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1.  Chronic atelectasis of the left lower lobe: a clinicopathological condition equivalent to middle lobe syndrome 
OBJECTIVES
Middle lobe syndrome is a well-known clinical condition. In this retrospective study, we report our experience with a similar clinicopathological condition affecting the left lower lobe.
METHODS
The data of 17 patients with atelectasis or bronchiectasis of the left lower lobe who underwent lobectomy during the period from January 2000 to December 2011 were reviewed. Demographic, clinical, radiological and surgical data were collected.
RESULTS
Seventeen patients were included in this study, only one adult male patient of 52 years and 16 children. The paediatric patients were 10 boys and 6 girls, their age ranged from 2 to 11 years, mean 6.19 ± 2.6 years. Most patients presented with recurrent respiratory infection 15/17 (88.2%). The lag time before referral to surgery ranged from 3 to 48 months, mean 17.59 ± 13.1 months. Radiological signs of bronchiectasis were found in 11 (64.7%) patients. Bronchoscopy showed patent lower lobe bronchus in all patients. The criteria for lobectomy were evidence of bronchiectasis [11 (64.71%) patients], persistent atelectasis of the lobe after bronchoscopy and intensive medical therapy for a maximum of 2 months [6 (35.29%) patients]. Histopathological examination showed bronchiectasis in 11 (64.71%) patients, fibrosing pneumonitis in 4 (23.53%) patients and peribronchial inflammation in 2 (11.76%) patients. Most patients were doing well 1 year after surgery.
CONCLUSIONS
Chronic atelectasis of the left lower lobe is a clinicopathological condition equivalent to middle lobe syndrome. Impaired collateral ventilation together with airway plugging with secretion is an accepted explanation. Surgical resection is indicated for bronchiectatic lobe or failure of 2-month intensive medical therapy to resolve lobar atelectasis.
doi:10.1093/icvts/ivs305
PMCID: PMC3445383  PMID: 22761114
Middle lobe syndrome; Atelectasis; Bronchiectasis; Lobectomy
2.  Role of infection in the middle lobe syndrome in asthma. 
Archives of Disease in Childhood  1992;67(5):592-594.
Twenty one children with asthma aged 1.0-10.5 years (mean (SD) 3.3 (2.5) years) were admitted to the hospital to evaluate pulmonary right middle lobe or lingular collapse lasting one to 12 months (mean (SD) 4.4 (3.8) months). Seven children had mild asthma and were treated with inhaled beta 2 agonists as needed. Nine had moderate asthma treated with either sodium cromoglycate or slow release theophylline. Five had severe asthma treated with inhaled steroids. Each child underwent fibreoptic bronchoscopy under local anaesthesia and a bronchoalveolar lavage. Differential cell counts of the lavage fluid revealed predominance of neutrophils in 12 patients (57%). In nine of these patients cultures grew pathogenic bacteria, mainly Haemophilus influenzae and Streptococcus pneumoniae. There was no correlation between the severity of asthma and a positive bacterial culture. There was also no correlation between the duration of the right middle lobe collapse and a positive culture. We conclude that longstanding right middle lobe collapse in asthmatic children is often associated with bacterial infection.
PMCID: PMC1793699  PMID: 1599294
3.  Lung Abscess: A Review of Three-Years Experience at the University College Hospital, Ibadan 
The experience with 45 patients with lung abscess over a three-year period at the University College Hospital (UCH), Ibadan, is presented. This study confirms the rarity of this disease among Nigerian children and its prevalence in young adults in the third and fourth decades of life. The most common presenting symptoms were purulent cough, chest pain, fever, and life-threatening hemoptysis which was the sole indication for emergency operation in 14 out of 16 patients who were treated surgically. The predominance of these abscesses in the right lung, especially in the superior segment of the lower lobe, supports the fact that aspiration of infected material, following depressed level of consciousness, esophageal obstruction, foreign bodies, and oral sepsis form the major causative factors in patients with lung abscess. The frequent association of sickle cell disease, bronchiectasis, hypertension, and pulmonary aspergilloma contribute significantly to the morbidity and mortality attendant to this disease in our environment. Twenty-nine patients were treated medically with five deaths and 16 patients were treated surgically with six deaths. The high operative mortality (37.5 percent) in this series was due to the extreme emergency conditions under which these patients were operated.
Images
PMCID: PMC2537236  PMID: 423274
4.  Right middle lobectomy for a primary pulmonary leiomyoma: a case report 
Cases Journal  2009;2:8673.
Introduction
Primary leiomyoma of the lung is a rare benign tumor that usually presents as a solitary lesion predominantly in young females. Fewer than 100 cases have been reported. Common symptoms include fever, chronic cough, hemoptysis, chest pain, shortness of breath, and pneumonias.
Case presentation
A 34-year-old, non-smoker female who presented with recurrent pneumonias. She was found to have a primary leiomyoma of the right middle lobe. This was treated by right middle lobectomy. 6-month follow up showed patient doing well without evidence of residual disease on computerized tomography.
Conclusion
Primary pulmonary leiomyoma is a rare tumor distinct from benign metastasizing leiomyoma. Histologic features include absence of mitotic count, low cellularity, lack of cytologic atypia and pleomorphism. Treatment is by conservative surgical resection and carries a favorable prognosis.
doi:10.4076/1757-1626-2-8673
PMCID: PMC2827106  PMID: 20184689
5.  Chyloptysis with right middle lobe syndrome complicated postoperatively by chylothorax: An unusual cause of right middle lobe syndrome 
Chyloptysis, in the context of middle lobe syndrome, and chylothorax are rare clinical entities. They are reported in the medical literature mostly as case reports, but never together in the same patient. The present report describes the case of a 34-year-old woman who presented with chyloptysis associated with recurrent right middle lobe syndrome since she was 20 years of age, and eventually underwent right middle lobectomy. A few weeks postoperatively, she developed a right-sided chylothorax, which was refractory to medical therapy, and was successfully treated with thoracic duct ligation. She has been symptom-free for two years postsurgery.
PMCID: PMC2687563  PMID: 19399303
Chyloptysis; Chylothorax; Right middle lobe syndrome
6.  Lobar pneumonia in Northern Zambia: clinical study of 502 adult patients. 
Thorax  1984;39(8):612-616.
From July 1981 to January 1983 502 adults were treated for lobar or segmental pneumonia in a general hospital in Northern Zambia. Consolidation was present in either the right or the left lower lobe in 78.8%, the right middle lobe in 10.2% and either the right or the left upper lobe in 10.7%. Penicillin treatment failed to give an improvement in 10.7%, many of whom recovered after receiving either gentamicin or kanamycin. A high risk of death was associated with an age of 65 years or over, absence of pyrexia, absence of a leucocyte response, disease affecting multiple lobes, irreversible hypotension, underlying neoplasm, and failure to respond to penicillin treatment (p less than 0.001 in all cases). Penicillin remains the initial treatment of choice for lobar pneumonia in rural central Africa. Mortality can probably be reduced by inpatient treatment of as many patients with pneumonia as local circumstances allow, and by adding broad spectrum treatment in patients who show no improvement after 48 hours of penicillin treatment.
PMCID: PMC1020516  PMID: 6474390
7.  An incidental and uncommon pulmonary sequestration with an uncommon feeding artery☆ 
INTRODUCTION
Pulmonary sequestration is a rare congenital anomaly and most intralobar sequestrations were located in lower lobes. There is little information on middle lobe intralobar sequestration.
PRESENTATION OF CASE
A 44 year-old man with right middle lobe syndrome was referred for surgical management. He underwent video-assisted thoracoscopic right middle lobectomy and his postoperative course was uneventful. Pathology is notable for an incidental intralobar sequestration.
DISCUSSION
Our case was unique in that the location of incidental pulmonary sequestration is uncommon and in that its feeding artery was uncommonly located in the fissure.
CONCLUSION
We report an extremely rare case of right middle lobe intralobar sequestration with a feeding artery in the fissure.
doi:10.1016/j.ijscr.2013.07.022
PMCID: PMC3785947  PMID: 23959421
Infection; Thoracoscopy; Surgery
8.  A Case of Swyer-James-Macleod Syndrome Associated with Middle Lobe Hypoplasia and Arteriovenous Malformation 
Case Reports in Medicine  2012;2012:959153.
A 58-year-old female patient presented to the hospital with hearing loss. In the chest radiography obtained before her ear surgery, volume decrease in the right hemithorax, elevation of the right diaphragm, and increase of ventilation in the right lung were detected. At the thorax CT-CT angiography, hypoplasia of the main pulmonary artery and its branches and arteriovenous malformation localized in the middle lobe of the right lung were detected. Thus, diagnosis of Swyer-James-Macleod syndrome associated with right lung middle lobe hypoplasia and arteriovenous malformation was made. This kind of association has not been reported earlier, so we are presenting it in the light of the literature knowledge.
doi:10.1155/2012/959153
PMCID: PMC3523543  PMID: 23304165
9.  AB 73. Pulmonary hyalinizing granuloma: case report 
Journal of Thoracic Disease  2012;4(Suppl 1):AB73.
Background
Pulmonary hyalinizing granuloma is an unusual condition, characterized by fibrosing nodules, consisting of the either unilateral or bilateral central whorled deposits of lamellar collagen hyaline. Although the etiology is uncertain there are evidences that suggest an autoimmune origin. Clinically and with imaging techniques it may be minic primary or metastatic carcinoma or nodular amyloidosis.
Patients and methods
We report case of 74 years old woman who admitted in our hospital with cough, dyspnea and chest pain. A CT scan of the chest revealed a mass located in the middle lobe of the right lung. The patient underwent thoracotomy for surgical excision of the mass macroscopic examination of the excised lobe revealed a well-circumscribed firm, grayish-white mass, measuring 3.1 cm × 2 cm × 1.3 cm. The sections were examined with H+E, PAS, and Congo-Red and followed by immunohistochemical study for Amyloid A and P, CD138, κ and λ light chains.
Results
The microscopic examination with H+E showed that the lung parenchyma presented extensive hyaline fibrosis PAS positive, areas of calcification and foci of bone metaplasia, accompanied by an inflammatory reaction. Congo-Red stain was positive but screening for birefringent material under polarized light was negative. Amyloid A and P were negative. The plasma calls were positive for CD138, κ and λ light chains. These histological findings were consistent with diagnosis of pulmonary hyalinizing granuloma.
Conclusions
The pulmonary hyalinizing granuloma should be considered in the differential diagnosis of pulmonary nodules or masses, even when they are cavitary or contain calcifications.
doi:10.3978/j.issn.2072-1439.2012.s073
PMCID: PMC3537332
10.  Complete video-assisted thoracoscopic surgery for pulmonary sequestration 
Journal of Thoracic Disease  2013;5(1):31-35.
Objective
To analyze the characteristics and technical difficulties of complete video-assisted thoracoscopic surgery (c-VATS) for treatment of pulmonary sequestration operation.
Methods
25 cases of c-VATS lobectomy for intrapulmonary sequestration performed between January 2009 and May 2012 were reviewed. The 25 patients included 13 (52%) males and 12 (48%) females, with a mean age of 34.7 years (range, 16-62 years). Preoperative imaging by CT scan and three-dimensional reconstruction of abnormal blood vessels diagnosed 19 cases as pulmonary sequestration, misdiagnosed 1 case as pulmonary cyst syndrome, 4 cases as bronchiectasis and 1 case as benign tumor.
Results
All the patients underwent c-VATS excision, 16 in the left lower lobe, 7 in the right lower lobe, 1 in right middle lobe and 1 extralobar pulmonary sequestration. Vascular abnormality was observed intraoperative including the thoracic aorta in 20 cases, abdominal aorta in 2 cases, phrenic arteries and intercostal artery in 1 cases and thoracic aorta combined with abdominal aorta in 1 case. No conversion to open was achieved in all cases. The mean operating time was 114.2 mins (range, 78-156 mins), the mean blood loss was 228 mL (range, 50-3,000 mL), the mean duration of chest drainage was 3.2 days (range, 2-7 days) and the mean length of post-operative hospital stay was 6.6 days (range, 3-13 days). There was no mortality, without significant postoperative complications, were cured and discharged. Patients were followed up for 2-32 months, mean 21.4 months, with no recurrence.
Conclusions
c-VATS is feasible, effective, and safe in treatment of pulmonary sequestration. It is worthy of clinical application.
doi:10.3978/j.issn.2072-1439.2013.01.01
PMCID: PMC3548003  PMID: 23372948
Complete video-assisted thoracoscopic surgery (c-VATS); pulmonary sequestration; treatment
11.  Surgical treatment of giant cavernous hemangiomas of the liver--analysis of 7 patients. 
Seven patients with giant cavernous hemangioma of the liver were treated surgically with success at Pusan Gospel Hospital, Kosin Medical College, Pusan, from 1980 through 1989. They were 3 males and 4 females, and their ages ranged from 6 to 59 years. The tumors were located on the right lobe of the liver in 5 patients and on the left lobe in 2. The lesions were solitary in all patients, and their sizes varied from 4cm to 15cm in diameter. All patients underwent hepatic resection: 1 right hepatic lobectomy and 4 partial resections for tumors on the right lobe, and 1 left lobectomy and 1 left lateral segmentectomy for tumors on the left lobe. There was no surgical death, but 1 patient had a postoperative complication: multiple stress ulcers on the stomach and ileum. The pathologic diagnosis was cavernous hemangioma in all cases. In the long-term follow-up, there was no recurrence of preoperative symptoms in any patient.
PMCID: PMC3049686  PMID: 1751017
12.  Intracranial Pial Arteriovenous Fistula Presenting with Hemorrhage: A Case Report 
Intracranial pial arteriovenous fistula (AVF) is a rare cerebrovascular malformation, which has a single or multiple arterial connections to a single venous channel without intervening nidus, and is different from arteriovenous malformation (AVM). We report on a case of a surgically treated pial AVF. A 15-year-old girl with an altered mental state was brought to our hospital. Computed tomography (CT) showed a subcortical hematoma of approximately 24 ml in her right temporal lobe. Cerebral angiography showed an AVF supplied by the right middle cerebral artery with early drainage into the Sylvian vein and the vein of Labbe. She underwent surgical treatment with feeding artery obliteration using a clip and hematoma removal. The patient was discharged without neurologic deficits. Despite the rarity of pial AVF, for correct diagnosis and treatment, neurosurgeons should recognize this condition. Pial AVF can be managed simply by disconnection of the shunt by surgery or endovascular treatment, and a good result can be achieved.
doi:10.7461/jcen.2012.14.4.305
PMCID: PMC3543917  PMID: 23346547
Intracranial; Pial; Arteriovenous fistula
13.  Normalization of Elevated CA 19-9 Level after Treatment in a Patient with the Nodular Bronchiectatic Form of Mycobacterium abscessus Lung Disease 
Carbohydrate antigen 19-9 (CA 19-9) is a widely-used tumor marker in patients with pancreatic cancer. However, some patients with respiratory disease also exhibit elevated serum CA 19-9 levels. We report a case of normalization of elevated serum CA 19-9 levels after treatment of the nodular bronchiectatic form of Mycobacterium ab scessus lung disease. A 40-year-old man visited our hospital because of chronic cough and sputum. A computed tomography scan revealed severe bronchiectasis in the right upper and right middle lobes. Nontuberculous mycobacteria were repeatedly isolated and identified as M. abscessus. The serum CA 19-9 level was elevated to 142.35 U/mL (normal range, <37 U/mL). Surgical resection was performed because of failure of sputum conversion after antibiotic treatment. The serum CA 19-9 level returned to the normal range after surgery. This case suggested that serum CA 19-9 levels could be elevated in patients with the nodular bronchiectatic form of M. abscessus lung disease.
doi:10.4046/trd.2013.75.1.25
PMCID: PMC3741470  PMID: 23946755
Bronchiectasis; CA 19-9 Antigen; Nontuberculous Mycobacteria
14.  Endobronchial Tuberculosis Presenting as Right Middle Lobe Syndrome: Clinical Characteristics and Bronchoscopic Findings in 22 Cases 
Yonsei Medical Journal  2008;49(4):615-619.
Purpose
Endobronchial tuberculosis (EBTB) presenting as right middle lobe syndrome (RMLS) is an uncommon clinical condition. We investigated the clinical characteristics in patients with EBTB presenting as RMLS.
Patients and Methods
We retrospectively reviewed the records of 22 patients with EBTB presenting as RMLS who were diagnosed at our hospital from 2003 to 2006.
Results
Its occurrence was more common in females than males (F, 18; M, 4). The mean age was 70.3 ± 8.5 years, and 17 patients were above the age of 65 years. Cough with sputum was the most common manifestation and 2 patients were asymptomatic. In bronchoscopic analysis, the most common finding was edematous-type EBTB, which was found in 15 patients, followed by actively caseating type in 6 and tumorous type in 1. Acid-fast bacilli (AFB) staining for bronchial washing fluid was positive in only 5 patients: 1 with edematous type and 4 with actively caseating type. Bronchoscopic biopsy showed chronic granulomatous inflammation in 16 patients. Follow-up chest X-ray after treatment showed complete disappearance of the lesion in 2 patients, more than 50% improvement in 5, less than 50% improvement in 5, and no change of lesion in 4.
Conclusion
Edematous-type EBTB was the most common type of EBTB presenting as RMLS, and it usually occurred in elderly patients. Culturing for mycobacterium and histologic examination by bronchoscopy are necessary for proper diagnosis in these patients.
doi:10.3349/ymj.2008.49.4.615
PMCID: PMC2615288  PMID: 18729304
Endobronchial tuberculosis; right middle lobe syndrome
15.  Multidrug resistant tuberculosis co-existing with aspergilloma and invasive aspergillosis in a 50 year old diabetic woman: a case report 
Cases Journal  2008;1:303.
Aspergilloma and invasive aspergillosis coexisting with multidrug resistant Mycobacterium tuberculosis (MDR-TB) in the same patient is a rare entity. We report a 50 year old South Indian woman, a diabetic, who presented to us with complaints of productive cough and hemoptysis for the past 2 months. She was diagnosed to have pulmonary tuberculosis 2 years ago for which she took irregular treatment. Lung imaging showed features of a thick walled cavity in the right upper lobe with an indwelling aspergilloma. She underwent a right lung upper lobe resection. Biopsy and culture of the resected specimen showed the coexistence of Aspergillus fumigatus and multi-drug resistant Mycobacterium tuberculosis. 2 blood cultures grew Aspergillus fumigatus. She was successfully treated with Voriconazole and anti tuberculous therapy against MDR-TB.
doi:10.1186/1757-1626-1-303
PMCID: PMC2585581  PMID: 18992166
16.  Clinicopathological analysis of pulmonary mucoepidermoid carcinoma 
Background
Mucoepidermoid carcinoma (MEC) of the lung is a rare malignant neoplasm. We aimed to investigate clinicopathological features, therapies, and prognoses of eight MEC cases.
Methods
Eight patients underwent surgical treatment for pulmonary MEC between 2005 and 2012 at the Thoracic Surgical Department of West China Hospital, Sichuan, China. The clinical data, radiological manifestation, treatment strategy, pathological findings, and prognoses of all patients were analyzed retrospectively.
Results
Among the eight cases (four males and four females), the age of patients ranged from 35 to 71 years (mean age 50.67 years). Two tumors were located in the upper lobes and three masses were located in the lower lobes. The other three lumps were located in the left main bronchus, middle segmental bronchus of the right lobe, and trachea, respectively. The characteristics of the tumors were consistent with low grade MEC (n = 6) and high grade MEC (n = 2). All of the patients were sent for oncological evaluations, and three patients with N1 or N2 disease received chemotherapy. One of the patients died from brain metastasis at 15 months. Seven of the eight patients were alive at the time of evaluation. The median survival time was 40 (range 8 to 88) months.
Conclusion
Mucoepidermoid tumors have to be treated by radical surgery with lymph node sampling and dissection. Patients with low grade tumors can be expected to be cured following complete resection. Careful histological typing plays a key role in prediction of late results, and further studies are needed.
doi:10.1186/1477-7819-12-33
PMCID: PMC3922271  PMID: 24507476
Mucoepidermoid carcinoma; Lung; Surgery; Pathological histology
17.  Clinical study on safety of adult-to-adult living donor liver transplantation in both donors and recipients 
AIM: To investigate the safety of adult-to-adult living donor liver transplantation (A-A LDLT) in both donors and recipients.
METHODS: From January 2002 to July 2006, 50 cases of A-A LDLT were performed at West China Hospital, Sichuan University, consisting of 47 cases using right lobe graft without middle hepatic vein (MHV), and 3 cases using dual grafts (one case using two left lobe, 2 using one right lobe and one left lobe). The most common diagnoses were hepatitis B liver cirrosis, 30 (60%) cases; and hepatocellular carcinoma, 15 (30%) cases in adult recipients. Among them, 10 cases had the model of end-stage liver disease (MELD) with a score of more than 25. Donor screening consisted of reconstruction of the hepatic blood vessels and biliary system with 3-dimension computed tomography and volumetry of whole liver and right liver volume. Various improved surgical techniques were adopted in the procedures for both donors and recipients.
RESULTS: Forty-nine right lobes and 3 left lobes (2 left lobe grafts for 1 recipient, 1 left lobe graft for 1 recipient who had received right lobe graft donated by relative living donor) were obtained from 52 living donors. The 49 right lobe grafts, without MHV, weighed 400 g-850 g (media 550 g), and the ratio of graft volume to recipient standard liver volume (GV/SLV) ranged from 31.74% to 71.68% (mean 45.35%). All donors’ remnant liver volume was over 35% of the whole liver volume. There was no donor mortality. With a follow-up of 2-52 mo (media 9 mo), among 50 adult recipients, complications occurred in 13 (26%) cases and 4 (8%) died postoperatively within 3 mo. Their 1-year actual survival rate was 92%.
CONCLUSION: When preoperative CT volumetry shows volume of remnant liver is more than 35%, the ratio of right lobe graft to recipients standard liver volume exceeding 40%, A-A LDLT using right lobe graft without MHV should be a very safe procedure for both donors and recipients, otherwise dual grafts liver transplantation should be considered.
doi:10.3748/wjg.v13.i6.955
PMCID: PMC4065937  PMID: 17352031
Adult-to-adult living donor liver transplantation; Middle hepatic vein; Dual grafts; Right lobe graft; Standard liver volume; Grafts; Weight; Complication
18.  Synchronous BALT Lymphoma and Squamous Cell Carcinoma of the Lung: Coincidence or Linkage? 
A 72-year-old man presented with weight loss, fever, and malaise. Chest radiograph and CT revealed two large ill-defined masses in middle and left lower lobes. CT-guided biopsy of left lower lobe mass disclosed bronchus-associated lymphoid tissue (BALT) lymphoma. Middle lobe mass was considered second deposit in contralateral lung. The patient received chemotherapy for BALT. Followup CT disclosed regression of left lower lobe mass and stability of middle-lobe mass and of right paratracheal lymph nodes. CT-guided biopsy of middle-lobe mass revealed squamous cell lung carcinoma. Surgical biopsy of right paratracheal lymph nodes revealed malignancy. Disease was staged T3, N2, and M0. Combined chemotherapy for lung cancer and BALT lymphoma was initiated.
doi:10.1155/2013/420393
PMCID: PMC3600273  PMID: 23533872
19.  Agenesis of the Right Hepatic Lobe 
Case Reports in Medicine  2012;2012:415742.
Introduction. Agenesis of the right lobe of the liver is a rare finding and was defined as the absence of liver tissue on the right side, with preservation of the middle hepatic vein, without previous disease or surgery. It is usually an incident finding reveled by imaging exams or during abdominal surgery. Case Report. A 32-year-old male patient was admitted to the hospital for abdominal discomfort and loss of appetite. Imaging studies revealed the absence of the right hepatic lobe and hypertrophied left hepatic segments. Discussion. Anomalies of hepatic morphology are rare and correspond to developmental defects during embryogenesis, are a rare diagnosis, and are generally diagnosed incidentally based on imaging. Agenesis or hypoplasia of the right lobe may predispose the patient to the development of portal hypertension and esophageal varices. Surgical knowledge of such anatomical agenesis is necessary for surgical planning, for the appropriate identification of intraoperative surgical findings, and for the design of the postoperative approach to therapy. Conclusion. Agenesis of the right hepatic lobe is a rare condition. We want to highlight the importance of understanding the condition. Surgeons must recognize the entity in order to deal appropriately with the findings.
doi:10.1155/2012/415742
PMCID: PMC3328917  PMID: 22550497
20.  Congenital Cystic Adenomatoid Malformation with Bronchial Atresia in Elderly Patients 
Congenital cystic adenomatoid malformation (CCAM) is an uncommon, nonhereditary anomaly caused by arrest of lung. Patients with CCAM may present with respiratory distress as newborns, or may remain asymptomatic until later in life. CCAM type I is rarely found in association with bronchial atresia (BA) in adults; we present such a case. Case: A 54-year-old female presented with chronic cough and blood-tinged sputum. Physical examination and laboratory tests were unremarkable. Chest radiographs and a CT scan of the chest showed multiple large air-filled cysts consistent with a CCAM in the right lower lobe, and an oval-shaped opacity in the distal right middle lobal bronchus. Based on the radiologic findings, right middle lobectomy and a medial basal segmentectomy of the right lower lobe were performed via a thoracotomy. These lesions were consistent with Stocker's Type I CCAM and BA in the different lobes.
doi:10.4046/trd.2012.72.6.501
PMCID: PMC3475458  PMID: 23101017
Cystic Adenomatoid Malformation of Lung, Congenital; Aged; Bronchi; Abnormalities
21.  Complete video-assisted thoracoscopic surgery upper left bronchial sleeve lobectomy 
Journal of Thoracic Disease  2013;5(Suppl 3):S298-S300.
This video demonstrates a case undergoing complete video-assisted thoracoscopic surgery (VATS) upper left bronchial sleeve lobectomy. The 18-year-old female patient was admitted for recurrent cough and intermittent hemoptysis for one month. Chest CT scan showed a neoplasm in the left main bronchus and the left upper lobe bronchus. Bronchoscopic biopsy indicated mucinous epithelial cancer. Based on the chest CT findings, the left lower lung was not affected. To preserve normal lung tissue and minimize the loss of lung function, we decided to perform this surgical procedure. A three-port technique was conducted, in which the hypoplastic oblique fissure, the left upper pulmonary vein, and the upper lobe branch of the left pulmonary artery were initially treated under complete VATS. Bronchial sleeve lobectomy of the upper lobe of the left lung was finally carried out. The key to success was the end-to-end anastomosis between the left main bronchus and the lower left bronchus under thoracoscope. The deep location of the operative field partly hidden under the left pulmonary artery trunk during bronchial anastomosis made it even more difficult to operate thoracoscopically. To improve exposure of the operative field, we managed to raise the left main bronchus by passing two 1-0 silk sutures, respectively ligated with both sides of the posterior wall of the left main bronchus, through the anterior and posterior chest walls using a crochet needle. Similarly, a 1-0 silk suture was advanced through the posterior chest wall with a crochet needle to lift the trunk of the left pulmonary artery. In this way, a widely open, exposed field was achieved. Postoperative recovery was smooth. Chest X-ray showed good expansion of the left lung. Bronchoscopy indicated a patent anastomosis. The patient was discharged after two weeks. In conclusion, complete VATS bronchial sleeve lobectomy is a minimally invasive approach for thorough removal of tumor lesions while sparing as most normal lung tissue as possible, which avoids pneumonectomy and satisfies the psychological and physiological needs of patients.
doi:10.3978/j.issn.2072-1439.2013.08.29
PMCID: PMC3771595  PMID: 24040547
Video-assisted thoracoscopic surgery (VATS); sleeve lobectomy; lung cancer
22.  AB 29. Malignant mediastinal tumor: restrictions in immunohistochemical evaluation 
Journal of Thoracic Disease  2012;4(Suppl 1):AB29.
Background
It is common ground that immunohistochemistry’s contribution in neoplasm’s origin identification is invaluable. However, in some cases there seem to exist certain limitations raising differential diagnosis problems.
Patients and methods
A young 23-year old woman, who was recently pregnant and breastfeeding, presented to our hospital with dyspnea and superior vena cava syndrome. A month ago she suffered from upper respiratory tract infection, which was treated with antibiotics. Axial computed tomography showed several mediastinal masses and right lower lobe lung invasion. This was followed by bronchoscopy and samples were taken for biopsy.
Results
Upon histological evaluation a malignant neoplasm with extensive necrosis was revealed. Diffuse distribution of oval, middle to large size cells, with conspicuous nucleoli and mitoses, tend to lead to the diagnosis of a lymphoproliferative neoplasm. During to gradual and extensive immunohistochemical examination, the neoplastic cells were found negative to stains specific for hemopoietic system diseases as well as other malignant neoplasm such as sarcoma, mesothelioma, germ cell tumor, melanoma and neuroendocrine carcinoma. On the other hand, they were strongly positive for p63 (squamous cell differentiation index), CD138 and only weak and focally for keratins (CKAE1/AE3, CK8/18, CK7, CK5/6). Morphological and immunohistochemical findings consisted with undifferentiated carcinoma, with squamous cell differentiation. The patient deceased 20 days later.
Conclusions
Neoplastic morphological features tend to lead to a correct diagnosis which should always be certified by immunohistochemical findings. However, in some cases immunohistochemistry’s role is diminished due to tumor specific factors as neoplastic cells’ poor differentiation or dedifferentiation and degenerative changes.
doi:10.3978/j.issn.2072-1439.2012.s029
PMCID: PMC3537357
23.  Massive hemoptysis and deep venous thrombosis presenting in a woman with Hughes-Stovin syndrome: a case report 
Introduction
Hughes-Stovin syndrome is a very rare disease with fewer than 30 cases reported in the literature. The disease is thought to be a variant of Behcet's disease and is defined by the presence of pulmonary artery aneurysm in association with peripheral venous thrombosis.
Case presentation
A previously healthy 23-year-old Saudi woman presented with massive hemoptysis a day prior to her admission to our hospital. She had a six-month history of recurrent fever, cough, dyspnea, and recurrent oral ulceration. Contrast-enhanced computed tomography scan of her chest and pulmonary angiogram demonstrated a single right-lower lobe pulmonary artery aneurysm. She underwent thoracotomy and right lower lobe resection. Her postoperative course was complicated by deep vein thrombosis. She also developed headache and papilledema, while a magnetic resonance imaging of her brain suggested vasculitis. Based on these clinical presentations, she was diagnosed and treated with Hughes-Stovin syndrome.
Conclusion
The majority of cases of Hughes-Stovin syndrome are reported among men, with only two cases occurring in women. A case of Hughes-Stovin syndrome occurring in a woman is presented in this report. She was treated successfully with multimodality treatment that includes surgery, steroids and cytotoxic agents.
doi:10.1186/1752-1947-4-109
PMCID: PMC2864281  PMID: 20409300
24.  Concurrent pulmonary zygomycosis and Mycobacterium tuberculosis infection: a case report 
A non-smoking 77-year old gentleman of Indian origin was admitted with a 4-month history of intermittent night sweats, haemoptysis and 6 kg of weight loss. CT scan of thorax demonstrated a 2.5 cm mass in the right middle lobe with multiple small nodules within the right lung and confirmed the presence of mediastinal and hilar lymph nodes.
Fibreoptic bronchoscopy demonstrated a distorted right main bronchus, anterior shift of the right upper lobe and occlusion of the right middle lobe bronchus with a black necrotic ulcer. Mycobacterium tuberculosis was found in the bronchoalveolar lavage and histology demonstrated numerous fungal hyphae with a morphological appearance of zygomycetes within necrotic areas of tissue. Medical management with anti-fungal and anti-mycobacterial treatment was instigated as the patient's pre-existing IHD did not permit surgical intervention. Subsequently CT imaging following completion of therapy demonstrated improvement of the mass and a resolution of the associated nodules. The patient has been followed for 6 months to date and there has been no recurrence of symptoms. Recent bronchoalveolar lavage cultures have been negative for M. tuberculosis and zygomycetes.
doi:10.1186/1752-1947-1-17
PMCID: PMC1868082  PMID: 17477864
25.  Multifocal Extranodal Involvement of Diffuse Large B-Cell Lymphoma 
Case Reports in Pulmonology  2013;2013:794642.
Endobronchial involvement of extrapulmonary malignant tumors is uncommon and mostly associated with breast, kidney, colon, and rectum carcinomas. A 68-year-old male with a prior diagnosis of colon non-Hodgkin lymphoma (NHL) was admitted to the hospital with a complaint of cough, sputum, and dyspnea. The chest radiograph showed right hilar enlargement and opacity at the right middle zone suggestive of a mass lesion. Computed tomography of thorax revealed a right-sided mass lesion extending to thoracic wall with the destruction of the third and the fourth ribs and a right hilar mass lesion. Fiberoptic bronchoscopy was performed in order to evaluate endobronchial involvement and showed stenosis with mucosal tumor infiltration in right upper lobe bronchus. The pathological examination of bronchoscopic biopsy specimen reported diffuse large B-cell lymphoma and the patient was accepted as the endobronchial recurrence of sigmoid colon NHL. The patient is still under treatment of R-ICE (rituximab-ifosfamide-carboplatin-etoposide) chemotherapy and partial regression of pulmonary lesions was noted after 3 courses of treatment.
doi:10.1155/2013/794642
PMCID: PMC3789283  PMID: 24159403

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