An air-locking port and high-flow nasal cannula in non-intubated uniportal video-assisted thoracic surgery for pneumothorax with pulmonary dysfunction: a case report.

BACKGROUND: Non-intubated video-assisted thoracic surgery is a therapeutic option for intractable secondary spontaneous pneumothorax in patients who are poor candidates for surgery with endotracheal intubation under general anesthesia. However, intraoperative respiratory management in this surgery is often challenging because of hypoxia caused by surgical pneumothorax. CASE PRESENTATION: A 75-year-old man with idiopathic pulmonary fibrosis who had been on home oxygen therapy underwent non-intubated uniportal video-assisted thoracic surgery for intractable spontaneous pneumothorax. During the operation, oxygen was administered using a high-flow nasal cannula at a high flow rate. An air-locking port for single-incision surgery was used to minimize the inflow of air into the pleural cavity. The intrapleural air was continuously suctioned through the chest tube. The air-leak point was easily identified and closed using ligation. Oxygenation was satisfactory throughout the operation. CONCLUSIONS: Non-intubated uniportal video-assisted thoracic surgery for secondary spontaneous pneumothorax with an air-locking port, continuous pleural suction, and high-flow nasal cannula may achieve satisfactory intraoperative oxygenation in patients with respiratory dysfunction. The intrapleural space can be feasible for surgical manipulation without surgical pneumothorax in non-intubated video-assisted thoracic surgery even when supplied with oxygen at a high flow rate using a high-flow nasal cannula.

Thoracoscopic surgery under local anesthesia for high-risk intractable secondary spontaneous pneumothorax.

OBJECTIVES: To evaluate the outcomes of thoracoscopic surgery for intractable secondary spontaneous pneumothorax (SSP) under local anesthesia in high-risk patients and report intraoperative findings useful for identifying air leakage points. METHODS: We analyzed outcomes of 14 consecutive thoracoscopic operations under local anesthesia for high-risk SSP from 2015 to 2019. Suspicious lesions were determined based on intraoperative direct or indirect detections. Direct detection involved identifying pleural fistulas or air bubbles. Indirect detection involved finding thin and transparent bullae without any other suspicious lesions. Identifications of culprit lesions were confirmed by arrest or significant decrease in air leakage after surgical repair. All surgical repairs were followed by immediate single pleurodesis for a definitive cure and prevention of recurrence. Success was defined as the removal of the thoracic tube by surgical repair combined with immediate postoperative single pleurodesis. RESULTS: The main underlying pulmonary diseases were emphysema (n = 7), carcinoma (n = 3), interstitial pneumonia (IP) (n = 3), and nontuberculous mycobacterial infection (n = 1). A leakage point was identified in 13 cases (six on direct and seven on indirect detections). Success was achieved in nine cases (four on direct and five on indirect detections). Adverse events included one case of acute exacerbation of IP and one case of carbon dioxide narcosis. CONCLUSION: Thoracoscopic surgery under local anesthesia can be the worthwhile definitive modality, among few remaining treatments, for highly fragile patients with SSP. Detecting air leakage directly and the presence of thin and transparent bullae without any other suspicious lesions can be clues for identifying culprit lesions.

Simple chest closure of open window thoracostomy for postpneumonectomy empyema: a case report.

BACKGROUND: Management of postpneumonectomy empyema requires comprehensive strategies, especially when the condition is associated with large bronchopleural fistulae. We report a case involving the simple chest closure of open window thoracostomy with remaining residual space. CASE PRESENTATION: We performed open window thoracostomy for empyema with a huge bronchial stump dehiscence after right pneumonectomy for a large lung cancer. We definitively closed the chest window infected with chronic persistent Pseudomonas aeruginosa via a simple chest closure technique with the remaining residual space, after repairing the bronchial dehiscence using an omental flap and the appearance of healthy granulation tissue throughout the cavity. The patient died of recurrent cancer 10 months after the definitive chest closure. Until the patient died, there were no symptoms or signs suggestive of recurrent empyema. CONCLUSION: This simple chest closure technique allows "silent empyema" to be observed carefully, is less invasive, and can even be applied to cases of recurrent cancer.

Immunotherapy for advanced lung cancer combined with surgery for mediastinal myxofibrosarcoma: a case report.

BACKGROUND: It is unclear whether simultaneous primary neoplasm resection and immunotherapy for advanced lung cancer is safe. We report a case of an elderly man with advanced lung cancer and myxofibrosarcoma. CASE PRESENTATION: The advanced lung cancer was treated with pembrolizumab, and partial response was achieved in 3 months. However, the mediastinal cyst enlarged rapidly. We resected the mediastinal tumor and diagnosed it as myxofibrosarcoma. The postoperative course was uneventful. Immunotherapy was resumed after the operation without any adverse effects. No recurrence of mediastinal sarcoma or progression of lung cancer was found until the patient died in an accident 8 months after surgery. CONCLUSION: Surgery for mediastinal sarcoma could be performed safely in combination with immunotherapy for advanced lung cancer.

Spindle cell component in pleomorphic carcinoma showing polypoid growth in the pulmonary vein.

We describe a rare case of a pleomorphic carcinoma forming polypoid growth in the pulmonary vein. A 69-year-old man was admitted with an abnormal shadow in his right lung. Thoracic computed tomography scans showed a polypoid lesion extending into the right lower pulmonary vein. We performed a right lower lobectomy without any evidence of tumor embolism perioperatively. Pathological examination revealed that the lesion was a pleomorphic carcinoma of the lung and that the polypoid lesion in the pulmonary vein was composed solely of spindle cell components. Early ligation of affected vessel is important to avoid tumor embolism through the pulmonary veins.

Tumor invasiveness as defined by the newly proposed IASLC/ATS/ERS classification has prognostic significance for pathologic stage IA lung adenocarcinoma and can be predicted by radiologic parameters.

OBJECTIVES: The International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society (IASLC/ATS/ERS) have collaborated to propose a new pathologic classification of lung adenocarcinoma. In this classification, noninvasiveness and invasiveness have been newly defined for lung adenocarcinoma. The aims of this study were to validate the prognostic significance of tumor invasiveness as defined by the new IASLC/ATS/ERS classification and to assess the relationship between pathologic invasiveness and radiologic findings in pathologic stage IA lung adenocarcinoma. METHODS: We retrospectively reviewed 123 consecutive patients with pathologic stage IA lung adenocarcinoma. Pathologic data were classified according to the new IASLC/ATS/ERS classification. The following radiologic parameters were assessed using thin-section computed tomography: the ground-glass opacity ratio, tumor disappearance rate, and consolidation diameter. RESULTS: There were 54 noninvasive and 69 invasive adenocarcinomas. Five-year overall survival rates for noninvasive adenocarcinoma and invasive adenocarcinoma were 100% and 78.4%, respectively; this difference was statistically significant (P < .01), indicating the prognostic value of this classification. Receiver operating characteristic curves of the ground-glass opacity ratio, tumor disappearance rate, and consolidation diameter identified the optimal cut-off values for predicting the presence of invasive tumors as 50%, 75%, and 10 mm, respectively. CONCLUSIONS: We found that by using the new IASLC/ATS/ERS classification, histologic subtypes of pathologic stage IA lung adenocarcinoma with prognostic value could be identified. Tumor invasiveness of lung adenocarcinoma as defined by this classification can be predicted by evaluating the ground-glass opacity ratio, tumor disappearance rate, and consolidation diameter on thin-section computed tomography.

Surgical resection for isolated myeloid sarcoma arising from a rib.

We report on a rare manifestation of myeloid sarcoma with chronic myelogenous leukemia. The neoplasm arising from a rib showed osteolytic changes and infiltrated the surrounding muscles. We resected the lesion to relieve chest pain caused by pathologic rib fractures. The patient has continued receiving systemic therapy and is doing well as of 1 year postoperatively. Experience with a surgical approach for myeloid sarcoma is limited in thoracic surgery. The clinical course in our case suggests that surgical resection can be a valid choice of treatment.

A case of Good's syndrome: a rare acquired immunodeficiency associated with thymoma.

The patient was a 76-year-old man who had a prior history of recurrent pneumonia and severe, chronic sinusitis. Computed tomography showed a thymoma, and laboratory results revealed hypogammaglobulinemia. Therefore, Good's Syndrome (GS, rare adult-onset immunodeficiency with thymoma) was diagnosed. To treat his sinusitis, we started the patient on long-term clarithromycin therapy, preoperatively. A thymothymectomy was performed, but the immunological disorder was not resolved. Although standard gamma globulin replacement was not given, his sinusitis symptoms were ameliorated, and he has not had pneumonia since the operation. Long-term macrolide therapy probably plays some role in managing sino-pulmonary infections associated with GS.

Simultaneous double thymic carcinoids: a rare initial manifestation of multiple endocrine neoplasia type 1.

A 53-year-old man was referred to our hospital for treatment of two anterior mediastinal tumors. The anterior mediastinal tumors were resected by thymectomy under the probable diagnosis of double thymomas. The final pathological diagnosis was multiple thymic carcinoids. Although 20%-25% of patients with thymic carcinoid have a family history of multiple endocrine neoplasia type 1 (MEN-1), radiographic screening just after the operation did not detect any endocrine tumors. However, the patient had a urinary calculus 4 months 7 months after the operation. Endocrinological examination then revealed mild hypercalcemia, hypophosphatemia, hyperinsulinemia, and hyperprolactinemia. Radiologically, a parathyroid tumor and a pancreatic tumor were found. The patient was referred to a university hospital and a mutation of MEN-1 gene was detected. The diagnosis of MEN-1 was confirmed about 1 year after the operation.

Resected osteochondroma of the rib in an elderly patient.

Solitary osteochondroma of the rib is a rare primary chest wall tumor. Herein, we report a case of a successfully resected osteochondroma of the rib. The patient was a 73-year-old asymptomatic woman who came to our hospital regularly for treatment of hypertension and hyperlipidemia. A checkup chest roentgenogram showed a shadow at the right anterior chest wall consistent with a mass, and computed tomography showed a tumor arising from the right fourth rib. Because it was impossible to exclude completely the diagnosis of a well-differentiated chondrosarcoma, we performed resection of the right anterior chest wall and a re construction with a rigid prosthesis. The post operative course of the patient was unremarkable. The final pathological diagnosis of the rib tumor was osteochondroma.

Chronic expanding hematoma in sternum resected 5 years after median sternotomy.

Chronic expanding hematomas occur at various locations in the body; however, their occurrence in the sternum has not been reported yet. We report a patient with chronic expanding hematoma in the sternum 5 years after undergoing a median sternotomy for cardiac surgery. Although preoperative biopsy specimens did not lead to a definitive diagnosis, we could not rule out the possibility of a malignant tumor because of the expanding and infiltrative behavior of the hematoma. We performed a sternectomy and reconstructed the chest wall using artificial materials.

Synovial sarcoma of the mediastinum: report of a case.

We report a case of synovial sarcoma of the mediastinum, a very rare tumor, in a 50-year-old man hospitalized with anterior chest pain. Chest X-ray and computed tomography (CT) on admission showed a 10 x 8-cm mass in the right anterior mediastinal space, compressing the superior vena cava. A diagnosis of sarcoma was established by a CT-guided percutaneous needle biopsy. Systemic examination revealed no metastasis to the contralateral pleural cavity or other distant organs, and we resected the mediastinal sarcoma. Pathological and immunohistochemical analyses confirmed a diagnosis of monophasic synovial sarcoma. The patient is alive with recurrence 9 months after his operation, and is receiving chemotherapy with ifosfamide.

Operation for lung cancer in patients with idiopathic pulmonary fibrosis: surgical contraindication?

BACKGROUND: Patients with idiopathic pulmonary fibrosis have an increased incidence of lung cancer. The purpose of this study was to determine the outcome of surgical treatment of lung cancer with idiopathic pulmonary fibrosis. METHODS: From January 1992 through December 2001, 64 patients who had simultaneous lung cancer and idiopathic pulmonary fibrosis were treated. Twenty-one (33%) of them underwent surgical resection of lung cancer, and their data were reviewed. RESULTS: There were 56 men and 8 women with an average age of 69 years (range, 43 to 85 years). In the surgical group, there were no early postoperative deaths, and nonfatal complications occurred in 2 patients (10%). Among the 14 patients with stage I cancer, a second primary lung cancer developed in 5 (36%). The causes of death in the surgical group were cancer related in 7 patients, exacerbation of idiopathic pulmonary fibrosis in 7, and other in 2. Five of the 7 patients who died of a cancer-related cause had development of a second primary lung cancer. The actuarial 2-year survival rate of the surgical group was 52% overall, 58% for patients with N0 or N1 disease and 25% for those with N2 disease (p = 0.05). CONCLUSIONS: The long-term results in one surgical group were poor partly because of the high incidence of a second primary lung cancer and partly because of the poor natural history of idiopathic pulmonary fibrosis. These patients require intensive surveillance even after curative resection of lung cancer.

Significance of serial real-time PCR monitoring of EBV genome load in living donor liver transplantation.

BACKGROUND: Quantitative analysis of the Epstein-Barr virus (EBV) genome has been recently reported to be helpful for early identification of EBV viremia which could reduce the risk of post-transplantation lymphoproliferative disorder (PTLD). AIM: To demonstrate the significance of serial monitoring of EBV genome load by real-time quantitative polymerase chain reaction (PCR) after living donor liver transplantation. METHODS: From March 1999 to April 2000, the EBV genome load in peripheral blood mononuclear cells (PBMNC) was measured serially in a total of 15 recipients of living donor liver transplantation (LDLT) who had a symptomatic EBV infection. RESULTS: In 15 patients, the mean values of the highest EBV DNA levels from the patients who had fever, URS, diarrhea, ascites, lymphadenopathy and PTLD were 36 232, 16 040, 15 968, 2485, 336 858 and 60 486 copies/microg DNA, respectively. Patients were treated by reduction or discontinuation of immunosuppressives and/or antiviral agents. The EBV DNA levels decreased in all these patients following the recovery from their symptoms. We encountered two cases of PTLD during this study period. One of them was referred to us after the onset of PTLD and one had been undergoing aggressive immunosuppression treatment for severe rejection. Both were successfully treated. CONCLUSIONS: Serial quantitative analysis of the EBV genome load by means of real-time PCR are thought to be useful for preventing PTLD through adjustment of the immunosuppression level in response to the viral genome load following symptomatic EBV infection.