Asymptomatic mature intrapericardial teratoma in an adult: a case report of a rare condition.

BACKGROUND: Benign mature teratomas are the most common type of anterior mediastinal germ cell tumor. Mature intrapericardial teratomas are generally diagnosed during infancy because of symptoms of cardiac compression. In contrast, mature adult intrapericardial teratomas are extremely rare, accounting for less than 1% of mature intrapericardial teratomas. We describe herein a case of a mature intrapericardial teratoma in an asymptomatic adult. CASE PRESENTATION: A 52-year-old woman was found by computed tomography during a health checkup to have an anterior mediastinal mass. She was asymptomatic and hemodynamically stable with no evidence of heart failure. The preoperative provisional radiological diagnosis was a mature intrapericardial teratoma. A median sternotomy revealed an approximately 5-cm diameter protruding intrapericardial mass with a smooth surface. The mass was completely resected. Histopathological examination resulted in a diagnosis of a mature intrapericardial teratoma. The patient did well and has no evidence of recurrence 5 years after surgery. CONCLUSIONS: Mature intrapericardial teratomas in adults are extremely rare. Given the risks of malignant transformation, rupture, compression of the heart, and infection, excision is indicated to prevent development of serious manifestations.

A Primary Pulmonary Meningioma That Grew Over 10 Years: A Surgical Case Report.

Primary pulmonary meningiomas (PPMs) are rare meningothelial proliferation that lacks characteristic imaging findings, making their distinction from other peripheral lung tumors challenging. Therefore, surgical resection is often performed for the diagnosis and treatment of PPM. Herein, we describe a surgical case of PPM that grew over 10 years. A 63-year-old woman was referred to our department due to right middle lobe lung tumor enlargement. No significant symptoms were observed. Chest computed tomography revealed a tumor in the middle lobe of the right lung. F-18 fluorodeoxyglucose positron emission tomography showed accumulation in the nodule; thus, lung cancer could not be ruled out. Therefore, the preoperative differential diagnosis was cStageIB lung cancer. A right middle lobectomy was performed, and a histopathology examination revealed meningioma. There were no primary lesions in the head and whole spine magnetic resonance imaging, thus, a final diagnosis of PPM was made. Cautious observation is required postoperatively due to the possibility of recurrence.

Dual-portal robotic-assisted thoracic surgery (DRATS) as a reduced port RATS: early experiences in three institutions in Japan.

Background: Robotic-assisted thoracic surgery (RATS) has gained increasing interest in recent years, with most procedures performed using the conventional multiportal approach. Uniportal RATS (URATS) approaches have recently been reported in the pursuit of minimally invasive procedures. However, URATS requires specific skills. Herein, we introduce dual-portal RATS (DRATS) performed with two incisions. Methods: Data of DRATS procedures performed from December 2022 to May 2023 were retrospectively reviewed. Twenty patients with lung cancer underwent anatomical lung resections via DRATS performed by our group at three institutes. Results: Among 20 cases of planned DRATS for anatomical pulmonary resections, there were no conversions to thoracotomy and no need for extra ports. The mean surgery time was 121±60 minutes and mean console time was 91±47 minutes. The mean intraoperative blood loss volume was 9.6±12.1 g. The mean duration of chest tube drainage and hospital stay were 2±1 and 5±2 days, respectively. The mean numerical rating scale for pain was 2±1 on the first postoperative day, 1±1 on the third day, and 1±1 at discharge. There were no postoperative complications or mortalities. Conclusions: Our primary experience shows that DRATS is safe and feasible for anatomical lung resection. We consider DRATS to be a very good preliminary step in the future transition to URATS.

Morvan Syndrome Converted from Isaacs' Syndrome after Thymectomy with Positivity for Both Anti-LGI1 and Anti-CASPR2 Antibodies.

Anti-voltage-gated potassium channel complex antibodies-mediated disorder includes Isaacs' syndrome, which is characterized by neuromyotonia, and Morvan syndrome, which is characterized by neuromyotonia, encephalopathy and autonomic dysfunction. We herein report a patient with Morvan syndrome that converted from Isaacs' syndrome after thymectomy. The patient first presented with myospasm in all extremities and positivity for both anti-leucine-rich glioma inactivated 1 (LGI1) and anti-contactin-associated protein like 2 (CASPR2) antibodies and subsequently developed encephalopathy after thymectomy, which was successfully improved by immunotherapy. This is the first case of Morvan syndrome wherein thymectomy worsened Isaacs' syndrome, suggesting that immunotherapy should be considered for Isaacs' syndrome accompanied by positivity for both anti-LGI1 and anti-CASPR2 antibodies to prevent worsening to Morvan syndrome.

Lung cancer with partial anomalous pulmonary venous connection in a different lobe: a case report.

BACKGROUND: Anomalous pulmonary venous connection (APVC) is a congenital malformation in which the pulmonary veins connect to the systemic venous system but not to the left atrium. APVC can be classified as total or partial (PAPVC). PAPVC is rare among surgical patients with lung cancer, and most cases are detected incidentally during surgery. We herein report a patient with lung cancer in whom PAPVC was diagnosed before surgery, which made it difficult to determine the surgical procedure. CASE PRESENTATION: A 71-year-old man was followed-up as an outpatient after surgery for renal cell carcinoma. Chest computed tomography showed a 22-mm nodule in the right lower lobe and PAPVC in the right upper lobe. He was diagnosed with lung adenocarcinoma (cT1cN0M0 stage IA3) and scheduled for surgery. Preoperative catheterization showed a pulmonary to systemic flow ratio (Qp/Qs) of 1.64 and mean pulmonary artery pressure (MPAP) of 16 mmHg. Surgical repair of PAPVC is indicated when a patient is symptomatic and has a Qp/Qs ≥1.5-2.0. The patient was scheduled for right lower lobectomy, but postoperative worsening of right heart strain was considered. Concomitant PAPVC repair was therefore considered, but he had no atrial septal defect and was asymptomatic; therefore, PAPVC treatment was considered unnecessary. However, we planned to perform concomitant PAPVC repair if his circulatory dynamics worsened during surgery or if his MPAP exceeded 25 mmHg. His MPAP was 20 mmHg and his circulatory dynamics remained stable, and right lower lobectomy was therefore completed. His postoperative course was favorable. Follow-up catheterization at 6 months showed a Qp/Qs of 1.19 and MPAP of 18 mmHg, with no evidence of increased right heart strain. There was no evidence of right heart failure or recurrence of lung cancer at last follow-up at 18 months after surgery. CONCLUSIONS: We present a case of right lower lung cancer complicated by PAPVC in the right upper lobe. This case suggests that concomitant repair of PAPVC in the right upper lobe may not be necessary when performing right lower lobectomy, although the patient's Qp/Qs and MPAP should be considered.

[Occult Thyroid Cancer Diagnosed by Metastasis to an Upper Mediastinal Lymph Node Removed during Surgery for Primary Lung Cancer].

A computed tomography (CT) scan revealed 2 nodules in the right upper and middle lobes of the lung and swelling of an upper mediastinal lymph node (#2R) in a 77-year-old male. Positron emission tomography (PET)/CT showed abnormal uptake only in the right middle lobe nodule, so we suspected a double primary lung cancer (cT1bN0M0, stage ⅠA), and performed a right upper and middle lobectomy with ND2a-2 dissection. Pathological investigation revealed that the lung nodules were adenocarcinomas and the lymph node swelling #2R was a metastasis of thyroid cancer. After surgery, careful examination was done for thyroid but the primary lesion was not found. Careful observation for an occult thyroid cancer is continuing at the outpatient.

Obstructive pneumonia owing to migration of a Teflon pledget at 8 years after surgery for a pulmonary carcinoid tumor: a case report.

BACKGROUND: It is uncommon for a bronchial stump-related complication to develop during the remote postoperative period in a case of obstructive pneumonia owing to migration of the suture material. Here, we describe a case of bronchial obstructive pneumonia that developed owing to migration of the suture material in the airway 8 years after pulmonary resection. CASE PRESENTATION: A 34-year-old woman underwent left lower lobectomy for a pulmonary carcinoid tumor (pT1bN0M0-stage IA) in 2010. She experienced obstructive pneumonia, and chest computed tomography revealed a mass protruding from the bronchial stump to the bronchial lumen in 2018. After treatment for pneumonia, flexible bronchoscopy showed the presence of a fibrous suture material (Teflon pledget) completely obstructing the left second carina. A week later, the Teflon pledget obstructing the bronchial lumen was removed using a flexible bronchoscope with the patient under general anesthesia. The procedure was completed without removing the small amount of granulation tissue because the bronchial lumen opened after removing the Teflon pledget. She has remained asymptomatic for 1 year after removal. CONCLUSIONS: In this case, the complication of obstructive pneumonia developed owing to migration of the non-absorbable suture materials used to suture the bronchial stump. Bronchoscopic management of this rare complication comprised endobronchial removal with the patient under general anesthesia. Given our experience with this case, we believe that such conservative management should allow for excellent results in most instances and avoid the need for reoperation.

[Lung Cancer in the Left Lingular Segment with a Displaced Anomalous Segmental Bronchus].

The rate of bronchial anomaly is reported to be about 0.6%.Most of cases showed a displaced bronchus, mostly in the right upper lobe. We experienced lung cancer in a displaced anomalous lingular bronchus. A 76-year-old male was referred to our hospital due to abnormal mass on a chest radiograph. Thoracic computed tomography( CT) revealed a tumor with a maximum diameter of 42 mm in the left lingular segment. Bronchoscopic examination indicated a displaced anomalous right upper bronchus branching from the trachea and left B4+5 branching from the stem of the left lower lobe bronchus. Curetting was performed through the left B4+5, and adenocarcinoma was diagnosed. Lobulation between the upper and lingular segments was noted during surgery, and left lingular segmentectomy was performed. The tumor was histologically diagnosed as adenocarcinoma. The postoperative course was uneventful.

[Pulmonary Adenocarcinoma with Heterotopic Ossification].

BACKGROUND: Although malignant tumor with heterotopic ossification have often been reported, it is very rare in lung cancer. We report a case of primary lung adenocarcinoma with heterotopic ossification. CASE: A 43-year-old woman undergoing a health check was found an abnormal nodular lesion on chest X-ray. Chest computed tomography (CT) showed a calcified tumor, which was diagnosed adenocarcinoma by transbronchial biopsy. Right lower lobectomy and ND2a-2 lymph node dissection was done. Postoperative pathological examination identified the tumor as a bronchioloalveolar adenocarcinoma with other mixed subtypes, associated with ossification containing bone marrow tissue in the tumor. An immunohistochemical examination showed that cancer cells around the ossification expressed bone morphogenetic protein-2 and osteopontin, which generally induce and stimulate bone formation. CONCLUSION: This finding may serve to elucidate a probable mechanism for the heterotopic ossification observed in cancer lesions.

Pulmonary embolism complicated with necrotic debris in the lung parenchyma, treated by right lower lobectomy: a case report.

BACKGROUND: It is uncommon for aseptic necrosis to occur in the lung parenchyma as a result of acute pulmonary embolism, because of the dual blood supply of the lung. We report a case in which acute pulmonary embolism led to pulmonary infarction and progressive lung necrosis, requiring treatment with right lower lobe resection. CASE PRESENTATION: A 63-year-old man was referred to our hospital for right-side pleuritic chest pain and fever. He was then admitted in another department in our hospital with a diagnosis of pneumonia. Antimicrobial therapy was initiated; however, laboratory testing elevated white blood cell counts and C-reactive protein. Chest computed tomography revealed acute pulmonary emboli within the right lower lobe segmental pulmonary arteries, as well as a small cavity lesion within the same lobe, which measured 1.2 cm in diameter. Treatment strategies included anticoagulation therapy, thoracic drainage of the affected side, and an antibiotic escalation protocol. However, the patient's fever did not subside; additionally, his leukocyte count increased after 3 days of the new treatment protocol. We considered it to be difficult to achieve cure with medical treatment alone; therefore, we performed a right lower lobectomy. CONCLUSIONS: We report an unusual case in which inflammation arose from lung necrosis secondary to lung embolism, which was not alleviated by conservative treatment; however, it was cured by right lower lobectomy.

[A Case of Myocardial and Cutaneous Metastases of Squamous Cell Lung Cancer Post Left Pneumonectomy and Radical Surgery for Cutaneous Metastasis during Nivolumab Therapy].

BACKGROUND: Concomitant myocardial and cutaneous metastases of squamous cell lung cancer after left pneumonectomy are very rare. Although nivolumab is used as a standard second-line chemotherapy for non-small cell lung cancer(NSCLC), its efficacy for concomitant myocardial and cutaneous metastases remains unclear. CASE: A 66-year-old man with no chief complaints was diagnosed with myocardial metastasis by CT scan. The patient underwent radical left pneumonectomy for squamous cell lung cancer 12 months previously and had rejected adjuvant chemotherapy with pT2aN1M0- II B(7th edition). A skin lesion in the left side of the neck was diagnosed as cutaneous metastasis by cytological examination. First-line treatment with cisplatin plus gemcitabine was administered; it was then replaced with nivolumab as a second-line chemotherapy after the progression of the disease due to myocardial metastasis. Fortunately, after 5 courses of nivolumab, there was a reduction in the cutaneous metastasis, which allowed complete resection, and reduction in the volume of myocardial metastasis. The patient is alive 30 months after left pneumonectomy and 18 months after the diagnosis of relapse. Nivolumab treatment is on-going. CONCLUSION: Complete resection of a cutaneous metastasis of squamous cell lung cancer and a reduction in the volume of myocardial metastasis were achieved following nivolumab treatment. Thus, nivolumab is a useful chemotherapy for concomitant cutaneous and myocardial metastases of squamous cell lung cancer.

Preoperative prognostic nutritional index as a predictor of outcomes in elderly patients after surgery for lung cancer.

BACKGROUND AND OBJECTIVE: The prognostic nutritional index (PNI) is based on the serum albumin level and lymphocyte count, and is a useful predictor of survival in various cancers. However, the utility of PNI in lung cancer has not been examined. The aim of this study is to assess PNI as a prognostic factor in elderly patients after surgery for primary lung cancer. METHODS: A retrospective review was performed in 131 elderly patients (≥75 years old) with lung cancer who underwent curative operations at our hospital from July 2008 to December 2014. Survival was calculated by the Kaplan-Meier method. The effects of PNI and clinicopathological factors on survival were evaluated in univariate and multivariate Cox regression analyses. RESULTS: The 5-year cancer-specific survival (CSS) rates of patients with PNI ≥ 45 and <45 were 76.2% and 47.8%, respectively (P = 0.0166), and the 5-year overall survival (OS) rates were 61.9% and 39.8%, respectively (P = 0.0275). Among patients who died within 5 years, mortality due to other diseases was 31%. Univariate analysis identified gender (P = 0.003), serum carcinoembryonic antigen (CEA) (P = 0.009), PNI (P = 0.027), c-stage (P = 0.005), histological type (P = 0.001) and p-stage (P < 0.001) as prognostic factors. In multivariate analysis, CEA (HR 2.487, P = 0.0169), PNI (HR 2.737, P = 0.0289) and p-stage (HR 3.294, P = 0.007) were independent prognostic factors in elderly patients after curative surgery for lung cancer. CONCLUSIONS: CEA, PNI and p-stage are independent prognostic factors in elderly patients after surgery for primary lung cancer. Therefore, determination of preoperative PNI may be useful for treatment planning in elderly patients with lung cancer.

[Successful Treatment of Acute Empyema Due to Rupture of Pyogenic Liver Abscess].

Cases of rescue after rupture of pyogenic liver abscess into the thorax are rare. Here, we report 2 cases of rescue in patients with acute empyema due to rupture of a suppurative abscess into the thorax. Case 1:A 61-year-old male had high fever of 39 °C and right abdominal pain. Thoracic computed tomography(CT) showed encapsulated pleural effusion in the right thorax and ring-like enhancement in the right liver. The diagnosis was acute empyema caused by rupture of liver abscess. The pathogenic bacteria were Streptococcus group. The drain was removed after 6 days and the patient was discharged 32 days after surgery without reefing the diaphragm. Case 2:A 74-year-old male had a high fever of 39 °C and right chest pain. CT showed encapsulated pleural effusion in the right thorax, but not in the lung, and a low density area in the posterior segment of the liver. The diagnosis was acute empyema caused by rupture of liver abscess. The pathogenic bacteria were Streptococcus group and Bacteroides. The drain was removed after 8 days and the patient was discharged 32 days after surgery without reefing the diaphragm. CONCLUSION: Pathogenic bacteria in a pyogenic liver abscess are usually Gram-negative rods, but recently have also been reported to be Streptococcus anginosus group( SAG). Coinfection with SAG and anaerobic bacteria occurs in elderly patients, compromised hosts, and patients with a severe malignant disease. Therefore, early drainage using surgical treatment regardless of reefing the diaphragm should be considered to control severe infection due to liver abscess rupture.

Thoracoscopic surgery versus open surgery for lung metastases of colorectal cancer: a multi-institutional retrospective analysis using propensity score adjustment†.

OBJECTIVES: Thoracoscopic surgery for lung metastasectomy remains controversial. The study aimed at determining the efficacy of thoracoscopic surgery for lung metastasectomy. METHODS: This was a multi-institutional, retrospective study that included 1047 patients who underwent lung metastasectomy for colorectal cancer between 1999 and 2014. Prognostic factors of overall survival were compared between the thoracoscopic and open thoracotomy groups using the multivariate Cox proportional hazard model. The propensity score, calculated using the preoperative covariates, included the era of lung surgery as a covariate. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. The difference between the radiological tumour number and the resected tumour number (delta_num) was also evaluated. RESULTS: The c -statistics and the P -value of the Hosmer-Lemeshow Chi-square of the propensity score model were 0.7149 and 0.1579, respectively. After adjusting for the propensity score, the thoracoscopy group had a better survival rate than the open group (stratified log-rank test: P = 0.0353). After adjusting for the propensity score, the most powerful predictive model for overall survival was that which combined thoracoscopy [hazard ratio (HR): 0.468, 95% CI: 0.262-0.838, P = 0.011] and anatomical resection (HR: 1.49, 95% CI: 1.134-1.953, P = 0.004). Before adjusting for the propensity score, the delta_num was significantly greater in the open group than in the thoracoscopy group (thoracoscopy: 0.06, open: 0.33, P = 0.001); however, after adjustment, there was no difference in the delta_num (thoracoscopy: 0.04, open: 0.19, P = 0.114). CONCLUSIONS: Thoracoscopic metastasectomy showed better overall survival than the open approach in this analysis. The thoracoscopic approach may be an acceptable option for resection of pulmonary metastases in terms of tumour identification and survival outcome in the current era.

Removal of foreign bodies from the respiratory tract of young children: Treatment outcomes using newly developed foreign-body grasping forceps.

BACKGROUND: Although a foreign body in the airway of children constitutes a medical emergency, most available therapeutic tools are insufficient, and treatment can be difficult. Herein, we evaluated the outcomes of various treatment methods of foreign body removal from the respiratory tract. METHODS: We retrospectively analyzed 24 children (13 boys, 11 girls; median age, 18months [range, 9-60months]) treated for airway foreign bodies from January 1994 to December 2013 by examining their preoperative diagnoses and anesthesia and surgical methods. RESULTS: The foreign body was a peanut, green soybean, almond, chestnut, dental prosthesis, and bead in 15, 3, 3, 1, 1, and 1 cases, respectively. General anesthesia was used in all cases, and flexible bronchoscopy was performed under airway maintenance using a laryngeal mask in 23 cases. The mean operation time was 51±32min. Grasping forceps, basket forceps, and a Fogarty catheter were used in 14, 7, and 2 cases, respectively. In July 2003, 3-pronged foreign-body grasping forceps with a 2.0-mm diameter designed for use with a thin bronchoscope were introduced. Of 16 treated cases, 9 were successfully treated with only forceps. The mean operation time was significantly shortened to 38±24min (range, 7-91min) compared to the traditional operation time of 82±42min (range, 23-147min) (p=0.01). CONCLUSIONS: These novel forceps are useful for reducing the operation time and are suitable for removing airway foreign bodies from children with a narrow tracheobronchial caliber.

[Pulmonary Lipomatous Hamartoma Suspected to be an Endobronchial Lipoma].

We report a rare case of pulmonary lipomatous hamartoma. A 61-year-old male was referred to our hospital due to abnormal mass densities on a chest radiograph. Thoracic computed tomography (CT) revealed a tumor with a maximum diameter of 42 mm. Bronchoscopic examination indicated the presence of a tumor at the orifice of the lateral segmental bronchus which was obstructed by the tumor. Endobronchial lipoma, was suspected by transbronchial biopsy, and we carried out a left upper lobectomy to prevent obstructive pneumonia. The pathological diagnosis was lipomatous hamartoma.

[Mediastinal Nonseminomatous Germ Cell Tumor with Sarcoid-like Reaction in the Regional Lymph Nodes].

A 26-year-old man was admitted because of an abnormal shadow on a chest roentgenogram. Computed tomography(CT) revealed a very large tumor in the anterior mediastinum and bilateral mediastinal lymphadenopathy. Examination of a CT-guided biopsy specimen revealed a yolk-sac tumor. The patient received 4 courses of bleomycin, etoposide, and cisplatin chemotherapy. After chemotherapy, the tumor was markedly reduced in size, but the lymphadenopathy remained. The patient underwent thoracoscopic biopsy of the mediastinal lymph nodes. Sarcoid nodules were found in all the biopsied nodes, and the lymphadenopathy was thought to be a sarcoid-like reaction associated with the germ cell tumor. Resection of the residual tumor was performed according to the treatment algorithm of the International Germ Cell Cancer Collaborative Group. There were no viable tumor cells in the resected tissue. The patient is free of recurrence and without any sign of generalized sarcoidosis 3 years after the surgery.

Stage II-IV lung cancer cases with lymphovascular invasion relapse within 2 years after surgery.

OBJECTIVE: For recurrent lung cancer, postoperative follow-up methods have not been adequately assessed, and no evidence-based postoperative surveillance methods currently exist. Herein, we evaluated postoperative lung cancer recurrence and the personalized postoperative surveillance periods and methods used. METHODS: Follow-up after surgery consisted of a regular outpatient clinic check-up, including physical examination, history, blood tests, and chest X-ray, which were conducted three or four times per year for 5 years. During the follow-up period, annual chest and brain computed tomography scanning was performed. Between May 2004 and December 2011, 547 lung cancer patients underwent complete resection in our institution. We retrospectively reviewed their prospectively collected data. RESULTS: We selected 106 patients (19.4 %) who had a postoperative recurrence. Multivariate analysis showed that advanced stage (stage II-IV; p < 0.01) and lymphovascular invasion positivity (LVI; p = 0.01) were independent risk factors for earlier recurrence. Overall, 90.8 % of patients with advanced-stage disease and LVI positivity experienced a relapse within 2 years after surgery, compared to 55.1 % of patients who did not have these factors (p < 0.01). Multivariate analysis showed that recurrence with symptoms (p < 0.01) and shorter time to recurrence (<24 months; p < 0.01) were independent prognostic factors after recurrence. CONCLUSIONS: Although this study was retrospective and included some biases, patients with advanced-stage lung cancer and LVI positivity should be intensively followed up. Personalized follow-up programs should be considered for lung cancer patients who have undergone resection.

[Giant cell tumor of the ribs that required emergency surgery due to massive hemothorax; report of a case].

A 63-year-old man with a left rib tumor, which had been diagnosed as a giant cell tumor 2 years previously, had been followed up at another hospital after embolization of a feeding artery of the tumor. He was admitted to the emergency room of our hospital with complaints of breathing difficulties. A chest computed tomography (CT) revealed a left chest wall tumor, about 11 cm in size, originating from the 8th rib and a massive left hemothorax. Emergency operation was performed to releave hemorrhagic shock. Bleeding from the tumor was confirmed at thoracotomy. Tumor was removed with combined resection of the adjacent chest wall and diaphragm. His postoperative course was uneventful and he was discharged on the 8th postoperative day.