0
Correspondence |

Tissue Verification of Stage I Sarcoidosis Response: The Question Is If, Not How FREE TO VIEW

Jerome M. Reich, MD, FCCP; James Asaph, MD, FCCP; James Patterson, MD, FCCP; Matthew Brouns, MD, FCCP
Author and Funding Information

Affiliations: Earl A. Chiles Research Institute,  The Oregon Clinic, Portland, OR,  Northwest Cancer Specialists, Vancouver, WA,  Medical University of South Carolina, Charleston, SC

Correspondence to: Jerome M. Reich, MD, FCCP, Earl A. Chiles Research Institute, 5251 NE Glisan, Bldg A, Portland, OR 97213-2967; e-mail: Reichje@dnamail.com



Chest. 2008;133(6):1529-1530. doi:10.1378/chest.07-2894
Text Size: A A A
Published online

The recent study by Garwood et al1(October 2007) demonstrates the utility of endobronchial ultrasound with transbronchial needle aspiration for confirmation of pulmonary sarcoidosis in patients with high pretest probability. They cite the study by Reich et al2 as arguing against the cost-effectiveness of mediastinoscopy to make a diagnosis.

In fact, the study by Reich et al2augments the analysis of Winterbauer et al3 and argues against the need for tissue confirmation in stage 1 sarcoidosis (S1S). Based on a comparison of the incidence of S1S with that of clinically relevant alternative diagnoses (ADs) presenting as asymptomatic bilateral hilar adenopathy, the authors2 estimated the upper-bound likelihood of ADs such as Hodgkin disease, non-Hodgkin lymphoma, and tuberculosis to be extraordinarily small, and computed a S1S pretest probability ≥ 99.95%. A diagnostic error rate ≤ 5 in 10,000 far exceeds the accuracy needed for clinical purposes, particularly considering that S1S rarely requires intervention, and that ADs will become apparent during S1S follow-up. The potential harm in delay of an AD is offset by the rarity of such an event compared to the frequency of S1S. York University staff abstracted this article at the request of the British National Health Service; observation over tissue confirmation was adopted as a guideline.

The cost of mediastinoscopy did not materially influence the cost/benefit analysis. The cost ineffectiveness reflects the extremely low probability of identifying an AD. Reich et al2estimated that if 33,000 persons with presumptive S1S underwent mediastinoscopy, 32,982 persons would be confirmed with S1S (or, rarely, a disorder not requiring intervention) and that, at most, 8 persons with tuberculosis, 9 persons with Hodgkin disease, and 1 patient with non-Hodgkin lymphoma would be identified. Transbronchial lung biopsy for S1S, in the same analysis, was less efficient than mediastinoscopy because of its lower sensitivity. To our knowledge, no exceptions have been reported in the 35 years since the dictum of Winterbauer et al3 that one could make a confident clinical diagnosis of SIS. The estimates of the incidence of ADs would have to err by a 1,000-fold order of magnitude to void these conclusions. Nullification of this recommendation on evidentiary grounds would require the demonstration that tissue verification in presumptive S1S identified a substantial number of ADs, and those persons identified with an AD earlier in their course were materially benefited. In this era of runaway health costs, we would like to suggest that skilled clinicians should first weigh the need for tissue confirmation in cases with high pretest probability of S1S.

The authors have no conflict of interest to disclose.

Dr. Silvestri has received grant support from Olympus in the past. Drs. Garwood, Judson, Hoda, Fraig, and Doelken have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Garwood, S, Judson, MA, Silvestri, G, et al (2007) Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis.Chest132,1298-1304. [PubMed] [CrossRef]
 
Reich, JM, Brouns, MC, O'Connor, EA, et al Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis.Chest1998;113,147-153. [PubMed]
 
Winterbauer, RH, Belic, N, Moores, KD Clinical interpretation of bilateral hilar adenopathy.Ann Intern Med1973;78,65-71. [PubMed]
 
To the Editor:

We appreciate Reich and colleagues’ interest in our article in CHEST (October 2007).1We were aware of their cited reference,2 and, in fact, it was a reference cited in our publication.1 However, we believe that the letter by Reich and coworkers addresses a different issue than the main topic of our manuscript. Our article dealt with the feasibility of diagnosing pulmonary sarcoidosis using the technique of endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA). We did not advocate attempting to make the diagnosis by EBUS-TBNA or any other technique in asymptomatic subjects with bilateral hilar adenopathy seen on a chest radiograph. In fact, as was clearly stated in our article, most of our patients (45 of 50 patients; 95%) were symptomatic. The remaining five patients presented with asymptomatic bilateral hilar adenopathy, but had a history of active malignancy, a positive purified protein derivative test result, or an acute pulmonary embolus that made the diagnosis problematic.

We agree with Winterbaurer et al3 and Reich and colleagues2 that patients with asymptomatic bilateral hilar adenopathy probably do not require a confirmatory biopsy in the appropriate clinical setting. However, given the advent of chest CT scanning that has allowed mediastinal lymphadenopathy to be more easily detected, the onset of AIDS, the use of tumor necrosis factor antagonists that might increase the risks of inappropriate treatment of tuberculosis or lymphoma, and the reductions in cost, morbidity, and mortality of TBNA/EBUS-TBNA compared to mediastinoscopy, we believe that this issue needs to be addressed again. However, this was not the focus of our article.

References
Garwood, S, Judson, MA, Silvestri, G, et al Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis.Chest2007;132,1298-1304. [PubMed] [CrossRef]
 
Reich, JM, Brouns, MC, O'Connor, EA, et al Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis.Chest1998;113,147-153. [PubMed]
 
Winterbauer, RH, Belic, N, Moores, KD Clinical interpretation of bilateral hilar adenopathy.Ann Intern Med1973;78,65-71. [PubMed]
 

Figures

Tables

References

Garwood, S, Judson, MA, Silvestri, G, et al (2007) Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis.Chest132,1298-1304. [PubMed] [CrossRef]
 
Reich, JM, Brouns, MC, O'Connor, EA, et al Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis.Chest1998;113,147-153. [PubMed]
 
Winterbauer, RH, Belic, N, Moores, KD Clinical interpretation of bilateral hilar adenopathy.Ann Intern Med1973;78,65-71. [PubMed]
 
Garwood, S, Judson, MA, Silvestri, G, et al Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis.Chest2007;132,1298-1304. [PubMed] [CrossRef]
 
Reich, JM, Brouns, MC, O'Connor, EA, et al Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis.Chest1998;113,147-153. [PubMed]
 
Winterbauer, RH, Belic, N, Moores, KD Clinical interpretation of bilateral hilar adenopathy.Ann Intern Med1973;78,65-71. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543