THORACIC: LUNG CANCER: LETTERS TO THE EDITOR techniques, the choice of a systematic sampling or a tar- The authors reported no conflicts of interest. geted sampling is based only on EBUS findings (Canada The Journal policy requires editors and reviewers Lymph Node Score). Based on their initial results, with an to disclose conflicts of interest and to decline incidence of missed mediastinal metastases of 5.45% for handling or reviewing manuscripts for which they targeted sampling, the authors affirm that targeted sampling may have a conflict of interest. The editors and re- is safe enough, and that there are no clinically significant viewers of this article have no conflicts of interest. differences between both strategies (although there is an in- crease in the detection of malignant nodes from 1.75% for targeted sampling to 7.27% for systematic sampling). However, in our opinion, these results must be interpretated with prudence. First, because not all negative results were SYSTEMATIC OR confirmed by surgery, and second, because all the included TARGETED SAMPLING patients had normal mediastinum on imaging techniques. In DURING such clinical scenario, with low prevalence of mediastinal ENDOBRONCHIAL involvement, it is well known that the sensitivity of EBUS- ULTRASOUND FOR TBNA declines and, therefore, differences between a targeted MEDIASTINAL sampling and a systematic sampling may appear lower than STAGING IN PATIENTS WITH LUNG they are in patients with abnormal mediastinum. CANCER AND ABNORMAL We agree with the authors that it is important to establish MEDIASTINUM strategies to reduce the timing of mediastinal staging in To the Editor: patients with lung cancer. This means avoiding redundant In the recently published article by Sullivan and col- explorations and reducing the length of the procedures. leagues,1 the authors describe the feasibility of a random- However, mediastinal staging is a crucial step in the man- ized controlled trial that aims to compare targeted with agement of patients with lung cancer and any of these mea- systematic endobronchial ultrasound–guided transbron- sures cannot affect its thoroughness. Systematic staging chial needle aspiration (EBUS-TBNA) sampling for medi- through EBUS-TBNA in patients with abnormal medias- astinal staging in patients with lung cancer. The authors tinum on PET-CT has demonstrated to be more precise hypothesize that targeted EBUS-TBNA sampling is not than targeted sampling and still must be recommended in inferior to systematic EBUS-TBNA. A targeted, selected, such clinical scenario. or “hit-and-run” EBUS-TBNA sampling is defined as a spe- cific investigation for malignancy-suspected mediastinal Jose Sanz-Santos, MD, PhDa,b nodes based on positron emission tomography-computed Pere Serra, MD, PhDc tomography (PET-CT) findings (fluorodeoxyglucose avid Antoni Rosell, MD, PhDc,d,e,f or short axis 10 mm).2 On the contrary, a systematic a Pulmonology Department EBUS-TBNA sampling is defined as a systematic investiga- Hospital Universitari Mutua Terrassa tion of all lymph nodes with a short axis 8 mm by EBUS, Terrassa, Barcelona, Spain regardless of their appearance on PET-CT. This is not the b University of Barcelona, School of Medicine first study that aims to compare both strategies. Previous Barcelona, Spain studies that included patients with abnormal mediastinum c Pulmonology Department on PET-CT have demonstrated the benefits of systematic Hospital Universitari Germans Trias i Pujol over targeted sampling in terms of clinically relevant infor- Badalona, Barcelona, Spain mation. Compared with targeted sampling, systematic d Universitat Autonoma de Barcelona (UAB) Cerdanyola sampling enhances the sensitivity of EBUS-TBNA for the del Valles diagnosis of mediastinal nodal metastases and determines Barcelona, Spain the extent of the mediastinal disease more accurately.2-4 e Centro de investigacion en red de enfermedades In the study of Sullivan and colleagues,1 the authors respiratorias (CIBERES) compare targeted sampling with systematic sampling based Madrid, Spain on 3 nodal features: appearance on CT, appearance on PET f Institut de recerca Germans Trias I Pujol (IGTP) (fluorodeoxyglucose avidity) and appearance on EBUS, Badalona, Barcelona, Spain based on the Canada Lymph Node Score.5 However, since all included patients present normal mediastinum on image References 1. Sullivan KA, Farrokhyar F, Leontiadis GI, Ptel YS, Churchill IF, Hylton DA, et al. Copyright Ó 2022 The Author(s). Published by Elsevier Inc. on behalf of The Routine systematic sampling vs. targeted sampling during endobronchial ultra- American Association for Thoracic Surgery. This is an open access article under the sound: a randomized feasibility trial. J Thorac Cardiovasc Surg. December 4, CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 2021 [Epub ahead of print]. 346 JTCVS Open c September 2022 Thoracic: Lung Cancer: Letters to the Editor 2. Crombag LMM, Dooms C, Stigi JA, Tournoy KG, Schuurbiers OCJ, Ninaber MK, improves radiotherapy planning in non-small cell lung cancer. ERJ Open Res. et al. Systematic and combined endosonographic staging of lung cancer (SCORE 2019;15;5:00004-2019. study). Eur Respir J. 2019;E3:18008800. 5. Hylton DA, Turner S, Kidane B, Spicer J, Xie F, Farrokhyar F, et al. The 3. Sanz-Santos J, Serra P, Torky M, Andreo F, Centeno C, Mendiluce L, et al. Sys- Canada lymph node score for prediction of malignancy in mediastinal lymph tematic compared with targeted staging with endobronchial ultrasound in patients nodes during endobronchial ultrasound. J Thorac Cardiovasc Surg. 2020;159: with lung cancer. Ann Thorac Surg. 2018;106:398-403. 2499-507. 4. Cole AJ, Hardcastle N, Turgeon GA, Thomas R, Irving LB, Jennings BR, et al. Systematic endobronchial ultrasound-guided transbronchial needle aspiration https://doi.org/10.1016/j.xjon.2022.01.030 JTCVS Open c Volume 11, Number C 347