Upper Right Lung Research Articles

MANAGEMENT AND IDENTIFICATION OF RARE COINFECTIONS

MANAGEMENT AND IDENTIFICATION OF RARE COINFECTIONS

WHEN A COUGH ISN'T ASTHMA; WHEN A MASS IS NOT CANCER

Introduction The differential of chronic cough is broad and changes in the pattern of cough should be evaluated. We present a case with a surprising finding during our evaluation of worsening cough. Case description A 68-year-old female former smoker with a history of breast cancer status post mastectomy, asthma and allergic rhinitis presented with complaints of worsening cough, hoarseness, and intermittent dysphagia of 3 months duration. Chest radiograph revealed a 2.4 × 1.6 cm right upper lung (RUL) nodule. Chest computed tomography showed a 2.4 cm x 2.1 cm RUL mass, without cavitary lesions, and no evidence of bronchiectasis. Biopsy of this lesion revealed a mycetoma with no features of invasive aspergillosis. Upon further questioning the patient revealed having night sweats and right axillary pain; however, no hemoptysis. Labs were significant for elevated Aspergillus fumigatus IgE and no eosinophilia. She completed 6 months of treatment with decrease in aspergillus IgE and resolution of her symptoms. Simultaneous ENT evaluation revealed moderate arytenoid edema, where therapy with ranitidine therapy was initiated. Discussion We present a case of pulmonary aspergilloma discovered during an evaluation for worsening cough in an immunocompetent patient with asthma and no evidence of cavitary lung lesions or ABPA. The literature reports antifungals and/or surgery is the mainstay of therapy. Our patient's cough improved with simultaneous treatment for GERD and aspergilloma. Changes in cough patterns should prompt further evaluation and aspergilloma should be considered in the differential diagnosis of mass lesions. The differential of chronic cough is broad and changes in the pattern of cough should be evaluated. We present a case with a surprising finding during our evaluation of worsening cough. A 68-year-old female former smoker with a history of breast cancer status post mastectomy, asthma and allergic rhinitis presented with complaints of worsening cough, hoarseness, and intermittent dysphagia of 3 months duration. Chest radiograph revealed a 2.4 × 1.6 cm right upper lung (RUL) nodule. Chest computed tomography showed a 2.4 cm x 2.1 cm RUL mass, without cavitary lesions, and no evidence of bronchiectasis. Biopsy of this lesion revealed a mycetoma with no features of invasive aspergillosis. Upon further questioning the patient revealed having night sweats and right axillary pain; however, no hemoptysis. Labs were significant for elevated Aspergillus fumigatus IgE and no eosinophilia. She completed 6 months of treatment with decrease in aspergillus IgE and resolution of her symptoms. Simultaneous ENT evaluation revealed moderate arytenoid edema, where therapy with ranitidine therapy was initiated. We present a case of pulmonary aspergilloma discovered during an evaluation for worsening cough in an immunocompetent patient with asthma and no evidence of cavitary lung lesions or ABPA. The literature reports antifungals and/or surgery is the mainstay of therapy. Our patient's cough improved with simultaneous treatment for GERD and aspergilloma. Changes in cough patterns should prompt further evaluation and aspergilloma should be considered in the differential diagnosis of mass lesions.

Relationship between acute radiation pneumonitis and dosimetric factors in intensity-modulated radiotherapy for lung caner: a study based on different lesion locations

Objective To explore the dosimetric factors for acute radiation pneumonitis (ARP) after restricted field intensity-modulated radiotherapy (IMRT) for lung caner based on different lesion locations. Methods A retrospective study of ARP was performed among 113 patients with lung cancer undergoing restricted field IMRT from 2013 to 2015. The Radiation Therapy Oncology Group criteria were used to grade ARP. Comparison was made by χ2 test and independent sample t-test. The logistic regression model was used for multivariate analysis. The receiver operating characteristic curve was used to predict the optimal cut-off value. Results The statistical analysis showed that the incidence of ARP was not related to clinical factors. The V5 of the diseased lung was an independent predictor of the incidence of grade>2 ARP (P=0.016). The optimal cut-off value of V5 was 71.6%. According to the lesion locations in patients, the rV5 was an independent predictor of the incidence rates of ARP in the right lung, upper right lung, and right middle/lower lung (P=0.020, 0.020, 0.049) with optimal cut-off values of 66.2%, 74.7%, and 87.5%, respectively. The aV5 was an independent predictor of the incidence of ARP in mediastinal lung cancer (P=0.009) with an optimal cut-off value of 66.73%. Conclusions The V5 of the diseased lung is an independent predictor of the incidence of grade>2 ARP. In terms of the different lesion locations, the rV5 is an independent predictor of the incidence rates of grade>2 ARP in the right lung, upper right lung, and right middle/lower lung. The aV5 is an independent predictor of the incidence of ARP in mediastinal lung cancer. Key words: Lung neoplasms/intensity-moduliated radiotherapy; Different lesion location; Acute radiation pneumonitis; Dosimetry

Recurrent renal cell carcinoma manifesting as a large intrathoracic fibrotic mass: A case report

Renal cell carcinomas (RCCs) have a strong tendency to metastasize, and the most common sites are the lungs, bones and liver. Late recurrence is another feature of the RCC, with lesions appearing ≥10 years after surgical treatment. However, fibrosis has rarely been associated with the disease. The present study reports a case of recurrent RCC that manifested as a fibrotic mass within the thorax. A 48-year-old man presented with dyspnea that had persisted for 3 days. The patient had undergone a right radical nephrectomy for stage II clear cell carcinoma of the kidney 6 years previously. The patient was a current smoker, with a smoking history of 20 pack-years. Chest radiography showed pleural effusion in the right thorax with an egg-sized mass shadow within the right upper lung (RUL) field. Computed tomography (CT) showed a main mass, 7 cm in diameter, within the RUL, with heterogeneous enhancement and multiple nodules of various sizes in the lungs, suggestive of primary lung cancer or metastatic RCC. A CT-guided percutaneous needle aspiration biopsy was obtained from the main mass, but histology revealed dense fibrous tissue without any malignant cells. Positron emission tomography-CT demonstrated an irregular hypermetabolic RUL mass, with a standardized uptake value (SUV) of 5.0, along the right pleura, and small pulmonary nodules (SUV, 2.0). Ultrasound-guided biopsy was attempted for a smaller hypermetabolic pleural nodule and the result was clear cell adenocarcinoma, consistent with the previous renal histology. The present study describes the case, along with a review of the relevant literature.

Pulmonary mucormycosis: A case report and review of the literature.

The current study reports the case of a 15-year-old male who presented to The First Affiliated Hospital of Soochow University (Suzhou, Jiangsu, China) with a 3-day history of anergy and epistaxis. The patient was diagnosed with T-cell acute lymphoblastic leukemia according to the results of a bone marrow examination and received chemotherapy. During the agranulocytosis period, the patient developed pneumonia of the right upper lung (RUL). Once complete remission was achieved, the patient underwent a lobectomy of the RUL, together with amphotericin B therapy, following the confirmation of pulmonary mucormycosis by the histopathological results. The patient experienced 12 months of uneventful follow-up post-surgery.

Uniportal video-assisted thoracoscopic surgical (VATS) segmentectomy with preoperative dual localization: right upper lobe wedge resection and left upper lobe upper division segmentectomy.

Clinical vignette A 75-year-old male presented with abnormalities upon chest computed tomography (CT) scanning at a routine check. He had a 1.7-cm sized ground glass opacity (GGO) on the posterior segment of the right upper lung (RUL) and a 1.2-cmsized semisolid lung nodule on the left upper lung (LUL). To differentiate synchronous metastasis, sequential CT-guided core biopsy was performed for the GGO lesion on the posterior segment of the RUL and the posterior segment of the LUL. Both lesions were suspected to be adenomatous hyperplasia or non-small cell lung cancer. Adenocarcinoma was detected in situ upon pathologic examination. A positron emission tomography (PET) scan showed no lymph node metastasis or extrathoracic distant metastasis. The LUL semisolid lesion showed mild hypermetabolism, while the RUL pure GGO lesion showed no definite uptake on PET scan. Pulmonary function was as follows: forced vital capacity (FVC), 3.07 L (75%); forced expiratory volume in 1 second (FEV1), 2.34 L (88%); carbon monoxide lung diffusion capacity (DLCO), 20.7 mL/mmHg/min (116%). The patient was referred for surgical resection of bilateral synchronous lung lesions. In this case, by employment of the dual localization technique (hook-wire and lipiodol), we performed bilateral uniportal video-assisted thoracoscopic surgery (VATS) resection. Wedge resection was carried out for the GGO lesion on the posterior segment of the RUL and left upper divisional segmentectomy was carried out for the semisolid lesion on

A lobe-specific lymphadenectomy protocol for solitary pulmonary nodules in non-small cell lung cancer.

We want to establish a lobe-specific mediastinal lymphadenectomy protocol for solitary pulmonary nodules (SPNs) in non-small cell lung cancer (NSCLC). We retrospectively analyzed 401 patients with pathological diagnoses of NSCLC who underwent lobectomy, bilobectomy, or pneumonectomy with systematic lymphadenectomy from March 2004 to June 2011 in our hospital. All of the patients enrolled had a SPN preoperatively. Information about the primary tumor location, lymph node metastasis, and other baseline data were collected. Stepwise logistic regression was used to identify the key factors indicating non-regional mediastinal lymph node metastases (NRM). Of the primary tumors, 117, 39, 74, 104, and 67 were in the right upper lung (RUL), right middle lung (RML), right lower lung (RLL), left upper lung (LUL), and left lower lung (LLL), respectively. Stepwise regression showed that #2,4, #10,11, and #10,11 as well as #7 was the key lymph node station for RUL, LUL, and lower lobes: #2,4 [odds ratio (OR)=28.000, 95% confidence interval (CI): 2.917-268.790, P=0.004] for RUL, #10,11 (OR=31.667, 95% CI: 2.502-400.833, P=0.008) for LUL, #10,11 (OR=19.540, 95% CI: 4.217-90.541, P<0.001) and #7 (OR=7.395, 95% CI: 1.586-34.484, P=0.011) for lower lobes, respectively. Patients with tumors >2 cm rarely had NRM without primary regional mediastinal involvement. With rigid consideration, a lobe-specific lymphadenectomy is feasible in practice. This protocol can be used when the lobe-specific key nodes are negative in intraoperative frozen sections, especially for NSCLC diagnosed as SPN <2 cm preoperatively.