Late recurrence of non-small cell lung carcinoma at a surgical staple site diagnosed by endobronchial ultrasound and treated with stereotactic body radiation therapy

Local recurrence at a surgical staple site is an uncommon but clinically important cause of diagnostic uncertainty during lung cancer surveillance. Although postoperative staple site thickening is frequently encountered, distinguishing benign postsurgical changes from true malignant recurrence can be challenging, particularly when early imaging findings are metabolically inactive. In an elderly woman previously treated with curative right lower lobectomy, imaging identified a small right hilar tissue density adjacent to the surgical staple site. Initial 18F-fluorodeoxyglucose (FDG) positron emission tomography-CT demonstrated no significant metabolic activity; however, interval progression in both size and FDG uptake on serial imaging raised concern for recurrence, highlighting the limitation of relying on SUVmax alone to exclude malignancy. Due to its hilar location and proximity to major vessels, percutaneous biopsy was not feasible. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) enabled minimally invasive tissue confirmation of recurrence of non-small cell lung carcinoma in an anatomically complex postoperative site. After multidisciplinary evaluation, repeat surgery was deemed high-risk; hence, definitive stereotactic body radiation therapy (SBRT) was delivered. The patient tolerated treatment well, with early follow-up imaging showing a reduction in lesion size and metabolic activity, followed by persistent low-level metabolic activity on later surveillance. This case underscores the importance of maintaining a high index of suspicion for staple site recurrence despite initially negative metabolic imaging, the value of tissue confirmation in progressive postoperative lesions, and the role of EBUS-TBNA and SBRT as pragmatic diagnostic and therapeutic options when reoperation is not feasible.