Counterpoint: Are >50 Supervised Procedures Required to Develop Competency in Performing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Lung Cancer Staging? No
2013; Elsevier BV; Volume: 143; Issue: 4 Linguagem: Inglês
10.1378/chest.12-2464
ISSN1931-3543
AutoresC. Matthew Kinsey, Colleen L. Channick,
Tópico(s)Pleural and Pulmonary Diseases
ResumoEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has significantly impacted the evaluation of patients undergoing lung cancer diagnosis and staging and has become a principal means of sampling mediastinal and hilar lymph nodes.1Annema JT van Meerbeeck JP Rintoul RC et al.Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial.JAMA. 2010; 304: 2245-2252Crossref PubMed Scopus (486) Google Scholar, 2Yasufuku K Pierre A Darling G et al.A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer.J Thorac Cardiovasc Surg. 2011; 142: 1393-1400Abstract Full Text Full Text PDF PubMed Scopus (412) Google Scholar Because of the demonstrated usefulness of EBUS-TBNA, this procedure has moved from being performed in a few small centers into mainstream clinical practice.How many supervised EBUS-TBNA procedures does an operator need to perform to acquire the minimum level of skill, knowledge, and expertise to safely and proficiently perform mediastinal staging? This is a challenging question, as the number of EBUS-TBNA procedures required to become competent to perform EBUS-TBNA in general is unknown. Published recommendations from the American Thoracic Society/European Respiratory Society and the American College of Chest Physicians suggest 40 and 50 supervised procedures, respectively, for competence in endobronchial ultrasound (EBUS).3Bolliger CT Mathur PN Beamis JF European Respiratory Society/American Thoracic Society et al.ERS/ATS statement on interventional pulmonology.Eur Respir J. 2002; 19: 356-373Crossref PubMed Scopus (480) Google Scholar, 4Ernst A Silvestri GA Johnstone D American College of Chest Physicians Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest. 2003; 123: 1693-1717Abstract Full Text Full Text PDF PubMed Scopus (521) Google Scholar Neither group, however, has published training recommendations specifically for EBUS-TBNA procedures.We counter the argument that >50 EBUS-TBNA procedures are required for mediastinal staging. For the pro side to successfully make their argument, they need to show increased safety and/or yield of the procedure in the hands of operators who have performed >50 cases as well as the practicality of having separate competency criteria for EBUS-TBNA performed for mediastinal staging vs other diagnostic purposes. The impact of such a requirement on patients' access to the procedure must also be considered. We address these areas point by point.EBUS-TBNA YieldData addressing the rate of acquisition of skills necessary for EBUS-TBNA are scarce. Several studies have examined the learning curve of a small number of practitioners. Adawi and Simoff5Adawi R Simoff MJ Endobronchial ultrasound guided transbronchial needle aspiration: a preliminary experience.Journal of Bronchology. 2008; 15: 87-90Crossref Scopus (4) Google Scholar evaluated the yield of the first 50 EBUS-TBNA procedures performed at their hospital and found that the yield increased from 62% for the first 23 procedures to 84% for the next 23 procedures. Groth et al6Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86: 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar performed a single-institution retrospective chart review of EBUS-TBNA for the indications of mediastinal lymphadenopathy and thoracic malignancy staging and reported a steep learning curve, with a sensitivity of 44.4% for their first 10 procedures, which increased to 94.1% for the subsequent 46 procedures.This finding is supported by Steinfort et al,7Steinfort DP Hew MJ Irving LB Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital.Intern Med J. 2011; 41: 815-824Crossref PubMed Scopus (88) Google Scholar who also showed the diagnostic sensitivity of EBUS-TBNA peaking at 92% by 50 procedures. In the multicenter, prospective, cohort study by Ost et at8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar (American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education [AQuIRE] Bronchoscopy Registry), there was a weak (OR =1.003) but statistically significant correlation between hospital volume and diagnostic yield. However, when the subgroup of patients with PET scans was evaluated, there was no correlation between volume and yield. In fact, the authors acknowledge that rather than operator experience, other factors, such as level of anesthesia, accuracy of the cytopathologists, and number of lymph nodes biopsied, could have accounted for the differences between high- and low-volume centers.8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar The available literature thus confirms that overall yield of EBUS-TBNA, although varying widely, is acceptable by 50 procedures.EBUS-TBNA SafetyEBUS-TBNA is an extremely safe procedure. Results of a meta-analysis of EBUS-TBNA performed in 1,627 patients for the indication of bronchopulmonary cancer revealed no major complications.9Varela-Lema L Fernández-Villar A Ruano-Ravina A Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review.Eur Respir J. 2009; 33: 1156-1164Crossref PubMed Scopus (336) Google Scholar Another meta-analysis that assessed EBUS-TBNA for lung cancer staging reported a 0.15% complication rate in 1,299 patients.10Gu P Zhao Y-Z Jiang L-Y Zhang W Xin Y Han B-H Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis.Eur J Cancer. 2009; 45: 1389-1396Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar In two studies that evaluated early institutional experience with EBUS-TBNA, there were no reported complications, supporting the safety of the procedure, even during the "learning" period.6Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86: 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 7Steinfort DP Hew MJ Irving LB Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital.Intern Med J. 2011; 41: 815-824Crossref PubMed Scopus (88) Google Scholar There is no evidence that mediastinal staging performed with EBUS has a higher complication rate than general diagnostic EBUS. Thus, based on the available safety data for EBUS-TBNA, there is no justification for requiring >50 EBUS procedures for initial competency when performed for the purpose of mediastinal staging.EBUS-TBNA for Mediastinal Staging vs NonstagingDo the cognitive and technical aspects of an EBUS-TBNA performed for the purpose of mediastinal staging differ significantly from one that is performed for nonstaging purposes? The cognitive skills necessary to properly perform EBUS-TBNA include patient evaluation; assessment of the pretest probability of disease; review of imaging studies; knowledge of the indications, risks, benefits, and expected outcome of the procedure; and a thorough knowledge of mediastinal anatomy. The technical aspects required to perform EBUS-TBNA include intubation with the EBUS scope, maintaining appropriate positioning of the EBUS convex probe, advancing the needle, and obtaining a specimen for cytopathologic analysis. These requirements do not differ whether the operator is performing a staging or a nonstaging EBUS-TBNA.There could be an argument that mediastinal staging requires biopsy of more lymph node stations and smaller lymph nodes, thus, making it a more challenging procedure. In the study by Herth et al,11Herth FJF Ernst A Eberhardt R Vilmann P Dienemann H Krasnik M Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum.Eur Respir J. 2006; 28: 910-914Crossref PubMed Scopus (284) Google Scholar which evaluated EBUS-TBNA of lymph nodes in the radiologically and PET-normal mediastinum of patients with lung cancer, biopsy was performed on an average of only 1.6 lymph nodes per patient. In a recent study comparing EBUS-TBNA with mediastinoscopy for mediastinal lymph node staging, biopsy was performed on an average of three lymph node stations per patient.12Yasufuku K Pierre A Darling G et al.A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer.J Thorac Cardiovasc Surg. 2011; 142: 1393-1400Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar The yield and safety of sampling three lymph node stations has not been specifically evaluated for operators who have performed more or fewer than 50 EBUS-TBNA procedures. In fact, for the diagnosis of sarcoidosis the literature supports sampling up to four lymph node stations.13Tremblay A Stather DR Maceachern P Khalil M Field SK A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis.Chest. 2009; 136: 340-346Abstract Full Text Full Text PDF PubMed Scopus (293) Google Scholar Should we, thus, require even more operator experience to perform EBUS-TBNA on a patient with suspected sarcoidosis? We think not.Procedures in which more than one lymph node station is biopsied will no doubt take longer. In the AQuIRE Bronchoscopy Registry this was most successfully overcome by using general anesthesia for the procedure.8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar Although staging EBUS could involve the biopsy of more lymph nodes 50 procedures to develop competency to biopsy these lymph nodes. Based on the previous information we believe that it is both unnecessary and impractical to have more stringent competency requirements for EBUS-TBNA performed for the indication of mediastinal staging vs other indications.Access to CareSince formal training programs in EBUS are limited, if we were to "raise the bar," fewer practitioners would be deemed competent to perform EBUS-TBNA mediastinal staging. By placing this minimally invasive staging procedure in the hands of a reduced number of "certified" practitioners at high-volume centers, the only option for many patients with lung cancer would be more invasive procedures (ie, mediastinoscopy).This reduced access could even prevent staging altogether. If we look at the survey performed by the Commission on Cancer of the American College of Surgeons regarding patterns of surgical care provided to patients with non-small cell lung cancer, we see that preoperative mediastinoscopy was performed in only 27.1% of operated patients, with lymph node biopsy in only 46.6% of these procedures.14Little AG Rusch VW Bonner JA et al.Patterns of surgical care of lung cancer patients.Ann Thorac Surg. 2005; 80: 2051-2056Abstract Full Text Full Text PDF PubMed Scopus (364) Google Scholar These data tell us that we must do a better job of performing mediastinal staging. Limiting staging EBUS procedures to a small number of providers will work against this goal. Convex probe EBUS is now being taught in many general pulmonary fellowship programs. Fifty supervised procedures is achievable during fellowship training and could allow for the training of a sufficient number of practitioners to serve the needs of the large number of patients with lung cancer.In conclusion, there are no data to support the argument that >50 EBUS-TBNA procedures are necessary for competence in mediastinal staging. In fact, arbitrarily requiring an inordinate number of staging procedures could be viewed as exclusionary of the many competent clinicians who are safely and effectively performing this important procedure. EBUS-TBNA is too vital a procedure to be denied to the thousands of patients with lung cancer who require invasive mediastinal staging each year. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has significantly impacted the evaluation of patients undergoing lung cancer diagnosis and staging and has become a principal means of sampling mediastinal and hilar lymph nodes.1Annema JT van Meerbeeck JP Rintoul RC et al.Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial.JAMA. 2010; 304: 2245-2252Crossref PubMed Scopus (486) Google Scholar, 2Yasufuku K Pierre A Darling G et al.A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer.J Thorac Cardiovasc Surg. 2011; 142: 1393-1400Abstract Full Text Full Text PDF PubMed Scopus (412) Google Scholar Because of the demonstrated usefulness of EBUS-TBNA, this procedure has moved from being performed in a few small centers into mainstream clinical practice. How many supervised EBUS-TBNA procedures does an operator need to perform to acquire the minimum level of skill, knowledge, and expertise to safely and proficiently perform mediastinal staging? This is a challenging question, as the number of EBUS-TBNA procedures required to become competent to perform EBUS-TBNA in general is unknown. Published recommendations from the American Thoracic Society/European Respiratory Society and the American College of Chest Physicians suggest 40 and 50 supervised procedures, respectively, for competence in endobronchial ultrasound (EBUS).3Bolliger CT Mathur PN Beamis JF European Respiratory Society/American Thoracic Society et al.ERS/ATS statement on interventional pulmonology.Eur Respir J. 2002; 19: 356-373Crossref PubMed Scopus (480) Google Scholar, 4Ernst A Silvestri GA Johnstone D American College of Chest Physicians Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest. 2003; 123: 1693-1717Abstract Full Text Full Text PDF PubMed Scopus (521) Google Scholar Neither group, however, has published training recommendations specifically for EBUS-TBNA procedures. We counter the argument that >50 EBUS-TBNA procedures are required for mediastinal staging. For the pro side to successfully make their argument, they need to show increased safety and/or yield of the procedure in the hands of operators who have performed >50 cases as well as the practicality of having separate competency criteria for EBUS-TBNA performed for mediastinal staging vs other diagnostic purposes. The impact of such a requirement on patients' access to the procedure must also be considered. We address these areas point by point. EBUS-TBNA YieldData addressing the rate of acquisition of skills necessary for EBUS-TBNA are scarce. Several studies have examined the learning curve of a small number of practitioners. Adawi and Simoff5Adawi R Simoff MJ Endobronchial ultrasound guided transbronchial needle aspiration: a preliminary experience.Journal of Bronchology. 2008; 15: 87-90Crossref Scopus (4) Google Scholar evaluated the yield of the first 50 EBUS-TBNA procedures performed at their hospital and found that the yield increased from 62% for the first 23 procedures to 84% for the next 23 procedures. Groth et al6Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86: 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar performed a single-institution retrospective chart review of EBUS-TBNA for the indications of mediastinal lymphadenopathy and thoracic malignancy staging and reported a steep learning curve, with a sensitivity of 44.4% for their first 10 procedures, which increased to 94.1% for the subsequent 46 procedures.This finding is supported by Steinfort et al,7Steinfort DP Hew MJ Irving LB Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital.Intern Med J. 2011; 41: 815-824Crossref PubMed Scopus (88) Google Scholar who also showed the diagnostic sensitivity of EBUS-TBNA peaking at 92% by 50 procedures. In the multicenter, prospective, cohort study by Ost et at8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar (American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education [AQuIRE] Bronchoscopy Registry), there was a weak (OR =1.003) but statistically significant correlation between hospital volume and diagnostic yield. However, when the subgroup of patients with PET scans was evaluated, there was no correlation between volume and yield. In fact, the authors acknowledge that rather than operator experience, other factors, such as level of anesthesia, accuracy of the cytopathologists, and number of lymph nodes biopsied, could have accounted for the differences between high- and low-volume centers.8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar The available literature thus confirms that overall yield of EBUS-TBNA, although varying widely, is acceptable by 50 procedures. Data addressing the rate of acquisition of skills necessary for EBUS-TBNA are scarce. Several studies have examined the learning curve of a small number of practitioners. Adawi and Simoff5Adawi R Simoff MJ Endobronchial ultrasound guided transbronchial needle aspiration: a preliminary experience.Journal of Bronchology. 2008; 15: 87-90Crossref Scopus (4) Google Scholar evaluated the yield of the first 50 EBUS-TBNA procedures performed at their hospital and found that the yield increased from 62% for the first 23 procedures to 84% for the next 23 procedures. Groth et al6Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86: 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar performed a single-institution retrospective chart review of EBUS-TBNA for the indications of mediastinal lymphadenopathy and thoracic malignancy staging and reported a steep learning curve, with a sensitivity of 44.4% for their first 10 procedures, which increased to 94.1% for the subsequent 46 procedures. This finding is supported by Steinfort et al,7Steinfort DP Hew MJ Irving LB Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital.Intern Med J. 2011; 41: 815-824Crossref PubMed Scopus (88) Google Scholar who also showed the diagnostic sensitivity of EBUS-TBNA peaking at 92% by 50 procedures. In the multicenter, prospective, cohort study by Ost et at8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar (American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education [AQuIRE] Bronchoscopy Registry), there was a weak (OR =1.003) but statistically significant correlation between hospital volume and diagnostic yield. However, when the subgroup of patients with PET scans was evaluated, there was no correlation between volume and yield. In fact, the authors acknowledge that rather than operator experience, other factors, such as level of anesthesia, accuracy of the cytopathologists, and number of lymph nodes biopsied, could have accounted for the differences between high- and low-volume centers.8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar The available literature thus confirms that overall yield of EBUS-TBNA, although varying widely, is acceptable by 50 procedures. EBUS-TBNA SafetyEBUS-TBNA is an extremely safe procedure. Results of a meta-analysis of EBUS-TBNA performed in 1,627 patients for the indication of bronchopulmonary cancer revealed no major complications.9Varela-Lema L Fernández-Villar A Ruano-Ravina A Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review.Eur Respir J. 2009; 33: 1156-1164Crossref PubMed Scopus (336) Google Scholar Another meta-analysis that assessed EBUS-TBNA for lung cancer staging reported a 0.15% complication rate in 1,299 patients.10Gu P Zhao Y-Z Jiang L-Y Zhang W Xin Y Han B-H Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis.Eur J Cancer. 2009; 45: 1389-1396Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar In two studies that evaluated early institutional experience with EBUS-TBNA, there were no reported complications, supporting the safety of the procedure, even during the "learning" period.6Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86: 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 7Steinfort DP Hew MJ Irving LB Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital.Intern Med J. 2011; 41: 815-824Crossref PubMed Scopus (88) Google Scholar There is no evidence that mediastinal staging performed with EBUS has a higher complication rate than general diagnostic EBUS. Thus, based on the available safety data for EBUS-TBNA, there is no justification for requiring >50 EBUS procedures for initial competency when performed for the purpose of mediastinal staging. EBUS-TBNA is an extremely safe procedure. Results of a meta-analysis of EBUS-TBNA performed in 1,627 patients for the indication of bronchopulmonary cancer revealed no major complications.9Varela-Lema L Fernández-Villar A Ruano-Ravina A Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review.Eur Respir J. 2009; 33: 1156-1164Crossref PubMed Scopus (336) Google Scholar Another meta-analysis that assessed EBUS-TBNA for lung cancer staging reported a 0.15% complication rate in 1,299 patients.10Gu P Zhao Y-Z Jiang L-Y Zhang W Xin Y Han B-H Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis.Eur J Cancer. 2009; 45: 1389-1396Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar In two studies that evaluated early institutional experience with EBUS-TBNA, there were no reported complications, supporting the safety of the procedure, even during the "learning" period.6Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86: 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 7Steinfort DP Hew MJ Irving LB Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital.Intern Med J. 2011; 41: 815-824Crossref PubMed Scopus (88) Google Scholar There is no evidence that mediastinal staging performed with EBUS has a higher complication rate than general diagnostic EBUS. Thus, based on the available safety data for EBUS-TBNA, there is no justification for requiring >50 EBUS procedures for initial competency when performed for the purpose of mediastinal staging. EBUS-TBNA for Mediastinal Staging vs NonstagingDo the cognitive and technical aspects of an EBUS-TBNA performed for the purpose of mediastinal staging differ significantly from one that is performed for nonstaging purposes? The cognitive skills necessary to properly perform EBUS-TBNA include patient evaluation; assessment of the pretest probability of disease; review of imaging studies; knowledge of the indications, risks, benefits, and expected outcome of the procedure; and a thorough knowledge of mediastinal anatomy. The technical aspects required to perform EBUS-TBNA include intubation with the EBUS scope, maintaining appropriate positioning of the EBUS convex probe, advancing the needle, and obtaining a specimen for cytopathologic analysis. These requirements do not differ whether the operator is performing a staging or a nonstaging EBUS-TBNA.There could be an argument that mediastinal staging requires biopsy of more lymph node stations and smaller lymph nodes, thus, making it a more challenging procedure. In the study by Herth et al,11Herth FJF Ernst A Eberhardt R Vilmann P Dienemann H Krasnik M Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum.Eur Respir J. 2006; 28: 910-914Crossref PubMed Scopus (284) Google Scholar which evaluated EBUS-TBNA of lymph nodes in the radiologically and PET-normal mediastinum of patients with lung cancer, biopsy was performed on an average of only 1.6 lymph nodes per patient. In a recent study comparing EBUS-TBNA with mediastinoscopy for mediastinal lymph node staging, biopsy was performed on an average of three lymph node stations per patient.12Yasufuku K Pierre A Darling G et al.A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer.J Thorac Cardiovasc Surg. 2011; 142: 1393-1400Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar The yield and safety of sampling three lymph node stations has not been specifically evaluated for operators who have performed more or fewer than 50 EBUS-TBNA procedures. In fact, for the diagnosis of sarcoidosis the literature supports sampling up to four lymph node stations.13Tremblay A Stather DR Maceachern P Khalil M Field SK A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis.Chest. 2009; 136: 340-346Abstract Full Text Full Text PDF PubMed Scopus (293) Google Scholar Should we, thus, require even more operator experience to perform EBUS-TBNA on a patient with suspected sarcoidosis? We think not.Procedures in which more than one lymph node station is biopsied will no doubt take longer. In the AQuIRE Bronchoscopy Registry this was most successfully overcome by using general anesthesia for the procedure.8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar Although staging EBUS could involve the biopsy of more lymph nodes 50 procedures to develop competency to biopsy these lymph nodes. Based on the previous information we believe that it is both unnecessary and impractical to have more stringent competency requirements for EBUS-TBNA performed for the indication of mediastinal staging vs other indications. Do the cognitive and technical aspects of an EBUS-TBNA performed for the purpose of mediastinal staging differ significantly from one that is performed for nonstaging purposes? The cognitive skills necessary to properly perform EBUS-TBNA include patient evaluation; assessment of the pretest probability of disease; review of imaging studies; knowledge of the indications, risks, benefits, and expected outcome of the procedure; and a thorough knowledge of mediastinal anatomy. The technical aspects required to perform EBUS-TBNA include intubation with the EBUS scope, maintaining appropriate positioning of the EBUS convex probe, advancing the needle, and obtaining a specimen for cytopathologic analysis. These requirements do not differ whether the operator is performing a staging or a nonstaging EBUS-TBNA. There could be an argument that mediastinal staging requires biopsy of more lymph node stations and smaller lymph nodes, thus, making it a more challenging procedure. In the study by Herth et al,11Herth FJF Ernst A Eberhardt R Vilmann P Dienemann H Krasnik M Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum.Eur Respir J. 2006; 28: 910-914Crossref PubMed Scopus (284) Google Scholar which evaluated EBUS-TBNA of lymph nodes in the radiologically and PET-normal mediastinum of patients with lung cancer, biopsy was performed on an average of only 1.6 lymph nodes per patient. In a recent study comparing EBUS-TBNA with mediastinoscopy for mediastinal lymph node staging, biopsy was performed on an average of three lymph node stations per patient.12Yasufuku K Pierre A Darling G et al.A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer.J Thorac Cardiovasc Surg. 2011; 142: 1393-1400Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar The yield and safety of sampling three lymph node stations has not been specifically evaluated for operators who have performed more or fewer than 50 EBUS-TBNA procedures. In fact, for the diagnosis of sarcoidosis the literature supports sampling up to four lymph node stations.13Tremblay A Stather DR Maceachern P Khalil M Field SK A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis.Chest. 2009; 136: 340-346Abstract Full Text Full Text PDF PubMed Scopus (293) Google Scholar Should we, thus, require even more operator experience to perform EBUS-TBNA on a patient with suspected sarcoidosis? We think not. Procedures in which more than one lymph node station is biopsied will no doubt take longer. In the AQuIRE Bronchoscopy Registry this was most successfully overcome by using general anesthesia for the procedure.8Ost DE Ernst A Lei X AQuIRE Bronchoscopy Registry et al.Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry.Chest. 2011; 140: 1557-1566Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar Although staging EBUS could involve the biopsy of more lymph nodes 50 procedures to develop competency to biopsy these lymph nodes. Based on the previous information we believe that it is both unnecessary and impractical to have more stringent competency requirements for EBUS-TBNA performed for the indication of mediastinal staging vs other indications. Access to CareSince formal training programs in EBUS are limited, if we were to "raise the bar," fewer practitioners would be deemed competent to perform EBUS-TBNA mediastinal staging. By placing this minimally invasive staging procedure in the hands of a reduced number of "certified" practitioners at high-volume centers, the only option for many patients with lung cancer would be more invasive procedures (ie, mediastinoscopy).This reduced access could even prevent staging altogether. If we look at the survey performed by the Commission on Cancer of the American College of Surgeons regarding patterns of surgical care provided to patients with non-small cell lung cancer, we see that preoperative mediastinoscopy was performed in only 27.1% of operated patients, with lymph node biopsy in only 46.6% of these procedures.14Little AG Rusch VW Bonner JA et al.Patterns of surgical care of lung cancer patients.Ann Thorac Surg. 2005; 80: 2051-2056Abstract Full Text Full Text PDF PubMed Scopus (364) Google Scholar These data tell us that we must do a better job of performing mediastinal staging. Limiting staging EBUS procedures to a small number of providers will work against this goal. Convex probe EBUS is now being taught in many general pulmonary fellowship programs. Fifty supervised procedures is achievable during fellowship training and could allow for the training of a sufficient number of practitioners to serve the needs of the large number of patients with lung cancer.In conclusion, there are no data to support the argument that >50 EBUS-TBNA procedures are necessary for competence in mediastinal staging. In fact, arbitrarily requiring an inordinate number of staging procedures could be viewed as exclusionary of the many competent clinicians who are safely and effectively performing this important procedure. EBUS-TBNA is too vital a procedure to be denied to the thousands of patients with lung cancer who require invasive mediastinal staging each year. Since formal training programs in EBUS are limited, if we were to "raise the bar," fewer practitioners would be deemed competent to perform EBUS-TBNA mediastinal staging. By placing this minimally invasive staging procedure in the hands of a reduced number of "certified" practitioners at high-volume centers, the only option for many patients with lung cancer would be more invasive procedures (ie, mediastinoscopy). This reduced access could even prevent staging altogether. If we look at the survey performed by the Commission on Cancer of the American College of Surgeons regarding patterns of surgical care provided to patients with non-small cell lung cancer, we see that preoperative mediastinoscopy was performed in only 27.1% of operated patients, with lymph node biopsy in only 46.6% of these procedures.14Little AG Rusch VW Bonner JA et al.Patterns of surgical care of lung cancer patients.Ann Thorac Surg. 2005; 80: 2051-2056Abstract Full Text Full Text PDF PubMed Scopus (364) Google Scholar These data tell us that we must do a better job of performing mediastinal staging. Limiting staging EBUS procedures to a small number of providers will work against this goal. Convex probe EBUS is now being taught in many general pulmonary fellowship programs. Fifty supervised procedures is achievable during fellowship training and could allow for the training of a sufficient number of practitioners to serve the needs of the large number of patients with lung cancer. In conclusion, there are no data to support the argument that >50 EBUS-TBNA procedures are necessary for competence in mediastinal staging. In fact, arbitrarily requiring an inordinate number of staging procedures could be viewed as exclusionary of the many competent clinicians who are safely and effectively performing this important procedure. EBUS-TBNA is too vital a procedure to be denied to the thousands of patients with lung cancer who require invasive mediastinal staging each year. Supplementary Material/cms/asset/acbdf9d1-4d6f-4c36-8226-40846c8e3085/mmc1.mp3Loading ... Download .mp3 (15.59 MB) Help with .mp3 files Supplement AudioHow Many Supervised EBUS-TBNA Procedures Are Needed for Competency for Mediastinal Staging?Duration: 34 minModerator: D. Kyle Hogarth, MD, FCCP, Podcast Editor, CHESTParticipants: Erik Folch, MD; Colleen L. Channick, MD, FCCP /cms/asset/acbdf9d1-4d6f-4c36-8226-40846c8e3085/mmc1.mp3Loading ... Download .mp3 (15.59 MB) Help with .mp3 files Supplement AudioHow Many Supervised EBUS-TBNA Procedures Are Needed for Competency for Mediastinal Staging?Duration: 34 minModerator: D. Kyle Hogarth, MD, FCCP, Podcast Editor, CHESTParticipants: Erik Folch, MD; Colleen L. Channick, MD, FCCP
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