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lot of literature exists in favor of endobronchial ultrasound (EBUS), I would like to make three comments. First, Dr Shrager [1] mentioned that there is very little evidence that the EBUS procedure can be reliably and reproducibly performed without general anesthesia, and concluded that a technique like EBUS- transbronchial needle aspiration (TBNA) that requires multiple needle sticks in multiple areas of the airway is unlikely to be done well without general anesthesia. The latter can not be stated for two reasons. Bronchoscopy procedures (with and without TBNA) are performed in topical anesthesia or conscious sedation in many countries without any problems, and recently Steinfort and Irving [3] showed that EBUS-TBNA is a safe procedure under conscious sedation. Second, Shrager [1] mentioned that a study that would com- pare cost strategy would be more appropriate. In 2008, we published an overview in which five different strategies of the actual costs for the procedures of 100 patients were calculated, including mediastinoscopy, TBNA, and EBUS-TBNA [4]. If the results were still negative after different procedures, mediasti- noscopy was performed. Standard TBNA combined with EBUS real time TBNA significantly reduces the costs for staging of the mediastinum. Finally, I agree with Drs Groth and Andrade [2] that we should preserve mediastinoscopy for restaging procedures because, as Shrager [1] also mentions, re-mediastinoscopy is not an optimal approach. Therefore, I believe that mediastinoscopy is still the gold standard, but it is complementary to other techniques that have to be performed first. Peter W. A. Kunst, MD, PhD Department of Pulmonology AMC Meibergdreef 9 Amsterdam, 1105 AZ, the Netherlands e-mail: [email protected] References 1. Shrager JB. Mediastinoscopy: still the gold standard. Ann Thorac Surg 2010;89:S2084 –9. 2. Groth SS, Andrade RS. Endobronchial and endoscopic ultra- sound-guided fine-needle aspiration: a must for thoracic surgeons. Ann Thorac Surg 2010;89:S2079 – 83. 3. Steinfort DP, Irving LB. Patient satisfaction during endobron- chial ultrasound-guided transbronchial needle aspiration performed under conscious sedation. Respir Care 2010;55: 702– 6. 4. Kunst P, Eberhardt R, Herth F. Combined EBUS real time TBNA and conventional TBNA are the most cost-effective means of lymph node staging. J Bronchol 2008;15:17–20. Reply To the Editor: We read with interest the letter by Dr Kunst [1]. We clearly recognize the role of mediastinoscopy in the diagnosis and staging of lung cancer, and we view mediastinoscopy as com- plementary to endobronchial ultrasound (EBUS) and en- doesophageal ultrasound (EUS). In our opinion, the facts on mediastinoscopy vs EBUS-EUS are as follow: ● Diagnostic performance: a direct prospective compari- son of mediastinoscopy vs EBUS-EUS has not been published to date; hence, we must rely on the available retrospective data from experienced centers. These data suggest that mediastinoscopy and EBUS-EUS are equiv- alent in diagnostic performance, except for a negative- predictive value of 91% to 98% for mediastinoscopy and 60% to 97% for EBUS [1]. It is the role of the operator to decide whether to trust a negative EBUS-EUS cytologic result, a decision that will have to be based on the pretest probability of lymph node metastasis and the operator’s and cytopathologist’s experience. When in doubt, a mediastinoscopy should be performed to con- firm a negative EBUS-EUS sample; at our institution, we perform a mediastinoscopy only in about 10% of patients who undergo EBUS-EUS for lung cancer staging [2, 3]. ● Invasiveness: EBUS-EUS is less invasive than mediasti- noscopy, particularly when performed under sedation; but this is not the strongest argument in favor of EBUS- EUS. However, in the setting of mediastinal restaging, mediastinoscopy is associated with a mortality rate of up to 1% and a threefold increase in morbidity compared with initial mediastinoscopy [4]. We believe that medi- astinal restaging should always be done with EBUS- EUS, since the morbidity appears to be lower than in redo mediastinoscopy and the diagnostic results are similar [5]. ● Cost: the issue of cost has not been sufficiently studied. The results of cost analyses depend on who is behind them, and it is doubtful that this issue will ever be addressed to everyone’s satisfaction. ● Versatility: the combination of EBUS-EUS allows for pathologic staging beyond peritracheal lymph nodes. EBUS-EUS can access N1 and paraesophageal lymph nodes, the liver, and the left adrenal gland. In addition, experienced operators can sample station 5 with EUS (transpulmonary approach). In summary, most patients with lung cancer can be accurately staged with EBUS-EUS, and only about 10% will require a mediastinoscopy. The question is: Why should we do EBUS- EUS instead of mediastinoscopy as a staging procedure? First, EBUS-EUS is a diagnostic procedure that is safe, accu- rate, versatile, and requires no incision; and, when in doubt, a mediastinoscopy can still be performed. Also, EBUS-EUS is safer for mediastinal restaging than mediastinoscopy. Second, EBUS-EUS does not mark the end of mediastinos- copy, but instead the beginning of a new era with expanded diagnostic tools for thoracic diseases. Currently, the argument of mediastinoscopy vs EBUS-EUS is entirely irrelevant: these pro- cedures complement each other. Third, we must recognize EBUS-EUS as a welcome advance that, with our input, will lead to further innovations and contin- ued improvement in patient care. A quote from my mentor, Dr Michael Maddaus, states in a very succinct way how to approach a new and inevitable situation: “You can either fight it or embrace it. I recommend the latter.” From the patient’s perspective, the choice of mediastinoscopy vs EBUS-EUS with equivalent results is straightforward— our patients clearly prefer the endoscopic procedure. Rafael Andrade, MD Division of General Thoracic and Foregut Surgery University of Minnesota 420 Delaware St SE, MMC 207 Minneapolis, MN 55455 e-mail: [email protected] 990 CORRESPONDENCE Ann Thorac Surg 2011;91:983–91 MISCELLANEOUS
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990 CORRESPONDENCE Ann Thorac Surg2011;91:983–91
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lot of literature exists in favor of endobronchial ultrasound(EBUS), I would like to make three comments. First, Dr Shrager[1] mentioned that there is very little evidence that the EBUSprocedure can be reliably and reproducibly performed withoutgeneral anesthesia, and concluded that a technique like EBUS-transbronchial needle aspiration (TBNA) that requires multipleneedle sticks in multiple areas of the airway is unlikely to bedone well without general anesthesia. The latter can not bestated for two reasons. Bronchoscopy procedures (with andwithout TBNA) are performed in topical anesthesia or conscioussedation in many countries without any problems, and recentlySteinfort and Irving [3] showed that EBUS-TBNA is a safeprocedure under conscious sedation.
Second, Shrager [1] mentioned that a study that would com-pare cost strategy would be more appropriate. In 2008, wepublished an overview in which five different strategies of theactual costs for the procedures of 100 patients were calculated,including mediastinoscopy, TBNA, and EBUS-TBNA [4]. If theresults were still negative after different procedures, mediasti-noscopy was performed. Standard TBNA combined with EBUSreal time TBNA significantly reduces the costs for staging of themediastinum.
Finally, I agree with Drs Groth and Andrade [2] that we shouldpreserve mediastinoscopy for restaging procedures because, asShrager [1] also mentions, re-mediastinoscopy is not an optimal
pproach. Therefore, I believe that mediastinoscopy is still theold standard, but it is complementary to other techniques thatave to be performed first.
eter W. A. Kunst, MD, PhD
epartment of PulmonologyMCeibergdreef 9
msterdam, 1105 AZ, the Netherlands-mail: [email protected]
References
1. Shrager JB. Mediastinoscopy: still the gold standard. AnnThorac Surg 2010;89:S2084–9.
2. Groth SS, Andrade RS. Endobronchial and endoscopic ultra-sound-guided fine-needle aspiration: a must for thoracicsurgeons. Ann Thorac Surg 2010;89:S2079–83.
3. Steinfort DP, Irving LB. Patient satisfaction during endobron-chial ultrasound-guided transbronchial needle aspirationperformed under conscious sedation. Respir Care 2010;55:702–6.
4. Kunst P, Eberhardt R, Herth F. Combined EBUS real timeTBNA and conventional TBNA are the most cost-effectivemeans of lymph node staging. J Bronchol 2008;15:17–20.
ReplyTo the Editor:
We read with interest the letter by Dr Kunst [1]. We clearlyrecognize the role of mediastinoscopy in the diagnosis andstaging of lung cancer, and we view mediastinoscopy as com-plementary to endobronchial ultrasound (EBUS) and en-doesophageal ultrasound (EUS).
In our opinion, the facts on mediastinoscopy vs EBUS-EUS areas follow:
● Diagnostic performance: a direct prospective compari-son of mediastinoscopy vs EBUS-EUS has not beenpublished to date; hence, we must rely on the available
retrospective data from experienced centers. These data esuggest that mediastinoscopy and EBUS-EUS are equiv-alent in diagnostic performance, except for a negative-predictive value of 91% to 98% for mediastinoscopy and60% to 97% for EBUS [1]. It is the role of the operator todecide whether to trust a negative EBUS-EUS cytologicresult, a decision that will have to be based on thepretest probability of lymph node metastasis and theoperator’s and cytopathologist’s experience. When indoubt, a mediastinoscopy should be performed to con-firm a negative EBUS-EUS sample; at our institution, weperform a mediastinoscopy only in about 10% of patientswho undergo EBUS-EUS for lung cancer staging [2, 3].
● Invasiveness: EBUS-EUS is less invasive than mediasti-noscopy, particularly when performed under sedation;but this is not the strongest argument in favor of EBUS-EUS. However, in the setting of mediastinal restaging,mediastinoscopy is associated with a mortality rate of upto 1% and a threefold increase in morbidity comparedwith initial mediastinoscopy [4]. We believe that medi-astinal restaging should always be done with EBUS-EUS, since the morbidity appears to be lower than inredo mediastinoscopy and the diagnostic results aresimilar [5].
● Cost: the issue of cost has not been sufficiently studied.The results of cost analyses depend on who is behindthem, and it is doubtful that this issue will ever beaddressed to everyone’s satisfaction.
● Versatility: the combination of EBUS-EUS allows forpathologic staging beyond peritracheal lymph nodes.EBUS-EUS can access N1 and paraesophageal lymphnodes, the liver, and the left adrenal gland. In addition,experienced operators can sample station 5 with EUS(transpulmonary approach).
In summary, most patients with lung cancer can be accuratelytaged with EBUS-EUS, and only about 10% will require aediastinoscopy. The question is: Why should we do EBUS-
US instead of mediastinoscopy as a staging procedure?First, EBUS-EUS is a diagnostic procedure that is safe, accu-
ate, versatile, and requires no incision; and, when in doubt, aediastinoscopy can still be performed. Also, EBUS-EUS is
afer for mediastinal restaging than mediastinoscopy.Second, EBUS-EUS does not mark the end of mediastinos-
opy, but instead the beginning of a new era with expandediagnostic tools for thoracic diseases. Currently, the argument ofediastinoscopy vs EBUS-EUS is entirely irrelevant: these pro-
edures complement each other.Third, we must recognize EBUS-EUS as a welcome advance
hat, with our input, will lead to further innovations and contin-ed improvement in patient care.A quote from my mentor, Dr Michael Maddaus, states in a
ery succinct way how to approach a new and inevitableituation: “You can either fight it or embrace it. I recommend theatter.”
From the patient’s perspective, the choice of mediastinoscopys EBUS-EUS with equivalent results is straightforward—ouratients clearly prefer the endoscopic procedure.
afael Andrade, MD
ivision of General Thoracic and Foregut Surgeryniversity of Minnesota
20 Delaware St SE, MMC 207inneapolis, MN 55455
-mail: [email protected]
991Ann Thorac Surg CORRESPONDENCE2011;91:983–91
References
1. Kunst PWA. Mediastinoscopy is complementary to EBUS-EUS (letter). Ann Thorac Surg 2011;91:989–90.
2. Groth SS, Andrade RS. Endobronchial and endoscopic ultra-sound-guided fine-needle aspiration: a must for thoracicsurgeons. Ann Thorac Surg 2010;89:S2079–83.
3. Andrade RS, Groth SS, Rueth NM, D’Cunha J, PambuccianSE, Maddaus MA. Evaluation of mediastinal lymph nodes
with endobronchial ultrasound: the thoracic surgeon’sperspective. J Thorac Cardiovasc Surg 2010;139:578–83.
4. Van Schil PE, De Waele M. A second mediastinoscopy: how todecide and how to do it? Eur J Cardiothorac Surg 2008;33:703–6.
5. Herth FJF, Annema JT, Eberhardt R, et al. Endobronchialultrasound with transbronchial needle aspiration for restag-
ing the mediastinum in lung cancer. J Clin Oncol 2008;26:3346–50.MIS
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