Abstract Introduction Prior thoracic or chest-wall radiotherapy confers a small but clinically relevant risk of a second primary lung cancer, often after long latency. Although relatively uncommon, the lung is particularly vulnerable due to incidental radiation exposure. Advances in robotic bronchoscopy with radial endobronchial ultrasound EBUS and cone-beam CT (CBCT) now support safer and more accurate diagnosis and staging of post-radiation pulmonary lesions. Case This is an 82-year-old woman with a history of tobacco use disorder and myxofibrosarcoma of the left upper back treated with resection and radiation in 2014, and re-irradiation for local recurrence in 2024, was found on surveillance imaging to have a new spiculated left lower-lobe pleural-based opacity with traction bronchiectasis adjacent to prior radiation fields. Positron emission tomography (PET) demonstrated avid FDG uptake. She underwent robotic navigational bronchoscopy by interventional pulmonology with radial-endobronchial ultrasound (EBUS) and cone beam computed tomography (CBCT) assistance, confirming adenocarcinoma. Given the lesion’s location within overlapping high-dose fields, multidisciplinary evaluation favored surgery over additional radiation. Robotic-assisted superior-segmentectomy (S6) with systematic nodal dissection achieved an R0 resection. Final pathology revealed a well-differentiated adeno-squamous carcinoma (2.2 cm, pN0). Postoperative recovery was uncomplicated, and she remains clinically well. Discussion This tumor fulfilled modified Cahan criteria for radiation-induced malignancy (new histology, in-field, and prolonged latency), while acknowledging remote smoking as a competing risk factor. The case highlights how robotic bronchoscopy + rEBUS + CBCT can optimize diagnostic yield for peripheral lesions in fibrotic, post-radiation lung, and how previous high-dose therapy may appropriately shift definitive treatment away from stereotactic body radiotherapy (SBRT) toward parenchyma-sparing segmentectomy to minimize cumulative toxicity. Conclusion In patients with prior thoracic irradiation, a new spiculated pleural-interface lesion should not be presumed benign. Robotic bronchoscopy with rEBUS/CBCT enables precise diagnosis and procedural planning, while robotic segmentectomy offers curative resection with low morbidity in carefully selected cases of radiation-associated lung cancer. This abstract is funded by: None
Etukudoh et al. (Fri,) studied this question.
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