Preoperative Watchful-Waiting Time and Surgical Outcome of Patients with Non-small Cell Lung Cancer Found by Chest Low-Dose CT Screening.

BACKGROUNDS: Chest low-dose CT screening (LDCTS) has been finding unprecedented numbers of peripheral non-small cell lung cancers (NSCLC) at an early stage and increased the number of patients with surgical indication. It is important to explore the influence of preoperative watchful-waiting time (WWT) on surgical outcomes. Objective is to clarify relationship between WWT and surgical outcomes of LDCTS-finding NSCLC from the view point of treatment delay. METHODS: Total 283 cases of NSCLC, found by LDCTS and consecutively resected, were surveyed for preoperative WWT and surgical outcomes. Validity of the present guideline for management of pulmonary nodules detected by LDCTS was verified whether WWT before surgery was suitable for eradication of NSCLC. RESULTS: The median value of WWT was 4.0 months in total, and the distribution of WWT exhibited long-tail-type pattern. That was 5.0 months in the group of pure ground-glass nodule (pGGN), 4.0 months in the group of part-solid nodule (PSN), and 1.7 months in the group of solid nodule (SON). During long-term postoperative observation time (median 79 months), 10-year progression-free survival rates were 100% in pGGN, 96% in PSN, and 72% in SON (P < .0001). They decreased significantly depending on enlargement of size: 91% or higher in size of 2 cm or smaller, and 71% or lower in size of larger than 2 cm (P < .0001). CONCLUSIONS: Limited to LDCTS-finding nodules, surgical outcome will depend mainly on some malignant potential of NSCLC per se, rather than on duration of WWT or treatment delay.

Pulmonary adenocarcinoma possibly developed from the cut-end of small-sized adenocarcinoma in the lung periphery as recurrence 13 years after its wedge resection.

BACKGROUND: It is a big topic for general thoracic surgery whether still curability can be obtained by limited resection for peripheral small-sized nodules of non-small cell lung cancer (NSCLC) in the current era of frequent computed tomography (CT) use. Accumulation of information on problematic cases would be meaningful for surgeons to select better surgical procedures. CASE PRESENTATION: A 69-year-old man was pointed out an enlarged 2.1-cm solid nodule on the edge of staple line of the residual right upper lobe by chest CT. He had past history of the lung cancer surgery, wedge resection of the same right upper lobe 13 years ago. The pathological findings were 1.1-cm, p-TlbN0M0, p-stage IA2-adenocarcinoma. Thereafter, he received no adjuvant therapy. This time, the trans-bronchial lung biopsy revealed adenocarcinoma. After the completion lobectomy of the residual right upper lobe, the tumor was diagnosed as adenocarcinoma consistent with recurrence of small-sized adenocarcinoma in the lung periphery developed from the cut-end because of similarities between present and previous tumors on histopathology and p53-positivity. CONCLUSIONS: When limited resection has been performed for small-sized NSCLC presenting solid nodule on thin-slice CT images, long-term postoperative follow-up time will be necessary for monitoring, considering the possibility of cut-end recurrence.

Recurrence of juxtacortical chondrosarcoma arising on the rib.

Juxtacortical chondrosarcoma developing on the surface of a bone is quite rare. We report a case of juxtacortical chondrosarcoma arising on the fourth rib of a 76-year-old man. Intraregional tumor resection was performed, but local recurrence was detected after 6 months. The patient underwent wide resection including the ribs, and reconstruction of the thoracic wall. He was released with a good prognosis after a year. This case emphasizes the importance of biopsy analysis before surgery to carefully evaluate tumor spread in the cartilage and performing wide resection even if the tumor is easily separated from the bone.

Birt-Hogg-Dubé syndrome detected incidentally by asymptomatic bilateral pneumothorax in health screening: a case of a young Japanese woman.

Birt-Hogg-Dubé syndrome (BHD) is an autosomal dominant disease caused by mutations of germline folliculin (FCLN) mapped in the chromosome 17p11.2 region. BHD commonly accompanies renal tumors, fibrofolliculomas, multiple pulmonary cysts, and spontaneous pneumothorax. We report a case of a young Japanese woman in whom asymptomatic bilateral pneumothorax was found incidentally in a health screening, which led to the diagnosis of BHD. She had developed neither renal tumors nor fibrofolliculomas. However, her father, uncle, and aunt also experienced pneumothorax. In Japan, BHD is not yet well known because skin-related symptoms of fibrofolliculomas are sometimes absent unlike in most cases in Europe and the United States. On the basis of this case, we propose that BHD should be considered at the time of pneumothorax examination.

[Thoracoscopic thymectomy using anterior chest wall lifting method by Kirschner wire].

We performed thoracoscopic thymectomy using a method in which the anterior chest wall was lifted by Kirschner wire passed through the subcutaneous tissue. Between April 2011 and May 2012, 5 cases underwent thoracoscopic thymectomy using this method. Postoperative complications, especially subcutaneous hematoma and pain in the anterior chest wall through which the Kirschner wire was passed, did not occur. This method provided a good operative field in the posterior sternum for safe thymectomy. In addition, the use of an Endocameleon was effective decreasing invisible field blind view during the operation. We concluded that this method is a simple and useful means of elevation of the sternum for thoracoscopic thymectomy.

Localized nodular amyloidosis of the lung.

Pulmonary localized nodular amyloidosis is a rare disorder and is not associated with primary systemic amyloidosis. We herein report a patient with a growing lung nodule who underwent thoracic surgery and was diagnosed with this condition. This case study suggests that localized nodular amyloidosis should be considered during a differential diagnosis of growing lung nodules and that a histological examination should be performed to distinguish this disorder from lung malignancies.

Occurrence of a simultaneous bilateral spontaneous pneumothorax due to a pleuro-pleural communication.

Herein we present a case of a simultaneous bilateral spontaneous pneumothorax caused by a pleuro-pleural communication. A 70-year-old man with a history of esophagectomy presented with dyspnea. A chest roentgenogram revealed a bilateral pneumothorax and bilateral chest drainage procedures were performed. A left bullectomy was also performed 3 days later due to persistent air leakage on the left side. During surgery, a small fistula was detected in the anterior mediastinal pleura and was found to be in communication with the bilateral pleural spaces.

Different efficacy of CT screening for lung cancer according to histological type: analysis of Japanese-smoker cases detected using a low-dose CT screen.

The efficacy of CT screening for lung cancers is still a controversial issue, although one of the recently publicized large randomized controlled trials of this methodology, the National Lung Screening Trial (NLST), reported a decrease in the lung cancer-specific mortality for heavy smokers. We here performed case-matched comparative analyses, as a retrospective study, of three lung cancer arms detected by CT screen, X-ray screen, and by individual analysis of the clinicopathological features and outcomes in smokers from a symptomatic-prompted group of patients. We also considered the impacts of various potential biases in this cohort. The total study cohort comprised 136 patients in the CT screen group, 263 in the X-ray screen group and 254 in the symptomatic-prompted group. The ratio of stage IA cancers in the CT screen group was 67.7% and the ratio of advanced cases (i.e. stages IIIB+IV) was 12.5%. The percentage of bronchioloalveolar carcinoma (BAC) was 28.7% in the CT screen group. The 5-year survival rates were 82.4% in the CT screen group, 38.0% in the X-ray screen group and 17.8% in the symptomatic-prompted group. CT screening was found to be an independent prognostic factor for lung cancer even when BAC cases were eliminated (HR 0.35, P<0.01). Based on our sub-analysis by individual histological sub-type, CT screen lung cancer cases had a better survival rate than non-screened patients, which included adenocarcinoma, squamous cell carcinoma and large/small cell carcinoma. However, by multi-variant analysis a CT scan would not be expected to reduce the risk of lung cancer mortality in patients with large/small cell carcinoma, although would be expected to reduce the risk of lung cancer death by 80% in cases of both adenocarcinoma and squamous cell carcinoma. In conclusion, our current findings indicate that CT screening for lung cancer is an effective strategy for smokers and that patients with adenocarcinoma and squamous cell carcinoma of all variant histological types may benefit from this test. In this regard, early stage large/small cell carcinomas are insufficiently detected by the existing annual screening system.

Efficacy of CT screening for lung cancer in never-smokers: analysis of Japanese cases detected using a low-dose CT screen.

CT-screening for lung cancer is fairly widely used for both smokers and never-smokers in East Asia because the mortality rate for never-smokers due to this cancer is relatively high in this region. We performed comparative analyses, as a retrospective study, on three lung cancer arms detected by CT-screen, X-ray-screen, and via analysis of clinicopathological features and outcomes in never-smokers from a symptomatic-prompted group of patients. The total study cohort comprised 218 patients in CT group, 160 in X-ray group, and 82 in symptomatic-prompted group. The percentage of bronchioloalveolar carcinoma (BAC) was 65.1% in CT-screen group. The ratio of stage IA tumors in CT-screen group was 88.5% and the ratio of advanced cases (i.e. stages IIIB+IV) was 2.3%. The 5-year-survival rates were 95.0% in CT-screen, 73.0% in X-ray-screen and 40.0% in symptomatic-prompted group. We performed further sub-analysis which excluded pure BACs (i.e. Noguchi types A and B) or pure GGOs within a 10mm diameter because this is indicative of a very favorable prognosis. Based on this sub-analysis the number of the subjects in each group became 76 in CT group; 140 in X-ray group and 77 in symptomatic-prompted group. The principal characteristics of the patients such as age and sex became almost even in the three arms. In CT-screen subgroup, the ratio of stage IA cancer was 69.7% and of advanced cases was 6.6%. This advanced ratio was lower than both X-ray-screen (22.1%) and symptomatic-prompted (61.9%) groups. The 5-year-survival rates were 89.9% among CT-screen group patients, 72.6% for X-ray screen cases and 39.1% in symptomatic-prompted group. A CT-screen was found to be one of the independent prognostic factors for lung cancer (HR, 0.28; 95% CI, 0.12-0.72) and based on this would be expected to reduce the risk of lung cancer death by 78% compared with non-screened cases. In conclusion, CT will improve the survival rate and decrease the rate of advanced cancers in never-smokers via the existing annual screening system. CT-screening is also an independent prognostic improvement factor in never-smokers, and will therefore reduce the risk of lung cancer death.

Clinical features of lung cancer in smokers with light and mild chronic obstructive pulmonary disease: a retrospective analysis of Japanese surgical cases.

OBJECTIVES: We estimated the influence of chronic obstructive pulmonary disease (COPD) upon the clinicopathological characteristics of lung cancer (LC) in Japanese surgical cases by comparing LC cases in non-COPD smokers. METHOD: A consecutive cohort comprising 157 COPD patients (78 in Global Initiative for Obstructive Lung Disease-1 (GOLD-1) and 79 in GOLD-2) and 374 non-COPD smoker-LC patients were enrolled in this study. Comparative analyses of the clinicopathological features of these two groups, including clinical outcomes, were performed. RESULTS: By analyzing all cases, we found that LC patients with COPD were older on average, more likely to be male, and heavier smokers than LC patients without COPD. In sub-analysis involving matched patient backgrounds, histological differentiation grade of LC in smokers with COPD was lower than in LC smokers without COPD, although distribution of clinical stages and histological types of LCs did not differ between smokers with and without COPD. The 5-year-survival rate in COPD patients was poorer than in non-COPD smokers in terms of both overall (38% vs 54%) and cancer-related mortality (45% vs 63%). By single-variant risk analysis, COPD became a prognostic factor. CONCLUSION: We concluded from our analysis that COPD-related LC may have a higher malignant potential than LC in non-COPD smokers, as the histological differentiation grade and clinical outcomes were poorer.

Intrathoracic rupture of an extraskeletal myxoid chondrosarcoma.

Extraskeletal myxoid chondrosarcoma (EMC) is typically a slow-growing tumor with a prolonged clinical course. We describe a case of EMC that was complicated by intrathoracic rupture of the tumor and took an aggressive clinical course. A 64-year-old man with a precordial tumor suddenly began suffering from acute chest pain. Radiographic examination revealed a massive pleural effusion. Emergency surgery was performed but resulted in rupture of the pleural side of the tumor. The tumor was resected with the chest wall. The patient died 16 months after surgery owing to abdominal wall recurrence.

Multiple schwannomas of the bilateral mediastinal vagus nerves.

Multiple schwannomas arising from the mediastinal vagus nerve are very rare, but herein we report a case with such lesions involving the bilateral intrathoracic vagus nerves. A 43-year-old man presented with multiple mediastinal tumors during a check-up. A chest computed tomographic scan revealed multiple lesions that appeared strung together like beads along the right vagus nerve. Three small tumors were also evident on the left side of the esophagus. We performed a complete resection of the bilateral mediastinal tumors through right thoracoscopic surgery. The pathologic diagnosis for each of these tumors was a schwannoma without malignant components.

A mediastinal somatic-type germ cell tumor with hepatic metastasis successfully treated by multiple modalities.

Rhabdomyosarcoma in the mediastinum coexisting with metastatic non-seminomatous germ cell tumor, so-called somatic-type malignancy, is a rare carcinoma and has poor survival. This study reports a case of diffuse and huge hepatic metastasis of non-seminomatous germ cell tumor associated with coexisting embryonal rhabdomyosarcoma in the mediastinum. A 31-year-old man presented with abdominal pain and was found to have multiple abnormal hepatic masses on abdominal computed tomography (CT). Concomitantly, an anterior mediastinal mass was found on chest CT. Chemotherapy was initiated because the hepatic lesion was diagnosed as choriocarcinoma, based on histological findings and the elevation of chorionic gonadotropin ß-subunit and α-fetoprotein. After six cycles of bleomycin, etoposide and cisplatin chemotherapy the metastatic liver tumors showed complete response. The remaining mediastinal tumor was completely and successfully resected. The histological findings revealed mature teratoma with embryonal rhabdomyosarcoma. The patient has remained well for over six years after the treatment without any signs of disease recurrence.

Benefits of video-assisted thoracic surgery for repeated pulmonary metastasectomy.

PURPOSE: The use of repeated pulmonary resection for metachronous pulmonary metastasis has increased. We assessed whether video-assisted thoracic surgery (VATS) produced greater benefits than classic thoracotomy for repeated pulmonary metastasectomy procedures. METHODS: A total of 46 patients who had undergone two or more pulmonary metastasectomies from 1995 to 2008 were analyzed in this study. These patients were classified into four groups as follows: group A (previous VATS/present VATS); group B (previous VATS/present thoracotomy); group C (previous thoracotomy/present VATS); group D (previous thoracotomy/present thoracotomy). The clinical features of these four groups were then compared. RESULTS: The operating time and the duration of thoracic drainage were longer in group D than in group A or B. The operating time was also longer in group C than in group A. Intraoperative bleeding was greater in group D patients than in other three groups. There were no discernible morbidities resulting from VATS in groups A or C. No differences were found in the occurrence of relapse among the groups. The mean interval from the previous to the present pulmonary metastasectomy also did not differ significantly among groups. CONCLUSION: VATS can result in a shortened operating time, reduced intraoperative bleeding, and generally fewer complications compared with repeated classic thoracotomy. VATS is also potentially a curative procedure as it is not inferior to classic thoracotomy in terms of the relapse rate after repeated pulmonary metastasectomy.

Colchicine as an effective treatment for postpericardiotomy syndrome following a lung lobectomy.

Postpericardiotomy syndrome (PPS) is a frequent complication of various cardiac procedures that involve entry into the pericardium, but rarely occurs after pulmonary surgery because the pericardium is usually preserved during this procedure. The standard treatment for PPS is the administration of non-steroidal anti-inflammatory drugs (NSAIDs). Recent studies have indicated however, that colchicine may be useful for the treatment and prevention of this syndrome. Here, we describe the successful use of colchicine to treat PPS in a lung cancer patient who developed this complication following a lung lobectomy. A 64-year-old woman with a stage IA lung tumor underwent a left upper lobectomy with a mediastinal lymph node dissection. Severe precordial pain occurred 10 days after surgery, and accumulations of pericardial and pleural fluid were revealed by chest X-ray, echocardiogram, and chest computed tomography. These symptoms were not alleviated by antibiotics, thoracic cavity drainage, or NSAIDs. However, the administration of colchicine (initial dose of 1.0 mg and maintenance dose of 0.5 mg daily for three months) in combination with NSAIDs resolved these symptoms immediately after the first dosage. In addition, the patient remains free of any recurrent pericarditis at six months after this episode.

[Delayed hemothorax due to blunt chest trauma].

We report 2 cases of delayed hemothorax due to blunt chest trauma. A 48-year-old man who fell down and got a blow at the right chest had a checkup with a 1st aid outpatient. By the X-rays at the time of the 1st examination, the hemothorax was not noted. The next day, He has been transported to our hospital for atypical absence. Hemothorax was suggested by computed tomography (CT) and chest drainage was enforced. A 79-year-old man got a blow at the anterior chest by traffic accident and had a checkup in the 1st hospital. The abnormality was not recognized in the chest CT at that time. For the left hemiparesis, he was transported to our hospital the next day. Hemothorax was suggested by CT and chest drainage was enforced.

Intraoperative ultrasonographic localization of pulmonary ground-glass opacities.

OBJECTIVES: Ground-glass opacities are typically difficult to inspect and to palpate during video-assisted thoracic surgery. We therefore examined whether ultrasonographic assessments could localize ground-glass opacities and help to achieve adequate resection margins. METHODS: An intraoperative ultrasonographic procedure was prospectively performed on 44 patients harboring ground-glass opacities of less than 20 mm in diameter to localize these lesions and to achieve adequate margins. We also examined whether there were any complications resulting from the intraoperative ultrasonogram, such as lung injury, heart injury, or arrhythmia. We excluded patients with both asthma and chronic obstructive pulmonary disease from this study inasmuch as the intraoperative ultrasonographic procedure is more difficult to interpret when residual air is present in the lung. RESULTS: A total of 53 ground-glass opacities were successfully identified by intraoperative ultrasonography without any complications. Of the 20 mixed ground-glass opacities that we examined, 15 were found on palpation. However, only 4 (12.1%) of the 33 pure ground-glass opacities could be palpated. In all instances in which complete collapse of the lung was achieved (30/53 of these cases), high-quality echo images were obtained. Additionally, a strong correlation was found between the resection margins measured by ultrasonogram and the margins determined by histologic examination in the resected lung specimens (r(2) = 0.954, P < .001). CONCLUSIONS: Intraoperative ultrasonography can both safely and effectively localize pulmonary ground-glass opacities in a completely deflated lung. This procedure is also useful for the evaluation of surgical margins in a resected lung. Hence, ultrasonography may assist surgeons to perform minimally invasive lung resections with clear surgical margins during the treatment of solitary lung ground-glass opacity.

Giant intraatrial septal aneurysm originating from a branch of the left coronary artery.

We present the case of a 38-year-old woman who had a large intraatrial aneurysm occupied by old thrombosis. The aneurysm was successfully removed, and the atrium was repaired. Pathohistological findings indicated that the inflow artery of the aneurysm had an anomalous origin from the left main coronary artery, and its pathogenesis was unknown. It is occasionally difficult to distinguish a large coronary aneurysm from a mediastinal tumor because this aneurysm is a rare entity, even more so in an atrial septum. A giant coronary aneurysm should be considered an alternative diagnosis in the event of a mediastinal mass. Surgery is recommended for a large coronary aneurysm.

[Tracheobronchial injury].

We studied 6 cases of tracheobronchial injury due to the blunt chest truma in our department. All patients were male of 19 to 60 years of age. Injured sites were main bronchus in 2, tracheobronchial portion in 2, cervical trachea and main bronchus in 1, cervical trachea in 1. In a case of cervical tracheal injury and 2 cases of tracheobronchial injury, emergent operation was performed on the day of accident. Other cases with the main bronchial injury underwent conservative treatment at first, but subsequent bronchoplasty was necessary for them due to the bronchial stenosis. After the surgery for 2 cases of tracheobronchial injury, mechanical ventilation with double lumen tube was continued to reduce the airway pressure for the anastomotic sites. In conclusion, early surgical treatment is recommended for the airway injury and the respiratory management using double lumen tube after surgery may be helpful in preventing trouble at the anastomosis.

A subtotal sternectomy successfully reconstructed with composix mesh.

Sternal tumors are uncommon, which often require extended resections with reconstructions. Various techniques have been used, including a choice of prostheses and the use of musculocutaneous flaps for reconstructions. A 74-year-old male presented with a metastatic sternal tumor. He underwent a subtotal sternectomy with partial resection of bilateral clavicles and ribs. A sternal reconstruction was performed with Composix mesh and pectoralis major (PM) muscle flaps. This prosthesis was thought to be very suitable due to the ease of handling, good stability, and prevention of adhesion. In comparison to conventional prostheses, these points could be advantageous.