Endoscopic ultrasound-guided fine needle aspiration of pleural deposits

The most efficient and cost-effective approach to undiagnosed exudative pleural effusion remains uncertain. Both closed pleural biopsy and thoracoscopy may be utilized for the acquisition of pleural tissue. The cumulative yield of imageassisted (either ultrasound or computed tomography [CT]) repeat thoracocentesis and pleural biopsy has been reported to approach that of thoracoscopy. Thoracoscopy, either medical (pleuroscopy) or surgical (video-assisted thoracoscopic surgery [VATS]), remains gold standard in undiagnosed pleural effusion with or without pleural thickening/nodularity or mass. However, thoracoscopy has its own limitations and contraindications. Image-guided pleural biopsy by endoscopic ultrasound (EUS) has never been explored in the past. We describe case series of EUS-guided FNA of pleural deposits in four patients. CASE 1: A 50-year-old man, chronic smoker, presented with cough and weight loss. A CT scan of chest revealed a 5 cm × 4 cm size lesion near the apex of lung with pleural effusion. Family was unwilling for thoracoscopy. Linear EUS was performed from esophagus. EUS revealed a well-defined hypoechoic mass above the aorta between esophagus and chest wall. Fine needle aspiration FNAC showed non-small cell lung cancer. CASE 2: A 58-year-old man, a smoker for 34 years, was evaluated for breathlessness and chest pain. CT scan revealed a pleural effusion and a nodule on the mediastinal aspect of pleura. He was unfit for bronchoscopy/thoracoscopy. EUS revealed 1.7 cm × 1 cm hypoechoic deposit on mediastinal pleura with pleural effusion. FNAC was diagnostic of nonsmall cell lung cancer. CASE 3: A 65-year-old man, a smoker for 40 years, presented with breathlessness. A CT chest showed a mass above right lobe of liver and right-sided pleural effusion. He had low baseline oxygen saturation and could not be stabilized even after supportive therapy. An EUS-guided examination was done without sedation. Hypoechoic deposit was seen extending from diaphragmatic aspect to mediastinal aspect of pleura. FNAC was diagnostic of nonsmall cell lung cancer. CASE 4: A 60-year-old morbidly obese (weight 124 kg) female presented with recurrent undiagnosed exudative pleural effusion. CT scan showed a mass close to right bronchus with massive right side pleural effusion. She was unfit for bronchoscopy or thoracoscopy. An EUS examination was done without any sedation. EUS revealed 5 cm × 6 cm hypoechoic mass (deposit) on mediastinal pleura with pleural effusion. FNAC showed multiple caseating granulomas suggestive of tuberculosis.