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Alain Tremblay, MDCM, FCCP; David R. Stather, MD; Paul MacEachern, MD; Moosa Khalil, MBBCh; Stephen K. Field, MDCM
Author and Funding Information

From the Division of Respiratory Medicine (Drs Tremblay, Stather, MacEachern, and Field) and the Department of Pathology and Laboratory Medicine (Dr Khalil), University of Calgary.

Correspondence to: Alain Tremblay, MDCM, FCCP, 3330 Hospital Drive NW, Calgary, AB, Canada T2N 4N1; e-mail: alain.tremblay@ucalgary.ca


Financial/nonfinancial disclosures: The authors have 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):236-237. doi:10.1378/chest.09-2641
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To the Editor:

We sincerely thank Drs Ferrer and Khosla and Dr Reich for their comments and interest in our recent article in CHEST (August 2009).1 Drs Ferrer and Khosla inquired about our technique for both standard transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guided (EBUS)-TBNA and criticized the study design, which left decisions regarding the site and numbers of samples to the discretion of the bronchoscopist. The fact that the number of nodes sampled was higher in the EBUS group is not surprising. This is a different technique from standard TBNA, and access to multiple nodal stations is a true advantage of the technique, not a bias in study design. Although we agree that stations 4R and 7 are the easiest stations to sample with standard TBNA, we disagree that these are more easily accessible with standard vs EBUS-TBNA, and we have not encountered any expert opinion to support this claim. In our opinion, all nodal stations are more easily sampled with EBUS guidance. In order to assess the adequacy of our standard TBNA procedures, it would be best to compare the number of stations and passes performed and results with published studies on this technique in sarcoidosis. As described in our discussion, we were at least as aggressive in sampling as many nodes and performing as many passes as were performed in all prior studies where this was reported.2-5 Moreover, our results were well within the range of the published diagnostic yield with this technique. As stated in our discussion, we disagree with the claim that the diagnostic yield of standard TBNA in sarcoidosis ranges from 72% to 90%, as the pooled results of all relevant studies is 66%,1 in keeping with our results of 53%, increasing to 73% following review by a cytopathologist with expertise in this condition. In addition, although a sensitivity for sarcoidosis of 90% was suggested in one trial, the diagnostic yield as defined in our study was only 60%.5 We agree with the importance of experienced pathologists, in particular those with expertise in cytology, in the interpretation of these samples. Nevertheless, significant improvements in diagnostic yields were noted after expert review in both groups, suggesting that both 19-gauge and 22-gauge sampling yields benefited from this expertise. In addition, we disagree that in comparison with cytology “the histological analysis is well standardized and easier to make,” given that the percentages of both adequate and diagnostic cytologic TBNA samples exceeded the percentages of histologic ones (87.5% and 70%, respectively, vs 36% and 22.5%, respectively) in a recent study of sarcoidosis.2

We should also clarify that we would still strongly encourage bronchoscopists to perform standard TBNA in patients with suspected sarcoidosis and enlarged lymph nodes when EBUS is not available. If EBUS is available, our study confirms the findings of previous case series and the superior diagnostic yield obtained with this technique over standard TBNA.

The issue raised by Dr Reich regards the rationale for performing an additional invasive test in a patient population wherein the pretest probability of the disease being present is already very high. Of course, our study did not specifically address this issue, and in the majority of cases enrolled, the clinical decision to proceed to bronchoscopy was not made by the investigators. It should be pointed out that much of the literature cited on this issue regards the clinical presentation of asymptomatic and symmetric bilateral hilar adenopathy in patients with a normal physical examination.6,7 We agree that in many such cases, a need for pathologic sampling is not required for clinical management and decision making. Nevertheless, the American Thoracic Society-European Respiratory Society-World Association of Sarcoidosis and Other Granulomatous Disorders statement on sarcoidosis does suggest that the provision of histologic confirmation of disease is one of the main goals in the initial evaluation of these patients,8 and we do believe that it remains reasonable to perform biopsy in patients with suspected sarcoidosis in several situations. These include the presence of significant B-type symptoms, risk factors for alternative diseases (eg, tuberculosis exposure, previous malignancy, older age, and significant smoking history), atypical radiographic presentations, significant extrathoracic disease (such as suspected neurosarcoidosis), and even in some cases to calm fear and anxiety relating to alternative diagnoses in certain patients. We also favor obtaining tissue confirmation of disease prior to embarking on systemic treatment given the multiple side effects associated with the treatment of this condition.

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]
 
Trisolini R, Tinelli C, Cancellieri A, et al. Transbronchial needle aspiration in sarcoidosis: yield and predictors of a positive aspirate. J Thorac Cardiovasc Surg. 2008;1354:837-842. [CrossRef] [PubMed]
 
Trisolini R, Agli LL, Cancellieri A, et al. The value of flexible transbronchial needle aspiration in the diagnosis of stage I sarcoidosis. Chest. 2003;1246:2126-2130. [CrossRef] [PubMed]
 
Morales CF, Patefield AJ, Strollo PJ Jr, Schenk DA. Flexible transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 1994;1063:709-711. [CrossRef] [PubMed]
 
Wang KP, Fuenning C, Johns CJ, Terry PB. Flexible transbronchial needle aspiration for the diagnosis of sarcoidosis. Ann Otol Rhinol Laryngol. 1989;984 Pt 1:298-300. [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]
 
Winterbauer RH, Belic N, Moores KD. Clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;781:65-71. [PubMed]
 
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]
 

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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]
 
Trisolini R, Tinelli C, Cancellieri A, et al. Transbronchial needle aspiration in sarcoidosis: yield and predictors of a positive aspirate. J Thorac Cardiovasc Surg. 2008;1354:837-842. [CrossRef] [PubMed]
 
Trisolini R, Agli LL, Cancellieri A, et al. The value of flexible transbronchial needle aspiration in the diagnosis of stage I sarcoidosis. Chest. 2003;1246:2126-2130. [CrossRef] [PubMed]
 
Morales CF, Patefield AJ, Strollo PJ Jr, Schenk DA. Flexible transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 1994;1063:709-711. [CrossRef] [PubMed]
 
Wang KP, Fuenning C, Johns CJ, Terry PB. Flexible transbronchial needle aspiration for the diagnosis of sarcoidosis. Ann Otol Rhinol Laryngol. 1989;984 Pt 1:298-300. [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]
 
Winterbauer RH, Belic N, Moores KD. Clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;781:65-71. [PubMed]
 
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]
 
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