C78-13 Transtracheal Endobronchial Ultrasound Guided Thoracentesis of a Loculated Apical Pleural Effusion for Cancer Diagnosis and Staging

Abstract Introduction Timely, comprehensive staging in lung cancer usually requires multiple procedures. Loculated apical pleural effusions can be difficult to access percutaneously, prolonging diagnosis and treatment decisions. By using EBUS, we obtained primary tumor samples, lymph node samples, and, uniquely, a transtracheal aspiration of an apical loculated pleural effusion, establishing M1a disease in a single session. Case Presentation An 88-year-old woman with ampullary carcinoma (post-Whipple 2019) and asthma presented with dyspnea, sputum production, and right chest pain. CT revealed a large right pleural effusion and right upper lobe/hilar mass. Thoracentesis met Light’s criteria for exudate; cytology was non-diagnostic, however the patient deferred further work-up. Six weeks later, she re-presented to the hospital febrile with pain and worsening dyspnea; CT showed near-complete RUL collapse from endobronchial tumor progression, septal thickening suggesting lymphangitic spread, and a loculated right pleural effusion.Interventional pulmonology performed a single bronchoscopy: EBUS-guided FNA of the RUL mass with mediastinal staging and transtracheal FNA of the right apical loculated pleural effusion by approximating the scope to the right tracheal wall. Cytology and histology confirmed pulmonary adenocarcinoma in both tumor and pleural fluid. Discussion This case highlights how comprehensive diagnosis and staging can be accomplished during one EBUS procedure. Simultaneous nodal sampling and pleural fluid aspiration avoided additional procedural needs from an oncologic diagnosis and staging standpoint. Transtracheal aspiration of loculated effusion is rarely reported but technically feasible in expert hands when effusions are inaccessible externally. This approach leverages real-time ultrasound guidance, minimizes sedation exposure, and may be particularly valuable for specific patient populations including the elderly/frail and those wanting to minimize procedural exposure both of which were the case here. When a malignant effusion is diagnosed rapidly, the focus of treatment shifts to systemic and palliative options while unnecessary local procedures are avoided. These strategies could streamline the cancer work-up, shorten time to treatment, and reduce the use of health care resources.Transtracheal EBUS-guided pleural aspiration is ideal for patients with loculated or difficult-to-reach pleural collections juxtaposed to the central airway, especially when bronchoscopy is already indicated for tumor or nodal sampling, or when the patient is frail or has a high procedural risk. Conclusion Innovative EBUS techniques, including targeted pleural aspiration, can yield full tissue diagnosis and TNM staging in a single minimally invasive session, streamlining care and minimizing risk for patients with advanced thoracic malignancy. References : Rajan P, et al. Aspiration of Parabronchial Pleural Effusion Using EBUS (Chest, 2013) This abstract is funded by: None