Endobronchial ultrasound-guided sheath placement to guide transbronchial biopsy of mediastinal lymphadenopathy and lung mass: a new technique.

A patient with a history of lung adenocarcinoma, which was treated with chemoradiation, presented to our interventional pulmonology clinic for suspicion of recurrent lung cancer. The patient had a PET-avid right upper-lobe mass and subcarinal lymphadenopathy. We performed a curvilinear endobronchial ultrasound (CP-EBUS) with transbronchial needle aspiration (TBNA), followed by transbronchial EBUS-guided biopsies (TBB) of the subcarinal lymph node using miniforceps. The EBUS needle sheath was inserted over the needle through the bronchial wall and advanced into the lymph node. The EBUS-guided placement of the transbronchial sheath facilitated the miniforcep insertion and the performance of multiple transbronchial biopsies. Given success with this method, we further developed this technique in a second patient with a right lower-lobe mass. In an effort to obtain adequate tissue and minimize repeated efforts at miniforcep guidance into the lesion, we inserted a radial EBUS guide sheath through the curvilinear EBUS scope and guided it into the lesion using the miniforceps. We therefore used the radial sheath as a placeholder while obtaining repeated TBB using miniforceps as described. These modifications of previously described techniques allow for maximal and expeditious sampling of target lymph nodes and masses, with sufficient material obtained for histopathologic analysis.

Short-term Placement of Multiple Self-expandable Metallic Stents for the Treatment of Bilateral Bronchial Dehiscences Complicating Lung Transplantation.

Bronchial dehiscence after lung transplantation is a rare complication yet has high morbidity and mortality. The majority of the patients are not surgical candidates. We present the case of a 59-year-old man with bilateral lung transplantation for interstitial pulmonary fibrosis who was readmitted with symptoms of acute rejection and severe hypoxemic respiratory failure on day 14. Bronchoscopy showed bilateral bronchial anastomotic dehiscences. A computerized tomography scan showed evidence of significant peribronchial air collection in the pleural space and the mediastinum. Owing to a high predictive operative mortality, endobronchial management was planned, and 3 uncovered self-expanding metallic stents (Ultraflex, Boston Scientific Corp) were placed (in the left main stem bronchus, the anterior segment of the right upper lobe, and the right intermediate bronchus). At 5 weeks bronchoscopy showed complete healing of the dehiscences with granulation. The stents were then removed by rigid bronchoscopy. Three weeks after the stent removal a bronchoscopic examination showed a normal tracheobronchial tree except for a slightly narrowed right anastomosis. We conclude that short-term placement of uncovered self-expanding metallic stents provides a safe and minimally invasive option in the management of bilateral dehiscences.

Endotracheal spindle cell lipoma presenting as a chronic cough.

An elderly gentleman with a chronic cough was found to have a large midtracheal lesion on computed tomography scan. Endotracheal extirpation with an electrocautery snare successfully removed the lesion. Histologic and immunohistochemical analyses revealed the lesion to be a spindle cell lipoma. We provide herein the case presentation and management, the differential diagnosis, and an overview of spindle cell lipoma.