case_images: PMC11324274_01
case_images: Timeline of the patient with lung adenocarcinoma. CT, computed tomography; EBUS-GS, endobronchial ultrasound with a guide sheath; NGS, next-generation sequencing.
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case_images: F1
case_images: A 71-year-old male, ex-smoker was evaluated for a band-like lesion in the left upper lung lobe (Fig. 1).
case_images: Chest radiological images of the patient with lung adenocarcinoma. A band-like lesion extends along the left major pleural fissure in the horizontal view (a) and in the frontal view (b). Two and a half years after the initial presentation, the lesion is enlarged as shown in the horizontal view (c) and frontal view (d). e This lesion remains invisible on conventional chest radiography. f The lesion shows the accumulation of 18F-fluorodeoxyglucose on positron emission tomography.
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case_images: F2
case_images: During systemic evaluation, incidental chest computed tomography (CT) revealed a 37 x 7 mm band-like lesion extending along the left pleural fissure (Fig. 2a, b); however, conventional chest radiography failed to detect the lesion. Two and a half years later, the band-like lesion had enlarged from 37 x 7 mm to 38 x 10 mm (Fig. 2c, d) but remained invisible on conventional chest radiography (Fig. 2e). Positron emission tomography revealed the accumulation of 18F-fluorodeoxyglucose in the pulmonary lesion, suggesting a potential malignancy (Fig. 2f).
case_images: Virtual bronchoscopic images of the patient with lung adenocarcinoma. The tracking line (yellow line) is drawn to the target lesion (yellow circle). a The oblique view of the bronchial tree is reconstructed from the data obtained from the thin-slice CT, indicating the route to the lesion through the left B1+2ciialpha. b The endoscopic view is also created, showing the orifice of the B1+2ciialpha.
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case_images: F3
case_images: B1+2 ciialpha bronchus that reached the inferior region of the lesion rather than through the B3aialpha (Fig. 3a, b, 4a). Subsequently, EBUS-GS was employed to explore the lesion and reduce the risk of bleeding and pneumothorax associated with antiplatelet medication and near-pleural lesions. Bronchoscopy was performed using a bronchoscope (BF-1T260; Olympus, Tokyo, Japan), guide sheath (SG-201C, Olympus), bronchial ultrasonic probe (UM-S20-20R, Olympus), cytology brushes (BC-202D-2010, Olympus), and normal-diameter biopsy forceps (FB-231D, Olympus).
case_images: The patient with lung adenocarcinoma. a Chest CT shows that the left B1+2ciialpha leads to the inferior region of the lesion (yellow arrow), while the left B3aialpha is located near the lesion (blue arrow). b Bronchoscopy indicates the orifice of the left B1+2ciialpha (yellow arrow). c X-ray fluoroscopy shows an endobronchial ultrasound probe with a guide sheath through the left B1+2 ciialpha. d The endobronchial ultrasound probe and a guide sheath are placed precisely within the lesion.
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case_images: F4
case_images: B1+2 ciialpha bronchus that reached the inferior region of the lesion rather than through the B3aialpha (Fig. 3a, b, 4a). Subsequently, EBUS-GS was employed to explore the lesion and reduce the risk of bleeding and pneumothorax associated with antiplatelet medication and near-pleural lesions. Bronchoscopy was performed using a bronchoscope (BF-1T260; Olympus, Tokyo, Japan), guide sheath (SG-201C, Olympus), bronchial ultrasonic probe (UM-S20-20R, Olympus), cytology brushes (BC-202D-2010, Olympus), and normal-diameter biopsy forceps (FB-231D, Olympus). Although X-ray fluoroscopy failed to detect the pulmonary lesion, the ultrasound probe successfully identified the lesion through the B1+2 ciialpha (Fig. 4b, c). A guide sheath was then placed within the lesion (Fig. 4d), allowing two brushings and four biopsies without massive bleeding or pneumothorax.
case_images: Photomicrographs of the specimens obtained from the patient with lung adenocarcinoma. Scale bars indicate 100 mum. a A small number of cancer cells are scattered in the highly fibrotic tissue (hematoxylin and eosin stain). b The immunohistological examination shows that the scattered cancer cells are positive for TTF-1. c Many cancer cells with deformed nuclei, consistent with adenocarcinoma, are found in the transbronchial brushing wash fluid (Papanicolaou stain).
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case_images: F5
case_images: Histological examination revealed that thyroid transcription factor (TTF)-1-positive adenocarcinoma cells were scattered in highly fibrotic tissues (Fig. 5a, b). By contrast, the cytological specimens from the brushing wash fluid contained a high percentage of cancer cells, exceeding >30% (Fig. 5c).