Lower Lobe Bronchus Research Articles

EXTRAMEDULLARY PULMONARY PLASMACYTOMA AS A COMPLICATION OF RELAPSED MULTIPLE MYELOMA

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Fellow Case Reports INTRODUCTION: Extramedullary plasmacytoma (EMP) are rare manifestations of multiple myeloma (MM). We report a case of pulmonary EMP presenting as hilar mass. CASE PRESENTATION: A 51 year old female presented with hearing loss and right facial palsy. Medical history was significant for MM diagnosed 2 years prior, treated with bortezomib-prednisone therapy. 6 months ago, thoracic spine plasmacytoma were found requiring surgical resection and local radiation. Remission was perceived and she was maintained on Thalidomide. MRI brain and spine revealed meningeal enhancement with lytic bony lesions, concerning for metastatic disease. CT chest abdomen pelvis revealed a 4.5 x 5.5 cm right hilar mass with complete right lower lobe (RLL) bronchus occlusion, post-obstructive pneumonia, right pleural effusion, pleural thickening and nodularity. She underwent bronchoscopy with endobronchial biopsy of RLL bronchial nodules and EBUS guided transbronchial needle aspiration of right hilar mass. Pathology was consistent with plasma cell myeloma with plasmablastic features. Given her MM history and absence of EBV, primary plasmablastic lymphoma was less likely. A bone marrow biopsy showed >10% myeloma cells, thus her diagnosis was consistent with relapsed MM with extramedullary plasmacytoma (EMP) rather than primary pulmonary plasmacytoma (PPP). Subsequently she underwent systemic and intrathecal second line chemotherapy, but her course was complicated by rapidly progressive refractory disease and patient chose to pursue hospice care. DISCUSSION: EMP are seen in 7 % patients with MM at the time of diagnosis, whereas another 6% develop it later in the course of illness; these portend poor prognosis. Among them, pulmonary EMP are extremely rare. Other pulmonary complications of multiple myeloma include pneumonia, including organizing pneumonia like consolidation, multiple pulmonary nodules, interstitial infiltrates and pleural thickening and effusion. In contrast, primary solitary extramedullary plasmacytoma is a rare discrete plasma cell neoplasm within soft tissue, without bone marrow involvement or other systemic features of MM. They commonly occur in the aero-digestive tract, of which solitary PPP is a rare type. PPP have better prognosis and longer survival rates compared to EMP associated with MM. Their management also differs, EMP associated with MM are treated aggressively with chemotherapy and local radiation or surgery as needed, whereas solitary PPP are treated with radiation only. CONCLUSIONS: Knowledge of pulmonary EMP and its clinical course is important for physicians, such that the etiology of pulmonary abnormalities in patients with multiple myeloma are evaluated and determined in order to ensure appropriate therapy and patient counseling. REFERENCE #1: Bladé J, et al. Soft-tissue plasmacytomas in multiple myeloma: incidence, mechanisms of extramedullary spread, and treatment approach. J Clin Oncol. 2011;29(28):3805-3812 REFERENCE #2: Varettoni M, Corso A, Pica G, Mangiacavalli S, Pascutto C, Lazzarino M. Incidence, presenting features and outcome of extramedullary disease in multiple myeloma: a longitudinal study on 1003 consecutive patients. Ann Oncol. 2010;21(2):325-330. doi:10.1093/annonc/mdp329 REFERENCE #3: Prasad R, Verma SK, Sodhi R. Multiple myeloma with lung plasmacytoma. Lung India. 2011 Apr-Jun; 28(2): 136-138. DISCLOSURES: No relevant relationships by Jyotirmayee Lenka, source=Web Response No relevant relationships by Naman Sharma, source=Web Response

ALL THAT PET POSITIVE IS NOT CANCER

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: PET (Positron emission tomography)/CT (Computed tomography) is a common modality used to diagnose and stage various malignancies. Radiotracer FDG (Fluoro18-deoxyglucose) is not cancer-specific and false-positive results may be observed in a wide variety of non-malignant conditions. Here we describe a patient with FDG avid left lower lobe endobronchial mass. CASE PRESENTATION: 75 years old female with a medical history significant for type 2 diabetes mellitus, seizure disorder was referred to pulmonology clinic with shortness of breath, intermittent wheezing, and non-productive cough for 2 months. She denied chest pain, orthopnea, fever, chills, weight or appetite changes, night sweats. The patient is a former smoker with less than 20 pack-year, quit two decades ago. On physical exam, the patient was saturating 92% in room air. BMI was 44.99 kg/m2. Lung examination showed reduced breath sounds at the left lung base. The rest of the exam was unremarkable. The pulmonary function test was normal. Outpatient evaluations were unremarkable. Chest X-ray showed left lower lobe infiltrates. CT chest showed left lower lobe consolidation vs atelectasis of left lung base followed with PET/CT which revealed increased FDG uptake in left lower lobe intraluminal density with SUV 6.5 concerning for malignancy with endobronchial involvement vs inflammatory process. Diagnostic bronchoscopy showed left lower lobe bronchus with significant mucosal hyperemia and edema with yellowish-white foreign body (FB) which was successfully retrieved with endobronchial biopsy forceps and noted to a piece of corn. The patient's symptoms resolved. DISCUSSION: The reported false positive rate of PET/CT was 13% and attributed to FDG uptake by inflammatory cells at the sites of inflammation or infection. Most common FDG avid non-infectious inflammatory etiologies include sarcoidosis, atherosclerosis, pneumoconiosis, and focal foreign body-related inflammation. FB aspiration in the tracheobronchial tree is rare in adults and usually presents with subtle respiratory symptoms with paucity in imaging. Risk factors include loss of consciousness from trauma, drug, seizure disorder or alcohol intoxication, dysphagia related to age-related slowing, stroke, dementia, or Parkinson's disease. In our case, false positives artifacts were related to a focal foreign body (FB) related inflammation with an elevated risk of aspiration related to a seizure disorder, and advanced age. Removal of FB from the tracheobronchial tree may be achieved with flexible bronchoscopy with biopsy forceps or retrieval basket. Rigid bronchoscopy may be needed if flexible bronchoscopy was unsuccessful. CONCLUSIONS: It is essential to understand false positive results while interpreting PET/CT results. FB aspiration in adults is rare and high clinical suspicion is necessary for the diagnosis. Removal of FB can usually be accomplished with bronchoscopy. REFERENCE #1: Common causes of False-positive F18 FDG PET/CT scans in oncology- Kevin R Carter, Eduard Kotlyarov; Vol,50, special number: pp.29-35, September 2007 Brazilian Archives of Biology and Technology- an International Journal. REFERENCE #2: Non-asphyxiating tracheobronchial foreign bodies in adults- Lan RS, Eur Respir J. 1994;7(3): 510 REFERENCE #3: Tracheobronchial foreign bodies in adults- Limper AH, Prakash UB, Ann Intern Med. 1990; 112(8):604 DISCLOSURES: No relevant relationships by Mansur Assaad, source=Web Response No relevant relationships by Rajamurugan Meenakshisundaram, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response

INCIDENTAL DIAGNOSIS OF PERICARDIAL EFFUSION ON ENDOBRONCHIAL ULTRASOUND

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Endobronchial Ultrasound (EBUS) is a state-of-the-art diagnostic tool for diagnosing and staging lung cancer and can recognize several structures of the mediastinum; lymph nodes, tumors, vessels, pericardium, and the heart. We herein report a case of an incidental de-novo finding of pericardial effusion seen during the EBUS. CASE PRESENTATION: A 55 year old male with a history of tobacco abuse presented to the clinic with worsening dyspnea, fatigue, cough, and weight loss, and a contrast-enhanced CT scan of the chest showed right lower lobe lung mass with enlarged mediastinal and hilar nodes. Pulmonary service was consulted, and the patient underwent a successful EBUS bronchoscopy with a fine need aspiration of the enlarged lymph nodes. EBUS imaging from the sub-carinal region through the anterior wall of the left lower lobe bronchus showed pericardial effusion and, the pericardium was identified above the left atrium. The patient underwent an urgent echocardiogram confirming pericardial effusion and pericardiocentesis drained 1200 ml fluid later proved to be metastatic adenocarcinoma of lung origin. DISCUSSION: EBUS is increasingly used to evaluate mediastinal lesions, diagnose and staging malignancy. Pericardiocentesis under echocardiographicGuidance is considered the procedure of choice for the evacuation of pericardial effusions. Given the advantage of visualizing pericardium and heart during the EBUS, multiple reports have documented aspiration of pericardial effusion through a regular EBUS-TBNA needle. CONCLUSIONS: We here report a rare case of incidental pericardial effusion seen during the EBUS and highlight the possibility of detecting pericardial effusions early as several mediastinum structures: lymph nodes, tumors, vessels, pericardium, and the heart are visualized during the EBUS. Therefore, physicians must be aware of the alternative use of EBUS as a new diagnostic approach in the early detection of pericardial effusions, allowing for early initiation of therapy in an otherwise potentially life-threatening condition. REFERENCE #1: (EBUS) Application for Benign and Malignant Pericardial Effusion (PE) Aspiration: Transbronchial Pericardial Effusion Aspiration (TPEA) with a Regular EBUS Transbronchial (TBNA) Needle under Apneic Nasal Jet-Catheter Ventilation.” J Biomed 1 (2016): 9-25. REFERENCE #2: Sharma, Rahul K., Arjun Khanna, and Deepak Talwar. "Endobronchial Ultrasound: A New Technique of Pericardiocentesis in Posterior Loculated Pericardial Effusion.” Chest 150.5 (2016): e121-e123. REFERENCE #3: Gella, Vishwanath, Snigdha Ghana, and Upendra Srinivas. "Concurrent diagnostic pericardiocentesis and subcarinal mediastinal lymph node aspiration by EBUS TBNA.” (2015). DISCLOSURES: No relevant relationships by Venkatkiran Kanchustambham, source=Web Response No relevant relationships by Swetha Saladi, source=Web Response No relevant relationships by Vinita Vaidya, source=Web Response

Inflammatory myofibroblastic tumor in children

Introduction. Inflammatory myofibroblastic tumor (IMT) is a rare volumetric neoplasm in the childhood which originates from the mesodermal tissue , and by the classification of soft tissue tumors refers to the tumors with intermediate biological potential.Purpose. To present a case of rare volumetric formation in the lungs and mediastinum in children.Material and methods. The publication presents three clinical observations of children with IMT. In all three boys (aged 6, 8 and 15), tumors were localized in the right hemithorax: lower lobe of the lung (two children), upper anterior mediastinum (one) without a reliable organ accessory.Results. There were no specific clinical symptoms of the disease. In two children, the volumetric formation was found accidentally: in one child, a rounded tumor above the liver was found during an ultrasound examination of the abdomen; in the other one, during chest X-ray prophylactic examination. Only in one case, the lung tumor caused respiratory failure during exercise due to the complete atelectasis of the lower lobe and emphysema of the middle lobe which was caused by the growth of the tumor from the parenchyma of the lower lobe into the lumen of the lower lobe and intermediate bronchi. There were no significant shifts in clinical and biochemical blood tests. Cancer markers were negative. Surgery was indicated because of the volume formation topography which was confirmed by the multispiral computed tomography with vascular contrast and fibrobronchoscopy. Surgical volume – thoracotomy, lobtumorectomy (1 child); thoracotomy, pulmonotomy, tumorectomy (1 child); thoracoscopy, removal of the mediastinal tumor (1 child). The most technically difficult was mobilization and removal of the mediastinal tumor when it was separated from the superior vena cava and in the chest aperture where it was intimately fused with the brachiocephalic vein. The postoperative period was without complications. All children recovered.Conclusion. IMT of the thoracic organs is not a rare case. It is not possible to reliably verify the nature of the tumor process in the preoperative period. Surgical treatment is radical and, in some cases, endovideotechnologies may be applied.

Effects of bronchial thermoplasty and cryoablation on airway smooth muscle.

Background:The effectiveness of bronchial thermoplasty (BT) has been reported in patients with severe asthma. This study compared the effects of BT and cryoballoon ablation (CBA) therapy on the airway smooth muscle (ASM).Methods:Eight healthy male beagle dogs were included in this experiment. In the preliminary experiment, one dog received BT treatment for both lower lobe bronchus, another dog received CBA treatment for 7 s on the upper and lower lobe of right bronchus, and 30 s on the left upper and lower lobe. The treatments were performed twice at an interval of 1 month. In subsequent experiments, the right lower lobe bronchus was treated with BT, and the left lower lobe bronchus was treated with CBA. The effects of treatment were observed after 1 (n = 3) month and 6 months (n = 3). Hematoxylin-eosin staining, Masson trichrome staining, and immunohistochemical staining were used to compare the effects of BT and CBA therapy on the ASM thickness, collagen fibers synthesis, and M3 receptor expression after treatment. One-way analysis of variance with Dunnett post hoc test was used to analyze the differences among groups.Results:In the preliminary experiment, the ASM ablation effect of 30-s CBA was equivalent to that of 7-s CBA (ASM thickness: 30.52 ± 7.75 μm vs. 17.57 ± 15.20 μm, P = 0.128), but the bronchial mucociliary epithelium did not recover, and large numbers of inflammatory cells had infiltrated the mucosal epithelium at 1-month post-CBA with 30-s freezing. Therefore, we chose 7 s as the CBA treatment time in our follow-up experiments. Compared with the control group (35.81 ± 11.02 μm), BT group and CBA group (13.41 ± 4.40 μm and 4.81 ± 4.44 μm, respectively) had significantly decreased ASM thickness after 1 month (P < 0.001). Furthermore, the ASM thickness was significantly lower in the 1-month post-CBA group than in the 1-month post-BT group (P = 0.015). There was no significant difference in ASM thickness between the BT and CBA groups after six months (9.92 ± 4.42 μm vs. 7.41 ± 7.20 μm, P = 0.540). Compared with the control group (0.161 ± 0.013), the average optical density of the ASM M3 receptor was significantly decreased in 6-month post-BT, 1-month post-CBA, and 6-month post-CBA groups (0.070 ± 0.022, 0.072 ± 0.012, 0.074 ± 0.008, respectively; all P < 0.001). There was no significant difference in the average optical density of ASM M3 receptor between the BT and CBA therapy groups after six months (P = 0.613).Conclusions:CBA therapy effectively ablates the ASM, and its ablation effect is equivalent to that of BT with a shorter onset time. A neural mechanism is involved in both BT and CBA therapy.

Case Report: Rare Cause of Hemoptysis in A Young Person

Introduction: Hemoptysis is an emergency, its diagnosis is often made on questioning, it must lead to rigorous etiological research. The thoracic CT angiography makes it possible to specify the exact mechanism and therefore to adapt the management. Observation: We report the case of a 20-year-old patient, with no particular pathological history, admitted for low-abundance hemoptysis that has progressed for 6 months. A thoracic CT angiography was performed showing a mediastino-pulmonary lesion process centered on the left lower lobe bronchus. Bronchoscopy with biopsy and pathological examination was indicated and demonstrated the presence of a bronchial carcinoid tumor. The patient underwent a lower left lobectomy, the operative consequences were simple, the patient was discharged after 10 days of hospitalization. Conclusion: Patients with recurrent respiratory symptoms should be carefully examined with chest CT and bronchoscopy followed by tissue biopsy for an accurate and early diagnosis.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Right Main Bronchus Transection Post Blunt Trauma: A Case Report

Tracheobronchial Injury is a relatively uncommon condition which is associated with high mortality. Majority occurring from blunt chest trauma sustained from deceleration injury in road traffic accidents. We present a case of a 17-year-old young male who presented in the acute setting of post motorcycle accident with respiratory distress, subcutaneous emphysema, right pneumothorax and fracture of posterior right 8th-9th ribs. CT shows right main bronchus anterior wall tear, with extensive subcutaneous emphysema, pneumomediastinum, bilateral pneumothorax and pneumoperitoneum. Thoracotomy confirmed the findings. Lacerated segment of right lower lobe bronchus was resected and (end-to-end) anastomosis was performed. Post-surgery was complicated with empyema thoracis which required decortication. Early detection and prompt surgical repair is fundamental and carries a high success rate in tracheobronchial injuries, however post-surgery complications need to be entertained and managed adequately to ensure safe outcome.

Assessment of Extensive Airway Obstruction Using Point-by-Point Lateral Pressure Measurements during Bronchoscopy

Background: The positioning of the stent at the flow-limiting segment is crucial for patients with extensive airway obstruction to relieve dyspnea. However, CT and flow-volume curves cannot detect the area of maximal obstruction. Objectives: The aim of this study is to physiologically evaluate extensive airway obstruction during interventional bronchoscopy. Methods: We prospectively measured point-by-point lateral airway pressure (P_lat) at multiple points from the lower lobe bronchus to the upper trachea using a double-lumen catheter in 5 patients. The site of maximal obstruction was evaluated continuously to measure point-by-point P_lat at multiple points when the airway catheter was withdrawn from the lower lobe bronchus to the upper trachea. Results: Remarkable pressure differences occurred at the site of maximal obstruction assessed by point-by-point P_lat measurements. After initial stenting in 1 case, migration of the maximal obstruction to a nonstented segment of the weakened airway was seen with extensive stenosis from the trachea to the bronchi. In the second case, in addition to radiological analysis, point-by-point P_lat measurements could identify the location of the maximal obstruction which contributed to dyspnea. Conclusions: Point-by-point P_lat measurement could be used to detect the site of maximal obstruction physiologically. Furthermore, P_lat measurement could assess the need for additional procedures in real time in patients with extensive airway obstruction.

Thoracoscopic Bilobectomy after Bilateral Single Sequential Lung Transplantation in a Cystic Fibrosis Patient with Post-Transplant Airway Stenosis

Introduction Airway complications following lung transplantation are associated with significant morbidity and mortality; they can result to significant functional impairment, poor quality of life and frequent hospitalizations. Anastomotic stenosis remains the commonest post-transplant airway complication with an estimated incidence between 1.6-32%. Non-anastomotic bronchial stenosis is rare and is not reported frequently. Case Report We present the case of a 46-year-old female cystic fibrosis patient requiring right lower bilobectomy following bilateral sequential lung transplant in April 2018, which was complicated by stricture of the right main bronchus requiring serial dilatations. Recurrent chest infections related to chronic Achromobacter xylosoxidans lead to complete right middle and lower lobe consolidation and collapse, with a ventilation/perfusion scan demonstrating almost complete absence of lobar ventilation and perfusion. Subsequent fibrotic narrowing of the bronchus intermedius resulted in bi-lobar failure and right lower bilobectomy in June 2020. Stenting of the bronchus intermedius was not considered feasible because the stenosis was in close proximity to the right upper lobar orifice. Thus, lung resection was undertaken utilizing a 2-port video assisted thoracoscopic technique. Intra-operatively the lung was found to be densely adhered to the chest wall and the diaphragm. Division of adhesions and lung mobilisation was challenging and utilization of various surgical techniques to avoid lacerations and prolonged leakage. Careful dissecting of the atrial cuff anastomosis was done to preserve the upper lobe venous supply. The pulmonary artery branches were dissected through their regular anatomical locations by accessing the oblique fissure. The middle and lower lobe bronchi were divided en bloc within their respective fissures to limit disruption of the vasculature of the bronchial stumps and prevent post-operative fistulae. Summary Treatment of stenotic anastomosis after lung transplantation can be challenging. Our case demonstrates that surgical management may be indicated when more conservative techniques have failed. Limits for surgery in lung failure need constant revisit; our experience shows that management in highly specialized centres improves overall outcomes.

Negative-pressure wound therapy in combination with bronchial occlusion to treat bronchopleural fistula: a case report

BackgroundBronchopleural fistula, which usually accompanies bronchial fistula and empyema, is a severe complication of lung cancer surgery. Negative-pressure wound therapy can enhance drainage and reduce the empyema cavity, potentially leading to early recovery. This therapy is not currently indicated for bronchopleural fistulas because of the risk of insufficient respiration due to air loss from the fistula.Case presentationA 73-year-old man, who was malnourished because of peritoneal dialysis, was referred to our hospital for the treatment of lung cancer. Right lower lobectomy with mediastinal lymph node dissection was performed via posterolateral thoracotomy, and the bronchial stump was covered with the intercostal muscle flap. His postoperative course was uneventful and he was discharged. However, he was readmitted to our hospital because of respiratory failure and diagnosed as having bronchopleural fistula on the basis of the bronchoscopic finding of a 10-mm hole at the membranous portion of the inlet of the remnant lower lobe bronchus. Thus, thoracotomy debridement and open window thoracostomy were immediately performed. After achieving infection control, bronchial occlusion was performed using fibrin glue and a polyglycolic acid sheet was inserted through a fenestrated wound. Bronchial fistula closure was observed on bronchoscopy; therefore, a negative-pressure wound therapy system was applied to close the fenestrated wound. The collapsed lung was re-expanded and the granulation tissue around the wound increased; therefore, thoracic cavity size decreased and thoracoplasty using the latissimus dorsi was performed.ConclusionsThis bronchopleural fistula was treated successfully after a right lower lobectomy using an extra-pleural bronchial occlusion and negative-pressure wound therapy.

Auscultating a pea: the stethoscope may matter in otorhinolaryngology emergency evaluation

&lt;p&gt;Foreign body sensation is a common complaint in the otorhinolaryngology emergency. Careful examination of the patient’s pharynx is mandatory, but sometimes the object is not visualized. In such scenario, it may be important to explore signs and symptoms indicating lower aerodigestive impaction. This work describes the case of a 73-year-old woman without relevant comorbidities attending to emergency care. She complained of a foreign body sensation on the right side of the throat after ingesting a meal, which motivated referral to otorhinolaryngology. Flexible transnasal nasopharyngoscopy was unremarkable and no foreign bodies were found. Auscultation was performed revealing low-pitch expiratory wheezing on her right hemithorax. The suspicion of bronchial foreign body was then raised, which was ultimately confirmed by imaging and bronchoscopy, showing an impacted pea on the right lower lobe bronchus. The stethoscope was hence determinant for detecting aspiration, by revealing consistent alterations. Its usage should be encouraged in similar scenarios, highlighting the role of this classic but sometimes forgotten tool. Importantly, higher neck/throat sensations should not exclude the possibility of a lower airway foreign body.&lt;/p&gt;

Hordeum murinum in The Right Lower Lobe Bronchus in a 2-year-old Patient Presenting with Hemoptysis

Hordeum murinum in The Right Lower Lobe Bronchus in a 2-year-old Patient Presenting with Hemoptysis

A tactics of surgical treatment of a lung echinococcal cyst ruptured into the bronchus

Relevance. The most severe complication of pulmonary echinococcosis is cyst rupture with contaminated leakage into the tracheobronchial tree.Material and methods. A 10-year-old boy was admitted to the clinic with diagnosis of fibroatelectasis of the lower lobe of the right lung. Anamnesis revealed that the boy was not well for more than 2 years. His treatment in several hospitals did not have any positive effect. Fibrobronchoscopy was performed during which a fragment of chitinous membrane was found in the orifice of lower lobe bronchus. Histological examination confirmed pulmonary echinococcosis.Results. A hydatid cyst in the projection of 9th and 10th segments of the lower lobe was revealed after thoracotomy on the right. Cystectomy with capitonage of the residual cavity was performed. Early postoperative period was uneventful. The child had conventional etiotropic therapy. A follow-up examination in 2 years with radiological and serological findings revealed no relapse of the disease. Child’s development corresponded to his age.Conclusion. The description of this case indicates that it is extremely important to have a detailed information about disease manifestations. In case of long-lasting lung disease , a diagnostic tracheobronchoscopy is recommended since radiological signs in complicated pulmonary echinococcosis may be not informative.

The left main bronchus transected incorrectly during video-assisted thoracoscopic lobectomy: a case report

BackgroundSeveral severe intraoperative complications of lung cancer surgery have been reported, but the incorrect transection of the main bronchus is a very rare and serious complication. We report a surgical case of a patient with left lower lobe lung cancer invading the inferior segment of the lingula, with fused interlobar fissure and dense pleural adhesion, in which the left main bronchus was mistaken for the left lower lobe bronchus and was transected.Case presentationA 64-year-old woman with lung adenocarcinoma was referred to our hospital for surgical treatment. Chest computed tomography (CT) scan showed a 30-mm nodule with a clear border and irregular margins in the center of the anterior (S8) segment of the lower lobe of the left lung and another similar 30-mm nodule in the lateral (S9) segment of the same lobe. Metastasis within the same lobe was suspected. A thoracoscopic left lower lobectomy was scheduled for the patient. As the patient had a moderately, fused fissure, dense pleural adhesion, and suspicious tumor invasion from the left S8 segment to the left S5 segment, and the interlobar node tightly adhered to the main PA at the site of basilar artery origin of the LLL, we performed left lower lobectomy and a left S5 segmentectomy using the fissureless fissure-last technique. During surgery, the left main bronchus was mistaken for the left lower lobe bronchus and was transected. After transecting the left main bronchus, we performed a sleeve bronchoplasty to prevent pneumonectomy.ConclusionsWe experienced the rare and serious intraoperative complication of the incorrect transection of the main bronchus. There are few reports of this intraoperative complication, and it should not be overlooked by surgeons.

RIGHT MIDDLE LOBE TORSION IN THE SETTING OF ABERRANT BRONCHIAL ANATOMY

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary torsion (PT) is defined as twisting of the entire lung or lobe around its bronchovascular pedicle. This disorder most commonly involves the right middle lobe (RML) following right upper lobe (RUL) lobectomy. The objective of this report is to describe a case of RML torsion following RUL lobectomy, in the setting of aberrant bronchial anatomy, which potentially led to this problem. CASE PRESENTATION: A 61-year-old African American woman with a RUL nodule, suspected to be cancerous, presented for RUL lobectomy. Flexible bronchoscopy revealed a right mainstem bronchus (RMB), which ended in a trifurcation of the upper, middle, and lower lobe bronchi. During thoracotomy, the inferior pulmonary ligament (IPL) was divided and RUL lobectomy was completed. Her major and minor fissures were noted to be partially complete and she had a short pedicle to the RML. As her risk of developing RML torsion was deemed to be low, no prophylactic fixation was done. Pathology confirmed the nodule to be a T1a N0M0 stage I adenocarcinoma. Post-operatively she complained of chest pain and hemoptysis. CT scan of the chest showed opacification of the right upper hemithorax, and RML torsion was suspected. Subsequent bronchoscopy showed that the RML bronchi were extrinsically compressed. Thoracoscopy demonstrated that the RML was torsed and engorged with venous blood (Figure 1). A thoracotomy and RML lobectomy were performed. Final pathology showed ischemic necrosis and hemorrhage. DISCUSSION: Ordinarily, the RMB gives rise to the RUL bronchus and the bronchus intermedius, which then bifurcates into the RML and right lower lobe (RLL) bronchi. The bronchus intermedius was absent in this patient and, instead, the RMB ended in a trifurcation of the RUL, RML, and RLL bronchi. The risk of RML torsion increases with division of the IPL in patients with complete pulmonary fissures and a lack of parenchymal bridges between the lobes prior to surgery. These factors increase the mobility of the RML, while the presence of a long pedicle predisposes to additional rotation along the bronchovascular pedicle.(1-3) This patient, despite lacking these risk factors, still developed RML torsion after RUL lobectomy. We speculate that the aberrantly located RUL takeoff, once resected, increased the range of rotational motion of the RML relative to the RLL, resulting in torsion of the RML. CONCLUSIONS: In patients at risk for RML torsion after RUL lobectomy, incomplete severing of the IPL and prophylactic inter-lobar fixation (or fixation to the thoracic wall or cardiac fat pad) are suggested. (2,3) Such measures may need to be considered in patients with a trifurcate RMB. Reference #1: Felson B. Lung torsion: Radiographic findings in 9 cases. Thoracic Radiology 1987 March; 162(3): 631-8. Reference #2: Moser E, Proto A. Lung torsion: Case report and literature review. Thoracic Radiology 1987 March; 162(3): 639-43. Reference #3: Kanemitsu S, Tenaka K, Suzuki H et al. Pulmonary torsion following right upper lobectomy. Ann Thorac Cardiovasc Surg 2006; 12: 417-9. DISCLOSURES: No relevant relationships by Batool Abuhalimeh, source=Web Response No relevant relationships by Joseph Lahorra, source=Web Response No relevant relationships by Tanya Marshall, source=Web Response No relevant relationships by Sanjiv Tewari, source=Web Response

UNMASKING CHRONIC COUGH AND ASTHMA: THE SILENT BODY

SESSION TITLE: Fellows Allergy and Airway Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Foreign body aspiration is an emergency situation which requires early bronchoscopy. Most of the patients will recall the event, however it could be a surprising finding in bronchoscopy procedures. Symptoms include shortness of breath, fever, and hemoptysis. In this case, it presents as chronic cough with uncontrolled asthma for several years despite optimized therapy. CASE PRESENTATION: Case of a 52-year-old man with past medical history of GERD, partly controlled severe asthma and chronic persistent cough who presented with bloody sputum without shortness of breath, chest pain or palpitation. Initial evaluation at ER with evidence of right lower lobe infiltrate and was admitted for treatment of pneumonia. He also recognized recurrent episodes of bronchitis, and fever episodes in the last 48 hours. He presented 3 months prior to admission to the emergency department with cough and subjective fever, by which had a chest x ray showing linear and patchy densities at the right lung base, azithromycin was prescribed and discharge home respectively. On examination, vital signs were stable. Chest auscultation revealed mildly decreased breath sounds and rhonchi in the right lower lung field. Chest transverse axial computer tomography with a right basilar lung consolidation with air bronchograms and hyperdense filling defect in the right lower lobe bronchus. Chest computer tomography 3 year prior to admission had evidence of right sided infiltrate believe to be secondary to pneumonia that was treated at that time. In view of hemoptysis and persistent right lower lobe infiltrate a flexible bronchoscopy was performed that revealed significant erythema with a foreign body visualized in the right lower lobe with associated granulation tissue . Subsequent evaluation visits with improved chronic cough and asthma respectively after the successful retrieval. DISCUSSION: Foreign bodies may result in serious complications if left unrecognized. This complication includes recurrent pneumonia, lung abscess, bronchopleuralcutaneus fistulas, atelectasis, and bronchiectasis with mucus impaction . However, in the case of chronic aspiration, bronchoscopy may show features of tissue reaction to the foreign body, by which object could be found incarcerated and difficult to be seen. Granulation reactions could eventually lead to airway strictures, and subsequently airway distortion, by which could present with unilateral wheezes in physical examination. Its important to note that bronchoscopy is present in chronic cough management algorithm. CONCLUSIONS: Chronic cough and persistent asthma that does not respond to standard therapy is the key to suggest a foreign body aspiration. Chronic cough is the most common symptom and is present in two-thirds of patients with foreign body aspiration. For that purpose, it’s important an early suspicion for a successful detection and a subsequent improvement of symptoms. Reference #1: Irwin RS, Madison JM. The diagnosis and treatment of cough. N Engl J Med. 2000;343:1715–21. Reference #2: Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM, Hoffstein, et al. Managing cough as a defense mechanism and as a symptom. A consensus panel report to the American College of Chest Physicians. Chest. 1998;114(2 suppl):133–81S. Reference #3: Al-Majed SA, Ashour M, Al-Mobeireek AF, Al-Hajjaj MS, Alzeer AH, Al-Kattan K. Overlooked inhaled foreign bodies: late sequelae and the likelihood of recovery. Respiratory Medicine. 1997;91(5):293–296. DISCLOSURES: No relevant relationships by Christian Castillo Latorre, source=Web Response No relevant relationships by Ilean Lamboy, source=Web Response No relevant relationships by Mariana Mercader-Pérez, source=Web Response No relevant relationships by William Rodriguez-Cintron, source=Web Response No relevant relationships by Jose Torres-Palacios, source=Web Response

PRIMARY PULMONARY ANAPLASTIC LARGE CELL LYMPHOMA IN A YOUNG MALE

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Anaplastic large cell lymphoma (ALCL) is a type of non-Hodgkin lymphoma which is subclassified into primary systemic anaplastic lymphoma kinase (ALK)-positive, primary systemic ALK-negative, primary cutaneous ALCL, and breast implant-associated ALCL (1). ALCL is considered an extremely rare type of primary pulmonary lymphomas (2). We report a case of primary pulmonary ALCL in a young immunocompetent male presenting with dyspnea. CASE PRESENTATION: 43 year-old male with no past medical history presented to the emergency department with dyspnea, fatigue and lower extremity swelling which have been worsening over a month. Physical exam showed 3+ pitting edema bilaterally and bilateral decreased breath sound. Laboratory workup showed an elevate d-dimer and an elevated absolute monocytes. Chest X-ray showed numerous nodules throughout the lungs. CT angiogram of the chest, abdomen and pelvis showed a large infiltrative opacity extending from the right hilum to the pleural surface in the right lower lobe, with some extension into the central right middle lobe and innumerable pulmonary and hepatic metastases and lymphadenopathy in the thoracic, abdominal and pelvic lymph node chains. Tumor markers were negative, with mildly elevated CA-125. A right supraclavicular lymph node biopsy showed necrotizing lymphadenitis with no evidence of metastatic disease. Bronchoscopy revealed an extensive obstruction of the bronchial lumen with an endobronchial lesion in the right lower lobe bronchus. Tissue biopsy was consistent with anaplastic large cell lymphoma. Patient was critically ill in the intensive care unit and was intubated due to acute respiratory failure. He had a poor prognosis due to the extensive metastasis of his ALCL. DISCUSSION: ALCL is characterized by large lymphoid cells with pleomorphic nuclei, and uniform CD30/Ki-1 expression (2). The most common form of ALCL presents as primary cutaneous lymphoma and may secondarily involve the lungs. However, primary pulmonary ALCL is extremely rare with 10 published cases between 1990 and 2015 (3). ALK protein expression is an important prognostic indicator for ALCL as ALK-positive lymphomas have a favorable prognosis with a much higher 5-year survival rate (2). The diagnosis of ALCL includes histopathology and immunohistochemistry staining, with strong immunoreactivity for CD30. Our patient had a primary pulmonary ALCL which was ALK-negative, indicating poor overall prognosis, with a strong immunoreactivity for CD30 and Ki-1. The treatment of primary pulmonary ALCL has not been standardized. However, first-line therapy includes anthracycline-based regimen, which is the standard treatment for non-Hodgkin lymphomas. CONCLUSIONS: Our case underlines the importance of maintaining a high index of awareness for the occurrence and impact of the recognition of primary pulmonary ALCL and its implications on the clinical course of critically ill patients. Reference #1: Laurent, Camille; Haioun, Corinne; Brousset, Pierre; Gaulard, Philippe (1 September 2018). “New insights into breast implant-associated anaplastic large cell lymphoma”. Current Opinion in Oncology. 30 (5): 292–300. Reference #2: J.-F. Cordier, E. Chailleux, D. Lauque et al., “Primary pulmonary lymphomas; a clinical study of 70 cases in nonimmunocompromised patients,” CHEST, vol. 103, no. 1, pp. 201–208, 1993. Reference #3: Q. Zhao, Y. Liu, H. Chen et al., “Successful chemo-radiotherapy for primary anaplastic large cell lymphoma of the lung: A case report and literature review,” American Journal of Case Reports, vol. 17, pp. 70–75, 2016. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Raheel Anwar, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Wael Kalaji, source=Web Response No relevant relationships by jad sargi, source=Web Response No relevant relationships by Viswanath Vasudevan, source=Web Response

SECONDARY SPONTENEOUS PNEUMOTHORAX AS A PRESENTATION OF BREAST CANCER RECURRENCE: CASE REPORT

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spontaneous pneumothorax is a common pathology described as gas trapped in the pleural space, not caused by an external event. When a lung associated pathology is found as the cause of the spontaneous pneumothorax then a subclassification arises and the events are characterized as Secondary spontaneous pneumothorax. Secondary spontaneous pneumothorax (SSP) are most frequently caused by chronic obstructive lung disease, necrotizing lung infections, genetically associated disease like cystic fibrosis or primary lung malignancy. There are lesser-known causes of SSP and, this is one such example where we showcase an unusual presentation revealing a unique etiology. CASE PRESENTATION: A 60-year-old Hispanic female with hypothyroidism who underwent left radical mastectomy 10 years ago for breast CA presented with sudden onset left-sided chest pain. She denied shortness of breath, recent trauma or smoking history. Heart rate, peripheral oxygen saturation, and laboratory tests were unremarkable, including 12 lead electrocardiogram. Physical examination was remarkable for decreased breath sounds on the left side of the chest. Chest CT scan revealed large left pneumothorax with paraaortic, right paratracheal and subcarinal lymph nodes with central necrosis. Also, a tissue density within the left main bronchus and hilum was identified, resulting in partial obstruction of the left lower lobe bronchus. General surgery service was consulted for emergent chest tube placement. A bronchoscopy was performed, and the endobronchial mass was biopsied. Pathology results showed metastatic recurrence of breast cancer. The patient was observed for three days after chest tube placement and chest radiography demonstrated resolution of pneumothorax. At that moment, the chest tube was removed, and the patient was discharged home the next day. DISCUSSION: Presently, the patient continues stable since being discharged from our institution. She was started on Letrozole and Palbociclib by the Oncology Service and has had no new episode of spontaneous pneumothorax. The patient will continue to receive conservative management by Oncology at our institution. CONCLUSIONS: This vignette illustrates a unique presentation of a metastatic breast cancer recurrence debuting as spontaneous pneumothorax. The most common type of malignancies associated with secondary spontaneous pneumothorax are primary lung cancer and sarcomas. To our knowledge, there are no cases that report an SSP as the presentation of breast cancer recurrence. Reference #1: Srinivas, S., & Varadhachary, G. (2000). Spontaneous pneumothorax in malignancy: A case report and review of the literature. Annals of Oncology, 11(7), 887–889. doi: 10.1023/a:1008323632078 Reference #2: Bini, Alessandro; Zompatori, Maurizio; Ansaloni, Luca; Grazia, Manuele; Stella, Franco; Bazzocchi, Ruggero. (2000). Bilateral recurrent pneumothorax complicating chemotherapy for pulmonary metastatic breast ductal carcinoma: Report of a case. Surgery today. 30. 469-72. 10.1007/s005950050628. DISCLOSURES: No relevant relationships by Juan Feliciano-FIgueroa, source=Web Response No relevant relationships by Angel Laureano, source=Web Response No relevant relationships by Giovanni Veloz Irizarry, source=Web Response

ACUTE ON CHRONIC DYSPNEA IN A PATIENT WITH METASTATIC BREAST CANCER ON ABEMACICLIB

SESSION TITLE: Medical Student/Resident Diffuse Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: We report a case illustrating the challenging diagnosis of interstitial pneumonitis caused by abemaciclib in an elderly woman with metastatic breast cancer. Lung toxicity is an uncommon but serious adverse effect of cyclin-dependent kinases 4 and 6 (CDK 4/6) inhibitors. Diagnosis is typically based on presentation, and non-contrast CT chest is the imaging modality of choice. Typical findings include ground-glass opacities with or without consolidation. The purpose of this case report is to highlight this uncommon toxicity of CDK4/6 inhibitors which requires high level of clinical suspicion for diagnosis. CASE PRESENTATION: A woman in the 8th decade of life with hormone-receptor positive, HER2 negative breast cancer with metastases to lungs and lumbar vertebrae, on treatment with abemaciclib and fulvestrant, was admitted to the hospital for exertional dyspnea for six weeks, with acute worsening to dyspnea at rest in the past one day. Prior to hospitalization, she had developed a fever three weeks after starting abemaciclib. She was treated for community-acquired pneumonia and COPD exacerbation, but had only partial relief of symptoms. CT chest showed ground glass opacities pronounced in right upper and middle lobes, with post-obstructive consolidation in left lower lobe, and soft tissue fullness around the left lower lobe bronchus and along the bronchovascular bundles suspicious for lymphangitic spread of tumor. Upon hospitalization, she was hypoxic and on 3 liters oxygen by nasal cannula. Repeat CT chest showed interval worsening of ground glass opacities in right upper lobe, new ground glass changes in left upper lobe, and worsening of left lower lobe consolidative change. Sputum cultures, fungal studies, and respiratory viral panel were negative. Symptoms improved with initiation of steroids. DISCUSSION: CDK 4/6 inhibitors are a relatively new class of drugs used in tandem with aromatase inhibitors or fulvestrant in the treatment of advanced hormone-receptor positive breast cancer. Diarrhea, nausea, fatigue, and pancytopenia were among common side effects noted in initial clinical trials. For our patient, a steroid course with taper was initiated, and the offending agent was held. A follow up CT scan three months later showed resolution of the ground glass opacities. This approach to management appears to be in line with the limited literature available. CONCLUSIONS: Our case documents an interesting diagnostic challenge in which a patient with developed pneumonitis in the setting of abemaciclib use. The diagnosis was delayed due to comorbid COPD and pneumonia, and confounded by partial resolution in symptoms with antibiotics. In September 2019, the FDA issued a safety warning that abemaciclib, palbociclib, and ribociclib may cause rare but severe pneumonitis. The temporal correlation between initiation of abemaciclib and development of symptoms remains unclear. Reference #1: Corona SP, Generali D. Abemaciclib: A CDK4/6 inhibitor for the treatment of HR+/HEeR2- advanced breast cancer. Drug Des Devel Ther. 2018;12:321-330. doi:10.2147/DDDT.S137783 Reference #2: Johnston S, Martin M, Di Leo A, et al. MONARCH 3 final PFS: a randomized study of abemaciclib as initial therapy for advanced breast cancer. npj Breast Cancer. 2019;5(1):1-8. doi:10.1038/s41523-018-0097-z Reference #3: FDA warns about rare but severe lung inflammation with Ibrance, Kisqali, and Verzenio for breast cancer | FDA. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-rare-severe-lung-inflammation-ibrance-kisqali-and-verzenio-breast-cancer. DISCLOSURES: No relevant relationships by Sameera Natarajan, source=Web Response No relevant relationships by Arjun Natarajan, source=Web Response