Clinicopathological Analysis of 17 Surgically Resected Pulmonary Pleomorphic Carcinoma Cases.

OBJECTIVES: To determine the outcomes and prognostic factors associated with pulmonary resection of pulmonary pleomorphic carcinoma (PPC). METHODS: During 2008-2017, 17 patients underwent pulmonary resection for primary PPC at the Saitama Cancer Center, Japan. We investigated clinicopathological characteristics and outcomes of these cases. Overall survival (OS) and disease-free survival (DFS) rates were determined using Kaplan-Meier method and compared using log-rank test. Univariate analysis was performed to identify prognostic factors. RESULTS: The 5-year OS and DFS rates were 27.2% and 51.0%, respectively. The median follow-up period was 30.8±24.9 (3.6-92.8) months after pulmonary resections. Patients with disease-free interval (DFI) <1 year of resection had poorer prognosis than those without (p = 0.001). Patients with N2 status and adenocarcinoma components had significantly poorer disease-free prognosis than their counterparts (p = 0.021 and p = 0.019, respectively). Univariate analysis revealed that DFI <1 year was an unfavorable prognostic factor for OS (p = 0.005); N2 pathological status and presence of adenocarcinoma components were unfavorable prognostic factors for DFS (p = 0.038 and p = 0.036, respectively). CONCLUSION: PPC patients with an adenocarcinoma component and N2 pathological status may have an earlier relapse and poorer prognosis than their counterparts. Further assessment of cases may help clarify the predictors of PPC.

Accessory diaphragm associated with pulmonary metastasis from cervical cancer.

In accessory diaphragm, a rare congenital anomaly, the hemithorax is divided into two compartments by a fibromuscular membrane. Herein, we report the case of a 34-year-old woman with an accessory diaphragm who underwent two lung resections for suspected lung metastasis following surgery for cervical cancer 3 years ago. She was asymptomatic; no pulmonary infection history. Computed tomography revealed well-defined solid nodule in the right upper lobe dorsal segment and accessory diaphragm. The pulmonary vessels and bronchus were abnormally distributed through the accessory diaphragm hiatus with no lung infection signs or adhesions upon thoracoscopy. Subsequently, dorsal segmentectomy was performed. She developed lung metastasis 2.5 years later, undergoing a second lung resection. Due to no lung adhesions, the remaining accessory diaphragm was removed owing to visual field obstruction. Accessory diaphragm associated with lung malignancies need not be removed but opened. However, it may be removed if it hindered the visual field.

Branching anomaly of the pulmonary ventrobasal and laterobasal arteries from the mediastinal lingular pulmonary artery.

The lingular pulmonary artery is known for being frequently subjected to bifurcation anomalies, thus asserting the importance of performing three-dimensional computed tomography angiography before lung surgery for safety reasons. We report a case of branching anomaly of the left ventrobasal and laterobasal arteries, which instead of branching from the interlobar artery, branched as a common trunk from the mediastinal lingular artery. A 68-year-old man with diagnosis of rectal cancer lung metastasis in the ventral segment of left upper lobe (S3) presented branching anomaly of the pulmonary artery, which was detected by a preoperative three-dimensional computed tomography angiography. Although there was a conversion from segmentectomy to left upper lobectomy to secure the margin with the tumor, the operation was safely performed and completed by video-assisted thoracic surgery, since the vascular branching anomalies were characterized preoperatively.

Sclerosing thymoma followed up for eight years as mediastinal goiter: A case report.

INTRODUCTION: Sclerosing thymoma (ST) is an extremely rare disease with less than 20 cases ever been described. Here, we present a case of sclerosing thymoma that was followed up as mediastinal goiter for eight years. PRESENTATION OF CASE: A 77-year-old man was presented with a superior mediastinal tumor. The patient was asymptomatic and not affected by myasthenia gravis. Computed tomography showed a well-defined superior mediastinal tumor whose size had regressed over time. Ultrasonography-guided core-needle biopsy revealed type B1 to B2 thymoma, and total-thymectomy was performed. Histopathologically, most of the tumor showed hyalinization and sclerosis, and slight signs of type AB thymoma were found at the tumor's periphery. The patient was diagnosed with ST. No evidence of recurrence was observed 12 months following surgery. DISCUSSION: Since sclerosing thymoma is mostly composed of fibrous tissue, small specimens such as needle biopsies do not contain tumor cell nests and are difficult to confirm. Complete resection is currently the most common treatment for ST. Spontaneous regression of ST has been reported; however, the mechanisms involved have not yet been elucidated. CONCLUSION: This rare case of sclerosing thymoma is an unusual case since it has follow up information for an eight year period due to the misdiagnosis of goiter. The follow up visits showed significant regression of the tumor over the eight year period without treatment; however, the etiology of sclerosis and regression remain unknown. The patient was treated by thymectomy with no recurrence after 12 months.

Mixed squamous cell and glandular papilloma of the lung-A case report and literature review in Japan.

INTRODUCTION: Mixed squamous cell and glandular papilloma (MSGP) of the lung is rare neoplasm, only 19 cases previously reported in Japan. MSGP is one of three separate categories of solitary endobronchial papillomas, which account for less than 0.5 % of all lung tumors. MSGP is rarest of the three. We present a rare case of MSGP and review the literature in Japan. PRESENTATION OF CASE: A 49-year-old man presented with a nodulous shadow in the right lower lung field identified on a chest X-ray performed for back pain. Computed tomography demonstrated a well-circumscribed, 9-mm mass in the S8 segment of the right lower lung lobe. Positron emission tomography showed accumulation of 18F-fluorodeoxyglucose in the tumor with a standardized uptake value of 2.29. Following thoracoscopic partial resection, adenocarcinoma was diagnosed by frozen section, and radical segmentectomy of S8 was performed. The final diagnosis was mixed squamous cell and glandular papilloma. The patient had an uncomplicated postoperative course and remains asymptomatic 3 years after the procedure. DISCUSSION: The etiology and pathological characteristics of MSGP remain unclear. There has been no report of recurrence in MSGP cases treated with complete resection; thus, limited resection that preserves pulmonary function is desirable. Further data including new cases are required. CONCLUSION: We present a rare case of mixed squamous cell and glandular papilloma (MSGP) of the lung and review the literature in Japan. Limited resection that preserves pulmonary function, while ensuring complete resection, is desirable. Further investigations with new cases are required.

A case of resected primary pulmonary pleomorphic carcinoma with long-term survival after multidisciplinary treatment.

BACKGROUND: Generally, primary pulmonary pleomorphic carcinoma is resistant to treatment and has a poor prognosis. We report a case of resected primary pulmonary pleomorphic carcinoma with long-term survival after multidisciplinary treatment. CASE PRESENTATION: A 74-year-old man with a history of emphysema, pneumoconiosis, and chronic bronchitis presented with left lung nodule and left adrenal tumor based on computed tomography. We suspected clinical T1bN0M1b, stage IVB lung cancer. Adrenalectomy of the left adrenal tumor yielded a definitive diagnosis of pleomorphic carcinoma. Chemotherapy was performed despite the spontaneous regression of lung lesions. Since lung lesions re-enlarged 11 months after adrenalectomy, the left lower lobe was partially resected followed by chemotherapy. The lung lesion was the primary lesion of the adrenal tumor. There was no recurrence 100 months after the lung resection. CONCLUSIONS: The patient experienced long-term survival after multidisciplinary treatment. Both multidisciplinary treatment and immunological mechanisms caused spontaneous regression of the primary lesion.

A Case of Primary Mediastinal Leiomyosarcoma in Which Long-Term Survival Was Achieved.

INTRODUCTION: Primary leiomyosarcomas (LMS) of the mediastinum are extremely rare malignant mesenchymal tumors developing from soft tissues or great vessels. We present a case of a primary leiomyosarcoma of the middle mediastinum in which long-term survival was achieved. CASE REPORT: A 77-year-old man presented to us for examination with an extrapleural sign in his upper mediastinum on chest X-ray. Computed tomography (CT) revealed a well-circumscribed mass in the middle mediastinum. Thoracoscopic resection of the mediastinal tumor and immunohistological findings, which were positive for smooth muscle actin (SMA), HHF-35, vimentin, and desmin confirmed primary leiomyosarcoma. It recurred twice with solid right pulmonary metastases, which were resected. He was followed-up for a total of 9 years and 6 months from the first surgery with no signs of recurrence after his last surgery. CONCLUSION: Surgical resection of both the primary tumor and pulmonary metastases remains the mainstay of treatment of primary leiomyosarcomas.

Surgical Treatment for Pulmonary Metastasis of Head and Neck Cancer: Study of 58 Cases.

PURPOSE: Although the number of surgeries performed for pulmonary metastasis of head and neck cancer has been increasing, there have been few reports of the surgical effectiveness. We collected the data of surgeries performed in our facility in order to discuss the surgical performance and indication. METHODS: We retrospectively examined the prognosis and predictors for 58 patients with pulmonary metastasis of head and neck cancer who underwent a surgery in our facility during the 15-year period, from January 2000 to December 2015. RESULTS: The 3-year and 5-year survival rates were 54.2% and 35.7%, respectively, and the median survival time was 42.2 months. The disease-free interval (DFI) was less than 24 months and patients with oral cavity cancer were poor prognostic factors. CONCLUSION: The effectiveness of surgical treatment for pulmonary metastasis of head and neck cancer was suggested.

Thoracoscopic surgery versus open surgery for lung metastases of colorectal cancer: a multi-institutional retrospective analysis using propensity score adjustment†.

OBJECTIVES: Thoracoscopic surgery for lung metastasectomy remains controversial. The study aimed at determining the efficacy of thoracoscopic surgery for lung metastasectomy. METHODS: This was a multi-institutional, retrospective study that included 1047 patients who underwent lung metastasectomy for colorectal cancer between 1999 and 2014. Prognostic factors of overall survival were compared between the thoracoscopic and open thoracotomy groups using the multivariate Cox proportional hazard model. The propensity score, calculated using the preoperative covariates, included the era of lung surgery as a covariate. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. The difference between the radiological tumour number and the resected tumour number (delta_num) was also evaluated. RESULTS: The c -statistics and the P -value of the Hosmer-Lemeshow Chi-square of the propensity score model were 0.7149 and 0.1579, respectively. After adjusting for the propensity score, the thoracoscopy group had a better survival rate than the open group (stratified log-rank test: P = 0.0353). After adjusting for the propensity score, the most powerful predictive model for overall survival was that which combined thoracoscopy [hazard ratio (HR): 0.468, 95% CI: 0.262-0.838, P = 0.011] and anatomical resection (HR: 1.49, 95% CI: 1.134-1.953, P = 0.004). Before adjusting for the propensity score, the delta_num was significantly greater in the open group than in the thoracoscopy group (thoracoscopy: 0.06, open: 0.33, P = 0.001); however, after adjustment, there was no difference in the delta_num (thoracoscopy: 0.04, open: 0.19, P = 0.114). CONCLUSIONS: Thoracoscopic metastasectomy showed better overall survival than the open approach in this analysis. The thoracoscopic approach may be an acceptable option for resection of pulmonary metastases in terms of tumour identification and survival outcome in the current era.

Routine genetic testing of lung cancer specimens derived from surgery, bronchoscopy and fluid aspiration by next generation sequencing.

After the development of EGFR tyrosine kinase inhibitors (TKIs), genetic testing of EGFR became required for effective treatment of lung cancer. Initially, the testing was conducted separately for each mutated region. However, many EGFR mutations have since been identified that determine the efficacy of EGFR-TKIs. Therefore, genetic testing of EGFR by next generation sequencing (NGS) may be a suitable strategy for lung cancer. Here we examined the applicability of the NGS method in regard to sensitivity, time and cost. A total of 939 specimens were obtained from 686 lung cancer patients at our hospital. DNA and RNA were simultaneously extracted from specimens derived from surgery, bronchoscopy, and fluid aspiration. Specimens included cerebrospinal fluid, pleural effusion, abdominal fluid, and pericardial effusion. From RNA, target regions (EGFR, KRAS, ALK fusion and RET fusion) were enriched by RT-PCR and sequenced with MiSeq. From DNA, PCR or PCR-RFLP conventional methods were performed. NGS and conventional methods were carried out routinely per week. Among the total 939 specimens, 38 specimens could not be examined with NGS. Among these, 34 specimens were analyzed by conventional testing with simultaneously extracted DNA. The remaining four specimens could not be tested with either method. Compared with the conventional method, the concordance rate of mutations was 99% (892/901), excluding specimens with NGS failure. The time period required from processing of specimens to results was 4 days, and the cost per sample was sufficiently low. In conclusion, the genetic testing with NGS method was useful for lung cancer treatment. The cost, sensitivity and time were able to tolerate routine examinations.

Solitary lung metastasis from gestational choriocarcinoma resected six years after hydatidiform mole: A case report.

INTRODUCTION: Recently, the opportunity to encounter lung metastasis from choriocarcinoma has become very rare for thoracic surgeons, since chemotherapy works very well and the operative indications for lung metastasis are limited. PRESENTATION OF CASE: A 45-year-old woman with a past history of hydatidiform mole six years previously was found to have a nodulous chest shadow in the right middle lung field on a chest radiography. She was also suspected of having an ovarian tumor and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. No malignancy was detected in the ovaries or uterus. A thoracoscopic partial pulmonary resection was then performed for the right lower lung nodule. The pathological diagnosis was choriocarcinoma. Her preoperative serum beta-human chorionic gonadotropin value was high (482.8mIU/mL). Thus, she was diagnosed as having a pulmonary metastasis from gestational choriocarcinoma arising six years after a complete hydatidiform mole. DISCUSSION: The possibility of choriocarcinoma arising as a solitary lung tumor should be considered regardless of the interval from the preceding molar pregnancy. The patient's medical history and high concentration of ß-hCG in preoperative residual serum were helpful in arriving at a diagnosis of metastatic gestational CCA. CONCLUSION: We presented pulmonary metastasectomy for very unique and rare metastatic choriocarcinoma arising six years after hydatidiform mole.

Equivalent Outcome of Patients with Locally Advanced NSCLC Treated with Salvage Surgery Compared to Induction Chemotherapy Followed by Surgical Resection.

BACKGROUND: There have, so far, been few previous reports concerning the use of salvage surgery in small number of patients with primary lung cancer and there are no reports currently available regarding salvage surgery compared to other treatments. PATIENTS AND METHODS: The postoperative complications and long-term survival of patients with non-small cell lung cancer (NSCLC) who received salvage surgery compared to induction chemotherapy followed by surgery from 2000 and 2013, were evaluated. RESULTS: During the study period, 1,847 consecutive patients with lung cancer underwent pulmonary resection at our Institution. Salvage operations were performed in 16 (0.9%) patients. The clinical stages were diagnosed as stage IIB in 1, IIIA in 8, IIIB in 6 and stage IV in 1 patient. The mean interval between initial treatment and surgery was 31.4 months. The surgical procedures were lobectomy in 9, pneumonectomy in 4 and partial resection in 3 patients. The operation was performed during a mean of 303 min; no case required blood transfusion. Complete resection was performed in 81% of the patients. Thus, the morbidity was 31.3% and the mortality rate was 0%. The five-year overall survival (OS) rates in the patients with induction chemotherapy followed by surgery and salvage surgery were 65.2 and 62.2%, respectively, (p=0.460) when OS was calculated from the date of registration to the date of initial treatment. The median survival for patients receiving salvage surgery was 64.4 months at any rate when OS was calculated from the date of registration for initial treatment or surgery. CONCLUSION: Salvage surgery can be performed safely with no mortality and is associated with a reasonable long-term survival, equivalent to the outcome of induction chemotherapy followed by surgical resection.

Long-term progress of six cases of malignant peripheral nerve sheath tumors of the mediastinum that underwent surgical treatment: Case report series.

INTRODUCTION: Malignant Peripheral Nerve Sheath Tumor is a rare type of soft tissue malignant tumor that occurs in only 5% of cases. It tends to occur in the arms and legs and trunk of the body, with mediastinal occurrence in only a few cases. Among mediastinal tumors, only 18.8% occur primarily in the nerves, and of these, only 10.3% are malignant, with very few reports indicating the long-term progress of patients with MPNST of the mediastinum. CASE PRESENTATION: We studied six cases of mediastinal primary malignant peripheral nerve sheath tumors in which surgery was carried out at this Center between 1977 and 2000. Four of the cases were men and two were women. The period of observation was between 14 and 277 months and the median follow-up time was 119.5 months. The tumors were contained in a membrane and completely excisable in three cases, with the patient demonstrating long-term survival with no recurrence in each case. The remaining three cases were not completely excisable due to invasion into the aorta. In two cases, the patients were treated post-surgically with chemotherapy; however, in all three cases the patient died as a result of the original condition. DISCUSSION AND CONCLUSIONS: Nerve sheath tumors localized within the membrane offer good long-term prognosis even if malignant. Furthermore, long-term survival is possible even if the tumor has invaded neighboring organs, provided it can be completely excised. In cases where complete excision is difficult, a multidisciplinary approach including radiotherapy and anti-cancer drug treatment may contribute to improved prognosis but this is a subject that requires further study.

Pulmonary Resection for Metastatic Gastric Cancer.

BACKGROUND: Pulmonary metastasectomy has come to be recognized as an effective treatment for selected patients with some malignancies. On the other hand, the role of pulmonary metastasectomy for gastric cancer is still unknown. Metastasectomy is rarely indicated in cases of pulmonary metastasis from gastric cancer, because in most cases, the metastasis occurs in the form of lymphangitic carcinomatosis and the lesions are numerous. The purpose of this study was to determine the surgical outcomes and prognostic factors for survival after pulmonary metastasectomy. METHODS: From 1985 to 2012, 10 patients underwent pulmonary metastasectomy for gastric cancer at Saitama Cancer Center, Japan. The overall survival rate was examined by the Kaplan-Meier method and univariate analysis was carried out to identify prognostic factors. RESULTS: The overall 3-year survival rate was 30.0 %. The median follow-up period was 26.8 months (range, 6.5-96.6) after the pulmonary metastasectomy. Univariate analysis revealed an advanced pathological stage of the gastric cancer and occurrence of extrapulmonary metastasis before the pulmonary metastasectomy as unfavorable prognostic factors. CONCLUSION: Pulmonary metastasectomy should be considered in selected patients with lung metastasis from gastric cancer. An advanced pathological stage of gastric cancer and occurrence of extrapulmonary metastasis before the pulmonary metastasectomy are unfavorable prognostic factors.

Abnormal branch of right pulmonary artery (A7): a case report and literature review.

In thoracic surgery, anatomic variations of pulmonary artery increase the risks for vessel injury and critical mistakes during pulmonary artery resection. We report a case of lung cancer with an extremely rare branch, a mediastinal A7 pulmonary artery. Some case reports of the mediastinal pulmonary artery exist until now. However, to the best of our knowledge, this is the first case of a medial basal segmental artery (from the following, it is referred to as A7) branching directly from main pulmonary artery in the literature. Therefore, there is no report that showed three-dimensional computed tomography (3D-CT) and operative findings. So, these information is very useful for thoracic surgeon. A 67-year-old man was admitted to our hospital in order to undergo operation for the treatment of lung cancer. We detected the anomalies preoperatively by 3D-CT. The 3D-CT shows the A7 pulmonary artery branches from the right main pulmonary artery directly. According to previous literature, the cases of a single branch from main pulmonary artery to lower lobe are only five cases. And, the only two of them are right side including our case. In spite of an extremely rare case, we were able to successfully perform a right middle lobectomy because the information obtained from the 3D-CT findings was sufficiently understood preoperatively.

Case report of two patients having successful surgery for lung cancer after treatment for Grade 2 radiation pneumonitis.

INTRODUCTION: Surgery for locally advanced lung cancer is carried out following chemoradiotherapy. However, there are no reports clarifying what the effects on the subsequent prognosis are when surgery is carried out in cases with radiation pneumonitis. In this paper, we report on 2 cases of non-small cell lung cancer with Grade 2 radiation pneumonitis after induction chemoradiotherapy, in which we were able to safely perform radical surgery subsequent to the treatment for pneumonia. PRESENTATION OF CASES: Case 1 was a 68-year-old male with a diagnosis of squamous cell lung cancer cT2aN2M0, Stage IIIA. Sixty days after completion of the radiotherapy, Grade 2 radiation pneumonitis was diagnosed. After administration of predonine, and upon checking that the radiation pneumonitis had improved, radical surgery was performed. Case 2 was a 63-year-old male. He was diagnosed with squamous cell lung cancer cT2bN1M0, Stage IIB. One hundred and twenty days after completion of the radiotherapy, he was diagnosed with Grade 2 radiation pneumonitis. After administration of predonine, the symptoms disappeared, and radical surgery was performed. In both cases, the postoperative course was favorable, without complications, and the patients were discharged. CONCLUSION: Surgery for lung cancer on patients with Grade 2 radiation pneumonitis should be deferred until the patients complete steroid therapy, and the clinical pneumonitis is cured. Moreover, it is believed that it is important to remove the resolved radiation pneumonitis without leaving any residual areas and not to cut into any areas of active radiation pneumonitis as much as possible.

The importance of determining surgical indications in cases of lung cancer and interstitial pneumonia with multiple intrapulmonary lymph nodes.

INTRODUCTION: When considering treatment for pulmonary cancer complicated by interstitial pneumonia, the greatest problem is acute exacerbation. We report two cases of pulmonary cancer complicated by interstitial pneumonia in which multiple intrapulmonary lymph nodes were noted. CASE PRESENTATIONS: Cases 1 and 2 were 76- and 62-year-old males, respectively. Both cases were diagnosed as pulmonary cancer complicated by interstitial pneumonia, and upon chest CT, it was noted that, in addition to the primary lesions, there were multiple nodule shadows under the pleura in the lung lobe, which required identification in order to rule out lung metastasis. In Case 1, the pulmonary nodules were first resected during surgery and a swift diagnosis was made, determining them to be intrapulmonary lymph nodes, which were then operated on curatively. In Case 2, the patient underwent thoracoscopic observation during surgery, the shadows were diagnosed visually as intrapulmonary lymph nodes, and curative surgery was implemented. DISCUSSION AND CONCLUSIONS: The greatest problem in treating pulmonary cancer complicated with interstitial pneumonia is acute exacerbation, wherein, in the absence of any surgical indications, alternative treatment is limited. Thus, contra-indicating surgery for a patient due to a diagnosis of metastasis within the lungs, based only on nodule images, should be avoided. If nodules are noted in the area of the pleura, the possibility exists that these could be intrapulmonary lymph nodes, along with metastasis within the lung, and thoracoscopic surgery should be implemented proactively while keeping these in mind.

Easy Diagnosis of Aortic Invasion in Patients with Lung Cancer Using Cine Magnetic Resonance Imaging.

Selecting the proper treatment strategy for locally advanced lung cancer, such as T4 tumors, is difficult. Therefore, obtaining an accurate diagnosis of T4 tumors is required. It can be difficult to determine whether the tumor invades adjacent structures. We describe the case of a patient easily diagnosed to be without aortic invasion using cine magnetic resonance imaging (MRI). We herein report the case of an 80-year-old male who presented a lung tumor. The transbronchial lung washing cytology findings were consistent with those of adenocarcinoma. In addition, the computed tomography findings indicated suspected aortic invasion of the lung tumor, as the mass girdled the descending aorta beyond 120° adjoining at a length of 10 cm. However, cine MRI display clearly demonstrated a clear area of isolation between the aorta and lung tissue based on differences in the heart rhythm from the patient's respiratory movements. Therefore, the lesion was clinically diagnosed as a stage IIB (T3N0M0) tumor. Radiation was administered due to the patient's advanced age and comorbidities such as chronic obstructive pulmonary disease. He remains alive without disease progression 6 months after the therapy. Our findings, therefore, indicate the usefulness of easily diagnosing the absence of aortic invasion in patients with lung cancer using cine MRI without the need for a special software program.

Two Cases of Single-Stage Closure of a Bronchopleural Fistula Using Latissimus Dorsi Musculocutaneous Flaps after Lung Surgery.

Two cases of successful primary closure of a bronchopleural fistula with favorable infection control using latissimus dorsi musculocutaneous flaps are reported. Case 1 was a 70-year-old man who underwent resection of the right lower pulmonary lobe due to right lung metastasis of sigmoid colon cancer. A bronchopleural fistula was found on day 28 after surgery. Infection was controlled by antibiotic administration and tube drainage. Closure of the bronchopleural stump, thoracoplasty and plombage of latissimus dorsi muscles were performed for single-stage closure without open treatment, based on a negative pleural effusion culture. Case 2 was a 64-year-old man who underwent right lower pulmonary lobe resection due to right lung cancer. A bronchopleural fistula was found on day 14 after surgery. In single-stage closure, thoracoplasty and plombage of latissimus dorsi muscles were performed due to infection control and a negative pleural effusion culture. Both cases had a good postoperative course.

[A Case of a Patient with Distal Bile Duct Carcinoma Who Underwent Surgical Resection Three Times for Pulmonary Metastases].

A 63-year-old woman attended our hospital after diagnosis of a solitary pulmonary metastasis from a distal bile duct carcinoma. She had undergone a subtotal stomach-preserving pancreaticoduodenectomy 1 year 9 months prior to the current presentation. She was treated with right thoracoscopic pulmonary partial resection. The specimen was a solitary nodule 5 mm in diameter. In addition, she was treated with adjuvant chemotherapy involving GEM for 6 months. One year 5 months later, she was diagnosed with a second pulmonary metastasis and was treated with a left thoracoscopic partial resection. Four months later, she experienced recurrence in the right lung stump and was treated with right thoracoscopic partial resection. The specimen was a solitary nodule 21 mm in diameter. Cytopathologic examination of the pleural fluid resulted in a diagnosis of Class Ⅴ. She was treated with adjuvant chemotherapy involving TS-1 for 6 months. Seven months later, she was experienced recurrence with multiple pulmonary metastases and an affected hilar lymph node. GEM/CDDP chemotherapy was started, but bone multiple metastases developed. After she received 30 Gy of radiotherapy, her pain improved. She died of cancer 5 years and 4 months after her initial pancreaticoduodenectomy, which was 3 years and 4 months after her initial pulmonary resection. We identified 14 other case reports of long-term survivors of distal bile duct carcinoma.