Endobronchial ultrasound-guided transbronchial cryo-nodal biopsy: a novel approach for mediastinal lymph node sampling

Abstract

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is preferred for evaluating malignant lymph nodes and staging of lung cancer. Nevertheless, larger tissue samples are increasingly needed, particularly for molecular analysis. We describe the feasibility, technical details, and complications of EBUS-guided transbronchial cryo-node biopsy (TBCNB) in four patients with mediastinal adenopathy. The samples obtained by EBUS-TBCNB in all cases were adequate for histopathological examination (HPE) and immunohistochemistry (IHC) staining. In case 1, HPE showed non-caseating epithelioid granuloma with giant cells and fibrosis consistent with sarcoidosis. Case 2 was diagnosed with adenocarcinoma with positivity for ROS1(D4D6). Case 3 showed features of metastatic adenocarcinoma from the breast (positive for Her2, ER, and GATA3). Case 4 was diagnosed with tuberculosis (necrotizing granuloma in histopathology, stain with Ziehl-Neelsen that showed few rod-shaped bacilli). Only one patient had minimal bleeding at the puncture site controlled with cold saline. There were no adverse events such as major bleeding, pneumomediastinum, or pneumothorax.

Keywords: Cryo‐biopsy; endoscopic ultrasound‐guided fine‐needle aspiration; lymph nodes; mediastinum.

Figure 1

(A) Performing endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA)—EBUS image showing a 19‐G needle in station 11L node; steps of inserting 1.1 mm cryo‐probe through the puncture site made by TBNA needle, (B) tip of cryo‐probe at the puncture site, (C) pushing the probe, and (D) a tip of cryo‐probe completely inside the node. (E) EBUS image showing the tip of 1.1 mm cryo‐probe within the lymph node. (F) Olympus EBUS scope (BF‐UC 180F) with 1.1 mm cryo‐probe in the working channel. The tip of the probe has the lymph node tissue obtained by cryo‐nodal biopsy. (G) Bronchoscopic view of the puncture site after taking cryo‐nodal biopsy.

Figure 2

Case 1: (A) Non‐contrast computed tomography (CT) thorax demonstrating sub‐carinal and hilar nodes, (B) non‐caseating epithelioid granuloma with giant cells and fibrosis (haematoxylin and eosin (H&E), 40×). CD4 cells (C) are more evident than CD8 cells (D) while few B lymphocytes are highlighted with CD20 (E). Case 2: (F) Contrast CT thorax showing left hilar mass with paratracheal lymph nodes, (G) adenocarcinoma cells (H&E, 10×), (H) with positivity for ROS1(D4D6) (10×). Case 3: (I) Contrast CT showing left interlobar node, (J) metastatic carcinoma from the breast (H&E, 10×), tumour cells are positive for Her2 (K), ER (L), and GATA3 (M). Case 4: (N) Non‐contrast CT of the right para‐hilar lesion with sub‐carinal lymph node, (O) necrotizing granuloma (H&E, 40×), (P) Ziehl–Neelsen stain highlights few pink rod‐shaped bacilli (red arrow), CD8 cells (Q) are more evident than CD4 cells (R) while few B lymphocytes are highlighted with CD20 (S).