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Rebuttal From Drs Wahidi and ErnstRebuttal From Drs Wahidi and Ernst FREE TO VIEW

Momen M. Wahidi, MD, MBA, FCCP; Armin Ernst, MD, MHCM, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Dr Wahidi) and Department of Medicine, Duke University Medical Center; and Reliant Medical Group (Dr Ernst).

Correspondence to: Momen M. Wahidi, MD, MBA, FCCP, Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Box 3683, Durham, NC 27710; e-mail: momen.wahidi@duke.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Wahidi has served as a consultant with Olympus Corp and received educational grants from Olympus Corp and Pentax of America Inc. Dr Ernst has reported 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. 2014;145(3):451-452. doi:10.1378/chest.13-2723
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Published online

Medical myths die hard! Drs Farjah and Wood1 point out deficiencies in the ultrasonographic approach that have been disproved by data or overcome by innovative solutions. These include a lack of effectiveness in sampling the radiographically normal mediastinum, an inability of endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) to collect adequate tissue for molecular analysis, and logistical difficulty in performing EBUS and EUS simultaneously. On the other hand, the authors claim an excellent track record of surgical staging in lung cancer. A survey in 2005 gathered information on the surgical care of the patient with lung cancer and illustrated the poor state of affairs in the United States: Only 27% of surgical patients underwent mediastinoscopy, and only 46% of those undergoing the procedure had documented evidence of lymph node biopsy material submitted to pathology.2 This is one of the reasons why new approaches and opportunities for staging access are desperately needed to provide patients with the best possible care.

The premise that EBUS and EUS are not effective in sampling the radiographically normal mediastinum is challenged by two studies where EBUS guided-transbronchial needle aspiration (EBUS-TBNA) was used to sample mediastinal lymph nodes that are < 1 cm on chest CT scan in one study and nodes that are < 1 cm and have no fluorodeoxyglucose activity on PET scan in another study. All patients had clinical stage I lung cancer and underwent subsequent surgical staging. The sensitivity of EBUS-TBNA in detecting malignancy in these two studies was 92.3% and 89%, respectively.3,4 Although we agree that these two studies were performed by EBUS experts, the same argument can be made about mediastinoscopy, which relies heavily on the experience of the surgeon.

The myth of the inability of needle-based techniques to obtain enough tissue for molecular markers testing and, hence, the need for core tissue obtained by CT imaging guidance or surgical resection has been soundly refuted by robust data illustrating a success rate of EBUS in evaluating epidermal growth factor receptor status and other novel genetic mutations in ≥ 90% of specimens.5-7 The concerns about the logistical difficulty of performing EBUS and EUS simultaneously are legitimate because getting pulmonologists and gastroenterologists to synchronize their calendars can be a significant challenge. However, thoracic surgeons have the capability of performing both procedures and should embrace them as necessary skills in their practice. The pulmonologists had to be more creative to overcome this barrier and found a solution: Why not use the same EBUS airway scope in the esophagus? Two studies did just that and evaluated the utility of a single linear EBUS bronchoscope in sampling mediastinal lymph nodes from the esophageal side (EUS fine needle aspiration) and from the bronchial side (EBUS-TBNA) in patients with suspected lung cancer.8,9 Both studies confirmed the feasibility of this one-scope combined approach with a sensitivity of 91% to 96% in detecting mediastinal metastases. Finally, the argument about the lack of EBUS/EUS training in pulmonary and thoracic surgery fellowships should not be viewed as an obstacle but, rather, as an opportunity to optimize acquisition of knowledge and skills in ultrasonographic endoscopy among future chest physicians.

This debate should not be about territorial battles among specialties but about the multidisciplinary team offering the most effective approach of mediastinal staging to the patient with lung cancer. The standard of surgical staging alone has not served the community as a whole well. For some patients, mediastinoscopy is the right procedure, but for the majority of patients, ultrasonographic endoscopy should be the first modality offered and performed by the most capable practitioner.

References

Farjah F, Wood DE. Counterpoint: should ultrasonographic endoscopy be the preferred modality for staging lung cancer? No. Chest. 2014;145(3):449-451.
 
Little AG, Rusch VW, Bonner JA, et al. Patterns of surgical care of lung cancer patients. Ann Thorac Surg. 2005;80(6):2051-2056. [CrossRef] [PubMed]
 
Herth FJ, Eberhardt R, Krasnik M, Ernst A. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer. Chest. 2008;133(4):887-891. [CrossRef] [PubMed]
 
Herth FJ, Ernst A, Eberhardt R, Vilmann P, Dienemann H, Krasnik M. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum. Eur Respir J. 2006;28(5):910-914. [CrossRef] [PubMed]
 
Billah S, Stewart J, Staerkel G, Chen S, Gong Y, Guo M. EGFR and KRAS mutations in lung carcinoma: molecular testing by using cytology specimens. Cancer Cytopathol. 2011;119(2):111-117. [CrossRef] [PubMed]
 
Nakajima T, Yasufuku K, Nakagawara A, Kimura H, Yoshino I. Multigene mutation analysis of metastatic lymph nodes in non-small cell lung cancer diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration. Chest. 2011;140(5):1319-1324. [CrossRef] [PubMed]
 
Navani N, Brown JM, Nankivell M, et al. Suitability of endobronchial ultrasound-guided transbronchial needle aspiration specimens for subtyping and genotyping of non-small cell lung cancer: a multicenter study of 774 patients. Am J Respir Crit Care Med. 2012;185(12):1316-1322. [CrossRef] [PubMed]
 
Herth FJ, Krasnik M, Kahn N, Eberhardt R, Ernst A. Combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest. 2010;138(4):790-794. [CrossRef] [PubMed]
 
Hwangbo B, Lee GK, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;138(4):795-802. [CrossRef] [PubMed]
 

Figures

Tables

References

Farjah F, Wood DE. Counterpoint: should ultrasonographic endoscopy be the preferred modality for staging lung cancer? No. Chest. 2014;145(3):449-451.
 
Little AG, Rusch VW, Bonner JA, et al. Patterns of surgical care of lung cancer patients. Ann Thorac Surg. 2005;80(6):2051-2056. [CrossRef] [PubMed]
 
Herth FJ, Eberhardt R, Krasnik M, Ernst A. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer. Chest. 2008;133(4):887-891. [CrossRef] [PubMed]
 
Herth FJ, Ernst A, Eberhardt R, Vilmann P, Dienemann H, Krasnik M. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum. Eur Respir J. 2006;28(5):910-914. [CrossRef] [PubMed]
 
Billah S, Stewart J, Staerkel G, Chen S, Gong Y, Guo M. EGFR and KRAS mutations in lung carcinoma: molecular testing by using cytology specimens. Cancer Cytopathol. 2011;119(2):111-117. [CrossRef] [PubMed]
 
Nakajima T, Yasufuku K, Nakagawara A, Kimura H, Yoshino I. Multigene mutation analysis of metastatic lymph nodes in non-small cell lung cancer diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration. Chest. 2011;140(5):1319-1324. [CrossRef] [PubMed]
 
Navani N, Brown JM, Nankivell M, et al. Suitability of endobronchial ultrasound-guided transbronchial needle aspiration specimens for subtyping and genotyping of non-small cell lung cancer: a multicenter study of 774 patients. Am J Respir Crit Care Med. 2012;185(12):1316-1322. [CrossRef] [PubMed]
 
Herth FJ, Krasnik M, Kahn N, Eberhardt R, Ernst A. Combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest. 2010;138(4):790-794. [CrossRef] [PubMed]
 
Hwangbo B, Lee GK, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;138(4):795-802. [CrossRef] [PubMed]
 
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