Solitary Splenic Metastasis of Lung Cancer Presenting as Benign Cystic Disease.

Solitary splenic metastasis from primary lung cancer is extremely rare. Here, we demonstrated a solitary splenic metastasis of primary lung cancer that was difficult to distinguish from benign cystic disease. A 69-year-old-female was diagnosed as middle lobe lung cancer. Although preoperative abdominal computed tomography (CT) demonstrated a low-density splenic nodule, fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed no fluorodeoxyglucose uptake in the splenic nodule. Therefore, the nodule was diagnosed as benign cystic disease and middle lobe lobectomy was performed. Postoperative pathologic examination demonstrated papillary-predominant adenocarcinoma with mucin, and the tumor was diagnosed as primary lung cancer. However, the splenic nodule continued to increase postoperatively. Splenectomy was undergone 30 months after the pulmonary resection and the splenic tumor was diagnosed as the splenic metastasis of lung cancer. In the 24 months since the splenectomy, no recurrence has been observed in the absence of treatment. Splenectomy was an effective treatment for solitary splenic metastasis of lung cancer in this case. FDG uptake in the splenic tumor was not evident due to marked mucus production.

Case report of thoracoscopic resection for broncholithiasis with severe obstructive pneumonia.

Broncholithiasis is a rare disease characterized by bronchial erosion or distortion due to hilar or parenchymatous calcification. When a broncholith has no mobility and there is a risk of major bleeding if removal is attempted, surgical intervention is required. Most operations for broncholithiasis are performed via a thoracotomy, and bronchial lithotripsy under complete video-assisted thoracoscopic surgery has been reported only rarely. We have experienced a case of broncholithiasis with severe obstructive pneumonia that was treated successfully by video-assisted thoracoscopic surgery. Thoracoscopic surgery is an effective treatment for broncholithiasis because it is minimally invasive and aids smooth recovery after surgery. When the adhesion between the pulmonary artery and the bronchus is highly advanced, it is advocated to cut them together using an endostapler.

Preoperative Smoking Cessation Period Is Not Related to Postoperative Respiratory Complications in Patients Undergoing Lung Cancer Surgery.

PURPOSE: Smoking is reported to be a risk factor for postoperative complications. However, there is no consensus regarding the length of time for which patients need to give up smoking. Therefore, we examined the relationship between preoperative smoking status and postoperative complications in patients who underwent lobectomy for treatment of lung cancer. METHODS: Between January 2009 and December 2014, 1380 patients underwent lobectomy for lung cancer at our institution. After excluding patients who had undergone induction therapy, 1248 patients were enrolled in this study. We examined the relationship between postoperative complications and preoperative smoking habitation. RESULTS: Among the enrolled patients, 1210 (97%) underwent video-assisted thoracoscopic lobectomy and 38 (3%) underwent lobectomy via open thoracotomy. The incidence of postoperative complications was higher in smokers than in nonsmokers, and the frequency of respiratory-related complications increased along with the number of pack-years. However, there was no relationship between the length of the preoperative smoking cessation period and the frequency of postoperative complications. CONCLUSION: The risk of postoperative complications does not increase even if smoking is continued within 2 weeks before surgery. It seems unnecessary to delay the timing of surgery to allow patients to cease smoking, especially those scheduled for thoracoscopic surgery.

Nodule around the staple line after pulmonary resection: benign granuloma or cancer recurrence?

PURPOSE: When a mass develops around the staple line after lung cancer surgery, differential diagnosis between lung cancer recurrence and benign granuloma can be clinically problematic. Therefore, we investigated the clinical characteristics of benign granuloma and cancer recurrence around the staple line to determine clinical factors that can distinguish staple line granuloma and cancer recurrence. METHODS: We retrospectively investigated the clinical records of 25 patients who developed a nodule around the staple line after pulmonary resection for lung cancer and conducted a comparative study of staple line granuloma and cancer recurrence. RESULTS: Among 25 patients, the nodule was diagnosed as benign granuloma in 9, recurrence of primary lung cancer in 8, and recurrence of metastatic lung cancer in 8. Among these three groups, there were no significant differences in age, maximum standardized uptake value of fluoro-deoxyglucose, laboratory data, or radiological findings. However, in comparison with the cancer recurrence cases, the proportion of patients who had undergone segmentectomy as initial surgery was significantly higher in the granuloma group. Moreover, in five patients in the granuloma group, mycobacterium was detected. CONCLUSION: It seemed difficult to differentiate between cancer recurrence and granuloma on the basis of radiological examination and laboratory findings. However, if a mass shadow around the staple line appeared after segmentectomy, the mass is likely to be a granuloma. Mycobacterial infection may be an important factor for development of granuloma on the staple line.

Video-assisted thoracoscopic surgery for lung cancer after induction therapy.

Background Although thoracoscopic surgery is widely performed for early-stage lung cancer, only a few small studies have evaluated the role of video-assisted thoracoscopic surgery in patients with locally advanced lung cancer who had received preoperative chemotherapy. Methods Among 1655 patients who underwent anatomical lung resection for lung cancer between January 2009 and December 2014 in our institution, we retrospectively examined the short- and long-term outcomes of 110 (6.6%) who had undergone induction therapy. Thoracoscopic surgery was performed in 79 of these patients and thoracotomy in 31. Results In the thoracoscopic group, conversion to a thoracotomy was required in 4 patients. More combined resections were included in the thoracotomy group, and combined resection of large vessels or the carina was carried out only via a thoracotomy. Postoperative complications of grade 3 or above were found in 15 (13.6%) patients, and there was no significant difference in the incidence of postoperative complications between the 2 groups. The 3- and 5-year survival rates for the patients overall were 58.6% and 50.3%, respectively. Although there was no significant difference in overall outcome between the 2 groups, the patients with postoperative ypN2 status in the thoracoscopic group had a significantly better outcome than those in the thoracotomy group. Conclusion Although video-assisted thoracoscopic surgery was not suitable for central advanced lung cancer requiring angioplasty or carinal resection, it seems to be useful for patients with locally advanced lung cancer who had undergone induction therapy, especially patients with peripheral lung cancer and mediastinal lymph node metastasis.

The outcomes of anatomical lung resection for nontuberculous mycobacterial lung disease.

BACKGROUND: The number of cases of nontuberculous mycobacterial (NTM) lung disease has been increasing in recent years, and the efficacy of surgical treatment has been recognized. We investigated the clinical characteristics and behavior of NTM lung disease and analyzed the outcomes of surgery. METHODS: The data of 25 patients who underwent anatomical resection for NTM lung disease in our institution between January 2004 and December 2014 were retrospectively examined. RESULTS: The patients included 10 men and 15 women (mean age, 63.1 years). Twenty patients had Mycobacterium avium, and 5 had Mycobacterium intracellular. The indications for lung resection in 20 definitively diagnosed patients included a remaining or worsening lesion despite medical treatment (n=16), massive hemoptysis or bloody sputum (n=5), and prolonged smear positivity (n=1); multiple reasons were allowed. In five cases without a definitive diagnosis, surgery was performed due to the suspicion of lung cancer. The surgical procedures included pneumonectomy, n=4; lobectomy, n=13; and segmentectomy, n=8. Complete resection was achieved in 10 cases (40.0%). Video-assisted thoracoscopic surgery (VATS) was performed in 17 cases (68.0%), especially in 6 of 8 cases (75.0%) that underwent segmentectomy and in 10 of 11 cases (90.9%) that received simple lobectomy. There was one case of hospital mortality. Among the 22 patients who were followed at our institution, relapse occurred in 4 patients, and new infection occurred in 1 patient. NTM lung disease was controlled in 17 patients (77.3%). In the four cases that relapsed, the median relapse-free interval was 29.5 months. CONCLUSIONS: Surgical resection was a feasible treatment for NTM lung disease and was associated with favorable outcomes, although there was 1 case of hospital mortality. VATS procedures were considered adequate for the treatment of NTM lung disease; however, the surgical indications must be carefully considered.

Significance of Body Mass Index for Postoperative Outcomes after Lung Cancer Surgery in Elderly Patients.

BACKGROUND: Although the frequency of elderly patients undergoing surgery for lung cancer has been increasing, indications for surgery in elderly patients are still controversial. Low body mass index is a significant predictor of poor prognosis in elderly patients with various medical conditions. Then, we examined the long-term outcome of elderly patients who had undergone thoracic surgery for lung cancer, focusing especially on body mass index. PATIENTS AND METHODS: Between January 2004 and March 2011, 1673 patients with lung cancer underwent surgical resection at our institution. Among these patients, we retrospectively examined 158 patients aged 80 years or older. RESULTS: Perioperative morbidity and mortality rates were 41.8 and 1.3%, respectively. Among 149 patients who were completely followed up, 80 patients (53.7%) died. The overall postoperative survival rates at 3 and 5 years were 66.9 and 49.9%, respectively. Univariate analysis demonstrated that sex (female), smoking index (pack-years <20), histology (non-squamous cell carcinoma), pathological stage (stage I) and BMI (within normal BMI) were statistically significant factors associated with better outcome. Multivariate analysis revealed that patients with a low (<18.5 kg/m2) or high (≥25 kg/m2) body mass index had a significantly and poorer prognosis than patients with a normal body mass index. CONCLUSION: Body mass index is a more useful prognostic factor than other clinical factors including pathological stage in elderly patients. Because elderly patients with low and high body mass index have a significant poor prognosis, surgeons and pulmonologist should take this into account when consider surgical indication for such elderly patients.

Phrenic Nerve Reconstruction and Bilateral Diaphragm Plication After Lobectomy.

A 49-year-old man with left phrenic nerve paralysis caused by mediastinal tumor resection 28 years earlier was found to have a nodule in the right upper lobe. The right phrenic nerve was severed during right upper lobectomy but was reconstructed along with bilateral plication of the diaphragm. The patient was weaned from the ventilator during the daytime on postoperative day 13 and was discharged home on postoperative day 48. Three months postoperatively, chest fluoroscopic imaging showed recovery of movement of the right diaphragm. Nerve conduction studies showed improvement of function of the reconstructed right phrenic nerve.

[Organizing Pneumonia with High Radiotracer Concentration on Fluorodeoxyglucose-positron Emission Tomography, Mimicking Pleural Dissemination of Lung Cancer;Report of a Case].

A 68-year-old man was referred to our hospital because of an abnormal shadow in the chest roentgenogram. Chest computed tomography (CT) showed the nodule in the right upper lobe (S3), 17 mm in size. One month later, fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT scanning revealed positive reaction in the right upper lobe lesion and new lesion close to another lobe. In addition, interloblar small nodules were detected, 5 mm and 7 mm in size. A transbronchial brush cytology by bronchoscopy was performed, and the microscopic findings demonstrated the presence of atypical cells, suspected adenocarcinoma. The video-assisted thoracoscopic surgery was performed to establish a diagnosis and a treatment. Histopathological examination showed no malignancy and organizing pneumonia with inflammation. In case of the PET-positive solitary nodule increasing in size, organizing pneumonia should be included in the differential diagnosis.

Clinical results of bronchial stump coverage using free pericardial fat pad.

OBJECTIVES: Bronchial fistula is a severe complication after thoracic surgery. Although many methods of coverage using various autologous tissues including pedicled pericardial fat pad have been reported to be useful for the prevention of bronchial fistula, the ideal roles of these approaches and the coverage techniques yielding the best results still remain unclear. The clinical use of an autologous free fat graft has been reported in the various surgical fields including otolaryngology, orthopaedics and plastic surgery. Therefore, we have used a free pericardial fat pad (FPFP) as the material for covering the bronchial stump instead of a pedicled pericardial fat pad. METHODS: Between January 2009 and December 2013, 1134 patients with lung cancer underwent pneumonectomy or lobectomy without bronchoplasty at our institution. Among them, 46 patients underwent bronchial stump coverage using a FPFP and we investigated the clinical results obtained retrospectively. RESULTS: Bronchial fistula occurred in 5 patients during the study period. Although we performed bronchial stump coverage mainly in patients with several risk factors for bronchial fistula, no bronchial fistula developed in this group. To investigate the viability of the FPFP, we examined the fat tissue around the bronchial stump demonstrated by chest computed tomography retrospectively. Although fat tissue at the bronchial stump gradually decreased in size, it remained evident for 5 months and was identified in almost half of the patients even at 1 year after surgery. CONCLUSIONS: No bronchial fistula developed in the FPFP group. Although the FPFP is a free flap, it remains viable for many months after surgery and may contribute to good wound healing of the bronchial stump by offering a wet environment. A pericardial fat pad is easy to make, can be used anywhere in the thoracic cavity and may be useful for bronchial stump reinforcement.

Severe Mediastinitis and Pericarditis After Transbronchial Needle Aspiration.

Endobronchial ultrasonographically guided transbronchial needle aspiration (EBUS-TBNA) is now widely performed for mediastinal lymph node staging of lung cancer. Although this procedure is less invasive than mediastinoscopy, some infectious complications have been reported. We report the successful use of pericardial and mediastinal drainage in a case of acute severe mediastinitis with pericarditis after EBUS-TBNA.

Intraoperative fine-needle aspiration biopsy (FNA) for lung cancer: diagnostic value and risk of pleural dissemination.

PURPOSE: Intraoperative fine-needle aspiration biopsy (FNA) is one of the most important diagnostic tools for undiagnosed lung nodules suspected of being lung cancer; however, the sensitivity and safety of FNA, including the risk of intrapleural dissemination of cancer cells, have not been established. METHODS: Between 2006 and 2008, 324 patients underwent lung resection for cancers located in the lung periphery. Intraoperative FNA for definite diagnosis was performed immediately after thoracotomy in 147 (45.4%) of these patients, but not in the other 177. RESULTS: A diagnosis of lung cancer was obtained by the intraoperative FNA in 124 (84.4%) of the 147 patients. During a median follow-up of 55 months, pleural dissemination or malignant effusion ipsilateral to the operated side as the first recurrent site occurred in 11 (7.4%) of the 147 patients who underwent the needle biopsy and 10 (5.6%) of the 177 patients who did not. This difference was not significant (P = 0.5046). CONCLUSION: Intraoperative FNA was safe and useful for the diagnosis of peripheral lung cancer and did not increase the risk of pleural dissemination in this series.

[Interlobar neurinoma with a cystic formation derived from the vagal pulmonary branches].

A 60-year-old woman was referred to our hospital because of an abnormal shadow in the chest roentgenogram. Chest computed tomography (CT) showed the mass with heterogeneous low attenuation in the right lower lobe (S6), 40 mm in size. Fluorodeoxyglucose-positron emission tomography (FDGPET)/CT scanning revealed slight positive reaction in the right lower lobe lesion. The video-assisted thoracoscopic surgery (VATS) was performed to establish diagnosis and treat. Intraoperative finding showed the tumor was located between the left upper lobe and the left lower lobe, and the inflow of the vagal pulmonary branches. Histopathological examination showed no malignancy and neurinoma with a cystic formation derived from the vagus nerve.

Four cases of contralateral pneumothorax after pneumonectomy.

Contralateral pneumothorax after pneumonectomy (CPAP) is a rare but potentially fatal condition. Therefore, when treating CPAP prevention of recurrence is very important. Despite a number of case reports about CPAP, its management is still controversial. We describe 4 cases of CPAP that were treated successfully by bullectomy and coverage with absorbable polyglactin mesh.

Video-assisted thoracoscopic pneumonectomy: retrospective outcome analysis of 47 consecutive patients.

BACKGROUND: Although video-assisted thoracoscopic surgery (VATS) lobectomy is widely accepted, VATS pneumonectomy remains an uncommon procedure in patients with complicated diseases. METHODS: Of 47 consecutive patients who were planned to undergo VATS pneumonectomy from May 2000 to May 2012 at the National Hospital Organization Himeji Medical Center, VATS pneumonectomy was completed successfully in 46 patients (2.1% conversion rate). Appropriate tissue retraction and cooperative dissection of hilum structures under only thoracoscopic visualization were applied to all candidates. We retrospectively reviewed morbidity, mortality, local disease control, and surgical considerations to evaluate the validity of this procedure. RESULTS: All patients had malignant tumors, including 45 with primary lung cancer. One patient with a severe adhesion around a tumor required conversion to open thoracotomy, with no subsequent specific complications. Of 46 patients in whom VATS pneumonectomy was completed, the mean operation time was 159 minutes and the mean blood loss was 258 g. Surgery-related death occurred in 1 patient (mortality rate: 2.2%) with recurrent heart failure after discharge. Seven patients (15.2%) had major complications defined as grade 3 or higher (Common Terminology Criteria for Adverse Effects, version 4.0) within 30 days postoperatively; however, no patients exhibited secretion retention that required bronchoscopy. There were no patients with locoregional recurrence within usual lymph node dissection areas and the ipsilateral thoracic cavity among 44 patients with primary lung cancer who underwent VATS pneumonectomy, with the median follow-up time of 27 months. CONCLUSIONS: Video-assisted thoracoscopic surgery pneumonectomy has developed into a common procedure with acceptable damage and lower morbidity among selected patients with complicated diseases.

Video-assisted thoracoscopic surgery for nontuberculous mycobacterial infection.

BACKGROUND: The number of patients with nontuberculous mycobacterium infection is increasing in Japan, and therefore surgical treatment is also being applied with increasing frequency. Although the effectiveness of surgery for nontuberculous mycobacterium disease has been established and reported by a number of authors, the role of video-assisted thoracoscopic surgery in the surgical treatment of nontuberculous mycobacterium disease has not been sufficiently investigated. PATIENTS AND METHODS: We retrospectively investigated 10 patients, comprising 5 males and 5 females, who underwent video-assisted thoracoscopic lobectomy or segmentectomy for nontuberculous mycobacterium disease at our institution between February 2006 and November 2012. The average patient age was 59.5 years (range 53-65 years). We performed lobectomy in 6 cases and segmentectomy in 4. RESULTS: All surgical procedures were completed under video-assisted thoracoscopic surgery and none required conversion to thoracotomy. Postoperatively, air leakage continuing for 7 days occurred in 2 patients but there was no severe postoperative complication. The median periods of postoperative drainage and hospitalization were 4.0 and 5.5 days, respectively. Among 8 cases followed up at our institution, reactivation of nontuberculous mycobacterium disease occurred in one case 4 years after surgery. CONCLUSION: Video-assisted thoracoscopic surgery is a safe and useful procedure for lobectomy and segmentectomy in patients with nontuberculous mycobacterium disease.

Video-assisted thoracic surgery lobectomy for lung cancer with displaced b(1+2.).

A 52-year-old man was diagnosed with lung adenocarcinoma in the left upper lobe (c-T1bN0M0). Preoperative bronchoscopy revealed a displaced anomalous B(1+2) arising from the left main bronchus. Multiplanar reconstruction computed tomography showed that the displaced B(1+2) was located behind the left main pulmonary artery, and the interlobar fissure was largely fused. Video-assisted thoracic surgery (VATS) left upper lobectomy was performed successfully. The "no-touch fissure" technique was efficient not only for avoiding accidental cutting of the displaced bronchus but also post-operative air leakage. This is the first reported case of VATS lobectomy for lung cancer associated with a displaced B(1+2).

Pulmonary hyalinizing granuloma detected in a family member after confirmation of tuberculosis in his father.

Pulmonary hyalinizing granuloma (PHG) is an uncommon lung disease that usually presents as bilateral multiple nodules, and more rarely as a solitary nodule. An exaggerated immune response to antigenic stimuli resulting from infection or an autoimmune process has been suggested as the cause of PHG. Here, we describe a rare case of solitary PHG that was detected in a family member after tuberculosis had been confirmed in his father, without any background of infectious disease or autoimmune abnormality.