Introduction:
Dyspnea due to tracheal invasion by malignant tumors is a common oncological emergency that is difficult to manage, and a common cause of death among patients with advanced cancer. Bronchoscopy-guided intervention therapy under conventional ventilation is very risky for patients with severe central airway stenosis. Extracorporeal membrane oxygenation (ECMO) provides strong cardiopulmonary support, but is rarely used in bronchoscopy-guided interventional therapy.
Patient concerns:
The patient had advanced esophageal cancer with metastases to the trachea and left and right main bronchi. Despite several sessions of radiotherapy, chemotherapy, and bronchoscopy-guided intervention therapy, the tumor in the airway became enlarged, the lumen was severely narrow, and the patient experienced respiratory distress.
Diagnosis:
A thoracic computed tomography scan performed at our hospital revealed invasion of the trachea and opening of the left and right main bronchi by the esophageal cancer, blockage of the stent by the tumor, and severe luminal narrowing. An emergency bronchoscopy showed slit-like stenosis of the middle and lower part of the trachea and the left and right main bronchi, and the tumor was highly vascular.
Interventions:
To reduce the risk of major airway bleeding and asphyxia during bronchoscopy under conventional ventilation, we finally performed argon plasma coagulation with a high frequency electric knife and cryotherapy with ECMO support.
Outcomes:
We successfully cleared the tumor tissue in the airway under ECMO support. The trachea and left and right main bronchi recovered smoothly, and the patient was soon discharged.
Conclusion:
ECMO can meet the oxygenation needs during bronchoscopy-guided intervention therapy. For patients with severe central airway obstruction due to malignant tumors, ECMO should be considered if conventional respiratory support cannot guarantee the safety of surgery.
Rationale:
Dieulafoy's lesions are characterized by the presence of a dysplastic artery in the submucosa, most frequently associated with gastrointestinal hemorrhage. They are rarely identified in the bronchial submucosa and can cause massive or fatal hemoptysis
Patient concerns:
The patient was a 62-year-old male farmer with intermittent hemoptysis of approximately 2 years duration and a definite diagnosis could not be established.
Diagnosis:
A thorax-computed tomography at our hospital revealed that the bronchus of left lower lobe was narrowed with associated local atelectasis, and lung cancer was suspected. A bronchoscopy showed a slit-like stenosis of the left lower lobe, swollen and smooth mucosa, and a significantly wider subsection carina.
Interventions:
A fatal hemorrhage occurred during biopsy and, rescue and resuscitation measures were immediately taken. A double-lumen endotracheal intubation was implanted and single-lung ventilation was started to maintain oxygenation. Hemoptysis completely stopped after bronchial artery embolization.
Outcomes:
The patient eventually died of disseminative intravascular coagulation and multiple organ failure. Bronchial arteriography and subsequent autopsy confirmed Dieulafoy's disease of the bronchus.
Lessons:
In cases with recurrent unexplained hemoptysis, where CT chest or thoracic radiography show no abnormalities, pulmonologist should suspect a bronchial Dieulafoy's disease and avoid blindly performing bronchoscopy guided biopsy, which may result in fatal hemoptysis.
Pulmonary papillary adenoma is extremely rare. The limited number of published articles describing pulmonary papillary adenoma emphasize that it is always detected by physical examination, is difficult to diagnose, and has malignant potential. To further expand our understanding of this disease, we report on 15 cases of pulmonary papillary adenoma diagnosed from 2013 to 2019 in our hospital.
The clinical and pathological data of 15 cases of pulmonary papillary adenoma were collected from the medical record system of our hospital. All the clinical data were checked by 2 independent researchers. All pathology outcomes were independently reassessed by 2 pathologists. A review of the relevant literature was performed.
Of 15 patients identified, 6 were men and 9 were women, and the average age at disease onset was 61.3 years. Chest computed tomography (CT) indicated pneumonia, an isolated nodule, bronchiectasis, a mass, ground glass opacity, and local interstitial fibrosis under the pleura. Thirteen cases had benign histopathology upon microscopy and immunohistochemistry examination: a papillary morphology, grade 2 or 3 papillary branches, and a slender nipple axis composed of fibers and vessels. More than 80% of the papillary epithelial cells were columnar or cubic, and single-layered or pseudostratified, with a round nucleus at the bottom of the cell. The cytoplasm was rich in mucus and neutral mucopolysaccharides. Except the above-mentioned features, there was also local epithelial dysplasia, carcinogenesis, and interstitial infiltration in two cases. The 2 patients with a cancerous mass underwent surgical resection, whereas the other patients were kept under surveillance. While one patient with cancer is deceased, follow-up indicates that the remaining patients have experienced a good outcome.
Pulmonary papillary adenoma is very rare in clinical practice, and its clinical manifestations and CT images are not specific. Some cases may be cancerous and surgical resection should be the preferred treatment.
Background
The value of magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS), and the combination of CEUS and MRI (CCWM) for the diagnosis of periampullary space-occupying lesions (PSOL) was investigated.
Methods
A total of 102 patients diagnosed with PSOLs by surgery or biopsy were recruited retrospectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI, CEUS, and CCWM were analyzed.
Results
MRI, CEUS, and CCWM allowed for the accurate detection of 91.17, 92.15, and 99.01% of PSOLs, respectively. The specificity, PPV, and accuracy of CCWM were significantly different from MRI and CEUS (
p
< 0.05). However, there the sensitivity and NPV were not significantly different among the three diagnostic technologies. In addition, the specificity, PPV, and accuracy were not significantly different between MRI and CEUS (all
p
> 0.05).
Conclusions
CCWM is valuable for differentiating benign and malignant PSOL, which provides important guiding significances for the clinic.
Relapsing polychondritis is an immune disorder of unknown etiology involving multiple systems that is characterized by persistent inflammation and destruction of cartilage, including the ears, nose, costal, joint, and airways. Airway involvement caused by relapsing polychondritis is common, and tracheobronchomalacia is the most serious complication, which is life-threatening. Currently, the exact mechanism of relapsing polychondritis with tracheobronchomalacia is unknown. Although glucocorticoids and immunosuppressive agents are administered, failures often occur. Currently, bronchoscopy-guided intervention therapy used in tracheobronchomalacia caused by chronic obstructive pulmonary disease or other etiology has gradually increased, but bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation assist used in tracheobronchomalacia caused by relapsing polychondritis has not been reported. Here, we report a case of relapsing polychondritis with severe tracheobronchomalacia. Although drug therapy was provided and airway stent implantation was performed, the tracheal stenosis was further aggravated. Because conventional anesthesia and mechanical ventilation cannot meet the needs of bronchoscopy-guided intervention therapy or guarantee sufficient safety. The intervention treatment was performed with the support of extracorporeal membrane oxygenation, which was successfully completed without obvious complications. The symptoms were significantly improved, and the patient was discharged uneventfully.
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