In Reply: Dr Navani and colleagues raise the issue of the optimal number of passes of the TBNA needle into each lymph node. In one study, up to 7 TBNA passes were needed to maximize the sensitivity, although in that study more than 80% of positive diagnoses were obtained by the third FNA pass.1 Another study of the relationship between number of passes and sensitivity using EUS-FNA found that 3 passes were needed to maximize the sensitivity.2 Given the need to make a fair head-to-head comparison, we chose a uniform number of passes (at least 3) for all 3 procedures. We accept that more passes by TBNA may have increased the yield, and it is appropriate in settings where EUS-FNA or EBUS-FNA are not available. Similarly, the use of ROSE is most helpful when ultrasound guidance is not available but does increase the cost and time needed for the procedure. In one study, ROSE did not increase the diagnostic yield compared with 3 empirical passes for EUS-FNA.2
Wallace MB. Lung Cancer Staging With Minimally Invasive Endoscopic Techniques—Reply. JAMA. 2008;299(21):2509–2511. doi:10.1001/jama.299.21.2510-b
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