BACKGROUND:Right middle lobe syndrome is part of a spectrum of relatively rare but serious conditions that may occur following right upper lobectomy. We aimed to assess whether the preoperative middle lobe bronchial angle on CT predicted patients at risk of developing middle lobe syndrome. METHOD:All patients who had a complete upper lobectomy over 4 years were retrospectively reviewed for clinical and imaging findings of middle lobe syndrome. Patients with previous lung surgery, preoperative chemo- or radiation therapy, or more extensive surgical resection were excluded. Patient demographics and symptoms, the surgical, pathologic and bronchoscopy reports, and pre- and post-operative chest imaging, to include 3D CT reconstructions and measurements of the middle lobe angles in a subset of patients, were retrospectively reviewed. RESULT:One hundred and twenty-eight patients met inclusion criteria. Ten (8%) had middle lobe syndrome based on symptoms and imaging features. Eight had severe middle lobe consolidation. Two had postoperative onset of wheezing, with middle lobe bronchial abnormality on CT. The pre- and postoperative middle lobe bronchial angles of 14 patients without middle lobe syndrome were compared to 10 patients with middle lobe syndrome. The middle lobe bronchus was completely obliterated postoperatively and could not be determined in 1 patient. There was no significant difference between the pre- and postoperative angles in patients with or without middle lobe syndrome. CONCLUSION:Middle lobe syndrome occurred in 8% of patients with right upper lobectomy. The preoperative middle lobe bronchial angle did not predict patients at risk for developing middle lobe syndrome.

Esophageal surgery has become quite specialized, and both dedicated diagnostic and refined surgical techniques are required to deliver state-of-the-art care. The field has evolved to include endoscopic mucosal resection and radiofrequency ablation for early-stage esophageal cancer and minimally invasive esophagectomy with the reconstruction of a gastric conduit for carefully selected patients with esophageal cancer or those with “end-stage” esophagus from benign diseases. Reoperative esophageal surgery after esophagectomy deserves special mention given that these patients, with improved survival, are presenting years after esophagectomy with functional and anatomic disorders that sometimes require surgical intervention. Different diagnostic modalities are essential for assessing patients and planning surgical treatment. Recognizing early and late postoperative complications on imaging may expedite and improve patient outcomes. Finally, endoscopic management of achalasia with peroral endoscopic myotomy and the use of the LINX device for gastroesophageal reflux disease are highly effective and minimally invasive treatments that may reduce complications, costs, and length of hospital stay.

Roughly 30% of carcinoids are found in the thoracic cavity, with the overwhelming majority of these being found in the lung parenchyma. We present a case of a rarely found primary pleural carcinoid incidentally diagnosed in a 73 year old male who presented with recalcitrant spontaneous pneumothorax requiring surgical intervention. The patient was taken to the operating room for a right video assisted thoracic surgery, partial pleurectomy, and talc pleurodesis. At the time of the operation, there were no abnormalities noted in the pleura or chest wall, and the patient did well post operatively. Pathologic examination of the pleura revealed a 3mm well differentiated neuroendocrine carcinoid tumor. Laboratory and imaging studies did not indicate another site of tumor. The importance of a multidisciplinary approach to the diagnosis, treatment, and surveillance is emphasized.

Occupational lung diseases (OLD) including silicosis, asbestosis, and pneumoconiosis progress to end stage lung disease requiring lung transplantation (LT). Prognosis and treatment of OLDs are poorly understood and a paucity of data exists regarding LT outcomes. Additionally, transplant operative complexity for patients with OLD is high. A single center retrospective review of all single and bilateral LT recipients between May 2005 and Oct 2016 was performed. Patients were grouped by OLD, and nearest neighbor matching was performed at a ratio of 1:3 cases to controls. Thirty cases were matched to 88 controls. Seventeen patients (57%) with OLD required intraoperative support with either extra‐corporeal membrane oxygenation (ECMO) or cardiopulmonary bypass ( P = 0.02), and 5 (17%) required delayed chest closure ( P = 0.05) which was more frequent than matched controls. In addition, operative time was significantly longer in patients with OLD ( P = 0.03). Despite these factors, there were no significant differences in immediate post‐operative outcomes including mechanical ventilator support, post‐operative ECMO, and tracheostomy. Chronic lung allograft dysfunction and long‐term survival were also similar between cases and controls. OLDs should not preclude LT. The operation should be performed at experienced centers.

A 29-year-old non-smoking female with a history of recurrent AML presented with worsening dyspnea. A CT scan revealed an 8 X 7 mm polypoid soft tissue nodule 8 mm distal to the carina in the left mainstem bronchus. She was brought to the operating room and a nearly obstructing soft fleshy tumor in the left mainstem bronchus just distal to the carina was removed with bronchoscopy. Pathology revealed a low grade mucoepidermoid carcinoma 0.8 cm in largest dimension with negative margins. The patient returned for a resection and was intubated with a right mainstem double lumen tube and placed in left lateral decubitus. After posterolateral thoracotomy, the azygos vein was divided to mobilize the esophagus and retract it laterally. Level 4 and 7 lymph node dissection were performed to obtain access to the anterior tracheal and subcarinal spaces. There was minimal dissection lateral to the trachea to minimize risk of ischemia. One centimeter of trachea just proximal to the carina was circumferentially isolated with umbilical tape for retraction. We bronchoscopically confirmed the location for transection and advanced a jet ventilator catheter distally. We resected one centimeter of left mainstem bronchus. We inspected the lumen of the airway to confirm no gross residual disease and confirmed negative pathologic margin before performing an end-to-end anastomosis with interrupted absorbable sutures under both jet and cross-table ventilation. Postoperatively, the patient had an uncomplicated course and was discharged without any supplemental oxygen on postoperative day 6. Final pathology was low grade mucoepidermoid carcinoma, T1aN0.

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Strollo, Diane C. MD, FACR; Sanchez, Manuel Villa MD; Folch, Erik E. MD, MSc Author Information

SESSION TITLE: Disorders of the Mediastinum 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: While lipomas characteristically arise in subcutaneous tissue, they comprise of roughly 2% of all primary mediastinal tumors and typically arise in the anterior compartment. This presentation discusses a patient with a large fatty anterior mediastinal mass extending into the left thoracic cavity, resulting in significant pulmonary symptoms due to a mass effect. CASE PRESENTATION: A 54-year-old sedentary man presented with complaints of cough and progressive dyspnea while climbing stairs. Imaging confirmed a large soft mediastinal mass extending into the left hemithorax (Figure 1). PFTs demonstrated a restrictive pattern with a VQ scan measuring 25% perfusion to the left lung. Biopsy revealed benign lipomatous tissue.Given the large size of the mass and patient symptoms, the patient was scheduled for resection. The patient was intubated and a bronchial blocker was placed into the left mainstem bronchus. We performed a median sternotomy and dissected the mass from the innominate vein and diaphragm. The sternum was split in the 6th intercostal space and a connecting thoracotomy was performed to facilitate dissection into the left hemithorax (Figure 2a). The mass was removed and three left chest tubes were placed. The specimen measured at 40 cm X 17.5 cm X 6.5 cm (Figure 2B and 2C). Histologic findings were consistent with a benign lipoma composed of uniform adipocytes and no cytologic atypia (Figure 3). Postoperative course was uncomplicated. Chest tubes were kept to suction to facilitate lung expansion and removed on POD3. The patient was discharged on POD4 and reported to clinic 3 months later with no complaints of dyspnea and complete re-expansion of the left lung with no evidence of recurrent disease. DISCUSSION: Intrathoracic mediastinal lipomas are rare and benign neoplasms within the thoracic cavity. They comprise of roughly 2% of all primary mediastinal masses and are well circumscribed mesenchymal tumors originating from adipose tissue. Majority of patients remain asymptomatic as the lipomas are often slow growing 2. These symptoms include but are not limited to shortness of breath, dyspnea, chest pain, coughing, dysrhythmias, and intermittent dysphagia. While most intrathoracic lipomas are detected at a relatively late stage, once identified, the management strategy is still controversial. However, once mass effect is identified, we believe that surgical resection is indicated. CONCLUSIONS: Extensive work-up of mediastinal masses is critical to ensure that the proper treatment pathway is provided. Various incisions may be used including a thoracotomy, sternotomy, clamshell incision, or a combination of any of the above. Given the large size of these masses and current recommendations to achieve complete en-bloc removal, careful planning of the surgical approach is crucial to obtain a complete R0 resection which is associated with a local recurrence rate of less than 5% Reference #1: 2. Chen M, Yang J, Zhu L, Zhao H. Intrathoracic giant pleural lipoma: case report and review of the literature. Journal of Cardiothoracic Surgery. 2013;8:196.3. Sakurai H, Kaji M, Yamazaki K, Suemasu K. Intrathoracic lipomas: their clinicopathological behaviors are not as straightforward as expected. The Annals of Thoracic Surgery. 2008;86:261-265. Reference #2: Chen M, Yang J, Zhu L, Zhao H. Intrathoracic giant pleural lipoma: case report and review of the literature. Journal of Cardiothoracic Surgery. 2013;8:196. Reference #3: Sakurai H, Kaji M, Yamazaki K, Suemasu K. Intrathoracic lipomas: their clinicopathological behaviors are not as straightforward as expected. The Annals of Thoracic Surgery. 2008;86:261-265. DISCLOSURES: No relevant relationships by Ernest Chan, source=Web Response No relevant relationships by Patrick Chan, source=Web Response No relevant relationships by Neil Christie, source=Web Response I own stock in this company relationship with Inntuitive SUrgical Please note: $20001 - $100000 Added 03/03/2018 by James Luketich, source=Web Response, value=None, I purchsed my self as an stock holder relationship with johnson and Johnson Please note: $20001 - $100000 Added 03/03/2018 by James Luketich, source=Web Response, value=none, I purchsed myself as an No relevant relationships by Karen Schoedel, source=Web Response No relevant relationships by Diane Strollo, source=Web Response

SESSION TITLE: Surgery cases SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/07/2018 04:45 PM - 05:45 PM INTRODUCTION: Bronchial atresia is a rare congenital anomaly caused by an atretic or interrupted lobar or segmental bronchus that results in a mucous filled bronchus and distal hyperinflation of the obstructed lung. Such malformations are generally diagnosed at an early age; however, it is diagnosed in adults as well. Due to its rarity, it is quite frequently misdiagnosed as the symptoms are commonly attributed to pulmonary infection. Surgical intervention is curative and minimally invasive options are safe and feasible. The goal of this case report is to highlight the clinical presentation, work-up and treatment of bronchial atresia in the adult. CASE PRESENTATION: A 28 year-old man presented with recurrent respiratory infections and right sided chest pain for the past decade. CXR showed a hyperlucent RLL (Fig 1). A CT scan of the chest demonstrated central RLL bronchi that were markedly dilated, branching and filled with mucous, with a “finger-in-glove” configuration, with distal hyperinflation and paucity of vascular markings. A central obstructing lesion was absent (Fig 2a and b). The patient had a perfusion scan showing that the RLL has decreased perfusion. Initially, the patient was taken to the operating room for a flexible bronchoscopy with biopsy and bronchiolar lavage. However, there was no evidence of any obstructing lesions on bronchoscopy. The patient was then later discussed at multidisciplinary lung conference. We decided to proceed to flexible bronchoscopy and video-assisted thoracoscopic right lower lobectomy. The post-operative course of the patient was uneventful and he discharged on POD 6. Pathology showed markedly dilated bronchioles that were impacted with viscous, tan-gray mucin (Fig 3). He has not had bouts of pneumonia since the removal of the right lower lobe. DISCUSSION: Bronchial atresia is usually asymptomatic and many cases are diagnosed in the second or third decades in life. Symptoms are usually consistent with recurrent pulmonary infections. Diagnosis can be made from a CT scan of the chest showing the pathognomonic findings of bronchial obstruction, hyper-lucency and hyperinflation of the distal airways with mucous impaction. However, due to its rarity, we suggest initial diagnostic bronchoscopy to rule out obstruction. If obstruction is ruled out, in symptomatic patients, surgical intervention should absolutely be taken and is curative. In asymptomatic patients, treatment is controversial. Follow-up is necessary to evaluate progression. Elective lobectomy or segmentectomy should be carefully considered in these patients. Overall, preferably, a minimally invasive approach should be taken. CONCLUSIONS: In patients with bronchial atresia, pulmonary infection and obstruction should be excluded before resection. Resection in an asymptomatic patient is still controversial and should be carefully considered. Minimally invasive approaches are preferable. Reference #1: Wang, Y., W. Dai, et al. (2012). "Congenital bronchial atresia: diagnosis and treatment." Int J Med Sci 9(3): 207-212. Reference #2: Traibi, A., A. Seguin-Givelet, et al. (2017). "Congenital bronchial atresia in adults: thoracoscopic resection." J Vis Surg 3(174). DISCLOSURES: No relevant relationships by Patrick Chan, source=Web Response No relevant relationships by Ernest Chan, source=Web Response No relevant relationships by Rajeev Dhupar, source=Web Response no disclosure on file for Matthew Schuchert; no disclosure on file for Anupama Sharma; No relevant relationships by Diane Strollo, source=Web Response

Diagnosis of a bronchopleural fistula (BPF) can be challenging in patients after pneumonectomy and Clagett window. Herein, we present a case of pneumonectomy for advanced lung cancer complicated by a BPF. Herniation of packing material from the open-chest cavity into the fistula and airways on computed tomography was an important clue to making the diagnosis.

SESSION TITLE: Disorders of the Pleura 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Carcinoid tumors are a rare occurrence of the thoracic cavity, constituting roughly 0.5 to 2.5% of all pulmonary neoplasms. This case discusses an incidental finding of a primary pleural carcinoid in a patient presenting with spontaneous pneumothorax requiring operative management. CASE PRESENTATION: A 73 year old male with a history of COPD presented with a shortness of breath and was transferred to our facility for a persistent spontaneous right pneumothorax. A CT scan was obtained showing multiple bilateral emphysematous blebs, but no pulmonary or chest wall lesions (Figure 1). The patient was taken to the operating room for a right VATS, partial pleurectomy, and talc pleurodesis after a persistent pneumothorax despite multiple chest tubes. Intraoperatively, no abnormalities were noted in the pleura or chest wall at the time of pleurectomy. Two chest tubes were positioned intraoperatively and placed to waterseal on POD3. They were removed on POD5 and patient was discharged POD7. The parietal pleural specimen was described as an irregularly shaped yellow membrane measuring 14.5X0.5X0.1 cm. There were no gross lesions. Microscopy revealed a well differentiated neuroendocrine carcinoid tumor with a maximum diameter of 3mm. Nests of neuroendocrine cells were present and stained positive for CD-56, CK7, synaptophysin, and CEA. ERG, CK20, WT-1, cam 5.2, TTF-1, CDX-2, and calretinin were negative (Figure 2). Follow-up PET-CT at clinic revealed no evidence of residual disease (Figure 3). DISCUSSION: The most common primary location of carcinoid tumors is the small intestine (30.4%), followed by pulmonary (29.8%) and colon (9.2%). A majority of reported pleural cases are of metastatic disease. Therefore, primary pleural carcinoid disease is a rarity. CT imaging can identify thoracic or gastrointestinal primary carcinoid tumors. In a retrospective review of 50 patients with carcinoid syndrome, Moss et al. identified pleural thickening in nine patients, of which 4 had a primary tumor. Presentation of these patients with primary pleural carcinoid is usually due to mass effect or as an incidental finding on imaging. In this case report, the patient was found to have a 3 mm focus in a pleurectomy specimen. Given the rarity of primary pleural carcinoid, this finding warranted further investigation to ensure that this was not metastatic disease. CONCLUSIONS: A multidisciplinary approach to these rare cases with pathology and radiology cannot be stressed enough. The first step is to rule out other more common pleural malignancies though a panel of histologic stains. Further imaging, including a PET CT, is suggested to identify FDG avid lesions that can be the primary origin. Reference #1: Bertino EM, Confer PD, Colonna JE, Ross P, Otterson GA. Pulmonary neuroendocrine/carcinoid tumors. Cancer. 2009;115:4434-4441. Reference #2: Townshend AP, Lakshminarayanan B, Ucar AE, Chaudry ZR, Duffy JP. Rare pleural recurrence of typical pulmonary carcinoid tumor 30 years after lobectomy. The Annals of thoracic surgery. 2007;83:1523-1524. Reference #3: Moss SF, Lehner PJ, Gilbey SG, et al. Pleural involvement in the carcinoid syndrome. QJM: An International Journal of Medicine. 1993;86:49-53. DISCLOSURES: No relevant relationships by Ernest Chan, source=Web Response No relevant relationships by Lawrence Crist, source=Web Response No relevant relationships by Rajeev Dhupar, source=Web Response I own stock in this company relationship with Inntuitive SUrgical Please note: $20001 - $100000 Added 03/03/2018 by James Luketich, source=Web Response, value=None, I purchsed my self as an stock holder relationship with johnson and Johnson Please note: $20001 - $100000 Added 03/03/2018 by James Luketich, source=Web Response, value=none, I purchsed myself as an no disclosure on file for Anupama Sharma; no disclosure on file for Diane Strollo

Traumatic diaphragmatic rupture remains a diagnostic challenge for both radiologists and surgeons. In recent years, multidetector CT has markedly improved the diagnosis of diaphragmatic injury in polytrauma patients. Herein, we describe two cases of subacute presentation of traumatic diaphragmatic rupture from a penetrating rib fracture and subsequent intrathoracic herniation of omental fat, representing the CT “funky fat” sign.

Distinction between multiple primary cancers and intrapulmonary metastases in patients with synchronous multifocal lung cancer can be challenging. Histological and genotypic assessment of multifocal lung tumors have been suggested to influence the staging. The aim of this study was to determine the role of morphology and genotype in staging of surgically treated multifocal non-small cell lung carcinoma. Synchronous lung cancers from 60 patients (42 with adenocarcinoma and 18 with squamous cell carcinoma), clinically considered to represent intrapulmonary metastases, were histologically subtyped according to the 2015 World Health Organization classification of lung tumors and subjected to genotypic analysis (KRAS, EGFR, BRAF, PIK3CA, ALK, MET and ROS1 in adenocarcinoma and PIK3CA and p16 in squamous cell carcinoma). Concordance between clinical criteria and histological subtyping was identified in about 50% of cases (P<0.0001). Genotypically, 44% of adenocarcinomas and 60% of squamous cell carcinomas with identified molecular alterations were considered to be intrapulmonary metastases. Concordance between histological and molecular staging was observed in 89% of adenocarcinomas and 56% of squamous cell carcinomas. Univariate survival analyses failed to demonstrate significant differences in overall or cancer-specific survival in patients with adenocarcinoma and squamous cell carcinomas restaged according to histology and/or molecular profile. Lymph node metastases (N1/N2 vs N0) (P=0.03) and age >65 years (P=0.05) were associated with shorter overall survival. In addition, squamous cell carcinomas with p16 deletion showed shorter overall survival when compared with squamous cell carcinomas without p16 deletion (P=0.05). No correlation between other molecular alterations, clinico-pathological characteristics and prognosis was found. Our study demonstrates that a comprehensive genotypic and morphological assessment of surgically treated multifocal lung cancers is feasible but not sufficient to establish their clonal relationship and prognosis.

Introduction The idiopathic interstitial pneumonias (IIPs) are a subgroup of diffuse parenchymal lung diseases (DPLDs), the latter of which also includes DPLD of known causes, such as drugs, or association, such as collagen vascular disease; granulomatous DPLD, such as sarcoidosis; and other distinct forms of DPLD, such as lymphangioleiomyomatosis and pulmonary Langerhans cell histiocytosis. In the revised American Thoracic Society/European Respiratory Society Classification of the Idiopathic Interstitial Pneumonias, the IIPs are grouped as follows: (1) chronic fibrosing (idiopathic pulmonary fibrosis [IPF] and idiopathic nonspecific interstitial pneumonia [NSIP]); (2) smoking related (respiratory bronchiolitisinterstitial lung disease and desquamative interstitial pneumonia); and (3) acute or subacute (acute interstitial pneumonia [AIP] and cryptogenic organizing pneumonia [COP]). The idiopathic interstitial pneumonias are a heterogeneous group of nonneoplastic disorders of unknown etiology—“idiopathic,” characterized by variable inflammation and fibrosis of the lung parenchyma—“interstitial pneumonia.” There are commonalities in this seemingly disparate group. Firstly, patients present with dyspnea, decreasing lung volumes, and normal flow rates. Secondly, open lung biopsy demonstrates variable alveolar wall thickening and inflammation, which can be difficult for pathologists to classify because of the variability.

Amyloidosis is a rare diverse condition caused by the pathologic extracellular deposition of abnormal insoluble proteins throughout the body. It may exist as a primary disease or, more commonly, may be secondary to a wide variety of pathologic processes ranging from chronic infection or inflammation to malignancy. Hereditary forms also exist. On the basis of the structure of the protein deposits, more than two dozen subtypes of amyloidosis have been described. A single organ or multiple organ systems may be affected. The radiologic manifestations of amyloidosis are varied and often nonspecific, making amyloidosis a diagnostic challenge for the radiologist. In the chest, the lungs, mediastinum, pleura, and heart may be involved. Lung involvement may manifest as diffuse reticulonodular interstitial thickening, consolidations, or solitary or multiple parenchymal nodules that may calcify, cavitate, and slowly enlarge. Pleural involvement most commonly manifests as pleural effusions. Tracheobronchial involvement may exhibit concentric airway thickening, mural and intraluminal nodules, submucosal calcification, and airway obstruction. Mediastinal and hilar lymph nodes may enlarge and frequently calcify. At cardiac magnetic resonance (MR) imaging, the left ventricular wall is typically thickened, with associated diastolic dysfunction. Delayed contrast material-enhanced cardiac MR imaging typically shows global transmural or subendocardial enhancement. The pathophysiology, classification, treatment, and prognosis of amyloidosis are reviewed, followed by case examples of the appearance of thoracic and cardiac amyloidosis on chest radiographs, computed tomographic (CT) images, and cardiac MR images.

OBJECTIVE. The purpose of this study was to assess the CT-pathologic features of cancer incidentally detected at lung transplantation.MATERIALS AND METHODS. Our lung transplant registry was reviewed over 7 years for incidental malignancy. Patient demographics, diffuse lung disease, surgical procedure, histopathology, and chest CT were recorded. We correlated lesion size, morphology, multiplicity, and location with surgical and pathology reports and histopathology. Cancers were pathologically staged.RESULTS. Of 759 lung transplant recipients, cancer was incidentally detected in 22 (2.9%). Half (11 of 258) or 4.3% were detected within the past 2 years. Four patients had a history of treated malignancy, and three had recurrence. Patients had emphysema (chronic obstructive pulmonary disease [COPD]) (n = 10), fibrosis (n = 10), or combined COPD and fibrosis (n = 2). Histopathology revealed 13 solitary lung carcinomas, four multifocal adenocarcinomas, three metastases, and two lymphoproliferative diseases. Lung cancer (n = 17) stages were I or II (n = 13), IIIA (n = 2), or IV (n = 2). Metastases (n = 3) and lymphoproliferative disease (n = 2) represented advanced disease. The interval between CT and surgery was a mean of 4 months. CT-positive cases (n = 10) represented lung cancer (n = 9) and posttransplantation lymphoproliferative disease (n = 1). Cases with no CT findings of malignancy (n = 12) included lung cancer (n = 8), metastases (n = 3), and lymphoma (n = 1). Ten cases (45%) had other histologically benign CT abnormalities that mimicked cancer.CONCLUSION. Detection of incidental malignancy at lung transplantation has increased over the past 2 years. Malignancies were typically stage I or II lung cancers that were occult or indeterminate on CT. Diffuse lung disease, multiple CT abnormalities, and a delay between CT and transplantation compromise the preoperative diagnosis of cancer.

Rationale: Severe asthma represents 5-10% of all asthma, yet remains problematic and poorly understood. Although it is increasingly recognized as consisting of numerous heterogenous phenotypes, their immunopathology, particularly in the distal airways and interstitium, remains poorly described.Objectives: To identify the pathobiology of atypical difficult asthma.Methods: We report 10 from a total of 19 patients (17 women and 2 men) meeting asthma and severe asthma definitions, requiring daily systemic corticosteroid (CS) use, with inconsistent abnormalities on chest computed tomography scans, who underwent video-assisted thoracoscopic biopsies for further diagnosis and management.Measurements and Main Results: The pathology of 10 of the 19 cases revealed small airway changes consistent with asthma (eosinophilia, goblet cell hyperplasia), but with the unexpected finding of interstitial nonnecrotizing granulomas. These patients had no evidence for hypersensitivity pneumonitis, but 70% of cases had a personal or family history of autoimmune-like disease. The 10 cases were treated with azathioprine, mycophenolic acid, methotrexate, or infliximab. Nine of 10 showed decreased CS requirements and improved or maintained FEV1 despite lower CS doses. Of the remaining nine patients, six manifested asthmatic small airway disease, alone or in combination with alveolar septal mononuclear cells, but no granulomas, whereas three manifested other pathologic findings (aspiration, pneumonia, or thromboemboli).Conclusions: These data suggest that a subset of severe "asthma" manifests a granulomatous pathology, which we term "asthmatic granulomatosis." Although identification of this disease currently requires a thorascopic biopsy, alternative approaches to therapy lead to improvement in outcomes.