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The Use of Endobronchial Ultrasonography With Transbronchial Needle Aspiration To Sample a Solitary Substernal Thyroid Nodule FREE TO VIEW

Michel Chalhoub, MD; Kassem Harris, MD
Author and Funding Information

From the Staten Island University Hospital, Staten Island, NY.

Correspondence to: Michel Chalhoub, MD, Staten Island Pulmonary Associates, 501 Seaview Ave, Ste 102, Staten Island, NY 10305; e-mail: chalhoubmichel@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(6):1435-1436. doi:10.1378/chest.09-2840
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Published online

Solitary thyroid nodules (STNs) are frequently encountered in clinical practice. When sampling of an STN is deemed necessary, ultrasound-guided fine needle aspiration biopsy (US-FNAB) is the procedure of choice. In substernal STNs, US-FNAB is not feasible, and the patients are usually offered either more invasive diagnostic testing (mediastinoscopy or surgical excision) or follow-up imaging studies based on the clinical suspicion of malignancy. We report a case in which a substernal STN was sampled using endobronchial ultrasonography with transbronchial fine needle aspiration (EBUS-TBNA). Our patient is a 74-year-old woman who was admitted with an asthma exacerbation. She underwent a chest CT scan with intravenous contrast (CTA) to rule out pulmonary embolism (PE). The CTA was negative for PE but showed a substernal STN that was successfully sampled by EBUS-TBNA without complications. The cytology was consistent with a colloid adenoma. EBUS-TBNA can sample substernal STNs that are not amenable to US-FNAB.

Figures in this Article

Solitary thyroid nodules (STNs) are a fairly common problem in clinical practice. It is estimated that 4% to 7% of adult subjects have a palpable thyroid nodule.1 Most STNs are benign and only one out of 20 palpable thyroid nodules is malignant.1 The clinical challenge, therefore, is to exclude malignancy. In most instances this is accomplished by ultrasound-guided fine needle aspiration biopsy (US-FNAB).2 US-FNAB, an office-based procedure, has been shown to decrease the rate of thyroidectomies by 50% and to reduce the overall medical cost by 25%.2 The reported yield of US-FNAB is about 80%, and besides local discomfort, it carries no significant risks. In substernal thyroid nodules, however, US-FNAB might be impossible, narrowing the choices to less-specific noninvasive testing (such as thyroid scanning) or follow-up imaging studies, or more invasive diagnostic procedures (such as mediastinoscopy or surgical excision).2 Endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) is a new bronchoscopic technique that allows sampling of mediastinal and hilar lesions under real-time ultrasonographic guidance. At the present time, EBUS-TBNA has a central role in staging as well as diagnosing lung cancer, and is being increasingly used in nonmalignant thoracic diseases, such as sarcoidosis.3,4 We report, to our knowledge, the first case of a substernal STN that was sampled using EBUS-TBNA.

A 74-year-old woman was admitted to the hospital for shortness of breath and dry cough. There was no history of dysphagia or dysphonia. On physical examination the patient was awake and alert, in no apparent distress, with normal vital signs. The examination of the neck revealed no palpable thyroid enlargement or nodules. There was no cervical or supraclavicular lymphadenopathy. She had no stridor, but there was faint bilateral end-expiratory wheezing. The rest of the physical examination was unremarkable. The initial blood work, including a thyrotropin-stimulating hormone, was within normal range. She underwent a CT scan of the chest with IV contrast to rule out pulmonary embolism. The chest CT scan with IV contrast was negative for pulmonary embolism, but showed a substernal goiter with an STN in contact with the trachea but without evidence of airway compression (Fig 1). After she responded to treatment of asthma exacerbation, she was offered an EBUS-TBNA to sample her thyroid nodule. The procedure was done on an outpatient basis under conscious sedation. The BF-UC169F-OL8 scope by Olympus (Tokyo, Japan) was used. The nodule was easily identified with ultrasonography, and using the NA-201SX-4022 needle, four TBNAs were performed under real-time ultrasonographic guidance (Fig 1). The patient tolerated the procedure very well, and there were no complications. The cytology was consistent with a colloid thyroid adenoma (Fig 2).

Figure Jump LinkFigure 1. CT image and endobronchial ultrasonography with transbronchial needle aspiration.Grahic Jump Location
Figure Jump LinkFigure 2. Benign follicular thyroid tissue (hematoxylin-eosin stain, magnification × 10).Grahic Jump Location

This is the first report, to our knowledge, to describe the use of EBUS-TBNA to sample a substernal solitary thyroid nodule. In a recent letter to the editor, Jeebun et al5 reported the use of EBUS-TBNA to sample a posterior mediastinal mass that was consistent with a mediastinal goiter on cytologic examination. EBUS-TBNA has become the initial invasive procedure of choice for staging non-small cell lung cancer with a reported sensitivity > 90% and a specificity of 100%.3 The procedure is done under conscious sedation on an outpatient basis, and, in experienced hands, the reported complication rate is low.3 In the appropriate setting, EBUS-TBNA can obviate the need for more aggressive diagnostic procedures, such as mediastinoscopy or surgical excisional biopsy. In addition, EBUS-TBNA is becoming the procedure of choice for sampling mediastinal lymph nodes in suspected sarcoidosis.4 The role of EBUS-TBNA in STN has not been defined yet, but seems to be promising. After history, physical examination, and serum thyrotropin level measurement, patients with STNs usually undergo US-FNAB.2 In substernal STN US-FNAB is not feasible, and patients are often offered more invasive surgical approaches or watchful waiting. The decision to proceed with more invasive diagnostic procedures vs noninvasive testing and follow-up imaging studies depends on certain clinical criteria as well as radiologic findings that increase the suspicion for malignancy. These criteria include family history of medullary thyroid cancer, subjects < 20 or > 70 years of age, men, prior head and neck irradiation, nodules > 4 cm, cervical lymphadenopathy, an increase in the size of the nodule, compression symptoms, or history of metastasis.2

In select cases when dealing with a substernal STN in close proximity with the trachea, EBUS-TBNA can be offered as a minimally invasive procedure to sample the STN, and can potentially save the patient a more invasive diagnostic procedure. This report presents another potential indication for EBUS-TBNA in sampling substernal thyroid nodules where US-FNAB is impossible.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

EBUS-TBNA

endobronchial ultrasonography with transbronchial fine needle aspiration

STN

solitary thyroid nodule

US-FNAB

ultrasound-guided fine needle aspiration biopsy

Singer PA, Cooper DS, Daniels GH, et al; American Thyroid Association American Thyroid Association Treatment guidelines for patients with thyroid nodules and well-differentiated thyroid cancer. Arch Intern Med. 1996;15619:2165-2172. [CrossRef] [PubMed]
 
Hegedüs L. Clinical practice. The thyroid nodule. N Engl J Med. 2004;35117:1764-1771. [CrossRef] [PubMed]
 
Hwangbo B, Kim SK, Lee HS, 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;1355:1280-1287. [CrossRef] [PubMed]
 
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;1362:340-346. [CrossRef] [PubMed]
 
Jeebun V, Natu S, Harrison R. Diagnosis of a posterior mediastinal goitre via endobronchial ultrasound-guided transbronchial needle aspiration. Eur Respir J. 2009;343:773-775. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. CT image and endobronchial ultrasonography with transbronchial needle aspiration.Grahic Jump Location
Figure Jump LinkFigure 2. Benign follicular thyroid tissue (hematoxylin-eosin stain, magnification × 10).Grahic Jump Location

Tables

References

Singer PA, Cooper DS, Daniels GH, et al; American Thyroid Association American Thyroid Association Treatment guidelines for patients with thyroid nodules and well-differentiated thyroid cancer. Arch Intern Med. 1996;15619:2165-2172. [CrossRef] [PubMed]
 
Hegedüs L. Clinical practice. The thyroid nodule. N Engl J Med. 2004;35117:1764-1771. [CrossRef] [PubMed]
 
Hwangbo B, Kim SK, Lee HS, 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;1355:1280-1287. [CrossRef] [PubMed]
 
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;1362:340-346. [CrossRef] [PubMed]
 
Jeebun V, Natu S, Harrison R. Diagnosis of a posterior mediastinal goitre via endobronchial ultrasound-guided transbronchial needle aspiration. Eur Respir J. 2009;343:773-775. [CrossRef] [PubMed]
 
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