Endobronchial Needle Aspiration in the Diagnosis of Small-Cell Carcinoma: Case Reports

Jun-5-2014

Case 1
A 49-year-old man presented with a 3-month history of cough and intermittent fever. The chest radiograph revealed left perihilar fullness and left upper lobe opacification. Computed tomography scan confirmed a 6.5X7.0-cm hilar mass with associated volume loss of the left lung. Bronchoscopy demonstrated an exophytic endobronchial tumor in the apical posterior segment of the left upper lobe.
Endobronchial washing, brushing, biopsy specimens, and paratracheal TBNA were all nondiagnostic. The forceps biopsy specimen exhibited a mechanically distorted cellular infiltrate, ie, “crush artifact.” Because of the high clinical suspicion of carcinoma, bronchoscopy was repeated and EBNA of the left upper lobe endobronchial lesion was performed. The EBNA specimens were diagnostic for small-cell undifferentiated carcinoma. The concurrent bronchial washing and brushing as well as multiple endobronchial forceps biopsy specimens were again nondiagnostic. A repeated transtracheal needle aspirate was also positive.
Case 2
A 65-year-old woman presented with dyspnea, right-sided chest pain, an exudative right pleural effusion, and a right hilar mass Source canadian helth& care mall. Pleural fluid cytologic study was negative. Subsequent bronchoscopy showed occlusion of the right lower lobe bronchus by an endobronchial lesion. A TBNA of the mediastinum was not performed. Bronchial brushing and washing were nondiagnostic. Forceps biopsy specimens were suspicious for carcinoma, but definitive diagnosis was precluded by crush artifact. Repeated bronchial washings, brushings, and forceps biopsy specimens were again nondiagnostic. An EBNA provided material that was diagnostic of small-cell undifferentiated carcinoma.
Case 3
An 83-year-old woman was found to have mediastinal enlargement on a chest radiograph. Computed tomography of the chest revealed a subcarinal mediastinal mass. Bronchoscopy revealed an endobronchial mass arising from the posterior wall of the bronchus intermedius. Bronchial washings, TBNA of the carina, and endobronchial forceps biopsy specimens were all nondiagnostic. Needle aspirates of the endobronchial lesion were consistent with small-cell carcinoma.
Case 4
A 65-year-old man with a history of multiple myeloma presented with dyspnea, cough, and mild hemoptysis. Serial chest radiographs revealed progressive infiltrates on the right side despite a course of empiric antibiotic therapy. Subsequent computed tomography of the chest additionally demonstrated a large right mediastinal hilar mass. Bronchoscopy revealed narrowing of the bronchus intermedius and complete occlusion of the right middle lobe orifice by an endobronchial mass. Forceps biopsy specimens demonstrated crush artifact (Fig 1). A TBNA of the main carina and bronchial washings were negative for tumor. Repeated bronchoscopy was performed and EBNA of the endobronchial mass was positive for small-cell carcinoma (Fig 2). A bronchial wash from the second bronchoscopy was of questionable adequacy but was interpreted as positive after comparison to the EBNA material.
Figure-1

Figure 1. Endobronchial forceps biopsy specimen. The biopsy specimen exhibits extensive crush artifact resulting in a loss of nuclear detail (hematoxylin-eosin, original magnification X300).

Figure-2

Figure 2. Endobronchial needle aspirate. The aspirate smear exhibits the typical cytologic features of small-cell carcinoma, including a very high nuclear-to-cytoplasmic ratio, nuclear molding, stippled chromatin, absence of nucleoli, and single cell necrosis (Papanicolaou, original magnification X850).