© 2007 American Thoracic Society
Bronchoscopy Should Be the First Test in theEvaluation of Patients with a Pulmonary MassTo the Editor:I was disappointed to find an article in the AJRCCM advocating esophageal ultrasound (EUS) as the diagnostic test of choice in the evaluation of a pulmonary mass without a discussion of the role of bronchoscopy in these patients (1). While Singh and colleagues are to be commended for demonstrating that EUS can be useful in the extrathoracic staging of lung cancer, they should be criticized for recommending that bronchoscopy be reserved for nondiagnostic transesophageal ultrasound–guided fine needle aspiration (EUS-FNA), and operable cases alone (1). The authors studied EUS following chest CT in 157 patients with "suspicious" lung masses, or a recent diagnosis of lung cancer. The study is flawed for several reasons. The authors cannot claim superiority of EUS over bronchoscopy without performing a head to head comparison between them. This is particularly relevant with endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA), which has similar yields and is superior to EUS for right-sided disease (2). Furthermore, the authors report a 79% sensitivity of EUS in patients with enlarged mediastinal lymph nodes (1). We have reported an 88% yield of "blind" TBNA in 202 patients with enlarged lymph nodes due to malignant disease (3). Needle aspiration, whether blind or ultrasound-guided, is particularly limited in patients who turn out to have benign disease, with yields < 50%. Interestingly, the overall yield of bronchoscopy in such cases can reach 85% (3). The incremental yield in these patients can be accounted for by conventional bronchoscopic techniques impossible to perform with EUS, such as BAL or biopsies. The limitations of EUS in such cases are obvious and clinically relevant. The authors recommend that EUS-FNA be considered the first test when there is CT evidence of mediastinal involvement (1). I could not disagree more. TBNA with rapid on-site examination (ROSE) should be performed in such patients. Not only is bronchoscopy cheaper, but far more versatile in the event samples prove adequate yet nondiagnostic (e.g., abundant lymphocytes are identified, but no tumor is seen). I was particularly disappointed by the editorial in the same issue, in which the authors recommend that pulmonologists begin training to perform EUS (4). I would suggest they focus on TBNA instead, for as recent surveys show, many of our colleagues still underuse this technique or find it unjustifiably useless (5). Finally, the editorial makes no mention of recent advances in bronchoscopy, such as electromagnetic navigation, which has a diagnostic yield of 74 and 100%, respectively, in the evaluation of pulmonary nodules and mediastinal adenopathy (6).
Clínica Universitaria de Navarra, Pamplona, Spain FOOTNOTES Conflict of Interest Statement: L.M.S. is currently a member of the European Advisory Board for Superdimension, which commercializes electromagnetic navigation for bronchoscopy; he has as yet received no paid consultancy fees from that company. REFERENCES
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