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Reply from author: Systematic or targeted sampling during endobronchial ultrasound for mediastinal staging in patients with lung cancer and abnormal mediastinum

Open AccessPublished:May 03, 2022DOI:https://doi.org/10.1016/j.xjon.2022.04.046
      Reply to the Editor:
      The author reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
      We thank Drs Sanz-Santos and colleagues
      • Sanz-Santos J.
      • Serra P.
      • Rosell A.
      Systematic or targeted sampling during endobronchial ultrasound for mediastinal 2 staging in patients with lung cancer and abnormal mediastinum.
      for their interest and comment on our most recent publication describing the feasibility of a randomized trial comparing systematic with targeted sampling during endobronchial ultrasound for mediastinal staging.
      • Sullivan K.A.
      • Farrokhyar F.
      • Leontiadis G.I.
      • Patel Y.S.
      • Churchill I.F.
      • Hylton D.A.
      • et al.
      Routine systematic sampling vs. targeted sampling during endobronchial ultrasound: a randomized feasibility trial.
      We agree with the authors of the letter that any interpretation of findings should be done with caution. The authors seem concerned that we are recommending targeted sampling. However, our study only aims to assess the safety and feasibility of a larger noninferiority crossover trial comparing targeted sampling with systematic sampling. Based on our results, the trial has met all safety milestones to proceed. As such, our recommendation was that it is safe to proceed with a larger trial, rather than a recommendation to adopt targeted sampling. I am delighted to disclose to the authors that the larger trial (National Clinical Trial 04342377) has now completed accrual and the results will be reported soon.
      We also would like to take the opportunity to make a distinction between patients with a radiologically normal mediastinum and those with abnormal findings. The authors are concerned, and correctly so, that we are recommending targeted sampling in patients with an abnormal mediastinum. However, our trial explicitly excludes patients with abnormal computed tomography and positron emission tomography findings, and subsequently only includes patients with a Canada Lymph Node Score of 1 or less.
      • Hylton D.A.
      • Turner S.
      • Kidane B.
      • Spicer J.
      • Xie F.
      • Farrokhyar F.
      • et al.
      The Canada Lymph Node Score for prediction of malignancy in mediastinal lymph nodes during endobronchial ultrasound.
      As such, only patients with triple normal lymph nodes were included in this trial.
      • Hylton D.A.
      • Kidane B.
      • Spicer J.
      • Turner S.
      • Churchill I.
      • Sullivan K.
      • et al.
      Endobronchial ultrasound staging of operable non-small cell lung cancer: do triple normal lymph nodes require routine biopsy?.
      Triple normal lymph nodes have a malignancy rate of 5.6%, which is close to the incidence of missed nodal metastases on the feasibility trial and pathological analyses. The authors mention that it is well known that the sensitivity of endobronchial ultrasound-guided transbronchial fine-needle aspiration decreases in this setting, which is why we hypothesize that systematic sampling may not be required.
      We thank the authors for their letter and look forward to discussing the results of our subsequent trial.

      References

        • Sanz-Santos J.
        • Serra P.
        • Rosell A.
        Systematic or targeted sampling during endobronchial ultrasound for mediastinal 2 staging in patients with lung cancer and abnormal mediastinum.
        J Thorac Cardiovasc Surg Open. 2022; 11: 346-347
        • Sullivan K.A.
        • Farrokhyar F.
        • Leontiadis G.I.
        • Patel Y.S.
        • Churchill I.F.
        • Hylton D.A.
        • et al.
        Routine systematic sampling vs. targeted sampling during endobronchial ultrasound: a randomized feasibility trial.
        J Thorac Cardiovasc Surg. 2022; 164: 254-261.e1
        • Hylton D.A.
        • Turner S.
        • Kidane B.
        • Spicer J.
        • Xie F.
        • Farrokhyar F.
        • et al.
        The Canada Lymph Node Score for prediction of malignancy in mediastinal lymph nodes during endobronchial ultrasound.
        J Thorac Cardiovasc Surg. 2020; 159: 2499-2507
        • Hylton D.A.
        • Kidane B.
        • Spicer J.
        • Turner S.
        • Churchill I.
        • Sullivan K.
        • et al.
        Endobronchial ultrasound staging of operable non-small cell lung cancer: do triple normal lymph nodes require routine biopsy?.
        Chest. 2021; 156: 2470-2476

      Linked Article

      • Systematic or targeted sampling during endobronchial ultrasound for mediastinal staging in patients with lung cancer and abnormal mediastinum
        JTCVS OpenVol. 11
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          In the recently published article by Sullivan and colleagues,1 the authors describe the feasibility of a randomized controlled trial that aims to compare targeted with systematic endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) sampling for mediastinal staging in patients with lung cancer. The authors hypothesize that targeted EBUS-TBNA sampling is not inferior to systematic EBUS-TBNA. A targeted, selected, or “hit-and-run” EBUS-TBNA sampling is defined as a specific investigation for malignancy-suspected mediastinal nodes based on positron emission tomography-computed tomography (PET-CT) findings (fluorodeoxyglucose avid or short axis ≥10 mm).
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