[Cardiac Tamponade After Left Upper Lobectomy:Report of Two Cases].

We report two rare cases of cardiac tamponade after left upper lobectomy. Case 1:A 76-year-old man underwent thoracoscopic left upper lobectomy and lymph node dissection for lung cancer. The patient suddenly developed cardiac tamponade the day after surgery. Emergency surgery was performed to stop bleeding and confirm the source of bleeding, and dark red pericardial fluid and hematoma were observed in the pericardial sac. There was no postoperative recurrence of cardiac tamponade. He died 1 year and 2 months after the operation. Case 2:A 77-year-old woman underwent thoracoscopic left upper lobectomy and lymph node dissection for lung cancer. The patient did well until the 6th postoperative day. On the 7th postoperative day, she complained of sudden severe back pain, immediately after which she lost consciousness and went into cardiopulmonary arrest. The echocardiography revealed cardiac tamponade, and emergency pericardiocentesis was performed. The patient died without circulatory improvement despite drainage of approximately 200 ml of bloody pericardial fluid. The pathological findings of autopsy revealed penetrating atherosclerotic ulcer at the descending aorta. We speculated that severe back pain caused the afterload of left ventricle and the increase in left atrial pressure through mitral regurgitation, which might result in a bleeding from the staple-line of superior pulmonary vein in the pericardium.

Efficacy of durvalumab plus chemotherapy in small-cell lung cancer with Lambert-Eaton myasthenic syndrome.

Lambert-Eaton myasthenic syndrome (LEMS) is a rare disease but is often associated with small-cell lung cancer (SCLC). We discuss the case of a 65-year-old man diagnosed with SCLC-LEMS and treated with carboplatin, etoposide, and durvalumab. Lower extremity weakness and high anti-P/Q voltage-gated calcium channel (VGCC) antibody levels were diagnostic and helpful. The patient showed a reduction in neurological symptoms with treatment for SCLC, including an immune checkpoint inhibitor (ICI), without standard treatment for LEMS. This treatment may be a treatment option, although the recurrence of LEMS as an immune-related adverse events (irAEs) should be noted.

First case report of erlotinib plus ramucirumab treatment for lung carcinosarcoma with EGFR L858R mutation.

Lung carcinosarcoma is acknowledged as a rare form of lung cancer. Due to its rarity, the inability to conduct large-scale clinical trials and interventions is currently carried out based on empirical evidence. In this study, we report the case of a 73-year-old female patient diagnosed with postoperative recurrence of lung carcinosarcoma. The resected tumor was diagnosed as lung carcinosarcoma, and genetic testing revealed the presence of the epidermal growth factor receptor (EGFR) exon21 L858R. Approximately 2 years postoperatively, the tumor recurred and the patient was treated with erlotinib plus ramucirumab, which were effective in controlling metastatic disease. Erlotinib plus ramucirumab is therefore a treatment option for EGFR mutation-positive lung carcinosarcoma.

Prediction of Postoperative Respiratory Complications after Lobectomy in Lung Cancer Patients with COPD by Quantitative Image Analysis: A Historical Cohort Study.

PURPOSE: We examined whether preoperative assessment of percentage of low attenuation area (LAA%) on the non-resected side can predict postoperative respiratory complications (PRC) after lobectomy. MATERIALS AND METHODS: We conducted a historical cohort study of 217 smokers (175 males and 42 females) who underwent lobectomy for primary lung cancer at our hospital between January 2014 and March 2021. First, the relationship between LAA% and respiratory function parameters (RFPs) calculated for both the bilateral and non-resected sides was used to estimate the most effective patient group. Next, multivariate analyses of the relationship between LAA% of the non-resected side and PRC were performed using logistic regression analysis after adjusting for basic patient attributes and respiratory function. RESULTS: A correlation was found between LAA% and RFP in smoking males. Multivariate analysis showed a strong relationship between model 3, adjusted for basic patient attributes and lung function factors, and PRC (odds ratio, 2.43; 95% confidence interval, 1.05-5.63). CONCLUSION: LAA% of the non-resected side suggested that it may be able to predict the occurrence of PRC after lung cancer lobectomy.

Coexistence of carcinoid tumor and adenocarcinoma of the lung; morphological, immunohistochemical and genetic analyses, a case report.

BACKGROUND: Pulmonary carcinoid tumors rarely coexist with non-small cell lung carcinoma, and only nine cases have been reported previously. The pathogenesis and origin of these combined tumors remain unclear because of its rarity. CASE PRESENTATION: We examined two cases of adenocarcinoma coexisting with a typical or atypical carcinoid tumor: Case 1 was a 77-year-old woman and Case 2 was an 83-year-old woman. Both of these cases had no respiratory symptoms, and underwent pulmonary lobectomies due to incidentally detected lung nodules. Recurrence and metastases were not detected after the surgery. Histologically, carcinoid and adenocarcinoma components were present in both cases. The two components coexisted without mixing with each other. Next-generation sequencing was performed on the two components in these cases. In each case, no common genetic variants were detected. CONCLUSION: We considered that our cases could histologically and genetically represent collision tumors that did not share common progenitor cells. Comprehensive analyses such as whole genome sequencing could provide important information for elucidating the pathogenesis of adenocarcinoma and carcinoid components.

Novel detection of the CAMTA1-WWTR1 fusion gene in extra-adrenal myelolipoma-like lesion: a case report.

A mediastinal mass was incidentally detected by chest X-ray in a 44-year-old man. Computed tomography findings revealed that the mass was a possible malignancy in the right and middle mediastinum and was removed by surgical resection. Macroscopically, the resected specimen was a well-demarcated yellowish, brownish, and whitish mass. Microscopically, a solid lesion with cords of epithelioid cells in the extra-adrenal myelolipoma-like lesion was observed. Immunohistochemically, the solid lesion was positive for typical vascular markers and CAMTA1, the expression of which is highly specific for epithelioid hemangioendothelioma (EHE). The endothelial cells and bone marrow elements of myelolipoma-like lesion were also positive for CAMTA1. Fluorescence in situ hybridization examination detected the CAMTA1-WWTR1 fusion gene not only in the solid lesion but also in the endothelial cells and bone marrow elements of myelolipoma-like lesion. To our knowledge, this is the first report suggesting common genetic abnormality, CAMTA1-WWTR1 fusion, in cases of EHE and extra-adrenal myelolipoma.

[Clinical Efficacy of Monotherapy with Immune Checkpoint Inhibitors for Advanced Non-Small Cell Lung Cancer].

OBJECTIVE: To retrospectively assess data on immune checkpoint inhibitors(ICIs)in an actual clinical setting, examine the factors that contribute to response and survival using real-world data, and compare the effectiveness of the 3 types of ICIs for patients with non-small cell lung cancer(NSCLC). METHODS: A retrospective analysis of 127 patients with NSCLC treated with ICIs at our hospital was conducted. RESULTS: Nivolumab(56 patients)showed a 3-year survival rate of 21.6% and a disease control rate of 57.1%. These results are consistent with the clinical trials of Nivolumab. Pembrolizumab(36 patients) showed a 2-year survival rate of 60.3%, a response rate of 50.0%, and a disease control rate of 63.9%. Atezolizumab(35 patients)displayed a particularly low response rate with a 1-year survival rate of 58.4%, response rate of 8.6%, and disease control rate of 25.7%. The treatment results for recurrence after surgery for lung cancer were comparable to those for unresectable lung cancer. CONCLUSION: Anti-PD-1 antibody displayed better therapeutic results than anti-PD-L1 antibody. The efficacy of ICI administration for postoperative recurrent lung cancer was also shown in this study.

[Acute Megakaryoblastic Leukemia Developed after the Surgical Treatment of Mediastinal Malignant Germ Cell Tumor].

A 26-year-old man was admitted to our hospital for an examination of a mediastinal tumor. Chest computed tomography(CT) showed a giant anterior mediastinal tumor narrowing the trachea and right main bronchus. Although needle biopsy could not be done because of patient respiratory condition, non-seminomatous mediastinal germ cell malignant tumor was strongly suspected by high level of serum AFP without no abnormal finding in his testis. After 1 cycle of chemotherapy by cisplatin, etoposide and bleomycin, the mediastinal tumor decreased in size. Percutaneous biopsy was challenged, however, definite diagnosis could not be established and the surgical resection was performed. The tumor was pathologically diagnosed as mature teratoma with elements of a yolk-sac tumor and some sort of sarcoma. Sudden onset of back pain and thrombocytopenia were encountered 5 months after the operation. Hematologic examination confirmed acute megakaryoblastic leukemia, and remission-induction therapy and allogeneic hematopoietic stem cell transplantation were performed. Twelve months after the operation, the patient is well without recurrence of either disease.

[Association Between Juvenile Spontaneous Pneumothorax and Smoking].

We assessed the relation between smoking and pneumothorax in patients aged <40. Of 526 patients who underwent surgery for pneumothorax in 2011~2015, 311 were under the age of 40 and they were included in this study. Of 311, 54 cases( 17.4%) were diagnosed with spontaneous pneumothorax associated with emphysematous change by pathological assessment. By the multivariate analysis, 2 parameters exhibited significance for the risk of these spontaneous pneumothorax:a Brinkmann index of ≥165 and a smoking period of ≥9.5 years. It was suggested that smoking is strongly related to the onset of spontaneous pneumothorax even in the younger population less than 40 years of age.

[Bronchial Artery Aneurysm with Hoarseness;Report of a Case].

The patient was a 72-year-old man with a history of bronchiectasis. He was admitted to our hospital for an examination of hoarseness. Chest computed tomography (CT) showed bronchiectasis in the bilateral lungs and bronchial artery aneurysm in the mediastinum. To prevent rupture of the aneurysm, we imaged the bronchial artery aneurysm by selective bronchial artery angiography and performed bronchial artery embolization (BAE) with 19 platinum coils. Three months after successful BAE, his hoarseness had improved, and the bronchial artery aneurysm was reduced in size after 12 months. To our knowledge, this is the 1st report of BAE improving hoarseness due to bronchial artery aneurysm.

[Idiopathic Bilateral Chylothorax which Presented Difficulty in Treatment].

A 57-year-old woman was referred to our hospital because of bilateral chylothorax. She was previously treated with dietary restriction and pleurodesis resulting in failure. She did not have diseases causing chylothorax, and was diagnosed as having idiopathic chylothorax. To control chylothorax, 2 surgical operations to ligate bilateral thoracic ducts, right pleurodesis, and 2 times of left pleurodeses was necessary.

The Prefectural Participation Rates of Lung Cancer Screening Had a Negative Correlation with the Lung Cancer Mortality Rates

Background: The participation rate is one of the most important indexes in the cancer screening. Historically in Japan, each local government has developed their own equations to calculate the subjects for population-based screening, which were different from each other, and therefore the participation rates of screening were not comparable. Recently, local governments were ordered to use the standardized equation in reporting data, which made it possible to compare the participation rates of cancer screening nationwide for the first time. We therefore investigated the correlation between the prefectural lung cancer mortality and several indicators of lung cancer screening. Methods: The prefectural participation rates of lung, gastric and colonic cancer screening, test positive rates, attendance rates for further examination, lung cancer detection rates and positive predictive values of lung cancer screening were collected from "Cancer Registration and Statistics" of the National Cancer Research Center website. The age-adjusted lung, gastric and colonic cancer mortality rates, smoking rates were also collected. The EZR software program was used for statistical analyses. Results: The participation rates of lung cancer screening had a strong positive correlation with the participation rates of gastric/colonic cancer screening (P<0.001). The prefectural lung cancer mortality rates had a moderate to weak negative correlation with the participation rates of lung cancer screening (P=0.009). A little correlation was noted between other quality assurance indicators of lung cancer screening and lung cancer mortality rates. Conclusion: These results suggested that participating in lung cancer screening might help reduce lung cancer mortality rates in some extent.

[Giant Solitary Fibrous Tumor Associated with Loss of Consciousness by Hypoglycemic Attack].

We herein report a rare case of solitary fibrous tumor (SFT) producing high-molecular-weight insulin-like growth factor Ⅱ(big IGF-Ⅱ). A 51-year-old woman with a large mass in the right thorax suffered from repeated loss of consciousness due to hypoglycemic attack. A hematological examination revealed low values of serum insulin and C-peptide despite her hypoglycemia. We therefore regarded her giant thoracic tumor as the cause of the hypoglycemic attack. She underwent resection of the tumor and was diagnosed with SFT pathologically. After the surgery, her blood sugar level stabilized immediately, and she has had no hypoglycemic attacks since. Although we identified big IGF-Ⅱ in a preoperative serum sample by a Western immunoblot analysis, it was not detected after surgical resection. Positivity for big IGF-Ⅱ was observed in the tumor cells by immunohistochemical staining. We therefore concluded that big IGF-Ⅱ produced by the SFT caused the hypoglycemic attack in this patient.

[Clinical Assessment of Fourteen Cases of Thoracic Endometriosis].

We retrospectively assessed the clinical and pathological features of 14 patients with thoracic endometriosis who were treated at our hospital from 2007 to 2017. Thirteen patients presented pneumothorax and 1 patient presented bloody sputum. All were treated surgically. Pneumothorax occurs on the right side in all 13 cases and bloody sputum was from left side lesion. Ten patients presented symptoms closely related with their menstrual cycle (days -2 to 5). At surgery, dark red or dark brown spots, small hiatus and scar-like findings on the surface of the visceral pleura or diaphragm were identified in all cases. Pathological or immunohistochemical examinations of diaphragm or lung tissue specimens revealed endometrial tissue in 6 cases of pneumothorax and a case of bloody sputum. Nine patients received hormonal therapy(8:pneumothorax, 1:bloody sputum). Pleurodesis was performed for 1 pneumothorax patient with recurrent pneumothorax after hormonal therapy. In case of young female with repeated pneumothorax, catamenial pneumothorax must be kept in mind as a differential diagnosis and appropriate timing for surgical treatment should be considered to establish pathologically correct diagnosis.

[Infectious Diseases after Lung Transplantation].

Lung transplantation is getting to be a common treatment for the end-stage respiratory failure. Therefore we might encounter the various issues associated with infection under immunosuppression. At 1st, virus infections occur by Cytomegalovirus, Epstein-Barr virus, hepatitis B and C virus and John Cunningham virus. The 2nd, bacterial infections exacerbate graft condition by methicillin-resistant Staphylococcus aureus, Pseudomonas, Burkholderia cepacia and coagulase negative staphylococci. The 3rd, fungal infections are induced by Aspergillus, Candida and Cryptococcus. Lastly there is mycobacterial infection. These opportunistic infections contribute poor prognosis for lung transplant recipients, so that we have to manage these infectious diseases.

[Heparin-induced thrombocytopenia developed during the acute phase after left upper lobectomy for lung cancer].

Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin administration. This must not be rarely encountered but is not often reported in Japan compared to Western countries. A 68-year-old woman underwent left upper lobectomy for lung cancer. Low-dose unfractionated heparin was administrated to prevent thromboembolism after the operation. Two days later, sudden dyspnea appeared and ultracardiosonography showing an extensive thromboembolus from the main trunk to both main branches of pulmonary artery indicated pulmonary embolization. After the establishment of percutaneous cardiopulmonary support (PCPS) support, the embolus was removed by emergent open heart surgery. However, despite further unfractionated heparin administration following embolization surgery, other thrombus was identified in both the bi-lateral internal jagular veins and inferior vena cava by ultrasonography and contrast computed tomography( CT). Her platelet count was decreased gradually despite platelet transfusion. Plate factor 4( PF4) antibody against heparin in her blood examination was found, and HIT II was diagnosed. Discontinuation of unfractionated heparin and administration of antithrombin agent improved platelet count, and no additional embolization was identified.

[Resected thymic hyperplasia with myasthenia gravis and Lambert-Eaton myasthenic syndrome].

A 61-year-old male who noticed muscular weakness of his extremities, diplopia and slur his words was found to have a thymic tumor on computed tomography. The immunological examination showed incremental of anti Acetylcholine receptor antibody titer and anti P/Q-type voltage-gated calcium channels antibody titer. Electromyography showed decremental response to low frequency stimulations, and incremental response to high frequency stimulations. So he was diagnosed with thymic tumor combined with myasthenia gravis and Lambert-Eaton myasthenic syndrome. He treated with extended thymomectomy resulting in the improvement of his neurological symptoms. Five years after operation, the patient is well without any malignant diseases.

[Examination using multivariate analysis of the risk factors by surgical approach in elderly intractable pneumothorax].

PURPOSE: In this study, we evaluated the risk factors for postoperative complications in elderly patients with intractable pneumothorax and constructed a risk assessment model. MATERIALS AND METHODS: Between January 2004 and December 2011, 83 elderly patients( age, 75 years or older) underwent an operation at our hospital for intractable pneumothorax. Preoperative factors of these cases were assessed to clarify which is contributory to the development of postoperative complications by using univariate analysis and multivariate logistic regression analysis. RESULTS: Thirty-five patients (42.2%) developed postoperative complications. In univariate analysis, total protein, albumin level, blood urea nitrogen, creatinine level, Paco2, body mass index, performance status, and preoperative respiratory complications showed statistically significant associations with the occurrence of postoperative complications. In the multivariate analysis, the performance status showed a statistically significant association( 95% confidence interval, 1.17〜4.44;odds ratio, 2.28;p=0.0157). CONCLUSION: The results suggested that the preoperative examinations were useful in predicting postoperative complications in the elderly patients with intractable pneumothorax. Poor performance status, low nutrition, respiratory failure, and preoperative respiratory complications are risk factors for postoperative complications in elderly patients with intractable pneumothorax.

[Schwannoma occurred in the right upper bronchial inlet; report of a case].

A 47-year-old woman was treated at a local hospital for obstructive pneumonia in February 2011. A computed tomography(CT)scan revealed a nodule obstructing the right upper bronchus. Histological diagnosis could not be established by biopsy under the bronchoscopic examination. She was referred to our hospital for further treatment. Since accumulation of fluoro-2-deoxy-D-glucose(FDG)was noted by positron emission tomography(PET)[standardized uptake value(SUV)max 5.67/7.52], primary lung cancer was suspected and right upper sleeve lobectomy was performed. Pathology during surgery suggested the tumor to be schwannoma. Postoperative course was uneventful.