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Correspondence |

Endobronchial Ultrasonography-Guided Transbronchial Needle Aspiration in Patients With Suspected Sarcoidosis FREE TO VIEW

Jerome M. Reich, MD, FCCP
Author and Funding Information

From the Earl A. Chiles Research Institute.

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


Financial/nonfinancial disclosures:The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):235-236. doi:10.1378/chest.09-2098
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To the Editor:

Although the objective of the authors in a recent CHEST article (August 2009)1 was to ascertain which method most efficiently provided tissue confirmation of sarcoidosis in persons with bilateral hilar adenopathy, the investigation tacitly assumed its necessity, or at least its desirability. Following the seminal analysis of Winterbauer et al,2 we estimated a positive predictive value of ≥99.95% for a clinical-radiographic presentation of stage I sarcoidosis (S1S).3 A back-of-the-envelope computation shows this estimate to be conservative: assuming a sarcoidosis incidence of 3 × 10−5, half with S1S, and a combined 1.3-billion population of regions—Europe, United States, Canada, Japan, and the United Kingdom—likely to report its simulation by alternative diagnoses (ADs), the annual number of S1S cases in these regions would be 20,000, or 720,000 in the 36 years since publication of Winterbauer’s dictum. If five cases in 10,000 were due to an AD, there would have been an opportunity to report on 360; none has appeared. Thus, AD simulating S1S is, quite literally, unheard of. The (British) National Health Service adopted a clinical diagnosis guideline; the combined American Thoracic Society, European Respiratory Society, and World Association of Sarcoidosis and Other Granulomatous Disorders Statement on Sarcoidosis4 cites a clinical reliability of 98%. The section authors in current editions of standard references—Baum, Fishman, Fraser and Páre, Murray and Nadel—found a clinical diagnosis acceptable. Hillerdal et al5 found a clinical diagnosis of stage II sarcoidosis acceptable as well.

Tremblay et al1 reported that, following confirmatory CT scanning, the optimal outcome in persons undergoing conscious sedation, esophageal or endobronchial ultrasound-guided transbronchial lymph node biopsy, and endobronchial and transbronchial lung biopsy, in nearly half (with moderate bleeding in a small number), was achieved by endobronchial ultrasound-guided transbronchial lymph node biopsy, which produced tissue confirmation in 83%, 17% short of the positive predictive value of the plain radiograph. The validity of the 100% specificity is open to question. Specificity = true negative/(true negative + false positive). The investigators excluded true negatives on clinical grounds, and the design precluded false positives. The authors relied on a clinical assessment a minimum of 6 months after the procedures to assign a diagnosis of sarcoidosis as confirmed, excluded, or uncertain. None was judged to have an AD.

Justification of tissue confirmation of S1S requires (1) documentation of a reasonable percentage with AD and (2) evidence that earlier diagnosis of an AD confers substantial benefit. Absent this justification, Kassirer’s6 dictum applies a fortiori: “Absolute certainty in diagnosis is unattainable, no matter how much information we gather, how many observations we make, or how many tests we perform. Our task is not to attain certainty, but rather to reduce the level of diagnostic uncertainty enough to make optimal therapeutic decisions.” There is justifiable concern about health-care costs generated by unnecessary medical procedures and the potential harm of high-radiation-level imaging. Would it not be more judicious, cost-effective, and beneficial to adopt a policy of observation?

Tremblay A, Stather DR, MacEachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest. 2009;1362:340-346. [CrossRef] [PubMed]
 
Winterbauer RH, Belic N, Moores KD. Clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;781:65-71. [PubMed]
 
Reich JM, Brouns MC, O’Connor EA, Edwards MJ. Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis. Chest. 1998;1131:147-153. [CrossRef] [PubMed]
 
Hunninghake GW, Costabel U, Ando M, et al. Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med. 1999;1602:736-755. [PubMed]
 
Hillerdal G, Nöu E, Osterman K, Schmekel B. Sarcoidosis: epidemiology and prognosis. A 15-year European study. Am Rev Respir Dis. 1984;1301:29-32. [PubMed]
 
Kassirer JP. Our stubborn quest for diagnostic certainty. A cause of excessive testing [editorial]. N Engl J Med. 1989;32022:1489-1491. [CrossRef] [PubMed]
 

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References

Tremblay A, Stather DR, MacEachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest. 2009;1362:340-346. [CrossRef] [PubMed]
 
Winterbauer RH, Belic N, Moores KD. Clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;781:65-71. [PubMed]
 
Reich JM, Brouns MC, O’Connor EA, Edwards MJ. Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis. Chest. 1998;1131:147-153. [CrossRef] [PubMed]
 
Hunninghake GW, Costabel U, Ando M, et al. Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med. 1999;1602:736-755. [PubMed]
 
Hillerdal G, Nöu E, Osterman K, Schmekel B. Sarcoidosis: epidemiology and prognosis. A 15-year European study. Am Rev Respir Dis. 1984;1301:29-32. [PubMed]
 
Kassirer JP. Our stubborn quest for diagnostic certainty. A cause of excessive testing [editorial]. N Engl J Med. 1989;32022:1489-1491. [CrossRef] [PubMed]
 
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