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More Than a Hunch: Need for Close Follow-up and Rebiopsy When Lymphadenopathy Is Not Behaving as Predicted by Infectious Diagnosis: A Case Report FREE TO VIEW

Andrew Kuykendall, MD; Frank Kaszuba, MD; Jennifer Cultrera, MD; John Greene, MD; Carla Moodie, PA-C; Joseph Garrett, ARNP-C; Eric Toloza, MD
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University of South Florida Morsani College of Medicine, Tampa, FL

Chest. 2014;146(4_MeetingAbstracts):353A. doi:10.1378/chest.1994859
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SESSION TITLE: Surgery Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: The differential diagnosis for thoracic lymphadenopathy includes primary or metastatic neoplasia, infection, sarcoidosis and tuberculosis. Accurate and timely diagnosis is imperative. Options for diagnostic approach include transbronchial needle aspiration (TBNA), endobronchial ultrasound-guided (EBUS)-TBNA, cervical mediastinoscopy, and video-assisted thoracoscopic (VATS) biopsy; all which have variable sensitivities, specificities and procedural complication risks.

CASE PRESENTATION: We present a 44-year-old woman with recurrent respiratory infections and persistent thoracic and upper abdominal lymphadenopathy. She underwent multiple nondiagnostic mediastinal and hilar lymph node (LN) biopsies, including an initial bronchoscopy with TBNA (13 months prior) revealing fibrotic lung parenchyma and histiocytic proliferation, cervical mediastinoscopy (2 months later) revealing right paratracheal LNs with reactive changes and left hilar EBUS-TBNA (4 months afterward) revealing benign bronchial cells, lymphocytes and polymicrobial infection, with cultures growing β-hemolytic Streptococcus (Group F) and Actinomyces turicensis. Serial computed tomography (CT) and positron emission tomography (PET) scans revealed increasing size and activity of mediastinal, bilateral hilar, and right supraclavicular lymphadenopathy despite multiple courses of antibiotics which, along with persistent respiratory symptoms led to high clinical suspicion for underlying neoplastic process. A request for VATS LN biopsy led to robotic-assisted mediastinal and hilar lymph node dissection, left lower lobe wedge resection, and right supraclavicular LN dissection. While intraoperative frozen sections of the mediastinal and hilar LNs were non-diagnostic for malignancy, final pathology revealed nodular sclerosing classical Hodgkin lymphoma. She underwent 6 cycles of standard chemotherapy and remains in remission two years later.

DISCUSSION: TBNA and the newer EBUS-TBNA provide minimally invasive approaches for tissue acquisition in patients with concerning lymphadenopathy. EBUS-TBNA has been shown to have superior sensitivity in diagnosing intrathoracic lymphadenopathies over TBNA1 and comparable results to mediastinoscopy in staging non-small cell lung cancer2.

CONCLUSIONS: Newer, less-invasive approaches for tissue acquisition in the setting of thoracic lymphadenopathy are promising, with high diagnostic rates and minimal procedural complication risks. Nevertheless, high clinical suspicion in the setting of non-diagnostic or benign needle biopsy results should warrant a more invasive diagnostic approach.

Reference #1: Herth et al. Conventional versus endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial. Chest 2004;125:322-5

Reference #2: Yasufuku et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thor Cardiovasc Surg 2011;142(1393-1400):e1

DISCLOSURE: The following authors have nothing to disclose: Andrew Kuykendall, Frank Kaszuba, Jennifer Cultrera, John Greene, Carla Moodie, Joseph Garrett, Eric Toloza

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