C78-01 Combined Rigid Bronchoscopy and Endobronchial Ultrasound: The Successful Diagnosis of Stage IIIb Lung Adenocarcinoma

Abstract Case Presentation A 56-year-old male presented with stridor, progressive dyspnoea and repeated Emergency Department visits for presumed COPD exacerbations. A CT (14th March 2025; Figure 1a) demonstrated a right upper lobe mass invading into the mediastinum, encasing the superior vena cava and compressing the trachea. He required an emergency Rigid Bronchoscopy (RB) when he desaturated, and stent insertion restored airway patency from the extrinsic compression. No biopsy was taken at the time of this procedure as there was no visible tumour invading the trachea. Therefore, a further diagnostic Endobronchial Ultrasound (EBUS) with biopsy was required at an enlarged node at station 4R. However, there were considerable risks of performing EBUS. These include stent displacement when trying to pass the EBUS scope beyond the stent, difficulties accessing the target nodes relative to the stent position, and bleeding which may occlude the narrow lumen. Therefore, a combined RB and EBUS was arranged under general anaesthetic, for stent removal and safe nodal sampling, followed by replacement of a new stent (Figure 1b, 1d). Post-operatively, the patient had a violent coughing episode and suddenly desaturated, requiring re-intubation. A chest x-ray excluded pneumothorax but confirmed stent migration distally to the left main bronchus and right sided collapse (figure 1c). An urgent repeat RB revealed distal migration of the stent into the left main bronchus, which was repositioned after urgent transfer back to theatre. Results from EBUS confirmed lung adenocarcinoma (T1cN3M0, PD-L1 100%) and treatment with carboplatin, pemetrexed and pembrolizumab was commenced. There was marked clinical and radiological response, therefore, further radiotherapy was planned. In this case, specific risks were considered pre-operatively. These could be potential life-threatening complications, particularly if EBUS was performed separately in an endoscopy suite without specialist thoracic anaesthetist support. Moreover, even in expert hands, complications can still arise. Distal stent migration occurred in this case, which was unusual as typically stents migrate proximally, but was quickly recognised and managed in a safe environment. Conclusion This combined procedure of RB and EBUS was the first case of its kind at St George’s Hospital. Without this procedure, a histological diagnosis would have been delayed due to the position of the tumour and overlying tracheal stent. Going forward, combined Rigid Bronchoscopy and EBUS should be considered in similar high-risk patients, with a view to reducing procedure risks, improving diagnostic yield and accelerating use of life-prolonging cancer treatments. This abstract is funded by: None