History of Present Illness
A 79-year-old man presented to the outpatient pulmonary clinic with upper right opacity that was demonstrated on chest radiography, which had been performed during follow-up for high-grade papillary urothelial carcinoma.
A subsequent chest computed tomography (CT) revealed pulmonary hyperdensity in the right upper lobe apical segment. The hyperdensity was located in the anterior subpleural area and showed necrotic–colliquative features. A subsequent 18 F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) showed that the pulmonary lesion had high glucose metabolism with maximum standardized uptake value (SUV max ) of 6.8 ( Fig. 20.1 ). Other small hyperdense lung lesions were evident, with negligible FDG uptake.
Past Medical History
The patient was a smoker (about 10 cigarettes/day). Eleven years earlier, he had undergone lower left lobectomy for lung cancer (adenocarcinoma, G3 pT2 pN0 M0) and subsequent adjuvant chemotherapy with cisplatin plus vinorelbine (three cycles; negative long-term follow-up).
Eight years after lobectomy, the patient had undergone transurethral resection of bladder tumor (TURBT) and subsequent intravesical instillations with bacillus Calmette-Guérin (BCG) for high-grade papillary urothelial carcinoma.
The patient suffered from arterial hypertension, chronic gastritis, hypercholesterolemia, and prostatic hypertrophy. He also had undergone total thyroidectomy for Graves’ disease and right total hip replacement for osteoarthritis, and he had recurrent venous thrombosis and bilateral pulmonary embolism. His usual therapy included levothyroxine, atenolol, amlodipine, esomeprazole, warfarin, atorvastatin, and tamsulosin.
Physical Examination and Early Clinical Findings
During pulmonary evaluation, the patient was alert, cooperative, fully active, and able to carry on normal activity, with breathlessness experienced only after moderate or intense effort. Despite his multiple pathologies, his performance status (PS) was 90%, according to the Karnofsky scale, corresponding to an Eastern Clinical Oncology Group PS (ECOG PS) score of 0. The patient was 177 cm tall and weighed 84 kg. Oxygen saturation (Sp O 2 ) was 95% while breathing ambient air, and heart rate was 75 beats/min at rest. The patient had no pallor, cyanosis, or peripheral edemas. Chest examination showed only a slight diffuse reduction of breath sounds. Skin scarring resulting from surgery on the left hemithorax was visible. The abdomen was globular, with no obvious masses. Blood test results were within normal limits, except for the international normalized ratio (INR), which was 2.8 because of the use of warfarin.
Three days after discontinuation of warfarin, the INR was 1.34, and platelet count was normal. The patient was admitted to the oncology department and underwent CT-guided transthoracic needle biopsy (TTNB). At the end of the procedure, small right pneumothorax was evident ( Fig. 20.2 ); therefore the patient was kept at rest. However, in the subsequent hours, he developed severe dyspnea, together with a slight reduction in Sp O 2 (93%) and an increase in heart rate (90 beats/min). Subsequent chest radiography showed extension of the right pneumothorax, with partial collapse of the lung and contralateral displacement of the mediastinal structures ( Fig. 20.3 ).
Chest tube placement (Seldinger Technique) (See )
Placement of a small-bore chest tube was proposed. After obtaining written consent from the patient, the thoracic surgeon injected a local anesthetic into the fifth right intercostal space, along the midaxillary line. When the needle reached the pleural space, air bubbles were evident in the syringe used for anesthesia. A 12-French (Fr) chest drain was then placed in this site and connected to a three-chamber drainage system ( Fig. 20.4 ). Subsequent chest radiography showed good expansion of the right lung ( Fig. 20.5 ). Given the patient’s history of recurrent venous thromboembolism (VTE), and the probable presence of malignancy, administration of anticoagulant therapy was resumed 12 hours after chest tube placement.The physicians chose to use subcutaneous enoxaparin (6000 units two times daily) because of its short half-life, which offered an advantage in case of bleeding or further invasive procedures.