Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration vs Conventional Transbronchial Needle Aspiration in the Diagnosis of Sarcoidosis

doi:10.1378/chest.13-2339

Chest

Volume 146, Issue 3, September 2014, Pages 547-556

https://doi.org/10.1378/chest.13-2339 Get rights and content

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is superior to conventional transbronchial needle aspiration (cTBNA) in the staging of lung cancer. However, its efficiency in diagnosis of sarcoidosis when combined with endobronchial biopsy (EBB) and transbronchial lung biopsy (TBLB) has not been studied. This randomized controlled trial compares diagnostic yield of EBUS-TBNA vs cTBNA in combination with EBB and TBLB.

METHODS

Patients with clinical diagnosis of sarcoidosis were randomized 1:1 to EBUS-TBNA or cTBNA. All patients underwent TBLB and EBB. The primary outcome was detection of granulomas. The secondary end points were the individual and cumulative yields of various procedures, serious adverse events, and procedure time.

RESULTS

Of the 130 patients, sarcoidosis was diagnosed in 117 (62 cTBNA, 55 EBUS-TBNA). The two groups were similar at baseline. Granulomas were demonstrated in 104 (53 cTBNA, 51 EBUS-TBNA) patients and were similar in two groups (85.5% vs 92.7%,P= .34). Individually, EBUS-TBNA had the highest yield (41 of 55, 74.5%), which was better than cTBNA (30 of 62, 48.4%,P= .004) or EBB (40 of 111, 36.3%,P< .0001) but not TBLB (78 of 112, 69.6%,P= .54). Adding EBB/TBLB to cTBNA led to an increase in granuloma detection, whereas the addition of TBLB (but not EBB) significantly enhanced the yield of EBUS-TBNA. The procedure time was significantly longer with EBUS-TBNA. No major adverse events occurred.

CONCLUSIONS

Individually, EBUS-TBNA has the highest diagnostic yield in sarcoidosis, but it should be combined with TBLB for the optimal yield. The diagnostic yield of cTBNA (plus EBB and TBLB) is similar to EBUS-TBNA plus TBLB.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01908868; URL: www.clinicaltrials.gov

Section snippets

Materials and Methods

This was a prospective, open-label, investigator-initiated, RCT conducted between November 2011 and December 2012 at a tertiary care research institute in India. The study protocol was approved by the Ethics Review Committee (1Trg/PG-2012/12563-601), and written informed consent was obtained from all subjects.

Results

Of the 168 consecutive patients with clinico-radiologic suspicion of sarcoidosis, 38 were excluded before randomization (16 refused consent, four had contraindications for the study procedure, four already had diagnosis from extrathoracic sites, 10 had received steroids for > 2 weeks in the preceding 3 months, and four had lymph node size < 10 mm on CT scan of the chest). Finally, 130 patients were randomized to either the cTBNA (68 patients) or the EBUS-TBNA group (62 patients). A final

Discussion

This study found that EBUS-TBNA had the highest diagnostic yield compared with conventional bronchoscopic procedures like cTBNA or EBB but not TBLB. The yield of EBUS-TBNA was significantly enhanced with the addition of TBLB (but not EBB). In fact, when EBB and TBLB were combined with either EBUS-TBNA or cTBNA, the achieved diagnostic yield was similar.

In our study, 77% of the study subjects were classified as stage I on chest radiograph, whereas the prevalence of stage I was 44% if CT scan of

Acknowledgments

Author contributions: D. G. is guarantor of the paper, taking responsibility for the integrity of the work as a whole, from inception to published article. D. G. contributed to conceiving the idea, patient management, and drafting and revising the manuscript for intellectual content; D. S. D. contributed to patient management, data collection, and drafting the manuscript; R. A. contributed to patient management and drafting and revising the manuscript; N. G. and A. B. contributed to patient

References (37)

JA Huang et al.
Counterpoint: should endobronchial ultrasound guide every transbronchial needle aspiration of lymph nodes? No
Chest
(2013)
MM Wahidi et al.
Point: should endobronchial ultrasound guide every transbronchial needle aspiration of lymph nodes? Yes
Chest
(2013)
S Garwood et al.
Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis
Chest
(2007)
R Agarwal et al.
Efficacy and safety of convex probe EBUS-TBNA in sarcoidosis: a systematic review and meta-analysis
Respir Med
(2012)
JM Reich et al.
Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis
Chest
(1998)
ML Ribeiro Neto et al.
Sarcoidosis—no business of the bronchoscopist
J Thorac Cardiovasc Surg
(2012)
A Gupta et al.
Ocular signs predictive of tubercular uveitis
Am J Ophthalmol
(2010)
A Tremblay et al.
A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis
Chest
(2009)
M Oki et al.
Prospective study of endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes versus transbronchial lung biopsy of lung tissue for diagnosis of sarcoidosis
J Thorac Cardiovasc Surg
(2012)
MJ Gilman
Transbronchial biopsy in sarcoidosis
Chest
(1983)

A Dasgupta et al.

Transbronchial needle aspiration. An underused diagnostic technique

Clin Chest Med

(1999)

KP Wang et al.

Transbronchial needle aspiration of a mediastinal mass: therapeutic implications

Thorax

(1983)

KP Wang et al.

Bronchoscopic needle aspiration biopsy of paratracheal tumors

Am Rev Respir Dis

(1978)

T Hürter et al.

Endobronchial sonography: feasibility and preliminary results

Thorax

(1992)

K Yasufuku et al.

Endobronchial ultrasound using a new convex probe: a preliminary study on surgically resected specimens

Oncol Rep

(2004)

K Adams et al.

Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis

Thorax

(2009)

JE Holty et al.

Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis

Thorax

(2005)

M Wong et al.

Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis

Eur Respir J

(2007)

Cited by (163)

Diagnosis of Pulmonary Sarcoidosis
2024, Clinics in Chest Medicine
High-Definition Videobronchoscopy for the Diagnosis of Airway Involvement in Sarcoidosis: The Enhance Sarcoidosis Multicenter Study
2023, Chest
The ability of high-definition (HD) videobronchoscopy to detect airway involvement in sarcoidosis has not been evaluated previously.
What is the role of HD videobronchoscopy in the identification of sarcoidosis-associated airway abnormalities (AAs)? What are the patterns of AAs more commonly observed and more frequently associated with the detection of granulomas in endobronchial biopsy (EBB)?
In this prospective international multicenter cohort study, consecutive patients with suspected sarcoidosis underwent airway inspection with an HD videobronchoscope and EBB using a standardized workflow. AAs were classified according to six patterns defined a priori: nodularity, cobblestoning, thickening, plaque, increased vascularity, and miscellaneous. We assessed diagnostic yield of EBB, prevalence of AAs, and interobserver agreement for different patterns of AAs.
AAs were identified in 64 of 134 patients with sarcoidosis (47.8%), with nodularity (n = 23 [17.2%]), plaque (n = 19 [14.2%]), and increased vascularity (n = 19 [14.2%]) being the most prevalent. The diagnostic yield of EBB was 36.6%. AAs were significantly more prevalent in patients with than in those without nonnecrotizing granulomas on EBB (67.4% vs 36.5%; P = .001). Likewise, parenchymal disease on CT scan imaging was significantly more common in patients with than in those without nonnecrotizing granulomas on EBB (79.6% vs 54.1%; P = .003). On a per-lesion analysis, nonnecrotizing granulomas were seen especially in EBB samples obtained from areas of cobblestoning (9/10 [90%]) and nodularity (17/29 [58.6%]). The overall diagnostic yield of random EBB was low (31/134 [23.1%]). The interobserver agreement for the different patterns of AA was fair (Fleiss κ = 0.34).
In a population with a large prevalence of White Europeans, HD videobronchoscopy detected AAs in approximately one-half of patients with sarcoidosis. The diagnostic yield of EBB was higher in patients with parenchymal involvement on CT scan imaging and in those with AAs, especially if manifesting as cobblestoning and nodularity.
ClinicalTrials.gov; No.: NCT4743596; URL: www.clinicaltrials.gov
Editorial commentary: Cardiac sarcoidosis in contemporary practice: Forward progress, but clinical quandaries persist
2023, Trends in Cardiovascular Medicine
Clinical diagnostic value of serum soluble IL-2 receptor for stage I sarcoidosis in benign isolated mediastinal and hilar lymphadenopathy
2023, Clinica Chimica Acta
Serum soluble interleukin-2 receptor (sIL-2R) is recognized as a marker of T-cell activation and is abnormally elevated in sarcoidosis. However, its value for stage I sarcoidosis in benign granulomatous diseases is unclear.
We enrolled 33 stage I sarcoidosis patients, 17 lymph node tuberculosis patients, 15 reactive lymphadenopathy patients, and 11 healthy controls. Serum biomarkers concentrations were collected and collated.
Serum sIL-2R concentrations were the highest in stage I sarcoidosis. The AUC of serum sIL-2R for stage I sarcoidosis was 0.7452 in all subjects and 0.6861 in granulomatous diseases. The AUCs of two combined diagnostic forms, sIL-2R with angiotensin-converting enzyme (ACE) and sIL-2R with ACE, erythrocyte sedimentation rate (ESR), and lactate dehydrogenase (LDH) were 0.7994 and 0.891 in all subjects, respectively. In granulomatous disease groups for ROC analysis, the best cut-off value of sIL-2R was 745.00 U/ml with 48.50% sensitivity and 84.40% specificity. The combination of four parameters increased the diagnostic accuracy for stage I sarcoidosis in granulomatous diseases (74.10% sensitivity and 100% specificity). Serum sIL-2R concentrations were positively correlated with serum ACE (r = 0.4652, P = 0.0126).
Serum sIL-2R appeared to be valuable in identifying stage I sarcoidosis in a group of benign granulomatous disorders.
Endobronchial ultrasound bronchoscopy Franseen fine needle biopsy tool versus standard fine needle aspiration needle: Impact on diagnosis and tissue adequacy
2023, Respiratory Medicine
The Franseen fine needle biopsy tool (Acquire®, Boston Scientific, Boston, MA) may provide better quality specimens than current endobronchial ultrasound-transbronchial needle aspiration (EBUS-TNBA) needles. We performed a comparative retrospective study evaluating the diagnostic yield of the Franseen fine needle biopsy (FNB) versus standard fine needle aspiration (FNA) for benign lymphadenopathy and tissue acquisition for next generation sequencing (NGS) in non-small cell carcinoma (NSCLC).
All EBUS-TBNA procedures performed between January 1st, 2019 to January 1st^, 2020 where both the FNB needle and the FNA needle were used were analyzed. All demographic, procedural, and diagnostic data were recorded. The median tumor surface area, tumor cellularity and adequacy for NGS was evaluated for NSCLC specimens.
A total of 69 target lesions in 66 patients were biopsied with both the FNB and FNA needles. The mean (SD) size of target biopsied was 1.8 cm (0.8); The most common stations were 7 (54%) and 4R (26%). The mean (SD) needle passes were 6 (2.2) and 4 (1.8) with FNA and FNB needles, respectively (p < 0.0001). Benign lymphadenopathy was diagnosed with FNA needle in 46% and in 82% with FNB (p < 0.0001). NGS tissue adequacy was 47% with FNA needle versus 76% with FNB (p = 0.02). Median tumor surface area and tumor cellularity were greater with FNB needle than FNA needle (80 mm² versus 9 mm², p = 0.002, and 81% versus 45%, p = 0.0004).
The FNB needle demonstrated higher diagnostic yield in benign lymphadenopathy and higher quality for NGS than standard FNA needle.
The role of endoscopy in exploration of the mediastinum, indications and results
2023, Revue des Maladies Respiratoires
Depuis les premières publications en 2005 concernant la réalisation de ponctions transbronchiques médiastinales à l’aiguille échoguidées par échoendoscope linéaire (EBUS-PTBA), cette technique s’est largement démocratisée en pneumologie. Cet examen reste très bien toléré, avec une morbidité faible et une mortalité quasi nulle. Une revue générale de cette technique a déjà fait le tour de la question en 2012. Cependant, de nombreuses études ont été réalisées depuis, autant dans les pathologies bénignes (sarcoidose, tuberculose, etc.) que malignes (cancer pulmonaires, métastases de cancers extrathoraciques, recherche de mutations et marqueurs spécifiques, etc.). Ceci a contribué à l’élargissement des indications d’EBUS-PTBA qu’il est indispensable de connaître, à la fois en diagnostic, mais aussi en termes de « staging ». Enfin, certaines publications reviennent sur les techniques d’utilisation de l’EBUS, sur des nouveaux outils disponibles (pince à biopsies, aiguilles plus grosses, etc.), et sur l’interprétation des images visualisées, en général dans le but d’optimiser la qualité des prélèvements ganglionnaires. Ces nouvelles données s’ajoutant aux anciennes, il semblait donc indispensable qu’une mise à jour soit réalisée sur ce merveilleux outil qu’est l’EBUS linéaire. Cette revue ne se veut pas exhaustive, mais essaye de résumer les nouveautés les plus importantes à connaître.
Since 2005, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a standard pulmonological tool. The procedure is safe and well tolerated by patients, with minimal morbidity and almost no mortality. A previous review on the technique was published in 2012. However, over the last ten years, a number of new studies have been published on “benign” (sarcoidosis, tuberculosis…) as well as “malignant” diseases (lung cancer, metastases of extra-thoracic cancers, search for mutations and specific oncogenic markers…). These developments have led to expanded indications for EBUS-TBNA, with which it is indispensable to be familiar, in terms of “staging” as well as “diagnosis”. In view of optimizing lymph node sampling, several publications have described and discussed EBUS exploration by means of newly available tools (biopsy forceps, larger needles…), and proposed interpretation of the images thereby produced. Given the ongoing evolution of linear EBUS, it seemed indispensable that information on this marvelous tool be updated. This review is aimed at summarizing the novel elements we have found the most important.

View all citing articles on Scopus

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

View full text

Chest

Original Research: Pulmonary ProceduresEndobronchial Ultrasound-Guided Transbronchial Needle Aspiration vs Conventional Transbronchial Needle Aspiration in the Diagnosis of Sarcoidosis

BACKGROUND

METHODS

RESULTS

CONCLUSIONS

TRIAL REGISTRY

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Chest

Chest

Chest

Respir Med

Chest

J Thorac Cardiovasc Surg

Am J Ophthalmol

Chest

J Thorac Cardiovasc Surg

Chest

Clin Chest Med

Transbronchial needle aspiration of a mediastinal mass: therapeutic implications

Thorax

Bronchoscopic needle aspiration biopsy of paratracheal tumors

Am Rev Respir Dis

Endobronchial sonography: feasibility and preliminary results

Thorax

Endobronchial ultrasound using a new convex probe: a preliminary study on surgically resected specimens

Oncol Rep

Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis

Thorax

Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis

Thorax

Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis

Eur Respir J

Original Research: Pulmonary Procedures
Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration vs Conventional Transbronchial Needle Aspiration in the Diagnosis of Sarcoidosis