Post written by Giacomo Emanuele Maria Rizzo, MD, from the Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS – ISMETT, and Ilaria Tarantino, MD, from the PhD program, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Palermo, Italy.

An 82-year-old man with a previous diagnosis of adenocarcinoma in the right side of the colon was referred to our thoracic unit because of a pulmonary lesion suspected of malignancy in the left upper lobe. CT scan showed a 40-mm lesion in the left upper lobe with no lymph nodes suspected of malignancies. EUS revealed the pulmonary lesion behind the aorta with a window for biopsy between the aortic arch and the left subclavian artery, so we performed a fine-needle biopsy (FNB) of the lesion.

At the end of the procedure, an abundant quantity of fresh blood started to flow out of the mouth, even when the esophagus had no sign of transparietal bleeding. The bleeding was identified as originating from the glottis with a frontal-view scope.

Immediately, the anesthesiologist performed endotracheal intubation and, simultaneously, the thoracic surgeon performed a bronchoscopy, showing a mixture of fresh blood and blood clots filling the left bronchus.

Therefore, treatment included administration of local tranexamic acid and simultaneous aspiration of the blood and clots. Bronchial toilette was performed repeatedly until saturation stayed permanently above 95%, and pressure was raised to 100/60 mm Hg without vasoactive drugs.

After the procedure, the patient’s left lung was monitored by serial chest x-rays over the following week. They displayed progressive clearing of the pulmonary parenchyma, and he was discharged 1 week later. Histology showed squamous cell carcinoma. At 1-month follow-up, he did not complain about further FNB-related bleeding signs, and the lung was clear at x-ray evaluation.

We think that early identification of adverse events (AEs) is the first, most fundamental step toward effectively managing intrabronchial bleeding because the risk of bleeding after EUS-FNB is not nullified despite preventive and recommended measures.

In view of our long experience with EUS-FNB procedures, management of AEs is best dealt with in a shared, dedicated room where both bronchoscopy and digestive endoscopy can be performed, and it should involve a multidisciplinary team including endoscopists, anesthesiologists, bronchoscopists, interventional radiologists, and thoracic surgeons.

Our experience will certainly help colleagues know about early AEs after EUS-FNB of lung masses and how to manage bleeding. The key to a successful outcome derived from both a dedicated endoscopic room and the expertise and responsiveness of a dedicated multidisciplinary team through an immediate, coordinated approach. Patients needing these procedures should be referred to a dedicated tertiary center where all approaches are available at the same time.

Bronchoscopy view showing (A) tracheal carina with fresh blood and blood clots filling the left main bronchus (red arrow) and (B) the right main bronchus with no clot and only supplied by fresh blood.

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