A 42-year-old asymptomatic male patient received thoracic CT scans on a routine health examination at a local hospital in February 2021 with an incidental finding of a 1.5 x 1.2 cm endobronchial nodule of the right bronchus intermedius and a 5.1 x 3.1 cm patchy lesion centrally located at the left upper lobe (Figure 1). The patient underwent fiberoptic bronchoscopy, which showed a neoplasm with an unsmooth surface at the opening of the right bronchus intermedius with normal distant bronchial tree. Transbronchial biopsy of the neoplasm was suggestive of low-grade mucinous epidermoid carcinoma. The patient further underwent PET/CT scans, which revealed weak FDG uptake in the endobronchial nodule and high uptake in the left upper lobe lesion. To discern the nature of the left upper lobe lesion, the patient underwent a CT-guided percutaneous lung biopsy. Pathological examination revealed a chronic granulomatous inflammatory disease, suggesting the diagnosis of tuberculosis. Due to the specific location of the endobronchial tumor, the patient was recommended by the treating physician at the local hospital to receive bronchoscopic cryoablation over surgical resection.
Because of concerns that the tumor might recur with bronchoscopic therapy, the patient was referred to our department for seeking surgical resection. The results of preoperative routine blood biochemistry were normal. Pulmonary function test showed mild obstructive ventilation dysfunction, with FEV1 being 2.38L and FEV1%PRED being 76%. Considering the patient's 30-year history of bronchial asthma (manifested as wheezing sounds in both lungs) and the fact that lung parenchymal resection might lead to decreased quality of life, the patient underwent a single-port thoracoscopic tumor resection, reconstruction of the secondary carina and systemic lymph node dissection (including stations 2, 4, 7, 9, 10, 11, 12) in March 2021 (Figure 2). The patient was placed in a left lateral decubitus position. After the intubation of the double-lumen tube, single lung ventilation of the contralateral lung was performed under general anesthesia. The utility incision was a 3-cm incision at the 4th intercostal space along the anterior axillary line. After the careful dissection of the right main bronchus, the right upper bronchus and the right bronchus intermedius, the tumor at the opening of the right bronchus intermedius was resected (see Supplementary Video 1). The stumps were trimmed and sent for intraoperative frozen section, which showed no residual cancer at any bronchial stumps. Then, the anastomosis procedure was initiated. First, the lateral walls of the right upper bronchus and the right bronchus intermedius were sutured continuously to join up with a 3-0 Prolene (one thread with two needles). Second, two another 3-0 Prolene (both sutured with one stitch in the bronchi nearby) were tied with the two ends of the first 3-0 Prolene into a knot outside of the bronchi, respectively. Subsequently, a circumferential and continuous suture of the right main bronchus with the right upper bronchus and the right bronchus intermedius was performed via these two 3-0 Prolene and a knot was tied outside of the bronchi. Last, the anterior wall of secondary carina was reinforced with interrupted sutures using a 3-0 Monocryl (Y316, one thread with one needle) and the anterior mediastinal fatty tissue was freed to cover the anastomosis with another 3-0 Monocryl. There were no air leakage from the anastomotic area after puffing of the lungs with the addition of warm saline to the chest cavity. The operation lasted 200 mins totally. Postoperative pathology showed solid adenoid arrangement of tumor cells and focal invasion of bronchial cartilage, consistent with a well-differentiated mucinous epidermoid carcinoma. No lymph node metastasis was observed. The patient recovered well after surgery and was discharged on postoperative day 3. He receive anti-tuberculosis treatment for 9 months postoperatively and did not complain of any specific discomfort at the 9-month postoperative follow-up, with no local recurrence observed.
Uniportal VATS secondary carinal resection and reconstruction for tracheobronchial mucoepidermoid carcinoma. Contrast-enhanced CT of the chest showed a 1.5 x 1.2 cm endobronchial nodule of the right bronchus intermedius (see arrow,.