Four months after the surgical lung biopsy, the patient complained of severe right back pain. A huge mass measuring 9 cm was detected in the right adrenal gland using CT imaging, which suggested a metastasis (Fig 3A). Examination of specimens from a needle biopsy revealed that the mass was a metastatic tumor from the lung cancer, which had been detected using TBLB (Fig 3B). The specimens from both the TBLB and the needle biopsy of the adrenal mass showed solid proliferation, and patterns of immunohistologic staining were also identical: AE1/3(+), CD56(±), and TTF1(−). Furthermore, genetic mutations of the epidermal growth factor receptor were not detected in either specimen. Although we re-reviewed the previously resected lung specimen by taking samples of other, deeper sections, no malignant cells were detected. Despite the introduction of chemotherapy, the patient experienced disseminated disease in the lungs and bones, and he died of the disease 14 months after the surgical lung biopsy.