Transesophageal Ultrasonography for Lung Cancer Staging: Learning Curves of Pulmonologists Lars Konge, MD, PhD, Jouke Annema, MD, PhD, Peter Vilmann,

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Transesophageal Ultrasonography for Lung Cancer Staging: Learning Curves of Pulmonologists Lars Konge, MD, PhD, Jouke Annema, MD, PhD, Peter Vilmann, MD, DMSc, Paul Clementsen, MD, PhD, DMSc, Charlotte Ringsted, MD, PhD Journal of Thoracic Oncology Volume 8, Issue 11, Pages 1402-1408 (November 2013) DOI: 10.1097/JTO.0b013e3182a46bf1 Copyright © 2013 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Schematic drawings and endosonographic examples of the six anatomical landmarks that should be identified in every transesophageal EUS procedure for mediastinal staging of non–small-cell lung carcinoma. The dot in the drawings and the “H” in the endosonographic pictures mark the cephalic orientation of the endoscope (= the direction from where the needle is coming). A, EUS view of the left liver lobe. The transducer is positioned in the distal esophagus/cardia. B, EUS view from the stomach visualizing the AO and CT. C, EUS view of the left adrenal gland depicting its body and two wings (sea gull sign). The EUS scope with the transducer is positioned in the stomach. D, EUS image of the subcarinal nodes (station 7) that are located between the left atrium and pulmonary trunk. The transducer is positioned in the esophagus at approximately 30 cm from the incissors. E, EUS image of the left paratracheal nodes (station 4 left) that are located between the aorta and left pulmonary artery. Notice the needle from the left upper corner entering the node. The distal end of the endoscope is positioned in the esophagus at approximately 25 cm from the teeth. F, EUS view of the right paratracheal node (station 4 right) that is located adjacent to the azygos vein and can often only be detected when enlarged because of the intervening air from the trachea. EUS, endoscopic ultrasound; AO, abdominal aorta; CT, celiac trunk. Journal of Thoracic Oncology 2013 8, 1402-1408DOI: (10.1097/JTO.0b013e3182a46bf1) Copyright © 2013 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 The individual learning curves of the four respiratory physicians performing fine-needle aspiration for mediastinal staging of non–small-cell lung carcinoma using transesophageal EUS-FNA. Each procedure was assessed using the validated EUS assessment tool, giving a score between 0 and 48 points. The dotted line shows the mean score of 15 procedures performed by experienced operators, who had performed approximately 200 EUS-FNA procedures each before assessment, and is used to indicate the level of competent performance. A, Participant number 1, institution 1 (Denmark). Prior EBUS experience: 200 procedures. B, Participant number 2, institution 1 (Denmark). Prior EBUS experience: 50 procedures. C, Participant number 3, institution 2 (The Netherlands). No prior EBUS experience. D, Participant number 4, institution 2 (The Netherlands). Prior EBUS experience: 35 procedures. EUS-FNA, endoscopic ultrasound fine-needle aspiration. Journal of Thoracic Oncology 2013 8, 1402-1408DOI: (10.1097/JTO.0b013e3182a46bf1) Copyright © 2013 International Association for the Study of Lung Cancer Terms and Conditions