What is the most cost-effective approach to diagnosing sarcoidosis?
—Melissa Magliocco, MD, Plainsboro, N.J.

The American Thoracic Society (ATS) says that diagnosis requires a compatible clinical picture and histologic evidence of noncaseating granulomas. Moreover, other diseases capable of producing a similar histologic or clinical picture must be excluded (Am J Respir Crit Care Med. 1999;160:736-755). If this guideline is explicitly followed, a patient will invariably require biopsy (usually a transbronchial lung biopsy but sometimes also diagnostic mediastinoscopy or other procedure), often at significant cost and with the associated risk of complications that can accompany such an invasive procedure. It has been estimated, however, that if 33,000 persons with asymptomatic bilateral hilar lymphadenopathy underwent mediastinoscopy, 32,982 (99.95%) would be found to have stage I sarcoidosis that would require no treatment other than observation (Chest. 1998;113:147-153). Therefore, some authors would advocate for observation without biopsy as a cost-effective approach for patients with asymptomatic bilateral hilar lymphadenopathy and presumed stage I sarcoidosis. This approach is clearly controversial, and most clinicians would agree that when more advanced disease is suspected, a biopsy would typically be unavoidable.
—Daniel G. Tobin, MD (102-15)

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