Importance of oesophageal
ultrasound in mediastinal
staging of lung cancer
To the Editors:
As researchers in endosonography, we read the paper
by Vial et al.
with great interest. We congratulate
the authors for exploring the role of endobronchial
ultrasound-guided transbronchial needle aspiration
(EBUS-TBNA) for staging of patients with non-small cell
lung cancer with no signs of N2/N3 disease at positron
emission tomography-computed tomography (PET-CT).
We are glad to note that the results are in accordance
with our own results, which were recently published.
Most remarkably, approximately 10% of the lung cancer
patients in our study unfortunately revealed N2 or N3
disease by surgery, after PET-CT and EBUS-TBNA unan-
imously showed no signs of malignancy in the mediasti-
num. In the study by Vial et al., a comparable 12% of
patients were reported to have N2 after both PET-CT
The important question is how we can reduce this risk
of overlooking spread to the mediastinum and thereby
subject our patients to futile surgery. Several studies
including a meta-analysis suggest that the combination
of the oesophageal and tracheal approaches increases
the sensitivity for detecting nodal mediastinal metastases
in lung cancer patients compared with EBUS-TBNA
The importance of oesophageal ultrasound with
ﬁne needle aspiration using the bronchoscope (EUS-B-
FNA) is supported by both our published work and Vial
In approximately half of the patients in these
studies, where both PET-CT and EBUS-TBNA ‘over-
looked’ spread to the mediastinum, the metastases were
ultimately found in lymph nodes that cannot be reached
by the EBUS procedure, most often station 5. Vial et al.
highlight one patient who had a malignant lymph node
in station 9, which is known to be accessible by EUS-B-
FNA. We want to stress, however, that station 5 can also
be visualized and biopsied using EUS-B-FNA,
of great relevance as this station was overrepresented as
malignant in the operated patients. We have demon-
strated how the EUS-B-FNA technique can be used to
biopsy station 5 (unpublished data).
In conclusion, the results of Vial et al.
the time has come for pulmonologists to learn and
implement EUS-B-FNA in combination with EBUS-
TBNA, to increase the precision of preoperative medi-
astinal staging of lung cancer patients.
Therese Maria Henriette Naur, MS
Paul F. Clementsen, MD, PhD, DMSc
Ida S. Christiansen, MD
and Lars Konge, MD, PhD
Copenhagen Academy for Medical Education and
Simulation (CAMES), University of Copenhagen and the
Capital Region of Denmark, Copenhagen;
of Internal Medicine, Zealand University Hospital,
Correspondence: Therese Maria Henriette Naur, Copenhagen Acad-
emy for Medical Education and Simulation (CAMES), University of
Copenhagen and the Capital Region of Denmark, Blegdamsvej 9, 2100
Copenhagen, Denmark. Email: firstname.lastname@example.org
1 Vial MR, O’Connell OJ, Grosu HB, Hernandez M, Noor L, Casal RF,
Stewart J, Sarkiss M, Jimenez CA, Rice D et al. Diagnostic perfor-
mance of endobronchial ultrasound-guided mediastinal lymph
node sampling in early stage non-small cell lung cancer: a prospec-
tive study. Respirology 2018; 23:76–81.
2 Naur TMH, Konge L, Clementsen PF. Endobronchial ultrasound-
guided transbronchial needle aspiration for staging of patients with
non-small cell lung cancer without mediastinal involvement at posi-
tron emission tomography-computed tomography. Respiration
2017; 94: 279–84.
3 Vilmann P, Clementsen PF, Colella S, Siemsen M, De Leyn P,
Dumonceau JM, Herth FJ, Larghi A, Vazquez-Sequeiros E, Hassan C
et al. Combined endobronchial and esophageal endosonography for
the diagnosis and staging of lung cancer: European Society of Gas-
trointestinal Endoscopy (ESGE) guideline, in cooperation with the
European Respiratory Society (ERS) and the European Society of
Thoracic Surgeons (ESTS). Endoscopy 2015; 47: c1.
4 Hwangbo B, Lee GK, Lee HS, Lim KY, Lee SH, Kim HY, Lee HS,
Kim MS, Lee JM, Nam BH et al. Transbronchial and transesophageal
ﬁne-needle aspiration using an ultrasound bronchoscope in mediasti-
nal staging of potentially operable lung cancer. Chest 2010; 138:
From the Authors:
We thank Dr Naur et al. for their interest in our study
in which we found endobronchial ultrasound-guided
transbronchial needle aspiration (EBUS-TBNA) to have
40% sensitivity for identifying N2/N3 disease in a popu-
lation with no mediastinal or distant metastasis after
positron emission tomography-computed tomography
Incidentally, this is a very similar estimate
to the 42% reported by Dr Naur et al.
We strongly agree that preoperative staging in these
potentially operable patients needs to be improved but
believe that presently the best strategy remains unclear.
The authors refer to the high number of unsuspected
metastasis in station 5 found in both studies, and seem
to advocate for the routine use of oesophageal ultra-
sound with ﬁne needle aspiration using the broncho-
scope (EUS-B-FNA) to sample this station as a strategy
to increase sensitivity. Although it is technically chal-
lenging to sample station 5 without traversing great ves-
sels, EUS-B-FNA and EBUS have both been used to
reach this station successfully.
This has most often
been reported in patients with enlarged lymph nodes at
© 2017 Asian Paciﬁc Society of Respirology Respirology (2018) 23, 434–437