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A patient with concurrent primary lung cancer and lymphoma diagnosed using endobronchial ultrasound

A.D.L. Marshall, D.R. Miller, L.J. Smith, M. Chetty, G.P. Currie
DOI: http://dx.doi.org/10.1093/qjmed/hct045 389-390 First published online: 6 February 2013

Sir,

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is an effective tool in the diagnosis and staging of the mediastinum in suspected primary lung cancer.1,2 We describe a patient who was found to have two separate malignant conditions using EBUS-TBNA.

A 70-year-old man with 125 pack-year smoking history presented with 4 weeks of breathlessness, cough, haemoptysis, weight loss and no night sweats. Chest computerized tomography revealed right lower lobe collapse, extensive mediastinal lymphadenopathy (right hilar: 27 mm, right paratracheal: 31 mm) and right axillary lymphadenopathy (21 mm) and a left upper lobe intrapulmonary mass; there was no hepatic or splenic enlargement, although incidental mild enlargement of the external iliac nodes was noted.

EBUS-TBNA of right paratracheal (R4) and hilar (R10) nodes was performed under light sedation using a 21-gauge needle with three and four passes per node, respectively. The aspirate from R4 included both clusters of and singly dispersed, medium-sized malignant cells with a moderate volume of cytoplasm, these cells having the morphology of non-small cell lung cancer (NSCLC) and showing positive immunocytochemical staining for CK5/6 and cytokeratin AE 1/AE 3. Negative staining was seen with p63, TTF1, CD45, CD20 and CD3. The R10 lymph node aspirate contained numerous singly dispersed, medium-sized malignant cells with a lymphoid appearance. A cell block prepared from the remainder of the R10 aspirate included small cores and microbiopsies of architecturally and cytologically abnormal lymphoid tissue. Immunocytochemistry demonstrated strong positive staining of the malignant cells with CD45 and CD20. CD10, Bcl2 and Bcl6 were positive in some cells. CD21, CD23, CD30, p63 and TTF1 were negative. These findings were reported as being highly suspicious of B-cell non-Hodgkin lymphoma. As is usual practice, a lymph node excision biopsy was advised for confirmation of the diagnosis and to allow accurate subtyping of the lymphoma. However, the patient died before this could be carried out.

As far as we are aware, this is the first documented case of NSCLC and lymphoma being diagnosed concurrently with EBUS-TBNA. This case emphasizes the importance of careful ultrasonic exploration of the mediastinum and sampling of all relevant lymph node stations. Although EBUS-TBNA is not advocated in patients with suspected lymphoma, making this diagnosis has previously been described using this sampling technique.3 To help facilitate cell typing, mediastinoscopy remains the gold standard investigation in this respect.

In summary, all physicians in training and using EBUS-TBNA should be made aware of the importance of aspirating all enlarged lymph nodes when diagnosing and staging patients with suspected malignancy, doing so may prevent two separate diagnoses being missed.

Conflict of interest: None declared.

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