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When Will We Finally Adopt Endoscopic Ultrasound?Endoscopic Ultrasound FREE TO VIEW

Jouke T. Annema, MD, PhD
Author and Funding Information

From the Department of Respiratory Medicine, Academic Medical Center Amsterdam.

CORRESPONDENCE TO: Jouke T. Annema, MD, PhD, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands; e-mail: j.t.annema@amc.nl


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.


Chest. 2014;146(3):e117. doi:10.1378/chest.14-1015
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To the Editor:

I read with interest the article in a recent issue of CHEST (August 2014) by Liberman et al,1 who performed a prospective lung cancer staging trial in which patients underwent both an endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) investigation followed by surgical staging. The combination of an endobronchial and esophageal approach was superior in detecting (sensitivity, 91%) and excluding (negative predictive value, 96%) mediastinal nodal metastases vs either technique alone.1 The findings of the study are in line with the conclusion of a recent meta-analysis2 and also support the current guideline recommendation that mediastinal nodal tissue staging should start with endosonography.3 However, there is discussion whether an EBUS investigation should be followed by EUS routinely or only in selected cases. Therefore, it would be of interest to know in which specific situations EUS provided an added value and whether this benefit could be predicted based on prior CT-PET imaging. Regarding mediastinal nodal sampling, I was surprised that lymph node station 5 was aspirated 88 times. These nodes are located laterally to the ligamentum arteriosum and are notoriously difficult to sample—unlike the neighboring station 4L—because of the interposition of the pulmonary artery and aorta.

In the present study, a separate EUS scope—and also a different endoscopist?—was used to perform an esophageal nodal investigation. Although a regular EUS scope should be regarded as the standard and has the advantage of providing easy access to the left adrenal gland, there is sufficient evidence available demonstrating that an esophageal investigation with an EBUS scope (EUS-B) provides similar outcomes.2,4 In my opinion, single-scope complete (EBUS + EUS-B) nodal staging performed by just one endoscopist should be the endoscopy standard, as it is practical, time efficient, cost-effective, and far easier to implement in comparison with the use of different scopes and endoscopists.

Chest physicians can be trained to perform EUS-fine needle aspiration for lung cancer staging.5 I suggest that EBUS operators should also be trained to perform mediastinal nodal sampling by the esophageal route. With this small additional effort—with the mental barrier of pulmonologists and surgeons to enter the esophagus with the EBUS scope as the main obstacle—we can make a significant difference for patients.

References

Liberman M, Sampalis J, Duranceau A, Thiffault V, Hadjeres R, Ferraro P. Endosonographic mediastinal lymph node staging of lung cancer. Chest. 2014;146(2):389-397. [CrossRef] [PubMed]
 
Zhang R, Ying K, Shi L, Zhang L, Zhou L. Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal lymph node staging of lung cancer: a meta-analysis. Eur J Cancer. 2013;49(8):1860-1867. [CrossRef] [PubMed]
 
Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e211S-e250S. [CrossRef] [PubMed]
 
Szlubowski A, Soja J, Kocon P, et al. A comparison of the combined ultrasound of the mediastinum by use of a single ultrasound bronchoscope versus ultrasound bronchoscope plus ultrasound gastroscope in lung cancer staging: a prospective trial. Interact Cardiovasc Thorac Surg. 2012;15(3):442-446. [CrossRef] [PubMed]
 
Annema JT, Bohoslavsky R, Burgers S, Smits M, Taal B, Venmans B, et al. Implementation of endoscopic ultrasound for lung cancer staging. Gastrointest Endosc. 2010;71(1):64-70. [CrossRef] [PubMed]
 

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References

Liberman M, Sampalis J, Duranceau A, Thiffault V, Hadjeres R, Ferraro P. Endosonographic mediastinal lymph node staging of lung cancer. Chest. 2014;146(2):389-397. [CrossRef] [PubMed]
 
Zhang R, Ying K, Shi L, Zhang L, Zhou L. Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal lymph node staging of lung cancer: a meta-analysis. Eur J Cancer. 2013;49(8):1860-1867. [CrossRef] [PubMed]
 
Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e211S-e250S. [CrossRef] [PubMed]
 
Szlubowski A, Soja J, Kocon P, et al. A comparison of the combined ultrasound of the mediastinum by use of a single ultrasound bronchoscope versus ultrasound bronchoscope plus ultrasound gastroscope in lung cancer staging: a prospective trial. Interact Cardiovasc Thorac Surg. 2012;15(3):442-446. [CrossRef] [PubMed]
 
Annema JT, Bohoslavsky R, Burgers S, Smits M, Taal B, Venmans B, et al. Implementation of endoscopic ultrasound for lung cancer staging. Gastrointest Endosc. 2010;71(1):64-70. [CrossRef] [PubMed]
 
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