A 58-year-old man presented with a complaint of headache of 2-month duration. There was no history of fever, vomiting, altered sensorium, or neurological deficit. The patient complained of breathlessness on exertion, but there were no symptoms of cough, chest pain, or hemoptysis. The patient was a smoker with a smoking history of 20 pack years. Auscultation of the chest revealed decreased breath sounds over the right upper lobe area. Laboratory investigations revealed anemia (hemoglobin, 9.2 g/dL) and hypoalbuminemia (albumin, 3.1 g/dL). Magnetic resonance imaging of the brain showed the presence of multiple space occupying lesions. CT of the thorax showed a large bulla in the right upper lobe and emphysema in both the lung fields. A spiculated nodule measuring 2.8 cm x 2.7 cm was seen in the right middle lobe, about 1.5 cm away from the hilum [Figure 1a and b].
Flexible bronchoscopy (BF-P180, Olympus, Japan; external diameter 4.9 mm, channel size 2.0 mm) was performed in the supine position under conscious sedation (midazolam and pentazocine) and topical anesthesia. Airway inspection revealed no abnormalities. The flexible bronchoscope was removed, and CP-EBUS bronchoscope (BF-UC-180F, external diameter 6.9 mm, Olympus, Japan) was inserted for sampling the lesion. However, the CP-EBUS scope could not be negotiated into the middle lobe. Subsequently, the radial EBUS probe (UM-S20-17S radial ultrasound probe, Olympus Japan; 1.4 mm distal end diameter, 20 MHz operating frequency) placed in a guide sheath (K-201, outer diameter 1.95 mm, Olympus, Japan) was used for localizing the nodule. The lesion was visualized adjacent to the lateral segment of the right middle lobe at the very proximal end of the segmental bronchus. The radial probe was removed, and TBNA was performed using a 21-G needle (Smooth Shot, NA-401D 1321; minimal channel size required 2 mm, Olympus, Japan) at the visually chosen site under endoscopic vision [Figure 1c]. The needle was moved to and fro 10-15 times within the mass. Three passes were obtained from the same site, and the aspirate was submitted for cytological examination. Brush cytology and TBLB were considered inappropriate due to the proximal location of the nodule.
Cytological examination revealed clusters of tumor cells with intracytoplasmic mucin suggestive of adenocarcinoma [Figure 1d]. The patient was administered dexamethasone and phenytoin in view of the brain metastases. He was planned for palliative radiotherapy and single agent chemotherapy in view of his poor performance status (Karnofsky Performance Score 60). However, the patient developed recurrent seizures and succumbed to his illness.