• Bronchoscopy
• rare lung diseases
• systemic disease and lungs
• madiastinal amyloidosis
• transbronchial needle aspiration

We read with interest the pulmonary puzzle by Khor et al1 on mediastinal lymph node amyloidosis diagnosed by direct real-time endobronchial ultrasound-guided (EBUS) transbronchial needle aspiration (TBNA). The development of EBUS-TBNA is improving the diagnostic yield of mediastinal lymphadenopathy.2 However, we offer some comments about the diagnostic approach used in the case described.

First, in our opinion, conventional TBNA continues to have a significant value in diagnosing mediastinal node involvement, especially in cases of lymph nodes with a short axis >1 cm that are readily accessible.3 The potential advantages of TBNA over EBUS-TBNA are the lower cost, routine availability, ease of mastery, reduced need for patient sedation and the possibility of using histology needles that allow acquisition of a core of tissue, improving diagnostic sensitivity for other lesions such as tuberculosis, lymphoma and sarcoidosis.3 Our group reported the first case of mediastinal amyloidosis diagnosed by TBNA using a histology TBNA needle.4 In our opinion, according to the characteristics of the patient described and CT chest images, the safest and most cost-effective probe that was indicated in this case was TBNA using a histology needle. Second, there is a previous report in the literature of mediastinal amyloidosis diagnosis made with EBUS-TBNA5 so the report was not, as the authors stated, the first published case. Finally, we agree with the authors that, although mediastinoscopy is still considered the ‘gold standard’ diagnostic approach for mediastinal nodal amyloidosis, conventional TBNA sampling has value and should be considered as a less costly alternative that is universal and accessible to any bronchoscopist compared with EBUS-TBNA. In fact, it should be considered the first step in the diagnostic sequence. The debate over the role of conventional TBNA in the era of EBUS remains unresolved.