Right Middle Lobe Research Articles

Ground-glass burden as a biomarker in neuroendocrine cell hyperplasia of infancy.

Neuroendocrine cell hyperplasia of infancy (NEHI) is a rare pediatric interstitial lung disease (ILD). Distinct chest computed tomography (CT) define its radiographic appearance-specifically, ground-glass (GG) opacities most prominent in the right middle lobe (RML) and lingula. We sought to quantitatively validate this description and correlate radiologic findings with clinical presentation. Twenty-one children with NEHI were identified retrospectively, alongside 10 age-matched controls without lung disease. Clinical histories were reviewed for NEHI subjects. Semiautomated image analysis was used to measure lung volume and density. A patient-specific Hounsfield unit threshold defining GG was developed to quantify GG and assess its distribution in each subject. NEHI subjects had more GG than controls (37.9 ± 11.3% vs 14.0 ± 2.7%, P < 0.0001). The proportion of GG in the RML and lingula was greater in NEHI patients compared to controls (1.43 ± 0.37 vs 0.45 ± 0.21, P < 0.0001). GG preferentially involved the RML and lingula in 20/21 NEHI subjects. There was more GG distribution in NEHI subjects who were prescribed continuous oxygen compared with those using only nocturnal oxygen (45.7 ± 8.9% vs 29.3 ± 6.1%, P = 0.003). We confirm the previously reported finding that most patients with childhood ILD and a distinctive pattern of GG distribution on CT scan are likely to have NEHI. The amount of GG may be a biomarker for severity of respiratory disease.

In prenatally diagnosed CPAM, does the affected lobe influence the timing of symptom onset?

We investigated the relationship between the affected lobe and symptom onset in prenatally diagnosed congenital pulmonary airway malformation (CPAM). 53 CPAM patients diagnosed prenatally were reviewed retrospectively by creating 2 groups according to symptom onset. Group Sneo: (symptomatic during the neonatal period; n = 13) and group S > neo: (symptomatic after the neonatal period; n = 40) were compared for type of CPAM, affected lobes, types of symptoms/infections, treatment, duration of follow-up, and histopathology. Requirement for surgery (Sx) was then used to create three subgroups: Sneo + Sx, S > neo + Sx, and Sx-. Some cases had multiple affected lobes. In Sneo, symptoms developed in 55.6%, 50.0%, 0%, 0%, and 36.8% of right upper lobes (RUL), right middle lobes (RML), right lower lobes (RLL), left upper lobes (LUL), and left lower lobes (LLL) diagnosed with CPAM, prenatally. In S > neo, symptoms developed in 0%, 0%, 6.3%, 55.6%, and 33.3% of RUL, RML, RLL, LUL, and LLL diagnosed with CPAM, prenatally. In prenatally diagnosed CPAM, RUL and RML lesions are more likely to become symptomatic in neonates, and LUL lesions in infants. Surgery is recommended before the onset of respiratory infections after 1year of age.

Nuisance Neighbors: Gut-Lung Cross Talk in a Case of Crohnʼs Disease

Crohn's disease (CD) is a systemic illness with a plethora of extra-intestinal manifestations (EIM) affecting various organs, of which lungs are relatively rare. The clinicopathological patterns of pulmonary involvement consist of subclinical alterations, airway diseases, lung parenchymal diseases, pleural diseases and drug-related diseases. Tracheobronchial involvement is the most common respiratory presentation, whereas CD-related interstitial lung disease (ILD) is seen less frequently. A 41-year-old woman with a past medical history of CD (s/p subtotal colectomy) presented to the hospital for an enlarging ground-glass opacity (GGO) in her right middle lobe (RML) detected on routine CT abdomen for a CD workup six months back. She was asymptomatic, HR- 62/min, BP- 90/70 mm Hg, FEV1-122%, DLCO 106% on PFT. Contrast-enhanced CT chest showed the GGO in RML had increased in size from 21 x 18 mm to 28 x 18 mm and another GGO in the right lower lobe (RLL) increased in size from 5 mm to 12.4 mm. A robotic RML lobectomy with lymph node dissection and bronchoscopy, to rule out adenocarcinoma with lepidic growth, showed benign nodular lymphoid hyperplasia and a single perivascular epithelioid granuloma. A year later, her relapsing episodes of a cough and shortness of breath were managed with prednisone 20 mg for a probable pulmonary manifestation of CD. A non-contrast CT (NCCT) chest showed interval resolution of RLL GGO. A year later, she presented to the hospital with increasing cough, shortness of breath and a new GGO RLL (14 x 14 mm) on NCCT chest and is being managed with steroids with consideration of immunosuppression. In conclusion, pulmonary manifestations of CD present in a myriad of varieties often representing confounding diagnostic problems necessitating an extensive work-up. Thus, CD should be kept in the differential list in the case of unusual clinical symptoms and radiological signs of a pulmonary presentation. These infrequent, and sometimes life-threatening, EIM need to be considered when dealing with CD, to avoid further impairment of health status and alleviate patient symptoms by prompt recognition and treatment.2082_A Figure 1. Initial CT Abdomen & CT Chest2082_B Figure 2. CT Chest six months later2082_C Figure 3. NCCT Chest s/p lobectomy and most recent one

PULMONARY NODULE IN A PATIENT WITH REMOTE HISTORY OF BREAST CANCER: AMBIGUOUS IMAGING AND HISTOLOGY CAN LEAD YOU ASTRAY

SESSION TITLE: Lung Pathology 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: When a pulmonary nodule is seen on surveillance imaging of a patient with a remote history of breast cancer, it can be tempting to assume that the lung nodule is pulmonary metastasis. We herein describe a case of right middle lobe (RML) typical carcinoid and simultaneous recurrence of breast cancer (ER positive, PR positive, HER2 negative) involving the right supraclavicular lymph node that was challenging to determine a treatment regimen due to ambiguous imaging and histology results. CASE PRESENTATION: We present a 63-year-old woman, who was diagnosed with Stage II-B (T2N1M0) breast carcinoma in 2003. She underwent right mastectomy, radiation to the right chest wall, and tamoxifen therapy. Annual surveillance in 2016 revealed an increase in tumor markers. Computed Tomography (CT) revealed a 1.5-cm RML nodule near the hilum, with a standardized uptake value of 2.8 on subsequent Positron Emission Tomography (PET) scan. The patient underwent navigation bronchoscopy with biopsy of the RML nodule. Pathology of the RML nodule revealed uniform tumor cells with minimal atypia expressing chromogranin, synaptophysin and TTF1-Napsin but not ER, mammaglobin or GATA3. Octreotide scan was performed, which oddly demonstrated increased activity in a small lymph node in the right supraclavicular fossa. After thoracic tumor board discussion, she underwent excisional biopsy of the 1.3-cm lymph node, which revealed metastatic breast cancer. DISCUSSION: Carcinoid tumors are expected to be positive on Octreotide scan and negative on PET, whereas breast cancer metastasis should be positive on PET and negative on Octreotide scan. However, it is important to note that these findings are not always guaranteed. In one large study, Octreotide scan localized only 86% of carcinoids (Krenning et al, 1993). Additionally, the specificity of PET scan for neuroendocrine tumors (NETs) is dependent on the level of malignancy of the tumor; with PET scans, high grade NETs are more likely to be localized, whereas low grade NETs (typical carcinoid), are more likely to be missed (Maxwell et al, 2015). Given that imaging findings differed from what was expected, the case was discussed with a multidisciplinary tumor board and investigated further with histopathology before determining a treatment course. During the tumor board meeting, neuroendocrine differentiation of breast cancer was discussed, however, it was determined that the pathology and immunohistochemistry of the RML nodule was suggestive of typical carcinoid despite the imaging findings. CONCLUSIONS: In the setting where tumor imaging findings are different from what is expected, it is important to discuss the case in a multidisciplinary tumor board and investigate further with histopathology before determining a treatment course. When imaging and histopathology results conflict with one another, treatment should be based on histopathology findings rather than imaging. Reference #1: Krenning EP, Kwekkeboom DJ, Bakker WH, et al. Somatostatin receptor scintigraphy with [111In-DTPA-D-Phe1]- and [123I-Tyr3]-octreotide: the Rotterdam experience with more than 1000 patients. Eur. J. Nucl. Med. 1993;20(8):716–731. Reference #2: Maxwell, Jessica E, and James R Howe. “Imaging in Neuroendocrine Tumors: an Update for the Clinician.” International Journal of Endocrine Oncology, vol. 2, no. 2, 2015, pp. 159–168., https://doi.org/10.2217/ije.14.40. DISCLOSURES: No relevant relationships by Matthew Gerling, source=Web Response No relevant relationships by Ali Saeed, source=Web Response No relevant relationships by Jessica Zimmerberg-Helms, source=Web Response

Bronchial Thermoplasty-Induced Acute Airway Effects Assessed with Optical Coherence Tomography in Severe Asthma

Background: Bronchial thermoplasty (BT) is an endoscopic treatment for severe asthma targeting airway smooth muscle (ASM) with radiofrequent energy. Although implemented worldwide, the effect of BT treatment on the airways is unclear. Optical coherence tomography (OCT) is a novel imaging technique, based on near-infrared light, that generates high-resolution cross-sectional airway wall images. Objective: To assess the safety and feasibility of OCT in severe asthma patients and determine acute airway effects of BT by OCT and compare these to the untreated right middle lobe (RML). Methods: Severe asthma patients were treated with BT (TASMA trial). During the third BT procedure, OCT imaging was performed immediately following BT in the airways of the upper lobes, the right lower lobe treated 6 weeks prior, and the untreated RML. Results: 57 airways were imaged in 15 patients. No adverse events occurred. Three distinct OCT patterns were discriminated: low-intensity scattering pattern of (1) bronchial and (2) peribronchial edema and (3) high-intensity scattering pattern of epithelial sloughing. (Peri)bronchial edema was seen in all BT-treated airways, and less pronounced in only 1/3 of the RML airways. These effects extended beyond the ASM layer and more distal than the directly BT-treated areas and were reduced, but not resolved, after 6 weeks. Epithelial sloughing occurred in 11/14 of the BT-treated airways and was absent in untreated RML airways. Conclusions: Acute BT effects can be safely assessed with OCT and 3 distinct patterns were identified. The acute effects extended beyond the targeted ASM layer and distal of directly BT-treated airway areas, suggesting that BT might also target smaller distal airways.

Variations of pulmonary vein drainage critical for lung resection assessed by three-dimensional computed tomography angiography.

BackgroundIt is important to understand pulmonary vein drainage pattern variations and their frequency in order to perform safe anatomical pulmonary resection.MethodsVariations and frequencies were assessed using three‐dimensional computed tomography angiography (3D‐CT) in 194 patients. In cases where the tumor or lymph node caused atelectasis or compression of hilar structures, the involved lobes were excluded from the analyses.ResultsWe confirmed variant drainage patterns in 15/189 (8.0%) patients in the right upper lobe (RUL), 29/189 (15.3%) in the right middle lobe (RML), 18/192 (9.5%) in the right lower lobe (RLL), and 5/187 (2.6%) in the left upper lobe (LUL). There was no variant type in the left lower lobe (LLL). There were 14 (7.4%) cases of anomalous superior posterior pulmonary vein of RUL (V2) drainage: V2 draining to the superior pulmonary vein (SPV) (n = 2, 1.1%), V2 to the inferior pulmonary vein (IPV) (n = 7, 3.7%), V2 to the left atrium (LA) (n = 2, 1.1%), and V6 to the apical pulmonary vein of the RLL (n = 3, 1.6%). There was a posterior pulmonary vein, V3 to RML pulmonary vein in one case (0.5%). The RML pulmonary vein drained into the IPV in 14 (7.4%) and into the LA in 15 (7.9%) cases. The right V6 directly drained into the LA in 15 (7.9%) and V6 into the SPV in 3 (1.6%) cases. The lingular pulmonary vein drained into the IPV in one case (0.5%) and into the LA in two cases (1.1%). The inferior lingular pulmonary vein V5 drained into the IPV and into the LA in one case (0.5%), respectively.ConclusionWe describe anomalous pulmonary venous drainage patterns and their frequencies particular to anatomic surgical resection. 3D‐CT is useful to find such variations.

A review of the etiology and clinical presentation of non-cystic fibrosis bronchiectasis: A tertiary care experience.

Non-cystic fibrosis(CF) bronchiectasis has been recognized in children for the past 200 years. Early childhood pneumonia and underlying conditions such as immunodeficiency, primary ciliary dyskinesia(PCD), and congenital lung pathology should be considered in the etiology. The aim of our study was to describe the clinical characteristics, laboratory, and radiological findings of a large population of patients with non-CF bronchiectasis at a tertiary center. We analyzed the clinical findings of 187 patients diagnosed with non-CF bronchiectasis over a period of 10 years (January 2005-December 2015) at the Hacettepe University Faculty of Medicine Department of Pediatric Pulmonology. The median age at the time of diagnosis of non-CF bronchiectasis was 8 years (1-18 years). Consanguinity was positive in 59.4% (n = 111) of patients and 19.8% (n = 37) of patients had a positive family history for non-CF bronchiectasis. Common causes were PCD in 51.3% (n = 96), immunodeficiency in 15% (n = 28), history of tuberculosis in 5.9% (n = 11), post-infectious complication in 3.2% (n = 6) and other anomalies in 2.1% (n = 4) of patients. The frequency of pulmonary lobe involvement was as follows: 71.1% left-lower lobe, 59.4% right lower lobe, 54% right-middle lobe, 26.8% left lingula, 13.9% right upper lobe, and 9.6% left upper lobe. Diagnosis of non-CF bronchiectasis is often delayed because of a failure to recognize the significance of symptoms. Through clinical investigation, including a HRCT scan of the chest, sweat test, studies of immune function, and ciliary function in a child with a prolonged suppurative cough, remains important. In Turkey, the most common causes of non-CF bronchiectasis are PCD and immunodeficiency, related to a high frequency of consanguinity.

Observation of different tumor motion magnitude within liver and estimate of internal motion margins in postoperative patients with hepatocellular carcinoma.

AimsTo assess motion magnitude in different parts of the liver through surgical clips in postoperative patients with hepatocellular carcinoma and to examine the correlation between the clip and diaphragm motion.MethodsFour-dimensional computed tomography images from 30 liver cancer patients under thermoplastic mask immobilization were selected for this study. Three to seven surgical clips were placed in the resection cavity of each patient. The liver volume on computed tomography image was divided into the right upper (RU), right middle (RM), right lower (RL), hilar, and left lobes. Agreement between the clip and diaphragm motion was assessed by calculating intraclass correlation coefficient, and Bland–Altman analysis (Diff). Furthermore, population-based and patient-specific margins for internal motion were evaluated.ResultsThe clips located in the RU lobe showed the largest motion, (7.5±1.6) mm, which was significantly more than in the RM lobe (5.7±2.8 mm, p=0.019), RL lobe (4.8±3.3 mm, p=0.017), and hilar lobe (4.7±2.7 mm, p<0.001) in the cranial–caudal direction. The mean intraclass correlation coefficient values between the clip and diaphragm motion were 0.915, 0.735, 0.678, 0.670, and the mean Diff values between them were 0.1±0.8 mm, 2.3±1.4 mm, 3.1±2.0 mm, 2.4±1.5 mm, when clips were located in the RU lobe, RM lobe, RL lobe, and hilar lobe, respectively. The clip and diaphragm motions had high concordance when clips were located in the RU lobe. Internal margin can be reduced from 5 mm in the cranial–caudal direction based on patient population average and to 3 mm based on patient-specific margins.ConclusionsThe motion magnitude of clips varied significantly depending on their location within the liver. The diaphragm was a more appropriate surrogate for tumor located in the RU lobe than for other lobes.

Evaluation of bronchiectasis in war chemically-injured patients via high resolution computed tomography

BackgroundSulfur mustard (SM) gas as a vesicant chemical warfare was used in the Iran-Iraq war (1981–1989) against the Iranian warriors. ObjectiveThis alkylating agent with the potential of producing chemical injury in the skin, eyes and lung, may damage both upper and lower respiratory tract, which in turn can cause different types of sequels such as asthma, bronchiectasis, chronic bronchitis and lung fibrosis. MethodsThis study was performed on 274 patients with documented history of SM gas exposure. All of the participants complained of respiratory problems. Patients with positive history of cigarette smoking, respiratory problems before the exposure to SM gas, cardiovascular problems, surgery of the lung, and exposure to occupational toxic chemicals were excluded from the study. Results of all chest HRCTs were evaluated by a radiologist. ResultsHRCT findings showed that bronchiectasis involved 53 patients (19.34%) of all cases. Varicose bronchiectasis and cystic bronchiectasis was observed in 10 (18.9%) and 6 cases (11.3%) respectively. Among patients with bronchiectasis, the involvement rate of different lobes was as follows: Right upper lobe (RUL) 7.5%, right middle lobe (RML) 11.3%, left upper lobe (LUL) 15.1%, left lower lobe (LLL) 26.4% and right lower lobe (RLL) 39.6%. Discussion and conclusionFindings of chest HRCT demonstrated tubular bronchiectasis was the most frequent type of this disease that involve the chemically injured patients and RLL had been the most frequently involved lobe of the lung with bronchiectasis.

Clinical and imaging features in lung torsion and description of a novel imaging sign.

We set out to identify the clinical and imaging features seen in lung torsion, a rare but emergent diagnosis leading to vascular compromise of a lobe or entire lung. We retrospectively identified 10 patients with torsion who underwent chest CT. We evaluated each case for the presence of bronchial obstruction and abnormal fissure orientation. In seven patients who underwent contrast-enhanced CTs, we assessed for the presence of the antler sign, a novel sign seen on axial images demonstrating abnormal curvature of the artery and branches originating on one side. Five patients had right middle lobe (RML) torsion after right upper lobectomy, and the remaining occurred following thoracentesis, aortic surgery, or spontaneously. Chest CTs demonstrated bronchial obstruction in eight cases and presence of abnormal fissure orientation in four patients. The antler sign was present in three patients with whole-lung torsion and one patient with lobar torsion; vascular swirling was seen on 3-D imagesin all seven patients with contrast-enhanced CTs. Lung parenchymal imaging findings in lung torsion may be non-specific. Identification of the antler sign on contrast-enhanced chest CT, in combination with other signs such as bronchial obstruction and abnormal fissure orientation, indicates rotation of the bronchovascular pedicle. The presence of this sign should prompt further evaluation with 3-dimensional reconstructions.

Bronchial angles are associated with nodular bronchiectatic non-tuberculous mycobacteria lung disease

The nodular bronchiectatic (NB) form of non-tuberculous mycobacteria (NTM) lung disease usually involves the right middle lobe (RML) and the left upper lobe lingular segment. However, the reason underlying this preference is not known. Fifty patients with NB NTM lung disease who had both positive NTM culture(s) and NB lesions in the RML or lingular segment on computed tomography (CT) of the chest, and 100 healthy subjects matched for sex, age, height and body weight with normal chest CT, were randomly selected. Using reconstructed curved multiplanar reformation (MPR) images, the lengths, diameters and angles of the RML and lingular bronchi were measured. Of the 150 individuals, 64% were female; the mean age was 55 years. The angles of the bronchi were significantly more acute in patients than in healthy subjects, both in the RML (patients, mean 46.75° ± standard deviation 8.87° vs. healthy subjects, mean 51.73° ± 7.76°; P = 0.001) and in the lingular segments (patients, mean 26.94° ± 8.16° vs. healthy subjects, mean 34.65° ± 9.75°; P < 0.001). In addition, the angles of the bronchi in the involved segments were more acute than those in the non-involved segments, both in the RML and the lingular segments. There were no differences in the lengths and bronchi diameters between groups. An acute angle (obtuse slope) of RML/lingular bronchi could be an anatomical risk factor for NB NTM lung disease.

Pulmonary Arteriovenous Malformations: A Rare Cause of Recurrent Stroke

SESSION TITLE: Lung Pathology 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary arteriovenous malformations (PAVMs) are exceedingly rare, with an estimated prevalence of 38/10,000.1 Like intra-cardiac shunts, PAVMs can lead to paradoxical emboli and stroke, and their detection and management is therefore critical.2 We present a case of recurrent stroke secondary to a large AVM, discovered via saline-contrast echocardiography (SCE), with particular attention to bubble transit time. CASE PRESENTATION: A 77 year old female presented to the Emergency Room with dysarthria, right-sided weakness, and gait imbalance. MRI/MRA brain revealed sub-acute infarcts in the left pons, left superior cerebral peduncle, and right posterior cerebellum. Intra-cranial and intra-cervical arteries were patent. Telemetry monitoring did not reveal atrial fibrillation, and prior Holter monitoring did not reveal significant arrhythmia. Transthoracic echocardiogram (TTE) did not reveal any shunt. Aspirin was switched to clopidogrel and high-intensity statin was added. Two months later, she developed acute left-sided weakness. MRI brain revealed an acute infarct in the posterior right parietal lobe. SCE was positive for right to left shunt with delayed transit time. Chest X-ray showed an irregular opacity within the right middle lobe (RML). This appeared to be in the same location as a previously known PAVM on comparison to old imaging done 6 years prior. CT chest then revealed an enlarging PAVM in the RML, now with a diameter of >6 mm. She subsequently underwent coil embolization and is doing well. DISCUSSION: In a normal individual, peripherally injected saline bubbles are not observed in the left heart as lung capillaries act as filters.2 Their presence therefore indicates a right-to-left shunt, and transit time can help differentiate between intra-cardiac and intra-pulmonary shunts, both of which can lead to recurrent stroke.3 Delayed transit time of >6 beats is highly suggestive of intra-pulmonary shunting.3 Our case illustrates the need to differentiate between these two shunts, as PAVMs are indeed a rare cause of recurrent stroke. CONCLUSIONS: Though there is currently no role for PAVM screening in the work-up of stroke, routine SCE should be done for intra-cardiac shunt evaluation. As SCE also has a sensitivity of around 1.00 in the detection of PAVMs, one can therefore pick up more rare etiologies of stroke using this modality.3 Reference #1: Nakayama M, Nawa T, Chonan T, et al. Prevalence of pulmonary arteriovenous malformations as estimated by low-dose thoracic CT screening. Internal Medicine. 2012; 51(13): 1677-1681. Reference #2: Attaran, RR, Ata I, Kudithipudi V, et al. Protocol for optimal detection and exclusion of a patent foramen ovale using transthoracic echocardiography with agitated saline microbubbles. Echocardiography. 2006; 23(7): 616-622. Reference #3: Gazzaniga P, Buscarini E, Leandro G, et al. Contrast echocardiography for pulmonary arteriovenous malformations screening: does any bubble matter? European Journal of Echocardiography. 2009; 10: 513-518. DISCLOSURE: The following authors have nothing to disclose: Lydia Winnicka, Charumathi Raghu Subramanian, Amirahwaty Abdullah, Amirtha Dileepan, James Walsh No Product/Research Disclosure Information

Occurrence of bronchial anthracofibrosis in respiratory symptomatics with exposure to biomass fuel smoke.

Bronchial anthracofibrosis (BAF), confirmed bronchoscopically, is characterised by bluish-black mucosal pigmentation and distortion/narrowing of the bronchus. We investigated the occurrence of BAF in respiratory symptomatics with biomass fuel smoke exposure and evaluated its clinico-radiological attributes and impact on functional status. Of the eighty subjects evaluated, 60 consented for fiberoptic bronchoscopy (FOB). All 60 subjects also underwent chest radiography, high resolution computed tomography (HRCT) of the thorax, complete pulmonary function testing including diffusion capacity and six-minute-walk test. Information regarding cardinal respiratory symptoms and duration of biomass fuel smoke exposure was documented. FOB evaluation revealed that 24 patients had BAF (Group 1), 17 had bronchial anthracosis (Group 2) and 19 had normal appearance (Group 3). Group 1 patients had significantly higher biomass fuel smoke exposure (p &lt; 0.0001), lower mean post bronchodilator FEV₁/FVC values (P = 0.02) and lower walk distance (p = 0.003) with greater desaturation. On HRCT, segmental collapse and consolidation were significantly higher in Group 1 while fibrotic lesions were the predominantly seen in Groups 2 and 3. A significant inverse correlation in Group 1 was seen between exposure index, six-minute-walk distance and spirometric parameters. In Group 1, the right middle lobe (RML) bronchus was most commonly involved (15/24 [62.5%]). In Group 2, RML and left upper lobe bronchi were affected in 8/17 (47.1%) patients each. All patients in our study were females. Those with BAF had poorer lung functions and functional status as compared to those with anthracosis only. On imaging, multifocal bronchial narrowing was specific to BAF. .

Bronchial Varices in a Patient with Behçet&amp;apos;s diasese: A Case Report

We report a case of a 65-year-old man with Behcet's disease who presented with massive hemoptysis caused by bronchial varices. A computed tomography (CT) scan and bronchoscopy were performed to identify the bleeding site. The CT scan revealed pneumonia and a combined hemorrhage in the right-middle and lower lobes. Massive bleeding was detected during the bronchoscopy and emergency embolization was attempted but angiographic findings were normal. An anteriojugulo-right femoral bypass operation was performed to relieve the tortuous and hypertrophied jugular venous obstruction. However, thrombectomy and thrombolysis followed because of graft thrombosis six days post-surgery. The patient was treated with steroid and high-dose cyclophosphamide therapy for his Behçet's disease, which caused the venous obstructions; the saccular bronchial varices in the right-middle and right lower lobes on bronchoscopy regressed slightly after four cycles of cyclophosphamide therapy

Evaluation of Bronchitis Caused by Mustard Gas Weapons in the War Combatants

: Sulfur mustard (SM) gas was used in the Iran-Iraq war (1981 - 1989) as a vesicant chemical warfare against the Iranian warriors. This alkylating agent with the potential of producing chemical injury in the skin, eyes, and lung, may damage both upper and lower respiratory tract, which in turn can cause different types of sequels such as asthma, bronchiectasis, chronic bronchitis and lung fibrosis. This study was performed on 274 patients with documented history of SM gas exposure. All of the participants complained of respiratory problems. Patients with a positive history of cigarette smoking, respiratory problems before the exposure to SM gas, cardiovascular problems, surgery of the lung, and exposure to occupational toxic chemicals were excluded from the study. Results of all chest HRCTs were evaluated by a radiologist. HRCT findings showed that bronchiectasis involved 53 patients (19.34%) of all cases. Varicose bronchiectasis and cystic bronchiectasis was observed in 10 (18.9%) and 6 cases (11.3%) respectively. Among patients with bronchiectasis, the involvement rate of different lobes was as follows: right upper lobe (RUL) 7.5%, right middle lobe (RML) 11.3%, left upper lobe (LUL) 15.1%, left lower lobe (LLL) 26.4% and right lower lobe (RLL) 39.6%. Findings of chest HRCT demonstrated tubular bronchiectasis was the most frequent type of this disease that involve the chemically injured patients and RLL had been the most frequently involved lobe of the lung with bronchiectasis.

Analysis of variation in bronchovascular pattern of the right middle and lower lobes of the lung using three-dimensional CT angiography and bronchography

ObjectivesGeneral thoracic surgeons must be familiar with anatomical variation in the pulmonary vessels and bronchi. Here, we analyzed the bronchovascular pattern of the right middle lobe (RML) and right lower lobe (RLL) of the lung using three-dimensional CT angiography and bronchography (3DCTAB).MethodsWe reviewed the anatomical patterns of the pulmonary vessels and bronchi in 270 patients using 3DCTAB images.ResultsThe branching patterns of vessels and bronchi of RML and S6 were classified according to the number of stems. The single-stem type was the most common, except in the artery of the RML, for which the two-stem type was the most common. The artery and bronchus of S*, which is an independent segment between S6 and S10, were observed in 20.4% of cases. The branching pattern of A7 (B7) was classified into four types. The A7a (B7a) type was observed in 74.8% of cases, and was the most common. The branching pattern of the artery and bronchus of S8−10 was classified into five and three types, respectively. The A8 and A9 + A10 type, and the B8 and B9 + B10 type, were observed in 68.1 and 80.4% of cases, respectively, and were the most common types. The branching pattern of V8−10 was more complex than that of A8−10 and B8−10.ConclusionWe explored the bronchovascular patterns of RML and RLL and their frequencies using a large number of 3DCTAB images. Our data can be used by thoracic surgeons to perform safe and precise lung resections.

Bilateral congenital lobar emphysema: staged management

BackgroundOnly a few isolated cases in the literature exist to guide management of bilateral congenital lobar emphysema (CLE). Here, we review our experience in infants with bilateral CLE. MethodsA case series of all infants presenting with bilateral CLE from 2014 to 2015 in a single institution. ResultsFour patients underwent intervention, with all having right middle lobe (RML) and left upper lobe (LUL) affected. Preoperative planning with computed tomography angiography (CTA) chest allowed a tailored approach based on specific radiologic features. All patients also underwent bronchoscopy to evaluate the anatomy and to assess for alternative causes of airway compression. Three patients underwent unilateral lobectomies, two RML and one LUL. All are growing normally and on room air more than one year later. The last patient underwent a staged procedure beginning with left upper lobectomy followed by right middle lobectomy two weeks later after exhibiting rebound hyperexpansion of the remaining diseased lobe. Thoracoscopy was precluded by mass effect in all patients. No patients underwent emergent lobectomies. One patient had pulmonary interstitial glycogenosis (PIG) in the setting of CLE, first reported case of bilateral CLE with PIG. ConclusionsThis study supports a staged, image-guided, physiology-based operative approach to bilateral CLE. Excision of both diseased lobes does not appear to be mandatory, at least in the short-term follow up, and comports with a “the least intervention that is the most effective” philosophy. CTA is critical for planning, but the role of V/Q scan is not defined. Thoracoscopy appears to have no role. Level of evidenceTreatment Study, Level IV.

P3.04-010 Changes of Right Lung Volume after Right Upper Lobectomy for Lung Cancer: Topic: Miscellaneous I

Many surgeons routinely perform the division of the inferior pulmonary ligament (IPL) during the right upper lobectomy for lung cancer. It is believed that the division of the IPL can facilitate mobilizing and expanding residual lobes, and decreasing dead space. We aimed to evaluate the volume changes of the right middle lobe (RML) and the right lower lobe (RLL) after right upper lobectomy according to IPL division. We performed a retrospective analysis of the medical records and images of 181 patients with lung cancer who had underwent right upper lobectomy via a video-assisted thoracic surgery (VATS) in Seoul Asian Medical Center from May 2009 to December 2013. The IPL was preserved in 76 patients (Group A) and was divided in 105 patients (Group B). Using in-house software with chest computed tomography (CT), we compared the difference volume changes of pre- and post-operative RML and RLL between the two groups. There were no significant differences between the two groups in terms of age, sex, height, tumor size, chronic obstructive pulmonary disease and smoking status. In group A, the adjusted mean volume change of difference RML (dRML) and difference RLL (dRLL) were -0.45 mL/kg and 6.03 mL/kg, respectively. In group B, the adjusted mean volume change of dRML and dRLL were -0.55 mL/kg and 5.28 mL/kg, respectively. The difference was not significant. Division of the IPL during the right upper lobectomy is not beneficial technique regarding remnant lung volume.

Severity of pulmonary emphysema and lung cancer: analysis using quantitative lobar emphysema scoring.

The aim of this study was to determine the relationship between lobar severity of emphysema and lung cancer using automated lobe segmentation and emphysema quantification methods.This study included 78 patients (74 males and 4 females; mean age of 72 years) with the following conditions: pathologically proven lung cancer, available chest computed tomographic (CT) scans for lobe segmentation, and quantitative scoring of emphysema. The relationship between emphysema and lung cancer was analyzed using quantitative emphysema scoring of each pulmonary lobe.The most common location of cancer was the left upper lobe (LUL) (n = 28), followed by the right upper lobe (RUL) (n = 27), left lower lobe (LLL) (n = 13), right lower lobe (RLL) (n = 9), and right middle lobe (RML) (n = 1). Emphysema ratio was the highest in LUL, followed by that in RUL, LLL, RML, and RLL. Multivariate logistic regression analysis revealed that upper lobes (odds ratio: 1.77; 95% confidence interval: 1.01–3.11, P = 0.048) and lobes with emphysema ratio ranked the 1st or the 2nd (odds ratio: 2.48; 95% confidence interval: 1.48–4.15, P < 0.001) were significantly and independently associated with lung cancer development.In emphysema patients, lung cancer has a tendency to develop in lobes with more severe emphysema.

Lobar Distribution in Non-Cystic Fibrosis Bronchiectasis Predicts Bacteriologic Pathogen Treatment

Non-cystic fibrosis bronchiectasis (NCFBr) is a major cause of morbidity due to frequent infectious exacerbations. We analyzed the influence of patient age and bronchiectasis location on the bacterial profile of patients with NCFBr. This retrospective cohort study included 339 subjects diagnosed with an infectious exacerbation of NCFBr during the 9-year period between January 2006 and December 2014. Bronchoalveolar lavage (BAL) cultures and high-resolution computed tomography scans (HRCT) were utilized to characterize the location of the bronchiectasis and bacteriologic pathogenic profile. In univariate logistic regression, the frequency of Haemophilus influenzae was higher in patients aged ≤64 years (OR = 0.969, p 64 years. The lobar distribution of bronchiectasis in the subjects was 25.9 % in the right middle lobe (RML), 20.7 % in the right lower lobe (RLL), 20.4 % in the left lower lobe (LLL), 13.8 % in the lingula, 13 % in the right upper lobe (RUL), and 6.2 % in the left upper lobe (LUL). In the lower lobes, H. influenzae was the dominant species isolated, whereas in the RUL it was P. aeruginosa and in the LUL it was non- tuberculous mycobacterium (NTM). H. influenzae was more prevalent in younger patients, whereas P. aeruginosa, Enterobacteriaceae and NTM predominated in older patients. Different pathogens were associated with different lobar distributions. The RML, RLL and LLL showed a greater tendency to develop bronchiectasis than other lobes.