Lower Pulmonary Lobe Research Articles

Acute fibrinous and organizing pneumonia: A case report and literature review

Acute fibrinous and organizing pneumonia (AFOP) is a rare lung disease with distinct histological characteristics that include the diffuse presence of intra-alveolar fibrin, and the absence of eosinophils and hyaline membrane. In the present study, a case of AFOP that was diagnosed by lung biopsy is described. The patient presented with high fever and a cough with expectoration. Computed tomography of the lung showed the presence of bilateral patchy infiltrates, predominantly in the lower lobes. Histopathological examination of lung biopsy from the lower pulmonary lobe confirmed the pathological diagnosis. The patient showed a poor response to treatment with prednisone. Based on a review of literature pertaining to documented AFOP cases, a summary of the clinical features, radiological characteristics, treatment outcomes and prognoses associated with AFOP are presented. The most common pulmonary symptoms included cough, dyspnea and fever. The primary imaging findings in AFOP were consolidation and ground-glass opacity in the bilateral lung.

Video-assisted thoracoscopic superior segmentectomy of the right lower lobe.

A 61-year-old male patient was referred to the thoracic surgery department due to repeated hemoptysis for more than one year. The computed tomography revealed a 5.2 cm × 3.1 cm mass in the right lower lobe and the nature of the mass was confirmed to be chronic inflammation by trans percutaneous lung biopsy. Bronchiectasis of the right lower lobe was considered based on the symptoms, signs, and imaging findings. Surgery for bronchiectasis is used only as part of a multimodality treatment approach. After the adequate pretreatment with a targeted antimicrobial, thoracoscopic resection of superior segment of the right lower pulmonary lobe was finally performed in the order of the superior segmental artery, the superior segmental vein, the superior segmental bronchus, and the pulmonary tissues of the superior segment. Total surgery time was 70 min and blood loss was 100 mL. The chest tube was removed on the 3(th) postoperative day. The patient was discharged home on the 8(th) postoperative day.

A case of asymptomatic Sjögren's syndrome who developed interstitial pneumonia during monoclonal antibody therapy of Crohn's disease

A 67-year-old woman was diagnosed with ileocolic Crohn's disease at 61 years of age. Remission had been induced by the monoclonal antibody adalimumab, and maintenance therapy had continued since her diagnosis. However, she developed respiratory symptoms, including a dry cough. A chest CT scan revealed interstitial shadows in the lower pulmonary lobes. Although no sicca symptoms were noted, she was serologically positive for both anti-Sjögren's syndrome-related antigen A and B antibodies, and salivary gland biopsy showed lymphocytic infiltration. Consequently, she was diagnosed as having asymptomatic Sjögren's syndrome. Infection or drug-induced pulmonary disease was considered unlikely, and the interstitial pneumonia was considered an extra-glandular presentation of Sjögren's syndrome. Thus, interstitial shadows, which appear during immunotherapy for Crohn's disease, could indicate asymptomatic Sjögren's syndrome; clinicians should consider this rare clinical picture when assessing such a patient.

Video-assisted thoracoscopic superior segmentectomy of the right lower lobe

A 61-year-old male patient was referred to the thoracic surgery department due to repeated hemoptysis for more than one year. The computed tomography revealed a 5.2 cm × 3.1 cm mass in the right lower lobe and the nature of the mass was confirmed to be chronic inflammation by trans percutaneous lung biopsy. Bronchiectasis of the right lower lobe was considered based on the symptoms, signs, and imaging findings. Surgery for bronchiectasis is used only as part of a multimodality treatment approach. After the adequate pretreatment with a targeted antimicrobial, thoracoscopic resection of superior segment of the right lower pulmonary lobe was finally performed in the order of the superior segmental artery, the superior segmental vein, the superior segmental bronchus, and the pulmonary tissues of the superior segment. Total surgery time was 70 min and blood loss was 100 mL. The chest tube was removed on the 3(th) postoperative day. The patient was discharged home on the 8(th) postoperative day.

Case 2/2016 - Scimitar Sign with Right Pulmonary Vein Drainage into the Right Atrium

Clinical data: the characteristic signs of the scimitar syndrome with right pulmonary hypoplasia were discovered in an asymptomatic patient through routine chest X-ray, in the presence of dengue. On physical examination, the patient was in good general health status, eupneic, normal skin color, with normal pulses. His weight was 54 kg, height 155 cm, blood pressure of 100/60 mmHg, heart rate of 88 bpm. The aorta was not palpable at the sternal notch. In the precordium, there were mild impulses at the left and right sternal borders and the apex beat was not palpable. Heart sounds were normal, with constant splitting of the second heart sound, with discreet and rough ejection systolic murmur in the pulmonary area. The liver was not palpable and in the lungs, breath sounds were less audible in the right lower pulmonary lobe.

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

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

Chronic Thromboembolic Pulmonary Hypertension and Assessment of Right Ventricular Function in the Piglet.

An original piglet model of Chronic Thromboembolic Pulmonary Hypertension (CTEPH) associated with chronic Right Ventricular (RV) dysfunction is described. Pulmonary Hypertension (PH) was induced in 3-week-old piglets by a progressive obstruction of the pulmonary vascular bed. A ligation of the left Pulmonary Artery (PA) was performed first through a mini-thoracotomy. Second, weekly embolizations of the right lower pulmonary lobe were done under fluoroscopic guidance with n-butyl-2-cyanoacrylate during 5 weeks. Mean Pulmonary Arterial Pressure (mPAP) measured by ritght heart catheterism, increased progressively, as well as Right Atrial pressure and Pulmonary Vascular Resistances (PVR) after 5 weeks compared to sham animals. Right Ventricular (RV) structural and functional remodeling were assessed by transthoracic echocardiography (RV diameters, RV wall thickness, RV systolic function). RV elastance and RV-pulmonary coupling were assessed by Pressure-Volume Loops (PVL) analysis with conductance method. Histologic study of the lung and the right ventricle were also performed. Molecular analyses on RV fresh tissues could be performed through repeated transcutaneous endomyocardial biopsies. Pulmonary microvascular disease in obstructed and unobstructed territories was studied from lung biopsies using molecular analyses and pathology. Furthermore, the reliability and the reproducibility was associated with a range of PH severity in animals. Most aspects of the human CTEPH disease were reproduced in this model, which allows new perspectives for the understanding of the underlying mechanisms (mitochondria, inflammation) and new therapeutic approaches (targeted, cellular or gene therapies) of the overloaded right ventricle but also pulmonary microvascular disease.

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

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

Ectopic adrenocorticotropic hormone and corticotropin-releasing hormone co-secreting tumors in children and adolescents causing cushing syndrome: a diagnostic dilemma and how to solve it.

Ectopic ACTH/CRH syndrome is a rare cause of Cushing syndrome (CS), especially in children. The localization, work-up, and management of ACTH/CRH-secreting tumors are discussed. A retrospective study was conducted of patients under 21 years of age evaluated at the National Institutes of Health (NIH) for CS and diagnosed with ectopic ACTH/CRH-secreting tumors during the period 2009-2014. Seven patients with ectopic ACTH/CRH CS are included in this study with a median age 13.6 years (range 1-21), and 3 are female. Clinical, biochemical, radiological features, treatment, and histological findings are described. Seven patients were found to have ACTH/CRH-secreting tumors, all with neuroendocrine features. The site of the primary lesion varied: pancreas (3), thymus (2), liver (1), right lower pulmonary lobe (1). PATIENTS underwent biochemical evaluation for CS, including diurnal serum cortisol and ACTH levels, urinary free cortisol levels (UFC), and CRH stimulation tests. All patients underwent radiological investigations including MRI, CT, and PET scan; imaging with octreotide and 68 gallium DOTATATE scans were performed in individual cases. Five patients underwent inferior petrosal sinus sampling; 4 patients had sampling for ACTH and CRH levels from additional sites. Three patients underwent trans-sphenoidal surgery (TSS), and 3 patients required bilateral adrenalectomy. Three patients (43%) died due to metastatic disease, demonstrating the high mortality rate. One of the unique findings in these seven patients is that in each case, their neuroendocrine tumors were ultimately proven to be co-secreting ACTH and CRH. This explains the enigmatic presentation, in which 3 patients initially thought to have Cushing's disease (CD) with corresponding pituitary hyperplasia underwent TSS prior to the correct localization of the causative tumor. Ectopic ACTH/CRH co-secreting tumors are extremely rare in children and adolescents. The diagnosis of this condition is frequently missed and is sometimes confused with CD due to the effect of CRH on the pituitary.

LOBAR TORSION FOLLOWING LEFT UPPER LOBECTOMY WITH VATS APPROACH: A CASE REPORT

Background: Torsion or twisting of the left lower lobe following left upper lobe lobectomy is a rare, but severe complication. According to the literature, the outcome of this complication is necrotic pneumonitis, most often followed by pneumonectomy. According to different authors its frequency ranges between 0,1% and 0,4% from all operated patients. We treated a patient with pulmonary torsion with a favorable outcome. Case report: A 56 years-old patient with peripheral carcinoma of the upper left lobe of the lung underwent a typical upper left lobectomy. On the third postoperative day, there was a sudden deterioration in patient’s condition, which led to the diagnosis of torsion of the lower pulmonary lobe. Using the video-thoracoscopic approach we were able to restore the proper position of the remaining lobe without any ischemic parenchymal alterations. The condition of the patient was stabilized, and she was discharged without any further complications. Discussion: The described clinical case is significant in several aspects. Firstly the emergency invasive diagnosis is essential when similar complications are suspected and is crucial for preserving the vitality of the lung parenchyma. Secondly the minimally invasive video-thoracoscopic approach is a safer procedure and it should, therefore, precede the thoracotomy. Conclusion: The rarity of this complication is the most likely reason for the lack of reports in the literature. In our case, we were able to avoid pneumonectomy and the patient recovered well. When there are more such cases described, then we will have a functional standard algorithm to follow.

Partial anomalous pulmonary venous connection (RCD code: II-3C.0)

A 48-year-old woman was admitted to our institution with a year’s history of uncharacteristic chest pain episodes and decrease in exercise tolerance. A CT lung scan performed nine months earlier revealed an anomalous vein arising from the right lower pulmonary lobe and draining into the inferior vena cava. A chest radiogram performed 2 months prior to the admission showed a curved shape adjacent to the right heart border. Right heart catheterization revealed: normal systolic, diastolic and mean pulmonary artery pressures, normal pulmonary resistance and insignificant shunt volume. Pulmonary artery angiography demonstrated an anastomotic vessel between the aberrant pulmonary vein and the right upper pulmonary vein. The patient was diagnosed with Partial Anomalous Pulmonary Venous Connection in form of Scimitar syndrome. Given a mild character of symptoms, no signs of the right-sided heart volume overload, insignificant shunt fraction and normal pulmonary circulation parameters, the patient was qualified to a conservative treatment with a close medical observation. JRCD 2013 ; 1 (2): 39–41 Key words: partial anomalous pulmonary venous connection, scimitar syndrome, left-to-right shunt, pulmonary hypertension

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

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

Closure of Bronchopleural Fistula With Porcine Dermal Collagen and Fibrin Glue in an Infant

The management of an 11-month-old infant who developed a bronchopleural fistula (BPF) 3 weeks after video-assisted thoracic surgery for congenital cystic adenomatoid malformation of the right lower pulmonary lobe is presented. Being refractory to treatment with chest tubes, the BPF was managed using a bronchoscopic approach using porcine dermal collagen (PDC) combined with a fibrin glue plug. The single session was sufficient to manage the BPF and the postoperative course was uneventful. This case highlights the novelty in the successful management of BPF in infants after pulmonary surgery using PDC and fibrin glue using the minimal access bronchoscopic approach.

Paciente com sequestro pulmonar intralobar: uma rara anomalia congênita

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

A Patient with Intralobar Pulmonary Sequestration: A Rare Congenital Anomaly

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

Left Atrial Compression by the Hyper-Expanded Right Lower Pulmonary Lobe

A 57-year-old woman with a past medical history of progressive bronchiectasis was referred for lung transplantation. During the preoperative assessment, a chest computed tomographic scan confirmed severe end-stage pulmonary disease and posterior compression of the left atrium and inferior pulmonary veins due to the hyperexpansion of the right lower pulmonary lobe (Figs 1, 2; AV = aortic valve; LA = left atrium; LIV = left inferior pulmonary vein; LSV = left superior pulmonary vein; LV = left ventricle; PV = pulmonary valve; RA = right atrium; RIV = right inferior pulmonary vein; RLL = right lower pulmonary lobe; RV = right ventricle; RSV = right superior pulmonary vein).

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

Delayed systemic air embolism in a child with severe blunt chest trauma treated with high-frequency oscillatory ventilation

Trauma is the leading cause of death in children over one year of age. Even with optimal field care, blunt chest trauma with hemoptysis is a potentially fatal injury due to exsanguination or arterial air embolism. Most often, cardiovascular collapse that is unresponsive to therapy develops shortly after endotracheal intubation and initiation of positive pressure ventilation. We present a case of arterial air embolism after blunt chest trauma that manifested atypically late, i.e., one hour after initiation of positive pressure ventilation. A 13-yr-old Caucasian boy was admitted to the emergency room after he had been run over by a car. While lung protective ventilation, including high frequency oscillatory ventilation, was performed, an alveolar to pulmonary venous fistula developed. Although the complication was diagnosed quickly, involvement of the cerebral and coronary arteries resulted in irreversible cerebral damage and fatal hemodynamic collapse. Necropsy confirmed severe damage of the right pulmonary lower lobe with involvement of the pulmonary vessels. Patients with blunt chest trauma and hemoptysis present a diagnostic dilemma with limited therapeutic options.

Treatment of superior lobe central lung cancer with lung replantation

背景与目的肺癌患者行根治性全肺切除术后生活质量往往较差，最大限度地保留健康肺组织具有临床价值。本文报道3例自体肺再植在上叶中心型肺癌治疗中的应用和经验总结。方法本组共3例患者，肿瘤侵犯支气管或转移性淋巴结融合包绕、累及主肺动脉，肿瘤跨越斜裂侵及下叶边缘，先做完全性全肺切除术，体外低钾右旋糖酐液（low-potassium dextran, LPD）顺、逆行灌注后从离体标本中摘取可保留的下肺叶；下肺静脉再植于上肺静脉残端，按肺静脉、支气管、肺动脉顺序依次吻合。结果手术总时间220 min-250 min，下叶肺离体时间120 min-150 min；术后3 d-5 d拔除胸管，胸部X线示再植肺膨胀良好；术后随访4个月-8个月，完成3个或4个周期辅助化疗，患者生活质量良好。结论自体肺叶再植是一种可行的、可供选择的肺癌完全切除术式，是最大限度地切除病变和保留健康肺组织的理想术式。

Congenital Peribronchial Myofibroblastic Tumor: A Case Report

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