Right Upper Lobe Research Articles

RARE CASE OF SEVERE NECROTIZING PNEUMONIA DUE TO STREPTOCOCCUS PYOGENES RESULTING IN REFRACTORY HYPOXEMIA

RARE CASE OF SEVERE NECROTIZING PNEUMONIA DUE TO STREPTOCOCCUS PYOGENES RESULTING IN REFRACTORY HYPOXEMIA

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

Application of three-dimensional computed tomography bronchography and angiography in thoracoscopic anatomical segmentectomy of the right upper lobe: A cohort study.

ObjectiveThree-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide detailed imaging information for pulmonary segmentectomy. This study aimed to investigate the safety and effectiveness of 3D-CTBA guidance of anatomical segmentectomy of the right upper lobe (RUL).MethodsThis was a retrospective analysis of anatomical segmentectomy of the RUL at the Thoracic Surgery Department of the Fourth Hospital of Hebei Medical University from December 9, 2013, to June 2, 2021. Preoperatively, all patients underwent contrast-enhanced CT of the chest (to determine the size of the pulmonary nodule) and a lung function test. 3D-CTBA has been performed since 2018; patients with vs. without 3D-CTBA were compared. Segmentectomy was performed according to nodule location.ResultsOf 139 patients (46 males and 93 females, aged 21–81 years), 93 (66.9%) completed single segmentectomy, 3 (2.2%) completed single subsegmentectomy, 29 had combined subsegmentectomy, 7 had segmentectomy combined with subsegmentectomy, and 6 had combined resection of two segments. Eighty-five (61.2%) patients underwent 3D-CTBA. 3D-CTBA cases had decreased intraoperative blood loss (67.4 ± 17.6 vs. 73.1 ± 11.0, P = 0.021) and shorter operation time (143.0 ± 10.8 vs. 133.4 ± 20.9, P = 0.001). 3D-CTBA (Beta = −7.594, 95% CI: −12.877 to −2.311, P = 0.005) and surgical procedure (Beta = 9.352, 95% CI: 3.551–15.153, P = 0.002) were independently associated with intraoperative blood loss. 3D-CTBA (Beta = −13.027, 95% CI: −18.632 to 17.422, P < 0.001) and surgical procedure (Beta = 7.072, 95% CI: 0.864–13.280, P = 0.026) were also independent factors affecting the operation time.ConclusionPreoperative use of 3D-CTBA to evaluate the pulmonary vessels and bronchial branch patterns of the RUL decreased blood loss and procedure time and so would be expected to improve the safety and effectiveness of thoracoscopic segmentectomy.

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.

TRACHEAL BRONCHUS OR BRONCHUS SUIS AND ITS IMPORTANCE IN LUNG TRANSPLANT

TYPE: Late Breaking Abstract TOPIC: Imaging INTRODUCTION: Tracheal bronchus (TB) is an aberrant bronchus arising from within 2cm of right lateral wall of supracarinal trachea. The term, bronchus suis, is given when the entire right upper lobe (RUL) is supplied by this bronchus. CASE PRESENTATION: Incidence is estimated at ∼1% (0.1-5%). TB can be classified into supernumerary - usual bronchial supply to affected lung segment is present or displaced - usual bronchial supply to affected lung segment is absent. It is usually an incidental finding, and most patients are asymptomatic. Occasionally patients may have recurrent RUL pneumonia due to focal emphysema or mucus impaction. Improvisation of airway anastomotic technique is required during lung transplantation (LT). DISCUSSION: 5 cases of donor, and 1 case of recipient TB have been reported in literature. Possible options for the airway anastomosis are en-bloc double LT with a tracheal anastomosis, left single LT alone, bilateral LT with left lung and right middle and lower lobe (following donor lung RUL lobectomy), and bilateral LT with a modified right tracheobronchial anastomosis. En-bloc double LT has higher airway anastomotic complication rate compared to bilateral sequential LT. Length of bronchial stump is made as short as possible in the donor lung to maximize the benefit of pulmonary-to-bronchial collateral blood supply. The neo-upper lobe bronchus created by suturing the apical TB and the RUL bronchus of the donor is anastomosed to the RUL bronchus of the recipient in a double-barrel fashion. CONCLUSIONS: Early identification of TB allows for appropriate recipient selection and advanced surgical planning for successful single or bilateral LT. DISCLOSURE: No significant relationships. KEYWORD: tracheal bronchus, bronchus suis, lung transplant

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.

Telescoping Stents to Maintain a 3-Way Patency of the Airway.

Central airway obstruction near the right upper lobe (RUL) airway orifice poses a dilemma for the clinician. Maintaining ventilation to the right middle and right lower lobes is of utmost importance. However, preserving ventilation to the RUL is desirable as well especially in patients with significant dyspnea. In this case report, we describe telescoping 2 covered self-expanding hybrid stents to relieve airway obstruction while maintaining RUL ventilation. Review of current literature revealed several additional documented approaches to overcome this challenge. The choice of intervention needs to be deliberated based on the available stents, delineation of the airway obstruction, and the patient's anatomy.

March 2022 Medical Image of the Month: Pulmonary Nodules in the Setting of Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH)

No abstract available. Article truncated after 150 words. A 62-year-old woman presented to an outside hospital with chronic cough, prompting a CXR. Findings further prompted unenhanced chest CT to evaluate possible pulmonary nodules. The CT demonstrated multiple scattered, solid and centrilobular pulmonary nodules, most of which were small but there were two &gt;1 cm nodules, one in the right upper lobe (RUL) and a second in the lingula (Figure 1A,B). A subsequent FDG PET-CT was performed demonstrating increased metabolic activity in the RUL nodule with no activity in the lingular nodule (Figure 1C,D). Biopsy of the RUL nodule was consistent with a carcinoid. At this point the patient was referred to our center for further management. A repeat chest CT failed to demonstrate any significant change in the nodules. MIP and MinIP reconstructions from that examination demonstrate multiple small, solid pulmonary nodules (arrows) (Figure 2A), many of which were associated with air-trapping resulting in pulmonary mosaicism (circled) (Figure …

Salvage surgery following immuno-chemo-radiotherapy for advanced non-small cell lung cancer

BackgroundSalvage surgery following definitive radiotherapy or systemic treatment has become a feasible treatment option in selected patients with advanced initially unresectable non-small cell lung cancer. Recent clinical trials of neoadjuvant treatment have showed that surgery following immuno-chemotherapy is safely performed. Here, we present the first case of salvage surgery following immuno-chemotherapy with concurrent definitive radiotherapy for advanced lung large cell carcinoma.Case presentationA 44-year male was admitted to our hospital for salvage surgery. Ten months prior to this administration, he had been diagnosed with unresectable large cell carcinoma with malignant pericardial effusion (clinical stage IVA/T3N2M1A; no driver-gene alteration) originating from the right upper lobe (RUL). Due to rapid intrabronchial tumor growth causing severe dyspnea, emergency bronchial stenting in the right main bronchus using an expandable metallic stent had been performed. Thereafter, he had received immuno-chemotherapy with concurrent definitive radiotherapy. Despite dramatic radiographic response, he had suffered from persistent and refractory Pseudomonas aeruginosa lung infection associated with bronchial stent placement. As pericardial effusion had disappeared and no distant metastasis had developed, he was diagnosed with a potentially curable disease and was referred to our hospital. An extended sleeve resection was successfully performed, and pathological sections revealed that pathologic complete response was achieved with immuno-chemo-radiotherapy. The patient received no subsequent treatment, and is alive without tumor recurrence at 8 months after surgery.ConclusionsSalvage surgery following immuno-chemotherapy with concurrent definitive radiotherapy for advanced non-small cell lung cancer may be feasible in selected patients, and may be considered as a treatment option to control local disease.

Prevalence and Factors Associated with the Loss of PTEN Expression in Patients with Lung Cancer

Background: Phosphatase and tensin homolog (PTEN) is a major tumor suppressor gene and is involved in cell survival control. PTEN loss of expression (PTEN-) is associated with a poor outcome. Our study investigated the prevalence of PTEN- in terms of its characteristics and disease prognosis for lung cancer patients.&#x0D; Materials and Methods: In total, 167 tissue blocks from lung cancer patients at Chareonkrung Pracharak Hospital between January 2010 and December 2020 were studied through immunohistochemistry staining (IHC) for PTEN expression. The clinicopathological factors, IHC features, and epidermal growth factor receptor (EGFR) status were analyzed in association with PTEN- in term of prognosis and the overall survival (OS).&#x0D; Result: Adenocarcinoma was the major subtype (85.6%) and most patients (90.6%) were diagnosed at stage IV of lung cancer. The prevalence of PTEN- was 66.5%. A location at the left lower lobe (LLL) location and the absence of tumor-infiltrating lymphocytes (TILs) were significantly associated with PTEN- (p=0.039, p=0.046), while the smoking was likely correlated but not statistically significant (p=0.09). The median OS for PTEN- was not significantly different from PTEN+ (8.88 vs 7.20 months, p=0.38). However, smoking, Eastern cooperative oncology group (ECOG) status and primary symptoms were significantly associated with poorer OS.&#x0D; Conclusion: The prevalence of PTEN- was higher in our studies. Absent TILs and a LLL location were independent factors associated with PTEN-. However, a right upper lobe (RUL) location with PTEN- tended to have a poor prognosis. Interestingly, better survival was found in active smokers with PTEN-. Further survival studies in cases with no TILs lesions and active smokers in associations PTEN expression and other immune-related biomarkers, such as programmed death–ligand 1 (PD-L1), are warranted.

Percutaneous fibrin injection for the successful closure of an iatrogenic bronchopleural fistula following percutaneous lung biopsy

Background: Bronchopleural fistula (BPF) following percutaneous lung mass biopsy is a very rare but challenging complication. We describe percutaneous fibrin injection as safe and successful in the treatment of BPF. Additionally, we present a thorough literature review of the reported treatment options of iatrogenic BPF. Summary: A 68-year-old man with a lung cancer, COPD, and multiple other comorbidities underwent an image-guided percutaneous biopsy of an enlarging right-upper lobe lung nodule that was complicated by a large iatrogenic right-sided pneumothorax requiring an image-guided placement of a drainage catheter. Four days after the catheter placement, he was diagnosed with a BPF after developing a continuous air leak, pneumomediastinum, and extensive subcutaneous emphysema. Because patient wished to avoid placement of a chest tube, endobronchial interventions, or any other invasive procedures for management of his BPF, he underwent an image-guided, percutaneous fistula closure by injection of fibrin sealant in the fistula tract. Conclusion: BPF represents a significant challenge requiring a multidisciplinary approach. Percutaneous fibrin injection in the fistula tract represents a less invasive option for patients who have small fistulae, are not operative candidates, or wish to avoid the morbidity of a major surgical interventions.

Boyden's triad: the past, present and future.

OBJECTIVESThe B3 downwards-shifting malformation was first proposed by Boyden in 1950. Here, we report 14 cases of this malformation in the right lung and the first case of segmentectomy for this malformation.METHODSAll patients with pulmonary lesions underwent three-dimensional computed tomography bronchography and angiography (3D-CTBA) between January 2019 and January 2020, prior to surgery. A consecutive 2356 patients were included, and 14 cases of this malformation were identified; bronchovascular patterns were analysed in each patient.RESULTSThe incidence of this malformation was 0.6%. It was further divided into 3 types: over downwards-shift, partial downwards-shift and normal downwards-shift. The normal downwards-shift type was the most common (8/14), where B3 shifted downwards completely to merge with B4 + 5. In the partial downwards-shift (5/14), only part of the B3 shifted. In the over downwards-shift type (1/14), both B3 and B1b shifted downwards. A bifurcated right upper lobe （RUL) bronchus (B1 defective) was observed in 3 cases. The incidence of V1a, V1b, V2a, V2b, V2c, V3a, V3b and V3c was 100% (14/14). The incidence rates of A1, A3a and A3b were 100% (14/14). The incidence of A2 rec and A2 asc was 92.9% (13/14) and 71.4% (10/14), respectively.CONCLUSIONSThe B3 downwards-shifting malformation or ‘Boyden’s triad’ is a rare anomaly. Anatomical exploration of this malformation is important for surgery.

NOT EVERY PET POSITIVE MASS IS CANCER

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: Tuberculosis (TB) is well known as a diagnostic chameleon.1 Both symptomatic and asymptomatic cases of TB can mimic lung cancer with cough, hemoptysis, and weight loss common for both diseases. Many radiological findings on CT imaging and PET avidity can occur with both.2 We present a patient who presented with abnormal imaging who was ultimately diagnosed with pulmonary TB. CASE PRESENTATION: A 55-year old man presented to pulmonary clinic with an enlarging right upper lobe (RUL) mass. The mass was first noted a year prior while being evaluated for anemia and lymphadenopathy thought to be autoimmune. Despite steroids and antibiotics, the mass increased in size. He also had diabetes, tobacco use, and treated latent TB (positive QuantiFERON gold). To evaluate the RUL mass, he had a diagnostic bronchoscopy with transbronchial biopsy which showed scant non-necrotizing granulomas but negative fungal/AFB stains and cultures, and no evidence of malignancy. Given lack of certainty, he underwent navigational bronchoscopy with repeat bronchial wash, and a biopsy of the right upper lobe mass was obtained. The MTB PCR was positive and pathology showed necrotizing granulomas. Despite negative fungal/AFB stains and cultures, the positive PCR and caseating granulomas were consistent with pulmonary TB and he was promptly started on rifampin, isoniazid, pyrazinamide, and ethambutol with pyridoxine. With treatment of TB, both his symptoms and anemia resolved. DISCUSSION: While a growing, PET-avid lung mass in a patient with tobacco exposure is most likely malignant, a broad differential, including granulomatous diseases, should be considered. Of note, some malignancies may co-exist with granulomatous infections, including intra-pulmonary lymphoma or mucinous adenocarcinoma, requiring careful attention to follow-up imaging and a low threshold for repeat biopsies. Repeat navigational bronchoscopy with bronchial wash confirmed the presence of necrotizing granulomas and a positive PCR test, sparing the patient from a surgical biopsy. CONCLUSIONS: Differentiating pulmonary TB from malignancy based on clinical and radiological evaluation can be challenging. Both diseases can present with similar symptoms and parenchymal infiltrates with high metabolic activity on the 18-FDG-PET. The presence of necrotizing granulomas on transbronchial biopsy along with positive PCR testing confirms the diagnosis, but careful attention to follow-up imaging with treatment is warranted. REFERENCE #1: Lang S, Sun J, Wang X, et al. Asymptomatic pulmonary tuberculosis mimicking lung cancer on imaging: A retrospective study. Exp Ther Med. 2017;14(3):2180-2188. doi:10.3892/etm.2017.4737 REFERENCE #2: Hammen I. Tuberculosis mimicking lung cancer. Respir Med Case Reports. 2015;16:45-47. doi:10.1016/j.rmcr.2015.06.007 DISCLOSURES: no disclosure on file for George Cheng; No relevant relationships by Brinda Desai, source=Web Response No relevant relationships by Russell Miller, source=Web Response No relevant relationships by Matthew Nobari, source=Web Response No relevant relationships by Rebecca Sell, source=Web Response

STENT-IN-STENT TECHNIQUE FOR MANAGEMENT OF PERIPHERAL MALIGNANT ENDOBRONCHIAL OBSTRUCTION

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Airway stenting is used to restore patency of airways with malignant obstruction. Stent-in-stent (SIS) technique has been used in central airway obstruction. We describe a case of malignant endobronchial obstruction in the right upper lobe (RUL) managed with SIS technique. CASE PRESENTATION: 56-year-old male with history of Laryngeal Carcinoma managed with surgical resection and chemo-radiation was transferred for management of recurrent hemoptysis and right lung atelectasis. He was tachypneic and hypoxic requiring 2L oxygen. Labs revealed leukocytosis, hemoglobin of 9.6gm/dl and no coagulopathy. CT Chest showed right lung atelectasis due to right mainstem endobronchial mass. Rigid bronchoscopy (RB) demonstrated a friable mass in the right main stem with frank blood in the central airway. Initially Diode laser was employed for removal of the pedunculated tumor originating in the RUL, followed by debulking with RB and cryoprobe from the right main stem and bronchus intermedius (BI). Rigid tamponade and argon plasma coagulation were used for hemostasis. BF-P190 Olympus scope was used to identify the distal airway in the RUL posterior segment and a 7x22 mm iCAST stent was placed for airway patency. Right middle lobe (RML) and lower lobe (RLL) airways were not localized at the time. A staged RB was performed a few days later. BF-P190 Olympus scope was used for inspection which revealed occlusion of distal end of stent with tumor, advancement of scope with mild pressure through the tumor revealed sub segmental airways, under fluoroscopy guidance a second 7x22mm iCAST stent was placed overlapping with the first stent. Additional tumor debulking from the BI revealed RLL segmental branches. Under direct visualization a 10x38 mm iCAST stent was placed to restore airway patency to the RLL. He remained stable off oxygen post procedure, with reinflation of the right lung. He was discharged with bronchodilators and hypertonic saline with significant improvement in his quality of life. DISCUSSION: Rigid bronchoscopy and airway stenting is commonly used for management of complex central airway obstruction. iCAST stent is a balloon expandable stainless steel stent that is fully encapsulated in two layers of polytetrafluoroethylene. The stent deployment is through the scope with the smallest size of 5x16mm and largest 10x38mm. The smaller size stent can be upsized with a larger sized balloon with the stent shortening in length. We present a SIS placement of two 7x22 mm iCAST stents in the airway likely traversing through the right hilar mass to establish airway patency, resulting in complete reexpansion of the lung. CONCLUSIONS: Peripheral airway stenting of occluded airway due to malignancy can result in lung reinflation, resulting in increased pulmonary reserves for patient to tolerate chemotherapy and radiation. We used SIS technique for customization and appropriate stenting of distal airway. REFERENCE #1: Sethi, Sonali, et al. "Clinical Success Stenting Distal Bronchi for 'Lobar Salvage’ in Bronchial Stenosis:” Journal of Bronchology & Interventional Pulmonology, vol. 25, no. 1, 2018, pp. 9–16, doi:10.1097/LBR.0000000000000422. REFERENCE #2: Majid A, Kheir F, Chung J, Alape D, Husta B, Oh S, Folch E.. Covered Balloon-Expanding Stents in Airway Stenosis. J Bronchology Interv Pulmonol. 2017 Apr;24(2):174-177. doi: 10.1097/LBR.0000000000000364.J Bronchology Interv Pulmonol. 2017. PMID: 28323735 DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response no disclosure submitted for Ali Saeed; No relevant relationships by Hursh Sarma, source=Web Response No relevant relationships by Andrew Talon, source=Web Response No relevant relationships by Cindrel Tharumia Jagadeesan, source=Web Response

DISSEMINATED ACTINOMYCOSIS PRESENTING AS PNEUMONIA WITH MULTIPLE PULMONARY NODULES AND PELVIC OSTEOMYELITIS

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Actinomycosis is a chronic granulomatous infectious disease caused by filamentous gram-positive anaerobic bacteria. Due to better oral hygiene and susceptibility to multiple oral antibiotics, it is rare. It occurs predominantly in males due to inapt oral hygiene and increased oral trauma [1]. A case of disseminated actinomycosis manifesting as pneumonia with multiple pulmonary nodules and pelvic osteomyelitis is presented here. CASE PRESENTATION: A 53-year-old healthy male was admitted to our medical center for five weeks of right hip & low back pain (LBP), fevers, productive cough with white phlegm, generalized malaise, weight loss, and progressively worsening dyspnea. He was an active smoker with 30 pack-years of smoking, sexually active with his girlfriend, and worked at a farm. He was treated two weeks prior by the emergency department for LBP with muscle relaxants and steroids. He returned in five days with no improvement and was diagnosed with right upper lobe (RUL) pneumonia requiring admission and treatment with antibiotics. Workup showed leukocytosis of 22,600/mL, C reactive protein of 16 mg/dl, procalcitonin of 4.63 ng/mL, and a negative human immunodeficiency virus test. Computed tomography (CT) of the chest, abdomen, and pelvis revealed RUL consolidation with multiple bilateral noncalcified nodules and a 17 x 11.8 x 10.5 cm multilevel lobulated cystic mass centered around the right diffusely permeative iliac bone with lateral extension into adjacent gluteal musculature (Figure A-B). On arrival, clinical examination revealed an ill, thin male with warm, tender right hip able to only raise the leg up to 20 degrees. A right gluteal abscess aspirate revealed 20 ml purulent fluid, and the right iliac biopsy was positive for osteomyelitis with acute & chronic granulomatous inflammation. Surgical debridement of the pelvic lesion was followed by bronchoscopy (RUL bronchioalveolar lavage {BAL}, lymph node biopsies). Aspiration cytology revealed Splendore-Hoeppli phenomenon, sulfur granules, and Actinomyces bacterial colonies (Figure C). BAL culture grew Actinomyces odontolyticus (>100,000 colonies/mL). His poor dentition was the source of this disseminated infection. His recovery was successful with tooth extraction, six weeks of ceftriaxone followed by 42 weeks of oral amoxicillin. DISCUSSION: Actinomycosis is the most misdiagnosed disease even by experienced clinicians. Disseminated actinomycosis is exceedingly rare, especially from the hematogenous spread as in our patient [1]. The source can be a disease at any location. Lungs are a common site, whereas musculoskeletal involvement is infrequent [2]. CONCLUSIONS: Clinicians should be aware of this indolent presentation with the extent of the disease appreciated. It should be considered in a patient with bad oral hygiene, pneumonia, and pelvic osteomyelitis. REFERENCE #1: Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ. 2011;343:d6099. REFERENCE #2: Apothéloz C, Regamey C. Disseminated infection due to Actinomyces meyeri: case report and review. Clin Infect Dis. 1996;22(4):621-5. DISCLOSURES: No relevant relationships by Jonathan Ross Ang, source=Web Response No relevant relationships by Phillip Beck, source=Web Response No relevant relationships by Andres Bran, source=Web Response No relevant relationships by Michael Hunter, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response

BRONCHOPLEURAL FISTULA POST LOBECTOMY: A RARE COMPLICATION WITH AN EVEN MORE UNUSUAL PRESENTATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The formation of a bronchopleural fistula (BPF) is a rare but known complication following major thoracic surgery. In a study by Nachira et al. looking at 835 patients in Italy who underwent major lung resection, 786 patients underwent lobectomy with 11 (1.3%) developing a BPF [1]. In other studies their incidence has been reported between 0.5-3% [2]. Here we present a case of an unusual presentation of this rare complication. CASE PRESENTATION: 73 y.o F former smoker was incidentally found to have right upper lobe (RUL) chondral myxoid tumor. She underwent bronchoscopy and video assisted thoracoscopy (VATS) with wedge resection of RUL and placement of chest tube without peri-operative complications. Later that day, rapid response was called as patient developed facial swelling, sensation of throat tightening and upper chest erythema with subcutaneous emphysema (SCE) (Figure 1). Initial thought was possible anaphylaxis from NSAIDs and treated as such. Patient later further deteriorated leading to intubation and transfer to the ICU. Second right-sided chest tube and skin holes placed on chest for relief of subcutaneous air. Patient was extubated next day. Due to persistent SCE (Figure 2) and need for respiratory support, patient received bilateral blow-holes and was downgraded to surgical floor after improvement. Symptoms again recurred requiring re-intubation. Blow-holes were extended and 3rd right-sided chest tube placed. She was taken for repeat VATS and found to have a BPF with adhesions. Lysis of adhesions was performed with RUL mediastinal drainage and mechanical pleural abrasion. The rest of patient's hospital course was uncomplicated with eventual removal of chest tubes and discharge. DISCUSSION: As discussed, our patient had a complicated post-operative course, complicated further by the unique presentation of her BPF. We found no previous literature or case reports illustrating similar presenting symptoms of BPFs. They typically present 1 - 12 weeks postoperatively [2]. Our patient did not fit this timeline and had a very atypical presentation which mimicked symptoms of an anaphylactoid reaction. Although diffuse subcutaneous emphysema has been a reported finding from BPFs [3], this was thought to be a normal result of recent surgical procedure. This uncommon presentation led to delay in appropriate management and extended hospital course for this patient. CONCLUSIONS: This case demonstrates a unique presentation of a potentially fatal complication of major thoracic surgeries. BPF formation may need to be considered in patients who present similarly in the future. REFERENCE #1: Nachira D, Chiappetta M, Fuso L, Varone F, Leli I, Congedo MT, Margaritora S, Granone P. Analysis of risk factors in the development of bronchopleural fistula after major anatomic lung resection: experience of a single centre. ANZ J Surg.2018 Apr;88(4):322-326.doi: 10.1111/ans.13886. Epub 2017 Feb 1.PMID: 28147437. REFERENCE #2: Gaur P, Dunne R, Colson YL, Gill RR. Bronchopleural fistula and the role of contemporary imaging. J Thorac Cardiovasc Surg. 2014 Jul;148(1):341-7. doi: 10.1016/j.jtcvs.2013.11.009. Epub 2013 Dec 16. PMID: 24355543. REFERENCE #3: Anas Riehani, Olivia Wilcox, Wassim Mohammed Odeh, Michael Kehdi, and John Armstrong. Bronchopleural Fistula Presenting as diffuse Subcutaneous Emphysema. C46. PLEURAL DISEASE: CASE REPORTS II. May 1, 2017, A5647-A5647 DISCLOSURES: No relevant relationships by Inessa Bronshteyn, source=Web Response No relevant relationships by Kyle Foster, source=Web Response No relevant relationships by Janeen Grant-Sittol, source=Web Response No relevant relationships by Ross Lavine, source=Web Response No relevant relationships by Anna-Belle Robertson, source=Web Response

A 2D\u20133D hybrid convolutional neural network for lung lobe auto-segmentation on standard slice thickness computed tomography of patients receiving radiotherapy

BackgroundAccurate segmentation of lung lobe on routine computed tomography (CT) images of locally advanced stage lung cancer patients undergoing radiotherapy can help radiation oncologists to implement lobar-level treatment planning, dose assessment and efficacy prediction. We aim to establish a novel 2D–3D hybrid convolutional neural network (CNN) to provide reliable lung lobe auto-segmentation results in the clinical setting.MethodsWe retrospectively collected and evaluated thorax CT scans of 105 locally advanced non-small-cell lung cancer (NSCLC) patients treated at our institution from June 2019 to August 2020. The CT images were acquired with 5 mm slice thickness. Two CNNs were used for lung lobe segmentation, a 3D CNN for extracting 3D contextual information and a 2D CNN for extracting texture information. Contouring quality was evaluated using six quantitative metrics and visual evaluation was performed to assess the clinical acceptability.ResultsFor the 35 cases in the test group, Dice Similarity Coefficient (DSC) of all lung lobes contours exceeded 0.75, which met the pass criteria of the segmentation result. Our model achieved high performances with DSC as high as 0.9579, 0.9479, 0.9507, 0.9484, and 0.9003 for left upper lobe (LUL), left lower lobe (LLL), right upper lobe (RUL), right lower lobe (RLL), and right middle lobe (RML), respectively. The proposed model resulted in accuracy, sensitivity, and specificity of 99.57, 98.23, 99.65 for LUL; 99.6, 96.14, 99.76 for LLL; 99.67, 96.13, 99.81 for RUL; 99.72, 92.38, 99.83 for RML; 99.58, 96.03, 99.78 for RLL, respectively. Clinician's visual assessment showed that 164/175 lobe contours met the requirements for clinical use, only 11 contours need manual correction.ConclusionsOur 2D–3D hybrid CNN model achieved accurate automatic segmentation of lung lobes on conventional slice-thickness CT of locally advanced lung cancer patients, and has good clinical practicability.

The unpredictable diagnosis of pulmonary nodules

Abstract Pulmonary nodules are single or multiple rounded opacities with a size of minimum 1 cm diameter visualised in the lung parenchyma. From an anatomopathological point of view, they can be benign or malignant. Most often, these nodules are asymptomatic or with minimal symptoms. Now, we present the case of a 62-year-old patient, a smoker, with exposure to occupational respiratory noxious (cellulose industry – 10 years and printing industry – 30 years) without significant personal respiratory pathological history. He has dyspnoea on moderate exertion, irritable cough, myalgia, arthralgia and physical asthenia. The physical examination reveals the presence of a right bayonet sign. Biologically, an inflammatory syndrome was present, the urine test shows no pathological changes, but the imaging is intriguing. On the other side, the imagistic workup [chest X-ray and computed tomography (CT) scan] was quite surprising: micro/macronodular opacities with variable wall thickness, irregular contours and a tendency to confluence at the bilateral lower lobes level. A bronchoscopy was also performed with bronchioloalveolar lavage (BAL) in the right upper lobe (RUL) and bronchial biopsy at the level of the right upper ventral. The hypotheses are multiple: pulmonary rheumatoid nodules, polyangiitis with granulomatosis, lymphangitis carcinomatosis and tuberculosis. Thoracic surgery determined the diagnosis.

Spectrum of Chronic Lung Allograft Pathology in Human Lung Transplantation

<h3>Purpose</h3> Long-term survival after a lung transplantation (LTx) remains limited by Chronic Lung Allograft Dysfunction (CLAD), which includes two main phenotypes: bronchiolitis obliterans syndrome (BOS), characterized by airway fibrosis and obliteration, and restrictive allograft syndrome (RAS), presenting with parenchymal and sub-pleural fibrosis (2019 ISHLT consensus). There can be overlap between these phenotypes. We aimed to detail and quantify pathological features of human CLAD sub-types. <h3>Methods</h3> Peripheral (from outer 1/3 of the lung tissue) and central (from middle 1/3) paraffin-embedded explanted lung samples were obtained from 20 consecutive patients undergoing a second LTx for CLAD (phenotyped clinically prior to retransplant), from 3 lobes: left lower lobe (LLL), left upper lobe (LUL) and right upper lobe (RUL). Thirteen lung samples, collected from lobectomies or pre-transplant donor lungs, were used as "normal" controls. Sections were stained with Hematoxylin & Eosin and Elastic Trichrome. Blinded semi-quantitative grading was performed: the percentage of evaluable lung tissue area affected by parenchymal fibrosis was estimated; peri-airway fibrosis and bronchiolitis obliterans (BO) were graded 0-4 for each airway. Pleural fibrosis, epithelial flattening and hyperplasia were graded on a scale 0-4 (fig 1A-C). <h3>Results</h3> CLAD lung samples had higher scores for all parameters compared to controls. There was a notable overlap in pathological scores between BOS (n=11) and RAS (RAS n=8, Mixed n=1), with a wide range of scores in both conditions. Parenchymal fibrosis score was significantly higher in RAS compared to BOS (p=0.0007), but other scores were not significantly different (figure 1D). BO was significantly heterogeneous between the lobes (p=0.008) (figure 1E). <h3>Conclusion</h3> Our results confirm that BO and parenchymal fibrosis can coexist to different degrees of severity in both patients with RAS and BOS. This scoring strategy will be useful for pathologic correlations in future studies.

Investigation of high-resolution computed tomographic (HRCT) outcomes associated with chronic pulmonary microaspiration (CPM) in Tehran and Zahedan, Iran

In patients with chronic pulmonary microaspiration (CPM) the recognition of high-resolution computed tomographic (HRCT) findings and their pattern is important. To investigate the HRCT detections in patients with CPM. This descriptive study enrolled 100 consecutive patients with CPM underwent HRCT of the lungs between 2017 and 2018 in Tehran and Zahedan Hospitals and private centers. The required variables were recorded for each patient with a questionnaire. Subsequently, HRCT was performed and abnormalities were then reported by two radiologists. Most of patients exhibited bronchial thickening in 33.6% of cases, followed by ground-glass opacity (12.4%), emphysema (11.1%), and bronchiectasis (8.5%). In addition, the most common HRCT findings were found in left lower lobe (LLL) (37.1%), followed by right lower lobe (RLL) (35.9 %), right upper lobe (RUL) (6,2%), and left upper lobe (LUL) (6%). Our data showed the most common findings in HRCT were bronchial thickening ground-glass opacity, emphysema, and bronchiectasis, where these findings was dominantly found in LLL, RLL, RUL, and LUL, indicating its high tendency to dependent areas.