The clinical application and cost analysis of fine-needle aspiration biopsy in the diagnosis of mass lesions in sarcoidosis

Reprint of: The pathology of pulmonary sarcoidosis: update

Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8+ T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.

How Many Passes Are Needed for Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Sarcoidosis? A Prospective Multicenter Study

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.

Five Top Stories in Cytopathology

Context.—Cytology relies heavily on morphology to make diagnoses, and morphologic criteria have not changed much in recent years. The field is being shaped predominantly by new techniques for imaging and for acquiring and processing samples, advances in molecular diagnosis and therapeutics, and regulatory issues.

Objective.—To review the importance of classical morphology in the future of cytopathology, to identify areas in which cytology is expanding or contracting in its scope, and to identify factors that are shaping the field.

Data Sources.—Literature review.

Conclusions.—Five stories paint a picture in which classical cytomorphology will continue to have essential importance, both for diagnosis and for improving our understanding of cancer biology. New endoscopy and imaging techniques are replacing surgical biopsies with cytology samples. New molecularly targeted therapies offer a chance for cytology to play a major role, but they pose new challenges. New molecular tests have the potential to synergize with, but not replace, morphologic interpretation of thyroid fine-needle aspirations. Ultrasound-guided fine-needle aspiration performed by cytopathologists is opening a new field of “interventional cytopathology” with unique value. For the productive evolution of the field, it will be important for cytopathologists to play an active role in clinical trials that document the ability of cytology to achieve cost-effective health care outcomes.

Sarcoidosis lung nodules in colorectal cancer follow-up: sarcoidosis or not?

OBJECTIVE

Sarcoidosis is a multisystem chronic granulomatous disease found predominantly in the lungs and lymph nodes. Its pathologic hallmark is the presence of noncaseating granulomas. Sarcoidosis is a chronic inflammatory condition that may increase the risk of cancer, yet at the same time, cancer can be associated with a sarcoid-like reaction.

METHODS

It is difficult to distinguish between sarcoidosis and sarcoid-like reactions because their imaging characteristics are identical. We report on 3 cases of sarcoidosis or sarcoid-like reactions in patients with colorectal cancer and highlight the diagnosis process.

RESULTS

Systemic symptoms observed in patients with sarcoidosis commonly can be masked or mimicked by symptoms related to the malignancy. Moreover, it is important to distinguish between the 2 entities to give patients adequate therapy.

CONCLUSION

Our cases focused on the usefulness of histologic proof in patients with cancer with sarcoidosis.

Recurrence of sarcoidosis: the follow-up of splenic involvement

We report the case of a 53-year-old woman who initially presented with an intermittent dry cough that had lasted for 6 months. An investigation into these symptoms with thoracic computed tomography demonstrated hyperdense shadows in her lungs, and ultrasonography showed the presence of multiple hypoechoic nodules on her spleen. A lung biopsy was then performed, which revealed noncaseating epithelioid cell granulomas. Magnetic resonance imagining of her spleen was performed, which showed low signal intensity. The patient was treated with glucocorticoids, and 3 months later the lesions in her lungs had disappeared completely. Five months later, the lesions in her spleen had disappeared also. However, after 13 months of low-dose prednisone, a miliary pattern was observed on the patient's chest x-ray, although no lesions were observed in her spleen. Laboratory tests demonstrated that her blood level of angiotensin-converting enzyme had increased to 96 IU/L. The dose of prednisone was then increased, and the lung images returned to normal after 2 months of therapy.

Sarcoidosis of the submandibular gland: A systematic review

INTRODUCTION

Submandibular gland sarcoidosis is rare and little is known about its clinical presentation besides the usual neck swelling. The aim of the study was to extract clinical knowledge on submandibular sarcoidosis from the literature.

METHODS

A systematic review was performed using a search in Medline with the key-words "sarcoidosis," "submandibular," "submaxillary."

RESULTS

Forty-six articles fitting the search criteria were found, whereas 31 had to be excluded because they did not report submandibular gland sarcoidosis. Twenty cases of submandibular gland sarcoidosis were considered suitable for analysis. Almost all reported cases concerned female patients. In some cases submandibular gland's swelling is the first and only manifestation of the disease.

CONCLUSION

Sarcoidosis should be considered in the differential diagnosis of all progressive and painless swellings of the submandibular gland, especially in women. Rarely, it may be the first manifestation of the disease.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The pathology of pulmonary sarcoidosis: update

Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8 + T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann's bodies, calcium oxalate crystals, and Hamazaki-Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/ salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.

Splenic focal lesions as manifestation of sarcoidosis: Characterization with contrast-enhanced sonography

We report the case of a 74-year-old woman with elevated liver enzyme levels in whom abdominal sonographic examination revealed a diffusely heterogeneous liver parenchyma and multiple hypoechoic subcentimetric splenic nodules. Contrast-enhanced sonography (CEUS) revealed that the splenic focal lesions did not enhance. CT examination revealed a low-density, multinodular pattern both in the liver and in the spleen. Core biopsy of 1 hepatic nodule revealed noncaseating epithelioid cell granuloma, and the patient was diagnosed with systemic sarcoidosis. CEUS has shown to be useful in the diagnosis of focal hepatic lesions, but studies referring to splenic lesions are lacking.

Diagnostic value of peripheral lymph node biopsy in sarcoidosis: a report of 67 cases

A peripheral lymph node (PLN) 1 cm or greater was found in 79 of 546 sarcoidosis patients (14.5%) between 1972 and 2005. Seventy-two of the 79 sarcoidosis patients had a lymph node biopsy performed. Sixty-seven of these biopsy specimens were histologically diagnosed as sarcoidosis, whereas five patients had a reactive adenopathy. For patients with histological diagnosis of sarcoidosis, localizations of the biopsies were as follows: cervical (n=21), supraclavicular (n=20), inguinal (n=11), axillary (n=8), epitrochlear (n=5) and submandibular (n=2). At the time of biopsy, 12 patients had stage 0 disease, 37 patients had stage I disease, 14 patients had stage II disease and four patients had stage III disease. Skin involvement (16.4%) was the most frequently observed type of organ involvement in patients who had enlarged PLNs due to sarcoidosis. In the presence of an enlarged PLN in sarcoidosis, biopsy had a greater diagnostic value compared with other methods, as well as having a relatively low cost (approximately US$120) in Turkey. No procedure-related complications were observed. In conclusion, it is recommended that PLNs be thoroughly examined when sarcoidosis is suspected. If an enlarged PLN is found, biopsy should be routinely performed because it is an easy, convenient and practical method, with a low complication risk and a high sensitivity.

Pulmonary sarcoidosis

Pulmonary sarcoidosis is one of the most common causes of idiopathic interstitial lung disease. Clinical presentation can range from asymptomatic to respiratory failure. Although some patients never require therapy, many patients with pulmonary sarcoidosis become symptomatic enough to require therapy. Treatment options include corticosteroids.In the past few years, alternatives to corticosteroids have been developed,especially for patients with a chronic condition.

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

BACKGROUND

Preliminary data show that endosonography guided fine needle aspiration (EUS-FNA) may be an accurate method for diagnosing sarcoidosis. However, these data were obtained in a small selected group of patients with a very high pretest probability of sarcoidosis. This retrospective study reports on the use of EUS-FNA in an unselected group of patients with mediastinal lymphadenopathy of unknown origin.

METHODS

The EUS database of a single tertiary referral centre was reviewed for patients who underwent EUS-FNA for mediastinal lymphadenopathy of unknown origin. Clinical presentation and imaging studies of each case were carefully reviewed and the diagnosis "sarcoidosis" or "no sarcoidosis" attributed if possible. The diagnoses were compared with the result of EUS-FNA.

RESULTS

One hundred and twenty four patients were investigated. In 35 cases EUS-FNA identified granulomas (group 1); in the other 89 cases (group 2) no granulomas were detected. The definite diagnoses in group 1 were sarcoidosis (n = 25), indefinite (n = 7), no sarcoidosis (n = 3). The definite diagnoses in group 2 were sarcoidosis (n = 3), indefinite (n = 9), no sarcoidosis (n = 77). Of the 77 cases with no sarcoidosis, 44 were diagnosed with other diseases. The other 33 showed non-specific changes in the FNA and sarcoidosis was excluded by negative non-EUS pathology (n = 17) and clinical presentation. The sensitivity and specificity for EUS-FNA were 89% (95% CI 82 to 94) and 96% (95% CI 91 to 98), respectively, after exclusion of the indefinite cases in both groups.

CONCLUSIONS

EUS-FNA is an accurate method for diagnosing sarcoidosis in an unselected group of patients with mediastinal lymphadenopathy. The reported sensitivity and specificity must be appreciated in the context of the difficult and often incomplete clinical diagnosis of sarcoidosis.

Newer MR imaging techniques for head and neck

Dynamic and functional imaging techniques are being developed to improve the evaluation of various pathologic processes of the head and neck region. These techniques include dynamic contrast-enhanced MR imaging for evaluating soft tissue masses and cervical lymph nodes, the use of ultrasmall superparamagnetic iron oxide contrast agent, and functional techniques such as in vivo and in vitro MR spectroscopy of head and neck cancer and lymph nodes and apparent diffusion coefficient mapping of parotid glands. These techniques can help to differentiate nonmalignant tissue from malignant tumors and lymph nodes and can aid in differentiating residual malignancies from postradiation changes. From methodological development, they are making the critical transition to preclinical and clinical validating methods and eventually to widespread clinical tools.

The pathology of sarcoidosis

Sarcoidosis is a multisystemic disease characterized by a nonnecrotizing granulomatous inflammatory process that can progress through various stages of activity. The distinctive histology of sarcoidosis is often associated with various morphologic findings in the lung and other organs. The rare variants, necrotizing sarcoidal granulomas and nodular sarcoidosis, share some of the histologic features of typical sarcoidosis, but may have different clinical and pathologic manifestations. The clinician and pathologist should be aware of the diverse pathologic appearances of sarcoidosis.

Sonographically guided biopsy and sonographic monitoring in the diagnosis and follow-up of 2 cases of sarcoidosis with hepatic nodules and inconclusive thoracic findings

OBJECTIVE

To report 2 cases in which abdominal sonography played a useful role in diagnosing sarcoidosis with early nodular hepatosplenic manifestations.

METHODS

In the first case, an asymptomatic woman with increased liver enzyme values underwent sonography, which showed multiple hypoechoic nodules in the liver and spleen. Computed tomography confirmed the hepatosplenic findings and showed micronodular infiltrates of both lung fields, without hilar and mediastinal lymphadenopathy. In the second case, in a woman with a cough, dyspnea, and increased liver enzyme levels, thoracic computed tomography showed right pleural effusion causing partial atelectasis of the lower and middle lobes and mediastinal lymphadenopathy.

RESULTS

Sonography and computed tomography showed multiple nodules of the liver and spleen and retroperitoneal lymphadenopathy. In both cases, bronchoscopy, bronchial and bronchioloalveolar lavages, and transbronchial and mediastinal biopsies had negative results. Sonographically guided biopsy of the hepatic nodules was carried out and sarcoid granulomas were detected in the portal areas. After 3 months of steroid therapy, liver enzyme values nearly normalized, and sonography showed the disappearance of all abdominal lesions. The first patient underwent control computed tomography, which confirmed the regression of the disease; the second patient refused control computed tomography.

CONCLUSIONS

Sarcoidosis can occur with atypical onset, and in selected cases sonography may play a useful role in its diagnosis and follow-up.

Aspiration biopsy of nodular sarcoidosis of the muscle

The nodular form of muscular sarcoidosis is rare and the condition is often confused with a soft tissue neoplasm. We present a case of nodular muscular sarcoidosis of the right calf in a 52-yr-old woman which was diagnosed by thin-needle aspiration biopsy (TNAB). In this patient, a calf mass was the initial manifestation of sarcoidosis. Contrast-enhanced computed tomographic scans of the calf showed a mass with peripheral ring-like enhancement. T2-weighted magnetic resonance images demonstrated a mass with central hypointensity and marked peripheral hyperintensity. TNAB revealed noncaseating epithelioid cell granulomas in association with multinucleated giant cells. Combined with the radiologic findings, TNAB is considered a useful modality for the diagnosis of nodular muscular sarcoidosis.