Reply to the Editor

Abstract

We thank Drs Ribeiro Neto, Culver, and Mehta for their comments regarding our study comparing the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and transbronchial lung biopsy (TBLB) by showing noncaseating granulomas for stage I and II sarcoidosis.1Oki M. Saka H. Kitagawa C. Kogure Y. Murata N. Ichihara S. et al.Prospective study of endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes versus transbronchial lung biopsy of lung tissue for diagnosis of sarcoidosis.J Thorac Cardiovasc Surg. 2012; 143: 1324-1329Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar We would like to address the issues raised by Dr Ribeiro Neto and colleagues. The first issue raised concerned patient selection. Our study included consecutive patients with suspected stage I or II sarcoidosis, regardless of symptoms. We agree that observation without biopsy for definitive diagnosis in patients with suspected typical asymptomatic stage I sarcoidosis is reasonable; however, we think pathologic confirmation of a definitive or differential diagnosis using a minimally invasive and highly accurate procedure is another valid choice. In fact, 33 of the 62 patients enrolled in our study were referred to our institution for EBUS-TBNA from physicians at 21 hospitals at which TBLB was available but not EBUS-TBNA. We assume this means that many physicians empirically know the diagnostic yield of TBLB is not sufficient, especially for stage I sarcoidosis. Moreover, many of them prefer to have a pathologic diagnosis for the treatment of patients with sarcoidosis, even with asymptomatic stage I sarcoidosis, if a highly accurate and minimally invasive procedure is available. The second issue raised regarded the method of obtaining a final diagnosis of sarcoidosis. As we mentioned, many patients enrolled in our study were referred for diagnosis and returned to be followed up by the referring physicians. We conducted a follow-up survey of the patients asking the physicians regarding the clinicoradiologic compatibility for having sarcoidosis. For patients who were followed up at our institution, we carefully reviewed the medical records and radiographs. Finally, the diagnosis of sarcoidosis was made by pulmonologists (M.O., H.S.). In Japan, the frequency of diseases (eg, histoplasmosis) other than sarcoidosis in patients with multiple hilar-mediastinal lymphadenopathy presenting with noncaseating epithelioid cell granulomas is quite low, and a similar result was also reported by another Japanese group.2Iwashita T. Yasuda I. Doi S. Kato T. Sano K. Yasuda S. et al.The yield of endoscopic ultrasound-guided fine needle aspiration for histological diagnosis in patients suspected of stage I sarcoidosis.Endoscopy. 2008; 40: 400-405Crossref PubMed Scopus (55) Google Scholar The third issue raised was the limitation of the nonrandomized design. As we reported in the “Discussion” section, the order of these procedures could affect the results. A large international multicenter comparative study would elucidate more detail on ultrasound-guided needle aspiration procedures versus conventional bronchoscopy.3National Institutes of Health. Trial for the diagnosis of sarcoidosis. Available at: http://clinicaltrials.gov/ct2/show/NCT00872612. Accessed July 15, 2012.Google Scholar At a time when only conventional procedures (eg, TBLB or mediastinoscopy) were available for the pathologic diagnosis of stage I sarcoidosis, simple observation without confirmatory biopsy was recommended because of risk/benefit and cost/benefit considerations.4Reich J.M. Brouns M.C. O’Connor E.A. Edwards M.J. Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis.Chest. 1998; 113: 147-153Crossref PubMed Scopus (96) Google Scholar However, a new approach, EBUS-TBNA, is a much less-invasive and more accurate procedure than these conventional procedures. We investigators must clarify the role of this new procedure, even for asymptomatic patients with stage I sarcoidosis, in a prospective trial approved by an institutional review board. Arguments advocating for confirmatory biopsy for asymptomatic stage I sarcoidosis were not the aim of our study; however, the indications should be debated whenever a promising procedure is developed. Sarcoidosis—no business of the bronchoscopistThe Journal of Thoracic and Cardiovascular SurgeryVol. 144Issue 5PreviewWe read with interest the report “Prospective study of endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes versus transbronchial lung biopsy of lung tissue for diagnosis of sarcoidosis” by Oki and colleagues,1 which appeared in the June issue of the Journal. While congratulating them for their effort in clarifying this controversial and relevant topic, we want to share some significant concerns we had as we read their report. Full-Text PDF