The role of EUS-FNA in the diagnosis and staging of Non-Small Cell Lung Cancer (NSCLC)| Rassegna di Patologia dell'Apparato Respiratorio

Abstract

A 38-year-old lifelong smoker woman with a diagnosis of lung adenocarcinoma was referred to us to perform an endoscopic ultrasound with fine-needle aspiration (EUS-FNA) procedure in order to define liver lesions suspicious for metastases. She had already performed a percutaneous procedure with ultrasound guidance, which turned out to be not diagnostic. EUS-FNA is an endoscopic technique that is increasingly acquiring a key role in the diagnosis, staging and therapy of lung cancer and lung cancer metastases.

Introduction

Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is a minimally invasive technique that has evolved to become a safe and efficacious alternative to percutaneous liver biopsies with comparable diagnostic tissue yield. It has grown up to play a pivotal role in the diagnosis and staging of NSCLC and may be part of the diagnostic armamentarium in Pulmonology.

Case report

A 38-year-old never smoker woman, was referred to GB Morgagni Hospital. Her past clinical history consisted of an acute Hepatitis B Virus (HV) infection; on admission, she was documented to be an inactive HBV carrier. Six months before, she sought medical attention for exertional dyspnoea. A chest X-ray revealed a right pleural effusion. Subsequently, a contrast-enhanced CT scan showed a pulmonary nodule on the right upper lobe along with right pleural effusion, bone osteolytic lesions and four tiny solid lesions in the liver. A diagnosis of primary pulmonary adenocarcinoma was made through a video-assisted thoracoscopy (VATS). The histological report on pleural biopsies described a G3 lung adenocarcinoma (CK7+, BerEP4+, TTF1+, napsin+, calretinin-PAX8-). Genetic mutations were studied by next generation sequencing and showed a EGFR -, ROS -, PD-L1 (TPS < 1%) Soon after, a chemotherapy regimen including cisplatinum and pemetrexed associated to the immune checkpoint inhibitor pembrolizumab was started. However, three months later, due to adverse effects (asthenia and nausea), treatment was stopped.

Upon discontinuation of the therapy, a new total body CT scan was performed, which revealed both progression and appearance of new liver nodules. Following discussion by the multidisciplinary oncology team, it was thus proposed to perform a characterization of this lesions, including genetic mutation analysis, in order to assess a potential new targeted therapy and also to rule out synchronous neoplasia (Figs. 1, 2). The patient underwent a previous percutaneous liver biopsy, but the pathologic evaluation showed only abundant necrosis. To better characterize these lesions, the patient was admitted to our Department. Physical examination revealed a normal blood pressure (130/80 mmHg), heart rate of 85 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation while breathing room air at rest of 95%. A diagnostic oesophageal ultrasound procedure was performed.

By introducing the endoscopic ultrasound-guided scope (Olympus GF UC 140P) into the oesophagus (EUS), liver lesions were visualized and a FNA was performed with a 22G needle. The rapid onsite analysis of the smears showed cluster of neoplastic cells (Fig. 3). The final pathologic report confirmed the diagnosis of metastasis of a lung adenocarcinoma (TTF1+, Napsin +). Immunohistochemistry showed ALK -, PD-L1 < 1%, ROS1 – while the biomolecular characterization by next generation sequencing (NGS) analyses did not reveal an druggable mutation/translocation/amplification.

Discussion

In patients with NSCLC, accurate assessment and identification of molecular profile and staging are crucial for treatment and prognosis ¹. This case demonstrates that EUS-FNA is a feasible procedure with a low risk of adverse events to sample solid liver lesions ¹. It provides large samples for deep molecular profiling of the neoplasms ^2,3. Furthermore, it is associated with less pain and fewer adverse events than the percutaneous approach ^4,5. Despite the limitation of the absence of images related to the performed EUS-FNA procedure, this case emphasizes the importance of interventional pulmonologists being proficient in diagnosing and staging secondary pulmonary lesions located below the diaphragm, including those in the left liver lobe, through esophageal endoscopic procedures (EUS-FNA).This is especially when other interventional procedures, whether transbronchial or pleuroscopic, appear to carry higher risks in fragile patients ^2,6.

Figure e tabelle

Figure 1.Multiple hypodense liver lesions of heterogeneous shape and size are visible on an abdominal contrast-enhanced CT scan.

Figure 2.Right pleural effusion with diffusely thickened pleura visible on chest contrast-enhanced CT scan.

Figure 3.EUS-FNA. Rapid onsite evaluation (ROSE) showing a cluster of neoplastic cells of pulmonary origin, consistent with adenocarcinoma.

Riferimenti bibliografici

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