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Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of Thyroid NodulesEndobronchial Ultrasound of the Thyroid Nodule: Pushing the Boundary Too Far? FREE TO VIEW

Marcus P. Kennedy, MD, FCCP; Micheal Breen, MB; Kevin O’ Regan, MB; Julie McCarthy, MB, PhD; Mary Horgan, MD; Michael T. Henry, MD
Author and Funding Information

From the Department of Respiratory Medicine (Drs Kennedy and Henry); the Department of Radiology (Drs Breen and O’Regan); the Department of Cytopathology (Dr McCarthy); and the Department of Infectious Diseases (Dr Horgan), Cork University Hospital.

Correspondence to: Marcus P. Kennedy, MD, FCCP, Cork University Hospital, Wilton, Cork, Ireland; e-mail: Marcus.kennedy@hse.ie


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.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(6):1690-1691. doi:10.1378/chest.12-1871
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Published online
To the Editor:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) helps bronchoscopists attain cytologic specimens from sites beyond the airway with accuracy, ease, and safety. Research has flourished, and publications have included reports of biopsying not only lymph nodes for lung cancer staging, but also lung and mediastinal masses, TB-infected lymph nodes, cysts, and thyroid nodules.1-5

The potential for complication from thyroid nodule biopsy via EBUS-TBNA is highlighted in the following case. A 49-year-old woman was referred for EBUS-TBNA of asymptomatic mediastinal adenopathy with a history of low-grade endometrial sarcoma resected through hysterectomy 3 months prior. At the time of surgery, small-volume mediastinal adenopathy and lung nodules were identified. On follow-up CT imaging, adenopathy had increased in size. A thyroid nodule was also identified (Fig 1A). Thus, the patient underwent airway inspection (normal) and EBUS-TBNA. Sampling of a 9-mm subcarinal lymph node identified noncaseating granuloma consistent with sarcoid-like lymphadenopathy on two passes, and follow-up CT imaging 3 months later identified stable disease. The thyroid nodule was also sampled through EBUS-TBNA, and cytologic analysis identified colloid consistent with a benign nodule. The patient presented to the ED 8 days later with fever and swelling and pain in her neck. Ultrasonography of her neck identified a thyroid abscess, which was drained (Fig 1B). She was treated with IV antibiotics, and repeat ultrasound-guided drainage was required 48 h later. Thyroid aspirate cultures grew Streptococcus mitis and mixed gram-positive and gram-negative organisms sensitive to penicillin. Mycobacterial staining and cultures of the abscess and mediastinal lymph node were negative. She was discharged without recurrence of symptoms, and follow-up thyroid function testing was normal.

Figure Jump LinkFigure 1. A, Contrast-enhanced axial enhanced CT scan through the thoracic inlet demonstrates a 2-cm, homogenously low-attenuation nodule in the right lobe of the thyroid accessible to ultrasound fine-needle aspiration (arrow). B, High-frequency transverse ultrasound image of the neck demonstrates a predominantly hypoechoic fluid-containing lesion in the right lobe of the thyroid. There is slight nodularity of the medial wall (arrows), and the lesion measured slightly larger than on a previous CT scan. Aspiration of this lesion revealed purulent material.Grahic Jump Location

The standard modality of sampling thyroid nodules is through ultrasound-guided fine-needle aspirate (US-FNA) with a low complication rate.6 US-FNA is aseptic; however, it is not possible to maintain the sterility of an EBUS-TBNA needle through the human mouth and oropharynx. Thyroid nodules visible by endobronchial ultrasound are present close to the proximal trachea below the vocal cords, an area prone to contamination of the oropharynx. Infectious complications postulated to be secondary to oropharyngeal contamination have been described previously.7 Until randomized comparisons of EBUS-TBNA with standard and safe procedures such as US-FNA of the thyroid are carried out, bronchoscopists should proceed with caution in expanding the use of EBUS-TBNA, especially in the proximal airway prone to oropharyngeal contamination. Retrosternal thyroid nodules beyond the reach of US-FNA are an ideal cohort for further investigation.5

References

Nakajima T, Yasufuku K, Fujiwara T, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrapulmonary lesions. J Thorac Oncol. 2008;3(9):985-988. [CrossRef] [PubMed]
 
Hassan T, McLaughlin AM, O’Connell F, Gibbons N, Nicholson S, Keane J. EBUS-TBNA performs well in the diagnosis of isolated thoracic tuberculous lymphadenopathy. Am J Respir Crit Care Med. 2011;183(1):136-137. [PubMed]
 
Casal RF, Jimenez CA, Mehran RJ, et al. Infected mediastinal bronchogenic cyst successfully treated by endobronchial ultrasound-guided fine-needle aspiration. Ann Thorac Surg. 2010;90(4):e52-e53. [CrossRef] [PubMed]
 
Chalhoub M, Harris K. The use of endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule. Chest. 2010;137(6):1435-1436. [CrossRef] [PubMed]
 
Chalhoub M, Harris K. Endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule: a new approach [published online ahead of print June 1, 2012]. Heart Lung Circ doi:10.1016/j.hlc.2012.04.022.
 
Polyzos SA, Anastasilakis AD. Clinical complications following thyroid fine-needle biopsy: a systematic review. Clin Endocrinol (Oxf). 2009;71(2):157-165. [CrossRef] [PubMed]
 
Haas AR. Infectious complications from full extension endobronchial ultrasound transbronchial needle aspiration. Eur Respir J. 2009;33(4):935-938. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. A, Contrast-enhanced axial enhanced CT scan through the thoracic inlet demonstrates a 2-cm, homogenously low-attenuation nodule in the right lobe of the thyroid accessible to ultrasound fine-needle aspiration (arrow). B, High-frequency transverse ultrasound image of the neck demonstrates a predominantly hypoechoic fluid-containing lesion in the right lobe of the thyroid. There is slight nodularity of the medial wall (arrows), and the lesion measured slightly larger than on a previous CT scan. Aspiration of this lesion revealed purulent material.Grahic Jump Location

Tables

References

Nakajima T, Yasufuku K, Fujiwara T, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrapulmonary lesions. J Thorac Oncol. 2008;3(9):985-988. [CrossRef] [PubMed]
 
Hassan T, McLaughlin AM, O’Connell F, Gibbons N, Nicholson S, Keane J. EBUS-TBNA performs well in the diagnosis of isolated thoracic tuberculous lymphadenopathy. Am J Respir Crit Care Med. 2011;183(1):136-137. [PubMed]
 
Casal RF, Jimenez CA, Mehran RJ, et al. Infected mediastinal bronchogenic cyst successfully treated by endobronchial ultrasound-guided fine-needle aspiration. Ann Thorac Surg. 2010;90(4):e52-e53. [CrossRef] [PubMed]
 
Chalhoub M, Harris K. The use of endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule. Chest. 2010;137(6):1435-1436. [CrossRef] [PubMed]
 
Chalhoub M, Harris K. Endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule: a new approach [published online ahead of print June 1, 2012]. Heart Lung Circ doi:10.1016/j.hlc.2012.04.022.
 
Polyzos SA, Anastasilakis AD. Clinical complications following thyroid fine-needle biopsy: a systematic review. Clin Endocrinol (Oxf). 2009;71(2):157-165. [CrossRef] [PubMed]
 
Haas AR. Infectious complications from full extension endobronchial ultrasound transbronchial needle aspiration. Eur Respir J. 2009;33(4):935-938. [CrossRef] [PubMed]
 
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