Successful use of left ventricular support device (Impella 5.0) and extracorporeal membrane oxygenation (ECMO) for postoperative cardiac arrest after lung cancer surgery: a case report.

Postoperative hemodynamic support with an Impella 5.0 was effective in a man who underwent lung lobectomy for lung cancer and cardiogenic shock. A 75-year-old man presented to hospital with an abnormal chest shadow on radiography. After thorough examination, the patient was diagnosed with lung cancer, and left lower lobectomy was performed. On the 2nd postoperative day, the patient experienced cardiac arrest because of a sudden drop in saturation of percutaneous oxygen. After a third defibrillation, his heartbeat resumed, and he was intubated and placed on a ventilator. Coronary angiography revealed acute coronary syndrome and the patient fell into a state of shock, which required venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Nevertheless, the circulatory dynamics are unstable, and Impella 5.0 was introduced. VA-ECMO and the Impella 5.0 were discontinued on the 6th and 8th postoperative days, respectively. The patient was eventually transferred to a nearby facility for further rehabilitation 109 days later.

Right upper lobectomy for lung cancer with a displaced right bronchus: Two case reports.

Case 1 describe a 73-year-old man with an abnormal opacity in the upper lobe of the right lung on chest computed tomography (CT), which was done during the postoperative follow-up for bile duct cancer. The chest CT scan showed a ground glass nodule (GGN) measuring 1.0 cm and another one measuring 0.6 cm of the right lung. Case 2 involved a 79-year-old woman with an abnormal opacity in the upper lobe of the right lung on a chest CT that was obtained after she fell down the stairs. The CT scan showed a solid mass measuring 3.0 cm in the right upper lung. Both the patients underwent bronchoscopy before surgery and showed bronchial branching abnormalities. The surgical procedures could be performed accurately since sufficient information had been acquired pre-operatively and they diagnosed lung cancer. Both the patients were able to undergo radical surgery for lung cancer and are currently doing well with no postoperative complications or recurrence of lung cancer.

Acute exacerbation of idiopathic pulmonary fibrosis model by small amount of lipopolysaccharide in rats.

Idiopathic pulmonary fibrosis, a chronic and progressive lung disease with poor prognosis, presents with acute exacerbation. Pathophysiology and treatments for this acute exacerbation, and an appropriate animal model to perform such examinations, have not established yet. We presented a rat model for assessing acute exacerbation in cases of idiopathic pulmonary fibrosis. Wistar rats were intratracheally administered bleomycin (3 mg/kg) to induce pulmonary fibrosis. After 7 days, lipopolysaccharide (0, 0.05, or 0.15 mg/kg) was administered. In the bleomycin or lipopolysaccharide group, there were almost no change in the oxygen partial pressure, arterial blood gas (PaO2), plasma nitrite/nitrate, nitric oxide synthase, and lung nitrotyrosine levels. In the bleomycin (+)/lipopolysaccharide (+) groups, these three indicators deteriorated significantly. The plasma nitrite/nitrate and PaO2 levels were significantly correlated in the bleomycin (+) groups (r = 0.758). Although lung fibrosis was not different with or without lipopolysaccharide in the bleomycin (+) groups, macrophage infiltration was marked in the bleomycin (+)/lipopolysaccharide (+) group. There were many NOS2-positive macrophages, and the PaO2 levels decrease may be induced by the nitric oxide production of macrophages in the lung. This model may mimic the pathophysiological changes in cases of acute exacerbation during idiopathic pulmonary fibrosis in humans.

[Sleeve Lobectomy for Right Middle Lobe and S6 Segment Lung Cancer:Report of a Case].

A 76-year-old man showed an abnormal chest shadow at the follow-up of treated gastric cancer. Chest computed tomography revealed mass lesions in the right middle and left upper lobes, and bronchoscopy revealed a nodular lesion at the entrance of the right B6. The right middle lobe and B6 lesions were diagnosed as lung cancer, and sleeve resection for the right middle lobe and S6 segment was performed. On postoperative day 98, partial resection of the left lung lesion was performed, and the pathological diagnosis was also lung cancer.

Tumor Size and N2 Lymph Node Metastasis Are Significant Risk Factors for Early Recurrence in Completely Resected Centrally Located Primary Lung Cancer Patients.

BACKGROUND/AIM: In centrally-located lung cancer treatment, it is difficult to attain a sufficient resection margin. It is important to investigate recurrent styles in centrally-located lung cancer patients. PATIENTS AND METHODS: Primary lung cancer located at the hilar area that requires pneumonectomy or sleeve lobectomy is defined as centrally-located lung cancer. Early recurrence was defined as that within 1 year after surgery. RESULTS: This study included 43 centrally-located lung cancer patients. Ten patients underwent pneumonectomy and 33 underwent sleeve lobectomy. Eleven patients experienced early recurrence. Non-squamous cell carcinoma (p=0.012), tumor size>64 mm (p<0.001) and pathological N2 (p=0.012) were significant predictors for early recurrence by univariate analysis. Also, tumor size >64 mm (p=0.006) and pathological N2 (p=0.019) were independent predictors by multivariate analysis. CONCLUSION: Non-squamous cell carcinoma, tumor size and pathological N2 were significant predictors of early recurrence in centrally-located lung cancer. The type of surgical procedure did not affect recurrence development.

Influence of caliber mismatch on patients' clinical course after sleeve lobectomy.

OBJECTIVE: Respiratory complications are critical events after sleeve lobectomy. A caliber mismatch is an important factor in wound healing at the anastomotic site. This study aimed to determine the influence of caliber mismatches on patients' clinical courses after sleeve lobectomy. METHODS: We investigated the clinical courses of 56 patients with primary lung cancer who underwent pulmonary resection with end-to-end bronchoplasty. Anastomoses between the main bronchus and the segmental, right upper or middle bronchus, and between the trunks intermedius and the segmental or middle bronchus are categorized as an "anastomosis with caliber mismatch". RESULTS: Among the 56 patients, 22 underwent bronchoplasty with caliber mismatch. There were no in-hospital deaths, and the mortality rates at the 30- and 90-day evaluations were zero. Respiratory complications (n = 10, 52%, p = 0.005), such as pneumonia (n = 7, 32%, p = 0.029), retention of pleural effusion (n = 6, 27%, p = 0.026) and bronchopleural fistula (n = 3, 14%, p = 0.027), were significantly increased after bronchoplasty with caliber mismatch. Lower body mass index (BMI) is a significant risk factor for respiratory complications after sleeve lobectomy with caliber mismatch (median value; 23.2 vs 21.2, p = 0.036). CONCLUSIONS: Significant respiratory complications are apparent after bronchoplasty with caliber mismatch, especially patients with low BMI have a high risk of respiratory complications. Appropriate patient selection and cautious perioperative management are mandatory for this type of lung-preserving surgery.

Surgical outcomes of primary lung cancers following esophagectomy for primary esophageal carcinoma.

BACKGROUND: The aim of this retrospective study is to evaluate the perioperative complications and prognosis of patients with a history of resected esophageal carcinoma who subsequently underwent pulmonary resection of a primary lung cancer. METHODS: The study cohort comprised 23 patients who had undergone curative resection of a primary lung cancer following esophagectomy for a primary esophageal carcinoma. Clinical characteristics and surgical outcomes were analyzed. RESULTS: The initial treatment for esophageal carcinoma was esophagectomy by thoracotomy in 10 patients and video assisted thoracoscopic surgery in 13. The treatments for lung cancer comprised wedge resection in three patients, segmentectomy in seven and lobectomy in 13. The pulmonary resections were performed by thoracotomy in six and video assisted thoracoscopic surgery in 17. The average operating time for the lung cancer surgeries was 202 min and average blood loss 122 ml. There were no perioperative deaths or severe complications. Three- and Five-year overall survival rates were 78.0% and 68.2%. According to univariate survival analysis, age, restrictive ventilatory impairment and histology of lung cancer were significant predictors of poor prognosis (all P < 0.05). Significantly more of the patients with than without restrictive ventilatory impairment died of other diseases (P = 0.0036). CONCLUSIONS: Pulmonary resection for primary lung cancers following esophagectomy for esophageal carcinoma is acceptable in selected patients. Such surgery requires caution concerning intrathoracic adhesions and postoperative prolonged air leakage. Patients with restrictive ventilatory impairment had a poorer prognosis, and the indication for surgery in these patients should be carefully considered.

Salvage surgery for local recurrence after carbon ion radiotherapy for lung cancer: A case report.

BACKGROUND: The good local control rate of radiation therapy has been reported due to recent advances in irradiation technology. Carbon ion radiation therapy (CIRT) has been shown to be effective for early lung cancer. We report a case of performing salvage surgery on the local recurrence of lung cancer after CIRT. CASE PRESENTATION: A 79-year-old man was referred to our hospital for treatment of local recurrence of left lung cancer at fifty nine months after CIRT. We performed wedge resection for diagnostic purposes. It was diagnosed as squamous cell carcinoma and was regarded as local recurrence. Subsequently, we performed left upper lobectomy and mediastinal lymph node dissection. The patient had recurrent lesions at 4 months after surgery and died 10 months after surgery. CONCLUSIONS: Surgery was safe even after CIRT. We considered that salvage surgery after CIRT may be one of the options of local control therapy for lung cancer.

Combined sleeve lobectomy for centrally located primary lung cancer and lung cancer with hilar lymph node metastasis.

BACKGROUND: Centrally located lung cancer or metastatic hilar lymph nodes can invade the airway and other hilar structures, and they must be removed to achieve complete resection. METHODS: We retrospectively assessed the clinical course of 47 patients with centrally located lung cancer or metastatic hilar lymph nodes who underwent sleeve lobectomy from January 2010 to December 2017. RESULTS: The invaded structure other than the airway was the pulmonary artery in 21 patients, chest wall in 3, esophageal muscular wall in 2, vagus nerve in 2, pericardium in 2, left atrium in 1, phrenic nerve in 1 and superior vena cava in 1. Twenty-four patients were treated with sleeve lobectomy alone (simple sleeve lobectomy), and 23 patients were treated with sleeve lobectomy with additional methods (combined sleeve lobectomy). Adverse events occurred in 10 patients (48%) in the simple sleeve lobectomy group and 7 patients (30%) in the combined sleeve lobectomy group. During the follow-up period, 15 patients developed recurrent disease and 12 patients died. Patients in the combined sleeve lobectomy group had significantly shorter overall survival (P = 0.004) and disease-free survival periods (P = 0.013). Combined sleeve lobectomy was a significantly poor prognostic factor in the univariate and multivariate analyses. Patients who underwent sleeve lobectomy with an additional method other than angioplasty had a significantly poorer prognosis. However, no patient developed recurrent disease in the hilar area. CONCLUSIONS: Combined sleeve lobectomy has acceptable adverse events and good local controllability. However, combined sleeve lobectomy is associated with a significantly poorer prognosis than simple sleeve lobectomy in terms of overall survival and disease-free survival.

Impact of Perioperative Chemotherapy on Prognosis of Patients with Esophageal Carcinoma Undergoing Pulmonary Metastasectomy.

PURPOSE: To evaluate prognosis of patients with esophageal carcinoma undergoing pulmonary metastasectomy, and help determine appropriate therapeutic strategies. METHODS: We retrospectively studied 16 patients (15 men and one woman; median age 66.5 years) with esophageal carcinoma, who underwent curative resection of pulmonary metastases. Clinical characteristics and surgical outcomes were analyzed. RESULTS: In all, 11 patients underwent wedge resection, three segmentectomy, and two lobectomies. The average operating time and blood loss were 147 min and 103 mL, respectively. There were no perioperative deaths or severe complications. Five-year overall survival rate was 40.2% and 2-year disease-free survival rate was 35.2%. All recurrences occurred within 2 years. Univariate and multivariate analyses revealed that absence of adjuvant chemotherapy after therapy for esophageal carcinoma was a significant predictor of poor prognosis and recurrence, respectively (p <0.05). The prognosis of seven patients who underwent esophagectomy with adjuvant chemotherapy was better than that of the other nine patients (p = 0.0166). CONCLUSION: Pulmonary metastasectomy in patients with esophageal carcinoma was only one choice of multimodal treatment, and perioperative chemotherapy was important for long-term survival after pulmonary metastasectomy. Pulmonary metastasectomy was effective in patients undergoing esophagectomy with adjuvant chemotherapy.

Correction to: Positive correlation between sarcopenia and elevation of neutrophil/lymphocyte ratio in pathological stage IIIA (N2-positive) non-small cell lung cancer patients.

In the original publication of the article, the title was incorrectly published as "Positive correlation between sarcopenia and elevation of neutrophil/lymphocyte ratio in pathological stage.

Thoracoscopic resection of mediastinal tumor in a patient with azygos continuation of the inferior vena cava.

A 68-year-old man was referred to our hospital because of mediastinal tumor on chest computed tomography (CT). Contrast-enhanced CT showed azygos continuation of the inferior vena cava (IVC). The retro-hepatic IVC was absent superior to the renal veins. The IVC continued into the dilated azygos vein, which joined the superior vena cava. The hepatic vein drained directly into the right atrium. The mediastinal tumor was close to the dilated azygos vein. Video-assisted thoracoscopic resection of the mediastinal tumor was performed, using four ports and CO2 insufflation. Histological examination of the resected specimen revealed a pericardial cyst without malignancy. After a favorable postoperative course, the patient was discharged 4 days after surgery. It is important to recognize this anomaly before thoracic surgery, because transection of the azygos vein can be fatal. Video-assisted thoracoscopic resection of mediastinal tumor close to the azygos vein using CO2 insufflation avoids injury to the azygos vein.

Prognosis associated with synchronous or metachronous multiple primary malignancies in patients with completely resected non-small cell lung cancer.

PURPOSE: To investigate the influence of multiple primary malignancies (MPMs) on the prognosis of patients with completely resected non-small cell lung cancer (NSCLC). METHODS: The subjects of this retrospective study were 521 patients who underwent complete curative pulmonary resection for NSCLC. Patients were divided into two groups: those with and those without MPMs. RESULTS: The 521 NSCLC patients included 184 patients (35.3%) with MPMs and 337 patients without MPMs. The overall 5-year survival rates for patients with vs those without MPMs were 66.1 and 75.6%, respectively (p = 0.0061). According to multivariate analysis, MPMs, age, gender, pathological stage, and interstitial pneumonia were independent predictors of prognosis. The 47 patients with synchronous MPMs and the 82 patients with metachronous MPMs found within the last 5 years had significantly poorer prognoses than patients without MPMs (p = 0.0048 and p = 0.0051, respectively). However, the prognoses of the 55 patients with metachronous MPMs that had been present for over 5 years did not differ from those of the patients without MPMs. CONCLUSIONS: NSCLC patients with synchronous MPMs or metachronous MPMs diagnosed within the last 5 years had poor prognoses. Decisions about the best therapeutic strategies require comprehensive consideration of the organ location, malignant potential, recurrence, and prognosis of the MPMs. In contrast, decisions about the best therapeutic strategies for NSCLC patients with metachronous MPMs present for over 5 years should be based solely on the NSCLC.

Positive correlation between sarcopenia and elevation of neutrophil/lymphocyte ratio in pathological stage IIIA (N2-positive) non-small cell lung cancer patients.

OBJECTIVE: Surgical indication in stage IIIA (N2) non-small cell lung cancer is still controversial. Hence, there is a need for the identification of predictors of the postoperative outcome in these patients. Although sarcopenia is expected to be a novel predictor of postoperative outcome in these patients, the underlying clinical features of sarcopenia have not been well investigated. Elevation of neutrophil/lymphocyte ratio indicates cancer-associated inflammation and depression of anticancer immunity. We analyzed the influence of sarcopenia on postoperative prognosis, and investigated the relationship between sarcopenia and neutrophil/lymphocyte ratio in patients with stage IIIA (N2) non-small cell lung cancer. METHODS: We retrospectively investigated 69 patients with stage IIIA (N2) non-small cell lung cancer. We used the L3 muscle index as a clinical measurement of sarcopenia, and divided patients into the sarcopenic (n = 21) and the non-sarcopenic group (n = 48). We then investigated the effect of sarcopenia on postoperative prognosis, and evaluated the correlation between sarcopenia and neutrophil/lymphocyte ratio. RESULTS: This study included 47 males and 22 females. Univariate analysis revealed that sarcopenia, performance status, and serum cytokeratin-19 fragment level were predictors of poor prognosis; multivariate analysis revealed that performance status and sarcopenia were independent predictors of poor prognosis. The presence of sarcopenia was significantly correlated with neutrophil/lymphocyte ratio elevation. CONCLUSIONS: Sarcopenia is a novel predictor of poor prognosis in patients with stage IIIA (N2) non-small cell lung cancer. Neutrophil/lymphocyte ratio elevation might be the reason for poor prognosis in sarcopenic patients.

Impact of multiple malignancies on surgical outcomes in patients with 1 cm or smaller non-small cell lung cancer.

BACKGROUND: Because most patients with small-sized non-small cell lung cancer (NSCLC) are asymptomatic, their lesions are detected by cancer screenings or routine checkups for other diseases. Incidences of multiple malignancies have been reported to be 27% in patients with stage I-III NSCLC. Some patients have treatment histories for other malignancies, and their small-sized NSCLC was incidentally detected during follow-up. There is no established report regarding the influence of multiple malignancies on small-sized NSCLC prognosis. Therefore, we investigated the correlation between multiple malignancies and surgical outcomes in patients with small-sized NSCLC. METHODS: In total, 44 patients underwent definitive pulmonary resection for NSCLC of 1 cm or smaller between January 2003 and December 2012. Tumor size was measured by macroscopic findings of the resected specimens, and we then retrospectively investigated their clinical courses. RESULTS: One patient had hemoptysis symptoms, whereas 43 patients were asymptomatic; among them, NSCLC was detected by examinations for other diseases in 31 patients and by cancer screening in 12 patients. In total, 20 patients (45%) had multiple malignancies. The median follow-up period was 68 months. One patient had a recurrence from current NSCLC. No patients died of current NSCLC. The overall 5-year survival rate was 90% for all patients. Patients with multiple malignancies had significantly poorer prognoses compared with those without multiple malignancies (P = 0.016). However, patients with treatment intervals of more than 5 years had prognoses equivalent to those of patients without multiple malignancies (P = 0.829). Only the presence of multiple malignancies was a significantly poor prognostic factor in univariate and multivariate analyses. CONCLUSION: NSCLC of 1 cm or smaller showed good prognoses. The presence of multiple malignancies was a significantly poor prognostic factor, and short treatment intervals also correlated with poor prognosis.

Platelet-to-lymphocyte ratio predicts the prognosis of patients with non-small cell lung cancer treated with surgery and postoperative adjuvant chemotherapy.

BACKGROUND: Markers of preoperative tumor immunity, such as platelet-to-lymphocyte ratio (PLR), have been reported to be prognostic factors for patients with various cancers. However, the relationship between PLR and the prognosis of non-small cell lung cancer (NSCLC) patients treated with surgery and adjuvant chemotherapy as a multidisciplinary treatment is unknown. METHODS: We enrolled 327 NSCLC patients treated surgically with or without adjuvant chemotherapy (78 and 249 patients, respectively) at our hospital from 2008 to 2012. Patients had no preoperative hematological disease or infection. Preoperative PLR and clinicopathologic characteristics were recorded and their potential associations and prognostic values were assessed by Kaplan-Meier and multivariate Cox regression. The optimal cut-off value for high and low PLR was calculated from receiver operating characteristic curves. RESULTS: The five-year overall survival rates for patients with low and high PLR were 78% and 57% (P < 0.01) for all patients, and 69% and 37% (P < 0.01) for patients who received adjuvant chemotherapy, respectively. Similarly, the five-year disease-free survival rates for patients with low and high PLR were 66% and 62% (P = 0.03) for all patients, and 47% and 14% (P < 0.01) for patients who received adjuvant chemotherapy, respectively. Cox proportional hazard regression indicated that high PLR was an independent prognostic factor for both overall and disease-free survival in the adjuvant chemotherapy group. CONCLUSION: Elevated PLR predicts poor prognosis in surgically treated NSCLC patients, especially those who receive adjuvant chemotherapy.

Elevation of Serum Carcinoembryonic Antigen Concentration Caused by Everolimus-Induced Lung Injury: A Case Report.

A 66-year-old woman underwent right nephrectomy for treatment of renal cell carcinoma (RCC). Two years later, she underwent wedge resection of the right lung for treatment of metastatic RCC and primary adenocarcinoma of the lung. She began oral sorafenib for the remaining nodules of the left lung, which were suspected to be metastatic RCC. Two years later, the sorafenib was changed to everolimus because of slight enlargement of the left pulmonary nodules. The carcinoembryonic antigen (CEA) concentration then increased to 25.7 ng/mL, and chest computed tomography (CT) revealed ground-glass opacities (GGO) in the bilateral lungs. Everolimus-induced lung injury was suspected, and she discontinued the everolimus. Two months later, the serum CEA concentration decreased to almost within the reference range at 5.9 ng/mL, and the GGO disappeared on chest CT. In conclusion, we encountered a patient who developed an elevated serum CEA concentration caused by everolimus-induced lung injury.

Solitary splenic metastasis from lung adenocarcinoma: A case report.

Solitary splenic metastasis is extremely rare, with only 27 reported cases in the literature. An 81-year-old woman was referred to our hospital for treatment of pulmonary and splenic lesions. Chest computed tomography showed a small lung nodule in the right upper lobe, abdominal computed tomography showed an 8 cm splenic mass with abnormal accumulation, and positron emission tomography revealed a maximum standardized uptake value of 7.9. She had elevated serum cancer antigen 19-9 (1847 U/mL) and carcinoembryonic antigen concentrations (17.9 ng/mL). She underwent laparoscopic splenectomy. Pathological examination revealed poorly differentiated adenocarcinoma. We performed partial lung resection and diagnosed the small lung lesion as lung adenocarcinoma. Both lesions were positive for thyroid transcription factor 1. Thus, primary lung adenocarcinoma and solitary splenic metastasis were diagnosed. The patient was still alive without recurrence four years postoperatively. Herein, we report a rare case of lung adenocarcinoma with solitary splenic metastasis and review the literature.

Cytomegalovirus-associated ulceration of gastric conduit after chemoradiotherapy following esophagectomy for cancer.

A 64-year-old man underwent radical esophagectomy for cancer and simultaneous reconstruction using the gastric conduit through the posterior mediastinum. Two courses of adjuvant chemotherapy were performed. Twenty-eight months postoperatively, recurrence of the cancer was detected in the mediastinal lymph nodes, and he underwent concurrent chemoradiotherapy and boost chemotherapy. Endoscopy was then performed to investigate the cause of epigastralgia, and multiple ulcerations were found in the lesser curvature of the gastric conduit. Although a proton-pump inhibitor was orally administered, the ulceration was intractable. Re-examination of the original biopsy specimens and serological testing revealed positivity for cytomegalovirus. The ulcers began to heal after administration of foscarnet sodium. After the treatment, no signs of exacerbation associated with reinstitution of chemotherapy were observed.