Lung Wedge Resection Research Articles

Clonal Bronchopulmonary B-Cell Proliferations of Indeterminate Malignant Potential in Patients with Common Variable Immune Deficiency (CVID) associated Granulomatous Lymphocytic Interstitial Lung Disease (GLILD)

Abstract Introduction/Objective Pulmonary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) is often challenging to distinguish from reactive nodular lymphoid hyperplasia, and assessing B-cell clonality in such cases is crucial in making the distinction. However, patients with common variable immune deficiency (CVID) can harbor clonal or oligoclonal lymphoid populations in their tissues, particularly in association with granulomatous lymphocytic interstitial lung disease (GLILD), making the distinction from MALT lymphoma extremely challenging. We report six cases of GLILD with clonal or oligoclonal B cell infiltrates in lung wedge resection specimens and describe their clinicopathologic characteristics, management, and outcomes. Methods/Case Report A retrospective review was performed to collect lung wedge resection specimens from patients with CVID showing atypical B-cell infiltrates associated with GLILD between 01/2015 and 08/2023. The clinicopathologic findings, management, and response to treatment were studied. Results (if a Case Study enter NA) A total of six GLILD cases were identified with variable degrees of architectural and cytologic lymphoid atypia. Clonality of the lymphoid infiltrate was assessed by kappa/lambda in situ hybridization staining in all six, flow cytometry in 3/6, and IGH gene rearrangement in 4/6 cases. The infiltrate showed frank lambda restriction in 1/6, lambda predominance in 1/6, polytypic expression in 1/6, and no significant plasmacytic component in 3/6 cases. Flow cytometry detected atypical light chain skewed B-cell populations in 3/3 of cases. IGH was positive for clonality in 3/4 and oligoclonal in 1/4 cases. Four patients received therapeutic intervention for GLILD, including one with Rituximab monotherapy, two with Rituximab+Azathioprine, and one with Rituximab+Mycophenolate leading to marked symptomatic and radiologic improvement in all four patients. The remaining two patients were observed to have stable disease. Conclusion Patients with CVID can harbor clonal B-cell populations due to their underlying immune dysfunction. Studies have shown that these can be transient and may not always progress to overt lymphoma. In the setting of GLILD, detecting these populations makes the distinction from MALT lymphoma very challenging. Given that the first- line therapy for both GLILD and MALT is anti-CD20 therapy, the malignant potential of these clones remains uncertain and can only be determined with long-term clinical follow-up.

6918 A Unique Case of Oncocytic Thyroid Cancer with an NBN Gene Pathogenic Variant

Abstract Disclosure: A. Grover: None. S. Jhawar: None. S. Shekhar: None. S.A. Avadhanula: None. G. Al-Naqeeb: None. G. Thota: None. P. Veeraraghavan: None. C. Cochran: None. M.Y. Kao-Hsieh: None. A. Gharib: None. F.E. Escorcia: None. J. Del Rivero: None. J. Klubo-Gwiezdzinska: None. S. Gubbi: None. Introduction: Oncocytic thyroid carcinoma (OTC), previously known as “Hürthle cell” carcinoma, makes up less than 5% of all thyroid cancers. OTCs are often aggressive with a high risk of metastasis, and a poorer prognosis compared to other forms of differentiated thyroid carcinoma (DTC). Molecular drivers of OTC include pathogenic variants (PVs) in NRAS, DAXX, CDKN1A, the mitochondrial genome and chromosomal alterations. PVs in the NBN gene in OTC have not been previously reported. Case: A 53-year-old male was noted to have a thyroid nodule on a routine physical examination. Patient denied any hyper/hypothyroid or compressive symptoms, and family history was unremarkable. Cytopathologic analysis of the fine needle aspiration biopsy of the nodule was consistent with a thyroid follicular neoplasm (Bethesda IV). A total thyroidectomy with central compartment neck dissection was performed. Histopathologic examination demonstrated a 7 cm x 4 cm x 4 cm OTC with capsular and lymphovascular invasion, but without extra-thyroidal extension or lymph node metastasis (pT3aN0Mx). Subsequently, adjuvant radioiodine (RAI) I131 therapy with 165 mCi was administered and post-therapy scan revealed neck uptake. One-year post-therapy RAI diagnostic scan was negative. Three years following the initial thyroid surgery, elevated serum thyroglobulin (Tg) levels were noted. A computed tomogram of the chest revealed multiple bilateral lung nodules. Further imaging ruled out involvement of other distant sites. A diagnostic lower lung wedge resection demonstrated metastatic OTC. The tumor stained positive for CK7, PAX8, TG, TTF-1 and negative for CK20 on immunohistochemistry. Next-generation sequencing of the tumor tissue (Oncomine Comprehensive Assay v3) revealed a PV in the NBN gene (c.2166_2167delGCinsAT; p.Trp722Ter). A year later, the serum Tg levels continued to rise, and the lung nodules had increased in size. Due to disease progression, lenvatinib was initiated. A [F18]-fluorodeoxyglucose positron emission tomography performed one year later demonstrated persistent pulmonary tumor burden with new osseous metastasis in the right scapula, left acetabulum, and the sternum. Zoledronic acid was initiated for the treatment of the skeletal metastases, and palliative external beam radiation (2000 cGy in 5 fractions) was administered to the sternal lesion to alleviate the bone pain. Conclusion: The NBN gene encodes for the protein nibrin, a member of the MRE11/RAD50 complex that is involved in DNA repair. PVs in NBN are commonly identified in non-thyroidal malignancies such as breast and lung carcinomas. While NBN PVs are rarely reported in DTCs, as per our knowledge, this is the first described case of OTC with a PV in NBN as the molecular driver, manifesting with an aggressive disease course. Identification of this novel PV therefore adds to the current knowledge of the molecular landscape of OTC. Presentation: 6/3/2024

Using a Double-Sided Bronchial Blocker for Differential Lung Ventilation for Robotic Bronchoscopy-Guided Marking and Subsequent Bilateral Lung Wedge Resections and Lobectomy

Using a Double-Sided Bronchial Blocker for Differential Lung Ventilation for Robotic Bronchoscopy-Guided Marking and Subsequent Bilateral Lung Wedge Resections and Lobectomy

EP.07A.04 Risk Factor Analysis and Predictive Model for Air Leakage after Thoracoscopic Lung Wedge Resection

EP.07A.04 Risk Factor Analysis and Predictive Model for Air Leakage after Thoracoscopic Lung Wedge Resection

Effect of perioperative chemotherapy on resection of isolated pulmonary metastases from colorectal cancer: A single center experience.

Numerous studies have assessed surgical resection as a standard treatment option for patients with colorectal cancer (CRC) and resectable pulmonary metastases (PM). However, the role of perioperative chemotherapy after complete resection of isolated PM from patients with CRC patients remains controversial. We hypothesize that perioperative chemotherapy does not provide significant survival benefits for patients undergoing resection of PM from CRC. To determine whether perioperative chemotherapy affects survival after radical resection of isolated PM from CRC. We retrospectively collected demographic, clinical, and pathologic data on patients who underwent radical surgery for isolated PM from CRC. Cancer-specific survival (CSS) and disease-free survival were calculated using Kaplan-Meier analysis. Inter-group differences were compared using the log-rank test. For multivariate analysis, Cox regression was utilized when indicated. This study included 120 patients with a median age of 61.6 years. The 5-year CSS rate was 78.2%, with 36.7% experiencing recurrence. Surgical resection for isolated PM resulted in a 5-year CSS rate of 50.0% for second metastases. Perioperative chemotherapy (P = 0.079) did not enhance survival post-resection. Factors associated with improved survival included fewer metastatic lesions [hazard ratio (HR): 2.51, P = 0.045], longer disease-free intervals (HR: 0.35, P = 0.016), and wedge lung resections (HR: 0.42, P = 0.035). Multiple PM predicted higher recurrence risk (HR: 2.22, P = 0.022). The log-rank test showed no significant difference in CSS between single and repeated metastasectomy (P = 0.92). Perioperative chemotherapy shows no survival benefit post-PM resection in CRC. Disease-free intervals and fewer metastatic lesions predict better survival. Repeated metastasectomy is warranted for eligible patients.

Primary pulmonary meningioma presenting as a pulmonary ground glass nodule: a case report and review of the literature

BackgroundA primary pulmonary meningioma is an extremely rare entity. Primary pulmonary meningiomas manifested with a ground glass nodule are a very rare occurrence in clinical practice.Case presentationIn this study, we report a case of a primary pulmonary meningioma with atypical computed tomography features. A 59-year-old Han Chinese female came to our hospital for treatment and reported that her physical examination revealed a ground glass nodule in the right lung for over 3 months. The histologic result revealed a primary pulmonary meningioma. The patient underwent a thoracoscopic lung wedge resection of the right upper lobe for a ground glass nodule. After 1 year of follow-up, the patient is still alive without evidence of metastasis or recurrence.ConclusionsPrimary pulmonary meningiomas could have a variety of radiological findings. As there are no specific radiologic features for the diagnosis of primary pulmonary meningiomas, complete resection of the lesion is required for both diagnosis and treatment. It is necessary to note the imaging features of primary pulmonary meningiomas, presenting as a ground glass nodule; this rare tumor should be considered in differential diagnoses.

What Is Early Recovery of Physical Abilities After Wedge Resection Surgery for Patients With Bone Tumor? An Observational Study

Background: The aim of this study is to describe the course of recovery of physical ability for patients undergoing lung wedge resection surgery for bone tumor metastases using the 1-minute sit-to-stand (1MSTS) test. Methods: All patients undergoing wedge resection for localized lung metastases from January 2022 to July 2023 were recruited consecutively. The recovery of physical performance was assessed by conducting the 1MSTS test the day before surgery and every day after surgery. A comparison was made between the number of repetitions performed in the preoperative test vs the performance on the sixth postoperative day. Results: A total of 52 patients were enrolled. The median age was 51 years and women made up 44.2% of the sample. The 1MSTS test on the sixth day was conducted in all patients with a median number of repetitions of 17.5, with a value comparable to the preoperative median. The patients able to recover to the preoperative repetitions were 38%. Multivariate analysis showed female gender as a protective factor and previous respiratory comorbidities and previous surgery to the upper limbs/trunk as risk factors. During preoperative assessment, higher heart rate and lower oxygen saturation (SpO2) after 1MSTS test were also predictors of a worse postoperative outcome. Conclusion: After wedge resection surgery for lung metastasis, the recovery of physical ability should be encouraged from the early postoperative phases and can be monitored through the use of the 1MSTS test during hospitalization. Aerobic training exercises in the preoperative phase may be useful to improve preoperative performance.

Primary Pulmonary Meningioma With Associated Multiple Micronodules: A Case Report With Comprehensive Diagnostic Overview

ABSTRACTBackgroundPrimary pulmonary meningioma (PPM) is an exceedingly rare neoplasm originating in the meninges within the lung. Despite sharing similarities with its central nervous system (CNS) counterparts, PPM presents unique diagnostic challenges and therapeutic considerations owing to its infrequent occurrence.CaseThis case report describes a 73‐year‐old male who underwent chest computed tomography (CT), which revealed a mass in the posterior basal segment of the right lower lobe, suggestive of a low‐grade malignant tumor approximately 30–40 mm in size. Single‐port video‐assisted thoracoscopic surgery (VATS) was performed to resect the mass via localized lesion excision (lung wedge resection). Intraoperative frozen section pathology indicated a low‐grade malignant epithelial tumor, leading to a decision for maximal lung function preservation, considering the patient's advanced age. The surgical team opted for a localized excision to ensure negative margins. Histopathological analysis confirmed the diagnosis of epithelioid PPM, a rare subtype even among PPM cases (World Health Organization [WHO] Grade I). The patient was discharged 9 days after surgery without complications and resumed normal daily activities 1 month postoperatively. The rarity of PPM precludes a standardized treatment protocol, with surgical resection as the primary approach. However, the efficacy of adjunctive therapies remains uncertain due to limited evidence.ConclusionThis case report contributes to a better understanding of PPM and emphasizes the importance of a comprehensive diagnostic evaluation and individualized treatment planning for this rare entity.

BipoJet Scissors as an Alternative to Laser in Lung Wedge Resection.

An important goal in every lung resection is airtight closure of the resected lung surface. This can be achieved with several techniques, including clamp resection, stapler, laser, and various high-frequency methods.By quantitatively measuring the air fistulaacross the resection surface of porcine lungs, two resection techniques were compared in our study: BipoJet dissecting scissors (Aesculap, Inc., Tuttlingen,Germany) and laser (Ceralas HPD®, Biolitec Inc., Jena, Germany). Following a stencil, wedge resections were performed in porcine lungs using water-irrigated bipolar scissors and laser (1350nm, 40watts, non-contact mode). The volumeof the air fistula was then measured. The irrigation technique involved the attachment of an irrigation channel to a pair of standard surgical scissors. Asodium chloride (NaCl) solution was fed at a defined flow rate, along the blades of the scissors onto the parenchyma. This technique was used on a total of 10 specimens each. Somewhat better pneumostasis was achieved with laser resection, though the difference was small and not statistically significant. The flow rate was 124mL/min/cm² after laser resection and 145 mL/min/cm² after using the BipoJet scissors. The difference was not statistically significant.Water irrigation during resection with the BipoJet scissors prevents the temperature in the tissue from exceeding 100°Cthus avoiding tissue carbonization. These scissors offer the following advantages: ease of use, no need to change instruments, no need for staff training, no protective measures, all-in-one incision/coagulation/dissection, low cost, and a clear surgical field due to the irrigation effect. Resection of lung parenchyma, e.g., during resection of metastases, is easier with BipoJet scissors and comparable to laser resection. This was established both experimentally and by resecting lung metastases.

Design and application of small-diameter closed thoracic drainage tube fixation following lung wedge resection: A randomised prospective study.

The use of indwelling closed thoracic drainage tubes in the wedge resection of the lungs is of great significance to postoperative recovery. However, there are potential risks. To explore the design feasibility and application effect of triple-buffer-system-fixed small-diameter (18 F) thoracic closed drainage tubes following lung wedge resection. A total of 136 patients with indwelling thoracic drainage tubes following pulmonary wedge resection were recruited, with 70 patients allocated to the control group and 66 to the experimental group. The drainage tube in the experimental group was fixed with the triple-buffer system, while that in the control group was fixed using the conventional lifting platform method. The incidence of unplanned extubation, the indwelling time of the drainage tube and the time and material costs, as well as information regarding any subcutaneous emphysema and skin tension blisters, were recorded following the operation. The pain and degree of comfort were assessed using a chi-square test and a rank sum t-test to compare the differences between the two groups. There were no statistically significant differences in terms of age, gender and sweating between the two groups. Compared with the control group, the unplanned extubation rate of the experimental group was lower (χ2= 8.513; P= 0.004), the indwelling time of the drainage tube was shorter (t= 2.108; P= 0.037), the cumulative material cost was lower (t= 3.778; P< 0.001), the time cost was also lower (Z= 2.717; P= 0.008), the degree of comfort was higher (Z= 2.752; P= 0.006), and the degree of pain was lower (Z= 4.019; P< 0.001). The incidence of subcutaneous emphysema was significantly lower in the experimental group than in the control group (χ2= 8.513; P= 0.004). The use of the triple-buffer system to fix small-diameter (18 F) thoracic closed drainage tubes can reduce the unplanned extubation rate, indwelling time of the drainage tube and the incidence of adverse reactions.

Comparison between use of a pleural drainage system with flutter valve and a conventional water-seal drainage system after lung resection: a randomized prospective study.

There is still a debate regarding the most appropriate pleural collector model to ensure a short hospital stay and minimum complications. To study aimed to compare the time of air leak, time to drain removal, and length of hospital stay between a standard water-seal drainage system and a pleural collector system with a unidirectional flutter valve and rigid chamber. A randomized prospective clinical trial was conducted at a high-complexity hospital in São Paulo, Brazil. Sixty-three patients who underwent open or video-assisted thoracoscopic lung wedge resection or lobectomy were randomized into two groups, according to the drainage system used: the control group (WS), which used a conventional water-seal pleural collector, and the study group (V), which used a flutter valve device (Sinapi® Model XL1000®). Variables related to the drainage system, time of air leak, time to drain removal, and time spent in hospital were compared between the groups. Most patients (63%) had lung cancer. No differences were observed between the groups in the time of air leak or time spent hospitalized. The time to drain removal was slightly shorter in the V group; however, the difference was not statistically significant. Seven patients presented with surgery-related complications: five and two in the WS and V groups, respectively. Air leak, time to drain removal, and time spent in the hospital were similar between the groups. The system used in the V group resulted in no adverse events and was safe. RBR-85qq6jc (https://ensaiosclinicos.gov.br/rg/RBR-85qq6jc).

Unusual mesentery metastasis of differentiated thyroid cancer: a case report.

Distant metastases of well-differentiated thyroid cancers (WDTCs) to bone and lungs are well known, while intra-abdominal, mesenteric metastases are very rare. Herein, we report a case of intra-abdominal, mesenteric metastasis of WDTC. A 62-year-old man underwent thyroid lobectomy for follicular thyroid cancer. One year later, lung metastasis was observed. The patient simultaneously underwent lung wedge resection and complete thyroidectomy. Eleven years later, serum thyroglobulin level was elevated. On the work-up study, a metastatic lesion in the lungs and a mass in the mesentery were identified. Two lesions of the lung and mesentery were surgically resected. The mass in the mesentery was pathologically diagnosed as metastatic WDTC.

Case of Metastatic Atypical Meningioma to Lung: Utility of Cytological Preparations for Intraoperative Diagnosis

Abstract Introduction/Objective Meningiomas are the most common primary intracranial and intraspinal tumors. They are typically benign with an indolent behavior but can metastasize extracranially to the skin, bone, lymph node and liver. Lung metastasis is exceptionally rare, and the diagnosis can be challenging, especially during intraoperative diagnosis without ancillary studies. We describe a metastatic atypical meningioma to the lung for which intraoperative cytology facilitated the diagnosis and guided management. Methods/Case Report A 53-year-old woman with a history of left frontal atypical meningioma and multiple surgical resections for recurrences at outside hospitals, presented with an incidental left lung nodule. A lung wedge resection was performed and submitted for intraoperative diagnosis. Gross examination revealed a well-circumscribed, tan- white, and rubbery subpleural nodule. Cytological preparations— Diff-Quik and H&amp;E stains—and frozen section were prepared. Cytologically, the nodule displayed cohesive distinctive papillary whorls of uniform eosinophilic cells with indistinct cell membranes, round to oval nuclei with central nucleoli and intranuclear pseudoinclusions. The frozen section exhibited similar cytological features, few identifiable whorls and predominantly solid sheets of tumor cells typical of non-small cell carcinoma. Based primarily on the cytological findings, the intraoperative diagnosis was a neoplasm with papillary growth pattern, and a metastasis was favored based on the whorled pattern and clinical history; no further resection was performed. Permanent sections displayed mitoses and no necrosis. Immunohistochemical analysis revealed positivity for somatostatin receptor 2a, progesterone receptor, and EMA (focal); no staining was seen with pancytokeratin, TTF-1, or p40. A diagnosis of atypical meningioma, WHO grade 2, was rendered. Subsequently, an atypical cranial and temporalis muscle meningioma at the site of the prior craniotomy bone flap was resected and had an identical molecular profile (1p36 deletion) to that in the lung, further supporting metastasis to the lung. Results (if a Case Study enter NA) NA Conclusion This case illustrates a rare presentation of metastatic atypical meningioma and highlights the distinctive intraoperative utility of cytology preparations—architectural and cytological details—for diagnosis and appropriate management. Cytology preparations can be a valuable tool and complement frozen sections, in which certain morphological features may be less obvious or confounded by freezing artifact.

A67Advanced cardiothoracic Simulation -how to do it and who is it for?

There is a large backlog in surgery due to covid as well as surgical training [1]. We explored the feasibility of a dry lab simulation environment to teach advanced surgical specialty skills to learners with different levels of experience. Session description: We ran 5 cardiothoracic surgical simulation courses over 2021-2022 with a total of 61 delegates. We covered coronary anastomosis, aortic valve replacement, video-assisted-thoracoscopic-surgery (VATS) lung wedge resection and pulmonary vessel dissection. Each skill station ran for 40 minutes including a 15-minute description and real-time demo. Target audience: Participants included 36 medical students, 14 specialty doctors and 11 foundation doctors. We used synthetic plastinated and resin printed models with modular metal frames to help with retraction and suspension of the area of interest for the cardiac models. For the VATS models a laptop with connected angled endoscopic camera was utilized. The lung models were 3D printed. 88% of all participants were able to complete all procedures successfully under supervision. 96% of all participants increased in confidence with the procedure following simulation compared to before. Interestingly only 44% of specialty trainees described themselves as confident in some procedures prior to simulation. Of the medical student cohort 95% had not had any previous simulation or surgical experience prior. We have demonstrated the feasibility of a dry lab simulation programme for candidates of all experiences in cardiothoracic surgery. Confidence in surgical technique is low during the COVID era. Simulation improved confidence in surgical technique and must be offered more widely to enhance training experiences. No experience is necessary for successful simulation. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

THU525 Atypical Presentation Of Parathyroid Carcinoma In The Lungs

Abstract Disclosure: J.N. Jacinto: None. O. Reyes: None. M. Cating-Cabral: None. R. Santiago: None. J. Andal: None. A 66-year-old female with a history of parathyroid adenoma underwent partial parathyroidectomy and thyroidectomy of the right lobe in 2006. She has the following comorbidities: pre-diabetes, hypertension, multiple liver cysts, medullary nephrocalcinosis and nephrolithiasis, ureterolithiasis and uterine intramural myoma. She also has a strong familial disposition of endocrine tumors. During the last quarter of 2018, parathyroid hormone and calcium levels were elevated and parathyroid imaging revealed an adenoma on the posteromedial aspect of the left thyroid lobe. Removal of the adenoma was offered but insisted on medical treatment. In 2022, she was admitted for subarachnoid hemorrhage due to fall. There was an incidental finding of a lung mass with minimal pleural effusion on the right lung lobe. PET-scan revealed five FDG-avid nodules (SUV up to 9.6) with the largest in the right middle lobe measuring 2 x 2 x 2 cm. Percutaneous needle biopsy was performed which showed a tumor with fairly uniform cells in organoid nests and solid clusters. By immunohistochemistry (IHC), the tumor cells were diffusely and strongly positive for CK and GATA-3; focally positive for chromogranin and synaptophysin; and negative for TTF-1, Pax-8, and S100. This was signed out as an epithelial tumor with neuroendocrine features; the differential diagnosis includes pulmonary neuroendocrine tumor versus metastasis from the prior parathyroid lesion. She subsequently underwent completion thyroidectomy and video-assisted thoracoscopic surgery. The lung wedge resections both showed tumors with similar morphology and IHC staining pattern as the biopsy. Additional stains were also performed to rule out other entities, which were all negative (CK7, CK20, CD56, mammaglobin, GCDFP-15, TTF-1, S100, ER, Pax-8, HSA, and SALL-4). The Ki-67 proliferation index was 17.26%. Because the overall findings were not definitive, comprehensive genomic profiling by next generation sequencing (NGS) was recommended and subsequently performed. NGS showed gene alteration in CDC73, with a variant allele frequency of 50%; this finding has been documented in parathyroid carcinoma. Pre-operative parathyroid hormone levels remained unchanged (408 to 397 pg/ml) despite surgery. Currently, there is no available targeted therapy to address her genomic alteration. Hyperparathyroidism-jaw tumor syndrome was entertained. The multidisciplinary team advised en-bloc resection of the lung tumor and additional gene testing for family members. She opted for palliative care and is on cinacalcet for her hyperparathyroidism. Presentation: Thursday, June 15, 2023

SAT205 99Technitiumm Sestamibi Negative Sporadic Metastatic Parathyroid Carcinoma In A Young Female-A Diagnostic Conundrum

Abstract Disclosure: D.V. Reddy: None. S. Paidipally: None. V. kyatham: None. S. Palle: None. C. Bhandiwad: None. Background: Parathyroid carcinoma (PC) is a very rare and indolent endocrine malignancy occurring a decade earlier than parathyroid adenoma. It can present as recurrent pancreatitis, anemia, and peptic ulcers. Serum calcium &amp;gt;14mg/dl, 3-10 times ULN of PTH, and concomitant renal and bone involvement should arise suspicion for PC. PC is diagnosed only through histopathology in the majority. It can also present during a prolonged follow-up, either by local recurrences or distant metastases. Clinical Case: A 27 year old female presented with hypercalcemic crises (as pancreatitis). At admission serum calcium and PTH were grossly elevated; 15.1 mg/dl (8.5-10 mg/dl) and 363 pg/ml (10-55 pg/ml) respectively. Abdominal CT revealed acute pancreatitis with medullary nephrocalcinosis. Ultrasonography of the neck revealed a colloid cyst in the right lobe of thyroid.99Tc m-sestamibi /SPECT-CT revealed no uptake. CT neck and chest showed a 13 mm X 13 mm well-defined round nodular lesion in the left apico-posterior segments of the lung. 18F-FDG PET/CT revealed uptake in the lesion with an SUV max of 10, suggestive of a metabolically active solitary pulmonary nodule. She had a similar presentation 8 years back and was diagnosed to have parathyroid adenoma for which she underwent resection. Serum PTH and calcium levels normalized postoperatively and also on follow-up till 3 years. Differentials include-recurrent ectopic parathyroid adenoma, parathyromatosis, and metastatic parathyroid carcinoma. After managing hypercalcemia medically, the patient underwent video-assisted thoracoscopic surgery with left lung wedge resection. Postoperatively serum calcium and PTH normalized. Histopathology revealed a grey-white nodule of 1.4X1.5X1.2 cm with sections, showing a well-defined lesion composed of lobules and nests of tumor cells separated by thin-walled vascular sinusoids. Tumor cells were polygonal with well-defined margins, moderate granular cytoplasm, and vesicular nuclei showing prominent nucleoli with a mitotic activity of 9/hpf. Immunohistochemistry revealed staining with PanCK, GATA3, and S100 with focal PAX 8 activity in the periphery. MIB index was 18%.IHC was suggestive of a neuroendocrine tumor consistent with metastatic parathyroid carcinoma. Whole exome sequencing did not reveal any pathogenic variants. Conclusion: Though 99Tc MIBI is useful in localizing PC, there are reports of false negative MIBI in documented cases of PC, which has been ascribed to the defective transport to the interior of the malignant cells. This demonstrates the importance of a multimodality imaging approach in such cases. 99Tc MIBI may miss certain cases of PC substantiating the importance of 18F-FDG PET/CT in diagnosis as well as follow-up. Reference: Evangelista L et al. FDG-PET/CT and parathyroid carcinoma: Review of literature and illustrative case series. World J Clin Oncol 2011; 2(10): 348-354. Presentation: Saturday, June 17, 2023

Opioid-sparing anesthesia with dexmedetomidine provides stable hemodynamic and short hospital stay in non-intubated video-assisted thoracoscopic surgery: a propensity score matching cohort study

ObjectivesDexmedetomidine is an alpha-2 agonist with anti-anxiety, sedative, and analgesic effects and causes a lesser degree of respiratory depression. We hypothesized that the use of dexmedetomidine in non-intubated video-assisted thoracic surgery (VATS) may reduce opioid-related complications such as postoperative nausea and vomiting (PONV), dyspnea, constipation, dizziness, skin itching, and cause minimal respiratory depression, and stable hemodynamic status.MethodsPatients who underwent non-intubated VATS lung wedge resection with propofol combined with dexmedetomidine (group D) or alfentanil (group O) between December 2016 and May 2022 were enrolled in this retrospective propensity score matching cohort study. Intraoperative vital signs, arterial blood gas data, perioperative results and treatment outcomes were analyzed.Of 100 patients included in the study (group D, 50 and group O, 50 patients), group D had a significantly lower degree of decrement in the heart rate and the blood pressure than group O. Intraoperative one-lung arterial blood gas revealed lower pH and significant ETCO2. The common opioid-related side effects, including PONV, dyspnea, constipation, dizziness, and skin itching, all of which occurred more frequently in group O than in group D. Patients in group O had significantly longer postoperative hospital stay and total hospital stay than group D, which might be due to opioid-related side effects postoperatively.ConclusionsThe application of dexmedetomidine in non-intubated VATS resulted in a significant reduction in perioperative opioid-related complications and maintenance with acceptable hemodynamic performance. These clinical outcomes found in our retrospective study may enhance patient satisfaction and shorten the hospital stay.

A surgical case of ciliated muconodular papillary tumor of the lung

Ciliated muconodular papillary tumor (CMPT) is a rare type of tumor with both benign and malignant characteristics. Herein, we report the surgical case of a 65-year-old man with CMPT. Chest computed tomography revealed a solitary cavitary lesion with a maximum diameter of 11-mm in S10b of the right lower lung. A thoracoscopic lung wedge resection was subsequently performed. On microscopic examination, the tumor was composed of highly columnar cells with tubular-to-papillary and cystic growth patterns. On immunostaining, it was positive for the epidermal growth factor receptor. The tumor was diagnosed as a CMPT, exhibiting no recurrence after two years of follow-up.

Spontaneous transient size reduction of a solitary pulmonary metastasis from a leiomyosarcoma

BackgroundA solitary pulmonary nodule (SPN) poses a diagnostic challenge, which includes both a benign and malignant etiology. A size enlargement often indicates malignancy. We herein describe a case of a solitary pulmonary metastasis from a leiomyosarcoma that regressed transiently during follow-up.Case presentationA 47-year-old woman presented with an SPN detected by follow-up computed tomography 7 years after surgery for a left forearm high-grade leiomyosarcoma. The nodule regressed spontaneously after an additional 6 months, and therefore, an inflammatory change was the most likely diagnosis at that time. However, the nodule enlarged again over the next 5 years. The growth rate led us to suspect a malignancy. A trans-bronchial biopsy was undiagnostic and a video-assisted thoracic surgery was planned. She underwent a wedge resection of the right lung, and a histopathological examination found it was a metastatic leiomyosarcoma.ConclusionsA pulmonary metastasis from a leiomyosarcoma could emerge as an SPN and reveal a subsequent transient size reduction. An SPN in patients even with a remote history of a soft tissue tumor should raise the possibility of metastasis, and periodic follow-up is essential even after the size reduction.

Morbidity, mortality, and surgical treatment of secondary spontaneous pneumothorax.

Pneumothorax in patients with underlying lung pathology is called secondary spontaneous pneumothorax (SSP). It is an important health problem worldwide, with significant morbidity, high health-care expenses, and possibility of mortality. This study aimed to evaluate the epidemiological characteristics, risk factors for mortality and morbidity, and treatment options of SSP. Outcomes of 133 patients with SSP were evaluated retrospectively. Patients with SP with evidence of underlying lung disease or a smoking history over 50 years of age were considered SSP. The patients were analyzed in terms of epidemiological fea-tures, underlying diseases, treatment methods, complications, and mortality. The treatment options included thoracotomy (T), video-assisted thoracoscopic surgery (VATS), tube thoracostomy, and conservative treatment. The mean age was 50.50±20.374 years, and the age range was 16-95. Ninety-three (69.9%) of the patients were smokers. The most common clinical finding was dyspnea in 77 (57.9%) patients. The most common underlying disease was chronic obstructive pulmonary disease in 62 patients (46.6%). Six (4.5%) patients received conservative treatment, a chest tube was placed in 89 (66.9%) patients, and 38 (28.6%) patients were treated with surgery. As an operative procedure, lung wedge resection was performed in 24 (18.0%) patients and bulla resection was performed in 6 (4.5%) patients. Parietal pleurectomy was performed in 27 (20.3%) patients. Axillary mini-T or T was performed more frequently in large pneumothorax, smokers, and in obstructive pulmonary disease. Tube thoracostomy was used more frequently in poor physical performance, comorbidities, and infectious diseases. Complications were ob-served in 55 patients (41.4%). The most common complication was persistent air leakage in 18 (13.5%) patients. Complications were associated with large pneumothorax (P=0.003), poor physical performance (P=0.009), infectious diseases (P= 0.030), and occupational risk factors (P=0.032). Recurrence was developed in 12 (9.0%) patients. Postoperative recurrence was observed in 1 patient. Four (3%) patients died. Mortality was higher in patients with poor physical performance (P=0.027), comorbidities (P=0.008), and patients with complications (P=0.027). The length of stay in the hospital was high in mini-axillary T (AT)/T (P<0.001) and VATS (P<0.001). There was no significant relationship between the mini-AT/T and VATS in terms of length of hospital stay. Large pneumothorax, poor physical performance, and comorbidity are associated with morbidity and mortality. Conservative treatment for small pneumothorax and chest tube for large pneumothorax is the most appropriate initial treatment. Resection of the bullous region through VATS or mini-AT/T is the most appropriate surgical technique.