Thymic basaloid carcinoma with aggressive invasion of the lung and pericardium: report of a case.

We report a case of basaloid carcinoma of the thymus, invading the lung and pericardium. The patient was a 72-year-old man who suffered thoracic trauma in a fall and was taken to his family physician. Computed tomography revealed a huge mediastinal tumor with cystic components, pressing into the lung. He was referred to our hospital, where magnetic resonance imaging showed suspicious invasion of the pericardium and mediastinum. We made an assumed diagnosis of a mediastinal malignancy and performed mediastinal tumor resection. The tumor was adherent to the lung, pericardium, and left innominate vein. The final pathological diagnosis was a basaloid carcinoma of the thymus. Basaloid carcinoma is often a component of a multiloculated thymic cyst (MTC) and should be considered when MTC is identified within an anterior mediastinal tumor.

A case of diffused malignant pleural mesothelioma forming small multiple disseminations with intraoperatively suspicious carcinoid tumors.

A 65-year-old male, having symptoms suggestive of pulmonary malignant tumor, underwent video-assisted thoracic surgery (VATS). Surgery revealed a solid tumor originating from the thoracic wall, with many small solid tumors in the thoracic wall and diaphragm near the tumor. The intraoperative observation of a frozen section typed the tumor as carcinoid; however, hematoxylin-eosin staining and immunohistological findings provided the definitive diagnosis of diffused, malignant pleural mesothelioma (MPM).

A complication of thoracic surgery: a late-onset chylomediastinum resulting from a left upper lobectomy and lymph node dissection through a median sternotomy.

A 63-year-old male with lung cancer underwent a left upper lobectomy and mediastinal lymph node dissection through a median sternotomy. Postoperatively, he received 4 cycles of adjuvant chemotherapy with cisplatin and gemcitabin. Chest computed-tomography (CT) scan after the adjuvant chemotherapy showed a large cystic mass originating from the tracheal bifurcation. Fiberoptic bronchoscopy (FOB) revealed chylomediastinum during the aspiration biopsy of the mass. The chylous effusion was first removed by aspiration under FOB, though 2 weeks later the patient returned with a fever, and the CT lead us to suspect mediastinitis. After performing primary surgery for the removal of chylomediastinum, there was no recurrence thus we concluded that it was the better method.

Complication of bovine pericardial buttress: pulmonary pseudotumor.

A 38-year-old man reported progressive back pain 4 years after undergoing partial resection of the lung for spontaneous pneumothorax, using staples buttressed with bovine pericardium. Chest computed tomography detected a mass near the staple line. Resection of the mass was performed successfully and the pain was relieved. The excised material was identified as an inflammatory pulmonary pseudotumor caused by the buttressing material.

Results of a pulmonary metastasectomy in patients with colorectal cancer.

PURPOSE: The lung is one of the key sites of hematogenous metastasis in patients with colorectal cancer. A metastasectomy of the lung is reported to improve the prognosis of colorectal cancer. We reviewed our experience in evaluating the surgical outcomes in colorectal cancer patients who have undergone a pulmonary metastasectomy. METHODS: A single-center retrospective evaluation of clinical prognostic factors (1996-2008) related to a pulmonary metastasectomy of patients with colorectal cancer was conducted. Fifty-seven consecutive patients in our hospital who had undergone a resection of pulmonary metastasis from colorectal cancer were retrospectively investigated. RESULTS: The mean age of the patients who underwent an initial pulmonary metastasectomy was 63.8 years. The average number of pulmonary metastases was 3.8. Pulmonary metastasectomy was performed an average of 1.6 times per head. A total of 32 patients had undergone a liver metastasectomy, and the 5-year survival of these 32 patients was 43.1%. The 5-year survival of the time from first pulmonary metastasectomy was 53.9%. There were no statistical differences with regard to the disease-free interval, interval from primary resection, or the number of pulmonary metastasectomies. CONCLUSIONS: A pulmonary resection for colorectal pulmonary metastases is therefore considered to be a favorable treatment for long-term survival even in the presence of liver metastases. Thoracic surgeons should therefore aggressively perform a pulmonary metastasectomy of colorectal cancer.

The results of surgery under general anesthesia in patients with lung cancer.

PURPOSE: There are few reports of surgical complications for underweight patients. This study evaluated the complications associated with lung cancer surgery and anesthesia in underweight patients in a comparison with obese ones. METHODS: A single-center retrospective evaluation of perioperative complications was conducted in 756 patients who underwent thoracic surgery under general anesthesia between 1996 and 2006. The body mass index showed that 39 were extremely underweight (<17.2 kg/m(2)), 45 were underweight (17.2-18.4 kg/m(2)), 513 were normal (18.5-24.9 kg/m(2)), and 159 were obese (>24.9 kg/m(2)). RESULTS: Extremely underweight patients had the most preoperative thoracic disease such as emphysema, whereas obese patients had the most preoperative cardiovascular disease such as hypertension. The postresection-predicted pulmonary function showed no difference among the four groups. Extremely underweight patients had an increased incidence of intraoperative hypotension and arrhythmia in comparison to underweight patients. On the other hand, obese patients had the majority of intraoperative thoracic complications such as hypoxia. Extremely underweight patients had more postoperative thoracic complications, especially pneumonia and pulmonary air leakage, than other patients. CONCLUSIONS: Extremely underweight patients as well as obese patients had a high risk of perioperative complications, especially postoperative thoracic complications. Extremely underweight patients should therefore be carefully observed with regard to respiratory management.

Thyroid cancer with a cystic mediastinal tumor invading the right main bronchus.

A 55-year-old woman presented with hemosputum. She had noted thyroid swelling and computed tomography was performed by her family physician. The computed tomographic scan revealed a thyroid tumor and a mediastinal cyst connecting to the thyroid tumor. Fiberoptic bronchoscopy showed direct invasion to the right main bronchus. She was preoperatively diagnosed with thyroid cancer combined with a mediastinal tumor and underwent a thyroidectomy and mediastinal tumor resection. These tumors were adherent to the esophagus, trachea, superior vena cava, and azygos vein; however, the mediastinal cyst, despite the fact that it directly invaded the right main bronchus, showed no malignant cells.

A long-term survivor with late-onset-repeated pulmonary metastasis of a PEComa.

A 59-year-old male underwent a surgical resection of a retroperitoneum tumor in 1990 that was diagnosed as leiomyoblastoma. Thereafter he demonstrated pulmonary metastases followed by a total of 3 pulmonary resections from 1995 to 1997. In 2008, he was incidentally found to have a tumor in the left lower lobe, which was diagnosed as a metastatic perivascular epithelioid cell (PEComa) neoplasm. Retrospectively, a primary tumor and pulmonary metastases were also diagnosed as PEComa. We experienced late-onset repeated pulmonary metastasis of a PEComa.

Feasibility study for biweekly administration of cisplatin plus gemcitabine as adjuvant-chemotherapy for completely resected non-small cell lung cancer.

PURPOSE: To evaluate the feasibility of biweekly administration of cisplatin and gemcitabine as adjuvant chemotherapy for patients with completely resected non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: This was a single-arm, single-institutional study. Patients with completely resected NSCLC (p-Stages IB-IIIA) with no previous chemotherapy or radiotherapy were eligible. Simon's optimal two-stage design was applied. Both cisplatin (50 mg/m(2)) and gemcitabine (1,000 mg/m(2)) were given on days 1 and 15, every 28 days. The primary endpoint of this study was the feasibility of this combination in the four cycles of treatment. RESULTS: Twenty patients (19 lobectomies and 1 pneumonectomy) were enrolled in this study. Nine (45%) of patients had grade 3/4 neutropenia, and 6 (30%) had grade 3/4 anemia. Severe non-hematologic toxicities were uncommon in this series. No treatment-related death was encountered. Thirteen (65%) patients completed the planned 4 cycles of chemotherapy. The median intensity was 24 (range 21-25) mg/(m(2) week) with an average of 24.0 (21-25) mg/(m(2) week) cisplatin and 483 (range 412-500) mg/(m(2) week) with an average of 481.0 (412-500) mg/(m(2) week) gemcitabine. The median relative dose intensity of cisplatin was 100 (range 25-100) % with an average of 87.4 (25-100) % and that of gemcitabine was 100 (range 25-100) % with an average of 86.8 (25-100) %. CONCLUSION: This regimen is feasible in the treatment of patients with completely resected NSCLC. A multicenter phase III trial is warranted to assess the efficacy of this regimen at promoting survival and preventing recurrence.

Can a thoracic surgeon identify lymph node metastases during surgery based on their size? Analysis of 844 metastatic and 10,462 nonmetastatic lymph nodes.

OBJECTIVE: A metastatic lymph node commonly becomes enlarge; however, there is limited data available with regard to the direct measurement of lymph nodes and their clinicopathologic characteristics. METHODS: The size of dissected lymph node was quantified in a total of 848 nodes with metastasis and 10,462 nodes without metastasis from 454 patients with lung cancer who underwent a pulmonary resection with lymph node dissection. RESULTS: The short axis and the volume of the metastatic lymph nodes were significantly greater than those of the nonmetastatic ones. The smaller the lymph node, the less frequently the lymph nodes were metastatic; however, the ratios of nodes smaller than the fifth largest lymph node with metastasis of adenocarcinoma and squamous cell carcinoma were 21.8 to 26.2%, respectively. When the hilar and mediastinal lymph node stations were examined, 1.14 to 4.00% of the lung cancer patients had lymph node metastasis in small lymph node despite having no metastases in the largest and second largest lymph nodes. CONCLUSIONS: The small lymph nodes in the hilar or mediastinal stations frequently had metastases of carcinoma even though largest and second largest lymph nodes were negative for metastases, especially in adenocarcinoma cases. Surgical oncologists should, therefore, perform systemic lymph node dissection, and not sampling, during a pulmonary resection of lung cancer.

The perioperative complications for elderly patients with lung cancer associated with a pulmonary resection under general anesthesia.

BACKGROUND: Surgery for elderly patients with lung cancer is relatively common due to the increasing elderly population. This study evaluated the perioperative complications associated with surgery in patients over 70 years of age with lung cancer. PATIENTS AND METHODS: A single-center retrospective evaluation was conducted of perioperative complications (1996-2006) in lung cancer surgical patients. We reviewed and analyzed the clinical records of 364 consecutive patients over 70 years of age and 392 control patients. RESULTS: The mean age of the elderly group was 75.5 years old and that of the control group was 59.4 years. A segmental or wedge resection was performed more frequently for the elderly group than in the control group, whereas pneumonectomies and lobectomies were performed more frequently in the control group. Preoperative comorbidities such as cardiac and thoracic diseases were more frequently recognized in the elderly group than in the control group. The quantity of propofol used as induction anesthesia in the elderly group was significantly smaller than that of the control group, furthermore, the operation time and operation room stay time of the elderly group were significantly shorter than that of the control group, however, extubation time was significantly prolonged. The ratio of thoracic complications in the elderly group was higher than that in the control group. The ratio of pulmonary leakage in the elderly group was higher than in the control group; however, there was no significant difference in length of stay in the hospital, the ratio of operative death and hospital death between the two groups. CONCLUSIONS: Elderly patients more frequently have perioperative complications than younger patients; however, there was no statistical difference in mortality. A pulmonary resection for elderly patients may therefore be as feasible as in younger patients.

Video-assisted thoracic surgery for fibropurulent thoracic empyema: a bridge to open thoracic surgery.

BACKGROUND: Thoracic empyema remains a serious problem. OBJECTIVE: We evaluated the feasibility and efficacy of video-assisted thoracic surgery (VATS) for fibropurulent thoracic empyema. PATIENTS AND METHODS: Twenty-six consecutive patients with thoracic empyema resistant to medical therapy were treated by VATS from 1997 to 2006. The presence of pleural adhesion was not a contraindication. Patients with destroyed lung, bronchopleural fistula, or excessively thickened pleura were excluded. RESULTS: Twenty-two were males and 4 were females with a mean age of 59 years (range 14 to 85). The length of preoperative period was 39.3 +/- 25.3 days, and the length of preoperative treatment was 11.2 +/- 14.3 days. The operating time was 127.6 +/- 45.1 minutes and intraoperative bleeding was 353.8 +/- 438.4 g. Postoperative complications were observed in two cases (8.0%). There were no hospital deaths. Twenty-two cases (84.6%) were cured with a postoperative drainage time of 12.5 +/- 8.2 days. Four cases required an additional operation. However, the VATS procedure was not required to perform additional thoracoplasty using pedicled chest wall muscles. CONCLUSIONS: VATS for fibropurulent thoracic empyema is effective and less invasive, and it may be important as a bridge between minimally invasive and conventional open thoracic surgical management.

Effect of body mass index on perioperative complications in thoracic surgery.

Obesity is perceived as a risk factor in general thoracic surgery. We conducted a single-center retrospective evaluation of perioperative complications in 822 patients who underwent thoracic surgery between 2000 and 2005. According to body mass index, 82 were underweight (< 18.5 kg m(-2)), 568 were normal (18.5-24.9 kg m(-2)), 155 were overweight (25.0-29.9 kg m(-2)), and 17 were obese (>or=30 kg m(-2)). A significant increase in preoperative comorbidity (hypertension and ischemic heart disease) was observed with increasing body mass index. There was no significant difference in operation time or length of stay in the operating room, but extubation time was significantly different among the 4 groups. Of the intraoperative complications, alveolar-arterial oxygen difference increased significantly with increasing obesity, and hypoxia was least common in the normal group. Postoperatively, there was more pulmonary leakage in the underweight group and less pneumonia in the normal group. Both the underweight and the obese are at increased risk of perioperative complications and need to be carefully observed and managed intraoperatively and postoperatively.

Favorable surgical results for patients with nonsmall cell lung cancer over 80 years old: a multicenter survey.

BACKGROUND: Surgery for elderly patients, especially those over 80 years old, with primary lung neoplasms is a relatively common treatment according to the increasing elderly population. We reviewed our experiences to evaluate surgical outcomes in over-80-year-old patients with nonsmall cell lung cancer (NSCLC). PATIENTS AND METHODS: We reviewed and analyzed the clinical records of 146 consecutive over-80-year-old patients (Group 1) and 926 control patients (65 years old and younger) (Group 2) with NSCLC who underwent surgical resections from 1981 to 2006. RESULTS: The mean ages of Group 1 and Group 2 were 82.6 and 56.2 years old, respectively. The ratio of the clinical and pathological Stage I was higher than the Stages II-IV in Group 1, and that of pathological Stage III was higher in Group 2. Segmental and wedge resection were selected more frequently in Group 1, otherwise, pneumonectomy and lobectomy were selected more frequently in Group 2. The ratio of squamous cell carcinoma was higher in Group 1 than in Group 2. When we divided the time of surgeries into decades, the 1980s, 1990s, and 2000s, the ratio of elder to younger patients was clearly increased according to era: 6.6%, 13.7%, and 18.8%. Furthermore, incomplete operation cases were significantly decreased in the two groups. There was no difference of overall survival in either. When examined for overall survival, except for patients with incomplete resection, there was no significant difference between the two groups. CONCLUSIONS: Surgery is the convenient treatment for elderly NSCLC patients, especially, for those who can undergo complete resection.

Resection of mediastinal granulocytic sarcoma triggered the rapid progression of acute myeloid leukemia.

Mediastinal granulocytic sarcoma (GS) is a relatively rare disease. We experienced a case of acute myeloid leukemia (AML) that took a rapid turn for the worse after the resection of a mediastinal GS. A healthy 60-year-old man had been in good general health all his life, but was diagnosed with a mediastinal tumor by his family physician and was referred to our department. The patient underwent resection of the mediastinal tumor because thymoma was highly suspected. On postoperative day (POD) 3, the patient suffered a fever as well as an elevated white blood cell (WBC) count and a high C-reactive protein level. His WBC count was 77,240 at its peak on POD 9, at which point the patient was diagnosed with AML by bone marrow aspiration. The immunohistological findings showed the features of leukemia, and GS was diagnosed. Despite chemotherapy, the patient died on POD 28 as a result of rapid disease progression.

Pulmonary typical carcinoid tumor and liver metastasis with hypermetabolism on 18-fluorodeoxyglucose PET: a case report.

Pulmonary carcinoid tumors are generally hypometabolic on 18-fluorodeoxyglucose (FDG)-positron emission tomography (PET). We experienced a case of pulmonary typical carcinoid that showed rapid growth and high FDG uptake at the primary site and liver metastasis. A 56-year-old man with hemosputum had a medical examination by his family physician. A roentgenogram and computed tomography of the chest showed a solitary solid mass on the right lower lung field. However, he had not been shown an abnormal shadow on a roentgenogram taken 8 months earlier. He had undergone fiber-optic bronchoscopy, but the cytological diagnosis showed no evidence of malignancy. After that, FDG-PET was examined and revealed hot spots in the pulmonary tumor and liver mass. A standard uptake value of this pulmonary tumor was 32.9 mg/mL, and that of the liver mass was almost the same value of pulmonary lesion. He had undergone a right lower lobectomy diagnosed as a typical carcinoid. Thereafter he underwent partial resection of he liver mass, and the histology was metastasis from pulmonary carcinoid. We first reported a typical pulmonary carcinoid that showed high FDG uptake at the primary site and liver metastasis.

A long-term survivor after aggressive treatment for tracheal adenoid cystic carcinoma: a case report.

A 61-year-old male underwent a tracheal resection and reconstruction with omentopexy for the treatment of tracheal adenoid cystic carcinoma. Postoperatively, he received radiotherapy for a microscopic residual tumor of the tracheal margin. It recurred with pulmonary metastasis and para-esophageal lymph nodal metastasis at 7 years and 10 months after the initial operation. A wedge resection and concurrent chemoradiotherapy were carried out to treat the recurrence, followed by consolidation chemotherapy. Eleven months later, he developed a second recurrence with a right hilar lymph nodal metastasis, and thereafter he also suffered from a left hilar lymph nodal metastasis. As a result, he received concurrent chemoradiotherapy twice over a 3-year period. One year and 2 months later, a new pulmonary metastasis appeared, and a wedge resection was carried out. Although the patient had five instances of recurrence over an 11-year period during his treatment course, he is presently doing well as a result of appropriate local treatments using multiple modalities.

Late-period-onset chylothorax after a pulmonary resection for lung cancer: a case report.

A 65-year-old female had been diagnosed with right lung cancer by her family physician, and she was introduced to our Department of Thoracic Surgery at Matsuyama Red Cross Hospital in May 2004. She underwent a right upper lobectomy and wedge resection of S6 with the systematic dissection of her mediastinal lymph nodes. The patient made an uneventful recovery and was discharged on postoperative day 19. However, chylothorax was detected on a chest roentgenogram when she consulted our outpatient clinic again for dyspnea on exertion and chest pain. Chylothorax occurred in postoperative day 34. The patient initially received conservative therapy, but subsequently underwent surgical treatment and fibrin glue intubation when conservative therapy proved to be unsuccessful.

Persistent and aggressive treatment for thymic carcinoma. Results of a single-institute experience with 25 patients.

OBJECTIVES: The aim of this study is to retrospectively evaluate the role of several therapies, mainly chemotherapy, for thymic carcinoma (TC). METHODS: From July 1973 to July 2005, 25 patients (15 males and 10 females) with histologically proven TC were treated at our department. The median age of the patients was 59 years, with a range of from 30 to 78 years. According to Masaoka's staging system, there was 1 stage I patient, 3 stage II, 7 stage III, 6 stage IVa, and 8 stage IVb patients. The histological subtype was in all cases squamous cell carcinoma, nonkeratinizing type. RESULTS: There were 6 complete surgical resections, 1 incomplete resection followed by chemoradiotherapy, 6 with radiotherapy alone, 3 with radiotherapy plus chemotherapy, and 9 with chemotherapy alone as the initial treatment. Eighteen patients were administered second-line therapy. The regimen obtaining the best response rate was doublet chemotherapy consisting of carboplatin (CBDCA) and paclitaxel. The median survival time and survival rate at 5 years for the patients excluding surgical cases with stage I/II disease were 32 months and 31%, respectively. CONCLUSION: The doublet of CBDCA and paclitaxel thus appears to be a promising regimen for TC and further investigation in a multi-institutional phase II trial is, therefore, strongly called for.