The patient was a 64-year-old female who had no smoking history and was admitted to our hospital because of cough and dyspnea. She denied other complaints and was not on any medications. Laboratory examinations showed hemoglobin 87 g/L, NSE 73.6 ng/mL, LDH 947.2 IU/L, and IgE 640 IU/mL, with no other abnormal findings. A chest contrast-enhanced CT revealed mediastinal and bilateral hilar lymphadenopathies with slight and heterogeneous enhancement during the arterial phase, bilateral pleural effusion, and left inferior pulmonary inflammation (Fig. 1a). A contrast-enhanced CT of the abdomen and pelvis discovered retroperitoneal, mesenteric, pelvic, and bilateral inguinal lymphadenopathies.
No preprocedure antibiotic drug was used. The regular bronchoscopy resulted in no positive finding. Therefore, an EBUS bronchoscopy was conducted under conscious sedation with intravenous midazolam, and the subcarinal lesion (Station 7) was localized. After four passes of TBNA with a 21-gauge needle (Biostar-S217, Broncus, China) (Fig. 1b), we advanced its sheath along with the needle stylet into the lesion, which was visualized with the EBUS scope. Thereafter, we pulled out the stylet of the TBNA needle, leaving the sheath in the target lesion that served as a working cannula for cryobiopsy (Fig. 1c). The cryoprobe was then advanced into the target lesion via the needle sheath under the real-time supervision (Fig. 1c). After cooling down to -60 C for 7 s, the cryoprobe tip attached with the rapidly frozen material was extracted from the biopsy site (Fig. 1d). The specimen was obtained by thawing in saline and being fixed in formalin. The time needed for needle aspiration was 9 min, while it took only 1.3 min for cryobiopsy. The whole procedure was well-tolerated, and the only adverse event was minor bleeding that stopped spontaneously without pharmacological intervention. In addition, no major complications were observed right after the procedure and during 1-month follow-up.
Histological examination of TBNA samples showed squeezed and deformed atypical cells (Fig. 2a). The specimens from cryobiopsy suggested a diagnosis of non-Hodgkin's lymphoma (Fig. 2b). Immunohistochemistry staining indicated CD20(+), CD79alpha(+), CD3(+), CD43(+), BCL-2(+), BCL-6(+), CD10(-), MUM1(+), Cyclin D1(-), Ki-67(+), CK(-), and EBER(-), confirming diffuse large B-cell lymphoma (Fig. 2c). This patient was referred to the Department of Hematology for further investigation and treatment.