Abstract Advanced bronchoscopic techniques, including navigation ion bronchoscopy and EBUS, have improved the diagnostic yield for pulmonary lesions. However, post-radiation airway stenosis and anatomical distortion can significantly limit the effectiveness of these modalities .Endoscopic ultrasound-guided (EUS-FNA) offers an alternative approach for tissue diagnosis when conventional and advanced bronchoscopic access compromised. This case highlights procedural limitations and demonstrates the diagnostic value of EUS-guided biopsy in a complex thoracic oncology patient. 64 yom individual with a 25-year,2pack smoking history and no prior medical history presented with atrial fibrillation with RVR and small-volume hemoptysis. Chest CT revealed a central left suprahilarmass obstructing the left upper lobe bronchus, with high FDG uptake of SUV10.3 on PET imaging. The patient was treated empirically for pneumonia and received tranexamic acid, resulting in resolution of hemoptysis. (EBUS-TBNA) provided tissue for histopathologic and molecular analysis, confirming squamous cell carcinoma. Mediastinal lymph node sampling were negative for malignancy.Staging wasT2b, pN0, cN0 and poor pulmonary reserve rendered the patient inoperable. The patient received concurrent chemoradiation(carboplatin/taxol, 66 Gy in 33 fractions) followed by consolidation immunotherapy with durvalumab. Surveillance PET imaging revealed a new left upper lobe nodule. During planning for navigation ion bronchoscopy for re-biopsy, the lesion appeared distant from accessible airways. Initial airway inspection with standard bronchoscopy revealed post-radiation obliteration of the left upper lobe, precluding safe passage of the navigation scope.The procedural options were to attempt airway dilation with significant bleeding risk and uncertain access, or to pursue endoscopic ultrasound-guided biopsy.EUS-FNA was selected as the safest option for sampling the left upper lobe mass and mediastinal lymph nodes. EUS-FNA was performed, targeting station 4L, station 7, and the left upper lobe mass. Pathological analysis of the left upper lobe FNA revealed a fungal organism morphologically compatible with Candida, and the patient was referred to infectious diseases for management. Discussion: This case illustrates several important points:• Post-radiation airway stenosis and anatomical distortion can severely limit the diagnostic yield and safety of advanced bronchoscopic techniques, including navigation ion bronchoscopy and EBUS.• EUS-guided biopsy provides a safe and effective alternative for sampling mediastinal and parenchymal lesions when airway access is compromised.•Individualized diagnostic strategy is essential in complex thoracic oncology patients, especially when post-treatment anatomical changes preclude standard approaches.This case underscores the need for procedural flexibility and highlights the diagnostic value of EUS-guided biopsy in patients with post-radiation airway changes, supporting its integration into the diagnostic algorithm for thoracic oncology This abstract is funded by: none
Ibrahim et al. (Fri,) studied this question.