Endoscopy 2010; 42(6): 462-467
DOI: 10.1055/s-0029-1244133
Original article
 
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound-guided fine-needle aspiration cytology in the evaluation of suspected tuberculosis in patients with isolated mediastinal lymphadenopathy

R.  Puri1 , P.  Vilmann2 , R.  Sud1 , M.  Kumar1 , S.  Taneja1 , K.  Verma3 , N.  Kaushik4
  • 1Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
  • 2Department of Surgical Gastroenterology, Herlev and Gentofte Hospital, Copenhagen University hospitals, Hellerup, Denmark
  • 3Department of Cytopathology, Sir Ganga Ram Hospital, New Delhi, India
  • 4Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, USA
Further Information

Publication History

submitted 1 August 2009

accepted after revision 18 February 2010

Publication Date:
29 April 2010 (online)

Background and study aims: Patients with suspected tuberculosis without pulmonary lesions and with mediastinal lymphadenopathy often pose a diagnostic challenge. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) cytology is an established modality to evaluate mediastinal and abdominal lesions. The aim of the present study was to evaluate the role of EUS-FNA in isolated mediastinal lymphadenopathy in patients suspected of having tuberculosis.

Methods: Consecutive patients suspected of having tuberculosis with isolated mediastinal lymphadenopathy were included in a prospective study. Mediastinal lymphadenopathy was diagnosed on a contrast-enhanced computed tomography scan of the chest. Patients with concomitant lung parenchymal lesions were excluded. Previous attempts to diagnose the etiology of lymphadenopathy had failed in 69 % of patients. EUS-FNA was performed on an outpatient basis under conscious sedation. The sensitivity, specificity, and diagnostic accuracy of EUS-FNA were calculated.

Results: A total of 60 consecutive patients (mean age 39.8 years, 58 % males) with mediastinal lymphadenopathy were included. EUS confirmed the presence of mediastinal lymph nodes ranging in size from 8 mm to 40 mm (mean 26 mm) in all patients. EUS-FNA provided an adequate tissue sample in 54 patients during the first examination and repeat EUS-FNA was necessary in six patients. A final diagnosis was obtained by EUS-FNA in 42 patients (tuberculosis in 32, sarcoidosis in six, and Hodgkin’s disease in four patients). An additional 14 patients were treated for tuberculosis based on EUS-FNA and clinical features. Mediastinoscopy was required for diagnosis in the remaining four patients. EUS-FNA had an overall diagnostic yield of 93 %, sensitivity of 71 %, specificity of 100 %, and positive predictive value of 100 %.

Conclusion: EUS-FNA is an accurate, safe, and minimally invasive modality for evaluating isolated mediastinal lymphadenopathy in patients suspected of having tuberculosis in an endemic area with a high prevalence of tuberculosis.

References

  • 1 Lloyd C, Silvestri G A. Mediastinal staging of non-small-cell lung cancer.  Cancer Control. 2001;  8 311-317
  • 2 Silvestri G A, Hoffmann B J, Bhutani M S. et al . Endoscopic ultrasound with fine needle aspiration in the diagnosis and staging of lung cancer.  Ann Thorac Surg. 1996;  61 1441-1446
  • 3 Gress F, Savides T, Sandler A. et al . Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study.  Ann Intern Med. 1997;  127 604-612
  • 4 Fritscher-Ravens A, Soehendra N, Schirrow L. et al . Role of transesophageal endosonography-guided fine-needle aspiration in the diagnosis of lung cancer.  Chest. 2000;  117 339-345
  • 5 Serna D L, Aryan H E, Chang K J. et al . An early comparison between endoscopic ultrasound-guided fine-needle aspiration and mediastinoscopy for diagnosis of mediastinal malignancy.  Am J Surg. 1998;  64 1014-1018
  • 6 Giovannini M, Seitz J F, Monges G. et al . Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients.  Endoscopy. 1995;  27 171-177
  • 7 Codecasa L R, Besozzi G, De Cristofaro L. et al . Epidemiological and clinical patterns of intrathoracic lymph node tuberculosis in 60 human immunodeficiency virus-negative adult patients.  Monaldi Arch Chest Dis. 1998;  53 277-280
  • 8 Pastores S M, Naidich D P, Aranda C P. et al . Intrathoracic adenopathy associated with pulmonary tuberculosis in patients with human immunodeficiency virus infection.  Chest. 1993;  103 1433-1437
  • 9 Catena E, De Simone G, Caramori G. et al .Extrapulmonary tuberculosis. In: Wilson R, ed Tuberculosis. Sheffield, UK; ERJ Ltd 1997 181: 176-177
  • 10 Report from the Medical Research Council Tuberculosis and Chest Diseases Unit. National survey of tuberculosis notifications in England and Wales in 1983: characteristics of disease.  Tubercle. 1987;  68 19-32
  • 11 Pitchenik A E, Fertel D, Bloch A B. Mycobacterial disease: epidemiology, diagnosis, treatment, and prevention.  Clin Chest Med. 1988;  9 425-441
  • 12 Snider Jr. D E, Roper W E. The new tuberculosis.  N Engl J Med. 1992;  326 703-705
  • 13 Snider D E, Onorato M. Epidemiology. In: Rossman MD, MacGregor RR, eds Tuberculosis: clinical management and new challenges. New York; McGraw-Hill 1995: 3-17
  • 14 Lado F L, Barrio Gomez H, Carballo Arceo H, Cabarcos Ortiz de Barren A. Clinical presentation of tuberculosis and the degree of immunodeficiency in patients with HIV infection.  Scand J Inject Dis. 1999;  31 387-391
  • 15 Lee M P, Chan J W, Ng K K, Li P C. Clinical manifestations of tuberculosis in HIV-infected patients.  Respirology. 2000;  5 423-426
  • 16 Gupta S K, Chugh T D, Sheikh Z A, al-Rubah N A. Cytodiagnosis of tuberculous lymphadenitis: a correlative study with microbiologic examination.  Acta Cytol. 1993;  37 329-332
  • 17 Radhika S, Gupta S K, Chakrabarti A. et al . Role of culture for mycobacteria in fine-needle aspiration diagnosis of tuberculosis lymphadenitis.  Diagn Cytopathol. 1989;  5 260-262
  • 18 Westcott J L. Percutaneous needle aspiration of hilar and mediastinal masses.  Radiology. 1981;  181 323-329
  • 19 Wernecke K, Vassallo P, Peters E P, Von Bassewitz D B. Mediastinal tumors: biopsy under US guidance.  Radiology. 1989;  172 473-476
  • 20 Van Sonnenberg E, Casola G, Ho M. et al . Difficult thoracic lesions: CT guided biopsy experience in 150 cases.  Radiology. 1988;  167 457-461
  • 21 Hanow E M, Oldenberg F A, Lingenfelter M S, Smith A M. Transbronchial needle aspiration in clinical practice: a five year experience.  Chest. 1989;  96 1268-1272
  • 22 Harkin T J, Ciotoli C, Adrizzo-Harris D J. et al . Transbronchial needle aspiration (TBNA) in patients infected with HIV.  Am J Respir Crit Care Med. 1998;  157 1913-1918
  • 23 Rex D K, Tarver R D, Wiersema M. et al . Endoscopic transesophageal fine needle aspiration of mediastinal masses.  Gastrointest Endosc. 1991;  37 (4) 465-468
  • 24 Wiersema M J, Hawes R H, Tao L C. et al . Endoscopic ultrasonography as an adjunct to fine needle aspiration cytology of the upper and lower gastrointestinal tract.  Gastrointest Endosc. 1992;  38 35-39
  • 25 Wiersema M J, Kochman M L, Chak A. et al . Real time endoscopic ultrasound guided fine needle aspiration of a mediastinal lymph node.  Gastrointest Endosc. 1993;  39 429-431
  • 26 Wegener M, Adamek R J, Wedmann B, Pfaffenbach B. Endosonographically guided fine-needle aspiration puncture of paraesophagogastric mass lesions: preliminary results.  Endoscopy. 1994;  26 586-591
  • 27 Ikenberry S, Gress F, Savides T, Hawes R. Fine-needle aspiration of posterior mediastinal lesions guided by radial scanning endosonography.  Gastrointest Endosc. 1996;  43 605-610
  • 28 Fritscher-Ravens A, Sriram P VJ, Bobrowski C. et al . Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNA-based differential cytodiagnosis in 153 patients.  Am J Gastroenterol. 2000;  95 2278-2284
  • 29 Mishra G, Sahai A V, Pennman I D. et al . Endoscopic ultrasonography with fine needle aspiration: an accurate and simple diagnostic modality for sarcoidosis.  Endoscopy. 1999;  31 377-3782
  • 30 Annema J T, Veselic M, Rabe K F. Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of sarcoidosis.  Eur Respir J. 2005;  25 405-409
  • 31 Wildi S M, Judson M A, Fraig M. et al . Is endosonography guided fine needle aspiration for sarcoidosis as good as we think?.  Thorax. 2004;  59 794-799
  • 32 Verma K, Kapila K. Aspiration cytology for diagnosis of tuberculosis-perspective in India.  Indian J Pediatr. 2002;  69 S39-S43

R. PuriMD 

Medanta Institute of Digestive and Hepatobiliary Sciences
Medanta, The Medicity

Sec-38, Gurgaon
Haryana – 122001
India

Fax: +91-124-4834111

Email: purirajesh69@gmail.comrajesh.puri@medanta.org