Eur J Cardiothorac Surg 2006;29:627-629
© 2006 Elsevier Science NL
Mediastinal bronchogenic cyst's recurrence treated with EBUS-FNA with a long-term follow-up
Giovanni Galluccio
a
,
Gabriele Lucantoni
b
,
*
a Center of Thoracic Endoscopy, Forlanini Hospital, Rome, Italy
b C.U.B.E. Department of Cardiovascular and Respiratory Sciences, University of Rome "La Sapienza" Forlanini Hospital, Rome, Italy
Received 24 October 2005;
received in revised form 11 December 2005;
accepted 15 December 2005.
* Corresponding author. Address: Largo Pannonia 1, 00183 Rome, Italy. Tel.: +39 0677209096. (Email: lucantonig{at}libero.it).
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Abstract
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Bronchogenic cysts are congenital abnormalities generally mediastinal and are frequently detected incidentally. We report a case of a symptomatic mediastinal cyst treated previously by video-assisted thoracoscopy (VATS) but complicated by pericystic adhesions. The subsequent incomplete excision led, after 8 months, to a cyst's recurrence that was accurately drained by endobronchial ultrasonography-guided fine needle aspiration (EBUS-FNA), with no new regrowth after 18 months. We hypothesized that the support of a high-definition diagnostic tool (EBUS) improved the FNA ability to make a deep and complete aspiration of the cyst. The usefulness of FNA in bronchogenic cyst's treatment is underestimated. Our experience is an attempt to encourage the use of EBUS-FNA as a new therapeutic option in the management of bronchogenic cyst.
Key Words: Chest-CT: chest computed tomography • VATS: video-assisted thoracoscopy • EBUS-FNA: endobronchial ultrasonography-guided fine needle aspiration
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1. Introduction
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The management of bronchogenic cyst is controversial, many authors consider the simple aspiration as a form of treatment that can lead to a high recurrence rate and indicate the surgical excision as mandatory. We report our experience in which we combined a standardized procedure of drainage (fine needle aspiration (FNA)) with a new diagnostic tool able to improve its yield, showing no regrowth after long-term follow-up.
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2. Case report
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A 50-year-old woman presented with disphagia, dispnea, and cough. Chest X-ray showed a right mediastinal mass. Chest computed tomography (chest-CT) revealed a 4 cmx 4 cm lesion with a typical homogeneous water density (20 Hounsfield Units) adjacent to the anterior tracheal wall (Fig. 1a). Surgery was performed on January 2003. The patient underwent mass resection by video-assisted thoracoscopy (VATS). The excision was incomplete because of pericystic adhesions to the tracheal wall; a small patch was left in place. The cyst was filled with a mucoid material without signs of purulence; the histological findings were consistent with a bronchogenic cyst.
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Fig. 1. (a) Bronchogenic cyst before VATS (January 2003). (b) Cyst's recurrence after VATS (June 2003). (c) EBUS water-filled balloon. (d) After 18 months from EBUS-FNA treatment.
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A new cystic recurrence, localized at the same place, was found at a CT control 8 months later (Fig. 1b). After informed consent, the patient underwent EBUS-guided FNA for a complete aspiration of the cyst.
We performed a fiberoptic bronchoscopy using a flexible bronchoscope (Olympus BF B3) equipped with a 20 MHz flexible probe connected to an endoscopic ultrasound system EU-M30 (Olympus, Tokyo, Japan). The use of a water-filled balloon permitted a perfect adhesion with the inner surface of the wall (Fig. 1c). During the procedure, a round hypoechoic structure, with ultrasound characteristics suspicious for a cystic lesion, was observed adjacent to the anterior wall of the trachea. After localization of the cyst, FNA was performed, in the same place indicated by EBUS, using a 22-gauge full length steel needle for its complete drainage.
According to literature, the patient received an antibiotic prophylaxis before and after EBUS-FNA in order to avoid infective side effects [1].
After 7 days, the patient underwent a second EBUS control, which confirmed the complete aspiration previously performed and the total collapse of the inner surface. No side effects were detected after these procedures.
Then, the patient was subjected to a 6-month CT follow-up and, after 18 months, no cyst's regrowth was found (Fig. 1d).
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3. Discussion
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Bronchogenic cysts are congenital bronchopulmonary malformations resulting from an abnormal development of the bronchial tree that can be observed not only in infants but also in adults [2]. They account for 10% of primary mediastinal lesions that are localized mostly in the middle and superior mediastinum [1,2]. Common symptoms are retrosternal pain, cough, dyspnea, disphagia, and fever [2,3].
At chest X-ray and CT, the bronchogenic cyst appears as a round mass, well circumscribed, with smooth outlines, usually unilocular and non-calcified, with an homogeneous water density [3,4].
Although some cysts are asymptomatic, they can eventually produce compression or irritation of adjacent structures causing symptoms and potentially serious complications [3–5]. Therefore, many authors indicated the necessity of an early therapy [3,5,6] and considered the complete surgical excision (by VATS or thoracotomy) as the treatment of choice for bronchogenic cyst [3,5–7]. Moreover, they maintained that a simple aspiration can lead to a high recurrence rate because of the not obliteration of the lining [5,6]. Past works considered the importance of FNA as a diagnostic procedure but limited its therapeutical use only in the management of bronchogenic cyst's recurrences [5], in case of acute compression [2] and in compromised or nonoperative candidates [8].
Kuhlman et al. [9] recommended FNA as a practical alternative to surgery but they were limited by a short follow-up (only 3 months).
Among these controversial and different therapeutical approaches, we experienced the application of fine needle aspiration biopsy (FNA) using a real-time ultrasonographic procedure (EBUS) able to improve its efficacy.
Endobronchial ultrasound (EBUS) is the latest, relatively not invasive procedure, that has widened the bronchoscopic vision beyond the bronchial wall [10]. This new diagnostic tool allowed us to make a real-time visualization of the cyst's structure so that we were able to make a deep and complete aspiration of it, obtaining a collapse of the lesion and a total obliteration of the lining (which is the first cause of cyst's recurrences) [4]. The efficacy of this procedure was also confirmed by the absence of regrowth after 18 months of follow-up (Fig. 1d).
In conclusion, our experience would encourage new studies on the use of this less invasive and more accurate procedure in the treatment of bronchogenic cyst.
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Abstract
1. Introduction
