Can a left adrenal gland biopsy be done through endoscopic ultrasound (EUS)?

Left Adrenal Gland Biopsy Through Endoscopic Ultrasound

Yes, a left adrenal gland biopsy can be performed through endoscopic ultrasound (EUS) with high diagnostic accuracy and safety. 1 This technique is well-established and recommended for evaluating suspected left adrenal metastases, particularly in patients with lung cancer.

Anatomical Accessibility and Technical Feasibility

• The left adrenal gland is consistently visualizable via EUS:
  • Visualization rate approaches 100% in multiple studies 1
  • The transgastric approach provides excellent access to the left adrenal gland
  • EUS can detect left adrenal masses even when not visualized by CT 2

Diagnostic Performance

• EUS-FNA of the left adrenal gland demonstrates:
  • Diagnostic yield of 95% for detecting left adrenal metastases 1
  • Sensitivity of at least 86% (95% CI 74%–93%) 1
  • Negative predictive value of 70% (95% CI 50%–85%) 1
  • Adequate tissue sampling in virtually all patients 1

Advantages Over Alternative Approaches

• EUS-FNA offers significant benefits compared to percutaneous biopsy:
  • Lower complication rate than percutaneous approaches (8.4% for percutaneous vs. rare for EUS) 1
  • Can be performed during the same session as mediastinal staging procedures 1
  • Avoids complications associated with percutaneous approaches (pneumothorax, hemorrhage, needle-tract seeding) 1
  • Particularly valuable for small lesions that might be difficult to access percutaneously

Clinical Applications

• Primary indications for left adrenal EUS-FNA:
  • Suspected metastatic disease, especially from lung cancer 1
  • Adrenal masses suspicious on FDG-PET-CT that require tissue verification 1
  • Evaluation of enlarged adrenal glands detected during other EUS procedures 2

Important Precautions

• Critical safety considerations:
  • Mandatory endocrinologic evaluation prior to the procedure if pheochromocytoma is suspected 1, 3
  • 24-hour urinary catecholamine testing is essential to exclude pheochromocytoma in all patients with adrenal masses 3
  • Biopsy of a pheochromocytoma without proper preparation can trigger a life-threatening hypertensive crisis

Technical Aspects

• Procedural details:
  • Typically performed with a linear echoendoscope
  • Transgastric approach with Doppler guidance to avoid vascular structures 2
  • Usually requires 2-4 needle passes to obtain adequate tissue 2
  • On-site cytopathology evaluation improves diagnostic yield when available 4

Limitations and Considerations

• Potential challenges:
  • Non-diagnostic biopsies are more common when sampling diffusely enlarged glands versus focal masses 5
  • Right adrenal gland EUS-FNA is technically more challenging but feasible in experienced hands 6
  • The quality of results depends significantly on the endosonographer's experience 7
  • Rare complications include adrenal hemorrhage 1

EUS-guided left adrenal biopsy represents an important diagnostic tool that combines high accuracy with excellent safety when performed by experienced operators, making it the preferred approach for tissue verification of suspicious left adrenal masses.