Cristiano Carbonelli

Cryobiopsy and multidisciplinary diagnosis of idiopathic pulmonary fibrosis.

Conventional transbronchial biopsy and bronchoalveolar lavage (BAL) can contribute to the diagnostic workup in diffuse lung diseases, especially when a bronchocentric involvement is suspected radiologically, or when a typical BAL profile is present. The interesting study by Pajares and colleagues demonstrates that the larger size of cryobiopsy sampling can improve the diagnostic yield of the bronchoscopic techniques in this setting. According to the interstitial lung disease guidelines, in patients without typical clinical and highresolution computed tomography (HRCT) features of idiopathic pulmonary fibrosis, multidisciplinary approach is considered the gold standard of diagnosis and the histological impression changes in a quarter of cases when all the clinical, radiological and pathological information is put together. Table 2 of the study by Pajares et al. shows that the most frequent histopathologic diagnosis observed in the cryoprobe group was nonspecific interstitial pneumonia (NSIP), found in 30.8% of cases. This percentage decreased after the multidisciplinary evaluation and only 25.7% of cases had a confirmed NSIP diagnosis after discussion. NSIP covers a number of separate clinico-radiological entities which share the same histological pattern. It is well demonstrated that the multidisciplinary evaluation has the role of integrating the results of the open lung biopsy, considering the histopathologic findings of NSIP in the clinical and radiological context even assuming the need of a follow-up period to exclude the association of the apparently idiopathic disease with other causes. Did the reduction of NSIP after multidisciplinary diagnosis derive from the reclassification of the histopathologic pattern in another clinical entity? So the 25.7% of multidisciplinary diagnosis referred to the idiopathic form of NSIP? Which standard did the authors use to exclude secondary NSIP? In the same table, the usual interstitial pneumonia (UIP) pattern, which was present in 17.9% of cases as histopathologic diagnosis in the cryoprobe group, disappears after multidisciplinary diagnosis. The authors in the discussion explain that ‘when the fibrotic pattern was identified at biopsy, the multidisciplinary team was still unable to reach a diagnosis’. Why? If histologic pattern is an integral part of the clinical diagnostic algorithm, it should be possible to evaluate its diagnostic value as histologic findings can influence the multidisciplinary diagnosis. The diagnostic perception at the multidisciplinary discussion would be the integration of the pre-test probability of the disease, all the clinical data and the finding of a UIP pattern on cryobiopsy. Open lung biopsy remains the reference standard in the histopathological evaluation, but this should not be an argument to exclude new ways to demonstrate a UIP pattern from the multidisciplinary evaluation. The ability of the cryobiopsy to identify ancillary findings to differentiate the idiopathic form of pulmonary fibrosis from other kinds of pulmonary fibrosis should be the aim of future larger multicentre trials; at the moment, any contribution of the research should be encouraged, including the publication of the details of Pajares et al.’s study, helping clinicians to face the therapeutic dilemma at the end of the diagnostic algorithm, which reserves new anti-fibrotic agents able to slow the progression of the disease only to the idiopathic fibrosis processes, while identifying the appropriate anti-inflammatory scheme in all the other cases where a diffuse lung disease is believed to be secondary to a recognizable cause.

Surgery and Survival of Patients with Diagnosis of Malignant Pleural Mesothelioma

in nodal staging of non–small-cell lung cancer (NSCLC). We want to evaluate the accuracy of EBUS-TBNA and mediastinoscopy for nodal staging. The 2-year result of 138 consecutive patients was that EBUS-TBNA was superior to mediastinoscopy. Previous study to compare the EBUS-TBNA with mediastinoscopy showed no advantage to mediastinoscopy, and later prospective randomized trial showed that the accuracy of EBUS was similar to mediastinoscopy. In addition, meta-analysis of 11 EBUS-TBNA studies reported the sensitivity of 93% and a specificity of 100%, which are superior to mediastinoscopy. There were meta-analysis papers for the complication rate, showing EBUS-TBNA of 0.05%, compared with mediastinoscopy of 2%. The cost-effectiveness of EBUSTBNA was analyzed to be lower mean cost and greater mean qualityadjusted life years compared with mediastinoscopy. There are increasing training opportunities for EBUS-TBNA. World Association of Bronchology and Interventional Pulmonology has actively spreading the educational activities around the world and American College of Chest Physicians (ACCP) and local Bronchology Societies. American Thoracic Society, European Respiratory Society, and ACCP recommend that 40 supervised procedures for initial training and 20 procedures per year to maintain competency. As the training activity of EBUS-TBNA are increasing, training accessibility will be better and better. ACCP and European Society of Thoracic Surgeons guidelines recommend that EBUS-TBNA should be first applied for nodal staging of NSCLC. In conclusion, it is an irresistible trend that EBUS-TBNA is the first and the best procedure in the nodal staging of NSCLC.

An unusual diagnosis of increasing respiratory failure after lung resection

A 77-year-old non-smoker female with an unremarkable medical history was admitted to the Thoracic Surgery Unit for a solitary pulmonary nodule (SPN) of the right lower lobe. At diagnostic workup, a brain CT scan showed multiple ischemic chronic lesions. Despite these findings, which could be suggestive of an asymptomatic chronic paradoxical embolism scenario, a transthoracic echocardiography (TTE) did not reveal cardiac defects or shunts. After clinical staging, the patient underwent sublobar resection for diagnostic purposes for suspicion of primary lung cancer. The frozen section analysis was indicative of a bronchial carcinoid tumor, and, accordingly, a right lower lobectomy was performed during the same surgical attempt. The postoperative course was uneventful, and the patient was discharged on the 7th post-op day. The final diagnosis was indicative of an atypical bronchial carcinoid. Two weeks later, the patient returned to the Emergency Department due to the occurrence of increasing dyspnoea; a hypoxic and hypocapnic respiratory failure was detected at blood gas analysis. Due to the clinical suspicion of a pulmonary thromboembolic event, a CT scan was performed, followed by lung scintigraphy: neither confirmed the diagnosis. At clinical examination, we noted that both the dyspnoea and the gas exchanges worsened (decreased to 20 % of the baseline SaO2 values,) when changing from the supine to the standing position. This condition, generally called platypnea orthodeoxia syndrome, was deemed to be related to a cardiopulmonary right-to-left shunt (RLS) [1]. A retrospective re-evaluation of the lung scintigraphy, showed a tracer uptake in both kidneys and in the brain [2], and a transcranial color-coded duplex sonography (TCCS) with saline contrast medium injection showed multiple high-intensity transient signals (HITS) even during normal breathing [3], confirming the clinical presence of a RLS. A transesophageal contrast echocardiography (TEE,) showed a severe tricuspid insufficiency and fibrotic endocardial plaques (Fig. 1), suggesting long-standing rightsided carcinoid heart disease [4, 5]. Moreover, a patent C. Carbonelli (&) G. Vezzani L. Zucchi Pulmonology Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Viale Risorgimento 80, 42123 Reggio Emilia, Italy e-mail: cristiano.carbonelli@asmn.re.it

Endobronchial Hamartoma Subtotally Occluding the Right Main Bronchus and Mimicking Bronchial Carcinoid Tumor

AbstractHamartomas are very rarely identified as an endobronchial lesion.Herein, we describe a peculiar case of a 55-year-old woman with persistent cough and increasing dyspnea and radiological detection of a solid lesion subtotally occluding the main right bronchus. Despite the radiological and radiometabolic (18-fluoro-2-deoxy-d-glucose positron emission tomography/computer tomography scan) features were highly suspected for bronchial carcinoid, the definitive diagnosis after endoscopic removal was indicative of an endobronchial hamartoma.When considering differential diagnosis of an endobronchial lesion, the physicians should take firmly in mind such rare entity and, accordingly, bronchoscopy and bronchoscopic biopsy should be done as first step in management of all cases presenting with endobronchial lesions.

Solitary Choroidal Metastasis From Atypical Carcinoid of the Lung Detected by 68 Ga DOTATATE PET/CT

A 71-year-old woman with a history of surgically treated bronchial atypical carcinoid underwent Ga DOTATATE PET/CT for restaging. Somatostatin receptor PET/CT revealed a focal area of mild radiopharmaceutical uptake corresponding to a thickening of the right choroid. No other areas of abnormal tracer uptake were detected in the rest of the body. Based on these PET/CT findings, the patient underwent examination of fundus oculi, MRI, and fluoroangiography, which confirmed the presence of a choroidal lesion interpreted as solitary choroidal metastasis of neuroendocrine tumor. Subsequently, the patient was referred for brachytherapy with radical intent.

Coexistent Sarcoidosis and Tuberculosis: A Case Report

Necrotizing granulomatous diseases of the lungs are usually dependent on a narrow range of differential diagnoses. Tuberculosis (TB) is responsible for the largest number of cases, while necrotizing sarcoidosis is generally considered a rare and easily distinguishable disease substantially based on histological features. However, this entity has become a viable diagnosis in the absence of mycobacteria isolation or when a remarkable clinical improvement cannot be achieved with the combination of anti-TB drugs at full dosage. The classic manifestations of TB and sarcoidosis have an overlapping range for which it is sometimes difficult to make a clinical diagnosis. Furthermore, the role of mycobacteria as a trigger antigen capable of evoking the clinical expression of sarcoidosis is a hypothesis supported by evidence from some cases. We report a case of bilateral tuberculous pleurisy in a 45-year-old male native of a North-African region with an atypical severe multisystem disease characterized by a fever resistant to anti-TB therapy and respondent to corticosteroid treatment. The choice to continue both steroid and anti-TB therapy proved to be correct for the late evidence of TB mycobacterial growth only on pleural specimens. The case described is suggestive of a coexistent systemic sarcoid manifestation and low-antigen TB, which is an underrecognized entity in the medical literature.

Synchronous Intrapulmonary Schwannoma and Primary Lung Cancer

A 67-year-old male underwent radiological examination as a consequence of a persistent cough. Chest X-ray first and computer tomography (CT) scan later showed an area of pulmonary consolidation at the level of lower right lobe (Fig. 1a, yellow arrow) and a round-shape pulmonary nodule in the lower left lobe (Fig. 1a, b, red arrow). The patient underwent bronchoscopy with trans-bronchial biopsy, and the histo/cytological examination showed a primary mucinous adenocarcinoma of the right lower lobe, while fine-needle biopsy of the left lesion was inadequate to achieve a certain diagnosis. Positron emission tomography (PET)/CT scan for staging purpose revealed a moderate uptake at the level of both right (SUVmax = 3.1, Fig. 1c, d, yellow arrow) and left (SUVmax = 3.2, Fig. 1c, d, red arrow) lung lesions, while no uptake was observed in other sites. Institutional Tumor Board interpreted the radiological scenario as a primary adenocarcinoma with single contralateral lung metastases scheduling sequential surgical lung resections. Thus, the patient underwent right lower lobectomy with mediastinal lymph-nodal dissection (confirming a pT2N0 adenocarcinoma) and, subsequently, a wedge resection of the right upper lobe. Macroscopically, the nodule appeared well defined by thin fibrous capsule (Fig. 2a), while microscopically fascicles of elongated cells with spindle-shaped nuclei (Fig. 2b), walled and ectatic vessels, and hemorrhagic area with perivascular hemosiderin deposition were observed (Fig. 2c). Immunohistochemical staining showed tumor cells positive for S-100 protein (Fig. 2d) and negative for cytokeratin AE1/AE3, smooth muscle actin, desmin, and CD34. A final diagnosis of intrapulmonary schwannoma was done, and no adjuvant chemotherapy was performed. Pulmonary schwannomas are extremely rare neoplasm accounting for \0.2 % of all pulmonary neoplasms [1].

An Unusual Case of Excavated Lung Lesion

A 62-year-old male patient with a long-lasting smoking habit was hospitalized in our center with a persistent fever associated with weight loss, anorexia, and cough. Chest X-ray first and computer tomography (CT) scan later showed a parenchymal consolidation with irregular margins and some areas of excavation at the level of the upper right pulmonary lobe (Fig. 1a). Lab test revealed a white blood cell count and CRP level within the range; Mantoux test was positive but the microscopic detection of Mycobacterium tuberculosis (MBT) in sputum was negative. Endoscopic evaluation showed a deformation of the segmental bronchi of the right upper lobe with severe hyperemia while the detection of MBT in alveolar lavage was negative. Finally, a transbronchial biopsy was indicative for a chronic non-specific inflammation process. Despite the radiological findings were more indicative of an inflammatory process, for the suspect of primary lung cancer developed on a previous scar (so-called ‘‘scar-cancer’’), we completed the staging evaluation with a 18Ffluorodeoxyglucose positron emission tomography (18FFDG PET)/CT scan and head-CT scan. PET/CT scan showed a focal area of increased radiopharmaceutical uptake in the upper right pulmonary lobe, corresponding to the lesion mentioned above (Fig. 1b–d), with a maximum standardized uptake value (SUVmax) of 4.2. Moreover, an uptake was detected also in correspondence of an ipsilateral hilar lymph node (SUVmax:3.2) while no other areas of abnormal 18F-FDG uptake were detected in the rest of the body. Head-CT scan was negative for neoplastic lesions but, interestingly, it revealed the presence of isodense material at the soft tissue near to the left maxillary sinus, indicative of flogistic lesion (Fig. 2a). Orthopantomogram (OPG) examination revealed the presence of a severe periodontopathy with large area of bone rarefaction and multiple peri-radicular pockets of the upper dental arch (see Fig. 2b, yellow arrows) indicative of periodontal dental abscesses. The patients underwent adequate dentistry care (confirm the presence of infection at this site) and broad-spectrum antibiotic treatment (Amikacin ? clavulanic acid for 2 weeks) obtaining a clinical improvement and a remarkable reduction of the pulmonary radiological findings in few weeks. Septic pulmonary embolism (SPE) is a rare type of pulmonary embolism in which emboli containing pathogens embolize to the pulmonary artery and cause pulmonary embolism and focal lung abscesses [1]. In a systematic review published from 1978 to 2012, among a total of 168 cases of SPE only 9 cases (5.36 %) had dental and periodontal infections. In the present case, the clinical and radiological onset was very insidious (parenchymal PET-positive partly excavated consolidation associated with ipsilateral lymph node), mimicking the occurrence of a pulmonary localization of MBT or a primary lung cancer. Despite very rarely reported in literature, the physicians should take in & Filippo Lococo filippo_lococo@yahoo.it

A 79-Year-Old Man With Interstitial Lung Disease and Cryptic Area of High 18Fluorodeoxyglucose Uptake in Left Upper Lobe

Seven years after left hemicolectomy and radical lymph nodal dissection followed by adjuvant chemotherapy for colorectal cancer (histotype, adenocarcinoma; stage, pT3N2M0; grading, G2), a slight increase in carcinoembryonic antigen levels (6.2 ng/mL; range, 0-5 ng/mL) was detected in a 79-year-old man. He was a heavy smoker with history of an interstitial fibrotic lung disease with associated areas of emphysema.