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• W1845503968 abstract "Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an increasingly used technique amongst respiratory physicians, having been initially described nearly two decades ago.1 Its endooesophageal counterpart, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has an even longer history among gastroenterologists, originally used for the pancreas.2 More recent data have been pivotal in promoting the use of endosonography in lung cancer staging.3 Prior to this, comparative studies of EBUS-TBNA and mediastinoscopy had shown varying conclusions, possibly linked to disease prevalence.4,5 The more recent multicentre ASTER trial demonstrated the superiority of combined endosonography over surgical staging alone, achieving a superior sensitivity and avoidance of unnecessary thoracotomies.3 However, it should be noted that surgical staging was used in negative cases where necessary in the combined endosonography group in this trial, that this was not a direct comparison of EBUS-TBNA as EUS-FNA was also used, and finally, that this was performed in subspecialist EBUS centers by expert international EBUS bronchoscopists. What are, then, the more widespread implications of this for respiratory physicians doing EBUS-TBNA outside these subspecialist centers? We know that the learning curve for EBUS-TBNA is a long one, even for experienced bronchoscopists.6 Training, therefore, is important and competency outside of subspecialist centers as well as guidelines from the British Thoracic Society are impending. Existing guidelines on radial and linear probe EBUS and EUS-FNA from other national bodies show marked variation.7–9 Having additional EBUS-FNA on site in a combined endosonography service is the ideal, but may not be possible due to the costs. Other centers have used the EBUS bronchoscope down the esophagus using the same equipment to provide a limited EUS-FNA, called EUS-B-FNA,10–12 which avoids the extra costs of EUS-FNA and may be advantageous in patients with intractable cough and poor lung function; there is however no existing training program for EUS-B-FNA perse. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) has updated its guidelines in the light of new studies and expert opinion promoting the use of EBUS-TBNA depending on nodal size.13 For nodes between 10 and 20 mm, EBUS-TBNA (or EUS-FNA) is recommended as the staging technique of choice – when available over conventional TBNA as the default option – reserving neck ultrasound or conventional TBNA for nodes greater than 20 mm. Centers with EBUS-TBNA (or EUS-FNA) available might opt to use these techniques ahead of conventional TBNA for smaller nodes which are not central, as comparative studies and systematic reviews suggest the superiority of EBUS-TBNA over its conventional counterpart here.14–16 The prospective study by Mohan et al. is timely.17 This adds to the existing studies demonstrating the good performance that can be achieved with EBUS-TBNA in newly developed services, whether they are subspecialist or not, and are in keeping with existing studies.18–20 The setting was very applicable to a real world setting in a UK district general hospital with a patient population of more than nearly 200 over a period of 3 years, using EBUS-TBNA in the assessment of both malignant and benign disease. Although 16% of the patients had nodes under 10 mm, the mean size of nodes was 23 mm, adding weight to the idea of using EBUS-TBNA (on the basis this test is superior to conventional TBNA) even when the node size is greater than 20 mm, in contrast to recent recommendations from NICE.13 This study also provides useful predictors of diagnostic yield for malignancy including increased node size (>17 mm), age (>60) and fewer intraprocedure complications (which may be a surrogate marker for lymph node size). Where do we go from here? More information is needed on whether EBUS-TBNA (as is postulated) will indeed improve the patient journey and reduce other health-care costs, investigations, and reduce time to treatment. In this regard, the lung-BOOST trial will help answer these questions.21 This may also help in fostering the development of new EBUS-TBNA services in cost-rationed health-care systems, which is probably the main reason for the paucity of services in the UK;22 correct coding of interventional procedures remains important with room for improvement.20,23,24 In the longer term, there is a need to look at the endpoints of morbidity and mortality and whether earlier diagnosis via EBUS-TBNA can achieve measurable improvements in quality of life and even survival, by starting specific oncological treatment more quickly. What else does the future hold for EBUS-TBNA? Evidence is growing that EBUS-TBNA has a complementary role in sarcoidosis and is likely to be included in algorithms for diagnosis of sarcoidosis in stage 1 and 2 disease. Centers have shown sensitivities varying from 71% to 90%.25–31 It should be performed in addition to endobronchial, transbronchial biopsy and bronchoalveolar lavage given its superiority to these techniques in this setting.25,32,33 Ancillary but predictive sonographic signs at EBUS-TBNA may become increasingly incorporated into clinical practice,34 as well as detection of other ancillary pulmonary vascular disease.35 Adjunctive sampling forceps (transbronchial needle forceps biopsy) may improve sample size in lymphoproliferative disease or granulomatous disease.36 Although very safe, further longer term studies are required to give greater reassurance regarding the observations of metal particle release into nodes37 and occasional mediastinal infections.38–41 EBUS-TBNA is therefore here to stay and its role continues to expand and evolve with time. The author has no conflict of interest." @default.
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• W1845503968 title "Endobronchial ultrasound-guided transbronchial needle aspiration: Onwards and upwards" @default.
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• W1845503968 doi "https://doi.org/10.1111/j.1759-7714.2011.00065.x" @default.
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