Thoracic Cancer ISSN 1759-7706
CASE REPORT
Endobronchial ultrasound-guided transbronchial needle aspiration in patients with superior vena cava obstruction Andrew R.L. Medford North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
Keywords Cytology; endobronchial; fine needle aspiration; lung cancer; mediastinum; ultrasonography. Correspondence Andrew R.L. Medford, North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK. Tel: +44 11 7323 6242 Fax: +44 11 7323 2947 Email: [email protected] Received: 29 July 2011; accepted: 17 August 2011. doi: 10.1111/j.1759-7714.2011.00071.x
Abstract Lung cancer is commonly encountered by community and hospital services and patients may present with early signs of superior vena cava obstruction (SVCO). SVCO requires prompt but minimally invasive investigation to avoid bleeding and for prompt treatment. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) provides respiratory physicians with a less invasive technique to sample mediastinal lymph nodes at bronchoscopy, avoiding the need for general anesthesia and mediastinoscopy, and allowing real-time imaging and sampling of the nodes. It is therefore safer than conventional bronchoscopic techniques of sampling the nodes (transbronchial needle aspiration), reducing the risk of bleeding. If neck ultrasound biopsy is unhelpful in SVCO, then EBUS-TBNA should be considered as the best initial option, reserving mediastinoscopy for a last resort. A clinical case is described here to demonstrate the use of EBUS-TBNA in SVCO. EBUS-TBNA is a safe and effective mediastinal sampling tool in patients with SVCO and should be considered before mediastinoscopy or conventional TBNA in this setting. This study adds shoes there should be more emphasis on the use of EBUSTBNA in the diagnosis of mediastinal disorders in settings where higher bleeding is anticipated, including SVCO. tca_71
Introduction Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively new but increasingly used and minimally invasive investigation for lung cancer staging.1,2 It is also used for the diagnosis of benign and malignant unexplained mediastinal lymphadenopathy.3 EBUSTBNA is now increasingly replacing mediastinoscopy as a staging and diagnostic tool, although mediastinoscopy is still required following negative EBUS-TBNA cases if malignancy remains likely.2 Mediastinoscopy yields a larger tissue core than EBUS-TBNA but is a more invasive technique, requiring a general anesthetic and is associated with significant, albeit uncommon, complications including death, arrhythmia, and bleeding.4 Superior vena cava obstruction (SVCO) is a common oncological emergency and possible presentation of undiagnosed lung cancer, especially small cell lung cancer (SCLC).5 SVCO is associated with a high risk of bleeding following biopsy and high complications following mediastinoscopy.6 A neck ultrasound biopsy can be a useful alternative
221..223
technique, which is less invasive, but this requires the presence of significant and accessible nodes in the neck and a fine needle aspirate may not yield a diagnosis.7 Conventional transbronchial needle aspiration (TBNA) can also be used, but its performance is inferior to EBUS-TBNA as it cannot be done under real-time sampling, yields a shorter tissue size, and performs less well for smaller or non-proximal nodes.2,8
Case report A 61-year-old woman was referred with a 5-week history of swelling and tightness in her throat. She also noted an ache in the right side of her chest anteriorly and some breathlessness. Her voice had also become huskier and she had become lethargic. She had a history of tuberculosis and drank 70 units of alcohol per week. She had accumulated a 46 pack year smoking history. On physical examination, she had evidence of SVCO, having fullness in her neck with venous collaterals on her anterior chest wall. Baseline blood tests were significant for elevated lactate dehydrogenase (628 IU/L) and
Thoracic Cancer 2 (2011) 221–223 © Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd
221
EBUS-TBNA in SVC obstruction
A.R.L. Medford
supine patient was intubated from behind via the oral route with a fiber-optic endobronchial ultrasound hybrid bronchoscope (EU-ME1 Ultrasound Processor and BF-UC260F-OL8 Ultrasound Bronchoscope, Olympus America Inc, Center Valley, PA, USA). Once past the vocal cords, the tracheobronchial tree was examined and the mediastinal lymph nodes assessed by viewing the ultrasonic image. This showed numerous mediastinal lymph nodes which were sampled under real-time imaging (Fig 2). A 21-gauge needle was passed into the node under direct vision and then a syringe attached for suction and four separate aspirates were taken per node for cytology analysis. The aspirate confirmed SCLC 24 h later (Fig 3) and the patient underwent prompt oncological treatment.
Discussion
Figure 1 Chest computed tomography (mediastinal window) showing mediastinal tumor (bold white arrow) and adenopathy (solid white arrows) with superior vena cava compression (dotted white arrow).
alkaline phosphatase (108 IU/L). Her chest radiography was abnormal and showed right-sided hilar and paratracheal adenopathy. Further imaging was undertaken with a computed tomography (CT) scan of the chest and upper abdomen. This showed extensive mediastinal tumor and adenopathy with some SVCO (Fig 1) as well as a 16 mm nodule in the right upper lobe. She was commenced on systemic steroids and underwent urgent insertion of a superior vena cava stent with prompt relief of her symptoms and signs of SVCO. Neck ultrasound was then performed in an attempt to achieve a histological diagnosis by the least invasive route to minimize the risk of bleeding. A fine needle aspirate (FNA) was performed under real-time sampling of a 6 mm left internal jugular chain node and sent for cytology. Three aspirates were taken using the capillary aspiration technique6 with the patient supine and neck hyperextended. A 21-gauge needle was rotated once inside the node without the need for suction or a syringe and the sample placed in liquid cytology solution for subsequent analysis. Unfortunately, the FNA was non-diagnostic. As mediastinoscopy was not available on site, would involve a longer wait time, and was felt to be too invasive in the context of recent SVCO and bleeding risk, EBUS-TBNA was performed; this was felt to be a better option than conventional TBNA as it allows a safer but longer length aspirate under real-time imaging, avoiding vascular puncture. EBUSTBNA was performed under intravenous conscious sedation and topical anesthesia as previously described.9 Briefly, the 222
This case illustrates the potential impact of EBUS-TBNA on the patient journey of significant malignant mediastinal disease presenting with SVCO, where bleeding risk is higher and therefore minimally invasive routes for biopsy are preferable. Neck ultrasound sampling is minimally invasive but often there are inadequate nodes to get a sufficiently cellular sample, although it should be considered in this setting prior to EBUS-TBNA7. EBUS-TBNA is achieved by endoscopic manipulation of the flexible hybrid bronchoscope with a convex ultrasound probe at its distal end with a slightly larger external diameter of about 6.9 mm. Oral intubation is required and the scope is manipulated watching initially the
Figure 2 Endobronchial ultrasound-guided transbronchial needle aspiration being performed in real time. A 3 ¥ 4 cm mediastinal lymph node is shown with the sampling needle (solid white arrow) coming in from top right of image. (Markers on right are 5 mm).
Thoracic Cancer 2 (2011) 221–223 © Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd
A.R.L. Medford
EBUS-TBNA in SVC obstruction
more accessible via EBUS-TBNA. In summary, when neck ultrasound sampling has been non-diagnostic, EBUS-TBNA can provide prompt safe diagnosis to allow treatment for serious thoracic disease presenting in the mediastinum with SVCO.
Disclosure The author has no conflict of interest.
References
Figure 3 Endobronchial ultrasound-guided transbronchial needle aspiration cytology sample showing numerous dark-stained malignant cells and lymphocytes consistent with anaplastic small cell lung cancer. Haematoxylin and eosin stain, magnification: ¥100.
endoscopic image to localize the correct area in the tracheobronchial tree. Then the ultrasonic image is viewed to optimize the correct position to sample the mediastinal node. In this case, EBUS-TBNA was able to rapidly diagnose a malignant condition safely, reducing patient anxiety and time to diagnosis and to a specific oncological treatment, compared to referring for a mediastinoscopy. EBUS-TBNA also avoided the need for a general anesthetic or overnight admission, and was performed by the same physician allowing continuity of care. Conventional TBNA would have been another alternative if EBUS-TBNA had not been available but would have yielded a shorter sample (due to the sample being of shorter length as the aspirate is taken blind with a shorter needle throw), without real-time sampling and has a lower diagnostic yield than EBUS-TBNA.2,8 A second alternative to EBUS-TBNA is an endo-esophageal approach, using endosonography to sample the lymph nodes,10 which can sometimes be tolerated better in patients with intractable cough or poor lung function. This technique has particular uses for subcarinal and paraesophageal lymph nodes, as well as the aortopulmonary window. In this case, the bulk of the mediastinal nodes were
1 Tranquart F, Palanchon P, Clade O et al. Feasability of human endobronchial imaging with a linear-array ultrasound catheter. J Clin Ultrasound 2008; 36: 457–61. 2 Detterbeck FC, Jantz MA, Wallace M et al. Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132 (3 Suppl.): 202–20. 3 Sheski FD, Mathur PN. Endobronchial ultrasound. Chest 2008; 133: 264–70. 4 Medford AR, Bennett JA, Free CM, Agrawal S. Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy. Curr Opin Pulm Med 2009; 15: 334–42. 5 Rowell NP, Gleeson FV. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clin Oncol (R Coll Radiol) 2002; 14: 338–51. 6 Dosios T, Theakos N, Chatziantoniou C. Cervical mediastinoscopy and anterior mediastinotomy in superior vena cava obstruction. Chest 2005; 128: 1551–6. 7 Kumaran M, Benamore RE, Vaidhyanath R et al. Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer. Thorax 2005; 60: 229–33. 8 Medford AR, Agrawal S, Free CM, Bennett JA. A prospective study of conventional transbronchial needle aspiration: performance and cost utility. Respiration 2010; 79: 482–9. 9 Medford AR, Agrawal S, Free CM, Bennett JA. A performance and theoretical cost analysis of endobronchial ultrasound-guided transbronchial needle aspiration in a UK tertiary respiratory centre. QJM 2009; 102: 859–64. 10 Singh S, Thakur M. Diagnosis of recurrent lung cancer in the mediastinum using endosonographically guided fine-needle aspiration biopsy. J Clin Ultrasound 2009; 37: 230–2.
Thoracic Cancer 2 (2011) 221–223 © Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd
223
CASE REPORT
Endobronchial ultrasound-guided transbronchial needle aspiration in patients with superior vena cava obstruction Andrew R.L. Medford North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
Keywords Cytology; endobronchial; fine needle aspiration; lung cancer; mediastinum; ultrasonography. Correspondence Andrew R.L. Medford, North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK. Tel: +44 11 7323 6242 Fax: +44 11 7323 2947 Email: [email protected] Received: 29 July 2011; accepted: 17 August 2011. doi: 10.1111/j.1759-7714.2011.00071.x
Abstract Lung cancer is commonly encountered by community and hospital services and patients may present with early signs of superior vena cava obstruction (SVCO). SVCO requires prompt but minimally invasive investigation to avoid bleeding and for prompt treatment. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) provides respiratory physicians with a less invasive technique to sample mediastinal lymph nodes at bronchoscopy, avoiding the need for general anesthesia and mediastinoscopy, and allowing real-time imaging and sampling of the nodes. It is therefore safer than conventional bronchoscopic techniques of sampling the nodes (transbronchial needle aspiration), reducing the risk of bleeding. If neck ultrasound biopsy is unhelpful in SVCO, then EBUS-TBNA should be considered as the best initial option, reserving mediastinoscopy for a last resort. A clinical case is described here to demonstrate the use of EBUS-TBNA in SVCO. EBUS-TBNA is a safe and effective mediastinal sampling tool in patients with SVCO and should be considered before mediastinoscopy or conventional TBNA in this setting. This study adds shoes there should be more emphasis on the use of EBUSTBNA in the diagnosis of mediastinal disorders in settings where higher bleeding is anticipated, including SVCO. tca_71
Introduction Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively new but increasingly used and minimally invasive investigation for lung cancer staging.1,2 It is also used for the diagnosis of benign and malignant unexplained mediastinal lymphadenopathy.3 EBUSTBNA is now increasingly replacing mediastinoscopy as a staging and diagnostic tool, although mediastinoscopy is still required following negative EBUS-TBNA cases if malignancy remains likely.2 Mediastinoscopy yields a larger tissue core than EBUS-TBNA but is a more invasive technique, requiring a general anesthetic and is associated with significant, albeit uncommon, complications including death, arrhythmia, and bleeding.4 Superior vena cava obstruction (SVCO) is a common oncological emergency and possible presentation of undiagnosed lung cancer, especially small cell lung cancer (SCLC).5 SVCO is associated with a high risk of bleeding following biopsy and high complications following mediastinoscopy.6 A neck ultrasound biopsy can be a useful alternative
221..223
technique, which is less invasive, but this requires the presence of significant and accessible nodes in the neck and a fine needle aspirate may not yield a diagnosis.7 Conventional transbronchial needle aspiration (TBNA) can also be used, but its performance is inferior to EBUS-TBNA as it cannot be done under real-time sampling, yields a shorter tissue size, and performs less well for smaller or non-proximal nodes.2,8
Case report A 61-year-old woman was referred with a 5-week history of swelling and tightness in her throat. She also noted an ache in the right side of her chest anteriorly and some breathlessness. Her voice had also become huskier and she had become lethargic. She had a history of tuberculosis and drank 70 units of alcohol per week. She had accumulated a 46 pack year smoking history. On physical examination, she had evidence of SVCO, having fullness in her neck with venous collaterals on her anterior chest wall. Baseline blood tests were significant for elevated lactate dehydrogenase (628 IU/L) and
Thoracic Cancer 2 (2011) 221–223 © Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd
221
EBUS-TBNA in SVC obstruction
A.R.L. Medford
supine patient was intubated from behind via the oral route with a fiber-optic endobronchial ultrasound hybrid bronchoscope (EU-ME1 Ultrasound Processor and BF-UC260F-OL8 Ultrasound Bronchoscope, Olympus America Inc, Center Valley, PA, USA). Once past the vocal cords, the tracheobronchial tree was examined and the mediastinal lymph nodes assessed by viewing the ultrasonic image. This showed numerous mediastinal lymph nodes which were sampled under real-time imaging (Fig 2). A 21-gauge needle was passed into the node under direct vision and then a syringe attached for suction and four separate aspirates were taken per node for cytology analysis. The aspirate confirmed SCLC 24 h later (Fig 3) and the patient underwent prompt oncological treatment.
Discussion
Figure 1 Chest computed tomography (mediastinal window) showing mediastinal tumor (bold white arrow) and adenopathy (solid white arrows) with superior vena cava compression (dotted white arrow).
alkaline phosphatase (108 IU/L). Her chest radiography was abnormal and showed right-sided hilar and paratracheal adenopathy. Further imaging was undertaken with a computed tomography (CT) scan of the chest and upper abdomen. This showed extensive mediastinal tumor and adenopathy with some SVCO (Fig 1) as well as a 16 mm nodule in the right upper lobe. She was commenced on systemic steroids and underwent urgent insertion of a superior vena cava stent with prompt relief of her symptoms and signs of SVCO. Neck ultrasound was then performed in an attempt to achieve a histological diagnosis by the least invasive route to minimize the risk of bleeding. A fine needle aspirate (FNA) was performed under real-time sampling of a 6 mm left internal jugular chain node and sent for cytology. Three aspirates were taken using the capillary aspiration technique6 with the patient supine and neck hyperextended. A 21-gauge needle was rotated once inside the node without the need for suction or a syringe and the sample placed in liquid cytology solution for subsequent analysis. Unfortunately, the FNA was non-diagnostic. As mediastinoscopy was not available on site, would involve a longer wait time, and was felt to be too invasive in the context of recent SVCO and bleeding risk, EBUS-TBNA was performed; this was felt to be a better option than conventional TBNA as it allows a safer but longer length aspirate under real-time imaging, avoiding vascular puncture. EBUSTBNA was performed under intravenous conscious sedation and topical anesthesia as previously described.9 Briefly, the 222
This case illustrates the potential impact of EBUS-TBNA on the patient journey of significant malignant mediastinal disease presenting with SVCO, where bleeding risk is higher and therefore minimally invasive routes for biopsy are preferable. Neck ultrasound sampling is minimally invasive but often there are inadequate nodes to get a sufficiently cellular sample, although it should be considered in this setting prior to EBUS-TBNA7. EBUS-TBNA is achieved by endoscopic manipulation of the flexible hybrid bronchoscope with a convex ultrasound probe at its distal end with a slightly larger external diameter of about 6.9 mm. Oral intubation is required and the scope is manipulated watching initially the
Figure 2 Endobronchial ultrasound-guided transbronchial needle aspiration being performed in real time. A 3 ¥ 4 cm mediastinal lymph node is shown with the sampling needle (solid white arrow) coming in from top right of image. (Markers on right are 5 mm).
Thoracic Cancer 2 (2011) 221–223 © Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd
A.R.L. Medford
EBUS-TBNA in SVC obstruction
more accessible via EBUS-TBNA. In summary, when neck ultrasound sampling has been non-diagnostic, EBUS-TBNA can provide prompt safe diagnosis to allow treatment for serious thoracic disease presenting in the mediastinum with SVCO.
Disclosure The author has no conflict of interest.
References
Figure 3 Endobronchial ultrasound-guided transbronchial needle aspiration cytology sample showing numerous dark-stained malignant cells and lymphocytes consistent with anaplastic small cell lung cancer. Haematoxylin and eosin stain, magnification: ¥100.
endoscopic image to localize the correct area in the tracheobronchial tree. Then the ultrasonic image is viewed to optimize the correct position to sample the mediastinal node. In this case, EBUS-TBNA was able to rapidly diagnose a malignant condition safely, reducing patient anxiety and time to diagnosis and to a specific oncological treatment, compared to referring for a mediastinoscopy. EBUS-TBNA also avoided the need for a general anesthetic or overnight admission, and was performed by the same physician allowing continuity of care. Conventional TBNA would have been another alternative if EBUS-TBNA had not been available but would have yielded a shorter sample (due to the sample being of shorter length as the aspirate is taken blind with a shorter needle throw), without real-time sampling and has a lower diagnostic yield than EBUS-TBNA.2,8 A second alternative to EBUS-TBNA is an endo-esophageal approach, using endosonography to sample the lymph nodes,10 which can sometimes be tolerated better in patients with intractable cough or poor lung function. This technique has particular uses for subcarinal and paraesophageal lymph nodes, as well as the aortopulmonary window. In this case, the bulk of the mediastinal nodes were
1 Tranquart F, Palanchon P, Clade O et al. Feasability of human endobronchial imaging with a linear-array ultrasound catheter. J Clin Ultrasound 2008; 36: 457–61. 2 Detterbeck FC, Jantz MA, Wallace M et al. Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132 (3 Suppl.): 202–20. 3 Sheski FD, Mathur PN. Endobronchial ultrasound. Chest 2008; 133: 264–70. 4 Medford AR, Bennett JA, Free CM, Agrawal S. Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy. Curr Opin Pulm Med 2009; 15: 334–42. 5 Rowell NP, Gleeson FV. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clin Oncol (R Coll Radiol) 2002; 14: 338–51. 6 Dosios T, Theakos N, Chatziantoniou C. Cervical mediastinoscopy and anterior mediastinotomy in superior vena cava obstruction. Chest 2005; 128: 1551–6. 7 Kumaran M, Benamore RE, Vaidhyanath R et al. Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer. Thorax 2005; 60: 229–33. 8 Medford AR, Agrawal S, Free CM, Bennett JA. A prospective study of conventional transbronchial needle aspiration: performance and cost utility. Respiration 2010; 79: 482–9. 9 Medford AR, Agrawal S, Free CM, Bennett JA. A performance and theoretical cost analysis of endobronchial ultrasound-guided transbronchial needle aspiration in a UK tertiary respiratory centre. QJM 2009; 102: 859–64. 10 Singh S, Thakur M. Diagnosis of recurrent lung cancer in the mediastinum using endosonographically guided fine-needle aspiration biopsy. J Clin Ultrasound 2009; 37: 230–2.
Thoracic Cancer 2 (2011) 221–223 © Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd
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