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Moishe Liberman, MD, PhD
Author and Funding Information

From the CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC) and Division of Thoracic Surgery, University of Montréal.

CORRESPONDENCE TO: Moishe Liberman, MD, PhD, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), Division of Thoracic Surgery, Centre Hospitalier de l’Université de Montréal, 1560 rue Sherbrooke Est, 8e CD-Pavillon Lachapelle, Bureau D-8051, Montréal, QC H2L 4M1, Canada; e-mail: moishe.liberman@umontreal.ca


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-e118. doi:10.1378/chest.14-1039
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To the Editor:

I would like to thank Dr Annema for his kind comments regarding our article.1 Endoscopic ultrasound (EUS) provided added value in all cases where lymph nodes (LNs) were biopsied out of the range of endobronchial ultrasound (EBUS) (stations 5, 6, 8, 9, adrenal gland, and liver). This accounts for 151 of the total 643 LNs (23%) biopsied using endosonography in our study. Furthermore, in certain circumstances, even though an LN is potentially accessible by EBUS, it is sometimes technically easier, with a resultant improved yield, when approached by EUS (eg, 2R, 2L, 4L). The dramatic improvement in sensitivity and accuracy when comparing EBUS alone (sensitivity, 0.72; accuracy, 0.91) with the combined EBUS-EUS procedure (sensitivity, 0.91; accuracy, 0.97) is the most compelling argument for the necessity for combining EBUS with EUS in the staging of potentially operable lung cancer.

We do recognize that EUS biopsy of station 5 is technically challenging (compared with station 4L) because of the requirement of carefully passing the needle out past the ligamentum arteriosum between the left main pulmonary artery and the aorta. However, we do make it a point to attempt biopsy of this station in all patients with left upper lobe tumors.

We used a dedicated EUS scope in this study because we believe that it gives better resolution and, in our experience, superior results when biopsying subcentimetric LNs, which was typically the case in this study because all the patients had potentially resectable disease. When aspirating enlarged LNs, the EBUS scope within the esophagus may provide adequate results; however, this was not the case in this study. All patients in this study underwent staging in a single setting by a single team, which comprised a thoracic surgical staff and thoracic surgery trainees. Similar to Dr Annema’s practice, the same operator performed the EBUS and EUS procedure, and we agree that a single operator can perform complete endosonographic mediastinal LN staging in lung cancer. The question will be in terms of appropriate training and credentialing of these endosonographers.

References

Liberman M, Sampalis J, Duranceau A, Thiffault V, Hadjeres R, Ferraro P. Endosonographic mediastinal lymph node staging of lung cancer. Chest.146(2):389-397. [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.146(2):389-397. [CrossRef] [PubMed]
 
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