Point: Are >50 Supervised Procedures Required to Develop Competency in Performing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Mediastinal Staging? Yes
2013; Elsevier BV; Volume: 143; Issue: 4 Linguagem: Inglês
10.1378/chest.12-2462
ISSN1931-3543
Autores Tópico(s)Pleural and Pulmonary Diseases
Resumoconvex-probe endobronchial ultrasound-guided transbronchial needle aspiration endobronchial ultrasound endobronchial ultrasound-guided transbronchial needle aspiration endoscopic ultrasound-fine needle aspiration Mountain-Dresler modification of the American Thoracic Society The incidence of lung cancer continues to increase worldwide. The cornerstone of therapy relies on appropriate staging and timely treatment. The Union for International Cancer Control seventh edition TNM classification for lung cancer is based on the retrospective analysis of >80,000 patients with lung cancer treated between 1990 and 2000. This classification uses the TNM to describe the anatomic extent of disease. The objectives of the TNM classification are as follows: help the clinician plan treatment, guide prognosis, assist in treatment evaluation, provide a common language for exchange of information, and contribute to the continued investigation of human cancer.1Gospodarowicz MK Miller D Groome PA Greene FL Logan PA Sobin LH The process for continuous improvement of the TNM classification.Cancer. 2004; 100: 1-5Crossref PubMed Scopus (207) Google Scholar In the last 10 years, the techniques of lymph node staging have rapidly evolved from CT scan to PET scan, endoscopic ultrasound-fine needle aspiration (EUS-FNA), convex-probe endobronchial ultrasound-guided transbronchial needle aspiration (CP-EBUS), and, the gold standard, mediastinoscopy. These techniques are considered noninvasive or minimally invasive, and, thus, provide clinical staging. On the other hand, pathologic staging is considered only after surgical resection.2Detterbeck FC Boffa DJ Tanoue LT The new lung cancer staging system.Chest. 2009; 136: 260-271Abstract Full Text Full Text PDF PubMed Scopus (785) Google Scholar In the last 5 years, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has revolutionized the acquisition of tissue for diagnosis and staging of lung cancer. The use of CP-EBUS has quickly replaced mediastinoscopy as the staging modality of choice, particularly in academic medical centers. Multiple studies have compared CP-EBUS and mediastinoscopy and have proven the overall sensitivity, specificity, and accuracy to be comparable for both modalities.3Yasufuku 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 (422) Google Scholar, 4Annema 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 (497) Google Scholar Furthermore, the relative ease for the use of CP-EBUS has quickly proliferated among pulmonologists and thoracic surgeons. Unfortunately, the implementation of such technology has not been accompanied by the necessary safeguards and peer-review process. The familiarity of pulmonologists with flexible bronchoscopy and the relative safety of this procedure gave practicing clinicians access to a needed diagnostic tool. Although current guidelines from the American Thoracic Society/European Respiratory Society and the American College of Chest Physicians recommend a minimum number of 40 to 50 procedures and 20 procedures per year for initial acquisition and maintenance of competency, respectively, most hospitals do not follow these recommendations.5Ernst 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 (531) Google Scholar, 6Bolliger CT Mathur PN Beamis JF et al.ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society.Eur Respir J. 2002; 19: 356-373Crossref PubMed Scopus (493) Google Scholar, 7Block MI Endobronchial ultrasound for lung cancer staging: how many stations should be sampled?.Ann Thorac Surg. 2010; 89: 1582-1587Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Certainly, we recognize that those recommendations were made before CP-EBUS was widely available and are based on expert opinion, but despite their arbitrary and controversial cutoff values, they constitute an effort to standardize the use of an important procedure. Interestingly, some authors have recently described their learning "from books" and without proctored cases as sufficient.8Kupeli E Memis L Ulubay G Akcay S Eyuboglu FO Transbronchial needle aspiration (TBNA) by the books [abstract].Chest. 2010; 138: 432AAbstract Full Text Full Text PDF Google Scholar Others have recommended a different standard: five proctored cases for thoracic surgeons7Block MI Endobronchial ultrasound for lung cancer staging: how many stations should be sampled?.Ann Thorac Surg. 2010; 89: 1582-1587Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar and 20 proctored cases for pulmonologists.9Sheski FD Mathur PN Endobronchial ultrasound.Chest. 2008; 133: 264-270Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar At the other end of the spectrum lie the interventional pulmonologists who by and large support ≥50 supervised cases. This concern stems in part from the international focus on patient safety and the growing societal pressures to reduce medical errors, particularly in the fields of surgery and interventional procedures.10Aggarwal R Darzi A Simulation to enhance patient safety: why aren't we there yet?.Chest. 2011; 140: 854-858Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar We should not forget the beginning of laparoscopic surgery in the late 1980s, described as "the biggest unaudited free-for-all in the history of surgery," for which the lack of guidelines and credentialing led to the late description of complications and poor outcomes. The interventional pulmonary and thoracic surgery community does not need to reenact mistakes of the past. We are capable of predicting the future and acting preemptively. Proponents of no minimum standards frequently quote the safety profile of the procedure. However, the most concerning issue is not the periprocedural complications but the consequences of upstaging or downstaging the individual patient. In the former case, the patient will be prevented from receiving potentially curative therapy. In the latter case, the patient may undergo unnecessary surgery and treatments without therapeutic benefit. In the broader sense, the results published by world experts will likely not be replicated by individuals with suboptimal training, which will affect the credibility; thus, CP-EBUS will not be the long-desired "Holy Grail" of mediastinal staging. The ability of a bronchoscopist to perform an airway examination and basic procedures, such as BAL, transbronchial needle aspiration, and endobronchial and transbronchial biopsy, is not enough for the use of CP-EBUS. The bronchoscopists trained in CP-EBUS should master interpretation of ultrasound imaging, chest anatomy, and endobronchial ultrasound navigation and technique. It is extremely important to have a thorough knowledge of the mediastinal and hilar anatomy and the landmarks that govern the three lymph node maps currently used in the literature. These include the Naruke map, the Mountain-Dresler modification of the American Thoracic Society (MD-ATS) map, and the International Association for the Staging of Lung Cancer lymph node map, including the proposed grouping of lymph node stations into "zones" for prognostic analysis.11Rusch VW Asamura H Watanabe H Giroux DJ Rami-Porta R Goldstraw P The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer.J Thorac Oncol. 2009; 4: 568-577Abstract Full Text Full Text PDF PubMed Scopus (860) Google Scholar As CP-EBUS has become widely available, and in the absence of formal training, many users do not perform a thorough evaluation of the mediastinum but rather concentrate on a focused examination, guided by the findings of CT or PET scan. Current guidelines from the American College of Chest Physicians and the European Society of Thoracic Surgeons recommend that mediastinoscopy should include exploration and biopsy of representative nodes in five mediastinal lymph node stations (2R, 2L, 4R, 4L, and 7).12Detterbeck FC Jantz MA Wallace M Vansteenkiste J Silvestri GA American College of Chest Physicians Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).Chest. 2007; 132: 202S-220SAbstract Full Text Full Text PDF PubMed Scopus (636) Google Scholar, 13De Leyn P Lardinois D Van Schil PE et al.ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer.Eur J Cardiothorac Surg. 2007; 32: 1-8Crossref PubMed Scopus (425) Google Scholar Despite the lack of data to demonstrate that a thorough mediastinal staging is superior to selective endobronchial staging, we can extrapolate the available data of pathologic staging at the time of resection. These data suggest that systematic sampling will yield more accurate staging than selective nodal staging.14Detterbeck F Puchalski J Rubinowitz A Cheng D Classification of the thoroughness of mediastinal staging of lung cancer.Chest. 2010; 137: 436-442Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Herth et al15Herth FJ 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 (289) Google Scholar have shown that CP-EBUS can identify micrometastasis in patients with lung cancer and normal mediastinum, defined as lymph nodes 50 cases should be proctored before a bronchoscopist is considered to have reached an appropriate level of competency. We should remember that the high sensitivity and specificity described in the literature represent the results of a small selected group of pulmonologists and thoracic surgeons with extensive training and experience with hundreds of cases. If we want CP-EBUS to be held at the highest standard, we should also hold ourselves to the highest standards of care, thoroughness, and reproducibility of the results. Little et al22Little 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 (368) Google Scholar described the wide variability of practice in mediastinoscopy for staging of lung cancer. Only 30% of patients undergoing lung resection underwent mediastinoscopy, and in >50% no lymph nodes were sampled. This variation will likely occur with CP-EBUS when used for staging in the absence of updated guidelines. We strongly believe that CP-EBUS has opened the door to increase the number of patients who can be staged before surgery. This process should be standardized, and guidelines of thoroughness should be followed. Language used to describe lymph node stations needs to be universal, and we should distinguish between diagnostic CP-EBUS and staging CP-EBUS. Finally, we would like to recommend that the Centers for Medicare Services review the available research data that support mediastinal staging with CP-EBUS as a cost-effective alternative to mediastinoscopy. At the present time, reimbursement is suboptimal. We strongly believe that creating a different code for a thorough staging that includes N3, N2, and N1 nodes would reflect appropriate reimbursement for time spent and at the same time would be an incentive for thoroughness in staging of lung cancer. /cms/asset/70f4e8ea-899e-41a6-8771-150446159987/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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