Thoracoscopic Surgical Biopsy Research Articles

A Rare Case of Tuberculous Constrictive Pericarditis Due to Disseminated Tuberculosis with Response to Anti-tuberculosis Chemotherapy and Steroids in a Developed City State

A 27-year-old man presented with a 1-week history of atypical chest pain and sinus tachycardia. His physical examination was unremarkable. His resting ECG showed sinus tachycardia with widespread T-wave inversion. His initial blood tests show mildly raised troponin T and inflammatory markers and marked raised D-dimer. A CT pulmonary angiogram was performed to exclude pulmonary embolism but incidentally revealed an anterior mediastinal mass. A transthoracic echocardiogram and cardiac MRI showed features of constrictive pericarditis. A video-assisted thoracoscopic surgical biopsy of the anterior mediastinal mass showed thymic tissue with necrotising granulomatous inflammation and an acid-fast bacilli culture was positive to tuberculosis infection. The patient was started on anti-tuberculosis chemotherapy and a 6-week tapering course of oral steroids. A repeat cardiac MRI performed after 6 weeks of treatment showed a significant response to treatment with resolution of constrictive physiology.

Spontaneous Ventilation Thoracoscopic Lung Biopsy in Undetermined Interstitial Lung Disease: Systematic Review and Meta-Analysis.

Thoracoscopic surgical biopsy has shown excellent histological characterization of undetermined interstitial lung diseases, although the morbidity rates reported are not negligible. In delicate patients, interstitial lung disease and restrictive ventilatory impairment morbidity are thought to be due at least in part to tracheal intubation with single-lung mechanical ventilation; therefore, spontaneous ventilation thoracoscopic lung biopsy (SVTLB) has been proposed as a potentially less invasive surgical option. This systematic review summarizes the results of SVTLB, focusing on diagnostic yield and operative morbidity. A systematic search for original studies regarding SVTLB published between 2010 to 2023 was performed. In addition, articles comparing SVTLB to mechanical ventilation thoracoscopic lung biopsy (MVTLB) were selected for a meta-analysis. Overall, 13 studies (two before 2017 and eleven between 2018 and 2023) entailing 675 patients were included. Diagnostic yield ranged from 84.6% to 100%. There were 64 (9.5%) complications, most of which were minor. There was no 30-day operative mortality. When comparing SVTLB to MVTLB, the former group showed a significantly lower risk of complications (p < 0.001), whereas no differences were found in diagnostic accuracy. The results of this review suggest that SVTLB is being increasingly adopted worldwide and has proven to be a safe procedure with excellent diagnostic accuracy.

Isolated pulmonary langerhans cell histiocytosis: A diagnostic challenge in oncologic patients.

Isolated pulmonary langerhans cell histiocytosis: A diagnostic challenge in oncologic patients.

Multiple pleural nodules diagnosed as IgG4-related disease: a case report

BackgroundImmunoglobulin G4 (IgG4)-related diseases are characterized by abnormal IgG4 levels, swelling, and marked infiltration and fibrosis of the lymphocytes and IgG4-positive plasma cells, causing hypertrophic lesions or nodules. The cause is currently not well understood. IgG4-related diseases involving lesions limited to the pleura are extremely rare. Herein, we report an IgG4-related disease presenting with multiple pleural nodules confirmed by thoracoscopic surgical biopsy.Case presentationA 74 year-old man was referred to our department for definitive diagnosis of multiple pleural nodules after 1 year of follow-up. Computed tomography of the chest revealed multiple pleural nodules, while 2-deoxy-2-( 18F)-fluorodeoxyglucose positron emission tomography imaging exhibited tracer accumulation in the nodules. A thoracoscopic surgical biopsy was performed. Histopathological examination revealed hyalinized fibrous tissue with a high degree of plasma cell-based inflammatory cell infiltration. Immunohistochemically, IgG4-positive cells were conspicuous, accounting for 70.5% of the plasma cells. The postoperative serum IgG4 concentration was 289 mg/dL. We diagnosed the patient with an IgG4-related disease with multiple pleural nodules. The postoperative course was good, and the patient is currently being followed up.ConclusionIgG4-related disease should be considered in cases presenting with multiple pleural nodules.

Uniportal surgical biopsy, without orotraqueal intubation, without thoracic drainage in intersticial pulmonary disease: initial results.

interstitial lung disease comprises a group of lung diseases with wide pathophysiological varieties. This paper aims to report the video thoracoscopic surgical biopsy in patients with interstitial lung disease through a single minimal chest incision, without orotracheal intubation, without chest drainage, and without the use of neuromuscular blockers. this study is a series of 14 cases evaluated retrospectively, descriptively, where patients underwent a pulmonary surgical biopsy from January 2019 to January 2020. The patients included in the study had diffuse interstitial lung disease without a defined etiological diagnosis. none of the patients had transoperative complications, there was no need for chest drainage in the postoperative period, and the patients pain, assessed using the verbal scale, had a mode of 2 (minimum value of 1 and maximum of 4) in the post immediate surgery and 1 (minimum value of 1 and maximum of 3) at the time of hospital discharge. The length of hospital stay was up to 24 hours, with 12 patients being discharged on the same day of hospitalization. therefore, it is concluded in this series of cases that the performance of uniportal video-assisted thoracoscopic surgery procedures to perform lung biopsies, without orotracheal intubation, without chest drainage, and without the use of neuromuscular blockers, bring benefits to the patient without compromising his safety. Further larger studies are necessary to confirm the safety and efficiency of this method.

MULTIFOCAL PULMONARY NODULAR HYPERPLASIA IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary nodular lymphoid hyperplasia (PNLH) is a rare lympho-proliferative disorder characterized by benign polyclonal lymphoid proliferation. We describe a case of a 44-year-old woman with biopsy proven multifocal pulmonary nodular lymphoid hyperplasia in the setting of SLE. CASE PRESENTATION: 44-year-old woman presented to the emergency room with complaints of intermittent pleuritic chest pain and exertional dyspnea for 3 months. Review of systems was positive for joint pains and morning stiffness. Physical examination was remarkable for tenderness and swelling at proximal interphalangeal joints. Cardiac work up including electrocardiogram, troponin levels and echocardiogram was unremarkable. CT scan of chest with contrast showed numerous bilateral cavitary ground glass opacities measuring about 1-2 cm in size. Transbronchial biopsy was non-diagnostic. A subsequent video-assisted thoracoscopic surgical biopsy revealed nodular lymphoid hyperplasia. Specimen was negative for malignancy, granulomatous disease or vasculitis. Lymphoma was also ruled out by flow cytometry. AFB, fungal and bacterial stains and cultures were negative. Hepatitis panel and HIV testing was negative. Rheumatologic work up showed negative rheumatoid factor and positive ANA, anti-SSA, anti-dsDNA Ab, anti smith and anti-U1-RNP antibodies. Inflammatory markers, ESR and CRP, were elevated. She was evaluated by rheumatology and further history revealed presence of alopecia and nasal sores in addition to serositis (pleuritis) and arthritis. Her clinical picture and serologies met the diagnostic criteria for SLE. DISCUSSION: Pulmonary lymphoid nodular hyperplasia is a rare benign lymphoproliferative disease. It is relatively more common in women and often an incidental finding on imaging. Most patients are asymptomatic, however symptoms such as cough, chest pain or dyspnea can be present. Diagnosis is made by surgical biopsy. It is essential to rule out malignancy, particularly mucosal associated lymphoid tissue lymphoma and infectious etiologies such as bacterial or fungal pulmonary infections. So far PNLH has been described in patients with Sjogren’s disease, without conclusive association. Most common pulmonary manifestation in SLE is pleurisy. Interstitial lung disease (ILD) is less common in SLE and is seen in patients who have anti–U1-RNP antibodies. Imaging findings are nonspecific; however, ground-glass opacities or consolidations may be present. PNLH has not been described in association to or as a manifestation of SLE in medical literature. There is paucity of data for correlation and larger studies are required to study this potential association. CONCLUSIONS: Pulmonary nodular lymphoid hyperplasia is a rare benign lymphoproliferative disorder. After malignancy and infectious etiology is ruled out autoimmune disease should be considered in patients with PNLH. Further work is warranted to establish this relation. Reference #1: Abbondanzo SL, Rush W, Bijwaard KE, Koss MN. Nodular lymphoid hyperplasia of the lung: a clinicopathologic study of 14 cases. Am J Surg Pathol. 2000;24(4):587–597. Reference #2: Song MK, Seol YM, Park YE, et al. Pulmonary nodular lymphoid hyperplasia associated with Sjögren's syndrome. Korean J Intern Med. 2007;22(3):192–196. doi:10.3904/kjim.2007.22.3.192. Reference #3: Quadrelli SA, Alvarez C, Arce SC, et al: Pulmonary involvement of systemic lupus erythematosus: analysis of 90 necropsies. Lupus 2009; 18: pp. 1053-1060 DISCLOSURES: No relevant relationships by William Han, source=Web Response No relevant relationships by Immad Munawar, source=Web Response No relevant relationships by Theresa Nicol, source=Web Response

VATS versus ultrasound-guided Abrams needle biopsy in undiagnosed pleural effusion: Old wisdom and new insights

BackgroundVideo Assisted Thoracoscopic surgical Biopsy (VATS) biopsy and transthoracic ultrasound-guided Abrams needle biopsy (TUS-GANB) are important tools in management of undiagnosed pleural effusion due to their high diagnostic yield in comparison to blind closed pleural biopsies. MethodsFrom November 2015 to July 2017, a prospective study included a total number of 90 patients of undiagnosed pleural effusion who were randomly divided into two groups: group A (45 patients who underwent VATS biopsy), and group B (45 patients who underwent TUS-GANB). Safety and efficacy of both procedures were compared. ResultsBoth procedures were safe with no perioperative mortality. A definitive histopathological diagnosis was obtained in 43 patients (95.6%) in group A and in 39 patients (86.7%) in group B (p = 0.266). VATS was superior to ultrasound guided biopsy in diagnosing pleural effusion due to pulmonary causes (p = 0.02). Both VATS and ultrasound guided biopsy were effective in diagnosing pleural effusion due to pleural causes (p = 0.358). Complications in group A were minor bleeding in 3 (6.7%), pain in 5 (11.1%), surgical emphysema in 1 (2.2%), prolonged air leakage in 3 (6.7%), pneumothorax in 5 (11.1%) and wound infection in 2 (4.4%). Complications in group B were minor bleeding in 1 (2.2%), pain in 2 (4.4%), surgical emphysema in 1 (2.2%), pneumothorax in 2 (4.4%) and haemoptysis in 2 (4.4%). ConclusionsVATS was superior to ultrasound guided biopsy in diagnosing pleural effusion due to pulmonary causes. Both VATS and ultrasound guided biopsy were effective in diagnosing pleural effusion due to pleural causes.

Miliary tuberculosis with bilateral recurrent pneumothoraces

A 13-year girl presented with fever, chest pain, cough, and decreased appetite of 15 days. General and respiratory examination was normal. Routine investigations were normal. Sputum for AFB was negative. Chest X-ray revealed bilateral miliary nodules. Eye examination showed choroid tubercles with chorioretinitis. She was diagnosed as disseminated TB and started on ATT daily regime with oral prednisolone. After 5 days, she developed pneumothorax and ICD was inserted. CECT chest showed bilateral multiple miliary nodules with bilateral pneumothorax. She had recurrence (6 times) of Pneumothoraces during 3 months and managed with ICD. She underwent thoracoscopic surgical biopsy for confirmation of diagnosis. Immunohistocytology was negative for CD1a and HMB45. Biopsy was consistent with TB. The final diagnosis was miliary tuberculosis with bilateral recurrent Pneumothoraces. ATT continue for 9 months with tapering of steroid. Chemical pleurodesis was performed. She was followed up for 2 years with no recurrent of pneumothorax. Bilateral recurrent pneumothorax is rare complication of miliary TB.

Mediastinal Fibrosis and Positive Antineutrophil Cytoplasmic Antibodies: Coincidence or Common Etiology?

Retroperitoneal fibrosis (RPF) with positive antineutrophil cytoplasmic antibodies (ANCA) has been reported in several cases. We herein present the case of a 52-year-old woman who was diagnosed with mediastinal fibrosis (MF) on a thoracoscopic surgical biopsy. The patient had positive myeloperoxidase ANCA and thereafter developed crescentic glomerulonephritis, which was considered to be a form of ANCA-related nephritis. Both the MF and crescentic glomerulonephritis favorably responded to immunosuppressive therapy. These findings suggest a common pathogenesis of these disorders involving ANCA positivity, as reported in patients with RPF.

Chronic Pulmonary Thromboembolism Pathologically Showing Homogeneous Cellular Alveolitis

A 60-year-old man was admitted to our hospital complaining of general malaise. Examination of arterial blood gases on room air revealed hypoxia. Pulmonary function test showed restrictive abnormality. Chest high-resolution CT showed diffuse mosaic attenuation without evident pulmonary artery abnormality on contrast chest CT. Based on these findings, interstitial pneumonia or chronic pulmonary thromboembolism was suspected. The findings of bronchoalveolar lavage revealed 4.4×10(5) cells/mL, including 89.6% macrophages, 9.4% lymphocytes, and 1.0% neutrophils. TBLB showed marked alveolitis. Moreover video-assisted thoracoscopic surgical biopsy was performed. Biopsies of the lung specimen showed focal infarct with surrounding mild mononuclear cell infiltrates (homogenous cellular alveolitis). (99m)Tc pulmonary perfusion and (81m)Kr ventilation scintigraphy showed V/Q mismatch. Furthermore, pulmonary angiography also revealed inadequate artery flow corresponding to the mismatch area of scintigraphy. Collagen vascular diseases and abnormality of coagulation factors were not detected. Multiple perfusion defects persisted for more than 6 months. Thus, finally the patient was diagnosed with chronic pulmonary thromboembolism, pathologically showing homogenous cellular alveolitis.

Intrathoracic Extramedullary Haematopoiesis Manifested as a Neoplastic Lesion Within Anterior Mediastinum

Intrathoracic extramedullary hematopoiesis (EMH), the formation of apparently normal blood cells outside the confines of the bone marrow, is an uncommon but well-defined entity. It is usually associated with hematologic disorders and located in the lower paravertebral sulci or rarely in the pleura. We report a case of EMH, which presented in a patient without hematologic disorders and was manifested as an anterior mediastinal mass. The first interesting aspect of our case was that EMH occurred in a patient with normal laboratory findings and no past medical history of anemia. The second remarkable characteristic was that EMH manifested as an anterior mediastinal mass, mimicking a neoplastic lesion. Definitive diagnosis of EMH was established by a video-assisted thoracoscopic surgical biopsy. In light of this diagnosis, no further surgical procedure was carried out.

An Unusual Case of Aspergillus Fibrosing Mediastinitis

Fibrosing mediastinitis due to Aspergillus is rare, particularly in the immunocompetent host. Fibrosing mediastinitis due to Aspergillus species in the immunocompetent patient can be indolent and may be treated with antifungal therapy rather than surgery. We present a 78-year-old nonsmoking, nondiabetic woman with chronic fibrosing mediastinitis due to Aspergillus. Multiple attempts at securing a tissue diagnosis were inconclusive. Ultimately, Aspergillus infection was diagnosed by a video-assisted thoracoscopic surgical biopsy. The patient was started on oral voriconazole, and she remains clinically stable with radiographic improvement. A prolonged, perhaps lifelong, course of antifungal therapy is planned.

Insidious Pulmonary Fibrosis Occurring at the Hypoperfusion Area in a Patient with Chronic Pulmonary Thromboembolism

A 69-year-old woman who had been diagnosed with chronic pulmonary thromboembolism (CPTE) developed ground glass opacities in the right lung where perfusion scintigraphy showed defects of the bloodstream. Bronchoalveolar lavage fluid (BALF) showed that some macrophages had phagocytosed hemosiderin. Video-assisted thoracoscopic surgical biopsy revealed lung fibrosis, narrowing of the pulmonary artery and organization of many cholesterol granulomas. We hypothesized that hyperperfusion of the bronchial artery, which occurred to compensate for hypoperfusion of the pulmonary artery, induced alveolar hemorrhage following thrombolytic and anticoagulation treatments, and that the degraded products from blood cells induced the formation of lung fibrosis and cholesterol granulomas.

Clinical differentiation between resistant asthma and chronic bronchiolitis: testing a practical approach.

Intractable asthma is a challenging clinical problem. This study was conducted to determine whether a subset of patients with Intractable asthma may be misdiagnosed and have a form of bronchiolitis instead and also to determine the effectiveness of macrolide therapy in these patients. Seventy six patients with Intractable asthma were re-treated with recommended maximal doses of oral prednisolone for 5 days, beclomethasone, cromolyn sodium, salbutamol and ipratropium bromide for 30 days. Thirty five patients were considered as unresponsive and constituted the study group. They underwent high-resolution CT (HRCT) scan following which they were offered with video-assisted thoracoscopic surgical biopsy. Group 1 (n= 27) refused biopsy and each was treated with macrolide therapy, while Group 2 (n=8) underwent biopsy, and then received macrolide therapy. The patients were treated and followed for three months. The study group consisted of 27 patients, with a mean age of 46.9 +/- 11.1 years. The mean duration of time between the onset of symptoms and the start of this study was 8.1 years. In group 2, no patient had pathologic findings of asthma, and 7/8 had a form of bronchiolitis. There was significant improvement in dyspnea, cough and pulmonary function indices at the end of the 3-month in both groups (p< 0.001). Our results suggest that patients with Intractable asthma could be misdiagnosed and some of them have some forms of chronic bronchiolitis. We believe that any patient who does not respond to standard treatments for Intractable asthma should be evaluated with expiratory HRCT; those with significant air trapping should be considered for a course of macrolide therapy or biopsy for better identification of the underlying disease.

A case that underwent bilateral video-assisted thoracoscopic surgical biopsy combined with left pneumonectomy

A case that underwent bilateral video-assisted thoracoscopic surgical (VATS) biopsy combined with pneumonectomy is presented. The patient developed hypoxia during the contralateral VATS biopsy. His hypoxia was treated with positive expiratory pressure (PEEP) to the dependent lung and apneic oxygen insufflation to the operative lung. The cause was probably airway obstruction due to his intraluminal tumor plus secretions. This case report contains interesting aspects in the anesthetic management.

Thoracoscopic lung biopsy for diffuse infiltrative lung disease.

Thoracoscopic lung biopsy is becoming the procedure of first choice for the diagnosis of many localized and diffuse lung diseases. We have performed thoracoscopic lung biopsy for 17 patients with diffuse infiltrative lung disease, in Kurume University Hospital. There were 13 females and 4 males with a mean age of 48 years (range: 19-71 years). Thoracoscopic surgical biopsy was performed in the right lung in 12 and in the left lung in 5. Adequate lung tissue from each case was obtained for pathological examination. The mean surgical biopsy time was 49 min (range: 25-72 min) and bleeding was negligible. The mean duration for chest tube drainage was 2.6 days. No postoperative complication such as prolonged air leakage occurred. A specific diagnosis from the biopsy was achieved in 13 (76.4%) of the 17 cases. In only 6 (35.2%) of the 17 cases, the pathological diagnosis was the same as that from the thoracoscopic biopsy. In these 6 cases, the same diagnosis was obtained only in those with idiopathic interstitial pneumonitis or diffuse panbronchitis. Thoracoscopic lung biopsy was safe and useful for diagnosis for diffuse infiltrative lung disease.