Transoral EUS-guided FNA of prevertebral cervical metastasis

A 73-year-old man with a history of 2 episodes of squamous cell lung cancer treated with resection, chemotherapy, and radiation, along with stage pT1bN0 esophageal adenocarcinoma treated with esophagectomy, presented to our hospital with 2 weeks of worsening cervical neck pain and dysphagia. A CT scan demonstrated a new 2.7-cm prevertebral rim-enhancing lesion in the oropharynx at C2 (Fig. 1A and B). Given the patient’s history of multiple prior cancers, the ear, nose, and throat service was consulted to sample the lesion. However, their approach would require an open surgical biopsy, which, given the patient's odynophagia, might worsen pain and impair healing. Accordingly, the interventional radiology service was next consulted to consider biopsy under CT guidance; however, they considered the location of the mass difficult to access. At this point, the patient was referred to the gastroenterology service for consideration of EUS-guided FNA (EUS-FNA) (Video 1, available online at www.VideoGIE.org).

Figure 1.

A, Axial view of 2.7-cm prevertebral rim-enhancing lesion at C2. B, Sagittal view.

General anesthesia was used to control the airway, and a curved linear array echoendoscope (GF-UCT160, Olympus, Center Valley, Pa, USA) was advanced into the posterior oropharynx. At this point, a firm indurated ill-defined masslike protrusion was noted in the oropharynx (Fig. 2). EUS identified a mixed echogenic (mostly hyperechoic) lesion measuring 2.7 × 2.2 cm invading the C2 cervical vertebra (Fig. 3). Visualization and determination of where to sample this lesion based on the endoscopic view were difficult, given its position; however, a window for aspiration was easily identified on EUS. Using a 25-gauge fine-needle biopsy needle (Medtronic, Minneapolis, Minn, USA), we made a total of 3 passes into the lesion (Fig. 4). The second pass was diagnostic for malignant squamous cells, as confirmed by the in-room cytologist. Final analysis of cytologic stains confirmed malignant epithelial cells consistent with a metastasis from the most-recent stage IIIA squamous cell lung cancer (Fig. 5A and B). The patient was treated with local radiation therapy, which helped control his pain, and was able to be discharged after a 2-day hospitalization.

Figure 2.

Endoscopic image of ill-defined, indurated mass protruding into oropharynx.

Figure 3.

Endosonographic view of 2.7-cm × 2.2-cm mixed echogenic lesion at level of C2 vertebra.

Figure 4.

EUS-FNA of prevertebral lesion with 25-gauge fine-needle biopsy needle.

Figure 5.

A, Low-power view of final cytologic specimen confirming metastatic lesion of squamous cell lung cancer (H&E, orig. mag. × 20). B, High-power view (H&E, orig. mag. × 40).

Endoscopy is typically reserved for lesions below the cricopharyngeus. Lesions in the oropharynx are typically managed by ear, nose, and throat physicians. Options for sampling retropharyngeal lesions include open surgical biopsy or CT-guided needle biopsy.¹ To date, EUS has not been considered a modality to sample such lesions.² Our case suggests that EUS-FNA of posterior cervical masses is feasible. Furthermore, by avoiding the need for open surgical biopsy, postprocedural pain is reduced and healing time is shortened.

Disclosure

Dr Irani is a consultant for Boston Scientific. The other author disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Transoral EUS-FNA of prevertebral cervical metastasis.