纤维支气管镜检查对结节病诊断的临床价值

目的 评价经纤维支气管镜下不同取材对结节病诊断的价值.方法 回顾性分析50例经纤维支气管镜检查,采用肺内活检(包括经支气管黏膜活检和经纤维支气管镜肺活检)、经气管镜针吸活检(TBNA)和经气管镜超声引导针吸活检术(EBUS-TBNA)等方法获取标本,经病理学或细胞学检查确诊为结节病的患者,比较不同取材及联合取材检测结节...     

Bronchoscopy in sarcoidosis: diagnostic and therapeutic interventions

Flexible bronchoscopy has revolutionized the evaluation of patients with suspected sarcoidosis and the treatment of sarcoid patients with significant endobronchial disease. The authors explore the diagnostic and therapeutic utility of flexible bronchoscopy by reviewing the pertinent literature with a special interest in recent studies. Bronchoscopy allows multiple diagnostic modalities in suspected sarcoidosis. Recent studies show sometimes surprising results, and the authors review the additive contributions of transbronchial lung biopsy, endobronchial biopsy, transbronchial needle aspiration, and bronchoalveolar lavage to diagnose sarcoidosis. New data specifically show the additive benefit of routine endobronchial biopsy and transbronchial needle aspiration to traditional transbronchial biopsy specimens. In addition, the techniques have been optimized via recent studies and these results are discussed. Endobronchial therapy is reviewed with the recent findings of the superiority of balloon bronchoplasty. Flexible bronchoscopy has a very high diagnostic yield in all stages of suspected sarcoidosis. Transbronchial lung biopsy and endobronchial biopsy should be used routinely, and transbronchial needle aspiration should be considered in cases of significant adenopathy. Bronchoalveolar lavage should be used routinely to exclude alternative diagnoses. Therapeutic bronchoscopy is rarely needed, but when necessary the authors' procedure of choice is bronchoscopic balloon dilatation.     

超声内镜引导下经气管针吸活检的临床应用

超声内镜引导下经气管针吸活检在原发性支气管肺癌、肺转移癌的诊断与治疗以及结节病、纵隔肿瘤、肺内病变的诊断方面发挥了重要的作用.超声内镜引导下经气管针吸活检并发症少,特异性和敏感性高,是一项非常有用的检查手段.     

超声内镜引导下经气管针吸活检的临床应用

超声内镜引导下经气管针吸活检在原发性支气管肺癌、肺转移癌的诊断与治疗以及结节病、纵隔肿瘤、肺内病变的诊断方面发挥了重要的作用.超声内镜引导下经气管针吸活检并发症少,特异性和敏感性高,是一项非常有用的检查手段.     

超声内镜引导下经气管针吸活检的临床应用

超声内镜引导下经气管针吸活检在原发性支气管肺癌、肺转移癌的诊断与治疗以及结节病、纵隔肿瘤、肺内病变的诊断方面发挥了重要的作用.超声内镜引导下经气管针吸活检并发症少,特异性和敏感性高,是一项非常有用的检查手段.     

Transbronchial fine needle aspiration cytological examination: a useful tool for diagnosing primary lung cancer

BACKGROUND: Obtaining a definitive preoperative diagnosis plays a critical role in deciding upon the treatment approach for lung carcinoma. However, success in making definitive diagnoses of small primary lung cancers will require new approaches because these cancers are difficult to detect using standard biopsy procedures. METHODS: We evaluated the results of morphologic definitive diagnosis together with various clinical factors in 1003 primary lung cancers resected surgically. Patients underwent transbronchial brushing, fine needle aspiration cytology, forceps biopsy, and/or forceps biopsy-stamp cytology for preoperative diagnoses, in conjunction with the use of Diff-Quik to confirm that hits had been made on the radiographic shadows before terminating the examinations. RESULTS: Sensitivities of the diagnostic procedures for primary lung cancers were as follows: 64.8% for brushing, 56.1% for transbronchial forceps biopsy, 72.0% for transbronchial forceps biopsy-stamp cytology, and 86.4% for transbronchial fine needle aspiration. The four transbronchial biopsy procedures had a combined overall sensitivity of 92.7%. In patients with peripheral lung cancers of 2 cm or less in diameter, transbronchial fine needle aspiration had a sensitivity of 75.9%, which was the highest sensitivity for all transbronchial examinations. In the subset of 296 patients who underwent all four transbronchial biopsy examinations, transbronchial fine needle aspiration had the highest sensitivity of preoperative diagnosis of all the transbronchial examination methods. CONCLUSIONS: The sensitivity of preoperative cytological diagnosis for primary lung cancers, especially transbronchial aspiration cytology, is high. Transbronchial fine needle aspiration cytology is useful for the preoperative diagnosis of primary lung cancer.     

Case of HLA-DR8 positive sarcoidosis following polymyositis and Sj?gren's syndrome]

A 69-year-old woman had been found to have idiopathic interstitial pneumonia (fibrotic NSIP) in 1997. Proximal muscle weakness appeared in April 2005. Chest CT revealed hilar and mediastinal lymphadenopathy. Polymyositis and Sj?gren's syndrome were subsequently diagnosed. We assumed that the interstitial pneumonia had preceded polymyositis and Sj?gren's syndrome. A muscle biopsy and transbronchial needle aspiration biopsy demonstrated noncaseating epithelioid cell granulomas. A diagnosis of sarcoidosis complicated with polymyositis and Sj?gren's syndrome was made from these findings. Moreover, her HLA genotype contained DR8. HLA-DR8 is considered to be associated with polymyositis, Sj?gren's syndrome, and sarcoidosis in Japanese patients. This case suggests the possibility that there are common immunological and genetical pathogenetic mechanisms in autoimmune diseases and sarcoidosis.     

Combination of endobronchial ultrasound-guided transbronchial needle aspiration with standard bronchoscopic techniques for the diagnosis of stage I and stage II pulmonary sarcoidosis

Background and objective: Standard bronchoscopic techniques (transbronchial lung biopsy and endobronchial biopsy) provide a diagnosis in 70% of patients with pulmonary sarcoidosis. Previous data suggest that endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has a high sensitivity in patients with sarcoidosis. The feasibility and utility of combining EBUS‐TBNA with standard bronchoscopic techniques is unknown. The aim of this study was to evaluate the feasibility, safety and efficacy of combined EBUS‐TBNA and standard bronchoscopic techniques in patients with suspected sarcoidosis and enlarged mediastinal or hilar lymphadenopathy. Methods: Forty consecutive patients with suspected pulmonary sarcoidosis and enlarged mediastinal or hilar lymph nodes (radiographical stage I and stage II) underwent EBUS‐TBNA followed by transbronchial biopsies and endobronchial biopsies under conscious sedation. Results: Thirty‐nine out of 40 patients successfully underwent combined EBUS‐TBNA and standard bronchoscopy. Twenty‐seven patients were diagnosed with sarcoidosis, eight had tuberculosis, two had reactive lymphadenopathy, two had lymphoma and one had metastatic adenocarcinoma. In patients with sarcoidosis, the sensitivity of EBUS‐TBNA for detection of non‐caseating granulomas was 85%, compared with a sensitivity of 35% for standard bronchoscopic techniques (P < 0.001). The diagnostic yield of combined EBUS‐TBNA and bronchoscopy was 93% (P < 0.0001). Conclusions: Combination of EBUS‐TBNA with standard bronchoscopic techniques is safe and feasible, and optimizes the diagnostic yield in patients with pulmonary sarcoidosis and enlarged intrathoracic lymphadenopathy.     

纤支镜与超声介入对肺癌检出率的比较

目的 探讨利用纤支镜与超声介入技术对肺癌检出率的比较。方法 选择肺部肿瘤患285例为受试，均先做纤支镜，第二日再做超声肺部肿瘤探查并行超声引导下肺肿块穿刺活检。上述二项检查标本做组织细胞学的病理检查。结果 纤支镜检出肺鳞癌99例、腺癌72例及未分化癌41例，而非肺癌73例。超声介入技术检出肺鳞癌97例、腺癌69例及未分化癌46例，而非肺癌73例。结论 纤支镜技术对中央型肺癌检出率方便准确，而超声介入技术对周围肺癌检出率高而方便。上述两项技术对肺癌检出具有叠加作用。     

多种技术联合应用对肺癌诊断的临床价值

目的评价多种技术联合应用对肺癌诊断的临床价值。方法 884例痰脱落细胞学、细菌学、常规支气管镜等检查均无阳性发现的疑似肺癌的患者行经支气管镜针吸活检术（TBNA）和活检刷检、经支气管镜超声引导针吸活检术（EBUS-TB-NA）、纵隔镜、超声或CT引导经皮肺穿刺活检术、PET-CT和内科电子胸腔镜胸膜活检术。结果 215例患者TBNA、刷检、活检的阳性率分别为81.58%、29.47%和16.84%。15例EBUS-TBNA的阳性率为91.67%,20例超声或CT引导经皮肺穿刺活检术阳性率为65%,10例PET-CT阳性率为80%,628例患者胸腔镜检查的总体阳性率为94.6%。结论多种技术联合应用可明显提高肺癌的早期诊断率。     

Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis.

A diagnosis of sarcoidosis should be substantiated by pathological means in order to thoroughly exclude other diseases. The role of real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of sarcoidosis has not been reported. The purpose of the present study is to evaluate the diagnostic yield of EBUS-TBNA in demonstrating the pathological features of sarcoidosis. In total, 65 patients with suspected sarcoidosis, with enlarged hilar or mediastinal lymph nodes on computed tomography, were included in the study. Patients with a suspected or known malignancy or previously established diagnosis of sarcoidosis were excluded. Convex probe endobronchial ultrasonography integrated with a separate working channel was used for EBUS-TBNA. Surgical methods were performed in those in whom no granulomas were detected by EBUS-TBNA. Patients were followed up clinically. EBUS-TBNA was performed on a total of 77 lymph node stations in 65 patients. A final diagnosis of sarcoidosis was made for 61 (93.8%) of the patients. The remaining four patients were diagnosed as having Wegener's granulomatosis (n=1) or indefinite (n=3). In patients with a final diagnosis of sarcoidosis, EBUS-TBNA demonstrated noncaseating epithelioid cell granulomas in 56 (91.8%) of the patients. No complications were reported. Endobronchial ultrasound-guided transbronchial needle aspiration proved to be a safe procedure with a high yield for the diagnoses of sarcoidosis.     

超声支气管镜引导下经支气管纵膈冷冻活检术的操作难度及安全性

目的 分析超声支气管镜(endobronchail ultrasound, EBUS)引导下经支气管纵膈冷冻活检术的操作难易程度和安全性。方法 选取2019年10月至2019年12月我院收治的25例纵膈病变患者,术前根据胸部CT等检查评估患者病变大小和位置,与周围组织关系,以及基础疾病情况。患者序贯接受EBUS引导下经支气管针吸活检术和纵膈冷冻活检术,对比两种术式的操作时间、术中指引情况、操作难度评分和围手术期并发症。结果 患者顺利完成EBUS引导下纵膈病变的活检操作。EBUS引导下纵膈活检的操作总体时间为(31.9±7.6)min。冷冻活检与针吸活检相比,两者的操作时间无统计学差异,穿刺活检(8.7±1.8)min vs.冷冻活检(9.3±4.3)min(P>0.05)。两种活检方式的术中指引情况和操作难度评分无统计学差别。患者未出现严重气道出血、纵膈气肿等围手术期并发症。结论 EBUS引导下经支气管纵膈冷冻活检术的操作难度与传统针吸活检无明显差异,安全性好,适合临床开展的纵膈活检新术式。     

Diagnostic utility of endobronchial ultrasound-guided transbronchial needle aspiration compared with transbronchial and endobronchial biopsy for suspected sarcoidosis

Background: Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is an accurate and minimally invasive technique that has been shown to have excellent diagnostic yield in the investigation of mediastinal and hilar lymphadenopathy. There is, however, little evidence comparing this procedure to the traditional diagnostic approach of transbronchial lung (TBLB) and endobronchial (EB) biopsies combined with characteristic clinical and radiological features in sarcoidosis. Aim: To compare the diagnostic yield of EBUS‐TBNA, TBLB and EB in patients with suspected sarcoidosis. Methods: Data from 40 consecutive patients with suspected sarcoidosis who underwent combined EBUS‐TBNA with TBLB and EB biopsies were recorded. Results: A total of 37 patients was confirmed as sarcoidosis, and three had other diagnoses. There was no difference in diagnostic accuracy rates between EBUS‐TBNA and TBLB for all stages of sarcoidosis (84% vs 78%, P= 0.77). Combined EBUS‐TBNA and TBLB procedures yielded a diagnostic accuracy of 100%. There was a highly significant difference in diagnostic accuracy between EBUS‐TBNA and EB in stage I (80% vs 27%) (P < 0.01) and stage II disease (86% vs 27%) (P < 0.01). Similarly, a highly significant difference in diagnostic accuracy was seen between TBLB and EB (P < 0.01). No adverse events occurred. Conclusion: Endobronchial ultrasound‐guided transbronchial needle aspiration alone has a high diagnostic yield with a very low complication rate for patients with suspected sarcoidosis.     

Real-time endobronchial ultrasound-guided transbronchial needle aspiration is useful for diagnosing sarcoidosis

BACKGROUND AND OBJECTIVE: Several studies of real-time endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) have reported a sensitivity of approximately 90% in the diagnosis of mediastinal and hilar malignancies. However, few studies have addressed its role in the diagnosis of sarcoidosis. The aim of the present study was to assess the utility of EBUS-TBNA in confirming a pathological diagnosis of sarcoidosis. METHODS: Fifteen consecutive patients with suspected sarcoidosis and mediastinal and/or hilar lymphadenopathy were investigated prospectively. EBUS-TBNA with an echo-bronchoscope and a dedicated echogenic 22-gauge needle was carried out in patients under conscious sedation, followed by conventional TBNA of the same lesion using a 19-gauge needle. RESULTS: EBUS-TBNA and/or TBNA demonstrated non-caseating epithelioid cell granulomas in 14 of 15 patients (93%). All 14 patients with a pathological diagnosis of sarcoidosis were considered to have sarcoidosis based on subsequent clinical assessments. The single patient with a negative EBUS-TBNA and TBNA had a malignant melanoma diagnosed following surgical biopsy. EBUS-TBNA confirmed a diagnosis of sarcoidosis in 13 of the 14 patients (93%) by identifying non-caseating epithelioid cell granulomas in 18 of 23 lymph nodes (78%) sampled. When two needle aspirates of one or two lymph nodes were carried out, the percentage positive pathological diagnosis for sarcoidosis for (i) EBUS-TBNA; (ii) TBNA; and (iii) the combination of EBUS-TBNA and TBNA were 93% (13 of 14 patients), 93% (13 of 14 patients) and 100% (14 of 14 patients), respectively. There were no complications associated with the procedures. CONCLUSION: EBUS-TBNA is less invasive and acceptably sensitive as a method for obtaining pathological confirmation of sarcoidosis.     

Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis

BACKGROUND: The diagnosis of pulmonary sarcoidosis can be established by a variety of techniques. Transbronchial lung biopsy is often the preferred approach, but it is frequently nondiagnostic and carries a risk of pneumothorax and bleeding. Mediastinoscopy is often suggested as the next diagnostic step but entails significant cost and associated morbidity. Endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA) is emerging as a safe, minimally invasive tool for the primary diagnosis of mediastinal and hilar lymphadenopathy. The purpose of this study was to assess the utility of EBUS-TBNA for pulmonary sarcoidosis. METHODS: Fifty consecutive patients who had been referred for EBUS-TBNA for suspected pulmonary sarcoidosis were included in the study. On-site cytology was used to assess the adequacy of the samples. The presence of noncaseating granulomas without necrosis in the appropriate clinical setting was deemed to be adequate for the diagnosis of pulmonary sarcoidosis. Patients with a negative EBUS-TBNA underwent further histologic biopsy or clinical follow-up to determine the final diagnosis. RESULTS: Eighty-two lymph nodes with a median size of 16 mm (range, 4 to 40 mm) were punctured. EBUS-TBNA demonstrated noncaseating granulomas without necrosis in 41 of 48 patients (85%) with a final diagnosis of sarcoidosis. EBUS-TBNA, therefore, has a sensitivity of 85% for the primary diagnosis of pulmonary sarcoidosis. CONCLUSIONS: EBUS-TBNA is a safe, minimally invasive tool for the primary diagnosis of pulmonary sarcoidosis that has a high diagnostic yield. EBUS-TBNA should be considered an appropriate alternative diagnostic technique for patients with suspected pulmonary sarcoidosis.     

Pulmonary amyloidoma. Histologic proof yielded by transthoracic coaxial fine needle biopsy.

Nodular pulmonary amyloidosis was diagnosed by percutaneous transthoracic fine needle biopsy specimen in an 88-year-old woman. Congo red staining should be performed whenever band-like hyalinized material is obtained on aspiration of a solitary nodule. Dense calcifications can occur in pulmonary amyloidomas. In selected cases, fine needle biopsy appears to be preferable to transbronchial forceps biopsy since the risk of a possibly life-threatening pulmonary hemorrhage may be lower.     

Recent advances in sarcoidosis

Sarcoidosis, a systemic granulomatous disease of undetermined etiology, is characterized by a variable clinical presentation and course. During the past decade, advances have been made in the study of sarcoidosis. The multicenter ACCESS (A Case Control Etiologic Study of Sarcoidosis) trial recruited > 700 subjects with newly diagnosed sarcoidosis and matched control subjects. Investigators were unable to identify a single cause of sarcoidosis, but ACCESS paved the way for subsequent etiologic studies. The Mycobacterium tuberculosis catalase-peroxidase protein has been identified as a potential sarcoidosis antigen. Genetic aspects of the disease have been elucidated further. Genome-wide scans have identified candidate genes. Gene expression analyses have defined cytokine dysregulation in sarcoidosis more clearly. Although the criteria for diagnosis have not changed, sarcoidosis remains a diagnosis of exclusion best supported by a tissue biopsy specimen that demonstrates noncaseating granulomas in a patient with compatible clinical and radiologic features of the disease. Endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes has facilitated diagnosis, often eliminating the need for more invasive procedures, such as mediastinoscopy. PET scanning has proven valuable in locating occult sites of active disease. Currently, no reliable prognostic biomarkers have been identified. The tumor necrosis factor inhibitors, a relatively new class of agents, have been used in patients with refractory disease. It is unclear whether phosphodiesterase-5 inhibitors, prostaglandin analogs, or endothelin antagonists should be used for the treatment of sarcoidosis-associated pulmonary hypertension.     

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

Fine needle aspiration biopsy cytology performed in three children with sarcoidosis expedited clinical investigation and diagnosis of their disease. Each patient had a different clinical presentation; in two of them lymphoma was part of the initial differential diagnosis. Aspiration cytology in all cases revealed collections of epithelioid histiocytes, and multinucleate foreign body-type giant cells, without accompanying necrosis or acute inflammation. A diagnosis of non-caseating granulomas consistent with sarcoidosis was made in all aspirates. Special stains for identification of organisms performed on the smears of one case, and culture of aspirate material from one case were negative. Subsequent serum angiotensin converting enzyme levels in all patients were elevated. Chest x-ray films in all patients showed mediastinal and hilar lymphadenopathy. One patient had an interstitial pulmonary infiltrate. All patients responded to steroid therapy. Fine needle aspiration biopsy can be a useful diagnostic tool in the evaluation of children with suspected sarcoidosis.     

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of sarcoidosis.

The objective of the current study was to assess the yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for the diagnosis of sarcoidosis in a large patient group. Bronchoscopy with transbronchial lung biopsy (TBLB) is nondiagnostic in 30% of patients with suspected sarcoidosis and has a risk of pneumothorax and haemoptysis. In order to obtain a diagnosis, mediastinoscopy is often performed as the next diagnostic procedure. EUS-FNA provides a nonsurgical alternative for the demonstration of noncaseating granulomas by aspirating mediastinal lymph nodes from the oesophagus. In total, 51 patients with suspected sarcoidosis stage I and II underwent EUS-FNA. Thirty-six patients (71%) previously underwent a nondiagnostic bronchoscopy. All patients were clinically followed (median 18 months) and surgical-pathological verification occurred in those patients with EUS aspirates that contained unrepresentative material. EUS-FNA demonstrated noncaseating granulomas without necrosis in 41 of 50 patients (82%) with the final diagnosis of sarcoidosis. Specific ultrasound features of clustered, well-demarcated iso-echoic lymph nodes were observed in 64% of patients with sarcoidosis. No complications occurred. Endoscopic ultrasound-guided fine-needle aspiration has a high yield in diagnosing sarcoidosis and qualifies as the next diagnostic step after a nondiagnostic bronchoscopy. The current authors expect that endoscopic ultrasound-guided fine-needle aspiration will reduce the number of mediastinoscopies for the diagnosis of sarcoidosis dramatically.     

经气管镜针吸活检术和经气管镜超声引导针吸活检术在结节病诊断中的价值

目的探讨经气管镜针吸活检术（TBNA）和经气管镜超声引导针吸活检术（EBUS-TBNA）在结节病诊断中的价值。方法选取15例临床表现和胸部CT检查疑似结节病患者,同时行TBNA和纵隔镜检查。另选取20例疑似结节病的患者行EBUS-TBNA检查。结果 15例同时行TBNA和纵隔镜检查患者中诊断为结节病的12例,TBNA诊断阳性率83.33%（10/12）;20例行EBUS-TBNA患者中诊断为结节病的18例,EBUS-TBNA诊断阳性率为88.89%（16/18）。结论 EBUS-TBNA和TBNA创伤性小、安全性好,在结节病的诊断中有较高的应用价值。