- Email: [email protected]
Closure of a Broncho-to-Neoesophageal Fistula Using an Amplatzer Septal Occluder Device
2010
CASE REPORT GREEN ET AL AMPLATZER CLOSURE OF AN AIRWAY FISTULA
2. Snell GI, Holsworth L, Fowler S, et al. Occlusion of a bronchocutaneous fistula with endobronchial one-way valves. Ann Thorac Surg 2005;80:1930 –2. 3. Waseem M, Jones J, Brutus S, et al. Giant bulla mimicking pneumothorax. J Emerg Med 2005;29:155– 8. 4. Oey IF, Peek GJ, Firmin RK, Waller DA. Post-pneumonectomy video-assisted thoracoscopic bullectomy using extra-corporeal membrane oxygenation. Eur J Cardiothorac Surg 2001;20:874 – 6. 5. Macarthur AM, Fountain SW. Intracavity suction and drainage in the treatment of emphysematous bullae. Thorax 1977; 32:668 –72. 6. Feller-Kopman D, Bechara R, Garland R, et al. Use of a removable endobronchial valve for the treatment of bronchopleural fistula. Chest 2006;130:273–5. 7. Toma TP, Kon OM, Oldfield W, et al. Reduction of persistent air leak with endoscopic valve implants. Thorax 2007;62: 830 –3. 8. Watanabe Y, Matsuo K, Tamaoki A. Bronchial occlusion with endobronchial Watanabe spigot. J Bronchol 2003;10:264 –7. 9. Tacconelli E, Smith G, Hieke K, et al. Epidemiology, medical outcomes and costs of catheter-related bloodstream infections in intensive care units of four European countries: literature- and registry-based estimates. J Hosp Infect 2009; 72:97–103.
Closure of a Broncho-toNeoesophageal Fistula Using an Amplatzer Septal Occluder Device David A. Green, MD, William B. Moskowitz, MD, and R. Wesley Shepherd, MD FEATURE ARTICLES
Divisions of Pulmonary and Critical Care Medicine and Pediatric Cardiology, Virginia Commonwealth University Health System, Richmond, Virginia
Fistulas between the airways and the digestive tract are a rare complication of esophagectomy. We describe such a fistula complicated by recurrent pneumonia. We successfully closed the fistula with an Amplatzer Septal Occluder (AGA Medical Corp, Plymouth, MN), a nitinol device designed for percutaneous closure of congenital heart defects. The device was deployed under direct visualization through rigid bronchoscopy. (Ann Thorac Surg 2010;89:2010 –2) © 2010 by The Society of Thoracic Surgeons
Ann Thorac Surg 2010;89:2010 –2
nocarcinoma of the esophagus 14 months earlier. He subsequently underwent primary radiotherapy and chemotherapy, followed by transhiatal esophagectomy with tubularization of the stomach into a neoesophagus. A jejunostomy tube was placed and served as the primary nutrition route for the duration of his care. He was hospitalized with aspiration pneumonia 4 months after the esophagectomy. A chest computed tomography (CT) scan and a barium esophagram revealed a fistula between the right mainstem bronchus (RMB) and the neoesophagus (Fig 1). Esophagoscopy could not be performed because of stricture at the surgical anastomosis in the cervical esophagus. Flexible bronchoscopy revealed a 6-mm fistula in the medial wall of the RMB at the level of the right upper lobe bronchus (Fig 2). The surrounding mucosa appeared healthy, with no suggestion of recurrent malignancy or necrosis. The fistula was traversed with the bronchoscope, confirming a direct communication with the neoesophagus. The patient was too debilitated to undergo surgical repair of the fistula. Initial treatment was attempted with an uncovered self-expanding metallic stent (Ultraflex, Boston Scientific, Natick, MA). The fistula was directly opposite the right upper lobe bronchus; thus, a covered stent could not be used because it would have occluded the upper lobe bronchus. We anticipated that the stent would induce granulation tissue and result in closure of the fistula, as described elsewhere [2, 3]. Surveillance bronchoscopy 1 month later revealed appropriate stent position with mucosal inflammatory changes at the fistula opening in the RMB but no change in diameter of the fistula. The patient was hospitalized 3 weeks later with right lower lobe pneumonia, respiratory failure, and septic shock. Flexible bronchoscopy revealed continuous leakage of secretions from the fistula into the airways of the right lower lobe. After clinical stabilization, the patient underwent rigid bronchoscopy to remove the metallic stent. A guidewire was advanced across the fistula. Under visualization through the rigid video telescope, an Am-
B
enign fistulas between the central airways and the neoesophagus are a rare complication of esophagectomy, occurring in less than 1% of cases [1]. The resulting recurrent bronchopneumonia can be life threatening. There is no standardized treatment for benign fistulas that develop after esophagectomy. Reports of management range from observation to stenting to resection of the neoesophagus with colonic interposition [1]. A 69-year-old man was referred to our interventional pulmonology service for evaluation of a tracheoesophageal fistula. The patient had been diagnosed with ade-
Accepted for publication Nov 12, 2009. Address correspondence to Dr Shepherd, Virginia Commonwealth University Health System, PO Box 980050, 1200 E Broad St, Richmond, VA 23298; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Axial computed tomography of the chest shows the fistula between the neoesophagus and the right mainstem bronchus (arrow). 0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.11.046
Fig 2. Flexible bronchoscopy image shows the fistula track in the medial wall of the right mainstem bronchus (arrow).
platzer Septal Occluder (AGA Medical Corp, Plymouth MN) with an 18-mm distal (neoesophageal) disk, a 6-mm waist, and a 14-mm proximal (bronchial) disk was advanced over the guidewire and across the fistula. The distal disk was expanded in the neoesophagus and the device was pulled snug against the wall with its waist across the fistula. The proximal disk was then expanded in the RMB. After deployment, all major airways were patent and right lower lobe bronchial contamination from the fistula ceased (Fig 3). The patient was subsequently liberated from mechanical ventilation and discharged home. He had no coughing, chest pain, hemop-
CASE REPORT GREEN ET AL AMPLATZER CLOSURE OF AN AIRWAY FISTULA
2011
Fig 4. Sagittal oblique computed tomography scan of the chest shows the Amplatzer Septal Occluder device (AGA Medical Corp, Plymouth, MN) is appropriately positioned between the neoesophagus and the right mainstem bronchus (arrow).
tysis, or other symptoms attributable to the Amplatzer device. The patient was readmitted 4 weeks later with altered mental status after dilation of his upper esophageal stricture. His blood cultures grew Streptococcus milleri, and a CT of the head revealed multiple brain abscesses. Aspiration pneumonia and respiratory failure developed during treatment, requiring mechanical ventilation. We believe this aspiration was through his upper airway and due to delirium, because a CT scan of the chest and repeat flexible bronchoscopy revealed good position of the Amplatzer device, with no evidence of leak at the fistula site (Fig 4). The patient was subsequently transitioned to comfort-focused care and died 2 weeks later. A postmortem examination of the patient was declined by the patient’s family.
Comment
Fig 3. Rigid bronchoscopy image shows the Amplatzer Septal Occluder device (AGA Medical Corp, Plymouth, MN) deployed across the fistula track in the medial wall of the right mainstem bronchus.
The Amplatzer Septal Occluder is a biocompatible dualdisk device composed of nitinol metal and polyester fabric. It is designed for percutaneous deployment in the closure of atrial septal defects. The variety of sizes available and established efficacy make the Amplatzer device suitable for use in the airways. Advantages of this device are the complete mechanical seal that it produces over the defect and possible induction of tissue granulation to facilitate long-term closure. In the heart, the Amplatzer device is covered by endothelium after 3 to 6 months. At bronchoscopy 4 weeks after deployment in our patient, the device appeared to have been covered by airway mucosa. Our review of the literature yielded three reports
FEATURE ARTICLES
Ann Thorac Surg 2010;89:2010 –2
2012
CASE REPORT BENIGN CCTL
HAN ET AL
(totaling 4 patients) in which Amplatzer devices were used in the airways to close bronchopleural and esophagorespiratory fistulas [4 – 6]. In this report, we describe the use of rigid bronchoscopy to deploy an Amplatzer device for closure of an acquired benign fistula between the airways and digestive tract. Because of the size of the deployment device, rigid bronchoscopy was necessary for simultaneous placement of the Amplatzer device and the telescopic camera into the airway. This enabled direct visualization of the deployment as well as confirmation that airway contamination had ceased once the fistula was closed.
References
FEATURE ARTICLES
1. Buskens CJ, Hulscher JB, Fockens P, Obertop H, van Lanschot JJ. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy. Ann Thorac Surg 2001;72:221– 4. 2. Mughal MM, Gildea TR, Murthy S, Pettersson G, DeCamp M, Mehta AC. Short-term deployment of self-expanding metallic stents facilitates healing of bronchial dehiscence. Am J Respir Crit Care Med 2005;172:768 –71. 3. Ranes JL, Budev MM, Murthy S, Mehta AC. Management of tracheomediastinal fistulas using self-expanding metallic stents. J Thorac Cardiovasc Surg 2006;131:748 –9. 4. Kramer MR, Peled N, Shitrit D, et al. Use of Amplatzer device for endobronchial closure of bronchopleural fistulas. Chest 2008;133:1481– 4. 5. Golbin JM, Prakash UB. Closure of a bronchopleural fistula using an Amplatzer Septal Occluder Device. Chest 2006;130(4 suppl):291S. 6. Rabenstein T, Boosfeld C, Henrich R, Ell C. First use of ventricular septal defect occlusion device for endoscopic closure of an esophagorespiratory fistula using bronchoscopy and esophagoscopy. Chest 2006;130:906 –9.
Benign Clear Cell Tumor of the Lung Bingqiang Han, MM, Gening Jiang, MD, Haifeng Wang, MM, Wenxin He, MM, Ming Liu, MM, and Nan Song, MM
Ann Thorac Surg 2010;89:2012– 4
C
lear cell tumor of the lung (CCTL) was primarily described by Liebow and Castleman in 1963 as an extremely rare benign pulmonary neoplasm [1]. This tumor is also known as a “sugar tumor” because of the abundant periodic acid-Schiff (PAS) staining positive for glycogen in cytoplasm. There have been only sporadic cases of this neoplasm reported in the world literature; therefore, we have limited information regarding this neoplasm. We present a case of CCTL and discuss the clinical and pathologic features of the tumor. A 51-year-old man was admitted to our hospital for an abnormal pulmonary nodule on the left lung, which was occasionally found on chest roentgenogram during routine examinations. A chest computed tomographic scan showed a solitary nodule of approximately 15 mm in diameter in the lingular segment of the left upper lobe, with round and smooth margins, uniform internal density, and a CT value of 15 Hounsfield Units. There was no sign of lobulation or spicules (Fig 1). Fiberoptic bronchoscopy showed no stenosis of the bronchi and was negative with brush biopsy. There were no significant findings in physical examinations and laboratory studies. The patient underwent wedge resection by videoassisted thoracoscopic surgery, but later a lobectomy was performed by thoracotomy because a frozen section study of the tumor was prone to borderline tumor or low-grade malignancy. Mediastinal lymph nodes (groups 5 to 7 and 9 to 11) were conventionally scavenged. Histologic examination revealed that the cytoplasm contained abundant glycogen granules observed by PAS staining. Light microscopy showed the tumor cells were round or irregular in shape and rich in transparent cytoplasm. The nuclei were small with uniform chromatin and without mitotic figures or necrosis. The tumor cells were arranged in a sheet with affluent capillaries and irregular sizes of thin-walled sinusoid (Fig 2). The immunohistochemical studies showed the tumor expressed human melanoma black (HMB)-45 (Fig 3), vi-
Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
Clear cell tumor of the lung is a rare benign tumor. Herein, we present a case of a 51-year-old man who had an abnormal pulmonary nodule occasionally found on chest roentgenogram. A computed tomographic scan showed a solitary nodule (approximately 15 mm in diameter) in the lingular segment of the left upper lobe. The patient underwent a lobectomy for the tumor. The pathologic report supported the diagnosis of clear cell tumor of the lung. The patient showed no evidence of recurrence or metastasis 2 years postoperatively. (Ann Thorac Surg 2010;89:2012– 4) © 2010 by The Society of Thoracic Surgeons Accepted for publication Oct 8, 2009. Address correspondence to Dr Jiang, Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, 507 Zheng Min Rd, Shanghai, 200433, China; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. A solitary nodule (approximately 15 mm in diameter) was observed in the lingular segment of the left upper lobe, with round and smooth margins and a uniform internal density of 15 Hounsfield Units (arrow). 0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.10.017
CASE REPORT GREEN ET AL AMPLATZER CLOSURE OF AN AIRWAY FISTULA
2. Snell GI, Holsworth L, Fowler S, et al. Occlusion of a bronchocutaneous fistula with endobronchial one-way valves. Ann Thorac Surg 2005;80:1930 –2. 3. Waseem M, Jones J, Brutus S, et al. Giant bulla mimicking pneumothorax. J Emerg Med 2005;29:155– 8. 4. Oey IF, Peek GJ, Firmin RK, Waller DA. Post-pneumonectomy video-assisted thoracoscopic bullectomy using extra-corporeal membrane oxygenation. Eur J Cardiothorac Surg 2001;20:874 – 6. 5. Macarthur AM, Fountain SW. Intracavity suction and drainage in the treatment of emphysematous bullae. Thorax 1977; 32:668 –72. 6. Feller-Kopman D, Bechara R, Garland R, et al. Use of a removable endobronchial valve for the treatment of bronchopleural fistula. Chest 2006;130:273–5. 7. Toma TP, Kon OM, Oldfield W, et al. Reduction of persistent air leak with endoscopic valve implants. Thorax 2007;62: 830 –3. 8. Watanabe Y, Matsuo K, Tamaoki A. Bronchial occlusion with endobronchial Watanabe spigot. J Bronchol 2003;10:264 –7. 9. Tacconelli E, Smith G, Hieke K, et al. Epidemiology, medical outcomes and costs of catheter-related bloodstream infections in intensive care units of four European countries: literature- and registry-based estimates. J Hosp Infect 2009; 72:97–103.
Closure of a Broncho-toNeoesophageal Fistula Using an Amplatzer Septal Occluder Device David A. Green, MD, William B. Moskowitz, MD, and R. Wesley Shepherd, MD FEATURE ARTICLES
Divisions of Pulmonary and Critical Care Medicine and Pediatric Cardiology, Virginia Commonwealth University Health System, Richmond, Virginia
Fistulas between the airways and the digestive tract are a rare complication of esophagectomy. We describe such a fistula complicated by recurrent pneumonia. We successfully closed the fistula with an Amplatzer Septal Occluder (AGA Medical Corp, Plymouth, MN), a nitinol device designed for percutaneous closure of congenital heart defects. The device was deployed under direct visualization through rigid bronchoscopy. (Ann Thorac Surg 2010;89:2010 –2) © 2010 by The Society of Thoracic Surgeons
Ann Thorac Surg 2010;89:2010 –2
nocarcinoma of the esophagus 14 months earlier. He subsequently underwent primary radiotherapy and chemotherapy, followed by transhiatal esophagectomy with tubularization of the stomach into a neoesophagus. A jejunostomy tube was placed and served as the primary nutrition route for the duration of his care. He was hospitalized with aspiration pneumonia 4 months after the esophagectomy. A chest computed tomography (CT) scan and a barium esophagram revealed a fistula between the right mainstem bronchus (RMB) and the neoesophagus (Fig 1). Esophagoscopy could not be performed because of stricture at the surgical anastomosis in the cervical esophagus. Flexible bronchoscopy revealed a 6-mm fistula in the medial wall of the RMB at the level of the right upper lobe bronchus (Fig 2). The surrounding mucosa appeared healthy, with no suggestion of recurrent malignancy or necrosis. The fistula was traversed with the bronchoscope, confirming a direct communication with the neoesophagus. The patient was too debilitated to undergo surgical repair of the fistula. Initial treatment was attempted with an uncovered self-expanding metallic stent (Ultraflex, Boston Scientific, Natick, MA). The fistula was directly opposite the right upper lobe bronchus; thus, a covered stent could not be used because it would have occluded the upper lobe bronchus. We anticipated that the stent would induce granulation tissue and result in closure of the fistula, as described elsewhere [2, 3]. Surveillance bronchoscopy 1 month later revealed appropriate stent position with mucosal inflammatory changes at the fistula opening in the RMB but no change in diameter of the fistula. The patient was hospitalized 3 weeks later with right lower lobe pneumonia, respiratory failure, and septic shock. Flexible bronchoscopy revealed continuous leakage of secretions from the fistula into the airways of the right lower lobe. After clinical stabilization, the patient underwent rigid bronchoscopy to remove the metallic stent. A guidewire was advanced across the fistula. Under visualization through the rigid video telescope, an Am-
B
enign fistulas between the central airways and the neoesophagus are a rare complication of esophagectomy, occurring in less than 1% of cases [1]. The resulting recurrent bronchopneumonia can be life threatening. There is no standardized treatment for benign fistulas that develop after esophagectomy. Reports of management range from observation to stenting to resection of the neoesophagus with colonic interposition [1]. A 69-year-old man was referred to our interventional pulmonology service for evaluation of a tracheoesophageal fistula. The patient had been diagnosed with ade-
Accepted for publication Nov 12, 2009. Address correspondence to Dr Shepherd, Virginia Commonwealth University Health System, PO Box 980050, 1200 E Broad St, Richmond, VA 23298; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Axial computed tomography of the chest shows the fistula between the neoesophagus and the right mainstem bronchus (arrow). 0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.11.046
Fig 2. Flexible bronchoscopy image shows the fistula track in the medial wall of the right mainstem bronchus (arrow).
platzer Septal Occluder (AGA Medical Corp, Plymouth MN) with an 18-mm distal (neoesophageal) disk, a 6-mm waist, and a 14-mm proximal (bronchial) disk was advanced over the guidewire and across the fistula. The distal disk was expanded in the neoesophagus and the device was pulled snug against the wall with its waist across the fistula. The proximal disk was then expanded in the RMB. After deployment, all major airways were patent and right lower lobe bronchial contamination from the fistula ceased (Fig 3). The patient was subsequently liberated from mechanical ventilation and discharged home. He had no coughing, chest pain, hemop-
CASE REPORT GREEN ET AL AMPLATZER CLOSURE OF AN AIRWAY FISTULA
2011
Fig 4. Sagittal oblique computed tomography scan of the chest shows the Amplatzer Septal Occluder device (AGA Medical Corp, Plymouth, MN) is appropriately positioned between the neoesophagus and the right mainstem bronchus (arrow).
tysis, or other symptoms attributable to the Amplatzer device. The patient was readmitted 4 weeks later with altered mental status after dilation of his upper esophageal stricture. His blood cultures grew Streptococcus milleri, and a CT of the head revealed multiple brain abscesses. Aspiration pneumonia and respiratory failure developed during treatment, requiring mechanical ventilation. We believe this aspiration was through his upper airway and due to delirium, because a CT scan of the chest and repeat flexible bronchoscopy revealed good position of the Amplatzer device, with no evidence of leak at the fistula site (Fig 4). The patient was subsequently transitioned to comfort-focused care and died 2 weeks later. A postmortem examination of the patient was declined by the patient’s family.
Comment
Fig 3. Rigid bronchoscopy image shows the Amplatzer Septal Occluder device (AGA Medical Corp, Plymouth, MN) deployed across the fistula track in the medial wall of the right mainstem bronchus.
The Amplatzer Septal Occluder is a biocompatible dualdisk device composed of nitinol metal and polyester fabric. It is designed for percutaneous deployment in the closure of atrial septal defects. The variety of sizes available and established efficacy make the Amplatzer device suitable for use in the airways. Advantages of this device are the complete mechanical seal that it produces over the defect and possible induction of tissue granulation to facilitate long-term closure. In the heart, the Amplatzer device is covered by endothelium after 3 to 6 months. At bronchoscopy 4 weeks after deployment in our patient, the device appeared to have been covered by airway mucosa. Our review of the literature yielded three reports
FEATURE ARTICLES
Ann Thorac Surg 2010;89:2010 –2
2012
CASE REPORT BENIGN CCTL
HAN ET AL
(totaling 4 patients) in which Amplatzer devices were used in the airways to close bronchopleural and esophagorespiratory fistulas [4 – 6]. In this report, we describe the use of rigid bronchoscopy to deploy an Amplatzer device for closure of an acquired benign fistula between the airways and digestive tract. Because of the size of the deployment device, rigid bronchoscopy was necessary for simultaneous placement of the Amplatzer device and the telescopic camera into the airway. This enabled direct visualization of the deployment as well as confirmation that airway contamination had ceased once the fistula was closed.
References
FEATURE ARTICLES
1. Buskens CJ, Hulscher JB, Fockens P, Obertop H, van Lanschot JJ. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy. Ann Thorac Surg 2001;72:221– 4. 2. Mughal MM, Gildea TR, Murthy S, Pettersson G, DeCamp M, Mehta AC. Short-term deployment of self-expanding metallic stents facilitates healing of bronchial dehiscence. Am J Respir Crit Care Med 2005;172:768 –71. 3. Ranes JL, Budev MM, Murthy S, Mehta AC. Management of tracheomediastinal fistulas using self-expanding metallic stents. J Thorac Cardiovasc Surg 2006;131:748 –9. 4. Kramer MR, Peled N, Shitrit D, et al. Use of Amplatzer device for endobronchial closure of bronchopleural fistulas. Chest 2008;133:1481– 4. 5. Golbin JM, Prakash UB. Closure of a bronchopleural fistula using an Amplatzer Septal Occluder Device. Chest 2006;130(4 suppl):291S. 6. Rabenstein T, Boosfeld C, Henrich R, Ell C. First use of ventricular septal defect occlusion device for endoscopic closure of an esophagorespiratory fistula using bronchoscopy and esophagoscopy. Chest 2006;130:906 –9.
Benign Clear Cell Tumor of the Lung Bingqiang Han, MM, Gening Jiang, MD, Haifeng Wang, MM, Wenxin He, MM, Ming Liu, MM, and Nan Song, MM
Ann Thorac Surg 2010;89:2012– 4
C
lear cell tumor of the lung (CCTL) was primarily described by Liebow and Castleman in 1963 as an extremely rare benign pulmonary neoplasm [1]. This tumor is also known as a “sugar tumor” because of the abundant periodic acid-Schiff (PAS) staining positive for glycogen in cytoplasm. There have been only sporadic cases of this neoplasm reported in the world literature; therefore, we have limited information regarding this neoplasm. We present a case of CCTL and discuss the clinical and pathologic features of the tumor. A 51-year-old man was admitted to our hospital for an abnormal pulmonary nodule on the left lung, which was occasionally found on chest roentgenogram during routine examinations. A chest computed tomographic scan showed a solitary nodule of approximately 15 mm in diameter in the lingular segment of the left upper lobe, with round and smooth margins, uniform internal density, and a CT value of 15 Hounsfield Units. There was no sign of lobulation or spicules (Fig 1). Fiberoptic bronchoscopy showed no stenosis of the bronchi and was negative with brush biopsy. There were no significant findings in physical examinations and laboratory studies. The patient underwent wedge resection by videoassisted thoracoscopic surgery, but later a lobectomy was performed by thoracotomy because a frozen section study of the tumor was prone to borderline tumor or low-grade malignancy. Mediastinal lymph nodes (groups 5 to 7 and 9 to 11) were conventionally scavenged. Histologic examination revealed that the cytoplasm contained abundant glycogen granules observed by PAS staining. Light microscopy showed the tumor cells were round or irregular in shape and rich in transparent cytoplasm. The nuclei were small with uniform chromatin and without mitotic figures or necrosis. The tumor cells were arranged in a sheet with affluent capillaries and irregular sizes of thin-walled sinusoid (Fig 2). The immunohistochemical studies showed the tumor expressed human melanoma black (HMB)-45 (Fig 3), vi-
Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
Clear cell tumor of the lung is a rare benign tumor. Herein, we present a case of a 51-year-old man who had an abnormal pulmonary nodule occasionally found on chest roentgenogram. A computed tomographic scan showed a solitary nodule (approximately 15 mm in diameter) in the lingular segment of the left upper lobe. The patient underwent a lobectomy for the tumor. The pathologic report supported the diagnosis of clear cell tumor of the lung. The patient showed no evidence of recurrence or metastasis 2 years postoperatively. (Ann Thorac Surg 2010;89:2012– 4) © 2010 by The Society of Thoracic Surgeons Accepted for publication Oct 8, 2009. Address correspondence to Dr Jiang, Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, 507 Zheng Min Rd, Shanghai, 200433, China; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. A solitary nodule (approximately 15 mm in diameter) was observed in the lingular segment of the left upper lobe, with round and smooth margins and a uniform internal density of 15 Hounsfield Units (arrow). 0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.10.017