The mass was ultimately identified as a T-lymphoblastic lymphoma, an aggressive cancer of immature T-cell lymphocytes that often announces itself as a rapidly enlarging mediastinal tumor. Lymphomas of this type are notorious among diagnosticians because they demand not just a sample of tissue but a well-preserved one. Pathologists need to see the architecture of the tissue, the shape of the cells, and the results of an entire panel of immunohistochemical stains, each of which reveals whether the malignant cells carry particular protein markers. A crushed or blood-soaked fragment of tumor can render all of that analysis impossible, forcing patients into more invasive surgery or delaying treatment of a fast-moving disease.

For decades, the gold standard for sampling mediastinal tumors was mediastinoscopy, a surgical procedure in which a camera is inserted through an incision above the breastbone to reach the space between the lungs. It provides generous tissue samples, but it requires general anesthesia in a operating room, leaves a scar, and carries the risks of any surgical approach to a crowded anatomical neighborhood. Endobronchial ultrasound-guided transbronchial needle aspiration, known as EBUS-TBNA, changed that calculus. In this minimally invasive technique, a bronchoscope equipped with an ultrasound probe at its tip is passed through the windpipe, allowing the physician to see lymph nodes and masses through the airway wall and to pierce them with a fine needle. EBUS-TBNA has become the standard first-line tool for staging lung cancer and sampling mediastinal lesions, with high accuracy for detecting metastatic disease in lymph nodes.

But lymphoma is where the needle technique hits its limits. The tiny cores of tissue obtained through a 22-gauge needle are often fragmented and distorted by crush artefact, the mechanical damage inflicted as the needle cuts through delicate lymphoid cells. Add blood contamination, and the pathologist may receive a specimen too poor to distinguish between the many subtypes of lymphoma or to rule out other malignancies. That is precisely what happened in this case. When the medical team performed EBUS-TBNA three times at the same site using a 22-gauge needle, the resulting specimen failed to yield definitive findings. The tissue was crushed and blood-stained, and the diagnosis remained out of reach.

The team then turned to a newer approach that has been generating enthusiasm in interventional pulmonology: endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy, or EBUS-Cryo. Cryobiopsy exploits one of the simplest physical effects in medicine, the fact that moisture instantly freezes and bonds to a very cold metal surface. Instead of cutting tissue with a blade or tearing it with forceps, the physician touches a cryoprobe cooled to extreme subzero temperatures against the target tissue for a few seconds. The tissue freezes onto the probe and is pulled away en bloc, retaining its cellular architecture far better than tissue harvested by cutting instruments. The technique has already shown promise in diagnosing pulmonary lymphomas and other lymphoproliferative disorders, and its extension into mediastinal sampling through the EBUS working channel represents a significant technical advance.

In this case, the procedure was performed under endotracheal intubation with an 8.5-millimeter tube, which secured the airway throughout. First, the EBUS-TBNA needle was used to create a tract through the airway wall into the mass. Then a 1.1-millimeter cryoprobe was threaded through that same tract and advanced under EBUS guidance into the tumor. The probe tip was frozen for seven seconds, after which the cryoprobe was withdrawn together with the bronchoscope as a single unit, bringing the frozen specimen with it. This maneuver was repeated until six cryobiopsy specimens had been collected. Notably, rapid on-site cytologic evaluation was not used, yet the samples proved diagnostically decisive. The entire examination proceeded without hypoxemia, bleeding, or any other adverse event, and the patient went home the very next day.

The pathological comparison between the two sampling methods was striking. The needle aspiration specimens were non-diagnostic, whereas the cryobiopsy material showed beautifully preserved tissue structure, with diffuse proliferation of atypical lymphocytes bearing round nuclei and a high nucleus-to-cytoplasm ratio. Immunohistochemical staining then told the full story. The atypical cells were positive for CD3, CD2, CD7, and CD99, a profile pointing firmly toward a T-cell lineage. They were negative for CD20, which argued against a B-cell lymphoma, and negative for AE1/AE3, which excluded an epithelial cancer such as thymoma or carcinoma. Markers including CD4, CD5, CD8, CD1a, CD34, c-kit, and SALL4 were also absent, narrowing the differential diagnosis further. Terminal deoxynucleotidyl transferase, or TdT, a hallmark of immature lymphoblasts, was expressed in only a small subset of cells, an atypical feature for T-lymphoblastic lymphoma. Weighing the full histopathological and immunophenotypic picture alongside the patient’s young age and the anterior mediastinal location of the tumor, the team arrived at a definitive diagnosis of T-lymphoblastic lymphoma, and she was referred promptly to hematology for systemic chemotherapy.

Safety deserves particular emphasis, because this case involved an unusually hazardous starting point. Mediastinal cryobiopsy, while generally considered relatively safe, carries recognized complications including bleeding, pneumomediastinum, and mediastinal infection. In a patient whose trachea was already markedly narrowed by extrinsic compression, even modest bleeding into the airway could have precipitated life-threatening obstruction. The authors note that the small 1.1-millimeter cryoprobe requires only a tiny puncture tract, which may theoretically reduce procedural risks compared with larger devices such as forceps or electrocautery instruments. The successful completion of the procedure, with discharge the following day and no airway compromise, suggests that in carefully selected patients, substantial airway compression need not disqualify a patient from this minimally invasive route to diagnosis.

The broader lesson of this case report, published in Respirology Case Reports, is that sampling technique can be the deciding variable in cancer diagnosis. EBUS-TBNA remains an outstanding tool for many mediastinal questions, particularly lung cancer staging, but when a suspected lymphoma demands assessment of tissue architecture and an extensive immunophenotypic workup, larger and better-preserved specimens can make the difference between an inconclusive result and an actionable answer. Cryobiopsy through the EBUS tract offers exactly that, using physical freezing rather than mechanical cutting to preserve the fragile cellular detail that immunohistochemistry depends upon. For patients with mediastinal masses, especially those compressing the airway, the prospect of a definitive diagnosis without open surgery, delivered through a probe thinner than a pencil lead and often within a single hospital day, represents a meaningful step forward in interventional pulmonology. As experience with EBUS-Cryo accumulates, this frozen needle may become a standard complement to conventional needle aspiration, ensuring that tumors like the one discovered on this young woman’s routine X-ray can be named, classified, and treated without delay.

Subject of Research: Diagnosis of primary mediastinal T-lymphoblastic lymphoma using endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy

Article Title: Primary Mediastinal T‐Lymphoblastic Lymphoma With Airway Stenosis Diagnosed Using Endobronchial Ultrasound‐Guided Transbronchial Mediastinal Cryobiopsy: A Case Report

Article References: Nagamine, H., Bungo, M., Nagaki, Y., Todoriki, A., Niina, K., Enomoto, K., Kakuno, S., Nakai, T., Yamada, K., Watanabe, T., Asai, K., Mukai, D., Nagasaki, J., Nakamae, H., & Kawaguchi, T. (2026). Primary Mediastinal T‐Lymphoblastic Lymphoma With Airway Stenosis Diagnosed Using Endobronchial Ultrasound‐Guided Transbronchial Mediastinal Cryobiopsy: A Case Report. Respirology Case Reports, 14(9), Article e70756. https://doi.org/10.1002/rcr2.70756

Image Credits: AI Generated

DOI: 10.1002/rcr2.70756

Keywords: T-lymphoblastic lymphoma, EBUS-Cryo, cryobiopsy, mediastinal mass, airway stenosis, EBUS-TBNA, interventional pulmonology, immunohistochemistry, bronchoscopy, lymphoma diagnosis, case report, Respirology Case Reports