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Joseph Cicenia, MD, FCCP; Atul C. Mehta, MBBS, FCCP; Kazuhiro Yasufuku, MD, PhD, FCCP
Author and Funding Information

From the Respiratory Institute (Drs Cicenia and Mehta), Cleveland Clinic; the Interventional Thoracic Surgery Program (Dr Yasufuku), University of Toronto; and Division of Thoracic Surgery (Dr Yasufuku), Toronto General Hospital.

CORRESPONDENCE TO: Atul C. Mehta, MBBS, FCCP, Respiratory Institute, Cleveland Clinic, A-90, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: Mehtaa1@ccf.org


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. 2015;148(3):e100-e101. doi:10.1378/chest.15-1398
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To the Editor:

We appreciate the response by Dr Dhooria and colleagues to our editorial in CHEST.1 In our editorial, we cited several studies in which endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) were combined and pointed out several flaws that call into question their ability to create a consensus regarding the standard use of a combined EBUS-EUS procedure to stage the mediastinum. Specifically we questioned the sensitivity of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) reported in these studies, especially at lymph node stations that should be easy to access with EBUS-TBNA, such as 4L and 7.2 Furthermore, we also questioned the practicality of accessing remote lymph node stations, such as 8 and 9, that are rarely isolated nodal metastases.3-5

Dr Dhooria and colleagues cite a meta-analysis in which the pooled additional yield of EUS-guided fine-needle aspiration (EUS-FNA) over EBUS-TBNA is 7.6%.6 Unfortunately, many of the studies used in this meta-analysis suffer from these exact issues we called into question, which may have biased the outcome in favor of a combined EUS-FNA/EBUS-TBNA procedure. Although a funnel plot was used in this meta-analysis to detect any publication bias, this would not detect the effect of methodologic or procedural flaws within the studies used in the analysis. As such, we believe an additional 7.6% may be an overestimation and not a basis of justification to support combined EBUS-EUS procedures using an EBUS-TBNA scope.

Although we admit there may be instances in which adding EUS-FNA may be advantageous to a patient, we do not believe this is ready for routine practice, especially in the setting where the operator is a pulmonologist who may not have received formal training in this procedure. The views expressed by reputable authors in a major medical journal have a significant impact not only on our students but also on the welfare of our patients. No procedure, no matter how noninvasive, should be glorified without a due emphasis on training and needed experience. This is of even greater importance when the procedure resides outside one’s own domain. It may be very easy to perform a procedure, yet its safety and legal consequences should never be undermined. Would authors approve otolaryngologists performing a staging bronchoscopy or an urologist performing a colonoscopy? For that matter, would the authors support mediastinal staging being performed solely by a gastroenterologist?

One has to be larger than their abilities. In our humble opinion, a chef without proper training is no better than a cook.

References

Mehta AC, Cicenia J, Yasufuku K. The chef has a knife…: endoscopic ultrasound-guided fine-needle aspiration by a pulmonologist. Chest. 2015;147(5):1201-1203. [CrossRef] [PubMed]
 
Oki M, Saka H, Ando M, Kitagawa C, Kogure Y, Seki Y. Endoscopic ultrasound-guided fine needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration: are two better than one in mediastinal staging of non-small cell lung cancer? J Thorac Cardiovasc Surg. 2014;148(4):1169-1177. [CrossRef] [PubMed]
 
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]
 
Liberman M, Hanna N, Duranceau A, Thiffault V, Ferraro P. Endobronchial ultrasonography added to endoscopic ultrasonography improves staging in esophageal cancer. Ann Thorac Surg. 2013;96(1):232-236. [CrossRef] [PubMed]
 
Wallace MB, Pascual JM, Raimondo M, et al. Minimally invasive endoscopic staging of suspected lung cancer. JAMA. 2008;299(5):540-546. [CrossRef] [PubMed]
 
Dhooria S, Aggarwal AN, Gupta D, Behera D, Agarwal R. Utility and safety of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration in mediastinal lymph node sampling: systematic review and meta-analysis. Respir Care. 2015;60(7):1040-1050. [CrossRef] [PubMed]
 

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References

Mehta AC, Cicenia J, Yasufuku K. The chef has a knife…: endoscopic ultrasound-guided fine-needle aspiration by a pulmonologist. Chest. 2015;147(5):1201-1203. [CrossRef] [PubMed]
 
Oki M, Saka H, Ando M, Kitagawa C, Kogure Y, Seki Y. Endoscopic ultrasound-guided fine needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration: are two better than one in mediastinal staging of non-small cell lung cancer? J Thorac Cardiovasc Surg. 2014;148(4):1169-1177. [CrossRef] [PubMed]
 
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]
 
Liberman M, Hanna N, Duranceau A, Thiffault V, Ferraro P. Endobronchial ultrasonography added to endoscopic ultrasonography improves staging in esophageal cancer. Ann Thorac Surg. 2013;96(1):232-236. [CrossRef] [PubMed]
 
Wallace MB, Pascual JM, Raimondo M, et al. Minimally invasive endoscopic staging of suspected lung cancer. JAMA. 2008;299(5):540-546. [CrossRef] [PubMed]
 
Dhooria S, Aggarwal AN, Gupta D, Behera D, Agarwal R. Utility and safety of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration in mediastinal lymph node sampling: systematic review and meta-analysis. Respir Care. 2015;60(7):1040-1050. [CrossRef] [PubMed]
 
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