagnostic procedures: the false-positive result. False-positive results by EBUS have been reported and are related to the proximity of the primary tumor to a hilar, thus more distal, lymph node.2 This occurrence is rare, as several prospective studies comparing EBUS to surgical staging (mediastinoscopy or lymph node dissection at lung resection) have not reported any cases of false-positive results.3,4

Some practitioners argue that a false-positive result is a problem presumably because it would lead to unnecessary procedures where a lesion is diagnosed as lung cancer but at resection, is not.5 Dr Dieter argues the opposite: His patient would not have undergone a potentially curative surgical resection because of a nodal metastasis diagnosis based on EBUS. Although his case may raise concern and make practitioners wary of their EBUS results, we have questions regarding Dr Dieter’s example. Which right-sided lymph node was positive on EBUS, mediastinal or hilar? If it was a hilar lymph node, the stage would likely be one in which curative resection was still possible despite lymph node metastasis. What made him doubt the results of the EBUS? The PET scan findings were considered positive, which supported the assumption that there was lymph node metastasis. Prior to surgical resection, should the patient have been referred for surgical confirmation with a mediastinoscopy if the EBUS-based diagnosis was in doubt? Before sending the patient for a thoracotomy, another method more invasive than EBUS but less invasive than thoracotomy to evaluate the mediastinum could have been performed. Was the lymph node that was positive at EBUS among the 18 hilar and mediastinal lymph nodes that were removed? This would verify the false-positive finding of the node sampled at EBUS. Is there any long-term follow-up on the patient to determine whether she has had subsequent recurrence?

Another aspect to consider in this case is the accuracy of the positive EBUS biopsy specimen. Part of the learning curve of performing EBUS lies in the ability to distinguish a lymph node and its borders from the surrounding structures. If the bronchoscopist guided the biopsy needle through the lymph node into the adjacent malignant mass, the needle could have become contaminated, resulting in the false-positive biopsy finding. Understanding the borders of the lymph node and avoiding contamination of the needle is crucial in all staging procedures.

Ultimately, false-positive results are rare. In most studies, when a positive result is obtained, that result is presumed to be a true positive. The clinical implications of this should be evaluated to determine whether further study is needed to verify all positive results.

References

Wang Memoli JS, El-Bayoumi E, Pastis NJ, et al. Using endobronchial ultrasound features to predict lymph node metastasis in patients with lung cancer. Chest. 2011;140(6):1550-1556. [CrossRef] [PubMed]
 
Khazai L, Kundu UR, Jacob B, et al. Endobronchial ultrasound-guided transbronchial needle aspiration biopsy is useful evaluating mediastinal lymphadenopathy in a cancer center. Cytojournal. 2011;8:10. [CrossRef] [PubMed]
 
Yasufuku K, Pierre A, Darling G, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393-1400. [CrossRef] [PubMed]
 
Herth FJ, Annema JT, Eberhardt R, et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol. 2008;26(20):3346-3350. [CrossRef] [PubMed]
 
Cerfolio RJ, Bryant AS, Eloubeidi MA, et al. The true false negative rates of esophageal and endobronchial ultrasound in the staging of mediastinal lymph nodes in patients with non-small cell lung cancer. Ann Thorac Surg. 2010;90(2):427-434. [CrossRef] [PubMed]
 

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References

Wang Memoli JS, El-Bayoumi E, Pastis NJ, et al. Using endobronchial ultrasound features to predict lymph node metastasis in patients with lung cancer. Chest. 2011;140(6):1550-1556. [CrossRef] [PubMed]
 
Khazai L, Kundu UR, Jacob B, et al. Endobronchial ultrasound-guided transbronchial needle aspiration biopsy is useful evaluating mediastinal lymphadenopathy in a cancer center. Cytojournal. 2011;8:10. [CrossRef] [PubMed]
 
Yasufuku K, Pierre A, Darling G, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393-1400. [CrossRef] [PubMed]
 
Herth FJ, Annema JT, Eberhardt R, et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol. 2008;26(20):3346-3350. [CrossRef] [PubMed]
 
Cerfolio RJ, Bryant AS, Eloubeidi MA, et al. The true false negative rates of esophageal and endobronchial ultrasound in the staging of mediastinal lymph nodes in patients with non-small cell lung cancer. Ann Thorac Surg. 2010;90(2):427-434. [CrossRef] [PubMed]
 
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