0
Correspondence |

Whither, Not WitherEUS-B-FNA: Endoscopic Ultrasound-Guided Fine-Needle Aspiration by an Interventional Pulmonologist Using an Echobronchoscope? FREE TO VIEW

Sahajal Dhooria, MD, DM; Inderpaul S. Sehgal, MD, DM; Ashutosh N. Aggarwal, MD, DM, FCCP; Ritesh Agarwal, MD, DM, FCCP
Author and Funding Information

From the Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research.

CORRESPONDENCE TO: Ritesh Agarwal, MD, DM, FCCP, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh-160012, India; e-mail: agarwal.ritesh@outlook.in


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):e99-e100. doi:10.1378/chest.15-1121
Text Size: A A A
Published online
To the Editor:

We read with interest the article by Oki et al1 and the accompanying editorial by Mehta et al2 in CHEST (May 2015) on the randomized trial comparing the performance of transbronchial vs transesophageal needle aspiration using an ultrasound bronchoscope for the diagnosis of mediastinal lesions. The authors demonstrated equivalent findings via endoscopic ultrasound bronchoscope-guided fine-needle aspiration (EUS-B-FNA) compared with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) from mediastinal lesions accessible by both techniques. Moreover, EUS-B-FNA was associated with significant benefits, including fewer doses of anesthetics and sedatives, shorter procedure times, and fewer oxygen desaturations during the procedure.1 However, the accompanying editorial by Mehta et al2 projects a very dismal outlook for EUS-B-FNA, with which we respectfully disagree.

As interventional pulmonologists, we are definitely more comfortable with EBUS-TBNA, and we would still prefer this technique to EUS-B-FNA in lesions accessible by both methods. This is because of poor visualization of the esophageal lumen with the endobronchial ultrasound (EBUS) bronchoscope, poorer ultrasound images with the EBUS bronchoscope as compared with the endoscopic ultrasound bronchoscope, and the narrower scanning range of the EBUS.3 However, we do not agree that EUS-B-FNA has no utility in the day-to-day practice of an interventional pulmonologist.3,4 Apart from being performed with a single bronchoscope and by a single operator, the combined technique has significant usefulness in several situations; for example, lymph nodes inaccessible by EBUS-TBNA, technical difficulties associated with EBUS-TBNA such as lymph nodes with fibrotic borders, intolerance of bronchoscopy due to cough or dyspnea, patients with raised intracranial tension, and medical conditions precluding bronchoscopy, such as coronary artery disease.5 In fact, in unselected patients with mediastinal lesions, the pooled additional yield of EUS-B-FNA compared with EBUS-TBNA was 7.6%.5

Further, Mehta et al2 cite a study that found adding EUS-B-FNA to EBUS-TBNA did not significantly increase the diagnostic accuracy; however, the sensitivity of EBUS-TBNA in this study was 92%.6 Understandably, every technique has a range of performance characteristics, and a very high yield achieved in one center cannot always be replicated by other centers in the real-world scenario. In fact, the sensitivity of EBUS-TBNA in mediastinal staging of lung cancer has ranged from as low as 69% to as high as 100%.7 Thus, in several centers, because of technical difficulties encountered during EBUS-TBNA, adding EUS-B-FNA would be beneficial. In a recent meta-analysis5 analyzing the efficacy of EUS-B-FNA, we have shown that the pooled sensitivity of the combined technique (EUS-B-FNA plus EBUS-TBNA) was significantly higher than EBUS-TBNA alone (91% vs 80%; P = .004) in the mediastinal staging of lung cancer (four studies, 465 subjects). This implies that only 10 combined procedures need to be performed to achieve a diagnosis in one additional patient, compared with EBUS-TBNA alone. Also, it is a relatively safe technique; in the systematic review, we did not find any studies reporting serious complication of the EUS-B-FNA procedure.5

Finally, we agree with Mehta et al2 that structured training is essential for endoscopic ultrasound, but this is true for any medical procedure. If an interventional pulmonologist can perform bedside percutaneous endoscopic gastrostomy tube placement with training, we are sure that he or she can perform EUS-B-FNA too.8 All surgeons have knives (EBUS), which should generally be restricted only to surgery (EBUS-TBNA), but they can occasionally cut vegetables (EUS-B-FNA) if need be.

References

Oki M, Saka H, Ando M, et al. Transbronchial vs transesophageal needle aspiration using an ultrasound bronchoscope for the diagnosis of mediastinal lesions: a randomized study. Chest. 2015;147(5):1259-1266. [CrossRef] [PubMed]
 
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]
 
Vallandramam PR, Sivaramakrishnan M, Srinivasan A. EUS-B-FNA: pulmonologist’s viewpoint: whose tube is it anyway? Lung India. 2015;32(3):285-286. [PubMed]
 
Dhooria S, Aggarwal AN, Singh N, et al. Endoscopic ultrasound-guided fine-needle aspiration with an echobronchoscope in undiagnosed mediastinal lymphadenopathy: first experience from India. Lung India. 2015;32(1):6-10. [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]
 
Kang HJ, Hwangbo B, Lee GK, et al. EBUS-centred versus EUS-centred mediastinal staging in lung cancer: a randomised controlled trial. Thorax. 2014;69(3):261-268. [CrossRef] [PubMed]
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389-1396. [CrossRef] [PubMed]
 
Yarmus L, Gilbert C, Lechtzin N, Imad M, Ernst A, Feller-Kopman D. Safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrostomy tube placement. Chest. 2013;144(2):436-440. [CrossRef] [PubMed]
 

Figures

Tables

References

Oki M, Saka H, Ando M, et al. Transbronchial vs transesophageal needle aspiration using an ultrasound bronchoscope for the diagnosis of mediastinal lesions: a randomized study. Chest. 2015;147(5):1259-1266. [CrossRef] [PubMed]
 
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]
 
Vallandramam PR, Sivaramakrishnan M, Srinivasan A. EUS-B-FNA: pulmonologist’s viewpoint: whose tube is it anyway? Lung India. 2015;32(3):285-286. [PubMed]
 
Dhooria S, Aggarwal AN, Singh N, et al. Endoscopic ultrasound-guided fine-needle aspiration with an echobronchoscope in undiagnosed mediastinal lymphadenopathy: first experience from India. Lung India. 2015;32(1):6-10. [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]
 
Kang HJ, Hwangbo B, Lee GK, et al. EBUS-centred versus EUS-centred mediastinal staging in lung cancer: a randomised controlled trial. Thorax. 2014;69(3):261-268. [CrossRef] [PubMed]
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389-1396. [CrossRef] [PubMed]
 
Yarmus L, Gilbert C, Lechtzin N, Imad M, Ernst A, Feller-Kopman D. Safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrostomy tube placement. Chest. 2013;144(2):436-440. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543