SESSION TITLE: Infectious Disease Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM
INTRODUCTION: Symptomatic bronchogenic cysts typically require surgical resection. Poor surgical candidacy makes management a challenge. We report a case where endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) was used to assist optimization of the hemodynamic status prior to surgical resection.
CASE PRESENTATION: 53 yo man presented with light-headedness and shortness of breath of 1-week duration. Evaluation revealed that the patient was in atrial fibrillation with a rapid ventricular response (Heart rate 165 and BP 99/73) that remained refractory to medical therapy. Routine blood work was unrevealing. CT chest failed to demonstrate pulmonary embolism. It however revealed a cystic 9.6 x 9.9 cm retro-cardiac mass. Cardiac MRI confirmed mass effect from this lesion on left atrium as well as the pulmonary veins. In light of the tenuous hemodynamic status of the patient, bronchoscopic interrogation prior to a more invasive surgical intervention was planned. Convex probe endobronchial ultrasound (EBUS) was used and the mass was confirmed to be cystic. Using EBUS-TBNA, 272 cc of purulent fluid was drained. Despite aggressive drainage, we were unable to completely evacuate the cyst. The procedure resulted in marked improvement in patient’s hemodynamic status instantaneously. The patient eventually underwent thoracotomy with surgical resection of the cyst. Surgical pathology confirmed the lesion to be a bronchogenic cyst.
DISCUSSION: Bronchogenic cysts are the most common cystic lesions in the middle mediastinum in adults. Although most are asymptomatic and diagnosed incidentally, literature suggests that majority of these cysts eventually become symptomatic and complications develop if they are left unattended. Traditional management of symptomatic mediastinal cystic lesions consists of surgical resection. Recent years have witnessed an expanding role for EBUS-TBNA for both diagnostic and therapeutic purposes. EBUS provides excellent delineation between solid and fluid structures as well as better imaging of loculations within cysts. Literature for long- term follow-up for this approach is scant. However, it may represent an extremely useful form of therapy for patients who are poor surgical candidates as was the case here.
CONCLUSIONS: To the best of our knowledge, this is the first report where EBUS-TBNA has been used palliatively for symptom control and hemodynamic improvement prior to subjecting the patient to a definitive surgical procedure.
Reference #1: Anantham D, Phua GC, et al. Role of endobronchial ultrasound in the diagnosis of bronchogenic cysts. Diagn Ther Endosc. 2011; 2011: 468237.
Reference #2: Twehues A, Islam S. Cystic lesions of the thorax: role of endobronchial ultrasound-guided transbronchial needle aspiration. J Bronchology Interv Pulmonol. 2011; 18(3): 265-8.
Reference #3: Galluccio G, Lucantoni G. Mediastinal bronchogenic cyst's recurrence treated with EBUS-FNA with a long-term follow-up. Eur J Cardiothorac Surg. 2006; 29(4): 627-9.
DISCLOSURE: The following authors have nothing to disclose: Tathagat Narula, Sonali Sethi, Siva Raja, Joseph Cicenia, Thomas Gildea, Michael Machuzak, Francisco Almeida
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