INTRODUCTION: Diagnosis of pulmonary lesions in Wegener's granulomatosis has historically been accomplished with open lung biopsy or bronchoscopy-assisted transbronchial biopsies. However, histologic diagnosis of peripheral cavitary lung lesions by bronchoscopy is limited because of size constraints. Ultra-thin (UT) bronchoscopes of <3 mm outer diameters have been useful for diagnosing peripheral solid lesions suspicious for malignancy; the small 1.2 mm working-channels allow only small forceps biopsies but can be used for contrast bronchography-guided diagnostic procedures. We report a case of Wegener's with an enlarging peripheral cavitary lesion that was biopsied with the use of the UT bronchoscope and contrast bronchography.
CASE PRESENTATION: A 50-year-old male smoker with a 17-year history of Wegener’s, diagnosed by renal biopsy and controlled on chronic steroids, presented with an enlarging thick-walled cavitary lesion in the right upper lobe of the lung. He denied dyspnea, fevers, or weight loss, but had a slight cough, with occasional blood-tinged sputum. He was recently hospitalized for acute sinusitis, and treated with antibiotics and increased steroid dose. However, Computed Tomography (CT) scan of the chest revealed an enlarging right upper lobe cavitary lesion measuring 13.7 x 6.4 x 4.9 cm. He was referred for bronchoscopy by his rheumatologist to rule out an infectious or neoplastic process before escalating immunosuppression for suspected recurrent Wegener's.Examination of the bronchial tree with a standard bronchoscope showed diffuse granular mucosa without endo-bronchial lesion. A 2.8mm Olympus BFXT160 ultrathin bronchoscope was advanced into the right upper lobe anterior segment, allowing entry into the cavity. Hypaque contrast material was then injected to fill the entire cavity. Under fluoroscopic guidance, bronchoscopic lavage and brushings were taken using ultrathin instruments of the inside of the cavity, and subsequent transbronchial biopsies were taken using standard sized forceps (1.8mm) through the tract into the cavity created by the ultra-thin scope. EBUS-Transbronchial needle aspiration was performed on 4R LN. All samples were negative for bacterial, viral, fungal, and acid-fast organisms, or neoplasm. Biopsies of the cavity revealed necrotizing granulomatous inflammation consistent with Wegener’s. The patient responded well to cytoxan, with complete radiographic resolution of the cavitary lesion 5 months later.
DISCUSSIONS: The UT bronchoscope can be a useful adjunct to the standard bronchoscope (SB) in diagnosing peripheral lung lesions. Previous use of UT bronchoscopes have focused on diagnosis of peripheral malignancies, demonstrating increased yield from 54.3% with SB to 62.8% with UT1. Contrast agents have also been injected via UT bronchoscope to mark lung parenchyma to guide VATS resection of small peripheral lung lesions.2 Our experience with a series of patients with benign conditions including Wegener's has demonstrated diagnostic success by allowing penetration of the UT scope into the cavity and injection of contrast to provide direct visualization of its interior, from where samples can be obtained. We believe that this enhanced localization may improve diagnostic yield, in comparison to those obtained non-specifically from the exterior of cavitary lesions. Careful prior review of high resolution CT imaging for the presence of an Air Bronchus Sign indicating airways leading to cavities can help guide approach.
CONCLUSION: Ultrathin bronchoscopy and contrast bronchography are useful in diagnosing benign cavitary masses such as Wegener’s granulomas, and had an important role in further managing this patient. This noninvasive approach can increase tissue specificity for histologic diagnosis, thereby avoiding the morbidity of an open lung biopsy traditionally used for peripheral, inaccessible lesions.
DISCLOSURE: Sonali Bose, No Financial Disclosure Information; No Product/Research Disclosure Information