Major Bronchi Research Articles

The relationship between lobar distribution and primary lung cancer histological types

Background: Lung cancer is the primary cause of cancer-related deaths globally. Accurate tumor location and subtype characterization are critical for optimizing treatment and predicting outcomes. This study aims to identify the relationship between lobar distribution and primary lung cancer histological types and describe the most recent patterns at the country-level origin. Methods: This cross-sectional study was conducted at a major tertiary care hospital in Bangladesh, including 165 patients recruited using purposive non-probability sampling. Data were collected using a semi-structured case record form and analyzed using SPSS version 28.0. Results: Tumors were most commonly found in the central area (58.2%). Squamous cell carcinoma was the most prevalent type (46.1%), followed by adenocarcinoma (38.8%), small cell carcinoma (13.9%), and large cell carcinoma (1.2%). The incidence of squamous cell carcinoma was significantly higher in the upper lobe of the right lung (55.9%) compared to other forms, particularly in the central region of the right lung (P < 0.001). Squamous cell carcinoma was more common in the lower part of the left lung (42.9%), while adenocarcinoma was exclusively observed in the lingular portion of the left lung (100%). The major bronchus of the left lung primarily exhibited squamous cell carcinoma (60%), but this finding was not statistically significant (p=0.899). Conclusion: The study highlights the significant association between lobar distribution and histological types of primary lung cancer, emphasizing the need for precise tumor characterization for better treatment strategies and prognostic evaluation.

Mounier-Kuhn syndrome: A case report of a 64-year-old male followed up after 8 years of the first diagnosis

Mounier-Kuhn Syndrome (MKS) is a rare congenital disorder characterized by the abnormal dilatation of the major airways, namely trachea and stem bronchi. It can be presented as the recurrent lower respiratory tract infection. Symptoms may vary from being asymptomatic to a wide range of infections which may lead to severe respiratory failure. Diagnosis can be performed by the means of computed tomography and bronchoscopy. The treatment is primarily symptomatic and supportive. Herein, we have presented a case of a 64-years old man, ex-smoker, who was referred after 4 episodes of antibiotic treated pulmonary infection. He was previously diagnosed with tracheobronchomegaly through CT scan in 2015. We have compared the lung function test and the radiological features between two time slots being 8 years apart (2015-2023), that showed insignificant change.

Area under the inspiratory flow-volume curve (AIN): Proposed normative values.

Area under expiratory flow-volume curve (AEX) has been shown to be a valuable functional measurement in respiratory physiology. Area under inspiratory flow-volume loop (AIN) also shows promise in characterizing upper and/or lower airflow obstruction. we aimed here to develop normative reference values for AIN, able to ascertain deviations from normal. We analyzed AIN in 4,980 spirometry tests recorded in non-smoking, healthy individuals in the Pulmonary Function Testing Laboratory. The mean (95% confidence interval, CI), standard deviation and median (25th-75th interquartile range) AIN were 16.05 (15.79-16.31), 9.08 and 14.72 (9.12-21.42) L2·sec-1, respectively. The mean (95% CI) and standard deviation of the best-trial measurements for square root of AIN (Sqrt AIN) were 3.84 (3.81-3.87) and 1.14; 4.15 (4.12-4.18) and 1.03 in men, and 2.68 (2.63-2.72) and 0.72 L·sec-1/2 in women. The mean (standard deviation) of pre- and post-bronchodilator Sqrt AIN were 3.71 (1.17) and 3.81 (1.19) L·sec-1/2, respectively. The mean (95% CI), standard deviation and lowest 5th percentile (lower limit of normal, LLN) of Sqrt AIN/Sqrt AEX (%) were 101.3 (100.82-101.88), 18.7, and 71.8%; stratified by gender, it was 102.2 (101.6-102.8), 18.6, and 72.8% in men, and 98 (96.9-99.2), 18.8, and 68.6% in women, respectively. The availability of area under the inspiratory flow-volume curve (AIN) and the derived indices offers a promising opportunity to assess upper airway disease (e.g., involvement of larynx, trachea or major bronchi), especially because some of these measurements appear to be independent of age, race, height, and weight.

Airway management for a patient with tracheobronchomegaly undergoing lobectomy: a case report

BackgroundTracheobronchomegaly (TBM) is a rare disorder mainly characterized by dilatation and malacia of the trachea and major bronchi with diverticularization. This will be a great challenge for airway management, especially in thoracic surgery requiring one-lung ventilation. Using a laryngeal mask airway and a modified double-lumen Foley catheter (DFC) as a “blocker” may achieve one-lung ventilation. This is the first report introducing this method in a patient with TBM.Case presentationWe present a 64-year-old man with TBM receiving left lower lobectomy. Preoperative chest computed tomography demonstrated a prominent tracheobronchial dilation and deformation with multiple diverticularization. The most commonly used double-lumen tube or bronchial blocker could not match the distorted airways. After general anesthesia induction, a 4# laryngeal mask was inserted, through which the modified DFC was positioned in the left main bronchus with the guidance of a fiberoptic bronchoscope. The DFC balloon was inflated with 10 ml air and lung isolation was achieved without any significant air leak during one-lung or two-lung ventilation. However, the collapse of the non-dependent lung was delayed and finally achieved by low-pressure artificial pneumothorax. The surgery was successful and the patient was extubated soon after the surgery.ConclusionsUsing a laryngeal mask airway with a modified double-lumen Foley catheter acted as a bronchial blocker could be an alternative method to achieve lung isolation.

Systematic literature study of trachea and bronchus morphology in children and adults.

Understanding the dimensions of the lower airway is critical for performing respiratory surgery, selecting and designing appropriate airway equipment, and removing aspirated foreign bodies via bronchoscopy, anaesthesia, and radiography. The purpose of this study was to analyse the trachea and bronchus morphologically in children and adults, as well as to standardise the data for these structures' measurements. Various databases were reviewed for studies on lower airway dimensions. The criteria for inclusion and exclusion were established. Finally, it was agreed to look into 28 studies that took place between 1984 and 2021. The length of the trachea, its anterior-posterior (AP) and transverse dimensions, the lengths and transverse diameters of the right and left major bronchus, and the subcarinal angle were also investigated in the study. In studies where measurements were performed with different methods and procedures. It was revealed that age and gender were effective in the difference in lower respiratory tract dimensions. The mean values of all parameters were greater in adults than in children, the AP diameter of the trachea in adults was greater than the transverse diameter. In children, it was observed that the transverse diameter was larger than the AP diameter on average, the left main bronchus was longer than the right main bronchus, and the transverse diameter was smaller than the right main bronchus in most of the studies. The articles reviewed for this study revealed that measurements were done using a variety of different procedures and approaches, and the resulting data were inconsistent and could not be standardized. The data collected will be beneficial both conceptually and clinically; we believe that additional comparison research involving children and adults in bigger groups are necessary.

Possible Use of Linear Echobronchoscope for Diagnosis of Peripheral Pulmonary Nodules.

Echobronchoscope-guided transbronchial needle aspiration (EBUS-TBNA) is mainly used as the transbronchial approach to hilar/mediastinal lymph nodes or lesions, for diagnostic or staging purposes. Moreover, the role of linear EBUS-TBNA as a diagnostic tool for central intrapulmonary lesions adjacent to the trachea or the major bronchi is also well established. However, since the tip of the ultrasound probe at the distal end of the echobronchoscope is very thin, it can be wedged through smaller peripheral bronchi, reaching the distal parenchyma and allowing for peripheral pulmonary lesion sampling. The main aim of this retrospective study was to evaluate the diagnostic yield and the safety of EBUS-TBNA in the diagnosis of pulmonary peripheral nodules. The database of the Interventional Pulmonology Unit of Azienda Ospedaliero-Universitaria delle Marche (Ancona, Italy) was evaluated to identify peripheral pulmonary nodules approached by EBUS-TBNA. Thirty patients with a single peripheral pulmonary nodule located peripherally to the subsegmental bronchi of the lower lobes and adjacent to a small bronchus greater than 3 mm in diameter were included in this study. The nodule was visible using endoscopic ultrasound in 28 patients and the diagnosis was obtained via EBUS-TBNA in 26 cases (12 adenocarcinoma, 5 typical carcinoid tumors, 4 hamartoma and 5 metastatic lesions). The diagnostic yield was 86.6% for all 30 patients and 92.8% if only the 28 patients in which the lesion was visualized via echobronchoscopy were considered. No relevant adverse events were observed. We conclude that EBUS-TBNA may be an effective and safe option to sample pulmonary peripheral nodules in selected patients with lower lobe peripheral pulmonary lesions adjacent to small bronchi greater than 3 mm in diameter and reachable with the EBUS-TBNA probe.

Tracheobronchial Foreign Body Inhalation

Background: Foreign body aspiration (FBA) is not an uncommon entity in the population. Objectives: In the current study, we discuss our experience in the management of 234 case series with tracheobronchial foreign body removal using bronchoscopy. Materials and Methods: The bronchoscopy database (from 2021 to 2022) was reviewed for subjects with a history of FBA managed with bronchoscopy. Demographic, clinical, and bronchoscopy data were collected and analyzed. Results: A total of 234 bronchoscopies were carried out for FBA throughout the study period. FBA was more prevalent in children under the age of two (29%) and in patients over the age of ten (24%). In 205 patients, a foreign corpse was found (87.6%). The majority of organic foreign bodies were sunflower seeds (22.4%). Nonetheless, the metallic pins (25.3%) were the most frequent foreign body. The preferred location for the impaction was the right major bronchus (45.9%). Just 90.2% of these individuals had a foreign body. History had an 89.7% sensitivity and a 31% specificity for detecting FBA. Laryngeal edema, which afflicted 32 patients (13.7%), and recurrent chronic chest infection, which affected 13 patients (5.5%), were the most frequent bronchoscopy-related side effects. Conclusions: Foreign body inhalation most frequently impacted children aged 1–2 years. The history is a major element in the diagnosis, and bronchoscopy findings were strongly correlated with the patient’s history of the incident. The most frequent clinical symptom among individuals who had a proven foreign body but no history of inhalation was protracted pneumonia. The location of the most frequent foreign body lodgment in the tracheobronchial tree depends on the type of foreign body, with metallic pins occurring more commonly in the left main bronchus. Laryngeal edema, which occurred in 13.7% of bronchoscopy patients, was the most frequent complication.

Impact of Radial Percentage K-Space Filling and Signal Averaging on Native Lung MRI Image Quality in 3D Radial UTE Acquisition: A Pilot Study

To assess the impact of radial percentage k-space filling and signal averaging on lung MRI image quality in 3D radial ultrashort echo-time (UTE) acquisition. In this IRB approved prospective study, 25 patients (10-30 years) referred for MRI examination for indications other than related to lungs were enrolled from January 2021 to November 2021. All the patients underwent lung MRI, using three different UTE sequence parameters with radial (R) percentage of 100 or 200 and number of signal averages (NSA) of one or two. Two radiologists independently assessed the images for the outline of pleural and mediastinal surface, visibility of lung parenchyma, major bronchi, and segmental bronchi. The quality of the images was assessed based on the degree of motion artifacts. For objective assessment, signal-to-noise ratio, contrast-to-noise ratio, and contrast ratio were calculated. The outline of pleural and mediastinal surface, lung parenchyma, and segmental bronchi were best demonstrated on R100_NSA2 sequence. The major bronchi were best demonstrated on R100_NSA2 and R100_NSA1 sequences. The intersequence difference was statistically significant for evaluating the pleural and mediastinal surface and segmental bronchi only (p < 0.05). Overall, the best image quality with least artifacts was seen with R100_NSA2 sequence. The objective assessment showed no statistically significant difference between the three sequences (p > 0.05). Interobserver agreement for different findings was substantial to almost perfect for R100_NSA2 and R200_NSA1 sequences. R100_NSA2 UTE sequence performed best for the evaluation of the different findings and showed the best image quality.

Tracheobronchomegaly (Mounier-Kuhn Syndrome) in Old Age - A Case Report

Tracheobronchomegaly or Mounier-Kuhn syndrome is a rare condition affecting the airways and is characterized by dilatation of the trachea and major bronchi secondary to atrophic or absent elastic fibres of the cartilage and thinning of the muscles.[1] The abnormally enlarged flaccid portions of the bronchial tree collapse and fail to maintain patency during expiration and coughing, predisposing the patient to stagnation of contents and recurrent lower respiratory tract infections, emphysema, bronchiectasis and chronic pulmonary suppuration.[2] The diagnosis is usually made on basis of specific radiographic features,[3] particularly on computed tomography (CT) scan. We report a case of a 69-year-old man who presented with recurrent lower respiratory tract infections and was found to have tracheobronchomegaly as an underlying primary airway abnormality on imaging and bronchoscopy that was initially undiagnosed.

A Case of Mounier Kuhn Syndrome with Bronchial Asthma

Tracheobronchomegaly (Mounier–Kuhn syndrome) is a rare disease characterized by dilatation of the trachea and major bronchi because of atrophy or absence of elastic fibers and smooth muscle cells. The clinical signs are diverse and not very specific. Imaging provides a positive diagnosis. We present a case of 40 year old male who presented with intermittent episodes of cough with productive sputum, wheezing and breathing difficulty since last 35 years and he was treated for Bronchial Asthma since last 25 years. He was later diagnosed with Mounier–Kuhn syndrome with Bronchial Asthma by clinical history supported by Radiological evidences.

Repeat Episodes of Massive Hemoptysis Due to an Anomalous Origin of the Right Bronchial Artery in a Patient with a History of Coccidioidomycosis

Anomalous bronchial arteries originate outside the space bound by the T5 and T6 vertebrae at the major bronchi. Here, we highlight a case of a 37-year-old man with a past medical history of coccidioidomycosis and who presented with massive hemoptysis. A bronchial angiogram showed the patient had a right bronchial artery originating anomalously from the left subclavian artery. The patient ultimately underwent a bronchial artery embolization, after which he achieved symptomatic remission.

A Distinct Difference Between Air and Mucosal Temperatures in Human Respiratory Tract.

Extensive evidence indicates that several types of temperature-sensitive ion channels are abundantly expressed in the sensory nerves innervating airway mucosa. Indeed, airway temperature is known to play an important role in regulating respiratory functions. However, the actual airway mucosal temperature and its dynamic changes during the respiratory cycle have not been directly measured. In previous studies, airway tissue temperature was often estimated by indirect measurement of the peak exhaled breath temperature (PEBT). In view of the poor thermal conductivity of air, we believe that the airway tissue temperature cannot be accurately determined by the exhaled air temperature, and this study aimed to test this hypothesis. We applied a miniature rapid-response temperature probe to measure directly the mucosal temperatures of trachea, major, lobar, and segmental bronchi in eight human subjects during a bronchoscopy procedure. Unlike the air temperature in the airway lumen, the mucosal temperature in these airway segments remained relatively stable and did not exhibit the phasic changes synchronous with respiratory cycles. The airway mucosal temperature increased progressively from the extra-thoracic trachea (35.7 ± 0.2°C) toward the segmental bronchus (36.9 ± 0.2°C). Most importantly, the temperatures measured directly at the mucosa of all these airway segments were substantially higher than the PEBT (31.7 ± 0.8°C). The recent findings of a close association between an increased PEBT and airway tissue inflammation have revealed the implication and potential of incorporating the PEBT measurement in the future clinical diagnosis of airway inflammation. Therefore, it is imperative to recognize this distinct difference in temperature between airway mucosa and exhaled air.

Компьютерная томография в диагностике синдрома Мунье-Куна

The article presents a clinical case of tracheobronchomegaly (Mounier-Kuhn syndrome). This is a congenital malformation characterized by dilatation of trachea and major bronchi due to underdevelopment of elastic and muscular elements of the tracheobronchial tree. The first manifestations appear as symptoms of recurrent bronchitis. A full-scale clinical picture in most cases appears at the age of 20-40, when infection adds, periodic recurrences become more frequent, and respiratory failure gradually builds up, which is associated with impairment of draining function of bronchi, and further leads to purulent bronchitis, bronchiectasis and pneumosclerosis. Traditional chest X-ray has limited capacities and cannot be used for diagnosis of Mounier-Kuhn syndrome, which is demonstrated in the described case. Thus, a female patient for a long time was observed for tracheobronchitis, but the conducted treatment did not give any significant improvement. Conclusion. Mounier-Kuhn syndrome is a rather rare pathology that can be diagnosed with multislice X-ray computed tomography permitting to more distinctly localize the pathological process and to determine its spread, dimensions of trachea and major bronchi in different anatomical planes, the condition of the neighboring tissues and structures and existence of complications. Also of importance is bronchoscopy that permits to identify alterations of bronchial mucosa in tracheobronchomegaly.

Anatomical partial lobectomy for the treatment of 3 336 cases of patients with lung nodule

Objective: To explore the feasibility, safety and effectiveness of anatomical partial lobectomy. Methods: The clinical data of 3 336 patients with lung nodules underwent anatomical partial lobectomy in our center from November 2013 to November 2019 were retrospectively analyzed. We set the safety margin distance according to the imaging feature of the lesion. The surgeons then anatomically detached the major vessels and bronchus in this region, resected the targeted lung tissue along the plane, and completed the resection of anatomical pulmonary lobe and clean and sampling of systemic lymph nodules. Results: A total of 668 cases were multiple nodules and 2 668 cases were solitary pulmonary nodules. According to the postoperative pathological results, 283 cases were benign, 1 197 cases were preinvasive lesions (including 38 cases of atypical adenomatous hyperplasia, 445 cases of adenocarcinoma in situ and 714 cases of minimally invasive adenocarcinoma), 1 713 cases were invasive adenocarcinoma, 73 cases were non-adenocarcinoma and 70 cases were metastatic carcinoma. Among 1 786 invasive primary lung cancers, 11 cases received preoperative neoadjuvant chemotherapy, and their postoperative pathologic diagnoses were stage ypIA. Other 1 775 cases who did not receive postoperative neoadjuvant treatment included 1 587 cases in stage ⅠA, 112 cases in stage ⅠB, 3 cases in stage ⅡA, 18 cases in stage ⅡB, 37 cases in stage ⅢA, 9 cases in stage ⅢB, 9 cases in stage Ⅳ. The average operation time was (127.3±55.3) minutes, and the mean postoperative hospital stay was (4.8±2.4) days. The incidence rate of complications (grade>2) was 1.1%(38/3 336), and no death occurred during 30 days after operation. Conclusion: Anatomic partial lobectomy has good clinical applicability, safety and effectiveness, which is worthy of clinical application and recommendation.

Bronchoscopic drainage with full personal protective equipment (PPE) saved a life of COVID-19 infected patient with ventilator associated pneumonic athelectasis from the Diamond Princess Cruise Ship

A 75 year-old American passenger was transferred to our hospital, infected in Diamond Princess, with pneumonia due to COVID-19 infection. At the beginning, he walked in but on day 4, he needed intubation and mechanical ventilation support because of worsening respiratory function due to wide-spread pneumonia. Despite the ventilation, his respiratory condition did not improve due to his left lower lobe atelectasis by an obstruction of left main bronchus. On day 9, interventional drainage of the major bronchus by disposable bronchoscopy was performed and built-up cast was removed by suctioning under the endoscopy. After the procedure, respiratory condition remarkably improved and he was extubated on day 14. COVID-19 infection with severe acute respiratory failure need mechanical ventilation support and if major airway obstruction was suspected, immediate interventional drainage may drastically change the patient clinical course and outcome.

Direct and indirect CT imaging features of esophago-airway fistula in adults.

BackgroundEsophago-airway fistula (EAF) is an abnormal connection between the esophagus and the trachea or a major bronchus. While contrast esophagography remains the primary radiographic tool for the diagnosis of EAF, computed tomography (CT) is often employed in its evaluation. A systematic analysis of CT findings of EAF in adults has not been previously published. The goal of our study is to determine the direct and indirect CT findings of EAF in adults.MethodsWe identified patients with EAF detected on CT at our institution between January 1, 2001 and December 31, 2019, with endoscopic or surgical confirmation. We collected patient clinicopathologic characteristics and assessed CTs for direct and indirect imaging features of EAF in these patients.ResultsTwenty-six patients (median age: 56 years; range, 25–79 years; F=13, 50% and M=13, 50%) with confirmed EAF were identified. Half of the patients had an underlying malignancy. On CT, a direct connection between the esophagus and the airway was identified in most cases (22/26; 85%). Common indirect CT findings of EAF included esophageal wall thickening (21/26, 81%), mediastinal fatty stranding (21/26, 81%), airway wall thickening (20/26, 77%), fluid or debris within the airways (17/26, 65%), and focal or diffuse esophageal dilation with air (17/26, 65%). Mediastinal fluid collections were infrequently seen (4/26, 15%), but findings of aspiration or other pneumonia were common (19/26, 73%).ConclusionsCT plays an essential role in both the primary and secondary evaluation of adult EAF resulting from both malignant and benign etiologies. CT may be the first diagnostic exam to suggest and detect the presence of EAF and may precede clinical suspicion, and it can detect a subset of fistulas not demonstrated on esophagography. There are several direct and indirect imaging findings on CT that can help in the detection of EAF.

Ectopic origin of bronchial arteries: still a potential pitfall in embolization

To evaluate the influence of ectopic origin of bronchial arteries (BAs) on bronchial artery embolization (BAE) for hemoptysis. CT and angiography images of 50 consecutive sessions in 39 patients (aged 26-93years; mean, 70.6years) who underwent BAE for hemoptysis from April 2010 to December 2019 were reviewed. We defined ectopic BA as a systemic artery originating from other than the T5-T6 vertebral level of the descending aorta with course along the major bronchi. The background of patients, number of BAs, culprit arteries, and treatment outcomes were compared between the cases with and without ectopic BAs. Seventeen patients (43.6%) demonstrated 19 ectopic BAs, originating from the subclavian artery (n = 7), aortic arch above the T5-T6 level (n = 6), internal mammary artery (n = 3), brachiocephalic trunk (n = 2) or lower descending thoracic aorta (n = 1). Total number of BAs in the cases with ectopic BA was significantly greater than those in cases without ectopic BA (p = 0.0062). Required sessions of embolization were similar in the two groups. No procedure-related significant complications were noted; however, four ectopic BAs caused unexpected filling of contrast media or migration of the embolic material from the orthotopic BA to ectopic BA originating from the arch vessels via tiny communication. Although BAE under the presence of ectopic BA is feasible and safe, detection of BAs with ectopic origin, even of small diameter, is needed to avoid risk of non-target coursing of embolic materials.

Rare case of bronchoscopic debulking of endobronchial leiomyoma

An endobronchial leiomyoma is a rare benign tumour of lung. It occurs from the smooth muscle of tracheobronchial tree or within lung parenchyma. It presents less than 2% of all benign lung tumours. We present a case report of a 39-year-old male, ex-smoker, with no family history of malignancies, presenting with cough and dyspnoea for 7 months with no symptomatic relief. CAT scan thorax showed well-defined oblong soft tissue mass lesion 24.2 mm × 15.4 mm in right major bronchus compromising central lumen. Flexible bronchoscopy revealed an endobronchial mass at right major bronchus. Patient underwent rigid bronchoscopy with endobronchial mass excision with an electrocautery snare and cryoprobe in the same seating. Complete debulking of tumour was achieved and histopathology report was suggestive of leiomyoma. Prompt investigations and intervention can give favourable outcomes in cases of endobronchial tumours.

Chest MRI Using Multivane-XD, a Novel T2-Weighted Free Breathing MR Sequence

ObjectiveTo compare image quality of free-breathing T2-weighted MultiVane-XD (MVXD) sequence (non-Cartesian k-space filling using radial rectangular blades) with conventional MR sequences (short tau inversion recovery [STIR],balanced true field echo [BTFE], T1 in phase fast field echo [T1 FFE], and T1-fat saturated postgadolinium [T1PG]) in MR imaging of chest. Materials and MethodsTwenty-one patients (10 men and 11 women) underwent chest MRI including T2W MVXD, STIR, BTFE (18/21), T1 FFE, T1PG (10/21) sequences at 1.5 T. Two reviewers (A.S.B and M.J. with 20 and 10 years of experience in pulmonary imaging, respectively) evaluated each sequence with respect to overall image quality, image sharpness, definition of mediastinal vessels including the aorta, pulmonary arteries, superior vena cava, intrapulmonary vessels; trachea, main bronchi, intrapulmonary airways; lung-mediastinal interface, pulmonary lesion detection, and artefacts in the upper, middle, and lower third of chest using 5-point scales. No sedation was given. Pairwise comparisons between T2W MVXD and the 4 conventional sequences were made using unpaired student's t test. ResultsMean age of patients was 30.67 years (range: 6-60 years). T2 MVXD showed significantly better overall image quality and sharpness than STIR, T1 FFE, and T1PG (P < 0.01) while it was comparable to BTFE. Mediastinal vessels were significantly better visualized on T2 MVXD as compared to STIR and T1 (P < 0.003). However, BTFE and T1PG were superior to T2 MVXD for visualization of great vessels, SVC, and intrapulmonary vessels (P < 0.01). Visualization of trachea, major bronchi, intrapulmonary airways as well as intrapulmonary lesion detection was significantly better on T2 MVXD images in comparison to any of the other 4 sequences (P < 0.03). Intrapulmonary artifacts were significantly lesser in BTFE images as compared to T2 MVXD (P < 0.01). No significant difference was found between the severity of intrapulmonary artifacts in other MR sequences as compared to T2 MVXD. ConclusionsBy virtue of its better overall image quality, sharpness, superior visualization of mediastinal airways, and lesion detection, T2 MultiVane-XD promises to be a robust addition in the armamentarium of thoracic radiologists.

Laser pulmonary metastasectomy by video-assisted thoracic surgery

Indications and surgical approach for pulmonary metastasectomy remain controversial as randomized clinical trials are lacking to validate its effectiveness. To this end, non-anatomical lung wedge resection, widely performed by staplers, persists as preferred surgical procedure. With the advent of new technologies, laser assisted surgery evolved and has been advocated mainly for multiple pulmonary metastases in open surgery fashion. However, video-assisted thoracic surgery (VATS) laser pulmonary metastasectomy has been rarely reported. This review is based on a selective search of the PubMed database for articles that were published from 1990 to 2018 and contained the keywords ‘laser assisted surgery’, ‘pulmonary metastasectomy’, ‘thoracoscopic laser metastasectomy’, and ‘VATS’. No prospective clinical trial has been performed to provide evidence whether to treat pulmonary metastasis with laser or conventional techniques. According to retrospective cohort studies and descriptive series, open approach laser assisted surgery facilitates the resection of a higher number of metastases, sparing healthy lung parenchyma, while obtaining similar recurrence rates compared to conventional staplers. In central lesions, optimal surgical margins can be achieved around the lesion avoiding injury to deep located structures such as major vessels or bronchus. However, evidence about thoracoscopic laser pulmonary metastasectomy is remarkably poor consisting in only a few small series of patients with one or two resected metastases. Laser assisted pulmonary metastasectomy is safe and effective. Video-assisted laser resection of lung metastases is a marginal technique to date. Postulated benefits of open laser assisted pulmonary metastasectomy could not be assumed by thoracoscopic approach with available data. Further studies are needed to demonstrate whether multiple and centrally lesions could be effectively resected by thoracoscopic laser metastasectomy.