When will we finally adopt endoscopic ultrasound?

I read with interest the article in a recent issue of CHEST (August 2014) by Liberman et al, 1 who performed a prospective lung cancer staging trial in which patients underwent both an endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) investigation followed by surgical staging. Th e combination of an endobronchial and esophageal approach was superior in detecting (sensitivity, 91%) and excluding (negative predictive value, 96%) mediastinal nodal metastases vs either technique alone. 1 Th e fi ndings of the study are in line with the conclusion of a recent meta-analysis 2 and also support the current guideline recommendation that mediastinal nodal tissue staging should start with endosonography. 3 However, there is discussion whether an EBUS investigation should be followed by EUS routinely or only in selected cases. Th erefore, it would be of interest to know in which specifi c situations EUS provided an added value and whether this benefi t could be predicted based on prior CT-PET imaging. Regarding mediastinal nodal sampling, I was surprised that lymph node station 5 was aspirated 88 times. Th ese nodes are located laterally to the ligamentum arteriosum and are notoriously diffi cult to sample—unlike the neighboring station 4L—because of the interposition of the pulmonary artery and aorta.