Endobronchial Lesions Research Articles

Diagnostic Yield of Transbronchial Cryobiopsy Guided by Radial Endobronchial Ultrasound and Fluoroscopy in the Radiologically Suspected Lung Cancer: A Single Institution Prospective Study.

Simple SummaryThe morphological diagnosis of peripheral lung lesions is challenging due to the anatomical location of these lesions and to the biopsy techniques that are currently available. Transbronchial forceps biopsies guided by fluoroscopy alone, or additional with radial mini probe endobronchial ultrasound (RP-EBUS), were well-known standardised procedures with an unsatisfactory diagnostic yield. Transbronchial cryobiopsy is a novel technique of lung parenchyma biopsy for the diagnosis of interstitial lung diseases, which has a very high diagnostic yield (80–96%) and relatively low incidence of complications (3–26%). Due to these reasons, transbronchial cryobiopsy guided by RP-EBUS and fluoroscopy in peripheral lung lesions are under active investigation, but still, there is limited data as only a few clinical trials of transbronchial cryobiopsy are published around the world. Our study showed that transbronchial cryobiopsy is a potentially safe procedure when obtaining a larger size of samples. Furthermore, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 85.1%, 100%, 100%, 12.5%, and 93% for TBCB as well as 91.5%, 100%, 100%, 20.0% and 96.7% for the combined procedures, respectively.Transbronchial cryobiopsy (TBCB) is being studied in the diagnosis of peripheral lung lesions; however, there are only a few clinical studies around the world. The aim of our study was to evaluate the diagnostic values and safety of transbronchial cryobiopsy for radiologically suspected peripheral lung cancer. The prospective clinical study was executed from September 2019 to September 2021 at a tertiary clinical centre in Lithuania. A total of 48 patients out of 102 underwent combined procedures of transbronchial forceps biopsy (TBFB) and TBCB. Diagnostic values and safety outcomes of TBFB and TBCB were analysed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were 72.9%, 100%, 100%, 7.7%, and 88.0% for TBFB, 85.1%, 100%, 100%, 12.5%, and 93% for TBCB, as well as 91.5%, 100%, 100%, 20.0% and 96.7% for the combined procedures, respectively, with a significantly higher accuracy for cryobiopsies compared to forceps biopsies (p < 0.05). The diagnostic values for transbronchial cryobiopsies were similar, irrespective of the radial mini probe endobronchial ultrasound (RP-EBUS) position, lesion size or bronchus sign, however, the sensitivity of the combined procedures in cases with RP-EBUS adjacent to the target was significantly higher compared to TBFB (86.2% vs. 64.3%, p = 0.016). Samples of cryobiopsies were significantly larger than forceps biopsies (34.62 mm2 vs. 4.4 mm2, p = 0.001). The cumulative diagnostic yield of transbronchial cryobiopsy was 80.0% after the second biopsy and reached a plateau of 84.1% after four biopsies. No severe bleeding, pneumothorax, respiratory failure or death was registered in our study. TBCB is a potentially safe procedure, which increases diagnostic values in diagnosing peripheral lung lesions compared to TBFB.

Bronchoscopic Features and Morphology of Endobronchial Tuberculosis: A Malaysian Tertiary Hospital Experience.

The diagnosis of endobronchial tuberculosis (EBTB) is difficult as it is not well visualized radiologically, and bronchoscopy is not routinely performed for tuberculosis (TB) patients. Bronchoscopic characterization via endoscopic macroscopic features can speed up the diagnosis of EBTB and prompt immediate treatment. In this study, we identified the clinical and bronchoscopic morphology of 17 patients who were diagnosed with EBTB from 2018 to 2020. Demographics, radiological, microbiological and histopathological data were recorded. Endobronchial lesions were classified according to Chung classification. The diagnosis was made based on a histopathological examination (HPE) of endobronchial biopsy, and/or positive ‘Acid-fast bacilli’ (AFB) microscopy/Mycobacterium tuberculosis (MTB) culture on microbiological examination of bronchial alveolar lavage (BAL) and/or positive MTB culture on endobronchial biopsy specimens. Furthermore, EBTB was predominant in young women, age 20 to 49 years old, with a male to female ratio of 1 to 2. Underlying comorbidities were found in 53% of the patients. Cough, fever and weight loss were the main symptoms (23.5%). The indications for bronchoscopy are smear-negative TB and persistent consolidation on chest radiographs. Consolidation was the main radiological finding (53%). An active caseating lesion was the main EBTB endobronchial subtype (53%). The leading HPE finding was caseating granulomatous inflammation (47%). All patients showed good clinical response to TB treatment. Repeated bronchoscopy in six patients post TB treatment showed a complete resolution of the endobronchial lesion. EBTB bronchoscopic characterization is paramount to ensure correct diagnosis, immediate treatment and to prevent complication.

Endobronchial tuberculosis with unusual linear ulceration from tracheal to right upper lobar bronchi.

The complications of endobronchial tuberculosis (TB) include bronchostenosis and fistula. We highly recommend that a TB test be included in the diagnosis of endobronchial lesions.

A comprehensive evaluation of bronchoscopy at a large urban public hospital in South Africa

ABSTRACT Background: A definitive diagnosis of respiratory pathology is often elusive without tissue biopsy. Bronchoscopy is indispensable to visualise and sample endobronchial lesions and lung parenchyma. Objectives: To describe the practise of fibreoptic bronchoscopy at Chris Hani Baragwanath Academic Hospital (CHBAH). Outcomes include patient demographics, as well as indications and findings of fibreoptic bronchoscopy. To define possible associations between demographic characteristics and final diagnosis. Methods: Retrospective record review of patients who had undergone fibreoptic bronchoscopy at CHBAH over a 8-year period (2011–2018). Results: Bronchoscopy records were retrieved for 830 patients. Two thirds of patients were male; the mean age of patients was 56.1 (+/−13.3) years. Human Immunodeficiency virus (HIV) status was reported in 74%. Twenty-two percent of this population was seropositive for HIV (median CD4 count 233 cells/mm3, IQR: 85–434 cells/mm3). Most were performed for suspected endobronchial lesions (52%), and 12% for pulmonary infiltrates. The most common final diagnosis was lung malignancy in 39% of patients. Squamous cell carcinoma was identified in 43%, followed by adenocarcinoma (31%). Women and HIV positive patients were less likely to be diagnosed with malignancy compared to men and HIV negative patients. The complication rate for bronchoscopy was 2%. Conclusion: Suspected endobronchial lesions were the most common indication for bronchoscopy, and the most common diagnosis was primary lung cancer. Bronchoscopy is a useful tool in the diagnosis of respiratory disease with a low complication rate.

Role of Endobronchial Needle Aspiration Cytology in Diagnosing Lung Cancer in Bronchoscopically Visible Tumors

Introduction: Bronchoscopy is an important diagnostic tool for the diagnosis of lung cancer, and various techniques have documented increase in diagnostic sensitivity. In this study, we have analyzed the role of bronchoscopy in diagnosis of lung cancer with special emphasis on endobronchial needle aspiration cytology (EBNA) in comparison to other conventional diagnostic techniques (CDTs) such as bronchial wash (BW) and forcep biopsy (FB). Materials and Methods: Prospective, observational study screened 1564 cases with suspected lung malignancy on clinical and radiological basis. Bronchoscopy-guided techniques such as EBNA, BW, and FB are used in exophytic endobronchial lesions (EELs) in confirming the diagnosis of lung cancer and to find additive yield over other techniques such as BW and FB. Rapid onsite evaluation (ROSE) analysis of all EBNA samples done in pathology lab allied center. Finally, histopathology proven 917 lung malignancy cases are included in this study. Statistical analysis is done by using chi-test. Results: In this study, 917 diagnosed lung cancer patients between 29 and 85 age group predominant 61.83% (567/917) and smokers by addiction in 52.12% (478/917) cases. Presented with cough in 80.80% (741/917), clubbing in 55.83% (512/917) cases, and mass lesion in chest radiograph in 53.10% (487/917) cases. Anatomical location is documented on the right side of tracheobronchial in 58.66% (538/917) cases during bronchoscopy. Yield of FB and FB plus BW in EEL is 86.69% (795/917) and 90.94% (834/917), respectively. Yield of EBNA, EBNA plus BW, and EBNA plus FB in EEL is 70.22% (644/917), 75.13% (689/917), and 97.16% (891/917), respectively. Overall yield of all bronchoscopy-guided techniques (EBNA + FB + BW) in our study in EEL is 100%. Additional yield of EBNA in EEL over other CDTs (FB plus BW) is 9.06%. Sensitivity of FB and EBNA in diagnosing lung malignancy in EEL is 86.69% and 70.22%, respectively. FB is more sensitive technique than EBNA in EEL (P &lt; 0.00001). Sensitivity of FB plus BW in EEL is 90.94% (834/917). Sensitivity of EBNA plus BW in EEL is 75.13% (689/917). Sensitivity of EBNA plus FB in EEL is 97.16% (891/917) (P &lt; 0.00001). Conclusion: EBNA is underutilized bronchoscopic technique in visible endobronchial lesions (exophytic endobronchial type) in spite of satisfactory diagnostic yield as compared with other CDTs. Although FB is most commonly preferred technique in bronchoscopically visible tumors, the addition of EBNA has improved overall diagnostic yield of bronchoscopy and decreased need for repeat bronchoscopy procedure.

Cryo-Biopsy versus 19G needle versus 22G needle with EBUS-TBNA endoscopy.

Introduction: We have been using cryo-biopsy for endobronchial lesions for lung cancer diagnosis and debulking. Cryo-biopsy is also known to be an excellent tool for diagnosis of lung interstitial disease. Recently cryo-biopsy with the 1.1mm probe was used for lymphnode biopsy.Patients and Methods: 311 patients participated with lymphadenopathy and at least one lung lesion. The following tools were used for diagnosis; 22G Mediglobe Sonotip, 22G Medigolbe, 21G Olympus, 19G Olympus and 1.1mm cryo probe ERBE CRYO 2 system (3 seconds froze). A PENTAX Convex-probe EBUS was used for biopsy guidance.Results: Cell-blocks slices had a higher number in the 19G needle group (19G> Cryo Probe>22G Mediglobe Sonotip >21G Olympus >22G Mediglobe).Conclusion: Cryo biopsy of the lymphnodes is safe with the 1.1mm cryo probe. Further studies are needed in order to evaluate new probes and the technique specifications.

A Case of Primary Racemose Hemangioma with Endobronchial Lesions Demonstrating Recurrent Hemoptysis Initially Treated with Bronchial Arterial Embolization

A Case of Primary Racemose Hemangioma with Endobronchial Lesions Demonstrating Recurrent Hemoptysis Initially Treated with Bronchial Arterial Embolization

AKCİĞERİN NADİR PRİMER MALİGN TÜMÖRLERİNDE KLİNİK VE RADYOLOJİK DEĞERLENDİRME

Objective&#x0D; The most common primary malignant tumors of the&#x0D; lung are squamous cell carcinoma, small cell carcinoma&#x0D; and adenocarcinoma. However, some rare malignant&#x0D; primary lung tumors can also affect the lung&#x0D; and cause difficulties in diagnosis and treatment.&#x0D; Conventional imaging methods do not help the diagnosis&#x0D; in most cases, and moreover, preoperative&#x0D; tissue samples may fail to establish a diagnosis. In&#x0D; cases with endobronchial lesions, small samples or&#x0D; lack of transthoracic biopsy in central tumors without&#x0D; endobronchial lesions can make diagnosis difficult.&#x0D; The definitive diagnosis can only be made after larger&#x0D; examinations with larger tissue samples taken after&#x0D; the operation. In addition, failure to differentiate benign-&#x0D; malignant in frozen examination may negatively&#x0D; affect the resection of the surgeon. It can cause incomplete&#x0D; or unnecessary resection.&#x0D; The aim of this study was to evaluate the clinical radiological&#x0D; and histopathological features of these tumors,&#x0D; which have been rarely reported in the literature,&#x0D; and to contribute to the diagnosis and treatment of&#x0D; these tumors.&#x0D; Material and Methods&#x0D; The study included 10 patients with rare malignant&#x0D; primary lung tumor who were operated on in our clinic&#x0D; between 2010 and 2019. All patients were retrospectively&#x0D; evaluated in respect of age, gender, symptoms,&#x0D; preoperative imaging methods and invasive diagnostic&#x0D; methods. Tumor localization, tumor size, type of&#x0D; surgical operation and survival were recorded.&#x0D; Results&#x0D; The 10 patients included in the study comprised 6&#x0D; males and 4 females. Postoperative histopathological&#x0D; diagnoses of the patients were reported as 2 carcinosarcomas,&#x0D; 2 large cell carcinomas, 2 epithelioid&#x0D; hemangioendothelioma, 1 glomangiosarcoma, 1 primary&#x0D; pulmonary leiomyosarcoma, 1 mucoepidermoid&#x0D; carcinoma, and 1 synovial sarcoma.&#x0D; Conclusion&#x0D; It can be difficult to diagnose in rare primary malignant&#x0D; lung tumors by preoperative imaging and preoperative&#x0D; invasive diagnostic methods. CT-guided fine needle&#x0D; biopsy and tru-cut biopsy, endobronchial biopsy&#x0D; and frozen samples performed before surgery may be&#x0D; insufficient in diagnosis, which may mislead the surgeon&#x0D; about lung resection.

A Case of Uncontrolled Asthma

A 50y/o female patient with severe uncontrolled asthma was presented to our hospital for anti-IgE therapy. She complained of persistent dyspnea and wheezing after a severe asthma attack five months before. Her asthma had not been controlled with adequate asthma treatment, including budesonide + formoterol b.i.d. combination, montelukast at 10 mg/day, and oral steroids (30–40 mg daily of prednisolone), during this period. She was hospitalized for evaluation of anti-IgE therapy. Chest X-ray revealed a left-sided hilar opacity. Fiberoptic bronchoscopy was done and showed an endobronchial lesion obstructing the left lower bronchus lumen. Computed tomography(CT) revealed a nodular lesion at the same site. The patient has undergone left lower lobe lobectomy and lymph node dissection (mediastinal lymphnode). Pathological examination was done and confirmed the diagnosis of typical carcinoid tumor. After surgery, her symptoms subsided, and she had no recurrence. A diagnosis of severe asthma requires confirmation of asthma to r/o other conditions. Uncontrolled symptoms that linger despite aggressive therapy need proper evaluation to rule out other etiologies, such as a carcinoid tumor, before selecting new treatment options.

Anatomical Variation in the Fissurization of Lung with Embryological and Clinical correlations- A Case Report

Lungs are paired conical organs present in the thoracic cavity, which are responsible for gaseous exchange for oxygenation of blood. Both the lungs are divided into lobes by fissures. The right lung is divided into upper, middle and lower lobes by two fissures. The fissures are horizontal and oblique fissure whereas the left lung is divided into upper and lower lobes by oblique fissure. The left lung is divided into upper and lower lobe by oblique fissure. Both the lungs have ten bronchopulmonary segments (structurally separate and functionally independent units). Embryological evidence showed that the lungs developed from the endodermal counterpart of the foregut. Around 22 days of embryonic period, diverticulum are develop, then between 26-28 days lung buds develop. The right bronchial buds and left bronchial buds are branched into secondary and tertiary buds at 5th and 6th week of embryonic life consecutively. During routine anatomy dissection and demonstration in the Department of Anatomy, a 50 year old male cadaver showed anatomical variation in the right lung. The present study observed that the right lung showed partial horizontal fissure. The reason for partial or incomplete fissure formation is due to incomplete or absence of obliteration of prenatal fissure which indicates partial fusion of lobes, generally fissures separating the broncho-pulmonary segments in prenatal life. The reports says that incomplete fissures of the lung may lead to spread of infection like pneumonia to adjacent lobe and collapse in endobronchial lesions and gradation of the fissures of the lungs are very important for lung surgeries. The present study concludes that the knowledge of anatomical variation of lung is of utmost important in the field of pulmonary medicine.

ENDOBRONCHIAL HAMARTOMA: A MISDIAGNOSIS OF COPD

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hamartomas are benign tumors composed of various mesenchymal cells including cartilage, connective tissue, bone and fat. Pulmonary hamartomas constitute about 8% of all benign lung neoplasms and have an incidence of 0.025-0.32%. They typically occur peripherally involving the lung parenchyma and rarely occur as endobronchial tumors. Here, we present a case of endobronchial hamartoma presenting as dyspnea and chronic cough. CASE PRESENTATION: A 61-year-old male non-smoker presented for 6 months of chronic productive cough. His chest x-ray was unremarkable. Pulmonary function testing was notable for mild obstruction with a forced expiratory volume in one second (FEV1) of 84.9%, forced vital capacity (FVC) of 102.1%, FEV1/FVC ratio of 63.74% and normal DLCO without bronchodilator response. He was initially diagnosed with chronic obstructive pulmonary disease (COPD) and prescribed a daily steroid inhaler and as needed short acting bronchodilator. Despite compliance with his inhalers, he continued to have persistent cough and was referred to a pulmonologist. A computed tomography scan of the chest showed two endobronchial soft tissue lesions in the right bronchus intermedius nearly occluding the bronchus intermedius. Diagnostic bronchoscopy showed a lobulated, mobile endobronchial mass obstructing approximately 85% of the lumen. Endobronchial biopsies returned as fragments of mature hyaline cartilage with adipose tissue and benign bronchial epithelium compatible with pulmonary hamartoma. He underwent rigid bronchoscopy and tumor resection with laser cautery to the base by thoracic surgery. Pathology confirmed the diagnosis of pulmonary hamartoma. After resection, he had improvement of his dyspnea and cough. DISCUSSION: Endobronchial hamartomas account for only 10% of pulmonary hamartomas. Most pulmonary hamartomas are asymptomatic as they typically involve the parenchyma. Endobronchial hamartomas most commonly present as post obstructive pneumonia or hemoptysis. Less frequently, non-specific pulmonary symptoms such as cough, wheezing, and/or dyspnea can be the presenting sign and can lead to a misdiagnosis of asthma or COPD. CONCLUSIONS: Although endobronchial tumors are common, endobronchial hamartomas are very rare. Most endobronchial lesions are malignant. Endobronchial hamartomas are typically slow growing and therefore often incidentally discovered on chest imaging. In some cases, they may be poorly or not visualized on chest radiograph. Patients with nonspecific pulmonary symptoms who fail standard management with an unremarkable chest radiograph should prompt further detailed chest imaging to rule out structural causes such as endobronchial hamartomas. The gold standard for management of symptomatic endobronchial hamartomas is rigid bronchoscopy with resection and laser therapy. REFERENCE #1: Cosío, Broja et al. "Endobronchial Hamartoma.” Chest. Vol. 122;1 (2002): 202-205. REFERENCE #2: Ahmed, Saman et al. "Endobronchial hamartoma; a rare structural cause of chronic cough.” Respiratory medicine case reports. Vol. 22 (2017): 224-227. REFERENCE #3: Stevic, Ruza, and Branislava Milenkovic. "Tracheobronchial tumors.” Journal of thoracic disease vol. 8,11 (2016): 3401-3413. DISCLOSURES: No relevant relationships by Kathy Chan, source=Web Response No relevant relationships by George Moran, source=Web Response No relevant relationships by Sudhir Rajan, source=Web Response No relevant relationships by Eduardo Solbes, source=Web Response

EXTRA-NODAL PULMONARY MARGINAL ZONE LYMPHOMA ASSOCIATED WITH SJÖGREN DISEASE

TOPIC: Lung Cancer TYPE: Fellow Case Reports INTRODUCTION: Mucosal-associated lymphoid tissue (MALT), is a system of lymphoid tissue found within various organs that plays a role in regulating local immunity. As this tissue contains T, B, and plasma cells, it is the potential site for the development of lymphoma. MALT lymphomas are a form of B-cell extranodal lymphoma that can originate from marginal zone lymphocytes within the lung, referred to as pulmonary marginal zone lymphoma (PMZL). CASE PRESENTATION: We present a 42-year-old female referred to our clinic for evaluation of pulmonary nodules and mediastinal adenopathy. She had a one year history of Sjogren's syndrome. At that time she had no pulmonary or B symptoms. To evaluate her mediastinal adenopathy, she was referred for endobronchial ultrasound where pathologic evaluation revealed only a polymorphous lymphoid population and was negative for malignancy. She had several endobronchial hypervascular and polypoid nodules within the mainstem airways. Pathology from these nodules demonstrated an atypical lymphoid infiltrate, but was unable to be characterized any further.Given ongoing concern for a lymphoproliferative process, she was referred for video-assisted thoracoscopic surgery (VATS). Pathology from her left upper and lower lobar wedge resections demonstrated follicular bronchiolitis. Biopsy of a pleural nodule demonstrated a lymphoproliferative process concerning for a low-grade B-cell neoplasm, thought to be extranodal PMZL. She was referred to oncology where PET/FDG demonstrated hypermetabolic multi-station adenopathy suggesting stage IV disease. Given her asymptomatic nature and anticipated indolent course, it was decided to defer chemotherapy pending resolution of the COVID-19 pandemic. DISCUSSION: MALT lymphoma can develop in response to continuous antigen stimulation, as is seen in Sjogren's syndrome or tobacco use. Radiographic features of MALT lymphoma are numerous, including consolidations, nodules, and masses being the most frequent patterns observed in ~50% of patients. Endobronchial lesions as observed in this patient occur in ~85% of cases. PET/FDG imaging commonly demonstrates mild uptake within identifiable lesions. It has a very favorable prognosis with an overall 5-year survival of 90% due to its indolent nature and excellent response rate to chemoimmunotherapy, typically combination Bendamustine and Rituximab. CONCLUSIONS: MALT lymphoma is an uncommon neoplasm that can occur due to chronic antigen stimulation, especially in patients with Sjogren's syndrome. It has numerous radiographic features, the most common being endobronchial lesions. When given these clinical features, establishing a diagnosis is of utmost importance due to the excellent response rate to therapy and favorable long-term prognosis. REFERENCE #1: Borie R, Wislez M, Thabut G, et al. Clinical characteristics and prognostic factors of pulmonary MALT lymphoma. Eur Respir J. 2009;34(6):1408-1416. REFERENCE #2: Husnain M, Kuker R, Reis IM, et al. Clinical and radiological characteristics of patients with pulmonary marginal zone lymphoma: A single center analysis. Cancer Med. 2020;9(14):5051-5064. REFERENCE #3: Stefanovic A, Morgensztern D, Fong T, Lossos IS. Pulmonary marginal zone lymphoma: a single centre experience and review of the SEER database. Leuk Lymphoma. 2008;49(7):1311-1320. DISCLOSURES: No relevant relationships by Brandon Jakubowski, source=Web Response No relevant relationships by Rosechelle Ruggiero, source=Web Response

ENDOBRONCHIAL BIOPSY FOR SARCOIDOSIS: TIME TO RECONSIDER?

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Endobronchial biopsy (EBB) following thoracic lymph node sampling has been reported to increase diagnostic yield for pulmonary sarcoidosis in two studies. Given the widespread use of endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA), the purpose of this study is to investigate the diagnostic yield for EBB in contemporary sarcoid population at University of Minnesota Sarcoidosis Center of Excellence. METHODS: We identified a cohort of patients who underwent bronchoscopy with EBUS-TBNA and EBB and were found to have granulomatous inflammation on histopathology. Each patient underwent a standardized workup for sarcoidosis which included imaging and pulmonary function testing. Data regarding transbronchial lung biopsy (TBB), TBB histopathology, location of EBB and the presence of visual endobronchial lesions were recorded. A biopsy was regarded as positive if pathology demonstrated non-caseating granulomatous inflammation for which no specific cause was present. RESULTS: Our cohort included 25 patients (mean age 52.5±8.0 years; 53.8% male; 3.8% Blacks). Five patients (20%) had a positive EBB. All patients with positive EBB also had a postive EBUS-TBNA or TBB. Four patients (16%) in our cohort had visible endobronchial lesions, three of which had a positive EBB. Three (12%) patients the EBB was performed using a cryoprobe and all were positive, for a diagnostic yield of 100%. The remainder of the cohort had EBB performed with forceps, with a diagnostic yield of 9.1%. CONCLUSIONS: Based on our experience, the diagnostic yiedl of EBB is lower than previously reported, with only 20% of EBBs demonstrating granulomatous inflammation, compared to prior reports by Schorr et al (62%) and Goktalay et al (43%). However, instrumentation used for obtaining EBB as well as the presence of visible lesions may influence the diagnostic yield. Studies with adequate power are needed before implementing changes in clinical practice. When performed alongside both EBUS-TBNA and TBB, EBB did not add to the diagnostic yield in sarcoidosis. CLINICAL IMPLICATIONS: Currently, the data informing expert opinion on performing EBB following EBUS is lacking. The existing data implies that EBB increases diagnostic yield for pulmonary sarcoidosis following EBUS or TBB; therefore, should be routinely performed. Our experience questions the diagnostic impact of EBB during these procedures; whereby, more robust studies are needed to confirm our findings. DISCLOSURES: No relevant relationships by Maneesh Bhargava, source=Web Response Consultant relationship with Toray Industries Please note: 1/2021 to 9/2021 Added 04/21/2021 by Roy Cho, source=Web Response, value=Grant/Research Support No relevant relationships by Vidhu Pandey, source=Web Response No relevant relationships by David Perlman, source=Web Response

MULTIFOCAL PULMONARY GRANULAR CELL TUMOR

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Granular cell tumors, also known as Abrikossoff tumors, are a rare group of Schwannian neoplasms typically found in the skin and tongue, but also occur in the lung. Granularity of the cells is due to accumulation of secondary lysosomes in the cytoplasm. Only 0.5-2% of pulmonary granular cell tumors (pGCT) are malignant, but some benign cases show similar behavior. Here, we describe a diagnostically challenging case of multifocal pGCT. CASE PRESENTATION: A 48-year old male with history of asthma, chronic obstructive pulmonary disease, hypertension, and alcoholic steatohepatitis presented for evaluation of a right lung mass found on chest X-ray 5 years ago. He endorsed progressive dyspnea poorly controlled with beclomethasone and albuterol inhalers. He had history of tobacco smoking with 31 pack-years, as well as alcohol abuse. He worked in a shipyard for 3 years with exposure to asbestos and welding fumes. Computed tomography of the chest showed a 4.1-cm solid mass in the right lower lobe, as well as a 1.1-cm endobronchial lesion in the right bronchus intermedius, multiple left lower lobe lesions, and mediastinal lymphadenopathy. Spirometry showed moderate obstructive disease with bronchodilator response. Biopsies of lower lobe and tracheal mucosal lesions obtained by bronchoscopy revealed sheets of epithelioid cells with abundant eosinophilic granular cytoplasm and small uniform nuclei consistent with pGCT. There was no evidence of necrosis or increased mitotic figures to suggest malignancy. Immunostaining was positive for S100, CD68, SOX10, inhibin, and PAS. He was referred to Interventional Pulmonology for laser debulking and endobronchial stenting. DISCUSSION: Determining whether pGCTs are malignant or benign can be challenging. Both types occur in all age groups. Both can cause dyspnea, cough, and pleuritic chest pain. Large tumor size is not predictive, as many malignant pGCT's are <4 cm at time of diagnosis. Additionally, 20% of benign pGCTs have multiple lung lesions. However, the presence of extrapulmonary metastases is diagnostic of malignancy. Malignant pGCTs also show 3 or more histologic features of the Fanburg-Smith criteria, including necrosis, spindling, pleomorphism, vesicular nuclei with large nucleoli, high nuclear/cytoplasmic ratio, and increased mitotic activity. Positive p53 or Ki67 immunostaining can indicate malignancy in indeterminate cases. Management of benign pGCTs is surgical. Small tumors <1.0 cm may be removed by bronchoscopic extirpation, laser therapy, or sleeve resection. Larger tumors are resected surgically. Prognosis for benign pGCT is good (2-8% recurrence) if complete margin-free removal is achieved. CONCLUSIONS: Malignant and benign pGCTs share many features that make them difficult to differentiate. Absence of extrapulmonary metastases, Fanburg-Smith criteria, and specific immunostaining helps rule out malignancy in cases with multifocal lung lesions. REFERENCE #1: Jiang M, Anderson T, Nwogu C, Tan D. Pulmonary malignant granular cell tumor. World J Surg Oncol. 2003;1(1):22. Published 2003 Oct 21. doi:10.1186/1477-7819-1-22. REFERENCE #2: Fanburg-Smith JC, Meis-Kindblom JM, Fante R, Kindblom LG. Malignant granular cell tumor of soft tissue. Diagnostic criteria and clinicopathologic correlation. Am J Surg Pathol. 1998;22:779–794. doi: 10.1097/00000478-199807000-00001. REFERENCE #3: Khansur T, Balducci L, Tavassoli M. Granular cell tumor: clinical spectrum of the benign and malignant entity. Cancer. 1987;60:220–222. DISCLOSURES: No relevant relationships by Ramiz Fargo, source=Web Response No relevant relationships by Joseph Mak, source=Admin input No relevant relationships by Bryce Mikel, source=Web Response

METASTATIC COLORECTAL CANCER PRESENTING AS AN OBSTRUCTING ENDOBRONCHIAL LESION

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Colorectal cancer is one of the most common malignancies worldwide with the pulmonary parenchyma a common site for distant metastasis. Colorectal endobronchial metastases, however, are exceedingly rare. We present a patient with previously resected colon cancer who was found to have an obstructing endobronchial colorectal metastasis. CASE PRESENTATION: A 66-year-old male with a 12 pack-year smoking history presented with dyspnea. On routine colonoscopy 4 years prior, he was diagnosed with moderately differentiated colorectal adenocarcinoma with negative tumor margins and without any lympho-vascular involvement. Imaging was without evidence of regional or distant metastases so he underwent hemicolectomy. Medical oncology recommended no adjuvant chemotherapy and 1 year follow-up. The patient did not follow-up. Four years later, he presented with fever, dyspnea, cough, and pleuritic chest pain. CT pulmonary angiography demonstrated a RUL mass with RML lobe collapse, a moderate right-sided pleural effusion, and no pulmonary embolism. He was started on empiric antibiotics. Thoracentesis revealed an exudative effusion with negative cultures and cytology. Bronchoscopy demonstrated a fungating endobronchial lesion completely occluding the right middle lobe for which cryobiopsy and cryo-excision were performed. Pathology was consistent with metastatic moderately differentiated colorectal adenocarcinoma, with morphology and histology identical to his prior colorectal cancer. Transbronchial needle aspiration using endobronchial ultrasound of the station 7 mediastinal lymph node was negative for malignant cells. Patient left against medical advice before further work-up was completed. DISCUSSION: About 20% of patients with colorectal cancer have distant metastases at presentation, with the lungs being a common site, usually involving the pulmonary parenchyma and very rarely as an endobronchial lesion. In fact, endobronchial metastases from extra-thoracic malignancies account for 1% of all endobronchial tumors, with the most common being colorectal, breast and renal. These patients may present with a variety of non-specific respiratory symptoms. It is also not uncommon for endobronchial metastasis to occur after resection of the primary tumor and without other signs of metastases. One should consider the possibility of endobronchial involvement of a tumor in a patient with a history of an extra-thoracic malignancy who presents with vague respiratory symptoms, as timely bronchoscopic intervention can improve quality of life and help mitigate the risk of post obstructive complications. CONCLUSIONS: Endobronchial metastasis from extra-thoracic malignancies are very rare, accounting for 1% of all endobronchial tumors. Diagnosis can be difficult due to vague respiratory complaints. Bronchoscopic intervention can assist in diagnosis, management, and it can lead to substantial improvement in pulmonary symptoms. REFERENCE #1: Akoglu S, Uçan ES, Celik G, et al. Endobronchial metastases from extrathoracic malignancies. Clin Exp Metastasis. 2005;22:587–591. REFERENCE #2: Coriat R, Diaz O, de la Fouchardiere C, et al. Endobronchial metastases from colorectal adenocarcinomas: clinical and endoscopic characteristics and patient prognosis. Oncology. 2007;73:395-400. REFERENCE #3: Lin CY, Chung FT. Central airway tumors: interventional bronchoscopy in diagnosis and management. J Thoracic Dis. 2016;8(10):E1168-E1176. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: 2014-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: 2019-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Advisory Committee Member relationship with Vapotherm, Inc Please note: 2020 Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Ken Dekitani, source=Web Response No relevant relationships by Michael Lewis, source=Web Response No relevant relationships by Roberto Mempin, source=Web Response No relevant relationships by Scott Oh, source=Web Response

Pulmonary anaplastic large-cell lymphoma: A case-based systematic review of world literature.

We describe a case of ALK1 negative (-) pulmonary anaplastic large-cell lymphoma (pALCL) in an adult female with an unfavorable outcome following combination chemotherapy and present a systematic review of 39 such sporadic cases reported over the past 28 years (1990-2018). pALCL occurred in 26 males and 13 females (median age, 43 years [5-81]) and 13/39 (33.33%) were ≤18 years. The lesions were endobronchial in 21 (53.85%) and parenchymal in 18 (46.15%) cases. Twenty-six cases were ALK1-; 13 were ALK1+ (positive); and 27/34 cases had a T cell phenotype (where tested). ALK- cases were characterized by higher age (P = 0.012) at presentation, more B symptoms (P = 0.002), and more parenchymal than endobronchial lesions (P = 0.039). The median survival (N = 29/39) was 60 months; pediatric group had a better survival than adult/elderly group (log-rank, P = 0.026). pALCL is rare and may have a distinct biological behavior.

A RARE CASE OF ENDOBRONCHIAL GRANULAR CELL TUMORS

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: Granular cell tumors are rare neoplasms primarily of neuroendocrine origin. They account for only 0.5% of soft tissue tumors. They most commonly occur in the head and neck region, with less than 10% of cases involving the respiratory tract. Due to their low prevalence, granular cell tumors are easily mistaken for more common tumors. This case highlights the presentation, diagnosis, and management of a patient with these rare tumors using a multidisciplinary approach. CASE PRESENTATION: A 41-year-old African American female smoker presented with atypical chest pain and dyspnea. Associated symptoms included fevers, chills, fatigue, cough productive of green sputum, and a 20 pound unintentional weight loss. She was hemodynamically stable with excellent oxygen saturation on room air. Physical exam was remarkable for slightly diminished breath sounds over the lower right lung field. CT chest demonstrated right hilar lymphadenopathy and a bulky, heterogenous 5.9 x 6.1 x 5.6 cm mass in the posterior medial right lower lobe. Bronchoscopy revealed several yellow, lobulated endobronchial lesions located in the right upper and lower lobes. Biopsies were obtained from both locations, resulting in PAS+, S100+, and SOX10+ stains. Fine needle aspiration (FNA) of hilar and mediastinal adenopathy was performed via endobronchial ultrasound (EBUS) and was negative for malignancy. The combined morphologic and immunohistochemical findings were determined to be consistent with a granular cell tumor.The case was presented at the hospital center's multidisciplinary thoracic conference with a recommendation for formal surgical evaluation. Cardiothoracic surgery performed a right video-assisted thoracoscopic surgery (VATS) exploration and second biopsy of the right upper lobe mass, with pathology again consistent with granular cell tumor. Definitive treatment for this patient concluded with a right pneumonectomy. DISCUSSION: Granular cell tumors are rare, slow growing tumors presenting most often in the head and neck region. Persons in their 4th-6th decade of life are most commonly affected, with an increased incidence in African American females. When pulmonary involvement occurs, granular cell tumors may present as an endobronchial lesion or small solitary lung mass less. Diagnosis requires tissue acquisition and immunohistochemical staining. Granular cell tumors are typically benign, with a malignancy rate of less than 3%. There is little evidence to support the use of chemoradiation in treatment of these tumors. Surgical resection offers the best therapeutic option for curative treatment. CONCLUSIONS: Granular cell tumors are rarely occurring pulmonary neoplasms with a lack of standardized management recommendations. This case illustrates a multidisciplinary approach to identification, evaluation, and management of these rare neoplasms. REFERENCE #1: Jobrack AD, Goel S, Cotlar AM. Granular Cell Tumor: Report of 13 Cases in a Veterans Administration Hospital. Military medicine. 2018 Sep 1;183(9-10):e589-e593. REFERENCE #2: Becelli R, Perugini M, Gasparini G, Cassoni A, Fabiani F. Abrikossoff's tumor. The Journal of craniofacial surgery. 2001 Jan;12(1):78-81. REFERENCE #3: Farooqui SM, Khan MS, Adhikari L, Doshi V. Multifocal Pulmonary Granular Cell Tumor Presenting with Postobstructive Pneumonia. Merrick DT, ed. Case Reports in Pulmonology. 2017:8513702 DISCLOSURES: No relevant relationships by Emily Breeding, source=Web Response No relevant relationships by Kelly Hill, source=Web Response No relevant relationships by Kari McCoy, source=Web Response No relevant relationships by Caroline Mears, source=Web Response no disclosure on file for Billur Samli

ENDOBRONCHIAL FOREIGN BODY ASPIRATION MIMICKING AN ENDOBRONCHIAL TUMOR

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Aspiration of foreign body (FB) into the airways may have an indolent presentation in adults. Although the majority of FB aspiration cases can be diagnosed easily and accurately by radiography and bronchoscopy, some patients are misdiagnosed as having endobronchial tumors. We describe an interesting case of bronchus intermedius FB that mimicked an endobronchial tumor. CASE PRESENTATION: A 61-year-old, male long-time heavy smoker with history of excessive alcohol use and stroke with residual left-sided hemiparesis presented with a 3-month history of worsening dry cough, hemoptysis and dyspnea. Chest computed tomography revealed occlusion of the bronchus intermedius with an enhancing lesion highly suspicious for an obstructing bronchial mass, along with moderate pleural effusion and enlarged subcarinal lymphadenopathy. Thoracentesis of the pleural effusion showed exudative fluid with predominantly neutrophilic cells that was negative for malignancy on cytology twice. Flexible bronchoscopy a firm, endobronchial lesion causing near total occlusion of the bronchus intermedius. Forceps endobronchial biopsy of the lesion and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of a subcarinal lymph node revealed no malignant cells. The patient then underwent flexible bronchoscopy with removal of the occluding lesion using cryoablation. The obstructing mass appeared to be freely movable when the cryoprobe was attached to it. A basket was used to retrieve the entire resected mass, which appeared to be an aspirated pill surrounded by granulation tissue on gross examination. Histopathology of the specimen showed no evidence of malignancy but was consistent with FB aspiration. DISCUSSION: Symptoms of FB aspiration in adults may be absent and often delayed, in some reports for up to 26 months. Dysphagia and impaired cough reflex are the main mechanisms for FB aspiration. This was likely the case in our patient with a history of stroke and excessive alcohol use. In case of such an indolent presentation and invisibility of the FB on chest imaging due to formation of granulation tissue, FB aspiration may be overlooked in adults. In our patient, this was further cofounded by the presence of pleural effusion and mediastinal lymphadenopathy, which were concerning lymphadenopathy, but were likely due to post-obstructive pneumonia. Bronchoscopic cryotherapy, which resulted in the correct diagnosis in this patient, has been described in the diagnosis of benign and malignant lesions of the airways and for recanalization. CONCLUSIONS: This case highlights the importance of suspecting FB aspiration when evaluating airway lesions. Choice of a noninvasive method, such as bronchoscopic cryotherapy, for removing an endobronchial lesion, may preclude the need for thoracotomy. REFERENCE #1: 1- Alharthi BJ, et al. Occult foreign body in the lung mimicking bronchogenic carcinoma. BMJ Case Rep. 2014;2014:bcr2014207438. Published 2014 Dec 17. doi:10.1136/bcr-2014-207438 REFERENCE #2: 2- Hewlett JC, et al. Foreign body aspiration in adult airways: therapeutic approach. J Thorac Dis. 2017 Sep;9(9):3398-3409. doi: 10.21037/jtd.2017.06.137. PMID: 29221325; PMCID: PMC5708401. REFERENCE #3: 3- Sehgal IS, et al. Use of cryoprobe for removal of a large tracheobronchial foreign body during flexible bronchoscopy. Lung India. 2016 Sep-Oct;33(5):543-5. doi: 10.4103/0970-2113.188978. PMID: 27625452; PMCID: PMC5006338. DISCLOSURES: No relevant relationships by Omar Abdulfattah, source=Web Response No relevant relationships by Muath Alsharif, source=Web Response No relevant relationships by Traves Crabtree, source=Web Response no disclosure on file for Keivan Shalileh

Diagnostic value of minimum-intensity projection computed tomography chest in diagnosis of endobronchial lesions

Background Fiberoptic bronchoscopy (FOB) is used to directly visualize the lumen of the trachea, as well as proximal and distal airways. It can be used to diagnose or treat abnormalities within or adjacent to these airways. However, it is an invasive procedure that may lead to several complications. Minimum-intensity projection (MinIP) in high-resolution computed tomography (CT) of the lungs is particularly useful because multiple lung diseases may present with reduced CT attenuation values. Patients and methods In this study, we included 115 patients admitted to the Chest Department, Mansoura University, Egypt. All patients were subjected to complete history taking, thorough physical examination, routine laboratory investigations, in addition to chest radiograph. CT and FOB were ordered for all cases. Results CT examination of the studied cases revealed mass in 43.5%, delayed resolved pneumonia in 30.4%, and collapse in 13% of cases. Furthermore, either of cavity, narrowing, or collapse was present in 4.3% of cases. Lesions were detected in the left lung in 43.5%, right lung in was 30.4%, and both lungs in 13% of cases. The sensitivity and specificity of MinIP was 69.4 and 100%, respectively, compared with FOB. The positive predictive value was 100%, whereas the negative predictive value was 71.4%, with an accuracy of 82.6%. The sensitivity of MinIP in the diagnosis was different according to the nature of the lesion. We found significant differences when comparing conventional CT with MinIP, especially in collapse, nodules, delayed resolved pneumonia, cavity, and narrowing. However, such a significant difference was not detected in the diagnosis of mass lesions. Conclusion We conclude that MinIP CT is a very important technique for detection of endobronchial lesion compared with conventional CT, and we recommend use of this technique when an endobronchial lesion is suspected.

A SOLITARY ENDOBRONCHIAL BRONCHOLITH AS AN UNCOMMON PRESENTATION OF HISTOPLASMOSIS

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Broncholithiasis refers to calcified material within the airway lumen, often resulting from granulomatous reaction to endemic pathogens such as M. tuberculosis or Histoplasma, or aspiration of foreign material. Histoplasma broncholiths are thought to originate from adjacent lymph nodes that erode into the airway lumen. Here we present a case of a large isolated endobronchial broncholith secondary to Histoplasma without associated lymphadenopathy or parenchymal lung lesions. CASE PRESENTATION: A 69 year-old female with GERD presented with one month of dyspnea, cough, and wheezing thought to occur after a popcorn kernel aspiration. She was treated twice for bronchitis without improvement and was diagnosed with COPD based on obstruction on spirometry. The patient denied smoking or other inhalational exposures. Vital signs and oxygenation were normal on our evaluation. A CT pulmonary angiogram showed a 1.3 cm calcified foreign body (FB) consistent with an aspirated tooth in the left mainstem bronchus without significant lymphadenopathy. Bronchoscopy showed a white-yellow multilobulated FB partially embedded in and nearly occluding the left mainstem bronchus. Removal of the FB revealed a deep but not transmural ulceration of the mucosa. Though it grossly resembled a popcorn kernel, histologic examination of the broncholith showed well-formed granulomas and yeast forms consistent with Histoplasma capsulatum. The patient felt immediate relief of dyspnea post-removal and on follow up denied any symptoms. She was discharged and scheduled for repeat testing to ensure no further evidence of fungal disease. DISCUSSION: Although broncholithiasis from Histoplasma granulomata is common, to our knowledge this is the first report of the disease presenting as a solitary endobronchial broncholith. Given that no adjacent lymphadenopathy and/or calcifications were noted on CT, this case was likely secondary to calcification of a primary endobronchial inoculum. Patients with symptomatic or obstructing broncholithiasis should undergo attempted removal either with bronchoscopy or surgical intervention. Bronchoscopic removal should be undertaken with great caution since the extraluminal origin of many broncholiths can result in airway perforation or major hemorrhage with manipulation. Large broncholiths such as this sometimes require laser lithotripsy to facilitate extraction. CONCLUSIONS: Broncholithiasis is a condition often associated with pulmonary and mediastinal histoplasmosis and can present with transmural bronchial invasion. Isolated endobronchial lesions are uncommon. Prompt imaging and endoscopic evaluation is key to accurate diagnosis. Careful consideration of transmural extension and involvement of extrabronchial structures is crucial. REFERENCE #1: Alshabani K, Ghosh S, Arrossi AV, Mehta AC. Broncholithiasis: A Review. Chest. 2019 Sep;156(3):445-455. REFERENCE #2: Krishnan S, Kniese CM, Mankins M, Heitkamp DE, Sheski FD, Kesler KA. Management of broncholithiasis. J Thorac Dis. 2018;10(Suppl 28):S3419-S3427. REFERENCE #3: Olson EJ, Utz JP, Prakash UB. Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med. 1999 Sep;160(3):766-70. DISCLOSURES: No relevant relationships by Gregory Eisinger, source=Web Response No relevant relationships by Molly Howsare, source=Web Response No relevant relationships by Meghana Moodabagil, source=Web Response No relevant relationships by Alberto Revelo, source=Web Response No relevant relationships by Konstantin Shilo, source=Web Response