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 Table of Contents  
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 92-94

Diagnosis and staging of lung cancer using transesophageal ultrasound: Training and assessment

Copenhagen Academy for Medical Education and Simulation, Centre for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark

Date of Submission11-May-2021
Date of Acceptance30-Nov-2021
Date of Web Publication23-Apr-2022

Correspondence Address:
Kristoffer Mazanti Cold
Region Hovedstaden, København Ø
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00129

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How to cite this article:
Cold KM, Clementsen PF. Diagnosis and staging of lung cancer using transesophageal ultrasound: Training and assessment. Endosc Ultrasound 2022;11:92-4

How to cite this URL:
Cold KM, Clementsen PF. Diagnosis and staging of lung cancer using transesophageal ultrasound: Training and assessment. Endosc Ultrasound [serial online] 2022 [cited 2022 Jul 2];11:92-4. Available from: http://www.eusjournal.com/text.asp?2022/11/2/92/343777

  Clinical Background Top

Lung cancer is the leading cause of cancer mortality.[1] Tumor tissue sampling is mandatory in the allocation of correct treatment and to enhance outcomes.[2] Diagnosing and staging of patients is comprised of imaging and invasive techniques. The latter includes endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and transesophageal EUS-FNA. Endoscopic staging has replaced operative interventions as mediastinoscopy, as endoscopic staging has a higher sensitivity in lymph node staging,[3] is less invasive with a lower complication rate,[4] and is recommended by current international guidelines as the first test in mediastinal testing in lung cancer patients.[4],[5],[6] EUS and EBUS complement each other. The diagnostic value of combining EBUS with EUS by using echo-bronchoscope (EUS-B) is superior to either performing EBUS or EUS-B alone, and reduces the need for surgical staging procedures.[7],[8]

EUS is excellent for the left and lower paraesophageal structures and structures under the diaphragm,[9] while EBUS provides access to structures close to the large airways on both sides. EUS-FNA can be performed with either conventional gastrointestinal EUS or EUS-B in the esophagus.[10] A single-scope approach (EBUS-TBNA and EUS-B-FNA) has also obvious logistical, practical, and economic advantages compared to a dual-scope approach (EBUS-TBNA and EUS-FNA).

Only a few pulmonologists perform EUS-FNA since it conventionally lies in the hands of gastroenterologists or gastric surgeons. EUS-B-FNA is a relatively new technique. Thus, there is a huge need for education and assessment of competencies in the procedure. Training requirements for EBUS-TBNA have been published by the European, American, and British Respiratory Society,[11],[12],[13] whereas no specific requirements have been defined for EUS-FNA for mediastinal staging of lung cancer.

We will briefly describe the current status for theoretical education, practical education, and validation of competency in EUS-B with suggestions to a training program.

  How to Learn Transesophageal Ultrasound Top

Miller described a four-layered pyramid for acquiring competence.[14] The two first steps (“knows” and “knows how”) relate to the theoretical knowledge that should establish a base for practical training and performance. Step 3 (“shows how”) is a performance in a simulated environment, and step 4 (“does”) is the supervised performance on patients. A systematic training program in transesophageal ultrasound should be based on the same steps: theoretical knowledge, simulation-based training, and supervised performance on patients. For the assessment of theoretical knowledge, a validated theoretical examination based on multiple-choice questions have been developed.[15] Unfortunately, evidence-based training requirements for transesophageal ultrasound for the diagnosis and staging of lung cancer do not exist.

We recommend for the development of a systematic and stepwise approach, learned through simulation-based training, where skill assessment relies on tests with a pass/fail criteria.

  Systematic and Stepwise Approach Top

When comparing a systematic approach to a targeted in EBUS, the former resulted in a higher diagnostic yield.[16] For bronchoscopy, a systematic approach is also correlated with inspection of more segments and a lower procedure time.[17] Therefore, we recommend using a stepwise and systematic approach when learning and performing the procedure. First, the trainee should learn to recognize the six anatomical landmarks in the following order by observing the procedure performed by an experienced colleague. (1) the left liver lobe, (2) the abdominal aorta with the celiac trunk and the superior mesenteric artery, (3) the left adrenal gland, (4) lymph node station 7, (5) lymph node station 4 L, and (6) lymph node station 4R.[18],[19] Similarly, six landmarks for learning EBUS-TBNA have been described.[19] The second and next step is to learn how to handle the endoscope, i.e., to insert it and to find the landmarks. The third step is to learn how to take biopsies.

  Apprenticeship-Based Learning Top

Early guidelines for gastrointestinal EUS recommended a minimum of 150 total supervised procedures. Studies on learning curves showed “substantial variability in achieving competency and a consistent need for more supervision than current recommendations.”[20],[21] Another study exploring learning curves for EUS for lung cancer staging found that 20 procedures were not enough to ensure basic competency.[22] Similar results were found for trainees performing 50 EBUS-TBNA procedures.[23],[24] Procedural experience is a surrogate marker for competence, as trainees learn at different paces.[25] Skill acquisition should rely on mastery learning where the trainee practices until proficiency targets are met,[26] and thereby relies on assessment tools, that can determine if the desired level of competence is achieved.[27] Measurement of competency can be based on a validated video-based tool (the EUSAT tool) for assessing technical abilities in EUS-FNA.[28] The assessment tool has a high intra- and inter-rater reliability and can discriminate between trainees and experienced physicians.

  Simulation Based Learning Top

Operators should train to perform EBUS and EUS-B at the same time to enable complete endoscopic staging in one session.[29] It is no longer acceptable to put the burden of initial training on the patients. In general, beginners should practice endoscopic procedures on rubber models, animal organs, live anesthetized animals, and virtual-reality simulators. However, no animal presents an anatomy suitable for learning the relevant human anatomy for the transesophageal ultrasound. It is surprising that no rubber models or virtual reality simulators for EUS-FNA and EUS-B-FNA for pulmonology exist, while there are several EBUS simulators on the market with validated tests.[30] Simulation-based learning is a cornerstone in the European Respiratory Society's educational program in EBUS-TBNA[31] and can replace apprenticeship-based learning in the initial part of the learning curve.[32] However, not all aspects can be practiced on simulators or phantoms. Even after passing a simulation-based test, the trainee should perform the initial procedures under supervision, and reach as high a procedure volume as possible, as dedicated interventional pulmonologists are more likely to perform procedures properly than general pulmonologists who do not perform the procedure regularly.[33]

  Final Remarks Top

There is a huge need to develop simulation-based training programs for EUS-B-FNA with validated tests to assess user competency and spare patients from the initial part of novices learning curves, in the same way, it has successfully been done for EBUS-TBNA.

Conflicts of interest

There are no conflicts of interest.

  References Top

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Goeckenjan G, Sitter H, Thomas M, et al. Prevention, diagnosis, therapy, and follow-up of lung cancer. Interdisciplinary guideline of the German Respiratory Society and the German Cancer Society – Abridged version. Pneumologie 2011;65:e51-75.  Back to cited text no. 2
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs. endosonography for mediastinal nodal staging of lung cancer: A randomized trial. JAMA 2010;304:2245-52.  Back to cited text no. 3
Vilmann P, Clementsen PF, Colella S, et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Endoscopy 2015;47:545-59.  Back to cited text no. 4
De Leyn P, Dooms C, Kuzdzal J, et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014;45:787-98.  Back to cited text no. 5
Silvestri GA, Gonzalez AV, Jantz MA, et al. 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 2013;143 Suppl 5:S211-50.  Back to cited text no. 6
Korevaar DA, Crombag LM, Cohen JF, et al. Added value of combined endobronchial and oesophageal endosonography for mediastinal nodal staging in lung cancer: A systematic review and meta-analysis. Lancet Respir Med 2016;4:960-8.  Back to cited text no. 7
Ohnishi R, Yasuda I, Kato T, et al. Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal nodal staging of lung cancer. Endoscopy 2011;43:1082-9.  Back to cited text no. 8
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Oki M, Saka H, Ando M, et al. Transbronchial vs. transesophageal needle aspiration using an ultrasound bronchoscope for the diagnosis of mediastinal lesions: A randomized study. Chest 2015;147:1259-66.  Back to cited text no. 10
Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society. Eur Res J 2002;19:356-73.  Back to cited text no. 11
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Du Rand IA, Barber PV, Goldring J, et al. Summary of the British Thoracic Society guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax 2011;66:1014-5.  Back to cited text no. 13
Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65 Suppl 9:S63-7.  Back to cited text no. 14
Savran MM, Clementsen PF, Annema JT, et al. Development and validation of a theoretical test in endosonography for pulmonary diseases. Respiration 2014;88:67-73.  Back to cited text no. 15
Sanz-Santos J, Serra P, Torky M, et al. Systematic compared with targeted staging with endobronchial ultrasound in patients with lung cancer. Ann Thorac Surg 2018;106:398-403.  Back to cited text no. 16
Cold KM, Svendsen MB, Bodtger U, et al. Using structured progress to measure competence in flexible bronchoscopy. J Thorac Dis 2020;12:6797-805.  Back to cited text no. 17
Konge L, Colella S, Vilmann P, et al. How to learn and to perform endoscopic ultrasound and endobronchial ultrasound for lung cancer staging: A structured guide and review. Endosc Ultrasound 2015;4:4-9.  Back to cited text no. 18
Jenssen C, Annema JT, Clementsen P, et al. Dietrich CF. Ultrasound techniques in the evaluation of the mediastinum, part 2: Mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques, clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography. J Thorac Dis 2015;7:E439-58.  Back to cited text no. 19
Eisen GM, Dominitz JA, Faigel DO, et al. Guidelines for credentialing and granting privileges for endoscopic ultrasound. Gastrointest Endosc 2001;54:811-4.  Back to cited text no. 20
Wani S, Coté GA, Keswani R, et al. Learning curves for EUS by using cumulative sum analysis: Implications for American Society for Gastrointestinal Endoscopy recommendations for training. Gastrointest Endosc 2013;77:558-65.  Back to cited text no. 21
Konge L, Annema J, Vilmann P, et al. Transesophageal ultrasonography for lung cancer staging: Learning curves of pulmonologists. J Thorac Oncol 2013;8:1402-8.  Back to cited text no. 22
Davoudi M, Colt HG, Osann KE, et al. Endobronchial ultrasound skills and tasks assessment tool: Assessing the validity evidence for a test of endobronchial ultrasound-guided transbronchial needle aspiration operator skill. Am J Respir Crit Care Med 2012;186:773-9.  Back to cited text no. 23
Kemp SV, El Batrawy SH, Harrison RN, et al. Learning curves for endobronchial ultrasound using cusum analysis. Thorax 2010;65:534-8.  Back to cited text no. 24
Gaisl T, Bratton DJ, Heuss LT, et al. Sedation during bronchoscopy: Data from a nationwide sedation and monitoring survey. BMC Pulm Med 2016;16:113.  Back to cited text no. 25
McGaghie WC, Issenberg SB, Cohen ER, et al. Medical education featuring mastery learning with deliberate practice can lead to better health for individuals and populations. Acad Med 2011;86:e8-9.  Back to cited text no. 26
Siddaiah-Subramanya M, Smith S, Lonie J. Mastery learning: How is it helpful? An analytical review. Adv Med Educ Pract 2017;8:269-75.  Back to cited text no. 27
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Konge L, Clementsen PF, Ringsted C, et al. Simulator training for endobronchial ultrasound: A randomised controlled trial. Eur Respir J 2015;46:1140-9.  Back to cited text no. 32
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  Clinical Background
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