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16. Kalajian AH, Van Meter JR, Callen JP. Sarcoidal anemia and
leukopenia treated with methotrexate and mycophenolate
mofetil. Arch Dermatol. 2009;145(8):905-909.
17. Kataria YP, Whitcomb ME. Splenomegaly in sarcoidosis.
Arch Intern Med. 1980;140(1):35-37.
18. Chilosi M, Menestrina F, Capelli P, et al. Immunohistochemical analysis of sarcoid granulomas. Evaluation of Ki67 1 and
interleukin-1 1 cells. Am J Pathol. 1988;131(2):191-198.
19. Liu W, Putnam AL, Xu-Yu Z, et al. CD127 expression inversely
correlates with FoxP3 and suppressive function of human
CD4 1 T reg cells. J Exp Med. 2006;203(7):1701-1711.
20. Idali F, Wahlström J, Müller-Suur C, Eklund A, Grunewald
J. Analysis of regulatory T cell associated forkhead box P3
expression in the lungs of patients with sarcoidosis. Clin Exp
Immunol. 2008;152(1):127-137.
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of human CD4 1 CD25hi T-regulatory cells. Blood. 2006;108(1):
22. Taflin C, Miyara M, Nochy D, et al. FoxP3 1 regulatory
T cells suppress early stages of granuloma formation but have
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23. Zaba LC, Smith GP, Sanchez M, Prytowsky SD. Dendritic
cells in the pathogenesis of sarcoidosis. Am J Respir Cell Mol
Biol. 2010;42(1):32-39.
The Use of Endobronchial
Ultrasonography With
Transbronchial Needle
Aspiration To Sample a Solitary
Substernal Thyroid Nodule
Michel Chalhoub, MD; and Kassem Harris, MD
Solitary thyroid nodules (STNs) are frequently encountered in clinical practice. When sampling of an STN
is deemed necessary, ultrasound-guided fine needle
aspiration biopsy (US-FNAB) is the procedure of
choice. In substernal STNs, US-FNAB is not feasible,
and the patients are usually offered either more
invasive diagnostic testing (mediastinoscopy or surgical excision) or follow-up imaging studies based
on the clinical suspicion of malignancy. We report a
case in which a substernal STN was sampled using
endobronchial ultrasonography with transbronchial
fine needle aspiration (EBUS-TBNA). Our patient
is a 74-year-old woman who was admitted with an
asthma exacerbation. She underwent a chest CT scan
Manuscript received November 29, 2009; revision accepted January
6, 2010.
Affiliations: From the Staten Island University Hospital, Staten
Island, NY.
Correspondence to: Michel Chalhoub, MD, Staten Island Pulmonary Associates, 501 Seaview Ave, Ste 102, Staten Island, NY 10305;
e-mail: [email protected]
© 2010 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from
the American College of Chest Physicians (www.chestpubs.orgⲐ
DOI: 10.1378Ⲑchest.09-2840
Downloaded From: on 10/06/2014
with intravenous contrast (CTA) to rule out pulmonary
embolism (PE). The CTA was negative for PE but
showed a substernal STN that was successfully sampled
by EBUS-TBNA without complications. The cytology
was consistent with a colloid adenoma. EBUS-TBNA
can sample substernal STNs that are not amenable to
CHEST 2010; 137(6):1435–1436
Abbreviations: EBUS-TBNA 5 endobronchial ultrasonography
with transbronchial fine needle aspiration; STN 5 solitary thyroid
nodule; US-FNAB 5 ultrasound-guided fine needle aspiration
olitary thyroid nodules (STNs) are a fairly common
problem in clinical practice. It is estimated that 4% to
7% of adult subjects have a palpable thyroid nodule.1 Most
STNs are benign and only one out of 20 palpable thyroid
nodules is malignant.1 The clinical challenge, therefore, is
to exclude malignancy. In most instances this is accomplished by ultrasound-guided fine needle aspiration
biopsy (US-FNAB).2 US-FNAB, an office-based procedure, has been shown to decrease the rate of thyroidectomies by 50% and to reduce the overall medical cost by
25%.2 The reported yield of US-FNAB is about 80%, and
besides local discomfort, it carries no significant risks. In
substernal thyroid nodules, however, US-FNAB might
be impossible, narrowing the choices to less-specific
noninvasive testing (such as thyroid scanning) or follow-up
imaging studies, or more invasive diagnostic procedures (such as mediastinoscopy or surgical excision).2
Endobronchial ultrasonography with transbronchial
needle aspiration (EBUS-TBNA) is a new bronchoscopic
technique that allows sampling of mediastinal and hilar
lesions under real-time ultrasonographic guidance. At
the present time, EBUS-TBNA has a central role in
staging as well as diagnosing lung cancer, and is being
increasingly used in nonmalignant thoracic diseases,
such as sarcoidosis.3,4 We report, to our knowledge, the
first case of a substernal STN that was sampled using
Case Report
A 74-year-old woman was admitted to the hospital for
shortness of breath and dry cough. There was no history of dysphagia or dysphonia. On physical examination
the patient was awake and alert, in no apparent distress,
with normal vital signs. The examination of the neck
revealed no palpable thyroid enlargement or nodules.
There was no cervical or supraclavicular lymphadenopathy. She had no stridor, but there was faint bilateral endexpiratory wheezing. The rest of the physical examination
was unremarkable. The initial blood work, including a
thyrotropin-stimulating hormone, was within normal range.
She underwent a CT scan of the chest with IV contrast to
rule out pulmonary embolism. The chest CT scan with IV
contrast was negative for pulmonary embolism, but showed
a substernal goiter with an STN in contact with the trachea
but without evidence of airway compression (Fig 1). After
she responded to treatment of asthma exacerbation, she was
offered an EBUS-TBNA to sample her thyroid nodule.
CHEST / 137 / 6 / JUNE, 2010
Figure 1. CT image and endobronchial ultrasonography with
transbronchial needle aspiration.
The procedure was done on an outpatient basis under conscious sedation. The BF-UC169F-OL8 scope by Olympus
(Tokyo, Japan) was used. The nodule was easily identified with ultrasonography, and using the NA-201SX-4022
needle, four TBNAs were performed under real-time
ultrasonographic guidance (Fig 1). The patient tolerated
the procedure very well, and there were no complications. The cytology was consistent with a colloid thyroid
adenoma (Fig 2).
This is the first report, to our knowledge, to describe
the use of EBUS-TBNA to sample a substernal solitary
thyroid nodule. In a recent letter to the editor, Jeebun
et al5 reported the use of EBUS-TBNA to sample a posterior mediastinal mass that was consistent with a mediastinal
goiter on cytologic examination. EBUS-TBNA has become
the initial invasive procedure of choice for staging non-
small cell lung cancer with a reported sensitivity . 90%
and a specificity of 100%.3 The procedure is done under
conscious sedation on an outpatient basis, and, in experienced hands, the reported complication rate is low.3 In the
appropriate setting, EBUS-TBNA can obviate the need for
more aggressive diagnostic procedures, such as mediastinoscopy or surgical excisional biopsy. In addition, EBUSTBNA is becoming the procedure of choice for sampling
mediastinal lymph nodes in suspected sarcoidosis.4 The
role of EBUS-TBNA in STN has not been defined yet,
but seems to be promising. After history, physical examination, and serum thyrotropin level measurement, patients
with STNs usually undergo US-FNAB.2 In substernal STN
US-FNAB is not feasible, and patients are often offered
more invasive surgical approaches or watchful waiting. The
decision to proceed with more invasive diagnostic procedures vs noninvasive testing and follow-up imaging studies
depends on certain clinical criteria as well as radiologic
findings that increase the suspicion for malignancy. These
criteria include family history of medullary thyroid cancer,
subjects , 20 or . 70 years of age, men, prior head and
neck irradiation, nodules . 4 cm, cervical lymphadenopathy, an increase in the size of the nodule, compression
symptoms, or history of metastasis.2
In select cases when dealing with a substernal STN
in close proximity with the trachea, EBUS-TBNA can be
offered as a minimally invasive procedure to sample the
STN, and can potentially save the patient a more invasive
diagnostic procedure. This report presents another potential indication for EBUS-TBNA in sampling substernal
thyroid nodules where US-FNAB is impossible.
FinancialⲐnonfinancial disclosures: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companiesⲐorganizations whose products or services may be discussed in this article.
Figure 2. Benign follicular thyroid tissue (hematoxylin-eosin stain,
magnification 3 10).
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1. Singer PA, Cooper DS, Daniels GH, et al. American Thyroid
Association. Treatment guidelines for patients with thyroid
nodules and well-differentiated thyroid cancer. Arch Intern
Med. 1996;156(19):2165-2172.
2. Hegedüs L. Clinical practice. The thyroid nodule. N Engl J
Med. 2004;351(17):1764-1771.
3. Hwangbo B, Kim SK, Lee HS, et al. Application of endobronchial ultrasound-guided transbronchial needle aspiration
following integrated PETⲐCT in mediastinal staging of potentially operable non-small cell lung cancer. Chest. 2009;135(5):
4. Tremblay A, Stather DR, Maceachern P, Khalil M, Field SK.
A randomized controlled trial of standard vs endobronchial
ultrasonography-guided transbronchial needle aspiration in
patients with suspected sarcoidosis. Chest. 2009;136(2):340-346.
5. Jeebun V, Natu S, Harrison R. Diagnosis of a posterior mediastinal goitre via endobronchial ultrasound-guided transbronchial needle aspiration. Eur Respir J. 2009;34(3):773-775.
Selected Reports