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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Currently the diagnosis of pulmonary sarcoidosis is shifting from conventional bronchoscopy procedures to other minimally invasive techniques&#44; which are safer and more effective&#46; In this issue of the Portuguese Journal of Pulmonology&#44; Ribeiro C and co-authors prospectively evaluated 39 patients with suspected sarcoidosis &#40;stages I or II&#41; and obtained 94&#37; diagnostic yield based on EBUS-TBNA findings&#44; without complications&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These results are in line with current international literature and certainly reflect the value of the technique in experienced hands&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Sarcoidosis is the most prevalent interstitial lung disease in Europe and in the United States and is characterized by accumulation of non-caseating granulomas in tissue&#46; Though it may involve virtually every organ&#44; it affects the lungs and intrathoracic lymph nodes in 90&#37; of cases&#46; Diagnosis is usually initially based on clinical and radiological suspicion but tissue confirmation is strongly recommended in order to exclude diseases of similar presentation&#44; such as tuberculosis&#44; fungal infections&#44; lymphoma and even lung cancer&#46; In clinical practice&#44; the vast majority of patients referred for the evaluation of pulmonary sarcoidosis present stages I or II&#46; In the absence of easily accessible biopsy sites &#40;skin or superficial lymph nodes&#41; for the current diagnostic work-up&#44; conventional flexible bronchoscopy endobronchial biopsy &#40;EBB&#41; and transbronchial lung biopsy &#40;TBLB&#41; are recommended&#44; however&#44; their sensitivity in detecting granulomas is moderate even when they are combined&#46; Moreover TBLB may be associated with serious adverse events such as pneumothorax and hemoptysis&#46; In cases of enlarged mediastinal or hilar lymph nodes an additionally &#8220;semi-blind&#8221; transbronchial needle aspiration &#40;TBNA&#41;&#44; guided by previous CT scans&#44; is able to increase diagnostic yield&#44; especially if puncture is performed in subcarinal and right paratracheal stations&#44; but this technique is highly operator-dependent&#46; Bronchoalveolar lavage &#40;BAL&#41; findings such as lymphocytosis in combination with a CD4&#43;&#47;CD8&#43; ratio &#62;3&#46;5 are considered helpful for the final diagnosis but are very variable&#46; If the diagnosis of sarcoidosis is not confirmed by bronchoscopy findings&#44; more invasive and expensive surgical procedures such as mediastinoscopy &#40;MS&#41; or video assisted thoracic surgery &#40;VATS&#41; lung biopsy may be required&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the XXI century&#44; tissue proof of non-caseating granulomas can instead be obtained by sampling intrathoracic lymph nodes under real-time ultrasound guidance&#46; Endobronchial ultrasound-guided transbronchial needle aspiration &#40;EBUS-TBNA&#41; and transesophageal ultrasound-guided fine-needle aspiration &#40;EUS-FNA&#41; are complimentary techniques regarding their diagnostic reach in combination&#46; Virtually they can reach all hilar&#44; interlobar and mediastinal lymph nodes including paratracheal&#44; subcarinal and paraoesophageal stations&#46; The decision to perform either EUS or EBUS is usually left to the local endoscopist and may depend on availability of equipment&#44; CT findings or the preference of either physician or patient&#46; In 2009&#44; a randomized controlled trial<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> showed that EBUS-TBNA improved the diagnostic sensitivity by 22&#37; compared to conventional TBNA and in 2013 a frequently cited study proved that the diagnostic yield of EBUS&#47;EUS &#40;80&#37;&#41; was better than bronchoscopy &#40;53&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These results agree with a meta-analysis that revealed a pooled accuracy of EBUS-TBNA of 80&#37; in sarcoidosis &#40;range 54&#8211;93&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore&#44; head-to-head comparisons between conventional techniques and EBUS-TBNA&#47;EUS-FNA in sarcoidosis have proved that endosonography is superior and it is expected that in the near future it will become the primary diagnostic tool in patients suspected of stage I&#47;II sarcoidosis&#46; With the growing experience of pathologists the demonstration of non-caseating epithelioid granulomas based on cytological material is feasible and reliable&#46; Some authors have pointed out the need to obtain histological core tissue biopsies with a 19-gauge needle because histological evaluation is more reliable in excluding lymphoproliferative disorders and tuberculosis &#40;at present 19-gauge needles are available only for conventional TBNA and EUS&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">One may wonder if every bronchoscopy unit all over the world should invest in echoendoscopes and if conventional procedures have already become redundant in the diagnosis of sarcoidosis&#46; Flexible bronchoscopy still seems to have some advantages because it is a widely available diagnostic tool&#46; A single scope can be used for the entire procedure enabling several sampling techniques&#46; It is quite easy to learn to use and is also maneuverable with optimal endobronchial image for the majority of bronchoscopists&#46; Finally&#44; standard flexible video bronchoscopes are less expensive as well as more robust compared to the echoendoscopes&#46; In addition&#44; some of the published endosonography trials have design problems such as&#44; patient selection bias&#59; the majority of lymph nodes were sampled in bulky stations 4R and 7 that are easily sampled by &#8220;semi-blind&#8221; TBNA with comparable yield&#59; and others have been criticized due to the exclusion of conventional TBNA in the bronchoscopy group&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Two recent studies have confirmed the importance of conventional procedures in the diagnosis of sarcoidosis&#46; Firstly&#44; a systematic review and meta-analysis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> has shown that conventional TBNA has a pooled efficacy of 62&#37; in sarcoidosis&#44; without any major complications&#44; and when TBNA and TBLB are combined the diagnostic yield increases to 83&#37;&#44; similar to EBUS&#47;EUS-FNA&#46; And secondly&#44; a well-designed randomized controlled trial<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> has demonstrated that individually EBUS-TBNA has the highest diagnostic yield &#40;74&#46;5&#37;&#41; and this is even better when combined with TBLB &#40;90&#46;9&#37;&#41; but the diagnostic yield of &#8220;semi-blind&#8221; TBNA plus EBB and TBLB allows comparable results &#40;85&#46;5&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; those who do not have EBUS&#47;EUS or cannot refer the patient to a center with this equipment still have a good chance to diagnose sarcoidosis by optimizing and combining conventional techniques&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">So&#44; is EBUS-TBNA the best tool available to diagnose pulmonary sarcoidosis&#63; Yes&#44; it is&#46; Is it the only tool&#63; No&#44; of course not&#33;</p></span>"
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Editorial
Endobronchial ultrasound in sarcoidosis: Time to rethink the diagnostic strategy?
Ecoendoscopia brônquica na sarcoidose: é tempo de repensar a estratégia de diagnóstico?
A. Bugalhoa,
Corresponding author
antonio.bugalho@netcabo.pt

Corresponding author.
, A. Szlubowskib
a Interventional Pulmonology Unit, Hospital Beatriz Angelo Loures, Associate Professor at Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
b Associate Professor at Silesian Medical University; Head of Endoscopy Unit, John Paul II Hospital, Kraków and Endoscopy Unit, Pulmonary Hospital, Zakopane, Poland
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Currently the diagnosis of pulmonary sarcoidosis is shifting from conventional bronchoscopy procedures to other minimally invasive techniques&#44; which are safer and more effective&#46; In this issue of the Portuguese Journal of Pulmonology&#44; Ribeiro C and co-authors prospectively evaluated 39 patients with suspected sarcoidosis &#40;stages I or II&#41; and obtained 94&#37; diagnostic yield based on EBUS-TBNA findings&#44; without complications&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These results are in line with current international literature and certainly reflect the value of the technique in experienced hands&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Sarcoidosis is the most prevalent interstitial lung disease in Europe and in the United States and is characterized by accumulation of non-caseating granulomas in tissue&#46; Though it may involve virtually every organ&#44; it affects the lungs and intrathoracic lymph nodes in 90&#37; of cases&#46; Diagnosis is usually initially based on clinical and radiological suspicion but tissue confirmation is strongly recommended in order to exclude diseases of similar presentation&#44; such as tuberculosis&#44; fungal infections&#44; lymphoma and even lung cancer&#46; In clinical practice&#44; the vast majority of patients referred for the evaluation of pulmonary sarcoidosis present stages I or II&#46; In the absence of easily accessible biopsy sites &#40;skin or superficial lymph nodes&#41; for the current diagnostic work-up&#44; conventional flexible bronchoscopy endobronchial biopsy &#40;EBB&#41; and transbronchial lung biopsy &#40;TBLB&#41; are recommended&#44; however&#44; their sensitivity in detecting granulomas is moderate even when they are combined&#46; Moreover TBLB may be associated with serious adverse events such as pneumothorax and hemoptysis&#46; In cases of enlarged mediastinal or hilar lymph nodes an additionally &#8220;semi-blind&#8221; transbronchial needle aspiration &#40;TBNA&#41;&#44; guided by previous CT scans&#44; is able to increase diagnostic yield&#44; especially if puncture is performed in subcarinal and right paratracheal stations&#44; but this technique is highly operator-dependent&#46; Bronchoalveolar lavage &#40;BAL&#41; findings such as lymphocytosis in combination with a CD4&#43;&#47;CD8&#43; ratio &#62;3&#46;5 are considered helpful for the final diagnosis but are very variable&#46; If the diagnosis of sarcoidosis is not confirmed by bronchoscopy findings&#44; more invasive and expensive surgical procedures such as mediastinoscopy &#40;MS&#41; or video assisted thoracic surgery &#40;VATS&#41; lung biopsy may be required&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the XXI century&#44; tissue proof of non-caseating granulomas can instead be obtained by sampling intrathoracic lymph nodes under real-time ultrasound guidance&#46; Endobronchial ultrasound-guided transbronchial needle aspiration &#40;EBUS-TBNA&#41; and transesophageal ultrasound-guided fine-needle aspiration &#40;EUS-FNA&#41; are complimentary techniques regarding their diagnostic reach in combination&#46; Virtually they can reach all hilar&#44; interlobar and mediastinal lymph nodes including paratracheal&#44; subcarinal and paraoesophageal stations&#46; The decision to perform either EUS or EBUS is usually left to the local endoscopist and may depend on availability of equipment&#44; CT findings or the preference of either physician or patient&#46; In 2009&#44; a randomized controlled trial<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> showed that EBUS-TBNA improved the diagnostic sensitivity by 22&#37; compared to conventional TBNA and in 2013 a frequently cited study proved that the diagnostic yield of EBUS&#47;EUS &#40;80&#37;&#41; was better than bronchoscopy &#40;53&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These results agree with a meta-analysis that revealed a pooled accuracy of EBUS-TBNA of 80&#37; in sarcoidosis &#40;range 54&#8211;93&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore&#44; head-to-head comparisons between conventional techniques and EBUS-TBNA&#47;EUS-FNA in sarcoidosis have proved that endosonography is superior and it is expected that in the near future it will become the primary diagnostic tool in patients suspected of stage I&#47;II sarcoidosis&#46; With the growing experience of pathologists the demonstration of non-caseating epithelioid granulomas based on cytological material is feasible and reliable&#46; Some authors have pointed out the need to obtain histological core tissue biopsies with a 19-gauge needle because histological evaluation is more reliable in excluding lymphoproliferative disorders and tuberculosis &#40;at present 19-gauge needles are available only for conventional TBNA and EUS&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">One may wonder if every bronchoscopy unit all over the world should invest in echoendoscopes and if conventional procedures have already become redundant in the diagnosis of sarcoidosis&#46; Flexible bronchoscopy still seems to have some advantages because it is a widely available diagnostic tool&#46; A single scope can be used for the entire procedure enabling several sampling techniques&#46; It is quite easy to learn to use and is also maneuverable with optimal endobronchial image for the majority of bronchoscopists&#46; Finally&#44; standard flexible video bronchoscopes are less expensive as well as more robust compared to the echoendoscopes&#46; In addition&#44; some of the published endosonography trials have design problems such as&#44; patient selection bias&#59; the majority of lymph nodes were sampled in bulky stations 4R and 7 that are easily sampled by &#8220;semi-blind&#8221; TBNA with comparable yield&#59; and others have been criticized due to the exclusion of conventional TBNA in the bronchoscopy group&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Two recent studies have confirmed the importance of conventional procedures in the diagnosis of sarcoidosis&#46; Firstly&#44; a systematic review and meta-analysis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> has shown that conventional TBNA has a pooled efficacy of 62&#37; in sarcoidosis&#44; without any major complications&#44; and when TBNA and TBLB are combined the diagnostic yield increases to 83&#37;&#44; similar to EBUS&#47;EUS-FNA&#46; And secondly&#44; a well-designed randomized controlled trial<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> has demonstrated that individually EBUS-TBNA has the highest diagnostic yield &#40;74&#46;5&#37;&#41; and this is even better when combined with TBLB &#40;90&#46;9&#37;&#41; but the diagnostic yield of &#8220;semi-blind&#8221; TBNA plus EBB and TBLB allows comparable results &#40;85&#46;5&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; those who do not have EBUS&#47;EUS or cannot refer the patient to a center with this equipment still have a good chance to diagnose sarcoidosis by optimizing and combining conventional techniques&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">So&#44; is EBUS-TBNA the best tool available to diagnose pulmonary sarcoidosis&#63; Yes&#44; it is&#46; Is it the only tool&#63; No&#44; of course not&#33;</p></span>"
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ISSN: 08732159
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