. Step 24 of 41
Clinical Stem 3
A patient with right upper lobe adenocarcinoma progressing on biomarker-directed therapy

Answer A
In this case, technical difficulties were encountered while sampling nodal stations 4R and 11R. ROSE confirmed the lack of representative tissues, prompting a change in strategy. Selecting the correct biopsy site for molecular testing may have implications on patient morbidity. When it is difficult to obtain enough tissue because of technical problems or intra-procedural complications, it is important to prioritize acquisition and use of tissue based on which information can be obtained with the limited specimen.

Performing TBNA at all cost by changing the puncture site again, prolonging the procedure, or switching to conventional TBNA may not be in the patient's best interest for at least two reasons: tissue can be obtained from another site of likely disease progression; in this case the enlarging right upper lobe mass, and multiple repeated needle aspirations are likely to result in a bloodier specimen that will be difficult to analyze.

The safety of obtaining a biopsy must be weighed against the need to select biomarker-driven therapy in fragile patients with lung cancer who often have significant cardiac and pulmonary comorbidities.
References:
  1. Maheswaran S, Sequist LV, Nagrath S, et al. Detection of mutations in EGFR in circulating lung-cancer cells. N Engl J Med. 2008 Jul 24;359(4):366-77.
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