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Blizzard Sign as a specific endobronchial ultrasound image for ground glass opacity: A case report.

Sasada S, Izumo T, Chavez C, Tsuchida T - Respir Med Case Rep (2014)

Bottom Line: The lesion was indistinguishable by real-time fluoroscopy but simultaneous endobronchial ultrasound scanning of the involved lung segment showed a hyperechoic shadow that was subtly more intense than a typical snowstorm appearance when scanning normal alveolar tissue.On hindsight, it was the aforementioned ultrasound pattern that helped us decide the sampling site for EBUS-GS guided TBB when fluoroscopy was equivocal.We hypothesize that this pattern is specific for GGO and we name it the Blizzard Sign.

View Article: PubMed Central - PubMed

Affiliation: Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.

ABSTRACT
We report a case of lung adenocarcinoma presenting as pure ground glass opacity (GGO) and diagnosed by bronchoscopy with the use endobronchial ultrasound with a guide sheath (EBUS-GS). The lesion was indistinguishable by real-time fluoroscopy but simultaneous endobronchial ultrasound scanning of the involved lung segment showed a hyperechoic shadow that was subtly more intense than a typical snowstorm appearance when scanning normal alveolar tissue. Transbronchial biopsy from this area revealed adenocarcinoma with lepidic growth. On hindsight, it was the aforementioned ultrasound pattern that helped us decide the sampling site for EBUS-GS guided TBB when fluoroscopy was equivocal. We hypothesize that this pattern is specific for GGO and we name it the Blizzard Sign.

No MeSH data available.


Related in: MedlinePlus

Photomicrographs of the Hematoxylin & Eosin staining of a transbronchial biopsy specimen from a pure ground glass opacity show adenocarcinoma with lepidic growth. A (×100); B (×400).
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fig3: Photomicrographs of the Hematoxylin & Eosin staining of a transbronchial biopsy specimen from a pure ground glass opacity show adenocarcinoma with lepidic growth. A (×100); B (×400).

Mentions: The representative case is that of an 81-year old female, non-smoker, with a 35 mm pure ground glass opacity (GGO) in the right lower lobe that was incidentally seen on computed tomography (CT) scan of the chest (Fig. 1A) but was indistinct on chest radiograph (Fig. 1B). The endobronchial route was carefully planned prior to bronchoscopy using 1-mm cross-sectional CT scan images and the topographical location of the target lesion on the coronal plane was mapped out on chest tomosynthesis. The patient underwent diagnostic bronchoscopy (1T260, Olympus) using radial EBUS (UM-S20-20R, Olympus) with large type GS (K-203, Olympus). Fluoroscopy was used concomitantly with endobronchial ultrasound scanning to find the target. During the initial attempt, it was difficult to distinguish the mass on fluoroscopy (Fig. 2A) and ultrasound signals only generated a snowstorm appearance that was ascribed as normal lung tissue (Fig. 2B). But we were certain that we were in the intended lung segment so the ultrasound probe was inserted more distally. At this point, a subtle but noticeable enhancement and increase in area of the snowstorm appearance was seen (Fig. 2C). After marking this location of the GS on fluoroscopy, seven TBB samples were obtained using a dedicated biopsy forceps with guide sheath kit (Fig. 2D). Histopathologic examination of the 3rd to the 7th consecutive biopsy specimens revealed adenocarcinoma with lepidic growth (Fig. 3). The patient was staged as T2aN0M0 but refused further treatment.


Blizzard Sign as a specific endobronchial ultrasound image for ground glass opacity: A case report.

Sasada S, Izumo T, Chavez C, Tsuchida T - Respir Med Case Rep (2014)

Photomicrographs of the Hematoxylin & Eosin staining of a transbronchial biopsy specimen from a pure ground glass opacity show adenocarcinoma with lepidic growth. A (×100); B (×400).
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4061420&req=5

fig3: Photomicrographs of the Hematoxylin & Eosin staining of a transbronchial biopsy specimen from a pure ground glass opacity show adenocarcinoma with lepidic growth. A (×100); B (×400).
Mentions: The representative case is that of an 81-year old female, non-smoker, with a 35 mm pure ground glass opacity (GGO) in the right lower lobe that was incidentally seen on computed tomography (CT) scan of the chest (Fig. 1A) but was indistinct on chest radiograph (Fig. 1B). The endobronchial route was carefully planned prior to bronchoscopy using 1-mm cross-sectional CT scan images and the topographical location of the target lesion on the coronal plane was mapped out on chest tomosynthesis. The patient underwent diagnostic bronchoscopy (1T260, Olympus) using radial EBUS (UM-S20-20R, Olympus) with large type GS (K-203, Olympus). Fluoroscopy was used concomitantly with endobronchial ultrasound scanning to find the target. During the initial attempt, it was difficult to distinguish the mass on fluoroscopy (Fig. 2A) and ultrasound signals only generated a snowstorm appearance that was ascribed as normal lung tissue (Fig. 2B). But we were certain that we were in the intended lung segment so the ultrasound probe was inserted more distally. At this point, a subtle but noticeable enhancement and increase in area of the snowstorm appearance was seen (Fig. 2C). After marking this location of the GS on fluoroscopy, seven TBB samples were obtained using a dedicated biopsy forceps with guide sheath kit (Fig. 2D). Histopathologic examination of the 3rd to the 7th consecutive biopsy specimens revealed adenocarcinoma with lepidic growth (Fig. 3). The patient was staged as T2aN0M0 but refused further treatment.

Bottom Line: The lesion was indistinguishable by real-time fluoroscopy but simultaneous endobronchial ultrasound scanning of the involved lung segment showed a hyperechoic shadow that was subtly more intense than a typical snowstorm appearance when scanning normal alveolar tissue.On hindsight, it was the aforementioned ultrasound pattern that helped us decide the sampling site for EBUS-GS guided TBB when fluoroscopy was equivocal.We hypothesize that this pattern is specific for GGO and we name it the Blizzard Sign.

View Article: PubMed Central - PubMed

Affiliation: Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.

ABSTRACT
We report a case of lung adenocarcinoma presenting as pure ground glass opacity (GGO) and diagnosed by bronchoscopy with the use endobronchial ultrasound with a guide sheath (EBUS-GS). The lesion was indistinguishable by real-time fluoroscopy but simultaneous endobronchial ultrasound scanning of the involved lung segment showed a hyperechoic shadow that was subtly more intense than a typical snowstorm appearance when scanning normal alveolar tissue. Transbronchial biopsy from this area revealed adenocarcinoma with lepidic growth. On hindsight, it was the aforementioned ultrasound pattern that helped us decide the sampling site for EBUS-GS guided TBB when fluoroscopy was equivocal. We hypothesize that this pattern is specific for GGO and we name it the Blizzard Sign.

No MeSH data available.


Related in: MedlinePlus