Surgical treatment of Bochodalek hernia incarcerated into the extra-pleural space: A rare case report.

INTRODUCTION: Bochdalek hernias are a type of diaphragm hernia. Almost all occur in the neonatal period, only 5% of these hernias occurring in adults. We here present a rare case of adult Bochdalek hernia incarcerated in the extra-pleural space. PRESENTATION OF CASE: An asymptomatic 51-year-old man was admitted to our hospital for a detailed examination after an abnormality had been detected on a chest radiograph. Chest computed tomography (CT) examination revealed findings consistent with a left Bochdalek hernia, which we repaied surgically. Intraoperatively, retroperitoneal fatty tissue was found to be incarcerated in the extra-pleural space. Thus, surgical repair required dissection of the parietal pleura and excision of the incarcerated fatty tissues. DISCUSSION: The incarceration of the Bochdalek hernia in the extra-pleural space could not be identified on a preoperative chest CT examination. To the best of our knowledge, no reports of incarceration of a Bochdalek hernia in the extra-pleural space have been published; thus, this phenomenon is extremely rare. CONCLUSION: Surgical treatment of a Bochdalek hernia incarcerated in the extra-pleural space requires dissection of the parietal pleura and repair via a transthoracic approach.

[Analysis of Advanced or Postoperative Recurrent Non-small Lung Cancer Cases Treated with Nivolumab].

Recent developments in cancer immunotherapy are remarkable. Many reports have described the clinical effects of immune checkpoint inhibitors (ICIs), supporting their utility as a promising therapy that will achieve prominent effects even in patients resistant to cytotoxic anticancer drugs or gene-targeting therapy. ICIs may also prolong overall survival. We analyzed 10 cases of advanced lung cancer targeted with nivolumab, which is one of ICIs in our hospital and reviewed the literature regarding ICIs. We retrospectively analyzed 10 cases that consisted of 6 males and 4 females, which comprised 7 adenocarcinomas, 2 squamous cell carcinomas and one pleomorphic carcinoma. Epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase mutations were negative in all the adenocarcinoma cases. The 10 analyzed cases included 9 inoperable cases and 1 postoperative recurrent case, 8 second-line cases, a third-line case, and a fourth-line case. The average frequency of administrations of nivolumab was 7.4 times. The survival rate was calculated by using the Kaplan-Meier method. The clinical responses to nivolumab were partial response in 2 cases, stable disease in 4 cases, and progressive disease in 4 cases. In the 10 cases, the response rate and disease control rate were 20% and 60%, respectively. The median progression-free survival time and median survival time were 115 days and 126 days, respectively. We observed 2 cases of dermatitis and one each of pyrexia, general fatigue and drug-induced pneumonia as adverse events (AEs). One of these AEs was severe (Stevens-Johnson syndrome grade 4) but could be treated by steroid pulse therapy, steroid ointment and instillation. Among the 10 examined cases of advanced lung cancer treated with ICIs at our hospital, ICIs proved effective in 2 cases. However, we also experienced a case with Stevens-Johnson syndrome grade 4 as a severe AE. These findings suggest that while ICIs may be effective in treating patients, candidates for ICIs must be carefully selected and cautiously observed.

A rare anomaly of the right superior pulmonary vein: Report of a case.

INTRODUCTION: Although there are a lot of variations of pulmonary veins (PVs) including dangerous type that could cause serous complications during the surgery, limited information has been reported about these variations. We have experienced an extremely rare anomaly of the right superior PV. PRESENTATION OF CASE: A 74-year-old man patient with right lung cancer visited our hospital. Chest computed tomography (CT) revealed a pulmonary nodule in the right lower lobe. Contrast-enhanced three-dimensional CT (3D-CT) showed that the right superior PV ran abnormally between the right main pulmonary artery (PA) and the right main bronchus. We performed right lower lobectomy and systematic nodal dissection. The operative findings confirmed that the right superior PV ran abnormally same as 3D-CT. DISCUSSION: In most reported cases, anomalous PVs pass behind the right bronchi or into the roof of the left atrium. The anomaly reported in the present case has been reported in only one case report. This case suggests that the space between the right main PA and the right main bronchus is not always safe for dissection. CONCLUSION: Preoperative 3D-CT is useful for avoiding unexpected bleeding.

Solitary fibrous tumor of the lung: a case report.

Solitary fibrous tumors (SFTs) are relatively rare neoplasms that commonly occur in the pleura. The pathological feature of SFTs is a proliferation of spindle-shaped cells in interlacing or storiform fascicles. SFTs appear to derived from pluripotential submesothelial cells, but not the covering mesothelium. SFTs distinctively show diffuse staining for CD34 but lack staining for smooth muscle markers. We herein report a relatively rare case of a 68-year-old male patient without symptoms, who underwent resection for what was considered to be SFT.

A primary cellular fibrohistiocytoma of the lung: Report of a case.

INTRODUCTION: Cellular fibrohistiocytoma (CFH) is a type of fibrohistiocytic tumor that commonly occurs in the dermis and superficial subcutis. The designation is used for lesions that show increased cellularity with a fascicular growth pattern and frequent extension. Our search of literature only revealed one case of a primary CFH of the lung. We experienced a rare patient with a primary CFH of the lung. PRESENTATION OF CASE: We herein present a rare case of a 77-year-old female patient without a cutaneous lesion, who underwent resection for what was considered to be a primary CFH of the lung. There has been no recurrence including a cutaneous lesion in a year after surgery. DISCUSSION: CFH is considered to be benign, but rare cases showing multiple recurrences and involving metastasis to the lymph nodes and internal organs have been reported. At present, it is not possible to predict this aggressive biological behavior based on the tumor histology. CONCLUSION: It is essential to perform resection with an adequate margin with close clinical follow-up.

A rare pulmonary hamartoma: fibroleiomyomatous hamartoma.

Pulmonary hamartomas are more common than expected because they are usually asymptomatic and are either discovered on routine chest radiography or when they are noted incidentally in approximately 0.25 % of autopsies. In contrast, pulmonary fibroleiomyomatous hamartoma, which consists of interlacing bundles of smooth muscle cells admixed with fibrous tissue and numerous tubular or cleft-like epithelial inclusions, is a rare type of hamartoma. Controversy exists regarding the pathogenesis of this tumor. We herein present a rare case of a 68-year-old male patient without a pre-existing smooth muscle tumor, who underwent resection for a tumor that was considered to be a true pulmonary fibroleiomyomatous hamartoma.

[Placement of An Expandable Metallic Stent for Malignant Tracheal Stenosis: A Case Report].

The utility of stent placements has been widely reported. We performed a thought-provoking stent placement for malignant tracheal stenosis recently. A 90-year-old woman who was admitted to our hospital because of a urinary tract infection was treated with a course of antibiotics, but she demonstrated a rapidly progressive course with dyspnea. Chest computed tomography showed severe tracheal stenosis due to an upper mediastinal mass. She was put on noninvasive positive pressure ventilation (NPPV) because of severe respiratory failure. Bronchoscopy showed severe tracheal stenosis due to direct invasion by the upper mediastinal mass. An expandable metallic stent (EMS) was placed in the trachea, after which a bronchoscopy showed a widely patent airway, and she got off NPPV. Then she did not need supplemental oxygen. She could seat herself, and have an enough meal, independently. However, takotsubo cardiomyopathy occurred and she died 11 days after the placement of the EMS. Since a malignant airway complication can be fatal, tracheal stent placement is a useful treatment in the management of malignancy with airway stenosis. In this case, it was thought that an early intervention of airway stenosis would have reduced the risk of takotsubo cardiomyopathy in a patient with severe symptoms of airway stenosis and stress.

Thoracoscopic plication for idiopathic eventration of the bilateral diaphragm: Report of a case.

INTRODUCTION: Diaphragmatic eventration, defined as permanent elevation of the diaphragm without defects, is a rare anomaly in adults. Trauma, neoplasms, infection, and degenerative disease are the most common causes of this condition, whereas idiopathic eventration of the diaphragm is relatively infrequent. PRESENTATION OF CASE: We herein present the rare case of an 85-year-old female with idiopathic eventration of the bilateral diaphragm. The patient demonstrated a rapidly progressive course with dyspnea; therefore, thoracoscopic surgery of the unilateral diaphragm was performed. She subsequently withdrew from home oxygen therapy, which had introduced preoperatively, and exhibited a significant improvement in her pulmonary function for one year after the operation. DISCUSSION: Various approaches for diaphragmatic plication have been reported, including open (transthoracic or transabdominal) and minimally invasive methods, such as thoracoscopic or laparoscopic plication. We consider thoracoscopic plication to be an effective minimally invasive method, although single-lung ventilation is required. CONCLUSION: We experienced a case in which thoracoscopic plication of the unilateral diaphragm resulted in adequate objective improvements in the pulmonary function in a patient with idiopathic eventration of the bilateral diaphragm.

Surgical management of pulmonary arteriovenous fistula in a female patient.

INTRODUCTION: We herein describe a rare case of a pulmonary arteriovenous fistula (PAVF). PRESENTATION OF CASE: The patient was a 20-year-old asymptomatic female, admitted to our hospital because of an abnormal shadow in the right lung field on chest X-rays. Chest computed tomography (CT) revealed two nodules with well-defined margins in the right upper and lower lobes. Contrast-enhanced three-dimensional CT (3D-CT) revealed two enhanced solitary lung nodules which were connected with linear structures suggestive of feeding arteries and drainage veins, respectively. Based on these findings, we made a preoperative diagnosis of PAVF. We performed partial pulmonary resection of the right upper and lower lobes by video-assisted thoracoscopic surgery (VATS). The histopathological findings revealed small and medium-sized vascular channels composed of arteries with mild and irregularly thickened muscle walls and juxtaposed or seemingly anastomosing dilated veins. Based on these findings, a diagnosis of PAVF was confirmed. The patient had an uneventful postoperative course. DISCUSSION: A PAVF is often associated with various complications, and pregnancy could be a risk factor for these complications because of the increase in the shunt fraction. Females with known PAVF should be maximally treated prior to becoming pregnant as complications of PAVF during pregnancy can have devastating consequences. Therefore, we thought that treatment should be recommended in this case in the event she might later choose to become pregnant. CONCLUSION: Surgical resection using VATS for a limited number of ipsilateral isolated pulmonary arteriovenous fistulae is recommended due to its safety, low recurrence and low mortality rate.

Lung granuloma mimicking pulmonary arteriovenous malformation: Report of a case.

INTRODUCTION: While hypervascular lesions in the lung are known to mimic pulmonary arteriovenous malformation (PAVM), here we report a rare case of lung granuloma mimicking PAVM, on which video-assisted thoracic surgery (VATS) was performed. PRESENTATION OF CASE: A 76-year-old woman without any symptom was admitted to our hospital because of abnormal shadow in the left lung field on chest X-ray. A 20mm×14mm nodule with well-defined margins and smooth contours in the left upper segment was detected in her chest computed tomography (CT). Contrast-enhanced three-dimensional CT (3D-CT) revealed an enhanced solitary lung nodule, which was connected with linear structures suggestive of feeding artery and drainage vein. Thus, we made a preoperative diagnosis of PAVM by performing partial pulmonary resection by VATS. Intraoperatively, elastic hard nodule was palpable in the left upper segment and bruit was not convincing. Histopathological findings revealed multiple foci of coagulative necrosis surrounded by epithelioid cell granuloma containing Langhans-type multinucleated giant cells, involving the medium-sized blood vessels in the pulmonary parenchyma. Abnormal vascular structures, such as PAVM were not convincing. Based on these findings, a diagnosis of left lung granuloma was made. DISCUSSION: Preoperatively, it was difficult to distinguish the left lung granuloma from PAVM, because hypervascular lesion, such as inflammatory changes can present as strongly enhanced nodules after injection of contrast material. CONCLUSION: Surgical approach seems appropriate, not only for the purpose of diagnosis, but also for the safety in treatment of a PAVM.

An idiopathic azygos vein aneurysm mimicking a mediastinal mass.

Azygos vein aneurysms are very rare causes of mediastinal masses and are usually accidental findings on chest roentgenography. Most are detected in patients with portal hypertension or venous malformations. An idiopathic azygos vein aneurysm is assumed to be congenital and is much more exceptional. We present the case of a 76-year-old man who underwent excision of an idiopathic azygos vein aneurysm by video-assisted thoracoscopic surgery (VATS).

[A case of long-term survival following combined modality therapy for peritoneal disseminated recurrence of duodenal cancer].

A 65-year-old man was diagnosed with primary duodenal cancer and he underwent pancreaticoduodenectomy in June 2006. S-1 was administered as the postoperative adjuvant chemotherapy. A peritoneal disseminated recurrence was diagnosed together with a right reniportal node and right hydronephrosis in February 2007. A ureteral stent was inserted. DOC +S-1 combination therapy was administered from March 2007. Following progression of the recurrence, CDDP+S-1 combination therapy was administered from August 2007. Temporal diminution of the recurrence was achieved with radiotherapy from May to June 2009. Following re-progression of the recurrence, biweekly CPT-11 therapy was administered from February 2010. Weekly PTX therapy was administered from January 2011. The patient died due to progression of the recurrence in June 2011, 5 years after the operation. Our patient maintained a good quality of life and achieved long-term survival by combined modality therapy for peritoneal disseminated recurrence of duodenal cancer.

[A case successfully treated with abdominoperineal resection after preoperative chemoradiation therapy for anal cancer].

A 46-year-old female was diagnosed with anal squamous cell carcinoma. Chemoradiation therapy was administered for a first-line therapy. Two courses of enforced 5-FU/MMC combination therapy were administered along with radiotherapy (60 Gy). This chemoradiation therapy had complete response. However, three months after, anal cancer had a local recurrence. Since there was no distant metastasis, abdoninoperineal resection was performed. No complications were observed after the operation. We conclude that abdominoperineal resection may be effective in the treatment of anal cancer in cases which the local recurrence was observed after chemoradiation therapy.

[A case of long-term survival by combined modality therapy for liver and pulmonary metastasis of rectal cancer].

We report a case of rectal cancer diagnosed in 2001, which enforced a rectal low anterior resection. Then, metastatic liver cancer and metastatic lung cancer recurred and we enforced an operation for both. Furthermore, metastatic lung cancer recurred again and enforced chemotherapy with radiation and systemic chemotherapy for approximately seven years. The metastatic lung cancer was reduced now in 2011, so that the chemotherapy has not been used since then. In our case, we mainly performed a surgical and radiation therapy for a local recurrent site therapy in the first half because we did not have much choice for a systemic chemotherapy like we have now. In the later half, we mainly performed a systemic chemotherapy to control the local recurrent site. A treatment policy for colon cancer recommends a surgical treatment by the guidelines, or even though chemotherapy has been developed at present, if a local therapy is practical. There were many cases where metastases had occurred right after surgery so a local site therapy by excision was good at all unconditionally. However, as a result of our case in a local site therapy combined with whole body chemotherapy, we report here that a long- term survival was obtainable. We also include a brief literature review.

The role of serum interleukin-8 in hepatic resections.

PURPOSE: Interleukin-8 (IL-8) is a neutrophil chemotactic factor, which is associated with some inflammatory diseases and various types of surgical stress. The aim of this study was to investigate whether the early postoperative serum IL-8 level may potentially be a new indicator of a surgical stress in patients undergoing a hepatic resection. METHODS: The serum IL-8 levels were measured in 37 patients who underwent a hepatectomy. The serum IL-8 levels were serially measured using an enzyme-linked immunosorbent assay both before and after a hepatic resection. In addition, the correlation between the postoperative IL-8 value and several clinical variables were examined. RESULTS: The mean level of IL-8 significantly increased immediately after the operation (P < 0.01 vs before the operation) and decreased on the first postoperative day (POD 1, P < 0.05 vs after the operation). The early postoperative IL-8 levels positively correlated with the length of the procedure (r = 0.383; P < 0.05), the estimated blood loss (r = 0.483; P < 0.01) and the serum bilirubin level on POD 1 (r = 0.390; P < 0.05), and inversely correlated with the white blood cell counts (r = -0.388; P < 0.05) and lymphocyte counts on POD 1 (r = -0.424; P < 0.05). In a comparison of the postoperative IL-8 levels with the surgical factors, there was a significant difference in the extension of the resection (P < 0.05) and in blood transfusion. The patients with a fever of more than 38 degrees C showed higher levels of IL-8 immediately after the operation than those without fever (P < 0.01). CONCLUSIONS: The early postoperative serum IL-8 level was found to correlate with the degree of the severity of surgery in patients undergoing a hepatic resection, and it is also considered to be a new indicator of surgical stress and liver injury.

[A case successfully treated with subtotal esophagectomy after preoperative second-line chemotherapy for cT4 esophageal cancer].

A 69-year-old male was diagnosed with type 2 advanced esophageal cancer in the upper and middle thoracic esophagus which invaded the left main bronchus and the aorta. Radio-chemotherapy was administered since a radical resection could not be performed due to the invasion. Two courses of enforced FP combination therapy (5-FU and CDDP) were administered along with radiotherapy. Although this radio-chemotherapy was effective to some degree in tumor reduction, a radical resection still could not be performed due to the invasion of the left main bronchus and the aorta. Thus, we administered four more courses of DCF combination therapy (docetaxel, CDDP and 5-FU). This chemotherapy reduced the esophageal cancer mass significantly, and subtotal esophagectomy was performed. No complications were observed after the operation. We conclude that DCF combination therapy may be effective in the treatment of esophageal cancer in cases which the desired effect cannot be achieved by FP combination therapy alone.

[A case of elderly advanced gastric cancer patient with multiple liver metastases effectively treated by hepatic arterial infusion chemotherapy].

An 85 years old man was performed systemic chemotherapy after the palliative gastrectomy for unresectable gastric cancer with multiple liver metastases. The response evaluation revealed a progressive disease after 4 courses of first-line S-1 therapy and 3 courses of second-line paclitaxel therapy. At this point, metastatic lesions were still localized in the liver, so hepatic arterial infusion chemotherapy (HAI) was introduced as third-line therapy. Despite the marked reduction of all target lesions and reduced tumor marker level after 25 weeks of HAI without any adverse event, novel multiple metastatic lesions had appeared in the lung and celiac LNs, resulted in the cessation of HAI. Then he had suffered grade 3 mucositis oral and anorexia throughout 2 courses of fourth-line S-1 + CDDP therapy and fifth-line docetaxel therapy. Considering that the goal of treatment for unresectable gastric cancer patients is to delay developing symptoms and to prolong their life with the least adverse event, HAI could be an effective therapy.

[A long-term survival after hepatectomy combined with hepatic arterial infusion chemotherapy for hepatic metastasis of colon cancer].

We report on a patient who presented in 2000 with multiple hepatic metastasis of sigmoid colon cancer. We chose the hepatic arterial infusion chemotherapy for this case since there was no effective chemotherapy at that time. After the intermittent chemotherapy for one and half years, we recognized that the tumor became smaller, though it couldn't cure completely. Therefore, two years after the first medical examination, we underwent a hepatic left lobectomy and S8 hepatectomy. No recurrence has been observed until now. As a recent treatment of the hepatic metastasis of colon cancer, there is a tendency to choose chemotherapy before operation. However, there are some cases in which chemotherapy isn't acceptable because of its side effect. Besides chemotherapy, we report another treatment (the hepatic arterial infusion chemotherapy) which has a similar effectiveness with fewer side effects for the hepatic metastasis of colon cancer.

[A case of duodenal penetration by indwelling catheter during hepatic arterial infusion chemotherapy].

We report a patient with hepatic metastasis of descending colon cancer who underwent hepatic arterial infusion chemotherapy using 5-fluorouracil (5-FU) and CDDP, with an indwelling catheter and port system by GDA coil method. Since the tumor became smaller after five months, we decided to follow her up as an outpatient. Considering the possibility of its recurrence, the catheter-port system remained in her. Two and half years later, the recurrent hepatic metastasis was recognised and the hepatic arterial infusion chemotherapy was fulfilled again. The tumor obviously reduced and the same treatment was continued. However, he was hospitalized with a complaint of hematemesis. Upper gastrointestinal endoscopy revealed a projection around the splitting catheter in the duodenal bulb. Therefore, we embolized with coil under angiographic guidance in order not to bleed from the artery and removed the port. With this experience, special attention for the catheter port system must be taken if one considers a long-term treatment. Thereby, we report on the complications of the catheter-port system.

Clinical significance of histone deacetylase 1 expression in patients with hepatocellular carcinoma.

OBJECTIVE: Histone deacetylases (HDACs) play an important role in chromatin remodeling, gene repression and regulating cell cycle progression and differentiation. This study was designed to clarify the role of HDAC1 expression in hepatocellular carcinoma (HCC). METHOD: The expression of HDAC1 in 47 patients with surgically resected HCC was immunohistochemically examined and analyzed in relation to their clinicopathological factors. The patients were divided into two groups according to the expression status of HDAC1: a high HDAC1 group (n = 25) with more than 20% of positively stained cells and a low HDAC1 group (n = 22) with 20% or fewer positively stained cells. RESULTS: A high HDAC1 expression indicated a higher incidence of cancer cell invasion into the portal vein, a poorer histological differentiation, and a more advanced TNM stage. The survival rates after a surgical resection in low and high HDAC1 patients at 1, 3, 5 and 10 years were 100, 95.5, 81.8 and 60.8% and 88.0, 60.0, 40.0 and 32.0%, respectively (p = 0.008). A multivariate analysis using the Cox regression analysis showed that a high HDAC1 expression was an independent prognostic factor of HCC in patients after hepatic resection (relative risk: 10.1, p = 0.0018). CONCLUSIONS: High HDAC1 expression might have an important role in the aggressiveness and cell dedifferentiation, and its expression status may be a useful biomarker for predicting the outcome of the patients with HCC.