C78-26 If at First You Don’t Succeed, TBNA, TBNA Again

Abstract Introduction Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is use to sample mediastinal and hilar lymph nodes (LNs) and accessible masses for diagnosis of benign and malignant diseases. Sensitivity for primary lung malignancies typically ranges 88-92%, so false negatives do occur despite appropriate technique and sampling. Considering repeat EBUS-TBNA or other modalities is important when initial testing is negative, but clinical suspicion remains high. Case 77-year-old Mexican-born former construction worker with 50 pack-year prior smoking history was evaluated 5 years prior for dyspnea on exertion, and imaging findings of mediastinal and hilar lymphadenopathy with a right upper lobe pulmonary nodule and ILD changes indeterminant for UIP. Workup included EBUS-TBNA which confirmed sarcoidosis. Nodule was PET negative (SUV 1.7) and stable over 2 years of imaging. He was then lost to follow up. He presented 5 years later with new dry cough. Labs showed hyponatremia and neutrophilic predominant leukocytosis. Pulmonary function testing showed preserved ratio with impaired spirometry and severe diffusion impairment. CT showed a new 4.8 x 3.7 cm left infrahilar mass with internal calcifications and air bronchograms. Mediastinal and hilar lymphadenopathy appeared unchanged. With concern for malignancy, EBUS-TBNA was done, sampling stations 4L and 7, adequate by cytology. Attempted biopsy of the mass was non-diagnostic. He then developed fatigue, weight loss, dyspnea, pleuritic chest pain, and fever, treated with antibiotics with negative cultures. PET/CT revealed larger left infrahilar mass (5.9 cm), PET avid (SUV 14.2) with hypermetabolic right supraclavicular, right prevertebral, and left lower paratracheal LNs with calcification. Given symptoms and PET avidity, EBUS-TBNA was repeated with adequate sampling of 4R, 7, and 4L all negative. Endobronchial biopsy near mass showed only atypical squamous metaplasia. EBUS-TBNA of the mass was not successful due to difficulty reaching it with the scope. Given ongoing high clinical suspicion of malignancy, a third EBUS-TBNA was performed with successful sampling of the mass, positive for carcinoma lung with squamous differentiation. Conclusion In this patient with known sarcoidosis with adenopathy and lung nodule plus smoking history, EBUS negative for malignancy, could be attributed to sarcoidosis with no further workup. High clinical suspicion with progressive dyspnea, chest pain, fever, and weight loss led to a total of 3 EBUS-TBNA procedures over 2 months eventually revealing squamous cell lung cancer. This workup spanned 2 months delayed by 6 intercurrent hospitalizations over 3 months related to presenting symptoms. Unfortunately, patient declined rapidly and died prior to any cancer treatment. This abstract is funded by: None