Endobronchial Ultrasound-guided Sheath Placement to Guide Transbronchial Biopsy of Mediastinal Lymphadenopathy and Lung Mass: A New Technique

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A patient with a history of lung adenocarcinoma, which was treated with chemoradiation, presented to our interventional pulmonology clinic for suspicion of recurrent lung cancer. The patient had a PET-avid right upper-lobe mass and subcarinal lymphadenopathy. We performed a curvilinear endobronchial ultrasound (CP-EBUS) with transbronchial needle aspiration (TBNA), followed by transbronchial EBUS-guided biopsies (TBB) of the subcarinal lymph node using miniforceps. The EBUS needle sheath was inserted over the needle through the bronchial wall and advanced into the lymph node. The EBUS-guided placement of the transbronchial sheath facilitated the miniforcep insertion and the performance of multiple transbronchial biopsies. Given success with this method, we further developed this technique in a second patient with a right lower-lobe mass. In an effort to obtain adequate tissue and minimize repeated efforts at miniforcep guidance into the lesion, we inserted a radial EBUS guide sheath through the curvilinear EBUS scope and guided it into the lesion using the miniforceps. We therefore used the radial sheath as a placeholder while obtaining repeated TBB using miniforceps as described. These modifications of previously described techniques allow for maximal and expeditious sampling of target lymph nodes and masses, with sufficient material obtained for histopathologic analysis.

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