Severe subglottic stenosis after resection of anterior mediastinal tumor using a double­lumen tube: a case report.

Background: Double­lumen tubes (DLTs) are commonly used for differential pulmonary ventilation during thoracic surgery. Few reports exist on subglottic stenosis among patients who underwent surgery involving DLTs; we lack immediate postoperative period documentation leading up to the onset and subsequent recovery of subglottic stenosis. Herein, we present a case of a 75-year-old woman successfully treated for subglottic stenosis after DLT. Case Description: A 75-year-old woman presented to our hospital with an abnormal chest shadow, which was identified during a medical examination. Chest computed tomography revealed an anterior mediastinal mass with a poor contrast effect measuring 6.0 cm × 3.1 cm × 1.9 cm, which grew from 2.2 to 6.0 cm over 21 months. Low and high signals were detected on T1- and T2-weighted thoracic magnetic resonance imaging, respectively. Concordantly, a thymic cyst was suspected. The patient underwent robotic-assisted thoracoscopic resection via the right lateral approach. A 35-Fr left-sided DLT was used for intubation and differential lung ventilation. Hoarseness and stridor were observed on postoperative day (POD) 1. Laryngoscopy showed submucosal hemorrhage around the vocal cords and mild subglottic stenosis; however, there was no arytenoid dislocation or findings necessitating emergency treatment. On POD 4, her stridor became more severe and laryngoscopy was re-performed and revealed subglottic stenosis progression prompting emergency tracheotomy. The stenosis further progressed, and almost complete airway obstruction was observed on POD 7. By POD 9, partially improving the subglottic stenosis, thereafter the subglottic stenosis was almost completely alleviated by POD 12. The tracheal cannula was removed on POD 22. Trachea-cutaneous fistula closure was performed on POD 35, and she was discharged on POD 42, remaining well. The pathological examination of the anterior mediastinal tumor confirmed the diagnosis of thymic cyst. Conclusions: Airway obstruction owing to subglottic stenosis may occur several days post-surgery with a DLT. Prompt tracheostomy is recommended to prevent complete airway obstruction in patients with progressive subglottic stenosis.

A case of pyothorax after treatment of burn inhalation injury. A case report.

INTRODUCTION: Inhalation injury is a major complication of fire accidents. Delayed onset of tracheal stenosis is one of the chronic complications of inhalation injury. Here, we report a case of acute empyema as a complication of inhalation injury. PRESENTATION OF CASE: A 38-year-old-man who underwent a tracheostomy following an inhalation injury when he was 25-years of age was admitted with a diagnosis of right-side pyothorax. We attributed the pyothorax to insufficient bronchial toilet secondary to preoperative tracheal stenosis and tracheal mucosal damage as a complication of inhalation injury, as confirmed using laryngofiberscopy. Conservative therapy was insufficient, therefore, surgical drainage was performed. At the time of surgery, following general anesthesia induction, the insertion of a single-lumen tube was difficult owing to severe tracheal stenosis. As a result, we performed an emergency tracheostomy followed by empyema curettage. DISCUSSION/CONCLUSION: Tracheal stenosis due to tracheal basal membrane injury and mucosal membrane injury resulted in sputum clearance disorder. These changes led to pyothorax. Preoperative airway safety should be carefully planned when operating on patients with tracheal stenosis.

Rupture of thymoma due to recurrent tumor hemorrhage: a case report.

Background: Rupture of a thymoma is rare, and due to its rarity, the mechanism of rupture remains unclear. Here we report a case of a ruptured thymoma that ruptured due to an increase in the intratumoral pressure caused by recurrent hemorrhaging. Case Description: A 70-year-old woman presented 2 days prior persistent right chest and shoulder pain. A chest computed tomography (CT) scan revealed the presence of a mass occupying the anterior mediastinum and a right pleural effusion. It was diagnosed as an anterior mediastinum tumor. The increase in the levels of inflammatory markers and tumor necrosis observed on CT were suggestive of infection. As the general status of the patient was stable and she initially received antibiotic medical therapy, an improvement in the inflammatory marker levels was observed with antibiotic therapy. A surgical resection was performed 10 days after admission. Median sternotomy revealed a tumor extending from the mediastinum to the right thoracic cavity. Since the adhesion was strong and tumor invasion was suspected, the tumor was completely resected by combining a partial resection of the right middle and lower lobes with the pericardium. Pathological examination revealed that the tumor was a type B2 thymoma with fibrosis, necrosis, hemosiderosis, and hemorrhaging, suggesting recurrent hemorrhaging within the tumor. Conclusions: Based on the findings of our case, recurrent hemorrhaging within the tumor led to an increase in the intratumoral pressure and chronic inflammation and necrosis weakened the tumor wall. These changes contributed to the subsequent rupture.

Retention index of FDG-PET/CT SUVmax of the primary tumor in non-small cell lung cancer as a predictor of lymph node metastasis: a retrospective study.

BACKGROUND: Accurate staging of non-small cell lung cancer is key in treatment planning and prediction of prognosis. We investigated the correlation between the maximum standardized uptake value (SUVmax) retention index (RI) of the primary tumor and lymph node metastasis in non-small cell lung carcinoma. We also evaluated the tendencies according to the histological types. METHODS: We retrospectively evaluated 218 non-small cell lung cancer (NSCLC) tumors from 217 patients who underwent preoperative fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) followed by lung surgery and lymph node resection between July 2015 and August 2020. All primary tumors were calculated as the SUVmax at 50 min (SUVmaxearly [SUVmaxe]) and 120 min (SUVmaxdelayed [SUVmaxd]), and RI. The clinicopathological factors of interest were compared based on lymph node metastasis status and NSCLC histopathological subtype. RESULTS: The median SUVmaxe and SUVmaxd of the primary tumors were 3.3 and 4.2, respectively, and the median RI was 0.25. The RI was significantly higher in the pN(+) (n = 44) group (0.30) compared to the pN0 (n = 174) group (0.24) (p = 0.01). In patients with adenocarcinoma (n = 145), the RI was also significantly higher in the pN(+) (n = 29) group (0.29) compared to the pN0 (n = 116) group (0.16) (p < 0.01). A high RI of the primary tumor was an independent risk factor for lymph node metastasis, particularly in patients with adenocarcinoma (odds ratio: 12.30, p < 0.05). CONCLUSIONS: The RI of primary NSCLC tumors can help predict lymph node metastases, particularly in patients with adenocarcinoma.

Anomalous systemic arterial supply to the basal lung segments with high serum carbohydrate antigen 19-9 levels-a case report.

Anomalous systemic arterial supply to the basal lung segments is relatively rare. A 39-year-old Japanese man was found to have high serum carbohydrate antigen 19-9 levels during a routine medical examination. He had no medical history and no symptoms. Although his serum carbohydrate antigen 19-9 level was high at 571 U/mL, his abdominal computed tomography (CT), gastrointestinal endoscopy, and abdominal ultrasonography findings were not abnormal. However, his chest CT scan revealed anomalous systemic arterial supply to the basal lung segment of the left lower lobe. He underwent partial resection of the left lung and stapling of the abnormal artery. After surgery, his serum carbohydrate antigen 19-9 level normalized. We consider that bronchiectasis of the basal left lung was involved in carbohydrate antigen 19-9 production and increase in its serum level. It is important to remain aware that various benign lung diseases can cause high serum carbohydrate antigen 19-9 levels.

Salvage surgery for primary lung cancer complicated with Trousseau's syndrome after chemotherapy: a case report.

A 65-year-old man was admitted to our hospital due to an abnormal shadow on chest radiographs. Chest computed tomography (CT) revealed a tumor (diameter: 38 mm × 27 mm) and another small nodule in the left upper lobe of the lung, which were accompanied by lymphangitis of the left upper lobe. The patient underwent a transbronchial lung biopsy, following which he was diagnosed with lung adenocarcinoma. Contrast-enhanced CT and ultrasound imaging revealed bilateral pulmonary artery thrombosis and multiple venous thromboses. He was thus diagnosed with stage IIB lung cancer complicated by Trousseau's syndrome. Chemotherapy was initiated using platinum doublets, while infusions of unfractionated heparin and Xa inhibitor were administered for anticoagulant therapy. Following chemotherapy, the main tumor had shrunk, and his lymphangitis, pulmonary artery thrombosis, and multiple venous thromboses had resolved. We then could perform a left upper lobectomy and lymph node dissection safely.

Computed tomography-guided tube thoracostomy for massive subcutaneous emphysema following lung resection: a case report.

A 70-year-old man underwent right-sided pulmonary bilobectomy (removal of the middle and lower lobes) for stage IIIA non-small-cell lung carcinoma. Following the operation, there was minor air leakage through the intercostal drain from postoperative day 0 to 2, which stopped completely by postoperative day 3. The subsequent postoperative course was uneventful, and the patient was discharged on postoperative day 7 after removal of the chest tube. On postoperative day 9, the patient returned to the hospital with complaints of nasal speech and bulging of the skin over his right breast region. He was diagnosed with postoperative subcutaneous emphysema. A chest computed tomography (CT) scan revealed that the emphysema was not associated with a collapsed lung, and the patient's relatively small-sized thoracic cavity left limited space for the placement of a chest tube. We performed a CT-guided tube thoracostomy with proper insertion and placement of an intercostal drain at the site of the air leakage, within the compact thoracic cavity. The procedure was effective in draining the trapped air, thus resolving the subcutaneous emphysema successfully.

A risk scoring system for predicting visceral pleural invasion in non-small lung cancer patients.

OBJECTIVE: This study aimed to construct a simple scoring system for predicting visceral pleural invasion of non-small cell lung cancer (NSCLC) from computed tomography (CT) findings and clinicopathological factors in lesions directly under the pleural membrane. METHODS: Among 376 cases of surgically treated NSCLC, cases in which the tumor was ≤ 7 cm in diameter and in contact with the pleura on the CT image were retrospectively extracted and examined. The CT findings and clinicopathological factors associated with the presence of pathological pleural invasion in each case were examined by Fisher's exact test. A score was then assigned based on the odds ratio obtained for each factor, and a risk scoring system for predicting pleural invasion was constructed. RESULT: In the 138 extracted cases, pathological visceral pleural invasion was found in 64 cases. The scoring system predicting pleural invasion could be defined as follows: pl risk score = 3 (tumor diameter in CT ≥ 24 mm) + 3 (tumor contact length with pleura in CT ≥ 16 mm) + 3 (smoking index ≥ 400) + 3 (clinically lymph node positive) + 2 (tumor with cavity in CT) + 2 (serum CEA level > 4.4 ng/mL). A score was calculated for each case and an ROC curve was created. The cutoff value was score 8 and the area under curve (AUC) was 0.68. CONCLUSION: Our findings suggest that visceral pleural invasion can be predicted using a score calculated from several simple CT findings and clinicopathologic factors.

A case of malignant mesothelioma detected hydropneumothorax.

A 61-year-old man was admitted to the emergency room because of sudden right chest pain and dyspnea. A chest X-ray and chest computed tomography (CT) revealed severe right pneumothorax with massive pleural effusion. Chest drainage was performed and approximately 1.2 L of pleural fluid was removed. Hemothorax was suspected based on the imaging findings, but the pleural effusion was serous. Active air leakage continued for 4 days after chest drainage, thus we decided to surgically control the air leakage and performed video-assisted surgery. A thoracoscopic examination revealed a large number of nodule parietal pleural and epiphrenic pleural nodule lesions. A pathological examination of frozen sections of the nodules indicated malignant pleural mesothelioma (MPM). Continuous air leakage was observed from the pleural surface of the right lower lobe. The air leak developed from the visceral pleura and the point of visceral pleura had a normal macroscopic appearance. The patient was treated with wedge lung resection and pleurodesis.

Postoperative hemorrhage after right upper lobectomy associated with apixaban use: a case report.

A 76-year-old Japanese man underwent right upper lung lobectomy for lung cancer. He had a medical history of atrial fibrillation and myocardial infarction, and was treated with medications including apixaban (5 mg twice daily). His postoperative course was uneventful, and he left the hospital on the ninth day postoperatively. Apixaban was restarted on postoperative day (POD) 10. On POD18, he was evaluated as an outpatient. He complained of fatigue, and his hemoglobin level decreased from 13.5 to 8.5 mg/dL. Chest plain radiography showed massive fluid in the right thoracic cavity. His condition was thought to be a postoperative bleeding complication due to apixaban; thus, we stopped apixaban and performed red blood cell transfusion and thoracic drainage. Postoperative hemorrhage associated with apixaban use is rare.

Experimental Study of Intraparenchymal Fibrinogen and Topical Thrombin to Seal Pleural Defects.

OBJECTIVE: Fibrin sealants are used to close surgical pleural defects, but may detach, causing a postoperative air-leak. We investigated a new means of applying fibrin glue for closing pleural defects. METHODS: Pleural defects (10-mm and 4-mm diameters, respectively) were created in swine and rats via thoracotomy. They were sealed by a) injection of a fibrinogen solution into the lung parenchyma after instillation of a thrombin solution onto the pleural defect (group A), b) fibrinogen and thrombin spray (group B), c) fibrinogen instillation and a thrombin-dipped polyglycolic acid sheet (group C), or d) fibrin glue-coated collagen fleece (group D). Resistance to airway pressure was compared and the sealed areas were histologically examined. RESULTS: In group A, the minimum seal-breaking airway pressure was consistently > 40 cmH2O, versus 37.2 ± 3.6 cmH2O in group B, 37.2 ± 4.0 cmH2O in group C, and 39.0 ± 1.7 cmH2O in group D, which was statistically significant. Histologically, the fibrin layer infiltrated the lung parenchyma and covered the defect in group A, but not in the other groups. CONCLUSIONS: The intraparenchymal injection of fibrinogen combined with instillation of thrombin created an effective fibrin layer associated with early pleural regeneration that reliably prevented pleural air leaks.

The experience of using Endo GIA™ Radial Reload with Tri-Staple™ Technology for various lung surgery.

Endo GIA™ Radial Reload with Tri-Staple™ Technology (RR) is a device for colorectal surgery. However, with its rounded staple line, Radial Reload is suitable for various lung surgeries. We use the device for lung wedge resection, and cutting bronchus in lung lobectomy. The total number of use counts up to 56 fires, and all fires came out well.

Large cell carcinoma on the bullous wall detected in a specimen from a patient with spontaneous pneumothorax: report of a case.

Bullous emphysema has been proven to be an important risk factor for lung cancer. Some reports have described pneumothorax caused by rupture of an emphysematous bulla, following which cancer is found in the resected specimen. A 72-year-old male patient was referred to our hospital because of dyspnea and high fever. Chest radiography and computed tomography (CT) revealed right pneumothorax and emphysematous bullae. There was also effusion in the bullae and thoracic cavity. Based on the diagnosis of pneumothorax and a lung infection associated with bullous emphysema, we resected the bullae. Pathological examination of the specimen revealed a mass and large cell carcinoma.

Myelolipoma of the posterior mediastinum: report of a case.

Myelolipoma is an uncommon tumor composed of adipose tissue and normal hematopoietic elements, and is most often found in the adrenal glands. We report a patient with a posterior mediastinal myelolipoma. The 68-year-old male patient showed a right lower mediastinal shadow in a chest X-ray. A computed tomographic scan demonstrated a right posterior mediastinal mass. Magnetic resonance imaging provided additional useful information. The patient underwent a successful resection under video-assisted thoracoscopic surgery.

[Assessing the usefulness of erlotinib in patients with unknown or negative epidermal growth factor receptor mutation status].

The patient involved in case 1 was an approximately 50-year-old woman with left lung adenocarcinoma (cT4N0M1), pleural dissemination, and carcinomatous pleural effusion. Chemotherapy with cisplatin and S-1 was administered as first-line therapy, and after the second course of chemotherapy, the thoracic drainage tube could be removed. Thereafter, the patient's performance status (PS) improved to 0. However, brain metastasis was detected, with symptoms of dizziness and headache, and activities of daily living (ADL) decreased, resulting in deterioration of the PS to 4. Although epidermal growth factor receptor (EGFR) mutation status was unknown, erlotinib (150 mg/day) was administered, which was evidently effective in reducing brain metastasis and resulted in recovery of the PS to 0. The patient involved in case 2 was an approximately 50- year-old man with a complaint of coughing. Chemotherapy with 4 courses of cisplatin and pemetrexed was administered as first-line therapy, and local radiation therapy (66 Gy) followed by 4 courses of docetaxel was administered as second-line therapy. However, the patient showed progressive disease (PD) and emergence of brain metastasis. Although the patient was negative for EGFR mutation, erlotinib (150 mg/day) was initiated as third-line therapy. Chemotherapy was successful and the local lesions were under control. We performed left pneumonectomy to improve quality of life (QOL), which had decreased because of repeated obstructive pneumonia caused by the tumor. Owing to the surgery, the patient was able to maintain a PS of 0 and a favorable QOL, while the administration of erlotinib was continued. In conclusion, erlotinib functions effectively in 3 ways. First, it can be used for emergency administration in cases of unknown EGFR mutation status. Second, its use facilitates the performance of salvage surgery in patients who are EGFR mutation negative. Finally, erlotinib is expected to be effective in the treatment of brain metastasis.

[A case of curatively resected gastric cancer through an effective response to chemotherapy].

The patient is a 66-year-old male who underwent gastrojejunostomy at another hospital with the diagnosis of type 3 unresectable gastric cancer. He was admitted to our hospital for adjuvant chemotherapy. A CT scan revealed both peritoneal dissemination and a large tumor directly invading the pancreas and liver. After 7 courses of combined chemotherapy with 5-FU, Leucovorin, cis-platinum and methotrexate, an effective response, tumor reduction and the disappearance of peritoneal dissemination, was verified by CT scan. Pancreatoduodenectomy with transverse colectomy was carried out and the pathological diagnosis was also curative (pT3, pN1, pP0, HO: stage III A). Although he unfortunately died from peritoneal recurrence after 9 months, he maintained good quality of life after re-operation. We think this case shows the possibility of NAC for patients with far advanced gastric cancer with peritoneal dissemination to improve their prognosis or QOL.