We read with interest the letter to the Editors by J. Janssen and coworkers regarding our editorial comment on endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA), which was featured in the March issue of the European Respiratory Journal 1.
Our comment resumes the present status concerning EUS-FNA in the chest 1. All available studies indicate that EUS-FNA is promising in lung cancer (LC) staging. However, as stated several times in our comment, final conclusions have to await large blinded, randomised comparative studies. So, what do we do in the mean time when dealing with the major cancer-related cause of death with a terrible prognosis, which is almost unchanged during the past 40 yrs?
Concerning the right paratracheal regions (2R+4R), we agree that these regions are not as easily accessible by EUS-FNA when compared with the left-sided mediastinal regions. At present, mediastinoscopy (MS) may be the best method for these regions. According to our experience, an important number of patients with 2–4R disease can be diagnosed with advanced inoperable disease by EUS-FNA 2.
With regards to transbronchial needle aspiration (TBNA) biopsy, we do agree that the results of this minimally invasive method should not be neglected and TBNA should be performed during initial bronchoscopy in patients suspected of LC. Only patients considered as surgical candidates after TBNA should undergo further invasive staging. That is the current practice at our centre and, we suppose, most other centres. However, in spite of TBNA and MS, ∼40% of intended curative operations for LC are either explorative without resection or followed by recurrence. This is due to undetected advanced disease prior to surgery. Therefore, new and minimally invasive methods are needed to improve LC staging.
In this context, we found EUS-FNA promising. As EUS-FNA is less invasive, has fewer complications and does not require general anaesthesia, we suggest that EUS-FNA is performed as the initial invasive staging modality after bronchoscopy plus TBNA.
Since the publication of our editorial comment, two further prospective studies have investigated the addition of EUS-FNA to a standard work-up for unselected LC patients 3, 4. In one of these studies, the results of EUS-FNA were blinded 3. The conclusions were clear; EUS-FNA, when added to MS (and TBNA), improves the pre-operative staging of LC, resulting in a reduced rate of futile thoracotomies.
How much additional proof do we need? Should we ask for more evidence from new less invasive methods that exists for the standard methods? When is the right time to change or add to standards? We believe, based on the current literature, that the time has come for EUS-FNA.
However, the aim of our editorial comment was not to claim the superiority of one method above the other, but to inform thoracic specialists that, according to the available evidence, the addition of endoscopic ultrasound-guided fine-needle aspiration to a standard work-up improves selection of surgically curable patients with lung cancer.
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