C78-02 Trans-Aortic Approach for Biopsy of the Para-aortic Lymph Nodes Using Linear EUS

Abstract Introduction Sub-aortic (station 5) and para-aortic (station 6) lymph nodes are not easily accessible due to the interposition of the aorta and the left pulmonary artery. Endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been proposed as a minimally invasive technique through the trans-aortic approach, with an acceptable diagnostic yield and safety profile. Case Report 66-year-old man with the history of hypertension, Type 2 diabetes mellitus and atrial fibrillation referred to oncology clinic for abnormal imaging. Patient reported that he started having nausea, vomiting, abdominal pain along with nights sweats and unintentional weight loss around 4 months ago. In addition, he also noticed painless lump on his left side of the neck. Computed tomography (CT) of the neck, chest, abdomen and pelvis was completed few weeks prior to his clinic presentation. CT imaging revealed rim-enhancing with central density in left supraclavicular lymph node concerning for metastatic disease along with mediastinal and retroperitoneal lymphadenopathy. An indeterminate left renal lesion was also found on imaging. Positron emission tomography (PET) whole body scan ordered by the oncology clinic was completed which revealed metabolically active left supraclavicular lymph node. PET scan also showed significantly metabolically active para-aortic (Image 1) and retroperitoneal lymph nodes concerning for lymphoma. Ultrasound-guided fine needle aspiration (FNA) biopsy of left supra-clavicular lymph node was completed with pathology revealing neoplastic cells with unknown origin and not consistent with lymphoma. At this point, patient was referred to interventional pulmonology clinic and plan to attempt biopsy of mediastinal lymph nodes was established. With the help of linear EUS, para-aortic lymph nodes (station 6) were identified. An uncomplicated FNA of para-aortic lymph node traversing through the aorta was completed (Image 2). Pathology came back surprisingly as carcinoma, favoring renal papillary carcinoma. Patient returned to oncology clinic with plan to initiate appropriate cancer treatment. Discussion Endoscopic ultrasound has become a major method of tissue acquisition in pancreatic tumors, mediastinal and abdominal lymph nodes. In this case, we report feasibility and safety of transaortic FNA of thoracic lymph node under EUS guidance. Lymph nodes immediately adjacent to the large vascular structures such as those in the aorto-pulmonary window have been safely and accurately sampled with EUS-FNA in numerous studies. Transvascular ultrasound-guided needle biopsy is technically very challenging it is fundamental to ensure that the tip of the needle remains in the target after each push-and-pull movement, avoiding unnecessary perforations in the vessel wall. This abstract is funded by: None