PMC4061420_01
A. Computed tomography scan of the chest shows pure ground glass opacity on segment 8 of the right lung. B. On chest radiograph (PA view), note that the area corresponding to right lung segment 8 does not clearly define an abnormality.
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The representative case is that of an 81-year old female, non-smoker, with a 35 mm pure ground glass opacity (GGO) in the right lower lobe that was incidentally seen on computed tomography (CT) scan of the chest (Fig. 1A) but was indistinct on chest radiograph (Fig. 1B).
A. Real-time fluoroscopy image of the chest during endobronchial ultrasound scanning. B. Initial endobronchial ultrasound scanning through the right B8bi showed a whitish acoustic shadow that represented normal air-filled alveoli. EBUS image shown is on a 2 mm scale. C. The Blizzard Sign. When the endobronchial ultrasound probe was inserted further and more distally, there was a subtle but noticeable increase in the intensity and radius of the whitish acoustic shadow more than 1 cm from the center of the EBUS image. D. Real-time fluoroscopy image during transbronchial biopsy using forceps and guide sheath (K-203 kit, Olympus).
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During the initial attempt, it was difficult to distinguish the mass on fluoroscopy (Fig. 2A) and ultrasound signals only generated a snowstorm appearance that was ascribed as normal lung tissue (Fig. 2B). At this point, a subtle but noticeable enhancement and increase in area of the snowstorm appearance was seen (Fig. 2C). After marking this location of the GS on fluoroscopy, seven TBB samples were obtained using a dedicated biopsy forceps with guide sheath kit (Fig. 2D).
Photomicrographs of the Hematoxylin & Eosin staining of a transbronchial biopsy specimen from a pure ground glass opacity show adenocarcinoma with lepidic growth. A (x100); B (x400).
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Histopathologic examination of the 3rd to the 7th consecutive biopsy specimens revealed adenocarcinoma with lepidic growth (Fig. 3).