Rhinovirus and asthma: reinfection, not persistence.

and therefore not different from the sensitivity reported usingEBUSTBNA in our article. They state that all non–small cell lung cancer– not otherwise specified (NSCLC-NOS) samples in their institution have immunocytochemistry (ICC) performed. However, in their illustrative retrospective cohort, only 19 of 24 NSCLC-NOS cases underwent ICC, implying that 21% of cases of NSCLC-NOS were inadequate for further testing despite ROSE. In our multicenter study of 774 patients, 101 had a diagnosis of NSCLC-NOS and in only 6 patients was immunohistochemistry not possible. Dr. Craig and colleagues unfortunately also do not refer to the randomized controlled trials of ROSE that also do not support its routine use. Even in patients undergoing conventional TBNA, the presence of ROSE does not appear to improve yield (2). In a randomized controlled trial of patients undergoing EBUS-TBNA with and without ROSE, the sensitivity was not significantly different between the arms (3). Dr. Craig and colleagues also suggest that the presence of malignant cells in one lymph node station as assessed by ROSE can preclude further investigation of other diagnoses such as tuberculosis in other lymph node stations. This is certainly not our practice in our high-tuberculosis-prevalence region (4). Dr. Craig and colleagues suggest some potential advantages of ROSE. They omit that it may improve the negative predictive value of a negative EBUS sample; however, they also do not include any potential disadvantages that must also be considered. For example, the process of ROSE will use up vital tissue that could be better used for further tumor characterization in the laboratory. The number of passes submitted to the pathologist in the room before a lymph node is labeled as benign is unknown, and the risk of false-positive diagnoses in the bronchoscopy suite must also be clarified. The cost-effectiveness of ROSE is also unknown; however, the number of cases reported by a pathologist in an EBUS session is less than if the equivalent time was spent in the cytology laboratory. Routine use of ROSEwill have enormous impact on pathology service provision and costs to the United Kingdom National Health Service. Dr. Craig and colleagues’ analysis of our data (225 patients with “lymphoid cells only” on EBUS-TBNA) also highlights a key point surrounding terminology of EBUS-TBNA samples. Dr. Craig and colleagues refer to this group of patients with lymphoid cells only or an inadequate sample as the “nondiagnostic” group. We believe this is an unhelpful and inaccurate term and should be restricted to the group of patients where EBUS-TBNA has provided an insufficient sample only. Lymphoid cells only may be entirely diagnostic of a reactive lymph node, which was the final diagnosis in 71% in this group. We currently classify these results as negative, appreciating that this negative result may be diagnostic (true negative) or a false negative if malignancy is subsequently confirmed. We agree with the authors that when a phenotypic diagnosis is not clear on initial assessment, ICC plays an important role in subtyping, and it is also our routine practice that this is performed as well as epidermal growth factor receptor mutation testing where appropriate. In addition to the tests routinely used in Dr. Craig and colleagues’ institution, we routinely analyze adenocarcinomas for the EML4-ALK gene rearrangement and are about to embark on multiplex testing of lung cancers, with a view to aiding recruitment to early-phase clinical trials. This emphasizes the pressure that specimens from EBUS-TBNA are likely to be subjected to in the future and highlights that using specimen at the bedside for ROSE may not be the best use of lung cancer tissue. The evidence is not currently available to suggest that ROSE is effective or cost-effective, and therefore, we do not agree with Dr. Craig and colleagues’ conclusion that availability of ROSE should be default. Although we agree that ROSE is helpful in the learning phase of the procedure (5), a recommendation for routine use of ROSE will add to the already high capital costs of embarking on EBUS-TBNA and may deter further centers from being commissioned. Finally, we agree that all EBUS-TBNA services should be subject to audit with a review of service specifications if standards are not being met.