PMC10011863_01
Both preoperative chest X-ray (A) and axial CT-scan with IV contrast (soft tissue window, B) 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.
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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).
EBUS-TBNA of mediastinal lymph node stations 4R (A), 7 (B), and 10R (C). LK, lymph node station; EBUS-TBNA, endobronchial ultrasound-guided transbronchial needle aspiration.
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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).
Two weeks after EBUS-TBNA, chest X-ray indicated massive pericardial effusion and concomitant heart failure (A). Axial CT-scan with IV contrast (soft tissue window) showed protein-rich pericardial effusion (B) and an organized mediastinal fluid collection (C), indicating a complicated pericardial effusion with possible mediastinal abscess formation. Additional pleural effusion reflected functional heart failure. EBUS-TBNA, endobronchial ultrasound-guided transbronchial needle aspiration; CT, computed tomography; IV, intravenous.
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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).
Intraoperative finding after evacuation of at least 300 mL opaque pericardial effusion and pericardial fenestration via left-sided video-assisted thoracoscopy.
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With broad-spectrum antibiotics (piperacillin-tazobactam and clindamycin), the patient underwent urgent left-sided thoracoscopic pericardial fenestration and mediastinal abscess drainage (Figure 4).
Interim coronal CT-scan with IV contrast (soft tissue window) displaying both residual pericardial effusion and residual mediastinal fluid collection as a possible indication for persistent abscess formation. CT, computed tomography; IV, intravenous.
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CT-monitoring showed a still detectable mediastinal fluid collection as with a possible persistent abscess formation (Figure 5). Clindamycin was replaced by linezolid.