Diagnostic Techniques in Sarcoidosis-Past, Present and the Future

Main Article Content

Syed Jawad Ahmad Ahmed Fahim

Abstract

Introduction: Sarcoidosis has historically been a challenging disorder to diagnose secondary to its non-specific symptoms and multi-system nature of organ involvement. Since the description of Kviem test in 1941, the diagnostic investigations have evolved substantially over time. We have witnessed refinement of the procedures to detect granulomatous inflammation with increasing utilisation of image guided modalities and more recently Transbronchial Lung Cryo-biopsy with an acceptable diagnostic yield.


Methods: In this review, we aim to describe the utility of diagnostic techniques over the decades and propose an algorithm to help General Physicians as well as Pulmonologists. We used search terms including Sarcoidosis, Diagnosis, Transbronchial as well as endobronchial biopsy, Ultrasound guided core biopsy, Endobronchial ultrasound, Transbronchial Lung Cryo-biopsy, Fine Needle Aspiration as well as peripheral lymph node biopsy.


Results: There has been significant advancement in the diagnostic techniques with improvement in the diagnostic yield for histological confirmation of Sarcoidosis.  clinical evidence and diagnostic utility of salient diagnostic investigations has been evaluated in this review. The description of diagnostic methods and clinical evidence is deliberately kept brief. Ultrasound guided core biopsy of cervical lymph nodes (even in the absence of palpable glands) should be considered as least invasive test in suspected cases of mediastinal sarcoidosis. Transbronchial Lung Cryo-biopsy is relatively recent development in the diagnostic pathway and is an advantageous tool when lung parenchymal abnormalities are coupled with lack or minimal mediastinal and or hilar adenopathy. 


Conclusion: We propose a diagnostic algorithm for patients with suspected Sarcoidosis. The choice of investigation should be decided following discussion in a multi-disciplinary meeting. In appropriate clinical/radiological setting and expertise, core biopsy of cervical lymph nodes should be considered the first line investigation as it may prevent the need for more invasive bronchoscopic procedures. However, in the absence of mediastinal/cervical lymphadenopathy, Cryobiopsy (if available) should be considered, in preference to more invasive thoracic surgical procedure (s) associated with higher morbidity and mortality.

Article Details

How to Cite
AHMAD, Syed Jawad; FAHIM, Ahmed. Diagnostic Techniques in Sarcoidosis-Past, Present and the Future. Medical Research Archives, [S.l.], v. 12, n. 5, may 2024. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/5278>. Date accessed: 19 june 2024. doi: https://doi.org/10.18103/mra.v12i5.5278.
Section
Research Articles

References

1. James DG. Centenary commemoration of sarcoidosis and of Jonathan Hutchinson. Br Med J. 1969;2(5649):109-110. Doi:10.1136/bmj.2.5649.109
2. SCADDING JG. Discussion on sarcoidosis. Proc R Soc Med. 1956;49(10):799-806.
3. Keijsers RG, Veltkamp M, Grutters JC. Chest Imaging. Clin Chest Med. 2015;36(4):603-619. Doi:10.1016/j.ccm.2015.08.004
4. Te HS, Perlman DM, Shenoy C, et al. Clinical characteristics and organ system involvement in sarcoidosis: comparison of the University of Minnesota Cohort with other cohorts. BMC Pulm Med. 2020;20(1):155. Published 2020 Jun 1. Doi:10.1186/s12890-020-01191-x
5. Crombag LMM, Mooij-Kalverda K, Szlubowski A, et al. EBUS versus EUS-B for diagnosing sarcoidosis: The International Sarcoidosis Assessment (ISA) randomized clinical trial. Respirology. 2022;27(2):152-160. Doi:10.1111/resp.14182
6. Bonifazi M, Tramacere I, Zuccatosta L, et al. Conventional versus Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Hilar/Mediastinal Lymph Adenopathies: A Randomized Controlled Trial. Respiration. 2017;94(2):216-223. Doi:10.1159/000475843
7. Dhooria S, Sehgal IS, Gupta N, et al. A Randomized Trial Evaluating the Effect of 10 versus 20 Revolutions Inside the Lymph Node on the Diagnostic Yield of EBUS-TBNA in Subjects with Sarcoidosis. Respiration. 2018;96(5):464-471. Doi:10.1159/000490192
8. Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146(3):547-556. Doi:10.1378/chest.13-2339
9. Gnass M, Szlubowski A, Soja J, et al. Comparison of conventional and ultrasound-guided needle biopsy techniques in the diagnosis of sarcoidosis: a randomized trial. Pol Arch Med Wewn. 2015;125(5):321-328. Doi:10.20452/pamw.2828
10. Dhooria S, Sehgal IS, Prasad KT, et al. Diagnostic yield and safety of the ProCore versus the standard EBUS-TBNA needle in subjects with suspected sarcoidosis. Expert Rev Med Devices. 2021;18(2):211-216. Doi:10.1080/17434440.2021.1876560
11. Madan K, Dhungana A, Mohan A, et al. Conventional Transbronchial Needle Aspiration Versus Endobronchial Ultrasound-guided Transbronchial Needle Aspiration, With or Without Rapid On-Site Evaluation, for the Diagnosis of Sarcoidosis: A Randomized Controlled Trial. J Bronchology Interv Pulmonol. 2017;24(1):48-58. Doi:10.1097/LBR.0000000000000339
12. Li K, Jiang S. A randomized controlled study of conventional TBNA versus EBUS-TBNA for diagnosis of suspected stage I and II sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2014;31(3):211-218. Published 2014 Oct 20
13. Tremblay A, Stather DR, MacEachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest. 2009;136(2):340-346. Doi:10.1378/chest.08-2768
14. Chee A, Khalil M, Stather DR, MacEachern P, Field SK, Tremblay A. Cytologic assessment of endobronchial ultrasound-guided transbronchial needle aspirates in sarcoidosis. J Bronchology Interv Pulmonol. 2012;19(1):24-28. Doi:10.1097/LBR.0b013e3182442925
15. Wälscher J, Büscher E, Bonella F, et al. Comparison of a 22G Crown-Cut Needle with a Conventional 22G Needle with EBUS Guidance in Diagnosis of Sarcoidosis. Lung. 2022;200(5):633-641. Doi:10.1007/s00408-022-00562-x
16. Pfeiffer J, Kayser G, Ridder GJ. Sonography-assisted cutting needle biopsy in the head and neck for the diagnosis of lymphoma: can it replace lymph node extirpation?. Laryngoscope. 2009;119(4):689-695. Doi:10.1002/lary.20110
17. Fahim A, Qasim MM, Rosewarne D. Neck as mediastinal extension: Diagnosis of sarcoidosis by core biopsy of cervical lymph nodes. Clin Respir J. 2020;14(1):16-20. Doi:10.1111/crj.13094
18. Kebbe J, Abdo T. Interstitial lung disease: the diagnostic role of bronchoscopy. J Thorac Dis. 2017;9(Suppl 10):S996-S1010. Doi:10.21037/jtd.2017.06.39
19. Shen Y, Pang C, Wu Y, et al. Diagnostic Performance of Bronchoalveolar Lavage Fluid CD4/CD8 Ratio for Sarcoidosis: A Meta-analysis. EBioMedicine. 2016;8:302-308. Doi:10.1016/j.ebiom.2016.04.024
20. Sindhu A, Jadhav U, Ghewade B, Wagh P, Yadav P. Unveiling the Diagnostic Potential: A Comprehensive Review of Bronchoalveolar Lavage in Interstitial Lung Disease. Cureus. 2024;16(1):e52793. Published 2024 Jan 23. Doi:10.7759/cureus.52793
21. Costabel U, Bonella F, Ohshimo S, Guzman J. Diagnostic modalities in sarcoidosis: BAL, EBUS, and PET. Semin Respir Crit Care Med. 2010 Aug;31(4):404-8. Doi: 10.1055/s-0030-1262207. Epub 2010 Jul 27. PMID: 20665390.
22. Levin DC, Wicks AB, Ellis JH Jr. Transbronchial lung biopsy via the fiberoptic bronchoscope. Am Rev Respir Dis. 1974;110(1):4-12. Doi:10.1164/arrd.1974.110.1.4
23. Wall CP, Gaensler EA, Carrington CB, Hayes JA. Comparison of transbronchial and open biopsies in chronic infiltrative lung diseases. Am Rev Respir Dis. 1981;123(3):280-285. Doi:10.1164/arrd.1981.123.3.280
24. Mitchell DM, Emerson CJ, Collins JV, Stableforth DE. Transbronchial lung biopsy with the fibreoptic bronchoscope: analysis of results in 433 patients. Br J Dis Chest. 1981;75(3):258-262. Doi:10.1016/0007-0971(81)90003-6
25. Zavala DC. Diagnostic fiberoptic bronchoscopy: Techniques and results of biopsy in 600 patients. Chest. 1975;68(1):12-19. Doi:10.1378/chest.68.1.12
26. Descombes E, Gardiol D, Leuenberger P. Transbronchial lung biopsy: an analysis of 530 cases with reference to the number of samples. Monaldi Arch Chest Dis. 1997;52(4):324-329
27. Mitchell DM, Mitchell DN, Collins JV, Emerson CJ. Transbronchial lung biopsy through fibreoptic bronchoscope in diagnosis of sarcoidosis. Br Med J. 1980;280(6215):679-681. Doi:10.1136/bmj.280.6215.679
28. Sehgal IS, Bal A, Dhooria S, et al. Predictors of Successful Yield of Transbronchial Lung Biopsy in Patients With Sarcoidosis. J Bronchology Interv Pulmonol. 2018;25(1):31-36. Doi:10.1097/LBR.0000000000000439
29. Poletti V, Casoni GL, Gurioli C, Ryu JH, Tomassetti S. Lung cryobiopsies: a paradigm shift in diagnostic bronchoscopy?. Respirology. 2014;19(5):645-654. Doi:10.1111/resp.12309
30. Raghu G, Remy-Jardin M, Richeldi L, et al. Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults: An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med. 2022;205(9):e18-e47. Doi:10.1164/rccm.202202-0399ST
31. Katgi N, Çimen P, Çirak AK, et al. Complication and cost analysis of transbronchial lung cryobiopsy and awake video-assisted thoracic surgery in diagnosis of interstitial lung disease. Sarcoidosis Vasc Diffuse Lung Dis. 2022;39(1):e2022005. Doi:10.36141/svdld.v39i1.12293
32. Zaizen Y, Tachibana Y, Ozasa M, et al. Sensitivity of transbronchial lung cryobiopsy in the diagnosis of different interstitial lung diseases. Sci Rep. 2022;12(1):22037. Published 2022 Dec 21. Doi:10.1038/s41598-022-26510-6
33. Häntschel M, Eberhardt R, Petermann C, et al. Diagnostic Yield of Transbronchial Lung Cryobiopsy Compared to Transbronchial Forceps Biopsy in Patients with Sarcoidosis in a Prospective, Randomized, Multicentre Cross-Over Trial. J Clin Med. 2021;10(23):5686. Published 2021 Dec 2. Doi:10.3390/jcm10235686
34. Hostettler KE, Tamm M, Bubendorf L, et al. Integration of transbronchial cryobiopsy into multidisciplinary board decision: a single center analysis of one hundred consecutive patients with interstitial lung disease. Respir Res. 2021;22(1):228. Published 2021 Aug 14. Doi:10.1186/s12931-021-01821-w
35. Gnass M, Filarecka A, Bartczak A, et al. Transbronchial lung cryobiopsy guided by radial mini-probe endobronchial ultrasound in interstitial lung diseases - a multicenter prospective study. Adv Respir Med. 2020;88(2):123-128. Doi:10.5603/ARM.2020.0086
36. Jacob M, Bastos HN, Mota PC, et al. Diagnostic yield and safety of transbronchial cryobiopsy in sarcoidosis. ERJ Open Res. 2019;5(4):00203-2019. Published 2019 Oct 21. Doi:10.1183/23120541.00203-2019
37. Dhooria S, Mehta RM, Srinivasan A, et al. The safety and efficacy of different methods for obtaining transbronchial lung cryobiopsy in diffuse lung diseases. Clin Respir J. 2018;12(4):1711-1720. Doi:10.1111/crj.12734
38. Aragaki-Nakahodo AA, Baughman RP, Shipley RT, Benzaquen S. The complimentary role of transbronchial lung cryobiopsy and endobronchial ultrasound fine needle aspiration in the diagnosis of sarcoidosis. Respir Med. 2017;131:65-69. Doi:10.1016/j.rmed.2017.08.003
39. Sriprasart T, Aragaki A, Baughman R, et al. A Single US Center Experience of Transbronchial Lung Cryobiopsy for Diagnosing Interstitial Lung Disease With a 2-Scope Technique. J Bronchology Interv Pulmonol. 2017;24(2):131-135. Doi:10.1097/LBR.0000000000000366
40. Crouser ED, Maier LA, Wilson KC, Bonham CA, Morgenthau AS, Patterson KC, Abston E, Bernstein RC, Blankstein R, Chen ES, Culver DA, Drake W, Drent M, Gerke AK, Ghobrial M, Govender P, Hamzeh N, James WE, Judson MA, Kellermeyer L, Knight S, Koth LL, Poletti V, Raman SV, Tukey MH, Westney GE, Baughman RP. Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020 Apr 15;201(8): e26-e51. Doi: 10.1164/rccm.202002-0251ST. PMID: 32293205; PMCID: PMC7159433.
41. Fahim A, Rosewarne D. Tissue Sampling in Suspected Sarcoidosis: Can We Avoid Mediastinal Procedures? Am J Respir Crit Care Med. 2020;202(9):1321. Doi:10.1164/rccm.202004-1501LE