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Masahide Oki, MD, FCCP; Hideo Saka, MD, FCCP
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FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Department of Respiratory Medicine, Nagoya Medical Center, Nagoya, Japan

CORRESPONDENCE TO: Masahide Oki, MD, FCCP, Department of Respiratory Medicine, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya 460-0001, Japan


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(4):985-986. doi:10.1016/j.chest.2015.10.025
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We thank Drs Annema and Konge for their enlightening comments regarding our study comparing the tolerance, efficacy, and safety of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (EBUS-TBNA) with transesophageal endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) with an EBUS scope for the diagnosis of mediastinal lesions.

In the study, we demonstrated that EUS-FNA with an EBUS scope had the advantage of comparable tolerance with fewer doses of anesthetics and sedatives, shorter procedure time, less oxygen desaturation, less coughing, and greater operator satisfaction compared with EBUS-TBNA. As Drs Annema and Konge commented, this procedure can be performed for patients with severe COPD for whom the transbronchial approach for the diagnosis of lung cancer seems impossible. This procedure plays an important role not only for initial diagnosis, as we demonstrated, but also for mediastinal staging, as a single or a combined procedure with EBUS-TBNA.

Traditionally, EUS-FNA has been performed by gastroenterologists, but the performance of the procedure by pulmonologists, who make the management decision for patients with mediastinal lesions, is quite reasonable in terms of feedback on the EUS-FNA results. In addition, pulmonologists are more familiar with the mediastinal lymph node mapping and staging than gastroenterologists. Although EUS-FNA with an EUS scope has the advantage of accessibility, especially to left adrenal glands or subaortic lymph nodes, and endoscopic/ultrasonographic visibility, EUS-FNA with an EBUS scope seems to be much more practical for pulmonologists in terms of equipment preparation and simple handling. The important thing for popularizing and widely implementing the useful procedure is that pulmonologists become aware of its clinical utility. Thus, we must continue efforts to inform pulmonologists as to the usefulness of this procedure.

To ensure the safety and accuracy of the procedure, training is essential. In the esophagus, there are no endoscopic landmarks like the carina in the airway, so we must confirm the exact location only by the ultrasound image. As Drs Annema and Konge commented, the challenge to mastering the procedure for pulmonologists, who are familiar with EBUS-TBNA, may be learning the mediastinal anatomy on the ultrasound image through the esophagus rather than acquiring the needle aspiration technique. A standard training protocol (including structured curriculum, simulation, and the assessment of technical skills or competency), which attaches importance to the ultrasound image of mediastinal structures through the esophagus, is needed. Until the way of training is established, pulmonologists should acquire substantial skills in EBUS-TBNA and training from an expert gastroenterologist prior to performing the EUS-FNA procedure; then, it should be performed under the supervision of an expert operator.

Drs Annema and Konge must be commended for their efforts to implement EUS-FNA performed by pulmonologists. We hope that the clinical usefulness of EUS-FNA with an EBUS scope will be noticed by many pulmonologists and that their standardized training procedure will be established.

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;147:1259-1266 [PubMed]journal. [CrossRef] [PubMed]
 
Oki M. .Saka H. .Kitagawa C. . Transesophageal bronchoscopic ultrasound-guided fine-needle aspiration for diagnosis of peripheral lung cancer. Ann Thorac Surg. 2011;91:1613-1616 [PubMed]journal. [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;148:1169-1177 [PubMed]journal. [CrossRef] [PubMed]
 
Annema J.T. .Rabe K.F. . Why respiratory physicians should learn and implement EUS-FNA. Am J Respir Crit Care Med. 2007;176:99- [PubMed]journal. [CrossRef]
 
Konge L. .Annema J. .Vilmann P. .Clementsen P. .Ringsted C. . Transesophageal ultrasonography for lung cancer staging: learning curves of pulmonologists. J Thorac Oncol. 2013;8:1402-1408 [PubMed]journal. [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;147:1259-1266 [PubMed]journal. [CrossRef] [PubMed]
 
Oki M. .Saka H. .Kitagawa C. . Transesophageal bronchoscopic ultrasound-guided fine-needle aspiration for diagnosis of peripheral lung cancer. Ann Thorac Surg. 2011;91:1613-1616 [PubMed]journal. [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;148:1169-1177 [PubMed]journal. [CrossRef] [PubMed]
 
Annema J.T. .Rabe K.F. . Why respiratory physicians should learn and implement EUS-FNA. Am J Respir Crit Care Med. 2007;176:99- [PubMed]journal. [CrossRef]
 
Konge L. .Annema J. .Vilmann P. .Clementsen P. .Ringsted C. . Transesophageal ultrasonography for lung cancer staging: learning curves of pulmonologists. J Thorac Oncol. 2013;8:1402-1408 [PubMed]journal. [CrossRef] [PubMed]
 
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