When staging for lung cancer, don't forget to screen the pulmonary artery.
Butler J, Simoff MJ, Zdraveska M, and Diaz-Mendoza J. When staging for lung cancer, don't forget to screen the pulmonary artery. Am J Respir Crit Care Med 2015; 191.
Am J Respir Crit Care Med
EBUS may be a useful diagnostic tool for central pulmonary embolus in cancer patients during bronchoscopy. CASE REPORT A 56 year old female lifelong non-smoker was referred to the pulmonary service for evaluation of multiple pulmonary nodules and mediastinal lymphadenopathy. She reported unintentional weight loss of 70lbs over a period of ten months, dyspnea, non-productive cough and generalized fatigue. She denied hemoptysis. CT chest non-contrast study revealed multiple lung masses and nodules, with the largest mass being 3cm in the right lower lobe as well as enlarged mediastinal lymph nodes. The patient underwent bronchoscopy with endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging, as well as transbronchial biopsy of the right lower lobe mass. During the EBUS assessment of the mediastinum, a large echogenic mass was observed in the lumen of the right main pulmonary artery that extended into the lobar segment of the PA. After the procedure CT chest with contrast was performed and confirmed the diagnosis of a large embolus in the right main pulmonary artery, extending to upper and lower lobe pulmonary arteries and few of the segmental branches in the right lower lobe. DISCUSSION EBUS-TBNA is a key tool in the diagnosis and staging of lung cancer. EBUS is also a potential useful tool for the visualization of pulmonary artery embolus during bronchoscopy; especially in lung cancer patients who have an increased risk of thromboembolic disease. As of now, computed tomography angiography is the gold standard imaging modality for pulmonary embolism. However in clinical practice, many patients have limitations for angio-CT such as allergy to iodinated contrast agents or renal failure. By scanning the pulmonary artery the bronchoscopist will be able to visualize central emboli in real time. The right pulmonary artery lies immediately anterior to the right main stem bronchus near the origin of the right upper lobe bronchus. The left pulmonary artery ascends over the anterior surface of the left main bronchus just distal to the arch of the aorta. It is known that cancer patients have a higher incidence of venous thromboembolism compared to the general population. Lung cancer in particular has a reported incidence of VTE 3-13.8% and that of PE up to 3.8%. The mortality of pulmonary embolism is high and requires prompt diagnosis and treatment. EBUS could become an early diagnostic tool in high risk cancer patients who may have silent thromboembolic disease. (Figure Presented).