We would like to thank Dr. Schmidt for highlighting the importance of verification bias. We agree that this is a frequent drawback of studies examining sensitivity and specificity based on histological follow-up. The use of histological follow-up usually lowers the number of true-positive cases in endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) specimens given that EBUS-FNAs with a positive diagnosis usually do not go on for confirmatory histological sampling. This is in contrast to other types of diagnostic accuracy studies in which a positive screening cytology finding will usually result in a gold-standard procedure, such as surgical resection, and thus more positive cytology cases will usually have histological follow-up than negative cases. For ethical reasons and good clinical practice, verification bias therefore cannot be truly eliminated in this clinical setting because it is often not feasible to perform an invasive mediastinoscopy after a positive EBUS diagnosis in which sufficient cellular material has been collected. In our study,1 there were 420 satisfactory EBUS-FNAs, 138 of which (33%) had a negative cytological diagnosis and 216 of which (51%) had a positive cytological diagnosis, but among the 97 histologically verified samples with a positive or negative EBUS-FNA diagnosis, 81 (84%) were initially negative and 16 (16%) were initially positive. Therefore, overall, more negative samples were followed with biopsy, and this verification bias may actually underestimate the study's sensitivity using histological follow-up.1 In prior, smaller studies that examined the sensitivity and specificity of EBUS-FNA based on cases with histological follow-up, the results were found to be similar, with sensitivity ranging from approximately 69% to 89%.2-5 In addition, the few EBUS studies incorporating clinical follow-up have demonstrated that the sensitivity increases to approximately ≥ 95%, given that patients with EBUS-FNAs that were positive for malignancy and never underwent surgery were included as having true-positive results based on clinical and radiological parameters.3, 4 We would like to thank Dr. Schmidt for his valuable comments and for highlighting the importance of verification bias. No specific funding was disclosed. The authors made no disclosures. Arivarasan Karunamurthy, MD Department of Pathology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Guoping Cai, MD Department of Pathology Yale University School of Medicine New Haven, Connecticut Sanja Dacic, MD, PhD Department of Pathology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Walid E. Khalbuss, MD, PhD Department of Pathology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Liron Pantanowitz, MD Department of Pathology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Sara E. Monaco, MD Department of Pathology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania