Extract
We read with great interest the study by Li et al. [1] evaluating endobronchial ultrasound (EBUS)-guided transbronchial mediastinal cryobiopsy (TBMC) in comparison with conventional bronchoscopic approaches for stage I/II sarcoidosis. The authors should be commended for addressing an important and evolving area in interventional pulmonology.
Shareable abstract
The reported superiority of EBUS-TBMC over EBUS-TBNA in sarcoidosis may be influenced by procedural and anatomical biases. Standardised sampling protocols and prospective comparative studies are needed to determine true diagnostic advantage. https://bit.ly/4uHvrBz
To the Editor:
We read with great interest the study by Li et al. [1] evaluating endobronchial ultrasound (EBUS)-guided transbronchial mediastinal cryobiopsy (TBMC) in comparison with conventional bronchoscopic approaches for stage I/II sarcoidosis. The authors should be commended for addressing an important and evolving area in interventional pulmonology.
Previous studies comparing cryobiopsy with needle-based techniques have demonstrated improved tissue quality and, in selected settings, higher diagnostic yield with cryobiopsy [2–4]. However, these studies have also highlighted the importance of careful patient selection, anatomical considerations and procedural standardisation when interpreting comparative outcomes.
In this context, several aspects of the present study warrant further clarification. The allocation of patients to EBUS-TBMC versus EBUS-guided transbronchial needle aspiration (TBNA) was non-random and operator-dependent. The TBMC group had larger lymph nodes (2.2 versus 1.8 cm) and a markedly higher proportion of sampling from station 7 (77.3% versus 45.7%), both of which are known to favour higher diagnostic yield. This raises the possibility of preferential selection of anatomically favourable targets for TBMC.
Furthermore, diagnostic yield was analysed at a technique-specific level, allowing individual patients to contribute to multiple sampling modalities. Such a non-mutually exclusive analysis may overestimate the incremental benefit of combined approaches.
In addition, the median number of TBNA passes was three, which is below commonly recommended thresholds, potentially leading to underestimation of TBNA performance [5].
Taken together, these factors may influence the observed superiority of TBMC over TBNA. Adjustment for key procedural and anatomical variables, as well as prospective comparative studies, would further strengthen the evidence base in this area.
Footnotes
Provenance: Submitted article, peer reviewed.
Conflict of interest: The authors report no financial or nonfinancial relationships, activities or interests that could have influenced the work reported in this study.
Support statement: No funding declared.
References
- 1.Li Z, Zhang Q, Tang F, et al. Diagnostic value of EBUS-guided transbronchial mediastinal cryobiopsy versus conventional bronchoscopic approaches for stage I/II sarcoidosis: DETECTION-SAR I. ERJ Open Res 2026; 12: 01281-2025. doi: 10.1183/23120541.01281-2025 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Zhang J, Guo JR, Huang ZS, et al. Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal lesions: a randomised trial. Eur Respir J 2021; 58: 2100055. doi: 10.1183/13993003.00055-2021 [DOI] [PubMed] [Google Scholar]
- 3.Mangold MS, Franzen DP, Hetzel J, et al. Ultrasound-guided transbronchial cryobiopsy of mediastinal and hilar lesions: a multicenter pragmatic cohort study with real-world evidence. BMJ Open Respir Res 2024; 11: e002617. doi: 10.1136/bmjresp-2024-002617 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Poletti V, Petrarulo S, Piciucchi S, et al. EBUS-guided cryobiopsy in the diagnosis of thoracic disorders. Pulmonology 2024; 30: 459–465. doi: 10.1016/j.pulmoe.2023.11.008 [DOI] [PubMed] [Google Scholar]
- 5.Gilbert CR, Dust C, Argento AC, et al. Acquisition and handling of endobronchial ultrasound transbronchial needle samples: an American College of Chest Physicians clinical practice guideline. Chest 2025; 167: 899–909. doi: 10.1016/j.chest.2024.08.056 [DOI] [PubMed] [Google Scholar]