Visceral Pleural Perforation from within a Tumor during Ultrathin Bronchoscopy

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This study describes a unique case of visceral pleural perforation during ultrathin bronchoscopy in a 65-year-old man with a history of asbestos exposure, who presented with a subpleural tumor in the right middle lobe. An ultrathin bronchoscope with a 3.0 mm outer diameter was used to obtain a biopsy specimen. During the procedure, the bronchoscope inadvertently caused a visceral pleura perforation, which led to mild pneumothorax, as confirmed by post-procedure computed tomography imaging. Although the pneumothorax did not require chest drainage, the potential risk of pleural tumor seeding prompted a wedge resection after 2 days. A histopathological examination revealed tumor invasion beyond the external elastic lamina, with pleural surface exposure. The tumor was subsequently diagnosed as Anaplastic lymphoma kinase (ALK) fusion gene-positive lung adenocarcinoma. The patient opted for treatment with an ALK inhibitor rather than further lymph node dissection. This case emphasizes the importance of careful handling of ultrathin bronchoscopes during procedures near the pleura because their increased precision and ability to reach peripheral airways can lead to rare but significant complications, such as pleural perforation.