Coronary artery calcification scoring system based on the coronary artery calcium data and reporting system (CAC-DRS) predicts major adverse cardiovascular events or all-cause death in patients with potentially curable lung cancer without a history of cardiovascular disease.

The coronary artery calcium data and reporting system (CAC-DRS) is a novel reporting system based on CAC severity. Lung cancer patients have a high risk of cardiovascular disease (CVD), for which CAC severity may provide additional prognostic information. Using non-gated, non-contrast computed tomography (CT), we evaluated the CAC-DRS for predicting CVD and all-cause death in patients with potentially curable resected lung cancer. We retrospectively studied 309 consecutive patients without a history of CVD (mean age 67.4 ± 8.2 years, 61% male) who underwent curative surgery for non-small-cell lung cancer between May 2012 and March 2019 at the Japanese Red Cross Okayama Hospital. Time to incidence of major adverse cardiac events (MACEs) (non-fatal myocardial infarction, non-fatal stroke and cardiovascular death) and all-cause death was analyzed using Fine and Gray and Cox regression models. The CAC-DRS score was assessed using standard chest CT without electrocardiogram gating. During 52-months' median follow-up, 43 patients (13.4%) developed incident MACEs or died from any cause; the pathological cancer stages were Ia (n = 20), Ib (n = 8), IIa (n = 2), IIb (n = 2) and IIIa (n = 11). Patients had a graded increase in incidence of MACEs or all-cause death with increasing categories of CAC-DRS. The CAC-DRS score was significantly associated with incident MACEs or all-cause death after adjusting for confounding factors (hazard ratio 1.18; 95% confidence interval 1.10-1.25, p < 0.01). In conclusion, the CAC-DRS score on non-gated standard CT can predict incident MACEs and/or all-cause death in patients with potentially curable resected lung cancer. Lung cancer survivors with a greater CAC-DRS category may need more active management of cardiovascular risk factors.

The clinical characteristics and surgical results of smoking-related young pneumothorax.

OBJECTIVE: Primary spontaneous pneumothorax is a common disease that develops in relatively young healthy patients. Although smoking is generally believed to have a negative effect on the lungs, some authors reported that smokers with primary spontaneous pneumothorax had significantly lower postoperative recurrence rates than nonsmokers. This unexpected result suggests that primary spontaneous pneumothorax is classified into two categories: smoking-related young pneumothorax and residual primary spontaneous pneumothorax. We compared these two categories to determine their characteristics and corresponding surgical results. METHODS: Between January 2009 and December 2018, we enrolled 267 consecutive cases that underwent first surgery for primary spontaneous pneumothorax in our hospital. A total of 252 eligible cases (211 residual primary spontaneous pneumothorax and 41 smoking-related young pneumothorax) underwent evaluation. Smoking-related young pneumothorax cases were defined as cases with characteristic HRCT findings and smoking habit. RESULTS: The mean ages for the residual primary spontaneous pneumothorax and smoking-related young pneumothorax groups were 25.9 ± 13.1 and 30.5 ± 6.9 years, respectively. The groups included 186 (88.2%) and 41 (100.0%) men, and the mean body mass indices were 19.1 ± 2.2 and 20.0 ± 1.9, respectively. Fifty-nine (28.0%) and 41 (100.0%) subjects were smokers, and there were 43 (20.4%) and 1 (2.4%) cases of postoperative recurrence, respectively. These results were significantly different between the two groups. CONCLUSIONS: Individuals with smoking-related young pneumothorax were older, predominantly men, and had higher body mass index and significantly lower postoperative recurrence rates than those with residual primary spontaneous pneumothorax.

A case of ectopic hamartomatous thymoma: controversy over the designation.

BACKGROUND: Ectopic hamartomatous thymoma, which usually occurs in the lower neck, is a rare benign tumor containing spindle cells, epithelial nests, and adipose tissue. Although the origin of this tumor is still unknown, recent reports suggest that the designation of this tumor is inappropriate. CASE PRESENTATION: A 38-year-old with an anterior cervical mass in the suprasternal region of her neck was referred to our hospital. An ultrasound examination showed that the well-defined oval mass was 31 × 23 × 17 mm in size. A non-enhanced computed tomography scan of the neck revealed that the distinct neck mass in the subcutaneous tissue had a mixture of soft tissue and fatty components. The cervical tumor was clinically diagnosed to be an unusual lipoma with degeneration. The patient underwent the neck mass extirpation. During the surgery, the cervical mass was well demarcated and did not adhere to the surrounding tissues. The postoperative course was uneventful. The gross pathology report showed that the neck mass measured 3.0 × 2.5 × 2.0 cm. Microscopically, the tumor was composed of spindle cells, epithelial nests, and mature adipose tissue. Immunohistochemical examination revealed that both spindle cells and epithelial nests were positive for cytokeratin AE1/AE3. These histopathological findings were consistent with the features of ectopic hamartomatous thymoma. Over a follow-up period of 30 months, this patient exhibited no evidence of recurrence. CONCLUSIONS: Ectopic hamartomatous thymoma should be considered in the differential diagnosis of subcutaneous tumors in the lower neck, when the CT shows the tumor has the mixed components of fat and soft tissues.

Restrictive ventilatory impairment is associated with poor outcome in patients with cT1aN0M0 peripheral squamous cell carcinoma of the lung.

BACKGROUND: Patients with squamous cell carcinoma (SqCC) of the lung sometimes have a comorbid pulmonary disease such as pulmonary emphysema or an interstitial lung disease (ILD), both of which negatively affect patient outcome. The aim of this study was to determine the outcome of patients in a multicenter database who underwent surgery for cT1aN0M0 peripheral SqCC lung cancer. METHODS: The medical records of a total of 228 eligible patients from seven institutions were reviewed to evaluate the impact of concomitant impaired pulmonary function and other clinicopathological factors on overall survival (OS) and relapse-free survival (RFS). RESULTS: Six patients with positive or unclear tumor margins were excluded. Of the 222 remaining study patients, 42 (18.9%) and 97 (43.7%) patients were found to have coexisting restrictive or obstructive ventilatory impairment, respectively. Over a median follow-up period of 30.6 months, the 5-year OS and RFS were 69.0% and 62.6%, respectively. By multivariate analysis, ILDs identified on high-resolution computed tomography (HRCT), pulmonary function test results indicating a restrictive ventilatory impairment, and wedge resection were found to be independent risk factors for poor OS. An increased level of serum squamous cell carcinoma antigen (SCC-Ag) (>1.5 ng/mL) and the same risk factors for poor OS were independent risk factors for recurrence. Among patients who underwent anatomical lung resection (lobectomy and segmentectomy, n=173), a restrictive ventilatory impairment was an independent risk factor for poor OS, and increased serum SCC-Ag level, ILDs on HRCT, and restrictive ventilatory impairment were independent risk factors for poor RFS by multivariate analysis. Factors such as visceral pleural invasion, and lymphatic or vascular invasion were not significantly associated with outcome. CONCLUSIONS: A restrictive ventilatory impairment negatively affects the outcome of patients with cT1aN0M0 peripheral SqCC lung cancer.

[Assessment of traumatic rib fractures caused by traffic accident].

We reviewed 66 cases of traumatic rib fracture by traffic accident between January 2009 and December 2011. The age of patients ranged from 18 to 88 years, with an average age of 55.6, and they were predominantly male. They met with traffic accident when driving automobiles in 30 cases, driving motorcycles in 15 cases, and walking in 9 cases. The average number of fractured ribs was 4.1±3.2.Multiple rib fractures were observed in 75.8% of patients. Injuries other than rib fractures were involved in all patients who suffered over 7 rib fractures. Except one who died of pneumonia 62 days after traffic accident, 7 of 8 patients died within 48 hours:6 in a shock state and 1 in cardiac pulmonary arrest on arrival. About 80 % of the patients with rib fractures were hospitalized. As traffic accidents could cause any type of injuries including rib fractures, it is important to examine the whole body when patients were transported to a hospital.

[Two cases of dural metastasis of breast cancer].

The first case of dural metastasis occurred in a 60s years old woman, who presented with bone metastasis to the right breast. Nine months later, disorientation and left hemiplegia developed, the right coronal bone metastasis enlarged, and dural metastases were detected close to the tumor, as observed by using cranial magnetic resonance imaging (MRI). Whole brain radiation and chemotherapy(weekly paclitaxel)were administered. The right coronal bone metastasis reduced remarkably, and the dural metastases almost disappeared, as observed on a cranial MRI scan. The second case of dural metastasis occurred in a 50s years old woman who presented with multiple bone metastases. Extensive bone metastases to the skull and dural metastases to the side of the head were observed on cranial MRI scans. Subsequently, the patient experienced a severe headache, and whole brain radiation and pharmacotherapy with anastrozole and trastuzumab were administered. Cranial MRI revealed that the skull bone metastasis reduced and the dural metastases almost disappeared. We report that radiotherapy and pharmacotherapy were effective in these 2 cases of dural metastases of breast cancer.

Off-the-job training for VATS employing anatomically correct lung models.

We evaluated our simulated major lung resection employing anatomically correct lung models as "off-the-job training" for video-assisted thoracic surgery trainees. A total of 76 surgeons voluntarily participated in our study. They performed video-assisted thoracic surgical lobectomy employing anatomically correct lung models, which are made of sponges so that vessels and bronchi can be cut using usual surgical techniques with typical forceps. After the simulation surgery, participants answered questionnaires on a visual analogue scale, in terms of their level of interest and the reality of our training method as off-the-job training for trainees. We considered that the closer a score was to 10, the more useful our method would be for training new surgeons. Regarding the appeal or level of interest in this simulation surgery, the mean score was 8.3 of 10, and regarding reality, it was 7.0. The participants could feel some of the real sensations of the surgery and seemed to be satisfied to perform the simulation lobectomy. Our training method is considered to be suitable as an appropriate type of surgical off-the-job training.

Bronchial arteriovenous malformation with large aneurysm, resected by video-assisted thoracic surgery.

Bronchial arteriovenous malformation with a large aneurysm appearing as a mass shadow in the right hilum on chest imaging was successfully extirpated thoracoscopically without any lung resection. Preoperative angiography showed tortuous, enlarged right bronchial arteries with an aneurysm connecting to the pulmonary artery, which could not be totally embolized via the transcatheter approach because of the length of the abnormal bronchial artery and possibility of embolotherapy-induced pulmonary infarction. Histological examination revealed defects of the media and internal elastic lamina of the resected bronchial arteries and aneurysm. The patient was free of hemoptysis and other airway symptoms 4 years after surgery.

Prognostic impact of intratumoral vessel invasion in completely resected pathologic stage I non-small cell lung cancer.

OBJECTIVE: Intratumoral vessel invasion of non-small cell lung cancer is a readily available tumor-related factor that provides direct evidence of microscopic tumor invasion. We assessed the prognostic influence of intratumoral vessel invasion and its ability to provide a differential prediction of prognosis for completely resected pathologic stage I non-small cell lung cancer. METHODS: We analyzed 258 patients with non-small cell lung cancer who underwent complete resection between January of 1996 and December of 2005 and were diagnosed with pathologic stage I disease. In addition to the conventional staging factors, intratumoral vessel invasion in the primary lesion was histologically evaluated by both hematoxylin-eosin and elastic staining. We examined the significance of intratumoral vessel invasion in prognosis and compared the outcomes between patients with and without this factor with stage IA and IB disease, respectively. RESULTS: Intratumoral vessel invasion was found in 124 patients (48%). Five-year survival of patients with or without intratumoral vessel invasion was 74% and 93%, respectively. On multivariate analysis, intratumoral vessel invasion and pleural invasion were shown to be independent prognostic factors. Subgroup analyses suggested that patients with pathologic-stage IA with intratumoral vessel invasion and patients with pathologic-stage IB with both intratumoral vessel and pleural invasion had significantly worse prognosis than patients with the same pathologic stage without these factors. CONCLUSION: The current study indicated that intratumoral vessel invasion and pleural invasion are independent prognostic factors. Intratumoral vessel invasion status can complement the size-dependent TNM staging system in pathologic stage I non-small cell lung cancer.

Multiple gastrointestinal stromal tumors in neurofibromatosis type 1 treated with laparoscopic surgery.

Gastrointestinal stromal tumors (GISTs) have been reported to occasionally occur in patients with neurofibromatosis type 1 (NF-1), and many cases have had multiple lesions predominantly involving the small intestine. We report herein a case of multiple GISTs associated with NF-1 from whom laparoscopic surgery was beneficial. In a 79-year-old female admitted with anemia and melena, the abdominal computed tomography revealed a tumor arising from the small intestine. Laparoscopic surgery was performed, and another small tumor was revealed during laparoscopic observation. Extracorporeal partial and wedge resection of the small intestine were undertaken. Both lesions were diagnosed as typical GISTs of low risk. Laparoscopic surgery would be useful for examination and a minimally invasive approach to tumors of the small intestine, especially on cases with the possibility of multiple tumors.

Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: evaluation of indications and long-term outcome compared with conservative treatment and open thoracotomy.

STUDY OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) is effective for primary spontaneous pneumothorax. We sought to evaluate the outcome of VATS compared to conservative treatment and open thoracotomy, and to discuss the indications for VATS in primary spontaneous pneumothorax. DESIGN: Retrospective study. PATIENTS AND INTERVENTIONS: Primary spontaneous pneumothorax was diagnosed in 281 consecutive patients between January 1989 and April 2001. Mean age was 29.1 years. Mean follow-up period was 78.3 months (range, 13 to 163 months). For these patients, conservative treatment, open thoracotomy, or VATS were performed, and the outcomes of the three treatments were evaluated. If recurrence occurred, outcome of treatment for the recurrence was also evaluated according to the number of times of recurrence. RESULTS: Recurrences were observed in 109 of 281 patients (38.8%). Forty-three patients (15.3%) had repeat recurrences. Regarding the outcome of the first episode, recurrence rates were 54.7% for conservative treatment, 7.7% for open thoracotomy, and 10.3% for VATS. Recurrence rates after the second episode were 60.3% for conservative treatment, 0% for open thoracotomy, and 18.6% for VATS. Overall recurrence rates of each treatment were 56.4%, 3.0%, and 11.7%, respectively. There was no statistical difference between the open thoracotomy and VATS groups (p = 0.15). Hospital stays from operation until discharge were 11.5 days for open thoracotomy and 4.1 days for VATS (p < 0.001). CONCLUSION: The outcomes of VATS were very good compared to conservative treatment and equal to those of the open thoracotomy, not only for the first episode but also for the case of recurrence. In terms of low morbidity, low invasiveness, and cosmetic issues, VATS is superior to open thoracotomy. VATS is standard in cases of recurrence and should be considered for treatment at the first episode.

Abdominal wall and thigh abscess resulting from the penetration of ascending colon cancer.

An unusual case is described in which an abdominal wall and thigh abscess was an initial symptom of ascending colon cancer. A 76-year-old woman was referred to our hospital for investigation of fever and abdominal and thigh swelling. Computed tomography revealed a right abdominal wall, retroperitoneal, psoas and thigh abscess formation suspected to be caused by colon perforation. Due to the patient's poor general condition, local drainage of the abscess was performed on the following day of hospitalization. Histological examination of necrotic tissues removed form the retroperitoneal cavity demonstrated adenocarcinoma of the colon. The patient subsequently underwent right hemicolectomy with lymph nodal dissection after 19 days of the drainage procedure and was transferred to another hospital on the 49th day following the second surgery.

Intercostal hemangioma.

This paper presents a case of intercostal hemangioma, in which a complete surgical resection was accomplished based upon a tentative diagnosis provided by magnetic resonance imaging (MRI). A 27-year-old man visited our hospital for the evaluation of chest pain and shortness of breath after exertion. Computed tomography showed a soft tissue mass, 5.5 x 3.5 cm in size, arising from the right lateral 7th intercostal space. Dynamic MRI showed that the mass was enhanced rapidly in the early phase and that this early enhancement was maintained during the delayed phase, which was compatible with a diagnosis of intercostal hemangioma. The patient underwent surgery, and a complete resection of the tumor with the right 7th and 8th ribs and their intercostal muscles was accomplished. Histopathological examination confirmed the diagnosis of intramuscular hemangioma of the large-vessel type. Presently, 6 months after the operation, the patient is doing well, without any evidence of local recurrence.