Is endosonography guided fine needle aspiration (EUS-FNA) for sarcoidosis as good as we think?

Role of Bronchoscopy in Diagnosis of Sarcoidosis

Sarcoidosis is a multisystem inflammatory disorder with unclear etiology and can often pose a diagnostic challenge. A tissue diagnosis is often necessary to illustrate the non-caseating granulomas on histopathology. This review aims to synthesize current evidence related to tissue diagnosis of sarcoidosis using various bronchoscopic techniques. We start by discussing standard bronchoscopic techniques which have remained the cornerstone of diagnostic workup such as bronchoalveolar lavage (BAL), endobronchial biopsy (EBB), conventional transbronchial needle aspiration (cTBNA) and transbronchial lung biopsy (TBLB) followed by newer modalities that incorporate real-time image guidance using endobronchial and endoscopic ultrasound. Although BAL, EBB, and TBLB have been employed as a diagnostic tool for several decades, their sensitivity and diagnostic yield is inferior to ultrasound-based endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). More recently, convincing evidence has also emerged to support the diagnostic accuracy and tissue yield of transbronchial lung cryobiopsy which will also be discussed in this review. These advances in bronchoscopic equipment and techniques over the last 2 decades have made it possible to obtain tissue samples using minimally invasive techniques thus avoiding invasive open lung biopsy and the risks that inherently follow. Up-to-date knowledge of these modalities is imperative for ensuring evidence-based medicine and improving patient-centric outcomes.

Endoscopic ultrasound-guided-fine-needle aspiration/fine-needle biopsy in diagnosis of mediastinal lymphadenopathy - A boon

Background/Objectives:

Evaluation of mediastinal lymphadenopathy (MLA) is a great diagnostic challenge considering the myriad of causes. In recent years, the role of endoscopic ultrasound (EUS) has been greatly extended in evaluation of MLA due to its safety, reliability, and accuracy. The present study details the role of EUS-guided-fine-needle aspiration/fine-needle biopsy (EUS-FNA/FNB) in MLA of unknown origin.

Methods:

Seventy-two patients (34 men) with MLA of unknown etiology were studied. Mediastinum was evaluated with linear echoendoscope and FNA/FNB was performed with 22-G needle and sent for cytology, histopathological, and mycobacterial growth indicator tube/GeneXpert evaluation. EUS-FNA/FNB diagnosis was based on cytology reporting by pathologists. Patients tolerated the procedure, and insertion of needle into the lesion was always successful without any complications.

Results:

EUS-FNA/FNB established a tissue diagnosis in 66/72 patients in first sitting, while six patients underwent repeat procedure. EUS-FNA diagnoses (after second sitting) were tuberculous lymphadenitis in 45/72 (62.5%), metastatic lymph nodes 12/72 (16.7%), reactive lymphadenopathy 6/72 (8.3%), sarcoidosis 4/72 (5.6%), and lymphoma 2/72 (2.8%), while it was nondiagnostic in 3/72 (4.1%) patients. Final diagnosis was based on combined clinical presentation, EUS-FNA/FNB result and clinicoradiological response to treatment on long-term follow-up of 6 months.

Conclusion:

EUS echo features along with EUS-FNA/FNB can diagnose MLA and surgical biopsy can be avoided.

The clinical conundrum of diagnosing and treating systemic sarcoidosis in a high TB burden area

A 53-year-old woman from Southern India presented with weight loss, anorexia, fever and asthenia. Whole body positron emission tomography/computed tomography (PET-CT) showed fluorodeoxyglucose-avid mediastinal and abdominal lymphadenopathy with hepatic, splenic, parotid and lacrimal glandular inflammations. Endoscopic ultrasound-guided fine needle aspiration of subcarinal lymph node showed non-caseating granulomas. Initial serum ACE level was elevated but with normal calcium. Despite the suspicion of sarcoidosis, a trial of antituberculosis therapy was started empirically due to similar presentations of disseminated tuberculosis (TB) in this high endemic area. The patient subsequently deteriorated and was admitted with symptomatic hypercalcaemia. Her subsequent ACE levels were very high, supportive of a diagnosis of systemic sarcoidosis. She was given steroid pulse therapy, and 5 months later had fully recovered. This case highlights the challenges faced by physicians in high TB-endemic areas when managing granulomatous diseases as they are concerned about missing TB, the difficulties in diagnosing sarcoidosis and the role of pulse steroid therapy.

Comparison of liquid-based preparation and conventional smear of fine-needle aspiration cytology of lymph node

Background:

In this paper, we have compared the cytomorphologic characteristics of liquid-based preparation (LBP) [SurePath (SP)] cytology and conventional smear (CP) preparations on fine-needle aspiration (FNAC) material by a semi-quantitative scoring system for cases of lymphadenopathy.

Materials and Methods:

In this prospective study, a total of 52 consecutive cases of FNAC of lymphadenopathy were included. The first pass was used for CP followed by LBP with the help of SP technique. The smears were independently compared and assessed by two observers (PS and PD).

Results:

The semiquantitative grading was compared in two groups by Wilcoxon signed-rank test. The background information, cell architecture, pleomorphism, nuclear and cytoplasmic details, and three-dimensional structures were significantly different in LBP and CP smears.

Conclusions:

Liquid-based cytology (LBC) is a relatively simple technique, which exhibits good nuclear and cytoplasmic details with the absence of obscuring background material. Even the number of slides and area per slide to be screened were less than the conventional preparation but caution must be applied to interpret the slides and secure a diagnosis, especially if LBC is the first and only method applied for diagnosis.

The role of EBUS-TBNA and standard bronchoscopic modalities in the diagnosis of sarcoidosis

BACKGROUND AND AIMS

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an accurate and minimally invasive technique that has been shown to have excellent diagnostic yield in the diagnosis of mediastinal and hilar lymphadenopathy. However, endoscopic bronchial biopsy (EBB) and transbronchial lung biopsy (TBLB) are still the standard method for making a pathologic diagnosis of sarcoidosis. The aim of this study was to compare the diagnostic yield of EBUS-TBNA and TBLB through a flexible bronchoscope in patients with stage I and II sarcoidosis.

METHODS

A total of 653 patients with suspected stage I and II sarcoidosis were included in this retrospective study. After radiological assessment, patients were qualified to bronchoscopy. Patients underwent sequential EBUS-TBNA followed by TBLB and/or EBB. In all patients, 1056 biopsies from mediastinal lymph nodes group were taken.

RESULTS

In all of the biopsied lymph nodes, positive results were obtained in 549 patients (84%). In 180 patients with stage II TBLB, a biopsy was taken from affected part of the lung. Positive results were found in 79 patients (43.9%). EBB was performed in 340 patients, with a positive result in 101 (29.7%). Mediastinoscopy was performed in 60 patients (9.2%) with a negative result in EBUS-TBNA, TBLB and/or EBB. Non-caseating granulomas were found in 48 patients. The sensitivity of TBLB technique alone was significantly lower at 43.9% (79/180) (P < 0.001). The sensitivity of EBB was significantly lower than EBUS-TBNA and TBLB and reached 29.7% (101/340) (P < 0.0001, P < 0.003). The overall diagnostic accuracy for EBUS-TBNA was 84%, and the combination of EBUS-TBNA with standard bronchoscopic techniques had a diagnostic accuracy of 89%.

CONCLUSION

The diagnostic yield of the EBUS-TBNA for stage I and II sarcoidosis is clearly higher than for TBLB and EBB. The combination of EBUS-TBNA with standard bronchoscopic techniques is safe and feasible, and optimizes the diagnostic yield in patients with pulmonary sarcoidosis and enlarged intrathoracic lymph nodes. EBUS-TBNA in combination with standard bronchoscopy may be considered to be the first-line investigation in patients with suspected sarcoidosis and enlarged intrathoracic lymphadenopathy.

Lymph node characteristics of sarcoidosis with endobronchial ultrasound

BACKGROUND

Sonographic features of lymph nodes on endobronchial ultrasound (EBUS) have been shown to be useful in prediction of malignancy in mediastinum and hilum. The aim of this study was to assess the utility of morphologic features of mediastinal and/or hilar lymph nodes obtained by EBUS in patients with sarcoidosis.

MATERIALS AND METHODS

We retrospectively reviewed the records of 224 patients with mediastinal/hilar lymph node enlargements who underwent EBUS for diagnostic purpose. The lymph nodes were characterized based on the EBUS images as follows: (1) Size; based on short-axis dimension, <1 cm or ≥1 cm, (2) shape; oval or round, (3) margin; distinct or indistinct, (4) echogenicity; homogeneous or heterogeneous, (5) presence or absence of central hilar structure, and (6) presence or absence of granular (sandpaper) appearance.

RESULTS

One hundred (24.4%) nodes exhibited indistinct margins while 309 (75.6%) had distinct margins. One hundred and ninety nine (48.7%) nodes were characterized as homogeneous, and 210 (51.3%) nodes as heterogeneous. Granular appearance was observed in 130 (31.8%) lymph nodes. The presence of granules in lymph nodes on EBUS had the highest specificity (99.3%) for the diagnosis of sarcoidosis. Logistic regression analysis revealed the finding of distinct margin alone as an independent predictive factor for the diagnosis of sarcoidosis.

CONCLUSIONS

The presence of granular appearance in lymph nodes by EBUS had the highest specificity (99.3%) for the diagnosis of sarcoidosis. Lymph nodes having distinct margins tend to suggest sarcoidosis.

How can an endosonographer assess for diagnostic sufficiency and options for handling the endoscopic ultrasound-guided fine-needle aspiration specimen and ancillary studies

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become well established as a minimally invasive technique in diagnosing and staging various gastrointestinal, pancreaticobiliary, and retroperitoneal malignancies. The diagnostic accuracy of this procedure is significantly enhanced by the presence of on-site cytopathology. However, in many EUS centers, cytopathology is not readily available for on-site evaluation. This article is intended to assist the independent endosonographer in the assessment of diagnostic sufficiency and in specimen handling.

Rescue Endoscopic Ultrasound (EUS)-Guided Trucut Biopsy Following Suboptimal EUS-Guided Fine Needle Aspiration for Mediastinal Lesions

Background/Aims

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and Trucut biopsy (TCB) are sensitive techniques for diagnosing mediastinal lesions, but it is unclear how either one or both should be used to obtain a pathologic diagnosis. The objective of our study was to evaluate whether EUS-TCB impacts the diagnosis of mediastinal lesions after the initial on-site review of EUS-FNA specimen suggests a suboptimal result.

Methods

We enrolled consecutive patients with mediastinal lesions who underwent EUS-TCB during the same procedure if the initial EUS-FNA demonstrated an inadequate FNA sample or suggested that histopathology was required for diagnosis. Diagnostic accuracies between procedures were compared as the main outcome.

Results

Twenty-seven patients (14 men; median age, 56 years; range, 19 to 82 years) underwent EUS-FNA and EUS-TCB to evaluate a mediastinal lymphadenopathy or mass (n=17), to determine the cancer stage (n=3) or to exclude tumor recurrence or metastasis (n=7). The overall diagnostic accuracies of EUS-FNA and EUS-TCB were 78% and 67%, respectively (p=0.375). The combined diagnostic accuracy of EUS-FNA plus EUS-TCB was 82%. In six patients with nondiagnostic EUS-FNA, EUS-TCB provided a final diagnosis in one patient (17%).

Conclusions

In the current series of patients with mediastinal masses or adenopathy, the administration of EUS-TCB following suboptimal results for the on-site cytology review did not increase the diagnostic yield.

Clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of mediastinal and intra-abdominal lymphadenopathy

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has proven to be helpful in obtaining tissue samples from enlarged mediastinal and intra-abdominal lymph nodes. This is especially beneficial in the diagnosis and staging of malignancy. We retrospectively reviewed the clinical utility of this method at a tertiary care cancer hospital in Pakistan.

PATIENTS AND METHODS

The medical records of 183 consecutive patients referred to the gastroenterology service from August 2008 to March 2012 were reviewed in this retrospective study. The mean age of the patients at presentation was 46.7 years (range 6-87; 62% males); 119 patients had mediastinal and 64 had intra-abdominal lymphadenopathy. Major indications for referral were diagnosis of lymphadenopathy of unknown origin detected on CT scan or PET-CT, to exclude lymph node metastasis in patients with a known primary tumor and to rule out relapse of lymphoma following treatment or during follow-up. Rapid on-site evaluation (ROSE) was performed in all patients to confirm the adequacy of sampling, followed by definitive cytopathological evaluation.

RESULTS

EUS-FNA with ROSE obtained adequate tissue for cytology in 97.3% of the patients in this cohort. These results were further confirmed on final cytopathological analysis in 96.2% of patients. Two patients (1.1%) had inadequate specimens for final interpretation (97.3 vs. 96.2; p = 0.001). Clinical utility was 95% for mediastinal lymphadenopathy and 98.4% for intra-abdominal lymphadenopathy. Only 1 patient had a serious complication requiring hospitalization and this was successfully managed conservatively.

CONCLUSION

EUS-FNA is safe and has a high clinical utility in diagnosing unexplained mediastinal and intra-abdominal lymphadenopathy.

The intubated patient with mediastinal disease--a role for esophageal access using the endobronchial ultrasound bronchoscope

Ultrasound-guided transbronchial needle aspiration using the bronchoscope with a dedicated curvilinear probe has emerged as a primary tool for the investigation of mediastinal pathology. Recently, the utility of this scope has been expanded to include access via the esophagus. In this case series, we describe a role for esophageal ultrasound using the endobronchial ultrasound bronchoscope in the diagnostic evaluation of critically ill/intubated patients with mediastinal disease. Esophageal access with the ultrasound bronchoscope allows the pulmonologist to diagnose mediastinal disease in the intubated patient with minimal risk.

Respiratory Tract and Mediastinum

Normal cytology, abnormal and atypical cells, non-cellular components, and infectious cell changes are largely described together with benign, malignant, and neuroendocrine lesions regarding exfoliative and aspiration cytology of the lung. A separate section broadly addresses diagnostic findings and differential diagnoses in bronchoalveolar washings.

The section ‘Fine needle aspiration biopsy of mediastinal disorders’ covers in particular biopsy techniques, accuracy of liquid-based cytology, and the complex lesions of the thymus gland. Cytodiagnostic algorithms of the major benign and malignant pulmonary and mediastinal lesions and their respective differential diagnoses are additionally presented in synoptic setups.

An uncommon cause of hiccups: sarcoidosis presenting solely as hiccups

Common causes of hiccups are over-distension of the stomach, a sudden change in gastrointestinal temperature, excessive alcohol and tobacco ingestion, and sudden excitement or emotional changes. Common presenting symptoms of sarcoidosis include cough, dyspnea, and chest pain. It is very rare for a sarcoidosis patient to present with hiccups. A 48-year-old man presented with hiccups of 2 weeks' duration. He denied having headaches, earache, cough, abdominal pain, fever, or body weight loss history. On physical examination, he had no peripheral lymphadenopathies in the neck, axilla and inguinal regions, no organomegaly in the abdomen and no skin abnormalities. A neurological examination showed normal findings. Laboratory investigations revealed a normal complete blood count, liver function, renal function, serum calcium, and tumor markers. Transabdominal ultrasound was negative, and panendoscopy revealed a small healing duodenal ulcer. Chest radiography showed an enlarged right lung hilum, while computed tomography showed enlargement of multiple mediastinal lymph nodes. Endoscopic ultrasound-guided fine-needle aspiration with a 22-gauge needle and trucut biopsy with a 19-gauge needle (quick-core biopsy needle) were performed, and cytology, cell block and histology revealed non-caseating granuloma, with negative tuberculous and fungus cultures. Mediastinal lymph node due to sarcoidosis can be a rare cause of hiccups.

EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

BACKGROUND

Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.

OBJECTIVE

Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.

DESIGN

Prospective, paired design.

SETTING

Six academic endoscopy centers.

PATIENTS

This study involved patients with upper abdominal pain referred for endoscopy.

INTERVENTION

All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion.

FOLLOW-UP

telephone interviews and chart reviews.

MAIN OUTCOME MEASUREMENTS

Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.

RESULTS

A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.

LIMITATIONS

No cost analysis.

CONCLUSION

The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

Diagnosis of mediastinal tuberculosis by using EUS-guided needle sampling in a geographic region with an intermediate tuberculosis burden

BACKGROUND

EUS-guided FNA (EUS-FNA) or trucut biopsy (TCB) is indispensible in the diagnosis of mediastinal malignancies. Less is known, however, about the usefulness of EUS-guided sampling for nonmalignant, mediastinal tuberculosis (TB), despite the increase in the incidence of TB.

OBJECTIVE

To assess the diagnostic yields of EUS-FNA/TCB in patients with mediastinal TB.

DESIGN

Retrospective study.

SETTING

Tertiary-care referral hospital in a geographic region with an intermediate TB burden.

PATIENTS

This study involved 24 consecutive patients with mediastinal TB, who underwent EUS-FNA/TCB from July 2005 to September 2008.

INTERVENTION

EUS-FNA/TCB.

MAIN OUTCOME MEASUREMENTS

Technical success and diagnostic yields of EUS-FNA/TCB.

RESULTS

Mediastinal lesions (mean diameter, 28.6 mm; range 17.0-49.5 mm) were targeted by using 22-gauge-needle FNA in 10 patients and 19-gauge-needle TCB in 14 patients. Before EUS, only 10 of the 24 patients had a presumptive diagnosis of mediastinal TB, whereas 11 patients were suspected of having malignancies. Six patients showed mass-like lung parenchymal lesions mimicking lung cancer, and 7 patients had a history of malignancy. Pathologic examination showed granulomatous inflammation in 16 patients (66.7%), including 10 patients with caseating granulomas. Positive microbiologic results were obtained in 10 patients (41.7%): 3 by Ziehl-Neelsen staining, 5 by Mycobacterium tuberculosis culture, and 5 by TB polymerase chain reaction (PCR) assay. EUS-FNA/TCB confirmed mediastinal TB in 20 of the 24 patients and directed 11 patients clinically suspected of having malignancies to anti-TB treatment. The diagnostic yields of FNA and TCB were similar (90.0% vs 78.6%).

LIMITATIONS

Retrospective design in a tertiary-care referral hospital.

CONCLUSION

EUS-FNA/TCB is sufficiently useful to confirm mediastinal TB and can exclude suspected malignancies in TB patients.

Endobronchial ultrasound-guided transbronchial needle aspiration cytology: a state of the art review

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a recently developed, accurate, safe and cost-effective technique that allows sampling of mediastinal lymph nodes and peribronchial lesions including pulmonary and mediastinal lesions. Its major indications are the nodal staging of non-small cell carcinomas of the lung, their restaging after chemotherapy and/or radiation, the diagnosis of sarcoidosis and of metastases from extrathoracic malignancies, and the diagnosis of mediastinal lymphadenopathy and masses of unknown aetiology. From our experience at the University of Minnesota and a comprehensive review of the literature, we discuss technical aspects of the procedure, its advantages and limitations in comparison with other methods of sampling mediastinal lymph nodes, focusing on the role of the cytopathologist in ensuring the effectiveness of the procedure. An algorithmic approach to the cytological diagnosis, starting with the determination of the adequacy of the sample, is also presented.

Endosonography in bronchopulmonary disease

The diagnostic approach to diseases of the mediastinum is divided into two phases: (1) imaging techniques and (2) procedures for obtaining tissue samples for cytologic and histologic examination. The latter has for many years represented a considerable challenge to the clinician. Often invasive procedures in general anaesthesia as mediastinoscopy or thoracoscopy have been necessary. However, the sampling of tissue from the mediastinum has been revolutionized by EBUS and EUS, since they give access to the middle and the posterior compartment via the trachea and the oesophagus, respectively. Both EUS FNA and EBUS-TBNA of mediastinal nodes and tumors can provide a specimen adequate for interpretation in over 95% of cases with a specificity of close to 100% and a sensitivity ranging between 88% and 96%. A growing number of studies including randomized trails and meta-analyses have demonstrated a major impact of EUSFNA as well as EBUS-TBNA on management of patients with lung cancer as well as in patients with unknown lesions in the mediastinum. The aim of the present review is to discuss the current role of endosonography in bronchopulmonary diseases focusing on endosonographically guided biopsy via the esophagus, trachea and main bronchi. The concept of complete echo-endoscopic staging of lung cancer is postulated as virtually all mediastinal nodes as well as regions relevant to pulmonal medicine (liver and adrenal glands) can be reached by these two methods in combination.

Diagnosis of sarcoidosis

PURPOSE OF REVIEW

To describe the recent advances in the diagnostic procedures for sarcoidosis and explore future directions.

RECENT FINDINGS

Novel imaging techniques have been explored in sarcoidosis, such as positron emission tomography using L-[3-F]-alpha-methyltyrosine, which is more specific for malignancy than F-fluorodeoxyglucose positron emission tomography. The combined modality of L-[3-F]-alpha-methyltyrosine-positron emission tomography with fluorodeoxyglucose-positron emission tomography could successfully discriminate sarcoidosis from malignancy. The finding of delayed enhancement in cardiac magnetic resonance imaging could identify cardiac involvement of sarcoidosis with higher sensitivity than echocardiography, thallium scintigraphy, and gallium scintigraphy. Endobronchial ultrasonograpy-guided transbronchial needle aspiration is a safe and useful tool for diagnosing sarcoidosis with a diagnostic accuracy, sensitivity and specificity of 85-93, 78-89, and 92-96%, respectively. Developments in genetics have demonstrated that 99% of the human leukocyte antigen DRB1*0301/DQB1*0201-positive patients with Löfgren's syndrome show a spontaneous remission, in contrast to only 55% of the human leukocyte antigen DRB1*0301/DQB1*0201-negative patients. These alleles could be novel promising factors for discriminating a prognosis in Löfgren's syndrome.

SUMMARY

Recent development including novel imaging techniques, novel biopsy procedures, and genetic analyses could be of value for the diagnosis of sarcoidosis.

Does FDG-PET add information to EUS and CT in the initial management of esophageal cancer? A prospective single center study

PURPOSE

There is no algorithm for the initial staging of esophageal cancer that is considered standard of care. This prospective blinded study analyzes the utility of FDG-PET as an adjunct to EUS and CT for the management of patients with esophageal cancer.

METHODS

Between December 2003 and October 2006, patients diagnosed with esophageal carcinoma underwent EUS, CT, and FDG-PET at their initial evaluation. Two thoracic surgeons were given staging EUS results and CT scan reports. They were asked if the patient needed surgical resection, neoadjuvant chemotherapy followed by resection, or palliation. With each case, one surgeon was unblinded to the FDG-PET results. The treatment decisions of each surgeon were compared to determine if PET altered clinical management.

RESULTS

A total of 50 patients (45 male, 5 female) were enrolled and data were prospectively collected. Forty-three (86%) had adenocarcinoma and 7 (14%) had squamous cell carcinoma. EUS was completed in 88% (44) of cases while 6 (12%) were incomplete secondary to tight stenosis. Nineteen were treated with surgery, 25 with neoadjuvant chemotherapy and surgery, and 6 with palliative chemoradiation. In 49 of 50 patients, the surgeons came to identical management decisions independent of PET results. In the one case that the treatment decision differed, the EUS was incomplete. The agreement on treatment strategy was 98% (kappa= 0.97, 95% CI 0.93-0.99).

CONCLUSION

This study shows that the addition of FDG-PET to EUS and CT offers little information to the initial treatment stratification of patients with esophageal cancer. However, in patients with incomplete EUS, FDG-PET may have some clinical utility.

[Transesophageal ultrasonography for mediastinum diagnostics]

Along with endosonographic fine needle aspiration, transoesophageal ultrasonography is now well established for staging gastrointestinal tumors. It is especially well suited to assessing mediastinal structures due to its transoesophageal approach and its high local definition. The mediastinum can be viewed all the way from the tracheal bifurcation to the diaphragm. This technique is already in regular use for pulmonary problems and especially for staging pulmonary carcinomas.

Real-time endobronchial ultrasound-guided transbronchial needle aspiration is useful for diagnosing sarcoidosis

BACKGROUND AND OBJECTIVE

Several studies of real-time endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) have reported a sensitivity of approximately 90% in the diagnosis of mediastinal and hilar malignancies. However, few studies have addressed its role in the diagnosis of sarcoidosis. The aim of the present study was to assess the utility of EBUS-TBNA in confirming a pathological diagnosis of sarcoidosis.

METHODS

Fifteen consecutive patients with suspected sarcoidosis and mediastinal and/or hilar lymphadenopathy were investigated prospectively. EBUS-TBNA with an echo-bronchoscope and a dedicated echogenic 22-gauge needle was carried out in patients under conscious sedation, followed by conventional TBNA of the same lesion using a 19-gauge needle.

RESULTS

EBUS-TBNA and/or TBNA demonstrated non-caseating epithelioid cell granulomas in 14 of 15 patients (93%). All 14 patients with a pathological diagnosis of sarcoidosis were considered to have sarcoidosis based on subsequent clinical assessments. The single patient with a negative EBUS-TBNA and TBNA had a malignant melanoma diagnosed following surgical biopsy. EBUS-TBNA confirmed a diagnosis of sarcoidosis in 13 of the 14 patients (93%) by identifying non-caseating epithelioid cell granulomas in 18 of 23 lymph nodes (78%) sampled. When two needle aspirates of one or two lymph nodes were carried out, the percentage positive pathological diagnosis for sarcoidosis for (i) EBUS-TBNA; (ii) TBNA; and (iii) the combination of EBUS-TBNA and TBNA were 93% (13 of 14 patients), 93% (13 of 14 patients) and 100% (14 of 14 patients), respectively. There were no complications associated with the procedures.

CONCLUSION

EBUS-TBNA is less invasive and acceptably sensitive as a method for obtaining pathological confirmation of sarcoidosis.

Endoscopic ultrasound-guided fine-needle aspiration and Trucut biopsy in thoracic lesions: when tissue is the issue

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) has a high accuracy in the evaluation of mediastinal lesions. The use of a core biopsy needle for EUS guided biopsy (EUS TCB) may further improve the yield of EUS. The aims of this study are to evaluate the safety of EUS TCB in thoracic lesions and to compare the diagnostic accuracy of TCB with FNA and FNA + TCB.

METHODS

A single-center retrospective study. All patients underwent EUS-FNA and TCB. A cytopathologist was not present during the procedure. EUS FNA, TCB and FNA + TCB diagnostic accuracy were compared.

RESULTS

A total of 48 patients were included. The lesions sampled included 41 lymph nodes (six aorto-pulmonary window, 32 subcarinal, two right paratracheal, one paraesophageal ATS station 8), five lung masses, and two esophageal masses. Twenty-nine patients had malignant disease and 19 had benign disorders. The overall diagnostic accuracy of FNA, TCB and FNA + TCB was 79%, 79% and 98% respectively (p = 0.007). TCB changed the diagnosis in nine cases missed by FNA. EUS TCB was better than FNA for benign diseases (89% vs. 63%, p = 0.04). All eight patients with a prior failed biopsy had a correct diagnosis established by EUS. No patient required mediastinoscopy or thoracoscopy after EUS.

CONCLUSION

The combination of TCB and FNA is superior to FNA alone. EUS-guided TCB should be considered in patients with benign disorders of the mediastinum when other modalities fail to yield a diagnosis.

EUS-guided FNA immediately after unrevealing transbronchial needle aspiration in the evaluation of mediastinal lymphadenopathy: a prospective study

BACKGROUND

Transbronchial needle aspiration (TBNA) and EUS-guided FNA (EUS-FNA) are minimally invasive diagnostic approaches to mediastinal lymphadenopathy. Rapid on-site cytopathologic evaluation (ROSE) may facilitate the decision whether to proceed to a second procedure in the same session. The aim of this study was to determine the utility of TBNA with ROSE, combined with the option for immediate EUS-FNA in a single-session approach to mediastinal lymphadenopathy.

METHODS

We prospectively recruited 20 patients (12 men; mean age 66.7 +/- 10.2 years) with mediastinal lymphadenopathy on CT who required cytopathologic evaluation. Bronchoscopy was first performed with TBNA and ROSE. If this was unrevealing, EUS-FNA was performed immediately afterward with ROSE. All procedures were performed with the patient under local anesthesia and sedation.

RESULTS

TBNA specimens were deemed adequate on-site in 13 patients, and EUS-FNA was performed in the remaining 7 patients. TBNA with ROSE was falsely negative in one patient. The diagnostic yield for TBNA and EUS-FNA alone was 65% and 86%, respectively. This single-session approach provided a yield of 90%, with no complications. The final diagnoses were 12 non-small-cell lung cancer, two small-cell lung cancer, one metastatic adenocarcinoma, two sarcoidosis, one tuberculosis, one lymphoma, and one with no definitive diagnosis.

CONCLUSIONS

Combining TBNA with the option for EUS-FNA immediately after unrevealing TBNA gave a yield approaching that of mediastinoscopy and, therefore, may reduce the need for invasive mediastinal sampling. This single-session endoscopic approach was safe, required only local anesthesia and sedation, was convenient, and obviated the need for patients to return for a second procedure.

Usefulness of contrast-enhanced endoscopic ultrasonography in the differentiation between malignant and benign lymphadenopathy

BACKGROUND/AIMS

Endoscopic ultrasonography (EUS) is considered the most useful diagnostic modality for regional staging; however, it is still difficult to diagnose lymph node metastasis by EUS images only. In this study, we report the usefulness of contrast-enhanced EUS (CE-EUS) in the evaluation of benign lymph nodes (BLN) or malignant lymph nodes (MLN) based on blood flow patterns.

SUBJECTS AND METHODS

In the retrospective study, CE-EUS was performed in 46 patients in whom EUS revealed lymph node in the mediastinum or abdominal cavity. The subjects consisted of 22 patients with BLN and 24 patients with MLN. The lesions were examined by EUS, and the maximal and minimal diameters of lymph nodes were measured. Thereafter, the shape and internal echoes were investigated, and the findings were morphologically classified based on Catalano's report. Enhancement effects and the diagnostic capability of CE-EUS were evaluated. In the prospective study, BLNs were differentiated from MLN using the enhancement patterns on CE-EUS based on the results of the retrospective study, and the diagnostic capability was evaluated.

RESULTS

In the retrospective study, there were no significant differences in the maximal diameter and maximal/minimal diameter ratio between MLN and BLN. The morphology was classified into four types. Based on the morphological classification, the sensitivity, specificity, and accuracy rate were 88.2%, 77.3%, and 82.1%, respectively. On CE-EUS, the enhancement pattern was classified into three types. The BLN lesions showed uniform enhancement (19/22). In all patients with MLN, a defect of enhancement was observed (24/24). The sensitivity, specificity, and accuracy rate of CE-EUS were 100%, 86.4%, and 92.3%, respectively. In the prospective study, the sensitivity, specificity, and accuracy rate of CE-EUS were 100%, 81.8%, and 92.0%, respectively.

CONCLUSIONS

CE-EUS is useful for differentiating BLN from MLN.

Esophageal endoscopic ultrasound with fine-needle aspiration with an on-site cytopathologist: high accuracy for the diagnosis of mediastinal lymphadenopathy

STUDY OBJECTIVES

To analyze the accuracy of esophageal endoscopic ultrasound (EUS) with real-time, guided fine-needle aspiration (EUS-FNA) with an on-site cytopathologist in patients with (presumed) lung cancer presenting with mediastinal lymphadenopathy (ML) or a suspect left adrenal gland (LAG).

DESIGN

A single-center prospective study.

PATIENTS

Sixty-seven outpatients with (presumed) lung cancer with ML or a suspect LAG on either CT and/or positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) scan.

INTERVENTIONS

All patients underwent EUS-FNA under conscious sedation. A cytopathologist was present during all procedures.

MEASUREMENTS

EUS with and without fine-needle aspiration (FNA) as compared to FDG-PET was evaluated for accuracy in diagnosing cancer, safety, and rate of avoidance for further surgery.

RESULTS

Of 67 consecutive patients (56 men; median age, 64 years), malignant ML or LAG were found in 47 patients (70.1%). In 20 patients (29.9%) without EUS-FNA proof of malignancy, confirmation was obtained by surgical procedure in 13 patients (sarcoidosis [n = 5], infection [n = 1], lung cancer [n = 7]) or by clinical follow-up in 5 patients suggesting benign disease. Sixty-five patients were included in the calculation of test characteristics. With malignancy as an end point, the accuracy for EUS-FNA was 100%. This was better than EUS without FNA (accuracy, 75.4%; p < 0.001) or FDG-PET (accuracy, 75.0% [n = 28]; p = 0.0011). When using final histopathologic diagnosis as an end point, the accuracy of EUS-FNA was 92.3%, since EUS-FNA was unable to show noncaseating granulomas in those patients with sarcoidosis diagnosed after mediastinoscopy. Related to the presence of the in situ cytopathologist, there were no inconclusive samples. No adverse events were recorded, and 67.7% of surgical interventions were avoided following EUS-FNA.

CONCLUSIONS

The accuracy in this series of EUS-FNA with cytopathologist-assisted rapid on-site evaluation is high. The technique is safe and greatly reduces the number of surgical interventions.