S4509 First Report of Trans-Esophageal Vertebral Osseous Biopsies for Metastatic Non-Small Cell Carcinoma

Introduction: Extra-intestinal applications of endoscopic ultrasound (EUS) have been rapidly expanding; however, vertebral osseous biopsies are rarely attempted due to the potential risk of aortic perforation. We report the first case of EUS-guided vertebral osseous biopsies for metastatic non-small cell carcinoma (NSCC). Case Description/Methods: Patient is a 72-year-old man with a history of squamous cell carcinoma (SCC) of the hypopharynx status post chemo-radiation. He had tracheostomy and percutaneous endoscopic gastrostomy placement followed by removal of both 2 years ago. Patient was admitted for 3 days of fever, chills, cough, dyspnea, epigastric pain, nausea, poor oral intake, and weight loss. Computed tomography scan of the chest showed severe emphysema, a soft tissue in the infra-hilar aspect of the left lower lobe, mediastinal lymphadenopathy, and destructive osseous lesions in the posterior left second rib, the left scapula, and the vertebral body at T8 level. Patient was suspected to have recurrence of SCC. Pulmonary service decided the lesions were not amenable to bronchoscopy-guided biopsies. GI was consulted for EUS-guided biopsies. Linear EUS demonstrated a 2.5 cm × 2.1 cm lesion in the vertebral body at T8 level. Color Doppler was utilized to visualize the thoracic aorta. Endoscopic maneuvering was applied to avoid puncture of the aorta. Once a lack of significant vascular structures within the needle path was confirmed, 3 passes were made with a 25-gauge needle using the trans-esophageal approach. Visible cores of tissue were obtained. In-room cytological examination showed malignant cells. Several hilar lymph nodes were biopsied as well. Patient tolerated the procedure well with no complications. Pathology of the vertebral bone and lymph node tissues showed non-small cell carcinoma from a lung primary. Oncology was consulted and planned for chemotherapy. Discussion: Biopsies under EUS guidance of the vertebral body have been largely avoided due to the risk of aortic perforation. EUS provides fast tissue acquisition, no ionizing radiation exposure, and real-time microscopic evaluation by in-room pathology. The use of power-color-Doppler allows real-time visualization of needle passage for safe biopsies. As demonstrated in this case, vertebral biopsies were feasible and safe. In-room pathology confirmed a new case of NSCC, not recurrence of SCC as initially suspected. EUS-guided biopsies of an osseous vertebral lesion allowed for appropriate treatment to start earlier, potentially improving clinical outcomes.