August 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 8/29/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, pathology, radiology, and thoracic surgery communities.

Four cases were presented:

1. Lewis Wesselius and Thomas Colby presented a 39 yo female with cough and small amounts of hemoptysis for over a year.  Chest x-ray was interpreted as perhaps showing some small nodules in the lower lobes which were more easily seen with CT scan. The scattered nodules were lower lobe predominant, non-calcified and surrounded by ground glass haloes. Coccidioidomycosis serology was negative and rheumatologic serologies were negative. Bronchoscopy showed blood in the airway but other than blood, bronchoalveolar lavage was negative. A video-assisted thorascopic (VATS) biopsy showed a hemangioendothelioma, a malignant neoplasm that falls between a hemangioma and angiosarcoma. These vascular tumors can originate in the heart and often metastasize to the lung and pleura amongst other sites. Treatment is varied and depends on the site and extent of tumor involvement, site(s) of metastasis, and specific individual factors.
2. Allen Thomas presented a 78 year old with a history of squamous cell carcinoma and right pneumonectomy done in Florida in 2002. He complained of right-sided chest pain and CT scan revealed a mass in the pneumonectomy space near the stump. Needle biopsy showed only fibrous tissue and hemorrhage. This was followed by a long discussion of what could be done but the patient chose to wait and obtain a follow up CT scan in about 3 months.
3. Dr. Thomas presented a second case of a 62 yo former smoker with cough and blood-streaked sputum, weight loss, and night sweats. Chest x-ray revealed a large cavity in right middle lobe. Bronchoscopic transbronchial biopsy showed a question of necrotizing granulomas. Two weeks later the lesion had nearly doubled in diameter and he felt worse. This was felt to be most consistent with an infectious process based on doubling times and he was empirically treated with fluconazole pending the results of the cultures obtained at bronchoscopy. Two weeks later the lesion had again nearly doubled in size and he felt worse. Resection of the lesion revealed a poorly differentiated carcinoma. It was felt that the lesion enlarged rapidly because of bleeding into the cavity rather than enlargement of the tumor mass.
4. Bridgett Ronan presented a 69 year old referred for recurrent hemoptysis. The hemoptysis was severe and the patient had been endotracheal intubated X 3, bronchoscoped X 2 and had bronchial artery embolization X 2 over the past year. The first episode occurred in July 2011 He was treated for presumed sepsis syndrome and improved. However, this sequence of fevers, rigors and hemoptysis recurred twice in Oct 2011 and again in November. In all instances chest x-ray and CT showed dense consolidation in the right upper lobe lung and he improved on antibioitics. After the November episode the patient was empirically treated with corticosteroids. He did well until January when his symptoms recurred while the corticosteroids were being tapered.  A repeat bronchoscopy in March was negative for infection and VATS showed nonspecific pathology with a question of capillaritiis. His rheumatology serologies including anti-nuclear cytoplasmic antibody (ANCA) were negative. He was begun on cyclophosphamide in addition to the corticosteroids. At his last follow up he had done well and the corticosteroids were slowly being tapered. This was felt to possibly be a case of small vessel, ANCA negative, pulmonary vasculitis but questions were raised about the adequacy of the biopsy.

There being no further business, the meeting was adjourned at 8 PM. The next meeting is scheduled for September 26 at Scottsdale Shea 6:30 PM.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. August 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:104-5. (Click here for a PDF version)

August 2012 Arizona Thoracic Society Notes