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Endobronchial Ultrasonography with Transbronchial Needle Aspiration to Sample a Solitary Substernal Thyroid Nodule: A New Approach
CLINICAL SPOTLIGHT
Clinical Spotlight
Endobronchial Ultrasonography with Transbronchial Needle Aspiration to Sample a Solitary Substernal Thyroid Nodule: A New Approach Michel Chalhoub, MD and Kassem Harris, MD ∗ Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY 10305, USA
Sampling of solitary thyroid nodules (STNs) is a common procedure performed for cytological diagnosis. The easiest and safest method is ultrasound guided fine needle aspiration biopsy (US-FNAB). This technique is usually performed under local anaesthesia in an office setting. In contrast, sampling a substernal STN could prove to be more difficult and problematic, and sometimes requires more invasive procedures. We describe a case of substernal thyroid nodule, where malignancy was excluded using endobronchial ultrasonography with transbronchial fine needle aspiration (EBUSTBNA). We emphasise the feasibility and safety of EBUS-TBNA in sampling retrosternal thyroid nodules. In appropriate settings, this procedure can help avoid more invasive testing, and subsequently decrease the cost and complications. (Heart, Lung and Circulation 2012;21:761–762) © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved. Keywords. Endobronchial ultrasound; Thyroid; Nodule; Substernal
Introduction
Case Report
T
A 72 year-old gentlemen with significant past medical history of chronic obstructive pulmonary disease (COPD) presented to the hospital with a two days history of worsening shortness of breath. The patient denied any other complaints like dysphagia or hoarseness. On physical examination, he was awake and alert, in no apparent discomfort. His vital signs were within normal limits. The head and neck examination was normal with no palpable thyroid and no neck masses. There was no cervical or supraclavicular lymphadenopathy. He had no evidence of stridor, and lung auscultation revealed bilateral end expiratory wheezing. The rest of the physical examination was unremarkable. Initial laboratory data including thyroid-stimulating hormone, was within normal range. The patient underwent a chest computed tomography (CT) of the chest with intravenous (IV) contrast to exclude pulmonary embolism. The chest CT was negative for pulmonary embolism, but showed a substernal goiter with a 2.2 cm STN in proximity with the trachea. There were no signs of airway compression (Fig. 1). The patient was treated for COPD exacerbation. He improved and was discharged home after five days of treatment. We offered him an outpatient EBUS-TBNA procedure to sample his thyroid nodule. The procedure was done under conscious sedation. The BF-UC169F-OL8 scope by Olympus (Tokyo, Japan) was used. The thyroid nodule was easily identified with endobronchial ultrasonography and four transbronchial needle aspirates were performed (NA201SX-4022 needle) (Fig. 1). The procedure was performed
hyroid nodularity is an extremely common condition, and in the era of advanced imaging modalities, thyroid nodules are being increasingly reported [1]. This condition is encountered in about 4–7% of adult subjects [2]. It is fourfold more common in women. Most thyroid nodules are benign and only 5% of palpable thyroid nodules are malignant [2]. Currently, US-FNAB is considered the procedure of choice for sampling the majority of thyroid nodules. In general, US-FNAB is a high yield office based procedure performed with or without local anaesthesia. It is a safe procedure that was determined to decrease the rate of surgical thyroidectomies and consequently, the overall medical cost by approximately 25% [3]. In contrast, sampling of substernal thyroid nodules is more challenging. In many cases, substernal thyroid nodules are not amenable to US-FNAB, and other diagnostic modalities become fundamental. Among many, mediastinoscopy and surgical excision are the most invasive alternatives. Our ambition was to use EBUS-TBNA to sample substernal thyroid nodule. EBUS-TBNA is currently the procedure of choice for staging as well as diagnosing lung cancer. It is being increasingly used for benign thoracic diseases, like sarcoidosis [4,5]. We report our second case of EBUS-TBNA in sampling a substernal STN [6]. Received 16 September 2011; received in revised form 1 February 2012; accepted 28 April 2012; available online 2 June 2012 ∗
Corresponding author. Tel.: +1 718 980 5700; fax: +1 718 226 1986. E-mail address: [email protected] (K. Harris).
© 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2012.04.022
762
Chalhoub and Harris Endobronchial Ultrasonography with Transbronchial Needle Aspiration
CLINICAL SPOTLIGHT
Figure 1. CT image and endobronchial ultrasonography with transbronchial needle aspiration. The substernal thyroid nodule is in contact with the trachea (arrow).
Heart, Lung and Circulation 2012;21:761–762
more than 90% and a specificity of 100% [4] averting the need for more invasive diagnostic procedures such as mediastinoscopy or surgical excisional biopsy. US-FNAB is currently the procedure of choice for sampling thyroid nodules. It is a harmless, office based procedure, performed by repetitively passing a 23–27 gauge needle through the nodule. In patients with malignant thyroid nodules, US-FNAB has an overall sensitivity of about 95% [7]. For substernal thyroid nodules however, US-FNAB is often not feasible and alternative approaches are often required depending on the suspicion of malignancy. Those approaches range from repeating imaging studies to more invasive excisional surgical biopsies. High risk STNs include the following: male sex, family history of thyroid cancer, history of prior neck irradiation, large nodules, and other history of malignancy [4]. EBUS-TBNA can be introduced as a new minimally invasive modality to sample STNs. It uses 21 or 22 gauge needles, and thus the sensitivity is expected to be at least as good as US-FNAB. In this report, we were able to simply and safely sample a substernal thyroid nodule using EBUS-TBNA.
Conclusion In cases where US-FNAB is impossible to perform, EBUSTBNA seems to be a reliable alternative to sample substernal thyroid nodules.
References
Figure 2. Benign follicular thyroid tissue (haematoxylin–eosin stain, magnification 4×).
in about 20 min without complications. The patient tolerated the EBUS-TBNA very well and was discharged home 2 h after his procedure. The cytology of the thyroid nodule was consistent with a colloid thyroid adenoma (Fig. 2).
Discussion Since its introduction in 1996, EBUS-TBNA is becoming widely available throughout the United States. Currently, it is the procedure of choice for staging lung cancer and the initial procedure for evaluating other mediastinal pathologies like sarcoidosis [4]. EBUS-TBNA is an outpatient procedure, performed under conscious sedation. It is a safe procedure, and carries a low complication rate when performed by experienced personnel [4]. When used to stage lung cancer, EBUS-TBNA prevails a sensitivity of
[1] Ezzat S, Sarti DA, Cain DR, Braunstein GD. Thyroid incidentalomas. Prevalence by palpation and ultrasonography. Arch Intern Med 1994;154(August (16)):1838–40. [2] Singer PA, Cooper DS, Daniels GH, Ladenson PW, Greenspan FS, Levy EG, et al. American Thyroid Association. Treatment guidelines for patients with thyroid nodules and well-differentiated thyroid cancer. Arch Intern Med 1996;156(19):2165–72. [3] Hegedüs L. Clinical practice. The thyroid nodule. N Engl J Med 2004;351(17):1764–71. [4] Hwangbo B, Kim SK, Lee HS, Lee HS, Kim MS, Lee JM, et al. Application of endobronchial ultrasound-guided transbronchial needle aspiration following integrated PET CT in mediastinal staging of potentially operable non small cell lung cancer. Chest 2009;135(5):1280–7. [5] Tremblay A, Stather DR, Maceachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest 2009;136(2):340–6. [6] Chalhoub M, Harris K. The use of endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule. Chest 2010;137(June (6)):1435–6. [7] La Rosa GL, Belfiore A, Giuffrida D, Sicurella C, Ippolito O, Russo G, et al. Evaluation of the fine needle aspiration biopsy in the preoperative selection of cold thyroid nodules. Cancer 1991;67(April (8)):2137–41.
Clinical Spotlight
Endobronchial Ultrasonography with Transbronchial Needle Aspiration to Sample a Solitary Substernal Thyroid Nodule: A New Approach Michel Chalhoub, MD and Kassem Harris, MD ∗ Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY 10305, USA
Sampling of solitary thyroid nodules (STNs) is a common procedure performed for cytological diagnosis. The easiest and safest method is ultrasound guided fine needle aspiration biopsy (US-FNAB). This technique is usually performed under local anaesthesia in an office setting. In contrast, sampling a substernal STN could prove to be more difficult and problematic, and sometimes requires more invasive procedures. We describe a case of substernal thyroid nodule, where malignancy was excluded using endobronchial ultrasonography with transbronchial fine needle aspiration (EBUSTBNA). We emphasise the feasibility and safety of EBUS-TBNA in sampling retrosternal thyroid nodules. In appropriate settings, this procedure can help avoid more invasive testing, and subsequently decrease the cost and complications. (Heart, Lung and Circulation 2012;21:761–762) © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved. Keywords. Endobronchial ultrasound; Thyroid; Nodule; Substernal
Introduction
Case Report
T
A 72 year-old gentlemen with significant past medical history of chronic obstructive pulmonary disease (COPD) presented to the hospital with a two days history of worsening shortness of breath. The patient denied any other complaints like dysphagia or hoarseness. On physical examination, he was awake and alert, in no apparent discomfort. His vital signs were within normal limits. The head and neck examination was normal with no palpable thyroid and no neck masses. There was no cervical or supraclavicular lymphadenopathy. He had no evidence of stridor, and lung auscultation revealed bilateral end expiratory wheezing. The rest of the physical examination was unremarkable. Initial laboratory data including thyroid-stimulating hormone, was within normal range. The patient underwent a chest computed tomography (CT) of the chest with intravenous (IV) contrast to exclude pulmonary embolism. The chest CT was negative for pulmonary embolism, but showed a substernal goiter with a 2.2 cm STN in proximity with the trachea. There were no signs of airway compression (Fig. 1). The patient was treated for COPD exacerbation. He improved and was discharged home after five days of treatment. We offered him an outpatient EBUS-TBNA procedure to sample his thyroid nodule. The procedure was done under conscious sedation. The BF-UC169F-OL8 scope by Olympus (Tokyo, Japan) was used. The thyroid nodule was easily identified with endobronchial ultrasonography and four transbronchial needle aspirates were performed (NA201SX-4022 needle) (Fig. 1). The procedure was performed
hyroid nodularity is an extremely common condition, and in the era of advanced imaging modalities, thyroid nodules are being increasingly reported [1]. This condition is encountered in about 4–7% of adult subjects [2]. It is fourfold more common in women. Most thyroid nodules are benign and only 5% of palpable thyroid nodules are malignant [2]. Currently, US-FNAB is considered the procedure of choice for sampling the majority of thyroid nodules. In general, US-FNAB is a high yield office based procedure performed with or without local anaesthesia. It is a safe procedure that was determined to decrease the rate of surgical thyroidectomies and consequently, the overall medical cost by approximately 25% [3]. In contrast, sampling of substernal thyroid nodules is more challenging. In many cases, substernal thyroid nodules are not amenable to US-FNAB, and other diagnostic modalities become fundamental. Among many, mediastinoscopy and surgical excision are the most invasive alternatives. Our ambition was to use EBUS-TBNA to sample substernal thyroid nodule. EBUS-TBNA is currently the procedure of choice for staging as well as diagnosing lung cancer. It is being increasingly used for benign thoracic diseases, like sarcoidosis [4,5]. We report our second case of EBUS-TBNA in sampling a substernal STN [6]. Received 16 September 2011; received in revised form 1 February 2012; accepted 28 April 2012; available online 2 June 2012 ∗
Corresponding author. Tel.: +1 718 980 5700; fax: +1 718 226 1986. E-mail address: [email protected] (K. Harris).
© 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2012.04.022
762
Chalhoub and Harris Endobronchial Ultrasonography with Transbronchial Needle Aspiration
CLINICAL SPOTLIGHT
Figure 1. CT image and endobronchial ultrasonography with transbronchial needle aspiration. The substernal thyroid nodule is in contact with the trachea (arrow).
Heart, Lung and Circulation 2012;21:761–762
more than 90% and a specificity of 100% [4] averting the need for more invasive diagnostic procedures such as mediastinoscopy or surgical excisional biopsy. US-FNAB is currently the procedure of choice for sampling thyroid nodules. It is a harmless, office based procedure, performed by repetitively passing a 23–27 gauge needle through the nodule. In patients with malignant thyroid nodules, US-FNAB has an overall sensitivity of about 95% [7]. For substernal thyroid nodules however, US-FNAB is often not feasible and alternative approaches are often required depending on the suspicion of malignancy. Those approaches range from repeating imaging studies to more invasive excisional surgical biopsies. High risk STNs include the following: male sex, family history of thyroid cancer, history of prior neck irradiation, large nodules, and other history of malignancy [4]. EBUS-TBNA can be introduced as a new minimally invasive modality to sample STNs. It uses 21 or 22 gauge needles, and thus the sensitivity is expected to be at least as good as US-FNAB. In this report, we were able to simply and safely sample a substernal thyroid nodule using EBUS-TBNA.
Conclusion In cases where US-FNAB is impossible to perform, EBUSTBNA seems to be a reliable alternative to sample substernal thyroid nodules.
References
Figure 2. Benign follicular thyroid tissue (haematoxylin–eosin stain, magnification 4×).
in about 20 min without complications. The patient tolerated the EBUS-TBNA very well and was discharged home 2 h after his procedure. The cytology of the thyroid nodule was consistent with a colloid thyroid adenoma (Fig. 2).
Discussion Since its introduction in 1996, EBUS-TBNA is becoming widely available throughout the United States. Currently, it is the procedure of choice for staging lung cancer and the initial procedure for evaluating other mediastinal pathologies like sarcoidosis [4]. EBUS-TBNA is an outpatient procedure, performed under conscious sedation. It is a safe procedure, and carries a low complication rate when performed by experienced personnel [4]. When used to stage lung cancer, EBUS-TBNA prevails a sensitivity of
[1] Ezzat S, Sarti DA, Cain DR, Braunstein GD. Thyroid incidentalomas. Prevalence by palpation and ultrasonography. Arch Intern Med 1994;154(August (16)):1838–40. [2] Singer PA, Cooper DS, Daniels GH, Ladenson PW, Greenspan FS, Levy EG, et al. American Thyroid Association. Treatment guidelines for patients with thyroid nodules and well-differentiated thyroid cancer. Arch Intern Med 1996;156(19):2165–72. [3] Hegedüs L. Clinical practice. The thyroid nodule. N Engl J Med 2004;351(17):1764–71. [4] Hwangbo B, Kim SK, Lee HS, Lee HS, Kim MS, Lee JM, et al. Application of endobronchial ultrasound-guided transbronchial needle aspiration following integrated PET CT in mediastinal staging of potentially operable non small cell lung cancer. Chest 2009;135(5):1280–7. [5] Tremblay A, Stather DR, Maceachern P, Khalil M, Field SK. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest 2009;136(2):340–6. [6] Chalhoub M, Harris K. The use of endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule. Chest 2010;137(June (6)):1435–6. [7] La Rosa GL, Belfiore A, Giuffrida D, Sicurella C, Ippolito O, Russo G, et al. Evaluation of the fine needle aspiration biopsy in the preoperative selection of cold thyroid nodules. Cancer 1991;67(April (8)):2137–41.