Investigating the predictive factors of thoracic aortic invasion and surgical outcomes in patients with primary lung cancer: A retrospective study.

BACKGROUND: This study aimed to investigate predictors of thoracic aortic invasion in lung cancer patients using preoperative clinical and imaging characteristics and elucidate surgical outcomes in cases of aortic invasion. METHODS: Of the 4751 lung cancer patients who underwent surgery at our hospital, we included 126 (6.8%) who underwent left-sided surgery and in whom tumor appeared to be in contact with the thoracic aorta on preoperative imaging. The patients were divided into two groups: group A, 23 patients (18%) who underwent combined aortic resection (+); group B, 103 patients (82%) who did not undergo combined aortic resection (-). RESULTS: The percentage of aortic invasion for tumor diameter <3 cm, 3-4 cm, 4-5 cm, 5-7 cm, and >7 cm was 0%, 13%, 23%, 16%, and 35%, respectively. The percentages of aortic invasion were 27%, 16%, and 0% for tumor localization in the upper division, S6, and S10, respectively. Multivariate analysis revealed that aortic depression due to tumor or loss of fatty tissue between tumor and mediastinum in the chest CT significantly predicted aortic invasion (odds ratio = 23.83, 16.66). Group A demonstrated significantly more blood loss, longer operative time, prolonged hospital stay, and increased percentage of recurrent nerve palsy (13%) compared to group B. The 1-, 3-, and 5-year survival rates for patients in group A were 53.4%, 24.3%, and 24.3%, respectively. CONCLUSION: If the chest CT of a patient demonstrates aortic depression due to tumor or loss of fatty tissue between tumor and mediastinum, aortic complications should be considered when planning surgery.

Predictive factors for postoperative delirium in thoracic surgery.

OBJECTIVE: We examined cases in which delirium developed after thoracic surgery under general anesthesia at our hospital to determine the predictive factors for postoperative delirium, as well as the perioperative findings in cases showing postoperative delirium. METHODS: This retrospective study included 1674 patients who underwent surgery under general anesthesia at our hospital between 2012 and 2022, A psychiatrist diagnosed postoperative delirium using the Confusion Assessment Method. RESULTS: There were 99 (5.9%) patients with postoperative delirium in our study, including 85 (86%) men, of whom 31 (31%) had a history of cerebrovascular disease. The incidence of postoperative delirium in patients aged > 80 years was 20% (36/182). The postoperative delirium group showed significantly longer hospital stays and more frequent postoperative complications than the group without postoperative delirium. In univariate analysis, age ≥ 80 years, male sex, history of cerebrovascular disease, hypertension, history of atrial fibrillation, and history of smoking were identified as significant factors, while multivariate analysis identified age ≥ 80 years, male sex, history of cerebrovascular disease, hypertension, and history of smoking as significant factors (odds ratios = 5.15, 2.04, 3.10, 1.67, and 2.36, respectively). In the 169 cases with none of these five factors, the postoperative delirium risk was 0% (0/169). CONCLUSIONS: In patients undergoing thoracic surgery, predictive factors for postoperative delirium include age ≥ 80 years, male sex, history of cerebrovascular disease, hypertension, and smoking history. The findings also indicate that patients with these risk factors may require psychiatric consultation before surgery.

Problems and countermeasures for surgical resection of primary pulmonary artery intimal sarcoma.

Background: Pulmonary artery intimal sarcoma (PAIS) is a rare but aggressive malignancy. This study clarified the problems and countermeasures of surgical treatment by examining surgical cases of PAIS. Methods: Between January 2007 and October 2020, 10 patients with PAIS who underwent surgery at our hospital were retrospectively examined. Results: The surgical procedure that aimed at complete resection was pulmonary resection only (three cases), along with pulmonary artery vascular replacement (six cases) and pulmonary endarterectomy (PE) (one case). The positive rate of vascular stumps was 7/10. In all cases, chest computed tomography scan showed positive margins of ≤20 mm between the tumor and surgical dissection (6/6). In addition, the distance between the location of the tumor on computed tomography and the dissection line during surgery needed to be at least 20 mm (2/3). However, even at a distance of 25 mm, one case with a positive margin was observed. Postoperative recurrence was 8/9 cases, and the median recurrence period was as short as 10 months (range, 3-19 months). Postoperative treatment was required in 7/9 cases (operation/chemotherapy/radiotherapy/chemoradiotherapy/heavy ion radiotherapy =1/2/2/1/1). The median survival was 15 months (range, 0.5-36 months). Conclusions: Extended surgery should be performed as much as possible, with a distance of at least 20 mm between the location of the tumor on computed tomography scan and the incision line during surgery. The median postoperative recurrence period was as short as 10 months. Therefore, intensive care for intrathoracic recurrence follow-up is required for 1 year after surgery.

Outcome and prognosis of secondary lung cancer surgery with interstitial lung disease.

BACKGROUND: The initial surgery for lung cancer with interstitial lung disease (ILD) is often followed by passive treatment due to the surgery-induced deterioration in respiratory function, and only a few studies have summarized the findings associated with a second surgery for lung cancer patients with ILD. METHODS: Of the 3932 lung cancer patients who underwent surgery at our hospital from August 2008 to July 2019, 404 (10%) patients (1) underwent preoperative computed tomography for imaging of interstitial pneumonia and (2) underwent initial surgery. We analyzed 45 cases (11%) suspected of showing metachronous lung cancer during the postoperative course. RESULTS: Thirty-four patients (76%) underwent a second surgery. The group that underwent a second surgery showed a significantly better prognosis than the group that did not (p = 0.0009). The surgical procedure was wide-wedge resection/segmentectomy/lobectomy and above in 15/7/12 cases, respectively. Postoperative complications were observed in nine cases (26%) (prolonged pulmonary fistula in five cases, ILD acute exacerbation in two cases, and wound dissection in two cases). Mortality within 30 days occurred in one case (ILD acute exacerbation at postoperative day 15). Twelve patients (35%) experienced recurrence. In the wide-wedge resection group, 2/15 (13%) patients showed stump recurrence. The 1-, 2-, 3-, and 5-year survival rates after surgery for secondary lung cancer were 80.4, 72.5, 68.2, and 39.4%, respectively. CONCLUSION: Surgery can be considered an effective treatment method for secondary lung cancer with ILD if the cases are carefully selected.

Penetrating chest trauma in Sauer's danger zone without serious heart or lung damage: An unusual case report.

INTRODUCTION AND IMPORTANCE: Sauer's danger zone is an area on the anterior chest where trauma is considered to cause heart and macrovascular injury. Herein, we report the case of an injured patient showing evidently fatal findings on chest radiography and computed tomography (CT) presenting almost no actual fatal injuries on surgical examination. CASE PRESENTATION: The patient was an 86-year-old man who was found by a family member with a 30-cm knife blade stuck in his left front chest (Sauer's danger zone). On chest CT findings, the knife was observed to be inserted through the 4th intercostal space, penetrating the lungs. The tip of the knife appeared to be anchored to the dorsal side of the 9th intercostal space. CLINICAL DISCUSSION: We found no damage to the heart, only a 2-cm-long and 1-cm-deep cut in the lingular segment area. CONCLUSION: We confirmed that the amount of bleeding in the inserted drain was an indicator of non-macrovascular injury. In cases of chest trauma, chest tube drainage and hemodynamics should always be observed, and the potential need for emergency surgery should be considered.

Can acute exacerbations occurring late after surgery with interstitial lung diseases be predicted?

BACKGROUND: The incidence of acute exacerbation (AE) 31 days after surgery in lung cancer (LC) patients with interstitial lung disease (ILD) has not yet been elucidated. This study aimed to identify the AE incidence rate, mortality rate, and risk factors in patients with late-stage LC with ILD. METHODS: We conducted a retrospective study on 410 patients with ILD on preoperative computed tomography among 3939 patients with LC who underwent their first surgery between August 2008 and July 2019. We divided the patients into Group A (early AE; 18cases), Group B (late AE; 40 cases), and Group C (no AE; 352 cases). RESULTS: There were no significant differences in the clinical background between Groups A and B. The AE incidence rates were 0.56 case per person-years at ≤ 30 days, 0.24 at 90 days, 0.14 at 180 days, 0.10 at 1 year, 0.078 at 2 years, 0.086 at 3 years, 0.064 at 4 years, and 0.059 at 5 years after surgery. The mortality rates of the first AE were 10/18 (56%), 3/5 (60%), 7/13 (54%), and 7/22 (32%) at onset ≤ 30 days, 31-90 days, 91-365 days, and 366-1825 days after surgery, respectively. Multivariate Cox proportional analysis showed that adjuvant chemotherapy and a usual IP (UIP) pattern on CT + KL-6 ≥ 1000 (hazard ratio 3.647, 2.631) were predictors of late AEs. CONCLUSIONS: Patients with adjuvant chemotherapy and a usual IP (UIP) pattern on CT + KL-6 ≥ 1000 are likely to develop later AEs. Therefore, early intervention with antifibrotic therapy is recommended.

Left pneumonectomy for primary lung cancer with Trousseau's syndrome.

Trousseau's syndrome is a paraneoplastic syndrome and a pathological condition that causes cerebral stroke symptoms due to hypercoagulation associated with malignant tumours. There have been many cases of advanced lung cancer, but few reports have described surgery for lung cancer with Trousseau's syndrome. We encountered a 76-year-old man suspected of having Trousseau's syndrome associated with lung cancer. He was transferred to our hospital on the second day after the onset. After admission, he was treated with heparin and edaravone, and his condition improved. On the 12th day after the onset, we performed left pneumonectomy and lymph node dissection (ND2a-2). The final pathological results were adenocarcinoma, pathological stage was T4 (tumour size: 77 mm, pulmonary artery invasion) N1(#11, #12u) M0, stage IIIA. He has been recurrence free for 23 months since the surgery. In the future, we need to follow his condition carefully.

Pulmonary Arterial Sarcoma With a Wide Range of Endovascular Intima Invasion Microscopically.

A 69-year-old man underwent right middle and lower lobectomy for suspected lung cancer (cT3 N1 M0). The final pathologic diagnosis was pulmonary artery (PA) sarcoma. The stump was positive despite having a sufficient surgical margin. After 11 months, we performed completion pneumonectomy and PA resection and replacement under extracorporeal circulation for local recurrence. Although the PA was macroscopically intact, the frozen pathologic diagnosis was positive 3 times. Because PA sarcoma extends microscopically through the intima of the PA, it is difficult to determine the extent of resection on imaging. We consider confirmation by a frozen pathologic diagnosis to be essential.

Surgical results and prognosis of lung cancer in elderly Japanese patients aged over 85 years: comparison with patients aged 80-84 years.

OBJECTIVE: With the increase in lung cancer patients over 80 years of age, lobectomy with mediastinal lymph node dissection is often performed in patients in a good general condition. However, the age limit for this procedure has not yet been determined. In this study, we examined the safety, therapeutic results, and prognosis of surgical treatment for lung cancer patients over 85 years of age. METHODS: Among the 4446 lung cancer patients who underwent surgery at our hospital from January 1997 to March 2019, we assessed 320 patients (7.2%, Group A, aged 80-84 years) and 74 patients (1.7%, Group B, aged over 85 years). RESULTS: The median age of the patients in Group B was 86 years. Compared to Group A, Group B had significantly more patients with a history of ischemic heart disease, lower pack-year smoking, and lobectomy and lobectomy less resection (reduced surgery), and a shorter operation time (P < 0.05). There was no significant difference between the two groups in terms of postoperative complications. There was no significant difference in survival rate and prognosis between the two groups, and the 2-, 3-, and 5-year survival rates were 79.0%, 74.7%, and 53.6%, respectively, in Group B. In Group B sex (female) and early stage of cancer were independent prognostic factors of non-small cell lung cancer (stage I). CONCLUSIONS: In a limited number of patients, surgical resection in patients aged over 85 years was safely performed, and the survival of these patients was comparable to those aged 80-84 years.

Pericardial Window for Methicillin-Resistant Staphylococcus aureus Pericarditis.

A 58-year-old man presented with tamponade and underwent an emergency pericardiocentesis. We made the diagnosis of methicillin-resistant Staphylococcus aureus pericarditis based on culture results and treated the patient with pericardial drainage and antibiotics as the first-line therapy. After temporary relief, reaccumulation of effusion developed. We successfully created a pericardial window using thoracotomy, and the patient's postoperative course was uneventful. Methicillin-resistant Staphylococcus aureus pericarditis is an extremely rare and life-threatening illness. No consensus exists concerning the ideal surgical intervention. Creating a pericardial window using thoracotomy can be an effective definitive therapy for methicillin-resistant Staphylococcus aureus pericarditis, especially for patients with significant pericardial adhesions.

A case report: hemothorax caused by rupture of the left atrial appendage.

Cardiac rupture is defined as a full-thickness myocardial tear; this injury after blunt chest trauma is rare, and is associated with high mortality. Blunt cardiac rupture typically presents with either cardiac tamponade or massive hemothorax, and is often unrecognized in the context of blunt chest trauma. It is a little known fact that pericardial effusions can decrease due to pericardial lacerations. Hence, cardiac rupture with pericardial lacerations may be easily overlooked especially by chest surgeons. We herein report a case of hemothorax caused by rupture of the left atrial appendage. An 80-year-old male was involved in a motor vehicle crash. We made the diagnosis of hemothorax on the basis of bloody thoracic effusion and left pleural effusion on computed tomography (CT). CT also showed small pericardial effusion in amount and non-displaced rib fractures. We made a tentative diagnosis of intercostal artery injury with rib fractures, we performed left thoracotomy. However, in the operating room, we recognized that cardiac rupture led to massive hemothorax, and that hemothorax was not associated with intercostal artery injury. We repaired left atrial appendage rupture, and his postoperative course was uneventful. Cardiac rupture can present as slight pericardial effusion with hemothorax. On the basis of this case, we propose that cardiac rupture should be considered at the time of hemothorax examination with careful attention to pericardial effusions.

Distinct clinicopathologic characteristics of lung mucinous adenocarcinoma with KRAS mutation.

Primary mucinous adenocarcinomas are uncommon, and their pathogenesis remains unclear. We recently reported the clinicopathologic characteristics of surgically resected mucinous adenocarcinoma, including the frequent involvement of the left and lower lung and absence of central fibrosis. The present study attempted to clarify the pathogenesis of mucinous adenocarcinoma based on KRAS mutation status. We selected 45 mucinous adenocarcinoma cases from among 2474 surgically resected primary lung adenocarcinomas. Of these, 22 had a KRAS mutation (48.9%), whereas only 7 (15.6%) had an epidermal growth factor receptor mutation, and 2 cases had both mutations. The mucinous adenocarcinomas with KRAS mutations were located in the lower lung lobe significantly more often (P < .05) than were tumors without KRAS mutation. The mucinous adenocarcinoma cases with KRAS mutations also had a significantly lower frequency of nuclear atypia (P < .05). We compared the degree of immunostaining for matrix metalloproteinase-7 (MMP-7), laminin-5, and geminin in the mucinous adenocarcinoma with and without KRAS mutation. The proportion of geminin-positive cells was lower among the cases with a mutation than among those without (0.7% versus 2.1%; P < .05). No significant differences in the extent of staining of the other markers were observed between the groups. The current study clearly demonstrated that mucinous adenocarcinomas with KRAS mutations have clinicopathologic characteristics different from those of mucinous adenocarcinoma without such mutations.

Cancer-initiating cell marker-positive cells generate metastatic tumors that recapitulate the histology of the primary tumors.

Cancer-initiating cell (CIC) hypothesis suggests that CICs may be responsible for the generation of tumors that recapitulate the histology of the primary tumor at distant sites. We investigated the distribution of CIC markers (podoplanin (PDPN), CD44, and p63) positive cells of lung squamous cell carcinoma (SqCC) within primary and matched lymph node (LN) metastatic tumors to confirm this hypothesis (n = 113). In 61 cases, the PDPN-positive cells were localized in more peripheral areas of the tumor nests than the CD44- and p63-positive cells. This distribution pattern corresponded to a 'hierarchical distribution (HD)' reported previously. Among the cases with HD-(+) primary tumors (n = 61), the number showing HD-(+) LN metastatic tumors was 31 (51%), while among the cases with HD-(-) primary tumors (n = 52), the number showing HD-(+) LN metastatic tumors was 7 (13%) (p < 0.01). Primary and matched pulmonary metastatic (PM) tumors were also analyzed (n = 31), and a significant relationship of the HD pattern between them was also detected (p = 0.01). These results indicate that PDPN-positive cells might reflect the most immature cells in the differentiation process of metastatic SqCC and might generate metastatic tumors that recapitulate the histologic heterogeneity of the primary tumor.

Clinicopathological characteristics of primary lung adenocarcinoma predominantly composed of goblet cells in surgically resected cases.

Primary lung adenocarcinomas predominantly composed of goblet cells (APGC) are relatively rare, and the clinicopathological characteristics have remained unclear. The aim of this study was to clarify the clinicopathological characteristics of APGC. We selected adenocarcinoma with a goblet cell-type component of ≥ 90% from 2228 cases of surgically resected primary lung adenocarcinoma. The clinicopathological characteristics of APGC (46 cases) were analyzed. APGC showed a significantly higher rate of tumor location on the left side, in the lower lobe and pathological stage I, when compared with the other types of adenocarcinoma. Furthermore, APGC displayed a lower frequency of central fibrosis, plural invasion, pulmonary metastasis, lymphatic permeation, and vascular invasion. APGC showed local recurrence in two of 46 cases (4.3%) and no incidents of distant metastasis. When compared with non-mucinous bronchioloalveolar adenocarcinomas (non-mucinous BAC) without central fibrosis, APGC without central fibrosis, corresponding to mucinous BAC, showed a significantly higher rate of tumor location on the left side and in the lower lobe. In conclusion, APGC formed a distinct subset and should be considered separately from lung adenocarcinoma based on frequent involvement of the left and lower lung and lack of central fibrosis.