© 2008 American Thoracic Society
Modalities for Diagnosis of Peripheral Lung DiseasesFrom the Authors:The comments by Dr. Stav on our article are well taken (1). As he points out, alternative methods for the diagnostic evaluation of peripheral lung lesions exist. Interestingly, the reported experience does not exactly match the quoted advantages of transthoracic needle aspiration (TTNA): In Dr. Stav's series, the yield is lower than the quoted optimum of up to 90% even though the study was in a population with moderately sized lesions (see his Table 1). Additionally, the number of pneumothoraces was substantial, taking into account the moderate pulmonary impairment of the patients as indicated by the fairly high FEV1. We believe that the data shown here actually support our assertion, that advanced bronchoscopic biopsies are an attractive option in the workup of peripheral lesions. The assertion that TTNA/B is clinically superior and more cost-effective is not supported by the evidence provided, and our study was not designed to assess the competing efficacy of bronchoscopy-based procedures versus TTNA. Up to the present, bronchoscopy has not played a significant role in the workup of peripheral lung lesions, mainly because of its documented low yields in this setting. Our study demonstrates that this has changed. In experienced hands, combining flexible bronchoscopy with adjuncts such as electromagnetic guidance and endobronchial ultrasound allows the biopsy of peripheral lesions with accuracy similar to that with CT-guided needle aspiration. This fact had to be established first, before the next step, a comparison and cost analysis between approaches, even makes sense (otherwise it would be putting the famous cart before the horse). Additionally, even though Dr. Stav correctly points out some advantages of TTNA, there are in our opinion more significant advantages associated with a bronchoscopic approach: the main one being the ability to also provide mediastinal staging with the use of transbronchial needle aspiration (2). This is a component that cannot be overemphasized and is one of the major shortcomings of TTNA. Last, the most important question is in whom diagnostic procedures are really indicated. Just because we can biopsy peripheral lesions does not mean that we need to do it in every case. In some patients primary surgical procedures are certainly indicated. Overall, we feel this area is in flux and requires reassessment on a larger scale. Advanced bronchoscopy with the ability to biopsy peripheral lesions and diagnose or stage mediastinal lesions has now certainly gained a prominent place at the table.
Beth Israel Deaconess Medical Center
University of Heidelberg FOOTNOTES Conflict of Interest Statement: A.E. has served on the scientific advisory board for Super Dimension and was reimbursed for time and travel; he has owned stock options in the past, which have been relinquished. D.A. has no financial relationship with a commercial entity that has an interest in the subject of this manuscript. D.F.-K. has no financial relationship with a commercial entity that has an interest in the subject of this manuscript. R.E. has no financial relationship with a commercial entity that has an interest in the subject of this manuscript. F.H. has no financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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