European Respiratory Society

To the Editors:

We read with interest the correspondence published by Park et al. [1] suggesting a potential role for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to differentiate pulmonary artery sarcoma and thromboembolism.

Pulmonary artery sarcoma usually has its origin in the pulmonary arterial trunk and extends towards pulmonary branches, and is indeed sometimes difficult to differentiate from chronic thromboembolic disease. However, we believe that the authors’ conclusions suggesting that EBUS-TBNA is safe in this setting are premature. Indeed, such an approach could be associated with significant complications.

Even if pulmonary artery sarcoma may mimic acute or chronic pulmonary thromboembolism, it has been reported [2, 3] that a careful analysis including medical history, chest computed tomography (CT), magnetic resonance imaging (MRI), pulmonary angiogram and positron emission tomography CT with 18F-2-fluoro-2-deoxy-d-glucose [4, 5] may be sufficient to detect patients with pulmonary artery sarcoma. Chest CT classically shows hyperdense lesions, beaded peripheral pulmonary arteries, and contiguously soft tissue-filled pulmonary arteries and extravascular spread [2]. Moreover, MRI may be more specific for pulmonary artery sarcoma, showing enhancement with gadolinium contrast [2].

Park et al. [1] performed EBUS-TBNA in a patient with acute pulmonary embolism, which was later confirmed by the complete reversibility of endovascular clots after 6 weeks of anticoagulation. Performing EBUS-TBNA in a patient with acute thromboembolism is certainly debatable and hazardous, and it is important to state that a diagnosis of acute thromboembolic disease is based on established imaging techniques, such as ventilation/perfusion lung scan, chest CT and pulmonary angiography [6].

Diagnosis of an endovascular tumour could be made by endovascular catheter biopsy [7]. In addition, as stated by Park et al. [1], surgery is the treatment of choice in the management of pulmonary artery sarcoma (pneumonectomy, pulmonary artery resection/reconstruction or pulmonary endarterectomy) and chronic thromboembolic pulmonary disease (pulmonary endarterectomy) [6]. It is therefore important to highlight that surgery should be proposed to eligible patients with pulmonary artery sarcoma or chronic thromboembolic pulmonary hypertension, allowing diagnosis confirmation and management.

Finally, a large proportion of patients with proximal pulmonary artery chronic obstruction by sarcoma or thromboembolic material may present with pulmonary hypertension, a condition associated with a high risk of complication following transbronchial needle aspiration. Indeed, it has been clearly demonstrated that proximal obstruction of pulmonary arteries may be associated with hypertrophy of systemic bronchial arteries (fig. 1), increasing the risk of haemorrhage from transbronchial needle aspiration.

Figure 1–

Computed tomography angiography with maximum-intensity reconstruction in the coronal plane showing hypertrophy of systemic bronchial arteries (arrows) in a case of proximal chronic thromboembolic pulmonary disease.

To conclude, we believe that physicians should be aware of the potential complications of EBUS-TBNA in patients with pulmonary artery sarcoma or pulmonary thromboembolic disease, and we consider that EBUS-TBNA should not be proposed in the management of pulmonary artery sarcoma or thromboembolic disease.