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Correspondence |

An Algorithm for Approaching Mediastinal Lymphadenopathy in Pulmonary HypertensionMediastinal Adenopathy in Pulmonary Hypertension FREE TO VIEW

Andrew R. L. Medford, MD, FCCP
Author and Funding Information

From the North Bristol Lung Centre, Southmead Hospital.

Correspondence to: Andrew R. L. Medford, MD, FCCP, North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, England; e-mail: andrewmedford@hotmail.com


Financial/nonfinancial disclosures: The author has 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. 2013;144(1):361-362. doi:10.1378/chest.13-0646
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To the Editor:

The recently published article by Moua et al1 (February 2013) is timely but raises more questions about how to study patients with mediastinal lymphadenopathy (MLAD) and idiopathic pulmonary arterial hypertension (IPAH). It would be particularly helpful for clinicians who treat such patients to be able to perform a risk assessment of the need for mediastinal sampling in a patient group where even minimally invasive endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) or conventional TBNA2 is likely to be tolerated less well compared with patients without IPAH. That said, EBUS-TBNA (or conventional TBNA) do provide less invasive alternatives to mediastinoscopy.2

A plethora of guidelines exist regarding the approach to pulmonary nodules and MLAD in the context of lung cancer or malignancy. However, there seems to be a need for guidelines on the approach to idiopathic or unexplained MLAD (without the context of a known cancer) and prospective controlled studies of adequate size to clarify whether conservative monitoring of patients with IPAH and MLAD between 1 and 2 cm with an effusion misses any significant mediastinal pathology. For patients with MLAD >2 cm with IPAH, a safer option might be to perform the less invasive neck ultrasound biopsy first before using EBUS-TBNA or conventional TBNA because it is known that there is a high incidence of pathologic supraclavicular lymphadenopathy in patients with MLAD, even though this may not be apparent on CT scan of the neck, as ultrasound is superior in this regard.3,4

In addition, IPAH represents one of many nonmalignant disorders where MLAD occurs; others would include bronchiectasis, pulmonary veno-occlusive disease, congestive cardiac failure, interstitial lung disease (without granulomatous disease), and reactive infective adenopathy, to name a few. In many of these disorders, pulmonary hypertension may be present, and avoiding invasive EBUS-TBNA sampling might be preferable (unless a specific treatable diagnosis, eg, mycobacterial infection, could be achieved). Could it be that the predominant mechanism for MLAD in all these conditions is actually from elevated right-sided (rather than left-sided) pressures?

In summary, further guidance on a stratified, sequential approach to the investigation of MLAD in suspected benign disorders with pulmonary hypertension would be welcome, reserving EBUS-TBNA or conventional TBNA for situations where neck ultrasound biopsy is unhelpful. Mediastinoscopy should also be reserved for cases where EBUS-TBNA or conventional TBNA is nondiagnostic and the pretest clinical probability of malignancy or treatable mediastinal pathology outweighs the risk of performing mediastinoscopy in the presence of significant pulmonary hypertension.

References

Moua T, Levin DL, Carmona EM, Ryu JH. Frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension. Chest. 2013;143(2):344-348. [CrossRef] [PubMed]
 
Medford AR, Bennett JA, Free CM, Agrawal S. Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy. Curr Opin Pulm Med. 2009;15(4):334-342. [CrossRef] [PubMed]
 
Kumaran M, Benamore RE, Vaidhyanath R, et al. Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer. Thorax. 2005;60(3):229-233. [CrossRef] [PubMed]
 
Medford AR, Bennett JA, Free CM, Agrawal S. Minimally invasive techniques for the diagnosis and staging of lung cancer. Clin Pulm Med. 2009;16(6):328-336. [CrossRef]
 

Figures

Tables

References

Moua T, Levin DL, Carmona EM, Ryu JH. Frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension. Chest. 2013;143(2):344-348. [CrossRef] [PubMed]
 
Medford AR, Bennett JA, Free CM, Agrawal S. Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy. Curr Opin Pulm Med. 2009;15(4):334-342. [CrossRef] [PubMed]
 
Kumaran M, Benamore RE, Vaidhyanath R, et al. Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer. Thorax. 2005;60(3):229-233. [CrossRef] [PubMed]
 
Medford AR, Bennett JA, Free CM, Agrawal S. Minimally invasive techniques for the diagnosis and staging of lung cancer. Clin Pulm Med. 2009;16(6):328-336. [CrossRef]
 
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