SESSION TYPE: Pleural Global Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Hemoptysis complicating paracentesis had been described with dry tap, we were able to find one case report of thoracentesis leading to fatal massive hemoptysis in the literature. The hemoptysis is usually caused by puncture of the lungs and puncture sites had been found on postmortem exam, it is unusual to get this complication with successful removal of pleural fluid when the lung is atelectatic.

CASE PRESENTATION:

79 YEAR OLD FEMALE WITH STAGE 4 LUNG CANCER NSCLCA WITH MALIGNANT PLEURAL EFFUSION, PRESENTED WITH DYSPNEA AND HYPOXEMIA AND ACCUMILATION OF RIGHT SIDED MASSIVE PLEURAL EFFUSION LEADING TO ATELECTASIS OF THE LEFT LUNG is 79-year-old female with stage IV non-small cell lung CA bronchogenic carcinoma with malignant pleural effusion, presented with dyspnea and hypoxemia, chest x-ray showed massive right-sided pleural effusion, with complete right lung atelectasis, the patient had mild episodes of hemoptysis which was attributed to the bronchogenic carcinoma, the patient was hemodynamically stable, nevertheless, her breathing was labored, and needed 60% oxygen supplement by Venturi mask, on a lateral decubitus chest x-ray film, the pleural fluid was freely floating in the pleural space, the patient underwent right thoracentesis with removal of 1000 cc of serous sanguinous pleural fluid, there was no blood through the needle upon entering the pleural space, the patient's dyspnea improved towards the end of the thoracentesis procedure, and the patient lied in bed comfortably, 5 minutes following the procedure the patient started coughing with large amounts of blood rushing through the airways, attempts to intubate the patient failed secondary to obscuring of the airways by the massive hemoptysis, the patient desaturated quickly, became bradycardic, and developed asystolic cardiac arrest, the family elected not to pursue CPR, patient expired.

DISCUSSION:

THIS UNEXPECTED COMPLICATION LEAD TO THE THINKING THAT LARGE VOLUME THORACENTESIS FOR MASSIVE PLEURAL EFFUSION MAY LEAD TO COMPLICATIONS RELATED TO THE REEXPANSION OF THE ATELECTATIC LUNG, WHICH IS NOT LIMITED TO REEXPANSION PULMONARY EDEMA . The mechanism of hemoptysis in this patient was thought not to be secondary to needle puncture of the lungs, rather, relieving a tympanotomy and pressure exerted by the malignant massive pleural effusion on the bronchogenic carcinoma, once the tympanotomy and pressure was relieved by thoracentesis, hemoptysis occurred. There had been a description of one case in the literature where the patient developed massive fatal hemoptysis. 3 minutes following a dry pleural tap. The cause of hemoptysis was described as direct puncture of the lungs, and puncture sites were found on the posterior surface of the lungs on the postmortem examination, in our case, there was massive pleural effusion, which provided a good distance between the needle and the lungs making the lung. Posterior much less likely, and our tap was not dry, on the contrary, large volume of fluid was removed with improvement of the patient's sense of dyspnea, since the patient did not get the postmortem exam is very difficult to determine whether the mechanism postulated of the sudden release of tympanotomy and pressure exerted by me pleural effusion had led to the decompression of the Brooklyn genic carcinoma, leading to the massive hemoptysis

CONCLUSIONS:

ALTHOUGH THIS IS AN UNUSUAL PRESENTATION AND COMPLICATION, ONME CAN LEARN TO BE CAREFUL WITH LARGE VOLUME THORACENTESIS IN A PATIENT WITH MALIGNANTPLEURAL EFFUSION AND HISTORY OF HEMOPTYSIS although this is an unusual presentation and complication of large-volume thoracentesis and malignant pleural effusions, one can learn to be more careful with the removal of pleural fluid and a patient with endobronchial extension of malignant neoplasms who had history of hemoptysis, insertion of the pigtail tube, and gradual removal of fluid may be preferred to large-volume thoracentesis in such patients, more research is needed to confirm this hypothesis.1) Seneff MG, Corwin RW, Gold LH, Irwin RS: Complications associated with thoracocentesis. Chest 1986; 90:97-1002) Virshup B, Coombs RH: Physicians' adjustment to retirement. West J Med 1993; 158: 142-1443) Collins TR, Sahn SA: Thoracocentesis: Clinical value, complications, technical problems, and patient experience. Chest 1987; 91:817-822DISCLOSURE: The following authors have nothing to disclose: Islam IbrahimNo Product/Research Disclosure InformationIMC, Jeddah, Saudi Arabia.

SESSION TYPE: Miscellaneous Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Pancoast's syndrome is characterized by a mass of the superior sulcus of the lung and involvement of the brachial plexus and cervical sympathetic nerves. Apical bronchial carcinoma is the most common cause of Pancoast's syndrome. Of the many other causes reported, infection is a rare one. A case of Pancoast's syndrome, secondary to apical lung abcess is reported.

CASE PRESENTATION:

45-year-old Caucasian female with past medical history including type 2 diabetes, hypertension, dyslipidemia, who presented to ED with increasing malaise, fatigue, weakness, and right-sided chest pain, neck pain and shortness of breath. Her chest x-ray on admission revealed no abnormalities. She was treated with pain medication. Her symptoms persisted. She had a CTA of the Chest which revealed a soft tissue mass located at the right lung apex medially and abuts the trachea, esophagus, and adjacent vertebral body. CT soft tissue of the neck revealed right apical lung mass, which is partially contiguous with the right scalene musculature. Patient complained of right hand numbness and weakness, for which MRI of the neck was done and confirmed earlier findings. Bronchoscopy showed normal endobronchial tree, and an ultrasound guided transbronchial needle aspiration of the right upper lobe mass was negative for malignant cells. Aspirate from the mass grew Streptococcus Viridans. Patient treated wit antibiotics and underwent anterior neck exploration of the right apical lung mass to relieve her brachioplexopathy

DISCUSSION:

Pancoast's syndrome includes Horner's syndrome, atrophy of he hand muscles and shoulder, axilla or arm pain. This syndrome is caused by an apical thoracic lesion, most commonly a bronchogenic carcinoma. Causes of Pancoast's syndrome not related to malignancy are recognized. Among the benign conditions causing Pancoast's syndrome, infections are extremely rare. A wide variety of organisms were identified but no single organism could be labeled as the most prevalent. Overall, bacteria (54.8%) seem to be the most common organisms with S aureus being the most frequent of these. Infection is a treatable etiology of Pancoast's syndrome.

CONCLUSIONS:

Infection is a treatable etiology of Pancoast's syndrome.1) Pancoast's Syndrome Secondary to Infectious Etiologies: A Not So Uncommon Occurrence Heath D. White, DO, MS, Bobbie Ann A. White, MA, Carl Boethel, MD and Alejandro C. Arroliga, MD. Send to: Pancoast's syndrome secondary to infectious etiologies: a not so uncommon occurrence. White HD, White BA, Boethel C, Arroliga AC. Am J Med Sci. 2011 Apr;341(4):333-6.2) Mehrotra A, Raj A, Tripathi K. Apical pulmonary tuberculosis presenting with Pancoast syndrome like features. J Assoc Physicians India 2001;49:380-13) Comet R, Monteagudo M, Herranz S, et al. Pancoast's syndrome secondary to lung infection with cutaneous fistulisation caused by Staphylococcus aureus. J Clin Pathol 2006;59:997- 8.DISCLOSURE: The following authors have nothing to disclose: Anas AlsadiNo Product/Research Disclosure Information, Temple, TX.

SESSION TYPE: Cancer Cases IPRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION:

Granular cell tumors (GCTs) are generally benign neoplasms of neuronal origin. They can occur in many organ systems, but rarely involve the lung; 6% of pulmonary GCTs are endobronchial. Here we report a GCT involving the left upper lobe bronchus in a patient found to have metastatic adenocarcinoma of the lung. To our knowledge, this is the 8th case of pulmonary GCT coexisting with lung cancer reported in the literature.

CASE PRESENTATION:

A 60-year-old African-American male presented with progressively worsening left supraclavicular pain radiating to the back and arm for several months. He noted weight loss, productive cough with occasional hemoptysis, and fatigue. He had a 100 pack/year smoking history. The only finding on examination was left supraclavicular tenderness without palpable adenopathy. Chest X-ray suggested a left upper lobe nodule. CT scan showed a noncalcified lesion in the upper lobe measuring 3cm. A second nodule was seen in the right lung apex measuring 2.4cm with adjacent cystic changes. Emphysema was noted. No endobronchial lesions were seen. Bronchoscopy revealed submucosal bulging in a tubular shape, measuring approximately 2cm in length, involving the left upper lobe bronchus (figure 1). Endobronchial biopsy revealed GCT. Immunohistochemical stains were reactive for S-100 and NSE. MRI of the neck showed extensive tumor involvement of the cervical and upper thoracic spine infiltrating the brachial plexus, left greater than right. CT-guided needle biopsy of the left upper lobe lesion showed poorly differentiated pulmonary adenocarcinoma. Chemotherapy and radiation were planned.

DISCUSSION:

GCTs rarely occur in the lung, and a minority of these is found in the airway. Simultaneous endobronchial and peripheral lesions have been reported. Typical endobronchial appearance is that of a solitary, discrete, nodular mass that is pale pink, gray, or yellow. It may be polypoid or pedunculated. The tumor is covered by a thin layer of bronchial epithelium, which accounts for the high diagnostic yield on forceps biopsy. In our case, the appearance was that of a submucosal bulging tumor in a tubular shape, which is uncharacteristic. Endobronchial GCTs may lead to obstruction or hemoptysis, but may also be asymptomatic and found incidentally on bronchoscopy. Our patient had coexisting metastatic adenocarcinoma of the lung. Seven cases of pulmonary GCT coexisting with lung cancer have been reported (4 adenocarcinoma, 2 squamous cell carcinoma and 1 small cell carcinoma).

CONCLUSIONS:

It is unclear if GCTs and lung cancer have a shared etiology, such as smoking, but the relationship deserves further study.1) Gabriel JB Jr., Thomas L, Mendoza CB, Chauhan PM. Granular cell tumor of the bronchus coexisting with a bronchogenic adenocarcinoma: A case report. J Surgic Onc. 1983;24(2):103-106.2) Hernandez OG, Haponik EF, Summer WR. Granullar cell tumor of the bronchus: bronchoscopic and clinical features. Thorax 1986;41(12):927-931.DISCLOSURE: The following authors have nothing to disclose: Eduardo Andre, Craig Thurm, Kelly Cervellione, Sicong Ren, Kunal PatelNo Product/Research Disclosure InformationJamaica Hospital Medical Center, Jamaica, NY.

SESSION TYPE: Cancer Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

We report a case of hypoxic respiratory failure caused by pneumonic type primary bronchogenic adenocarcinoma with extensive metastasis to contralateral lung in the absence of extra-pulmonary metastasis.

CASE PRESENTATION:

A 53 year old Hispanic man with no significant past medical history was admitted with progressive dyspnea on exertion of 5 weeks duration. This was associated with a significant weight loss, productive clear cough and low grade fever. His symptoms shortly started after a trip to Mexico. On examination he had decrease breath sounds in the left side. Chest Radiography (CXR) was positive for consolidation on the left upper lobe with multiple bilateral small pulmonary nodular opacities, Computerized tomography (CT) scan of the chest identified Innumerable randomly distributed pulmonary nodules in both lungs and dense airspace consolidation within the left upper lobe. Bronchoalveolar lavage ruled out Tuberculosis and other infections but was positive for atypical cells. Left upper lobe trans-bronchial lung biopsies were positive for invasive poorly differentiated adenocarcinoma with tumor cells completely occupying and obliterating the alveolar spaces. Staging work up did not show any other organ involvement. The patient was referred for oncology however shortly after that he progressed to hypoxic respiratory failure and died 4 weeks after the diagnosis.

DISCUSSION:

This case has an uncommon presentation with a consolidation however the unique findings is that of widespread and likely aerogenic metastatic bronchogenic adenocarcinoma to both lungs causing respiratory failure with no extra-pulmonary metastasis. Tumor presentation as an airspace consolidative lesion is a atypical but well-recognized pattern of adenocarinoma formaly named "bronchiolo-alveolar carcinoma". In this unique case the tumor had metastasized extensively to both lungs with no extra pulmonary metastasis in autopsy supporting the argument for possible aerogenic metastasis

CONCLUSIONS:

Physicians should be aware of atypical presentation of tumors and consider adencarnioma in the differential of non-resolving consolidation even in the absence of mass lesion. Our case may possibly represent an aerogenic spread of tumor cells to the ipsilateral and contralateral lungs.1) William D. Travis, Brambilla E, Noguchi, M et al. International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society: International Multidisciplinary Classification of Lung Adenocarcinoma: Executive Summary Proc Am Thorac Soc 2011; 8: 381-385.2) Gandara DR, Aberle D, Lau D, et al. Radiographic imaging of bronchioloalveolar carcinoma: screening, patterns of presentation and response assessment. J Thorac Oncol. 2006 Nov;1(9 Suppl):S20-6.DISCLOSURE: The following authors have nothing to disclose: Bashar Farjo, Anandhi Murugan, Weissferdt AnnikkaNo Product/Research Disclosure InformationUniversity of Texas, Health Science Center, Houston, TX.

SESSION TYPE: Lung Cancer Posters IIPRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE:

Lung cancer problem in Egypt is not yet well estimated. The present study was conducted to identify some features of bronchogenic carcinoma regarding risk factors, clinical presentations, radiological findings, diagnostic procedures, histopathological types and clinical staging.

METHODS:

A total of 212 patients (101 cases and 111 controls) were studied at Alexandria Main University Hospital (MUH). The cases were included when lung cancer diagnosis was confirmed by tissue diagnosis. The controls were patients who had no lung disease or cancer lesion at the time of the study. Both cases and controls were subjected to a predesigned questionnaire, while the cases were subjected to clinical, radiological examination, tissue biopsy and clinical staging.

RESULTS:

Smoking was the most important risk factor as ever smoker carried more than 7 times risk. Duration of smoking was more risky than number of packs smoked per day. Males, elderly people and urban residents had about 3 times increased risk. Exertional dyspnea was the commonest manifestation. Bronchoscopy was the commonest procedure performed to diagnose central tumor while transthoracic needle biopsy diagnosed most of peripheral tumors. Pleural effusion was present in one third of the cases but malignant pleural effusion was confirmed in 72% of them. Thoracoscopy was used to diagnose some of the cases with malignant pleural effusion secondary to lung cancer. Large cell carcinoma was the commonest histopathological type followed by squamous cell carcinoma.Long duration of smoking was the commonest factor related to the late presentation of most of the cases.

CONCLUSIONS:

Features of bronchogenic carcinoma in our study population are similar to those present worldwide regarding risk factors, clinical and radiological presentation. However we have found a unique distribution of histopathological types. There is a delay in presentation and management of most of our cases.

CLINICAL IMPLICATIONS:

Unusual incidence of large cell carcinoma deserves further investigations. The burden of environmental pollutants especially industrial one has to be well studied. Health education and multidisciplinary teamwork are essential for better management of lung cancer.DISCLOSURE: The following authors have nothing to disclose: Eman Mohammad, Mohammad ElHofy, Mahmoud Mahmoud, Mohamed Samy Atta, Ali HasabNo Product/Research Disclosure InformationUniversity of Alexandria, Faculty of Medicine, Chest Diseases Department, Alexandria, Egypt.

SESSION TYPE: Bronchology Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

The granular cell tumors (GCT) was first described by Abrikossoff in 1926. Early classification of GCT as a myoblastic origin has been discarded; it was reclassified in 1974 as neuronal tumors with similarity to schwannomas, with positive S100 staining. GCT usually occurs in midlife, are predominantly solitary. Only 6-10% of them are found as endobronchial lesions, usually distributed in central and peripheral airways, along the bifurcation of the bronchus. Although rare, Malignant GCT (MGCT) has been described. Only 6 GCT cases have been described to be associated with bronchogenic carcinoma in the literature.

CASE PRESENTATION:

45 year old female, with discoid lupus, was referred to chest clinic for evaluation of worsening chronic cough, productive of yellow sputum especially at night, with 15 pound weight loss over last year. She has 15 pack years of smoking history, along with exposure to secondary smoke. Her surgical history was significant for resection of a posterior pharyngeal mass in 2006 diagnosed as GCT. PFT showed mild obstruction. Radiographic studies revealed bilateral emphysematous changes, predominant in upper lobes. Nodules 0.8cm in left upper lobe and 1.3cm in right upper lobe, both with spiculated margins, and with increased uptake on PET. No mediastinal lymph node involvement. Bronchoscopy revealed 10 mm serpengenous, yellow colored endobronchial lesion in the RUL anterior segment. Pathology revealed polygonal spindle shaped cells with granular cytoplasm, which was positive for Immunohistochemical stain with S100. Cytobrush and bronchoalveolar lavage were negative for malignant cells. Biopsy of both tumors showed adenocarcinoma which were surgically removed. Patient unfortunately has local right sided chest wall recurrence and is undergoing chemo- radiotherapy.

DISCUSSION:

Pulmonary GCTs are uncommon and predominantly benign. MGCT is a rarer disease entity that was described in 1945. Since the originally described case, 42 additional MGCTs have been reported in various body sites, with only one case reported to involve the lungs. In most cases there is a smoking history but no established causal relationship. The coexistence of GCTs with bronchogenic carcinoma is rare, without a specific cell type predominance. Treatment of pulmonary GCTs is primarily surgical resection, with no role for medical therapy. Watchful waiting in asymptomatic cases is also a suggested approach.

CONCLUSIONS:

Our case adds to the sparse literature on pulmonary GCT, and is unique in that it is associated with bilateral primary bronchogenic carcinoma.1) Pulmonary Granular Cell Tumor Coexisting With Bronchogenic Carcinoma R.T. Cutlan, MD. Ann Diagn Pathol 5: 74-79, 20012) Pulmonary malignant granular cell tumor. Ming Jiang World J Surg Oncol. 2003 Oct 21;1(1):22DISCLOSURE: The following authors have nothing to disclose: Shivanck Upadhyay, Sunil Dhunna, Peter SpiroNo Product/Research Disclosure InformationColumbia University at Harlem Hospital Center, New York, NY.

Background:

Lung cancer is the most frequent cancer among men and second highest among women overall, including in Turkey. Cigarette smoking is the most important etiologic factor for the development of cancer in both men and women.

Objective:

To determine the lung cancer incidence in Northeastern Anatolia Region of Turkey with a focus on clinical properties, cancer subtypes, the relationships of tumors with cigarette smoking and radiological properties of the lesions. Materials and

Methods:

In a retrospective study design, 566 lung cancer cases diagnosed at the Pathology Department of Ataturk University in Erzurum over the last seven years extending from January 2006 to June 2012 were investigated. The results were compared with statistical analyses.

Results:

The most common histopathological subtype of primary bronchogenic carcinoma in our study was found to be the squamous cell carcinoma, 46.1% (261 out of 566), and the second was small cell lung carcinoma 15.7% (89 out of 566). Based on our data, an overall male predominance was noted with a male/female ratio of 6.1/1. While 296 (52.2%) of the patients were found to be smokers at the time of diagnosis, 125 (22.0%) were nonsmokers and 145 (25.6%) were ex-smokers. Smoking status was found to have a strong correlation with primary lung cancer (p <0.05), and there were significant differences between males and females (p<0.001).

Conclusion:

Although relative prominence of subtypes of lung cancers differ between Turkish and other populations, lung cancer overall remains as an important health problem in Turkey. Our findings stress the critical need for effective cancer prevention programs such as anti-smoking campaigns.

Non-resolving pneumonia is often an area of concern for pulmonologists. Fiber optic bronchoscopy (FOB) may have a special role in etiologic evaluation of non-resolving pneumonias. There is paucity of recent studies in this field.This study aimed to assess the patients of non-resolving or slowly resolving pneumonia with special emphasis on efficacy of FOB and computed tomography (CT)-guided fine needle aspiration cytology (FNAC) in diagnosis.Prospective, observational study conducted in a tertiary care institute over a period of one year.After fulfilling the definition of non-resolving pneumonia by clinical and radiological parameters, patients were evaluated by FOB with relevant microbiological, cytological, histopathological investigations and CT scan of thorax. CT-guided FNAC was done in selected cases where FOB was inconclusive.Sixty patients were enrolled in the study. Mean age was 51.33 ± 1.71 years with male to female ratio 2:1. Right lung was more commonly involved (65%), and right upper lobe was the commonest site (25%). Pyogenic infection was the commonest etiology (53.3%), bronchogenic carcinoma and tuberculosis accounted for 26.7% and 16.7% cases, respectively. Both, FOB (85.7%) and CT-guided FNAC (91.67%) were very useful for etiological diagnosis of non-resolving pneumonia. Both the procedures were safe, and no major complication was observed.Because of the high yield of FOB, it is very useful and safe diagnostic tool for evaluation of non-resolving pneumonia. CT-guided FNAC also gives good yield when cases are properly selected.