Tuberc Respir Dis.  2014 Oct;77(4):188-192. 10.4046/trd.2014.77.4.188.

New-Onset Malignant Pleural Effusion after Abscess Formation of a Subcarinal Lymph Node Associated with Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

• Jang SM
• Kim MJ
• Cho JS
• Lee G
• Kim A
• Kim JM
• Park CH
• Park JM
• Song BG
• Eom JS

• KMID: 2320577
• DOI: http://doi.org/10.4046/trd.2014.77.4.188

Abstract

We present a case of an unusual infectious complication of a ruptured mediastinal abscess after endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which led to malignant pleural effusion in a patient with stage IIIA non-small-cell lung cancer. EBUS-TBNA was performed in a 48-year-old previously healthy male, and a mediastinal abscess developed at 4 days post-procedure. Video-assisted thoracoscopic surgery was performed for debridement and drainage, and the intraoperative findings revealed a large volume pleural effusion that was not detected on the initial radiographic evaluation. Malignant cells were unexpectedly detected in the aspirated pleural fluid, which was possibly due to increased pleural permeability and transport of malignant cells originating in a ruptured subcarinal lymph node from the mediastinum to the pleural space. Hence, the patient was confirmed to have squamous cell lung carcinoma with malignant pleural effusion and his TNM staging was changed from stage IIIA to IV.

Keyword

Endoscopic Ultrasound-Guided Fine Needle Aspiration; Lung Neoplasms; Pleural Effusion, Malignant

MeSH Terms

Abscess*
Debridement
Drainage
Endoscopic Ultrasound-Guided Fine Needle Aspiration
Humans
Lung
Lung Neoplasms
Lymph Nodes*
Male
Mediastinum
Middle Aged
Needles*
Neoplasm Staging
Permeability
Pleural Effusion
Pleural Effusion, Malignant*
Thoracic Surgery, Video-Assisted

Figure

• 

  Figure 1 A 48-year-old male with squamous cell lung cancer and metastatic involvement of subcarinal (white arrows) and right lower paratracheal (black arrows) lymph nodes. (A, B) Initial chest computed tomography scan shows subcarinal and right lower paratracheal lymph node enlargement. (C, D) An endobronchial ultrasound image of the subcarinal and right lower paratracheal lymph nodes shows hypoechoic texture, a round shape, and well-demarcated borders. (E, F) The tumor cells formed sheets of hyperchromatic cells with a high nuclear-cytoplasmic ratio and focal keratinization. The specimen has a necrotic and hemorrhagic background (H&E stain, ×400).

• 

  Figure 2 Computed tomography scan obtained 4 days after endobronchial ultrasound-guided transbronchial needle aspiration demonstrates an increase in size of the subcarinal lymph node with ill-defined soft tissue density and fluid collection in the mediastinum, suggesting mediastinitis associated with subcarinal abscess leakage.

• 

  Figure 3 Microscopic findings of the specimens obtained via video-assisted thoracoscopic surgery. (A) The subcarinal lymph node is mostly replaced with an abscess and clusters of squamous cell carcinoma are present (black arrows) in the abscess (H&E stain, ×40). (B) Squamous cell carcinoma is present in the background of the abscess in a high power field of the circled area in A (H&E stain, ×400). (C) Mediastinal pleura show chronic inflammation with fibrosis (H&E stain, ×100). (D) Cytological smear of the pleural fluid shows squamous cell carcinoma. The tumor cells have a high nuclear-cytoplasmic ratio, irregular nuclear membrane, dense cytoplasm, and well-defined borders (Papanicolaou stain, ×1,000).

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