We have read with great interest the recent comments regarding the SEPAR Guidelines for lung cancer staging.1 We agree with your comments about the inaccessibility of the lymph nodes at station 5 using EBUS. Although our study affirms the inaccessibility of station 6 using EBUS and EUS, there may be confusion about station 5. Some early publications confirm the accessibility of this station by means of EBUS,2 but later articles, published after drafting our guidelines, have clarified that this was due to a possible confusion between stations 4L and 5.3,4 Thus, we agree with the need for surgical techniques to reach said station.

With regards to the meta-analysis by Gu et al.,5 we believe that, despite the limitations of some of the studies included, the authors are able to recognize these, including the possible confusions regarding station 5, which is thus expressed in their article. As for the negative predictive value (NPV) of EBUS and EUS, as has usually happened with the advent of new procedures, it is possible that the excellent results reported by the first authors are optimistic and it will be necessary to wait for the communication of other related experiences.6 For a proper evaluation of the performance of EBUS and EUS, many aspects need to be considered. Not only the “gold standard” method of confirmation, which is ideally as rigorous as possible, but also, among others, some that are quite important such as the details entailed with the execution of the procedure (number of biopsies per lymph node, presence or absence of cytopathologist in situ), experience of the team and patient selection criteria that determine the prevalence of mediastinal lymph node affectation.

Finally, we would like to acknowledge the comments expressed in said letter as we believe that they contribute to specifying the reach and the limitations of a technique that is providing important advances in lung cancer staging.