case_images: PMC11804959_01
case_images: Computed tomography images. (a) A solitary round pulmonary mass detected in right lower lobe, with dimensions of approximately 3.3 cm in length and 2.8 cm in width, exhibited well-defined margins and a homogeneous density. (b) A fistula in the right main bronchus 20 days postsurgery. (c) Tumor recurrence and metastasis. (d) Tumor progression. (e) Partial response. (f) CR. RLL: Right lower lobe; RMB: Right main bronchus; PR: Partial response; CR: Complete response
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case_images: PMC11804959_01_ATM-20-82-g001.jpg
case_images: F1
case_images: We report a 65-year-old male, a long-term smoker with chronic obstructive pulmonary disease (COPD), who underwent a right lower lobe (RLL) resection for a mass detected in the RLL [Figure 1a]. Subsequent diagnostic investigations confirmed a BPF at the right main bronchus (RMB) [Figure 1b and Figure 3a], accompanied by a concurrent lung infection and hydropneumothorax. A follow-up chest CT on April 20, 2021, revealed tumor recurrence and metastasis [Figure 1c], accompanied by an increase in serum CEA levels from normal to 20.3 ng/mL, prompting the initiation of oral anlotinib due to the patient's intolerance to chemotherapy. Subsequent chest CT on May 21, 2021, demonstrated an increase in metastatic lesions [Figure 1d], accompanied by a further rise in the patient's serum CEA levels to 30.4 ng/mL, indicating a poor response to anlotinib. Three months following treatment, notable improvements were documented [Figure 1e], including a significant reduction in pulmonary metastases and resolved pleural effusion, and normalization of the patient's serum CEA levels, which facilitated the removal of the chest tube. On May 10, 2023, both immunotherapy and anlotinib were discontinued as the patient sustained CR [Figures 1f and 3f].
case_images: Pathological images of invasive lung adenocarcinoma. (a) Invasive adenocarcinoma in the right lower lobe, comprising approximately 60% alveolar and 40% solid patterns. (b) Station 4R lymph node
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case_images: F2
case_images: Postoperative pathology revealed invasive adenocarcinoma [Figure 2a], invading the visceral pleura without involvement of the bronchial margins. Lymph node involvement was identified in groups 11R, 7, and 4R [Figure 2b].
case_images: Images under endobronchial view. (a) A fistula in the right main bronchus (RMB). (b) Deployment of silicone stent in RMB. (c) Fistula in RLL. (d) Deployment of metal stents. (e) Metal stents removed. (f) RML and closed fistula in RLL. RMB: Right main bronchus; RLL: Right lower lobe; RML: Right middle lobe
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case_images: F3
case_images: Subsequent diagnostic investigations confirmed a BPF at the right main bronchus (RMB) [Figure 1b and Figure 3a], accompanied by a concurrent lung infection and hydropneumothorax. To facilitate fistula healing and manage infection, a custom Y-shaped silicone stent (DUMON  Novatech, France) was inserted on December 31, 2020, under general anesthesia during a rigid bronchoscopy procedure [Figure 3b]. A new fistula was discovered at the anastomosis site of the RLL resection [Figure 3c]. To address this, a combination of self-expandable covered metallic stents (Micro-Tech, China) was employed [Figure 3d]. On August 23, 2021, the metal stents were extracted following confirmation of the complete healing of the fistula [Figure 3e]. On May 10, 2023, both immunotherapy and anlotinib were discontinued as the patient sustained CR [Figures 1f and 3f].
case_images: Flowchart of the diagnostic and treatment process
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case_images: PMC11804959_01_ATM-20-82-g004.jpg
case_images: F4
case_images: A flow chart detailing the entire diagnostic and treatment process is depicted in Figure 4.