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Transesophageal endoscopic ultrasound-guided transcarotid fine needle aspiration of a positron emission tomography (PET)-positive mediastinal lymph node.

We report an unusual case of a positron emission tomography (PET)-positive para-aortic lymph node (●" Fig.1) in a patient with breast cancer that was punctured with transesophageal endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) by traversing the carotid artery, with multiple needle passes performed. EUSwas performed by an experienced endosonographer (A. L.) using a conventional linear echoendoscope. It confirmed the presence of a 15×20-mm lymph node, which was located near to the origin of the left common carotid artery from the aortic arch (●" Fig.2). A window that would allow the lymph node to be punctured without traversing any vascular structure could not be found. Therefore, transcarotid EUS-FNA was performed using a 25-gauge needle (Echotip Ultra, Cook Medical Inc., Bloomington, Indiana, USA;●" Fig.3a and●" Video 1). After the first needle pass, a hyperechoic halo appeared around the vessel, suggestive of a small leakage of blood, but there were no ultrasonographic signs of overt bleeding (●" Fig.3b). Two additional needle passes were performed. The patient was observed for 1 hour in the recovery room then for the following 24 hours with no evidence of complications. She was discharged on the day after the procedure. A definitive diagnosis of metastatic breast cancer was made on cytological examination (●" Fig.4a) with evidence of positivity for the estrogen receptor (●" Fig.4b). Recently, Wallace and colleagues [1] have reported the first case of transbronchial endobronchial ultrasound (EBUS)-guided transaortic FNA in a patient with metaFig.2 Transesophageal endoscopic ultrasound (EUS) confirmed the presence of a large (15×20mm) mediastinal lymph node located in proximity to the origin of the left common carotid artery from the aortic arch.