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Point/Counterpoint Editorials |

Counterpoint: Should Endobronchial Ultrasound Guide Every Transbronchial Needle Aspiration of Lymph Nodes? NoEBUS for TBNA? No

Jian An Huang, MD, PhD; Robert Browning, MD, FCCP; Ko-Pen Wang, MD, FCCP
Author and Funding Information

From the Department of Respiratory Medicine (Dr Huang), The First Affiliated Hospital of Soochow University; Division of Interventional Pulmonology (Dr Browning), Walter Reed National Military Medical Center; and Division of Interventional Pulmonology (Dr Wang), The Johns Hopkins Hospital.

Correspondence to: Ko-Pen Wang, MD, FCCP, Division of Interventional Pulmonology, The Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287; e-mail: Kwang7@jhmi.edu


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. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(3):734-737. doi:10.1378/chest.13-0704
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The utility, feasibility, and safety of conventional transbronchial needle aspiration (C-TBNA) was demonstrated in several landmark articles almost 30 years ago at Johns Hopkins.1-5 Until the recent introduction of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (EBUS-TBNA), C-TBNA has been the worldwide accepted standard for evaluating mediastinal lymphadenopathy of unknown etiology. Despite the large number of studies involving EBUS-TBNA that have been published, limited evidence directly compares C-TBNA with real-time linear EBUS-TBNA among a comprehensive spectrum of patients and diseases. The most recent of these direct-comparison studies showed no significant difference between the two techniques in 100 patients.6 Questions about the appropriate clinical application for the respective techniques still exist. C-TBNA can not only be used for staging lung cancer but also for the diagnosis of hilar and mediastinal lymph node abnormalities. The diagnostic yield of transbronchial needle aspiration (TBNA) in lung cancer varies greatly depending on several factors. The sensitivity of this procedure ranges from 37% to 89% with a specificity of 96%.7 Overall, the TBNA procedure is minimally invasive, safe, and less costly and has been shown to preclude surgery in up to 29% of patients.8 The success of TBNA relies on knowing the anatomic relationships between the lymph node location and the endobronchial puncture site, successful puncture of the needle through the tracheobronchial wall, proper biopsy technique and specimen preparation, and accurate pathologic interpretation.9 The operator’s ability and experience are among the most important factors influencing TBNA sensitivity. For example, the overall diagnostic yield for staging is as high as 85% overall for lung cancer and 96% in right-sided lesions, even in initial reports 30 years ago.1 C-TBNA has a high specificity with rare false-positive results, and compared with EBUS-TBNA or mediastinoscopy, is less expensive, is more widely available, and offers less anesthetic risks for the patient. Multiple lymph node stations can be sampled during one procedure, including right- and left-paratracheal (stations 2-4 according to the International Association for the Study of Lung Cancer), subcarinal (station 7), and posterior carinal, and hilar (stations 10-12) lymph nodes.1,9,10 It seems logical that C-TBNA should still be used as the initial diagnostic procedure for mediastinal adenopathy and staging in centers that perform C-TBNA. In this way, TBNA provides a unique opportunity for the efficient diagnosis and staging of lung cancer with one procedure, avoiding the need for additional investigations.

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