Dear Editor,
Endobronchial ultrasonography (EBUS) offers impor- tant contributions in sampling of mediastinal and hilar lymph nodes, and in evaluation of esophageal invasi- ons, such as to the vena cava, main pulmonary arteri- es, that are difficult to diagnose by conventional radi- ological methods (1). EBUS provides valuable infor- mation in interventional bronchoscopy procedures as well as in the diagnosis and staging. In decision-ma- king for curative endobronchial treatment of early lung cancer, the tumor must be limited bounded by the wall.
EBUS helps in determination of the best treatment mo- dality because it allows for detailed analysis of the la- yers of the bronchial wall with its high resolution (2).
Recent literature reveals two reports on the efficiency of EBUS in detection of pulmonary thromboembolism (3,4). In our patient a mass in the right hilar region and mediastinal lymphadenopathy was visualized and diag- nostic transbronchial needle aspiration was performed in the guidance of EBUS (EBUS-TBNA). Moreover, the thrombus in the right pulmonary artery that was obser- ved on the CT pulmonary angiography was confirmed through EBUS.
A 63-year-old male patient presented with acute dysp- nea and pain in his right chest. Chest radiography re- vealed fullness in the right hilar region. Arterial blood gase sampling revealed respiratory alkalosis and hypo-
xemia. Plasma D-dimer level (quantitative) was high (5.12 mg/L). Bedside echocardiography revealed en- larged right cardiac chambers, left ventricle hyperth- rophy; diastolic dysfunction in the left ventricle, severe pulmonary hypertension. Systolic pulmonary arterial pressure was 110 mmHg. The patient was suspected of having pulmonary thromboembolism and was evalu- ated by contrast-enhanced, computed tomography-an- giography of the chest (angio-CT). In the evaluation, the following findings were determined: a hypodense lesion of approximately 3 cm in diameter that was limi- ted to a lobule in the right hilus; multiple lymphadeno- pathy, the largest of which was 23 mm in diameter, in the right lower paratracheal and subcarinal locations, and a thrombus that was 18 mm thick and adherent to the anterior wall in the right main pulmonary artery.
The border between the thrombus and the soft tissue of the right hilar could not be discriminated (Figure 1). Af- ter ten days of low molecular weight heparine treat- ment, patient became hemodynamically stable. Arteri- al blood gas (collected in room temperature) analysis after the treatment was pH: 7.40, PaCO2: 39.2, PaO2: 67 and oxygen saturation: 94%. After that, to obtain di- agnostic samples from the lymphoadenopathies and to evaluate the relationship between the soft tissue of the right hilar and the right pulmonary artery, we perfor- med convex probe (CP) endobronchial ultrasound (EBUS). Pulmonary arteries (PA) were echo free. On
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Yazışma Adresi (Address for Correspondence):
Dr. Aydın YILMAZ, SB Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, 7. Servis Sanatoryum, Keçiören 06280 ANKARA - TURKEY
e-mail: aydnylmaz@yahoo.com
Editöre mektup/Letter to the editor
A case of pulmonary embolism confirmed by endobronchial ultrasound
Erdoğan ÇETİNKAYA1, Aydın YILMAZ2, Akif ÖZGÜL1, Seda ONUR1, Atayla GENÇOĞLU1, Sedat ALTIN1
1 SB Yedikule Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, İstanbul,
2 SB Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, Ankara.
the image of the embolus in the right PA, an echogenic mass that was surrounded by blood flow and floating within the wall was visualized. The blood flow surroun- ding the embolus was easily seen by the power dopp- ler mode of the EBUS bronchoscope (model BF 240, EU-ME1 Olympus, Tokyo, Japan) (Figure 2). There was also a heterogenous lymph node with irregular borders. However, the border between this lymph node and the right pulmonary artery was definite. In additi- on, a homogenous, vascular, lobulated lymphadeno- pathy with regular contours in the subcranial area and a heterogenous, irregularly contoured lesion extending from the right lower paratracheal area to the upper pa- ratracheal area were detected. Histopathological evalu- ation of the fine needle aspiration from the subcranial lymphadenopathy and the lesion showed adenocarci- noma (Figure 3).
Conventional pulmonary angiography is considered a gold standart in PTE because it provides definitive diag-
nosis. The mortality rate with conventional angiography has been reported to be 0.5%, and major morbidity, 1%.
Thus, conventional angiography procedures are avo- ided when possible (5). CT angiography can directly show the thrombus in the pulmonary artery at a seg- ment level. With increased number of detectors (≥ 4), the sensitivity of spiral CT in detecting subsegments of and beyond peripheral thrombi increases (6). CT angio is the most common method for diagnosis of pulmonary embolism (7). CT-angio is counterindicated in those with renal failure and allergy to contrast matter. Altho- ugh it is not counterindicated, exposure to radiation should be avoided during pregnancy. In the study PI- OPED II, in 24% of the patients with suspected acute PE, one or more counterindications were found (6).
With CP-EBUS, the pulmonary arteries around the central airways can be evaluated (3,4). Casoni et al.
used EBUS in distinguishing intraarterial appearance of low density in the right pulmonary artery from a sus- pected right pulmonary artery sarcoma detected on pulmonary angiography. They imaged an embolism in the right main pulmonary artery that was not infiltra- ting the arterial wall and established a definitive diag- nosis of pulmonary thromboembolism by using EBUS (3). In our patient, the power mode of EBUS easily dis- tinguished the embolism surrounded by blood circula- ting in the artery, and the diagnosis of pulmonary em- bolism was confirmed.
Aumiller et al. in their multicenter prospective study, evaluated the cases in whom they had detected central PE by CT-angio by CP-EBUS within 24 hours. They compared EBUS images and CT findings. In 32 pati- ents, 101 PE were detected by CT-angio and 97 of the- se PEs were confirmed by EBUS. Because they had de- termined at least one embolism in each patient, EBUS Çetinkaya E, Yılmaz A, Özgül A, Onur S, Gençoğlu A, Altın S.
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Tüberküloz ve Toraks Dergisi 2011; 59(3): 318-320 Figure 2. CP-EBUS images, showing the defect in filling of pulmonary artery because of thrombus.Figure 1. Thrombus in the right pulmonary artery and subca- rinal lymphadenopathy.
A case of pulmonary embolism confirmed by endobronchial ultrasound
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was considered effective in confirming the diagnosis of central PE. The authors did not encounter any bronc- hoscopy associated complications and reported EBUS as a reliable and safe method of diagnosis for central PE (4).
Ventilation/perfusion (V/Q) lung scintigraphy requires the use of radioactive materials. With increasing age and in the presence of chronic disease such as COPD, the rate of non-diagnostic scintigraphy increases (8,9).
The value of contrast-enhanced CT pulmonary angiog- raphy in the diagnosis of pulmonary embolism is indis- putable (10). However, its use in those with renal failu- res and allergy to contrast matter is counterindicated. It also has a limited use in pregnant individuals because of radiation exposure (6). EBUS can be performed with the patient under local anesthesia and conscious seda- tion. It does not require contrast-matter use or radiati- on exposure. Endobronchial ultrasonography might as- sume its place in diagnostic algorithm for pulmonary embolism, particularly for patients in whom contrast- matter use is counterindicated.
The purpose of this letter is not to give a place to EBUS in the diagnosis of pulmonary embolism, rather that, we suggest that during an EBUS session, great arteries
in the mediastinum must carefully be evaluated in or- der to detect incidental pathologies. Embolus in the proximal portions of great arteries could be clearly de- monstrated by EBUS. But this approach must be limi- ted to very selected, hemodinamically stable patients.
CONFLICT of INTEREST None declared.
REFERENCES
1. Herth F, Ernst A, Schulz M, Becker H. Endobronchial ultraso- und reliably differentiates between airway infiltration and compression by tumor. Chest 2003; 123: 458-62.
2. Herth F, Becker HD. EBUS for early cancer detection. J Bronc- hol 2003; 10: 249-53.
3. Casoni GL, Gurioli C, Romagnoli M, Poletti V. Diagnosis of pul- monary thromboembolism with endobronchial ultrasound Eur Respir J 2008; 32: 1416-7.
4. Aumiller J, Herth FJ, Krasnik M, Eberhardt R. Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study. Respiration 2009; 77: 298-302.
5. Stein PD, Athanasoulis C, Alavi A, Greenspan RH, Hales CA, Saltzman HA, et al. Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation 1992;
85: 462-8.
6. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al. Multi-detector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317-27.
7. Resten A, Mausoleo F, Valero M, Musset D. Comparison of doses for pulmonary embolism detection with helical CT and pulmonary angiography. Eur Radiol 2003; 13: 1515-21.
8. Scarsbrook AF, Bradley KM, Gleeson FV. Perfusion scintig- raphy: diagnostic utility in pregnant women with suspected pulmonary embolic disease. Eur Radiol 2007; 17: 2554-60.
9. Chan WS, Ray JG, Murray S, Coady GE, Coates G, Ginsberg JS. Suspected pulmonary embolism in pregnancy: clinical presentation, results of lung scanning, and subsequent mater- nal and pediatric outcomes. Arch Intern Med 2002; 162: 1170- 5.
10. Fedullo PF, Tapson VF. The evaluation of suspected pul- monary embolism. N Engl J Med 2007; 349: 1247-56.
Figure 3. CP-EBUS image, showing transbronchial needle aspiration biopsy of a lymphadenopathy (thin and thick ar- rows indicate needle and lymph node respectively).
