Ann Thorac Surg 2007;84:1019-1021
© 2007 The Society of Thoracic Surgeons
Case Reports
Transaortic Fine-Needle Aspiration of Centrally Located Lung Cancer Under Endoscopic Ultrasound Guidance: The Final Frontier
Michael B. Wallace, MD, MPHa,*,
Timothy A. Woodward, MDa,
Massimo Raimondo, MDa,
Mohammad Al-Haddad, MDa,
John A. Odell, MDb
a Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
b Division of Thoracic Surgery, Mayo Clinic, Jacksonville, Florida
Accepted for publication March 5, 2007.
* Address correspondence to Dr Wallace, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 (Email: wallace.michael{at}mayo.edu).
| Dr Wallace discloses a financial relationship with Olympus and Cook.
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Abstract
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We describe endoscopic ultrasound guided fine-needle aspiration of a mass adjacent to the descending thoracic aorta, which was performed without complication.
Endoscopic ultrasound (EUS) is a safe, accurate, and minimally invasive method for sampling lymph nodes and masses located in the posterior mediastinum. One limitation of EUS is access to the anterior mediastinum and lymph nodes on the far side (relative to the esophagus) of major blood vessels. The recent development of endobronchial ultrasound (EBUS) has overcome most of these limitations. The "final frontier," which EUS or EBUS has not yet accessed, is the lymph node stations immediately anterior to the aortic arch and lateral to the descending aorta.
A 77-year-old female presented with an enlarging mass in the superior segment of the left lower lobe of the lung immediately adjacent to the descending thoracic aorta and mediastinum. Thirteen years prior she was diagnosed with squamous cell carcinoma of the lung treated with definitive radiation therapy. A routine follow-up computed tomographic scan 12 years after treatment found a 1.7-cm mass that had increased in size within 3 months to 2.6 cm (Fig 1). Positron emission tomography was positive at the site. Evaluations by a multidisciplinary thoracic team confirmed suspicion for malignancy; however the patient’s comorbid disease made her a marginal candidate for surgery. Tissue confirmation by EBUS and EUS-guided biopsy was chosen as the best option to confirm malignancy. Endobronchial ultrasound was performed using a standard EBUS instrument (BF UC 160F [Olympus, Center Valley, PA]). Two lymph nodes measuring <1 cm were sampled by 22 g EBUS fine-needle aspiration (FNA) (Olympus, Center Valley, PA) in the subcarina and periaortic region (not transaortic), and both were confirmed onsite to be cytologically benign. Under the same sedation episode, EUS was performed (GFUC140P [Olympus Co, Center Valley, PA]). The mass was confirmed immediately adjacent to the descending thoracic aorta. A single puncture with a 25-gauge EUS needle (Cook, Winston Salem, NC) was performed through the aorta under continued EUS guidance (Fig 2). Onsite cytopathology confirmed the presence of malignant cytological material, and final pathology revealed nonsmall cell carcinoma.
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Fig 1. Computed tomographic scan demonstrating mass (arrow) in the medial left upper lobe immediately adjacent to the descending aorta.
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Fig 2. Endoscopic ultrasound view of periaortic mass with 25-gauge needle passing through the descending aorta and into the mass.
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The patient was taken to the operating room 13 days after the EUS. A video-assisted thoracoscopic resection of the involved segment was performed without complication. An intraoperative picture of the needle puncture site revealed a 5-mm spot at the needle site with no significant inflammation or hematoma (Fig 3). Pathology reveals a T2 poorly differentiated squamous cell carcinoma and 1 of 10 interlobar positive lymph nodes (N1). All mediastinal lymph nodes were negative.
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Fig 3. Surgical view at the time of video-assisted thoracoscopic resection of the tumor 13 days after endoscopic ultrasound. The dashed line arrow shows the path of the needle. The white arrow shows the small blood stain on the aortic wall. No periaortic hematoma was present.
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Because of the N1 lymph node, the patient received adjuvant therapy with carboplatin (Bristol-Myers Squibb, New York, NY), paclitaxel (Taxol; Abbott Labs, Abbott Park, IL), but she had significant side effects after one dose and declined further treatment. Fourteen months after surgery, the patient is alive and well with no evidence of disease.
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Comment
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In this case, we report the preliminary feasibility and safety of transaortic FNA of thoracic tumors under EUS guidance. Endoscopic ultrasound has become a major method for tissue acquisition in pancreatic tumors, abdominal, and mediastinal lymph nodes. Tumors or lymph nodes within 3 to 4 cm of the gastrointestinal tract, including the intrathoracic esophagus, are readily sampled by EUS-FNA. Lymph nodes immediately adjacent to the large vascular structures such as those in the aortopulmonary window have been safely and accurately sampled with EUS-FNA in numerous studies [1–3]. Although lymph nodes on the "far-side" of major blood vessels can be visualized by EUS, FNA of these has traditionally been avoided due to concern for bleeding complications.
Transvascular access with small gauge needles is routinely used in radiological and interventional vascular procedures. Celiac plexus neurolysis, performed percutaneously under computed tomographic or fluoroscopic guidance, has traditionally accessed the celiac ganglia through a transaortic approach with low risk of complications [4]. Endoscopic ultrasound-guided FNA, although typically done with efforts to avoid vascular puncture, still results in inadvertent arterial and venous puncture on occasion with little or no consequence. The risk of major bleeding after EUS-FNA of pancreatic tumors that typically lie adjacent to or invade the portal vein is <0.5% [5]. In an animal study, evaluating the initial accuracy of 19-gauge trucut needles, intentional biopsy of the thoracic aorta in two pigs, followed by necropsy, revealed no significant hemorrhage [6].
Although this case report raises the possibility of safe, transvascular access to masses and lymph nodes, major caution is still warranted. In many cases in which tissue acquisition is required, there are less invasive options, including surgical biopsy, which do not carry the potential for risk of traversing a major blood vessel. Tissue confirmation, although often desirable prior to major surgery, is not always necessary in the setting of a highly suspicious mass or lymph node. However, in the setting of lung cancer staging, the American College of Chest Physicians does recommend tissue confirmation of lymph nodes, regardless of computed tomography or positron-emission tomographic status [7].
The major advantage of this procedure is its ability to reach virtually all lymph nodes in the mediastinum. In our own prior work we have demonstrated that the combination of EUS and EBUS can reach virtually all mediastinal lymph nodes with a sensitivity of 97%. The one region of false negative EUS and EBUS in lung cancer patients was the region anterior to the aorta [8]. In summary, we demonstrate the early feasibility of transvascular EUS-FNA of masses and lymph nodes. Clearly, further study and very careful selection by expert EUS operators is needed before this procedure can be routinely recommended.
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References
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- LeBlanc JK, Devereaux BM, Imperiale TF, et al. Endoscopic ultrasound in non-small cell lung cancer and negative mediastinum on computed tomography Am J Respir Crit Care Med 2005;171:177-182.[Abstract/Free Full Text]
- Wallace MB, Ravenel J, Block MI, et al. Endoscopic ultrasound in lung cancer patients with a normal mediastinum on computed tomography Ann Thorac Surg 2004;77:1763-1768.[Abstract/Free Full Text]
- Wallace MB, Fritscher-Ravens A, Savides TJ. Endoscopic ultrasound for the staging of non-small-cell lung cancer Endoscopy 2003;35:606-610.[Medline]
- Lee JM. CT-guided celiac plexus block for intractable abdominal pain J Korean Med Sci 2000;15:173-178.[Medline]
- Eloubeidi MA, Tamhane A, Varadarajulu S, Wilcox CM. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation Gastrointest Endosc 2006;63:622-629.[Medline]
- Wiersema MJ, Levy MJ, Harewood GC, Vazquez-Sequeiros E, Jondal ML, Wiersema LM. Initial experience with EUS-guided trucut needle biopsies of perigastric organs Gastrointest Endosc 2002;56:275-278.[Medline]
- Detterbeck FC, DeCamp Jr MM, Kohman LJ, Silvestri GA. Invasive staging: the guidelines Chest 2003;123167S–75.
- Wallace MB, Pascual J, Raimondo M, et al. A prospective blinded comparison of bronchoscopic versus endobronchial ultrasound versus endoscopic ultrasound fine needle aspiration for the mediastinal staging of lung cancer Lung Cancer 2005;49:S13.[Medline]
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M. B. Wallace
Lung Cancer Staging With Minimally Invasive Endoscopic Techniques--Reply
JAMA,
June 4, 2008;
299(21):
2510 - 2511.
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Abstract
Introduction
