Lingular Segment Research Articles

Secondary systemic artery to pulmonary artery and pulmonary vein fistulas following the video-assisted thoracic surgery for pneumothorax: a case report

BackgroundThe systemic artery to pulmonary vessel fistula (SAPVF) is a vascular anomaly characterized by penetration of nonbronchial systemic chest wall arteries into the lung parenchyma. To our knowledge, about 150 cases of SAPVF have been reported to date. Fifteen percent of SAPVF are congenital and occur in the presence of cardiopathy or pulmonary artery hypoplasia. Secondary SAPVF are caused by pleural adhesions that occur subsequent to inflammatory changes associated with conditions such as pleuritis, empyema, trauma, and surgery. Though several cases of secondary SAPVF as a post coronary artery bypass graft (CABG) complication have been reported, secondary SAPVF especially following video-assisted thoracic surgery (VATS) are relatively rare.Case presentationA 19-year-old man was admitted to our hospital because of recurrence of left pneumothorax. His previous history included left and right pneumothorax at the ages of 15 and 16 years, respectively, which were treated by VATS. VATS was planned for the surgical indication of second postoperative recurrence. In the operation, the lingular segment with dilated pulsating pulmonary vessels adhered to the port scar of the chest wall, which was made at first VATS for pneumothorax. The computed tomography showed an abnormal connection between the branch of the systemic artery of the chest wall and the dilated pulmonary artery and pulmonary vein in the lingular segment. Left subclavian selective arteriography also showed hypertrophic blood vessels arose from the internal thoracic artery, the lateral thoracic artery, and the subscapular artery, which drained into the both the pulmonary artery and the pulmonary vein in the lingular segment. Despite of four sessions of embolization for aberrant arteries, the abnormal blood flow persisted. Partial resection of the left lingular segment was therefore performed. The patient has been disease-free about SAPVF for 2 years and 2 months after the last operation.ConclusionsWe described our experience with a case of secondary SAPVF that was associated with fistulas between a systemic artery and both the pulmonary artery and pulmonary vein, which was developed after first VATS for pneumothorax. Radical resection was safely performed and effective after four sessions of embolization.

Bronchial angles are associated with nodular bronchiectatic non-tuberculous mycobacteria lung disease

The nodular bronchiectatic (NB) form of non-tuberculous mycobacteria (NTM) lung disease usually involves the right middle lobe (RML) and the left upper lobe lingular segment. However, the reason underlying this preference is not known. Fifty patients with NB NTM lung disease who had both positive NTM culture(s) and NB lesions in the RML or lingular segment on computed tomography (CT) of the chest, and 100 healthy subjects matched for sex, age, height and body weight with normal chest CT, were randomly selected. Using reconstructed curved multiplanar reformation (MPR) images, the lengths, diameters and angles of the RML and lingular bronchi were measured. Of the 150 individuals, 64% were female; the mean age was 55 years. The angles of the bronchi were significantly more acute in patients than in healthy subjects, both in the RML (patients, mean 46.75° ± standard deviation 8.87° vs. healthy subjects, mean 51.73° ± 7.76°; P = 0.001) and in the lingular segments (patients, mean 26.94° ± 8.16° vs. healthy subjects, mean 34.65° ± 9.75°; P < 0.001). In addition, the angles of the bronchi in the involved segments were more acute than those in the non-involved segments, both in the RML and the lingular segments. There were no differences in the lengths and bronchi diameters between groups. An acute angle (obtuse slope) of RML/lingular bronchi could be an anatomical risk factor for NB NTM lung disease.

How to manage tumor located between upper division and lingular segment "S3+S4 segmentectomy and S3b+S4 segmentectomy".

Segmentectomy is one of the treatment of choice for small-sized non-small cell lung cancer (NSCLC). Although simple segmentectomy is feasible even if under thoracoscopy, complicated segmentectomy which contains more than two segmental plane divisions is difficult especially thoracoscopic surgery. We here present the case of totally thoracoscopic segmentectomy between upper division and lingular segment. In the first case, the 64-year-old female patient admitted for further examination and treatment of left lung ground glass nodule. Tumor located between upper division (S3) and lingular (S4) segment was operated by bi-segmentectomy and intraoperative frozen section pathology showed minimally invasive adenocarcinoma. Systematic nodal dissection was followed after retrieval of specimens. A3b A3a+c, and A4 was individually divided and followed by division of B3 and B4. Finally, intersegmental veins V1+2a and V1+2d was identified between segments and V3a+b was divided. In the second case, the 76-year-old female patient with left lung nodule between upper division (S3b) and lingular (S4) segment was operated by bi-segmentectomy. Since sealing test revealed air leakage from resected segmental planes, fibrin glue was applied to stop air leakage and direct suturing by 4-0 prolene between S3a+S3c and S5 was performed. Target lesion between upper division and lingular segments may be resected safely if appropriate demarcation lines are identified regardless of without highly sophisticated imaging systems.

Postoperative Lung Torsion With Retained Viability: The Presentation and Surgical Indications

We review our experience with postoperative lung torsion with retained viability. A total of 2165 patients underwent pulmonary resection (lobectomy or segmentectomy) at our institution between 1 January, 1986, and 31 March, 2017. Eight (0.3%, six males and two females: median age, 68 years) had lung torsion with retained viability. The right upper lobe was resected in seven patients, while the left upper segment was resected in one patient. The lung torsion with retained viability was the right middle lobe in seven patients and the left lingular segment in one patient. A bronchoscopic examination was performed in four patients to diagnose the pulmonary torsion; however, it demonstrated no specific findings. Subsequently, computed tomography (CT) was performed in all the patients, and lung torsion was diagnosed in all the patients based on the CT findings. None of the patients showed any symptoms when lung torsion was diagnosed in them. The diagnosis of pulmonary torsion was made at a median of 4 days (range, 1-22 days) after the initial surgery. Six patients underwent detorsion of the affected lung, while one patient had a lobectomy, and one patient received conservative management. The lungs of all patients in which detorsion was performed adequately re-expanded. Frequent pneumonia in the viable torsed lung was diagnosed as a cause of death in the one patient who received conservative management. The timely decision to follow a surgical approach for lung torsion with retained viability can lead to a satisfactory outcome.

Endobronchial embolization for life-threatening hemoptysis with Endobronchial Watanabe Spigot

BackgroundMassive hemoptysis is a common encounter in respiratory medicine. Bronchoscopy plays an important role in localizing the origin of bleeding, as well as endoscopic treatment of centrally located lesions. Endobronchial embolization is a novel technique enabling the management of hemoptysis arising even from peripheral lesions, via occlusion of the culprit bronchus, thereby securing the airway. Endobronchial Watanabe Spigot had been advocate in the treatment of bronchopleural fistula and the use of this novel technique had since then been expanded into the management of massive hemoptysis. To the best of our knowledge, this is the first reported case in Malaysia.Case presentation78-year-old lady who presented with life-threatening hemoptysis leading rapidly to cardiac arrest upon arrival. Spontaneous circulation was restored after resuscitation with an urgent thoracic computed tomography angiogram revealed bleeding likely from the posterior basal segment of left lower lobe, with bronchiectatic changes. Urgent flexible bronchoscopy revealed airway flooding, with bleeding originating from the lingular and posterior-basal segment of the left lower lobe. Airway toileting was performed and two 7 mm Endobronchial Watanabe Spigots were plugged into the culprit bronchi. Urgent bronchial artery embolization was then attempted, but was unsuccessful. She was managed conservatively, as surgical resection was deemed high risk. The spigots were removed 4 days later uneventfully. There was no recurrence of hemoptysis, and patient remained well during 1-month follow up.ConclusionsThe utmost priority in managing life-threatening hemoptysis is to prevent airway flooding. Endobronchial embolization with Endobronchial Watanabe Spigot is useful as a temporary measure before definitive therapy, or can itself be the main therapeutic player in the hemoptysis armament for high-risk patients.

How to manage the tumors located between upper division and lingular segment

How to manage the tumors located between upper division and lingular segment

Bilateral Accessory Lung Fissures with a Variant Left Bronchial Tree

Accessory lung fissures are commonly noted, while bronchial branching abnormalities are less frequently found and are proposed to occur in 0.1–2% of the general population. Multiple accessory fissures, variant normal fissures of both lungs, and an altered left bronchial tree are unique to this case and is being reported due to its clinical significance. During a routine dissection of the thoracic cavity of an 85‐year‐old female cadaver, abnormal fissures were noted on both the right and left lungs, which were photographed. The bronchial branching was further dissected by tracing the bronchus from the hilum to the lung tissue. The right lung had a normal oblique fissure, while the horizontal fissure was shallow and incomplete. The left lung had a normal oblique fissure, and a minor fissure was noted running along the junction of the anterior (S3) and superior lingular (S4) bronchopulmonary segments. Accessory fissures were noted on both right and left lungs. The left bronchus was short and displayed an early division into upper and lower divisions. The dissection of the bronchial tree of the left lung showed trifurcation of the upper division into apicoposterior, anterior, and lingular bronchi. The lower division was normal. The right bronchial tree showed normal division. Examination of the heart revealed an atrial septal defect. The other thoracic and abdominal structures were examined and appeared normal. Knowledge of accessory fissures in the lung have importance in the clinical diagnosis of lobar pneumonia versus atelectasis with imaging and during resection of bronchopulmonary segments. Understanding this bronchial variation and anomalies have implications in diagnosis and endobronchial treatment, including airway stenting, bronchoscopy, endoscopy biopsy, and laser therapy.Support or Funding InformationTouro College of Osteopathic Medicine, Department of Anatomy

SC19.01 Diagnosis of Lung Cancer: Multimodal Devices for Peripheral Pulmonary Lesions

SC19.01 Diagnosis of Lung Cancer: Multimodal Devices for Peripheral Pulmonary Lesions

Heart-Lung Herniation After Left Thoracotomy

SESSION TITLE: Global Case Report Poster - Cardiothoracic Surgery SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Heart - Lung herniation is a rare clinical event; it is unusual to see both heart and lung herniated through chest wall defect. Most of the causes are traumatic. We reported a case of Heart - Lung herniation after left thoracotomy for CABG operation CASE PRESENTATION: 59 year female patient with history of hypertension, insulin dependent DM, dyslipidemia and Coronary artery disease with previous coronary angiography, underwent CABG with left thoracotomy technique. Patient was discharged to ICU on IABP, adrenaline and dopamine infusion because of refectory hypotension and bradycardia. Chest x ray showed left lung collapse and picture of left side pleural effusion, there was no drainage from chest tube. For 3 dayspost-op, ECG showed new ischemic changes. CT chest was done and showed dehiscence of the left thoracotomy and bulging of the cardiac shadow and part of the lingular segment through the defect. Surgical repair with correction of the position of the heart and lung with suturing of intercostal muscles to prevent re∖re herniation. Patient was weaned off off IABP and inotropes. DISCUSSION: Heart - lung herniation after thoracic surgery is a rare complication, few cases had been reported for lung or heart herniation, Most of cardiac herniations are caused following blunt trauma producing rupture of the pericardium. Lung hernias have also been described as a result of tumors, chest-wall abscess, or invasion from tuberculosis. Diagnosis is made with chest radiograph or CT. Cardiopulmary compromise is the most serious complications which may include cardiogenic shock, and picture of cardiac tamponad, which can cause systemic hypoperfusion and increase inotropic, and pressores requirement, and delay the weaning from MV post operatively. Conservative management is an option in stable patient's, however, surgical repair should be instituted. In unstable patients. CONCLUSIONS: Chest imaging Order view is of paramount importance operatively, especially with hemodynamic instability that is refractory to inotropic and vasopressor support. Diagnosis can be made by CXR but in this case it was diagnosed accidently by doing CT chest. Early diagnosis is required to prevent further deterioration. Surgical repair in unstable patients should be pursued. Reference #1: 1-Sasidharan et al. / Cardiac herniation following closure of atrial septal defect through limited posterior thoracotomy, Interactive CardioVascular and Thoracic Surgery 5 (2006) 272-274. Reference #2: John S Emberger et al. / Lung Hernia Associated With Hemothorax Following Cardiopulmonary Resuscitation, Respir Care 2011;56(7):1037-1039. DISCLOSURE: The following authors have nothing to disclose: Islam Ibrahim, Mahmoud Abdullah, Ahmed Abdelsalam, Mohamed Badawy No Product/Research Disclosure Information

Neuroendocrine Cell Hyperplasia of Infancy

Neuroendocrine cell hyperplasia of infancy (NEHI) is a disease of the unknown etiology which is one of the rare, insufficiently explored interstitial lung diseases. It might be encountered among children up to two years old and it is characterized by persistent tachypnea, crackles, hypoxemia without being oxygen-dependent and hyperplasia of bombesin-positive neuroendocrin cells of peripheral respiratory tracts in lung biopsy. The lung CT shows that there are mosaic attenuation air trapping involving more than four lung segments and ground glass opacity mostly marked in the middle lobe of the right lung and lingular segments of the left lung. А precise diagnosis establishment based on a combination of clinical signs and HRCT data is possible without implementation of invasive research methods, lung biopsy in particular. At present there is no specific treatment for this disease; infants diagnosed with NEHI require special monitoring since it is not known whether this disease has a connection with idiopathic diffusive hyperplasia of PNE-cells of adults (IDYPNC) and how this pathology might affect lung development and their function in adults. The most part of patients with NEHI have satisfactory clinical results and there have been no fatal cases. Despite such positive data on this understudied disease, infants with NEHI require special monitoring and comprehensive research since long-term effects of this disease in an older age are still undiscovered. In this article case of NEHI in 1,5 years old child with a complaint for tachypnea and cough is submitted.

Pioglitazone as a novel therapeutic approach in chronic granulomatous disease

Pioglitazone as a novel therapeutic approach in chronic granulomatous disease

Video-assisted thoracic surgery experience of calcified lymph nodes for lingular sparing lobectomy.

Video-assisted thoracic surgery (VATS) is commonly used for posterior, superior and lingular segmentectomy. Segmental resections involving the left upper lobe are the following: upper division (S1+2 and S3) (lingular sparing lobectomy), apicoposterior segmentectomy (S1 + S2), and lingulectomy (S4 + S5). Lingular sparing lobectomy is still a challenge for more technical demanding and more anatomic variations, especially when facing calcified lymph nodes. A 73 years old woman was admitted for founding a ground glass opacity (GGO) during the screening test (1.0 cm × 1.0 cm). Her pulmonary function result was forced expiratory volume in 1 second (FEV1): 1.51 L (54.7% predicted). She was a non-smoker, with negative bronchoscopy findings. She received general anesthesia with double-lumen endotracheal intubation and right lung ventilation. Right lateral decubitus position was chosen. The first 1.5-cm incision was selected in the 8th intercostal space in the midaxillary line, and was used for the camera. A 4-cm long incision was made in the 4th intercostal space in the preaxillary line. A third 1.5-cm incision was performed in the 9th intercostal space in the postaxillary line for assistant. Pulmonary ligament and the entire left hilum were mobilized. The superior pulmonary vein has usually three major tributaries. The superior branch drains the apicoposterior segments and frequently blocks the access to the apicoposterior arteries. The middle branch drains the anterior segment, and the lowermost branch drains the lingula. The lingular vein must be preserved. The apicoposterior and anterior segment vein was transected with a vascular stapler. Anterior pulmonary artery and anterior bronchus were then divided and stapled. The upper lobe bronchus splits immediately into the lingular bronchus and a common stem. All these segmental bronchi have short course and a calcified lymph node located between the apicoposterior pulmonary artery and apicoposterior bronchus. These situations make the dissection and identification very difficult. Following many failure attempts of trying take the calcified lymph node out. Staple the left apicoposterior pulmonary artery together with the apicoposterior bronchi is completed. And left upper division (S1+2 and S3) was taken out after stapling lung tissue above the level of lingular segment with a 60-mm green linear stapler. Mediastinal lymph nodes of level 9, 7, 4L and 5 were cleared afterwards. Pathology was confirmed with adenocarcinoma (ancinar component dominant). There were no complications and the patient was discharged 6 days postoperatively. Staple the left apicoposterior pulmonary artery together with the apicoposterior bronchi is a safe and feasible way when facing the difficult dissection of the calcified lymph nodes during segmentectomy.

左肺上舌区域間に明瞭な過分葉を伴う肺癌に対し区域切除を施行した2例

左肺上舌区域間に明瞭な過分葉を伴う肺癌に対し区域切除を施行した2例

Use of a Standardized Learning Tool to Enhance Residents Ability to Diagnose Pneumonia on Chest Radiographs

Objective: Resident doctors are required to gain skills in reading chest X-rays. There have been few studies regarding the effectiveness of resident education in reading chest X-ray. Here, we examined the effectiveness of an educational method we developed for radiographic interpretation. Methods: A standardized lecture about diagnosis of pneumonia on chest X-ray was developed in 2012 and given to all first-year postgraduate (PGY1) residents at St Luke’s International Hospital in Japan. The examination was composed of 30 chest X-ray images representing either no disease or pneumonia. For pneumonia films, respondents identify disease location from a choice of 6 answers (right upper lobe, right middle lobe, right lower lobe, left upper segment, left lingular segment and left lower lobe). Total scores were compared before and after the intervention, and again 1 year later. Results: Twenty-one residents completed the 1-year follow-up exam. The overall percentage of correct answers for pre-lecture, post-lecture, and 1-year exams was 58%, 72% and 62% respectively. When we analyzed the data by disease location between pre- and post- educational intervention, percentage of correct answers increased only for images of left lower lobe (LLL) disease, rising from 61% to 88 % (p<0.01), and right middle lobe (RML), increasing from 61% to 88 % (p=0.015). For RML disease images, the percentage of correct answers remained 64 % after 1 year (p=0.007). Conclusion: A standardized lecture on chest X-ray reading enhanced residents’ ability to diagnose pneumonia. While improvements were short-lived, the intervention was particularly effective for difficult-to-diagnose areas such as right middle lobe disease.

Port-access thoracoscopic anatomical right anterior segmentectomy.

Thoracoscopic lung segmentectomy is a complicated and thus controversial procedure. The term "segment" comprises several genres. Each segment or subsegment is defined anatomically as the lung area for ventilation of the bronchial branches. Human lungs consist of 18 segments as well as block segments such as lingular or basal segments. Therefore, thoracoscopic lung segmentectomy includes various types of procedures. We developed pulmonary segmentectomy method under three-dimensional multidetector computed tomography simulation and so far performed 248 port access thoracoscopic anatomic lung segmentectomies. Also we developed a slip-knot technique for creating the inflation-deflation line to delineate the intersegmental plane and used this method as standard since 2010. The intersegmental plane was identified using the intersegmental veins as landmarks and the demarcation between the resected (inflated) and preserved (collapsed) lungs. The success rate of segmentectomy performed under complete thoracoscopy was 99%. Minithoracotomy was required for two patients because of arterial bleeding. The chest tubes were left in place for 1-8 d (median duration, 1 d). There were no recurrences of the primary tumor in the curative-intent resection group patients for lung cancer treatment. Thoracoscopic lung segmentectomy achieved by multidetector computed tomography for use in respective anatomical interpretation enabled precise parenchymal dissection. Our slip-knot technique facilitated the creation of inflation-deflation line under thoracoscopic surgery and shortened the surgical time consequently. Herein, we present the representative case of an 84-year-old man who underwent port-access anatomical resection of the anterior segment of right upper lobe (S3). In this patient, we used a vessel sealing system for cutting the vessels and dissecting the parenchyma.

A new quantitative index of lobar air trapping in chronic obstructive pulmonary disease (COPD): Comparison with conventional methods

PurposeTo determine the usefulness of newly-proposed index (attenuation–volume index, AVI: increase in mean value of lung attenuation (MVLA) divided by volume decrease ratio (VDR)) for quantitative assessment of lobar air trapping (LAT) using expiratory/inspiratory (E/I) computed tomography (CT) by minimizing influence of respiratory level. Materials and methodsInstitutional review board approved study protocol. Twenty-one moderate or severe COPD (group A), 16 mild COPD (group B) and 26 normal volunteers (group C) underwent both E/I scans via 320-row CT and pulmonary functional test (PFT). Volume image data were automatically segmented into six lung lobes with minimal manual intervention. AVI, pixel index (PI), air trapping ratio (ATR) and relative volume change (RVC860–950) were calculated in total lung (TL) and each lobe. Four indices in TL were correlated with both PFT result and VDR and those in TL and each lobe were compared between three groups. ResultsSimilar to ATR, AVI correlated with both FEV1/FVC (r=0.772, p<0.01) and RV/TLC (r=−0.726, p<0.01) and demonstrated a significant difference between three groups in both TL (group A: 1.69±0.45, group B: 2.21±0.45 and group C: 2.80±0.44) and five lobes except for left lingular segment. In a lobe-based analysis regarding relationship with VDR, AVI was much less dependent than ATR, although regression lines of groups A and C were separated for AVI as well as ATR. Coefficient of variation of either PI or RVC860–950 was significantly larger than that of AVI. ConclusionAVI can be a more suitable CT index for quantitative evaluation of LAT, minimizing influence of respiratory level.

COMBINED USE OF INTERFERON-GAMMA RELEASE ASSAY AND LOW-DOSE COMPUTED TOMOGRAPHY FOR TUBERCULOSIS SCREENING PROGRAM OF HEALTH CARE WORKERS

To evaluate the value of the interferon-gamma release assays and low-dose computed tomography for the pulmonary tuberculosis screenings program of health care workers. For the pulmonary tuberculosis (TB) screenings program, T-SPOT.TB (one of interferon-gamma release assays: IGRA) were performed on 332 health care workers (HCWs) with normal chest roentgenogram and without the history of TB treatment. Low-dose computed tomography (LDCT) was also performed on IGRA positive HCWs. Ten of 332 subjects were positive IGRA. LDCT was performed on IGRA positive 10 subjects. Abnormal findings were noted in 2 of 10 subjects by LDCT. One had CT findings compatible with active TB and finally diagnosed as active TB. Another had scarring shadow at right S5 and lingular segment. Nine of 10 IGRA positive subjects were judged as latent tuberculosis infection (LTBI). Three hundred twenty-one subjects with negative and borderline IGRA of 332 HCWs were judged as not infected with TB. Combined use of IGRA and LDCT for tuberculosis screening program of HCWs was found to be effective for early diagnosis of TB, accurate diagnosis of LTBI and judgment of non-infective subjects.

Carbohydrate Antigen 19-9 (CA19-9) Represents the Disease Activity of Nontuberculous Mycobacteria

Pulmonary MAC disease causes pulmonary involvement, such as bronchiectasis and small nodules, particularly in the middle lobe and lingular segment. An evaluation of the efficacy of pulmonary MAC disease treatment is difficult. The investigation of biomarkers against MAC infection may lead to a more precise evaluation of the treatment for MAC infection. We experienced several cases of pulmonary MAC disease and found carbohydrate antigen 19-9 (CA19-9) concentrations correlated with the activity of pulmonary MAC disease. In this study, we evaluated the role of CA19-9 as a biomarker in pulmonary MAC disease. We found an elevation of CA19-9 during pulmonary MAC disease, but not in tuberculosis, suggesting a relationship between CA19-9 and the disease activity in the elevated CA19-9 group. CA19-9 may be a promising biomarker for the evaluation of the disease activity of pulmonary MAC disease.

Aberrant Bronchial Artery to Non-Sequestrated Left Upper Lobe in Massive Hemoptysis.

Systemic arterial supply from the descending thoracic aorta to the basal segment of the left lower lobe without a pulmonary arterial supply is a rare congenital anomaly within the spectrum of sequestration lung disease. The most common pattern of anomalous systemic artery to the lung arises from the descending thoracic aorta and feeds the basal segments of the left lower lobe. We report an extremely rare case of a 29-year-old woman who underwent a successful left upper lobectomy for the treatment of recurrent massive hemoptysis from anomalous bronchial arterial supply to the lingular segment of left upper lobe.

Coexistent lung adenocarcinoma and giant cell carcinoma in different lung lobes of the same patient.

Lung giant cell carcinoma is a specific type of lung carcinoma characteristically associated with a highly aggressive clinical behaviour. This tumour is usually defined as a malignant epithelial tumour with large nuclei, prominent nucleoli and abundant cytoplasm without the features of squamous cell, small cell or adenocarcinoma. Lung giant cell carcinoma, belonging to the group of pleomorphic carcinoma, occurs mainly in men who smoke heavily [1]. It is not routinely treated surgically, owing to the fact that it is metastatic at the time of diagnosis, but resection or radiation have been suggested to prolong survival time. We experienced a rare case of lung giant cell carcinoma accompanied by lung adenocarcinoma in a different lobe of the same patient. A 64-year-old man presented to our hospital with a seven-month history of shortness of breath. Smoking history was 40 cigarettes per day for 30 years. Physical examination and routine blood examination showed normal. Plasma levels of tumour markers were as follows: squamous cell carcinoma antigen, 4.1 ng/ml (normal range, 0 to 2.0 ng/ml); cytokeratin fragment, 2.62 ng/ml (normal range, 0 to 3.5 ng/ml); carcinoembryonic antigen, 70.4 ng/ml (normal range, 0 to 4.3 ng/ml); neuron specific enolase, 11.63 ng/ml (normal range, 0 to 17 ng/ml); CA19-9, 47.52 U/ml (normal range, 0 to 27 U/ml) and pro-gastrin-releasing peptide, 24.3 pg/ml (normal range, 0 to 46.0 pg/ml). Arterial blood gas analysis yielded the following: pH = 7.42, PO2 = 74 mm Hg, PCO2 = 40 mm Hg and oxygen saturation of 96%. The chest CT showed a ca. 2.5-cm soft-tissue density in the right upper lung field (Fig. 1A, ​,B).B). Bronchoscopy was performed, revealing a neoplasm existing in the bronchial lumen of the left lingular segment, but normal mucosa in the right upper bronchi. By bronchoscopy, biopsy of the neoplasm revealed giant cell carcinoma in left lingular segment, with immunohistochemical characteristics positive for pan-cytokeratin and thyroid transcription factor 1 (TTF-1), weakly positive for vimentin and S-100 protein, and negative for desmin, chromogranin A, synaptophysin, P63 and CD68 (Fig. 2). Ultrasound-guided percutaneous lung biopsy of the node in the right upper lobe exhibited a poorly differentiated adenocarcinoma with immunohistochemical characteristics positive for cytokeratin 7 and TTF-1, and negative for cytokeratin 17 (Fig. 3). Metastatic disease was detected by brain CT, abdominal CT and bone scan, but the patient did not present with metastasis. Fig. 1 A) CT image showing nodular shadow in right upper lobe obtained from lung window. B) Nodular shadow from mediastinal window settings Fig. 2 Pathologic findings of the tumour obtained from biopsied neoplasm. The tumour was diagnosed as giant cell carcinoma. HE, magnification 100× Fig. 3 The tumour was diagnosed as adenocarcinoma. HE, magnification 100× At this time, the case was diagnosed as coexistent lung adenocarcinoma in the right upper lung field and giant cell carcinoma in the left lingular segment. Subsequently, the patient received radiotherapy in the bilateral upper lobes with a linear accelerator (6 MV). The field size of radiotherapy included the bilateral upper fields and mediastinal lymph node, and was treated with 2 Gy every day on a schedule of five fractions per week. The total dose was 64 Gy. At the same time as radiotherapy, cisplatin 50 mg (30 mg/m2) was administered weekly as a sensitizer of radiation. After radiotherapy, chest CT imaging revealed no change to the node in the right upper lobe, but the bronchial lumen of the left lingular segment became unobstructed by bronchoscopy (Fig. 4A, ​,B).B). Subsequently, the patient underwent chemotherapy consisting of intravenous cisplatin 140 mg (75 mg/m2) on the 1st day and vinorelbine 40 mg (25 mg/m2) on the 1st and 8th days. The treatment was to be repeated every 21 days. After two chemotherapy cycles, the nodular shadow in the right upper lobe remained unchanged. Bronchoscopy was performed, and the bronchial lumen of the left lingular segment remained unobstructed. After ten months the patient died of respiratory failure because of obstructive pneumonia in the right upper lobe. Fig. 4 A) Neoplasm was discovered by bronchoscopy in the left lingular segment. B) The neoplasm of bronchial lumen in the left lingular segment disappeared after radiotherapy