Access to the mediastinum—The standard has changed
Abordagem do Mediastino—A norma foi alterada
F.J.F. Herth
Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg, German Center for Lung Research, University of Heidelberg, Heidelberg, Germany

100 years ago, lung cancer was a rare disease.1 Over time it has become one of the leading causes of cancer death worldwide.2 Along with this the diagnostic and also the therapeutic implications have changed several times over the last few decades. In 1968 the first TNM description was published, trying to standardize the tumor staging and thereby the specific therapeutic recommendations. Today the 7th edition of the TNM system is still in use and the fact that the staging of the mediastinum is one of the most important topics has still not been challenged.3

In 1964 Werner Maaßen published his first full report about mediastinoscopy as a staging technique and in the following years the technique was established as the gold standard for the mediastinum.4

Even after the implementation of improved imaging techniques like computer tomography (CT) and Positron emissions tomography (PET), the surgical option was not discussed.3

Watching and learning from gastroenterologists, Olympus Medical introduced the world's first curved linear array ultrasonic bronchoscope in 2004. The development of the endoscope had started more than 5 years earlier based on a request to minimise existing EUS-FNA technology so that can be used for diagnosis from within the bronchial system.

The success story of EBUS-TBNA starts in 2003 with the publication in the journal Thorax by Krasnik and Vilmann,5 followed by an article by Yasufuku in Chest.6 Both articles gave an initial description of the principle of EBUS-TBNA. In 2006, the biggest case series on 502 patients showed that EBUS-TBNA resulted in 93% diagnostic yield, a sensitivity of 94%, specificity of 100% and accuracy of 94%.7

Over the last ten years the evidence about EBUS-TBNA has grown rapidly and after several meta-analyses8–10 the endoscopic technique is quoted now as the first test for evaluation of the mediastinum, replacing mediastinoscopy.11

In this issue Dr. Bugalho12 writes about his experience with this method in Portugal. The paper nicely demonstrates that there has been a rapid learning curve; the results achieved are consistent with previous published results and, especially in relation to the initial results, the negative predicted value has increased dramatically. Particularly in line with the most recent publications on this topic,13–16 it is clear that nowadays not only have the tissue samplers been adapted to the new technique, but also the tissue readers, mainly cytopathologist, primed to read cells instead of tissue.

And today? As mentioned, EBUS-TBNA has become the Gold standard for diagnosing and staging the mediastinum. But we still need to get better. Due to modern oncological options, cell analysis is no longer enough. Molecular staging will become the future standard and therefore we have to work on our techniques, to provide sufficient material for such questions.But for the moment, endobronchial ultrasound has replaced mediastinoscopy.

C.M. Fletcher,D. Horn
Smoking and health
WHO Chron, 24 (1970), pp. 345-370
R. Siegel,D. Naishadham,A. Jemal
Cancer statistics, 2013
R. Rami-Porta,J.J. Crowley,P. Goldstraw
The revised TNM staging system for lung cancer
Ann Thorac Cardiovasc Surg, 15 (2009), pp. 4-9
W. Maassen,M. Kirsch,M. Thuemmler
Indications and preliminary results in 300 mediastinoscopies
Prax Pneumol, 18 (1964), pp. 65-77
M. Krasnik,P. Vilmann,S.S. Larsen,G.K. Jacobsen
Preliminary experience with a new method of endoscopic transbronchial real time ultrasound guided biopsy for diagnosis of mediastinal and hilar lesions
Thorax, 58 (2003), pp. 1083-1086
K. Yasufuku,M. Chiyo,Y. Sekine,P.N. Chhajed,K. Shibuya,T. Iizasa
Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes
F.J.F. Herth,R. Eberhardt,P. Vilmann,M. Krasnik,A. Ernst
Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes
S.E. Cameron,R.S. Andrade,Pambuccian SE
Endobronchial ultrasound-guided transbronchial needle aspiration cytology: a state of the art review
K. Adams,P.L. Shah,L. Edmonds
Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis
L. Varela-Lema,A. Fernandez-Villar,A. Ruano-Ravina
Effectiveness and safety of endobronchial ultrasound—transbronchial needle aspiration: a systematic review
Eur Respir J, 33 (2009), pp. 1156-1164 http://dx.doi.org/10.1183/09031936.00097908
G.A. Silvestri,A.V. Gonzalez,M.A. Jantz
Methods for staging non-small cell lung cancer. Diagnosis and management of lung cancer, 3rd ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Chest, 143 (2013), pp. e211S-e250S http://dx.doi.org/10.1378/chest.12-2355
A. Bugalho,D. Ferreira,R. Barata,C. Rodrigues,S.S. Dias,F. Medeiros
Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer diagnosis and staging in 179 patients
Portuguese J Pulmonol, (2013),
F.J. Herth,M. Krasnik,N. Kahn
Combined endoesophageal–endobronchial ultrasound-guided, fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer
Chest, 138 (2010), pp. 790-794 http://dx.doi.org/10.1378/chest.09-2149
B. Hwangbo,G.K. Lee,H.S. Lee
Transbronchial and transesophageal fine needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer
Chest, 138 (2010), pp. 795-802 http://dx.doi.org/10.1378/chest.09-2100
M. Oki,H. Saka,C. Kitagawa,Y. Kogure,N. Murata,T. Adachi
Rapid on-site cytologic evaluation during endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing lung cancer: a randomized study
Respiration, 85 (2013), pp. 486-492 http://dx.doi.org/10.1159/000346987
A. Pillai,A.R. Medford
Greater physician involvement improves coding outcomes in endobronchial ultrasound-guided transbronchial needle aspiration procedures
Respiration, 85 (2013), pp. 417-421 http://dx.doi.org/10.1159/000346574
Copyright © 2013. Sociedade Portuguesa de Pneumologia


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  • 5-years Impact Factor: 1,100
  • SCImago Journal Rank (SJR):0,29
  • Source Normalized Impact per Paper (SNIP):0,685