Medical image of the week: lung entrapment

No abstract available. Article truncated at 150 words. A 74-year-old woman with a history of breast cancer 10 years ago treated with lumpectomy and radiation presented for evaluation of shortness of breath. She was diagnosed with left sided pleural effusion which was recurrent requiring multiple thoracenteses. There was increased pleural fludeoxyglucose (FDG) uptake on PET-CT indicative of recurrent metastatic disease. She underwent a medical pleuroscopy since the pleural effusion analysis did not reveal malignant cells although the suspicion was high and tunneled pleural catheter placement as adjuvant chemotherapy was initiated. Figure 1 shows a pleurscopic view of the collapsed left lung and the effusion in the left hemi thorax. Figure 2 shows extensive involvement of the visceral pleura with metastatic disease preventing complete lung inflation. Figure 3 shows persistent pneumothorax-ex-vacuo despite pleural catheter placement confirming the diagnosis of entrapment. Incomplete lung inflation can be due to pleural disease, endobronchial lesions or chronic telecasts. Lung entrapment and trapped lung ..

Medical image of the week: granulation tissue

A 57 year old woman presented with a tickling sensation in the back of throat and intermittent bleeding from the healing stoma one month after decannulation of her tracheostomy tube. On bronchoscopy a granuloma with surrounding granulation tissue was present in the subglottic space (Figure 1). Argon plasma coagulation (APC) was performed to cauterize the granulation tissue (Figure 2). Formation of granulation tissue after tracheostomy is a common complication which can result in tracheal stenosis. APC and electrocautery using flexible bronchoscopy has been shown to safely and effectively remove the granulation tissue

Medical image of the week: mediastinal lipomasosis

No abstract available. Article truncated after 150 words. A 61-year-old man presented to the pulmonary clinic for evaluation of a chronic cough of 6 months’ duration. Other medical problems included class three obesity, obstructive sleep apnea on CPAP therapy, and hypertension. Chest X-Ray (Figure 1) revealed a right mediastinal mass which then prompted a chest CT to be performed. The chest CT (Figure 2) demonstrated a homogenously enhancing, well circumscribed and fat-attenuating 8 x 5 cm mass in the right paratracheal region without invasion or compression into surrounding structures. Mediastinal lipomatosis was diagnosed. This is a benign soft tissue tumor made of mature adipocytes that can be seen with obesity, chronic corticosteroid use, and Cushing’s syndrome. They are thought to represent up to 2.3% of all primary mediastinal tumors (1). They are occasionally associated with compression of surrounding structures which can cause superior vena cava syndrome, dry cough, dysphagia, and occasionally arrhythmias (2). Management is typically conservative with

Medical image of the week: post pneumonectomy syndrome

No abstract available. Article truncated after 150 words. A 73 year-old woman with a history of left pneumonectomy in 2012 for Stage IB adenocarcinoma of the lung presented to the outpatient pulmonary clinic with dyspnea on exertion and fatigue. Computed tomography of the chest reveals hyperexpansion of the right lung with complete shift of the heart and mediastinal structures into the left hemithorax, (Figure 1). There is tethering of the right mainstem bronchus and right-sided vessels with a stretched configuration of the trachea, esophagus and right-sided vasculature. The heart is rotated toward the midline. The central airways are patent, however, the tethering and rotation of the mediastinal structures are concerning for post-pneumonectomy syndrome (PPS). PPS is a rare and late complication after pneumonectomy and results from extreme shift and rotation of the mediastinum. Symptoms can include progressive dyspnea, cough, inspiratory stridor and recurrent pneumonia (1). Dyspnea can be caused by bronchial compression or by compression of the pulmonary

Medical image of the week: tracheal stenosis

A 43-year-old woman was seen in clinic for dyspnea on exertion that began several months ago. Prior workup included a computed tomography of the chest with mild narrowing noted in the upper trachea. Pulmonary function tests (Figure 1) showed a flat inspiratory loop with a normal expiratory loop, which suggests a variable extrathoracic obstruction. On bronchoscopy, a tracheal stenosis was seen just past the vocal cords (Figure 2, Figure 3). Balloon dilation (Figure 4) of the stenosis returned the area to normal caliber

Medical image of the week: EBUS

This patient with a history of smoking was referred from an outside pulmonary clinic for a CT chest showing two enlarged right paratracheal nodes. The larger structure (Image 1) was found to have a hypoechoic appearance under endobronchial ultrasound, which is atypical of a lymph node. Upon needle aspiration, the structure collapsed and serous fluid was collected. The smaller lymph node (Image 2) showed the normal hyperechoic presentation and yielded normal lymphatic tissue when sampled

September 2015 Tucson pulmonary journal club: genomic classifier for lung cancer

No abstract available. Article truncated at 150 words. Silvestri GA, Vachani A, Whitney D, et al. A bronchial genomic classifier for the diagnostic evaluation of lung cancer. N Engl J Med. 2015;373(3):243-51. Pulmonary lesions are a common diagnostic dilemma for clinicians. Current literature describes the sensitivity of bronchoscopic techniques to be between 34 and 88%; which varies significantly depending on size and location of the biopsied lesion (1). Previously described gene expression patterns have been found to be associated with malignancy in healthy epithelial cells of the proximal airways\(2). The primary aim of this study was to prospectively validate a specific gene expression classifier in patients undergoing bronchoscopic biopsy for suspected lung cancer. The study involved two independent, prospective, multicenter, observational studies (AEGIS-1 and AEGIS-2) conducted in the U.S., Canada and Ireland at 28 sites. Patients were excluded if they were never smokers, under age 21, or current cancer or former lung cancer patients. Patients were followed for ..

Medical image of the week: saber sheath trachea

No abstract available. Article truncated after 150 words. A 79-year-old man with chronic obstructive pulmonary disease (COPD) and an active smoker was transferred for evaluation of tracheal narrowing and concerns of malignant external compression versus tracheobronchomalacia for possible stenting. The patient underwent both chest computed tomography (Figure 1) and bronchoscopy (Figure 2) that confirmed the diagnosis of saber-sheath trachea and ruled out external compression. The airway was still adequately patent during inspiration and expiration with no clear dynamic collapse. Saber-sheath trachea is commonly described as intra-thoracic coronal narrowing and sagittal widening of the trachea (like a sword sheath). Repetitive cartilaginous injury from excessive coughing and elevated intra-thoracic pressure causes degeneration and calcification of the trachea cartilage, leading to remodeling and bending of the tracheal cartilage (1). Presence of saber-sheath trachea is highly associated with obstructive lung disease, which is present in our patient (2). There is no known specific treatment for saber-sheath trachea, however if patient with saber-sheath