A 63-year-old man with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and cigarette smoking was admitted to the hospital following episodes of massive hemoptysis in the previous 24 hours. Admission laboratory work did not reveal a coagulopathy or thrombocytopenia. A chest radiograph demonstrated a radiodensity in the medial aspect of his left lower lung. A follow-up chest computed tomography (CT) scan was significant for a 4-cm spiculated cavitary mass in the superior segment of the left lower lobe that abutted the posterior mediastinum along with several subcentimeter nodules inferior to the lesion.
His presentation was highly suspicious for a primary bronchogenic carcinoma. The patient underwent bronchoscopy. The takeoff to the superior segment was significantly stenotic with induration and heaped-up mucosa. The FOB was advanced into the cavity. Forceps biopsies through the working channel of the bronchoscope were taken inside the cavity. This led to bleeding from the orifice of the superior segment that was initially controlled using a combination of recombinant thrombin and balloon bronchoplasty with a 4-Fr Fogarty balloon. Although the bleeding slowed, it, nevertheless, continued unabated.
At that point, two pieces of oxidized regenerated cellulose (ORC, Surgicell , Johnson and Johnson's, London) approximately 15x15 mm were folded and placed into the jaws of a flexible biopsy forceps. The forceps were then withdrawn into the operating channel of the bronchoscope, and the scope was reinserted into the airways. The forceps were inserted into the cavity, and the ORC was deployed. No further samples were taken to prevent dislodgement of the ORC.
The pathology on the forceps biopsy was consistent with inflammatory changes. He then underwent thoracotomy 1 week later due to a continued concern for a malignancy. Prior to the thoracotomy, there were no further episodes of bleeding. The mass was noted to be quite fibrotic with involvement of a branch of the inferior pulmonary artery. Acid-fast bacilli were noted on pathology staining, and DNA probe was positive for Mycobacterium tuberculosis.