Right Lower Lobe Research Articles

The Azygos Esophageal Recess Is Not to Be Missed in Screening Lung Cancer With LDCT.

Lesion overlooking and late diagnostic workup can compromise the efficacy of low-dose CT (LDCT) screening of lung cancer (LC), implying more advanced and less curable disease stages. We hypothesized that the azygos esophageal recess (AER) of the right lower lobe (RLL) might be an area prone to lesion overlooking in LC screening. Two radiologists reviewed the LDCT examinations of all the screen-detected incident LCs observed in the active arm of 2 randomized clinical trials: ITALUNG and national lung screening trial. Those in the AER were compared with those in the remainder of the RLL for possible differences in diagnostic lag according to the Lung-RADS 1.1 recommendations, size, stage, and mortality. Six (11.7%) of 51 screen-detected incident LCs of the RLL were located in the AER. The diagnostic lag time was significantly longer (P=0.046) in the AER LC (mean 14±9mo) than in the LC in the remaining RLL (mean 7.3±1mo). Size and stage at diagnosis were not significantly different. All 6 subjects with LC in the AER and 16 (35.5%) of 45 subjects with LC in the remaining RLL (P=0.004) died of LC after a median follow-up of 12 years. Our retrospective study indicates that AER might represent a lung region of the RLL prone to have early LC overlooked due to detection or interpretation errors with possible detrimental consequences for the subject undergoing LC screening.

Chest computed tomography findings among adult Aboriginal Australians with bronchiectasis in the Top End Northern Territory of Australia.

There is limited evidence in the literature illustrating chest computed tomography (CT) characteristics among adult Aboriginal Australians with bronchiectasis. This retrospective study evaluates the radiological characteristics of bronchiectasis in Aboriginal Australians residing in the Top End, Northern Territory of Australia. Patients aged >18 years with chest CT-confirmed bronchiectasis between 2011 and 2020 were included. Demographics and relevant clinical parameters were collected. Alongside confirming bronchiectasis, chest CT reports were assessed for (i) lobar location (ii) unilateral or bilateral involvement and (iii) bronchiectasis type when available. A total of 459 patients were identified with chest CT-confirmed bronchiectasis, with a median age of 47 years, and 55% were females. Bronchiectasis was predominantly recorded in the left lower lobe (LLL) (73%), followed by the right lower lobe (RLL) (62%) and the left upper lobe (LUL) was least common (22%). Females recorded the right middle lobe (RML) affected significantly more often than males (50 vs. 34%, P = 0.012). Bilateral involvement was common (74%), with the strongest pairwise correlation associated between the right upper lobe (RUL) and LUL (P < 0.001). Cylindrical (50%) and cystic (28%) types were most common. The RML and LLL showed positive correlation with cylindrical and LUL with cystic bronchiectasis. Neither lobar location nor bronchiectasis type showed any significant association with lung function parameters other than RML, Lingula and LUL involvement being associated with better percent predicted values of diffusing capacity for carbon monoxide. There were no significant associations between sputum culture and type or lobar locations of bronchiectasis except for non-Aspergillus fungus culture prevalence was higher with cystic or cylindrical types. The results of this study may be an avenue to develop CT bronchiectasis severity scale in the future specific for Aboriginal Australians.

Abstract PO2-20-09: Hiding in plain sight: A heterogeneous response in a patient with metastatic HR+/HER2- breast cancer

Abstract INTRODUCTION: Metastatic breast cancer is an infamously heterogeneous disease—characterized by a range of clinical presentations and treatment responses. In light of this heterogeneity, ASCO guidelines recommend patients with new, accessible metastatic tumors undergo a biopsy to inform treatment decisions. Here, we present a patient with HR+/HER2- disease with a long history of unusually heterogeneous responses—and a repeat metastatic biopsy that provided an answer. CASE: A 55-year-old woman presented for consultation of treatment-refractory metastatic breast cancer. She was originally diagnosed with a right-sided Stage III HR+/HER2- invasive ductal carcinoma (IDC) at the age of 33. Upon staging, she was incidentally found to have a right lower-lobe lung carcinoid tumor that was removed by lobectomy. She underwent a partial mastectomy, axillary lymph node dissection, followed by adjuvant chemo- and radiation therapy. She tolerated one week of tamoxifen which was discontinued due to adverse effects. Fifteen years later, screening mammography revealed a suspicious lesion in the right breast—biopsy consistent with a new IDC. She underwent bilateral mastectomies which showed a pT1cNxM0 G2 IDC with associated DCIS (ER+/PR+/HER2 IHC 2+, FISH-negative, Oncotype RS 12). Genetic testing was negative. The patient trialed adjuvant tamoxifen, which was discontinued due to repeat adverse effects. Two years later, rising tumor markers prompted restaging scans that demonstrated an enlarging liver lesion. Liver biopsy was consistent with metastatic adenocarcinoma of the breast (ER+/PR+/HER2 IHC 0), GATA3 positive. Patient was started on letrozole with lupron and palbociclib with disease control for two years until progression in the bone, prompting a switch of letrozole to fulvestrant with continued palbociclib. Her disease was stable for two additional years until progression of multiple liver lesions. She was then started on single-agent paclitaxel. At this point, she was seen in our office for consultation and next-line therapy options. Repeat staging scans showed heterogeneous response in the liver with overall progression. ctDNA testing revealed a mutation in MEN1 (p.Q354*, 2.8% VAF) without other actionable alterations. Patient opted to enroll into a clinical trial of an experimental ER-antagonist but experienced progression of her liver lesions on first staging scans. A second liver biopsy was performed on a progressive lesion which showed ER-/PR-/HER2- disease. She opted to enroll into a Phase 1b/2 trial with sacituzumab govitecan-hziy in combination with a PARPi. Staging scans again showed a mixed response in the liver. Given a history of mixed responses and discordant receptor staining, the differential diagnosis included loss of hormone receptor expression in the breast carcinoma versus metastases from an occult neoplasm. Additional immunohistochemical studies were performed on a subsequent liver biopsy showing positivity for chromogranin, synaptophysin, and INSM1, and negative results for ER, PR, GATA3, and TRPS1. Next-generation sequencing of the progressive lesion revealed a MEN1 SNV (p.Q354*, VAF 82%) as well as loss of 11q (MEN1 locus) suggestive of biallelic loss of MEN1—providing molecular evidence of a metastatic carcinoid tumor. A history of mixed response in the liver was concluded to be two coexisting neoplasms—a metastatic HR+/HER2- breast cancer as well as a late recurrence of a right-lower lobe carcinoid tumor from 22 years prior. DISCUSSION: The unanticipated discovery of an occult, coexisting neoplasm in the setting of a metastatic HR+/HER2- breast cancer illustrates the value of meticulous pathological review, repeat molecular testing and the use of next-generation diagnostic tools such as tumor sequencing in the advanced setting—particularly when a clinical story defies conventional expectations—to personalize care and optimize oncologic management in the face of complex biology. Citation Format: Nolan Priedigkeit, Jane Brock, Olivia Cunningham, Molly Skeffington, Melissa Hughes, Nancy Lin, Susan Lester, Heather Parsons. Hiding in plain sight: A heterogeneous response in a patient with metastatic HR+/HER2- breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-20-09.

The co-infection of pulmonary hydatid cyst, lophomoniasis and tuberculosis in a patient with resistant respiratory symptoms; a case report study

BackgroundLophomonas blattarum is a rare protozoan that causes opportunistic infections, and the co-infection of lophomonas with tuberculosis and human hydatidosis is a serious public problem in the co-endemic areas of developing countries.Case reportWe presented a 58-year-old female with fever, losing weight, and cough with whitish-yellow sputum that started one month ago. Increasing inflammatory markers and hypereosinophilia in laboratory tests, and a cavity with thick, regular walls and undulating air-fluid levels measuring 43 × 30, evident in the upper segment of the right lower lobe (RLL), along with consolidation and the ground glass opacity of the upper segment and posterior basal of the RLL is apparent in CT scan were reported. Then, a bronchoscopy was requested, and the BAL specimen reported a negative fungal and bacterial infection in the samples. Several live and oval flagellated lophomonas protozoa, hydatid cyst protoscoleces (the larval forms of the parasites), and M. tuberculosis were observed in microscopic evaluation. The patient was treated with metronidazole, oral albendazole, and a combination of TB regimen.ConclusionPhysicians should always consider the possibility of co-infections of lophomonas with tuberculosis and human hydatidosis and investigate patients with risk factors such as immunodeficiency conditions or treated with immunosuppressive medications.

Comparison of Radiation Dose and Image Quality of Pediatric High-Resolution Chest CT Between Photon-Counting Detector CT and Energy-Integrated Detector CT: A Matched Study.

BACKGROUND. Photon-counting detector (PCD) CT has been shown to reduce radiation dose and improve image quality in adult chest CT examinations; its potential impact in pediatric CT is not well documented. OBJECTIVE. The purpose of our study was to compare radiation dose, objective image quality, and subjective image quality of PCD CT and energy-integrating detector (EID) CT in children undergoing high-resolution CT (HRCT) of the chest. METHODS. This retrospective study included 27 children (median age, 3.9 years; 10 girls, 17 boys) who underwent PCD CT between March 1, 2022, and August 31, 2022, and 27 children (median age, 4.0 years; 13 girls, 14 boys) who underwent EID CT between August 1, 2021, and January 31, 2022; all examinations comprised clinically indicated chest HRCT. The patients in the two groups were matched by age and water-equivalent diameter. Radiation dose parameters were recorded. One observer placed ROIs to measure objective parameters (lung attenuation, image noise, and SNR). Two radiologists independently assessed subjective measures (overall image quality and motion artifacts) using 5-point Likert scales (1 = highest quality). Groups were compared. RESULTS. PCD CT, in comparison with EID CT, showed lower median CTDIvol (0.41 vs 0.71 mGy, p < .001), DLP (10.2 vs 13.7 mGy × cm, p = .008), size-specific dose estimate (0.82 vs 1.34 mGy, p < .001), and tube current-exposure time product (48.0 vs 202.0 mAs, p < .001). PCD CT and EID CT showed no significant difference in right upper lobe (RUL) lung attenuation (mean, -793 vs -750 HU; p = .09), right lower lobe (RLL) lung attenuation (mean, -745 vs -716 HU; p = .23), RUL image noise (mean, 55 vs 51 HU; p = .27), RLL image noise (mean, 59 vs 57 HU; p = .48), RUL SNR (mean, -14.9 vs -15.8; p = .89), or RLL SNR (mean, -13.1 vs -13.6; p = .79). PCD CT and EID CT showed no significant difference in median overall image quality for reader 1 (1.0 vs 1.0, p = .28) or reader 2 (1.0 vs 1.0, p = .17) or median motion artifacts for reader 1 (1.0 vs 1.0, p = .07) or reader 2 (1.0 vs 1.0, p = .22). CONCLUSION. PCD CT showed significantly reduced dose levels without a significant difference in objective or subjective image quality compared with EID CT. CLINICAL IMPACT. These data expand understanding of the capabilities of PCD CT and support its routine use in children.

Effectiveness of T2 biologics in patients with common variable immune deficiency and allergic respiratory disease

IntroductionMany patients with common variable immune deficiency (CVID) have a history suggestive of allergic respiratory disease including chronic rhinosinusitis (CRS) and asthma. The underlying immunologic defect, the presence of comorbid conditions such as bronchiectasis or interstitial lung disease, and recurrent infections may make the diagnosis of these conditions difficult. T2 biologics targeting allergic inflammatory pathways are now the standard of care for severe persistent asthma and CRS with nasal polyposis (CRSwNP). The efficacy of these agents in patients with CVID is unknown. MethodsWe performed a retrospective analysis of patients with CVID at a single academic medical center and identified those who had ever been prescribed a T2 biologic. ResultsWe identified 8 patients with CVID who had ever been prescribed T2 biologics: 6 patients with severe persistent asthma and 2 patients with CRSwNP. All patients had CVID without inflammatory complications with therapeutic IgG levels on immune globulin replacement therapy. Comorbid bronchiectasis was identified in 3 patients and no patients had GLILD. Two patients were taking omalizumab, two on mepolizumab, 1 on benralizumab, and 1 on dupilumab for severe persistent asthma and 2 on dupilumab for CRSwNP. Only 4 patients in this group (50%) had subjective improvement of symptoms and objective clinical benefit based on ability to wean off of corticosteroids and fewer exacerbations per year. Only 1 of these patients had objective improvement in FEV1 by >200mL. Neither of the 2 patients treated with dupilumab for CRswNP reported improvement and the biologic was discontinued. Of the 2 patients with asthma who were found to have eosinophilia on bronchoalveolar fluid analysis, both of these patients had clinical improvement on eosinophil-targeted biologic therapy. All 3 patients who were tested were found to have elevated serum T2 cytokines including IL-4, but this did not predict response to therapy.Table 1(abstract: 191) Demographic and immunologic data of 8 patients with CVID on T2 biologiesAgeGenderT2 biologicIndicationBronchiectasisIncrease in FEV1 by >200mLClinical responseIgG (mg/dL)IgA (mg/dL)IgM (mg/dL)IgE (kU/L)Absolute eosinophil count(K/μL)CD19B cell count (cells/μL)Th2 Cytokine PanelBAL Eosinophils%CT ThoraxBronchoscopy-Pathology82Fomalizumabsevere persistent asthmayesnono1551522923430049Not availableNot availableBasal abnormalitycharacterized by ground glass opacities (GGO), centrilobular nodularity with small focus of consolidation posterior right lower lobe (RLL). Additional focus of patchy groundglass posterior right lung (RL).Not available74Mmepolizumabsevere persistent asthmayesnoyes11681623141681600176Not available25Resolution of right upper lobe (RUL) apical nodule and branching tubular opacity. New clustered nodularity in the posterior RLL with faint GGO in the upper lobes. Moderate bronchial wall thickening, greatest in the lower lobes.Bronchial wall with smooth muscle hypertrophy. Lung parenchyma without evidence of inflammation, fibrosis, or malignancy.57Fomalizumabsevere persistent asthmanonoyes89725221687100103Not available0Diffuse bronchial dilation without bronchial wall thickening. Mild patchy air trapping.Largely denuded and edematous bronchial wall with minima] chronic inflammation, focal subepithelial elastosis, focal expansion of the subbasal lamina, mild increase in mucous secretion.37Fdupilumabchronic rhinosinusitis with nasal Polyposisnonot applicableno787<10<20<2100187elevated IL-4, IL-6Not availableResolved patchy GGO with exception of a new tiny focus of GGO in the basal RLL. Stable mild diffuse bronchial wall thickening.Not available73Fbenralizumabsevere persistentnoyesyes84635<20<2100179Not available4Mild to moderate airway inflammation and diffuse air-trapping. Minimal left basilar linear atelectasis/scarring is new. TracheobronchomalaciaBronchial wall with moderate chronic inflammation and eosionphils (peak 12/hpf), thickened subbasal lamina, mild smooth muscle hypertrophy.43Fdupilumabsevere persistent asthmanonot availableyes12614313556.5056elevated IL-4, IL-5, IL-6Not availableBenign right oblique fissure. 2 small nodules.Not available56Fdupilumabyesnot applicableno95476602.625027Not available1chronic rhinosinusitis with nasal polyposisMultiple new areas of peribronchovascular consolidation and confluent GGO. Widespread tree-inbud nodularity. Mild cylindricalbronchiectasis. Dilated main pulmonary trunk.Bronchial wall with moderate chronic inflammation and scattered eosinophils (6/hpf), thickened subbasal lamina. No granulomas. Right lung bronchial wall with moderate chronic inflammation. Lung parenchyma with airway centered mild interstitial chronic inflammation49 Fmepolizumabsevere persistent asthmanonono166845189510049Not available0Mild bronchial wall thickening and scattered air trapping. Patchy GGO in the left upper lobe with minimal involvement of the lower lobes. Dynamic expiratory images demonstrates evidence of tracheobronchomalacia.Bronchial wall with patchy mild to moderate chronic inflammation with rare neutrophils and eosinophils. Mild smooth muscle hypertrophy. Patchy squamous metaplasia and respiratory bronchiolitis in the left lung.*Clinical response is measured by reduction in exacerbations and/or ability to wean off of corticosteroids for individuals with severe asthma and is measured by improvement in sinonasal symptoms and reduced nasal polypoid burden for CRSwNP. [Display omitted] [Display omitted] ConclusionPatients with CVID may benefit from more direct sampling of nasal mucosal and bronchial secretions (sputum, bronchoalveolar lavage) to determine the potential benefit from T2 biologics in severe allergic respiratory disease. Prospective analyses in larger cohorts following objective indices of improvement as well as changes in serum and mucosal biomarkers are necessary.

Characteristics and comparison of rapidly growing and slowly growing nontuberculous mycobacterial pulmonary disease.

Nontuberculous mycobacterial (NTM) pulmonary disease (PD) has rapidly increased globally. The characteristics and comparison of rapidly growing mycobacteria PD (RGM-PD) and slowly growing mycobacteria PD (SGM-PD) are still unclear. Our study enrolled 31 NTM-PD patients. Clinical data, including baseline, symptoms, underlying disease, laboratory tests, metagenomic next-generation sequencing (mNGS) results, radiological images, treatment, and outcome were recorded and analyzed. Of the 31 patients with NTM-PD, 22 patients were female and 9 were male. It included 11 RGM-PD and 20 SGM-PD. There was no difference in age (P = 0.425) and body mass index (P = 0.152) between the two groups. The common respiratory diseases in prevalence included bronchiectasis and chronic obstructive pulmonary disease. Three patients had positive results of T-SPOT tuberculosis (TB), and none had positive Xpert-Mycobacterium tuberculosis/rifampin results. On admission, patients were symptomatic and included cough/sputum production, fever, weight loss, fatigue, and hemoptysis. In comparison to RGM-PD, patients with SGM-PD had a greater chance of experiencing fatigue (P = 0.012). No significance was found in serum biomarkers between RGM and SGM-PD, including CD4/CD8 ratio, white blood cells, neutrophils, lymphocytes, procalcitonin, ferritin, C-reactive protein, and erythrocyte sedimentation rate. No liver or kidney impairment was found. Patients with RGM-PD were more likely to have right lower lobe (RLL) impairment (P = 0.021) and a cavity characteristic (P = 0.012). All 31 cases had positive mNGS results. The duration of mNGS was shorter than conventional methods (3.4 ± 0.7 vs. 26.4 ± 20.9, P < 0.001). Patients with SGM-PD were more likely to experience fatigue. The cavity and RLL involvement were more frequent in the RGM-PD. mNGS increases the identification of NTM specimens and complements the capabilities of conventional methods.

The anatomical landmarks for positioning of double lumen endotracheal tube using flexible bronchoscopy: A prospective observational study

BackgroundTo examine the tracheobronchial anatomy and its common variations after double-lumen tube (DLT) placement, and to determine the anatomical landmarks that can be easily identified by practitioners for DLT positioning. MethodIn total, 200 patients with American Society of Anesthesiologists I–II, who were aged 20–75 years and scheduled for video-assisted thoracic surgery (VATS), were prospectively enrolled. The types of DLT position in each patient was recorded [Type I, the DLT bronchial end was in the left main bronchus (LMB), and the primary carina could be observed; Type Ⅱ, the DLT bronchial end was in the right bronchus intermedius (RBI); and Type III, an unidentified trachea or bronchus wall was observed from the DLT tracheal lumen] and the main tracheobronchial tree images were collected using Flexible bronchoscopy (FB). ResultFive patients were excluded due to excessive bronchus secretions impacting image collection. Type Ⅰ, II, and III positions of DLT were detected in 134 (68.7%) patients, 28 (14.4%) patients, and 33 (16.9%) patients, respectively. Examples of the tracheobronchial tree, common features, and variations in each lung lobe were demonstrated using FB. Furthermore, image analysis showed that each superior segment orifice of the right lower lobe (RLL) and the left lower lobe (LLL) was less variable and recognizable, determining it an important anatomical landmark for DLT positioning. ConclusionThe tracheobronchial tree and its common variations after DLT placement were described. The superior segment orifice of the RLL and LLL can be considered as an important landmark for DLT positioning.

Variability of Inter-Fraction Target Motion during Hypofractionated Lung Radiation Therapy

<h3>Purpose/Objective(s)</h3> Pre-treatment 4D-CTs are used in planning for motion management of lung RT. The target excursion (E) at the time of planning may differ between planning and treatment. Additionally, the tumor excursion can change between fraction deliveries. The objective of this study is to investigate patterns of excursion variability (∆E) during hypofractionated radiotherapy (HRT) and the clinical factors that correlate with ∆E. <h3>Materials/Methods</h3> 41 patients with primary or metastatic lung tumors underwent HRT. For each patient, planning was performed on 4D-CT imaging. Patients underwent daily pre- and post- treatment 4D-CBCT for setup conformation and motion assessment. Respiration-induced excursion (E) was quantified in the planning 4D-CT, and in each daily excursion 4D-CBCT. All excursion values were measured in 3 dimensions: AP, LR, and SI. ∆E was calculated as the difference between daily 4D-CBCT excursion values and the planning 4D-CT excursion value. The clinical statistics and excursion statistics were evaluated for all fractions. Finally, Pearson correlation was performed to associate clinical factors with ∆E. <h3>Results</h3> 377 4D-CBCTs were analyzed. ∆E was largest in the SI direction, with ∆E_avg in the SI, LR, and AP directions being 0.16, 0.05, and 0.08 cm respectively. Only 7.1% of all 4D-CBCT's displayed ∆E ≥ 4mm. The average age of patients with ∆E ≥ 4mm was 58.63 y/o, and that of patients with ∆E<4mm was 71.73 y/o (P<0.001). The average baseline weight of patients with ∆E ≥ 4mm and ∆E<4mm were 84.94 kg and 72.82 kg respectively (P<0.001). 71.1% of males and 28.9% of females gave ∆E ≥ 4mm (P=0.003). 58.3% of tumors with ∆E ≥ 4mm were in the right lower lobe (RLL) and 20.8% of tumors with ∆E ≥ 4mm were in the left lower lobe (LLL) (P<0.001). An average AP planning excursion of 0.34cm gave ∆E<4mm and that of 0.53 cm gave ∆E ≥ 4mm (P =0.008). The average Charlson Comorbidity Index (CCI) was 3.58 for tumors with ∆E<4mm, and 5.17 for tumors with ∆E ≥ 4mm (P=0.004). Pearson correlation between the left and right lungs didn't yield statistically significant results (P=0.76). <h3>Conclusion</h3> Large ∆E seems predictable, with ∆E ≥ 4mm seen more in young patients with higher baseline weight, male gender, tumors in the lower lobes, and with large 4D-CT excursion displayed in the AP direction. There was no correlation found between ∆E and right versus left lung. Additionally, CCI did not correlate with excursion variability. Finally, the largest degree of ∆E is displayed in the SI direction.

A RIDDLE WRAPPED IN A MYSTERY: MUCOEPIDERMOID CARCINOMA (MEC) FOUND DURING EVALUATION OF PERSISTENT LUNG COLLAPSE

A RIDDLE WRAPPED IN A MYSTERY: MUCOEPIDERMOID CARCINOMA (MEC) FOUND DURING EVALUATION OF PERSISTENT LUNG COLLAPSE

SAVED BY CLOSE FOLLOW-UP: A UNIQUE CASE OF RECURRENT SQUAMOUS CELL CARCINOMA OF THE LUNG MARKED FOR OBLITERATION

SAVED BY CLOSE FOLLOW-UP: A UNIQUE CASE OF RECURRENT SQUAMOUS CELL CARCINOMA OF THE LUNG MARKED FOR OBLITERATION

Two Distinct Primary EGFR-Mutated Lung Adenocarcinoma Within the Same Patient: A Case Report

Introduction Lung cancer remains the most common cause of cancer-related deaths worldwide, with Non-Small Cell Lung Cancer (NSCLC) the predominant histologic subtype. Increasingly, molecular mutations are identified and used as therapeutic targets. We describe the case of a woman diagnosed with locally metastatic NSCLC, and distinct pulmonary masses, later identified as two independent primary lung tumors based on molecular profiling. Case Report A 58-year-old-female presented with cough and hemoptysis. Chest Computed Tomography (CT) revealed a 4.3cm mass in the right lung apex, 2.0 cm nodule in the right lower lobe (RLL), and right paratracheal/hilar adenopathy. Subsequent Positron Emission Tomography-Computed Tomography (PET-CT) showed uptake in the right upper lobe (RUL) (SUV 12.2) and RLL (standard uptake value (SUV) 2.5) masses and mediastinal lymph nodes, but no distant metastases. Bronchoscopic biopsy of the RUL mass and 4R lymph node were positive for poorly differentiated adenocarcinoma, and molecular analysis revealed Epidermal Growth Factor Receptor (EGFR) L858R mutation. Subsequent Electromagnetic Navigation (EMN) biopsy of the RLL lesion also showed adenocarcinoma, but with an EGFR exon-19 deletion. Both were negative for T790M mutation. She was therefore diagnosed with two separate primaries instead of intrathoracic metastases. She started erlotinib and after 4 months, repeat PET-CT showed complete response (CR) in the RLL and partial response (PR) in the RUL. Decision was made to pursue surgery with RUL/RLL bilobectomy. Pathology showed evidence of N2 disease; therefore, at time of surgery she was stage IIIA, presumably from the RUL mass. The RLL mass was presumed to be stage I. These were successfully resected, and she was deemed to have no evidence of disease (NED) post-operatively. Discussion Although co-mutations within the same tumor have been reported in up to 12% of patients,28 we are not aware of other cases in which a single patient was diagnosed with two separate primary lung tumors based on genetic profiles. Consequently, she was able to be treated with curative rather than palliative intent.

Risk of Each of the Five Lung Lobectomies: A Society of Thoracic Surgeons Database Analysis

BackgroundThe perioperative risk of pulmonary lobectomy as a solitary procedure has been extensively studied, yet the differences in outcomes between lobes, which have unique anatomy and a different amount of lung parenchyma, are entirely unknown. The purpose of this study was to define the risk of each of the 5 lobectomies. MethodsThe Society of Thoracic Surgeons Database was queried for patients undergoing lobectomy between 2008 and 2018. Patient and disease characteristics, operative variables, major morbidity, and 30-day mortality were examined. A multivariable logistic regression model (using the same variables in the current Society of Thoracic Surgeons lobectomy risk model) was developed to assess the contribution of lobectomy site to adverse outcomes. ResultsThere were 65 006 patients analyzed. Adjusted perioperative mortality rate is lowest for right middle lobe (RML), 0.63%; intermediate for right upper lobe (RUL), left upper lobe (LUL), and left lower lobe (LLL), 1.08 to 1.24%; and highest for right lower lobe (RLL), 1.63%. The adjusted major morbidity rate is lowest for RML, 5.36%; intermediate for LLL and LUL, 7.82% to 8.33%; and highest for RUL and RLL, 8.94% to 9.32%. Adjusted intraoperative transfusion rate is lowest for RML, 1.37%; intermediate for RLL and LLL, 1.81% to 1.94%; and highest for RUL and LUL, 2.47% to 2.72%. ConclusionsThere are clear differences in postoperative outcomes by lobectomy location. Mortality, major morbidity, and transfusion rate are lowest for RML but vary across other lobectomies. These differences should be appreciated in evaluating risk of operation, deciding on best therapy, counseling patients, and comparing outcomes.

Asynchronous changes of normal lung lobes during respiration based on quantitative computed tomography (CT).

This study aimed to explore the coordinated and independent actions of lung lobes during respiration using quantitative computed tomography (CT) in order to increase our in vivo understanding of pulmonary anatomy. Cases for whom test results showed normal pulmonary function tests (PFTs) results, and normal paired inspiratory-expiratory chest CT findings, as assessed by 2 radiologists, were retrospectively included in this study. From the chest CT results, we measured quantitative indices of lung volume (LV) and mean lung density (MLD) for the total lung (TL), left lung (LL), right lung (RL), and 5 lobes in inspiratory and expiratory phases. The differences of these measures between bilateral lungs and among the lobes were evaluated to study whether they were consistent or different during respiration. A total of 70 cases were included {median age of 49.5 [interquartile range (IQR), 38.0 to 60.3] years; 32 males; 38 females}. Overall, the inspiratory and expiratory volumes of the LL were smaller than those of the RL (both P<0.001). For the ventilation workload (λ, which indicates the ratio of lobar volume to total LV), the end-expiratory volume ratio (λex ) of the LL was 0.44 (IQR, 0.43 to 0.46), while the end-inspiratory volume ratio (λin ) had risen to 0.46 (IQR, 0.45 to 0.47) (P<0.001). Comparing the 5 lobes, not all lobes shared the same LV. However, the left lower lobe (LLL) and right lower lobe (RLL) showed some similarities. The λin-LLL and λin-RLL was higher than λex-LLL and λex-RLL , respectively (both P<0.001), while the ratios of the other lobes reduced. The pairwise mean absolute difference (PMAD) on λin and λex of the bilateral lower lobes was low in inspiration (0.0288) and expiration (0.0346). The MLD of bilateral lower lobes showed consistency in inspiration or in expiration (inspiration: P>0.999; expiration: P=0.975). In addition, the PMADs between the right middle lobe (RML) and other lobes were significantly larger than the PMAD between other pairs of lobes in both inspiration and expiration. Beyond that, the expiratory MLD of RML [-789.6 (IQR, -814 to -762.05) HU] was the lowest among the 5 lobes. We found that the LL assumes a higher workload during ventilation than it does during respiration. The 5 normal lobes were non-synchronous during respiration and contributed differently to ventilation. The bilateral lower lobes showed similarities and had a high-ventilation function, while and the LV and MLD of the RML showed the least changes within a respiration cycle.

Bronchial morphological changes are associated with postoperative intractable cough after right upper lobectomy in lung cancer patients.

To date, postoperative intractable cough (PIC) has not received adequate attention, and the complex perioperative factors when performing pulmonary resection often prevent researchers from addressing this issue. This study aimed to investigate the clinicopathological and radiographic indicators related to PIC in lung cancer patients. In all, 112 patients who had had right upper lobectomy for primary lung cancer from January 2019 to December 2020 were retrospectively reviewed. We collected data via the electronic medical database of our department. Bronchial morphological features were investigated comprehensively via three-dimensional chest computer tomography reconstruction images. During outpatient follow-up visits, 41 (36.6%) patients complained about persistent dry cough after surgery. Compared with the non-cough group, patients in the refractory cough group showed significant differences in smoking history, right upper lobe stump length, changes of right bronchus intermedius (RBI) diameter, changes of right lower lobe (RLL) basal bronchus diameter, changes of RBI/RLL bronchial angle, and bronchial kink. However, according to multivariable regression analysis, stump length, bronchial kink, and diameter change of the right lower lobe basal bronchus were independently associated with postoperative refractory cough. A nebulization drug was prescribed for the 41 patients diagnosed with PIC, and 33 (80.5%) patients had improved by the next visit. After right upper lobectomy, the morphology of the remaining bronchial tree in the residual lung changed significantly. The bronchial morphological alterations were independent risk factors for PIC.

Use of on-therapy ctDNA monitoring in a patient with KIF5B-RET fusion positive advanced non-small cell lung cancer: a case report

Molecular characterization of non-small cell lung cancer (NSCLC) has led to marked improvements in the treatment of patients with advanced disease who harbor driver mutations, including those with alterations in the RET proto-oncogene. Liquid biopsy to detect circulating tumor DNA (ctDNA) is a clinically validated tool to identify genomic alterations in advanced NSCLC at diagnosis and disease progression. Whether ctDNA assessment can be integrated into other aspects of patient care is an area of ongoing active research. Here, we present the case of a 65-year-old female with KIF5B-RET fusion-positive advanced NSCLC who underwent on-therapy ctDNA surveillance while being treated on a phase 1b trial with the oral RET inhibitor RXDX-105. The patient initially presented with right-sided flank discomfort, with a CT scan identifying a large right lower lobe (RLL) lung mass and right-sided pleural effusion. CT-guided biopsy confirmed thyroid transcription factor 1 (TTF-1) positive lung adenocarcinoma. Subsequent video-assisted thoracoscopic surgery to assess resectability identified pleural studding, with pleural biopsy confirming advanced unresectable disease. Next-generation sequencing (NGS) of tumor tissue and peripheral blood confirmed the presence of a KIF5B-RET fusion, prompting initiation of trial therapy RXDX-105. After 1 year on therapy, ctDNA became detectable prompting early scans which identified disease progression. The patient was subsequently enrolled onto a phase II trial of the RET inhibitor pralsetinib, on which she continues to this day (2+ years) without detectable KIF5B-RET ctDNA and with an ongoing minor response [stable disease per response evaluation criteria in solid tumors (RECIST) v1.1] on imaging. This case illustrates a potential role for on-therapy ctDNA monitoring as a non-invasive method to evaluate treatment response and detect early relapse in patients with advanced NSCLC. Prospective investigation is required to clearly define the optimal integration of ctDNA testing into on-treatment surveillance in patients with advanced NSCLC.

Comparison of pulmonary computed tomography scan findings and clinical symptoms of COVID-19 in three outbreak peaks in Isfahan, Iran.

The aim of the present study was to investigate and compare the relationship between the anatomical distribution of pulmonary lesions in computed tomography scan of patients with COVID-19. This is a cross-sectional study that was performed in 2020-2021 in Isfahan on 300 patients infected with COVID-19 pneumonia. We collected data on the age, gender, and comorbidities of patients. In addition, we gathered data on the clinical manifestations of the patients from their medical records. We noted a significant decline in symptoms such as fever and sputum production in the second and third peak in comparison to the first peak (P < 0.05). Moreover, cough and muscular pain were higher in the second and third peaks compared to the first peak (P < 0.05). Cough was the most common clinical manifestation related to the peripheral distribution of the involvements, bilateral lung disease, and right lower lobe (RLL) involvements in the first peak. In the second COVID-19 peak, fever and cough were the most common clinical findings, respectively, that were mostly associated with peripheral distribution and left lower lobe involvement. Cough was the most common clinical manifestation related to the peripheral distribution of the involvements, bilateral lung disease, and RLL involvements in the first peak. In the second COVID-19 peak, fever and cough were the most common clinical findings.

HERE TODAY, GONE TOMORROW: AN UNUSUAL CASE OF WAXING AND WANING PULMONARY NODULES

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: An elderly man presents with a waxing and waning pulmonary lesion which was biopsy-proven lymphoma. This case highlights the use of robotic-assisted bronchoscopy which was integral in making a definitive diagnosis. CASE PRESENTATION: A 70-year-old man with chronic pancreatitis and a 53 pack-year smoking history presented with waxing and waning nodules seen on CT imaging. A nodule in the right lower lobe (RLL) was identified in 2019 and was followed with serial imaging showing shrinkage in 2020. However, in April 2021, the mass enlarged to 4 x 2 cm with stable mild mediastinal and right hilar adenopathy. PET scan demonstrated an SUV max of 4.28. The lesion was felt to not be amenable to CT-guided biopsy, and the patient was referred for robotic bronchoscopic biopsy.He reported occasional cough that was attributed to his ongoing reflux. He denied dyspnea, fever, and night sweats. He had lost 10 pounds in a month due to decreased appetite. The patient underwent general anesthesia and robotic assisted bronchoscopy. The robotic sheath was navigated to the RLL within millimeters of the lesion located 34 mm away from the pleura. A 23 gauge needle was inserted into the RLL mass, and a cone beam CT spin was performed that verified tool in lesion. Needle aspirations demonstrated atypia but inability for further clarification. Therefore, multiple biopsies were taken with forceps and sent to frozen section with an intraprocedural finding of abnormal lymphoid population of cells consistent with lymphoma of mucosa-associated lymphoid tissue. Additional sampling of stations 4L, 7, and 4R lymph nodes were negative for malignancy. DISCUSSION: Over the last decade, several guided bronchoscopic technologies have been developed to improve the diagnostic yield for sampling. This case highlights how minimally invasive biopsy can be achieved through robotic bronchoscopy when highly-relied on forms of tissue acquisition, like CT-guidance, are not recommended. Real-time 3D planar imaging also verifies needle location and can reduce doubts associated with sampling error when tool in lesion is captured and available to the referring provider. This approach was integral in making a rare diagnosis of primary pulmonary lymphoma (PPL).PPL is defined as clonal lymphoid proliferation in one or both lungs with no detectable extrapulmonary involvement at diagnosis or during the subsequent 3 months. This represents 0.5–1% of primary pulmonary malignancies. The diagnosis is made on histological examination of the tissue, and despite no consensus on treatment, patients typically have a favorable outcome with the median survival of more than 10 years. Treatment typically includes surgical excision for localized disease. CONCLUSIONS: The combination of robotic bronchoscopy, CIOS C spin imaging system, and frozen section was integral in making a rare diagnosis of primary pulmonary lymphoma. REFERENCE #1: Cadranel J, Wislez M, Antoine M. Primary pulmonary lymphoma. Eur Respir J. 2002 Sep;20(3):750-62. doi: 10.1183/09031936.02.00404102. PMID: 12358356. REFERENCE #2: Graham BB, Mathisen DJ, Mark EJ, Takvorian RW. Primary pulmonary lymphoma. Ann Thorac Surg. 2005 Oct;80(4):1248-53. doi: 10.1016/j.athoracsur.2005.04.014. PMID: 16181848. REFERENCE #3: Lee KS, Kim Y, Primack SL. Imaging of pulmonary lymphomas. AJR Am J Roentgenol. 1997 Feb;168(2):339-45. doi: 10.2214/ajr.168.2.9016202. PMID: 9016202. DISCLOSURES: No relevant relationships by Jennifer Duke, source=Web Response No relevant relationships by Sangita Goel, source=Web Response Research grant relationship with Intuitive Surgical Please note: $5001 - $20000 by Janani Reisenauer, source=Web Response, value=Grant/Research Support

IRON PILL ASPIRATION MIMICKING ASTHMA

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Foreign body aspiration can be a life-threatening event. Aspiration of iron pill can cause significant bronchial destruction via necrosis. Iron pill quickly disintegrates in the airway, inducing deep mucosal necrosis responsible for severe complications if not diagnosed promptly. We report a case of iron pill aspiration with asthma like presentation leading to severe bronchial stenosis. CASE PRESENTATION: A 50-year-old nonsmoking female, with past medical history of hypertension and arthropathy was referred to pulmonology for wheezing and shortness of breath that started after she had accidentally aspirated an iron pill. Examination was significant for expiratory wheezing. X-ray of the chest was normal. Bronchoscopy performed for the removal of the iron pill revealed complete obstruction of the right lower lobe (RLL) bronchus with thick mucoid secretions coated in iron and granulation tissue. Follow up bronchoscopy showed similar findings which included severe persistent airway inflammation. Cultures obtained grew cryptococcus neoformans. For which patient was she was treated with oral Diflucan for 1 year. Pulmonary function test showed no evidence of restriction or obstruction Once the infection was fully treated patient underwent endobronchial ultrasound (EBUS) which was performed as a therapeutic intervention for the RLL lesion as patient still had persistent symptoms of wheezing. EBUS showed severe stenosis of the RLL which was relieved following CRE balloon-tipped catheter insertion into the stenotic segment of the lower trachea followed by local intralesional steroid injection. On follow up three months later patient reported significant improvement in her symptoms. DISCUSSION: Iron pill aspiration syndrome is a relatively rare cause of severe bronchial inflammation leading to endobronchial stenosis [1,2]. The diagnosis is made by the presence of history of aspiration, airway inflammation and iron deposition as noted on histopathology. Oxidation of iron pill can cause bronchial mucosal inflammation, ulceration and necrosis which progresses to bronchial narrowing and possibly irreversible stenosis [3]. Early diagnosis with bronchoscopy and treatment plays a crucial role in overall prognosis. Our case represents a remarkable recovery with balloon dilation and intralesional steroid injection resulting in relief of stenosis. CONCLUSIONS: •Physicians should be very prudent with prescribing iron pills in individuals who are at high risk of aspiration in order to avoid serious bronchial complications. •Prompt bronchoscopic intervention and management is required to prevent progression to serious complications. •Physicians should consider balloon dilation with intralesional steroid injection for patients with refractory symptoms after removal of the foreign object. REFERENCE #1: Caterino U., Battistoni P., Batzella S., Iacono R. Dello, Lucantoni G., Galluccio G. Syndrome of iron pill inhalation in four patients with accidental tablet aspiration: severe airway complications are described. Respir. Med. Case Rep. 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501451/ REFERENCE #2: Management of Iron Pill Aspiration Syndrome: Advanced Bronchoscopic InterventionMonali Patil MD* Arjun Mohan MD; and Kassem Harris MD University at Buffalo, Buffalo, NY, https://journal.chestnet.org/article/S0012-3692(16)57346-2/pdf REFERENCE #3: The Iron Lung: When Iron Pill Aspiration Results in an Immediate Bronchoscopy. A Successful Medical Therapy to a Serious ConditionSarah Abuseif, Mohamed Elsawaf, Gustavo De La Luz, https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A5565 DISCLOSURES: No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Adel El Abbassi, source=Web Response No relevant relationships by Saman Saeed, source=Web Response No relevant relationships by Haniya Saeed, source=Web Response No relevant relationships by Dima Youssef, source=Web Response

AN UNEXPECTED PULMONARY BIOPSY FINDING: SIMULTANEOUS SMALL CELL AND NON-SMALL CELL LUNG CANCER

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: There are rare instances in which patients are found to have small cell and non-small cell lung cancer simultaneously. combined small cell lung cancer (cSCLC) is a rare type of SCLC in which a tumor contains SCLC and another non-small cell component. (1). Mutiple primary lung cancer (MPLC) occurs when malignancies develop at anatomically separate sites in the lungs. (2) CASE PRESENTATION: A 71-year-old female with a 60-year history of cigarette smoking presented with two weeks of generalized weakness and fatigue. A computerized tomography (CT) scan of the chest (Figure 1) revealed a large subpleural thick-walled cavitary mass in the right lower lobe (RLL) measuring 10 cm in the largest dimension. Additionally, there was a peribronchovascular mass in the right upper lobe with right-sided hilar and mediastinal adenopathy. Given the patient's clinical history and radiographic findings malignancy was suspected. Bronchoscopy with TBNA of mediastinal lymph nodes and the cavitary RLL mass was performed. Immunohistochemistry of the RLL mass biopsy was consistent with moderately differentiated invasive SCC. However, immunohistochemistry of the subcarinal lymph nodes biopsies revealed a different cancer type, high-grade SCLC. Based on the biopsy results, the diagnosis could have been either cSCLC in which separate biopsy sites sampled tumor different components or MPLC. Following these findings, the patient elected for comfort care. DISCUSSION: The ACCP guidelines for the diagnosis and management of lung cancer recommend that lung cancer diagnosis be made by the least invasive method possible which is often bronchoscopy with TBNA or endobronchial ultrasound-guided needle aspiration when extensive mediastinal disease is present. (3) In this case presentation, isolated sampling of subcarinal lymph nodes would have led to an incorrect or incomplete diagnosis, as the peripheral tumor site biopsy found an additional cancer type. While it is important to minimize morbidity associated with tumor tissue collection, bronchoscopists are also tasked with obtaining adequate samples for molecular and histologic subtyping of tumors. cSCLC and MPLC present a unique challenge because limited tissue sampling can lead to under diagnosis of these cancers. As such, these cancers are likely under underdiagnosed (1,2). When possible, maximizing tissue acquisition from tumor sites and nodal stations can help prevent misdiagnosis of cSCLC and MPLC. In both MPLC and cSCLC, characterization of all malignant cell lines is needed for the effective management of patients. CONCLUSIONS: cSCLC and MPLC are both important, likely under-diagnosed cancers to consider when investigating pulmonary tumors. Bronchoscopists should balance the need to minimize morbidity with the need for obtaining adequate tissue from nodal stations and tumor sites to prevent misdiagnosis of cSCLC and MPLC. REFERENCE #1: Zhao X, McCutcheon JN, Kallakury B, et al. Combined Small Cell Carcinoma of the Lung: Is It a Single Entity? Journal of Thoracic Oncology. 2018;13(2):237-245. REFERENCE #2: Chen C, Huang X, Peng M, Liu W, Yu F, Wang X. Multiple primary lung cancer: a rising challenge. J Thorac Dis. 2019;11(Suppl 4):S523-S536. doi:10.21037/jtd.2019.01.56 REFERENCE #3: Rivera MP, Mehta AC, Wahidi MM. Establishing the Diagnosis of Lung Cancer. Chest. 2013;143(5):e142S-e165S. doi:10.1378/chest.12-2353 DISCLOSURES: No relevant relationships by Amad Chohan, source=Web Response No relevant relationships by Hannah Hameed, source=Web Response No relevant relationships by Anjan Kumar, source=Web Response No relevant relationships by mohammad Razaq, source=Web Response No relevant relationships by Mashal Tahirkheli, source=Web Response