Left Pulmonary Lobe Research Articles

Esophageal pulmonary fistula \u2013 a rare complication of radiation therapy: a\xa0case report

BackgroundEsophageal respiratory fistulae are abnormal communications between the esophagus and the respiratory system. They are either congenital or acquired. Most acquired esophageal respiratory fistulae are of the esophageal tracheal and esophageal bronchial type and are caused by infections or malignant neoplasms, whereas esophageal pulmonary fistulae are rare.Case presentationWe report a case of a 72-year-old Caucasian man with squamous cell carcinoma of the lung presenting with abrupt-onset dyspnea during localized mediastinal radiotherapy. His laboratory test results suggested major respiratory infection. A chest x-ray revealed left apical lung radiopacity along with excavated lesions, consistent with secondary tumor infection. No clinical improvement was observed despite antibiotic treatment. A contrast-enhanced computed tomographic scan of the chest confirmed persistent lung infection with unfavorable progression and air in the mediastinum; the latter suggested a fistula from the upper third of the esophagus to the upper left pulmonary lobe. Videofluoroscopy confirmed the diagnosis of an acquired esophageal pulmonary fistula. The patient underwent endoscopy, and an esophageal self-expandable metallic stent was deployed.ConclusionsEsophageal pulmonary fistulae must be suspected whenever patients undergoing local mediastinal radiotherapy present with acute pulmonary complications, particularly pneumonia resistant to antibiotic treatment. Esophageal pulmonary fistulae are diagnosed by means of radiological imaging. Because esophageal respiratory fistulae are acute life-threatening conditions, prompt treatment with an endoscopically placed covered stent proves vital.

Giant thymoma successfully resected via median sternotomy and anterolateral thoracotomy: a case report

BackgroundSome patients with thymoma present with a very large mass in the thoracic cavity. Although the most effective treatment for thymoma is surgical resection, it is difficult to perform because of the size of the tumor and the infiltration of tumor into the surrounding organs and vessels. We report a patient with a giant thymoma that was completely resected via a median sternotomy and left anterolateral thoracotomy.Case presentationA 63-year-old woman presented with a mass in the left thoracic cavity that was incidentally found on a chest X-ray. Chest computed tomography revealed a giant mass (16 × 10 cm) touching the chest wall and diaphragm and pressed against the heart and left upper pulmonary lobe. Complete resection was performed via a median sternotomy and left anterolateral thoracotomy. The tumor was histologically diagnosed as a WHO type B2 thymoma, Masaoka stage II.ConclusionsGiant thymomas tend to grow expansively without invasion into surrounding organs and vessels. Surgical resection that employs an adequate approach must be considered, regardless of the size of the tumor.

Late gastrobronchial fistula postsleeve gastrectomy

A 50-year-old woman presented to the emergency department with a 1-day history of hemoptysis and a deteriorating general condition over the previous month. She took a self-prescribed nonsteroidal anti-inflammatory drug. Her chief surgical history consisted of a sleeve gastrectomy 5 years previously when her body mass index (BMI) was 42 kg/m2 without metabolic co-morbidities, complicated by staple-line gastric leak at the esophagogastric junction, treated successfully by 2 endoscopic stents. A thoraco-abdominal computed tomography scan with oral contrast found a gastrobronchial fistula (Fig. 1). The original fistula had extended across the diaphragm into the left inferior pulmonary lobe. The patient’s BMI was 23 kg/m2. For this rare complication [ 1 Silva L.B. Moon R.C. Teixeira A.F. et al. Gastrobronchial fistula in sleeve gastrectomy and Roux-en-Y gastric bypass--a systematic review. Obes Surg. 2015; 25: 1959-1965 Crossref PubMed Scopus (24) Google Scholar , 2 Sakran N. Assalia A. Keidar A. Goitein D. Gastrobronchial fistula as a complication of bariatric surgery: a series of 6 cases. Obes Facts. 2012; 5: 538-545 Crossref PubMed Scopus (28) Google Scholar ], a surgical solution was chosen after a multidisciplinary discussion. Eight days after medical preparation by parenteral nutrition and noninvasive ventilation, she underwent surgery. The first step was a posterolateral left thoracotomy through the sixth intercostal space for a left inferior lobectomy (Fig. 2A). The second step was a total gastrectomy through a left subcostal incision (Fig. 2B) with a Roux-en-Y limb and a jejunostomy. Her postoperative course was smooth. At 1 month follow-up, she was on a full oral diet with a BMI 23.5 kg/m². Fig. 2(A) Left inferior lobectomy with the fistula. (B) Fistula on the esophagogastric junction after sleeve gastrectomy. View Large Image Figure Viewer Download Hi-res image

Pulmonary lobe eventration in a dog: case report

A mixed breed dog, six years old was referred, after an episode of thoracic trauma bite, with posterior swelling in the thoracic region, to perform chest radiographs due to dry cough after physical exertion or dorsal position. Through radiographs, pulmonary protrusion through the fifth left intercostal space was observed. Thoracotomy and resection of cranial portion of the left cranial pulmonary lobe and eventration repair were performed. Postoperative chest radiographs confirmed the normal expansion of the remaining left cranial lobe. The intercostal eventration should be considered a differential diagnosis in cases of increased thoracic volume and episodes of trauma.

Infarction of left upper pulmonary lobe after patent ductus arteriosus surgery in a preterm neonate

Patent ductus arteriosus (PDA) in preterm babies is common and related to high morbidity and mortality if left untreated. Although its optimal management is still debated, surgical ligation or clipping remain the only available options for pharmacologically unresponsive PDAs. The surgical procedure adds its own risk to this fragile population. We report the first case of premature neonate with a left upper pulmonary lobe venous infarction, following PDA ligation.

Congenital malformations and other reproductive losses in goats due to poisoning by Poincianella pyramidalis (Tul.) L.P. Queiroz (=Caesalpinia pyramidalis Tul.)

In the semiarid region of Brazil, in areas with vegetation composed mainly of Poincianella pyramidalis, several cases of congenital malformation and reproductive losses were observed in goats and sheep from 2012 to 2014. To determine the teratogenic effect of P. pyramidalis, two groups of eight goats each were used. Goats from Group 1 received fresh P. pyramidalis, harvested daily, as the only roughage during the whole breeding and pregnancy period. Goats in Group 2 (control) received Cynodon dactylon (tifton) hay free choice. Ultrasound examination for pregnancy diagnosis was performed every 28 days. Four goats from Group 1 were pregnant on day 28 but not on day 56, suggesting embryonic death or abortion. Another goat from Group 1 died at day 70 of pregnancy, and the fetuses exhibited micrognathia. The other three goats bore six kids, three of which showed bone malformations in the limbs, spine, ribs, sternum, and head, including arthrogryposis, scoliosis and micrognathia. One kid also showed hypoplasia of the left pulmonary lobes. In the control group, all goats bore a total of 13 kids and none of them exhibited malformations. These results demonstrated that P. pyramidalis causes congenital malformations and other reproductive losses in goats.

Video-assisted thoracoscopic segmentectomy of lingual segment of the left upper pulmonary lobe for chronic focal bronchiectasis.

A 46-year-old male patient was admitted into the hospital due to repeated hemoptysis for more than seven months. Bronchiectasis of the left upper lobe was considered based on the symptoms, signs, and imaging findings. Thoracoscopic resection of lingual segment of the left upper pulmonary lobe was finally performed in the order of the lingual segmental vein, the lingual segmental bronchus, the lingual segmental artery, and the pulmonary tissues of the lingual segment. Total surgery time was 60 min and blood loss was 40 mL. The chest tube was removed on the 4th postoperative day. The patient was discharged home on the 8(th) postoperative day.

Robotic-assisted segmentectomy of lingual segment of the left upper pulmonary lobe.

The patient was admitted due to “repeated hemoptysis for more than half a year”. The patient began to cough up blood about 6 months ago. The blood was bright red in color, and the patient spitted about 6 times during each attack. She spitted up fresh blood again one month ago and received antiinflammatory and hemostasis treatment in a local hospital. Then, she visited our hospital for further management. She did not suffer from fever. Her physical performance was normal, and the body weight did not obviously change.

Unidirectionally progressive resection of left upper pulmonary lobe under video-assisted thoracoscopy.

The case is a nodule in the upper left lobe, and intraoperative frozen section pathological diagnosis on the removed nodule confirmed well differentiated mucinous adenocarcinoma. Unidirectionally progressive resection of the left upper pulmonary lobe under video-assisted thoracoscopy is selected as the surgical method. Right below the operation hole, surgeons gradually advanced in one direction, and dissociated and divided in such order: the upper left pulmonary vein, the upper left lobe bronchus, the upper left pulmonary arterial branches and the fissures. Endoscopic linear cutters and hem-o-lok clip applicator were used to deal with the blood vessels, bronchus, and under-differentiated fissures. At last, the removed upper left lobe was put into a size eight sterile glove and taken out through the main operation hole. General anesthesia with double-lumen endotracheal intubation is used. The patient took a 90 degree decubitus on his contralateral side. The surgeons were on the ventral side of the patient, and operated with endoscope apparatus under the monitor.

Radical treatment for left upper-lobe cancer via complete VATS.

Along with the development of video-assisted thoracic surgery (VATS), its role in radical treatment is basically the same as the conventional open surgery. Meanwhile, as a minimally invasive technique, it can achieve quick recovery. Nowadays the value of VATS has been globally recognized, and its indications have been further expanded. The common procedures of VATS lobectomy include anatomic lobectomy, single-direction lobectomy, simultaneous stapling, and retrograde lobectomy. Retrograde lobectomy is particularly useful for patients who are not feasible for anatomic lobectomy due to the swollen lymph nodes at the hilum of lung or because the tumors have invaded the pulmonary artery. This article describes a 60-year-old female patient with left upper lobe carcinoma who underwent complete VATS retrograde lobectomy due to swollen lymph nodes at the hilum of lung. Chest CT indicated a shadow at the left upper pulmonary lobe, along with swollen lymph nodes at the hilum of lung. The mass invaded the first branch of the pulmonary artery. Retrograde lobectomy was then performed. The postoperative recovery was good. Pathology showed an invasive adenocarcinoma at the left upper lung, along with lymph node metastases at the hilum of lung and mediastinum. No cancer was found at the bronchial stumps and vascular stumps. Complete VATS retrograde lobectomy is safe and feasible for patients with swollen lymph nodes at the hilum of lung.

Primary lung adenocarcinoma occurring in a PTEN related syndrome (Cowden's disease): Routine EGFR sequencing also highlights two rare somatic mutations S768I and V769L

Cowden's syndrome is a rare autosomal dominant disorder that has been linked to germline mutations in the phosphatase and TENsin homolog (PTEN) gene. PTEN is a tumour suppressor gene that negatively regulates the PI3K–AKT–mTOR pathway. Cowden's syndrome is a multi-system disease with increased risks for a number of malignancies but very rarely for lung cancer.A systematic follow-up chest CT scan was performed to a 42 year's old female, light smoker. It showed a 20mm opacity of the left upper pulmonary lobe. Differential diagnose with benign tumours (such as hamartoma) was carefully searched. Procedures led to the diagnosis of a primitive lung adenocarcinoma. EGFR sequencing shows two rare somatic mutations (S768I and V769L).Lack of expression of PTEN is a non-sufficient condition leads to lung cancer formation alone. Nevertheless, it increases cell oncogenic potential. PTEN lacking in non small cell lung cancer is a frequent issue. It could be an alternative mechanism of non-efficacy of EGFR-TKI in cells with a sensitizing EGFR mutation.This case report, a very rare entity: a patient with a PTEN germline mutation and a lung adenocarcinoma harbouring two concomitant rare somatic mutations of EGFR. This observation comforts PTENs role in lung oncogenesis.

Pulmonary vein spontaneous echocontrast and stroke after pulmonary lobectomy

Assessment of possible cardiac sources of cerebral embolism is a frequent indication for transesophageal echocardiography. We report the case of a patient with a previous left upper pulmonary lobe resection who presented with an ischemic stroke suggestive of cardioembolic origin. A dense spontaneous echo contrast was found in the left upper pulmonary vein stump, which, in the absence of other potential causes of stroke, was considered to be related to the embolic event. We discuss the clinical significance of this finding as a possibly underappreciated source of systemic embolization.

Use of computed tomography and silicon endocasts to identify pulmonary veins with echocardiography

The pulmonary veins were identified from the silicone endocast heart models of 19 dogs. Although variation in the number of the more peripheral veins on each specimen existed, all of the casts had a consistency with regards to the most proximal coalescence of the pulmonary veins as they entered the body of the left atrium. That is, the confluence of the veins formed three ostia at the atrial entry point that consisted of 1) right cranial and right middle pulmonary lobe veins; 2) right caudal, accessory, and left caudal pulmonary lobe veins; and 3) both the left cranial and left caudal pulmonary lobe veins of the left cranial lung lobe. The location of these structures identified by the 3-dimensional endocasts were then used to assist in the identification of the pulmonary veins using computed tomography of 2 dogs. Slices were made that approximated those commonly performed during echocardiographic examination. Understanding which pulmonary veins are seen by echocardiography in the different imaging planes will permit prospective evaluations of pulmonary vein size and abnormal flow patterns.

Mid-term follow-up of interventional closure of atrial septal defect using Solysafe™ Septal Occluder — Impact of standardized fluoroscopy for complication detection

Interventional closure of secundum type atrial septal defects (ASD II) and patent foramen ovale (PFO) has been developed as standard of care for the majority of pediatric patients, with different types of occlusion devices available [1]. The SolysafeTM Septal Occluder (Swissimplant AG, Solothurn, Switzerland) has been developed for interventional closure of ASD II and PFO and has been evaluated in clinical studies for adult [2,3] and pediatric patients [4]. In August 2010, due to a voluntary recall of SolysafeTM Septal Occluder (SSO) by Swissimplant caused by sporadic clinical reports about irregularities of the device in follow-up controls the use of SSO stopped immediately [www.swissimplant.com]. Therefore, we analyzed the incidence of irregularities associated with SSO during mid-term follow-up in our institution by analyzing patients after successful implantation of SSO. Criteria for ASD closure using SSO were size of balloon stretched ASD diameter between 5 and 25 mm, relevant left to right shunt, determined by Fick with Qp: Qs≥1.5:1, and/or echocardiographic signs of right atrial or right ventricular volume overload. The procedure was performed as recently published [2,4]. Post-procedural follow-up included clinical assessment, transthoracic echocardiography, electrocardiography (ECG) including Holter. Data are presented as mean±standard deviation, range, and percentages. We focussed our analysis on the results of standardized fluoroscopic loops recorded after recall of the device in August 2010. We performed four radiographic views (straight anterior posterior, straight lateral, lateral and en-face profile of the device) as recommended by the company. SSO were successfully implanted in 51 pediatric patients (male: female=24:27) at an age (mean±SD) of 8.0±4.6 years (range 1.6– 17.8 years) and a bodyweight of 29.1±18.1 kg (9.5–86) between April 2007 and June 2010. ASD II presented as solitary defects (n=39), two defects (n=11), or multiple defects (n=1) with a significant left to right shunt: Qp:Qs=1.7±0.7 (1.0–4.0), native and balloon stretched size of 10.0±3.9 mm (5–20) and 12.5±4.7 mm (6.5–23), respectively, determined by transesophageal echocardiography. During midterm follow-up of 2.1±0.9 years (0.5–3.7), patients were clinically asymptomatic and echocardiography revealed a complete closure rate of 94.9% (48 of 51 patients). All patients were clinically asymptomatic, routine ECG and Holter ECG did not show any significant findings. Transthoracic echocardiography did not reveal signs of wire fractures. But, fluoroscopy showed new complications in two patients (3.9%), not determined by transthoracic echocardiography before. The cases are presented in the section below. In a 7.9-year-old boy a 25 mm SSO was implanted. Left-to-right shunt (Qp:Qs) was 1.6 to 1. Two defects with a native size of 11 mm and 3 mmwere found in trans-thoracic echocardiography. The balloon stretched diameter of the larger defect was 16 mm and completely occluded both defects during balloon sizing. The post-procedural course was uneventful, transthoracic echocardiography did not reveal any residual shunt. But, two years after implantation, fluoroscopy revealed a fixed singular fracture of one wire loop not leaving the perimeter of the occluder occurred (Fig. 1). Without any further therapeutic consequences, the patient is still asymptomatic after six months follow-up including normal Holter electrocardiography. In a second boy (age 5.0 years, body weight 19 kg) 30 mm SSOwas implanted in a solitary central defect with native and stretched diameter of 20 and 23 mm, respectively. During follow-up a small residual shunt remained. Two years later, fluoroscopy visualized multiple fractures of wire loops on both sides of the device, with embolization of wire parts to the left and right pulmonary lower lobe artery (Fig. 2). Due to fractured wire ends striking out of the septum on both sides causing injury of the anterior mitral valve leaflet, cardiac surgery was performed with complete explantation of the SSO including successful mitral valve repair and patch closure of the ASD (Fig. 3). Postoperative course and further follow-up was uneventful (N6 months). In the past, fractured legs of ClamshellTM devices have been frequently seen, but did not lead to significant complications over a 12 year follow-up [1]. Similarly, fractures in the CardioSEALTM and STARFlexTM devices have been described, but the incidence and the

Tc-99m MAA Findings in Dilated Cardiomyopathy With Partial Anomalous Venous Connections

Tc-99m MAA showed asymmetric uptake in the lung field in a 21-year-old man with dilated cardiomyopathy. CT revealed partial anomalous venous connections in the left upper lobe. Angiogram of the left pulmonary upper lobe showed all the contrast material drained into the left vertical vein. The possible cause of relative increase in the left upper lobe blood flow is that right pulmonary blood flow is slowed by the high pressure in the left atrium due to dilated cardiomyopathy, whereas the flow from the left upper lobe drains into the superior vena cava which has less pressure than left atrium.

Paraneoplastic polymyositis associated with primary lung cancer: diagnosis with PET-CT

0212-6982/$ see front matter © 2010 Elsevier Espana, S.L. and SEMNIM. All rights reserved. A 63-year-old male was studied for cough, dysphagia, fever, pain and functional impotence of both shoulders. He presented an elevation in serum creatinin phosphokinase (42.150 IU/L, normal range: 25-90) and acute phase reactants. A pulmonary nodule was observed on chest radiography, being confirmed by CT in the upper left pulmonary lobe suggestive of malignancy. Non significant millimetric lymph nodes and a right apical pulmonary lesion were observed probably in relation to chronic changes. PET-CT with 18F-FDG was performed showing two nodules in the anterior segment of the upper left lobe (fig. 1) and the posteriorapical segment of the upper right lobe of 2.1 and 1.4 cm, respectively, both of which were hypermetabolic (SUVmax. 2.7 and 2.8) suggestive of malignancy. Likewise, an important diffuse increase in glycidic metabolism was observed in the muscular system (fig. 2) compatible with polymyositis, considering the absence of a history of diabetes and normal glycemia values (103 mg/dL) prior to the injection of 18F-FDG after 12 h of fasting. The left wall of the esophagus showed focal augmentation of glycidic metabolism (SUVmax. 7.2) of 0.8 cm in diameter (fig. 3) compatible with muscular activity without pathological significance, although evaluation was recommended due to the impossibility of ruling out neoplastic disease at this level in view of the clinical manifestations of dysphagia presented by the patient. Fine needle aspiration puncture and prognostic mediastinoscopy were performed with anatomopathological results of pulmonary adenocarcinoma. On evaluation by the Neurology Department by cervical magnetic resonance, electromyogram and blood analysis, the patient was diagnosed with inflammatory myopathy or probable paraneoplastic origin. Upper digestive endoscopy did not show either intraluminal lesion or extrinsic compressions, with the esophageal lesion being labeled as probable paraneoplastic muscular involvement. Initial corticoid treatment was implemented with clinical and analytical improvement, although functional impotence and dysphagia persisted. Chemotherapy was begun on the patient not being a candidate for surgery due to the contralateral pulmonary metastasis. Polymyositis may be of neoplastic origin in up to 20 % of the cases.1 PET-CT with 18F-FDG has shown to be useful in the study of paraneoplastic syndromes to confirm and localize the primary tumor.2 The typical finding is an augmentation of glycidic metabolism in the muscular masses affected by inflammation of the same and usually has a good correlation with the clinical manifestations, also allowing localization of the primary tumor and its extension.3 The case presented here was a pulmonary carcinoma, one of the malignant tumors most frequently related to paraneoplastic polymyositis. PET demonstrated the typical findings of this disease. We believe that PET-CT may be a first choice technique on suspicion of paraneoplastic inflammatory myopathy. Interesting image

Endovascular stent-graft implantation for a cecum of an aberrant artery from a systemic arterial supply to the basal segment of the left pulmonary lobe

A 64-year-old man with a history of repeated pneumonia underwent left lower lobectomy with a diagnosis of a systemic arterial supply to the basal segment of the left pulmonary lobe. Three months after the operation, follow-up computed tomography revealed a large cecum of the stump of the feeding artery. We performed endovascular aortic repair for the cecum.

Sternoclavicular Joint Infection Necessitating Through Skin and Lung Parenchyma

Infections of the sternoclavicular joint associated with extensive local soft tissue involvement or abscess formation often require surgical debridement and drainage. This condition typically presents with joint pain, local erythema, and swelling. This case demonstrates the simultaneous extension of a sternoclavicular joint infection into the left upper pulmonary lobe and through the overlying skin.

Usefulness of molecular biology performed with formaldehyde-fixed paraffin embedded tissue for the diagnosis of combined pulmonary invasive mucormycosis and aspergillosis in an immunocompromised patient

Immunocompromised patients who develop invasive filamentous mycotic infections can be efficiently treated if rapid identification of the causative fungus is obtained. We report a case of fatal necrotic pneumonia caused by combined pulmonary invasive mucormycosis and aspergillosis in a 66 year-old renal transplant recipient. Aspergillus was first identified during the course of the disease by cytological examination and culture (A. fumigatus) of bronchoalveolar fluid. Hyphae of Mucorales (Rhizopus microsporus) were subsequently identified by culture of a tissue specimen taken from the left inferior pulmonary lobe, which was surgically resected two days before the patient died. Histological analysis of the lung parenchyma showed the association of two different filamentous mycoses for which the morphological features were evocative of aspergillosis and mucormycosis. However, the definitive identification of the associative infection was made by polymerase chain reaction (PCR) performed on deparaffinized tissue sections using specific primers for aspergillosis and mucormycosis. This case demonstrates that discrepancies between histological, cytological and mycological analyses can occur in cases of combined mycotic infection. In this regard, it shows that PCR on selected paraffin blocks is a very powerful method for making or confirming the association of different filamentous mycoses and that this method should be made available to pathology laboratories.

Aneurisma de la arteria pulmonar en Enfermedad de Behçet

Behçet disease is a systemic disease with diverse clinical symptoms which vary according to the organs and systems involved. Typically, patients have oral and genital ulcers and episodic ocular involvement with periods of clinical improvement. We report an 18-year-old mole presenting with chest pain and hemoptysis and a history of ulcers in the oral cavity and scrotum. A chest CAT scan showed a mass located adjacent to the heart that a pulmonary arteriography defined as a left pulmonary artery aneurism. The patient was operated, excising left inferior pulmonary lobe. Due to skin and ocular involvement, the patient complied with criteria for Behçet disease. Immunosuppressive treatment with prednisone and azathioprine was started and the patient was discharged from the hospital.