The Clinical Application and Cost Analysis of Fine-Needle Aspiration Biopsy in the Diagnosis of Mass Lesions in Sarcoidosis

doi:10.1378/chest.117.4.1004

Chest

Volume 117, Issue 4, April 2000, Pages 1004-1011

https://doi.org/10.1378/chest.117.4.1004 Get rights and content

Background

Sarcoidosis is a prevalent disease of unknown cause characterized by granulomatous inflammation that often creates deep and/or superficial mass lesions. Tissue samples are considered the “gold standard” in diagnosis; however, it is a medically treated disease. We analyzed the utility and relative cost-effectiveness of fine-needle aspiration biopsy (FNAB) in the clinical investigation of patients with both suspected and unsuspected sarcoidosis.

Methods

All FNAB cases with sarcoidosis either as the cytologic diagnosis or mentioned as part of the differential diagnosis were retrospectively reviewed for clinical history, follow-up, cytologic features, and surgical pathology findings. Comparative analysis of cost of FNAB and excisional biopsy were also made.

Results

Thirty-two FNABs in 28 patients included 17 women and 11 men. Anatomic sites included lymph node (n = 17), lung (n = 5), salivary gland (n = 8), and liver (n = 2). Sarcoidosis had already been diagnosed or was a clinical consideration prior to FNAB in 14 cases. Chest radiograph showed abnormal findings in 19 cases. Angiotensin-converting enzyme (ACE) was measured in seven patients and was elevated in four. All aspirates showed granulomatous inflammation; in 22 patients, special stains or cultures for microorganisms were negative. Simultaneous or subsequent excisional biopsies confirmed the FNAB findings in 17 patients. Institutional ratios of excisional biopsy to FNAB in the diagnosis of sarcoidosis ranged from 4 to 19:1. The cost of FNAB was only 12.5 to 50% that of tissue biopsy.

Conclusions

FNAB appears to be underutilized in the diagnosis of sarcoidosis. When used in conjunction with radiologic and laboratory data, FNAB may be a reliable and cost-effective method of diagnosis, especially in patients with an established diagnosis of sarcoidosis.

Section snippets

Materials and Methods

Cytology files were searched for all FNAB cases of granulomatous inflammation in which sarcoidosis was either noted as a cytologic diagnosis or mentioned in the differential diagnosis of the cytopathology report. The organ sampled by FNAB, the cytologic features, especially the presence and character of granulomatous inflammation, and performance of special stains for microorganisms were evaluated. When available, surgical pathology reports and clinical records were reviewed to determine the

Results

Thirty-two patients were identified in whom granulomatous inflammation was found on FNAB with sarcoidosis mentioned in the cytologic differential diagnosis. Slides for review or a sufficiently detailed microscopic report were available for 28 patients who thus made up the study group.

Discussion

Sarcoidosis is an illness of unknown etiology characterized by nonnecrotizing granulomatous inflammation involving one or more organs. Estimates vary, but between 20 to 40% of patients present with asymptomatic bilateral hilar lymphadenopathy.² In the remainder, a variety of tissues may be affected and mass lesions may result. Tests formerly believed to be diagnostic of sarcoidosis have proven to be nonspecific. These include serum ACE, which can be elevated in a variety of granulomatous

ACKNOWLEDGMENT

The authors would like to express their gratitude to Dr. W. Stephen Black-Schaffer for his assistance with the financial data.

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Citation Excerpt :
As far as lung carcinomas are concerned, granulomatous reactions occur mostly with squamous cell carcinomas and rarely with small cell carcinoma.86,87 The finding of this type of granulomatous inflammation can create problems in accurate diagnosis in small biopsies obtained via mediastinoscopy, video-assisted thoracoscopy, or transthoracic needle biopsy.74 Although there have been many advances in the understanding of sarcoidosis, its etiology and pathogenesis remain unknown.
Sarcoidosis is a multi-system disease of unknown etiology, usually affecting the respiratory tract and other organs, and is characterized by the formation of nonnecrotizing epithelioid granulomas. The diagnosis depends on a combination of a typical clinicoradiological presentation, the finding of nonnecrotizing epithelioid granulomas in a tissue biopsy, and exclusion of other possible diseases, especially those of infectious etiology. The granulomas contain epithelioid cells, giant cells, CD4+ T cells in their center, and CD8+ T lymphocytes and B lymphocytes at their periphery. The granulomas are present in a lymphatic pattern around bronchovascular structures and, because of this, may show angioinvasion. The bronchial involvement produces a high diagnostic yield for transbronchial and endobronchial biopsies in this disease. Finally, small amounts of fibrinoid necrosis may occur within granulomas of sarcoidosis and do not exclude the diagnosis. Larger amounts suggest either infection or the rare disease necrotizing sarcoid granulomatosis (NSG). A number of cytoplasmic structures/inclusions can be identified within the granulomas of sarcoidosis, including asteroid bodies, Schaumann’s bodies, calcium oxalate crystals, and Hamazaki–Wesenberg bodies; the last two of these can cause difficulties in differential diagnosis. Extra-pulmonary sarcoid can be an important factor in prognosis. Involved sites include (in decreasing frequency): skin, endocrine organs, extra-thoracic lymph nodes, neurologic sites, eyes, liver, spleen, bone marrow, cardiac, ear/nose/throat, parotid/salivary, muscles, bones/joint, and kidney. NSG is a controversial variant of sarcoidosis consisting of granulomatous pneumonitis with sarcoid-like granulomas, variable amounts of necrosis, and granulomatous vasculitis. The lesions are most often confined to lung, and they usually appear as multiple nodules or nodular infiltrates, but occasionally as solitary or unilateral nodules ranging up to 5 cm in diameter. Nodular sarcoidosis is rare, varying from 1.6% to 4% of patients with sarcoidosis, and, as the name suggests, it shows radiographic nodules measuring 1 to 5 cm in diameter that typically consist of coalescent granulomas. Lung transplantation can be used in selected patients with fibrotic late-stage sarcoidosis. There is a high reported frequency of recurrence of disease in the pulmonary allograft, ranging from 47% to 67%, but recurrence is usually not clinically significant. Studies of the pathogenesis of sarcoidosis suggest that it is a chronic immunological response produced by a genetic susceptibility and exposure to specific environmental factors.
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In case of mediastinal nodes, fine-needle aspiration cytology can effectively differentiate cancer from sarcoidosis and appears less invasive than mediastinoscopy. Tambouret et al8 reported that fine-needle aspiration cytology is a good method for sarcoidosis diagnosis when combined with clinical, radiologic, and laboratory data. This procedure is simple and safe, and can be performed easily in the outpatient setting.
Sarcoidosis is a multisystem chronic granulomatous disease found predominantly in the lungs and lymph nodes. Its pathologic hallmark is the presence of noncaseating granulomas. Sarcoidosis is a chronic inflammatory condition that may increase the risk of cancer, yet at the same time, cancer can be associated with a sarcoid-like reaction.
It is difficult to distinguish between sarcoidosis and sarcoid-like reactions because their imaging characteristics are identical. We report on 3 cases of sarcoidosis or sarcoid-like reactions in patients with colorectal cancer and highlight the diagnosis process.
Systemic symptoms observed in patients with sarcoidosis commonly can be masked or mimicked by symptoms related to the malignancy. Moreover, it is important to distinguish between the 2 entities to give patients adequate therapy.
Our cases focused on the usefulness of histologic proof in patients with cancer with sarcoidosis.
Recurrence of sarcoidosis: The follow-up of splenic involvement
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We report the case of a 53-year-old woman who initially presented with an intermittent dry cough that had lasted for 6 months. An investigation into these symptoms with thoracic computed tomography demonstrated hyperdense shadows in her lungs, and ultrasonography showed the presence of multiple hypoechoic nodules on her spleen. A lung biopsy was then performed, which revealed noncaseating epithelioid cell granulomas. Magnetic resonance imagining of her spleen was performed, which showed low signal intensity. The patient was treated with glucocorticoids, and 3 months later the lesions in her lungs had disappeared completely. Five months later, the lesions in her spleen had disappeared also. However, after 13 months of low-dose prednisone, a miliary pattern was observed on the patient's chest x-ray, although no lesions were observed in her spleen. Laboratory tests demonstrated that her blood level of angiotensin-converting enzyme had increased to 96 IU/L. The dose of prednisone was then increased, and the lung images returned to normal after 2 months of therapy.
Mediastinum
2012, Orell & Sterrett's Fine Needle Aspiration Cytology
Infectious Diseases
2012, Orell & Sterrett's Fine Needle Aspiration Cytology
Infectious diseases
2011, Orell and Sterrett's Fine Needle Aspiration Cytology

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PA; and the University of Arkansas for Medical Sciences (Dr. Bardales), Little Rock, AR.

Presented in abstract form at the Annual Meeting of the American Society of Cytopathology, Boston, MA, November 4–8, 1997.

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Chest

Clinical InvestigationsSARCOIDOSISThe Clinical Application and Cost Analysis of Fine-Needle Aspiration Biopsy in the Diagnosis of Mass Lesions in Sarcoidosis

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

ACKNOWLEDGMENT

Clin Chest Med

Chest

Chest

Sarcoidosis

N Engl J Med

Sarcoidosis

Postgrad Med J

Fine needle aspiration biopsy cytology as an adjunct in the diagnosis of childhood sarcoidosis

Pediatr Pulmonol

Fine-needle aspiration of the mediastinum: a clinical, radiologic, cytologic, and histologic study of 42 cases

Diagn Cytopathol

Directed fine needle biopsy of anterior and middle mediastinal masses

Oncology

Fine-needle aspiration biopsy of the mediastinum, a multi-institutional analysis

Am J Clin Pathol

Ultrasound-guided fine-needle aspiration cytology of non-palpable supraclavicular lymph nodes in sarcoidosis

Acta Radiol

Ultrasound-guided aspiration cytology of enlarged lymph nodes

Acta Radiol

Fine needle aspiration biopsy in the management of children and young adults with peripheral lymphadenopathy

Cancer

Aspiration biopsy of the spleen in patients with sarcoidosis

Acta Radiol

Fine needle aspiration biopsy in patients with diffusely enlarged spleens

Acta Cytol

Fine-needle aspiration biopsy: efficacy in the diagnosis of head and neck sarcoidosis

Laryngoscope

Cytologic diagnosis of salivary gland lesions in adult and pediatric surgical patients

Acta Cytol

Sarcoidosis diagnosed on fine- needle aspiration cytology of salivary glands: a report of three cases

Diagn Cytopathol

Fine needle aspiration biopsy of granulomatous disorders

Sarcoidosis

Pulmonary sarcoidosis: roentgenologic analysis of 150 patients

Am J Radiol

Complications of fine needle aspiration biopsy: the reality behind the myths

Clinical Investigations
SARCOIDOSIS
The Clinical Application and Cost Analysis of Fine-Needle Aspiration Biopsy in the Diagnosis of Mass Lesions in Sarcoidosis