Electromagnetic Navigational Bronchoscopy-Guided Diagnosis of Left Upper Lobe Spiculated Lung Nodule after Prior Right Upper Lobectomy for Non-Small Cell Lung Cancer.

Eric M Toloza, MD, PhD¹, Lila B Cohen, MD², Joseph R Garrett, ARNPC, MPH¹, Carla C Moodie, PAC¹, John N Greene, MD¹. ¹Moffitt Cancer Center, ²University of South Florida Morsani College of Medicine

Introduction: Second primary lung cancer requires accurate diagnosis to avoid unnecessary lung resection after lobectomy for a first primary non-small cell lung cancer (NSCLC).

Case Presentation: A 61-year-old man, with history of positive purified protein derivative (PPD) skin test and multiple subcentimeter bilateral upper lobe  lung nodules, was found to have a right upper lobe (RUL) lung nodule that enlarged from 0.6 cm to 1.3 cm over 4-1/2 months.  He underwent robotic-assisted RUL wedge resection, followed by robotic-assisted completion RUL lobectomy and hilar and mediastinal lymph node (LN) dissection.  Final pathology revealed 1.1-cm poorly-differentiated squamous cell carcinoma, with 2 positive level-11 LNs out of 15 total hilar and mediastinal LNs, T1N1M0, stage 2A.  The patient was offered, but declined, adjuvant chemotherapy and was not candidate for pemetrexed clinical trial due to alcohol abuse.  He underwent lung cancer surveillance by serial computerized tomography (CT) scans every 4-6 months.  Over 3-1/2 years, a left upper lobe (LUL) spiculated lung nodule became slightly larger and denser.  Rather than surgical resection or transthoracic needle biopsy for diagnosis, the patient underwent electromagnetic navigational bronchoscopy (ENB) for biopsy of the LUL lung nodule.  Via 90-degree Edge catheter, ENB-guided needle aspiration, brushing, lavage, forceps biopsies revealed no evidence of malignancy, but did reveal irregular, hyposeptated, ribbon-like hyphae consistent with Zygomycetous fungi.  The patient was prescribed oral voriconazole 200 mg twice daily and resumed lung cancer surveillance with serial CT scans every 6-8-months.

Discussion: Unnecessary surgical resection may be avoided by accurate less-invasive diagnostic techniques, especially after prior pulmonary lobectomy.  Transthoracic CT-guided needle aspiration biopsies are associated with risk of pneumothorax averaging 20%, but as high as 54%.  Electromagnetic navigational bronchoscopy-guided biopsies are associated with risk of pneumothorax less than 10%, with diagnostic yield as high as 80%.  We present a case of a patient who had a prior right upper lobectomy for NSCLC and who has a slowly enlarging contralateral spiculated lung nodule that was suspicious for second primary lung cancer, but which was diagnosed by ENB to be Zygomycetoma.  He is undergoing antifungal therapy and resumed lung cancer surveillance by serial CT scans.

Conclusion: Electromagnetic navigational bronchoscopy can diagnosis suspicious lung nodules in patients who had prior pulmonary lobectomy for NSCLC without need for additional surgical resection and with minimal risk of pneumothorax.