Virginia Tech Carilion School of Medicine, Roanoke, VA
Disclosure: There is no conflict of interest or other disclosures.
Reprints: Edmundo Rubio, MD, Virginia Tech Carilion School of Medicine, 1906 Bellevue Avenue Office 320, Roanoke, VA 24018 (e-mail: firstname.lastname@example.org).
Received April 14, 2013
Accepted November 13, 2013
Endobronchial ultrasound has become routinely utilized to improve sampling of mediastinal and hilar lymph nodes in the evaluation of suspected lung cancer. In addition, unconventional uses of this technology have also been occasionally reported, such as to drain a bronchogenic cyst. We present a case where endobronchial ultrasonography allowed for a safe approach to the biopsy of a vertebral body tumor. The case further illustrates how this technology may allow the bronchoscopist to diagnose metastatic disease, which may not reside within the lung or be directly attached to the main airways.
Endobronchial ultrasound (EBUS) is one of the foremost advances in diagnostic bronchoscopy. It allows more accurate sampling of mediastinal and hilar lymph nodes. This has led to accurate cancer staging, without the need for mediastinoscopy in many cases.1 In addition, there have been case reports of its unconventional uses, such as the diagnosis of a pulmonary artery sarcoma, pulmonary embolism, and a transbronchial needle aspiration (TBNA) through the pulmonary artery to biopsy a bronchogenic cyst.2–5
We report a case where EBUS guidance allowed diagnosis of a tumor from within a thoracic vertebral body.
A 50-year-old white man presented to our hospital with a 3-day history of nausea, vomiting, and dizziness. He denied fevers, chills, headaches, cough, or hemoptysis. He worked as a wood cutter and handyman for most of his life. He smoked 3 packs of cigarettes a day for approximately 25 years and denied any specific occupational exposure to asbestos, chemicals, or dust. His past medical history revealed chronic obstructive pulmonary disease, hyperlipidemia, idiopathic pericarditis, and carotid endarterectomy. Physical examination showed an overweight middle-aged man in no distress. His oxygen saturation was 97% while breathing room air. Breath sounds were normal on auscultation and his cardiovascular examination was unremarkable.
A head computed tomography (CT) scan demonstrated a 2.3 cm left cerebellar mass. As part of his work up, CT imaging of the abdomen and chest were obtained. The latter revealed a 2.2×2.5 cm mass between the posterior margin of the lateral aspect of the left main pulmonary artery and the lateral aspect of the descending thoracic aorta, extending into the left paratracheal and subcarinal regions. Furthermore, there was tumor involving the anterior aspect of the sixth thoracic (T6) vertebral body (Fig. 1). No other lymphadenopathy or masses were identified in the chest or the abdomen.
As the vertebral body abnormality was anterior, it was felt that a transcutaneous approach to sample the mass was not optimal. Therefore, the decision was made to first attempt acquiring tissue through a TBNA of either the left paratracheal or subcarinal mass, under EBUS guidance.
We used a convex EBUS probe (Olympus America Inc.) with a 21 G Vizishot needle. The patient had a laryngeal mask airway placed under general anesthesia to facilitate bronchoscopy. Onsite pathology was provided to allow rapid reading of the samples obtained. Seven TBNA samples from the left paratracheal portion of the mass were nondiagnostic. Seven more samples from the subcarinal mass revealed similar findings, failing to demonstrate any malignancy.
In the process of evaluating the mass and nodes with EBUS, the abnormality located in the anterior aspect of the vertebral body (Fig. 2) was visualized. The image in Figure 2, acquired looking through the posterior wall of the left main stem bronchus, correlated with the CT images of chest, confirming the presence of tumor infiltration at the level of the T6 vertebral body. Then, with the EBUS scope directed posteriorly and pressing on the airway wall, the aorta and esophagus were “pushed away” from the passage of our needle to sample the vertebral tumor (Fig. 3). A total of 6 aspirates were performed. The preliminary pathology was consistent with malignancy and the final report showed a poorly differentiated adenocarcinoma (Fig. 4). The final reports from the subcarinal and left paratracheal mass biopsies remained negative for malignancy.
After the needle aspirate procedure, the airway was inspected with a 5.1 mm external diameter flexible Type Q 180 diagnostic Olympus bronchoscope (Olympus America Inc.) to ensure that there was no trauma to the posterior wall of the airway. We noticed the needle marks, but there were no tears (Fig. 5). The patient was evaluated postprocedure and had no complaints, with an unchanged physical examination. The remainder of his hospital course was uneventful.
With the advent of bronchoscopic ultrasonography being still new, there continues to be reporting of interesting cases of unconventional indications. On the basis of our review of the literature, this is the first case of an EBUS-guided biopsy of a vertebral body. Similar to most of the other reported original uses of EBUS techniques, these new applications are being considered during the procedure and are not usually preplanned. In our particular case, targeting the vertebral body was only considered after failure to achieve a diagnosis with the previous biopsies. On the basis of this experience, we believe that adequate airway inspection should be routinely conducted with the EBUS system to approach unconventional target sites, particularly if rapid on-site pathology analysis fails to achieve a diagnosis through traditional approaches. In addition, further staging can be accomplished in this manner, as well. Keeping in mind that such approaches are possible, one may better strategize how to tackle these cases. Careful CT scan image review with considerations to target such unconventional sites should be routinely performed. An initial thought would be that such an approach to similar lesions may only be possible in thin patients. Nevertheless, our patient was actually mildly overweight, yet tomographic measurements suggested that the lesion was within reach of a bronchoscopic approach. Another consideration in our case was that in performing this, the needle may have traversed through the esophagus. Nevertheless, this was not of great concern because transesophageal biopsies have been performed for sampling of mediastinal lymph nodes with minimal risks of bleeding or infection.6 In addition, to decrease this potential risk in our case, the scope was fully flexed against the airway wall, such that this would help approximate this posterior wall to the vertebral body while pushing other structures, such as the esophagus, out of the way.
A final concern has to do with avoiding wall trauma (such as lacerations) while performing TBNA. The occurrence of EBUS-guided iatrogenic complications is rare, but tracheal tears can occur.7 Given that the posterior airway wall has no cartilaginous support, this area may be more prone to such injury. To limit the risk of this complication, we made sure to avoid displacement of our scope while performing the TBNA.
In summary, our case highlights an unconventional, yet safe approach to biopsying a vertebral body, under EBUS guidance. Such approach could also be considered with other nonlung primary malignancies presenting with vertebral metastases.
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