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• W2034823032 abstract "We read with great interest and humility the comments by Drs Huang, Browning, and Wang1Huang JA Browning R Wang K-P Counterpoint: should endobronchial ultrasound guide every transbronchial needle aspiration of lymph nodes? No.Chest. 2013; 144: 734-737Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar about conventional transbronchial needle aspiration (C-TBNA). If we were patients in the waiting room of a bronchoscopy suite and found out that Drs Huang, Browning, and Wang were about to perform our tranbronchial needle aspiration (TBNA), we would be ecstatic and want no “extra” endobronchial ultrasound (EBUS) scope to traverse our airways. However, Drs Huang, Browning, and Wang are a rarity in the world of TBNA and, per their comments, “the operator's ability and experience are among the most important factors influencing TBNA sensitivity,” spanning a wide range of 39% to 78%”.1Huang JA Browning R Wang K-P Counterpoint: should endobronchial ultrasound guide every transbronchial needle aspiration of lymph nodes? No.Chest. 2013; 144: 734-737Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar As we pointed out in our argument, many chest physicians have tried to emulate the skills of Drs Huang, Browning, and Wang but have faltered. EBUS-guided TBNA (EBUS-TBNA) has proven easier to learn and to execute with high diagnostic yields from centers small and large, private and academic, from China to Egypt, and not just in the hands of a few skilled physicians.2Holty JE Kuschner WG Gould MK Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis.Thorax. 2005; 60: 949-955Crossref PubMed Scopus (239) Google Scholar, 3Yang H Zhao H Garfield DH Teng J Han B Sun J Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of non-lymph node thoracic lesions.Ann Thorac Med. 2013; 8: 14-21Crossref PubMed Scopus (19) Google Scholar, 4Sharples LD Jackson C Wheaton E et al.Clinical effectiveness and cost-effectiveness of endobronchial and endoscopic ultrasound relative to surgical staging in potentially resectable lung cancer: results from the ASTER randomised controlled trial.Health Technol Assess. 2012; 16: 1-75Crossref PubMed Scopus (103) Google Scholar, 5Safwat T Khattab A Haddad SE et al.Endobronchial ultrasound-directed transbronchial needle aspiration in diagnosis of mediastinal lesions: initial Egyptian experience.J Bronchology Interv Pulmonol. 2009; 16: 18-21Crossref PubMed Scopus (3) Google Scholar We agree that large-scale randomized clinical trials comparing C-TBNA and EBUS-TBNA have not been performed, but we believe that the scientific burden of proof has been met satisfactorily with large meta-analyses and smaller disease-specific prospective comparative studies in lung cancer and sarcoidosis.6Wallace MB Pascual JM Raimondo M et al.Minimally invasive endoscopic staging of suspected lung cancer.JAMA. 2008; 299: 540-546Crossref PubMed Scopus (374) Google Scholar, 7Tremblay A Stather DR Maceachern P Khalil M Field SK A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis.Chest. 2009; 136: 340-346Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar We also agree that C-TBNA should continue to be used in centers throughout the world that cannot afford EBUS technology. We hope that increasing competition among EBUS manufacturers and continued human innovation will either drive down the price of EBUS, making it available to centers and patients with limited resources, or invent a less-expensive portable EBUS attachment to a regular scope. After all, large ultrasound machines of the past are now matched with hand-held devices.8Schleder S Dendl LM Ernstberger A et al.Diagnostic value of a hand-carried ultrasound device for free intra-abdominal fluid and organ lacerations in major trauma patients.Emerg Med J. 2013; 30: e20Crossref PubMed Scopus (18) Google Scholar The suggested approach by Drs Huang, Browning, and Wang1Huang JA Browning R Wang K-P Counterpoint: should endobronchial ultrasound guide every transbronchial needle aspiration of lymph nodes? No.Chest. 2013; 144: 734-737Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar of performing C-TBNA as a first diagnostic choice and then escalating to more advanced techniques, such as EBUS-TBNA, has many limitations, including the smaller number of mediastinal lymph node stations that can be reached by C-TBNA, prolonged procedure time when both modalities have to be used, and the complete reliance on rapid on-site evaluation, a coveted, costly service that is not available in many institutions. We would counter that the best approach to sampling the mediastinum is with EBUS-TBNA first followed by mediastinoscopy for patients with negative results on EBUS-TBNA yet a high suspicion of malignancy. In fact, an Australian cost-benefit analysis comparing C-TBNA, EBUS-TBNA, and mediastinoscopy demonstrated that EBUS-TBNA with negative results confirmed surgically is the most cost-beneficial approach (Australian $2,961 vs $3,754 for EBUS-TBNA vs C-TBNA, respectively).9Steinfort DP Liew D Conron M Hutchinson AF Irving LB Cost-benefit of minimally invasive staging of non-small cell lung cancer: a decision tree sensitivity analysis.J Thorac Oncol. 2010; 5: 1564-1570Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar We could not agree more with Drs Huang, Browning, and Wang1Huang JA Browning R Wang K-P Counterpoint: should endobronchial ultrasound guide every transbronchial needle aspiration of lymph nodes? No.Chest. 2013; 144: 734-737Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar that EBUS-TBNA is highly effective and should be considered the alternative staging procedure of choice. The data suggest so, as does the broad embrace by pulmonologists and thoracic surgeons throughout the world. Although there are many painters in the world, only a few (eg, Picasso, da Vinci, van Gogh) are renowned for their skill. EBUS might just be that magical brush that elevates many of us close enough to a masterful performance of TBNA." @default.
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• W2034823032 title "Rebuttal From Drs Wahidi and Yasufuku" @default.
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