Video-assisted Thoracoscopic Surgery Lung Biopsy Research Articles

Sequential development of diffuse panbronchiolitis and myasthenia gravis after thymectomy for thymic neoplasm: a case report

BackgroundMyasthenia gravis (MG) is the most common paraneoplastic disorder associated with thymic neoplasms. MG can develop after thymectomy, and this condition is referred to post-thymectomy myasthenia gravis (PTMG). Diffuse panbronchiolitis (DPB), is a rare form of bronchiolitis and is largely restricted to East Asia, has been reported in association with thymic neoplasms. Only three cases of combined MG and DPB have been reported in the literature.Case presentationA 45-year-old Taiwanese woman presented to our hospital with productive cough, rhinorrhea, anosmia, ear fullness, shortness of breath, and weight loss. She had a history of thymoma, and she underwent thymectomy with adjuvant radiotherapy 7 years ago. Chest computed tomography scan revealed diffuse bronchitis and bronchiolitis. DPB was confirmed after video-assisted thoracoscopic surgery lung biopsy, and repeated sputum cultures grew Pseudomonas aeruginosa. She has been on long-term oral azithromycin therapy thereafter. Intravenous antipseudomonal antibiotics, inhaled amikacin, as well as oral levofloxacin were administered. Three months after DPB diagnosis, she developed ptosis, muscle weakness, and hypercapnia requiring the use of noninvasive positive pressure ventilation. MG was diagnosed based on the acetylcholine receptor antibody and repetitive stimulation test results. Her muscle weakness gradually improved after pyridostigmine and corticosteroid therapies. Oral corticosteroids could be tapered off ten months after the diagnosis of MG. She is currently maintained on azithromycin, pyridostigmine, and inhaled amikacin therapies, with intravenous antibiotics administered occasionally during hospitalizations for respiratory infections.ConclusionsTo our knowledge, this might be the first case report of sequential development of DPB followed by PTMG. The coexistence of these two disorders poses a therapeutic challenge for balancing infection control for DPB and immunosuppressant therapies for MG.

Impact of intubated vs. non-intubated anesthesia on postoperative diaphragmatic function: Results from a prospective observational study.

Background: An altered diaphragmatic function was associated with the development of postoperative pulmonary complications following thoracic surgery. Methods: To evaluate the impact of different anesthetic techniques on postoperative diaphragmatic dysfunction, patients undergoing video-assisted thoracoscopic surgery (VATS) lung biopsy for interstitial lung disease were enrolled in a monocentric observational prospective study. Patients received intubated or non-intubated anesthesia according to risk assessment and preferences following multidisciplinary discussion. Ultrasound measured diaphragmatic excursion (DIA) and Thickening Fraction (TF) were recorded together with arterial blood gases and pulmonary function tests (PFT) immediately before and 12 h after surgery. Pain control and postoperative nausea and vomiting (PONV) were also evaluated. Results: From February 2019 to September 2020, 41 consecutive patients were enrolled. Five were lost due to difficulties in collecting postoperative data. Of the remaining 36 patients, 25 underwent surgery with a non-intubated anesthesia approach whereas 11 underwent intubated general anesthesia. The two groups had similar baseline characteristics. On the operated side, DIA and TF showed a lower residual postoperative function in the intubated group compared to the non-intubated group (54 vs. 82% of DIA and 36 vs. 97% of TF; p = 0.001 for both). The same was observed on the non-operated side (58 vs. 82% and 62 vs. 94%; p = 0.005 and p = 0.045, respectively, for DIA and TF). No differences were observed between groups in terms of pain control, PONV, gas exchange and PFT. Conclusion: This study suggests that maintenance of spontaneous breathing during VATS lung biopsy is associated with better diaphragmatic residual function after surgery.

Lymphangioleiomyomatosis associated with prolactinoma: A case report and literature review

The thirty-five-year-old woman had been experiencing dyspnea on exertion since her second child's birth five years before presenting to hospital A, where she was diagnosed with lymphangioleiomyomatosis (LAM) based on video-assisted thoracoscopic surgery lung biopsy and referred to our hospital. She was treated with sirolimus for one year. Although her subjective symptom of dyspnea improved, she found that her amenorrhea had persisted for six years. A blood test revealed high prolactin (PRL) levels of 98 ng/mL and head magnetic resonance imaging revealed a pituitary adenoma, which was complicated by a prolactinoma. We continued with follow-up observation without any pharmacotherapy for the prolactinoma. However, she was administered oral cabergoline (0.25 mg per week) when her PRL levels were elevated to 250 ng/mL 38 months after therapeutic intervention with sirolimus. For the next 14 months, her respiratory function and PRL concentration both demonstrated improvement and her condition did not worsen any further. It has been reported that prolactin may exacerbate LAM. Our case suggests that a clinical reduction in PRL levels may also improve LAM.

AN ATYPICAL PRESENTATION OF CYTOMEGALOVIRUS PNEUMONIA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cytomegalovirus (CMV) is a viral pathogen that is seen in 40-100% of adults by the fourth decade (1). Infection in an immunocompetent individual is usually subclinical, with severe life-threatening infection seen in immunocomprised individuals. Steroid use has a weak association for infection reactivation in an immunocompetent host. We present the case of a chronic kidney disease (CKD) patient on steroids who was diagnosed and treated for CMV interstitial pneumonia. CASE PRESENTATION: 78-year-old female with a past medical history of interstitial lung disease, idiopathic thrombocytopenia purpura on steroids, CKD stage III who presented from a nursing facility where she was recuperating from a recent hospitalization due to pneumonia. During her prior admission, she was treated with steroids, vancomycin and cefepime for a presumed bacterial pneumonia. Patient presented with shortness of breath. Vital signs were notable for a temperature of 98.4 F, heart rate 102 bmp, RR 24/min, and SaO2 90% on 7L NC. Physical exam revealed bibasilar rales. Labs showed a white blood cell count of 10.1 Thou/uL, creatinine of 1.5 mg/dL, lactic acid 2.8 mmol/L, procalcitonin of 0.12 ng/mL, lactate dehydrogenase (LDH) of 544 U/L. Computed tomography (CT) of the chest showed increasing ground glass changes compared to previous admission imaging. Patient was started on steriods, vancomycin and cefepime. Given worsening radiographical findings, history of ILD, and elevated LDH in the setting of chronic steroids, there was a suspicion for pneumocystis pneumonia. She underwent a video-assisted thoracoscopic surgery lung biopsy, bronchoalveolar lavage and wedge resection of the right lung. Pathology showed microscopic honey combing and extensive subpleural fibrosis, consistent with interstitial pneumonia. CMV cytopathic effect was confirmed with immunoperoxidase staining. PCR testing and tissue culture also returned positive for CMV; viral load was 81,581 IU/mL. Patient was started on a six-week course of valganciclovir with a plan to taper steroids as an outpatient. Patient was unfortunately lost to follow up thereafter. DISCUSSION: Severe life threatening CMV infection is seen in immunocomprised risk groups particularly transplant recipients, patients affected with AIDS, malignancy and neonates. Steroid use has a weak association with CMV reactivation; CKD also has been postulated as a risk factor for reactivation due to malfunctioning white cells. CONCLUSIONS: Although CMV pneumonia targets a subtype of immunosuppressed patients, it should be considered a differential in patient’s on chronic steroid treatment and CKD. This case emphasizes the importance of having a high degree of suspicion of CMV pneumonia in a patient on chronic high dose steroids, in clinical setting, such as this one. Without the correct diagnosis, obtained by PCR of a BAL sample, treatment opportunities will be missed, leading to poor outcomes. Reference #1: Grilli, Elisabetta, et al. “Cytomegalovirus Pneumonia in Immunocompetent Host: Case Report and Literature Review.” Journal of Clinical Virology : the Official Publication of the Pan American Society for Clinical Virology, U.S. National Library of Medicine, Dec. 2012. Reference #2: Al-Omari, A., Aljamaan, F., Alhazzani, W., Salih, S., & Arabi, Y. (2016). Cytomegalovirus infection in immunocompetent critically ill adults: literature review. Annals of intensive care, 6(1), 110 Reference #3: Carpani, G., Foresti, S., Dell'Oro, R., Grassi, G., & Bombelli, M. (2019). Severe systemic cytomegalovirus infection in an immunocompetent patient outside the intensive care unit: a case report. BMC infectious diseases, 19(1), 34. https://doi.org/10.1186/s12879-018-3621-8 DISCLOSURES: No relevant relationships by Antonie Auguste, source=Web Response No relevant relationships by Amreet Aujla, source=Web Response No relevant relationships by Sarah Banks, source=Web Response No relevant relationships by Manmeet Grewal, source=Web Response No relevant relationships by Ann Palmer, source=Web Response

Novel Lung Biopsy Surgical Technique for Definitive Diagnosis of Pulmonary Capillary Hemangiomatosis

The 2015 European Society of Cardiology/European Respiratory Society Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension state that lung biopsy is still the gold standard for confirming pulmonary capillary hemangiomatosis; however, the surgical lung biopsy is no longer recommended in most cases for its inherent risks. Nonintubated and uniportal video-assisted thoracoscopic surgery are the new developments in video-assisted thoracoscopic surgery technology. We combined these 2 technologies to create a novel approach for pulmonary capillary hemangiomatosis lung biopsy. A incision is made in chest wall. Sponge forceps are used to pull the lung out of the pleural space, and to resect target lung tissue. The incised margin is sutured with 3-0 Prolene (Ethicon, Somerville, NJ), and a negative pressure suction tube is used to fully expand the lung. Three patients were definitively diagnosed with pulmonary capillary hemangiomatosis by this technology. One patient developed a postoperative fever, with no other complications. The tubeless and uniportal video-assisted thoracoscopic surgery lung biopsy is a safe, effective, and feasible technology for definitively diagnosing patients with pulmonary capillary hemangiomatosis.

Histologic Findings of Severe/Therapy-Resistant Asthma From Video-assisted Thoracoscopic Surgery Biopsies.

The histologic changes occurring in severe/therapy-resistant asthma (SA) as defined by the European Respiratory Society/American Thoracic Society guidelines, particularly at the level of the distal airways are unknown. This study describes the clinical, radiologic, and histologic characteristics of 29 SA patients who underwent video-assisted thoracoscopic surgery lung biopsy. Pathologic observations were correlated with clinical features, especially the presence of autoimmune disease (AID) (15/29, 51.7%). Ten biopsies (10/29, 34.5%) showed only small airway manifestations of asthma, whereas in 19 (65.5%) asthmatic granulomatosis, manifested by asthmatic bronchiolitis supplemented by an alveolar septal mononuclear infiltrates with non-necrotizing granulomas, was present. SA patients without asthmatic granulomatosis showed more striking small airway injury, subbasement membrane thickening, and neutrophilic infiltrates. Cases with concurrent AID had a tendency to more parenchymal eosinophilic inflammation, more bronchiolocentric granulomas, and a suggestion of increased responsivity to nonsteroidal immunosuppressive therapy. Histologic examination of video-assisted thoracoscopic surgery lung biopsies in SA demonstrates diverse pathologies including cases associated with granulomatous inflammation in addition to eosinophilic infiltrates. This spectrum of histologies may link to a high incidence of AID.

Intraoperative chest tube removal following thoracoscopic lung biopsy results in improved outcomes

BackgroundTraditionally, chest tubes are left following video assisted thoracoscopic surgery (VATS) to treat a potential air leak or significant drainage. Recognizing the potential complications, our aim was to determine if intraoperative chest tube removal in children undergoing VATS lung biopsy is safe and if outcomes differ from when a chest tube is left in place. MethodsWe identified all children who underwent VATS lung biopsies from 2009 to 2013 and performed a retrospective review of the medical records. Pulmonary resection patients were excluded as were those with an air leak present in the operating room. ResultsA total of 90 VATS lung biopsies were performed. 41 children had a postoperative chest tube left in place (Group A), and 49 children had it removed intraoperatively (Group B). Mean age was 9±6.4 years. One child in Group A and 2 children in Group B required replacement of a chest tube (p=NS). Group B patients had a lower postoperative pain score on day one, fewer postoperative chest X-rays, and a shorter length of postoperative stay. ConclusionsThese data suggest that intraoperative chest tube removal is safe and may be associated with improved outcomes following lung biopsy in children.

The efficacy of video-assisted thoracoscopic surgery lung biopsies in patients with interstitial lung disease: a retrospective study of 66 patients

BackgroundDiagnosing a specific type of Interstitial Lung Disease (ILD) is a challenging process and often necessitates that a Video-assisted Thoracoscopic Surgery (VATS) Lung Biopsy be performed. By analysing the proportion of patients who have their treatment changed after undergoing a VATS lung biopsy, this study aimed to determine the utility of performing this procedure in patients with ILD.MethodsThe clinical data from sixty-six patients with suspected ILD, who underwent VATS lung biopsies at the New Royal Infirmary of Edinburgh (NRIE) in the period of 16th May 2011 – 11th February 2013, were analysed retrospectively. The main outcome measures considered in this study were: CT scan differential diagnoses, VATS lung biopsy histological differential diagnoses, post-VATS lung biopsy consensus diagnoses, 30-day mortality, surgical complications (minor and major), resultant changes in treatment and responses to these changes in treatment.ResultsFollowing VATS biopsy a definite pathological diagnosis was made in 74.2% of cases. A change in treatment was initiated in 47.2% of patients, including in 80% of patients diagnosed with Hypersensitivity Pneumonitis and 60% of patients diagnosed with sarcoidosis. A positive response to treatment was experienced in 58% of patients whom underwent a change in treatment. Only 54% of patients who received a consensus diagnosis of UIP after VATS lung biopsy, had been given a differential diagnosis of “probable UIP” at CT scan. 15% of patients who received a differential diagnosis of “probable UIP” at CT scan, had their diagnosis changed to Hypersensitivity Pneumonitis after lung biopsy. There was one mortality (1.5%) in this series of patients and no other major complications. Minor complications to surgery were experienced in 28.8% of patients.ConclusionsThis study highlights the effectiveness of performing VATS lung biopsies in patients with suspected ILD. The procedure leads to a change in treatment in almost half of all patients, including in the vast majority of cases of Hypersensitivity Pneumonitis. It also prevents what would be the inappropriate over-treatment of UIP. It has been shown to be a relatively safe procedure and thus, should be performed in all patients with suspected ILD, indeterminate in type from prior CT imaging.

Case of polycythemia vera with unusual organizing pneumonia mimicking the clinical features of military tuberculosis and possibly caused by the involvement of neoplastic megakaryocytes

Polycythemia vera (PV) is a clonal myeloproliferative neoplasm (MPN) of hematopoietic stem cells. Although the management of MPN patients generally focuses on the prevention of thromboembolic events caused by hypercoagulability, it is true that the patients with hematological malignancy often suffer from pulmonary diseases with atypical radiological patterns. We present here a 56-year-old woman with PV harboring a JAK2(V617F) mutation that had a diffuse reticulonodular pattern on chest radiography and was initially suspected of having military tuberculosis. Pathological assessment of a video-assisted thoracoscopic surgery lung biopsy revealed that the lesions were in fact organizing pneumonia (OP). Interestingly, pulmonary extramedullary hematopoiesis with a diffuse plugging of the alveolar blood capillaries by numerous atypical megakaryocytes was also observed around the granulation components. The histological findings of our case of unusual OP suggest that local activated neoplastic megakaryocytes and platelets played an important role in the development of spreading fibrotic lesions. JAK2 mutation or the preleukemic phase of MPN may accelerate the activation of megakaryocytes and result in the proliferative process of fibrosis.

Do patients undergoing lung biopsy need a postoperative chest drain at all?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether insertion of an intercostal chest drain prolongs the length of stay of patients undergoing lung biopsy. Altogether 210 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that where an intraoperative check reveals no air leak, chest drain should be avoided if possible in order to discharge patients earlier. Where chest drain is used following video-assisted thoracoscopic surgery lung biopsy, early removal results in reduced pain and earlier discharge. Four studies advocate early chest tube removal, allowing discharge of 95% within 24 h in one study, reduced hospital stay from 3.9+/-2.1 days to 2+/-1 days (P=0.001) in another, and a median stay of 1.2 days (range 0-7 days) in a third. Removal of chest drain within 1 h of the operation was possible in 92% of patients (one study), significantly reducing pain (P=0.03, P=0.005; two studies) and postoperative complications (P=0.01; one study) compared with conventional treatment. Five studies in which patients were managed without chest drain following intraoperative air leak checks, reduced hospital stay vs. conventional management (two studies; 2 vs. 3, P<0.001, 1 vs. 3, P<0.01) but results in no difference in complication rates (three studies: pneumothoraces requiring chest drain; 2 vs. 2, P=non-significant; 0 vs. 0; 0 vs. 0) or pain score (two studies; 0.77 vs. 0.76, P=0.894; 5 vs. 5, P=0.81).

The Inadvisability of Thoracoscopic Lung Biopsy on Patients With Pulmonary Hypertension

The use of video-assisted thoracoscopic surgery (VATS) sometimes leads to additional and unnecessary risks compared with thoracotomy. We report a troubling case of VATS lung biopsy in a 43-year-old woman with mild pulmonary hypertension. A progressive elevation of pulmonary artery pressure (PAP) was noted after the commencement of right unilateral ventilation. When the systolic PAP reached 90 mm Hg (390 min after induction of anesthesia), a massive blood discharge through the chest drain occurred. At repeat thoracotomy, continuous blood spouting was seen from > 10 of the surgical sites. It was supposed that the endoscopic staplers were unable to maintain hemostasis with such a high PAP.

Thoracoscopic Surgery: Indications and Outcome

Video-assisted thoracoscopic surgery (VATS) has become an established technique in both diagnostic and therapeutic thoracic surgery procedures. In an attempt to evaluate the current indications and outcome of this technique, 143 VATS procedures, which were performed over a three-year period, were retrospectively evaluated. Indications included lung biopsy in 46, recurrent or persistent pneumothorax in 42, and pleural disease in 16 patients. Other indications included sympathectomy in eight, mediastinal mass in three, pericardial window in three, metastasectomy in three, and staging of lung cancer in two patients. There was one postoperative death (0.7%), a patient with massive pleural effusion and end-stage renal and hepatic failure. Conversion to formal thoracotomy was necessary in six patients (4.2%), and was the result of adhesions in four, bleeding in one, and failure to identify the lesion in one patient. Diagnostic procedures were considered successful in 44 out of 46 lung biopsies (95.7%), 15 out of 16 pleural disease cases (93.8%), and two lung cancer staging cases. The other 79 therapeutic VATS procedures were all effective, both in the long and short term, apart from two cases of prolonged air leak after VATS for pneumothorax, one of which was considered a failure (2.4%). VATS should be available in each thoracic surgery unit. It is both safe and effective in a variety of diagnostic and therapeutic procedures.