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Choose WiselyEBUS-TBNA and cTBNA in Sarcoidosis: Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Sarcoidosis FREE TO VIEW

Atul C. Mehta, MBBS, FCCP; Francisco A. Almeida, MD, FCCP
Author and Funding Information

From the Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic.

CORRESPONDENCE TO: Atul C. Mehta, MBBS, FCCP, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, A-90, Cleveland, OH 44195; e-mail: mehtaa1@ccf.org


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. See online for more details.


Chest. 2014;146(3):530-532. doi:10.1378/chest.14-0374
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You must choose. But choose wisely.

Indiana Jones and the Last Crusade1

Confirming the diagnosis of sarcoidosis presents a plethora of options to the pulmonologist, ranging from a close follow-up to an open lung biopsy. Flexible bronchoscopy and conventional transbronchial needle aspiration (cTBNA) have empowered bronchoscopists in the confirmation of sarcoidosis since their introduction in the late 1960s and 1980s, respectively.2 The last decade has witnessed the addition of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound (EUS) to the bronchoscopist’s armamentarium for confirming sarcoidosis.3 In fact, some investigators now consider EBUS-TBNA and EUS-guided TBNA as the “only game in town” for the confirmation of sarcoidosis.3-5 We, however, believe that although EBUS-TBNA and EUS-guided TBNA have an undisputed role in staging non-small cell lung carcinoma, its usefulness as an exclusive test for sarcoidosis warrants careful consideration.

The elephant in the room is, “is it really essential to establish the diagnosis in all patients with suspected sarcoidosis?” In most cases, clinical presentation of stage I sarcoidosis is characteristic, and, hence, invasive diagnostic testing would be unnecessary. The astute remarks by Winterbauer and colleagues6 have withstood the test of time and are further corroborated by the statistical analysis of Reich and colleagues.6,7 Accordingly, one would have to perform > 10,000 invasive diagnostic procedures to identify no more than five alternative diagnoses in patients presenting with stage I sarcoidosis.7,8 Furthermore, close clinical follow-up in a majority of these patients can easily establish sarcoidosis without any intervention. Thus, the results of the endobronchial ultrasound (EBUS)- and EUS-related studies that have included stage I sarcoidosis should be interpreted with great caution.9

Additional parameters affecting the choice of a diagnostic procedure for confirming sarcoidosis include availability, affordability, accuracy, and safety in conjunction with the performer’s ability and competence.10 Currently, in developing countries, the availability and affordability of EBUS-TBNA remains questionable. In addition, training for EBUS-TBNA can be challenging and is complicated by lung ailments that mimic sarcoidosis, especially in developing countries.11 Moreover, incorporating EUS in the diagnostic algorithm further adds to competency problems all over the world.9

In this issue of CHEST (see page 547), Gupta and colleagues12 address the issue of accuracy and safety of EBUS-TBNA over cTBNA in patients suspected to have sarcoidosis, when performed in conjunction with conventional transbronchial and endobronchial biopsies. They make a convincing argument that even though individually EBUS-TBNA has the highest diagnostic yield in sarcoidosis, it should be combined with transbronchial lung biopsy for optimal results. Besides, the diagnostic yield of cTBNA plus endobronchial and transbronchial biopsies is similar to EBUS-TBNA plus the transbronchial lung biopsy. We applaud their efforts and agree with the conclusions. However, we would like to point out that > 50% of the patients in this study had pulmonary infiltrates, possibly explaining the lack of superiority of EBUS-TBNA compared with the transbronchial lung biopsy in detecting granulomas.13 Although this fact does not undermine the results, it reinforces the concept of “choosing wisely.”

A very small number of individuals in this study were treated for or diagnosed with sarcoidosis in the absence of a pathologic confirmation. Perhaps in these patients bronchoscopy may not be necessary.14 On the other hand, considering the prevalence of TB in the community, it is possible that the samples obtained made the latter diagnosis less likely.13 From a pure clinical perspective, diagnostic uncertainty must be considered before subjecting a patient to an invasive diagnostic procedure.12 Thus, if the finding of a “good granuloma” (nonnecrotizing granuloma) will not change the management, invasive tests are not necessary.5,6

Second, the operator must be familiar with the yield of the chosen procedure for the specific diagnosis under consideration. To that end, we believe that a nondiagnostic bronchoscopy can be more harmful than the fear of complications. Therefore, the bronchoscopist must be equipped with the minimal necessary tools and skills to avoid a nondiagnostic outcome.9 Although no major adverse events were observed in this study, transbronchial lung biopsy is commonly associated with more complications compared with other bronchoscopic techniques.15,16 If a rapid on-site cytologic evaluation is available, EBUS-TBNA can avoid additional sampling (endobronchial and transbronchial biopsies) and related complications, especially among patients without parenchymal infiltrates.17,18 On the other hand, in patients with predominant pulmonary infiltrates from presumed sarcoidosis, rapid on-site cytologic evaluation has no benefit either with EBUS or cTBNA.13,19 From a global perspective, the cost and the required skills associated with EBUS, EUS, and rapid on-site cytologic evaluation can interfere with the worldwide use of these technologies in the near future.19

Thus, although the present study suggests that cTBNA in combination with endobronchial and transbronchial lung biopsies, and perhaps the latter alone in patients with parenchymal infiltrates, is sufficient to establish the diagnosis of sarcoidosis, we believe that unavailability of EBUS should not hinder an experienced bronchoscopist. We, therefore, encourage standard bronchoscopy with conventional tools in the appropriate clinical setting and propose the notion of “choosing wisely,” wherein both pulmonologists and institutions select their techniques and investments based on their patient population and available skills.

Acknowledgments

Other contributions: We thank Nirupama Mulherkar, PhD, for writing assistance.

Indiana Jones and the Last Crusade. Dir: Steven Spielberg. Paramount Pictures, 1989. Film.
 
Wang KP, Fuenning C, Johns CJ, Terry PB. Flexible transbronchial needle aspiration for the diagnosis of sarcoidosis. Ann Otol Rhinol Laryngol. 1989;98(4 pt 1):298-300. [PubMed]
 
von Bartheld MB, Dekkers OM, Szlubowski A, et al. Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial. JAMA. 2013;309(23):2457-2464. [CrossRef] [PubMed]
 
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245-2252. [CrossRef] [PubMed]
 
Culver DA, Costabel U. EBUS-TBNA for the diagnosis of sarcoidosis: is it the only game in town? J Bronchology Interv Pulmonol. 2013;20(3):195-197. [CrossRef] [PubMed]
 
Winterbauer RH, Belic N, Moores KD. Clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;78(1):65-71. [CrossRef] [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;113(1):147-153. [CrossRef] [PubMed]
 
Reich JM. Tissue confirmation of presumptive stage I sarcoidosis. J Bronchology Interv Pulmonol. 2013;20(2):103-105. [CrossRef] [PubMed]
 
Narula T, Baughman RP, Mehta AC. “Sarcoidosis Americana-route Europa.” J Bronchology Interv Pulmonol. 2013;20(4):293-296. [CrossRef] [PubMed]
 
Mehta AC, Mazzone PJ. An attempt to reach the galaxy of the pulmonary nodules. Am J Respir Crit Care Med. 2013;188(3):264-265. [CrossRef] [PubMed]
 
Mehta AC, Wang KP. Teaching conventional transbronchial needle aspiration. A continuum. Ann Am Thorac Soc. 2013;10(6):685-689. [CrossRef] [PubMed]
 
Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146(3):547-556.
 
de Boer S, Milne DG, Zeng I, Wilsher ML. Does CT scanning predict the likelihood of a positive transbronchial biopsy in sarcoidosis? Thorax. 2009;64(5):436-439. [CrossRef] [PubMed]
 
Ribeiro Neto ML, Culver DA, Mehta AC. Sarcoidosis—no business of the bronchoscopist. J Thorac Cardiovasc Surg. 2012;144(5):1276-1277. [CrossRef] [PubMed]
 
Almeida FA, Casal RF, Jimenez CA, et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782. [CrossRef] [PubMed]
 
Hernández Blasco L, Sánchez Hernández IM, Villena Garrido V, de Miguel Poch E, Nuñez Delgado M, Alfaro Abreu J. Safety of the transbronchial biopsy in outpatients. Chest. 1991;99(3):562-565. [CrossRef] [PubMed]
 
Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest. 1995;107(2):430-432. [CrossRef] [PubMed]
 
Plit ML, Havryk AP, Hodgson A, et al. Rapid cytological analysis of endobronchial ultrasound-guided aspirates in sarcoidosis. Eur Respir J. 2013;42(5):1302-1308. [CrossRef] [PubMed]
 
Cicenia J, Almeida F, Machuzak M, et al. The utility of rapid on-site evaluation (ROSE) in the detection of granulomas in mediastinal lymph nodes. Chest. 2013;144(4_MeetingAbstracts):797A. [CrossRef]
 

Figures

Tables

References

Indiana Jones and the Last Crusade. Dir: Steven Spielberg. Paramount Pictures, 1989. Film.
 
Wang KP, Fuenning C, Johns CJ, Terry PB. Flexible transbronchial needle aspiration for the diagnosis of sarcoidosis. Ann Otol Rhinol Laryngol. 1989;98(4 pt 1):298-300. [PubMed]
 
von Bartheld MB, Dekkers OM, Szlubowski A, et al. Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial. JAMA. 2013;309(23):2457-2464. [CrossRef] [PubMed]
 
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245-2252. [CrossRef] [PubMed]
 
Culver DA, Costabel U. EBUS-TBNA for the diagnosis of sarcoidosis: is it the only game in town? J Bronchology Interv Pulmonol. 2013;20(3):195-197. [CrossRef] [PubMed]
 
Winterbauer RH, Belic N, Moores KD. Clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;78(1):65-71. [CrossRef] [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;113(1):147-153. [CrossRef] [PubMed]
 
Reich JM. Tissue confirmation of presumptive stage I sarcoidosis. J Bronchology Interv Pulmonol. 2013;20(2):103-105. [CrossRef] [PubMed]
 
Narula T, Baughman RP, Mehta AC. “Sarcoidosis Americana-route Europa.” J Bronchology Interv Pulmonol. 2013;20(4):293-296. [CrossRef] [PubMed]
 
Mehta AC, Mazzone PJ. An attempt to reach the galaxy of the pulmonary nodules. Am J Respir Crit Care Med. 2013;188(3):264-265. [CrossRef] [PubMed]
 
Mehta AC, Wang KP. Teaching conventional transbronchial needle aspiration. A continuum. Ann Am Thorac Soc. 2013;10(6):685-689. [CrossRef] [PubMed]
 
Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146(3):547-556.
 
de Boer S, Milne DG, Zeng I, Wilsher ML. Does CT scanning predict the likelihood of a positive transbronchial biopsy in sarcoidosis? Thorax. 2009;64(5):436-439. [CrossRef] [PubMed]
 
Ribeiro Neto ML, Culver DA, Mehta AC. Sarcoidosis—no business of the bronchoscopist. J Thorac Cardiovasc Surg. 2012;144(5):1276-1277. [CrossRef] [PubMed]
 
Almeida FA, Casal RF, Jimenez CA, et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782. [CrossRef] [PubMed]
 
Hernández Blasco L, Sánchez Hernández IM, Villena Garrido V, de Miguel Poch E, Nuñez Delgado M, Alfaro Abreu J. Safety of the transbronchial biopsy in outpatients. Chest. 1991;99(3):562-565. [CrossRef] [PubMed]
 
Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest. 1995;107(2):430-432. [CrossRef] [PubMed]
 
Plit ML, Havryk AP, Hodgson A, et al. Rapid cytological analysis of endobronchial ultrasound-guided aspirates in sarcoidosis. Eur Respir J. 2013;42(5):1302-1308. [CrossRef] [PubMed]
 
Cicenia J, Almeida F, Machuzak M, et al. The utility of rapid on-site evaluation (ROSE) in the detection of granulomas in mediastinal lymph nodes. Chest. 2013;144(4_MeetingAbstracts):797A. [CrossRef]
 
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