Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a minimally invasive method with excellent diagnostic accuracy and low risk of complications in the diagnosis of thoracic diseases (1). In general, EBUS-TBNA is mostly indicated for patients with suspect lung cancer, specifically those who has central thoracic disease with negative bronchoscopy or in the suspicion of advanced disease with mediastinal lymphadenopathy (2,3).
Similarly, EBUS-TBNA can also be important in the evaluation of benign and malignant mediastinal diseases, such as sarcoidosis and lymphoma (4-6). Furthermore, this procedure may be useful in the suspicion of thoracic metastasis from distant tumors, such as gastrointestinal and gynecological cancers. For this propose, we report an interesting and rare case of mediastinal metastasis of ovarian carcinoma diagnosed by EBUS-TBNA.
A 54-year-old woman with 15 kg weight loss, abdominal and chest pain for the past 3 months was submitted to a chest and abdominal computed tomography (CT). The exam demonstrated multiple mediastinal and abdominal lymph nodes without other abnormalities (Figure 1). Due to this findings, the patient was referred for EBUS-TBNA (EBUS, Fujinon Corporation, Japan), revealing multiple enlarged mediastinal lymph nodes, measuring about 3 cm × 2 cm, located in subcarinal and bilateral para-tracheal regions (Figure 2). EBUS-TBNA (Figure 3) of the subcarinal lymph node (SonoTip® EBUS Pro needle, Medi-Globe Corporation, Germany) demonstrated partial replacement of the tissue by a metastatic epithelial neoplasm, composed of large atypical cells forming glandular structures (Figure 4). Immunohistochemical reactions showed positivity for CA125 and CK7 being negative for all other markers tested, confirming the diagnosis of ovarian carcinoma (Figure 5).
Thoracic lymph nodes are often present on imaging studies and it may correspond a benign or malignant disease. The correct staging and pathological analysis are important steps in patient management. For this propose, it’s possible to perform a surgical invasive method or a non-invasive method, such as endoscopic ultrasound (EUS) and endoscopic ultrasound endobronchial (EBUS) (7-11).
EUS can be an interesting alternative in the presence of lymph nodes located on the upper/lower left paratracheal stations (2L and 4L), subaortic station , subcarinal station , para-esophageal station , pulmonary ligament stations (9R and 9L) (8,12,13). Moreover, EBUS is most suitable in situations where there is involvement of upper and lower paratracheal bilateral stations (2R, 2L, 4R and 4L), subcarinal station  hilar stations (10R and 10L) and interlobar stations (11R and 11L). Through both methods it is possible to collect material by fine needle aspiration for cytological, histological and immunohistochemistry/molecular biology analysis, with excellent results and low rates of complications (14-16).
In case of symptomatic patients with multiple lymphadenopathy or lymph nodes larger than 1 cm should be suggested the diagnosis of primary mediastinal malignancy or metastasis from other organs. In this case report, it was initially proposed the diagnosis of lymphoma, due to the presence of multiple enlarged abdominal and thoracic lymph nodes and no other findings on the chest and abdomen CT scan. However, EBUS-TBNA and pathological study confirmed the unexpected diagnosis of mediastinal metastasis of ovarian carcinoma.
Ovarian carcinoma remains one of the main causes of cancer mortality in women. The prognosis is closely related to the stage at diagnosis. The tumor can spread by local extension, lymphatic, hematogenous and transdiaphragmatic dissemination. Outside the peritoneal cavity, ovarian cancer may rarely spread to the pleural cavity, lungs and mediastinum. Mediastinal involvement is a rare phenomenon in patients with ovarian cancer and only a few cases have been reported in the literature (17-23).
EUS and EBUS have emerged as a safe and accurate technique for the diagnosis of both benign and malignant thoracic diseases. Accurate identification of the presence of mediastinal involvement and pathological confirmation are important for determining prognosis and selecting appropriate treatment of this patients. In this case report, we could demonstrate a rare case of mediastinal metastasis of ovarian carcinoma diagnosed by EBUS-TBNA.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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