Granulomatous mediastinal adenopathy: can endoscopic ultrasound-guided fine-needle aspiration differentiate between tuberculosis and sarcoidosis?

Fritscher-Ravens, Annette; Ghanbari, Atefeh; Topalidis, Theodoros; Pelling, Marc; Kon, Onn Min; Patel, Kirti; Arlt, Alexander; Bhowmik, Angshu

doi:10.1055/s-0031-1271110

Cited by 50 publications

(41 citation statements)

References 23 publications

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“…Their background is usually clean, with only a minority of cases showing a hemorrhagic background. A necrotic, ‘dirty' background was the only morphologic finding which proved specific enough to suggest a tubercular etiology of the granulomatous inflammation over a sarcoidal one in the present series, as already observed by Fritscher-Ravens et al [14,25] in two studies aimed at assessing the role of EUS-NA in sarcoidosis and tuberculosis. It should be kept in mind, however, that the presence of a necrotic background is useful only when present, as the cytologic findings from tubercular lymphadenopathy may also include nonnecrotizing granulomas as well as necrotic, caseous material without granulomas [21,22].…”

Section: Discussionsupporting

confidence: 85%

Sarcoidal Granulomas in Cytological Specimens from Intrathoracic Adenopathy: Morphologic Characteristics and Radiographic Correlations

Cancellieri¹,

Leslie

Tinelli

et al. 2012

Respiration

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Background: Clinical experience and literature data suggest that the ability of pathologists to identify granulomas in cytological specimens from intrathoracic lymphadenopathy varies considerably and may negatively influence the yield of transbronchial needle aspiration (TBNA), both conventional and ultrasound-guided (EBUS-TBNA). Objectives: To describe the cytomorphology of sarcoidal granulomas on TBNA cytology specimens and to analyze the presence of associations between the cytological characteristics of granulomas and the radiographic stage of sarcoidosis. Methods: TBNA cytological specimens from 123 sarcoidosis patients and 14 tuberculosis patients (control population) were reviewed independently by two pathologists blinded to the clinical-radiological details. Results: Sarcoidal granulomas were small [median (IQR) largest diameter: 0.478 (0.318-0.701) mm] and well-formed, round or elliptical in shape, and almost invariably had a regular contour. Background elements lacked necrotic debris or exudate. The density [median (IQR) number of granulomas per slide: 6.85 (3.66-11) vs. 5.25 (2.5-8), p = 0.073] and size [median (IQR) largest diameter: 0.51 (0.319-0.733) vs. 0.398 (0.318-0.522), p = 0.071] tended to be larger in stage I than in stage II sarcoidosis. A necrotic background was common in the tuberculosis cohort studied (79 vs. 0%, p < 0.0001). Conclusions: Granulomas can be reliably identified on TBNA cytological material once their characteristic cytomorphology is delineated. A higher density of granulomas in lymphadenopathy of stage I sarcoidosis patients could partly explain the higher success rate constantly obtained by TBNA and EBUS-TBNA in this stage of the disease. A necrotic background suggests a tubercular etiology of the granulomas over a sarcoidal one, in the appropriate clinical setting.

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Section: Discussionsupporting

confidence: 85%

Sarcoidal Granulomas in Cytological Specimens from Intrathoracic Adenopathy: Morphologic Characteristics and Radiographic Correlations

Cancellieri¹,

Leslie

Tinelli

et al. 2012

Respiration

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“…10 Endosonography in the present study had a diagnostic yield of 80% to detect noncaseating granuloma in patients with suspected sarcoidosis; this is similar to previous findings reporting a sensitivity of approximately 80% (range, 54%-100%). [11][12][13][14] A recent prospective cohort study showed that endosonography had a sensitivity of 71% in diagnosing sarcoidosis after a previous nondiagnostic bronchoscopy result. 8 Additionally, 2 small prospective studies evaluating bronchoscopy and endosonography reported a significantly higher yield for endobronchial ultrasonography-guided TBNA (85%-94%) compared with TBLB (31%-37%) to detect granulomas.…”

Section: Discussionmentioning

confidence: 99%

Endosonography vs Conventional Bronchoscopy for the Diagnosis of Sarcoidosis

Bartheld

Dekkers

Szlubowski

et al. 2013

JAMA

212

142

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Importance Tissue verification of noncaseating granulomas is recommended for the diagnosis of sarcoidosis. Bronchoscopy with transbronchial lung biopsies, the current diagnostic standard, has moderate sensitivity in assessing granulomas. Endosonography with intrathoracic nodal aspiration appears to be a promising diagnostic technique. ObjectiveTo evaluate the diagnostic yield of bronchoscopy vs endosonography in the diagnosis of stage I/II sarcoidosis. Design, Setting, and Patients Randomized clinical multicenter trial (14 centers in 6 countries) between March 2009 and November 2011 of 304 consecutive patients with suspected pulmonary sarcoidosis (stage I/II) in whom tissue confirmation of noncaseating granulomas was indicated.Interventions Either bronchoscopy with transbronchial and endobronchial lung biopsies or endosonography (esophageal or endobronchial ultrasonography) with aspiration of intrathoracic lymph nodes. All patients also underwent bronchoalveolar lavage. Main Outcomes and MeasuresThe primary outcome was the diagnostic yield for detecting noncaseating granulomas in patients with a final diagnosis of sarcoidosis. The diagnosis was based on final clinical judgment by the treating physician, according to all available information (including findings from initial bronchoscopy or endosonography). Secondary outcomes were the complication rate in both groups and sensitivity and specificity of bronchoalveolar lavage in the diagnosis of sarcoidosis.Results A total of 149 patients were randomized to bronchoscopy and 155 to endosonography. Significantly more granulomas were detected at endosonography vs bronchoscopy (114 vs 72 patients; 74% vs 48%; PϽ.001). Diagnostic yield to detect granulomas for endosonography was 80% (95% CI, 73%-86%); for bronchoscopy, 53% (95% CI, 45%-61%) (PϽ.001). Two serious adverse events occurred in the bronchoscopy group and 1 in the endosonography group; all patients recovered completely. Sensitivity of the bronchoalveolar lavage for sarcoidosis based on CD4/CD8 ratio was 54% (95% CI, 46%-62%) for flow cytometry and 24% (95% CI, 16%-34%) for cytospin analysis. Conclusion and RelevanceAmong patients with suspected stage I/II pulmonary sarcoidosis undergoing tissue confirmation, the use of endosonographic nodal aspiration compared with bronchoscopic biopsy resulted in greater diagnostic yield.

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“…We read with interest the article by Fritscher-Ravens et al [1] on the utility of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) in differentiating between tuberculosis and sarcoidosis in patients with granulomatous mediastinal lymphadenopathy. We compliment the authors for conducting such a good study and agree with them that EUS-FNA has a high diagnostic yield for mediastinal tubercular lymphadenopathy; this has also been our experience [2,3].…”

Section: Endoscopic Ultrasound Features Of Mediastinal Tuberculosismentioning

confidence: 99%

Endoscopic ultrasound features of mediastinal tuberculosis

Rana¹,

Bhasin²,

Singh³

2011

Endoscopy

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Granulomatous mediastinal adenopathy: can endoscopic ultrasound-guided fine-needle aspiration differentiate between tuberculosis and sarcoidosis?

Abstract: EUS - FNA offers a high diagnostic yield for the differential diagnosis of tuberculosis and sarcoidosis that have not been diagnosed by conventional methods.

Cited by 50 publications

References 23 publications

Sarcoidal Granulomas in Cytological Specimens from Intrathoracic Adenopathy: Morphologic Characteristics and Radiographic Correlations

Sarcoidal Granulomas in Cytological Specimens from Intrathoracic Adenopathy: Morphologic Characteristics and Radiographic Correlations

Endosonography vs Conventional Bronchoscopy for the Diagnosis of Sarcoidosis

Endoscopic ultrasound features of mediastinal tuberculosis

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