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• W1491055111 abstract "The advent of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has revolutionized how mediastinal lesions are accessed in a noninvasive fashion. Although earlier systems used a separate radial probe to guide the procedure, the introduction of the hybrid endobronchial ultrasound (EBUS) scope allows for real-time visualization of the transbronchial needle aspiration.1Gress FG Savides TJ Sandler A et al.Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study.Ann Intern Med. 1997; 127: 604-612Crossref PubMed Google Scholar, 2Herth F Becker HD Ernst A Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial.Chest. 2004; 125: 322-325Abstract Full Text Full Text PDF PubMed Scopus (363) Google Scholar, 3Yasufuku K Chhajed PN Sekine Y et al.Endobronchial ultrasound using a new convex probe: a preliminary study on surgically resected specimens.Oncol Rep. 2004; 11: 293-296PubMed Google Scholar, 4Yasufuku K Chiyo M Sekine Y et al.Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes.Chest. 2004; 126: 122-128Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar In addition, given the anatomy of the esophagus as it traverses through the chest, the mediastinum can also be accessed with endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Although EUS-FNA and EBUS-TBNA share several anatomic stations within the mediastinum, they each separately access areas unreachable by the other. Consequently, they have been put forward as complementary procedures; several studies report the superiority of the combination over the individual procedure.5Zhang 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: 1860-1867Abstract Full Text Full Text PDF PubMed Scopus (101) Google ScholarEven though the literature on their combined use mainly revolves around the staging of lung cancer, it also favors its use in benign processes.6von Bartheld MB Dekkers OM Szlubowski A et al.Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial.JAMA. 2013; 309: 2457-2464Crossref PubMed Scopus (171) Google Scholar To date, however, there are no randomized studies comparing EBUS-TBNA head to head with EUS-FNA in patients with lesions accessible to both. In this issue of CHEST (see page 1259), Oki et al7Oki 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: 1259-1266Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar addresses this question. Patients with lesions accessible to both modalities, primarily in nodal stations 2L, 3p, 4L, 7, and/or adjacent masses, were randomized to either EBUS-TBNA or EUS-FNA. Procedures were performed under conscious sedation. Interestingly, the proceduralists were all pulmonologists, and a dedicated EBUS scope was used for both approaches. At face value, the study showed similar yield and patient satisfaction among both groups. Understandably, less topical anesthesia and sedation were required and there were less frequent desaturation events in EUS-FNA compared with the EBUS-TBNA group. The study, however, brings up broader issues; specifically, should the esophagus be accessed during EBUS procedures, and if so, who should be performing the procedure and using which scope?In a nonstaging, diagnostic procedure where the lesion in question is inaccessible to EBUS-TBNA and more suited for EUS-FNA, the latter should be considered. The current study demonstrates that for regions that can be visualized by both modalities, yield is similar. However, the practicality of these findings in a given clinical setting is limited; seldom are all of the regions of interest confined to those that can be accessed by both modalities. The question of adding EUS-FNA to EBUS-TBNA in the setting of staging is an even more complicated one. Even though several studies have shown that the combined use of both modalities is superior to either modality alone, they have limitations.5Zhang 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: 1860-1867Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar One is that some of the studies have much lower than expected EBUS-TBNA yield.8Rintoul RC Skwarski KM Murchison JT Wallace WA Walker WS Penman ID Endobronchial and endoscopic ultrasound-guided real-time fine-needle aspiration for mediastinal staging.Eur Respir J. 2005; 25: 416-421Crossref PubMed Scopus (266) Google Scholar, 9Liberman M Sampalis J Duranceau A Thiffault V Hadjeres R Ferraro P Endosonographic mediastinal lymph node staging of lung cancer.Chest. 2014; 146: 389-397Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 10Liberman 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: 232-236Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 11Wallace MB Pascual JM Raimondo M et al.Minimally invasive endoscopic staging of suspected lung cancer.JAMA. 2008; 299: 540-546Crossref PubMed Scopus (370) Google Scholar Several of the other studies demonstrated superiority of endoscopic ultrasound (EUS) in nodes that should be easily accessed by EBUS, such as stations 7 and 4L.12Oki 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: 1169-1177Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Other studies demonstrated a high rate of metastases to nodal stations 8 and 9 which may have biased the data in favor of EUS-FNA.9Liberman M Sampalis J Duranceau A Thiffault V Hadjeres R Ferraro P Endosonographic mediastinal lymph node staging of lung cancer.Chest. 2014; 146: 389-397Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 10Liberman 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: 232-236Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 11Wallace MB Pascual JM Raimondo M et al.Minimally invasive endoscopic staging of suspected lung cancer.JAMA. 2008; 299: 540-546Crossref PubMed Scopus (370) Google Scholar It is unclear how often nodal stations 8 and/or 9 have isolated metastases. Indeed, a more recent randomized controlled trial showed no added benefit of EUS-FNA to EBUS-TBNA when the EBUS was the first modality used; notably, the accuracy of EBUS-TBNA in this study was 93%.13Kang HJ Hwangbo B Lee GK et al.EBUS-centred versus EUS-centred mediastinal staging in lung cancer: a randomised controlled trial.Thorax. 2014; 69: 261-268Crossref PubMed Scopus (76) Google Scholar In our opinion, practicality of the “EUS-FNA alone” or the “combined” approach remains debatable.Another potential flaw of these studies includes use of an EBUS scope for the EUS procedures. Indeed, it is possible to reach station 8 and 9 with the EBUS scope, but obviously it cannot reach the adrenal glands. The more obvert limitation of the EBUS scope is that it is not made to flush air during the procedure. Thus, the procedure is more blinded in inexperienced hands. Additionally, the EBUS scope has inferior image quality and a narrower scanning plane than the EUS scope.Perhaps the most important limitation of some studies is having a pulmonologist rather than a gastroenterologist performing the EUS. It is well known that pulmonary training in the United States does not include esophagogastroduadenoscopy procedures. The esophagus has historically been accessed solely by gastroenterologists, general surgeons, and thoracic surgeons. Knowledge of esophageal anatomy within the mediastinum is necessary when performing the EUS-FNA. The esophagus is a much different organ than the trachea, requiring knowledge of its structure for the procedure to be performed safely. That said, the rate of serious complications directly related to the EUS procedures is very low at 0.3%, with mediastinal infection and esophageal perforation being the most common.14von Bartheld MB van Breda A Annema JT Complication rate of endosonography (endobronchial and endoscopic ultrasound): a systematic review.Respiration. 2014; 87: 343-351Crossref PubMed Scopus (104) Google Scholar, 15Merchea A Cullinane DC Sawyer MD et al.Esophagogastroduodenoscopy-associated gastrointestinal perforations: a single-center experience.Surgery. 2010; 148: 876-880Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar However, this rate is found in the hands of expert endoscopists with enough experience worthy of publishing. A single major complication in the hands of a pulmonologist could raise major issues.It should also be noted that most published studies recommending the use of EUS by the pulmonogist are published from outside of North America where the training curriculum may be very different. Whether similar success can be expected from the American pulmonologist remains unclear.16Narula T Baughman RP Mehta AC Sarcoidosis Americana-route Europa.J Bronchology Interv Pulmonol. 2013; 20: 293-296Crossref PubMed Scopus (8) Google Scholar Cardiologists who access the esophagus to perform echocardiograms or the gastroenterologists who perform EUS undergo additional Accreditation Council for Graduate Medical Education-approved training before embarking on their procedures.It may be safe to say that accessing the esophagus should only be performed by an experienced endoscopist. Given the setting where most EBUS-TBNA is performed, the possibility of having an additional operator to perform EUS may not be practical. Although this issue may not be problematic with thoracic surgeons, it certainly is an issue with pulmonologists who are not routinely trained in EUS-FNA. In our opinion, no one should attempt EUS-FNA using an EBUS scope without “proper training.” The definition of the proper training remains to be written. The level of training and competency measures should be entertained and developed before the routine use of combined EBUS-EUS procedures by pulmonologists is undertaken. We feel that it is time for the thoracic and gastroenterology societies to jointly recommend minimal requirement for the pulmonologist to perform the EUS procedures in the United States.“Just because the chef has a knife that doesn't mean he/she can perform a surgery.” This is in the best interest of the welfare of the patients. The advent of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has revolutionized how mediastinal lesions are accessed in a noninvasive fashion. Although earlier systems used a separate radial probe to guide the procedure, the introduction of the hybrid endobronchial ultrasound (EBUS) scope allows for real-time visualization of the transbronchial needle aspiration.1Gress FG Savides TJ Sandler A et al.Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study.Ann Intern Med. 1997; 127: 604-612Crossref PubMed Google Scholar, 2Herth F Becker HD Ernst A Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial.Chest. 2004; 125: 322-325Abstract Full Text Full Text PDF PubMed Scopus (363) Google Scholar, 3Yasufuku K Chhajed PN Sekine Y et al.Endobronchial ultrasound using a new convex probe: a preliminary study on surgically resected specimens.Oncol Rep. 2004; 11: 293-296PubMed Google Scholar, 4Yasufuku K Chiyo M Sekine Y et al.Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes.Chest. 2004; 126: 122-128Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar In addition, given the anatomy of the esophagus as it traverses through the chest, the mediastinum can also be accessed with endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Although EUS-FNA and EBUS-TBNA share several anatomic stations within the mediastinum, they each separately access areas unreachable by the other. Consequently, they have been put forward as complementary procedures; several studies report the superiority of the combination over the individual procedure.5Zhang 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: 1860-1867Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar Even though the literature on their combined use mainly revolves around the staging of lung cancer, it also favors its use in benign processes.6von Bartheld MB Dekkers OM Szlubowski A et al.Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial.JAMA. 2013; 309: 2457-2464Crossref PubMed Scopus (171) Google Scholar To date, however, there are no randomized studies comparing EBUS-TBNA head to head with EUS-FNA in patients with lesions accessible to both. In this issue of CHEST (see page 1259), Oki et al7Oki 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: 1259-1266Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar addresses this question. Patients with lesions accessible to both modalities, primarily in nodal stations 2L, 3p, 4L, 7, and/or adjacent masses, were randomized to either EBUS-TBNA or EUS-FNA. Procedures were performed under conscious sedation. Interestingly, the proceduralists were all pulmonologists, and a dedicated EBUS scope was used for both approaches. At face value, the study showed similar yield and patient satisfaction among both groups. Understandably, less topical anesthesia and sedation were required and there were less frequent desaturation events in EUS-FNA compared with the EBUS-TBNA group. The study, however, brings up broader issues; specifically, should the esophagus be accessed during EBUS procedures, and if so, who should be performing the procedure and using which scope? In a nonstaging, diagnostic procedure where the lesion in question is inaccessible to EBUS-TBNA and more suited for EUS-FNA, the latter should be considered. The current study demonstrates that for regions that can be visualized by both modalities, yield is similar. However, the practicality of these findings in a given clinical setting is limited; seldom are all of the regions of interest confined to those that can be accessed by both modalities. The question of adding EUS-FNA to EBUS-TBNA in the setting of staging is an even more complicated one. Even though several studies have shown that the combined use of both modalities is superior to either modality alone, they have limitations.5Zhang 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: 1860-1867Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar One is that some of the studies have much lower than expected EBUS-TBNA yield.8Rintoul RC Skwarski KM Murchison JT Wallace WA Walker WS Penman ID Endobronchial and endoscopic ultrasound-guided real-time fine-needle aspiration for mediastinal staging.Eur Respir J. 2005; 25: 416-421Crossref PubMed Scopus (266) Google Scholar, 9Liberman M Sampalis J Duranceau A Thiffault V Hadjeres R Ferraro P Endosonographic mediastinal lymph node staging of lung cancer.Chest. 2014; 146: 389-397Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 10Liberman 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: 232-236Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 11Wallace MB Pascual JM Raimondo M et al.Minimally invasive endoscopic staging of suspected lung cancer.JAMA. 2008; 299: 540-546Crossref PubMed Scopus (370) Google Scholar Several of the other studies demonstrated superiority of endoscopic ultrasound (EUS) in nodes that should be easily accessed by EBUS, such as stations 7 and 4L.12Oki 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: 1169-1177Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Other studies demonstrated a high rate of metastases to nodal stations 8 and 9 which may have biased the data in favor of EUS-FNA.9Liberman M Sampalis J Duranceau A Thiffault V Hadjeres R Ferraro P Endosonographic mediastinal lymph node staging of lung cancer.Chest. 2014; 146: 389-397Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 10Liberman 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: 232-236Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 11Wallace MB Pascual JM Raimondo M et al.Minimally invasive endoscopic staging of suspected lung cancer.JAMA. 2008; 299: 540-546Crossref PubMed Scopus (370) Google Scholar It is unclear how often nodal stations 8 and/or 9 have isolated metastases. Indeed, a more recent randomized controlled trial showed no added benefit of EUS-FNA to EBUS-TBNA when the EBUS was the first modality used; notably, the accuracy of EBUS-TBNA in this study was 93%.13Kang HJ Hwangbo B Lee GK et al.EBUS-centred versus EUS-centred mediastinal staging in lung cancer: a randomised controlled trial.Thorax. 2014; 69: 261-268Crossref PubMed Scopus (76) Google Scholar In our opinion, practicality of the “EUS-FNA alone” or the “combined” approach remains debatable. Another potential flaw of these studies includes use of an EBUS scope for the EUS procedures. Indeed, it is possible to reach station 8 and 9 with the EBUS scope, but obviously it cannot reach the adrenal glands. The more obvert limitation of the EBUS scope is that it is not made to flush air during the procedure. Thus, the procedure is more blinded in inexperienced hands. Additionally, the EBUS scope has inferior image quality and a narrower scanning plane than the EUS scope. Perhaps the most important limitation of some studies is having a pulmonologist rather than a gastroenterologist performing the EUS. It is well known that pulmonary training in the United States does not include esophagogastroduadenoscopy procedures. The esophagus has historically been accessed solely by gastroenterologists, general surgeons, and thoracic surgeons. Knowledge of esophageal anatomy within the mediastinum is necessary when performing the EUS-FNA. The esophagus is a much different organ than the trachea, requiring knowledge of its structure for the procedure to be performed safely. That said, the rate of serious complications directly related to the EUS procedures is very low at 0.3%, with mediastinal infection and esophageal perforation being the most common.14von Bartheld MB van Breda A Annema JT Complication rate of endosonography (endobronchial and endoscopic ultrasound): a systematic review.Respiration. 2014; 87: 343-351Crossref PubMed Scopus (104) Google Scholar, 15Merchea A Cullinane DC Sawyer MD et al.Esophagogastroduodenoscopy-associated gastrointestinal perforations: a single-center experience.Surgery. 2010; 148: 876-880Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar However, this rate is found in the hands of expert endoscopists with enough experience worthy of publishing. A single major complication in the hands of a pulmonologist could raise major issues. It should also be noted that most published studies recommending the use of EUS by the pulmonogist are published from outside of North America where the training curriculum may be very different. Whether similar success can be expected from the American pulmonologist remains unclear.16Narula T Baughman RP Mehta AC Sarcoidosis Americana-route Europa.J Bronchology Interv Pulmonol. 2013; 20: 293-296Crossref PubMed Scopus (8) Google Scholar Cardiologists who access the esophagus to perform echocardiograms or the gastroenterologists who perform EUS undergo additional Accreditation Council for Graduate Medical Education-approved training before embarking on their procedures. It may be safe to say that accessing the esophagus should only be performed by an experienced endoscopist. Given the setting where most EBUS-TBNA is performed, the possibility of having an additional operator to perform EUS may not be practical. Although this issue may not be problematic with thoracic surgeons, it certainly is an issue with pulmonologists who are not routinely trained in EUS-FNA. In our opinion, no one should attempt EUS-FNA using an EBUS scope without “proper training.” The definition of the proper training remains to be written. The level of training and competency measures should be entertained and developed before the routine use of combined EBUS-EUS procedures by pulmonologists is undertaken. We feel that it is time for the thoracic and gastroenterology societies to jointly recommend minimal requirement for the pulmonologist to perform the EUS procedures in the United States. “Just because the chef has a knife that doesn't mean he/she can perform a surgery.” This is in the best interest of the welfare of the patients." @default.
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