INTRODUCTION:

Lung mass biopsy is sometimes not feasible using EBUS, making a multidisciplinary approach essential; therefore, we present this case as a representative example.

CASE REPORT:

A 74-year-old woman presented with a 27×16 mm pulmonary nodule in the right lower lobe on chest CT, adjacent to the esophagus [Image 1], suspicious for malignancy. As the lesion was not accessible by EBUS, she was referred to our Unit to evaluate the feasibility of a transesophageal lung biopsy using endoscopic ultrasound (EUS). EUS examination identified—at 30 cm from the dental arcade, near nodal station 8—a hypoechoic pulmonary lesion measuring 29×7×11 mm, in contact with the esophagus but without invasion of its wall, showing smooth borders on the esophageal side and irregular borders on the pulmonary side [Images 2 and 3].

Fine-needle biopsy (FNB) was performed using a 25G needle, with three passes employing fanning technique and 12–15 to-and-fro movements per pass [Image 4]. Prophylactic antibiotics (ciprofloxacin 400 mg IV) were administered beforehand. The procedure was completed without complications.

Histology demonstrated large cells with abundant cytoplasm, anisokaryosis, irregular nuclear contours, and heterogeneous chromatin, arranged in glandular structures, positive for TTF1 and negative for p53 and synaptophysin, consistent with pulmonary adenocarcinoma [Image 5 and 6].

DISCUSSION:

Diagnosing central lung masses adjacent to the esophagus can be challenging, as they may not be accessible for biopsy via bronchoscopy or EBUS. In such cases, EUS has emerged as a complementary tool for tissue acquisition, allowing transesophageal sampling of central pulmonary lesions, with a diagnostic accuracy of 87.5–93.4% and an adverse event rate of 0.7–5.36%, mostly self-limited mild bleeding. These data support the role of EUS as a safe and effective alternative when conventional strategies cannot reach the lesion.

In our case, the pulmonary lesion was located near nodal station 8, which is not accessible via EBUS. EUS enabled direct, stable, and safe access, yielding sufficient material to confirm the diagnosis. We opted for a 25G needle to theoretically reduce bleeding risk, although no statistically significant differences in adverse event rates have been reported compared with 22G needles.

In conclusion, EUS-guided transesophageal biopsy is a valid alternative for central pulmonary lesions that are not accessible by EBUS.