Correct!
2. Broncholithiasis
While bronchogenic malignancies can uncommonly calcify, the calcification is often stippled or eccentric in morphology and invariably a significant component of non-calcified tissue is present. In this patient, the focus of calcification at the orifice of the superior segmental left lower lobe bronchus has no associated soft tissue component. Similarly, neuroendocrine tumors, particularly typical carcinoid tumors, may calcify, but the pattern of calcification may be more chondroid in morphology and substantial non-calcified soft tissue components are also typically present. Inflammatory myofibroblastic tumors are rare proliferative lesions, now considered clonal neoplasms, that present in a number of different ways, including calcified pulmonary opacities and endobronchial lesions. Nevertheless, as with bronchogenic malignancies and neuroendocrine neoplasms showing calcification, significant non-calcified soft tissue components are usually present. Finally, a hyperattenuating aspirated endobronchial foreign body is a definite possibility and would be very difficult to differentiate from a broncholith. However, in this patient, the presence of adjacent peribronchial lymph node calcifications favors broncholithiasis.
The patient underwent left thoracotomy and, as the surgeon suspected, significant inflammation was encountered in the superior segment of the left lower lobe. Significant difficulty identifying and isolating the superior segmental artery and bronchus was encountered, but the broncholith was identified and the left lower lobe successfully resected (Figure 8).
Figure 8. Left lower lobe resection specimen shows a broncholith (arrows) at the origin of the superior segmental left lower lobe bronchus.
The patient tolerated the procedure well, but a persistent air leak was encountered in the first post-operative week, as the surgeon suspected may happen.
Which of the following represents an appropriate next step for the patient’s management? (Click on the correct answer to proceed to the eleventh and final page)