PD-1/PD-L1-negative tracheal mucoepidermoid carcinoma: A case report and systematic review of the literature

Background: Tracheal mucoepidermoid carcinoma is a rare form of non-small cell lung carcinoma and is defined as a tumor characterized by a combination of squamous, mucus-secreting, and intermediate cell types. This carcinoma is usually located in the lobar or segmental bronchus. Currently, surgery is the preferred treatment for this disease, which includes pneumonectomy, lobectomy, and sleeve lobectomy. Case presentation: A 50-year-old Chinese male presented with cough, shortness of breath and hemoptysis, and the effect of antibiotic therapy was not good. Subsequently, the airway occupied lesion was found by chest CT, and he was transferred to our hospital for surgical resection. Histologically, the tumor contained squamous epidermal cells, mucoepidermoid cells and intermediate cells. Immunohistochemistrically, the tumor cells were positive for p63, CK5/6, CK7 and Ki67. However, the tumor is generally negative for TTF-1 and neuroendocrine markers. The patient had no recurrence 15 months after the surgery. Conclusions: We report a rare case of mucoepidermoid carcinoma in the distal trachea in which the surgery was difficult and could not be performed like a traditional pulmonary resection. We first provide a comprehensive description of airway management and anesthesia intubation. After surgery, we reviewed the literature and found that PD-1/PD-L1 detection had never been reported in tracheal mucoepidermoid carcinoma. Therefore, we studied the PD-1/PD-L1 pathway in this patient, and the results were negative, which may indicate that potential adjuvant therapy with immune checkpoint inhibitors (ICIs) is not useful in this case.

ENDOSCOPIC MANAGEMENT OF PIN STUCK INTO THE SEGMENTAL BRONCHUS

This case is a challenging case review of a successful removal of sharp and deep located airway foreign body using ventilating bronchoscopy.

Predictors of failure of intersegmental line creation using bronchoscopic jet ventilation for thoracoscopic pulmonary segmentectomy

Background During pulmonary segmentectomy, identification of the target segment is essential. We used bronchoscopic jet ventilation (BJV) to delineate the intersegmental plane by selectively sending air into the target segment. The purpose of this study was to investigate the factors associated with BJV failure. Methods Data were retrospectively collected from 48 patients who underwent pulmonary segmentectomy with BJV between March 2014 and May 2019 at a single center. Data were compared between BJV succeeded cases and failed cases. Results In 13 cases (27%), BJV were unsuccessful. The Brinkman index was significantly higher in failed cases (962 ± 965 failed vs. 395 ± 415 successful, P = 0.0067). The success rate was significantly lower when BJV was applied to the posterior basal segmental bronchus (B10) (B10: 1/5 (20%) vs others: 34/43 (79%), P = 0.015). Conclusion Long-term smoking and the bronchus corresponding to the posterior basal segment might make successful performance of BJV difficult.

Right apical-posterior segmentectomy with abnormal anterior segmental bronchus and artery: a case report

Background Displaced anterior segmental bronchus and pulmonary artery is extremely rare. A keen knowledge of such variations is required in the field of pulmonary segmentectomy, for unawareness of the structural variation could lead to intra- and postoperative complications. Case presentation A 50-year-old female presented to our department with suspected lung adenocarcinoma. Preoperative 3-dimensional computed tomographic bronchography and angiography revealed anterior segmental bronchus and anterior segmental pulmonary artery variation: the anterior segmental bronchus derived from the middle lobe bronchus, accompanied by a distally distributed anterior segmental pulmonary artery branch. A right apical-posterior segmentectomy using inflation-deflation technique was performed successfully. Conclusions The keen observation and proper application of modern imaging technology and operative technique could greatly aid segmentectomy, preventing intra- and postoperative complications from happening.

PD-1/PD-L1-negative tracheal mucoepidermoid carcinoma: A case report and systematic review of the literature

Background: Tracheal mucoepidermoid carcinoma is a rare form of non-small cell lung carcinoma and is defined as a tumor characterized by a combination of squamous, mucus-secreting, and intermediate cell types. This carcinoma is usually located in the lobar or segmental bronchus. Currently, surgery is the preferred treatment for this disease, which includes pneumonectomy, lobectomy, and sleeve lobectomy. Case presentation: A 50-year-old Chinese male presented with cough, shortness of breath and hemoptysis, and the effect of antibiotic therapy was not good. Subsequently, the airway occupied lesion was found by chest CT, and he was transferred to our hospital for surgical resection. Histologically, the tumor contained squamous epidermal cells, mucoepidermoid cells and intermediate cells. Immunohistochemistrically, the tumor cells were positive for p63, CK5/6, CK7 and Ki67. However, the tumor is generally negative for TTF-1 and neuroendocrine markers. The patient had no recurrence 15 months after the surgery.Conclusions: We report a rare case of mucoepidermoid carcinoma in the distal trachea in which the surgery was difficult and could not be performed like a traditional pulmonary resection. We first provide a comprehensive description of airway management and anesthesia intubation. After surgery, we reviewed the literature and found that PD-1/PD-L1 detection had never been reported in tracheal mucoepidermoid carcinoma. Therefore, we studied the PD-1/PD-L1 pathway in this patient, and the results were negative, which may indicate that potential adjuvant therapy with immune checkpoint inhibitors (ICIs) is not useful in this case.

Lung segmentectomy assisted by highly selective independent segmental ventilation: a series of three cases

Background The identification of targeted intersegmental planes and resection with adequate surgical margins are among the crucial steps in anatomical pulmonary segmentectomy, and technical improvements are still needed. Case presentation We reported three cases of intersegmental plane identification using highly selective independent segmental ventilation during segmentectomy. All cases required cooperation with an anesthesiologist who was able to perform segmental ventilation and double confirmation of segmental bronchus branches by the surgeon. The surgical procedure provides a direct visualization of spare segment inflation and saves time in deflation over the conventional residual segment inflation method. Conclusions Highly selective independent segmental ventilation could be considered a suitable option for pulmonary intersegmental plane identification and could be universally used for lung segmentectomy.

Case report of recurring pneumonia due to unusual foreign body aspiration in the airway

Foreign body aspiration is a rare but life-threatening event. Most accidental aspiration events occur in children. In adults, it can represent up to 25% of cases. Bronchoscopy remains the gold standard for diagnosing and treating foreign body aspiration from the lower respiratory tract. A 63-year-old female smoker with a history of chronic alcoholism and exposure to pyrotechnic smoke presented a productive cough, with whitish expectoration, dyspnea and pleuritic chest pain on the right side. On chest X-ray, she presented opacity in 2/3 of the right hemithorax. Computed axial tomography revealed consolidation with an air bronchogram on the right hemithorax, cylindrical bronchiectasis, ground glass pattern and centrilobular nodules. Bronchoscopic examination revealed a foreign body covered with granulation tissue in the right segmental bronchus (B6). The granulation tissue was integrated into the foreign body. In a second attempt, the foreign body could be removed, which was of bone consistency, seemingly a bird bone, confirmed by pathological anatomy results. After further questioning, the patient reported that two years before, she had choked when eating chicken. She had a cough and an episode of hemoptysis, but she chose not to ask for medical advice.

Fluorescence visualization of the intersegmental plane by bronchoscopic instillation of indocyanine green into the targeted segmental bronchus: determination of the optimal settings

Objective To determine the appropriate amount of indocyanine green for bronchial insufflation. Methods We enrolled 20 consecutive patients scheduled for anatomical segmentectomy in the Kochi Medical School Hospital. After inducing general anesthesia, 6 to 60 mL of 200-fold-diluted indocyanine green (0.0125 mg/mL) was insufflated into the subsegmental bronchi in the targeted pulmonary segmental bronchus. The volume of the targeted pulmonary segments was calculated using preoperative computed tomography. Fluorescence spread in the segmental alveoli was visualized using a dedicated near-infrared thoracoscope. Results The targeted segment was uniformly visualized by indocyanine green fluorescence in 16/20 (80.0%) cases after insufflating indocyanine green. A receiver operating characteristic curve indicated that the area under the curve was 0.984; the optimal cut-off volume of diluted indocyanine green for insufflation was 8.91% of the calculated targeted pulmonary segment volume. Conclusions The setting for indocyanine green insufflation was optimized for near-infrared fluorescence image-guided anatomical segmentectomy. By injecting the correct amount of indocyanine green, fluorescence-guided anatomical segmentation may be performed more appropriately.