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).