3. Investigation
A bronchofibroscopy was performed, finding direct signs of malignancy and stenosis of the left bronchial branch. For this reason, transbronchial biopsy samples of the left lung mass and bronchial lavage were taken, obtaining an SFT. The tumor immunohistochemistry results were BCL2 +, CD34 + focal, CD99 Focal cytoplasmic, Actin negative, S100 negative, EMA negative, Panker negative (Fig. 2), and Papanicolaou and Block cell with a positive result for malignant tumor cells. In addition, Bone scintigraphy was performed with a negative result for metastasis.
The patient continues to present symptomatic and recurrent hypoglycemia, considering endogenous hyperinsulinism in the differential diagnosis. Since the IGF II value was found to be 721 U/I, we considered non-island cell hypoglycemia and paraneoplastic syndromes of IGF-II-producing tumors as a definite diagnosis.
A pulmonary ventilation/perfusion scintigraphy was performed indicating absence of left lung perfusion and preserved in the right lung. A multidisciplinary medical meeting was carried out deciding to excise the lung tumor by the chest surgery team. Surgical intervention was performed 31 days after admission, and the operating time was 11 hours. Complete removal of the endothoracic tumor (weight: 3.1 kg) was successfully achieved, which was sent for a pathological study and two left thoracic drainage tubes were placed: anterior and posterior (Fig. 3).
At 8.10 pm on the same day, the patient presented cardiorespiratory arrest with asystole rhythm due to type III and IV acute respiratory failure, and haemorrhagic shock. Cardiopulmonary resuscitation was performed for 2 minutes with the administration of vasoconstrictor drugs and transfusion of 4 concentrated blood cells. The patient responded to extubation 2 days after the operation, and there were no sequelae of cardiorespiratory arrest. Five days later, both chest drainage tubes are removed. On the sixth day after surgery, the patient was discharged without re-presenting hypoglycemic episode after surgery. On evaluation by outpatient consultation 3 weeks after discharge, the chest radiograph shows pulmonary reexpansion in the left hemithorax (Figure 4).