[A Case of Recurrent Lung Adenocarcinoma with Right Aortic Arch Treated with Pembrolizumab].

Only a few cases of primary lung cancer associated with the right aortic arch have been reported. A treatment report of recurrent lung cancer with the right aortic arch is rare. A woman in her late 70s was diagnosed with lung cancer associated with the right aortic arch. A 3.4-cm tumor was detected in the right middle lobe on CT performed before a knee joint surgery. The tumor was diagnosed as lung adenocarcinoma and categorized as cT2aN0M0 with cStage ⅠB. Subsequently, a right middle lobectomy was performed. Histopathological study revealed pT1cN1M0 with pStage ⅡB tumor. Molecular analysis revealed 85% expression of programmed death-ligand 1(PD-L1). One year after surgery, mediastinal lymph nodes recurred with multiple lung metastases. The number of metastatic lymph nodes reduced after pembrolizumab was administered, followed by the disappearance of lung metastasis. The outcome was recorded as a partial response. She has been alive 2 years after surgery.

[Nivolumab Therapy for Synchronous Double Primary Lung and Gastric Cancers].

A 70-year-old man who was diagnosed with a cStage ⅣA lung adenocarcinoma was in a stable condition for a long time after the first chemotherapy with gefitinib. However, 2 years 4 months later, the lung cancer progressed, and he was diagnosed with Stage Ⅲ gastric cancer. Since the administration of afatinib as the second-line chemotherapy was ineffective, nivolumab was administered as the third-line chemotherapy. The lung cancer showed a partial response to nivolumab treatment, but the gastric cancer remained unresponsive. We report a rare case of immune checkpoint inhibitor administration for synchronous double primary cancers.

[A Case of Recurrent Thymoma Treated with Pembrolizumab as the Fifth-Line Chemotherapy].

The option of chemotherapy for recurrent thymoma is limited. Postoperative adjuvant therapy has yet to be established. A 71-year-old male underwent extended thymectomy for thymoma with Masaoka stage Ⅲ, and subsequently, radiation was performed as adjuvant therapy in 2012. Since recurrence was detected in 2014, multidisciplinary treatment was performed for 4 years. An increase of intrathoracic dissemination was detected in 2018. Tumor tissue samples by re-biopsy showed 70% expression of programmed death-ligand 1(PD-L1). Pembrolizumab was administered as fifth-line chemotherapy every 4 weeks at a dosage of 200 mg. After 3 courses, the lesions had remarkably decreased. This suggests that pembrolizumab for thymoma with high PD-L1 expression is efficacious.

Desmoid tumor requiring differentiation from port-site relapse after surgery for lung cancer.

Thoracoscopic left lower lobectomy with lymph node dissection for lung cancer was performed in a 76-year-old man. The diagnosis was pT2aN2M0 adenocarcinoma. Sixteen months after surgery, CT revealed a pleural tumor measuring 38 mm at the surgical port wound. CT-guided biopsy revealed fibroma. However, the tumor size increased 4 months after biopsy, and surgery was performed. An intraoperative diagnosis revealed benign fibroma. Thoracoscopic tumorectomy was conducted. The pathological diagnosis was desmoid tumor. As the margins of the resected specimen were positive, radiotherapy was performed. During the 16-month follow-up period, there has been no relapse. Pleural desmoid tumors must be differentiated from port-site relapse.

Thymic metastasis of breast cancer 22 years after surgery: a case report.

We report a rare case of thymic metastasis of breast cancer. A 68-year-old woman, who had undergone surgery for cancer in her right breast and had been free of recurrence for 22 years, was noted to have an abnormal shadow on a chest X-ray at a regular medical checkup. Further workup, including chest CT, revealed a 22 × 18-mm mass in the anterior mediastinum. Fluorine-18-fluorodeoxyglucose-PET showed increased fluorine-18-fluorodeoxyglucose uptake that was highly suggestive of thymoma. Thoracoscopic thymothymectomy was performed. The tumor had invaded the pericardium, which was also resected. A small nodule was found in the right lung, and it was also resected. The intraoperative frozen-section diagnosis was breast cancer metastasis to the thymus and lung. The pathological diagnosis was luminal A solid tubular carcinoma (strongly estrogen receptor and progesterone receptor positive, HER2 negative) with an MIB-1 index of less than 5%. After surgery, the patient was treated with an aromatase inhibitor. As of August 2013, she has been free of recurrence for more than 36 months. It is extremely rare for breast cancer to metastasize to the thymus more than 20 years after surgery.

Radiation-induced synovial sarcoma of the lung diagnosed by gene analysis after the surgical resection of chondrosarcoma arising from the scapula.

The patient was a 62-year-old male who underwent wide resection and radiotherapy for right scapular chondrosarcoma 12 years ago. An abnormal shadow was detected in the right upper lung field included in the irradiated field on chest X-ray. Since the nodule tended to enlarge, a malignant lung tumor was suspected, and surgery was performed. On histological examination, spindle cells densely proliferated in a bundle pattern. Vimentin, bcl-2 protein, and CD99 were positive, and CD34, cytokeratin, AE1/AE3, and EMA were partially positive on immunohistochemical staining. The SYT-SSX (synaptotagmin- synovial sarcoma X) fusion gene was detected employing RT-PCR, based on which primary synovial sarcoma of the lung was diagnosed. The findings also matched the diagnostic criteria of radiation-induced sarcoma, suggesting radiation-induced primary synovial sarcoma of the lung. Primary synovial sarcoma of the lung is a rare tumor. It is difficult to diagnose based on cellular findings, and immunohistochemical and genetic investigations are essential. Radiation-induced sarcoma may develop through a long-term course, as seen in this patient, for which long-term follow-up after radiotherapy is important.

A successful case of robotic bronchoplastic lobectomy for lung cancer.

We performed robotic bronchoplastic upper lobectomy for squamous cell carcinoma of the right hilum of the lung. The patient was a 56-year-old male and surgery was performed using 3 robotic arms and 1 assistance. Deeply wide wedge resection and interrupted suture were applied to the bronchus of the upper lobe. The pathological stage was pT1bN1M0, IIA. Chest drain tube was removed on postoperative day 2 and no postoperative respiratory complication occurred. The key for success of this procedure is accustoming to robotic manipulation, especially suturing technique because of the absence of a tactile sense.

Squamous cell carcinoma of the lung invaded to esophagus: a case report of successful surgical treatment after preoperative transesophageal echographic evaluation.

We describe a successful surgical case of a 78-year-old man with a squamous cell carcinoma of the lung invaded to the esophagus. Chest computed tomography on admission showed a tumor mass shadow in the left lower lobe (S(6)). The tumor was adjacent to the esophagus, which was a strongly suspected lung cancer with esophageal invasion. We performed the transesophageal endoscopic ultrasound (EUS) for a detailed evaluation of the degree of invasion, and we obtained the findings of localized tumor invasion into the muscular coat of the esophagus. The tumor invaded to the esophagus perioperatively, and we could remove all the involved area with enough surgical margin. We believe that the preoperative evaluation using EUS is a useful procedure, if we suspect the lung cancer with esophageal invasion.

Thoracoscopic resection with intraoperative use of methylene blue to localize mediastinal parathyroid adenomas.

We report a case of thoracoscopic resection of mediastinal parathyroid adenomas using methylene blue to localize the tumors during the operation. After methylene blue 4 mg/kg was injected intravenously, we easily identified methylene blue-stained parathyroid glands and successfully resected them with sufficient surgical margins. The use of methylene blue for detection of parathyroid adenoma is a useful technique.

First experience of robotic extended thymectomy in Japan for myasthenia gravis with thymoma.

We performed robot (da Vinci)-assisted thoracoscopic extended thymectomy (rThx) for myasthenia gravis with thymoma. The patient was a 66-year-old woman who complained of palpebral heaviness. Robotic operation was performed in the supine position by placing four ports in the right chest wall under 10 mmHg CO(2) insufflation using three arms and one assist port. Compared with conventional video-assisted thoracic surgery (VATS), the bilateral upper horns, fat around the diaphragm, and aortopulmonary window could be resected more easily. The tumor measured 41 mm maximum diameter and was diagnosed as type AB noninvasive thymoma. The operating time was 298 min, console operating time was 203 min, and the amount of bleeding was small. The postoperative course was uneventful with no complications. This is a report of the first Japanese case of rThx for myasthenia gravis. rThx is a promising technique, and further improvement in the procedure is expected.

Sister Mary Joseph's nodule that originated from lung adenocarcinoma.

Umbilical metastasis of cancer, known as Sister Mary Joseph's nodule (SMJN), is a rare phenomenon. It is usually due to intraabdominal malignancies and is quite rare from lung cancer. Here we describe a case of SMJN that originated from advanced lung adenocarcinoma. SMJN should be noted as an important sign of some hidden malignancy including lung cancer.

Thoracoscopic resection of a thoracic duct cyst that developed during follow-up for a thymic cyst.

A 29-year-old man had been diagnosed with an anterior mediastinal cyst 6 years earlier and was undergoing follow-up. At a follow-up visit, a newly developed cystic lesion was found in the middle mediastinum; therefore, the anterior mediastinal cyst and the middle mediastinal cyst were resected by thoracoscopic surgery. It was observed that the middle mediastinal cyst originated from the thoracic duct, and the thoracic duct was clipped. Pathologically, the diagnosis was a thymic cyst of the anterior mediastinum and a thoracic duct cyst of the middle mediastinum. The patient developed chylothorax after surgery, and a second thoracoscopic operation was performed. It revealed that part of the clipping of the caudal thoracic duct was incomplete, and leakage of chyle was observed. Hence, the clipping was performed again. The course after the second surgery was good. Thoracic duct cysts are rare even among mediastinal cysts and thus require caution due to their tendency to expand.

Mediastinal malignant lymphoma difficult to diagnose: a patient report.

We report a 58-year-old man who suffered from shortness of breath on exertion with wheezing. A chest enhanced computed tomography (CT) scan showed an irregular tumor in the middle mediastinum involving the right main pulmonary artery, vena cava superior and right main bronchus. Transbronchial lung biopsy and endobronchial ultrasound-guided transbronchial needle aspiration yielded no evidence for a pathological diagnosis of malignancy. We employed mediastinoscopy, which led to a diagnosis of lymphoid reactive change. 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scan revealed a high FDG uptake in the tumor lesion. Because the CT scan and FDG-PET findings led to a marked suspicion of malignancy, we decided to attempt biopsy by a video-assisted thoracoscopic surgery (VATS) approach. Flow cytometry showed a monoclonal pattern, and the final diagnosis was mediastinal follicular lymphoma both pathologically and immunohistologically. The patient achieved a complete remission by following chemotherapy. Low-grade malignancy type of lymphoma such as follicular lymphoma that generally contains small-cell components often presents a diagnostic challenge and the VATS approach was effective for the diagnosis of such type of mediastinal lymphoma.

Spontaneous regression of lung adenocarcinoma: Report of a case.

This report presents a rare case of lung adenocarcinoma accompanied by partial spontaneous regression (SR). A 69-year-old woman with an abnormal shadow on chest X-ray was admitted to the hospital. She was diagnosed to have lung adenocarcinoma with right adrenal metastasis based on a thorough examination. However, a month after the diagnosis, the primary and metastatic lesions markedly shrank on the following computed tomography scan and (18)F-fluorodeoxyglucose positron emission tomograph. This was thought to be a partial SR of the cancer, and she was treated with a surgical procedure. She has since remained free of disease for 14 months after the surgery.

['Lung age' predicts post-operative complications and survival in lung cancer patients].

The Japanese Respiratory Society (JRS) recently proposed 'lung age' as an easily understood concept of respiratory function. In this study, we evaluated whether 'lung age' could be a useful predictor of post-operative respiratory complications and survival patients with lung cancer treated surgically. The study recruited 308 patients who underwent surgery for primary non-small cell lung cancer. All patients had pre-operative pulmonary function testing. 'Lung age' was determined using the methods advocated by the JRS. Based on the difference between real age' (R) and 'lung age' (L), patients were classified into five groups: group A: R-L > 15 (n = 37), B: 5 < R-L < or = 15 (n = 50), C: -5 < or = R-L < or = 5 (n = 73), D: -15 < or = R-L < -5 (n = 54), E: -15 > R-L (n = 94). Clinicopathological factors, post-operative respiratory complications and survival were compared between the groups. Gender, smoking status and index, histology, operative approach and FEV1 were significantly associated with the group classification. The incidence of complications was significantly higher in group E compared with other groups (p < 0.01). Multivariate analysis showed that the group classification by 'lung age' was an independent predictor of postoperative respiratory complications (p = 0.02). Overall survival differed significantly between the groups (p = 0.03). 'Lung age' could be useful for the prediction of post-operative respiratory complications and survival in patients with lung cancer treated surgically.

Pulmonary mucinous cystadenoma: a rare benign tumor of the lung.

Pulmonary mucinous cystadenoma (PMCA) is rare, with few reported cases. This tumor is histologically characterized by a benign proliferation of mucin-producing epithelial cells and bulky mucin inside the tumor. We present the case of a 71-year-old woman with increasing mass shadow on chest radiography who underwent tumor resection by video-assisted thoracic surgery. The tumor was diagnosed histologically as PMCA.

Surgical outcome of video-assisted thoracic surgery for acute thoracic empyema using pulsed lavage irrigation.

PURPOSE: The essential points of video-assisted thoracic surgery (VATS) for acute thoracic empyema are the decortication of thickened pleura, resection of necrotic tissues and fibrin blocks, and drainage. Pulsed lavage irrigation, which is commonly used in orthopedic surgery as a method of sufficiently performing the technique, was used under a thoracoscope to study the efficacy of the treatment for acute thoracic empyema. METHODS: The subjects comprised 31 patients who had undergone VATS for acute thoracic empyema. There were 26 men and 5 women with an average age of 60.5 years. For the surgical technique, the thickened pus-producing pleura were decorticated under a thoracoscope. The pulsed lavage irrigation system was used after the intrathoracic space had become a single cavity. Using the tip for an intraspinal space, lavage and suctioning were repeated with 5-10 l of a pressurized warm saline solution. RESULTS: Fibrin blocks and necrotic tissues were easily removed by spray washing with pressurized fluid. The operating time was 150.8 min; the amount of bleeding, including suctioned pleural effusion, was 478.5 g; and the postoperative duration of drainage was 10.7 days. During the postoperative course, the addition of open window thoracotomy due to the relapse of empyema due to methicillin-resistant Staphylococcus aureus was observed in only one patient (3.2%). All of the other patients improved despite their concomitant diseases. CONCLUSION: The use of pulsed lavage irrigation under a thoracoscope for acute thoracic empyema provides simple, efficient débridement or drainage.

'Lung age' predicts post-operative complications and survival in lung cancer patients.

BACKGROUND AND OBJECTIVE: The Japanese Respiratory Society recently proposed 'lung age' as an easily understood concept of respiratory function. In this study, we evaluated whether 'lung age' could be a useful predictor of post-operative respiratory complications and survival patients with lung cancer treated surgically. METHODS: The study recruited 308 patients who underwent surgery for primary non-small-cell lung cancer. All patients had preoperative pulmonary function testing. 'Lung age' was determined using the methods advocated by the Japanese Respiratory Society. Based on the difference between 'real age' (R) and 'lung age' (L), patients were classified into five groups: group A: R-L > 15 (n = 37), B: 5 < R-L R-L (n = 94). Clinicopathological factors, post-operative respiratory complications and survival were compared between the groups. RESULTS: Gender, smoking status and index, histology, operative approach and FEV(1) were significantly associated with the group classification. The incidence of complications was significantly higher in group E compared with other groups (P = 0.003). Multivariate analysis showed that the group classification by 'lung age' was an independent predictor of post-operative respiratory complications (P = 0.02). Overall survival differed significantly between the groups (P = 0.03). CONCLUSIONS: 'Lung age' could be useful for the prediction of post-operative respiratory complications and survival in patients with lung cancer treated surgically.

Thoracoscopic resections of bronchogenic cysts arising in the posterior mediastinum: a report on 3 patients.

We report 3 cases of patients with bronchogenic cyst arising in the posterior mediastinum. The patients were a 19-year-old male, a 36-year-old female and a 33-year-old female, whose cysts were detected as abnormal shadows in the chest. In 2 of them, neurogenic tumors were suspected preoperatively. We performed thoracoscopic resection for the 3 tumors. Bronchogenic cysts may occur ectopically, and the posterior mediastinum must be sufficiently recognized as a rare but possible ectopic site.

Thoracoscopic extended thymothymectomy for myasthenia gravis with aplastic anemia.

It is very rare for both myasthenia gravis and aplastic anemia to be complicated with a thymoma. A 74-year-old female was diagnosed to have aplastic anemia with pancytopenia and systemic myasthenia gravis with severe restrictive respiratory dysfunction. Chest CT showed a 5-cm diameter thymoma. After platelets and packed red blood cells were transfused before surgery, an extended thymothymectomy was performed with a bilateral thoracoscopic approach. The thymoma was noninvasive, stage I, and was classified as B1 according to the World Health Organization classification. After the operation, the patient was managed on artificial ventilation with no complications. The myasthenia gravis remitted with the concomitant administration of steroids and immunosuppresants, but the aplastic anemia was not ameliorated. A thoracoscopic thymothymectomy for such a high-risk case of infection and respiratory distress is appropriate surgical procedure, but the complications associated with aplastic anemia are intractable.