Rebuttal From Dr Huang et al

Abstract

Although the argument by Drs Wahidi and Yasufuku1Wahidi MM Yasufuku K Point: should endobronchial ultrasound guide every transbronchial needle aspiration of lymph nodes? Yes.Chest. 2013; 144: 732-734Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar for the use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in all patients is interesting, the question we must answer as a professional community is whether the exclusive use of EBUS-TBNA in all patients throughout the world is beneficial or harmful to patients.2Yarmus L Feller-Kopman D Browning R Wang KP TBNA: should EBUS be used on all lymph node aspirations?.J Bronchology Interv Pulmonol. 2011; 18: 115-117Crossref PubMed Scopus (10) Google Scholar Diagnostic performance of conventional transbronchial needle aspiration (C-TBNA) compared with EBUS-TBNA varies among the studies they cited, yet even in the cited studies, EBUS-TBNA only increased yield about 10% to 20% over C-TBNA. If a standard of practice included C-TBNA initially followed by EBUS-TBNA only if nondiagnostic, only a small percentage of the total patients would require EBUS-TBNA. C-TBNA has been performed successfully with the Wang lymph node map for decades without EBUS to show us the needle in the lymph node or on-site cytology to confirm an adequate specimen.3Stratakos G Porfyridis I Papas V et al.Exclusive diagnostic contribution of the histology specimens obtained by 19-gauge transbronchial aspiration needle in suspected malignant intrathoracic lymphadenopathy.Chest. 2008; 133: 131-136Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The main advantage of EBUS-TBNA is visualizing the needle inside the lesion in real time. Despite this advantage, EBUS still does not have 100% yield on every pass or in every case. Technique, lesion characteristics, and specimen preparation, handling, and interpretation are essentially the same with or without EBUS and, therefore, are unlikely to play a significant role in any difference. When EBUS is nondiagnostic, the patient is referred for another procedure to obtain the diagnosis. This same logic should apply to C-TBNA. When C-TBNA is nondiagnostic, escalate to EBUS or endoscopic ultrasound. When comparing costs of transbronchial needle aspiration (TBNA) methods, future studies need to compare a scenario where all TBNA procedures are performed with EBUS exclusively with a scenario where C-TBNA is performed first followed by EBUS-TBNA only if nondiagnostic.4Kunst PWA Eberhardt R Herth FJF Combined EBUS real time TBNA and conventional TBNA are the most cost-effective means of lymph node staging.J Bronchology Interv Pulmonol. 2008; 15: 17-20Google Scholar It may be true that EBUS-TBNA is more effective in smaller lymph nodes and higher paratracheal lymph nodes, but this has yet to be demonstrated in a direct comparative study with C-TBNA. In lung cancer with metastasis or in sarcoidosis, multiple and massive mediastinal lymph nodes often are involved. Whether the ability of sampling small, normal-sized lymph node metastasis will affect overall management of the patient is most interesting. We should continuously strive to improve and simplify the current EBUS-TBNA scope and methodology to develop a hybrid scope and method for TBNA.5Wang KP Turner JF Symanowski J A retrospective review of different methods of endobronchial ultrasound-guided transbronchial needle aspiration: a preliminary study.J Bronchology Interv Pulmonol. 2011; 18: 94-96Crossref PubMed Scopus (4) Google Scholar, 6Xiang Y Zhang F Akulian J Yarmus L Feller-Kopman D Wang KP EBUS-TBNA by a new Fuji EBUS scope (with video).J Thorac Dis. 2013; 5: 36-39PubMed Google Scholar The simple fact will not change: With adequate training, the difference in yield with TBNA with or without EBUS is relatively small. EBUS experts have the anatomic knowledge and skills to easily liberate themselves from the dependency of EBUS. To start, first use EBUS to confirm and reinforce an understanding of the lymph node location in relation to the airway, then gradually perform TBNA without the use of EBUS. EBUS-TBNA is like driving a car with a GPS (global positioning system), but we would not recommend that we stop driving cars without GPS. EBUS-TBNA is a great clinical and teaching tool that adds another dimension to bronchoscopy. It has the potential to enable more bronchoscopists to be able to learn and perform TBNA with or without the need of ultrasound guidance.7Wang KP Browning R TBNA is the issue, not EBUS guided [abstract].J Thorac Oncol. 2011; 6: S220-S221PubMed Google Scholar It is a major accomplishment in medicine.