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with a maximum standard uptake volume &#40;SUV&#41; of 25&#46;8 and a few subcentimetric LN at 4R &#40;SUV of 5&#46;1&#41; and 11R &#40;SUV of 4&#46;9&#41;&#46; Additionally&#44; they revealed bilateral adrenal lesions &#40;right&#58; 23<span class="elsevierStyleHsp" style=""></span>mm&#44; SUV of 22&#46;7&#44; and left&#58; 28<span class="elsevierStyleHsp" style=""></span>mm&#44; SUV of 19&#46;9&#41;&#44; as well as a left femur lesion &#40;SUV of 16&#46;1&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">An endobronchial ultrasound &#40;EBUS&#41; was initially performed&#44; sampling the 4L LN and the mediastinal mass&#46; In the same sitting&#44; the procedure was completed via the esophagus with the same EBUS scope &#40;EB19-J10U&#44; Pentax&#41;&#46; At the level of the lesser curvature of the stomach a 19&#46;7<span class="elsevierStyleHsp" style=""></span>mm heterogeneous lesion in the RAG was visualized&#46; Three punctures were made with a 22-gauge needle &#40;SonoTip EBUS ProFlex&#44; MediGlobe&#41;&#46; Similarly&#44; an EUS-B-FNA of the LAG &#40;14&#46;1<span class="elsevierStyleHsp" style=""></span>mm&#41; was performed&#46; The entire procedure was completed in 33<span class="elsevierStyleHsp" style=""></span>min without any complications&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The anatomic pathology findings of the RAG showed numerous medium-to-large atypical cells&#44; which were positive for TTF-1&#46; The molecular study was positive for the p&#46;L858R mutation in EGFR&#44; thereby rendering the patient eligible for treatment with tyrosine-kinase inhibitors&#46; The PD-L1 expression was weakly positive &#40;&#60;50&#37;&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">These findings were consistent with metastasis of pulmonary adenocarcinoma&#46; The results of both the LAG and the mediastinal mass biopsies were comparable&#46; 4L was negative for malignancy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical stage was determined to be IVB&#44; based on the 9th edition of the TNM classification for lung cancer &#40;9th TNM&#41;&#46; The tumor committees proposed the initiation of treatment with Osimertinib&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Adrenal metastases are present in 8&#37; of metastatic lung cancers&#46; It is possible to perform EUS-B to complete extra-thoracic staging during a single procedure and this is a feasible and safe &#40;0&#46;2&#37; minor complications&#44; no major complications&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> procedure recommended by international guidelines&#46; Moreover&#44; it may have a significant impact on the treatment plan<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and may obviate the need for multiple supplementary procedures&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to its anatomical location &#40;typically in close proximity to the second part of the duodenum&#41;&#44; RAG is not usually accessible to EBUS&#44; and thus is not included in lung cancer staging recommendations or guidelines&#46; The puncture of the RAG with an echoendoscope has been previously described&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> however&#44; even by gastroenterologists the access to the RAG is more challenging than that of the LAG&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">An alternative approach to the adrenals is CT-guided percutaneous puncture&#44; which has been associated with a higher reported complication rate &#40;2&#46;5&#37;&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Nevertheless&#44; if accessible&#44; it is crucial to confirm the location and number of extrathoracic metastases&#44; particularly considering the proposed changes in the 9th TNM&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> as these may influence prognosis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion&#44; this is the first report to confirm a right adrenal metastasis using an echobronchoscope and performed by a pulmonologist&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Study concept and design&#44; JCH&#46; Acquisition of data&#44; JCH&#44; JLG&#44; IS&#46; Drafting of the manuscript&#44; JCH&#46; Critical revision of the manuscript for important intellectual content&#44; JCH&#44; JLG&#44; IS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Informed consent form</span><p id="par0070" class="elsevierStylePara elsevierViewall">The patient has signed the informed consent form&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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        "texto" => "<p id="par0080" class="elsevierStylePara elsevierViewall">Dr&#46; Rosa Cordovilla &#40;Interventional Pulmonology Unit&#41; and Dr&#46; Antonio Velasco and Dr&#46; Alberto &#193;lvarez &#40;Endoscopy Unit&#41; of the University Hospital of Salamanca&#44; for all the tips on the EUS-B technique&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Dr&#46; Francisco L&#243;pez&#44; Dr&#46; Luc&#237;a Garc&#237;a-Alfonso&#44; Dr&#46; Miguel Ariza &#40;IP Unit&#44; HUCA&#41; for all their advice&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Dr&#46; Luis Fern&#225;ndez&#44; Dr&#46; H&#233;ctor Torres &#40;Pathology Department&#44; HUCA&#41; for the analysis of the samples&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Inmaculada S&#225;nchez and Mar&#237;a Gil &#40;Nurses&#44; IP Unit&#44; HUCA&#41; for taking care of the patient&#46;</p>"
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Clinical Letter
Right Adrenal Metastasis of Lung Cancer Diagnosed via Endoscopic Ultrasound (EUS-B) by a Pulmonologist
Juan Cascón-Hernándeza,
Corresponding author
jcasconh@gmail.com

Corresponding author.
, Javier López-Garcíab, Imane Saidic
a Interventional Pulmonology Unit, Department of Respiratory Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
b Department of Respiratory Medicine, Hospital Universitario Virgen de la Victoria, Malaga, Spain
c Department of Respiratory Medicine, UM6P Hospital, Faculty of Medical Sciences, Mohammed VI Polytechnic University, Ben Guerir, Morocco
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with a maximum standard uptake volume &#40;SUV&#41; of 25&#46;8 and a few subcentimetric LN at 4R &#40;SUV of 5&#46;1&#41; and 11R &#40;SUV of 4&#46;9&#41;&#46; Additionally&#44; they revealed bilateral adrenal lesions &#40;right&#58; 23<span class="elsevierStyleHsp" style=""></span>mm&#44; SUV of 22&#46;7&#44; and left&#58; 28<span class="elsevierStyleHsp" style=""></span>mm&#44; SUV of 19&#46;9&#41;&#44; as well as a left femur lesion &#40;SUV of 16&#46;1&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">An endobronchial ultrasound &#40;EBUS&#41; was initially performed&#44; sampling the 4L LN and the mediastinal mass&#46; In the same sitting&#44; the procedure was completed via the esophagus with the same EBUS scope &#40;EB19-J10U&#44; Pentax&#41;&#46; At the level of the lesser curvature of the stomach a 19&#46;7<span class="elsevierStyleHsp" style=""></span>mm heterogeneous lesion in the RAG was visualized&#46; Three punctures were made with a 22-gauge needle &#40;SonoTip EBUS ProFlex&#44; MediGlobe&#41;&#46; Similarly&#44; an EUS-B-FNA of the LAG &#40;14&#46;1<span class="elsevierStyleHsp" style=""></span>mm&#41; was performed&#46; The entire procedure was completed in 33<span class="elsevierStyleHsp" style=""></span>min without any complications&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The anatomic pathology findings of the RAG showed numerous medium-to-large atypical cells&#44; which were positive for TTF-1&#46; The molecular study was positive for the p&#46;L858R mutation in EGFR&#44; thereby rendering the patient eligible for treatment with tyrosine-kinase inhibitors&#46; The PD-L1 expression was weakly positive &#40;&#60;50&#37;&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">These findings were consistent with metastasis of pulmonary adenocarcinoma&#46; The results of both the LAG and the mediastinal mass biopsies were comparable&#46; 4L was negative for malignancy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical stage was determined to be IVB&#44; based on the 9th edition of the TNM classification for lung cancer &#40;9th TNM&#41;&#46; The tumor committees proposed the initiation of treatment with Osimertinib&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Adrenal metastases are present in 8&#37; of metastatic lung cancers&#46; It is possible to perform EUS-B to complete extra-thoracic staging during a single procedure and this is a feasible and safe &#40;0&#46;2&#37; minor complications&#44; no major complications&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> procedure recommended by international guidelines&#46; Moreover&#44; it may have a significant impact on the treatment plan<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and may obviate the need for multiple supplementary procedures&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to its anatomical location &#40;typically in close proximity to the second part of the duodenum&#41;&#44; RAG is not usually accessible to EBUS&#44; and thus is not included in lung cancer staging recommendations or guidelines&#46; The puncture of the RAG with an echoendoscope has been previously described&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> however&#44; even by gastroenterologists the access to the RAG is more challenging than that of the LAG&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">An alternative approach to the adrenals is CT-guided percutaneous puncture&#44; which has been associated with a higher reported complication rate &#40;2&#46;5&#37;&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Nevertheless&#44; if accessible&#44; it is crucial to confirm the location and number of extrathoracic metastases&#44; particularly considering the proposed changes in the 9th TNM&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> as these may influence prognosis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion&#44; this is the first report to confirm a right adrenal metastasis using an echobronchoscope and performed by a pulmonologist&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Study concept and design&#44; JCH&#46; Acquisition of data&#44; JCH&#44; JLG&#44; IS&#46; Drafting of the manuscript&#44; JCH&#46; Critical revision of the manuscript for important intellectual content&#44; JCH&#44; JLG&#44; IS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Informed consent form</span><p id="par0070" class="elsevierStylePara elsevierViewall">The patient has signed the informed consent form&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0080" class="elsevierStylePara elsevierViewall">Dr&#46; Rosa Cordovilla &#40;Interventional Pulmonology Unit&#41; and Dr&#46; Antonio Velasco and Dr&#46; Alberto &#193;lvarez &#40;Endoscopy Unit&#41; of the University Hospital of Salamanca&#44; for all the tips on the EUS-B technique&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Dr&#46; Francisco L&#243;pez&#44; Dr&#46; Luc&#237;a Garc&#237;a-Alfonso&#44; Dr&#46; Miguel Ariza &#40;IP Unit&#44; HUCA&#41; for all their advice&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Dr&#46; Luis Fern&#225;ndez&#44; Dr&#46; H&#233;ctor Torres &#40;Pathology Department&#44; HUCA&#41; for the analysis of the samples&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Inmaculada S&#225;nchez and Mar&#237;a Gil &#40;Nurses&#44; IP Unit&#44; HUCA&#41; for taking care of the patient&#46;</p>"
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Article information
ISSN: 03002896
Original language: English
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