The Essential cTBNA Bronchoscopist

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References1. Alsharif M, Andrade RS, Groth SS et al. Endobronchial ultrasound-guidedtransbronchial fine needle aspiration: the University of Minnesota experience, withemphasis on usefulness, adequacy assessment, and diagnostic difficulties. Am J ClinPathol 2008;130: 434-443.2. Lee HS, Lee GK, Lee HS et al. Real-time endobronchial ultrasound guidedtransbronchial needle aspiration in mediastinal staging of nonsmall cell lung cancer:how many aspirations per target lymph node station. Chest 2008;134:368-374.3. Trisolini R, Lazzari A, Patelli. Conventional vs endobronchial ultrasound-guidedtransbronchial needle aspiration of the mediastinum. Chest 2004;126:1005-1006.4. Diacon AH, Schuurmans J, Theron K et al. Transbronchial needle aspirations: how manypasses per target site? Eur Respir J 2007;29:357-362.32
Question I.18 While performing cTBNA from a large right lower pretracheal node in anasymptomatic 30 year old non-smoking African American woman, the cytologist tells you thatthere is «non-caseating granulomatous inflammation». Based on this information, which of thefollowing is the most likely diagnosis?A. Primary lung carcinomaB. SarcoidosisC. TuberculosisD. LymphomaAnswer: BThis patient has a high pre-test probability for sarcoidosis (non-smoking African Americanfemale under 50 years). In sarcoidosis, lymph node enlargement is usually seen in the rightparatracheal, aorto-pulmonary window and hilar regions. The cytology specimens when usedin conjuction with clinical findings, radiological and laboratory investigations, is a useful tool inthe diagnosis of sarcoidosis. In patients with granulomatous disease, cTBNA and endobronchialultrasound guided (EBUS-TBNA) are of great value. In a randomized study with Sarcoidosispatients, EBUS-TBNA was found to have the highest diagnostic yield when combined withtransbronchial lung biopsy, but on the other hand the diagnostic yield of cTBNA plusendobronchial biopsy (EBB) and TBLB was found similar. Demonstration of granulomasremains an essential criterion, but as granulomatous inflammation can be seen in host ofconditions, it is necessary to exclude all possible cause, as well as to correlate with otherfindings, before arriving at the diagnosis of sarcoidosis. One should keep in mind that lymphnodes harboring both necrotizing and non-necrotizing granulomas and malignancy have beendescribed 2,3 . In general, to establish a diagnosis of sarcoidosis it is necessary that granulomatamust be present in two or more organs, with no agent known to cause a granulomatousresponse being identified. A search should be made for other causes of granulomatousinflammation, including mycobacteria, fungi, parasites, and foreign bodies. Tuberculosis may33
Page 2 and 3: FIRST EDITIONThe EssentialcTBNA Bro
Page 4 and 5: The Essential cTBNABronchoscopistCo
Page 6 and 7: Bronchoscopy International, Laguna
Page 8 and 9: Funding statementFunding for The Es
Page 11 and 12: MODULE 1THIRTY MULTIPLE CHOICE QUES
Page 13 and 14: Question I.1 The right pulmonary ar
Page 15 and 16: Question I.3 While performing trans
Page 17 and 18: Question I.5 Where are the right pa
Page 19 and 20: Aortic archNeedle through bifurcati
Page 21 and 22: Question I.8 Which of the following
Page 23 and 24: needle through the airway wall. Onc
Page 25 and 26: Question I.11 A patient with subcar
Page 27 and 28: Question I.12 Flexible bronchoscopy
Page 29 and 30: Proposed indications include stagin
Page 31 and 32: Question I.15 Which of the followin
Page 33: Question I.17 After two aspirates f
Page 37 and 38: Question I.19 A patient is referred
Page 39 and 40: Question I.20 While performing cTBN
Page 41 and 42: Question I.22 A 39-year-old man wit
Page 43 and 44: Question I.23 During a cTBNA stagin
Page 45 and 46: may develop unless flow, respirator
Page 47 and 48: helps identify multiloculation and
Page 49 and 50: Example of an endobronchial lesion
Page 51 and 52: Example of transbronchial needle as
Page 53 and 54: Question I.29 A 69 year old smoker
Page 55 and 56: management.References1. Herth F, Be
Page 57 and 58: insertion depth of the needle. By t
Page 59 and 60: CONGRATULATIONSYou have now complet
Page 61 and 62: The Essential cTBNA BronchoscopistM
Page 63 and 64: Question 8.Each of the following is
Page 65 and 66: ANSWERSTO MODULE 1, TWELVE QUESTION
Page 67 and 68: CONGRATULATIONSYou have now complet
Page 69 and 70: CONTRIBUTORSHenri Colt M.D. is Prof
Page 71: THE ESSENTIAL cTBNA BRONCHOSCOPIST

The Essential cTBNA Bronchoscopist

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