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Harper LJ, Farver CF, Yadav R, Culver DA. A framework for exclusion of alternative diagnoses in sarcoidosis. J Autoimmun 2024:103288. [PMID: 39084998 DOI: 10.1016/j.jaut.2024.103288] [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: 04/29/2024] [Revised: 07/02/2024] [Accepted: 07/13/2024] [Indexed: 08/02/2024]
Abstract
Sarcoidosis is a multisystem granulomatous syndrome that arises from a persistent immune response to a triggering antigen(s). There is no "gold standard" test or algorithm for the diagnosis of sarcoidosis, making the diagnosis one of exclusion. The presentation of the disease varies substantially between individuals, in both the number of organs involved, and the manifestations seen in individual organs. These qualities dictate that health care providers diagnosing sarcoidosis must consider a wide range of possible alternative diagnoses, from across a range of presentations and medical specialties (infectious, inflammatory, cardiac, neurologic). Current guideline-based diagnosis of sarcoidosis recommends fulfillment of three criteria: 1) compatible clinical presentation and/or imaging 2) demonstration of granulomatous inflammation by biopsy (when possible) and, 3) exclusion of alternative causes, but do not provide guidance on standardized strategies for exclusion of alternative diagnoses. In this review, we provide a summary of the most common differential diagnoses for sarcoidosis involvement of lung, eye, skin, central nervous system, heart, liver, and kidney. We then propose a framework for testing to exclude alternative diagnoses based on pretest probability of sarcoidosis, defined as high (typical findings with sarcoidosis involvement confirmed in another organ), moderate (typical findings in a single organ), or low (atypical/findings suggesting of an alternative diagnosis). This work highlights the need for informed and careful exclusion of alternative diagnoses in sarcoidosis.
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Affiliation(s)
- Logan J Harper
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Carol F Farver
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Ruchi Yadav
- Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Culver
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
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Nathani A, Keshishyan S, Cho RJ. Advancements in Interventional Pulmonology: Harnessing Ultrasound Techniques for Precision Diagnosis and Treatment. Diagnostics (Basel) 2024; 14:1604. [PMID: 39125480 PMCID: PMC11312290 DOI: 10.3390/diagnostics14151604] [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: 03/28/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 08/12/2024] Open
Abstract
Medical ultrasound has emerged as an indispensable tool within interventional pulmonology, revolutionizing diagnostic and procedural practices through its non-invasive nature and real-time visualization capabilities. By harnessing the principles of sound waves and employing a variety of transducer types, ultrasound facilitates enhanced accuracy and safety in procedures such as transthoracic needle aspiration and pleural effusion drainage, consequently leading to improved patient outcomes. Understanding the fundamentals of ultrasound physics is paramount for clinicians, as it forms the basis for interpreting imaging results and optimizing interventions. Thoracic ultrasound plays a pivotal role in diagnosing conditions like pleural effusions and pneumothorax, while also optimizing procedures such as thoracentesis and biopsy by providing precise guidance. Advanced ultrasound techniques, including endobronchial ultrasound, has transformed the evaluation and biopsy of lymph nodes, bolstered by innovative features like elastography, which contribute to increased procedural efficacy and patient safety. Peripheral ultrasound techniques, notably radial endobronchial ultrasound (rEBUS), have become essential for assessing pulmonary nodules and evaluating airway structures, offering clinicians valuable insights into disease localization and severity. Neck ultrasound serves as a crucial tool in guiding supraclavicular lymph node biopsy and percutaneous dilatational tracheostomy procedures, ensuring safe placement and minimizing associated complications. Ultrasound technology is suited for further advancement through the integration of artificial intelligence, miniaturization, and the development of portable devices. These advancements hold the promise of not only improving diagnostic accuracy but also enhancing the accessibility of ultrasound imaging in diverse healthcare settings, ultimately expanding its utility and impact on patient care. Additionally, the integration of enhanced techniques such as contrast-enhanced ultrasound and 3D imaging is anticipated to revolutionize personalized medicine by providing clinicians with a more comprehensive understanding of anatomical structures and pathological processes. The transformative potential of medical ultrasound in interventional pulmonology extends beyond mere technological advancements; it represents a paradigm shift in healthcare delivery, empowering clinicians with unprecedented capabilities to diagnose and treat pulmonary conditions with precision and efficacy. By leveraging the latest innovations in ultrasound technology, clinicians can navigate complex anatomical structures with confidence, leading to more informed decision-making and ultimately improving patient outcomes. Moreover, the portability and versatility of modern ultrasound devices enable their deployment in various clinical settings, from traditional hospital environments to remote or resource-limited areas, thereby bridging gaps in healthcare access and equity.
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Affiliation(s)
| | | | - Roy Joseph Cho
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (A.N.); (S.K.)
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Dhooria S, Sehgal IS, Prasad KT, Muthu V, Dogra P, Saini M, Gupta N, Bal A, Aggarwal AN, Agarwal R. Diagnostic Yield and Safety of the 19-Gauge versus 22-Gauge Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Needle in Subjects with Sarcoidosis (GUESS). Respiration 2024; 103:336-343. [PMID: 38531335 DOI: 10.1159/000538121] [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: 11/28/2023] [Accepted: 02/27/2024] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION Observational data suggest that the 19-gauge (G) needle for endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) offers a higher diagnostic yield than the 22-G needle in sarcoidosis. No randomized trial has compared the yield of the two needles. METHODS We randomized consecutive subjects with suspected sarcoidosis and enlarged thoracic lymph nodes to undergo EBUS-TBNA with either the 19-G or the 22-G needle. We compared the study groups for diagnostic sensitivity (primary outcome) assessed by the yield of granulomas in subjects finally diagnosed with sarcoidosis. We also compared the sample adequacy, difficulty performing the needle puncture assessed on a visual analog scale (VAS), the subject's cough intensity on an operator-rated VAS, and procedure-related complications (secondary outcomes). RESULTS We randomized 150 (mean age, 43.0 years; 55% women) subjects and diagnosed sarcoidosis in 116 subjects. The diagnostic sensitivity of the 19-G needle (45/60, 75.0%) was not higher (p = 0.52) than the 22-G needle (39/56, 69.6%). We obtained adequate aspirates in 90.0% and 85.7% of subjects in the respective groups (p = 0.48). The operators had greater difficulty puncturing lymph nodes with the 19-G needle (p = 0.03), while the operator-assessed cough intensity was similar in the groups (p = 0.41). Transient hypoxemia was the only complication encountered during EBUS-TBNA (two subjects in either group). CONCLUSION We did not find the 19-G needle superior to the 22-G in diagnostic sensitivity, specimen adequacy, or safety of EBUS-TBNA in sarcoidosis. Puncturing the lymph nodes was more difficult with the 19-G needle.
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Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pooja Dogra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Saini
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nalini Gupta
- Department of Cytology and Gynecologic Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Ding O, Chen W, Zhang O, Li M. Clinical diagnostic value of serum soluble IL-2 receptor for stage I sarcoidosis in benign isolated mediastinal and hilar lymphadenopathy. Clin Chim Acta 2023; 545:117372. [PMID: 37127231 DOI: 10.1016/j.cca.2023.117372] [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: 11/16/2022] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Serum soluble interleukin-2 receptor (sIL-2R) is recognized as a marker of T-cell activation and is abnormally elevated in sarcoidosis. However, its value for stage I sarcoidosis in benign granulomatous diseases is unclear. METHODS We enrolled 33 stage I sarcoidosis patients, 17 lymph node tuberculosis patients, 15 reactive lymphadenopathy patients, and 11 healthy controls. Serum biomarkers concentrations were collected and collated. RESULTS Serum sIL-2R concentrations were the highest in stage I sarcoidosis. The AUC of serum sIL-2R for stage I sarcoidosis was 0.7452 in all subjects and 0.6861 in granulomatous diseases. The AUCs of 2 combined diagnostic forms, sIL-2R with angiotensin-converting enzyme (ACE) and sIL-2R with ACE, erythrocyte sedimentation rate (ESR), and lactate dehydrogenase (LDH) were 0.7994 and 0.891 in all subjects, respectively. In granulomatous disease groups for ROC analysis, the best cut-off value of sIL-2R was 745.00 U/ml with 48.50% sensitivity and 84.40% specificity. The combination of four parameters increased the diagnostic accuracy for stage I sarcoidosis in granulomatous diseases (74.10% sensitivity and 100% specificity). Serum sIL-2R concentrations were positively correlated with serum ACE (r = 0.4652, P = 0.0126). CONCLUSION Serum sIL-2R appeared to be valuable in identifying stage I sarcoidosis in a group of benign IMHL disorders.
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Affiliation(s)
- Ounli Ding
- Affiliated Hospital of Medical School Ningbo University.
| | - Weili Chen
- Affiliated Hospital of Medical School Ningbo University
| | - Oipan Zhang
- Affiliated Hospital of Medical School Ningbo University
| | - Mingcai Li
- Affiliated Hospital of Medical School Ningbo University
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Shen HS, Lin FC, Tung SM, Chang CY, Chen YM, Chao HS. Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of pulmonary sarcoidosis: A 9-year experience at a single center. J Chin Med Assoc 2023; 86:191-196. [PMID: 36508498 DOI: 10.1097/jcma.0000000000000866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is valuable for diagnosing pulmonary sarcoidosis. We aimed to evaluate the diagnostic yield of EBUS-TBNA and cytology in sarcoidosis during the first 9 years at our institution. METHODS Patients who underwent EBUS-TBNA for suspected sarcoidosis between January 2011 and November 2019 were identified retrospectively. EBUS-TBNA was performed with rapid on-site cytological evaluation of the samples. The final diagnosis was based on the pathology and/or cytology results, radiologic features, and clinical follow-up findings. The yield rate was analyzed annually. RESULTS Eighty patients underwent 83 EBUS-TBNA procedures for suspected sarcoidosis. In total, 136 lymph nodes were sampled. The mean number of lymph node stations sampled was 2.0 ± 0.6; the mean number of needle passes per lymph node was 3.5 ± 0.8. Sixty-five patients were diagnosed with sarcoidosis, with a total of 68 procedures. Nonnecrotizing granulomatous inflammation was detected in the EBUS-TBNA samples from 49/68 procedures (yield rate: 72.1%). Of 19 patients with sarcoidosis who did not obtain a pathological diagnosis with EBUS-TBNA, epithelioid cells and/or multinuclear giant cells suggestive of granulomatous inflammation were detected in five. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) for pathological diagnosis of sarcoidosis using EBUS-TBNA were 72.1%, 100%, 100%, and 24.0%, respectively. On using cytology, the sensitivity and NPV increased to 79.4% and 26.3%, respectively. The yield rate did not increase until 2016. CONCLUSION EBUS-TBNA is useful for diagnosing sarcoidosis. Cytology resulted in an additional yield rate of 7.3%, which improved as the number of cases increased.
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Affiliation(s)
- Hsiang-Shi Shen
- Division of General Medicine, Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
| | - Fang-Chi Lin
- Division of Clinical Respiratory Physiology, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Su-Mei Tung
- Division of General Chest Medicine, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Yueh Chang
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
- Division of Chest Medicine, Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
| | - Yuh-Min Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Heng-Sheng Chao
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of General Chest Medicine, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Wallyn F, Fournier C, Jounieaux V, Basille D. [The role of endoscopy in exploration of the mediastinum, indications and results]. Rev Mal Respir 2023; 40:78-93. [PMID: 36528503 DOI: 10.1016/j.rmr.2022.12.001] [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: 07/10/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
Since 2005, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a standard pulmonological tool. The procedure is safe and well tolerated by patients, with minimal morbidity and almost no mortality. A previous review on the technique was published in 2012. However, over the last ten years, a number of new studies have been published on "benign" (sarcoidosis, tuberculosis…) as well as "malignant" diseases (lung cancer, metastases of extra-thoracic cancers, search for mutations and specific oncogenic markers…). These developments have led to expanded indications for EBUS-TBNA, with which it is indispensable to be familiar, in terms of "staging" as well as "diagnosis". In view of optimizing lymph node sampling, several publications have described and discussed EBUS exploration by means of newly available tools (biopsy forceps, larger needles…), and proposed interpretation of the images thereby produced. Given the ongoing evolution of linear EBUS, it seemed indispensable that information on this marvelous tool be updated. This review is aimed at summarizing the novel elements we have found the most important.
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Affiliation(s)
- F Wallyn
- Service endoscopie respiratoire. CHRU Lille, clinique de pneumologie, 59000 Lille, France
| | - C Fournier
- Service endoscopie respiratoire. CHRU Lille, clinique de pneumologie, 59000 Lille, France
| | - V Jounieaux
- Unité de soins continus cardio-thoracique-vasculaire-respiratoire. service de pneumologie, CHU d'Amiens-Picardie, 80054 Amiens, France
| | - D Basille
- Unité de soins continus cardio-thoracique-vasculaire-respiratoire. service de pneumologie, CHU d'Amiens-Picardie, 80054 Amiens, France.
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Gonzalez AV, Ost DE, Shojaee S. Diagnostic Accuracy of Bronchoscopy Procedures: Definitions, Pearls, and Pitfalls. J Bronchology Interv Pulmonol 2022; 29:290-299. [PMID: 36066281 DOI: 10.1097/lbr.0000000000000892] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/17/2022] [Indexed: 11/26/2022]
Abstract
The field of diagnostic bronchoscopy has developed at an accelerated pace. Certain limitations have plagued the evaluation of advanced bronchoscopy techniques, including the use of inconsistently defined measures of diagnostic accuracy, and confusion around the definition of "diagnostic yield." This methodological review outlines standard measures of diagnostic accuracy and highlights how these differ from "diagnostic yield." We draw examples from the interventional bronchoscopy literature to illustrate key concepts and potential pitfalls.
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Affiliation(s)
- Anne V Gonzalez
- Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre Research Institute
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Romatowski NPJ, Gillson AM, Stollery D, Dumoulin E, Vakil E, Dhaliwal I, MacEachern P, Hergott CA, Tyan CC, Mitchell M, Schieman C, Fortin M, Tremblay A. Endobronchial Ultrasound Transbronchial Needle Aspiration With a 19-Gauge Needle vs 21- and 22-Gauge Needles for Mediastinal Lymphadenopathy. Chest 2022; 162:712-720. [PMID: 35381259 DOI: 10.1016/j.chest.2022.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/18/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used to evaluate mediastinal lymphadenopathy. Studies focusing on malignant lymphadenopathy have compared 21- and 22-gauge (21G and 22G, respectively) needles and have not identified an advantage of one needle size over the other in terms of diagnostic yield. RESEARCH QUESTION Does the 19-gauge (19G) EBUS needle offer greater diagnostic yield and sensitivity vs the 21G and 22G EBUS needles for a diagnosis of sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed? STUDY DESIGN AND METHODS This study retrospectively examined records of 730 patients from the Stather Canadian Outcomes Registry for Chest Procedures (SCOPE) database who underwent EBUS-TBNA for a diagnosis of suspected sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed. A propensity score analysis of two groups was performed. One group comprised patients undergoing EBUS-TBNA with a 19G needle, the other with a 21G or 22G needle. Cases for analysis were selected with a 1:2 ratio of 19G vs 21/22G using logistic regression and random matching with all eligible 19G cases included. RESULTS There were 137 patients (312 targets) in the 19G group and 274 patients (631 targets) in the 21/22G group in the propensity score analysis. The diagnostic yield was 107 of 137 (78.1%) in the 19G group vs 194 of 274 (70.8%) in the 21/22G group (difference, 7.3%; 95% CI, -1.9 to 15.6; P = .116). The sensitivity of EBUS-TBNA for sarcoidosis was 80 of 84 (95.2%) in the 19G group vs 150 of 156 (96.2%) in the 21/22G group (difference, 1.0%; 95% CI, -4.2 to 8.2; P = .71). In patients with a final diagnosis of lymphoma, EBUS was diagnostic in 10 of 13 (76.9%) in the 19G group vs 12 of 12 (100%) in the 21/22G group (difference, 23.1%; 95% CI, -5.4 to 50.3; P = .08). INTERPRETATION The study did not identify an advantage of the 19G EBUS needle over the 21/22G EBUS needles for diagnostic yield nor sensitivity for sarcoidosis or lymphoma.
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Affiliation(s)
| | | | | | - Elaine Dumoulin
- Department of Medicine, Division of Respirology, University of Calgary Cumming School of Medicine
| | - Erik Vakil
- Division of Respirology, University of Calgary Faculty of Medicine, Medicine
| | | | - Paul MacEachern
- Department of Medicine, Division of Respirology University of Calgary Faculty of Medicine
| | - Christopher A Hergott
- Department of Medicine, Division of Respirology University of Calgary Faculty of Medicine
| | - Chung Chun Tyan
- Department of Medicine, Division of Respirology, Critical Care and Sleep Medicine University of Saskatchewan College of Medicine
| | - Michael Mitchell
- Department of Medicine, Division of Respirology, London Health Sciences Centre
| | - Colin Schieman
- Division of Thoracic Surgery, University of Calgary Faculty of Medicine
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Chami HA, Abu Khouzam R, Makki M, Kahwaji S, Hochaimi N, Tamim H, Shabb NS. Randomized Cross-over Trial of Endobronchial Ultrasound Transbronchial Needle Aspiration With or Without Suction in Suspected Malignant Lymphadenopathy. J Bronchology Interv Pulmonol 2022; 29:131-139. [PMID: 34369402 DOI: 10.1097/lbr.0000000000000801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 07/06/2021] [Indexed: 11/25/2022]
Abstract
RATIONALE The benefit from applying suction during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is unclear. BACKGROUND The purpose of this study was to evaluate the impact of applying suction during EBUS-TBNA of lymph nodes (LN) on the diagnostic yield and specimen quality of EBUS-TBNA smears and cellblocks. METHODS We conducted a randomized blinded cross-over trial comparing the diagnostic yield and quality of EBUS-TBNA samples obtained with suction (S+) and without suction (S-) from suspected malignant mediastinal LN. Each LN was aspirated 4 times in a randomly assigned alternating order: S+/S-/S+/S- or S-/S+/S-/S+, resulting in 2 matched S+/S- smears pairs and 1 matched S+/S- cellblocks pairs. Specimen were assessed by a blinded cytopathologist. The primary outcome was the diagnostic yield of EBUS-TBNA smears and cellblocks. Secondary analyses accounted for LN size (≤2 vs. >2 cm) and station (mediastinal vs. hilar). RESULTS Of 234 EBUS-TBNA smears and 114 cellblocks were obtained from 59 LN. The concordance of S+ and S- cellblocks diagnostic yield was low (43.8%; 95% confidence interval: 30.7-57.6) with a significantly higher diagnostic yield among S+ compared with S- cellblocks (56.1% vs. 10.5%, respectively, P<0.001), regardless of LN station and size. However, S+ and S- smears were moderately concordant (66.7%; 95% confidence interval: 57.4-75.1) with no overall difference in their respective diagnostic yield. Numerically higher diagnostic yield among S+ smears in LN≤2 cm or hilar LN was not statistically significant. Results were similar for specimen adequacy, sensitivity and diagnosis of malignancy. CONCLUSION Applying suction during EBUS-TBNA of suspected malignant LN enhanced the diagnostic yield of cellblocks regardless of mediastinal LN station or size, but not of smears.
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Affiliation(s)
| | | | | | | | | | | | - Nina S Shabb
- Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
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10
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Scano V, Fois AG, Manca A, Balata F, Zinellu A, Chessa C, Pirina P, Paliogiannis P. Role of EBUS-TBNA in Non-Neoplastic Mediastinal Lymphadenopathy: Review of Literature. Diagnostics (Basel) 2022; 12:diagnostics12020512. [PMID: 35204602 PMCID: PMC8871250 DOI: 10.3390/diagnostics12020512] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 02/01/2023] Open
Abstract
Mediastinal lymphadenopathy is a condition in which one or more mediastinal lymph nodes are enlarged for malignant or benign causes, generally more than 10 mm. For a long time, the only way to approach the mediastinum was surgery, while in last decades endoscopic techniques gained their role in neoplastic diseases. At the present time, EBUS is the technique of choice for studying the mediastinum in the suspicion of cancer, while there are not strong indications in guidelines for the study of benign mediastinal lymphadenopathy. We reviewed the literature, looking for evidence of the role of EBUS in the diagnostics of non-neoplastic mediastinal lymphadenopathy, with special regard for granulomatous disease, both infectious and non-infectious. EBUS is a reliable alternative to surgery in non-neoplastic mediastinal lymphadenopathy, even if more evidence is needed for granulomatous diseases other than tuberculosis and sarcoidosis.
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Affiliation(s)
- Valentina Scano
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (A.G.F.); (A.M.); (F.B.); (P.P.); (P.P.)
- Correspondence: ; Tel.: +39-340-926-5637
| | - Alessandro Giuseppe Fois
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (A.G.F.); (A.M.); (F.B.); (P.P.); (P.P.)
- Unit of Respiratory Diseases, University Hospital Sassari (AOU), 07100 Sassari, Italy
| | - Andrea Manca
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (A.G.F.); (A.M.); (F.B.); (P.P.); (P.P.)
| | - Francesca Balata
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (A.G.F.); (A.M.); (F.B.); (P.P.); (P.P.)
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy;
| | - Carla Chessa
- Postgraduate School in Hospital Pharmacy, University of Sassari, 07100 Sassari, Italy;
| | - Pietro Pirina
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (A.G.F.); (A.M.); (F.B.); (P.P.); (P.P.)
- Unit of Respiratory Diseases, University Hospital Sassari (AOU), 07100 Sassari, Italy
| | - Panos Paliogiannis
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (A.G.F.); (A.M.); (F.B.); (P.P.); (P.P.)
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11
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Effect of Needle Size on Diagnosis of Sarcoidosis with Endobronchial Ultrasound-guided Transbronchial Needle Aspiration: Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2022; 19:279-290. [PMID: 35103562 DOI: 10.1513/annalsats.202103-366oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background: Sarcoidosis is a multisystem disease characterized by noncaseating granulomatous inflammation that most commonly involves the lungs. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an invaluable tool in the assessment of patients with mediastinal and/or hilar lymphadenopathy. Objective: It has been hypothesized that use of the larger 19-gauge (G) needle with EBUS-TBNA improves diagnostic sensitivity in sarcoidosis. However, it is unclear whether the existing literature supports this supposition. Data Sources: A literature search of Embase and Medline was performed by two reviewers. Included articles were evaluated for bias using the QUADAS-2 tool. Data Extraction: For quantitative analysis, we performed a meta-analysis using a binary random-effects model to determine pooled sensitivity. Subgroup analysis was performed based on needle size, use of rapid on-site evaluation (ROSE), study design, and prevalence of sarcoidosis in study group. Synthesis: Sixty-five studies with a total of 4,242 patients were included in the meta-analysis. Overall pooled sensitivity for diagnosis of sarcoidosis was 83.99% (95% confidence interval [CI], 81.22-86.53) among all studies. The 19G subgroup had a significantly higher sensitivity (93.73%; 95% CI, 89.72-97.74%; I2 = 0.00%; P < 0.01) compared with the 21G subgroup (84.61%; 95% CI, 78.80-90.42%; I2 = 69.83%), 22G subgroup (84.07%; 95% CI, 80.90-87.24%; I2 = 85.21%) or unspecified 21G/22G subgroup (78.85%; 95% CI, 70.81-86.90%; I2 = 84.47%). There were no significant differences with use of ROSE or prevalence of sarcoidosis or by study design. Conclusions: The use of 19G needles during EBUS-TBNA had the highest diagnostic sensitivity based on available studies. Further randomized controlled trials using 19G needles should be considered in patients with suspected sarcoidosis.
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Crombag LMM, Mooij-Kalverda K, Szlubowski A, Gnass M, Tournoy KG, Sun J, Oki M, Ninaber MK, Steinfort DP, Jennings BR, Liberman M, Bilaceroglu S, Bonta PI, Korevaar DA, Trisolini R, Annema JT. EBUS versus EUS-B for diagnosing sarcoidosis: The International Sarcoidosis Assessment (ISA) randomized clinical trial. Respirology 2021; 27:152-160. [PMID: 34792268 PMCID: PMC9299594 DOI: 10.1111/resp.14182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/15/2021] [Accepted: 10/12/2021] [Indexed: 12/17/2022]
Abstract
Background and objective Endosonography with intrathoracic nodal sampling is proposed as the single test with the highest granuloma detection rate in suspected sarcoidosis stage I/II. However, most studies have been performed in limited geographical regions. Studies suggest that oesophageal endosonographic nodal sampling has higher diagnostic yield than endobronchial endosonographic nodal sampling, but a head‐to‐head comparison of both routes has never been performed. Methods Global (14 hospitals, nine countries, four continents) randomized clinical trial was conducted in consecutive patients with suspected sarcoidosis stage I/II presenting between May 2015 and August 2017. Using an endobronchial ultrasound (EBUS) scope, patients were randomized to EBUS or endoscopic ultrasound (EUS)‐B‐guided nodal sampling, and to 22‐ or 25‐G ProCore needle aspiration (2 × 2 factorial design). Granuloma detection rate was the primary study endpoint. Final diagnosis was based on cytology/pathology outcomes and clinical/radiological follow‐up at 6 months. Results A total of 358 patients were randomized: 185 patients to EBUS‐transbronchial needle aspiration (EBUS‐TBNA) and 173 to EUS‐B‐fine‐needle aspiration (FNA). Final diagnosis was sarcoidosis in 306 patients (86%). Granuloma detection rate was 70% (130/185; 95% CI, 63–76) for EBUS‐TBNA and 68% (118/173; 95% CI, 61–75) for EUS‐B‐FNA (p = 0.67). Sensitivity for diagnosing sarcoidosis was 78% (129/165; 95% CI, 71–84) for EBUS‐TBNA and 82% (115/141; 95% CI, 74–87) for EUS‐B‐FNA (p = 0.46). There was no significant difference between the two needle types in granuloma detection rate or sensitivity. Conclusion Granuloma detection rate of mediastinal/hilar nodes by endosonography in patients with suspected sarcoidosis stage I/II is high and similar for EBUS and EUS‐B. These findings imply that both diagnostic tests can be safely and universally used in suspected sarcoidosis patients. This global RCT in patients with suspected sarcoidosis stage I/II with an indication for endosonographic nodal sampling showed a similarly high granuloma detection rate and sensitivity for diagnosing sarcoidosis with endobronchial ultrasound versus endoscopic ultrasound‐B. The findings imply that both diagnostic tests (endobronchial/oesophageal) can be used safely and universally in suspected sarcoidosis patients.
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Affiliation(s)
- Laurence M M Crombag
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kirsten Mooij-Kalverda
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Maciej Gnass
- Endoscopy Unit, John Paul II Hospital, Kraków, Poland
| | - Kurt G Tournoy
- Department of Respiratory Medicine, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jiayuan Sun
- Department of Respiratory Endoscopy and Interventional Pulmonology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Maarten K Ninaber
- Department of Respiratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel P Steinfort
- Department of Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Barton R Jennings
- Department of Respiratory Medicine, Monash Health, Clayton, Victoria, Australia
| | - Moishe Liberman
- Division of Thoracic Surgery, University of Montreal, CR-CHUM, Montreal, Québec, Canada
| | - Semra Bilaceroglu
- Department of Respiratory Medicine, Health Sciences University, Izmir, Turkey.,Dr. Suat Seren Training and Research Hospital for Thoracic Medicine and Surgery, Yenişehir Mahallesi, Izmir, Turkey
| | - Peter I Bonta
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniël A Korevaar
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rocco Trisolini
- Interventional Pulmonology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jouke T Annema
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Kang N, Shin SH, Yoo H, Jhun BW, Lee K, Um SW, Kim H, Jeong BH. Infectious complications of EBUS-TBNA: A nested case-control study using 10-year registry data. Lung Cancer 2021; 161:1-8. [PMID: 34481209 DOI: 10.1016/j.lungcan.2021.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/02/2021] [Accepted: 08/26/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a standard procedure, but little is known about its infectious complications. The aim of this study is to evaluate the incidence and risk factors of infectious complications of EBUS-TBNA and its clinical course, including effects on anti-cancer treatment. METHODS This is a nested case-control study of patients who received EBUS-TBNA and were followed for at least 2 months at Samsung Medical Center from August 2009 to April 2019. Patients with clinical symptoms of infection and correlating chest images were defined as the infection group (n = 33). The controls were randomly selected from patients without infectious complication. Multivariate logistic regression with backward selection was used to identify the risk factors of infectious complications. RESULTS Of the 6826 patients, 33 (0.48%) infectious complications were identified, comprising pneumonia (n = 20) and mediastinal infections (n = 13). Target lesions with necrotic features on chest computed tomography (CT) scan (adjusted odds ratio [aOR], 3.08; 95% confidence interval [CI], 1.49-6.40; P = 0.002) and procedures that were performed via the esophagus (aOR, 3.19; 95% CI, 1.47-6.88; P = 0.003) were independently associated with infectious complications. Among patients ultimately diagnosed with cancer, the infection group tended to refuse anti-cancer treatment compared to controls (32/459, 7.0% vs. 5/30, 16.7%; P = 0.066). However, among the patients who received anti-cancer treatment, there was no delay in onset of treatment. CONCLUSIONS Infectious complications of EBUS-TBNA are rare; however, attention should be paid if the target lesion appears necrotic on chest CT or if the procedure is performed via the esophagus. Although it was not conclusive due to its rarity, patients with infectious complications tended not to receive anti-cancer treatment.
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Affiliation(s)
- Noeul Kang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sun Hye Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hongseok Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung Woo Jhun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyungjong Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Won Um
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Carbonelli C, Rossi A, Ciliberti G, Grimaldi MA, Notarangelo S, Parente P, Copetti M, Zanforlin A, Lococo F, Taurchini M, Maiello E, De Cosmo S, Graziano P. Which are the limiting factors in lung tissue sampling and diagnostic accuracy for a new Interventional Pulmonology Unit? From expert consensus-based evidence to results of a new-born Unit. J Thorac Dis 2021; 13:2942-2951. [PMID: 34164185 PMCID: PMC8182518 DOI: 10.21037/jtd-20-2990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background There is a gap of knowledge about the factors that may determine the quality and the accuracy of diagnostic bronchoscopic procedures when setting up a new Interventional Pulmonology Unit. As little evidence-based medicine is available on this matter, an online consensus opinion of experts was gathered and compared with real-life data coming from a new Interventional Pulmonology (IP) Unit. Methods A survey was emailed to the heads of all Italian IP Units to investigate the factors influencing the success of the diagnostic yield of a new IP Unit. The survey consisted of 24 items grouped by topic; the level of agreement ranged from 1 (no influence) to 7 (strong influence). After responses were collected, we submitted the data on the accuracy of the endoscopic procedures performed during the first two years of our new IP Unit to the attention of the participants for a second round of survey; the level of consistency between the first and second round of responses was assessed. Results After having been shown the results of the first two years of activity of our Unit, in the second round of the survey the responders indicated the personal skills of the Interventional Pulmonologist, the availability of echoendoscopic technology and the expertise in evaluating cytological samples as the factors able to positively influence the performance of a newly established IP Unit. Neither the role of dedicated nursing assistance, the availability of a rapid on-site evaluation, nor the presence of anesthesiology assistance were considered to be limiting factors for the final accuracy results. Conclusions A consensus of opinion of a group of expert interventional pulmonologists highlighted the factors that may be responsible for the diagnostic success of a newly established Italian IP Unit. These factors are mainly three: personal skills of the interventional pulmonologist, the availability of echoendoscopic technology, and the expertise in reading cytological samples.
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Affiliation(s)
- Cristiano Carbonelli
- Department of Medical Sciences, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Antonio Rossi
- Oncology Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Gianluca Ciliberti
- Department of Medical Sciences, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Maria Arcangela Grimaldi
- Department of Medical Sciences, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Stefano Notarangelo
- Department of Medical Sciences, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Paola Parente
- Pathology Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Massimiliano Copetti
- Unit of Biostatistics, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | | | - Filippo Lococo
- Department of Thoracic Surgery, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Taurchini
- Thoracic Surgery Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Evaristo Maiello
- Oncology Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
| | - Paolo Graziano
- Pathology Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, (FG), Italy
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Kumari R, Jain K, Agarwal R, Dhooria S, Sehgal IS, Aggarwal AN. Fixed dexmedetomidine infusion versus fixed-dose midazolam bolus as primary sedative for maintaining intra-procedural sedation during endobronchial ultrasound-guided transbronchial needle aspiration: a double blind randomized controlled trial. Expert Rev Respir Med 2021; 15:1597-1604. [PMID: 33849367 DOI: 10.1080/17476348.2021.1918000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: The utility and safety of fixed dexmedetomidine infusion was compared to fixed-dose midazolam bolus among patients undergoing EBUS-TBNA.Methods: In this randomized double-blind study, 197 patients were assigned to receive dexmedetomidine (Group D, 1 μg/kg before, and 0.6 μg/kg/hour during, procedure) or midazolam (Group M, 2 mg before procedure) sedation. The primary outcome was number of rescue midazolam boluses administered to achieve Ramsay Sedation Scale (RSS) score of two or more. We also studied sedation depth during procedure, adverse hemodynamic and hypoxemic events, bronchoscopist and patient satisfaction, and time-to-discharge from recovery room.Results: Rescue midazolam requirement was significantly lesser in 99 Group D (0.9 ± 1.2 boluses) than in 98 Group M (2.0 ± 2.4 boluses), subjects. Mean RSS score was significantly higher in Group D subjects (2.5 ± 0.7 vs. 2.3 ± 0.7). Significantly more subjects in Group D developed hypotension (46 vs. 27) or bradycardia (37 vs. 5), but none required specific intervention. Bronchoscopists reported significantly greater overall procedure satisfaction in Group D subjects.Conclusion: Fixed dexmedetomidine infusion reduced need for rescue sedation during EBUS-TBNA, and allowed slightly faster post-procedure recovery, as compared to fixed-dose midazolam bolus. However, it caused hypotension and bradycardia more frequently.Clinical trial registration: www.clinicaltrials.gov identifier is NCT02713191.
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Affiliation(s)
- Renu Kumari
- Pulmonary Medicine Department, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kajal Jain
- Anesthesiology and Intensive Care Department, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Pulmonary Medicine Department, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Pulmonary Medicine Department, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Pulmonary Medicine Department, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Pulmonary Medicine Department, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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16
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Dhooria S, Sehgal IS, Prasad KT, Muthu V, Gupta N, Bal A, Ram B, Aggarwal AN, Agarwal R. Diagnostic yield and safety of the ProCore versus the standard EBUS-TBNA needle in subjects with suspected sarcoidosis. Expert Rev Med Devices 2021; 18:211-216. [PMID: 33435733 DOI: 10.1080/17434440.2021.1876560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: No randomized trial has compared the yield of the ProCore needle, a novel needle for endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA), with standard needles.Research design and methods: Consecutive subjects with intrathoracic lymphadenopathy due to suspected sarcoidosis were randomized 1:1 to undergo EBUS-TBNA with either the 22-gauge ProCore (EchoTip-ProCore, Cook-Medical) or the 22-gauge standard (Vizishot, Olympus) needle. The primary outcome was the diagnostic sensitivity; the secondary outcomes included the number of adequate aspirates obtained and procedure-related complications.Results: We randomized 100 (mean age, 43.4 years; 53% women) subjects. Of the 84 subjects finally diagnosed with sarcoidosis, the sensitivity of EBUS-TBNA was higher with the ProCore (36/42, 85.7%) versus the standard needle (31/42, 73.8%), although not statistically significant (p = 0.18). We obtained adequate aspirates in 95.2% and 90.5% subjects in the ProCore and the standard needle groups, respectively (p = 0.68). One complication (transient hypoxemia) occurred in each group. There were two incidences of the ProCore needle getting bent during the procedure.Conclusions: We found no difference in the sensitivity, specimen adequacy, or safety of EBUS-TBNA when performed with the ProCore or the Olympus needle in subjects with sarcoidosis. Larger studies are required to confirm our findings.[clinicaltrials.gov: NCT03656003].
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Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nalini Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.,Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Cytopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Babu Ram
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kang HJ, Kim Y, Bae JY, Chang JH, Lee SH. Sarcoid-Like Reaction after Complete Remission of Malignancy: CT and 18F-FDG PET/CT Features for the Differential Diagnosis from Lymph Node Metastasis. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:903-913. [PMID: 36238067 PMCID: PMC9514401 DOI: 10.3348/jksr.2020.0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/15/2020] [Accepted: 09/15/2020] [Indexed: 11/15/2022]
Abstract
Purpose Materials and Methods Results Conclusion
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Affiliation(s)
- Hyun Ji Kang
- Department of Radiology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Yookyung Kim
- Department of Radiology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - June Young Bae
- Department of Radiology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Jung Hyun Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Soo-Hyun Lee
- Department of Radiology, National Cancer Center, Goyang, Korea
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Kasper L, Andrychiewicz A, Gross-Sondej I, Soja J, Kasper M, Tomaszewska R, Urbanczyk K, Sladek K. Combination of endosonography-guided fine-needle aspiration and conventional endoscopic techniques in sarcoidosis diagnosis. Optimal strategy to achieve high diagnostic yield. CLINICAL RESPIRATORY JOURNAL 2020; 15:203-208. [PMID: 33012129 DOI: 10.1111/crj.13285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 09/01/2020] [Accepted: 09/21/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Diagnosis of sarcoidosis is based on clinical status and radiologic specific findings. Tissue confirmation of noncaseating granulomas is crucial. Pathological confirmation of pulmonary sarcoidosis is most commonly accomplished by bronchoscopy, which has a diagnostic yield of approximately 60%-70%. OBJECTIVES In this prospective study, we analysed potential benefit of EBUS-TBNA and EBB combination, application of cell blocks and smears with puncturing more than one station of lymph nodes in order to determine optimal strategy in diagnosis of sarcoidosis. METHODS About 133 patients with suspicion of sarcoidosis (stage I and stage II) were included in this study. Each patient underwent conventional bronchoscopy with endobronchial biopsy (EBB) followed by the EBUS and puncturing at least two different lymph node stations. RESULTS Positive cytopathological verification of sarcoidosis in our study was obtained in 123 patients (92.5%). EBUS-TBNA was diagnostic in 116 patients (87.2%). EBB was positive in 26 patients (19.55%). Combination of EBUS-TBNA and EBB statistically increased diagnostic yield of sarcoidosis to 92.5%. Sensitivity of EBUS-TBNA with EBB was 93.9%, specificity 100%, PPV 100% and NPV 20%. CONCLUSIONS Combining EBUS-TBNA from at least two lymph node stations and EBB increased diagnostic yield of sarcoidosis. Such diagnostic strategy had almost 93% of diagnostic yield in stage I and stage II of sarcoidosis. Taking into account the safety of the whole procedure with endobronchial ultrasonography combined with conventional endoscopy with EBB and its cost effectiveness, TBLB can be intended to diagnose stage III or IV of pulmonary sarcoidosis.
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Affiliation(s)
- Lukasz Kasper
- Department of Pulmonology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Andrychiewicz
- Department of Pulmonology, Jagiellonian University Medical College, Krakow, Poland
| | - Iwona Gross-Sondej
- Department of Pulmonology, Jagiellonian University Medical College, Krakow, Poland
| | - Jerzy Soja
- Department of Pulmonology, Jagiellonian University Medical College, Krakow, Poland
| | - Marta Kasper
- Department of Internal and Community Nursing, Institute of Nursing and Midwifery, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Romana Tomaszewska
- Department of Pathology, Jagiellonian University Medical College, Krakow, Poland
| | - Katarzyna Urbanczyk
- Department of Pathology, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Sladek
- Department of Pulmonology, Jagiellonian University Medical College, Krakow, Poland
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Taniguchi J, Nakashima K, Ito H, Tanaka Y, Otsuki A, Shiroshita A, Yoshimi M, Kubota N, Aoshima M. Pulmonary Sarcoidosis Presenting with Acute Respiratory Failure: A Report of a Case Diagnosed by Endobronchial Ultrasound-guided Transbronchial Needle Aspiration on Ventilation after Intubation. Intern Med 2020; 59:2291-2295. [PMID: 32536645 PMCID: PMC7578599 DOI: 10.2169/internalmedicine.4624-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown etiology and is pathologically characterized by non-caseating granulomas in the organs involved. We herein report a case of sarcoidosis in a Japanese woman with acute respiratory failure, diagnosed using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) on the ventilator after intubation. Only a few cases of previously undiagnosed sarcoidosis presenting acute respiratory failure have been reported. It is important to be aware that undiagnosed sarcoidosis may present with acute respiratory failure. Therefore, EBUS-TBNA under mechanical ventilation may be useful for the immediate diagnosis of patients.
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Affiliation(s)
| | - Kei Nakashima
- Department of Pulmonology, Kameda Medical Center, Japan
| | - Hiroyuki Ito
- Department of Pulmonology, Kameda Medical Center, Japan
| | - Yu Tanaka
- Department of Pulmonology, Kameda Medical Center, Japan
| | - Ayumu Otsuki
- Department of Pulmonology, Kameda Medical Center, Japan
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Chopra A, Avadhani V, Tiwari A, Riemer EC, Sica G, Judson MA. Granulomatous lung disease: clinical aspects. Expert Rev Respir Med 2020; 14:1045-1063. [PMID: 32662705 DOI: 10.1080/17476348.2020.1794827] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Granulomatous lung diseases (GLD) are heterogeneous group of diseases that can be broadly categorized as infectious or noninfectious. This distinction is extremely important, as the misdiagnosis of a GLD can have serious consequences. In this manuscript, we describe the clinical manifestations, histopathology, and diagnostic approach to GLD. We propose an algorithm to distinguish infectious from noninfectious GLD. AREAS COVERED We have searched PubMed and Medline database from 1950 to December 2019, using multiple keywords as described below. Major GLDs covered include those caused by mycobacteria and fungi, sarcoidosis, hypersensitivity pneumonitis, and vasculidities. EXPERT OPINION The cause of infectious GLD is usually identified through microbiological culture and molecular techniques. Most noninfectious GLD are diagnosed by clinical and laboratory criteria, often with exclusion of infectious pathogens. Further understanding of the immunopathogenesis of the granulomatous response may allow improved diagnosis and treatment of GLD.
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Affiliation(s)
- Amit Chopra
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center , NY, USA
| | - Vaidehi Avadhani
- Department of Pathology and Laboratory Medicine, Emory University , Atlanta, USA
| | - Anupama Tiwari
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center , NY, USA
| | - Ellen C Riemer
- Department of Pathology, Medical University of South Carolina , SC, USA
| | - Gabriel Sica
- Department of Pathology and Laboratory Medicine, Emory University , Atlanta, USA
| | - Marc A Judson
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center , NY, USA
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Aravena C, Almeida FA, Culver DA, Ribeiro Neto ML. The utility of endobronchial ultrasound-transbronchial needle aspiration in patients with suspected extra-pulmonary sarcoidosis without thoracic lymphadenopathy. Respir Med 2020; 171:106074. [PMID: 32917351 DOI: 10.1016/j.rmed.2020.106074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/24/2020] [Accepted: 06/25/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diagnosis of extra-pulmonary sarcoidosis can be difficult, and a biopsy is usually required. We evaluated the utility of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) in patients with suspected extra-pulmonary sarcoidosis with thoracic lymph nodes ≤10 mm on chest computed tomography (CT) and no or minimal pulmonary infiltrates. METHODS The Cleveland Clinic bronchoscopy registry was screened. Patients with thoracic lymph nodes >10 mm on short axis or significant pulmonary infiltrates in the chest CT scan were excluded. Two separate analyses using expert consensus (before and after release of bronchoscopy results) were the reference standard. RESULTS 15 patients met the inclusion criteria. 40% had suspected ocular, 33% cardiac and 27% neurologic sarcoidosis. Six patients (40%) had EBUS-TBNA compatible with sarcoidosis. When the reference standard was the consensus diagnosis blinded to bronchoscopy results, the sensitivity, specificity, positive predictive value and negative predictive value of EBUS-TBNA were 56%, 83%, 83%, and 56% respectively. The combination of a positive EBUS-TBNA and BAL CD4/CD8 improved the specificity from 83 to 100%, but the difference was not statistically significant (p = 0.074). When the reference standard was the consensus diagnosis with the bronchoscopic results, the sensitivity, specificity, positive predictive value and negative predictive value of EBUS-TBNA were 75%, 100%, 100%, and 78% respectively. CONCLUSIONS In patients with suspected extra-pulmonary sarcoidosis, the EBUS-TBNA may be useful in the diagnosis of patients with thoracic lymph nodes ≤10 mm and no or minimal pulmonary infiltrates on chest CT. Larger and prospective studies are needed to validate our findings.
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Affiliation(s)
- Carlos Aravena
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Respiratory Diseases, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco A Almeida
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manuel L Ribeiro Neto
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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Crouser ED, Maier LA, Wilson KC, Bonham CA, Morgenthau AS, Patterson KC, Abston E, Bernstein RC, Blankstein R, Chen ES, Culver DA, Drake W, Drent M, Gerke AK, Ghobrial M, Govender P, Hamzeh N, James WE, Judson MA, Kellermeyer L, Knight S, Koth LL, Poletti V, Raman SV, Tukey MH, Westney GE. Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 201:e26-e51. [PMID: 32293205 PMCID: PMC7159433 DOI: 10.1164/rccm.202002-0251st] [Citation(s) in RCA: 478] [Impact Index Per Article: 119.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: The diagnosis of sarcoidosis is not standardized but is based on three major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure. Methods: Systematic reviews and, when appropriate, meta-analyses were performed to summarize the best available evidence. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach and then discussed by a multidisciplinary panel. Recommendations for or against various diagnostic tests were formulated and graded after the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability. Results: The clinical presentation, histopathology, and exclusion of alternative diagnoses were summarized. On the basis of the available evidence, the expert committee made 1 strong recommendation for baseline serum calcium testing, 13 conditional recommendations, and 1 best practice statement. All evidence was very low quality. Conclusions: The panel used systematic reviews of the evidence to inform clinical recommendations in favor of or against various diagnostic tests in patients with suspected or known sarcoidosis. The evidence and recommendations should be revisited as new evidence becomes available.
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Iriarte A, Rubio-Rivas M, Villalba N, Corbella X, Mañá J. Clinical features and outcomes of asymptomatic pulmonary sarcoidosis. A comparative cohort study. Respir Med 2020; 169:105998. [PMID: 32442109 DOI: 10.1016/j.rmed.2020.105998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the clinical characteristics and outcomes of patients with asymptomatic pulmonary sarcoidosis (APS) detected incidentally and compare them with symptomatic non-Löfgren sarcoidosis (SnLS) patients. METHODS Patients diagnosed as having APS at a University hospital in Barcelona, Spain, followed prospectively from 1976 to 2018. APS was defined as the presence of bilateral hilar lymphadenopathy (BHL) with or without lung parenchymal involvement discovered incidentally on chest radiograph or CT scan. APS was compared with SnLS. RESULTS APS was diagnosed in 50 (13.6%) and SnLS in 317 (86.4%) patients. At diagnosis, stage I chest radiograph was significantly more frequent in APS than in SnLS (p < 0.001) and there were no asymptomatic patients with stages III and IV. SnLS showed more severe impairment in FVC (p = 0.009) and forced expiratory volume in 1st second (FEV1) (p = 0.003) than APS, while DLco was similar in both groups. Extrathoracic involvement at diagnosis and during the follow up was less frequent in APS than in SnLS patients (p < 0.005). Endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS) was the most used diagnostic tool. Treatment was more frequently required in the SnLS than in APS (p < 0.001). At five years, APS patients showed less presence of active disease than SnLS (p = 0.054). CONCLUSIONS APS showed earlier radiological stages, lesser impairment in lung function, extrapulmonary organ involvement and need for treatment than SnLS. EBUS was the most useful diagnostic tool. In spite of its benign presentation, around one third of patients evolved to persistent disease but usually with mild clinical and functional impairment.
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Affiliation(s)
- Adriana Iriarte
- Autoimmune Diseases Unit, Department of Internal Medicine, Bellvitge University Hospital-IDIBELL. L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Manuel Rubio-Rivas
- Autoimmune Diseases Unit, Department of Internal Medicine, Bellvitge University Hospital-IDIBELL. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Nadia Villalba
- Autoimmune Diseases Unit, Department of Internal Medicine, Bellvitge University Hospital-IDIBELL. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Corbella
- Autoimmune Diseases Unit, Department of Internal Medicine, Bellvitge University Hospital-IDIBELL. L'Hospitalet de Llobregat, Barcelona, Spain; Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Juan Mañá
- Autoimmune Diseases Unit, Department of Internal Medicine, Bellvitge University Hospital-IDIBELL. L'Hospitalet de Llobregat, Barcelona, Spain
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24
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Abedini A, Razavi F, Mehravaran H, Toutkaboni MP, Kashefizadeh A, Emami H, Kazempour-Dizaji M, Farahani M, Kiani A. Identification of Sonographic Features for Predicting Benign Versus Malignant Mediastinal or Hilar Lymph Nodes Using Endobronchial Ultrasound. Oman Med J 2020; 35:e112. [PMID: 32405434 PMCID: PMC7199125 DOI: 10.5001/omj.2020.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/21/2019] [Indexed: 12/25/2022] Open
Abstract
Objectives In countries with a high prevalence of tuberculosis, such as Iran, the differentiation of malignant from non-malignant tumors is crucial. We attempted to find a reliable model in determining malignant nodes by investigating the sonographic characteristics of lymph nodes (LNs). Methods In this prospective study, the morphologic characteristics of LNs, including size, shape, vascular pattern, echogenicity, margin, coagulation necrosis sign, calcification, and central hilar structure, which had been obtained during endobronchial ultrasound-guided transbronchial needle aspiration, were compared with the final pathology results. Results We examined 253 LNs from 93 patients. Round shape, non-hilar vascular pattern, heterogeneous echogenicity, hyperechogenicity, distinct margin, and the existence of necrosis signs were significantly higher in malignant nodes. On the other hand, the existence of calcification, as well as the presence of central hilar structure, were highly suggestive of benign nodes (p < 0.050). Multivariate logistic regression revealed that size > 1 cm, heterogeneous echogenicity, hyperechogenicity, the existence of necrosis signs, and the lack of central hilar structure are independent predictive factors for malignancy. The accuracy of each of the aforementioned characteristics are 42.3%, 71.5%, 71.9%, 73.5%, and 65.6%, respectively. Of 74 malignant LNs, 100% had at least one of these independent factors. Conclusions The morphological features of LNs based on endobronchial ultrasound-guided transbronchial needle aspiration can play a role in predicting malignancy.
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Affiliation(s)
- Atefeh Abedini
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Razavi
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Mehravaran
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mihan Pourabdollah Toutkaboni
- Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Kashefizadeh
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Habib Emami
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Kazempour-Dizaji
- Mycobacteriology Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Farahani
- Departemant of Interventional Pulmonology, Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences,Tehran, Iran
| | - Arda Kiani
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Shen H, Lou L, Chen T, Zou Y, Wang B, Xu Z, Ye Q, Shen H, Li W, Xia Y. Comparison of transbronchial needle aspiration with and without ultrasound guidance for diagnosing benign lymph node adenopathy. Diagn Pathol 2020; 15:36. [PMID: 32293480 PMCID: PMC7158000 DOI: 10.1186/s13000-020-00958-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/08/2020] [Indexed: 12/25/2022] Open
Abstract
Background Transbronchial needle aspiration (TBNA) is a minimally invasive procedure performed to diagnose lymph node (LN) adenopathy. TBNA with and without endobronchial ultrasound (EBUS) guidance has a high diagnostic yield for malignant LN enlargement, but the value for diagnosing benign LN enlargement has been less thoroughly investigated. Methods We retrospectively evaluated 3540 patients with mediastinal LN enlargement who received TBNA. One hundred sixty-six patients with benign mediastinal lymphadenopathy were included and 293 LNs were biopsied. A positive result was defined as a specific histological abnormality. Conventional TBNA (cTBNA) and EBUS-TBNA, as well as cTBNA and transbronchial forceps biopsy (TBFB), were compared. The subgroup analysis was stratified by disease type and LN size. Results A diagnosis was made in 76.84% of the EBUS-TBNA and 61.31% of the cTBNA (P < 0.05). EBUS-TBNA was superior to cTBNA for both granulomatous (65.18% vs. 45.45%, P < 0.05) and non-granulomatous disease (96.92% vs. 84.06%, P < 0.05). In contrast, the diagnostic yield of EBUS-TBNA was higher than that of cTBNA for LNs < 20 mm (79.44% vs. 64.29%, P < 0.05), but for LNs > 20 mm the difference was marginal. These findings were confirmed in a group of independent patients who received cTBNA plus EBUS-TBNA. The diagnostic yield did not differ between cTBNA and TBFB, but significantly increased to 76.67% when both modalities were employed. Conclusions EBUS-TBNA is the preferred minimally invasive diagnostic method for benign mediastinal LN disease. Combined cTBNA and TBFB is a safe and feasible alternative when EBUS is unavailable.
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Affiliation(s)
- Hui Shen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China.,Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Huzhou, Zhejiang, 313000, China
| | - Lingyun Lou
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China.,Department of Respiratory and Critical Care Medicine, Fouth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, Zhejiang, 322000, China
| | - Ting Chen
- Department of Endoscopic Center, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Yi Zou
- Department of Pathology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Bin Wang
- Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Huzhou, Zhejiang, 313000, China
| | - Zhihao Xu
- Department of Respiratory and Critical Care Medicine, Fouth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, Zhejiang, 322000, China
| | - Qin Ye
- Department of Pathology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Huahao Shen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Wen Li
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Yang Xia
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China.
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Helalah LA, Madkour AM, Elfattah NMA, Mohammed RM, Farghaly AAH, Fawzy RA, Elasser AMA. The role of convex probe endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of hilar and mediastinal lesions. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_57_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
PURPOSE OF REVIEW To review the diagnostic approach to sarcoidosis. There is no gold standard diagnostic test, procedure or algorithm for sarcoidosis. The diagnosis is based on a compatible clinical presentation, histologic findings of granulomatous inflammation, exclusion of alternative diseases, and evidence of systemic involvement. Occasionally, there may be exceptions to several of these requirements. RECENT FINDINGS The diagnostic specificity of several specific clinical features are discussed. Typical histologic findings of sarcoidosis are described. Several diseases that may mimic sarcoidosis are reviewed. SUMMARY The diagnosis of sarcoidosis usually involves weighing the clinical evidence for and against the diagnosis, coupled in most cases with histologic evidence of granulomatous inflammation. This approach requires knowledge of the varied presentations of the disease and other alternative conditions as well as histologic examination of an affected tissue in most instances.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York, USA
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28
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Cheng G, Mahajan A, Oh S, Benzaquen S, Chen A. Endobronchial ultrasound-guided intranodal forceps biopsy (EBUS-IFB)-technical review. J Thorac Dis 2019; 11:4049-4058. [PMID: 31656681 DOI: 10.21037/jtd.2019.08.106] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) have changed the landscape of pulmonology. Mediastinal structures beyond the confines of airway walls are visualized in real-time with EBUS, leading to improved accuracy of tissue sampling and diagnostic yield. With the development of various needle sizes ranging from 25-G to 19-G, the sampling of lymph nodes is becoming easier and more commonplace. Yet, certain conditions such as sarcoidosis and lymphoma may still be difficult to diagnose via EBUS-TBNA. Furthermore, in the age of targeted therapy, there are more demands on EBUS-TBNA samples for molecular marker testing and next-generation sequencing. Here, we present a complementary methodology, EBUS-guided intranodal forceps biopsy (EBUS-IFB), for tissue acquisition that may help address these deficiencies. Specifically, we aim to propose indications, contraindications, outline approaches in performing IFB, and provide an overview of the data for this complementary technique.
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Affiliation(s)
- George Cheng
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, Durham, NC, USA
| | - Amit Mahajan
- Inova Cardiac and Thoracic Surgery, Inova Fairfax Hospital, Fairfax, VA, USA
| | - Scott Oh
- Division of Pulmonary, Critical Care Medicine, UCLA Medical Center, Santa Monica, CA, USA
| | - Sadia Benzaquen
- Division of Pulmonary, Critical Care Medicine, University of Cincinnati Medical School, Cincinnati, OH, USA
| | - Alexander Chen
- Division of Pulmonary, Critical Care Medicine, Washington University Hospital, St Louis, MO, USA
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29
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Ibrahim MA, Yousef AM, Hantera MSA, Ahmed MA, Abdelhafez SAM. Endoscopic transbronchial needle aspiration in sampling mediastinal lesions. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_96_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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30
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Pedro C, Melo N, Novais E Bastos H, Magalhães A, Fernandes G, Martins N, Morais A, Caetano Mota P. Role of Bronchoscopic Techniques in the Diagnosis of Thoracic Sarcoidosis. J Clin Med 2019; 8:E1327. [PMID: 31466346 PMCID: PMC6780968 DOI: 10.3390/jcm8091327] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/04/2019] [Accepted: 08/26/2019] [Indexed: 01/09/2023] Open
Abstract
The diagnosis of sarcoidosis relies on clinical and radiological presentation, evidence of non-caseating granulomas in histopathology and exclusion of alternative causes of granulomatous inflammation. Currently, a proper diagnosis, with a high level of confidence, is considered as key to the appropriate diagnosis and management of the disease. In this sense, this review aims to provide a brief overview on the role of bronchoscopy in the diagnosis of thoracic sarcoidosis, incorporating newer techniques to establish, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), transesophageal ultrasound-guided needle aspiration with the use of an echo bronchoscope (EUS-B-FNA) and transbronchial lung cryobiopsy (TBLC). Most of the literature reports the diagnostic superiority of endosonographic techniques, such as EBUS-TBNA alone or in combination with EUS-FNA, over conventional bronchoscopic modalities in diagnosing Scadding stages I and II of the disease. Moreover, TBLC may be considered a useful and safe diagnostic tool for thoracic sarcoidosis, overcoming some limitations of transbronchial lung biopsy (TBLB), avoiding more invasive modalities and being complementary to endosonographic procedures such as EBUS-TBNA.
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Affiliation(s)
- Cecília Pedro
- Faculty of Medicine, University of Porto, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Natália Melo
- Department of Pulmonology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Hélder Novais E Bastos
- Faculty of Medicine, University of Porto, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Pulmonology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, Rua Alfredo Allen 208, 4200-319 Porto, Portugal
| | - Adriana Magalhães
- Department of Pulmonology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Gabriela Fernandes
- Faculty of Medicine, University of Porto, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Pulmonology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Natália Martins
- Faculty of Medicine, University of Porto, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Pulmonology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, Rua Alfredo Allen 208, 4200-319 Porto, Portugal
| | - António Morais
- Faculty of Medicine, University of Porto, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Pulmonology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Patrícia Caetano Mota
- Faculty of Medicine, University of Porto, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Pulmonology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
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Candoli P, Ceron L, Trisolini R, Romagnoli M, Michieletto L, Scarlata S, Galasso T, Leoncini F, Pasini V, Dennetta D, Marchesani F, Zotti M, Corbetta L. Competence in endosonographic techniques. Panminerva Med 2019; 61:249-279. [DOI: 10.23736/s0031-0808.18.03570-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
Sarcoidosis is a multisystemic granulomatous disease that affects individuals worldwide. The lungs are most commonly involved but any organ can be involved. It has variable manifestations and clinical course. Diagnosis of sarcoidosis is based on clinicopathologic findings and the exclusion of other causes of granulomatous disease. Its hallmark is the formation of granulomas in affected organs. Immunosuppressive therapy is the cornerstone of the management of sarcoidosis and is indicated when there is evidence of symptomatic or progressive disease or when critical organs (ocular, cardiac, nervous system) are involved.
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Affiliation(s)
- Oscar Llanos
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Nabeel Hamzeh
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
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Natali F, Cancellieri A, Tinelli C, De Silvestri A, Livi V, Ferrari M, Romagnoli M, Paioli D, Trisolini R. A Trained Pulmonologist Can Reliably Assess Endosonography-Derived Lymph Node Samples during Rapid On-Site Evaluation. Respiration 2019; 97:540-547. [PMID: 30982053 DOI: 10.1159/000496549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/31/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The widespread use of rapid on-site evaluation is hampered by constraints related to time and resources, inadequate reimbursement, and evidence from randomized trials that show a lack of increase in diagnostic yield and specimen adequacy associated with its usage. OBJECTIVE We aimed to verify whether a pulmonologist can assess endosonography-derived lymph node samples after a comprehensive and reproducible training provided by a specialist pathologist. METHODS Prospective, observational trial structured in three phases. In the first (training) phase, a pathologist critically evaluated the smears from 150 archival endosonography cases with a pulmonologist. In the second (test) phase, the pulmonologist was asked to assess 50 archival endosonography-derived samples. In the last (real-life) phase, the pulmonologist classified the samples from 200 patients during the endosonography. The overall agreement between pulmonologist and pathologist (gold standard), assessed through κ-statistics, was the primary outcome. The agreement for the identification of specific cytological categories was the secondary outcome. RESULTS The overallagreement between pulmonologist and pathologist was 84% (κ0.765, 95% CI 0.732-0.826) in the test phase and 89.7% (κ 0.844, 95% CI 0.799-0.881) in the real-life phase. The agreement for specific cytological categories was 92.7% (95% CI 0.824-0.980) for inadequate samples, 90.3% (95% CI 84.5-94.5%) for reactive lymphadenopathies, 90.5% (95% CI 0.845-0.946) for malignancy, and 73% (95% CI 0.515-0.897) for granulomatous samples. CONCLUSIONS A trained pulmonologist can reliably assess adequacy and malignancy for endosonography-derived samples, which could be useful in institutions where a cytopathologist/cytotechnician is not available regularly.
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Affiliation(s)
- Filippo Natali
- Interventional Pulmonology Unit, Policlinico Sant'Orsola-Malpighi and Ospedale Maggiore, Bologna, Italy
| | | | - Carmine Tinelli
- Clinical Epidemiology and Biometry Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Vanina Livi
- Interventional Pulmonology Unit, Policlinico Sant'Orsola-Malpighi and Ospedale Maggiore, Bologna, Italy
| | - Marco Ferrari
- Interventional Pulmonology Unit, Policlinico Sant'Orsola-Malpighi and Ospedale Maggiore, Bologna, Italy
| | - Micaela Romagnoli
- Interventional Pulmonology Unit, Policlinico Sant'Orsola-Malpighi and Ospedale Maggiore, Bologna, Italy
| | - Daniela Paioli
- Interventional Pulmonology Unit, Policlinico Sant'Orsola-Malpighi and Ospedale Maggiore, Bologna, Italy
| | - Rocco Trisolini
- Interventional Pulmonology Unit, Policlinico Sant'Orsola-Malpighi and Ospedale Maggiore, Bologna, Italy,
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Diagnostic of mediastinal lymphadenopathy in extrathoracic cancer: A place for EBUS-TBNA in real life practice? Respir Med Res 2019; 75:1-4. [PMID: 31235451 DOI: 10.1016/j.resmer.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/06/2019] [Accepted: 03/20/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Mediastinal lymphadenopathy in patients with extrathoracic malignancy is common. To obtain tissue proof of metastatic spread, EBUS-TBNA is an alternative to mediastinoscopy or thoracoscopy, but there are limited data about its diagnostic performance. The aim of this study was to determine the diagnostic accuracy of EBUS-TBNA for the evaluation of mediastinal lymphadenopathy in patients with extrathoracic cancers. METHODS We performed a multicenter retrospective study based on an online questionnaire to collect data from January 2011 to December 2012 in all patients with proven extrathoracic malignancy (current or past) and suspected mediastinal lymph node metastases who underwent EBUS-TBNA for diagnosis. RESULTS Hundred and eighty-five patients were included. Extrathoracic malignancies observed were urological (43), breast (35), gastrointestinal (33), head and neck (30), melanoma (11), lymphoma (6), and others (27). EBUS-TBNA confirmed malignancy in 93 patients (50.3%): concordant metastases in 67 (36.2%); new lung cancer in 25 (13.5%); and 1 unidentified cancer. The diagnostic accuracy, sensitivity, specificity, negative predictive value, and positive predictive value were respectively 54.6%, 68.4%, 100%, 53.3%, and 100%. CONCLUSION Mediastinoscopy remain the reference, but EBUS-TBNA may be considered as first line investigation in patients with suspected mediastinal lymph node metastases and extrathoracic malignancy. It prevented a surgical procedure in 50.3% of patients.
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Effect of Routine Clopidogrel Use on Bleeding Complications After Endobronchial Ultrasound-guided Fine Needle Aspiration. J Bronchology Interv Pulmonol 2019; 26:10-14. [PMID: 29664760 DOI: 10.1097/lbr.0000000000000493] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endobronchial ultrasonography has proven to be highly sensitive and specific in the diagnoses of patients with mediastinal and hilar adenopathy. Many of these patients are on a combination of clopidogrel (a compound that inhibits adenosine diphosphate-induced platelet aggregation) and aspirin due to neurological and/or cardiac-related comorbidities, and stopping anticoagulation may place these patients at high risk for potential complications. Our group has previously showed that thoracentesis with an 8-french catheter is safe in patients receiving clopidogrel and aspirin with low risk of complications. In this manuscript, we report the outcomes of the largest prospective multicenter series of patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) while receiving clopidogrel. METHODS Patients presenting to our institutions with mediastinal/hilar adenopathy, requiring EBUS-TBNA, and actively taking clopidogrel and aspirin were included in the study. If the medication could be held for 5 to 7 days before the procedure, the patient was excluded. EBUS-TBNA was performed by an interventional pulmonology faculty on a total of 42 patients. All patients received total intravenous anesthesia, and a total of 92 nodes were sampled. First, 3 passes were performed with a 22-G needle. If no complications were encountered, we followed with additional 3 passes with a 21 G. Rapid onsite evaluation was performed in all patients. Bleeding at the puncture site was considered significant if it required cold saline, topical sympathomimetic, or balloon tamponade for hemostasis. Bleeding was considered nonsignificant if no interventions were required to achieve hemostasis. RESULTS We were able to perform all procedures successfully using both the 21 and 22-G needles. One patient required 30 mL cold saline installation to accomplish hemostasis with the 21 and 22-G needles. Our yield was comparable with the current literature. No statistically significant complications occurred during the procedure. All patients were contacted within 24 hours, and none reported bloody sputum. CONCLUSION We suggest that EBUS-TBNA, using 22 and 21-G needles, is safe with high yields in patients with mediastinal/hilar adenopathy, actively taking clopidogrel and aspirin, and are at high risk for thrombotic complications if the medication is discontinued.
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Sampling Utility of the Convex Probe Endobronchial Ultrasound Visible Intrapulmonary Lesion. J Bronchology Interv Pulmonol 2018; 25:290-299. [PMID: 29901532 DOI: 10.1097/lbr.0000000000000509] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the mediastinal staging of lung cancer has been well established. However, data regarding its utility in the diagnosis of intrapulmonary lesions has been sparse. This study assesses the sampling utility of convex probe EBUS-visible intrapulmonary lesions not visualized by the white-light bronchoscopy. METHODS A retrospective analysis of EBUS-TBNA of EBUS-visible intrapulmonary lesions was performed between January 2010 and March 2015. Patients with visible endobronchial lesions by white-light bronchoscopy were excluded from analysis. RESULTS Among 108 procedures, the diagnostic yield of EBUS-TBNA for EBUS-visible intrapulmonary lesions was 87%. Following diagnoses were established: lung cancer (73/67.6%), lung metastases (10/9.2%), infection (5/4.6%), lymphoma (1/<1%), sarcoma/spindle cell sarcoma or neoplasm (3/2.8%), unspecified malignancy (1<1%), and hamartoma (1/<1%). EBUS-TBNA was nondiagnostic in 14 (13%); among these, 9 turned out to have benign disease based on additional bronchoscopy samples or other testing and/or follow-up imaging. Five were ultimately diagnosed with a malignant condition: lymphoma (1), epithelioid hemangioendothelioma (1), and non-small cell lung cancer (3). The sensitivity and the negative predicted value of EBUS-TBNA for differentiating malignancy from benign disease was 94.7% and 75%, respectively, while the accuracy for diagnosing the neoplastic disease was 95.3%. There was one major bleeding requiring bronchial artery embolization and 1 pneumothorax requiring chest tube drainage. CONCLUSION EBUS-TBNA is safe and effective in the diagnosis of EBUS-visible intrapulmonary lesions. It should be considered as the diagnostic test of choice in patients with these lesions undergoing EBUS-TBNA for the staging of suspected lung cancer.
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A Prospective Randomized Controlled Trial Comparing the Efficacy and Safety of Cup vs Alligator Forceps for Performing Transbronchial Lung Biopsy in Patients With Sarcoidosis. Chest 2018; 149:1584-6. [PMID: 27287583 DOI: 10.1016/j.chest.2016.03.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 03/15/2016] [Indexed: 11/20/2022] Open
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Cehajic Kapetanovic J, Jones NP, Steeples LR. Atypical sarcoidosis-associated uveitis: diagnostic challenges. BMJ Case Rep 2018; 2018:bcr-2018-225137. [PMID: 29848539 PMCID: PMC5976088 DOI: 10.1136/bcr-2018-225137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Sarcoidosis is a multisystem disease of unknown aetiology with pulmonary involvement in most patients. Uveitis is common and often characteristic. We report a case of ocular sarcoidosis with grossly atypical contiguous optic neuropathy and choroiditis and describe the diagnostic challenges in this highly unusual presentation. High-dose systemic corticosteroid and immunosuppressive treatment was required for sustained control of intraocular inflammation.
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Affiliation(s)
- Jasmina Cehajic Kapetanovic
- Ophthalmology, Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Institute of Human Development, University of Manchester, Manchester, UK
| | - Nicholas P Jones
- Ophthalmology, Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Institute of Human Development, University of Manchester, Manchester, UK
| | - Laura R Steeples
- Ophthalmology, Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Institute of Human Development, University of Manchester, Manchester, UK
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Endobronchial Ultrasound-guided Transbronchial Needle Aspiration With a 19-G Needle Device. J Bronchology Interv Pulmonol 2018; 25:218-223. [PMID: 29771773 DOI: 10.1097/lbr.0000000000000500] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration is a well-established first-line minimally invasive modality for mediastinal lymph node sampling. Although results are excellent overall, the technique underperforms in certain situations. We aimed to describe our results using a new 19-G EBUS-guided transbronchial needle aspiration device to determine safety and feasibility of this approach. METHODS We completed a retrospective chart review of all cases performed to the time of data analysis at each of 3 study sites. RESULTS A total of 165 procedures were performed with a total of 297 individual lymph nodes or lesions sampled with the 19-G device by 10 bronchoscopists. Relatively large targets were selected for sampling with the device (mean lymph node size: 20.4 mm; lung lesions: 33.5 mm). A specific diagnosis was obtained in 77.3% of cases with an additional 13.6% of cases with benign lymphocytes, for a procedural adequacy rate of 90.9%. Procedure sample adequacy was 88.6% in suspected malignant cases, 91.0% in suspected sarcoidosis/lymphadenopathy cases, and 85.7% of cases with suspected lymphoma. On a per-node basis, a specific diagnosis was noted in 191/280 (68.2%) of samples, with an additional 61 showing benign lymphocytes for a per-node sample adequacy rate of 90%. One case (0.6%) of intraprocedure bleeding was noted. CONCLUSIONS A new flexible 19-G EBUS needle was successfully and safely applied in a large patient cohort for sampling of lung and enlarged mediastinal lesions with high diagnostic rates across clinical indications.
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Ahmadzai H, Huang S, Steinfort C, Markos J, Allen RK, Wakefield D, Wilsher M, Thomas PS. Sarcoidosis: a state of the art review from the Thoracic Society of Australia and New Zealand. Med J Aust 2018; 208:499-504. [PMID: 29719195 DOI: 10.5694/mja17.00610] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 11/01/2017] [Indexed: 12/28/2022]
Abstract
Sarcoidosis is a systemic disease of unknown aetiology, characterised by non-caseating granulomatous inflammation. It most commonly manifests in the lungs and intrathoracic lymph nodes but can affect any organ. This summary of an educational resource provided by the Thoracic Society of Australia and New Zealand outlines the current understanding of sarcoidosis and highlights the need for further research. Our knowledge of the aetiology and immunopathogenesis of sarcoidosis remains incomplete. The enigma of sarcoidosis lies in its immunological paradox of type 1 T helper cell-dominated local inflammation co-existing with T regulatory-induced peripheral anergy. Although specific aetiological agents have not been identified, mounting evidence suggests that environmental and microbial antigens may trigger sarcoidosis. Genome-wide association studies have identified candidate genes conferring susceptibility and gene expression analyses have provided insights into cytokine dysregulation leading to inflammation. Sarcoidosis remains a diagnosis of exclusion based on histological evidence of non-caseating granulomas with compatible clinical and radiological findings. In recent years, endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes has facilitated the diagnosis, and whole body positron emission tomography scanning has improved localisation of disease. No single biomarker is adequately sensitive and specific for detecting and monitoring disease activity. Most patients do not require treatment; when indicated, corticosteroids remain the initial standard of care, despite their adverse side effect profile. Other drugs with fewer side effects may be a better long term choice (eg, methotrexate, hydroxychloroquine, azathioprine, mycophenolate), while tumour necrosis factor-α inhibitors are a treatment option for patients with refractory disease.
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Affiliation(s)
- Hasib Ahmadzai
- Prince of Wales Clinical School, UNSW Sydney, Sydney, NSW
| | - Shuying Huang
- Prince of Wales Clinical School, UNSW Sydney, Sydney, NSW
| | | | | | | | | | | | - Paul S Thomas
- Prince of Wales Clinical School, UNSW Sydney, Sydney, NSW
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Velu PP, Reid PA, Wallace WA, Skwarski KM. Isolated mediastinal lymphadenopathy - performance of EBUS-TBNA in clinical practice. J R Coll Physicians Edinb 2018; 47:52-56. [PMID: 28569283 DOI: 10.4997/jrcpe.2017.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Isolated mediastinal lymphadenopathy is an increasingly common finding as a result of the increasing use of cross-sectional thoracic imaging. We investigated the performance of endobronchial ultrasoundguided transbronchial needle-aspiration (EBUS-TBNA) in establishing a pathological diagnosis in patients with isolated mediastinal lymphadenopathy. Methods We retrospectively analysed all consecutive EBUS-TBNA examinations performed over a 4-year period at a single tertiary referral centre. Final diagnoses were made using pathology reports, correlated with clinical features and the results of any other investigations. Results In total, 126 EBUS-TBNA examinations were performed to investigate isolated mediastinal lymphadenopathy. A positive pathological diagnosis was made following EBUSTBNA in 54 cases (43%). When the results of further investigations and variable radiological follow up were included, the final sensitivity of EBUS-TBNA for making a diagnosis in isolated mediastinal lymphadenopathy was 80% (95% CI 69%-89%). Conclusions This study confirms that EBUS-TBNA has acceptable sensitivity for detecting both benign and malignant pathologies underlying isolated mediastinal lymphadenopathy.
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Affiliation(s)
- P P Velu
- PP Velu, Department of Respiratory, Medicine Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
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Benzaquen S, Aragaki-Nakahodo AA. Bronchoscopic modalities to diagnose sarcoidosis. Curr Opin Pulm Med 2018; 23:433-438. [PMID: 28590291 DOI: 10.1097/mcp.0000000000000398] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Several studies have investigated different bronchoscopic techniques to obtain tissue diagnosis in patients with suspected sarcoidosis when the diagnosis cannot be based on clinicoradiographic findings alone. In this review, we will describe the most recent and relevant evidence from different bronchoscopic modalities to diagnose sarcoidosis. RECENT FINDINGS Despite multiple available bronchoscopic modalities to procure tissue samples to diagnose sarcoidosis, the vast majority of evidence favors endobronchial ultrasound transbronchial needle aspiration to diagnose Scadding stages 1 and 2 sarcoidosis. Transbronchial lung cryobiopsy is a new technique that is mainly used to aid in the diagnosis of undifferentiated interstitial lung disease; however, we will discuss its potential use in sarcoidosis. SUMMARY This review illustrates the limited information about the different bronchoscopic techniques to aid in the diagnosis of pulmonary sarcoidosis. However, it demonstrates that the combination of available bronchoscopic techniques increases the diagnostic yield for suspected sarcoidosis.
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Affiliation(s)
- Sadia Benzaquen
- Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of Cincinnati, Ohio, USA
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Wu X, Shi L, Xia Y, Wang KP, Li Q. Intrabronchial display of hilar-mediastinal lymph nodes by virtual bronchoscopic navigation system. Thorac Cancer 2018; 9:415-419. [PMID: 29377573 PMCID: PMC5832480 DOI: 10.1111/1759-7714.12555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/11/2017] [Accepted: 10/11/2017] [Indexed: 12/25/2022] Open
Abstract
The description of precise intrabronchial positions for the sampling of mediastinal‐hilar lymph nodes is critical to successfully perform conventional transbronchial needle aspiration. Previously published maps of mediastinal‐hilar lymph nodes were primarily drawn based on experts’ experience. We generated a virtual map of the most frequently sampled intrathoracic lymph nodes from an intrabronchial perspective using a virtual bronchoscopic navigation system, to assist with training in conventional transbronchial needle aspiration.
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Affiliation(s)
- Xiaodong Wu
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lingzhi Shi
- Department of Respiratory Medicine, Wuxi People's Hospital, Nanjing Medical University, Wuxi, China
| | - Yang Xia
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ko-Pen Wang
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Qiang Li
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
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Oki M, Saka H, Ando M, Nakashima H, Shiraki A, Murakami Y, Kogure Y, Kitagawa C, Kato T. How Many Passes Are Needed for Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Sarcoidosis? A Prospective Multicenter Study. Respiration 2018; 95:251-257. [PMID: 29320774 DOI: 10.1159/000485661] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/23/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is widely used as an initial diagnostic procedure for pathological confirmation of sarcoidosis, it is unclear how many passes are required to obtain diagnostic materials. OBJECTIVES The aim of this study was to determine the number of needle passes needed for the diagnosis of stage I/II sarcoidosis using EBUS-TBNA. METHODS At three institutions, 109 patients with suspected stage I/II sarcoidosis were recruited and underwent 6 passes of EBUS-TBNA for the main target lesion. Additional EBUS-TBNA for other lesions was permitted. The cumulative yields of needle passes for detecting noncaseating epithelioid cell granulomas were analyzed. RESULTS A total of 109 patients underwent EBUS-TBNA for 184 lesions. EBUS-TBNA identified specimens containing granulomas in 81 of 92 patients (88%) with a final diagnosis of sarcoidosis. The cumulative yields through the first, second, third, fourth, fifth, and sixth passes for the main target lesion were 63, 75, 82, 85, 86 and 88%, respectively. In the 55 patients that underwent EBUS-TBNA for multiple lesions, the cumulative yields of 2 passes per lesion for 2 lesions (total of 4 passes) and of 4 passes for single lesions were 86 and 84%, respectively (p = 1.00). CONCLUSIONS If rapid on-site cytological evaluation is not available, we recommend at least 4 passes per patient for either single or multiple lesions with EBUS-TBNA for pathological diagnosis of stage I/II sarcoidosis.
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Affiliation(s)
- Masahide Oki
- Department of Respiratory Medicine, Nagoya Medical Center, Nagoya, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, Nagoya Medical Center, Nagoya, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Harunori Nakashima
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Akira Shiraki
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Yasushi Murakami
- Department of Respiratory Medicine, Nagoya Medical Center, Nagoya, Japan
| | - Yoshihito Kogure
- Department of Respiratory Medicine, Nagoya Medical Center, Nagoya, Japan
| | - Chiyoe Kitagawa
- Department of Respiratory Medicine, Nagoya Medical Center, Nagoya, Japan
| | - Tatsuo Kato
- Department of Pulmonary Medicine, National Hospital Organization Nagara Medical Center, Gifu, Japan
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Hu J, Li M, Xu L. Ectopic thyroid cancer diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration. Thorac Cancer 2017; 8:703-705. [PMID: 28881088 PMCID: PMC5668473 DOI: 10.1111/1759-7714.12486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/03/2017] [Accepted: 07/03/2017] [Indexed: 01/29/2023] Open
Abstract
We report a case of papillary carcinoma in a mediastinal ectopic thyroid diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In this case, the tumor was adjacent to the central airway; therefore, we attempted to perform EBUS-TBNA to obtain specimens for a diagnosis of papillary thyroid carcinoma. Surgical resection was conducted, and histological evaluation of the resected specimen confirmed ectopic papillary thyroid carcinoma, consistent with the histology from the EBUS-TBNA specimen. As a safe and minimally invasive procedure, EBUS-TBNA may be considered for the diagnosis of mediastinal lesions, including papillary carcinoma in mediastinal ectopic thyroid.
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Affiliation(s)
- Jingwen Hu
- Department of Thoracic Surgery, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, China
| | - Ming Li
- Department of Thoracic Surgery, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, China
| | - Lin Xu
- Department of Thoracic Surgery, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, China
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Erer OF, Cimen P, Unlu M, Katgi N. Four cases of pulmonary thromboembolism diagnosed by endobronchial ultrasound. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:441-444. [PMID: 27813098 DOI: 10.1002/jcu.22420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/11/2016] [Accepted: 09/23/2016] [Indexed: 06/06/2023]
Abstract
Endobronchial ultrasound (EBUS) is a technique for the detection of mediastinal abnormalities. A total of 548 EBUS procedures were performed for various indications, and in four cases (0.7%), filling defects in central pulmonary arteries were demonstrated fortuitously during the procedure. Subsequently, all patients underwent contrast-enhanced CT of the thorax to confirm the diagnosis of pulmonary thromboembolism (PTE). In three of the four cases, there was a concomitant lung cancer. PTE can be incidentally detected during EBUS; therefore, pulmonary arteries should be examined carefully during EBUS in all patients, particularly in patients with suspected or proven malignancy. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:441-444, 2017.
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Affiliation(s)
- Onur Fevzi Erer
- Izmir Training and Research Hospital for Thoracic Medicine and Surgery, Pulmonary Division, Izmir, Turkey
| | - Pinar Cimen
- Izmir Training and Research Hospital for Thoracic Medicine and Surgery, Pulmonary Division, Izmir, Turkey
| | - Mehmet Unlu
- Luleburgaz State Hospital, Pulmonary Division, Kirklareli, Turkey
| | - Nuran Katgi
- Izmir Training and Research Hospital for Thoracic Medicine and Surgery, Pulmonary Division, Izmir, Turkey
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Abstract
Interstitial lung diseases (ILDs) form one of the most fascinating fields in pulmonary medicine. They also pose one of the greatest challenges for accurate diagnosis and proper treatment. Even within the recommended and warranted multidisciplinary approach, differentiating between one disease and another may lead to frustration, especially when proper lung tissue is not available for adequate pathological review. A surgical lung biopsy (SLB) might render enough tissue for histopathology, but this could come at the expense of high morbidity and even mortality, as in the case of usual interstitial pneumonia (UIP). Could bronchoscopy and its various techniques offer a safer and higher yield alternative? Since the very late 19th century, efforts have been made to better examine the airways, obtain tissue and treat various conditions. This resulted in the successive emergence of bronchoalveolar lavage (BAL), endobronchial and transbronchial forceps biopsies, until recently when transbronchial cryobiopsy surfaced as a nascent technique with much promise. The use of endobronchial ultrasound revolutionized the diagnosis and staging of lung cancer, while adding to the yield of other conditions such as sarcoidosis. Ongoing research, efforts and studies have continuously scrutinized the roles of various techniques in the approach to ILDs. For example, BAL seems to serve mostly to eliminate infection as an etiology or a complicating factor in the acute worsening of a fibrotic lung disease, while a predominant cellular component might be diagnostic, such as eosinophilia in eosinophilic lung disease, or lymphocytosis in hypersensitivity pneumonitis (HP). On the other hand, endobronchial biopsy's (EBB) role appears limited to sarcoidosis. As for transbronchial biopsy by forceps, the small sample size and related artifact appear to be limiting factors in making an accurate diagnosis. Recently, however, the use of cryotherapy via employing a cryoprobe in obtaining transbronchial lung biopsies is unfolding into a refined interventional method which might transform indefinitely our approach to the pathological diagnosis of the various ILDs.
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Affiliation(s)
- Jad Kebbe
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center and Oklahoma City VA Medical Center, Oklahoma, USA
| | - Tony Abdo
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center and Oklahoma City VA Medical Center, Oklahoma, USA
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Aragaki-Nakahodo AA, Baughman RP, Shipley RT, Benzaquen S. The complimentary role of transbronchial lung cryobiopsy and endobronchial ultrasound fine needle aspiration in the diagnosis of sarcoidosis. Respir Med 2017; 131:65-69. [PMID: 28947045 DOI: 10.1016/j.rmed.2017.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/25/2017] [Accepted: 08/02/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Transbronchial lung cryobiopsy (TBLC) is a novel technique that has proved to be useful in diagnosing various interstitial lung diseases (ILD). The use of TBLC to diagnose sarcoidosis in an unselected patient population is unknown, and could be complimentary to endobronchial ultrasound fine needle aspiration (EBUS-FNA). METHODS A retrospective analysis of 36 patients in a single, tertiary-care, academic medical center was conducted to describe the yield of both EBUS-FNA and TBLC in the diagnosis of suspected sarcoidosis over a three year period. A grading system to evaluate the presence and extent of specific radiographic features on computed tomography chest imaging studies was compared to the results of EBUS-FNA and TBLC. Complications associated with the procedures were also noted. RESULTS The overall diagnostic yield in our cohort (all pathologic diagnosis considered) was 80.6% (29 out of 36 patients had a definite pathologic diagnosis). Eighteen patients referred for possible sarcoidosis had a positive bronchoscopic specimen confirming the diagnosis of sarcoidosis. For those patients with a pathologic diagnosis of sarcoidosis, the diagnostic yield for EBUS-FNA and TBLC was 66.7% each (12 out of 18 patients), while the combined diagnostic yield for EBUS-FNA and TBLC increased to 100%. For all cases, the pneumothorax rate was 11.1%. CONCLUSIONS TBLC appears to be a safe and complimentary technique to diagnose sarcoidosis and could be considered part of the diagnostic armamentarium in bronchoscopic centers.
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Affiliation(s)
| | - Robert P Baughman
- Department of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Ralph T Shipley
- Department of Radiology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Sadia Benzaquen
- Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
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Harris K, Oakley E, Bellnier D, Shafirstein G. Endobronchial ultrasound-guidance for interstitial photodynamic therapy of locally advanced lung cancer-a new interventional concept. J Thorac Dis 2017; 9:2613-2618. [PMID: 28932569 DOI: 10.21037/jtd.2017.07.45] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Recent advances in interventional pulmonology led to a significant expansion of the diagnostic and therapeutic role of endobronchial ultrasound. In this paper, we describe a new concept for using endobronchial ultrasound to guide interstitial photodynamic therapy (PDT). For this purpose, we conducted in vitro and in vivo experiments using a phantom and animal models, respectively. A new 0.5 mm optical fiber, with cylindrical diffuser end, was used to deliver the therapeutic light through the 21-gauge endobronchial ultrasound needle. The animal experiments were performed under real-time ultrasonography guidance in mice and rabbits' tumor models. Safe and effective fiber placements and tumor illumination was accomplished. In addition, computer simulation of light propagation suggests that locally advanced lung cancer tumor can be illuminated. This study demonstrates the potential feasibility of this new therapeutic modality approach, justifying further investigation in the treatment of locally advanced lung cancers.
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Affiliation(s)
- Kassem Harris
- Westchester Medical Center, Department of Medicine, Interventional Pulmonary Section, Valhalla, NY, USA.,Department of Medicine, Interventional Pulmonary, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Emily Oakley
- Department of Cell Stress Biology, Photodynamic Therapy Center, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - David Bellnier
- Department of Cell Stress Biology, Photodynamic Therapy Center, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Gal Shafirstein
- Department of Cell Stress Biology, Photodynamic Therapy Center, Roswell Park Cancer Institute, Buffalo, NY, USA
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