What is the next step in managing a patient with a PET avid lung nodule scheduled for EBUS biopsy with Dr. Galvez and currently taking Breo Ellipta (fluticasone furoate/vilanterol)?

Management of a Patient with PET-Avid Lung Nodule Scheduled for EBUS Biopsy

Proceeding with EBUS biopsy is the appropriate next step for this patient with a PET-avid lung nodule, while continuing Breo Ellipta therapy and arranging follow-up in one month. 1, 2

Rationale for EBUS Biopsy

The management of this patient with a PET-avid lung nodule follows evidence-based guidelines for pulmonary nodule evaluation:

1. PET-avid nodule significance:

   • PET avidity strongly suggests malignancy and requires tissue diagnosis before definitive treatment 1
   • The American College of Chest Physicians (ACCP) guidelines recommend obtaining a pretreatment pathological diagnosis before any curative treatment 2

2. EBUS as preferred diagnostic approach:

   • EBUS is recommended as a first-line diagnostic procedure for PET-avid nodules 1, 2
   • EBUS offers high diagnostic yield (77.8-86.0%) for intrathoracic lesions with lower complication rates than surgical approaches 3
   • For patients with abnormal mediastinal lymph nodes on PET, endosonography (EBUS/EUS) is recommended over surgical staging 2

Medication Management

• Continue Breo Ellipta (fluticasone furoate/vilanterol):
  • No evidence suggests discontinuing inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) therapy before EBUS procedure
  • Maintaining respiratory medication is important for symptom control and optimizing lung function before the procedure 4
  • The once-daily dosing of Breo Ellipta simplifies medication adherence during this diagnostic period 4

Post-Procedure Management

• Follow-up in one month is appropriate to:
  • Review biopsy results
  • Discuss treatment options based on pathology findings
  • Assess response to continued Breo therapy
  • Plan next steps in management based on diagnosis

Important Considerations

• If EBUS is non-diagnostic: Additional diagnostic procedures may be needed, especially if clinical suspicion for malignancy remains high 1, 2

• Staging implications: If malignancy is confirmed, complete staging workup including brain MRI should be considered 2

• Multidisciplinary approach: Treatment planning should involve discussion at a multidisciplinary tumor board once diagnosis is established 2

Potential Complications of EBUS

Be aware of potential EBUS complications, though rates are low:

• Bleeding (0.90%)
• Pneumomediastinum (0.49%)
• Pneumothorax (0.49%)
• Pneumonia (0.33%) 3

The current management plan with EBUS biopsy, continued Breo therapy, and one-month follow-up aligns with evidence-based guidelines and represents the optimal approach for this patient with a PET-avid lung nodule.