Successful thoracoscopic enucleation of a calcifying fibrous tumor of the lower mediastinum in a young woman.

BACKGROUND: Calcifying fibrous tumor (CFT) arising from the pleura is a relatively rare benign lesion in young and middle-aged adults. We report a 31-year-old woman with pleural CFT who underwent successful complete thoracoscopic enucleation. CASE PRESENTATION: An asymptomatic woman presented with a mass in the right lower lung field that was incidentally detected on a chest X-ray during a routine medical checkup. Chest computed tomography showed a well-defined mass in the lower mediastinum, with a maximum diameter of approximately 5.5 cm. Esophagogastroduodenoscopy showed no abnormal findings in the esophagus. An endoscopic ultrasonography (EUS) revealed a well-defined tumor with no internal blood flow. EUS-fine needle aspiration failed to establish a definitive diagnosis. Therefore, thoracoscopic tumor enucleation was performed for diagnostic and therapeutic purposes. Based on the histopathological findings of the resected specimen, the presence of a tumor with a high fibrous component in a young woman, and the identification of granulomatous calcifications, a diagnosis of CFT was established. CONCLUSIONS: Complete thoracoscopic tumor enucleation was successfully performed for CFT arising from the pleura in a young adult woman.

Successful Treatment with Definitive Concurrent Chemoradiotherapy Followed by Durvalumab Maintenance Therapy in a Patient with Tracheal Adenoid Cystic Carcinoma.

Adenoid cystic carcinoma (ACC) is a rare type of malignant tracheal tumor originating from the secretory glands. Complete surgical resection is the current standard of care for tracheal ACC. However, there have been few case reports of chemoradiotherapy for unresectable tracheal ACC. We herein report a 28-year-old man with unresectable tracheal ACC who received concurrent chemoradiotherapy (CCRT) followed by maintenance therapy with durvalumab. CCRT was completed with a good response and safety, and the patient is currently receiving durvalumab as maintenance therapy. Durvalumab after CCRT can be a treatment option for patients with unresectable tracheal ACC.

Communication Site Ligation and Polyglycolic Acid Sheet Use for the Treatment of Hydrothorax in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis.

INTRODUCTION: Hydrothorax due to pleuroperitoneal communication (PPC) can occur in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). We report our experiences of the safety and efficacy of the treatment of four patients with a novel video-assisted thoracoscopy method. METHODS: Single-port video-assisted thoracoscopic surgery (VATS) was performed with a mini-thoracotomy of 5 cm in length. The PPC site was identified on the diaphragm and ligated using an endoscopic loop. The diaphragm was then covered using a polyglycolic acid (PGA) sheet, over which adhesive chemicals (OK432 and tetracycline) were sprayed. RESULTS: We assessed the efficacy of our approach in four patients (one female and three males) aged 42-74 years (mean: 62.0 years). The hydrothoraxes were right sided in all the patients. The mean operation and postoperative drainage times were 92.5 min and 3.0 days, respectively. The hydrothoraxes did not recur in any patient during follow-up periods of 8-46 months. CONCLUSION: Our suture- and staple-free technique is not only easy to perform but also appears to be safe and effective for the management of hydrothorax in patients receiving CAPD. Larger scale studies are now indicated.

Prognostic effect of incompletely lobulated fissures in p-Stage I non-small-cell lung cancer.

OBJECTIVES: Division of incompletely lobulated fissures is often performed during surgical resection of non-small-cell lung cancer (NSCLC); however, the effect of lobulation on tumour recurrence is unclear. This study aimed to assess the prognostic effect of lobulation in patients with NSCLC according to their preoperative and operative findings. METHODS: A retrospective study of patients with p-stage I NSCLC who underwent lobectomy was conducted between April 2008 and April 2016. A receiver operating characteristic curve of the number of stapling cartridges was constructed to determine the optimal cut-off value. Patients who underwent division of the interlobar fissure using 2 or more stapling cartridges (H group) were compared with those who did not undergo division of the interlobar fissure or who underwent division of the interlobar fissure using only 1 cartridge (L group). RESULTS: The study included 85 patients, and of these patients, 46 were included in the L group and 39 in the H group. Survival analysis showed better disease-specific survival (P = 0.0135) and disease-free survival (P = 0.0412) in the L group. Cox regression analysis showed better disease-specific survival in patients who underwent division of the interlobar fissure with few stapler cartridges than in those who underwent division with more stapler cartridges (P = 0.021). CONCLUSIONS: The extent and status of incompletely lobulated fissures are significant risk factors for disease-specific survival in patients with resected p-stage I NSCLC.

Factors Determining the Choice of Surgical Procedure in Elderly Patients with Non-Small Cell Lung Cancer.

BACKGROUND: In the elderly patients, optimal surgical treatment can be difficult to achieve, because of comorbidity. Therefore, we aimed to clarify the preferred surgical management in this patient group. METHODS: A retrospective study was conducted between April 2008 and March 2015 that included patients with non-small cell lung cancer (NSCLC) aged ≥ 75 years. RESULTS: We included 44 patients who underwent partial resection (n = 20) or lobectomy (n = 24). There were no significant differences between the two groups on most variables, except for some character. Survival analysis revealed a significant difference in overall survival (OS) between the two groups; however, no significant differences existed in the disease-free survival or in the OS for stage I disease. Postoperative complications led to poor prognoses. Cox regression analysis revealed statistical significance for the Brinkman Index, the ratio of the pulmonary artery diameter to the ascending aorta diameter (PA:A), and the alveolar-arterial oxygen gradient. Only the PA:A ratio remained significant after multivariate analysis, with a higher ratio associated with better survival. CONCLUSION: In elderly patients with NSCLC, surgical resection should not be denied because of age alone. However, partial resection should be favored to lobectomy when possible.

Safe transection of aberrant arteries associated with pulmonary sequestrations.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) lobectomy is increasingly used for pulmonary sequestration; however, there are few descriptions of safe handling of the aberrant artery. Here we clarify the safe handling of an aberrant artery using a clinical review and an experimental model. METHODS: We retrospectively reviewed the records of patients who underwent lobectomy for pulmonary sequestration with aberrant arteries at the Nippon Medical School between January 2008 and December 2010. This was supplemented by an experimental pressure test using vessels obtained from pigs. RESULTS: We identified four patients with aberrant arteries that were successfully occluded via either stapling. In the experimental model, we divided pig vessels into small-diameter (S) and large-diameter (L) groups. The 1.0-mm-high staples were stronger in the S group than in the L group (p = 0.028). In the L group, the 2.0-mm-high staples were stronger than the 1.0-mm staples (p = 0.015). Leakage from the staple line was associated with a poorer B-shape of inserted staples. CONCLUSIONS: The techniques described in this report are useful in successful minimally invasive transection of an aberrant artery (other than very thin vessels) when resecting a pulmonary sequestration by stapler only. A detailed investigation should be performed to determine the most appropriate stapler or cartridge.

Local recurrence of lung adenocarcinoma 10 years after left upper lobectomy resembling pseudomesotheliomatous adenocarcinoma: a case report.

The form and timing of the local recurrence of lung cancer can be unpredictable and unexpected. Pseudomesotheliomatous adenocarcinoma is a rare tumor that mimics malignant pleural mesothelioma both clinically and pathologically. Distinguishing pseudomesotheliomatous adenocarcinoma from malignant pleural mesothelioma on the basis of clinical findings can be difficult; therefore, a biopsy is usually required for diagnosis. Here we report on a 73-year-old Japanese man who presented with extensive dissemination along the pleural surfaces and clinical findings similar to those of pseudomesotheliomatous lung cancer 10 years after undergoing left upper lobectomy for lung adenocarcinoma. This report provides information that will help physicians establish an accurate diagnosis in similar cases.

Mediastinal Neurofibroma Originating from the Pulmonary Branch of the Right Vagus Nerve in a Patient without von Recklinghausen Disease.

Intrathoracic neurofibromas originating from the vagus nerve in patients without von Recklinghausen disease is rare and poses a problem in etiological diagnosis. Surgical resection is usually necessary for precise diagnosis of such tumors. We report the first case of a neurofibroma originating from the right pulmonary branch of the vagus nerve in a 34-year-old male without von Recklinghausen disease. The diagnosis was suggested by the radiological features and was confirmed histologically after resection.

Mediastinal cystic hemangioma presenting as bilateral bloody pleural effusion: a case report.

A 58-year-old man was admitted to our hospital because of dyspnea, dysphagia, and back pain. A chest roentgenogram showed bilateral pleural effusion. Bloody fluid was aspirated via thoracocentesis, but no malignancy was detected on cytological examination. Computed tomography revealed a hypodense circular mass approximately 8 cm in diameter with well-defined margins in the posterior mediastinum. Furthermore, T2-weighted magnetic resonance imaging showed the lesion to be a hyperintense mass. Video-assisted thoracoscopic surgery was performed, and the tumor was diagnosed as a mediastinal cystic hemangioma. The bilateral bloody pleural effusion was attributed to the cystic tumor.

Surgical results of completion pneumonectomy.

PURPOSE: We report our experience with completion pneumonectomy (CP). METHODS: We report on operative procedure and morbidity, mortality, and survival rates. RESULTS: CP was performed for malignancy in 12 patients and postoperative complications after the first operation in 4 patients. Intrapericardial dissection of vessels was performed in 14 patients (87.5%). Partial vertebrectomy from the second to the fifth vertebrae was performed in 1 patient. Carinal resection was performed in 2 patients. Morbidity including bronchopleural fistula, pulmonary insufficiency, pyothorax, and pulmonary infarction developed in 6 of the 16 patients (37.5%). Mortality rate was 18.8%. The actuarial 1-, 3-, and 5-year overall survival after CP for all malignancy was 80.8%, 49.0%, and 49.0% respectively. CONCLUSIONS: The morbidity and mortality rates are high in CP. Combined resection, especially carinal resection, appears to be contraindicated in CP. CP is one of the treatments of choice, even for malignancy, if complete resection is possible because of the good long-term survival.

Surgical treatment of metachronous nonsmall cell lung cancer.

PURPOSE: We report surgical results of metachronous nonsmall cell lung cancer (NSCLC). METHODS: We report mortality and analyze prognostic factors for overall survival in patients with metachronous NSCLC at Nippon Medical School from July 1982 to July 2008. RESULTS: Thirty-three out of 1726 patients (1.9%) who underwent lung resection had metachronous NSCLC. Mortality rate was 10%. On univariate analyses, the different histologies at the first and second operations were the only significant poor prognostic factor. Twenty-two patients (73%) had the same histology at the first and second operations: adenocarcinoma in 18 (60%) and squamous cell carcinoma in 4 (13%). Their actuarial 5- and 10-year overall survivals were both 71%, compared to 47% and 16% for patients with different histology (p = 0.0174). Sex (p = 0.1742), locations of the first and second cancers (p = 0.3957), operative procedures in patients with p-stage I at the second operation (p = 0.2782), pathological stage at the first operation (p = 0.5958), and pathological stage at the second operation (p = 0.0609) were not prognostic factors. Different histology at the first and second operations was significant based on a multivariate analysis (Hazard ratio: 3.918; p value: 0.0269; 95% confidence interval: 1.169-13.131). The actuarial 5- and 10-year overall survivals for the first cancer was 86% and 64%, compared to 65% and 45% for the second (p = 0.0609). CONCLUSIONS: Our study shows that a surgical approach is beneficial for patients with metachronous NSCLC. Good prognosis in patients with the same histology may support the current criteria of metachronous NSCLC mainly based on the histology.

Locally infiltrative glomus tumor of the bronchus: a case report.

We report a glomus tumor of the bronchus that showed invasion of the neural area and extrabronchial extension without significant histological malignancy. The patient was a male in his late 30s with the chief complaint being hemosputum. CT revealed a nodal shadow 15 mm in diameter in the right bronchus intermedius. An irregularly protruding lesion on the tumor surface was observed by bronchoscopy immediately under the second carina in the right truncus intermedius, but could not be diagnosed because of bleeding. Sleeve lobectomy of the right upper lobe was performed, since carcinoid tumor was suspected in open chest biopsy and intraoperative frozen section diagnosis. A solid growth of spherical and cubic uniform cells with a clear eosinophilic cytoplasm and spherical nuclei was observed. Immunohistochemistry was positive for α-smooth muscle actin and type IV collagen, weakly positive for synaptophysin, and negative for keratin, neural cell adhesion molecule, chromogranin A, desmin, CD34, and S100, leading to a diagnosis of glomus tumor. Neuroinvasion and extrabronchial tumor extension were observed, but an atypical cytology, bleeding, or necrosis was found histologically. This is the first description of infiltrative glomus tumor of the bronchus.

Surgical results of lung cancer associated with postobstructive pneumonia.

PURPOSE: We report surgical results of lung cancer associated with postobstructive pneumonia. MATERIALS AND METHODS: We report on morbidity and mortality, and we analyze the risk factors for them and the prognostic factors for overall survival of patients without mortality. RESULTS: Morbidity developed in 13 of the 38 patients (34.2%). Mortality rate was 10.5%. Hemoglobin concentration before surgery and predicted postoperative forced expiratory volume in one second were significantly low in patients with morbidity and mortality based on the univariate analyses. Predicted postoperative forced expiratory volume in one second was a significant risk factor for morbidity based on a multivariate analysis. Poor prognostic factors for overall survival were serum albumin concentration, hemoglobin concentration, and performance status before surgery, combined resection, and pathological stage. Serum albumin concentration was significant based on a multivariate analysis. CONCLUSIONS: Morbidity and mortality are high in patients with lung cancer associated with postobstructive pneumonia. Morbidity demonstrates significant association with low predicted postoperative forced expiratory volume in one second and hemoglobin concentration, indicating the need for preoperative transfusion in severe anemia or bronchoplasty if possible. Poor nutritional state before surgery possibly derived from cachexia may influence not only morbidity and mortality, but also prognosis.

Type B3 thymic epithelial tumor in an adolescent detected by immunohistochemical staining for CD5, CD99, and KIT (CD117): a case report.

A 16-year-old male patient was admitted to the hospital for a medical workup to examine an anterior mediastinal tumor in April 2000. A tumor excision and a right lower lung lobe nodule resection were performed in June 2000. The tumor tissue showed a cobblestone-like proliferation of atypical cells containing a discrete nucleolus that were aligned in an epithelial fashion against mainly lymphocytic inflammatory cells in the background; also shown were undifferentiated tumor cells with epithelioid characteristics. Immunohistochemical staining for CD5, CD99, and KIT (CD117) revealed that the tumor cells were CD5-negative and that some of the lymphocytes infiltrating the tumor tissue stained positive for CD99 and negative for KIT. The lesion was therefore diagnosed to be a type B3 thymic epithelial tumor.

A true pulmonary carcinosarcoma that required diagnostic differentiation from a pleomorphic adenoma: a case report.

Pulmonary carcinosarcoma is a rarely encountered tumor. We treated a patient who had an intrabronchial polypoid lesion that required a diagnostic differentiation from epithelial-mesenchymal mixed neoplasms inclusive of pleomorphic adenoma, and that was diagnosed by immunohistochemical staining to be a true carcinosarcoma. A 69-year-old man underwent left pneumonectomy in November 2000 with a diagnosis of atelectasis resulting from a tumor obstructing the left lower lobar bronchus, and also a lung abscess. The tumor was initially diagnosed as pleomorphic adenoma, since it contained both benign-looking epithelial and mesenchymal elements, but immunohistochemical staining demonstrated myoglobin-positive rhabdomyosarcomatous elements along with cytokeratin-positive squamous cell carcinoma elements. A definite diagnosis of pulmonary carcinosarcoma was confirmed.

Mediastinal lymph node metastasis of lung cancer with an unknown primary lesion having concurrent endocrine abnormality and acanthosis nigricans: report of a case.

We herein describe a patient we encountered in whom mediastinal lymph node metastasis of lung cancer with an unknown primary lesion was complicated by both an endocrine abnormality and acanthosis nigricans. A 66-year-old male visited a local hospital and was diagnosed as having acanthosis nigricans. The patient was referred to our hospital for further examination. Computed tomography scans of the chest and the abdomen showed no adverse findings except for an enlargement of the mediastinal lymph node. No malignant lesions were detected in examinations of the upper gastrointestinal tract. Based on the above findings, the lesion was thus considered to possibly be mediastinal lymph node metastasis of an unknown primary tumor or malignant lymphoma. A thoracoscopic biopsy of the mediastinal lymph node was performed. The patient was diagnosed to have mediastinal lymph node metastasis of lung cancer with an unknown primary lesion and endocrine abnormality resulting from paraneoplastic syndrome. Palliative radiation therapy was initiated to prevent superior vena cava syndrome and esophageal passage failure or dysphagia. The cutaneous lesions markedly improved thereafter. The serum levels of adrenocorticotropic hormone decreased.

A case report: thoracic extramedullary hematopoiesis found by occurring spontaneous pneumothorax.

Extramedullary hematopoiesis (EMH) is a rare disease associated with hematologic disorders. This report describes a case of posterior mediastinal mass found by occurring spontaneous pneumothorax in a 48-year-old male. The intrathoracic mass resected using video-assisted thoracic surgery (VATS) was diagnosed thoracic EMH (TEMH). No disorders were found by hematologic exams before or after surgery. This report suggests that such lesions must therefore be considered in the differential diagnosis of posterior mediastinal tumors presenting with no hematologic disorders.

Characteristics of multiple primary malignancies associated with lung cancer by gender.

BACKGROUND: There are gender differences in multiple primary malignancies associated with lung cancer (MPMLC) in terms of clinical characteristics. However, the importance of these differences in the management of patients has not been clarified. OBJECTIVE: Differences in characteristics affected by gender were investigated in MPMLC to identify factors important for the proper management of the patients. METHODS: Univariate and multivariate analyses were performed between 82 male and 34 female patients with MPMLC treated from August 1982 to March 2002. RESULTS: In univariate analysis, the numbers of smokers or ex-smokers, smoking-related cancer and synchronous multiple primary malignancies were significantly increased in males with MPMLC (p < 0.0001, p < 0.05 and p < 0.05, respectively). In multivariate analysis, synchronous multiple primary malignancies and the number of smokers or ex-smokers were significantly different between male and female MPMLC. Gastric, lung and colon cancers were major constituents in male MPMLC, and 40.2% of all malignancies were smoking-related cancers. On the other hand, breast and uterine cancers were major constituents in female MPMLC, and only 20.6% of all MPMLC were smoking-related cancers. CONCLUSIONS: Male patients with MPMLC demonstrated significant smoking history and synchronous multiple primary malignancies, indicating the need for different approaches to properly manage and follow up male versus female MPMLC patients.

Mucinous carcinoma identified as lung metastasis from an early rectal cancer with submucosal invasion by immunohistochemical detection of villin.

We encountered a male patient aged 64 with pulmonary mucinous carcinoma in whom a diagnosis of pulmonary metastasis from early rectal cancer with submucosal invasion was made based on an immunohistochemical examination. A rectal cancer was detected together with a mass in the lung. The mass in the lung was consistent with mucinous adenocarcinoma, whereas the invasion of rectal cancer was confined to the submucosa; thus, distant metastases appeared unlikely. These lesions were assessed using immunohistochemical staining for cytokeratin and thyroid transcription factor-1, which failed to make a definite diagnosis. A further assessment was made by staining for villin. Both neoplasms were positive for this protein, demonstrating a common brush-border pattern. A lung metastasis from rectal cancer with submucosal invasion was diagnosed. Villin is considered useful for detecting primary neoplastic lesions based not only on its specificity but also on its staining pattern, which is different from that of other proteins.

Analysis of risk factors for postpneumonectomy bronchopleural fistulas in patients with lung cancer.

BACKGROUND: Bronchopleural fistula is a potentially fatal complication of pulmonary resections, especially pneumonectomy. METHODS: Univariate and multivariate analyses of the development of bronchopleural fistula were performed in 12 patients with bronchopleural fistula and 102 patients without bronchopleural fistula who had undergone pneumonectomy from January 1983 through December 2005. RESULTS: Bronchopleural fistula developed after pneumonectomy in 12 patients (8.5%). Seven (58.7%) of the 12 patients died of bronchopleural fistula. Univariate analysis showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease significantly contributed to the development of postpneumonectomy bronchopleural fistula (p=0.0002, p=0.0043, and p=0.0387, respectively). Multivariate analysis also showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease were significant risk factors for postpneumonectomy bronchopleural fistula. CONCLUSIONS: Bronchopleural fistula is strongly associated with preoperative infection, right pneumonectomy, and pathological N2, 3 disease. Bronchial stump coverage with pedicled tissue flaps and preservation of the bronchial arteries during mediastinal lymph node dissection are recommended to maintain the blood supply to the bronchial stump in patients at risk.