[Giant Thrombus in the Left Atrium Showing a Rapid Growth:Report of a Case].

A 74-year-old woman had been on hemodialysis for about 2 months using a short-term indwelling dialysis catheter due to chronic kidney disease. A 20 mm-diameter left atrial neoplastic lesion was noted during a screening echocardiogram performed at the time of induction of hemodialysis. The lesion rapidly increased to 30 mm 2 months later and was referred to our hospital for surgical resection. Under cardiopulmonary bypass and cardiac arrest, tumor resection was performed. Although the lesion was myxomatous with a thin stalk on the left atrial ceiling, the pathological diagnosis was thrombus. After the initiation of anticoagulation, the patient was discharged.

Closure of open window thoracostomy due to MRSA pyothorax by EWS bronchial occlusion and modified extraperiosteal air plombage: a case report.

BACKGROUND: Refractory pyothorax caused by methicillin-resistant Staphylococcus aureus (MRSA) is a challenging clinical condition; complications such as bronchopleural fistulae can further hinder its treatment. To avoid a fatal state caused by aspirating pneumonia, open window thoracotomy is not only sometimes performed, but subsequent closure of the window can also be difficult. In this report, we describe the case of a patient with MRSA pyothorax with bronchopleural fistula in whom a successful closure of window thoracostomy was achieved by utilizing Endobronchial Watanabe Spigot　(EWS; Novatech, La Ciotat, France) bronchial occlusion and a modified extraperiosteal air plombage technique. CASE PRESENTATION: A 66-year-old man underwent an open window thoracotomy for pyothorax with bronchopleural fistula with MRSA infection at the age of 59. After 7 years, he was referred to our department for the closure of the window. Initially, we occluded the right B6a + b by EWS under bronchoscopy. Subsequently, we dissected the intercostal muscles between the 3rd, 4th, 5th, and 6th ribs to collapse the pyothorax cavity and ensure the coverage of the fistula of lung including the hypertrophied parietal pleura and soft tissues of the chest wall. We filled the extrapleosteal space with a pedicled anterior serratus muscle flap to compress the parietal pleura. Postoperatively, lung expansion was satisfactory, and there has been no recurrence for 6 years since the window closure surgery. CONCLUSIONS: We were able to achieve closure and healing in a patient who underwent open window thoracostomy for MRSA bronchopleural fistula by applying EWS and modified extraperiosteal air plombage technique.

[Requiring Differential Diagnosis of Pulmonary Arteriovenous Fistula and Pulmonary Venous Aneurysm: Report of a Case].

A pulmonary arteriovenous fistula (PAVF) is a direct abnormal connection between the pulmonary artery and pulmonary vein, lacking capillary tissue. On the other hand, a pulmonary venous aneurysm (PVA) is a localized dilation and aneurysmal formation in the pulmonary vein without reflux issues. Treatment approaches for PAVF and PVA differ, considering surgery or catheter embolization for PAVF due to the risk of cerebral infarction or rupture caused by the abnormal shunt. PVA cases, being rare in rupture and embolism, are usually recommended for observation. Therefore, distinguishing between these two conditions is crucial. This article presents a case where both PVA and PAVF were present, necessitating a differential diagnosis.

[Staged Hybrid Repair Including Abdominal Branches Bypass Grafting for Crawford Typeâ ¡ Thoracoabdominal Aortic Aneurysm:Report of a Case].

A 64-year-old female with a diagnosis of Crawford typeⅡ thoracoabdominal aortic aneurysm( TAAA) including enlargement of the ascending aorta underwent a staged hybrid repair including visceral artery debranching thoracic endovascular aortic repair( TEVAR). First, total arch replacement with elephant trunk method was performed, followed by TEVAR for the descending thoracic aorta, and finally visceral artery debranching TEVAR for the thoracoabdominal aorta. Complications such as spinal cord infarction did not occur throughout the procedure. Surgical repair of Crawford typeⅡ TAAA involves a wide range of treatment and is highly invasive, requiring ingenuity in terms of preventing complications such as spinal cord infarction. Hybrid repair including visceral artery debranching TEVAR may be an effective treatment modality for complex aortic lesions including TAAA, but requires careful follow-up including remote complications.

Malignant Pleural Mesothelioma (MPM) Presenting as Hydropneumothorax.

An 86-year-old man presented with bilateral lower limb edema and was found to have hydropneumothorax on chest radiography. CT revealed a substantial pleural effusion and plaques. The patient had a history of working in a stone workshop, but the extent of asbestos exposure remained unknown. Thoracic drainage and subsequent thoracoscopic surgery confirmed the presence of biphasic malignant mesothelioma through pathological examination. Hydropneumothorax as a presentation of malignant pleural mesothelioma (MPM) is rare, with only a few similar cases reported. Remarkably, despite the coexistence of plural effusion and pneumothorax, the patient did not experience dyspnea. The examination also revealed tumor rupture and disruption of the pleura. Considering the possibility of MPM in patients with asymptomatic hydropneumothorax is essential for early diagnosis and appropriate management.

[Total Arch Replacement using the Frozen Elephant Trunk for Kommerell Diverticulum with Right Aortic Arch:Report of a Case].

A 42-year-old woman with dysphagia was referred to our hospital. Computed tomography (CT) revealed Kommerell diverticulum( KD) associated with right aortic arch( RAA) and aberrant left subclavian artery (ALSCA). We performed total arch replacement (TAR) using a frozen elephant trunk (FET) technique. We ligated ALSCA at the distal portion of the KD after perfusing from a 8 mm tubular graft from left axillar artery. We inserted a FET from the ascending aorta to avoid locating the nonstented portion at the steep-angled site of RAA. Postoperatively dysphagia disappeared and CT scan showed complete exclusion of KD without leakage of the stent graft and successful reconstruction of the arch. The TAR and FET technique is an effective procedure for KD with RAA and ALSCA.

[Comparison of Three Methods of Sternal Closure after Open Heart Surgery:Analysis of 722 Cases for 11 Years].

722 patients who returned to the intensive care unit( ICU) after completing the cardiac surgery and closing the median sternotomy from Jan 2010 to Feb 2021 at our hospital were divided into 3 groups according to the different sternal closures. Sternum was fixed with 6 wires alone in group A (n=333), with 2 absorbable plates and 6 wires in group B( n=259) or with 3 titanium plates with 20 screws and 4 wires in group C (n=130). Background characteristics were not different between the 3 groups. Total number of 3 complications (postsurgical bleeding, mediastinitis and delayed cardiac tamponade) was significantly less in group B and C than group A. Among them postsurgical bleeding needed hemostasis surgery was significantly less in group C than in group A. Surgical nor hospital mortality were not significantly different in 3 groups. Postsurgical complications were significantly less when the sternum closure was fixed with plates( absorbable, not absorbable).

[Repeated Rupture of Infective Thoracic Aortic Aneurysm:Report of a Case].

A 79-year-old man was diagnosed with rupture of infective thoracic aortic aneurysm following septicemia caused by infective cholangitis. He underwent emergent endovascular aortic repair and discontinued antibiotics. Graft infection occurred and was treated 29 days after the first operation. He underwent emergent resection of the abscess with graft coverage using pedicled intercostal muscle flaps. Aortic re-rupture was found and treated 183 days after the second operation. He underwent emergency additional thoracic endovascular aortic repair and continued to take antibiotics again. We should continue a careful follow up.

[Aortic Para-annular Abscess Following Infective Endocarditis Requiring Three Times of Operation:Report of a Case].

A 45-year-old man was diagnosed with active aortic valve endocarditis accompanied by massive aortic regurgitation, complete atrioventricular block, para-annular abscess and a mobile large vegetation. He underwent emergency resection of the aortic valve, direct closure of the abscess with an autologous pericardium patch and mechanical valve replacement. Acquired communication between the left ventricle and the right atrium was closed simultaneously. Then, adjacent mitral para-annular abscess and another vegetation were revealed by echocardiography, and treated surgically 20 days after the first operation. He underwent mitral valve replacement and closure of the annular abscess. Twenty-one days after the second operation, aortic annular false aneurysm was detected by echocardiography, and closure of the false aneurysm and aortic valve re-replacement were performed successfully.

[Simple Evaluation of Left Hand Function after Thoracic Endovascular Aortic Repair with Obstruction of Left Subclavian Artery].

We evaluated left hand function with or without obstruction of left subclavian artery for 29 cases of thoracic endovascular aortic repair (TEVAR). 18 cases of distal true aortic aneurysm were undergone surgery with simple direct closure of left subclavian artery (LSCA). The other 11 cases of true arch aneurysm were revascularized by axilla-carotid-axilla bypass grafting with TEVAR. Later 26 cases were evaluated by blood pressure, maximal grasping power, persisting duration of 60% maximal grasping power, circumferential length of upper and forearms, and simple test for evaluating hand function (STEF). Left hand blood pressure was significantly reduced than right side in obstruction group. But left hand function was not reduced in any other test. We concluded that no relationship between the obstruction of LSCA and the left hand function, and the influence of late survival and mobidity.

Posterior mediastinal hematoma after a simple fall in a patient with normal coagulation.

Case: A 77-year-old woman presented with neck swelling and odynophagia following a fall from standing height. She had no history of antiplatelet or anticoagulant use. Computed tomography of the chest showed an isodense to hypodense soft tissue mass in the bilateral carotid space, retropharyngeal space, and posterior mediastinum. With no airway obstruction symptoms, the patient was placed on bed rest under close observation. Outcome: The mass decreased in size spontaneously over the 10 days following symptom onset, accompanied by overall clinical improvement. The patient was diagnosed with a posterior mediastinal hematoma. Conclusion: This is the first reported case of posterior mediastinal hematoma caused by a neck hyperextension injury secondary to a simple fall in a patient with normal coagulation. The outcome was good; however, emergency physicians should be aware that hematomas necessitating airway management may occur after a fall.

Immunostaining for thyroid transcription factor 1, Napsin A, p40, and cytokeratin 5 aids in differential diagnosis of non-small cell lung carcinoma.

The present study aimed to examine the effectiveness of immunostaining of cytological specimens in discerning squamous from non-squamous cell carcinoma. Various combinations of six antibodies were examined in order to determine the optimal combination for use in differential diagnosis. Immunostaining was performed using tumor imprint smears obtained from 70 lung carcinoma cases. The results were scored based on positive area and intensity. For objective evaluation, scores for thyroid transcription factor 1 (TTF-1), napsin A, and CK CAM5.2 were expressed with positive values, while those for p40, cytokeratin (CK) 5/6 and CK5 were expressed with negative values. Histograms were produced to evaluate which combination was the most effective in differentiating squamous cell carcinoma from adenocarcinoma. The sensitivity for these molecules in adenocarcinoma was 88% for TTF-1, 85% for napsin A, and 100% for CAM5.2. In squamous cell carcinomas, sensitivity was determined to be 90% for p40, 86% for CK5, and 76% for CK5/6. The specificity for these molecules was calculated as 100%, 95%, 43%, 98%, 100% and 95%, respectively. Each combination was evaluated for scoring and the values were averaged. The most effective combination for mode and mean was TTF-1, napsin A, p40, and CK5, for which all adenocarcinomas had a score >1, and all squamous cell carcinomas scored <-2. Immunostaining scoring may therefore be useful for the differential diagnosis of these carcinomas when a limited number of tumor cells are present.

Acute onset of mediastinal cystic lymphangioma in the puerperium.

Lymphangioma is a benign congenital malformation developing from the prenatal lymphatic vessels. Lymphangiomas are typically slow-growing and asymptomatic, but can occur throughout the body; there are few documented cases of either mediastinal or rapid growing lymphangiomas. Here, we report a case of a 27-year-old female who experienced sudden-onset nocturnal dyspnea 1 month after delivery. Ultrasound and computed tomography revealed a cystic tumor (diameter, 8 cm), which posteriorly displaced the superior vena cava and trachea. Ultrasound-guided aspiration was performed and the tumor disappeared on chest X-ray, only to return on subsequent chest X-ray performed the following day. Therefore, thoracoscopic excision of the mediastinal tumor was performed, and pathological diagnosis confirmed mediastinal cystic lymphangioma. In this report, we discuss the rare nature of this case and the treatment of lymphangioma in pregnancy.

Mediastinitis of bronchogenic cyst caused by endobronchial ultrasound-guided transbronchial needle aspiration.

Here, we describe the case of a 56-year-old female patient who was diagnosed with an anterior mediastinal cyst measuring 26 × 16 mm in size. An endobronchial ultrasound-guided transbronchial needle aspiration was performed, and punctures occurred three times. The patient was then prescribed cefditoren pivoxil. Three days after the procedure, the patient developed infective mediastinitis. Panipenem/betamipron, clindamycin, and human immunoglobulin were administered, and her symptoms improved over 2 weeks. Five months after developing mediastinitis, surgical resection of the cyst was performed with inverted L-shaped mini-sternotomy. The cystic lesion strongly adhered to the surrounding tissues. The final pathological diagnosis was a bronchogenic cyst. Endobronchial ultrasound-guided transbronchial needle aspiration is not a completely sterile procedure and can lead to severe infective complications in the mediastinum. Although this procedure may not be contraindication for use with mediastinal cystic lesions, physicians must take into account the risk of severe infective complications.

Radiologically indeterminate pulmonary cysts in Birt-Hogg-Dubé syndrome.

Birt-Hogg-Dubé (BHD) syndrome is an inherited disease characterized by recurrent pneumothorax. We report some unusual clinicopathologic features of the lung in a Japanese family with this syndrome presenting with recurrent pneumothorax. Radiologic imaging did not show detectable lesions; however, at video-assisted thoracic surgery (VATS), multiple diffusely distributed microcysts were visible on the pleura. This characteristic morphologic feature was common to all affected family members. The proband underwent genetic testing and BHD syndrome was diagnosed. Although many patients with BHD syndrome with pneumothorax show obvious pulmonary cysts, this case suggests that radiologically indeterminate cysts have the potential to cause pneumothorax.

Spontaneous hemopneumothorax: epidemiological details and clinical features.

PURPOSES: Spontaneous hemopneumothorax (SHP) may cause life-threatening blood loss. The objective of this study was to elucidate the epidemiological and clinical features of SHP. METHODS: We reviewed the records of 26 patients who underwent surgery for SHP between 1989 and 2010. We evaluated their epidemiology and clinical features by comparing them with those of 681 patients with spontaneous pneumothorax treated during the same period. RESULTS: The proportion of smokers in the SHP group was higher than that in the spontaneous pneumothorax group (P < 0.01). Seventeen cases (65.4 %) of SHP occurred on the left side. The most frequent bleeding area was the superior thoracic aperture (STA:17 cases, 65.4 %), followed by the left superior mediastinum (six cases, 23.1 %). Ten cases had intrathoracic clots greater than 500 mL, which could not be drained preoperatively. The postoperative stay of patients treated with video-assisted thoracic surgery (VATS) was shorter than that of patients treated with open thoracotomy (21 versus five cases; P < 0.05). CONCLUSIONS: A higher proportion of smokers was revealed in the SHP patients. VATS shortened the hospital stay of the patients. The particular areas that should be observed intraoperatively are the STA and the left superior mediastinum.

Preoperative symptoms and postoperative sequelae of intrathoracic neurogenic tumors: a single institution's experience.

OBJECTIVE: Most intrathoracic neurogenic tumors are resected for therapeutic diagnosis; many adult tumors are benign. However, few studies have reported the preoperative symptoms, postoperative modalities, and sequelae of these tumors. We focused on and evaluated the diversity and postoperative prognosis of these tumors. METHODS: We assessed 31 consecutive cases of intrathoracic neurogenic tumors resected at Tsuchiura Kyodo General Hospital between 1988 and 2012. Two cases involved multiple tumors; therefore, complete resection or enucleation was performed only in the remaining 29 cases. The patients' clinical records were investigated retrospectively. RESULTS: All tumors were benign. Five cases (16.1 %) presented with preoperative symptoms; 2 cases with non-neurologic symptoms (dysphagia due to tumor oppression and a massive hemothorax with neurofibromatosis type 1) improved after surgery, but 3 others with neurologic symptoms (back pain, hand motor paralysis, and Horner's syndrome) did not. Ten cases (32.3 %) presented with postoperative modalities or sequelae. Eight cases presented with neurologic sequelae (Horner's syndrome, 4 cases; grip weakness, 3 cases; hypohidrosis, 3 cases; and hand numbness, 2 cases). All the patients presenting with neurologic sequelae had tumors proximal to the first or second thoracic vertebra; no tumors proximal to or under the third thoracic vertebra caused neurologic sequelae. Severe neurologic sequelae in daily life were observed in 2 cases, but they did not radically improve. CONCLUSIONS: While the non-neurologic symptoms caused by intrathoracic neurogenic tumors can be resolved by resection, the neurologic symptoms may not improve. Tumors proximal to the first or second thoracic vertebra can cause postoperative neurologic sequelae.

Isolation of the mouse Tsll1 and Tsll2 genes, orthologues of the human TSLC1-like genes 1 and 2 (TSLL1 and TSLL2).

We have recently identified the human TSLL1 and TSLL2 genes, which are highly homologous to the human lung tumor suppressor gene, TSLC1. Loss of expression of the TSLL1 or TSLL2 in several cancers suggests that these genes could also act as tumor suppressors. Here, we report the isolation of the mouse orthologous genes, Tsll1 and Tsll2. The Tsll1 and Tsll2 cDNAs contain a single open reading frame of 1188 and 1164 bp encoding a putative immunoglobulin-like cell adhesion molecules of 396 and 388 amino acids, which display 95% and 98% identity with those of human TSLL1 and TSLL2, respectively. The Tsll1 and Tsll2 genes are both composed of nine exons and mapped on mouse chromosome 1q H2-H4 and on 7q A3-B2, respectively, both of which conserve syntenies with human chromosomes 1q and 19q. Like the human TSLL1, the mouse Tsll1 was expressed exclusively in the brain and neurogenic cells, while Tsll1 expression was lost in one of four rodent neuroblastoma cell lines. Tsll2 was expressed in the brain and several organs including the kidney and liver, whereas loss of Tsll2 expression was detected in some rodent cancer cells derived from these tissues. Furthermore, both murine TSLL1 and TSLL2 proteins were expressed on the plasma membrane, especially at the cell-cell attached site. These data, together with their strong conservation during the vertebrate evolution, suggest that TSLL1and TSLL2 could play an important role in cell-cell interaction as well as in tumor suppression.

Association of a lung tumor suppressor TSLC1 with MPP3, a human homologue of Drosophila tumor suppressor Dlg.

We have previously identified the tumor suppressor in lung cancer 1 (TSLC1) gene as a novel tumor suppressor in human non-small cell lung cancer (NSCLC) by functional complementation. TSLC1 encodes a membrane glycoprotein belonging to an immunoglobulin superfamily and participates in cell adhesion. A truncating mutation of the TSLC1 corresponding to its cytoplasmic domain in a primary NSCLC tumor suggests that this domain is important for tumor suppressor activity. Here, we report that TSLC1 directly associates with MPP3, one of the human homologues of a Drosophila tumor suppressor gene, Discs large (Dlg). This interaction was dependent on the presence of a PDZ-binding motif at the carboxyl terminus of TSLC1. Furthermore, TSLC1 and MPP3 were colocalized at the cell-cell attachment sites in both a low and a high cell density. The MPP3 gene was expressed in normal lung as well as in many tissues examined except for peripheral blood lymphocytes but lost its expression in one of the nine NSCLC cell lines. These results suggest that TSLC1 and MPP3 are involved in the same cascade of cell-cell interaction, and that the disruption of this cascade might lead cells to malignant growth and tumor formation in lung cancer.

Promoter methylation of the TSLC1 gene in advanced lung tumors and various cancer cell lines.

We previously identified TSLC1, a tumor suppressor gene in human nonsmall cell lung cancer (NSCLC). TSLC1 belongs to immunoglobulin superfamily molecules and is involved in cell adhesion. Loss of TSLC1 expression was strongly correlated with the promoter hypermethylation in several NSCLC cell lines. Here, we examined the methylation status of the TSLC1 gene promoter in 48 primary NSCLC tumors by bisulfite SSCP in combination with bisulfite sequencing. Six CpG sites around the promoter regions were significantly methylated in 21 of 48 primary NSCLC tumors (44%). Promoter methylation was more likely to be observed in relatively advanced tumors with TNM classification of pT2, pT3 or pT4 (19 of 33, 58%) than in those with pT1 (2 of 15, 13%), suggesting that alteration of TSLC1 would be involved in the progression of human NSCLC. Loss of TSLC1 expression was also observed in 20 of 46 (43%) human cancer cell lines, including those from esophageal (3 of 3), gastric (8 of 9), ovarian (2 of 5), endometrial (2 of 2), breast (1 of 3), colorectal (2 of 8) and small cell lung cancers (2 of 10). Combined analysis of promoter methylation and the allelic state in these cell lines indicated that the TSLC1 gene was often silenced not only by mono-allelic methylation associated with loss of the other allele but also through bi-allelic methylation. These results suggest that alteration of TSLC1 would be involved in advanced NSCLC as well as in many other human cancers.