Lung Apex Research Articles

Advances in Physiological Research: Consideration on Arterial Hypercapnia in Acute Cardiogenic Pulmonary Edema (ACPE)

The causes of hypercapnia in Acute Cardiogenic Pulmonary Edema are still unknown. Our hypothesis recognizes an alteration of the ventilation-perfusion ratio in the apical areas of the lung as the major cause. The redistribution of blood to the apical lung zone in hypertensive pulmonary circulation determines an excess of perfusion compared to ventilation and consequently hypercapnia. Our suggestion might be in favor of Bilevel-PAP over Continuous Positive Airway Pressure (CPAP) as the first line of therapy.

Radiomics approach for identifying radiation-induced normal tissue toxicity in the lung

The rapidly evolving field of radiomics has shown that radiomic features are able to capture characteristics of both tumor and normal tissue that can be used to make accurate and clinically relevant predictions. In the present study we sought to determine if radiomic features can characterize the adverse effects caused by normal tissue injury as well as identify if human embryonic stem cell (hESC) derived extracellular vesicle (EV) treatment can resolve certain adverse complications. A cohort of 72 mice (n = 12 per treatment group) were exposed to X-ray radiation to the whole lung (3 × 8 Gy) or to the apex of the right lung (3 × 12 Gy), immediately followed by retro-orbital injection of EVs. Cone-Beam Computed Tomography images were acquired before and 2 weeks after treatment. In total, 851 radiomic features were extracted from the whole lungs and < 20 features were selected to train and validate a series of random forest classification models trained to predict radiation status, EV status and treatment group. It was found that all three classification models achieved significantly high prediction accuracies on a validation subset of the dataset (AUCs of 0.91, 0.86 and 0.80 respectively). In the locally irradiated lung, a significant difference between irradiated and unirradiated groups as well as an EV sparing effect were observed in several radiomic features that were not seen in the unirradiated lung (including wavelet-LLH Kurtosis, wavelet HLL Large Area High Gray Level Emphasis, and Gray Level Non-Uniformity). Additionally, a radiation difference was not observed in a secondary comparison cohort, but there was no impact of imaging machine parameters on the radiomic signature of unirradiated mice. Our data demonstrate that radiomics has the potential to identify radiation-induced lung injury and could be applied to predict therapeutic efficacy at early timepoints.

One-Year Surveillance of a Patient Cohort’s Lung Ultrasonography Findings Post Mild-Moderate COVID-19 Infection

Objective: Lung involvement due to COVID-19 infection relates to patient clinical outcomes. However, little evidence exists on whether an abnormal lung sonogram, during an initial outpatient infection, may signal an abnormal immunologic response and lasting abnormalities. The aim of this study was to observe whether high-risk outpatients, previously infected with SARS CoV-2 and found to have an initial abnormal lung sonogram, had persistent diagnostic findings at a 1-year re-examination. Materials and Methods: A prospective longitudinal cohort study was performed, based on a prior study completed in January 2022 wherein 55/201 (27%) of consecutive outpatients infected with SARS-CoV-2 received therapy at an outpatient monoclonal antibody clinic and had presented with an abnormal lung ultrasound containing at least 3 apical lung B-line artifacts (LUS+). One year later, the original 55 LUS+ patients were contacted for re-examination; as a result, 14 LUS+ patients consented to a repeat LUS tospecifically recheck the apical area of the lungs for persistent B-line artifacts. The same ultrasound equipment system and imaging methodology were used for this cohort of patients. Additional data was collected regarding COVID-19 test-positive re-infection, persistent pulmonary symptoms during the past year, and COVID-19 vaccination status. Results: Of the 14 LUS+ patients, the mean cohort age was 63 ± 9 years, of which 71% were men. Over the ensuing year, 43% had persistent symptoms, 71% had updated vaccination, and 36% had a self-reported re-infection. The re-infection was reported to have occurred a median of 7 months after the initial infection. The cohort was sub-divided into those with persistent LUS+ compared to those that reverted to a normal scan. The mean age was 69 ± 10 years among those LUS+ compared to 56 ± 8 years in the normalized group. The body mass index (BMI) was 32 kg/m2 in those LUS+ compared to 27 kg/m2 in the normalized group. The cohort has 6 men and 2 women in the LUS+ group compared to 4 men and 2 women in the normalized group. One LUS+ patient out of eight reportedly had been reinfected compared to four normalized patients out of six stated being reinfected. Three LUS+ patients out of eight reported having persistent symptoms compared to three normalized patients out of six complaining of continued COVID-19 symptoms. Conclusion: Based on the 1-year repeated LUS, for this cohort, there was a high prevalence of persistent symptoms and lung abnormalities, in those who had mild-moderate outpatient COVID-19 and received monoclonal antibody therapy. The longitudinal data collection on this cohort of COVID-19 positive outpatients may suggest that individual immune responses or viral virulence factors may play a role in B-line persistence. Certainly, future LUS results may be confounded by a previous COVID-19 infection.

Morphological variations of fissures, lobes, and hilar pattern of the lung in a select South African sample.

The lungs are essential respiratory organs divided into lobes by the horizontal and oblique fissures. The hilum, located on the mediastinal surface of each lung, is where the bronchus, pulmonary veins, and pulmonary arteries enter and exit. This study aims to investigate and record the variations in the morphology of lung fissures, lobes, and hilar patterns observed in a South African sample. This cross-sectional observational study employed descriptive analysis. A total of 48 formalin-fixed bodies, comprising 24 females and 24 males from the Department of Human Biology at the University of Cape Town were studied were examined. Fissures were classified according to the Craig and Walker criteria. Incomplete oblique fissures were found in 25 right lungs and 30 left lungs. Incomplete horizontal fissures were observed in 39 right lungs, and one right lung exhibited the absence of both horizontal and oblique fissures. Accessory fissures were present in five right and seven left lungs. Variations in the hilar pattern were noted, including differences in the number and arrangement of structures in both right and left lungs. Variations were observed in the lobes, fissures and the hilar patterns of several lungs. Awareness of these morphological variations is crucial for surgeons and radiologist to avoid misdiagnosis and complications during surgical procedures.

Brachial plexopathy following stereotactic body radiation therapy in apical lung malignancies: A dosimetric pooled analysis of individual patient data

Background and objectivesThe aim of this study is to establish dosimetric constraints for the brachial plexus at risk of developing grade ≥ 2 brachial plexopathy in the context of stereotactic body radiation therapy (SBRT). Patients and MethodsIndividual patient data from 349 patients with 356 apical lung malignancies who underwent SBRT were extracted from 5 articles. The anatomical brachial plexus was delineated following the guidelines provided in the atlases developed by Hall, et al. and Kong, et al.. Patient characteristics, pertinent SBRT dosimetric parameters, and brachial plexopathy grades (according to CTCAE 4.0 or 5.0) were obtained. Normal tissue complication probability (NTCP) models were used to estimate the risk of developing grade ≥ 2 brachial plexopathy through maximum likelihood parameter fitting. ResultsThe prescription dose/fractionation schedules for SBRT ranged from 27 to 60 Gy in 1 to 8 fractions. During a follow-up period spanning from 6 to 113 months, 22 patients (6.3 %) developed grade ≥2 brachial plexopathy (4.3 % grade 2, 2.0 % grade 3); the median time to symptoms onset after SBRT was 8 months (ranged, 3–54 months). NTCP models estimated a 10 % risk of grade ≥2 brachial plexopathy with an anatomic brachial plexus maximum dose (Dmax) of 20.7 Gy, 34.2 Gy, and 42.7 Gy in one, three, and five fractions, respectively. Similarly, the NTCP model estimates the risks of grade ≥2 brachial plexopathy as 10 % for BED Dmax at 192.3 Gy and EQD2 Dmax at 115.4 Gy with an α/β ratio of 3, respectively. Symptom persisted after treatment in nearly half of patients diagnosed with grade ≥2 brachial plexopathy (11/22, 50 %). ConclusionsThis study establishes dosimetric constraints ranging from 20.7 to 42.7 Gy across 1–5 fractions, aimed at mitigating the risk of developing grade ≥2 brachial plexopathy following SBRT. These findings provide valuable guidance for future ablative SBRT in apical lung malignancies.

Clinical characteristics of apical segment lung abscess: a 10-year retrospective study.

Lung abscess in the apical segment of the lung is not rare and is often underestimated in clinical practice. However, the clinical features of apical segment lung abscess (AL) have scarcely been reported. Hence, this study aimed to determine the clinical characteristics of AL and explore moderate therapeutic strategies. This was a retrospective, single-center cohort study. We reviewed the medical records of consecutive patients who were admitted to Shanghai Pulmonary Hospital in Shanghai, China, from January 2009 to December 2018. This study collected information on patients with lung abscess, including demographics, symptoms, clinical findings, and treatment. The statistical methods used were descriptive statistics, Chi-squared test, Fisher's exact test, t-tests, and logistic regression analysis. Of 824 patients, 431 with lung abscess were finally eligible after a review of medical records. The patients were divided into two groups: the AL group (n=68) and the non-apical segment lung abscess (NAL) group (n=363). Compared with patients in the NAL group, those in the AL group had lower rates of chronic obstructive pulmonary disease (COPD) (5.9% vs. 17.4%, P=0.02), diabetes (14.7% vs. 32.2%, P=0.004) and hypoprealbuminemia (10.3% vs. 25.3%, P=0.007). Regarding clinical symptoms, patients in the AL group exhibited lower fever (38.2% vs. 58.4%, P=0.002) and less purulent sputum (32.4% vs. 45.5%, P=0.045). Moreover, regarding radiological features, the AL group had a lower proportion of air-fluid level on chest computed tomography (CT) (7.4% vs. 16.8%, P=0.047). In addition, the study demonstrated that the AL group had a shorter duration of intravenous antibiotic treatment [8 (7-8) vs. 10 (8-12) days, P <0.001]. Surprisingly, the AL group had a high rate of surgical treatment (36.8% vs. 15.4%, P<0.001). In multivariate analysis, surgical treatment occurred more frequently in patients with AL [odds ratio (OR): 2.58, 95% confidence interval (CI): 1.40-4.77, P=0.002], lower in patients who had fever (OR: 0.55, 95% CI: 0.31-0.98, P=0.04), and imaging features of liquefaction necrosis (OR: 0.32, 95% CI: 0.15-0.69, P=0.004). Patients with AL presented with atypical and relatively mild clinical symptoms. However, the rate of surgical treatment was significantly higher. These data should be considered when managing the AL.

Ewing sarcoma presenting in the lung: a case report

BackgroundEwing sarcoma is a malignant round-cell tumor that primarily affects bones in children. It can also arise in extraosseous tissues, such as the lung, kidneys, and liver. The presentation symptoms of Ewing sarcoma may include cough, dyspnea, and chest pain.Case presentationThis report details the history of a 15-year-old Syrian boy with a previous diagnosis of Hodgkin lymphoma who presented with chronic shoulder pain. Imaging studies revealed an 80 mm mass in the apex of the left lung, which was confirmed through histopathological examination to be Ewing sarcoma following a computed-tomography-guided biopsy. The patient received multiple cycles of chemotherapy and subsequently underwent surgical resection of the remaining mass.ConclusionsThis case highlights the rare occurrence of Ewing sarcoma in the lung and the unusual clinical presentation of shoulder pain without other accompanying symptoms.

Endovascular treatment of contained ruptured internal thoracic artery aneurysm mimicking a tumor in a patient with neurofibromatosis type 1: a case report

BackgroundAn internal thoracic artery aneurysm (ITAA) is an exceedingly rare condition, with approximately two-thirds of reported cases being iatrogenic pseudoaneurysms. The remainder are attributed to various causes, including vasculitis, connective tissue disease, and neurofibromatosis type 1 (NF-1). NF-1 is an autosomal dominant disorder characterized by distinct clinical manifestations that occasionally include life-threatening vascular complications. Although NF-1 patients may develop various vascular abnormalities, ruptured ITAA is rarely reported, with only seven published cases.Case presentationA 32-year-old man with NF-1 consulted for a three-day history of persistent left back and upper arm pain. Initial chest radiography indicated left pleural effusion and an opacity at the left lung apex. Computed tomography scan revealed a mass in the left upper mediastinum that was initially suspected to be a tumor. Subsequent contrast-enhanced computed tomography revealed the mass to be a subclavian artery aneurysm. Detailed contrast-enhanced computed tomography with 1-mm slices was performed for surgical planning, identifying the mass as a left ITAA with contained rupture. Given the risk of re-rupture, emergency angiography was performed, which confirmed rupture of the left ITAA without extravasation. The ITAA was successfully treated with multiple microcoils at the proximal and distal ends. The patient had an uneventful recovery and was discharged on the fourth postoperative day.ConclusionsThis case highlights the importance of considering vascular lesions in NF-1 patients who present with pleural effusion. It also emphasizes the challenges in diagnosing ITAA and the effectiveness of thin-slice contrast-enhanced computed tomography scans and endovascular treatment.

Cervical lung herniation of the azygous lobe: a case report and literature review.

To report an adult case of cervical lung herniation involving the azygous lobe and to review the literature. A trauma patient was incidentally found to have a cervical lung herniation involving the azygous lobe. We reviewed the literature on cervical lung herniation, described techniques used to diagnose and evaluate cervical lung herniations and summarized management options. Cervical lung herniation results in a defect in Sibson's fascia allowing the apical lung to protrude above the thoracic inlet. In the adult population, these are commonly seen after trauma or surgical intervention, but congenital forms have also been described in the pediatric population. Apical herniation of the lung can cause symptoms due to mass effect on the esophagus or trachea. We report an adult case of cervical lung herniation involving the azygous lobe. Cervical lung herniation is a relatively rare entity compared to lung herniation through the rib cage. Knowledge of this entity is essential to properly evaluate trauma patients and to diagnose patients who have symptoms of cough, dysphagia or a bulging neck mass.

Solitary extramedullary plasmacytoma of the lung with rapid transition to multiple myeloma : A rare case report and brief literature review.

Solitary extramedullary plasmacytomas (SEPs) are disease entities characterized by the local proliferation of neoplastic plasma cells, representing less than 6% of plasma cell tumors. They typically produce monoclonal immunoglobulin and are usually found in the head, neck, and, less commonly, in the lungs. SEP, in rare instances, can transition to multiple myeloma (MM) with an estimated risk between 8 and 31%. We report the case of a 72-year-old woman who sought medical attention at the emergency department due to acute onset dyspnea and syncope. Laboratory results revealed elevated creatinine, hypercalcemia, and anemia, all of which were absent at a hospitalization three months prior for tuberculosis. A chest x-ray showed a right upper lobe opacity, and a computed tomography (CT) scan demonstrated an apical lung mass with calcifications. A CT-guided needle aspiration of the mass indicated SEP. Bone marrow biopsy subsequently confirmed MM. The patient was admitted to the intensive care unit and treated with chemotherapy; however, following a complicated hospital course, she died. SEPs are an exceedingly rare form of malignancy with the potential for conversion to MM. Although the likelihood of transformation to MM in months is rare, we call for attention to the possibility of such transition and the clinical prognosis of patients with SEP. Prompt and aggressive treatment is essential, and this, to our knowledge, is the first case of conversion to MM in less than four months following the initial diagnosis of SEP of the lung.

Spontaneous hemopneumothorax causing life-threatening hemorrhage: a case report

BackgroundSpontaneous hemopneumothorax is a rare condition that can be life-threatening if not promptly diagnosed and treated. We report a case of early treatment with transcatheter arterial embolization and video-assisted thoracoscopic surgery.Case presentationA 19-year-old Japanese male was diagnosed with left pneumothorax and underwent chest tube drainage. A total of 10 hours after admission, the patient developed dyspnea, chest pain, and sudden massive bloody effusion. Contrast-enhanced computed tomography revealed contrast extravasation near the left lung apex, and spontaneous hemopneumothorax was diagnosed. Angiography revealed bleeding from a branch of the subscapular artery and transcatheter arterial embolization was performed. The patient underwent video-assisted thoracoscopic surgery and recovered uneventfully.ConclusionsAnesthesiologists involved in urgent surgeries must be aware that a patient with spontaneous pneumothorax can develop a hemopneumothorax, even when full lung expansion has been obtained following chest tube drainage, owing to latent aberrant artery disruption. Interprofessional team engagement is essential for spontaneous hemopneumothorax management.

Determinant of Bronchoarterial Ratio in a Patient Undergoing Computed Tomography Chest

Background: Respiratory diseases pose a significant challenge in Nepali clinical settings due to elevated smoking rates and environmental risks. This study explores the structural changes in conditions such as asthma, chronic obstructive pulmonary disease, and bronchiectasis, utilizing noninvasive multi-detector computed tomography to assess airway remodeling. Despite conflicting western literature on bronchoarterial ratios, this research emphasizes the importance of evaluating these ratios in the Nepalese context for predicting airway disease severity. Materials and Methods: The cross-sectional study conducted at Nobel Medical College and Teaching Hospital involved 129 participants aged over 20 undergoing chest computed tomography. It aimed to measure the bronchoarterial ratio and investigate its associations with age, gender, smoking history, and altitude of residence. Bronchoarterial ratios was calculated using averaged short-axis diameters of the right apical and right posterior basal segmental bronchi, excluding the left lung due to motion artifacts. Results: Analysis indicated a Mean Bronchoarterial Ratio of 0.823 (SD 0.151), with the apical and basal segment BARs at 0.832 (SD 0.148) and 0.814 (SD 0.153), respectively. Notably, individuals aged over 65 who were smokers exhibited a significant increase in BAR. Additionally, a higher altitude of residence demonstrated a significant correlation with the Bronchoarterial ratio in the apical lung segment. Conclusion: This study provides valuable insights into the bronchoarterial ratio within the Nepalese population, considering age, gender, smoking history, and altitude of residence. The findings underscore the potential relevance of these ratios in conditions involving airway remodeling, contributing to the understanding of respiratory diseases in this specific demographic.

Incidental Apical Pleuroparenchymal Scarring on Computed Tomography: Diagnostic Yield, Progression, Morphologic Features and Clinical Significance.

Apical pleuroparenchymal scarring (APPS) is commonly seen on chest computed tomography (CT), though the imaging and clinical features, to the best of our knowledge, have never been studied. The purpose was to understand APPS's typical morphologic appearance and associated clinical features. A random generator selected 1000 adult patients from all 21516 chest CTs performed at urban outpatient centers from January 1, 2016 to December 31, 2016. Patients with obscuring apical diseases were excluded to eliminate confounding factors. After exclusions, 780 patients (median age: 64y; interquartile range: 56 to 72y; 55% males) were included for analysis. Two radiologists evaluated the lung apices of each CT for the extent of abnormality in the axial plane (mild: <5mm, moderate: 5 to 10mm, severe: >10mm), craniocaudal plane (extension halfway to the aortic arch, more than halfway, vs below the arch), the predominant pattern (nodular vs reticular and symmetry), and progression. Cohen kappa coefficient was used to assess radiologists' agreement in scoring. Ordinal logistic regression was used to determine associations of clinical and imaging variables with APPS. APPS was present on 65% (507/780) of chest CTs (54% mild axial; 80% mild craniocaudal). The predominant pattern was nodular and symmetric. Greater age, female sex, lower body mass index, greater height, and white race were associated with more extensive APPS. APPS was not found to be associated with lung cancer in this cohort. Classifying APPS by the extent of disease in the axial or craniocaudal planes, in addition to the predominant pattern, enabled statistically significant associations to be determined, which may aid in understanding the pathophysiology of apical scarring and potential associated risks.

Bullet lung injury in adolescent: a case report

Gunshot injuries to adolescents involve a proportionate minority of the overall injury population. Especially thorax bullet injuries are even less common. This report aimed to express our experience by sharing the clinical process of our patient with this injury. A fourteen-year-old female patient was injured by a gunshot from a distance of approximately 10 meters while she was in the garden. It was understood that the bullet entry hole was from the scapular supraspinatus region towards the clavicle and the apex of the left lung. It was determined that the exit hole was in the hemithorax region below the left clavicle. The patient was admitted for follow-up and treatment. Since the patient's general condition was stable, after clinical follow-up, a thoracotomy was performed under elective conditions, intraparenchymal bone fragments were cleaned, and the left apical lobe was excised. Clinical follow-up is problem-free, and post-discharge follow-up is also problem-free.

Pancoast Syndrome Due to Metastatic Hepatocellular Carcinoma

Pancoast tumors are aggressive and locally invasive apical lung cancers that often compress and infiltrate adjacent structures including the brachial plexus, stellate ganglion, ribs, and vertebral bodies. Symptoms of Pancoast tumors include Pancoast Syndrome, characterized by Horner Syndrome and pain and weakness of the ipsilateral upper extremity. Pancoast tumors by definition are primary lung cancer and are nearly always non-small cell lung cancer (NSCLC). There are rare case reports of metastatic non-pulmonary malignancies forming apical lung tumors mimicking Pancoast tumors and causing Pancoast Syndrome. Here, we present a case of a 66-year-old male with a history of unresectable hepatocellular carcinoma (HCC) who presented with one year of progressive left wrist and forearm pain and hand weakness and was found on cross-sectional imaging to have a left upper lobe lung mass invading the T1 and T2 vertebral bodies. Pathology showed very poorly differentiated carcinoma that required specialized testing to achieve diagnostic clarity. The tumor was positive for albumin mRNA, which aided in confirming the lung mass as metastatic HCC. This case highlights a rare incidence of Pancoast Syndrome due to metastatic HCC and emphasizes the importance of considering this diagnosis as an etiology of left upper extremity pain in a patient with previously diagnosed malignancy. This case also demonstrates the utility of albumin mRNA in-situ hybridization as an additional tool in identifying metastatic HCC and reviews general principles of symptomatic management of Pancoast Syndrome.

Pulmonary BRAF-driven Langerhans cell histiocytosis following selpercatinib use in metastatic medullary thyroid cancer.

RET mutations are implicated in 60% of medullary thyroid cancer (MTC) cases. The RET-selective tyrosine kinase inhibitor selpercatinib is associated with unprecedented efficacy compared to previous multi-kinase treatments. Langerhans cell histiocytosis (LCH) is a clonal histiocytic neoplasm usually driven by somatic BRAF mutations, resulting in dysregulated MAPK signalling. We describe a 22-year-old woman with metastatic MTC to regional lymph nodes, lung and liver. Tumour tissue harboured a somatic pathogenic RET variant p.(M918T) and selpercatinib was commenced. She experienced sustained clinical, biochemical and radiological responses. Two years later, she developed rapidly progressive apical lung nodules, prompting biopsy. Histopathology demonstrated LCH with a rare BRAF variant p.(V600_K601>D). The lung nodules improved with inhaled corticosteroids. We hypothesize that selective pressure from RET blockade may have activated a downstream somatic BRAF mutation, resulting in pulmonary LCH. We recommend continued vigilance for neoplasms driven by dysregulated downstream MAPK signalling in patients undergoing selective RET inhibition. Patients with RET-altered MTC can experience rapid disease improvement and sustained disease stability with selective RET blockade (selpercatinib). LCH is a clonal neoplasm driven by MAPK activation, for which the most common mechanism is BRAF mutation. Both MTC and pulmonary LCH are driven by dysregulated MAPK signalling pathway activation. We hypothesise that the RET-specific inhibitor selpercatinib may have caused the activation of dormant LCH secondary to selective pressure and clonal proliferation.

Pulmonary cyst newly formed after lobectomy in various underlying lung conditions

BackgroundIt has been recently recognized that pulmonary cyst may develop after pulmonary resection, causing various symptoms. Most previously reported cases were after upper lobectomy in patients with chronic obstructive lung disease (COPD).Case presentationCase 1 was a man in his 70 s with interstitial pneumonia (IP). Right lower lobectomy was performed for metastatic lung tumor using video-assisted thoracoscopic surgery (VATS). On postoperative day (POD) 19, computed tomography (CT) revealed a large cyst at the upper interlobular surface of the middle lobe, with pneumoderma and pneumomediastinum. The cyst was incised, polyglycolic acid (PGA) sheet and fibrin glue were applied, and the cyst was sutured. The sutured line was covered again with PGA sheet and fibrin glue. Case 2 was a man in his 70 s with COPD. Right upper lobectomy for primary lung cancer was performed using VATS. On POD 17, CT revealed a large pulmonary cyst at the apex of S6 and massive air leakage was observed. The same surgical procedure as that used in case 1 was performed. Cases 3 and 4 were healthy donors for living-donor lung transplantation. Two months after the right lower lobectomy in Case 3 and 3 months after the left lower lobectomy in Case 4, the patients had respiratory symptoms such as dyspnea and hemosputum. CT revealed a large cyst on the diaphragmatic surface of the right middle lobe in Case 3 and on the posterior mediastinal surface of the left upper lobe in Case 4. Cyst incision, soft coagulation, and application of PGA sheet with fibrin glue were performed in both cases. CT performed 1 year after surgery showed no development of a pulmonary cyst or air space in these four cases.ConclusionsPulmonary cysts newly formed after lobectomy can develop not only in COPD or IP but also in healthy lungs. Our findings suggest that incision of the cyst and application of fibrin glue and PGA sheet with or without suturing the cyst wall is effective for management.

Pneumothorax After Superior Plating of Clavicle Fractures: Are the Concerns Warranted?

The primary goal of this study was to determine the anatomic relationship between the clavicle and the apical lung segment. The secondary goal was to determine the incidence of pneumothorax (PTX) in patients who underwent clavicle ORIF to analyze the utility of postoperative chest radiographs. Six hundred thirty-one patients with a midshaft clavicle fracture who underwent superior plating at a single institution were identified. Forty-two patients had a CT scan of the chest. Three points on the uninjured clavicle were defined: 2 cm from the medial end of the clavicle, the mid-point of the clavicle, and 2 cm from the lateral end of the clavicle. At each point, the distance from both the inferior cortex and the superior cortex of the clavicle to the apical lung segment was measured. All 631 patients who underwent Open Reduction and Internal Fixation had a postoperative chest radiograph to evaluate implant placement, restoration of clavicular length, and presence of PTX. From the lateral end of the clavicle, the mean distance of the lung was 60.0 ± 14.9 mm (20.1 to 96.1 mm) from the inferior cortex of the clavicle. At the mid-point, the mean distance of the lung was 32.3 ± 7.2 mm (20.4 to 45.5 mm) from the inferior cortex of the clavicle. At the medial end, the mean distance of the lung was 18.0 ± 5.5 mm (8.1 to 28.9 mm) from the inferior cortex of the clavicle. A review of postoperative radiographs for all 631 patients revealed none (0%) with a postoperative iatrogenic PTX. The risk of injury is minimal in all three zones. Postoperative chest radiographs after clavicle fracture repair to rule out PTX are unnecessary.

Duodenal tuberculosis with gastric outlet obstruction: a case report of successful diagnosis and treatment, with review of literature

BackgroundDuodenal tuberculosis (TB) is extremely rare, and its diagnosis is challenging owing to the lack of specific symptoms and radiological or endoscopic findings. When it leads to gastric outlet obstruction (GOO), diagnosing it accurately and providing appropriate treatment is crucial. However, this is often overlooked.Case presentationA 35-year-old man presented with abdominal pain, fullness, vomiting, and weight loss. Upper gastrointestinal endoscopy and radiography revealed nearly pinpoint stenosis with edematous and reddish mucosa in the D1/D2 portion of the duodenum. Computed tomography (CT) showed the duodenal wall thickening, luminal narrowing, multiple enlarged abdominal lymph nodes, and portal vein stenosis. Conventional mucosal biopsy during endoscopy revealed ulcer scars. We initially suspected stenosis due to peptic ulcers; however, chest CT revealed cavitary lesions in both lung apices, suggesting tuberculosis. Due to the suspicion of duodenal TB and the need to obtain deeper tissue samples, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed. The tissue sample showed caseating granulomas with multinucleated giant cells, and acid-fast bacilli were positive by Ziehl–Neelsen staining. The patient was diagnosed with duodenal TB and subsequent GOO. Because the patient had difficulty eating, surgical intervention was prioritized over antitubercular drugs, and laparoscopic gastrojejunostomy was performed. The patient started an oral diet on the 3rd postoperative day and began antitubercular treatment immediately after discharge on the 11th day. During the 6th month of treatment, endoscopic examination revealed residual duodenal stenosis; however, the bypass route functioned well, and the patient remained asymptomatic.ConclusionsAn aggressive biopsy should be performed to diagnose duodenal TB. EUS-FNA has proven to be a useful tool in this regard. Both nutritional improvement and antitubercular treatment were achieved early and reliably by performing laparoscopic gastrojejunostomy for duodenal TB with GOO.

Shoulder and arm pain: A “red herring” chief complaint in a smoker diagnosed with Pancoast-Tobías syndrome

Introduction: A Pancoast tumor is a rare apical lung cancer that can lead to a constellation of signs and symptoms known as Pancoast-Tobías syndrome, which involves ipsilateral shoulder and arm pain, Horner’s syndrome, and atrophy of the intrinsic hand muscles. As a Pancoast tumor progresses, it first invades the brachial plexus and causes unrelenting shoulder and arm pain in the C8-T2 nerve distributions. However, when evaluating this presenting symptom, it is often considered benign, especially in aging patients. Consequently, Pancoast-Tobías syndrome is easily misdiagnosed or delayed in diagnosis, resulting in poor prognosis, particularly for patients with advanced disease. Case Report: We present the case of an elderly Afro-Caribbean woman with a 24-pack-year smoking history who presented with unrelenting pain to the right shoulder and arm for two months. During that time, she visited multiple family physicians. Onset of pain coincided with a wasp sting that was complicated by a large local reaction. Despite clinical resolution of the inflammatory reaction, the pain persisted even with multi-modal oral analgesics. Detailed physical examination later revealed ipsilateral atrophy of the intrinsic hand muscles and focal chest findings concerning for an underlying consolidative lung process. This prompted diagnostic chest imaging, which identified a right-sided Pancoast tumor aggressively invading adjacent structures. She soon developed Horner’s syndrome, resulting in clinicoradiologic confirmation of Pancoast-Tobías syndrome. Conclusion: It is important to consider Pancoast-Tobías syndrome as an important differential of unrelenting shoulder and arm pain, even in the absence of pulmonary symptoms, in patients with risk factors for lung cancer, such as chronic smokers.