Ann Thorac Surg 2005;80:2346-2349
© 2005 The Society of Thoracic Surgeons
Case report
Endoscopic Ultrasound-Guided Fine Needle Aspiration for Diagnosis of Recurrent Nonsmall Cell Lung Cancer
Rebecca Lai, MD
*
Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota USA
Accepted for publication June 16, 2004.
* Address correspondence to Dr Lai, Division of Gastroenterology, Hennepin County Medical Center, 701 Park Ave S, Minneapolis, MN55415 (Email: laixx008{at}umn.edu).
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Abstract
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Diagnosis of recurrent lung cancer by various imaging studies is often difficult because a recurrent tumor can resemble scar tissue or postoperative changes. This article reports how an endoscopic ultrasound-guided fine needle aspiration was used to obtain a tissue diagnosis of locoregional lung cancer recurrence, which changed the management of the patients.
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Introduction
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The overall long-term survival after surgery with curative intent for nonsmall cell lung cancer is disappointing largely because of the high rate of recurrence [1, 2]. Diagnosis of local recurrence at the tumor bed is often quite difficult because most imaging studies cannot clearly distinguish posttreatment changes from recurrent malignancy. This case series demonstrates the use of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for tissue diagnosis of locoregional lung cancer recurrence. As such, this represents the first article reporting the use of an EUS in diagnosing recurrent lung cancer.
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Case Reports
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Patient 1
A 68-year-old man who was diagnosed with squamous cell lung cancer in 2000 underwent a right upper lobectomy without adjuvant therapy. He presented in 2003 with right-sided pleuritic chest pain and dyspnea on exertion. A computerized tomographic scan showed irregular thickening at the right main bronchus, considered to be either postoperative scarring or recurrent malignancy. Subsequently the patient had a bronchoscopy and postoperative changes were found at the right mainstem bronchus. Brush biopsies from the lobectomy site were negative. When the patient presented for a second opinion at our hospital, a positron-emission tomography (PET) scan was obtained, which showed hypermetabolic foci at the right suprahilar and paratracheal region suggestive of tumor recurrence. An EUS was performed with a linear array echoendoscope (EG-3630U [Pentax Precision Instruments, Orangeburg, NY]) in an attempt to obtain tissue confirmation of recurrence. A 5 cm, irregularly shaped, hypoechoic mass with hyperechoic foci was seen at the right hilum at the previous surgical site (Fig 1). The lesion was sampled with a 25-gauge Echotip needle (Wilson Cook, Winston-Salem, NC), and final cytology showed recurrent squamous cell carcinoma.
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Fig 1. (A) Linear array endosonographic image of a hypoechoic mass with an irregular margin located at the surgical bed of a previous right upper lobectomy. (B) Corresponding diagram showing periesophageal mass (1), acoustic shadowing from surgical clips (2), and air artifact (3).
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Patient 2
A 67-year-old woman with a history of adenocarcinoma of the right upper lobe, status post resection in 2000, was subsequently diagnosed with an isolated brain metastasis in 2001 that was treated with resection and radiation therapy. She was doing well until May 2002 when she had a persistent cough and dyspnea on exertion develop. Computed tomographic scan revealed a bulky soft tissue abnormality at the subcarina compressing the bronchus intermedius and right lower lobe bronchus, along with two left lung nodules suspicious of metastasis. An EUS was performed with a linear array echoendoscope (EG-3630U [Pentax Precision Instruments, Orangeburg, NY]) in order to obtain a tissue diagnosis of the mediastinal mass. A 6.5 cm hypoechoic mass was seen in the subcarinal region along with several smaller lymph nodes. The mass was sampled with a 25-gauge Echotip needle (Wilson Cook, Winston-Salem, NC) and cytologic examination showed lymphocytes and adenocarcinoma consistent with nodal recurrence.
Patient 3
A 47-year-old woman was diagnosed with Pancoast squamous cell carcinoma of the right upper lobe in July 2003. An initial PET scan and medistinoscopy were negative. After neoadjuvant chemoradiation, the patient underwent right upper lobectomy with en bloc chest wall resection and right partial vertebrectomy. Three months postoperatively, a soft tissue density was noted on computed tomography. A repeat PET scan showed new foci of hyperactivity in the right paratracheal location consistent with recurrence. An EUS was performed with a linear array echoendoscope (EG-3630U [Pentax Precision Instruments, Orangeburg, NY]). An irregularly shaped, 3-cm hypoechoic mass was seen in the right paratracheal region at the surgical bed, along with a few 1 cm hypoechoic nodes in the left lower paratracheal region. Both sites were sampled with separate 25-gauge Echotip needles (Wilson Cook, Winston-Salem, NC) (Fig 2). Final cytology from both sites showed presence of malignancy, confirming local recurrence and distant nodal metastasis.
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Fig 2. (A) Fine needle aspiration of a hypoechoic mass at right paratracheal region using a 25-gauge needle. (B) Corresponding diagram showing right paratracheal mass (1), fine-needle aspiration (2), and pleural lining (3).
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Comment
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Despite aggressive treatment with curative intent, long-term survival in lung cancer patients is <60%. A large number of patients have recurrence, local or distant [1, 2]. Locoregional recurrence within the tumor bed or in mediastinal lymph nodes ranges from 10% to 30% [1–3]. The median time to local recurrence is about 2 years [2, 4]. Distant metastases occurs even more frequently [1, 2, 5]. In selected patients with postresection locoregional recurrence, some advocate aggressive therapy with completion pneumonectomy, chest wall resection, radiation therapy, and so forth [4, 6]. Early detection and confirmation of recurrence may benefit patients by affording an opportunity for curative reresection or instituting noncurative medical therapies [6].
Accurate radiologic diagnosis of recurrent lung cancer is difficult because fibrotic tissue and posttreatment changes can resemble a tumor unless there is a substantial volume change over time [7]. A PET scan can potentially assist in this determination. However, false positive results are occasionally seen with active infection and radiation pneumonitis especially within 12 months of treatment, thus limiting its specificity [7, 8]. Another major disadvantage is that it does not provide a histologic diagnosis. It is recommended that in PET scans positive lesions, tissue proof of malignancy should be obtained before proceeding to potentially curative surgery, because the false positive rate can be as high as 25% to 30% [6, 8]. Nevertheless, the PET scan is useful in guiding selection of a biopsy site.
Endoscopic ultrasound has been advocated as an accurate pre-therapeutic lung cancer staging tool because of its ability to detect and obtain pathologic confirmation of mediastinal nodal metastasis [9]. There has been no report on the use of EUS for detection or diagnosis of recurrent lung cancer.
In this case series, we report 3 patients whose lung cancer recurrences at the surgical bed or at the mediastinal nodes, or at both, were histologically established by an EUS-guided FNA. Local recurrences at the surgical bed after a lobectomy in these cases were located within the mediastinum, adjacent to the esophagus, without any intervening air-filled structures. Thus the lesions could be clearly imaged by EUS. Although the sonographic appearance could not distinguish between malignancy and benign scarring or inflammatory tissue, EUS-guided FNA allowed tissue diagnosis of recurrence. The potential for a false negative biopsy, as with all other methods of sampling, still remains. Thus a negative cytology does not completely exclude possibility of recurrence, especially if the PET scan was positive. As illustrated by patients 2 and 3, EUS could also diagnose locoregional nodal recurrence, similar to its use for staging of the primary tumor. In patient 3, EUS-guided FNA diagnosed recurrence in a small contralateral mediastinal node which was not detected by the PET scan. This finding established metastatic disease and precluded any further attempts of reresection. In all three patients, the findings and results from EUS and FNA changed the management of these patients.
In conclusion, this case series of 3 patients demonstrated the ability of EUS-guided FNA to detect and pathologically confirm locoregional lung cancer recurrence at the surgical bed and mediastinal nodes. As such, this is the first report on the use of EUS-FNA for work-up of lung cancer recurrence. Further study is necessary to characterize its efficacy and safety, especially regarding the FNA of recurrence in the surgical bed.
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References
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Abstract
Introduction
