CME INDIA Case Presentation by Dr. Viswesvaran Balasubramanian, MD, DM, Senior Consultant- Interventional Pulmonology & Sleep Medicine, Yashoda Hospitals, Somajiguda, Hyderabad.

CME INDIA Case Study

How Presented?

  • 56-year, female.
  • Complaints: Cough, back pain, loss of weight and appetite for 1 month.
  • PET CT: Right hilar lymphadenopathy, avid lesion in D3 vertebrae.

'Two roads diverged in front of me. Good I took both and that made all the difference!'
'Two roads diverged in front of me. Good I took both and that made all the difference!'

  • Referred from Neurosurgery team for EBUS TBNA (Endobronchial ultrasound-guided transbronchial needle aspiration) sampling of right hilar node as patient and attender were not willing to undergo CT guided biopsy in view of risk of pneumothorax.

What was done further?

Procedure:

EBUS TBNA: Sub centimetric hilar lymph node: ROSE: Reactive lymph node.

'Two roads diverged in front of me. Good I took both and that made all the difference!'

EUS – B: Hypoechoic lesion in the upper posterior aspect of oesophagus.

'Two roads diverged in front of me. Good I took both and that made all the difference!'
'Two roads diverged in front of me. Good I took both and that made all the difference!'

EUS – B FNA attempted – Pus aspirated and sent for analysis

Final Diagnosis

  • EUS – B FNA: GeneXpert: Tuberculosis detected.

CME INDIA Discussion

Dr. H. K. Jha, MD, CGHS:

  • Highly appreciated

Dr. Om TS:

  • Did you prefer to go for PET CT prior to EBUS for mediastinal ln.?

Dr. Viswesvaran, Pulmonologist Hyderabad:

  • Generally, not. This case was referred to us with a PET by neurosurgery team. If not for benign lesions like TB no Indication of PET.

Dr. Om TS:

  • Really interesting one and an eye opener case.
  • Was lymph node visualised on CECT thorax or only in PET.

Dr. Viswesvaran, Pulmonologist Hyderabad:

  • Only PET. And very low avid. Only the D3 lesion was highly avid.

CME INDIA Learning Points

  • EUS – B (Using convex probe linear EBUS to perform EUS) performed by Pulmonologist is a well-established modality which is often underutilized.
  • EUS – B: Better patient comfort, reduced need for sedation, decreased desaturation.
  • Can access mediastinal nodes not amenable to FNA by conventional EBUS TBNA (Increases sensitivity of staging EBUS for lung cancer).
  • EBUS should always be performed first followed by EUS-B-FNA – to avoid cross contamination.

CME INDIA Learning Edge

Knowing EBUS-TBNA

  • Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) provides a less invasive alternative to mediastinoscopy, offering additional access to hilar nodes, a superior safety profile, and eliminating the expenses and risks associated with theater time and general anesthesia. Despite having comparable sensitivity, EBUS-TBNA falls slightly behind mediastinoscopy in terms of negative predictive value and sample size.
  • Notably, EBUS-TBNA yields larger samples compared to conventional TBNA, demonstrating enhanced performance and potential safety advantages by enabling real-time sampling under direct vision. Its predictive value extends to both sonographic appearances of nodes and histological characteristics.
  • EBUS-TBNA finds applications in non-small cell lung cancer (NSCLC) staging, the diagnosis of lung cancer in the absence of endobronchial lesions, and the diagnosis of both benign conditions (especially tuberculosis and sarcoidosis) and malignant mediastinal lesions. The procedure differs from flexible bronchoscopy, requiring more time and additional training.
  • While EBUS-TBNA is more costly than conventional TBNA, it can result in overall cost savings by reducing the need for more expensive mediastinoscopies. Looking ahead, endobronchial ultrasound holds promise for applications in airways disease and pulmonary vascular disease.
  • The introduction of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has brought about a revolutionary transformation in the field of respiratory medicine. Since its inception, this technique has swiftly become an essential component of the bronchoscopist’s diagnostic toolkit. As proficiency with EBUS-TBNA has advanced, so too have the indications for its use, accompanied by various innovations, particularly in the realms of needle sizes, visual optics, and associated accessories.

Knowing PET Avid Lesion

  • A PET avid lesion refers to an area in the body that exhibits increased uptake of a radiotracer called 18F-fluorodeoxyglucose (FDG) during a positron emission tomography (PET) scan. FDG is a glucose analog, and tissues with high metabolic activity, such as cancer cells, tend to take up more FDG. Consequently, PET scans are often used in oncology to identify and characterize cancerous lesions based on their increased metabolic activity.
  • A lesion that is “PET avid” typically appears as a region of elevated FDG uptake on the PET scan images. The intensity of FDG uptake is quantified and can be visualized as bright spots on the images. While PET avidity is commonly associated with malignant tumors, it’s important to note that certain non-cancerous conditions, such as infections and inflammatory processes, can also result in increased FDG uptake and appear as PET avid lesions.
  • Therefore, the interpretation of PET avid lesions requires careful consideration of clinical information, imaging findings, and sometimes additional diagnostic tests to accurately determine the nature of the lesion.

References:

  1. Aziz F. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a concise review. Transl Lung Cancer Res. 2012 Sep;1(3):208-13. doi: 10.3978/j.issn.2218-6751.2012.09.08. PMID: 25806182; PMCID: PMC4367563.
  2. Working Group. Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations. Lung India 40(4):p 368-400, Jul–Aug 2023. | DOI: 10.4103/lungindia.lungindia_510_22
  3. Li Y, Behr S. Acute Findings on FDG PET/CT: Key Imaging Features and How to Differentiate Them from Malignancy. Curr Radiol Rep. 2020;8(11):22. doi: 10.1007/s40134-020-00367-x. Epub 2020 Sep 12. PMID: 32953250; PMCID: PMC7486592.


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