Left Lower Pulmonary Lobe Research Articles

SAT560 A Case of Medullary Thyroid Carcinoma with Increasing Carcinoembryonic Antigen and Stable Calcitonin Levels

Abstract Disclosure: K.N. Youssef: None. L. Salej: None. A. Gavrila-Filip: None. Background: Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor arising from the parafollicular or C cells of the thyroid gland that secretes different tumor markers, including calcitonin (CT) and carcinoembryonic antigen (CEA). CT is only produced by parafollicular cells, while CEA is a non-specific marker produced in various normal tissues, such as epithelial cells of the gastrointestinal tract, lung, breast, and prostate. Different benign and malignant conditions are associated with elevated serum CEA levels. Clinical case: A 69 years-old active smoker male with a history of nasal squamous cell carcinoma (SCC) status post resection in the remote past and bilateral pulmonary nodules underwent total thyroidectomy for a thyroid nodule with FNA positive for medullary carcinoma. Surgical pathology revealed a unifocal 1.5 cm medullary carcinoma with clean surgical margins and no lymphadenopathy. Pre-operative studies included an elevated serum CT of 388 pg/mL (normal ≤ 10 pg/mL), normal serum calcium and PTH levels and a normal 24-hour urinary test for pheochromocytoma. Family history was irrelevant, and the RET proto-oncogene test was negative. Initial post-operative serum CT levels were undetectable and CEA levels were normal (0-4 ng/mL). CT levels increased slowly over the next five years and then they remained stable in the range of 32 to 45 pg/mL. Serum CEA started to rise progressively 7 years after the thyroid surgery up to 6.5 pg/mL. Follow-up neck ultrasounds showed no local recurrence or lymphadenopathy. An extensive evaluation was performed to search for possible MTC metastases and other etiologies for the elevated CEA levels. Bone scan was negative. Chest CT scans revealed enlarging small bilateral pulmonary nodules; stable calcified mediastinal lymph nodes were noted, consistent with chronic granulomatous disease. PET-CT scan showed pulmonary nodules, too small to characterize. The patient underwent a left lower pulmonary lobe robotic-assisted wedge resection. Surgical pathology revealed keratinizing SCC, though to represent primary lung SCC versus metastases from his prior nasal SCC. Upper endoscopy and colonoscopy with biopsy were negative for malignancy. On further workup, the patient was diagnosed with prostate adenocarcinoma and underwent surgery followed by external beam radiation with hormonal therapy. Serum CEA levels normalized one year after the prostate cancer treatment. Serum CT levels remained stable. Conclusion: In patients with MTC who show increasing serum CEA and stable CT levels during follow-up after the initial treatment, it is important to exclude other etiologies before concluding that this change is related to a progression of the medullary cancer. Reference: Carcinoembryonic Antigen. Kankanala VL, Mukkamalla SKR.2022 Jan 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Presentation Date: Saturday, June 17, 2023

Electroacupuncture pretreatment protects septic rats from acute lung injury by relieving inflammation and regulating macrophage polarization.

Macrophage polarization toward the M2 phenotype may attenuate inflammation and have a therapeutic effect in acute lung injury (ALI). To investigate the role of electroacupuncture (EA) pretreatment on the inflammatory response and macrophage polarization in a septic rat model of lipopolysaccharide (LPS)-induced ALI. Male Sprague Dawley rats (n = 24) were randomly divided into three groups (n = 8 each): control (Ctrl), ALI (LPS) and pre-EA (LPS + EA pretreatment). ALI and pre-EA rats were injected with LPS via the caudal vein. Pulmonary edema was assessed by left upper pulmonary lobe wet-to-dry (W/D) ratios. Lung injury scores were obtained from paraffin-embedded and hematoxylin and eosin-stained sections of the left lower pulmonary lobe. Inflammatory activation was quantified using serum tumor necrosis factor (TNF)-α, interleukin (IL)-1β, transforming growth factor (TGF)-β and IL-10 levels measured by enzyme linked immunosorbent assay (ELISA). Macrophage phenotype was determined by real-time quantitative polymerase chain reaction (RT-qPCR) and Western blotting. Mean lung W/D ratio was significantly lower and serum IL-1β levels were decreased in pre-EA rats compared to ALI rats (P < 0.05). TNF-α mRNA expression was decreased and mannose receptor (MR) and Arg1 mRNA expression was increased in the lung tissues of pre-EA rats compared to ALI rats (P < 0.01). Arg1 protein expression was similarly increased in the lung tissues of pre-EA rats compared to ALI rats (P < 0.05). EA pretreatment may play a protective role by promoting macrophage polarization to the M2 phenotype in a septic rat model of LPS-induced ALI.

Pulmonary metastasectomy for esophageal basaloid squamous cell carcinoma component at 66\u2009months after esophagectomy

BackgroundSolitary pulmonary metastasis from esophageal basaloid squamous cell carcinoma (BSCC) components is an extremely rare recurrence of esophageal squamous cell carcinoma (SCC).Case presentationA 68-year-old Japanese woman was found to have a suspected malignant mass, approximately 2 cm in diameter, in her left lower pulmonary lobe, at 66 months after undergoing a curative esophagectomy with three-field lymph node dissection for esophageal SCC with a focal basaloid component. After a CT-guided biopsy, pathological examination indicated a metastasis from esophageal BSCC components. She underwent a thoracoscopic partial resection of the left lower pulmonary lobe for the solitary pulmonary metastasis. The pathohistology of the resected specimen led to diagnosis of metastatic esophageal BSCC, which showed immunohistochemical findings similar to those of the primary esophageal carcinoma. The patient received two courses of adjuvant chemotherapy (5-fluorouracil, docetaxel plus nedaplatin) and recovered to resume a normal life with maintenance therapy. However, multiple lung and brain metastases were diagnosed at 2 years after the pulmonary metastasectomy. She survived 5 years and 6 months after the pulmonary metastasectomy, but died at 10 years and 6 months after her initial esophagectomy.ConclusionThis was a rare surgical resected case of solitary pulmonary metastasis from esophageal BSCC components.

BHD: Colon Cancer and Its Association With a Rare Genetic Syndrome

Burt-Hogg-Dube (BHD) is a rare autosomal dominant genodermatosis characterized by benign tumors of the hair follicle known as fibrofolliculomas, trichodiscomas and acrochordons, pulmonary cysts with recurrent and frequently spontaneous pneumothoraces, and increased susceptibility to renal cancers. We present a case of a woman who presented with early onset CRC and pulmonary cysts, and was found to have BHD on subsequent germline testing. Our goal is to promote the use of multi-gene tumor testing combined with a thorough family and personal history to diagnose underlying familial syndromes early, and subsequently modify screening protocols in those patients at risk for syndromic cancers. A 46yo woman was diagnosed with CRC via colonoscopy. Her mother had two spontaneous pneumothoraces; family history was otherwise unremarkable. Staging CT demonstrated a 0.4cm left lower lobe pulmonary nodule and small left lower lobe cysts vs pneumatoceles (see figure 1). Genomic tumor testing (Foundation Medicine, Cambridge, MA) reported tumor mutations in FLCN S333fs*56 and TP53 C238Y. She was referred to our institution's Genetic Clinic where she underwent multi-gene panel testing for inherited colon cancer genes, in addition to the FLCN mutation found in her tumor. A germline mutation in FLCN (S333fs*56) was confirmed and post-test counselling was performed. Multi-gene tumor testing can identify candidate genes for germline testing, to be used in combination with a good personal and family history to identify rare heritable cancer syndromes. In this case, the history of recurrent spontaneous pneumothoraces in the family coupled with the FLCN mutation identified in the tumor was suggestive of BHD.Although the association between BHD and CRC has not been yet established, any patient presenting with early onset cancer warrants a workup for a possible inherited familial syndrome as many syndromes are still poorly described. As the use of NGS broadens, more diagnoses of rare syndromes such as BHD will be made, and additional phenotypic manifestations may possibly be identified. The diagnosis of BHD in this patient necessitates increasing surveillance to monitor the evolution of her syndrome. Early diagnosis of inherited genetic syndromes is crucial to prevent unnecessary morbidity and mortality of patients, as many of these syndromes are associated with cancers that require stricter screening protocols, which can be implemented as soon as a diagnosis is made.1625 Figure 1. Chest CT with lower lobe pulmonary nodule and LLL cysts

P2.01-042 Perioperative Chemotherapy with Pemetrexed and Cisplatin for Pulmonary LCNEC: A Case Report and Literature Review

Pulmonary large cell neuroendocrine carcinoma (LCNEC) is associated with poor prognosis, and its treatment strategy is still controversial, especially chemotherapy regimens. Case Report: A 49-year-old Chinese male with primary pulmonary LCNEC treated by neoadjuvant and adjuvant chemotherapy with cisplatin plus pemetrexed was presented in this paper. A suspected quasi-circular mass in the left lower pulmonary lobe and an enlarged mediastinal lymph node were found. The patient was diagnosed with adenocarcinoma with neuroendocrine differentiation based on CT guided percutaneous lung biopsy. EGFR gene mutation test showed negative results. Cisplatin and pemetrexed were administered as the neoadjuvant chemotherapy regimen. The primary lesion had remarkably reduced and the enlarged mediastinal lymph node had disappeared after two cycles of neoadjuvant chemotherapy. He was performed left lower lobectomy and mediastinal lymph node dissection. The lesion was confirmed as LCNEC based on postoperative histopathological analysis and immunohistochemical results. The patient underwent four cycles of adjuvant chemotherapy with cisplatin and pemetrexed for a month postoperatively, followed by postoperative adjuvant radiotherapy. The patient is still alive after a follow-up of 24 months, with no evidence of tumor recurrence. Cisplatin combined with pemetrexed is effective and safe for patients with pulmonary LCNEC.

Aortic Aneurysm as a Cause of Hemoptyses

Infected aortic aneurysms are a clinical condition associated with high morbidity and mortality. Hemoptysis has been reported following erosion of the aneurysm into the lung parenchyma. We present a 79-years-old woman, with history of a pseudoaneurysm of the descending aorta submitted to an endovascular correction with tubular stent in 2010. She arrived at the emergency department, in January/2016, referring asthenia and weight loss, with three months of evolution, associated with small volume hemoptysis, that had begun that day. The patient presented anemia and with hypoxemic respiratory failure. Angio-CT scan revealed hematoma of the aneurysmal sac, without indication for urgent intervention. She was admitted at an intermediate care unit. The patient kept small volume hemoptysis. A new thoracoabdominal angio-CT was performed compatible with infectious process/abscess of the periprosthetic aortic wall, associated with areas of parenchyma necrosis of the left lower pulmonary lobe, that may be the origin of hemoptysis. Empirical antibiotic therapy was instituted with pipracilina/tazobactam and linezolid. A methicillin resistant Staphylococcus aureus was identified in bronchial lavage, and piperacillin/tazobactam was suspended. After 6 weeks of antimicrobial therapy, she presented clinical improvement. This case demonstrates the complexity of managing a patient in which the infectious focus control is not possible, given the high surgical risk in a patient with multiple comorbidities. Doubts remain about the antibiotic therapy to be maintained and its duration.

Pulmonary artery atresia with ventricular septal defect, segmental pulmonary hypertension, major aortopulmonary collaterals (MAPCAs) and giant MAPCA aneurysm

A 32-year-old woman with pulmonary artery atresia with ventricular septal defect (VSD) was admitted because of New York Heart Association (NYHA) class worsening from II to III during the last 6 months. The patient presented resting cyanosis, short 6-minute walk test (6MWT) distance (370 m with desaturation – baseline: 84%, after 6MWT: 67%). N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level was 194–262 pg/ml. She also suffered from significant kyphoscoliosis with stable chronic ventilation disturbances: forced vital capacity (FVC) = 1.38 l, forced expiratory volume in 1 s (FEV1) = 0.94 l, FEV1/FVC = 68%. Imaging methods (transthoracic echocardiography, transoesophageal echocardiography, magnetic resonance imaging – MRI, angio-computed tomography – CT) confirmed the presence of VSD (Figures 1 A, B), enlarged ascending aorta up to 49 mm above VSD and moderate aortic valve insufficiency. Angio-CT and MRI revealed occurrence of major aortopulmonary collaterals (MAPCAs) (Figure 1 C) with a giant aneurysm of one of them (Figure 1 D) and no pulmonary artery. Coronarography showed abnormality of the left artery descdending (LAD) orifice from the right coronary artery. We simultaneously excluded coronary and mammary artery to MAPCA shunts. The aortography followed by selective catheterization showed five MAPCAs: three on the left side (the one that supplied the left lower pulmonary lobe was stenosed in the proximal part) and two on the right side, among others a MAPCA creating a giant (6 cm) aneurysm (Figure 1 E). Each individual part of the lungs is supplied from a single source. In catheterization using a Swan-Ganz catheter we obtained the following outcomes: the mean collateral pressure was high in the MAPCAs that were not stenosed (69 mm Hg) and there was no response to iloprost (Figure 1 F); the mean collateral pressure was quite low in the stenosed MAPCA (14 mm Hg). According to single case reports and limited research [1, 2] and our hemodynamic outcomes, we prescribed bosentan, with quite a good clinical effect. During bosentan therapy the patient’s NYHA class decreased from III to II. The patient was disqualified from surgical treatment. In the literature we have found some reports of large MAPCA aneurysm diagnosed in vivo but not surgically treated [3] and one case concerning successful invasive treatment [4]. During 2-years follow-up we increased the dose of bosentan to 125 mg twice daily and we obtained a very good result. The patient is still in NYHA functional class II without any progression of pulmonary hypertension symptoms. There still remains the question whether the above described MAPCA aneurysm should be percutaneously occluded or surgically treated in prevention of aneurysm rupture and sudden death. Taking into account coexisting kyphoscoliosis and ventilation disturbances, the risk of interventions seems to be very high. Figure 1 Multimodality imaging: A – transthoracic echocardiography – parasternal long axis view, arrow: large VSD; B – CT scan, arrows: MAPCAs; C – CT scan, 3D reconstruction, arrow: MAPCA; D – CT scan, arrows: MAPCAs, arrow: ...

Le syndrome de Cushing paranéoplasique, un vrai défi diagnostique et thérapeutique : à propos d’un cas et revue de la littérature

IntroductionParaneoplastic Cushing's syndrome is a rare cause of endogenous hypercortisolism attributable to ectopic ACTH secretion by non-pituitary tumors. Imaging and biochemical results are often inconclusive and differential diagnosis with Cushing's disease can then be challenging. Moreover, these tumors may be occult and difficult to find and thus the need of new imaging tools such as 18FDG-PET scan and 18DOPA-PET scan. Case reportWe report a 50-year-old man who presented with very aggressive clinical features related to Cushing's syndrome. Biological work-up confirmed the hypercortisolism and was consistent with an ectopic ACTH secretion. Conventional localization techniques failed to show any tumor and bilateral adrenalectomy was performed because of life-threatening complications. Two years later, thoracic computed tomography reveals an 11 mm mass in the left lower pulmonary lobe, 18FDG-PET scan found a non-specific mild hypermetabolism of the lung nodule, and the 18DOPA-PET scan confirmed the high uptake of this nodule suggesting an endocrine carcinoma. Histology confirmed a typical carcinoid tumor. The tumor cells stained positive for ACTH, CD56, chromogranin and synaptophysin. ConclusionThis case illustrates the dilemma between the need for morphological diagnosis of the ectopic ACTH source and control of the life-threatening hypercortisolism. 18FDG-PET scan and 18DOPA-PET scan should be considered early as a secondary diagnostic tool when conventional imagery fails to show any tumor.

Bubbles in a Row: Finding of Pulmonary Arteriovenous Fistula on Transesophageal Echocardiography

A 31-year-old woman referred to evaluate the cause of sudden dizziness. She had no history of diabetes, hypertension, arrhythmias or stroke. Auscultation showed clear lung sound and no cardiac murmurs. Chest radiography and electrocardiogram did not show any abnormalities. Laboratory tests for hypercoagulability and vasculitis were all negative. In the previous hospital, she took brain magnetic resonance imaging, which revealed newly developed multiple right cerebellar infarction (Fig. 1). Transthoracic echocardiography and transesophageal echocardiography (TEE) for the evaluation of embolic source showed the right-to-left shunt, but the cause of shunt was inconclusive. After transfer, we repeated contrast echocardiography using agitated saline and reaffirmed a delayed appearance of a substantial amount of microbubbles in the left atrium (Fig. 2). However, we could not depict a passage of microbubbles through the gap between interatrial septum to confirm the presence of patent foramen ovale (PFO). Thus, we evaluated all the pulmonary veins, one by one during TEE and finally revealed the microbubbles in a row coming from the left lower pulmonary vein (Fig. 3 and Supplementary movie 1). These findings suggested the presence of a pulmonary arterio-venous fistula (PAVF) in the left lower pulmonary lobe, possibly causing paradoxical embolisms. The diagnosis was confirmed by a computed tomography pulmonary angiography which revealed the fistula located posteriorly in the left lower pulmonary lobe (Fig. 4, arrow). After successful occlusion of the fistula, the patient was discharged with warfarin. Fig. 1 Diffusion-weighted magnetic resonance imaging of brain shows multiple high-intensity signals in the right cerebellum. Fig. 2 Contrast transthoracic echocardiogram illustrating delayed right-to-left passage of agitated saline contrast (microbubbles) in left atrium and left ventricle. Fig. 3 Color flow imaging of transesophageal echocardiogram showing the inflow from left lower pulmonary vein (LLPV) and left upper pulmonary vein (LUPV). Contrast echocardiogram showing microbubbles in a row (arrows) draining into left atrium from LLPV but ... Fig. 4 Chest computed tomography angiogram with volume rendered reconstruction showing the fistula (arrow) located posteriorly in the left lower pulmonary lobe. Both PFO and PAVF could contribute to the development of right-to-left shunt.1) Presence of PAVF and the draining pulmonary vein could be accurately identified by TEE. We need to routinely examine the presence of PAVF during TEE in the evaluation of embolic source.

Paciente com sequestro pulmonar intralobar: uma rara anomalia congênita

Paciente do sexo masculino, com 51 anos de idade, com história de pneumonias de repetição desde a segunda década de vida. As radiografias de tórax curiosamente demonstravam o mesmo padrão radiológico com envolvimento do lobo inferior esquerdo. Foi realizada tomografia helicoidal de tórax, que revelou vaso arterial anômalo emergindo da aorta torácica descendente em direção ao lobo pulmonar inferior esquerdo, caracterizando sequestro pulmonar. Os achados foram confirmados por aortografia torácica, sendo o paciente encaminhado para tratamento cirúrgico.

A Patient with Intralobar Pulmonary Sequestration: A Rare Congenital Anomaly

A 51-year-old male patient had a history of recurrent pneumonia since the second decade of life. Interestingly enough, chest X-rays showed the same radiological pattern with involvement of the left lower lobe. A multislice spiral CT scan of the chest was performed and depicted an anomalous arterial vessel emerging from the descending thoracic aorta towards the left lower pulmonary lobe, characterizing pulmonary sequestration. The findings were confirmed by thoracic aortography, and the patient was referred for surgical treatment. Paciente com Sequestro Pulmonar Intralobar: Uma Rara Anomalia Congênita Paciente do sexo masculino, com 51 anos de idade, com história de pneumonias de repetição desde a segunda década de vida. As radiografias de tórax curiosamente demonstravam o mesmo padrão radiológico com envolvimento do lobo inferior esquerdo. Foi realizada tomografia helicoidal de tórax, que revelou vaso arterial anômalo emergindo da aorta torácica descendente em direção ao lobo pulmonar inferior esquerdo, caracterizando sequestro pulmonar. Os achados foram confirmados por aortografia torácica, sendo o paciente encaminhado para tratamento cirúrgico.

Congenital Peribronchial Myofibroblastic Tumor: A Case Report

We describe a rare occurrence of congenital peribronchial myofibroblastic tumor of the lung presenting in early fetal life. A female patient in the 24th week of gestation who presented with polyhydramnios was admitted for examination. Ultrasound examination revealed a mass compromising the lungs. Because the intrauterine fetal death was revealed by the ultrasound, delivery was induced. Necropsy revealed a pulmonary lesion compromising the left lower pulmonary lobe together with hepatomegaly. Microscopic analysis of the lung showed a lesion with a storiform arrangement of spindle cells with focal peribronchial distribution. Hepatic architecture was diffusely altered by fibrotic tissue. Immunohistochemical analysis on the pulmonary lesion showed high vimentin positivity in the fusocellular components, pointing to the mesenchymal nature of the lesion. Significant differentiation of smooth muscle tissue, as indicated by high HHF35 positivity, was also observed. Electron microscopy on the pulmonary lesion revealed elongated cells with some cytoplasmatic processes, a finding that is also compatible with mesenchymal differentiation.

Macrocystic Lymphatic Malformation in the Pulmonary Parenchyma

We present a young girl with a diffuse, macrocystic lymphatic malformation with associated venous dilation involving the left lower pulmonary lobe and mediastinum. Recurrent hemoptysis necessitated left lower lobectomy. This is the first reported case of a macrocystic lymphatic lesion with venous anomalies located within the parenchyma of the lung.

Rezidivierender pulmonaler Rundherd bei Colitis ulcerosa

A 46-year-old patient with ulcerative colitis, known since she was 27 years old, was found to have a mesenteric granulomatous necrotizing inflammation containing acid-fast bacilli ten years ago. Treatment against tuberculosis was initiated. The ulcerative colitis was treated with mesalazin and, in times of peak activity, additionally with prednisolon. During periods of chronic activity the patient received azathioprin. Six years ago a solitary pulmonary nodule (coin lesion) was detected radiologically in the inferior lobe of the left lung. Laboratory investigations revealed mild inflammation (CRP 1.5 mg/dl). Computed tomography showed a solitary nodule in the left lower pulmonary lobe (diameter 27 mm). Fungi, actinomyces and mycobacteria were not found. The pulmonary nodule was resected. During the following years several relapses occurred. After the second relapse lobectomy was performed revealing mycobacterial DNA (not further identified). Treatment against non-tuberculous mycobacteria with clarithromycin, rifampicin and ethambutol was started for 12 months. A third relapse in the form of another solitary pulmonary node occurred one year later. But this nodule regressed spontaneously in part without any additional therapy. In this case the spontaneous regression after the third relapse may represent better control of the ulcerative colitis. An infection seems less likely retrospectively.

Pancoast Hydatid Cyst Leading to Horner Syndrome

Fig. 1. (A) Preoperative chest X-ray showing: (1) the leftward displacement of the heart, (2) a linear shape of the left cardiac silhouette (arrow), and (3) a flattened right cardiac silhouette by erasure of its normally lower convexity (solid arrow). (B) Operative surgeon’s view after median pericardiotomy showing congenital partial absence of the left pericardium; note the inferior left lower pulmonary lobe (asterisk).

A scanning electron microscopy analysis of a spontaneous hemodialysis catheter fracture

Central venous catheters have become increasingly important in hemodialysis treatment. With their increased use, catheter-related problems will be seen more frequently, and more rare complications may be observed. We describe the first case of asymptomatic spontaneous breakdown of a tunneled cuffed silicone catheter used for long-term hemodialysis treatment. This was discovered on removal of the catheter, leaving behind a catheter fragment in the left lower pulmonary lobe. An extensive scanning electron microscopy study showed accumulation of lumps of nonsilicone material at the place of the fracture, leading to severe disruption of the original cross-linked elastomer structure. Using energy-dispersive X-ray spectral analysis, which shows all elements with an atomic number of 11 or greater in a material, we found the lumps were aggregates of barium sulfate particles used to visualize the catheter on fluoroscopy. We suggest that the use of too small or too many barium sulfate particles led to high viscosity of the raw silicone before polymerization, causing improper mixing of barium sulfate particles in the silicone matrix. This resulted in insufficient removal of admixed air bubbles and unequal dispersion of barium sulfate, with the potential for weak spots after extrusion of the silicone into its definitive shape. With the increasing use of hemodialysis catheters for prolonged periods, catheter-related complications related to materials or manufacturing errors can be expected to occur more often. © 2001 by the National Kidney Foundation, Inc.

Liver tumors and minimally invasive surgery: a feasibility study.

Laparoscopic liver resection has not yet been established, although recent reports document that liver resection can be performed safely by the laparoscopic approach. Other interventional procedures like cryoablation have also been introduced in treatment of liver metastases. In this report 11 liver resections performed laparoscopically in eight patients are presented. Six patients had colorectal metastases, one a metastases from a malignant melanoma, and one patient had focal nodular hyperplasia. Two patients received synchronous cryoablation of remaining liver metastases. During follow up, two patients received percutaneous cryoablation of liver recurrences monitored by an open configuration magnetic resonance scanner. All except one of the tumors we attempted to remove had free resection margins (re-resection of new metastasis). No complications occurred except an atelectasis of the left lower pulmonary lobe in one patient. Median postoperative hospital stay was 3 days, and median postoperative opioid-dependent days was 1. The report demonstrates that minimally invasive techniques may safely be combined in hepatic intervention, and that the advantages of minimally invasive surgery, such as reduced hospital stay and less patient discomfort, also applies to liver resections.

Ocular Aspergillosis Isolated in the Anterior Chamber

In all cases in which ocular involvement has been reported in endogenous aspergillosis, the posterior segment of the eye was involved. The authors examined a patient who had been intubated and treated with corticosteroid therapy for status asthmaticus and in whom a mass later developed in the anterior chamber of the right eye. Computed tomography showed a solitary lesion in the left lower pulmonary lobe and multiple brain lesions that enhanced with contrast. Aspergillus fumigatus was cultured from the endotracheal tube. However, ocular and blood cultures were negative, as were the results of a bone marrow biopsy, lung biopsy, and anterior chamber paracentesis. Disseminated aspergillosis was confirmed when a biopsy of the anterior chamber mass was performed, and results of histopathologic examination showed the presence of hyphae. The patient responded to a regimen of antifungal drugs. This is the first known reported case in which the diagnosis of disseminated aspergillosis was confirmed with biopsy of an anterior chamber mass. This case demonstrates that Aspergillus organisms may disseminate to the anterior chamber of the eye without involving the posterior segment.

Branches of the Left Pulmonary Artery Supplying the Basal Segments of the Lung

The studies were carried out on 100 left lungs taken from dead human bodies of both sexes whose age varied from 16 to 80 years. The pulmonary artery and the bronchus were injected with a 65% solution of duracryl and then digested in sulfuric acid. The specimens obtained were then examined to determine the number and dimensions of the branches of the basal portion of the left pulmonary artery penetrating into the basal segments of the left lower pulmonary lobe. Their length was 60 mm at the most, and their diameter 9.8 mm. Three types of ramification of the basal portion of the left pulmonary artery were distinguished on the basis of the trunks, segmental and subsegmental branches present. In 70% of the cases the branches penetrating into the basal segments showed tree-like type, in 3% of the cases showed bushy-like type, and in 27% of the cases middle type.

Fetal pulmonary hypoplasia with hydrothorax

Described is a case of fetal congenital malformation with hydrothorax, for which left pulmonary hypoplasia was initially presumed by ultrasonography and for which hypoplasia was diagnosed postnatally only in the left lower pulmonary lobe by a pulmonary technetium Tc-99m scintigram. The pathogenesis of this disease is discussed.