Correct!
4. Resect the right upper lobe
The right upper lobe should be resected. At surgery, the entire lesion in the right upper lobe can be sampled and both peribronchial and right mediastinal and subcarinal lymph nodes can be sampled as well, which should provide a definitive diagnosis and stage any neoplasm subsequently proven. Upper endoscopy could sample the subcarinal lymph nodes, as could repeat bronchoscopy with endobronchial ultrasound-guided fine needle aspiration, but neither of these procedures alone can sample the right upper lobe lesion, peribronchial lymph nodes, and mediastinal lymph nodes completely and assure that they all reflect the same process or actually reflect different coincident pathologies. Extended cervical mediastinoscopy can be used to sample left-sided lymph nodes [station 5, aorto-pulmonary lymph nodes in particular], but would not be a useful procedure in this patient. Serial imaging evaluation would not play a role in the management of this patient’s current imaging findings at this point.
The patient underwent cervical mediastinoscopy followed by video-assisted thoracoscopy with right upper lobe surgical resection (Figure 10) without complication.
Figure 10. Resected right upper lobe specimen shows a focal, 1.6 cm lesion originating from a subsegmental airway within the apical segment of the right upper lobe.
Lymph nodes in the right peribronchial region (stations 10 and 11), right paratracheal region (station 4), subcarinal region (station 7), and pulmonary ligament (station 9) were resected and showed no evidence of malignancy but did show non-necrotizing granulomatous inflammation without any organisms on dedicated stating. The findings within the lymph nodes were most consistent with sarcoidosis. The right upper lobe lesion showed positive staining of the epithelial component for AE1/AE3, positive staining of the myoepithelial and spindle cell component for SMA and S-100 protein, patchy staining of both components for TTF-1, and no staining for ALK, desmin, or CD34, supporting the diagnosis of pneumocytic adenomyoepithelioma.
Diagnosis: Bronchial pneumocytic adenomyoepithelioma on a background of sarcoidosis
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References