Multiple cerebral infarctions associated with lung cancer-induced hypereosinophilia: a case report

Background Hypereosinophilia (HE) is caused by various conditions, including solid and hematologic tumors. Nonetheless, there exist no reports on cerebral infarctions caused by HE associated with lung cancer metastasis to the bone marrow. Case presentation We report a case of a 67-year-old man with multiple cerebral infarctions associated with HE. His white blood cell and eosinophil counts were 38,900/μL and 13,600/μL, respectively, at 4 weeks before admission. During treatment for HE, he presented with dysarthria and walking difficulties. Magnetic resonance imaging of the brain showed multiple small infarcts in regions such as the bilateral cortex, watershed area, and cerebellum. Chest computed tomography showed small nodes in the lung and enlargement of the left hilar lymph nodes. Bronchoscopic biopsy did not reveal a tumor; however, bone marrow biopsy showed infiltration of tumor cells. We considered a diagnosis of lung cancer metastasizing to the bone marrow, which induced HE and later caused cerebral infarctions. Conclusions This case report demonstrates that metastatic cancer in the bone marrow can induce HE, which can consequently cause multiple cerebral infarctions. Clinicians should consider HE as a cause of multiple cerebral infarctions in patients with cancer.

EP.TU.182Surgical Serendipity: The Accident that Exposed an Autoimmune disease

Objectives IgG4 related disease is an autoimmune condition that often leads to diagnostic challenges which can often delay timely treatment. It rarely presents with pulmonary findings which can radiologically mimic cancer. We describe a unique case of an incidentally diagnosed IgG4- related lung disease (IgG4-RLD). Case description A 32-year-old healthy female suffered a car accident and had a CT Trauma. This revealed an indeterminate soft tissue lesion in the middle lobe of the right lung with an endobronchial component of uncertain histology which had central extension into the right inferior hilum. She had a bronchoscopic biopsy revealing that the mass was an Inflammatory Myofibroblastic Tumour (IMT). Due to the close relationship of this tumour with the root of her right lung, she was planned for a right pneumonectomy. However, it was agreed for that she underwent another bronchoscopy with biopsy to obtain more histology before proceeding with a pneumonectomy for the uncertainty about the diagnosis of an IMT and due to the absence of distinct clinical features from this mass. This revealed that the mass was highly suggestive of IgG4-RLD. Her blood tests revealed high serum IgG4 levels which confirmed the diagnosis of IgG4-RLD. Conclusion IgG4-RLD is a rare condition which can seldom be diagnosed incidentally. Patients with biopsies suggestive of IMT should undergo a repeat biopsy before proceeding to surgical resection of the tumour. Alternatively, a serum IgG4 level can also be deemed a useful tool for screening such patients.

Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy

Partnership between anesthesia providers and proceduralists is essential to ensure patient safety and optimize outcomes. A renewed importance of this axiom has emerged in advanced bronchoscopy and interventional pulmonology. While anesthesia-induced atelectasis is common, it is not typically clinically significant. Advanced guided bronchoscopic biopsy is an exception in which anesthesia protocols substantially impact outcomes. Procedure success depends on careful ventilation to avoid excessive motion, reduce distortion causing computed tomography (CT)-to-body-divergence, stabilize dependent areas, and optimize breath-hold maneuvers to prevent atelectasis. Herein are anesthesia recommendations during guided bronchoscopy. An FiO2 of 0.6 to 0.8 is recommended for pre-oxygenation, maintained at the lowest tolerable level for the entire the procedure. Expeditious intubation (not rapid-sequence) with a larger endotracheal tube and non-depolarizing muscle relaxants are preferred. Positive end-expiratory pressure (PEEP) of up to 10–12 cm H2O and increased tidal volumes help to maintain optimal lung inflation, if tolerated by the patient as determined during recruitment. A breath-hold is required to reduce motion artifact during intraprocedural imaging (e.g., cone-beam CT, digital tomosynthesis), timed at the end of a normal tidal breath (peak inspiration) and held until pressures equilibrate and the imaging cycle is complete. Use of the adjustable pressure-limiting valve is critical to maintain the desired PEEP and reduce movement during breath-hold maneuvers. These measures will reduce atelectasis and CT-to-body divergence, minimize motion artifact, and provide clearer, more accurate images during guided bronchoscopy. Following these recommendations will facilitate a successful lung biopsy, potentially accelerating the time to treatment by avoiding additional biopsies. Application of these methods should be at the discretion of the anesthesiologist and the proceduralist; best medical judgement should be used in all cases to ensure the safety of the patient.

A Pulmonary Pleomorphic Carcinoma Patient with Exudative Retinal Detachment Secondary to Choroid Metastasis as Initial Presentation—A Case Report

Choroid metastasis is the initial presentation of pleomorphic carcinoma (PC) of the lung. PC is classified as poorly differentiated non-small cell lung carcinoma. It has a tendency to metastasize early and has a poor response to chemotherapy, which often results in poor prognosis. We report the case of a 63-year-old woman with a one-month history of deteriorating vision in the left eye. Fundus examination, fluorescein angiography, indocyanine green angiography, and B-scan sonography demonstrated choroidal metastasis of the left eye. Positron emission tomography/computed tomography (PET/CT) revealed a tumor with increased uptake in the left upper lung. Subsequent bronchoscopic biopsy confirmed a pleomorphic carcinoma of the lungs. Choroid metastasis as an initial presentation of PC in the lung is rare. Usually, it represents the late course of disseminated disease with hematogenous spread. Prompt diagnosis is imperative for patients to immediately initiate treatment.

Crazy‐paving patterns as rare radiological manifestations of pulmonary cryptococcosis: a case report

Background Crazy-paving patterns are rarely reported as radiological manifestations of pulmonary cryptococcosis. Case presentation Herein, we presented a very rare case of a crazy-paving pattern as a radiological manifestation of pulmonary cryptococcosis in a patient with primary ciliary dyskinesia. The diagnosis of pulmonary cryptococcosis and primary ciliary dyskinesia was ultimately confirmed by bronchoscopic biopsy, fungus culture, whole exome sequencing of blood, etc. The patient received flucytosine (PO, 5 g per day) and amphotericin B (IV, 70 mg per day) during hospitalization and sequential therapy with voriconazole (PO, 200 mg twice a day) after discharge. He recovered during follow-up. Conclusions We concluded that pulmonary cryptococcosis should be considered a possible cause of crazy-paving patterns in chest CT scans.

DNA methylation profiles of bronchoscopic biopsies for the diagnosis of lung cancer

Background Lung cancer is the leading cause of cancer-related death in most western countries in both, males and females, accounting for roughly 20–25% of all cancer deaths. For choosing the most appropriate therapy regimen a definite diagnosis is a prerequisite. However, histological characterization of bronchoscopic biopsies particularly with low tumor cell content is often challenging. Therefore, this study aims at (a) determining the value of DNA methylation analysis applied to specimens obtained by bronchoscopic biopsy for the diagnosis of lung cancer and (b) at comparing aberrantly CpG loci identified in bronchoscopic biopsy with those identified by analyzing surgical specimens. Results We report the HumanMethylation450-based DNA methylation analysis of paired samples of bronchoscopic biopsy specimens either from the tumor side or from the contralateral tumor-free bronchus in 37 patients with definite lung cancer diagnosis and 18 patients with suspicious diagnosis. A differential DNA methylation analysis between both biopsy sites of patients with definite diagnosis identified 1303 loci. Even those samples were separated by the set of 1303 loci in which histopathological analysis could not unambiguously define the dignity. Further differential DNA methylation analyses distinguished between SCLC and NSCLC. We validated our results in an independent cohort of 40 primary lung cancers obtained by open surgical resection and their corresponding controls from the same patient as well as in publically available DNA methylation data from a TCGA cohort which could also be classified with high accuracy. Conclusions Considering that the prognosis correlates with tumor stage at time of diagnosis, early detection of lung cancer is vital and DNA methylation analysis might add valuable information to reliably characterize lung cancer even in histologically ambiguous sample material.

High Accuracy of Digital Tomosynthesis-Guided Bronchoscopic Biopsy Confirmed by Intraprocedural Computed Tomography

<b><i>Background:</i></b> Digital fluoroscopic tomosynthesis-guided electromagnetic navigational bronchoscopy (F-ENB) is a novel adjunct to ENB associated with higher diagnostic yield. The likelihood of F-ENB allowing accurate placement of a biopsy needle within a target remains unclear. <b><i>Objective:</i></b> This study intends to determine the accuracy of F-ENB as confirmed by cone-beam computed tomography (CBCT) scan. <b><i>Methods:</i></b> Patients undergoing CBCT-assisted ENB for lung nodule biopsy were prospectively enrolled. ENB was performed followed by digital tomosynthesis correction. Once optimal F-ENB alignment was achieved, and a needle was advanced into the expected location of the nodule followed by CBCT. The primary outcome was the percentage of “needle-in-lesion” hits, defined as needle tip within the nodule in 3 planes. Secondary outcomes were diagnostic yield, procedure and room time, complications, radiation, and distance between the needle tip and nodule. <b><i>Results:</i></b> Twenty-six patients with a total of 29 nodules were enrolled. Mean nodule size was 13 mm (±4 mm) in maximal axial dimension, 83% (<i>n</i> = 24) were located in the peripheral third of the chest, and 17% (<i>n</i> = 5) had a bronchus sign. F-ENB guidance resulted in needle-in-lesion in 21 of 29 nodules (72%). Mean needle tip-to-nodule distance for nonhits was 1.75 mm (±1.35 mm). There were no complications. <b><i>Conclusion:</i></b> F-ENB resulted in a needle-in-lesion biopsy in greater than 70% of nodules despite features traditionally associated with poor diagnostic yield (size, absence of bronchus sign). Mean distance between needle tip and target for nonhits was less than 2 mm. These data suggest F-ENB alignment is accurate for small peripheral nodules.

Bilateral Pulmonary Nodules after Surgery for Ameloblastoma: A Case of Misdiagnosis for 32 Years

Background: We describe a rare case of metastatic ameloblastoma in a 68-year-old Chinese woman diagnosed with ameloblastoma of the right mandible in 1974. Case presentation: Despite radical resection, she experienced repeated local recurrences, including asymptomatic bilateral pulmonary nodules, cough, and hemoptysis diagnosed as non-malignant inflammatory cell infiltration. The patient developed an aggravated cough, palpitations, and dyspnea and was admitted to our respiratory department in September 2018. Chest computed tomography revealed multiple bilateral lung nodules, masses, and soft tissue opacities. She was diagnosed with advanced metastatic ameloblastoma in bilateral lungs via bronchoscopic biopsy, with a misdiagnosis time of 32 years. Because her systemic condition was poor, systemic chemotherapy and radiotherapy were not recommended. Dyspnea significantly improved after interventional bronchoscopic therapy and tumor electroexcision; she died of respiratory failure 1 year after diagnosis. Conclusions: Clinicians should carefully explore the medical histories of patients with surgical histories of ameloblastoma and subsequent unexplained pulmonary metastatic tumors to avoid misdiagnosis.

Adenomatous hyperplastic intratracheal ectopic thyroid tissue: a case report

Intratracheal ectopic thyroid (ITET) is a rare disease, with limited cases reported in the literature. ITET is an unusual congenital abnormality and can be easily mistaken for a respiratory illness. We present a case of a 61-year-old man with a history of slight discontinuous hemoptysis for 2 years. A tracheal mass, which appeared to be connected to the left thyroid gland, was found by chest computed tomography scan. Ultrasound revealed one suspiciously malignant, solid and hypoechoic nodule in the left thyroid gland. After the thyroid origin of the mass was confirmed by bronchoscopic biopsy, the patient underwent segmental resection and anastomosis of the trachea, together with left thyroidectomy. Histopathology of the tracheal tumor showed adenomatous hyperplastic ITET, and the orthotopic left thyroid gland showed nodular goiter with atypical adenomatous hyperplasia. Clinical suspicion is warranted in patients presenting with a tracheal tumor seemingly connected to the thyroid gland, particularly in patients who have imaging features suggestive of a malignant tumor in the orthotopic thyroid but without confirmative histopathology of malignancy before surgery.

Diagnostic Utility of Bronchoalveolar Lavage and Bronchial Brush Cytology in Lung Lesions

Background: In 1960’s, flexible fiberoptic bronchoscope, was first used to give a better yield to diagnose pulmonary diseases. Bronchial brushing cytology (BBC) and Broncho-alveolar lavage (BAL) are two important adjuncts done along with bronchoscopic biopsy. Bronchial brushings yield better diagnostic material than simple exfoliative cytology. Therefore, both techniques are of much diagnostic value and is widely accepted as it is safe, economical and evaluation requires much less time. Methods: All the bronchial brush and bronchoalveolar lavage smears obtained from January 2018 to December 2018 were assessed. Correlation was done with histopathology wherever was available. Result: BBC showed a sensitivity and specificity of 59.28% and 100%. The positive predictive value and negative predictive value were 100% and 47.62%. BAL showed a sensitivity and specificity of 51% and 100%. The positive predictive value and negative predictive value was 100% and 43.18%. The diagnostic accuracy of BBC and BAL were 70.27% and 64.86%. Conclusion: Universally bronchial washings and bronchial brushings should be considered important adjunct to bronchoscopic biopsies to diagnose pulmonary lesions as both are safe, economical and can will give better diagnostic yield if incorporated together.