An alternate approach: transesophageal bronchoscopic ultrasound-guided fine needle aspiration (eus-b-fna) to assess pleural mesothelioma

SESSION TITLE: Tales in BronchoscopySESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: The use of transesophageal fine needle aspiration with an EBUS scope (EUS-B-FNA) is an emerging technique for biopsy of mediastinal lymph nodes and left adrenal glands by trained interventional pulmonologists. We report a case of paraoesophageal EUS-B-FNA of pleural thickening in a man with radiographic presentation of diffuse pleural thickening encasing the right lung.CASE PRESENTATION: A 76-year-old male with a history of prostate cancer presented to our ED following a syncopal event. Circumferential thickening of the right pleura along with pleural calcifications near the right diaphragm was found on CXR (Figure 1). CT of chest confirmed diffuse pleural thickening, encasing the right lung. Trace left pleural effusion with pleural calcifications were also present. Right lung contraction was present, causing minimal right mediastinal shift. The choice of an endoscopic approach with EUS-B-FNA was made because of its feasibility and location of pleural thickening which was in close proximity to the esophagus. Endobronchial ultrasound-guided transbronchial fine-needle aspiration was first performed to obtain samples from mediastinal and hilar lymph node stations. Following this, the EBUS scope was then inserted into the esophagus and advanced to the gastroesophageal junction. It was then pulled proximally with identification of liver. Next, the scope was then rotated clockwise and pulled proximally with identification of paraesophageal right pleural thickening. Using ultrasound guidance, 6 FNA biopsy samples were obtained.DISCUSSION: The use of EUS-B-FNA allows for ultrasound examination and biopsy of pleural tissue that was previously inaccessible by bronchoscopy. Notably, a recent meta-analysis showed a diagnostic yield of 90% when EUS-B-FNA and EBUS-TBNA are used concurrently for evaluation of mediastinal lymphadenopathy. A recent study found that experienced bronchoscopists can easily gain proficiency in EBUS-TBNA with minimal complications. In the current report we bring awareness for interventional pulmonologists to consider pleural biopsies using EUS-B-FNA as a feasible biopsy approach. More research is required to assess the difference in outcomes between conventional techniques for biopsying pleura. The mediastinal and hilar lymph nodes were benign, the pleural biopsy was non diagnostic. Patient underwent VATS for final diagnosis of epithelioid mesothelioma.CONCLUSIONS: EUS-B-FNA is a safe, effective, and worthwhile technique in the evaluation of mediastinal, left adrenal, and paraesophageal pleural tissue abnormalities.Reference #1: Ng, Jeffrey & Chan, Hiang Ping & Kee, Adrian & Khoo, Kay & See, Kay. (2021). Transitioning to Combined EBUS EUS-B FNA for Experienced EBUS Bronchoscopist. Diagnostics. 11. 1021. 10.3390/diagnostics11061021.Reference #2: Madan K, Mittal S, Madan NK, Tiwari P, Jain D, Arava S, Hadda V, Mohan A, Garg P, Guleria R. EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial. Clin Respir J. 2020 Nov;14(11):1076-1082. doi: 10.1111/crj.13244. Epub 2020 Aug 19. PMID: 32748463.Reference #3: Dhooria, S.; Aggarwal, A.N.; Gupta, D.; Behera, D.; Agarwal, R. Utility and Safety of Endoscopic Ultrasound with BronchoscopeGuided Fine-Needle Aspiration in Mediastinal Lymph Node Sampling: Systematic Review and Meta-Analysis. Respir. Care 2015, 60, 1040–1050.DISCLOSURES: No relevant relationships by Sailendra ChunduNo relevant relationships by Moiz JavedNo relevant relationships by Ali SaeedNo relevant relationships by Andrew Talon SESSION TITLE: Tales in Bronchoscopy SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: The use of transesophageal fine needle aspiration with an EBUS scope (EUS-B-FNA) is an emerging technique for biopsy of mediastinal lymph nodes and left adrenal glands by trained interventional pulmonologists. We report a case of paraoesophageal EUS-B-FNA of pleural thickening in a man with radiographic presentation of diffuse pleural thickening encasing the right lung. CASE PRESENTATION: A 76-year-old male with a history of prostate cancer presented to our ED following a syncopal event. Circumferential thickening of the right pleura along with pleural calcifications near the right diaphragm was found on CXR (Figure 1). CT of chest confirmed diffuse pleural thickening, encasing the right lung. Trace left pleural effusion with pleural calcifications were also present. Right lung contraction was present, causing minimal right mediastinal shift. The choice of an endoscopic approach with EUS-B-FNA was made because of its feasibility and location of pleural thickening which was in close proximity to the esophagus. Endobronchial ultrasound-guided transbronchial fine-needle aspiration was first performed to obtain samples from mediastinal and hilar lymph node stations. Following this, the EBUS scope was then inserted into the esophagus and advanced to the gastroesophageal junction. It was then pulled proximally with identification of liver. Next, the scope was then rotated clockwise and pulled proximally with identification of paraesophageal right pleural thickening. Using ultrasound guidance, 6 FNA biopsy samples were obtained. DISCUSSION: The use of EUS-B-FNA allows for ultrasound examination and biopsy of pleural tissue that was previously inaccessible by bronchoscopy. Notably, a recent meta-analysis showed a diagnostic yield of 90% when EUS-B-FNA and EBUS-TBNA are used concurrently for evaluation of mediastinal lymphadenopathy. A recent study found that experienced bronchoscopists can easily gain proficiency in EBUS-TBNA with minimal complications. In the current report we bring awareness for interventional pulmonologists to consider pleural biopsies using EUS-B-FNA as a feasible biopsy approach. More research is required to assess the difference in outcomes between conventional techniques for biopsying pleura. The mediastinal and hilar lymph nodes were benign, the pleural biopsy was non diagnostic. Patient underwent VATS for final diagnosis of epithelioid mesothelioma. CONCLUSIONS: EUS-B-FNA is a safe, effective, and worthwhile technique in the evaluation of mediastinal, left adrenal, and paraesophageal pleural tissue abnormalities. Reference #1: Ng, Jeffrey & Chan, Hiang Ping & Kee, Adrian & Khoo, Kay & See, Kay. (2021). Transitioning to Combined EBUS EUS-B FNA for Experienced EBUS Bronchoscopist. Diagnostics. 11. 1021. 10.3390/diagnostics11061021. Reference #2: Madan K, Mittal S, Madan NK, Tiwari P, Jain D, Arava S, Hadda V, Mohan A, Garg P, Guleria R. EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial. Clin Respir J. 2020 Nov;14(11):1076-1082. doi: 10.1111/crj.13244. Epub 2020 Aug 19. PMID: 32748463. Reference #3: Dhooria, S.; Aggarwal, A.N.; Gupta, D.; Behera, D.; Agarwal, R. Utility and Safety of Endoscopic Ultrasound with BronchoscopeGuided Fine-Needle Aspiration in Mediastinal Lymph Node Sampling: Systematic Review and Meta-Analysis. Respir. Care 2015, 60, 1040–1050. DISCLOSURES: No relevant relationships by Sailendra Chundu No relevant relationships by Moiz Javed No relevant relationships by Ali Saeed No relevant relationships by Andrew Talon