Tracheobronchial Tumors Research Articles

EP.14C.03 Long-Term Outcomes of Unresectable Tracheobronchial Tumors Treated with Radiotherapy- Analysis from a Tertiary Cancer Centre

EP.14C.03 Long-Term Outcomes of Unresectable Tracheobronchial Tumors Treated with Radiotherapy- Analysis from a Tertiary Cancer Centre

Achieving Targeted Delivery of Chemotherapeutic Particles to Small Airway Tumors via Pulmonary Route Using Endotracheal Catheters: A CFPD Study.

Tracheobronchial tumors, while uncommon, are often malignant in adults. Surgical removal is the primary therapy for non-metastatic lung malignancies, but it is only possible in a small percentage of non-small-cell lung cancer patients and is limited by the number and location of tumors, as well as the patient's overall health. This study proposes an alternative treatment: administering aerosolized chemotherapeutic particles via the pulmonary route using endotracheal catheters to target lung tumors. To improve delivery efficiency to the lesion, it is essential to understand local drug deposition and particle transport dynamics. This study uses an experimentally validated computational fluid particle dynamics (CFPD) model to simulate the transport and deposition of inhaled chemotherapeutic particles in a 3-dimensional tracheobronchial tree with 10 generations (G). Based on the particle release maps, targeted drug delivery strategies are proposed to enhance particle deposition at two lung tumor sites in G10. Results indicate that controlled drug release can improve particle delivery efficiencies at both targeted regions. The use of endotracheal catheters significantly affects particle delivery efficiencies in targeted tumors. The parametric analysis shows that using smaller catheters can deliver more than 74% of particles to targeted tumor sites, depending on the location of the tumor and the catheter diameter used, compared to less than 1% using conventional particle administration methods. Furthermore, the results indicate that particle release time has a significant impact on particle deposition under the same inhalation profile. This study serves as a first step in understanding the impact of catheter diameter on localized endotracheal injection for targeting tumors in small lung airways.

A TRACHEAL FIBROEPITHELIAL POLYP

A TRACHEAL FIBROEPITHELIAL POLYP

Clinical Analysis of Primary Tracheobronchial Tumors in Children and Evaluation of the Predicting Models for Mucoepidermoid Carcinoma.

To determine the clinical characteristics and prognosis of primary tracheobronchial tumors (PTTs) in children, and to explore the most common tumor identification methods. The medical records of children with PTTs who were hospitalized at the Children's Hospital of Chongqing Medical University from January 1995 to January 2020 were reviewed retrospectively. The clinical features, imaging, treatments, and outcomes of these patients were statistically analyzed. Machine learning techniques such as Gaussian naïve Bayes, support vector machine (SVM) and decision tree models were used to identify mucoepidermoid carcinoma (ME). A total of 16 children were hospitalized with PTTs during the study period. This included 5 (31.3%) children with ME, 3 (18.8%) children with inflammatory myofibroblastic tumors (IMT), 2 children (12.5%) with sarcomas, 2 (12.5%) children with papillomatosis and 1 child (6.3%) each with carcinoid carcinoma, adenoid cystic carcinoma (ACC), hemangioma, and schwannoma, respectively. ME was the most common tumor type and amongst the 3 ME recognition methods, the SVM model showed the best performance. The main clinical symptoms of PPTs were cough (81.3%), breathlessness (50%), wheezing (43.8%), progressive dyspnea (37.5%), hemoptysis (37.5%), and fever (25%). Of the 16 patients, 7 were treated with surgery, 8 underwent bronchoscopic tumor resection, and 1 child died. Of the 11 other children, 3 experienced recurrence, and the last 8 remained disease-free. No deaths were observed during the follow-up period. PTT are very rare in children and the highest percentage of cases is due to ME. The SVM model was highly accurate in identifying ME. Chest CT and bronchoscopy can effectively diagnose PTTs. Surgery and bronchoscopic intervention can both achieve good clinical results and the prognosis of the 11 children that were followed up was good.

Localized Bronchial Dilatations Revealing an Endobronchial Lipoma

Benign tracheobronchial tumors are rare and represent 1.9% of all intrathoracic tumors. Endobronchial lipoma accounts for less than 0.5% of benign bronchopulmonary tumors. The clinical signs are not specific. We report a case of a 45-year-old patient with chronic bronchorrhoea who consulted for the worsening of his bronchorrhea. The clinical examination was normal. Chest CT revealed atelectasis of the left lower lobe and localized bronchial dilatations revealing an endobronchial tumor on bronchoscopy. The histological study was in favor of a lipoma. The evolution was favorable.

End-to-side anastomosis in complex tracheal resection and reconstruction: a case series study.

BackgroundThe development of current anesthetic and surgical techniques has increased the success rate of complex tracheal resection and reconstruction. End-to-end anastomosis is the prevailing method, while the end-to-side approach has also been reported to be practical and suitable. The current study aimed to demonstrate the feasibility and advantages of the end-to-side anastomosis method in specific cases.MethodsWe summarized 6 cases of patients with tracheobronchial tumors who received different end-to-side airway reconstructions in our center. Their clinical features and surgical procedures were also described. Postoperative follow-up was conducted to monitor their complications and prognosis.ResultsAmong the patients involved in the study, 2 patients with tumors involving the bronchus intermedius received auto-lung transplantations under general anesthesia, 3 patients with tumors involving the lower trachea and carina underwent reconstruction under non-intubated combined anesthesia, and 1 patient with left main bronchus (LMB) involvement received surgery under venoarterial extracorporeal membrane oxygenation (VA ECMO)-supported non-intubated anesthesia. The surgical procedures were completed successfully without surgical or anesthetic incidents. Patients 1 and 2 underwent auto-lung transplantation with distal stumps and trachea end-to-side anastomosis (right lower lobe and right basal segment). Patients 3 and 4 received right main bronchus (RMB) to lateral trachea reconstruction, while Patients 5 and 6 underwent LMB to tracheal wall anastomosis. Anastomotic buttressing was performed using the thymus and mediastinal tissue. The patients were discharged within 2 weeks of the operation. No severe postoperative complications were reported, with the exception of Patient 5, who required a prolonged intensive care unit (ICU) stay with antibiotics due to pneumonia. Anastomotic necrosis, dehiscence, or stenosis were not observed in the postoperative bronchoscopy.ConclusionsEnd-to-side anastomosis is a feasible and effective surgical method in airway reconstructions. This method facilitates tension-free anastomosis, which is crucial for surgical prognosis and decreasing complications. The reported cases had ideal surgical results during follow-up. The long-term outcomes of the end-to-side method require further evaluation.

Surgical treatment of primary tracheobronchial tumors: 16-year experience in a single center.

BackgroundPrimary tracheobronchial tumor (TBT) is a rare disease, and the prognostic factors of surgical treatment have not been well identified.MethodsPatients with primary TBT and accepted surgical treatment between January 2004 and January 2020 at our institution were retrospectively analyzed. The univariate analysis and multivariate analysis were conducted on the malignant cases. The overall survival (OS) was analyzed using Kaplan-Meier method, and potential prognostic factors were analyzed using Cox regression analysis.ResultsA total of 69 patients (29 males and 40 females) were included. The median follow-up duration was 75.7 months (1.2–177.4 months). The most common histology was adenoid cystic carcinoma (ACC) (37.7%) followed by squamous cell carcinoma (SCC) (23.2%). For patients with malignant tumors, the estimated 5-year OS of the overall population was 77.2% and the estimated 5-year OS of SCC patients was 73.8% especially. The univariate Cox regression analysis identified that age and tumor size had significant effects on OS. The multivariate analysis showed that age (≤50 or >50 years) was independent prognostic factor for OS (P<0.05).ConclusionsAge is independent factor affecting the OS of primary TBT treated by surgery. And patients of TBT with younger age should be much more referred for surgery.

ENDOBRONCHIAL HAMARTOMA: A MISDIAGNOSIS OF COPD

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hamartomas are benign tumors composed of various mesenchymal cells including cartilage, connective tissue, bone and fat. Pulmonary hamartomas constitute about 8% of all benign lung neoplasms and have an incidence of 0.025-0.32%. They typically occur peripherally involving the lung parenchyma and rarely occur as endobronchial tumors. Here, we present a case of endobronchial hamartoma presenting as dyspnea and chronic cough. CASE PRESENTATION: A 61-year-old male non-smoker presented for 6 months of chronic productive cough. His chest x-ray was unremarkable. Pulmonary function testing was notable for mild obstruction with a forced expiratory volume in one second (FEV1) of 84.9%, forced vital capacity (FVC) of 102.1%, FEV1/FVC ratio of 63.74% and normal DLCO without bronchodilator response. He was initially diagnosed with chronic obstructive pulmonary disease (COPD) and prescribed a daily steroid inhaler and as needed short acting bronchodilator. Despite compliance with his inhalers, he continued to have persistent cough and was referred to a pulmonologist. A computed tomography scan of the chest showed two endobronchial soft tissue lesions in the right bronchus intermedius nearly occluding the bronchus intermedius. Diagnostic bronchoscopy showed a lobulated, mobile endobronchial mass obstructing approximately 85% of the lumen. Endobronchial biopsies returned as fragments of mature hyaline cartilage with adipose tissue and benign bronchial epithelium compatible with pulmonary hamartoma. He underwent rigid bronchoscopy and tumor resection with laser cautery to the base by thoracic surgery. Pathology confirmed the diagnosis of pulmonary hamartoma. After resection, he had improvement of his dyspnea and cough. DISCUSSION: Endobronchial hamartomas account for only 10% of pulmonary hamartomas. Most pulmonary hamartomas are asymptomatic as they typically involve the parenchyma. Endobronchial hamartomas most commonly present as post obstructive pneumonia or hemoptysis. Less frequently, non-specific pulmonary symptoms such as cough, wheezing, and/or dyspnea can be the presenting sign and can lead to a misdiagnosis of asthma or COPD. CONCLUSIONS: Although endobronchial tumors are common, endobronchial hamartomas are very rare. Most endobronchial lesions are malignant. Endobronchial hamartomas are typically slow growing and therefore often incidentally discovered on chest imaging. In some cases, they may be poorly or not visualized on chest radiograph. Patients with nonspecific pulmonary symptoms who fail standard management with an unremarkable chest radiograph should prompt further detailed chest imaging to rule out structural causes such as endobronchial hamartomas. The gold standard for management of symptomatic endobronchial hamartomas is rigid bronchoscopy with resection and laser therapy. REFERENCE #1: Cosío, Broja et al. "Endobronchial Hamartoma.” Chest. Vol. 122;1 (2002): 202-205. REFERENCE #2: Ahmed, Saman et al. "Endobronchial hamartoma; a rare structural cause of chronic cough.” Respiratory medicine case reports. Vol. 22 (2017): 224-227. REFERENCE #3: Stevic, Ruza, and Branislava Milenkovic. "Tracheobronchial tumors.” Journal of thoracic disease vol. 8,11 (2016): 3401-3413. DISCLOSURES: No relevant relationships by Kathy Chan, source=Web Response No relevant relationships by George Moran, source=Web Response No relevant relationships by Sudhir Rajan, source=Web Response No relevant relationships by Eduardo Solbes, source=Web Response

ENDOBRONCHIAL SCHWANNOMA: VERY RARE TUMOR DISCOVERED ACCIDENTLY DURING FOB FOR LEFT LOWER LOBE COLLAPSE

TOPIC: Lung Cancer TYPE: Global Case Reports INTRODUCTION: In the mediastinum, Schwannomas are fairly common. Endobronchial position is extremely uncommon, with only a few cases reported in the literature. CASE PRESENTATION: An 80-year-old man presented in the emergency department with a 3-day history of fever 39 ◦C, general malaise, dry cough, myalgia, headache &loss of appetite. Chest X-ray on admission (IMAGE 1) revealed partial right lower lobe collapse (RLL). A diagnosis of aspiration pneumonia secondary to dysphagia was established, received AB with chest physiotherapy with gradual improvement of his condition. CKD, former smoker SI 20, AF, daistoic dysfunction. Then the patient started to be deteriorated with decrease conscious level due to metabolic cause where invasive mechanical ventilation was initiated. CXR was done which revealed left lower lobe collapse. IMAGE 2). Fiberoptic bronchoscopy showed Mucous plug obstructing left lower lobe bronchus which relieved by frequent suction.a nodule in the left bronchial tree, at the ridge between left upper lobe bronchus and left lower lobe bronchus. (IMAGE 3) The nodule was about 1 cm diameter, surface was smooth, shiny and vascularized. o Bronchoscopic removal of this nodules with mild bleeding which controlled spontaneously.o Another nodule on right side detected on ridge between right lower lobe bronchus and middle lobe bronchus. (IMAGE 4) Microscopic description:Given microphotographs (IMAGE 5 and IMAGE 6 display histological features of Bronchial schwannoma, comprising of a relatively circumscribed sub bronchial spindle cell neoplasm showing compact hypercellular (Antoni A) and hypocellular (Antoni B) areas. Nuclear palisading around fibrillary process (verocay bodies) is also appreciable.Cytologicaly cells are narrow, elongated and wavy with tapered ends interspersed with collagen fibers. Tumor cells have ill-defined cytoplasm, dense chromatin and mild atypia. No mitotic figures identified.o (IMAGE 7) S100: Immunohistochemical stains show diffuse S100 positivity. Extended panel of immunohistochemical including Cytokeratin, CD117, SMA, CD34 and H-Caldesomon also performed and all turns negative.consultation to thoracic surgery team was done to elect the best way of management as the patient has is not candidate for surgery at time being. DISCUSSION: Despite being a rare neoplasm schwannoma can occur in any area of the tracheobronchial tree(1,2,3,4). Most of symptoms are nonspecific(5) The accurate diagnosis depends upon histopathological criteria including presence of typical Antoni A formation and Verocay bodies in hematoxylin and eosin stains (6) Bronchoscopic treatment has been recently utilized for benign tracheobronchial tumors. It has been shown to be a safe and effective tool.(7,8) CONCLUSIONS: This is a case of endobronchial schwannoma was discovered accidently during FOB for left lower lobe collapse due to mucous plug, diagnosed according to histopathological criteria. REFERENCE #1: Shah H, Garbe L, Nussbaum E, Dumon JF, Chiodera PL, Cavaliere S. Benign tumors of the tracheobronchial tree: endoscopic characteris- tics and role of laser resection. Chest 1995; 107: 1744-51.2. Kasahara K, Fukuoka K, Konishi M, et al. Two cases of endobronchial neurilemmoma and review of the literature in Japan. Intern Med 2003; 42: 1215-8.3. Stack PS, Steckler RM. Tracheal neurilemmoma: case report and re- view of the literature. Head Neck 1990; 12: 436-9.4. Shirakusa T, Takada S, Yamazaki S, et al. Intrabronchial neurilem- moma: review of cases in Japan. Thorac Cardiovasc Surg 1989; 37: 388-90.5. Oxner CR, Shinners MJ, Godin DA, Lyn IT, Brent RB, McFadden PM. Obstructing tracheobronchial schwannoma. J La State Med Soc 2005; 157: 159-61.6.Lee BR, Choi YD, Kim YI, Lim SC, Kwon YS. Endobronchial schwannoma treated by rigid bronchoscopy with argon plasma co- agulation. Tuberc Respir Dis 2012; 73: 174-7. 7. Suzuki H, Sekine Y, Motohashi S, et al. Endobronchial neurogenic tumors treated by transbronchial electrical snaring and Nd-YAG la- ser abrasion: report of three cases. Surg Today 2005; 35: 243-6.8. Kwon YS, Kim H, Koh WJ, et al. Clinical characteristics and efficacy of bronchoscopic intervention for tracheobronchial leiomyoma. Respirology 2008; 13: 908-12. DISCLOSURES: No relevant relationships by Shereef AbdelWahab, source=Web Response No relevant relationships by Usama Abu Elhassan, source=Web Response No relevant relationships by MOHAMED HUSSEIN AHMED, source=Web Response No relevant relationships by MUHAMMAD RIZWAN BASHIR, source=Web Response No relevant relationships by Mohammed Elgazzar, source=Web Response No relevant relationships by Sidra Jahangir, source=Web Response No relevant relationships by Magda Rizk, source=Web Response no disclosure on file for Ayman Shaalan

Predicting Histology of Tracheobronchial Neoplasms: A CT Based Differentiation Model

Background: Tracheobronchial (TB) tumors follow same pathological classification as lung neoplasms; however, some entities are known to favor airways. Distinction of pathological types is necessary for suggesting appropriate management strategy.Purpose: To evaluate utility of multidetector CT (MDCT) in differentiation of primary TB tumors; and assess validity of a scoring system based on imaging biomarkers to differentiate tumor types.Methods: MDCT features of 45 patients were analyzed for location, shape, calcification, attenuation, parenchymal changes, bronchoceles, extraluminal extension, lymphadenopathy, metastases. The two largest groups were compared with each other and remaining entities using Chi square tests. Six-point scoring system combining the differentiating features was devised and receiver operating characteristic curve analysis performed.Results: The most frequent type was neuroendocrine tumors (NET) (51.1%), followed by salivary gland tumors (SGT) (20%); including adenoid cystic carcinoma (ACC) (13.3%) and mucoepidermoid carcinoma (MEC) (6.7%). Comparing NETs with other entities as a whole, and independently with SGTs, significant difference was found among location (p = 0.05 and 0.001 respectively), shape (p < 0.001), calcification (p = 0.038 and 0.041 respectively), attenuation (p = 0.001 and 0.019 respectively), bronchoceles (p = 0.013 and 0.010 respectively). Significant difference was found among ACC and MEC in location (p = 0.01) and morphology (p < 0.001).On receiver operating characteristic (ROC) curve analysis of the score, areas under curve for NET, SGT and ACC were 0.913, 0.872 and 0.962 respectively. Suggested cut-off values were >3.5 for carcinoid (sensitivity 70%, specificity 91%), <2.5 for SGT (sensitivity 78%, specificity 75%), <1.5 for ACC (sensitivity 83%, specificity 92%).Conclusion: Use of a scoring system enables maximum diagnostic accuracy in MDCT differentiation of TB tumors.

Pneumothorax as a Rare Presentation of Bronchial Schwannoma

Tracheobronchial schwannomas are rare diseases. Common signs and symptoms of this tumor include cough, wheezing, and dyspnea. In contrast, pneumothorax is an exceptional presentation. This study reports the first case of bronchial schwannoma presenting with pneumothorax. A 79-year-old woman was diagnosed with pneumothorax by chest radiography. Chest computed tomography unexpectedly revealed a tumor occluding the right main bronchus. Following the pathological diagnosis of bronchial schwannoma, the patient underwent thoracoscopic tumor enucleation. The airway lumens are consequently secured postoperatively. Pneumothorax should be aware of a rare presentation of non-malignant tracheobronchial tumors.

Total Lung-sparing Surgery for Tracheobronchial Low-grade Malignancies

Total lung-sparing tracheobronchial sleeve resections are a step forward in the treatment of low-grade bronchial tumors in which minimal resection margins are required to achieve complete control of the disease. This study retrospectively collected data on patients who underwent total lung-sparing procedures for low-grade tracheobronchial tumors at 2 thoracic surgical centers from January 1984 to October2019. The study included 98 patients, 46 -female (47%) and 52 -male (53%), with a median age of 39 years (range, 7 to 70 years). Thirty-four patients underwent operative endoscopy before surgery (32 had laser treatment, and 2 had endobronchial stenting). The surgical resections were as follows: 9 (9%), tracheal carina; 18 (18%), second carina; 31 (32%), left main bronchi; 25 (26%), right main bronchi; and 15 (15%), intermediate bronchus. The median length of the resected bronchus was 2.2 cm. The median postoperative in-hospital stay was 8 days, and no perioperative mortality was observed. Postoperative complications were recorded in 26-patients (27%). The final histologic classification was as follows: 37 typical carcinoids (38%); 10 atypical carcinoids (10%); 29 adenoid cystic carcinomas (30%); 15 mucoepidermoid carcinomas (15%); 6 inflammatory myofibroblastic tumors (6%); and 1 glomic tumor (1%). Twenty-two patients had positive resection margins and underwent adjuvant radiotherapy. Three patients with adenoid cystic carcinoma had recurrences (1 local and 2 systemic). After a median follow-up time of 54.5 months (range, 4 to 360 months), the overall actuarial 5-year survival was 97%. Total lung-sparing tracheobronchial sleeve resection for low-grade malignant disease requires advanced surgical skills, but the hospital morbidity and mortality are very low. This technique is adequate and safe for highly selected patients with low-grade endobronchial malignant diseases, and its use should be encouraged in experienced centers.

TRACHEAL LIPOMA CAUSING NEAR COMPLETE OBSTRUCTION: A MULTI-MODAL TECHNIQUE FOR MANAGEMENT

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tracheal lipomas are a rare cause of major airway obstruction and account only for 0.1% to 0.5% of all lung tumors (1). Management of these has involved flexible or rigid bronchoscopy guided resection (1,2). Here we report a multi-modal approach to resection of a tracheal lipoma causing 80% obstruction of the distal trachea. CASE PRESENTATION: A 70-year-old male with 40 pack year cigarette smoking history and chronic obstructive pulmonary disease (COPD), had presented with progressively worsening dyspnea and wheezing. He had been using his prescribed budesonide/formoterol inhaler without significant relief. A CT-Chest without contrast showed a lesion in the distal trachea. An endobronchial tumor was suspected and evaluation with rigid bronchoscopy was planned. He was first intubated in an atraumatic fashion with the 12mm rigid bronchoscope. A vascular appearing polypoid tumor was protruding from the posterior membrane of the trachea and obstructed 80% of the lumen. Endobronchial ultrasound (EBUS) was used to examine the tumor further and it appeared solid without significant vascularity within the lesion. Rigid forceps were used for biopsy and the specimen was sent for frozen section analysis. Then electrocautery snare was used to remove the largest component of the tumor. Subsequently, Nd:YAG laser was used while holding ventilation to destroy the base of the tumor and left a crater like appearance. This was done with the intention to facilitate healing of the mucosa. The final pathology was consistent with a benign tracheal lipoma. DISCUSSION: Tracheal lipomas are 1.4–13.0% of benign tumors of the lung (1). Multiple cases in the literature report use of electrocautery or endobronchial lasers (1,2). Our approach involved using EBUS, which allowed us to examine the lesion to assess its margins and vascularity. Hemorrhage could prove to be fatal in a patient with high risk obstructive lesion. This method allowed a safe excision without significant bleeding. Furthermore, use of Nd:YAG laser achieved superior destruction of the tumor base which allowed for better healing of the mucosa. We do recommend using the laser at a low energy setting to avoid rare complications such as fire when used in high fat content lesions. A surveillance bronchoscopy 5 months following the procedure showed a completely healed posterior tracheal membrane with no evidence of recurrence. CONCLUSIONS: Combined use of rigid bronchoscopy, EBUS and Nd:YAG laser as a multi-modal approach to maximize safety while minimizing chances of recurrence should be considered. Reference #1: Stevic R, Milenkovic B. Tracheobronchial tumors. J Thorac Dis. 2016;8(11):3401-3413. doi:10.21037/jtd.2016.11.24 Reference #2: Pollefliet C, Peters K, Janssens A, et al. Endobronchial lipomas: rare benign lung tumors, two case reports. J Thorac Oncol. 2009;4(5):658-660. doi:10.1097/JTO.0b013e31819c9a59 DISCLOSURES: No relevant relationships by Brian Cody Adkinson, source=Web Response No relevant relationships by Sisir Akkineni, source=Web Response No relevant relationships by Sixto Arias, source=Web Response No relevant relationships by Jose Garcia Blanco, source=Web Response

AN OBSTACLE AROUND THE CORNER

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Post obstructive pneumonia (POP) is found in 2-5% of patients with community acquired pneumonia (CAP), characterized by infection distal to a mechanical obstruction of the bronchus. Post obstructive pneumonia is in the differential diagnosis in patients with recurrent infections in the same lung segment(s). Bronchoscopic intervention is usually diagnostic and may also be therapeutic in certain cases. We present a case of post obstructive pneumonia which was later found to be secondary to foreign body aspiration. CASE PRESENTATION: A 60-year old woman was admitted to the hospital for recurrent right lower lobe pneumonia. She endorsed cough with dark green sputum, shortness of breath, drenching night sweats and a 30lb unintentional weight loss in the preceding 6 months. She had a history of recurrent pneumonias for the past eighteen months, with chest imaging that revealed similar right lower lobe infiltration. On physical examination she was afebrile with unremarkable vital signs. Auscultation revealed right lower lobe crackles. Procalcitonin was 0.06 ng/mL and WBC was 10.32. A CT chest demonstrated a right lower lobe infiltrate and possible endobronchial lesion. (Figure 1) Due to concern for endobronchial mass, bronchoscopy was performed which revealed a mobile obstructing mass in the right lower lobe that was retrieved with forceps. There was moderate amount of purulent secretion distal to the obstruction. (Figure 2) Pathology revealed “probable vegetable matter” (Figure 3) and bronchoalveolar lavage (BAL) cultures grew Streptococcus Sanguinis. She was discharged with amoxicillin/clavulanic acid. DISCUSSION: In patients with recurrent pneumonia in the same lung segment, the differential is broad and includes post obstructive pneumonia (POP), ”non-resolving pneumonia” (due to infectious and non-infectious causes) and aspiration. In patients with POP, the most common etiology of obstruction is malignancy, including malignant and benign tracheobronchial tumors. [1,3] The microbiology is diverse and spans gram positive, gram negative and anerobic bacteria thus broad coverage is often initially indicated. [2] Features that distinguish POP from CAP include a lower likelihood of leukocytosis, bandemia, elevated procalcitonin, or fever. With POP there is often >5% weight loss and have increased duration of symptoms. [1] Foreign body aspiration in adults occurs with swallowing disorders of varying etiologies and in states of impaired consciousness. Food causes a more prominent inflammatory reaction (acute and chronic bronchus inflammation in our patient) compared with inorganic objects. CONCLUSIONS: In a patient with recurrent pneumonia in the same lung segment with constitutional symptoms consider post obstructive pneumonia. Workup and treatment includes CT imaging, bronchoscopy and antibiotics. Reference #1: Abers, M.S., et al., Postobstructive Pneumonia: An Underdescribed Syndrome. Clin Infect Dis, 2016. 62(8): p. 957-61. Reference #2: Rolston, K.V.I. and L. Nesher, Post-Obstructive Pneumonia in Patients with Cancer: A Review. Infect Dis Ther, 2018. 7(1): p. 29-38. Reference #3: Stevic R, Milenkovic B. Tracheobronchial tumors. J Thorac Dis. 2016;8(11):3401–3413. DISCLOSURES: No relevant relationships by Giuliana Cerro, source=Web Response No relevant relationships by George Chaux, source=Web Response No relevant relationships by Michael Lewis, source=Web Response No relevant relationships by Jason Wong, source=Web Response

Carinal Resection and Reconstruction for Tracheo-bronchial Neoplasms-Surgical Outcomes of 20 Consecutively Operated Cases.

Carinal resections for trachea-bronchial neoplasms are technically challenging and have high operative morbidity and mortality. This study examines the clinical experience of carinal resections for various tracheo-bronchial tumors in a dedicated thoracic surgery center. Medical records were retrospectively reviewed from March 2012 to December 2019 to identify all patients who underwent carinal resection. An analysis of demographic characteristics, perioperative variables including complications, was carried out. Perioperative outcome was the primary outcome measure. Twenty carinal resections were performed with a median follow-up of 2.4years (range 0.5-4.1). Procedures included 8 isolated carinal resections (40%), 6 right carinal pneumonectomy (30%), 1 left carinal pneumonectomy (5%), and 5 carinal right upper sleeve lobectomy (25%). Age of the patients range from 18 to 62years with 9/11 male-female ratio. Mean duration from symptom onset to diagnosis was 6.1months. All post-operative complications occurred in 7 (35%) patients. Anastomotic complications occurred in 2 (10%) patients. Out of these, 1 patient was initially managed with stent placement, ultimately requiring pneumonectomy. Post-operative events were significantly higher in group of patients who underwent carinal resection with concomitant pulmonary resection (P = 0.01). No perioperative (90-day) mortality was found. Despite advances in perioperative management, carinal resection poses challenges for both patient and surgeon. Concomitant pulmonary resection was associated with increased risk of peri-operative complications. Appropriate patient selection, meticulous surgical technique, and stringent post-operative protocols are the key for success.

Central airway obstruction in a patient of tracheobronchial carcinoma: A case report

Surgery is one of the curative treatments for patients with tracheobronchial tumours. And endoscopic debridement is one of the palliative therapies for unresectable tumour. Respiratory distress is the commonest complication that can occur in both the procedures. We present the case of 25 year old patient of adenoid cystic carcinoma of lower trachea and left bronchus. He had respiratory distress after induction of anaesthesia which was managed successfully with one lung anaesthesia with single lumen endobronchial tube. It was inoperable tumour and after endobronchial debridement he had episode of tumour embolism to oppossite bronchus causing respiratory distress. This was detected immediately and managed successfully with flexible bronchoscopy.

Pediatric airway tumors: A report from the International Network of Pediatric Airway Teams (INPAT).

Primary tracheobronchial tumors (PTTs) are rare heterogeneous lesions arising from any part of the tracheobronchial tree. Nonspecific symptoms may lead to delayed diagnosis that requires more aggressive surgical treatment. An analysis of cases collected by the International Network of Pediatric Airway Team was undertaken to ensure proper insight into the behavior and management of PTTs. Patients <18 years of age with a histological confirmation of PTT diagnosed from 2000 to 2015 were included in this multicenter international retrospective study. Medical records, treatment modalities, and outcomes were analyzed. The patient presentation, tumor management, and clinical course were compared between malignant and benign histotypes. Clinical and surgical variables that might influence event-free survival were considered. Among the 78 children identified, PTTs were more likely to be malignant than benign; bronchial carcinoid tumor (n = 31; 40%) was the most common histological subtype, followed by inflammatory myofibroblastic tumor (n = 19; 25%) and mucoepidermoid carcinoma (n = 15; 19%). Regarding symptoms at presentation, wheezing (P = 0.001) and dyspnea (P = 0.03) were more often associated with benign growth, whereas hemoptysis was more frequently associated with malignancy (P = 0.042). Factors that significantly worsened event-free survival were age at diagnosis earlier than 112 months (P = 0.0035) and duration of symptoms lasting more than 2 months (P = 0.0029). The results of this international study provide important information regarding the clinical presentation, diagnostic workup, and treatment of PTTs in children, casting new light on the biological behavior of PTTs to ensure appropriate treatments. NA Laryngoscope, 130:E243-E251, 2020.

Clinical and Imaging Manifestations of Primary Benign Tracheobronchial Tumors

Objective To improve our knowledge of primary benign tracheobronchial tumors and increase the early diagnosis rate. Method The clinical and imaging features of 22 patients with benign tracheobronchial tumors were retrospectively analyzed. The lesions were surgically or pathologically confirmed as schwannomas(n=2),lipomas(n=3),hamartomas(n=3),leiomyomas(n=9),inflammatory myofibroblastoma(n=1),and pleomorphic adenomas(n=2).The early symptoms were concealed and atypical,accompanied by misdiagnoses at different time points.The tumors were located at trachea in 5 patients and at bronchus in 17 patients.All lesions manifested as intraluminal growth with mild to moderate enhancement,without thickening of the tracheobronchial wall.They had smooth margins and wide basements.The lesions were cast-shaped and occluded the lumen in 3 cases;in the remaining 19 cases,the lesions appeared as round or oval nodules. Conclusions Primary benign tracheobronchial tumors are rare.Patients with repeated cough and expectoration that respond poorly to treatment should be screened for benign tracheobronchial tumors.On CT,the benign tracheobronchial tumors are small intraluminal nodules with the smooth surface and wide basement,without thickening of the wall.

Carinal resection.

Tracheobronchial tumors with involvement of the carina represent a challenging problem in the pulmonary surgery. Carinal resection is referred to removal and reconstruction of the airway itself, whereas concomitant removal of the lung parenchyma (usually a whole lung) is termed as carinal pneumonectomy. Thorough preoperative workup of these patients is mandatory. Meticulous surgical technique and aggressive postoperative management is required for the best outcomes in these difficult cases. In the paper authors review surgical technique, evaluation and management of this challenging patient population.

A Teenager With Chronic Cough and Wheeze

SESSION TITLE: Lung Cancer 2 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Tuesday, October 31, 2017 at 07:30 AM - 08:30 AM INTRODUCTION: Carcinoid is the most common primary lung malignancy in children and diagnosis is often delayed. CASE PRESENTATION: A previously healthy 13 year old female developed a dry cough and hemoptysis which resolved with antibiotics. Her cough quickly returned along with an audible wheeze, dyspnea, orthopnea, and fatigue. Albuterol did not relieve her symptoms. A chest radiograph demonstrated a right middle lobe opacity concerning for atelectasis or pneumonia so she was referred to pediatric pulmonology. The patient presented with monophonic wheeze over her right middle lobe. A CT chest with contrast demonstrated a mass in the right bronchus intermedius (Fig. 1), and bronchoscopy revealed an obstructive mass (figure 2). Following manipulation and biopsy of the mass, the patient developed a hypertensive crisis, and prolonged bleeding at the biopsy site. She was treated for presumed carcinoid crisis. After 36 hours, her blood pressure normalized and she was extubated. Histology revealed spindle cell proliferation with squamous epithelial lining and IHC stain for chromogranin was negative. It was determined that the tissue obtained from the biopsy was a reactive process overlying an unsampled neoplasm. Serum markers for carcinoid were negative. However, because of the mass location/appearance and intraoperative hypertensive crisis/bleeding, carcinoid was highest on the differential. The patient underwent right pneumonectomy with nodal dissection. A lung sparing procedure was unable to be performed due to invasion of the mass outside of the bronchial wall with involvement of major vessels. IHC staining of the mass demonstrated positivity for chromogranin, CD56, and synaptophysin, with no lymph node involvement, confirming primary pulmonary carcinoid. DISCUSSION: Pulmonary carcinoid is a well differentiated malignant tumor, classified by the WHO as a subtype of lung neuroendocrine tumor. Although rare, they are the most common primary pulmonary malignancy in children. Carcinoid crisis results from an abrupt release of neuroendocrine mediators, typically perioperatively, and can result in hypo/hyper tension, flushing, bronchospasm, or complete vasomotor collapse(1). CONCLUSIONS: This case is the first reported carcinoid crisis resulting from manipulation of a primary pulmonary carcinoid in a child. Reference #1: (1) Varela, Patricio et. al. Primary tracheobronchial tumors in children. Sem. Ped. Surg., 2016-06-01, Vol 25;3;p15-155 DISCLOSURE: The following authors have nothing to disclose: Adam Van Mason, Alvin Singh No Product/Research Disclosure Information