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Reis, A.S. Costa, B. Conde" "autores" => array:3 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Reis" ] 1 => array:2 [ "nombre" => "A.S." "apellidos" => "Costa" ] 2 => array:2 [ "nombre" => "B." "apellidos" => "Conde" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215914000506?idApp=UINPBA00004E" "url" => "/08732159/0000002000000004/v2_201509071023/S0873215914000506/v2_201509071023/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "EBUS in pulmonary sarcoidosis: What to expect?" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "229" "paginaFinal" => "231" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "I. Neves, M. Sucena, A. Magalhães, G. Fernandes" "autores" => array:4 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Neves" "email" => array:1 [ 0 => "inesneves.porto@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Sucena" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Magalhães" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Fernandes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Pulmonology of Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculty of Medicine, University of Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "EBUS (ecografia endobrônquica) na sarcoidose pulmonar: o que esperar?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2234 "Ancho" => 3335 "Tamanyo" => 340978 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart showing confirmation of diagnosis in 48 patients with suspected stage I and II sarcoidosis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The utility of EBUS-TBNA in the diagnosis of sarcoidosis has recently been reported.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Studies published have shown a higher diagnostic yield in favour of EBUS-TBNA, compared to standard bronchoscopic diagnostic techniques, particularly for stage I sarcoidosis.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> The main advantages identified, beside the high diagnostic yield, are the low complication rate and being able to avoid invasive procedures, like mediastinoscopy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several recent editorials reviewed the value of EBUS-TBNA in excluding other diagnoses in patients with suspected sarcoidosis. In a recent editorial published in the <span class="elsevierStyleItalic">Journal of Bronchology and Intervention Pulmonology</span>, Reich and colleagues estimated that 10,000 patients with stage I sarcoidosis would have to be submitted to an invasive diagnostic procedure to identify, at most, 5 people with an alternative pathology, and questioned the need for tissue confirmation in asymptomatic stage I sarcoidosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the series published with patients in suspected stage I and II sarcoidosis that have undergone EBUS-TBNA, only 10% obtained an alternative diagnosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However, these alternative diagnoses should not be ignored. A delay in this context can be harmful to the patient.</p><p id="par0020" class="elsevierStylePara elsevierViewall">What data exists that is available in relation to these questions?</p><p id="par0025" class="elsevierStylePara elsevierViewall">In our experience, 48 patients with clinical and radiological findings suggestive of sarcoidosis underwent EBUS-TBNA (74% stage I and 26% stage II; mean age 45 years). Final diagnosis of sarcoidosis was established in 81% of the patients (39 of 48 patients). The diagnostic yield of EBUS-TBNA for sarcoidosis was 73%, with a sensitivity and specificity of 67% and 100%, respectively. The negative predictive value was 41%. Nine different diagnoses were found: silicosis (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2), tuberculosis (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3), non-Hodgkin lymphoma (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1) and reactive adenopathy (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3). Thirteen patients received the final diagnosis of sarcoidosis after a negative EBUS-TBNA result. Among them, an additional histological biopsy was only performed in 3 patients (bronchial biopsy, peripheral lymph node biopsy (found after whole-body gallium scan) and surgical lung biopsy). In the remaining 10 patients, 9 had stage I sarcoidosis and 1 had asymptomatic stage II sarcoidosis, the diagnosis was supported by broncoalveolar lavage (CD4+/CD8+ ratio<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>3.5), radiologic criteria and at least a minimum 6 months follow-up (mean 19<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.7 months) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Tournoy et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> published the results of large diagnostic algorithm implementation trial for sarcoidosis. A total of 137 patients were included (75% stage I). Bronchoscopy was done in 121 patients establishing the definite diagnosis of sarcoidosis in 57 cases (42%). The sensitivity of endoscopic ultrasound following non-diagnostic standard bronchoscopic techniques was 71% and endoscopic ultrasound prevented a surgical procedure in 47 of the 80 patients. The author found that by adding EBUS<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>EUS to prior nondiagnostic bronchoscopy, three patients had to be investigated in order to avoid one surgical diagnostic procedure. Of the 33 patients left without pathological confirmation, 22 underwent a surgical procedure and an alternative diagnosis was found in only 6 patients. The other 11 patients were submitted to clinical surveillance.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Garwood et al. included<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> 50 patients with suspected sarcoidosis and a final diagnosis of sarcoidosis was confirmed in 48 patients (one patient was lost to follow-up). The diagnostic yield of EBUS-TBNA was 85% (41 of 48 patients) and was highest in stage I, followed by stage II disease (94% vs. 80% respectively). When EBUS-TBNA result was negative a further histological biopsy was performed in 5 patients (EBUS-targeted TBNA, transbronchial lung biopsy (TBLB) or supraclavicular lymph node biopsy) and 2 were followed up clinically. No patient was submitted to mediastinoscopy and no alternative diagnosis was found.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Wong et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> included 65 patients with clinical and radiological findings suggestive of sarcoidosis (74% stage I). The decision to proceed to TBLB was left to the discretion of the operators. In 61 patients the final diagnosis of sarcoidosis was obtained, 56 by EBUS-TBNA and 5 by mediastinoscopy. Three patients with indefinite diagnosis were followed up for ≥18 months and showed no clinical or radiological deterioration. One patient underwent video-assisted thoracoscopic surgery (VATS), after an inadequate EBUS-TBNA specimen, which showed Wegener's granulomatosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the Granuloma clinical trial,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> 303 patients with a clinical and radiologic suspicion of sarcoidosis stage I/II (51% stage I) were randomized: 149 to conventional bronchoscopy and 155 to endosonography. The final diagnosis was sarcoidosis in 278 of the 303 patients (92%) which was based on tissue-proven granulomas in 250 of the 278 patients (90%) and in 28 of the 278 patients (10%) on clinical and radiologic follow-up. For stage I sarcoidosis, endosonography had a significantly higher diagnostic yield than bronchoscopy (84% vs. 38%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). For stage II sarcoidosis, the difference was not statistically significant (66% vs. 77%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.18). In the bronchoscopy group, biopsies demonstrated eosinophilic and granulomatous vasculitis in one patient and metastasized thyroid cancer in another. In the endosonography group, non-caseating granulomas without necrosis were found in 2 patients, of whom one received a diagnosis of tuberculosis and the other of metastasized non-small cell lung carcinoma. In 2 more patients, a non-small cell lung carcinoma and colon carcinoma nodal metastasis were found.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The EBUS-TBNA increases the diagnostic yield of sarcoidosis (range 71–90% in the studies presented), and reduces the need for more invasive procedures. In every study illustrated above, alternative diagnoses were obtained in a minority of patients. Similar to our results, all authors described clinical follow-up as an alternative to invasive methods after negative EBUS-TBNA,</p><p id="par0055" class="elsevierStylePara elsevierViewall">The role of EBUS-TBNA in the diagnosis of sarcoidosis has become irreplaceable, not only to confirm the diagnosis, but also to exclude other diseases, especially malignancy. Nevertheless, EBUS-TBNA can provide additional difficulties when a differential diagnosis, such as lymphoma, is concerned, and in these cases further invasive procedures can have considerable value.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In our experience, there was no question of performing EBUS-TBNA, since tuberculosis and lymphoma were diagnosed. On the other hand, among negative EBUS-TBNA patients who did not perform additional investigations, no alternative diagnosis emerged.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Nowadays, the great challenge is to know when just EBUS is enough or when to proceed with invasive investigation. What is the correct approach after an EBUS-TBNA negative result?</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our opinion, although looking for granulomatous inflammation is the concern, lymph node sampling by EBUS-TBNA can give us significant information. The appropriate patient selection is the key for the use of EBUS-TBNA in sarcoidosis, and the decision to proceed to further investigation must be based in the pre-test probability of sarcoidosis vs. alternative diagnosis, mainly in stage I sarcoidosis. This approach should be prospectively confirmed.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2234 "Ancho" => 3335 "Tamanyo" => 340978 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart showing confirmation of diagnosis in 48 patients with suspected stage I and II sarcoidosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. 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Year/Month | Html | Total | |
---|---|---|---|
2024 November | 13 | 8 | 21 |
2024 October | 100 | 36 | 136 |
2024 September | 124 | 50 | 174 |
2024 August | 153 | 45 | 198 |
2024 July | 111 | 45 | 156 |
2024 June | 95 | 48 | 143 |
2024 May | 112 | 52 | 164 |
2024 April | 94 | 37 | 131 |
2024 March | 93 | 28 | 121 |
2024 February | 91 | 22 | 113 |
2024 January | 82 | 28 | 110 |
2023 December | 76 | 25 | 101 |
2023 November | 94 | 32 | 126 |
2023 October | 122 | 45 | 167 |
2023 September | 81 | 29 | 110 |
2023 August | 73 | 21 | 94 |
2023 July | 60 | 28 | 88 |
2023 June | 76 | 14 | 90 |
2023 May | 89 | 24 | 113 |
2023 April | 80 | 21 | 101 |
2023 March | 139 | 22 | 161 |
2023 February | 82 | 24 | 106 |
2023 January | 51 | 19 | 70 |
2022 December | 87 | 22 | 109 |
2022 November | 64 | 38 | 102 |
2022 October | 89 | 34 | 123 |
2022 September | 51 | 24 | 75 |
2022 August | 66 | 30 | 96 |
2022 July | 54 | 37 | 91 |
2022 June | 44 | 30 | 74 |
2022 May | 70 | 42 | 112 |
2022 April | 59 | 32 | 91 |
2022 March | 62 | 37 | 99 |
2022 February | 74 | 31 | 105 |
2022 January | 62 | 30 | 92 |
2021 December | 43 | 40 | 83 |
2021 November | 57 | 38 | 95 |
2021 October | 45 | 46 | 91 |
2021 September | 72 | 41 | 113 |
2021 August | 72 | 30 | 102 |
2021 July | 56 | 25 | 81 |
2021 June | 55 | 32 | 87 |
2021 May | 87 | 30 | 117 |
2021 April | 254 | 94 | 348 |
2021 March | 162 | 34 | 196 |
2021 February | 138 | 26 | 164 |
2021 January | 87 | 24 | 111 |
2020 December | 92 | 14 | 106 |
2020 November | 99 | 20 | 119 |
2020 October | 84 | 23 | 107 |
2020 September | 107 | 17 | 124 |
2020 August | 114 | 28 | 142 |
2020 July | 140 | 18 | 158 |
2020 June | 132 | 21 | 153 |
2020 May | 128 | 24 | 152 |
2020 April | 145 | 7 | 152 |
2020 March | 147 | 17 | 164 |
2020 February | 132 | 33 | 165 |
2020 January | 133 | 28 | 161 |
2019 December | 129 | 28 | 157 |
2019 November | 145 | 19 | 164 |
2019 October | 808 | 19 | 827 |
2019 September | 135 | 25 | 160 |
2019 August | 143 | 17 | 160 |
2019 July | 144 | 20 | 164 |
2019 June | 111 | 16 | 127 |
2019 May | 203 | 31 | 234 |
2019 April | 160 | 31 | 191 |
2019 March | 179 | 28 | 207 |
2019 February | 139 | 14 | 153 |
2019 January | 166 | 21 | 187 |
2018 December | 92 | 5 | 97 |
2018 November | 36 | 0 | 36 |
2018 October | 26 | 10 | 36 |
2018 September | 47 | 8 | 55 |
2018 August | 49 | 24 | 73 |
2018 July | 68 | 19 | 87 |
2018 June | 83 | 18 | 101 |
2018 May | 75 | 20 | 95 |
2018 April | 90 | 18 | 108 |
2018 March | 103 | 19 | 122 |
2018 February | 48 | 15 | 63 |
2018 January | 77 | 19 | 96 |
2017 December | 47 | 12 | 59 |
2017 November | 45 | 20 | 65 |
2017 October | 36 | 12 | 48 |
2017 September | 48 | 19 | 67 |
2017 August | 68 | 17 | 85 |
2017 July | 68 | 16 | 84 |
2017 June | 104 | 21 | 125 |
2017 May | 119 | 20 | 139 |
2017 April | 29 | 4 | 33 |
2017 March | 70 | 7 | 77 |
2017 February | 95 | 3 | 98 |
2017 January | 28 | 6 | 34 |
2016 December | 24 | 16 | 40 |
2016 November | 43 | 11 | 54 |
2016 October | 62 | 6 | 68 |
2016 September | 154 | 3 | 157 |
2016 August | 15 | 7 | 22 |
2016 July | 8 | 6 | 14 |
2016 June | 2 | 3 | 5 |
2016 May | 11 | 0 | 11 |
2016 April | 45 | 1 | 46 |
2016 March | 70 | 19 | 89 |
2016 February | 78 | 17 | 95 |
2016 January | 63 | 18 | 81 |
2015 December | 65 | 9 | 74 |
2015 November | 51 | 8 | 59 |
2015 October | 72 | 11 | 83 |
2015 September | 68 | 12 | 80 |
2015 August | 67 | 9 | 76 |
2015 July | 62 | 4 | 66 |
2015 June | 54 | 6 | 60 |
2015 May | 40 | 6 | 46 |
2015 April | 33 | 14 | 47 |
2015 March | 51 | 8 | 59 |
2015 February | 46 | 17 | 63 |
2015 January | 61 | 22 | 83 |
2014 December | 55 | 17 | 72 |
2014 November | 61 | 18 | 79 |
2014 October | 54 | 26 | 80 |
2014 September | 66 | 28 | 94 |
2014 August | 97 | 49 | 146 |
2014 July | 87 | 61 | 148 |