Aberrant mediastinal basal pulmonary artery encountered at anatomical lung resection: A case report and review of the literature.

INTRODUCTION: Abnormal branching of the pulmonary artery is often encountered in anatomical lung resection, which can potentially result in accidental vessel injury with life-threatening bleeding or extra lung resection. The mediastinal basal pulmonary artery (Arteria Praebronchialis, AP) is a very rare but potentially critical variant. PRESENTATION OF CASE: We present the case of a patient with lung cancer accompanied by the left basal segmental pulmonary artery, independent A8a+9, which was liable to be injured during lower lobectomy with poor interlobar fissure development. This variation was preoperatively recognized using three-dimensional contrast-enhanced computed tomography (3D-CECT) angiography, and vessel injury was avoided. DISCUSSION AND LITERATURE REVIEW: 3D-CECT angiography was effective in identifying this rare but potentially critical variation, and it is desirable to perform it routinely before anatomical lung resection. A review of 31 AP cases revealed that the branching pattern of AP was independent (15 patients, 48 %) and common trunk type (16 patients, 52 %), one half for each. Mediastinal branching of the lingular artery was more frequent among the reported AP cases (71 %) than in general reports. CONCLUSION: When mediastinal branches of left pulmonary artery are encountered, the possibility that it is AP should be always taken into account.

Which bioabsorbable sheet is optimal for combined application with fibrin sealant against alveolar air leakage?

Background: There are few basic comparative data on the sealing effect of various bioabsorbable sheets in combination with fibrin sealant (FS), which is a more effective tool for the control of alveolar air leakage than the single use of FS alone. The objective of this study was to investigate which bioabsorbable sheet had the best sealing effect against alveolar air leakage when used in combination with FS, in terms of material quality, weaving pattern, and/or thickness. Methods: Standardized 20 mm × 30 mm pleural defects were covered with three pieces of the following sheets using the Rub + Soak B technique in an ex vivo porcine lung model. Seal-breaking burst pressure (SBBP) was compared between groups. Experiment 1: 0.15 mm-thick (Group 1), 0.3 mm-thick (Group 2) and 0.5 mm-thick (Group 3) non-woven polyglycolic acid (PGA) felt were compared. Experiment 2: 0.15 mm-thick non-woven PGA felt (Group 1), 0.15 mm-thick meshed oxidised regenerated cellulose (ORC) (Group 4); 0.11 mm-thick woven PGA (Group 5) and 0.18 mm-thick knitted PGA (Group 6) were compared. Experiment 3: TachoSil® alone (Group 7), TachoSil® combined with FS (Group 8) and 0.15 mm-thick non-woven PGA felt (1 piece) (Group 9) were compared. Results: In Experiment 1, SBBP was significantly higher in Group 1 than in Group 3. The SBBP in Group 2 was significantly higher than that in Group 3. In Experiment 2, SBBP in Group 4 was significantly lower than that in Groups 1, 5, and 6. In Experiment 3, SBBP in Group 7 was significantly lower than that in Groups 8 and 9. Conclusions: Regarding the sheet thickness of PGA felt, the 0.15 mm was the most effective. Regarding the material quality, the ORC was the least suitable. TachoSil® combined with FS was comparable to the most effective 0.15 mm-thick non-woven PGA felt.

Clinical efficacy of intraoperative Cell Saver autologous blood salvage in emergency surgery for massive hemothorax.

The objective of this study was to investigate the efficacy of intraoperative Cell Saver blood salvage during emergency surgery for massive hemothorax on minimizing perioperative allogeneic red blood cell (RBC) transfusion. Fourteen consecutive patients of massive hemothorax with more than 800 cc of intrathoracic bleeding estimated by chest X-ray and/or chest computed tomography (CT) scan at presentation between 2009 and 2021 were retrospectively reviewed. Intraoperative Cell Saver blood salvage was performed in 11 patients (Cell Saver group) with a median volume of 820 cc (range, 421-1700 cc). The amount of perioperative allogeneic RBC transfusion in the Cell Saver group (median, 4 units) was significantly smaller than that in the non-Cell Saver group (median, 10 units) (P = 0.009). The volume of Cell Saver autologous transfusion in 6 patients without preoperative chest tube drainage (median, 1114 cc) was significantly larger than that in 5 patients who had preoperative drainage (median, 660 cc) (P = 0.0173). In conclusion, the utilization of intraoperative blood salvage in emergency surgery for massive hemothorax along with limiting the amount of preoperative chest tube drainage is an efficient strategy to minimize perioperative allogeneic RBC transfusion.

Heterologous sarcomatoid pleural mesothelioma with osteosarcomatous differentiation: a report of autopsy case that accomplished trimodality therapy and review of the literature.

Heterologous mesothelioma is a very rare subtype of sarcomatoid mesothelioma characterized by the presence of malignant heterologous elements. A 69-year-old man with a strong history of asbestos exposure presented with a 5-cm mass in his chest wall, destroying the right 5th rib and spreading along the parietal pleura, on a CT. Biopsy revealed heterologous mesothelioma with osteosarcomatous elements, following which left extrapleural pneumonectomy was performed with combined resection of pericardium, hemidiaphragm, and 4th, 5th, and 6th costal segments. A small cytokeratin-positive epithelioid component in the resected tumor definitively confirmed the diagnosis. Post-operative chemotherapy and intensity-modulated radiotherapy were undertaken. After 12-month disease-free period post treatment, rapid intraperitoneal recurrence resulted in death. Autopsy revealed no tumors in the left thorax. We present here a case of heterologous osteosarcomatous pleural mesothelioma that followed a unique clinical course after trimodality therapy. In addition, literature of 54 cases of the similar heterologous mesothelioma was reviewed.

Management of malignant carinal involvement using 'side-by-side' method of bilateral self-expandable metallic stents.

Central airway obstruction caused by cancer requires urgent interventional pulmonology. Malignant main carinal involvement is one of the most challenging situations, usually treated by rigid bronchoscopic intervention under general anaesthesia. However, these patients tend to be in poor condition due to underlying malignancy. Therefore, less-invasive strategies are needed. Six patients with lung cancer exhibiting malignant carinal involvement treated using the 'side-by-side' method of bilateral self-expandable metallic stents using fibre-optic bronchoscopy under topical anaesthesia were retrospectively investigated. The median procedure time was 29.5 min (range: 23-38), and the palliation of dyspnoea was achieved in all cases. The median survival time after intervention was 58.5 days (range: 23-172). The cause of death was acute coronary syndrome in two patients, aspiration pneumonia in two, upper gastrointestinal perforation in one, and catheter-related blood stream infection in one. This strategy was less invasive and suitable for patients with poor performance status.

Successful management of malignant carinal involvement by "side-by-side" method of self-expandable metallic stents followed by chemotherapy.

Bilateral self-expandable metallic stents may be useful in the management of malignant carinal involvement and may improve the performance status of patients. This strategy may allow patients with poor performance status to receive additional chemotherapy.

Successful treatment of limited-stage small-cell lung cancer in the right mainstem bronchus by a combination of chemotherapy and argon plasma coagulation.

The current standard-of-care treatment for patients with limited-stage small-cell lung cancer (SCLC) is concurrent chemoradiotherapy for local and systemic control. However, standard-of-care treatment strategies have not been established for those with limited-stage SCLC who have a history of thoracic radiotherapy due to concerns with complications associated with radiation overdose. A 37-year-old male developed an aspergilloma in the postoperative left thoracic space after he was treated with concurrent chemoradiotherapy for mediastinal type lung adenocarcionoma and subsequent left upper lobectomy for heterochronous dual adenocarcinoma. Fiberoptic bronchoscopy was performed to examine the status of the suspected bronchopleural fistula when a polypoid mass was observed in the right mainstem bronchus. A histological examination showed that the mass was SCLC at a clinical stage of cTisN0M0, stageIA, without local invasion. Since thoracic radiotherapy was not an option due to a previous history of thoracic irradiation, a combination treatment of carboplatin and etoposide was administered for 4 cycles and resulted in good partial response. In addition, argon plasma coagulation (APC) was performed as an alternative to curative radiotherapy on day 22 of the 4th cycle. The 5th cycle was administered 7 days after APC at which the anticancer therapy was completed. The patient remains disease-free 60 months after the completion of treatment, which suggests that this combination therapy may resolve very early-stage SCLC.

Osimertinib administration via nasogastric tube in an EGFR-T790M-positive patient with leptomeningeal metastases.

Patients with an epidermal growth factor receptor (EGFR) mutation are usually administered EGFR-tyrosine kinase inhibitors (TKIs) as standard-of-care treatment. However, acquired resistance occurs between 9 and 13 months. The T790M-resistant mutations are the most common, and osimertinib has been found to be effective in treating EGFR-T790M-positive patients. A 73-year-old female lung cancer patient with an EGFR-sensitizing mutation was receiving fourth-line chemotherapy when she complained of anorexia, headache, and irritability. A lumbar puncture showed adenocarcinoma in the cerebrospinal fluid (CSF), which led to the diagnosis of leptomeningeal metastasis. Her performance status (PS) deteriorated quickly and she also developed dysphagia. The EGFR mutation testing of the CSF demonstrated L858R+T790M double mutations, and an osimertinib suspension was subsequently administered through a nasogastric tube. The PS improved to 1, oral intake became possible after 20 days, and further improvements were observed by gadolinium-enhanced magnetic resonance imaging. The patient remains progression-free for 10 months after osimertinib administration.

Minimally-invasive complete resection of intrathoracic mediastinal lesions with a Linder-Dahan spreadable-blade video mediastinoscope system: A report of two cases.

INTRODUCTION: Cervical mediastinoscopy can provide a minimally invasive access to the paratracheobronchial mediastinum within its reachable range, but its operability is substantially limited because of its small operative field, poor visualisation, and one-handed operation. PRESENTATION OF CASES: Patient 1, a 56-year-old woman, presented with a 22×17mm, non-symptomatic, (18)F-fluorodeoxy glucose (FDG)-avid, solid schwannoma originating from the vagus nerve trunk in the right upper paratracheal space. Patient 2, a 55-year-old man, presented with a 55×41mm cystic mass in the left upper paratracheal space that extensively compressed and dislocated the trachea toward the right, which caused dyspnoea and cervicothoracic pain. The masses in both cases were completely resected using a Linder-Dahan spreadable-blade video mediastinoscope. DISCUSSION: The addition of the video system and spreadable blades to the conventional scope combined with a scope-holding device has enabled effective bi-manual preparation and more precise and safer mediastinoscopic procedures than those performed using the conventional one-handed mediastinoscope. Owing to the improved operability, more complex or extended procedures could be performed in wider and more stable operative spaces with better visualisation, although the system has the same minimal invasiveness as that of the conventional mediastinoscope. CONCLUSION: We describe two patients with mediastinal lesions that were effectively resected by using this sophisticated video mediastinoscope system.

Long progression-free survival by pemetrexed continuation maintenance therapy following cisplatin-based chemotherapy in malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is associated with a poor prognosis. The combination of cisplatin and pemetrexed has been established as a standard chemotherapy that confers a survival benefit. Because the regimen is sometimes hampered by the renal toxicity of cisplatin and no second-line chemotherapy has yet been established, the strategy of administering a higher total dose of pemetrexed to optimize the regimen could be promising. We herein describe the case of a 69-year-old man with MPM who underwent five cycles of cisplatin plus pemetrexed and exhibited a partial response. Because his serum creatinine increased, pemetrexed maintenance therapy (PMT) was adopted, and 18 cycles were successfully delivered and the patient achieved a complete response. This case suggests that PMT could thus be useful for treating MPM.

Direct transbronchial administration of liposomal amphotericin B into a pulmonary aspergilloma.

Pulmonary aspergillomas usually occur in pre-existing lung cavities exhibiting local immunodeficiency. As pulmonary aspergillomas only partially touch the walls of the cavities containing them, they rarely come into contact with the bloodstream, which makes it difficult for antifungal agents to reach them. Although surgical treatment is the optimal strategy for curing the condition, most patients also have pulmonary complications such as tuberculosis and pulmonary fibrosis, which makes this strategy difficult. A 72-year-old male patient complained of recurrent hemoptysis and dyspnea, and a chest X-ray and CT scan demonstrated the existence of a fungus ball in a pulmonary cavity exhibiting fibrosis. Although an examination of the patient's sputum was inconclusive, his increased 1-3-beta-D-glucan level and Aspergillus galactomannan antigen index were suggestive of pulmonary aspergilloma. Since the systemic administration of voriconazole for two months followed by itraconazole for one month was ineffective and surgical treatment was not possible due to the patient's poor respiratory function, liposomal amphotericin B was transbronchially administered directly into the aspergilloma. The patient underwent fiberoptic bronchoscopy, and a yellow fungus ball was observed in the cavity connecting to the right B(2)bi-beta, a biopsy sample of which was found to contain Aspergillus fumigatus. Nine transbronchial administrations of liposomal amphotericin B were conducted using a transbronchial aspiration cytology needle, which resulted in the aspergilloma disappearing by seven and a half months after the first treatment. This strategy could be suitable for aspergilloma patients with complications because it is safe and rarely causes further complications.

Bilateral self-expandable metallic stents for lung cancer involving the carina.

Central airway obstruction needs interventional pulmonology and malignant main carinal involvement is one of the most challenging scenarios requiring rigid bronchoscopic intervention under general anesthesia. However, these patients tend to be in poor condition for such interventions. A 91-year-old male patient with lung cancer accompanied by obstructive pneumonia underwent an Ultraflex self-expandable metallic stent placement in the right mainstem bronchus. The extranodal extension of the carcinoma from mediastinal lymph nodes metastases to the carina was so fast that severe stenosis of the bilateral mainstem bronchi was observed 6 weeks later accompanied by the deterioration of dyspnea. To salvage the carina, bilateral Ultraflex covered stents were placed by "side-by-side" method using fiberoptic bronchoscopy under topical anesthesia. This strategy was quite safe and the time needed for the entire procedure was within 20 min. He never experienced dyspnea thereafter and died of a cardiac sudden death 7 months after the initial stenting.

Clinical utility of three-dimensional integrated 18F-fluorodeoxyglucose positron-emission tomography/computed tomography virtual mediastinoscopy.

The objectives of this study were to devise a new image processing technique to reconstruct dynamic three-dimensional (3D) virtual mediastinoscopic images on the basis of positron-emission tomography/computed tomography (PET/CT) datasets, and to examine the clinical utility of this technique for preoperative simulation of and intraoperative guidance during mediastinoscopic nodal biopsy. Of 54 patients with suspected or proven lung cancer (LC) who underwent mediastinoscopy between January 2005 and December 2007, 37 also underwent preoperative PET/CT. Of these 37 patients, we tested our image processing protocol in 15 consecutive patients with significant mediastinal uptake of fluorodeoxyglucose (FDG). We reconstructed 3D virtual mediastinoscopy movies in two mutually complementary demonstration modes--the tracheobronchial- and vessel-modes--with accurate representation of actual mediastinoscopic procedures. The benefit of these virtual imaging was evaluated with regard to their utility in mediastinoscopic nodal biopsy. Our new technique enabled better understanding of the spatial interrelationship between FDG-avid nodes and mediastinal structures. It facilitated more accurate and safer nodal biopsy under virtual guidance. In conclusion, we showed the feasibility of our virtual mediastinoscopic technique, which may improve the procedural safety and diagnostic accuracy of mediastinoscopic nodal biopsy and nodal staging in LC.

Transthoracic Collis-Nissen repair for massive type IV paraesophageal hernia.

An 80-year-old woman presented with type IV massive hiatal hernia with intrathoracic upside-down stomach and transverse colon. She was dyspneic and vomited upon consuming food or water. Consequently, she developed aspiration pneumonia. Both esophagoscopy and upper gastrointestinal series demonstrated significant cephalad displacement of the gastroesophageal junction. A Collis-Nissen hernial repair by muscle-sparing mini-thoracotomy was performed successfully. To date, 3 years after surgery, the patient is enjoying normal oral intake, has an excellent activities of daily living level, and there is no hernia recurrence. Cases of massive paraesophageal hernia are frequently associated with esophageal shortening that causes tension on the repairs and late failure. Advantages of the transthoracic approach in such cases include feasibility of direct esophageal mobilization, accurate assessment of esophageal tension, and facilitation of Collis gastroplasty. The true indication for transthoracic Collis-Nissen repair among cases of paraesophageal hiatal hernia with a short esophagus should be acknowledged more in the era of laparoscopy.

The optimal technique for combined application of fibrin sealant and bioabsorbable felt against alveolar air leakage.

OBJECTIVES: The combination of fibrin sealant and bioabsorbable sheet is known to provide a better sealing effect on alveolar air leakage compared to the single use of fibrin sealant. However, there is little evidence that reveals the optimum techniques for their combined application. Presently we developed a novel Rub + Soak B method that comprises the attachment of thrombin-impregnated sheet to the fibrinogen-rubbed lung tissue area. This study aimed to evaluate its sealing effect compared to various combined application techniques. METHODS: Experiment I: The viscosity and osmolality of each fibrin sealant component were measured. Experiment II: Pleural defects produced by electrocauterization in retrieved swine lungs (n=24) were covered with fibrin sealant and polyglycolic acid felt by using the following five techniques: concomitant spraying of fibrinogen and thrombin solutions over the pleural defect area (Group I, Control); rubbing the thrombin solution on the area, attaching the felt soaked in the fibrinogen solution, and applying the remaining thrombin and fibrinogen solutions (half the original quantity) alternately to the area (Group II, Rub + Soak A); rubbing the fibrinogen solution on the area, attaching the felt soaked in the thrombin solution, and applying the remaining fibrinogen and thrombin solutions alternately to the area (Group III, Rub+Soak B); rubbing the fibrinogen solution on the area, attaching the dry felt, and spraying both the remaining solutions concomitantly (Group IV, Rub+Spray); and spraying both the solutions, attaching the dry felt, and respraying the remaining solutions over the area (Group V, Spray Sandwich). The minimum seal-breaking airway pressure was compared among the groups. Samples were histologically assessed. RESULTS: Experiment I: The fibrinogen solution was 34.8 times more viscous and had 3.5 times higher osmolality than the thrombin solution. Experiment II: The seal-breaking pressure was significantly higher in Group III than in Groups I, II, and V (p<0.05). Histologically, clot penetration into the tissue was significant in Group III. CONCLUSIONS: The novel Rub+Soak B technique was the most effective and reasonable combination technique wherein the sealing mechanism was supported by the physical properties of the fibrin sealant components.

Non-small cell lung cancer coexisting with pulmonary aspergilloma.

A 77-year-old male with a long-standing history of smoking and working in mines was referred to our department for the evaluation of an enlarging subpleural mass in the right upper lobe. Both transbronchial and computed tomography-guided biopsies of the mass were non-diagnostic. A partial resection of the right S2 mass under video-assisted thoracic surgery (VATS) confirmed the diagnosis of primary non-small cell lung cancer. VATS right upper lobectomy (ND2a) was then performed for complete resection. Histological examination revealed that the mass composed of adenocarcinoma and the dilated bronchioles contained Aspergillus, the fungal component. Here we report a rare case of non-small cell lung cancer coexisting with pulmonary aspergillosis. The morphologic coexistence pattern of the two pathologies was believed to be the colonization of saprophytic Aspergillus in the bullous air spaces, obstructed by or contained within the tumor, according to the progression of the lung cancer.

Nontraumatic chest wall systemic-to-pulmonary artery fistula.

A congenital chest wall systemic-to-left pulmonary artery fistula fed by the left internal mammary and left gastric arteries in a 31-year-old man is reported. Attempted sclerosis was complicated by rupture of the communicating vessel, hemothorax, and deep vein thrombosis of the legs. Fistula resection and pulmonary decortication were successfully performed.

Endobronchial gene transfer of soluble type I interleukin-1 receptor ameliorates lung graft ischemia-reperfusion injury.

BACKGROUND: Soluble type I interleukin-1 receptor is a competitive inhibitor of interleukin-1 and may reduce its proinflammatory actions. The objective of this experiment was to demonstrate that endobronchial gene transfer of soluble type I interleukin-1 receptor IgG to donor lung grafts reduces posttransplant ischemia-reperfusion injury. METHODS: All experiments utilized an orthotopic left lung isograft transplant model. Donors were divided into three groups (n = 6 each) for endobronchial transfection: group I received 2 x 10(7) plaque-forming units of adenovirus encoding soluble type I interleukin-1 receptor IgG; group II received 2 x 10(7) plaque-forming units of nonfunctional control adenovirus encoding beta-galactosidase; and group III received 0.1 mL of saline. Left lungs were harvested 24 hours after transfection and stored for 18 hours before transplantation. Graft function was assessed 24 hours after reperfusion using three measurements: isolated graft oxygenation, wet-to-dry lung weight ratio, and tissue myeloperoxidase activity. Transgene expression of soluble type I interleukin-1 receptor IgG was also evaluated using enzyme-linked immunosorbent assay and immunohistochemistry. RESULTS: Isolated graft arterial oxygenation was significantly improved in group I compared with groups II and III (281.8 +/- 134.8 versus 115.7 +/- 121.5 and 88.0 +/- 58.9 mm Hg, p = 0.0197 and p = 0.0081, respectively). Myeloperoxidase activity was also significantly reduced in group I compared with groups II and III (0.083 +/- 0.044 versus 0.155 +/- 0.043 and 0.212 +/- 0.079 optical density units per minute per milligram protein, p = 0.0485 and p = 0.0016, respectively). Expression of soluble type I interleukin-1 receptor IgG was detected only in lungs from group I. CONCLUSIONS: Endobronchial gene transfer of soluble type I interleukin-1 receptor IgG to donor lung grafts subjected to prolonged cold ischemia ameliorates ischemia-reperfusion injury by improving graft oxygenation and reducing lung edema and neutrophil sequestration.