A 72-year-old man with a history of heavy smoking presented initially with increasing dyspnea. Chest radiograph revealed a large right-sided mass. Computerized tomography scan of the chest confirmed a large tumor in the right upper lobe immediately adjacent to the right main pulmonary artery and mediastinal lymphadenopathy. On computerized tomography, it could not be determined if the mass was extrinsically compressing or actually invading the pulmonary artery. The overall scenario was consistent with an advanced lung cancer.
The patient underwent diagnostic bronchoscopy to identify the tumor and sample mediastinal lymph nodes. Endobronchial ultrasound (EBUS) was used to directly visualize the lymph nodes and assist in obtaining biopsy samples. During the use of EBUS, tumor invasion into the right pulmonary artery (Fig. 1) and into the right pulmonary vein (Fig. 2) was visualized. Tumor invasion was extensive and, in the images shown, nearly occluded the artery and vein. The structures were confirmed to be vascular by Doppler flow imaging (Fig. 3).
The patient's mediastinal and right hilar lymph nodes were also visualized and aspirated. Bronchial washings were also taken. Biopsy results confirmed an adenocarcinoma, without involvement of N2 or N3 lymph nodes. The EBUS images allowed for confirmation of tumor invasion into the great vessels and therefore, a T4 lesion. The EBUS images were later helpful in the patient's course when he was erroneously diagnosed with a pulmonary embolus on the basis of a pulmonary artery filling defect in the location of the previously visualized tumor invasion.
EBUS is a relatively new technology, which allows direct ultrasound visualization of lymph nodes and lesions that are below the mucosal surface of the airways. It can safely be performed in a bronchoscopy suite under local anesthetic and conscious sedation. The main benefit of EBUS is that it allows real time direct visualization of lesions, which can then be aspirated with a needle.1
EBUS has been most studied in patients with suspected or known cancer and when used appropriately has excellent sensitivity and specificity in distinguishing malignant and benign lymph nodes.2 It has the ability to reduce the need for surgical mediastinoscopies3 even in patients with radiologically normal mediastinums.4 The ability of EBUS to sample mediastinal nodes has expanded its use into the investigation of other conditions; namely sarcoidosis.5,6 Case reports exist of EBUS being used for mediastinal cyst aspiration as well.7
In addition to lymph nodes, EBUS also has excellent ability to visualize other mediastinal structures. Visualization of a pulmonary embolus has been reported.8 It is, therefore, not surprising that information regarding local tumor invasion into vascular structures can also be obtained. To our knowledge, this is the first case of EBUS being used to assess the T stage of the primary tumor with respect to great vessel involvement. We demonstrate in this case the use of EBUS to document direct tumor invasion into the pulmonary vasculature. The additional availability of Doppler allowed confirmation blood flow within these vessels. This case demonstrates that images acquired during EBUS can offer additional information in the staging of lung cancer and expands its use in the imaging of mediastinal structures.
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