Utilizing robotic assisted bronchoscopy and endobronchial ultrasound to successfully biopsy a para-aortic lymph node 

M. Macdougall*^a (Dr), R. Feng^a (Dr), A. Sweidan^a (Dr), N. Patel^a (Dr), J. Longoria^a (Dr)

^a UCI Medical Center, Orange, UNITED STATES

* mrmacdou@hs.uci.edu

BACKGROUND:

The diagnosis of indeterminate aortopulmonary (AP) window lymph nodes is challenging due to the position of the aorta and the left pulmonary artery. We describe a combined approach using both a shape-sensing robotic-assisted bronchoscopy (SSRAB) and an endobronchial ultrasound (EBUS) scope to biopsy a paraaortic lymph node (LN) without traversing the aorta.

CASE REPORT:

A 79-year-old female with squamous cell cancer of the neck and melanoma presented with four years of persistent PET avid AP window. The initial EBUS guided-FNA (fine needle aspiration) of the para-aortic LN was negative for metastasis. She was treated with resection and immunotherapy, but the LN continued to be FDG avid. Therefore, she was referred to Interventional Pulmonary for a repeat biopsy. At this time, the mediastinal blood pool was 1.6 SUV, the hepatic blood pool was 2.2, and the lesion was 6.75.

The SSRAB was utilized to access the para-aortic LN and positioning was confirmed with radial EBUS. Transbronchial needle aspirations were performed. The EBUS scope was then used to biopsy the node as the robotic bronchoscope turns were too sharp to successfully pass the instruments. Biopsy from the combined approach resulted in a successful diagnosis, confirming metastasis of the patient’s malignant melanoma.

CONCLUSION:

Typically, aortopulmonary window lymph nodes are accessed surgically. While these stations and the surrounding structures can be visualized with EBUS, accessing the nodes for biopsy without passing through the aorta is not feasible. However, by combining SSRAB and an EBUS scope, we were able to biopsy paraaortic LN without traversing the aorta. This technique allowed for an accurate diagnosis to be made with less risk than the surgical approach.

SOURCES:

Ravaglia, Claudia et al. “Diagnostic Yield and Safety of EUS-FNA Biopsy in Sub-Aortic and Para-Aortic Lymph Node Stations with the Trans-Aortic Approach: a Case Series and Literature Review.”

Disclosure of funding source(s): none