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The description of precise intrabronchial positions for the sampling of mediastinal-hilar lymph nodes is critical to successfully perform conventional transbronchial needle aspiration. Previously published maps of mediastinal-hilar lymph nodes were primarily drawn based on experts' experience. We generated a virtual map of the most frequently sampled intrathoracic lymph nodes from an intrabronchial perspective using a virtual bronchoscopic navigation system, to assist with training in conventional transbronchial needle aspiration.

Background: In evaluating patients with suspected lung cancer, it is important to not only obtain a tissue diagnosis, but also to obtain enough tissue for both histologic and molecular analysis in order to appropriately stage the patient with a safe and efficient strategy. The diagnostic approach may often be dependent on local resources and practice patterns rather than current guidelines. We Describe lung cancer staging at two large academic medical centers to identify the impact different procedural approaches have on patient outcomes. Methods: We conducted a retrospective cohort study of all patients undergoing a lung cancer diagnostic evaluation at two multidisciplinary centers during a 1-year period. Identifying complication rates and the need for multiple biopsies as our primary outcomes, we developed a multivariate regression model to determine features associated with complications and need for multiple biopsies. Results: Of 830 patients, 285 patients were diagnosed with lung cancers during the study period. Those staged at the institution without an endobronchial ultrasound (EBUS) program were more likely to require multiple biopsies (OR 3.62, 95% CI: 1.71–7.67, P=0.001) and suffer complications associated with the diagnostic procedure (OR 10.2, 95% CI: 3.08–33.58, P Conclusions: Lung cancer evaluation at centers with a dedicated EBUS program results in fewer biopsies and complications than at multidisciplinary counterparts without an EBUS program.

Background The optimal procedure for maximizing the diagnostic yield and minimizing the procedural complexity of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is controversial. We conducted a prospective randomized controlled trial to determine the optimal procedure of EBUS-TBNA for mediastinal and hilar lymphadenopathy, with a particular focus on the roles of the inner-stylet and suction. Methods Consecutive patients with enlarged mediastinal and hilar lymph nodes (LNs), detected by computed tomography (CT) or positron emission tomography-CT (PET-CT), who underwent EBUS-TBNA were included. Each LN was sampled with three needle passes using suction–stylet, suction–no stylet, and stylet–no suction procedures. The samples were smeared onto glass slides for cytological evaluation. A single, blinded cytopathologist evaluated each set of slides. The primary outcomes were cytological specimen adequacy rate and diagnostic yield of malignant LNs. The secondary outcomes were tissue-core acquisition rate, procedural time, and the amount of bleeding. Results This study evaluated 97 patients with a total of 255 LNs. The final LN diagnosis was benign in 144, malignant in 104, and inadequate in 7 cases. There were no significant differences among the suction–stylet, suction–no stylet, and stylet–no suction groups in specimen adequacy rate (87.1, 88.2, 85.9%, respectively) or diagnostic yield of malignancy (32.2, 31.8, 31.0%, respectively). However, the use of suction was associated with an increase in tissue-core acquisition rate (P

Background. Lung cancer is the leading cause of malignancy related mortality in the United States. Accurate staging of NSCLC influences therapeutic decisions. Transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guided TBNA (EBUS-TBNA) has been accepted as a procedure for the diagnosis and staging of lung cancer. The aim of this study is to evaluate the efficacy and adequacy of TBNA and EBUS-TBNA for sampling of mediastinal adenopathy using the Wang’s eleven lymph node map stations. Methods. We retrospectively reviewed 99 consecutive cases diagnosed with malignancy by EBUS-TBNA and a series 74 patients evaluated for mediastinal adenopathy or a pulmonary lesion using conventional transbronchial needle aspiration. The IASLC lymph node map was correlated with Wang’s map. Results. A total of 182 lymph node stations were sampled using EBUS-TBNA. 96 were positive for nodal metastasis. A total of four cases of samples taken from station 2R showed malignant cells. From the 74 cases series using cTBNA 167 nodes were sampled in 222 passes. Lymphoid or malignant tissue was obtained in 67 (91.8%) cases; 55.1% of the nodes were 1 cm or less. Conclusions. The use of the eleven stations described in Wang’s map to guide TBNA of the mediastinal nodes allows sampling of radiologically considered nonpathological nodes. These data suggest that Wang’s map covers the most frequent IASLC nodal stations compromised with metastasis.

Background The role of transbronchial needle aspiration (TBNA) in the diagnosis and staging of lung cancer has been well established. Recently, the efficacy of conventional TBNA in the staging of lung cancer has been enhanced by the use of endobronchial ultrasound (EBUS)-TBNA. Our study sought to evaluate the adequacy of TBNA of International Association for the Study of Lung Cancer (IASLC) stations 4R, 4L and 7 using endobronchial landmarks provided by the Wang nodal mapping system in the staging of lung cancer. Methods We retrospectively analyzed all bronchoscopic cases with conventional TBNA punctures positive for malignancy at our institution from 1 January to 31 October 2014. The endobronchial puncture site was guided by the Wang nodal mapping system. The Wang stations were correlated with the IASLC lymph node map. No endobronchial ultrasound or rapid on-site evaluation was used. Pathological analysis included cytological and histological examination. Results Diagnosis by histological analysis was obtained in 115 (55.3%) out of 208 puncture sites. The metastatic lymph nodes were distributed at IASLC stations 4R (W1, 3, 5) 46.6 %, 7 (W2, 8, 10) 19.7%, 4L (W4, 6) 11.5%, 11R (W7, W9) 11.1% 11L (W11) 9.6%, 2R (high station W3) 0.5%, and the proximal portion of station 8 (station W10 beyond the middle lobe orifice) 1%. No complications were observed. Conclusion IASLC station 4R (W1, 3, 5), 7 (W2, 8, 10) and 4L (W4, 6) are adequate for the staging of lung cancer.

BACKGROUND: Transbronchial needle aspiration (TBNA), serving as a remarkably invaluable and minimally invasive technique, has been widely used for the diagnosis and staging of mediastinal adenopathy and masses. To date, the International Association for the Study of Lung Cancer (IASLC) and Wang's nodal map are two well-documented intrathoracic lymph node guidelines for the TBNA procedure. METHOD: We characterized IASLC's and Wang's map, and interpreted the correlation of the two maps station by station. RESULTS: The pivotal role of IASLC map is to determine N descriptor in the tumor node metastasis (TNM) staging system of lung cancer, whilst Wang's map is employed to facilitate the localization of biopsy sites for bronchoscopists during TBNA performance. Furthermore, stations 1, 3 and 5 in Wang' map are equivalent to 4R station in IASLC' system, while stations 4 and 6 in Wang's account for IASLC station 4L as N2 stations. In addition, Wang's stations 2, 8 and 10 are correlated with station 7 in IASLC's. Wang's stations 7 and 9 are responsible for station 11R in IASLC's map. CONCLUSION: Given their unique benefits and limitations, and the practical links between the two maps, it appears reasonable to highlight the significance of their complementary utilization upon TBNA performance and lung cancer staging.

Background: The optimal method for EBUS-TBNA to maximize diagnostic accuracy and to minimize operational complexity is controversial.­ Aims: We conducted the randomized controlled clinical trial to evaluate the effects of suction and inner-stylet usage on EBUS-TBNA, the feasibility of omitting stylet, and the necessity of using suction. Methods: Consecutive patients with enlarged mediastinal and hilar lymph nodes (LNs) detected by imaging tests underwent EBUS-TBNA. Each LN was sampled three passes, randomly by with suction-with stylet, with suction-no stylet, and no suction-with stylet technique. A single, blinded cytopathologist respetively evaluated each set of cell slides. The primary outcome was diagnostic accuracy of different EBUS-TBNA techniques. The secondary outcomes were specimen adequacy, cytological quality, operational time and the amount of bleeding. Result: 43 patients with a total of 124 LNs were evaluated. The final diagnosis of patients was benign in 23, malignant in 20. The final diagnosis of LNs was benign in 83, malignant in 39, inadequate in 2. The use of stylet did not improve diagnosis accuracy and the use of suction did not decrease diagnosis accuracy (each P value >0.5). But the use of suction was associated with an increase in the specimen adequacy(P=0.000). Without-stylet technique significantly reduced operational time(P=0.000). There was no significant difference in the amount of bleeding, cytological quality between techniques. Conclusion: When EBUS-TBNA is necessary, our recommendation is eliminating stylet and applying suction to improve diagnostic accuracy and to reduce operational complexity.

Proponents of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) propose that in this era of EBUS-TBNA, training for conventional transbronchial needle aspiration (C-TBNA) should be abandoned. The authors of this editorial provide the opposing view. C-TBNA has a short and a steep learning curve and adds to the diagnostic yield of flexible bronchoscopy in a cost-effective fashion. Considering its simplicity, availability, affordability, safety, and several unique indications, C-TBNA continues to contribute to the welfare of patients worldwide. It should remain as an integral part of pulmonary fellowship training programs.

The invaluable role of transbronchial needle aspiration (TBNA) in the diagnosis and staging of mediastinal adenopathy and lung cancer has been well established. Different lymph nodes regional nomenclatures and maps had been described over the years. The international association for the study of lung cancer (IASLC) and Wang’s maps complement each other benefiting patients with lung cancer. In this article we briefly reviewed the roles of IALSC, Wang’s maps and ROSE in TBNA.

Transbronchial needle aspiration (TBNA) has been used for over three decades in the diagnosis and staging of mediastinal adenopathy and masses. Although first described in Argentina in 1949 by Dr. Eduardo Schieppati, this rigid bronchoscope technique received very little attention until 1978 at Johns Hopkins Hospital where Wang and colleagues described in detail the diagnosis of a paratracheal mass by TBNA biopsy through a rigid bronchoscope using a 25-gauge esophageal variceal needle. In 1983, a novel flexible needle that could be used with the flexible bronchoscope to perform TBNA was developed and introduced for diagnosis and staging of bronchogenic carcinoma. Immediately to follow was the expansion of its use in the diagnosis of peripheral pulmonary nodules and benign mediastinum and hilar disorders by obtaining histological core specimens. Recent development of the endobronchial ultrasound-guided TBNA is most exciting and promising. Whether this will enhance the result of TBNA and spread the TBNA technique as a standard lung cancer staging procedure is yet to be seen. TBNA is simpler and easier. Endobronchial ultrasound-guided TBNA currently is more complicated and more difficult. Its future relies on a hybrid instrument and methodology to be widely applied to the diagnosis and staging of bronchogenic carcinoma.

Study objectives: To compare two different imageregistration methods for accurately displaying the position of aflexible bronchoscope on a previously acquired three-dimensional CTscan during bronchoscopy. Setting: Bronchoscopy suiteof a university hospital. Patients: Fifteen adultpatients scheduled for nonemergent bronchoscopy. Methods: A miniature electromagnetic positionsensor was placed at the tip of a flexible bronchoscope. Previouslyacquired three-dimensional CT scans were registered with the patient inthe bronchoscopy suite. Registration method 1 used multiple skinfiducial markers. Registration method 2 used the inner surface of thetrachea itself for registration. Method 1 was objectively assessed bymeasuring the error distance between the real skin marker position andthe computer display position. Methods 1 and 2 were subjectivelyassessed by the bronchoscopist correlating visual bronchoscopicanatomic location with the computer display position on the CTimage. Results: The error distance (± SD) from knownpoints for registration method 1 was 5.6 ± 2.7 mm. Objective errordistances were not measured for method 2 because no accurate placementof the bronchoscope sensor could be correlated with CT position. Subjectively, method 2 was judged more accurate than method 1 whencompared with the fiberoptic view of the airways through thebronchoscope. Additionally, method 2 had the advantage of not requiringplacement of fiducial markers before the CT scan. Respiratory motioncontributed an error of 3.6 ± 2.6 mm, which was partially compensatedfor by a second tracking sensor placed on the patient’s chest. Conclusion: Image registration method 2 of surface fittingthe trachea rather than method 1 of fiducial markers was subjectivelyjudged to be superior for registering the position of a flexiblebronchoscope during bronchoscopy. Method 2 was also more practicalinasmuch as no special CT scanning technique was required beforebronchoscopy.

The purpose of this study was to determine whether intravenous injection of a magnetic resonance (MR) contrast agent, ultrasmall superparamagnetic iron oxide (ferumoxtran-10), can be useful in characterizing lymph nodes in patients with lung cancer. Twelve patients with known or suspected lung cancer were studied. Pre- and postcontrast injection of ferumoxtran-10 MR scans of the chest were obtained. Analysis of the signal intensities and bronchoscopic fine needle aspiration of a single node were performed in each patient. Six of 12 patients had a final diagnosis of lung cancer. T1-weighted images were best for localizing mediastinal lymph nodes. Signal intensity changes before and after contrast were best visualized on T2-weighted and gradient-echo images. All four patients with lung cancer who had nodes positive for malignancy at biopsy had no change in signal intensity of the nodes on T2 images. The signal intensity decreased in the remaining two patients, and the nodes were benign. Of the eight patients with benign disease, five had no change in signal intensity of the nodes. Therefore the sensitivity for tumor involvement of the nodes is 100%, but the specificity is only 37.5%. Ferumoxtran-10 is a contrast agent that can alter the signal intensity of lymph nodes. Lack of signal change may be due to malignant or inflammatory change. Studies in a larger population of lung cancer patients may help to characterize the utility of this agent further. J. Magn. Reson. Imaging 2000;12:899–904. © 2000 Wiley-Liss, Inc.

Dieulafoy lesion (DL), also known as Cirsoid aneurysm, and submucosal arterial malformation was originally described by Gallard in 1884. In 1898, the French surgeon, Dieulafoy, reported 3 patients with hematemesis and gastric bleeding emanating from a submucosal vascular anomaly. Although DL is seen most commonly in the gastrointestinal tract, the presence of this lesion in the bronchus has been reported in 12 cases previously. In this report, we present the 13th reported case of hemoptysis resulting from bronchial DL, review the previously reported cases, and comment on the appropriate diagnostic and therapeutic strategy.

Transbronchial needle aspiration (TBNA) is a 30 year old procedure for diagnosing and staging of lung cancer. There has been renewed interest in TBNA due to the development of a curvilinear array endobronchial ultrasound (EBUS) scope for TBNA. Reports indicate an increased diagnostic yield compared to standard TBNA. In 9 of 11 patients EBUS-TBNA is performed with the second generation Olympus EBUS scope (BF-UC180F) and the ViziShot (NA-201SX-4022) needle in addition to the standard WANG™ TBNA needle. Three punctures were made by the ViziShot needle. The first puncture, the guidewire is partially retracted and without suction the needle is moved back and forth inside the lesion. The second puncture, the guidewire is completely removed and suction is applied during needle movement. The third puncture is without the guidewire but with suction. In five patients with a positive diagnosis of cancer, the first punctures were all positive with a better quality and quantity of tumor cells. Three patients, standard TBNA needle was used, all were positive. Four patients with standard TBNA preceded the EBUS-TBNA were all positive. We conclude, EBUS TBNA is highly effective and dependable and suggest the use of EBUS needle can be simplified. Standard TBNA needle can be used for EBUS-TBNA and standard TBNA in relation to EBUS-TBNA needs to be further investigated.

Spiral or helical computed tomography (CT)-generated multiplanar reconstructions were used in the radiological assessment of the pulmonary hila in patients with central lung cancer. Twelve patients with non-small-cell lung cancer and hilar abnormalities were examined with contrast-enhanced spiral CT. Studies were performed on a Siemens Somatom S or Plus-S scanner using either a 24- or 32-second spiral. The study volume was from the arch of the aorta to the inferior pulmonary veins done in a single breath-hold, using 4-mm collimation, and reconstructed at 2-mm intervals. We assessed the quality of vascular enhancement and of multiplanar reconstructions. Bronchoscopic, surgical, and pathological findings were correlated. Excellent vascular opacification and good-quality reconstructions were obtained in all patients. No interscan motion was detected. No problems were encountered with the breathholding technique or in the reconstruction of images, even in patients with poor respiratory function. Multiplanar reconstructions were useful for the evaluation of mediastinal including vascular and airways invasion, for optimal definition of lymph node groups, for the planning of bronchoscopically guided biopsy, as well as for endobronchoscopic laser coagulation therapy and surgical treatment. Spiral CT-generated multiplanar reconstructions of the hila are helpful for staging, solving problems, guiding bronchoscopy, and planning surgery. Even patients with limited respiratory reserve can successfully complete the examination.

In summary, knowledge of the exact location of lymph nodes in mediastinum and hilar areas and their relationship to the puncture site of TBNA is the first step to a successful TBNA. The necessity to determine the N3 status and multistation status of patients with bronchogenic carcinoma being evaluated for surgery and the current financial restraint of the medical care system further highlight the potential of this simple, effective, and safe procedure. TBNA can markedly enhance the diagnostic yield of flexible bronchoscopy. TBNA and PCNA are complimentary procedures.

In a prospective study (1989–1992) of pulmonary nodules/masses and/or mediastinal/hilar lesions, 329 patients underwent transbronchial needle aspiration (TBNA) using a cytology or a histology needle with or without fluoroscopy via flexible bronchoscopy as the initial procedure to sample mediastinal lesions (169) or lung lesions (160). TBNA established the diagnosis of malignant or benign disease in 68.1% (224 patients). The diagnostic yield was 89.3% (151/169) for mediastinal and 45.6% (73/160) for lung lesions without abnormal mediastinal/hilar areas. The undiagnosed patients (105) underwent transthoracic needle aspiration (TTNA) using a 19-gauge needle under fluoroscopy or computed tomography guidance. TTNA established the diagnosis in 69.5% (73). The diagnostic yield was 83.3% (15/18) for mediastinal lesions and 66.7% (58/87) for lung lesions. Benign disease was diagnosed by TBNA in 8.8% (20/224) and by TTNA in 23% (17/73). The benign disease most commonly diagnosed by TBNA was sarcoidosis, and TTNA was most useful in diagnosing various benign lung lesions. Neither TBNA nor TTNA established the diagnosis in 9.7% (32). Overall diagnostic rates for TBNA and TTNA were 68.1 and 22.2%, respectively. The combined diagnostic rate was 90.3%. There were no complications from TBNA but TTNA was complicated by pneumothorax in 20%. We suggest that TBNA should be the diagnostic procedure of choice in patients with mediastinal/hilar lesions. BNA and TTNA are complementary procedures.

Transbronchial needle aspiration (TBNA), in comparison with cytology brush and forceps biopsy, in the diagnosis of a pulmonary mass or coin lesions has been studied by Shure and Wang in the past. Both studies concluded that TBNA markedly increased the diagnostic yield. A new instrument, a "needle brush" (Mill Rose Lab), has been developed and compared with the following three instruments: a regular cytology brush was used first, followed by needle brush, TBNA, and forceps biopsy under fluoroscopy. Twenty-four patients were studied. A specific diagnosis was made in 16 patients (15 malignancies; one granuloma); in three patients, results were suspicious for malignancy, three patients had negative results, and in two patients the study was not complete. "Needle brush" biopsy was positive in 11 patients (exclusively in four); TBNA was positive in eight (exclusively in two). Regular brush biopsy was positive in seven (exclusively in none). Forceps biopsy was positive in four (exclusively in one; granuloma). We conclude that the needle brush and TBNA have a higher diagnostic yield in malignant lung masses or nodules. The use of regular brush and forceps biopsy did not increase the diagnostic yield in malignancy. Forceps biopsy might be more useful in benign diseases.

In order to determine if the diagnostic yield of the transbronchial lung biopsy in sarcoidosis is dependent upon the number of biopsies, a study was designed to examine individual specimens from 6 biopsies in patients with Stage II sarcoidosis. It was found that the probability of obtaining a positive specimen per biopsy was 46%, and this percentage remained constant for each biopsy. The diagnostic yield followed a logarithmic curve, gradually increasing from 1 through 4 biopsies until about 90% of true positive diagnoses were obtained, then approaching a plateau with successive biopsies. We therefore recommend that 4 transbronchial lung biopsies are sufficient to diagnose stage II sarcoidosis in the majority of patients with diffuse lung disease.

From March 1986 to April 1987, 70 percutaneous needle aspiration (PCNA) procedures were performed in 66 consecutive patients. Seven immunocompromised patients had the procedure performed to obtain culture material from the lung, and 59 patients with chest lesions were analyzed. This includes 49 patients with either a lung nodule or mass. In the remaining ten patients, there were three chest wall or pleural lesions, two aortic pulmonary window lesions, two right hilar lesions, and three anterior mediastinal lesions. Forty of these 59 patients were ultimately proven to have a malignancy. The diagnostic yield for malignant disease by cytology and histology of PCNA was 97.5 percent (39 of 40). Twelve patients had a final diagnosis of benign disease. The diagnostic yield in benign diseases by PCNA was 91.6 percent (11 of 12). The remaining seven patients do not yet have a final diagnosis, though the clinical course favors benign disease in six of these patients. We attribute the major reason for this high specific diagnostic yield in both malignant and benign diseases to the ability of obtaining histologic specimens for interpretation.

Flexible transbronchial needle aspiration (TBNA) provides access to mediastinal lymph nodes, but its role in staging bronchogenic carcinoma is unknown. To determine the efficacy and safety of this procedure for staging the extent of mediastinal disease, the results of TBNA performed during fiberoptic bronchoscopy in 39 patients without known extrathoracic metastases were reviewed. Flexible TBNA was found to be a safe, effective method for determining the presence or absence of mediastinal metastases from bronchogenic carcinoma. Furthermore, TBNA results compare favorably with roentgenographic staging techniques, with the added advantage of providing cytopathologic information.

To investigate the importance of fiberoptic bronchoscopy with transbronchial biopsy (TBB) in clinical decision making, we reviewed 242 consecutive TBB procedures with respect to clinical presentation, roentgenographic pattern of disease, bronchoscopy result, and patient outcome. The specific yield of TBB was greatest in patients with multilobar disease and suspected sarcoidosis, metastatic neoplasm, or opportunistic infection. The value of a nonspecific TBB was estimated from its influence in changing clinically-derived suspicions of disease. Using pretest probabilities based on prebronchoscopic suspicions and likelihood ratios derived from our TBB results, Bayes's theorem was applied to estimate posttest probabilities. Nonspecific TBB reduced the probability of granulomatous pneumonitis. However, only small differences in posttest probabilities were associated with this bronchoscopy result in other patients with multilobar infiltrates, and no differences were observed in those with localized disease.

To determine the role of transbronchial needle aspiration (TBNA) in the diagnosis of peripheral pulmonary lesions, TBNA was performed in 20 patients who had unexplained nodules (15) or masses (five) and no endobronchial abnormality. The TBNA cytopathology was positive for malignancy in 11 patients, and provided the only diagnostic specimen in seven. The TBNA yield was significantly higher than that of forceps biopsy or bronchial brushing, either alone or in combination (p less than 0.05). The procedure was complicated by pneumothorax in one patient. Transbronchial needle aspiration is diagnostically useful and safe for evaluation of the peripheral pulmonary nodule.

Chest CT of 36 patients with proven sarcoidosis were reviewed retrospectively. In all cases CT was obtained in an attempt to answer a diagnostic dilemma, either a patient with abnormal chest radiography and no clinical diagnosis or a patient with a history of known sarcoidosis and an atypical presentation on chest radiography. Computed tomography was superior to chest radiography in detecting and defining the presence of adenopathy. In addition, CT was more accurate in detecting the presence and extent of infiltrates. Secondary findings in sarcoidosis including pleural effusions, bullous disease, bronchiectasis, cavitation with and without mycetoma, and fibrosing mediastinitis were detected using CT. Using the information obtained from CT, we were able to arrive at the correct diagnosis in the majority of cases and to decide which modality would be most useful to secure tissue confirmation (bronchoscopy, transtracheal biopsy, or percutaneous needle biopsy of a solitary mass).

Flexible transbronchial needle aspiration provides a bronchoscopic method for the diagnosis and staging of mediastinal neoplasms. Increasing experience has confirmed the usefulness of this procedure and has identified several technical factors that influence its yield and safety.

To determine the value of transbronchial needle aspiration biopsy in the diagnosis of sarcoidosis, we reviewed a one-year experience of consecutive patients with sarcoidosis presenting with hilar and/or paratracheal adenopathy. The sensitivity of transbronchial needle aspiration biopsy in obtaining noncaseating granulomas was 90%. This yield exceeds that of most published reports of transbronchial lung biopsy and bronchial mucosal biopsy and suggests that transbronchial needle aspiration biopsy may be a valuable diagnostic tool in the evaluation of these forms of sarcoidosis.

Five patients with bronchogenic or enteric cysts were diagnosed by using a combination of CT and transbronchial or transesophageal needle aspiration. Serous or mucoid fluid was successfully aspirated in each case. Cultures of the fluid were negative for pathogens, and cytologic examinations showed no malignancy. Mediastinoscopy and thoracotomy were avoided in all patients, including one symptomatic patient whose symptoms resolved after needle aspiration. CT with transbronchial or transesophageal needle aspiration represents a practical alternative to surgery in the evaluation of congenital mediastinal cysts.

To determine the value of transbronchial needle aspiration biopsy in the diagnosis of sarcoidosis, we reviewed a 1-year experience of consecutive patients with sarcoidosis presenting with hilar and/or paratracheal adenopathy. The sensitivity of transbronchial needle aspiration biopsy in obtaining specimens of noncaseating granulomas was 90%. This yield exceeds that of most published reports of transbronchial lung biopsy and bronchial mucosal biopsy and suggests that transbronchial needle aspiration biopsy may be a valuable diagnostic tool in the evaluation of these forms of sarcoidosis.

We have described an endoscopic method of performing small intestinal capsule biopsy that offers several advantages over alternative biopsy techniques. In comparison with conventional capsule biopsy methods, incorporation of the capsule into the endoscope significantly reduces the time of the procedure and eliminates the need for fluoroscopy, while maintaining a high yield of suitable mucosal specimens. The combination of the Carey capsule and endoscope provides an apparatus less complex than the previously described endoscope/capsule technique? and more durable than the steerable biopsy apparatus, which has been reported to have a limited lifespan. ,10 Because of the small diameter of the PE 160 tubing (1.55 mm), both air and suction channels remain functional even when the thinner scopes (Olympus Q, ACMI TX-SLM) are used. Conventional biopsy forceps or brushings can be used simultaneously, only if a two-channel instrument like GIF-2T is employed. This technique should not be used routinely since localized lesions in the esophagus, stomach, and proximal duodenum are best approached by routine endoscopic forceps biopsy. However, patients in whom malabsorption or chronic diarrhea is suspected and in

Thirty-two consecutive patients with mediastinal lesions suggestive of bronchogenic carcinoma underwent transbronchial needle aspiration. Eighteen of 20 patients (90 percent) with proved bronchogenic carcinoma had malignant cytology specimens or tissue fragments. Of 12 patients with normal cytology specimens, six were subsequently proved to have nonneoplastic disease. Transbronchial needle aspiration appears to offer a sensitive and specific alternative to more invasive surgical techniques used in the diagnosis of malignancies with mediastinal involvement

A case of a blood clot simulating an intrabronchial neoplasm on computed tomography is presented. Although an intrabronchial lesion in a patient with hemoptysis is usually a malignancy, other etiologies must be considered. Computed tomography is an excellent modality for detecting and evaluating intrabronchial pathology but bronchoscopy is necessary for tissue diagnosis.