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A Case of Real-Time Endobronchial Ultrasonography-Guided Bronchial Needle Aspiration Using a Double-Channel Flexible Bronchoscope

Kanoh, Koji M.D.*; Kurimoto, Noriaki M.D., Ph.D.; Miyazawa, Teruomi M.D., Ph.D.; Iwamoto, Yasuo M.D., Ph.D.; Miyazu, Yuka M.D.; Kohno, Nobuoki M.D., Ph.D.§

Brief Reports

A 72-year-old man with atelectasis in the right lower lobe of the lung underwent endobronchial ultrasonography (EBUS)-guided bronchial needle aspiration (BNA) because a routine bronchoscopy failed to confirm a diagnosis. The bronchoscope used has a double-channel with a 2.0-mm channel for the BNA catheter system and a 2.8-mm channel for the EBUS transducer system. A hyperechoic spot with an acoustic shadow was generated by EBUS as the needle penetrated the tumor. The histologic specimen obtained from EBUS-guided BNA with one penetration confirmed squamous cell carcinoma. BNA under real-time EBUS guidance could be performed and was simple to perform with the double-channel flexible bronchoscope.

*Department of Internal Medicine, Fukushima Co-op Hospital; †Department of Surgery, Hiroshima National Hospital; ‡Department of Pulmonary Medicine, Hiroshima City Hospital; and §Second Department of Internal Medicine, Hiroshima University School of Medicine, Hiroshima, Japan

Address reprint requests to Dr. Teruomi Miyazawa, Department of Pulmonary Medicine, Hiroshima City Hospital, 7-33 Naka-ku, Moto-machi, Hiroshima, Japan; e-mail:

EBUS, endobronchial ultrasonography, BNA, bronchial needle aspiration

Bronchial needle aspiration (BNA) is one of the examinations used to confirm the diagnosis of pulmonary disease. Endobronchial ultrasonography (EBUS) is useful to detect mediastinal and hilar lymphadenopathy as well as to assess the depth of tracheobronchial tumor invasion. 1–4 Because EBUS can identify the lesion and the surrounding structures, it is helpful in deciding the penetration site of the target lesions in BNA. 1,2 However, BNA under real-time EBUS guidance has not been reported. We report the first case of EBUS-guided BNA using a double-channel flexible bronchoscope.

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A 72-year-old man complaining of a productive cough and hoarseness was referred to Hiroshima City Hospital. A chest radiograph showed atelectasis in the right lower lobe (Fig. 1A). Computed tomography of the chest revealed atelectasis in the right lower lobe (Fig. 1B) and mediastinal lymph adenopathy (paratracheal, pretracheal, and subcarinal lymphadenopathy). A bronchoscopy was performed. A smooth-surface mass was observed in the truncus intermedius. The diagnosis was not achieved by forceps biopsy. To confirm a diagnosis, EBUS-guided BNA was performed on the lesion.

FIG. 1.

FIG. 1.

The procedure of EBUS-guided BNA was as follows: A 550-mm-long flexible bronchoscope (XBF-2T40Y2; Olympus, Tokyo, Japan) with an external diameter of 7.2 mm and double channels (2.8 mm and 2.0 mm) was inserted via the transoral method without an endotracheal tube. An ultrasonic probe (2.5 mm diameter, radial mechanical transducer operating at 20 MHz [UM-BS20–26R; Olympus]) with a flexible balloon sheath (MAJ-643R; Olympus) was connected to an ultrasonic unit (EU-M 20; Olympus) and inserted through the 2.8-mm channel. The balloon was subsequently filled with sterile water to eliminate the air between the lesion and the probe, and the lesion was examined by EBUS. The BNA catheter (Wang's 19-gauge Transbronchial Needle [MWF-319; Mill–Rose Laboratories, Mentor, OH, U.S.A.]) was inserted through the 2.0-mm channel (Fig. 2). When the tip of the BNA catheter was located between the probe with the balloon and the lesion, the needle was advanced from the catheter sheath into the target lesion. After the needle was identified as a hyperechoic spot in the lesion by real-time EBUS (Fig. 3), suction using a 20-mL syringe was performed at the proximal side port of the BNA catheter. On seeing the hyperechoic spot in the lesion on the EBUS image, we moved the BNA catheter system back and forth within the lesion. After completion of the process, suction was released and was withdrawn from the lesion. The histologic specimen obtained was flushed from the needle using 10-mL saline. The histologic specimen obtained from EBUS-guided BNA confirmed squamous cell carcinoma.

FIG. 2.

FIG. 2.

FIG. 3.

FIG. 3.

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BNA is a valuable procedure used in diagnosing and staging lung cancer. In addition, the use of BNA during routine bronchoscopy has been reported to improve further diagnosing malignancies. 5–7 However, because of the lack of visual guidance, the advancement of the BNA needle into the lesion is not always accurate. Computed tomographic fluoroscopic guidance for BNA has also been reported as a useful means of examining pulmonary lesions. 8 However, this technique is not available at our institution and has the problem of radiation exposure to the patients and the operators.

Recently, EBUS has been found to be useful in identifying lesions, clarifying anatomy, and determining the depth of target lesions. 1,2 Also EBUS is easy to handle and lacks radiation exposure. Therefore, we speculated that EBUS would be an ideal means of visualizing accurately the target lesions for BNA.

The reason we performed EBUS-guided BNA in this patient was to make the most of assessing a lesion, such as a peripheral mass, an endobronchial lesion, and mediastinal lymphadenopathy with EBUS before biopsy. Therefore, BNA combined with EBUS is performed as a second-line examination in our institution when diagnosis by routine bronchoscopy cannot be established, as in this patient. However, the penetration site is not always accurate when using a single-channel bronchoscope because the EBUS probe and the BNA catheter are not inserted simultaneously. Thus, we performed BNA under EBUS guidance using a double-channel flexible bronchoscope to make diagnosis more accurate during a single penetration.

In our case, a hyperechoic spot with an acoustic shadow was generated by EBUS as the needle penetrated the tumor. When EBUS confirmed adequate localization, we obtained an acceptable histologic specimen with one penetration. Therefore, rapid, on-site cytopathologic evaluation was not necessary.

However, EBUS-guided BNA has a limitation. Because our transducer is a radial type, we cannot visualize the entire course of the needle from the channel into the lesion.

In conclusion, BNA under real-time guidance was simple to perform with a double-channel flexible bronchoscope.

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Endobronchial ultrasonography; Bronchial needle aspiration; Double-channel fiberscope; Bronchoscopy

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