Combined Imaging for Benign Mediastinal Lymphadenopathy: Response

Abstract

We note the comments of Dr Sharma in response to our initial publication1Medford ARL Agrawal S Single bronchoscope combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration for tuberculous mediastinal nodes.Chest. 2010; 138: 1274Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar on using combined endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) in the diagnostic evaluation of benign diseases, such as TB, by an endobronchial ultrasound (EBUS) scope, EBUS-transbronchial needle aspiration (EBUS-TBNA), and endoscopic ultrasound bronchoscope-guided needle aspiration (EUS-B-FNA). To clarify the purpose of our observations, we were seeking to highlight the potential usefulness of EUS-B-FNA for those practitioners trained in this application, particularly in situations where EBUS-TBNA was not tolerated as well for reasons of refractory cough, poor lung function, or significant comorbid lung disease. In these situations, in particular for an enlarged subcarinal node or paraesophageal lesion, we would use EUS-B-FNA to sample the lesion at the same sitting, with the same equipment, to avoid a nondiagnostic procedure. Our center currently does not have ready access to an endoscopic ultrasound (EUS) scope. If an EUS scope were available, however, we concur that this would allow greater access and scanning range for a complete EUS procedure, but that was not the purpose of our observation. We are not advocating EUS-B-FNA as a replacement or substitute for complete EUS-FNA, which requires training with an EUS scope, as the authors have stated. We also agree with the authors that EUS-B-FNA should not be performed unless the operator is trained in this particular application of the EBUS scope. We do not agree that EUS should be the first investigation for suspected benign lymphadenopathy in all situations; EBUS-TBNA is also a safe and technically straightforward procedure (as is EUS-FNA), although cough (which is not encountered with EUS) may be an issue. In our opinion, the first minimally invasive needle aspiration procedure should be guided by the location and accessibility of the lymphadenopathy, which may mean EUS-FNA for some locations or EBUS-TBNA for others. There are many centers that might have EBUS or EUS but not both modalities available, limited by the costs of these techniques. We suggest, therefore, that the available technique in the institution might also dictate which is the first-line investigation. If both are available, then, as discussed, anatomic factors should be considered. However, there is no evidence in the literature to clarify this choice, and, thus, we also agree that comparative studies are required. Combined Imaging for Benign Mediastinal Lymphadenopathy: Endoscopic Ultrasonography First or Endobronchial Ultrasonography First?CHESTVol. 140Issue 2PreviewI read with interest in a recent issue of CHEST (November 2010) the correspondence by Drs Medford and Agrawal1 about the use of combined endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) in the diagnostic evaluation of benign diseases, such as TB, by an endobronchial ultrasound (EBUS) scope. In their correspondence, the authors discussed the feasibilities of combining the imaging modalities to perform fine needle aspiration (FNA) initially from the respiratory tract (EBUS-FNA) and then, using the same scope, from the esophagus (EBUS-transesophageal-FNA). Full-Text PDF