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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the last 10 years&#44; the treatment of lung cancer&#44; especially non-small cell lung cancer &#40;NSCLC&#41; has changed following the development of new interventions targeting mutations detected in pathological samples of NSCLC&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Some of the available molecular genes include epidermal growth factor receptor &#40;EGFR&#41;&#44; anaplastic lymphoma kinase &#40;ALK&#41;&#44; and ROS proto-oncogene 1 &#40;ROS1&#41;&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Endobronchial ultrasound with transbronchial needle aspiration &#40;EBUS-TBNA&#41; is a minimally invasive technique with a high diagnostic yield&#44; especially for central airway lesions&#46; This technique is safe&#44; and the European Respiratory Society &#40;ERS&#41;&#44; European Thoracic Society &#40;ETS&#41;&#44; European Society of Medical Oncology &#40;ESMO&#41;&#44; and American College of Chest Physician &#40;ACCP&#41; have suggested starting with this approach when diagnosing and staging lung cancer&#44; especially NSCLC&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> The aim of this study is to identify the presence of 3 genetic alterations that can be targeted by specific therapeutic inhibitors&#44; EGFR&#44; ALK&#44; and ROS1&#44; collected by endobronchial ultrasound with transbronchial needle aspiration &#40;EBUS-TBNA&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a descriptive&#44; prospective study of EBUS-TBNA samples between July 2014 and June 2015 in a reference center in Chile&#46; Consent forms were signed by all patients and the protocol was approved by the ethics committee of our institution&#46; The inclusion criteria were&#58; &#40;1&#41; adult patients &#40;&#62;18 years old&#41; with a lesion suggestive of lung cancer on clinical and radiological studies who underwent EBUS-TBNA &#40;EBUS Olympus<span class="elsevierStyleSup">&#174;</span> and EBUS Fuji<span class="elsevierStyleSup">&#174;</span>&#41; and &#40;2&#41; confirmed lung cancer by a pathological study &#40;adenocarcinoma or not otherwise specified &#91;NOS&#93;&#41;&#46; We performed mediastinal EBUS when CT scan showed lymphnodes greater than 10<span class="elsevierStyleHsp" style=""></span>mm&#44; or peripheral pulmonary lesions greater or equal to 30<span class="elsevierStyleHsp" style=""></span>mm&#44; or any central pulmonary lesions&#46; Not all patients had undergone PET before EBUS was performed&#46; We did not exclude patients with disseminated disease &#40;EBUS performed for diagnosis purpose&#41;&#46; Patients younger than 18 years&#44; or who did not consent to the procedure were excluded&#46; A minimum of 4 samples were obtained by EBUS-TBNA&#46; Cell blocks were prepared from cytology samples and fixed with 10&#37; formalin solution&#46; All samples were covered with a paraffin solution followed by hematoxylin-eosin staining&#46; Immunohistochemical staining&#44; including TTF-1&#47;napsin-A&#44; CK 5&#47;6 and p40 was performed in cases with no clear adenocarcinoma or squamous cell carcinoma morphology&#46; Samples were subject to sequential molecular testing using the Sanger sequencing analysis &#40;when tumor cell count was over 30&#37;&#41; or Cobas 4800 &#40;needs less tumoral DNA&#44; faster results&#44; more expensive automatic technique&#41; for EGFR mutation&#44; depending on the volume of sample&#46; In cases in which EGFR was negative&#44; we proceeded to analyze the presence of ALK translocation using fluorescence in situ hybridization &#40;FISH&#41; &#40;ZytoLight<span class="elsevierStyleSup">&#174;</span> SPEC ALK&#47;EML4 TriCheck&#8482; Probe&#41;&#46; Finally&#44; a third molecular test using FISH was performed for ROS1 &#40;ZytoLight<span class="elsevierStyleSup">&#174;</span> SPEC ROS1 Dual Color Break Apart Probe&#41;&#46; The primary objective was to determine if EBUS tissue samples were sufficient for molecular testing analysis&#46; &#8220;Sufficient tissue sample&#8221;&#58; we defined sufficient sample as the minimum concentration of a tumor marker achieved by EBUS-TBNA for which a mutation can be processed &#40;a minimum mutated allele of 25&#37; by Sanger method&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Eighty-six patients were included in this study&#44; with 216 EBUS-TBNA performed&#46; Forty-seven &#40;54&#46;65&#37;&#41; participants were female&#44; and average age was 65&#46;70 years &#40;range 37&#8211;91&#41;&#46; No complications were reported&#46; Samples were obtained from lymphnodes in 60&#47;86 &#40;69&#46;76&#37;&#41; patients and from lung parenchyma in 26&#47;86 &#40;30&#46;24&#37;&#41; patients&#46; Sufficient tissue sample was achieved in 97&#46;67&#37; &#40;84&#47;86&#41; of samples for EGFR mutation&#44; 94&#46;23&#37; &#40;49&#47;52 samples&#41; for ALK translocation and 83&#46;33&#37; &#40;10&#47;12 samples&#41; for ROS1 mutation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Molecular testing was positive in 30&#46;23&#37; &#40;26&#47;86 samples&#41;&#44; and the most frequent mutation was EGFR&#44; which was present in 22&#47;86 &#40;25&#46; 58&#37;&#41;&#44; followed by 1&#47;12 cases for ROS1 &#40;8&#46;3&#37;&#41; and 3&#47;52 cases for ALK &#40;5&#46;76&#37;&#41;&#46; A summary of results is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Genetic profile of EGFR demonstrated that deletion in exon 19 was the most frequent mutation &#40;13 cases of delE746-A750 and 2 cases of del2235-2249&#41;&#44; which was followed by an L858R amino acid substitution in exon 21 in 4 cases&#44; and G719A amino acid substitution at position 719 in exon 18 was reported in 2 cases&#46; Finally&#44; exon 20 T790M acquired resistance mutation to tyrosine kinase inhibitors &#40;TKIs&#41; was identified in 1 patient&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This is the first report evaluating the efficacy of EBUS-TBNA for lung cancer and mutational testing in South America&#46; Previous reports were performed in post-surgical samples&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">EBUS-TBNA is a safe method with a high diagnostic yield for lung cancer&#46; In a randomized controlled trial&#44; mediastinal staging by EBUS-TBNA was compared with standard techniques&#44; consisting of imaging and surgical biopsy&#46; The time to &#8220;confirmed&#8221; diagnosis was 2 weeks with this approach versus 4 weeks when using the conventional methods&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In addition&#44; the number of complications and economic analysis was lower in the EBUS-TBNA arm&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Several studies have evaluated the efficacy of EBUS-TBNA for molecular testing in lung cancer&#46; In a multicenter study of 774 patients&#44; EGFR analysis was possible in 90&#37; of the patients analyzed&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;8</span></a> This is consistent with the prevalence described in our series&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In a recent study by Casadio et al&#46;&#44; EBUS-TBNA was performed in 306 consecutive patients with stage IIIB-IV lung cancer by TNM&#46; EGFR analyses were performed in 195 patients&#44; and a cytological diagnosis was achieved in 95&#46;1&#37;&#46; EGFR mutations were present in 16&#46;9&#37;&#44; ALK in 3&#46;9&#37; and KRAS in 31&#46;6&#37;&#46; In addition&#44; chi-square analysis to compare the percentage of mutations in a historical surgical series found no differences&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> This is consistent with the prevalence described in our series&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The genetic profile is similar to that reported by other South American countries&#46; De Melo et al&#46;&#44; reported the mutational profile for 125 patients with lung adenocarcinoma&#44; and EGFR mutations were found in 21&#46;6&#37;&#44; ALK in 4&#46;8&#37; and KRAS in 26&#46;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Our study is one of the few to have reported the utility of EBUS-TBNA for identifying ROS1 mutation&#44; and resistance mutation to TKIs&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This study has limitations&#46; We did not compare our negative EBUS results with surgery or response to target molecular therapy&#46; In our center&#44; we perform an average of 220 EBUS-TBNA procedures per year&#44; with diagnosis of lung adenocarcinoma in approximately 70&#37; of cases&#46; Since we are a regional reference center for EBUS-TBNA&#44; some patients are lost to follow-up and complete their sample processing in the referral center&#46; This is why the number of patients who underwent mutational testing was low&#46; The number of samples for ROS1 testing was limited&#44; thus a study with more cases is required for further analysis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; EBUS-TBNA is a useful minimally invasive technique for collecting cytopathological samples and performing molecular mutation analysis in our lung cancer patients&#46; Samples can also be used to evaluate acquired resistance mutation&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sufficient samples&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84 &#40;97&#46;67&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;83&#46;33&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#40;&#37;&#41; Positive test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;3&nbsp;\t\t\t\t\t\t\n
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Scientific Letter
Molecular Testing of EGFR, EGFR Resistance Mutation, ALK and ROS1 Achieved by EBUS-TBNA in Chile
Análisis moleculares de EGFR, mutación de resistencia al EGFR, ALK y ROS1 en muestras obtenidas mediante PATB-USEB en Chile
Sebastián Fernandez-Bussya,
Corresponding author
sfernandezbussy@alemana.cl

Corresponding author.
, Gonzalo Labarcab, Yumay Piresc, Iván Caviedesd, Mauricio Burottoe
a Unidad de Neumología Intervencionista, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
b Facultad de Medicina, Universidad San Sebastián, Concepción, Chile
c Servicio de Anatomía Patológica, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
d Servicio de Medicina Respiratoria, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
e Servicio de Oncología, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the last 10 years&#44; the treatment of lung cancer&#44; especially non-small cell lung cancer &#40;NSCLC&#41; has changed following the development of new interventions targeting mutations detected in pathological samples of NSCLC&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Some of the available molecular genes include epidermal growth factor receptor &#40;EGFR&#41;&#44; anaplastic lymphoma kinase &#40;ALK&#41;&#44; and ROS proto-oncogene 1 &#40;ROS1&#41;&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Endobronchial ultrasound with transbronchial needle aspiration &#40;EBUS-TBNA&#41; is a minimally invasive technique with a high diagnostic yield&#44; especially for central airway lesions&#46; This technique is safe&#44; and the European Respiratory Society &#40;ERS&#41;&#44; European Thoracic Society &#40;ETS&#41;&#44; European Society of Medical Oncology &#40;ESMO&#41;&#44; and American College of Chest Physician &#40;ACCP&#41; have suggested starting with this approach when diagnosing and staging lung cancer&#44; especially NSCLC&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> The aim of this study is to identify the presence of 3 genetic alterations that can be targeted by specific therapeutic inhibitors&#44; EGFR&#44; ALK&#44; and ROS1&#44; collected by endobronchial ultrasound with transbronchial needle aspiration &#40;EBUS-TBNA&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a descriptive&#44; prospective study of EBUS-TBNA samples between July 2014 and June 2015 in a reference center in Chile&#46; Consent forms were signed by all patients and the protocol was approved by the ethics committee of our institution&#46; The inclusion criteria were&#58; &#40;1&#41; adult patients &#40;&#62;18 years old&#41; with a lesion suggestive of lung cancer on clinical and radiological studies who underwent EBUS-TBNA &#40;EBUS Olympus<span class="elsevierStyleSup">&#174;</span> and EBUS Fuji<span class="elsevierStyleSup">&#174;</span>&#41; and &#40;2&#41; confirmed lung cancer by a pathological study &#40;adenocarcinoma or not otherwise specified &#91;NOS&#93;&#41;&#46; We performed mediastinal EBUS when CT scan showed lymphnodes greater than 10<span class="elsevierStyleHsp" style=""></span>mm&#44; or peripheral pulmonary lesions greater or equal to 30<span class="elsevierStyleHsp" style=""></span>mm&#44; or any central pulmonary lesions&#46; Not all patients had undergone PET before EBUS was performed&#46; We did not exclude patients with disseminated disease &#40;EBUS performed for diagnosis purpose&#41;&#46; Patients younger than 18 years&#44; or who did not consent to the procedure were excluded&#46; A minimum of 4 samples were obtained by EBUS-TBNA&#46; Cell blocks were prepared from cytology samples and fixed with 10&#37; formalin solution&#46; All samples were covered with a paraffin solution followed by hematoxylin-eosin staining&#46; Immunohistochemical staining&#44; including TTF-1&#47;napsin-A&#44; CK 5&#47;6 and p40 was performed in cases with no clear adenocarcinoma or squamous cell carcinoma morphology&#46; Samples were subject to sequential molecular testing using the Sanger sequencing analysis &#40;when tumor cell count was over 30&#37;&#41; or Cobas 4800 &#40;needs less tumoral DNA&#44; faster results&#44; more expensive automatic technique&#41; for EGFR mutation&#44; depending on the volume of sample&#46; In cases in which EGFR was negative&#44; we proceeded to analyze the presence of ALK translocation using fluorescence in situ hybridization &#40;FISH&#41; &#40;ZytoLight<span class="elsevierStyleSup">&#174;</span> SPEC ALK&#47;EML4 TriCheck&#8482; Probe&#41;&#46; Finally&#44; a third molecular test using FISH was performed for ROS1 &#40;ZytoLight<span class="elsevierStyleSup">&#174;</span> SPEC ROS1 Dual Color Break Apart Probe&#41;&#46; The primary objective was to determine if EBUS tissue samples were sufficient for molecular testing analysis&#46; &#8220;Sufficient tissue sample&#8221;&#58; we defined sufficient sample as the minimum concentration of a tumor marker achieved by EBUS-TBNA for which a mutation can be processed &#40;a minimum mutated allele of 25&#37; by Sanger method&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Eighty-six patients were included in this study&#44; with 216 EBUS-TBNA performed&#46; Forty-seven &#40;54&#46;65&#37;&#41; participants were female&#44; and average age was 65&#46;70 years &#40;range 37&#8211;91&#41;&#46; No complications were reported&#46; Samples were obtained from lymphnodes in 60&#47;86 &#40;69&#46;76&#37;&#41; patients and from lung parenchyma in 26&#47;86 &#40;30&#46;24&#37;&#41; patients&#46; Sufficient tissue sample was achieved in 97&#46;67&#37; &#40;84&#47;86&#41; of samples for EGFR mutation&#44; 94&#46;23&#37; &#40;49&#47;52 samples&#41; for ALK translocation and 83&#46;33&#37; &#40;10&#47;12 samples&#41; for ROS1 mutation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Molecular testing was positive in 30&#46;23&#37; &#40;26&#47;86 samples&#41;&#44; and the most frequent mutation was EGFR&#44; which was present in 22&#47;86 &#40;25&#46; 58&#37;&#41;&#44; followed by 1&#47;12 cases for ROS1 &#40;8&#46;3&#37;&#41; and 3&#47;52 cases for ALK &#40;5&#46;76&#37;&#41;&#46; A summary of results is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Genetic profile of EGFR demonstrated that deletion in exon 19 was the most frequent mutation &#40;13 cases of delE746-A750 and 2 cases of del2235-2249&#41;&#44; which was followed by an L858R amino acid substitution in exon 21 in 4 cases&#44; and G719A amino acid substitution at position 719 in exon 18 was reported in 2 cases&#46; Finally&#44; exon 20 T790M acquired resistance mutation to tyrosine kinase inhibitors &#40;TKIs&#41; was identified in 1 patient&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This is the first report evaluating the efficacy of EBUS-TBNA for lung cancer and mutational testing in South America&#46; Previous reports were performed in post-surgical samples&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">EBUS-TBNA is a safe method with a high diagnostic yield for lung cancer&#46; In a randomized controlled trial&#44; mediastinal staging by EBUS-TBNA was compared with standard techniques&#44; consisting of imaging and surgical biopsy&#46; The time to &#8220;confirmed&#8221; diagnosis was 2 weeks with this approach versus 4 weeks when using the conventional methods&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In addition&#44; the number of complications and economic analysis was lower in the EBUS-TBNA arm&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Several studies have evaluated the efficacy of EBUS-TBNA for molecular testing in lung cancer&#46; In a multicenter study of 774 patients&#44; EGFR analysis was possible in 90&#37; of the patients analyzed&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;8</span></a> This is consistent with the prevalence described in our series&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In a recent study by Casadio et al&#46;&#44; EBUS-TBNA was performed in 306 consecutive patients with stage IIIB-IV lung cancer by TNM&#46; EGFR analyses were performed in 195 patients&#44; and a cytological diagnosis was achieved in 95&#46;1&#37;&#46; EGFR mutations were present in 16&#46;9&#37;&#44; ALK in 3&#46;9&#37; and KRAS in 31&#46;6&#37;&#46; In addition&#44; chi-square analysis to compare the percentage of mutations in a historical surgical series found no differences&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> This is consistent with the prevalence described in our series&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The genetic profile is similar to that reported by other South American countries&#46; De Melo et al&#46;&#44; reported the mutational profile for 125 patients with lung adenocarcinoma&#44; and EGFR mutations were found in 21&#46;6&#37;&#44; ALK in 4&#46;8&#37; and KRAS in 26&#46;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Our study is one of the few to have reported the utility of EBUS-TBNA for identifying ROS1 mutation&#44; and resistance mutation to TKIs&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This study has limitations&#46; We did not compare our negative EBUS results with surgery or response to target molecular therapy&#46; In our center&#44; we perform an average of 220 EBUS-TBNA procedures per year&#44; with diagnosis of lung adenocarcinoma in approximately 70&#37; of cases&#46; Since we are a regional reference center for EBUS-TBNA&#44; some patients are lost to follow-up and complete their sample processing in the referral center&#46; This is why the number of patients who underwent mutational testing was low&#46; The number of samples for ROS1 testing was limited&#44; thus a study with more cases is required for further analysis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; EBUS-TBNA is a useful minimally invasive technique for collecting cytopathological samples and performing molecular mutation analysis in our lung cancer patients&#46; Samples can also be used to evaluate acquired resistance mutation&#46;</p></span>"
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ISSN: 15792129
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