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Persky O, Kassirer M, Ostrovsky D, Osyntsov L, Raviv Y. Comparison between diffuse and partial involvement of thoracic lymph nodes on the outcome of sarcoidosis patients. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2024; 41:e2024016. [PMID: 38940712 PMCID: PMC11275541 DOI: 10.36141/svdld.v41i2.15336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/26/2023] [Indexed: 06/29/2024]
Abstract
BACKGROUND AND AIM Sarcoidosis is a systemic disease of unknown etiology with diverse clinical manifestations. Disease may resolve spontaneously or require immunosuppression to control progression. Currently, there is no predictive model to direct treatment, and management is guided by symptoms and functional impairment. This study examines the association between biopsy features and prognosis. METHODS This is a retrospective population-based cohort study. New cases of biopsy-proven sarcoidosis were divided into two groups: those with diffuse thoracic lymph nodes (TLN) involvement, versus partial TLN involvement (Defined as Non-necrotizing granuloma (NNG) found in some but not all sampled TLN). We compared outcomes one year after diagnosis. We assessed the need for immunosuppression, the number of hospitalizations, and lung function deterioration. RESULTS 77 cases were included in the final analysis. 48.1% demonstrated extensive TLN involvement, and 51.9% demonstrated partial or non-involvement of sampled TLN. The partial positive group had a more aggressive disease, reflected by a significantly higher need for steroid therapy in the first year after diagnosis (45.0% vs. 18.9% p=0.015). The number of hospitalizations and lung functions were not significantly different between groups. CONCLUSIONS Our findings demonstrate a significantly increased need for steroidal therapy among sarcoidosis patients with a partial positivity of TLN. These findings suggest that the degree of TLN involvement can help predict worse outcome and guide therapeutic decisions.
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Affiliation(s)
- Ofir Persky
- Department of internal medicine, Soroka university medical center, Beer sheva, Israel
| | - Michael Kassirer
- Pulmonary institute, Soroka university medical center, Beer sheva, Israel
- Health science faculty, Ben-Gurion university, Beer sheva, Israel
| | - Daniel Ostrovsky
- Health science faculty, Ben-Gurion university, Beer sheva, Israel
- Clinical research center, Soroka university medical center, Beer sheva, Israel
| | - Lydia Osyntsov
- Pathology Institute, Soroka university medical center, Beer sheva, Israel
| | - Yael Raviv
- Pulmonary institute, Soroka university medical center, Beer sheva, Israel
- Health science faculty, Ben-Gurion university, Beer sheva, Israel
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Moretti A, Kovacevic B, Vilmann P, Annema JT, Korevaar DA. Performance of EUS-FNA and EUS-B-FNA for the diagnosis of left adrenal glands metastases in patients with lung cancer: A systematic review and meta-analysis. Lung Cancer 2023; 186:107391. [PMID: 37827042 DOI: 10.1016/j.lungcan.2023.107391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/09/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES For diagnosing left adrenal gland metastasis in lung cancer, clinical guidelines recommend to perform EUS, but EUS-B (EUS using an EBUS-scope) is increasingly being used. We evaluated the diagnostic performance of both procedures. MATERIALS AND METHODS We did a systematic review (PROSPERO, CRD42023416205) and searched MEDLINE and EMBASE on 04-July-2023 for studies evaluating EUS and/or EUS-B in diagnosing left adrenal gland metastases in adults with (suspected) lung cancer. Outcomes were: (1) ability to visualize the left adrenal gland, (2) ability to sample (in those with successful visualization and in whom sampling was attempted), (3) ability to obtain adequate material (in those with successful sampling), (4) malignancy detection rate (in those with successful sampling), and (5) remaining risk of malignancy (in those with a negative EUS(-B)-FNA and undergoing a reference standard). We performed random-effects meta-analyses. RESULTS We included 19 studies (EUS: n = 11, EUS-B: n = 6, both: n = 2), covering 1712 patients. All studies had high (n = 18) or unclear (n = 1) risk of bias (QUADAS-2). Average ability to visualize the left adrenal gland was 0.94 (95 %CI 0.82-0.98; n = 7 studies). Average ability to sample was 1.00 (95 %CI 0.99-1.00; n = 9). Average ability to obtain adequate material was 0.96 (95 %CI 0.93-0.98; n = 18). Average malignancy detection rate was 0.42 (95 %CI 0.34-0.49; n = 18). Remaining risk of malignancy was 0.07 (95 %CI 0.04-0.12; n = 8). Ability to visualize was slightly higher for EUS (0.99; 95 %CI 0.90-1.00) than EUS-B (0.84; 95 %CI 0.70-0.92; p = 0.025), but the other performance characteristics were similar. No major complications were reported. CONCLUSION Both EUS and EUS-B have good performance and are safe for left adrenal gland analysis in patients with lung cancer, but the number of high-quality studies is limited and further well-constructed prospective studies are needed.
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Affiliation(s)
- Antonio Moretti
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands; Unit of Respiratory Diseases, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Bojan Kovacevic
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Jouke T Annema
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Daniël A Korevaar
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands.
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3
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Grutters JC. Establishing a Diagnosis of Pulmonary Sarcoidosis. J Clin Med 2023; 12:6898. [PMID: 37959363 PMCID: PMC10650830 DOI: 10.3390/jcm12216898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
Pulmonary sarcoidosis is the most prevalent manifestation of sarcoidosis and the commonest diagnosis in clinics for ILD. Due to the lack of a simple and reliable test, making the diagnosis is often challenging. There are three criteria that must always be considered: (1) compatible clinical presentation; (2) evidence of granuloma formation (usually non-caseating); and (3) exclusion of alternative causes of granulomatous disease. There are various tools available for diagnosis, amongst which serum biomarkers like sACE and sIL-2R, HRCT, BAL, EBUS/EUS and sometimes bronchoscopic or surgical lung biopsy are most contributive. However, the degree of invasiveness of the applied test and associated risk to the patient must be weighed against management consequences. In specific situations (e.g., presentation as Löfgren's syndrome) or when there is high suspicion based on HRCT in the context of supportive clinical findings, it might be justifiable to decide on a "working diagnosis of sarcoidosis" and to refrain from further invasive procedures for the patient. This should, however, preferably be agreed upon after discussion in an experienced multidisciplinary team and requires close follow-up of the patient. In general, it is advisable to always maintain a healthy dose of skepticism when making the diagnosis of sarcoidosis, especially when the clinical course of disease gives rise to this.
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Affiliation(s)
- Jan C. Grutters
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands;
- Division of Heart and Lungs, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
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4
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Li SP, Zhang ZM, Bao Y, Zhou LX, Zhao R, Li JM, Zhou YH, Chen X, Hu SZ, Liu WS. The Diagnostic and Prognostic Value of EBUS-TBNA for Intrathoracic Metastasis in Previously Treated Patients With Head and Neck Cancer. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2661-2672. [PMID: 37449666 DOI: 10.1002/jum.16302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The present study assessed the diagnostic and prognostic significance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for suspected intrathoracic metastasis after HNC treatment. METHODS A retrospective analysis was conducted on 75 patients with a prior history of head and neck cancer treatment who underwent EBUS-TBNA for suspected intrathoracic metastases between March 2012 and December 2021. RESULTS A total of 126 targeted lesions, including 107 mediastinal/hilar lymph nodes and 19 intrapulmonary/mediastinal masses, were sampled. The metastatic head and neck cancer (HNC) cases detected by EBUS-TBNA consisted of nasopharyngeal carcinoma (n = 24), oropharyngeal carcinoma (n = 3), hypopharynx carcinoma (n = 6), laryngeal carcinoma (n = 6), and oral cavity carcinoma (n = 6). Cases with negative EBUS-TBNA results consisted of tuberculosis (n = 9), sarcoidosis (n = 3), anthracosis (n = 9), and reactive lymphadenitis (n = 9). Six false-negative cases were found among the 75 patients with suspected intrathoracic metastases. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the EBUS-TBNA procedure for metastatic HNC were 88.2, 100.0, 100.0, 80, and 92.0%, respectively. The diagnosis of HNC intrathoracic metastasis by EBUS-TBNA correlated with an adverse prognosis in terms of overall survival (OS) (P = .008). The log-rank univariate analysis and Cox regression multivariate analysis results indicated that the detection of metastatic HNC through EBUS-TBNA was a significant independent prognostic factor for patients with HNC who had received prior treatment. CONCLUSIONS Endobronchial ultrasound-guided transbronchial needle aspiration is a safe, effective, and minimally invasive procedure for assessing suspected intrathoracic metastasis in HNC patients after treatment. The intrathoracic metastasis detected by EBUS-TBNA has crucial prognostic significance in previously treated HNC patients.
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Affiliation(s)
- Sheng-Ping Li
- Department of Endoscopy Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Zhen-Ming Zhang
- Department of Endoscopy Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Yu Bao
- Department of Endoscopy Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Ling-Xiao Zhou
- Department of Endoscopy Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Rui Zhao
- Department of Endoscopy Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Ji-Man Li
- Department of Pathology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Ye-Han Zhou
- Department of Pathology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Xi Chen
- Department of Endoscopy Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Shang-Zhi Hu
- Department of Endoscopy Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Wu-Song Liu
- Department of Endoscopy Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
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Livi V, Sivokozov I, Annema JT, Candoli P, Vasilev I, Kramer T, Ferrari M, Madan K, Fielding D, Murgu S, Cancellieri A, Semyonova LA, Puci M, Sotgiu G, Trisolini R. High-Definition Videobronchoscopy for the Diagnosis of Airway Involvement in Sarcoidosis: The Enhance Sarcoidosis Multicenter Study. Chest 2023; 164:1243-1252. [PMID: 37121391 PMCID: PMC10635836 DOI: 10.1016/j.chest.2023.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/07/2023] [Accepted: 04/23/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND The ability of high-definition (HD) videobronchoscopy to detect airway involvement in sarcoidosis has not been evaluated previously. RESEARCH QUESTION What is the role of HD videobronchoscopy in the identification of sarcoidosis-associated airway abnormalities (AAs)? What are the patterns of AAs more commonly observed and more frequently associated with the detection of granulomas in endobronchial biopsy (EBB)? STUDY DESIGN AND METHODS In this prospective international multicenter cohort study, consecutive patients with suspected sarcoidosis underwent airway inspection with an HD videobronchoscope and EBB using a standardized workflow. AAs were classified according to six patterns defined a priori: nodularity, cobblestoning, thickening, plaque, increased vascularity, and miscellaneous. We assessed diagnostic yield of EBB, prevalence of AAs, and interobserver agreement for different patterns of AAs. RESULTS AAs were identified in 64 of 134 patients with sarcoidosis (47.8%), with nodularity (n = 23 [17.2%]), plaque (n = 19 [14.2%]), and increased vascularity (n = 19 [14.2%]) being the most prevalent. The diagnostic yield of EBB was 36.6%. AAs were significantly more prevalent in patients with than in those without nonnecrotizing granulomas on EBB (67.4% vs 36.5%; P = .001). Likewise, parenchymal disease on CT scan imaging was significantly more common in patients with than in those without nonnecrotizing granulomas on EBB (79.6% vs 54.1%; P = .003). On a per-lesion analysis, nonnecrotizing granulomas were seen especially in EBB samples obtained from areas of cobblestoning (9/10 [90%]) and nodularity (17/29 [58.6%]). The overall diagnostic yield of random EBB was low (31/134 [23.1%]). The interobserver agreement for the different patterns of AA was fair (Fleiss κ = 0.34). INTERPRETATION In a population with a large prevalence of White Europeans, HD videobronchoscopy detected AAs in approximately one-half of patients with sarcoidosis. The diagnostic yield of EBB was higher in patients with parenchymal involvement on CT scan imaging and in those with AAs, especially if manifesting as cobblestoning and nodularity. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT4743596; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Vanina Livi
- Division of Interventional Pulmonology, Department of Neurosciences, Sense Organs and Thorax, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Ilya Sivokozov
- Endoscopy Department, Central TB Research Institute, Moscow, Russia
| | - Jouke T Annema
- Department of Respiratory Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Piero Candoli
- Interventional Pulmonology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna
| | - Igor Vasilev
- State Research Institute of Phtisiopulmonology, St. Petersburg, Russia
| | - Tess Kramer
- Department of Respiratory Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marco Ferrari
- Interventional Pulmonology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - David Fielding
- Department of Thoracic Medicine, The Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Septimiu Murgu
- Section of Pulmonary and Critical Care Medicine/Interventional Pulmonology, The University of Chicago, Chicago, IL
| | | | - Lyudmila A Semyonova
- Department of Pathomorphology, Cell Biology and Biochemistry, Central TB Research Institute, Moscow, Russia
| | - Mariangela Puci
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Rocco Trisolini
- Division of Interventional Pulmonology, Department of Neurosciences, Sense Organs and Thorax, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Hearth, Rome.
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6
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Bispo M, Marques S, de Campos ST, Rio-Tinto R, Fidalgo P, Devière J. Mediastinal Abscess Formation after EUS-Guided Sampling in a Young Patient with Sarcoidosis: Be Aware of the Increased Risk! GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:17-20. [PMID: 38020820 PMCID: PMC10661712 DOI: 10.1159/000526508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/15/2022] [Indexed: 12/01/2023]
Abstract
International guidelines establish EUS-guided sampling as safe and accurate for the evaluation of mediastinal solid lesions, such as lymphadenopathies of unknown origin, and point out an increased risk of severe infectious complications induced by needle puncture in mediastinal cystic lesions. A retrospective case series and a systematic review documented an increased risk of mediastinal abscess formation after EUS-guided lymph nodes sampling in patients with sarcoidosis. The authors describe a case of a 38-year-old male patient with a final diagnosis of sarcoidosis, who developed a large mediastinal abscess after EUS-guided fine-needle biopsy of mediastinal lymphadenopathies. Endoscopists should be aware of the potential increased risk of severe infectious complications when sampling mediastinal lymph nodes in suspected sarcoidosis, and a strategy to minimize such risk should be pursued.
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Affiliation(s)
- Miguel Bispo
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| | - Susana Marques
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| | - Sara Teles de Campos
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| | - Ricardo Rio-Tinto
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| | - Paulo Fidalgo
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| | - Jacques Devière
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital − Université Libre de Bruxelles, Brussels, Belgium
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7
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Hong G, Oki M. Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration for diagnostic and staging purposes: a narrative review. J Thorac Dis 2023; 15:5088-5098. [PMID: 37868849 PMCID: PMC10586997 DOI: 10.21037/jtd-23-681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/10/2023] [Indexed: 10/24/2023]
Abstract
Background and Objective Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is a feasible and well-tolerated modality that is increasingly used to diagnose intrathoracic lesions. This narrative review summarizes the current application of EUS-B-FNA for diagnosing lung cancer, thoracic sarcoidosis, and metastases from extrathoracic malignancies. Methods A comprehensive and systematic online literature search via Medline/PubMed for the period January 2005 to December 2022 was conducted for articles published using the keywords "EUS-B-FNA", "endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)", "endoscopic ultrasound fine-needle aspiration (EUS-FNA)", "lung cancer", "staging", and "sarcoidosis". Key Content and Findings Recent data prove the efficacy and safety of EUS-B-FNA for providing complete lung cancer staging, when combined with EBUS-TBNA, and in the evaluation of para-esophageal lesions. EUS-B-FNA allows access to inferior mediastinal lymph nodes and para-esophageal masses that are not accessible by EBUS-TBNA. Additional advantages of using EUS-B-FNA include significantly lower doses of anesthetics and sedatives, a shorter procedural time, fewer incidents of oxygen desaturation due to a poor respiratory reserve, significantly less cough, and higher operator satisfaction. Moreover, this procedure can be performed sequentially in the same setting with EBUS-TBNA by one operator. Other benefits include a lower cost, a single setting, and scope use. Conclusions As EUS-B-FNA and EBUS-TBNA have complementary access to the mediastinum, the diagnostic yield of EUS-B-FNA combined with EBUS-TBNA is higher than that of endosonographic techniques alone in the diagnostic workup of intrathoracic lesions.
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Affiliation(s)
- Goohyeon Hong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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Steinfort DP, Evison M, Witt A, Tsaknis G, Kheir F, Manners D, Madan K, Sidhu C, Fantin A, Korevaar DA, Van Der Heijden EHFM. Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official World Association for Bronchology and Interventional Pulmonology Expert Panel consensus statement. Respirology 2023; 28:722-743. [PMID: 37463832 DOI: 10.1111/resp.14549] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes. METHODS A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes. RESULTS Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented. CONCLUSION This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres.
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Affiliation(s)
- Daniel P Steinfort
- Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Matthew Evison
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ashleigh Witt
- Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Georgios Tsaknis
- Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- Department of Respiratory Medicine, Kettering General Hospital, UK
| | - Fayez Kheir
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Manners
- St John of God Midland Public and Private Hospitals, Midland, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Calvin Sidhu
- School of Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Alberto Fantin
- Department of Pulmonology, University Hospital of Udine (ASUFC), Udine, Italy
| | - Daniel A Korevaar
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- University of Amsterdam, Amsterdam, The Netherlands
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9
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Mohan A, Madan K, Hadda V, Mittal S, Suri T, Shekh I, Guleria R, Khader A, Chhajed P, Christopher DJ, Swarnakar R, Agarwal R, Aggarwal AN, Aggarwal S, Agrawal G, Ayub II, Bai M, Baldwa B, Chauhan A, Chawla R, Chopra M, Choudhry D, Dhar R, Dhooria S, Garg R, Goel A, Goel M, Goyal R, Gupta N, Manjunath BG, Iyer H, Jain D, Khan A, Kumar R, Koul PA, Lall A, Arunachalam M, Madan NK, Mehta R, Loganathan N, Nath A, Nangia V, Nene A, Patel D, Pattabhiraman VR, Raja A, Rajesh B, Rangarajan A, Rathi V, Sehgal IS, Shankar SH, Sindhwani G, Singh PK, Srinivasan A, Talwar D, Thangakunam B, Tiwari P, Tyagi R, Chandra NV, Sharada V, Vadala R, Venkatnarayan K. Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations. Lung India 2023; 40:368-400. [PMID: 37417095 PMCID: PMC10401980 DOI: 10.4103/lungindia.lungindia_510_22] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/30/2022] [Accepted: 01/31/2023] [Indexed: 07/08/2023] Open
Abstract
Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.
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Affiliation(s)
- Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tejas Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Irfan Shekh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Abdul Khader
- Institute of Pulmonology, Allergy and Asthma Research, Calicut, India
| | | | | | | | | | - Ritesh Agarwal
- Department of Pulmonary Medicine, PGIMER, Chandigarh, India
| | | | - Shubham Aggarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gyanendra Agrawal
- Department of Internal Medicine, Respiratory and Critical Care Medicine, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Irfan Ismail Ayub
- Department of Pulmonology, Sri Ramachandra, Medical Centre, Chennai, India
| | - Muniza Bai
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bhvya Baldwa
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Chauhan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Chawla
- Department of Pulmonary Medicine, Jaipur Golden Hospital, Delhi, India
| | - Manu Chopra
- Department of Medicine, Command Hospital Eastern Command Kolkata, India
| | - Dhruva Choudhry
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | - Raja Dhar
- Department of Pulmonology, Calcutta Medical Research Institute, Kolkata, India
| | | | - Rakesh Garg
- Department of Onco-Anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Goel
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Goel
- Department of Pulmonology, Fortis, Gurugram, India
| | - Rajiv Goyal
- Department of Respiratory Medicine, Rajiv Gandhi Cancer Institute, Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - BG Manjunath
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | - Hariharan Iyer
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajmal Khan
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, India
| | - Raj Kumar
- Director, Vallabhbhai Patel Chest Institute, Delhi, India
| | - Parvaiz A. Koul
- Director, Sher-e-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ajay Lall
- Department of Pulmonary Medicine, Max Hospital, Saket, Delhi, India
| | - M. Arunachalam
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neha K. Madan
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ravindra Mehta
- Department of Pulmonary and Critical Care Medicine, Apollo Hospitals, Bengaluru, India
| | - N Loganathan
- Department of Pulmonary Medicine, Sri Ramakrishna Hospital, Coimbatore, India
| | - Alok Nath
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, India
| | - Vivek Nangia
- Department of Pulmonology and Respiratory Medicine, Max Super Speciality Hospital Saket, New Delhi, India
| | - Amita Nene
- Bombay Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Arun Raja
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Benin Rajesh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Amith Rangarajan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vidushi Rathi
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sujay H. Shankar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Girish Sindhwani
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Pawan K. Singh
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | | | | | | | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Tyagi
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naren V. Chandra
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - V. Sharada
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Vadala
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kavitha Venkatnarayan
- Department of Pulmonary Medicine, St. John’s National Academy of Health Sciences, Bengaluru, India
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Giorgiutti S, Jacquot R, El Jammal T, Bert A, Jamilloux Y, Kodjikian L, Sève P. Sarcoidosis-Related Uveitis: A Review. J Clin Med 2023; 12:jcm12093194. [PMID: 37176633 PMCID: PMC10178951 DOI: 10.3390/jcm12093194] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Sarcoidosis is an inflammatory disease that involves the eyes in 10-55% of cases, sometimes without systemic involvement. All eye structures can be affected, but uveitis is the most common ocular manifestation and causes vision loss. The typical ophthalmological appearance of these uveitis is granulomatous (in cases with anterior involvement), which are usually bilateral and with synechiae. Posterior involvement includes vitritis, vasculitis and choroidal lesions. Tuberculosis is a classic differential diagnosis to be wary of, especially in people who have spent time in endemic areas. The diagnosis is based on histology with the presence of non-caseating epithelioid granulomas. However, due to the technical difficulty and yield of biopsies, the diagnosis of ocular sarcoidosis is often based on clinico-radiological features. The international criteria for the diagnosis of ocular sarcoidosis have recently been revised. Corticosteroids remain the first-line treatment for sarcoidosis, but up to 30% of patients require high doses, justifying the use of corticosteroid-sparing treatments. In these cases, immunosuppressive treatments such as methotrexate may be introduced. More recent biotherapies such as anti-TNF are also very effective (as they are in other non-infectious uveitis etiologies).
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Affiliation(s)
- Stéphane Giorgiutti
- Department of Clinical Immunology and Internal Medicine, National Center for Systemic Autoimmune Diseases (CNR RESO), Strasbourg University Hospital, 67000 Strasbourg, France
- INSERM UMR-S1109, Université de Strasbourg, 67000 Strasbourg, France
| | - Robin Jacquot
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
| | - Thomas El Jammal
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
- Laboratory of Tissue Biology and Therapeutic Engineering, CNRS UMR5305, IBCP, University of Lyon, 69007 Lyon, France
| | - Arthur Bert
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
| | - Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- UMR5510 MATEIS, CNRS, INSA Lyon, Université de Lyon 1, 69100 Villeurbanne, France
| | - Pascal Sève
- Department of Internal Medicine, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France
- Faculté de Médecine et de Maïeutique Lyon-Sud-Charles Mérieux, Université de Lyon, 69000 Lyon, France
- Pôle IMER, Hospices Civils de Lyon, 69002 Lyon, France
- The Health Services and Performance Research (EA 7425 HESPER), Université de Lyon, 69003 Lyon, France
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11
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Abstract
Sarcoidosis is characterized by noncaseating granulomas which form in almost any part of the body, primarily in the lungs and/or thoracic lymph nodes. Environmental exposures in genetically susceptible individuals are believed to cause sarcoidosis. There is variation in incidence and prevalence by region and race. Males and females are almost equally affected, although disease peaks at a later age in females than in males. The heterogeneity of presentation and disease course can make diagnosis and treatment challenging. Diagnosis is suggestive in a patient if one or more of the following is present: radiologic signs of sarcoidosis, evidence of systemic involvement, histologically confirmed noncaseating granulomas, sarcoidosis signs in bronchoalveolar lavage fluid (BALF), and low probability or exclusion of other causes of granulomatous inflammation. No sensitive or specific biomarkers for diagnosis and prognosis exist, but there are several that can be used to support clinical decisions, such as serum angiotensin-converting enzyme levels, human leukocyte antigen types, and CD4 Vα2.3+ T cells in BALF. Corticosteroids remain the mainstay of treatment for symptomatic patients with severely affected or declining organ function. Sarcoidosis is associated with a range of adverse long-term outcomes and complications, and with great variation in prognosis between populations. New data and technologies have moved sarcoidosis research forward, increasing our understanding of the disease. However, there is still much left to be discovered. The pervading challenge is how to account for patient variability. Future studies should focus on how to optimize current tools and develop new approaches so that treatment and follow-up can be targeted to individuals with more precision.
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Affiliation(s)
- Marios Rossides
- Department of Respiratory Medicine and Allergy, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden.,Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Darlington
- Department of Clinical Science and Education, Södersjukhuset and Karolinska Institutet, Stockholm, Sweden.,Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Susanna Kullberg
- Department of Respiratory Medicine and Allergy, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Respiratory Medicine Division & Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth V Arkema
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
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12
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Annema JT, Rozman A. Endobronchial ultrasound-guided cryobiopsy-when it is indicated? THE LANCET. RESPIRATORY MEDICINE 2023; 11:e23. [PMID: 36480955 DOI: 10.1016/s2213-2600(22)00486-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Jouke T Annema
- Department of Respiratory Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam 1105, Netherlands.
| | - Ales Rozman
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
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13
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Ye T, Zong Y, Zhao G, Zhou A, Yue B, Zhao H, Li P. Role of Endoscopy in Esophageal Tuberculosis: A Narrative Review. J Clin Med 2022; 11:jcm11237009. [PMID: 36498584 PMCID: PMC9740747 DOI: 10.3390/jcm11237009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/29/2022] Open
Abstract
Esophageal tuberculosis (ET) is a rare infectious disease of the gastrointestinal tract. Awareness of ET is deficient due to its low incidence. Unexplained dysphagia and upper gastrointestinal bleeding are the most common symptoms of ET. The prognosis is generally good if patients are diagnosed properly and receive anti-tubercular treatment promptly. However, ET is difficult to differentiate from other diseases. Endoscopic techniques such as esophagogastroduodenoscopy (EGD), endoscopic ultrasonography (EUS), contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS), elastography, and endoscopic ultrasound--guided fine-needle aspiration (EUS-FNA) improve the diagnosis of ET. Thus, the characteristics of ET and other difficult-to-detect diseases according to EGD and EUS were summarized. Intriguingly, there is no literature relevant to the application of CH-EUS and elastography in ET. The authors' research center was first in introducing CH-EUS and elastography into the field of ET. The specific manifestation of ET based on CH-EUS was discovered for the first time. Correlative experience and representative cases were shared. The role of endoscopy in acquiring esophageal specimens and treatment for ET was also established. In this review, we aim to introduce a promising technology for the diagnosis and treatment of ET.
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Affiliation(s)
| | | | | | | | | | | | - Peng Li
- Correspondence: (H.Z.); (P.L.)
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14
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Wälscher J, Büscher E, Bonella F, Karpf-Wissel R, Costabel U, Theegarten D, Rawitzer J, Wienker J, Darwiche K. Comparison of a 22G Crown-Cut Needle with a Conventional 22G Needle with EBUS Guidance in Diagnosis of Sarcoidosis. Lung 2022; 200:633-641. [PMID: 36045227 PMCID: PMC9526690 DOI: 10.1007/s00408-022-00562-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/12/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a standard procedure in cases of enlarged mediastinal lymph nodes. Recently, new tools were developed aiming to improve the diagnostic yield. A novel crown-cut needle is considered to obtain tissue cores which can be beneficial for the evaluation by the pathologist. This study aimed to compare the novel 22G crown-cut needle with a conventional 22G needle with EBUS guidance in the diagnosis of sarcoidosis. METHODS We designed a single-center prospective randomized clinical trial between March 2020 and January 2021 with 30 patients with mediastinal lymphadenopathy and suspected sarcoidosis. RESULTS 24 patients (mean age 49.5 vs 54.1, mean FVC 73.7% vs 86.7%, mean DLCO 72.4% vs 72.5% for crown-cut needle vs conventional needle, respectively) were diagnosed with sarcoidosis. In the remaining six patients, sarcoidosis was reasonably excluded. The diagnostic yield for sarcoidosis was 77% with the crown-cut needle vs. 82% with the conventional needle (p > 0.05). In patients with histopathologic hallmarks typical of sarcoidosis (n = 19), the crown-cut needle was superior in detecting granulomas (8.3 vs 3.8 per cytoblock, p < 0.05) and histiocytes (502 vs 186 per cytoblock, p < 0.05). Four of seven bronchoscopists experienced difficulties passing through the bronchial wall with the crown-cut needle and one episode of bleeding occurred in this group which made interventions necessary. CONCLUSIONS Despite equivalence in diagnostic accuracy, the crown-cut needle was superior to the conventional needle in detecting granulomas and histiocytes. This indicates greater potential for obtaining higher quality sample material with the crown-cut needle in cases of granulomatous inflammation.
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Affiliation(s)
- J Wälscher
- Department of Pulmonary Medicine, Center for Interstitial and Rare Lung Diseases, Ruhrlandklinik University Hospital Essen, Essen, Germany.
| | - E Büscher
- Department of Pulmonary Medicine, Section for Interventional Pneumology, Ruhrlandklinik University Hospital Essen, Tüschener Weg 40, 45239, Essen, Germany
| | - F Bonella
- Department of Pulmonary Medicine, Center for Interstitial and Rare Lung Diseases, Ruhrlandklinik University Hospital Essen, Essen, Germany
| | - R Karpf-Wissel
- Department of Pulmonary Medicine, Section for Interventional Pneumology, Ruhrlandklinik University Hospital Essen, Tüschener Weg 40, 45239, Essen, Germany
| | - U Costabel
- Department of Pulmonary Medicine, Center for Interstitial and Rare Lung Diseases, Ruhrlandklinik University Hospital Essen, Essen, Germany
| | - D Theegarten
- Institute of Pathology, University Hospital Essen, Essen, Germany
| | - J Rawitzer
- Institute of Pathology, University Hospital Essen, Essen, Germany
| | - J Wienker
- Department of Pulmonary Medicine, Section for Interventional Pneumology, Ruhrlandklinik University Hospital Essen, Tüschener Weg 40, 45239, Essen, Germany
| | - K Darwiche
- Department of Pulmonary Medicine, Section for Interventional Pneumology, Ruhrlandklinik University Hospital Essen, Tüschener Weg 40, 45239, Essen, Germany
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