Tierra Sanders, DO1, Saeed Graham, MD1, Shiva Poola, MD2, Karissa Lambert, MD3, Prashant Mudireddy, MD3 1East Carolina University, Greenville, NC; 2East Carolina University Medical Center, Greenville, NC; 3East Carolina Gastroenterology, Greenville, NC
Introduction: Lung cancer remains the most fatal malignancy worldwide, accounting for 18.4% of cancer deaths per year. Despite advancements in diagnostic imaging, direct tissue sampling remains essential to confirm cancer and enable treatment selection through molecular testing. The traditional approach for sampling pulmonary lesions is bronchoscopy with endobronchial ultrasound (EBUS), but endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) via a transesophageal approach may be appropriate in select cases. We present two cases of successful EUS-FNB diagnostic of lung lesions after inadequate tissue sampling from EBUS.
Case Description/Methods: A 66-year-old male was found to have a 4 cm irregular mass in the right upper lobe (RUL) with increasing density at the medial aspect of the right upper lobe with hypermetabolic activity on PET scan. EBUS yielded cytology that was negative for malignancy. Therefore, EUS-FNB was pursued, which demonstrated a 25 x 42 mm irregular hypoechoic mixed solid and cystic with poorly defined borders in the distal esophagus (Figure 1. A-D). FNB with 5 passes was made with the 25g needle to the RUL. Pathology demonstrated Stage IIA adenocarcinoma with no complications post-procedure.
A 63-year-old male with a history of Stage IIA poorly differentiated adenocarcinoma previously treated with chemoradiation presented with concern for recurrence after imaging found an infiltrative soft tissue density of the upper mediastinum adjacent to the esophagus. EBUS was nondiagnostic for malignancy. FNB showed a 21x 33 mm poorly defined hypoechoic and heterogeneous irregular mass was identified in the mediastinum adjacent to the upper third of the esophagus (Figure 1. E-H). FNB was performed with 3 passes made with the 25g needle. Pathology confirmed adenocarcinoma with no complications post-procedure.
Discussion: These cases demonstrate that EUS-guided biopsy of pulmonary lesions is safe and effective. The decision to pursue EUS was based on the central location of the lung parenchymal masses near the esophagus. Mangiavillano et al. has reported a successful 95% diagnostic yield in cases via EUS FNB for lung lesions. Similarly, Giri et al. suggest that the EUS-FNB and EBUS-FNB combined approach may be the superior for difficult-to-diagnose lesions. Although pulmonary lesion sampling is generally done by interventional pulmonology, we demonstrate that an endoscopic approach is safe and useful with endoscopic ultrasound-guided FNB
Figure: (A) PET/CT scan revealed increasing density at the medial aspect of the right upper lobe with associated hypermetabolic activity. (B-C) Ultrasonographic image of hypoechoic and mixed solid and cystic, suggesting a necrotic component. The mass measured 25 mm by 42 mm in maximal cross-sectional diameter. The endosonographic borders were poorly defined. (D) The upper third of the esophagus after 5 passes with the 25-gauge biopsy needle. (E) PET/CT scan showing the progression of infiltrative soft tissue density of the upper mediastinum, particularly posterior and left to the upper thoracic esophagus, with new hypermetabolic activity adjacent to the esophagus (F) EGD showing a moderate-sized area of extrinsic compression found in the upper third of the esophagus at 21-25 cm (G) EGD s/p procedure. (H) Hypoechoic and heterogeneous mass, poorly defined, measuring 21 mm by 33 mm, located in the mediastinum adjacent to the upper third of the esophagus, positioned at 21 cm from the incisors.
Disclosures:
Tierra Sanders indicated no relevant financial relationships.
Saeed Graham indicated no relevant financial relationships.
Shiva Poola indicated no relevant financial relationships.
Karissa Lambert indicated no relevant financial relationships.
Prashant Mudireddy indicated no relevant financial relationships.
Tierra Sanders, DO1, Saeed Graham, MD1, Shiva Poola, MD2, Karissa Lambert, MD3, Prashant Mudireddy, MD3. P4532 - They Want Us to FNB the Lung? Of Course!, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
