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Correspondence |

A “ROSE” in Every “EBUS” Keeps Transbronchial Lung Biopsy AwayRapid On-site Evaluation FREE TO VIEW

Sachin Kumar, MD, DM, FCCP; Sandipan Chandra, MD(Physician)
Author and Funding Information

From the Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences.

CORRESPONDENCE TO: Sachin Kumar, MD, DM, FCCP, Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, C-15, Delhi Government Residential complex, D-2 pocket, Vasant Kunj, New Delhi, PIN: 110070, New Delhi, India; e-mail: sachin.drk@gmail.com


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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.

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Chest. 2014;146(3):e97. doi:10.1378/chest.14-0341
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To the Editor:

We read with great interest the article by Gupta et al1 in this issue of CHEST (see page 547) on endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). We agree with the authors that, individually, EBUS-TBNA has the highest diagnostic yield in sarcoidosis. However, we are concerned about the conclusion of combining EBUS-TBNA with transbronchial lung biopsy (TBLB) for the optimal yield.

Interestingly, rapid on-site evaluation (ROSE) was not used in either arm in the study. According to our research, studies that have not used ROSE have reported a diagnostic yield of EBUS-TBNA of 83% to 85%, against 87% to 92% with ROSE, in the diagnosis of sarcoidosis.2,3 EBUS-TBNA with ROSE, thus, has a higher diagnostic yield compared with standard cytologic processing. Additionally, it provides a sufficiently robust diagnostic yield to inform the bronchoscopist as to whether additional lymph node passes or TBLB are needed prior to the patient leaving the theater.

In a study by Plit et al,3 granulomas were seen on ROSE in 46 patients, out of which 43 were sarcoidosis (hence, these 43 were subjected to unnecessary TBLB). In the remaining three cases, two were diagnosed to be anthracosis on ROSE and one as cancer. Hence, 46 patients in total underwent unnecessary TBLB when diagnosis was already made on ROSE. In contrast, only four patients (8%) with nondiagnostic ROSE had sarcoidosis confirmed on TBLB or endobronchial biopsy, thus, justifying the undertaking of additional procedures in this subgroup of patients. EBUS-TBNA with ROSE not only prevented the need to undertake unnecessary TBLB, but informed the bronchoscopist at the same session as to when additional passes and procedures were likely to benefit the patient.3 EBUS-TBNA with ROSE followed by TBLB in a few cases, rather than EBUS-TBNA with TBLB in all cases, would, therefore, provide sufficiently robust diagnostic information with a safety profile that would consolidate its role as the first-line investigation in patients with suspected sarcoidosis. More importantly, it might obviate the need for subjecting patients to unwarranted TBLB and its attendant risks.

References

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.
 
Navani N, Booth HL, Kocjan G, et al. Combination of endobronchial ultrasound-guided transbronchial needle aspiration with standard bronchoscopic techniques for the diagnosis of stage I and stage II pulmonary sarcoidosis. Respirology. 2011;16(3):467-472. [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]
 

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References

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.
 
Navani N, Booth HL, Kocjan G, et al. Combination of endobronchial ultrasound-guided transbronchial needle aspiration with standard bronchoscopic techniques for the diagnosis of stage I and stage II pulmonary sarcoidosis. Respirology. 2011;16(3):467-472. [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]
 
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