Endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) of mediastinal lymph nodes: Experience from region with high prevalence of tuberculosis

Abstract

Utility of EUS-FNA in diagnosing granulomatous lesions of mediastinum in regions with high prevalence of tuberculosis has not yet been evaluated. In the present study, utility and limitations of EUS-FNA of mediastinal lesions from a tertiary care center with high prevalence of tuberculosis were studied. All cases where EUS-FNA had been performed to diagnose mediastinal lymphadenopathy from January 2006 to December 2008 were retrieved from the files of cytopathology laboratory. These were reviewed by the cytopathologist. Two hundred and eighty one EUS-FNA aspirates from 269 patients were evaluated. Satisfactory aspirates were available in 259 cases. A cytological diagnosis of granulomatous lymphadenitis was rendered in 206 cases. Of these, tuberculosis could be established as an etiology in 76 cases and sarcoidosis in 7 cases only. In remaining 123 cases the etiology of granulomatous lymphadenitis could not be established and clinical correlation was suggested. Malignancies were diagnosed or suspected in 24 and 5 cases, respectively. The study highlights that the dilemma of tuberculosis versus sarcoidosis persists in regions with high prevalence of tuberculosis. However, EUS-FNA is useful in diagnosing unsuspected malignancies and confirming the presence of granulomatous lymphadenitis.

Can cytomorphology of granulomas distinguish sarcoidosis from tuberculosis? Retrospective study of endobronchial ultrasound guided transbronchial needle aspirate of 49 granulomatous lymph nodes

“…Though EUS FNA confirmed the presence of granulomatous lymphadenitis, the dilemma of TB versus sarcoidosis could not be resolved in patients with overlapping clinico-radiologic features from tubercular endemic areas. [9]…”

Endoscopic ultrasound in the diagnosis of mediastinal diseases

“…Manucha et al (2011) on the other hand evaluated 281 EUS-FNA aspirates from 269 patients and satisfactory aspirates were available in 259 cases [19]. In addition a cytologic diagnosis of granulomatous lymphadenitis was rendered in 206 cases.…”

Transesophageal endoscopic ultrasound (EUS) in pulmonary medicine

“…Another indication of EUS-FNA is the diagnosis of mediastinal masses and benign granulomatous lymphadenopathy, e.g. tuberculosis (20)(21)(22), and sarcoidosis, with a sensitivity in the detection of lymph nodal non-necrotizing granulomas of about 87% (23). The contraindications to EUS-FNA are fundamentally represented by a status of known current bleeding or obstruction of the esophagus, and the suspicion that the lesion to be sampled is a cystic lesion, because of the high risk of infection and mediastinitis in these cases (24,25).…”

“…Tuberculosis is another granulomatous disease that most often comes in the differential diagnosis of sarcoidosis, and the sensitivity of the diagnostic methods varies depending on different endemicity of the disease. An Indian retrospective study was recently published, conducted in a tertiary care center in an area with a high prevalence of tuberculosis in 269 patients with mediastinal lymphadenopathy who underwent EUS-FNA (54). In 206 cases (76.5%) a cytological diagnosis of granulomatous lymphadenitis was obtained, but only in 36.8% of cases it was possible to establish with certainty a diagnosis of tuberculosis (Ziehl Neelsen positive), while in only 7 cases (3.2%) a definite diagnosis of sarcoidosis was possible, in the absence of a definitive typing of granulomatous lym-…”

“…Thus, these results showed that in areas with a high prevalence of tuberculosis there is still a very high dilemma in the differential diagnostic between tuberculosis and sarcoidosis (54). Another recent Indian study, a prospective one, has evaluated 60 patients with mediastinal lymphadenopathy and suspected tuberculosis, in the absence of parenchymal lung lesions: EUS-FNA obtained a final diagnosis in 42 patients (32 tuberculosis, 6 sarcoidosis, and 4 Hodgkin's lymphoma) (54).…”