A 54-year-old woman with a 6-week history of progressive dyspnea and productive cough presented with the radiologic suspicion of a lung carcinoma of the right upper lobe (Figure 1A,1B). Relevant secondary diagnosis was chronic obstructive pulmonary disease (COPD) GOLD grade 2 with excessive nicotine consumption (almost 80 pack years). Her medical history was otherwise unremarkable. In order to receive both diagnosis and rough mediastinal staging, EBUS-TBNA target structures were:besides airway mapping biopsies:lymph node stations 4R, 7 and 10R (Figure 2A-2C). Lymph node station 7 (size: 8 mm) was punctured once using a 22G Olympus needle, lymph node station 4R (size: 17 mm) was punctured multiple times as the received samples were constantly "crumbly", and lymph node station 10R (size 15 mm) was punctured in vain a multiple times. There was no bleeding or any other complication related to the procedure and the patient was discharged two days after the intervention with an unremarkable chest X-ray and normal laboratory findings without prophylactic antibiotics.
During the waiting period for histologic result, tumor board indicated PET-CT to rule out distant metastases. Unfortunately, as events turned out differently, the patient was readmitted exactly two weeks after EBUS-TBNA with symptoms of cardiogenic/septic shock: hypotension [Riva-Rocci (RR) 70/50 mmHg], tachycardia (140 beats per minute), tachypnea (35 breaths per minute), SpO2 84% without oxygen supply, chest pain and fever (39 C). Electrocardiogram showed low voltage and ST-segment elevation in a wide range of leads. As already presumed in chest X-ray (Figure 3A), echocardiography revealed a circumferential pericardial effusion (size 2.5 cm) with tamponade physiology. CT-scan confirmed circular pericardial effusion with an intensity scale of 27 Hounsfield units (HU), indicating a complicated protein-rich effusion (Figure 3B). In addition, a thereof separate liquid formation in the anterior mediastinum with an extension of 69x21x37 mm (intensity scale 21 HU) pointed out a possible mediastinal abscess (Figure 3C). Laboratory results were as follows: white blood cells 30.2x103/microL (cut-off <11.3x103/microL), C-reactive protein level 149.5 mg/L (cut-off <10 mg/L), and procalcitonin level 1.44 ng/mL (cut-off <0.5 ng/mL).
With broad-spectrum antibiotics (piperacillin-tazobactam and clindamycin), the patient underwent urgent left-sided thoracoscopic pericardial fenestration and mediastinal abscess drainage (Figure 4). Even though postoperative catecholamine dose could be initially reduced, persistent tachycardia (120 beats per minute) prompted an echocardiographic control, which revealed a relevant residual pericardial effusion in the area around right atrium and ventricle. In addition, CT-monitoring showed a still detectable mediastinal fluid collection as with a possible persistent abscess formation (Figure 5). Clindamycin was replaced by linezolid. Subsequent right-sided thoracoscopic pericardial fenestration and residual mediastinal abscess drainage was unavoidable seven days after the initial intervention. Renewed rise in infectious blood values was expression of residual purulent effusion in the right-sided pleura not being drained via the inserted chest tubes. Re-thoracoscopy for fluid discharge and further adjustment of antibiotics (linezolid replaced by meropenem) rounded the therapy off.
Even though cultures from various pericardial/mediastinal fluid probes remained inconspicuous, surgical intervention and antibiotic therapy were finally a breakthrough: both cardiac function and laboratory findings recovered. Meanwhile, histologic examination of the mediastinal lymph nodes revealed necrotic material with squamous cell carcinoma in lymph node station 4R. As the final chest drainage was removed 20 days after the initial operation, the patient could be discharged on day 23 after readmission.
In the successive oncologic course, PET-CT could substantiate the initial suspicion of a stage IIIA NSCLC (T2 N2 M0). To precisely determine mediastinal nodal status, video-assisted mediastinal lymphadenectomy (VAMLA) confirmed tumor-positive lymph node station 4R with extranodal extension (ENE+) and tracheal penetration. Subsequent to induction chemotherapy, the patient underwent definitive sequential chemoradiotherapy. Twelve-month follow-up confirmed stable disease.
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
implicates a NSCLC of the right upper lobe with tumor-positive lymph node station 4R (provisional TNM classification: T2 N2 Mx). NSCLC, non-small cell lung cancer; CT, computed tomography; IV, intravenous; TNM, tumor node metastasis.