Schwannomas are classified as neurogenic tumors and are the most frequent nerve sheath tumors in the paravertebral mediastinum. Recently, the addition of endobronchial ultrasound-guided intranodal forceps biopsy (EBUS-IFB) using standard-sized biopsy forceps (SBFs) to endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for metastatic lymph nodes in lung cancer patients reportedly improved the quality and quantity of the obtained specimens without significant complications. However, reports on the usefulness of this technique for benign diseases remain scarce. Here we report a case of schwannoma in the middle mediastinum, which was diagnosed by EBUS-IFB using SBFs, despite inadequate specimens obtained via EBUS-TBNA. An 80-year-old woman presented with dyspnea and a 5-cm sized middle mediastinal tumor. EBUS-TBNA and EBUS-IFB using SBFs were performed for histological diagnosis. No complications were associated with the bronchoscopy procedure, and schwannoma was solely diagnosed using the EBUS-IFB specimens. EBUS-IFB using SBFs is potentially useful for diagnosing benign diseases, including schwannomas, which are often difficult to diagnose with EBUS-TBNA.

Sarcoidosis is a multisystemic granulomatous disease that is frequently localized in the lungs and lymph nodes. We herein report a case of pulmonary sarcoidosis secondary to shin\'iseihaito administration. During remission with 5 mg prednisolone/day of maintenance treatment, chest computed tomography revealed a mass in the left lower lobe with re-enlarged bilateral hilar/mediastinal lymph nodes. Transbronchial lung biopsy of the mass and endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes revealed adenocarcinoma and noncaseating granulomas, respectively. Based on these findings, the patient was diagnosed with sarcoidosis recurrence associated with lung cancer without cancer metastasis. We present the case of sarcoidosis recurrence associated with lung cancer after drug-induced pulmonary sarcoidosis with lung injury. To our knowledge, this is the first report of sarcoidosis triggered by drug administration and lung cancer. Histological diagnosis of mediastinal lymphadenopathy with lung cancer is essential for differentiating metastasis from sarcoidosis.

OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic procedure with adequate performance; however, its ability to provide specimens of sufficient quality and quantity for treatment decision-making in advanced-stage lung cancer may be limited, primarily due to blood contamination. The use of a 0.96-mm miniforceps biopsy (MFB) permits true histological sampling, but the resulting small specimens are unsuitable for the intended applications. Therefore, we introduced a 1.9-mm standard-sized forceps biopsy (SFB) and compared its utility to that of MFB.
METHODS: We prospectively enrolled patients from three institutions who presented with hilar/mediastinal lymphadenopathy and suspected advanced-stage lung cancer, or those who were already diagnosed but required additional tissue specimens for biomarker analysis. Each patient underwent MFB followed by SFB three or four times through the tract created by TBNA using a 22-gauge needle on the same lymph node (LN). Two pathologists assessed the quality and size of each specimen using a virtual slide system, and diagnostic performance was compared between the MFB and SFB groups.
RESULTS: Among the 60 enrolled patients, 70.0% were diagnosed with adenocarcinoma. The most frequently targeted sites were the lower paratracheal LNs, followed by the interlobar LNs. The diagnostic yields of TBNA, MFB and SFB were 91.7%, 93.3% and 96.7%, respectively. The sampling rate of high-quality specimens was significantly higher in the SFB group. Moreover, the mean specimen size for SFB was three times larger than for MFB.
CONCLUSIONS: SFB is useful for obtaining sufficient qualitative and quantitative specimens.

Neurosarcoidosis is a rare complication of sarcoidosis and unusually presents as optic neuritis. We present the case of a 51-year-old man who complained of right vision loss. Brain magnetic resonance imaging showed asymmetrical enlargement of the right optic nerve. Chest computed tomography detected mediastinal and hilar lymphadenopathy. There were cutaneous nodules on the back. Biopsy of the mediastinal lymph node by endobronchial ultrasound-guided transbronchial needle aspiration and the skin showed noncaseating granulomas consistent with sarcoidosis. Serum angiotensin-converting enzyme level was elevated (34.2 IU/L) (normal: 8.3-21.4 IU/L). Based on these findings, he was diagnosed as neurosarcoidosis with optic neuritis. He was started on 1000-mg/day methylprednisolone intravenously for 3 days, followed by oral 50-mg/day prednisolone, which was gradually tapered for 8 weeks. Thereafter, the skin nodules and lymphadenopathy decreased and the right vision partially improved. Based on this rare case, sarcoidosis should be considered as a differential diagnosis in cases of optic neuritis.

Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been reported to be a minimally invasive and relatively safe procedure, mediastinitis is a serious complication related to the procedure. The median time of mediastinitis onset is approximately 12 days after EBUS-TBNA. Here we report two rare cases with mediastinitis onset 40 and 53 days after EBUS-TBNA. Surgical drainage was performed since systemic treatment with antibiotics was insufficient in both cases. Eikenella corrodens, which is a slow-growing microorganism, was identified as the causative pathogen in one case. To our knowledge, this is the first report of mediastinitis occurring over a month after EBUS-TBNA. Clinicians should consider the diagnosis of mediastinitis even if symptoms appear over a month after EBUS-TBNA.

A 71-year-old man, who had received long-term oxygen therapy for respiratory failure caused by chronic obstructive pulmonary disease, had an enlarged mediastinal lymph node for one year. As his lung function was poor, we tried performing endobronchial ultrasound-guided transbronchial needle aspiration under non-invasive positive pressure ventilation for diagnosis but could not obtain sufficient specimens. Later, we performed an endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) using a transesophageal approach. Rapid on-site cytology revealed that adequate specimens were obtained, and we could terminate the procedure in 12 min without any complications. The histological findings revealed lung adenocarcinoma. EUS-B-FNA, which can be performed by a pulmonologist, is a useful alternative for diagnosing mediastinal lesions in patients with respiratory failure.

A 77-year-old man was referred to our hospital due to enlarging mediastinal/hilar lymphadenopathy with calcification. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and bone marrow aspiration were performed. Subsequently, monoclonal gammopathy of undetermined significance (MGUS) associated with mediastinal amyloidosis was diagnosed. We hereby report a case in which EBUS-TBNA led to a successful diagnosis of amyloidosis.