|Year : 2018 | Volume
| Issue : 1 | Page : 41-43
The Sonoelastographic Characters of Noncomplicated Bronchogenic Cyst: An Evaluation Using CP-EBUS
Sharad Joshi, Rajesh Gupta, Ankit Bhatia, Syed J Ali
Department of Pulmonology, Max Super Speciality Hospital, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||3-Jan-2018|
Department of Pulmonology, Max Super Speciality Hospital, Vaishali, Ghaziabad 201012, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Endobronchial ultrasound (EBUS) is a relatively newer technique useful in the mapping and guiding of the needle aspirates/biopsy of the mediastinal nodes and lesions. Sonoelastography attached to the latest-generation EBUS machines has enabled the mapping of the elasticity of the lymph nodes leading to better guidance while taking samples. We present the sonographic images and characteristics of a bronchogenic cyst visualized on EBUS elastography.
Keywords: Bronchogenic cyst, elastography, ultrasound
|How to cite this article:|
Joshi S, Gupta R, Bhatia A, Ali SJ. The Sonoelastographic Characters of Noncomplicated Bronchogenic Cyst: An Evaluation Using CP-EBUS. J Assoc Chest Physicians 2018;6:41-3
|How to cite this URL:|
Joshi S, Gupta R, Bhatia A, Ali SJ. The Sonoelastographic Characters of Noncomplicated Bronchogenic Cyst: An Evaluation Using CP-EBUS. J Assoc Chest Physicians [serial online] 2018 [cited 2019 Nov 14];6:41-3. Available from: http://www.jacpjournal.org/text.asp?2018/6/1/41/220986
| Introduction|| |
Endobronchial ultrasound (EBUS)-based elastography is a noninvasive technology performed during EBUS, in which the relative stiffness of the tissues can be assessed as a color map, which can be used to differentiate the malignant from benign lesions. This could guide the fine-needle aspirate site and could improve the diagnostic yields. There has been a paucity of reports describing EBUS elastography images and color combinations for nonmalignant lesions. Herein, we report the EBUS elastography image of a mediastinal bronchogenic cyst, which looked homogenous, with a single color enhancement on the elastography mode.
| Case|| |
An 18-year-old female was referred to the pulmonology clinic for complaints of dry cough. The patient was referred for a pre-anesthetic checkup for a planned thyroid nodule surgery. Computerised tomography (CT) thorax showed a smooth-walled mediastinal mass in right paratracheal position. Fiberoptic bronchoscopy with EBUS transbronchial needle aspiration (TBNA) was planned to evaluate the lesion before thyroid surgery. After local anesthesia to the pharynx with 4% lidocaine spray, each patient was placed under conscious sedation with intravenous propofol. The convex probe EBUS (CP-EBUS; BF-UC260FW, Olympus, Tokyo, Japan) was inserted through the oral route, with an intermittent instillation of 2-ml aliquot doses, which had 2% lidocaine. Scanning was done on a 7.5-MHz frequency US, and images were generated using a new, dedicated US processor (EU-ME2 PREMIER PLUS, Olympus, Tokyo, Japan).
On the CP-EBUS, there was a distinct smooth homogenous round lesion towards the right intermediate bronchus wall [Figure 1]. Sonoelastography showed homogenous green color with a few streaks of yellow [Figure 2]. Based on the findings, it was inferred to be a cystic lesion. No attempt was made to aspirate the cyst, because it would have led to complications associated with the leakage of cystic contents. Thoracic surgery opinion was taken. An open thoracotomy and subsequent excision of the cyst confirmed the presence of a bronchogenic cyst.
|Figure 1: CP-EBUS image on elastography showing a distinct smooth homogenous round lesion with a homogenous green appearance|
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| Discussion|| |
Conventional endobronchial ultrasonography has gained importance in recent years for the diagnosis of a mediastinal lymphadenopathy of unknown etiology particularly in the staging of lung cancer. Endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) is also considered a highly accurate and safe procedure for diagnosing the mediastinal lymphadenopathy of granulomatous origin. With EBUS, the yield of TBNA from the mediastinal/hilar lymph nodes has significantly improved. A pooled sensitivity of 88% and a pooled specificity of 85% with EBUS elastography has been reported from meta-analysis for the discrimination of malignant versus benign superficial lymphadenopathy.
The evolution of EBUS-TBNA has also been synonymous by innovation in EBUS instruments. Elastography is the latest ultrasonography-associated technology that measures tissue compressibility. It is an established minimally invasive modality for diagnosing the mediastinal masses or lymph nodes. Lymph node infiltrations such as malignancy make tissues stiff or less deformable. The compression of the surrounding structures produces a deformity or strain effect that is inversely related to the hardness of the pathological tissue. Real-time elastography with different colors shows the difference of tissue after different compression deformation. Because of the difference of imaging principle and method, ultrasound elasticity imaging compared with the traditional ultrasonic imaging technology is a new kind of ultrasonic imaging diagnostic technique. There is a different color elastic coding for different nodal characteristics. The elastic code reflects the nodal hardness, with the colors associated with the hard, intermediate, and soft tissues being blue, green, and red.
Based on the very good negative predictive value of elastography, unnecessary biopsies may be prevented increasing the yield of the overall procedure.
One of the first reported literatures on the use of EBUS elastography is by Izumo et al., who analyzed 75 LNs and classified the findings based on color distribution: Type 1, predominantly nonblue (green, yellow, and red); Type 2, partially blue, partially nonblue (green, yellow, and red); and Type 3, predominantly blue. The elastographic patterns in the targeted lymph nodes were compared with the final pathologic results from EBUS-TBNA. On a pathological evaluation of the LNs, 42 were malignant, while 33 were found to be benign. The nodes that were classified as Type 1 were benign by 100%; for Type 2 LNs, 46.9% were benign and 57.1% were malignant; and for Type 3 LNs, 5.4% were benign (2/37) and 94.6% were malignant (35/37).
EBUS elastography can also be used to characterize and biopsy nonmalignant benign mediastinal lesions. EBUS-TBNA has been studied extensively for the diagnosis of sarcoidosis and tuberculosis. EBUS-TBNA has been now used beyond the usual indications into other mediastinal lesions. Nakajima et al. reported one case of central airway stenosis caused by a mediastinal cyst, which was subsequently therapeutically aspirated.Preliminary reports suggest that elastography is a promising diagnostic tool for the differentiation between benign and malignant lymph nodes. A EBUS-based confirmation of mediastinal cysts may prevent unnecessary aspiration and subsequent complications. The homogenous color of the bronchogenic elastography image may help in the characterization of the lesion, and has been reported in literature for the first time. There is a need to evaluate different color patterns in varied nonmalignant cystic lesions, which could expand the understanding and horizons of this new technology.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sivokozov IV, Silina TL, Korolev VN, Pravednikov PA, Lenskiĭ BS. The first experience in using elastography in combination with endobronchial ultrasonography for mediastinal pathology: Preliminary assessment of feasibility and comparison of characteristics via different approaches. Vestn Rentgenol Radiol 2014;13-9.
Gahlot T, Parakh U, Verma K, Bhalotra B, Jain N. Endobronchial ultrasound-guided transbronchial needle aspiration in diagnosing mediastinal lymphadenopathy. Lung India 2017;34:241-6.
] [Full text]
Ying L, Hou Y, Zheng HM, Lin X, Xie ZL, Hu YP. Real-time elastography for the differentiation of benign and malignant superficial lymph nodes: A meta-analysis. Eur J Radiol 2012;81:2576-84.
Jiang JH, Turner JF Jr, Huang JA. Endobronchial ultrasound elastography: A new method in endobronchial ultrasound-guided transbronchial needle aspiration. J Thorac Dis 2015;7(Suppl 4):S272-8. doi: 10.3978/j.issn. 2072-1439. 2015.12.53
Izumo T, Sasada S, Chavez C, Matsumoto Y, Tsuchida T. Endobronchial ultrasound elastography in the diagnosis of mediastinal and hilar lymph nodes. Jpn J Clin Oncol 2014;44:956-62. doi: 10.1093/jjco/hyu10.
Nakajima T, Yasufuku K, Shibuya K, Fujisawa T. Endobronchial ultrasound-guided transbronchial needle aspiration for the treatment of central airway stenosis caused by a mediastinal cyst. Eur J Cardiothorac Surg 2007;32:538-40.
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