[Primary malignant peripheral nerve sheath tumor of the lung; report of a case].

We report a patient with primary malignant peripheral nerve sheath tumor (MPNST) of the lung. A 84-year-old man was referred to our hospital because of an abnormal shadow on chest X-ray. The computed tomography( CT) of the chest revealed a 6 cm tumor close to the posterior chest wall in the left thorax. He was followed-up because a benign tumor from posterior mediastinum was suspected. But the CT after 17 months showed the tumor enlargement. We performed complete resection under video-assisted thoracic surgery. It arose from the left lower lobe and was diagnosed as primary MPNST of the lung by immuno-histopathological examination. MPNSTs have a poor prognosis with tendency to recur. Although there is no sign of recurrence a year after surgery, we should follow-up carefully.

[Empyema that was diagnosed as primary ciliary dyskinesia by electron microscopical image of nasal mucosa].

A patient was 17-year-old. She had a history of repeated pneumonia and sinusitis. She was admitted to our hospital with the diagnosis of pneumonia. Although she was prescribed a course of antibiotics, chest roentgenogram and computed tomography showed increased and capselized pleural effusion, suggesting the development of acute empyema. Capsulized effusion and pus in thorax were removed by surgery. A part of lingular segment was raptured necessitating the partial resection of lingular segment. Her postoperative course was well. Her history of repeated pneumonia and sinusitis indicated the existence of primary ciliary dyskinesia, and the biopsy of nasal mucosa was done. The electron microscopical image of nasal mucosa showed defect of inner dynein arm. We made a diagnosis of primary ciliary dyskinesia based on her previous history and electron microscopical image.

[Long-term survival with complete response by gefitinib treatment followed by noncurative operation for lung cancer].

A 54-year-old man was referred to our hospital because of an abnormal shadow on chest X-ray. A computed tomography( CT) scan of the chest revealed a 6.5 cm tumor in the right upper lobe suspected of superior vena cava (SVC) infiltration. He was diagnosed as lung cancer(adenocarcinoma), and the right upper lobectomy with partial resection of SVC was performed. But the pathology confirmed the surgery to be non-curative. Nine months after operation, carcinomatous pleuritis was detected on chest X-ray. Since deoxyribonucleic acid (DNA)analysis revealed a mutation of epidermal growth factor receptor (EGFR) gene in exon 21, gefitinib treatment was started. Nine months later, pleural effusion regressed and his cerum carcinoembrionic antigen( CEA) level was normalized. 4 years later, gefitinib was discontinued by patient's request, however, he is alive without any signs of relapse 9 years after the operation.

[Typical bronchial carcinoid with repeated recurrence observed for 17 years after radical operation].

A 68-years-old male patient had been diagnosed as having bronchial carcinoid in B2 and right upper lobectomy with systematic hiler and mediastinal lymphadenectomy had been performed in 1996. Pathological diagnosis was a typical carcinoid (pT1aN0M0, stage I A). In 2004, 4 tumors were found in the trachea, right bronchial stump, right main bronchi and right B6 orfice. These were diagnosed as typical carcinoids by pathology. In 2005 argon plasma coagration was performed.In 2013, a localized recurrence was found in the right S6 by chest computed tomography (CT). The segmentectomy of the right S6 was performed. Even after radical operation for typical carcinoids, we should conduct long-term observation.

[The influence of difference of surgical procedure for the young spontaneous pneumothorax to the recurrence rate after surgery].

INTRODUCTION: In spontaneous pneumothorax (SP) in patients under the age of 30, we studied the postoperative recurrence rate due to differences in the surgical procedures and the patient's age. MATERIALS AND METHODS: Between October 2003 and September 2012, 351 operations were performed for the young(30 years or younger)SP in our hospital. The recurrence rate was calculated in 2 age groups( under 20 or older) with different surgical procedures which were classified into 5 groups on the basis of the combination of the covering site with the polyglycol acid (PGA) seat and the presence or absence of ligation at both ends of staple-line. RESULTS: The mean age of all patients was 21.0±4.4, 320 were male. The recurrence rate of all was 8.8%.The group 20 years or younger in comparison with the group 21 years or older had significantly high recurrence rate after surgery(11.9% v.s. 5.1%;p=0.034).However, covering the staple-line with ligation of both ends and covering the staple-line and the bullae common site were both significantly lower recurrence rate compared with the group with covering only to the staple-line in 20 years or younger group(0% v.s. 23.8%;p=0.041, 4.9% v.s. 23.8%;p=0.041). CONCLUSION: The results suggest that we need to choose the appropriate procedure of the surgery for SP considering the patient's age. The recurrence rate in the patient 20 years or younger can be reduced by covering the bullae common site and/or the ligating both ends of staple-line in addition to covering the staple-line.

[Primary pulmonary malignant melanoma].

The patients was 63-year-old man. He had a chest abnormally shadow pointed out in examination of March, 2012 and referred to our hospital for a close inspection. The chest computed tomography(CT)revealed a mass shadow of 60 mm in left lung. Bronchoscopic examination was done and it was diagnosed as non-small-cell lung cancer by cytology. The clinical stage was cT2bN1M0 and video-assistedthoracic surgery (VATS) left pneumonectomy with mediastinal lymph node dissection was performed. A lot of neoplastic cells which contained melanin in cytoplasm were recognized by pathology and the diagnosis of malignant melanoma was comfirmed. Lymph node metastasis were recognized in #10, #11, #12 and the pathological stage of a disease was pT2bN1M0, pStage IIB. Further examination to find another lesion after surgery was in vain suggesting primary site to be left lung. A adjuvant chemotherapy has not been done. Surgical resection of primary pulmonary malignant melanoma is reported with reference to literatures.

[Mixed squamous and glandular papilloma].

The patient was a 64-year-old man. He had a smoking history for 43 years (20 cigarettes per day). Being pointed out a mass shadow in the left lower lung field on chest X-ray in a regular checkup, he was referred to our hospital. The chest computed tomography (CT) revealed a tumor shadow of 30 mm diameter in the left S8. Blood tests showed that carcinoembryonic antigen (CEA) and squamous cell carcinoma-related antigen (SCC) were elevated. Accumulation of standardized uptake value (SUV) max 9.78/15.17 match the tumor shadow in fluorodeoxyglucose positron emission tomography (FDGPET),suspected of malignancy. As a result of bronchoscopy, squamous cell carcinoma was suspected by cytology, and he was introduced to us for surgery. Video-assisted thoracic surgery (VATS)-left lower lobectomy and lymph node dissection was performed. By pathology, the tumor showed papillary growth in peripheral bronchus, with squamous cell and high columnar epithelial cell components. The tumor was diagnosed as mixed squamous and glandulas papilloma. In addition, a part of the squamous cells was considered to be atypical, indicating squamous cell carcinoma in situ in a mixed epithelial and glandular papilloma.

[Re-operation for recurrent pulmonary metastases].

Fifty two patients with metastatic lung tumors were treated surgically in our hospital. Second pulmonary resections were performed in 6 patients. They consist of 1 male and 5 females, their age ranged from 59 to 80 years old( average 66 years old). Tumors originate from laryngeal cancer, colorectal cancer in 2 cases respectively, lung cancer and hepatic cancer in 1 case respectively. Three-year and 5-year survival was seen in 75% and 75% of patients, respectively.

[Treament using a free omental flap for pulmonary Aspergillosis with chronic methicillin-resistant Staphylococcus aureus( MRSA) empyema after fenestration].

A case is 48-year-old man who had a history of Blalock-Taussig shunt and the radical operation for Fallot's tetralogy, had been performed cavernostomy and fenestration operation for aspergilloma of left upper lobe in the previous hospital due to control blood spitting. Although the contents of the abscess cavity were removed, the opened cavity was again infected by methicillin-resistant Staphylococcus aureus (MRSA) and he was referred to our hospital. The plombage of free omental flap with vascular anastomosis was performed. He has been well without any symptoms or recurrence of empyema for 6 years after surgery.

A technique for retrieving a lung lobe in a bag from a small wound during thoracoscopic surgery.

We herein describe our technique for removing lung specimens during thoracoscopic resection. This technique allows extraction of intact lung specimens through a small incision. We believe that it is feasible, can be easily and rapidly performed, and facilitates thoracoscopic lung resection by reducing the technical difficulties involved in specimen removal; we also think that it may be used in other thoracoscopic interventions.

Anatomic thoracoscopic pulmonary segmentectomy under 3-dimensional multidetector computed tomography simulation: a report of 52 consecutive cases.

OBJECTIVE: The purpose of this retrospective study was to evaluate the efficacy of anatomic thoracoscopic pulmonary segmentectomy performed under the guidance of 3-dimensional multidetector computed tomography simulation. METHODS: Between September 2004 and June 2009, 52 patients (median age, 68 years; range, 16-85 years) underwent thoracoscopic segmentectomy without mini-thoracotomy. Images were obtained by using 64-channel multidetector computed tomography and a contrast agent. The pulmonary arteriovenous structure was mainly determined using a 3-dimensional volume-rendering method. The preoperative simulation was performed at the initial stage of the study and the intraoperative at a later stage. The simulated images were used to identify the venous branches in the affected segment for division and the intersegmental veins to be preserved. Four 5- to 20-mm ports were used. Segmentectomy was performed by separating the pulmonary arteries and bronchi followed by dissection along the intersegmental plane. RESULTS: Fifty-one patients underwent a complete thoracoscopic segmentectomy. A mini-thoracotomy was performed in 1 case because of arterial bleeding. The success rate of segmentectomies under complete thoracoscopy was 98%. The procedure was classified into 3 categories according to the degree of surgical difficulty. Before introducing the simulation, there were 4 easy cases and 1 fairly difficult case. After introducing preoperative simulation, 7 cases were classified as fairly difficult among 12 segmentectomy cases. Furthermore, 7 cases of difficult segmentectomy were performed using intraoperative simulation. No local recurrence or metastasis and no mortality were observed during the follow-up. CONCLUSIONS: Thoracoscopic pulmonary segmentectomy under 3-dimensional multidetector computed tomography simulation is a safe technique.

Anatomical lung segmentectomy simulated by computed tomographic angiography.

We describe the benefits of simulating lung segmentectomy by using multi-detector computed tomographic angiography. Preoperative determination of the anatomical, intersegmental plane is possible by visualizing the branches of the pulmonary veins. This new technique could be useful in thoracoscopic segmentectomy of the lung.

Total thoracoscopic pulmonary segmentectomy.

OBJECTIVE: In lung resection, thoracoscopy has been mainly used for wedge resection and lobectomy. There have been very few reports on pulmonary segmentectomy, mainly because of its complex nature. The present report evaluates the safety and efficacy of thoracoscopic pulmonary segmentectomy for the treatment of benign lung diseases or small lung carcinomas. METHODS: The study involved 30 patients who underwent thoracoscopic segmentectomy without a minithoracotomy from September 2004 to March 2008. The median age of the patients was 69 years (range, 16-81 years). Four 5-20 mm ports were used. The pulmonary vessels were ligated, and the bronchi were closed using a stapler. An electrocautery was used for intersegmental dissection. Chest tubes were inserted in all cases. RESULTS: Twenty-eight patients underwent complete thoracoscopic segmentectomy. A minithoracotomy was created in one case because of arterial bleeding, and open lobectomy was performed in another case owing to the diagnosis of small cell carcinoma. The operative time ranged from 147 to 425 min (median time, 216 min). The inserted chest tubes were maintained in position for 1-7 days (median duration, 1 day). One patient developed subcutaneous emphysema that spontaneously resolved. No mortality was observed for 30 days after the surgery. Further, no local recurrence or metastases were observed during follow-up in cases of malignancy. CONCLUSIONS: Thoracoscopic pulmonary segmentectomy is a feasible and safe technique. Reduced postoperative pain and an improved cosmetic outcome are considered advantages of this minimally invasive procedure.

Role of diffusion-weighted magnetic resonance imaging for predicting of tumor invasiveness for clinical stage IA non-small cell lung cancer.

OBJECTIVES: Recently, diffusion-weighted MR imaging (DWI) for the whole body has become available for clinical use, as has been previously used for the central nervous system. Favorable results have been reported using this imaging system to differentiate between benign and malignant lesions in some organs, and to correlate with the degree of cell differentiation in lung cancer. The purpose of this study was to assess the role of DWI for predicting tumor invasiveness of non-small cell lung cancers (NSCLC), especially for clinical stage IA patients. METHODS: From January 2006 to September 2007, preoperative DWI and 18F-FDG-PET/CT were performed on 41 patients with clinical stage IA NSCLC who had undergone curative operations. Lung cancers that exhibited nodal, lymphovascular or pleural invasion were defined as invasive lung cancers. Nodules with strong dark signal, as observed by DWI in spinal cords, were defined as DWI-positive. We analyzed the associations between the pathological findings and the following preoperative clinical factors: age, gender, smoking history, preoperative CEA levels (<5.0 or >/=5.0ng/ml), preoperative tumor size, SUV max on PET/CT (<5.0 or >/=5.0) and DWI (positive or negative). RESULTS: A total of 15 lesions (37%) were assessed as DWI-positive and 26 lesions (63%) were DWI-negative. Univariate analyses showed positive correlations for development of invasive cancer with the preoperative CEA level (p=0.049), SUV max (p=0.001) and DWI (p<0.001). Multivariate analysis showed that DWI (p=0.005) was an independent predictive factor for tumor invasiveness. CONCLUSION: Our results suggest that DWI might be a useful method for predicting tumor invasiveness for clinical stage IA NSCLC.