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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/S2173511514000682?idApp=UINPBA00004E" "url" => "/21735115/0000002000000004/v1_201407050113/S2173511514000682/v1_201407050113/en/main.assets" ] "en" => array:16 [ "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" => 1341 "Ancho" => 2002 "Tamanyo" => 186875 ] ] "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 "fechaRecibido" => "2014-03-12" "fechaAceptado" => "2014-04-27" "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" => 1341 "Ancho" => 2002 "Tamanyo" => 186875 ] ] "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 | |
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2024 November | 7 | 9 | 16 |
2024 October | 29 | 27 | 56 |
2024 September | 34 | 26 | 60 |
2024 August | 49 | 38 | 87 |
2024 July | 38 | 37 | 75 |
2024 June | 27 | 19 | 46 |
2024 May | 32 | 23 | 55 |
2024 April | 29 | 19 | 48 |
2024 March | 24 | 28 | 52 |
2024 February | 35 | 27 | 62 |
2024 January | 21 | 25 | 46 |
2023 December | 20 | 24 | 44 |
2023 November | 20 | 28 | 48 |
2023 October | 22 | 37 | 59 |
2023 September | 19 | 29 | 48 |
2023 August | 12 | 15 | 27 |
2023 July | 16 | 19 | 35 |
2023 June | 25 | 18 | 43 |
2023 May | 25 | 24 | 49 |
2023 April | 10 | 11 | 21 |