Yonsei Med J.  2013 Nov;54(6):1416-1421. 10.3349/ymj.2013.54.6.1416.

Usefulness of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Diagnosis of Sarcoidosis

• Hong G
• Lee KJ
• Jeon K
• Koh WJ
• Suh GY
• Chung MP
• Kim H
• Kwon OJ
• Han J
• Um SW

• KMID: 1798138
• DOI: http://doi.org/10.3349/ymj.2013.54.6.1416

Abstract

PURPOSE
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an accurate and minimally invasive technique used routinely for investigation of mediastinal and hilar lymphadenopathy. However, few studies have addressed its role in comparison to the traditional diagnostic approaches of transbronchial lung biopsy (TBLB), endobronchial biopsy (EBB), and bronchoalveolar lavage (BAL) in the diagnosis of sarcoidosis. We evaluated the usefulness of EBUS-TBNA in the diagnosis of sarcoidosis compared to TBLB, EBB, and BAL.
MATERIALS AND METHODS
Consecutive patients with suspected sarcoidosis (stage I and II) on chest radiography and chest computed tomography were included. All 33 patients underwent EBUS-TBNA, TBLB, EBB, and BAL during the same session between July 2009 and June 2011. EBUS-TBNA was performed at 71 lymph node stations.
RESULTS
Twenty-nine of 33 patients, were diagnosed with histologically proven sarcoidosis; two patients were compatible with a clinical diagnosis of sarcoidosis during follow-up; and two patients were diagnosed with metastatic carcinoma and reactive lymphadenopathy, respectively. Among 29 patients with histologically proven sarcoidosis in combination with EBUS-TBNA, TBLB, and EBB, only EBUS-TBNA and TBLB revealed noncaseating granuloma in 18 patients and one patient, respectively. The overall diagnostic sensitivities of EBUS-TBNA, TBLB, EBB, and BAL (CD4/CD8 > or =3.5) were 90%, 35%, 6%, and 71%, respectively (p<0.001). The combined diagnostic sensitivity of EBUS-TBNA, TBLB, and EBB was 94%.
CONCLUSION
EBUS-TBNA was the most sensitive method for diagnosing stage I and II sarcoidosis compared with conventional bronchoscopic procedures. EBUS-TBNA should be considered first for the histopathologic diagnosis of stage I and II sarcoidosis.

Keyword

Endobronchial ultrasound; transbronchial needle aspiration; sarcoidosis; mediastinal lymphadenopathy

MeSH Terms

Adult
Aged
Biopsy, Fine-Needle/*methods
Bronchoscopy
Female
Humans
Lymph Nodes/pathology
Male
Middle Aged
Sarcoidosis/*diagnosis/*ultrasonography
Young Adult

Figure

• 

  Fig. 1 Diagnostic flowchart for 33 patients with suspected stage I and stage II sarcoidosis. EBUS-TBNA, endobronchial ultrasound-guided transbronchial needle aspiration; TBLB, transbronchial lung biopsy; EBB, endobronchial biopsy.

Reference

1. Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med. 2007; 357:2153–2165.

2. Lynch JP 3rd, Kazerooni EA, Gay SE. Pulmonary sarcoidosis. Clin Chest Med. 1997; 18:755–785.

3. Shorr AF, Torrington KG, Hnatiuk OW. Endobronchial involvement and airway hyperreactivity in patients with sarcoidosis. Chest. 2001; 120:881–886.

4. Winterbauer RH, Lammert J, Selland M, Wu R, Corley D, Springmeyer SC. Bronchoalveolar lavage cell populations in the diagnosis of sarcoidosis. Chest. 1993; 104:352–361.

5. Yasufuku K, Chiyo M, Sekine Y, Chhajed PN, Shibuya K, Iizasa T, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest. 2004; 126:122–128.

6. Herth FJ, Eberhardt R, Vilmann P, Krasnik M, Ernst A. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax. 2006; 61:795–798.

7. Wong M, Yasufuku K, Nakajima T, Herth FJ, Sekine Y, Shibuya K, et al. Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis. Eur Respir J. 2007; 29:1182–1186.

8. Garwood S, Judson MA, Silvestri G, Hoda R, Fraig M, Doelken P. Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis. Chest. 2007; 132:1298–1304.

9. Oki M, Saka H, Kitagawa C, Tanaka S, Shimokata T, Kawata Y, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration is useful for diagnosing sarcoidosis. Respirology. 2007; 12:863–868.

10. Navani N, Booth HL, Kocjan G, Falzon M, Capitanio A, Brown JM, 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; 16:467–472.

11. Rusch VW, Asamura H, Watanabe H, Giroux DJ, Rami-Porta R, Goldstraw P, et al. The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol. 2009; 4:568–577.

12. 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; 160:736–755.

13. Thomas KW, Hunninghake GW. Sarcoidosis. JAMA. 2003; 289:3300–3303.

14. Costabel U. CD4/CD8 ratios in bronchoalveolar lavage fluid: of value for diagnosing sarcoidosis? Eur Respir J. 1997; 10:2699–2700.

15. Gilman MJ, Wang KP. Transbronchial lung biopsy in sarcoidosis. An approach to determine the optimal number of biopsies. Am Rev Respir Dis. 1980; 122:721–724.

16. Koonitz CH, Joyner LR, Nelson RA. Transbronchial lung biopsy via the fiberoptic bronchoscope in sarcoidosis. Ann Intern Med. 1976; 85:64–66.

17. de Boer S, Milne DG, Zeng I, Wilsher ML. Does CT scanning predict the likelihood of a positive transbronchial biopsy in sarcoidosis? Thorax. 2009; 64:436–439.

18. Roethe RA, Fuller PB, Byrd RB, Hafermann DR. Transbronchoscopic lung biopsy in sarcoidosis. Optimal number and sites for diagnosis. Chest. 1980; 77:400–402.

19. Bilaçeroğlu S, Perim K, Günel O, Cağirici U, Büyükşirin M. Combining transbronchial aspiration with endobronchial and transbronchial biopsy in sarcoidosis. Monaldi Arch Chest Dis. 1999; 54:217–223.

20. Shorr AF, Torrington KG, Hnatiuk OW. Endobronchial biopsy for sarcoidosis: a prospective study. Chest. 2001; 120:109–114.

21. Kantrow SP, Meyer KC, Kidd P, Raghu G. The CD4/CD8 ratio in BAL fluid is highly variable in sarcoidosis. Eur Respir J. 1997; 10:2716–2721.

22. Newman LS, Rose CS, Maier LA. Sarcoidosis. N Engl J Med. 1997; 336:1224–1234.

23. Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial. Chest. 2004; 125:322–325.

24. Nakajima T, Yasufuku K, Kurosu K, Takiguchi Y, Fujiwara T, Chiyo M, et al. The role of EBUS-TBNA for the diagnosis of sarcoidosis--comparisons with other bronchoscopic diagnostic modalities. Respir Med. 2009; 103:1796–1800.