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3. Endoscopic ultrasound with needle biopsy
Endoscopic ultrasound with needle biopsy is the most useful procedure for the evaluation of the posterior superior mediastinal mass among those listed. Given the proximity of the mass to the posterior wall of the esophagus, the lesion should be readily visible and accessible by endoscopic ultrasound. The lesion is not readily accessible with percutaneous transthoracic needle biopsy given its location near the narrow thoracic inlet (the inlet’s osseous structures effectively surround the access routes to the mass) as well as the proximity of the great vessels in this region. The Chamberlain procedure, or left anterior mediastinotomy, is a surgical approach through a left superior intercostal space used to access the left anterior mediastinum and subaortic space, typically in the context of lung cancer staging; the superior posterior mediastinal mass in this patient is not accessible with this procedure. Similarly, cervical mediastinoscopy is commonly used in the setting of lung cancer staging and accesses the paratracheal and anterior subcarinal spaces, but the mass in this patient is too posteriorly located to be sampled with cervical mediastinoscopy. Finally, given that the mass bulges the pleura bilateral, video-assisted thoracoscopic surgery (VATS) sampling may be feasible, but the access to the mass is limited and a VATS approach would be difficult, and certainly not preferable to an endoscopic approach.
The patient underwent endoscopic ultrasound with needle biopsy of the superior posterior mediastinal lesion (Figure 4).
Figure 4. Endoscopic ultrasound with needle biopsy shows a heterogeneous, predominantly hypoechoic mass (arrow) just posterior to the esophagus. Needle placement into the lesion is shown (arrowheads).
The esophageal mucosa appeared normal, and the mass seen at CT was noted to be inseparable from the posterior wall of the esophagus. The mass was non-vascular at color Doppler ultrasound. No regional lymph node enlargement was seen. Biopsy was performed and material sent for cytology and culture.
Which of the following represents the next most appropriate step for the evaluation of this patient? (Click on the correct answer to proceed to the seventh of eight panels)