Transbronchoscopic Lung Biopsy in Sarcoidosis: Optimal Number and Sites for Diagnosis

doi:10.1378/chest.77.3.400

Chest

Volume 77, Issue 3, March 1980, Pages 400-402

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By obtaining five transbronchoscopic biopsies of the lung from each of the right upper and lower lobes, the diagnosis of sarcoidosis was made in 36 of 37 prospectively studied patients. The diagnosis was made in all ten patients with stage-1 disease, but seven of the ten showed diagnostic tissue from only one lobe. Only one of the ten biopsies was diagnostic in four of those patients with a stage-1 disease. In disease of stage 2 and 3, there was good correlation between diagnostic biopsies and the radiographic distribution of infiltrates. Biopsies from the predominantly rather than the lesser involved lobe proved the diagnosis in all of these patients, except for the two patients with nodular sarcoid. We conclude that ten biopsies are optimal for obtaining the diagnosis in stage-1 disease; however, five biopsies may be adequate in non-nodular disease of stage 2 and 3 if the biopsies are of the lobe predominantly involved on the roentgenogram of the chest.

Section snippets

MATERIALS AND METHODS

Thirty-eight consecutive patients with suspected sarcoidosis seen at the USAF Medical Center Scott, Scott Air Force Base, Illinois, between January 1977 and February 1979 were studied prospectively. The presumptive diagnosis of sarcoidosis was made on the basis of the clinical and radiographic findings. Any patient who eventually proved to have positive cultures for mycobacteria or fungal organisms or elevated fungal serologic results was to be eliminated from the study. No patient had

RESULTS

Of the 38 patients studied, one was eliminated from further consideration after the data obtained showed the patient to have histoplasmosis. Of the 37 other patients, 36 had transbronchial biopsies of lung showing granulomas consistent with sarcoidosis (Table 1). The remaining patient (patient 2) had normal transbronchoscopic biopsies of lung, but the diagnosis of sarcoidosis was confirmed with mediastinoscopic examination.

Of the 37 patients, ten had stage-1 disease, 23 had stage-2 disease, and

DISCUSSION

Sarcoidosis is a disease which lends itself well to diagnosis with the fiberoptic bronchoscope because the diagnostic changes may be recognized on the small specimens obtained. Furthermore, the apparently diffuse involvement of the lungs by the disease should minimize the chance of sampling error with this type of diagnostic procedure; however, some nonunif ormity of the distribution of the abnormality does exist, as mirrored in the fact that previous investigators have been able to establish

ACKNOWLEDGMENT

We thank Lt Col Howard P. Tchou, MC, USAF, and the Department of Pathology, USAF Medical Center Scott, Scott Air Force Base, Illinois, for their critical review of the biopsies.

REFERENCES (5)

KoontzCH
Lung biopsy in sarcoidosis (editorial)
Chest
(1978)
KoernerSK et al.
Transbronchial lung biopsy for the diagnosis of sarcoidosis
N Engl J Med
(1975)

There are more references available in the full text version of this article.

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Citation Excerpt :
In addition, the small sample size may make this study underpowered to detect a difference in this parameter. Previous studies have shown that a larger number of specimens obtained via TBLB increases the yield of diagnosis (up to ten) [26,27], and current guidelines recommend obtaining at least six specimens in order to increase the yield of this procedure [28,29]. We therefore believe our findings may still be relevant and clinically significant, although larger similar studies are obviously needed.
Although massive bleeding following transbronchial lung biopsies (TBLB) is rare, even minor hemorrhage may prolong the procedure and result in inadequate sampling. Tranexamic acid (TXA) is an antifibrinolytic agent, which reduces bleeding in numerous scenarios, however, its prophylactic use in mitigating post-TBLB bleeding has not been investigated. We conducted a prospective, randomized, double-blind, placebo-controlled trial to determine whether topical infusion of TXA prior to TBLB would reduce bleeding, shorten procedure duration and increase the number of biopsies obtained.
We blindly randomized patients undergoing TBLB to receive topical TXA or placebo in the lobar bronchus prior to biopsies. Vital signs, procedure length, fluid balance (as a measure of the amount of bleeding), operator's assessment of bleeding, and number of biopsies obtained were measured. Data was analyzed using the two-tailed Student's T-Test, Chi-square or Mann-Whitney tests as appropriate.
Fifty patients were randomized, 26 to the TXA arm. The bleeding in the TXA group was significantly lower (P = 0.0037), with more specimens being obtained (placebo 7 (6, 9) (median and interquartile range) vs. TXA 9 (8, 10), P = 0.023) and no difference in procedure length (placebo 30 min (29.3, 34.3) vs. TXA 30 (24.8, 36), P = 0.90). There were no clinically significant adverse events in any of the groups up to one month of follow up.
Endobronchial installation of TXA prior to obtaining TBLB results in less bleeding and allows more biopsies to be obtained with no additional adverse events. The prophylactic use of TXA during TBLB may be considered as standard.
Basic Bronchoscopy: Technology, Techniques, and Professional Fees
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Originally performed through a catheter inserted through the nose7 or via a rigid endoscope,8 TBLB is now routinely performed through a flexible bronchoscope and is considered a basic diagnostic procedure for the pulmonologist. TBLB has been extensively studied in the diagnosis of sarcoidosis,9,10 hypersensitivity pneumonitis, malignancy, infections, and interstitial lung disease.11 TBLB can be performed with or without fluoroscopic guidance.
Flexible bronchoscopy has evolved over the last few decades, allowing chest physicians to use advanced high-definition scopes to inspect the airways and perform various sampling techniques. Although the techniques of basic bronchoscopic sampling have not changed dramatically, documentation requirements, coding, and billing have become more complex and require a better understanding on the part of the proceduralists and practice administrators. Areas in need of attention include learning about the multiple endoscopy rule, appropriate use of modifiers, and recent changes to the Current Procedural Terminology codes, associated work relative value units for moderate sedation, and therapeutic aspiration of secretions. This article describes basic bronchoscopic procedures and the principles needed for their coding and billing.
Bronchoscopic Modalities to Diagnose Sarcoidosis
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Several studies have investigated different bronchoscopic techniques to obtain tissue diagnosis in patients with suspected sarcoidosis when the diagnosis cannot be based on clinicoradiographic findings alone. In this review we will describe the most recent and relevant evidence from different bronchoscopic modalities to diagnose sarcoidosis.
Despite multiple available bronchoscopic modalities to procure tissue samples to diagnose sarcoidosis, the vast majority of evidence favors endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) to diagnose Scadding stages 1 and 2 sarcoidosis.
Transbronchial lung cryobiopsy (TBLC) is a new technique that is mainly used to aid in the diagnosis of undifferentiated interstitial lung disease. Endobronchial ultrasound-guided miniforceps biopsies (EBUS-MFB) from hilar/mediastinal lymph nodes have been described recently as well. We will discuss their potential use in sarcoidosis.
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The complimentary role of transbronchial lung cryobiopsy and endobronchial ultrasound fine needle aspiration in the diagnosis of sarcoidosis
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Citation Excerpt :
The ATS/ERS/WASOG Statement on Sarcoidosis written in 1999 recommends transbronchial lung biopsy (TBLB) as the procedure of choice for tissue diagnosis [1]. However, the diagnostic yield of TBLB ranges 40%–90% [3–6]. Factors influencing yield of TBLB include chest X ray (CXR) appearance and experience of the operator.
Transbronchial lung cryobiopsy (TBLC) is a novel technique that has proved to be useful in diagnosing various interstitial lung diseases (ILD). The use of TBLC to diagnose sarcoidosis in an unselected patient population is unknown, and could be complimentary to endobronchial ultrasound fine needle aspiration (EBUS-FNA).
A retrospective analysis of 36 patients in a single, tertiary-care, academic medical center was conducted to describe the yield of both EBUS-FNA and TBLC in the diagnosis of suspected sarcoidosis over a three year period. A grading system to evaluate the presence and extent of specific radiographic features on computed tomography chest imaging studies was compared to the results of EBUS-FNA and TBLC. Complications associated with the procedures were also noted.
The overall diagnostic yield in our cohort (all pathologic diagnosis considered) was 80.6% (29 out of 36 patients had a definite pathologic diagnosis). Eighteen patients referred for possible sarcoidosis had a positive bronchoscopic specimen confirming the diagnosis of sarcoidosis. For those patients with a pathologic diagnosis of sarcoidosis, the diagnostic yield for EBUS-FNA and TBLC was 66.7% each (12 out of 18 patients), while the combined diagnostic yield for EBUS-FNA and TBLC increased to 100%. For all cases, the pneumothorax rate was 11.1%.
TBLC appears to be a safe and complimentary technique to diagnose sarcoidosis and could be considered part of the diagnostic armamentarium in bronchoscopic centers.

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The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force or the Department of Defense

Manuscript received April 11; revision accepted June 7.

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Chest

Clinical InvestigationsTransbronchoscopic Lung Biopsy in Sarcoidosis: Optimal Number and Sites for Diagnosis

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

ACKNOWLEDGMENT

Chest

Transbronchial lung biopsy for the diagnosis of sarcoidosis

N Engl J Med

Clinical Investigations
Transbronchoscopic Lung Biopsy in Sarcoidosis: Optimal Number and Sites for Diagnosis