Traversing Uncharted Territory: Endobronchial Ultrasound Utilized For Diagnosis Of Pericardial Mass

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA) is a widely-used modality for mediastinal lymph node sampling & lung cancer staging. In the literature, there are a small number of case reports that have described its novel uses. These reports have described the sampling of endovascular masses, detection of central pulmonary emboli [1], and drainage of pleural [2] & pericardial fluid collections [3]. We present a unique case in which EBUS-TBNA was utilized to sample and achieve diagnosis of a large pericardial mass. CASE PRESENTATION: A 42-year-old male, never-smoker, without any past medical history, presented at an outside facility with dull right-shoulder pain that had become un-remitting and constant over a one month period. After conservative measures did not alleviate his pain, a chest CT was obtained. It revealed bilateral, faint sub-centimeter pulmonary nodules. When his symptoms did not improve 2 weeks later, CT scan was repeated, & the nodules had increased in size and number. Lytic lesions were also noted in his right clavicle. Biopsy of a left lower lobe lung nodule and clavicular bone biopsy were both deemed inconclusive. The patient sought a second opinion at our center. At this time, he had worsening dyspnea & reduced exertional capacity. A CT chest on presentation showed further increase in size & number of bilateral pulmonary nodules, which were newly surrounded by ground-glass opacities suggestive of hemorrhagic changes. New subcarinal lymphadenopathy & a large pericardial mass were also noted. Within 24 hours, he began to have mild hemoptysis and increased oxygen need of 3-4L by nasal cannula. We proceeded with EBUS-TBNA of the mediastinal lymph nodes and pericardial mass. The mass was 26.2 mm on linear endobronchial ultrasound. A 22 G needle was used to obtain samples of the mass, accessed at the distal left mainstem bronchus. Lymph node stations 7 and 4R were also sampled. The pathology of the pericardial mass was consistent with angiosarcoma of a high-grade epithelioid type. The station 7 and 4R lymph nodes each revealed a polymorphous lymphoid population. The outside hospital pathology slides of the left lower lobe nodule and clavicular biopsy were ultimately obtained and interpreted as consistent with angiosarcoma of the same type. DISCUSSION: EBUS-TBNA may present itself as a non-invasive & efficient way to achieve diagnosis of large pericardial masses. Our patient was able to immediately start therapy for his newly-diagnosed malignancy. Interestingly, the sampled mediastinal lymph nodes & drained left pleural effusion were unrevealing. CONCLUSIONS: In selected patients, pericardial masses may be sampled by EBUS-TBNA, allowing for a minimally-invasive and rapid diagnosis. This may be of use in patients without confirmed diagnosis, & who are experiencing rapidly progressing symptoms that may preclude them from more invasive procedures. Reference #1: Sachdeva A, Lee HJ, Malhotra R, Shepherd RW. Endobronchial ultrasound diagnosis of pulmonary embolism. Journal of bronchology & interventional pulmonology. 2013;20(1):33-4. Reference #2: Aspiration of Parabronchial Pleural Effusion Using Endobronchial Ultrasound Rajan, Preethi et al.CHEST, Volume 144, Issue 4, 29A Reference #3: Sharma RK, Khanna A, Talwar D. Endobronchial Ultrasound: A New Technique of Pericardiocentesis in Posterior Loculated Pericardial Effusion. Chest. 2016;150(5):e121–e123. doi:10.1016/j.chest.2016.03.013 DISCLOSURES: no disclosure on file for Mohit Chawla; No relevant relationships by Saamia Hossain, source=Web Response