Video-assisted thoracoscopic right anterior, lateral, and medial segmentectomy for primary lung cancer of the middle lobe with incomplete interlobar fissures.

A 63-year-old woman was referred to our hospital due to an abnormal shadow in the right middle lung field on chest X-ray. Chest computed tomography revealed a 2.0 cm nodule in the right lateral segment of the middle lobe. The nodule was confirmed to be lung adenocarcinoma by transbronchial lung biopsy. Because the tumor was located near the incomplete interlobar fissures, resection might traditionally be performed by right upper and middle lobectomy. However, we chose a minimally invasive intervention and performed anterior, lateral, and medial segmentectomy under video-assisted thoracic surgery. This technique resulted in complete tumor resection with minimal adverse effects.

New technique for fixing rib fracture with bioabsorbable plate.

Fixation of a bone fracture with a bioabsorbable plate made of poly-L-lactide and hydroxyapatite has received attention. We adopted this technique for a rib fracture by bending the plate into a U-shape and fixing it with suture through the holes in the mesh of the plate and holes that are drilled in the edge of the fractured rib. The suture is also wound around the plate.

Proposal of new nodal classifications for non-small-cell lung cancer based on the number and ratio of metastatic lymph nodes.

OBJECTIVE: The study aimed to evaluate the effectiveness of two new nodal classifications based on the number of metastatic lymph nodes (LNs) or ratio of metastatic to examined LNs (LNR) in making a prognosis, compared with the current nodal classification based on the location of metastatic LNs. METHODS: We analyzed 651 non-small-cell lung cancer patients who had undergone complete resection with the removal of more than five LNs between 1986 and 2003, excluding preoperative treatment cases, and a Tis, T4, N3, and M1 status, along with limited resection and operative death cases. The cutoff numbers for each category in the two new nodal classifications (number of metastatic LNs (nN0-2): 0, 1-2, and >3, and LNR (rN0-2): 0, 1-12, and >12%) were defined so that the numbers corresponded with paired categories within the current nodal classification. RESULTS: The 5-year survival rate was 75.4% for patients with the N0 categories in all three classifications. The 5-year survival rates for patients with N1 and N2 categories were 52.2% and 42.6% according to the current nodal classification, 54.3% and 39.8% according to the number of metastatic LNs, and 58.8% and 35.0% according to the LNR, respectively. Although all three nodal classifications were independent prognostic factors along with the age and pathological T status, when the three nodal classifications were entered into multivariate analysis individually, the hazard ratio of rN2 was the highest, at 3.15, followed by that of nN2 at 2.96. CONCLUSIONS: The LNR followed by the number of metastatic LNs may be more effective prognostic indicators than the current nodal classification based on the location of metastatic LNs. For the future revision, the number of metastatic LNs and LNR should be evaluated as indicators for the nodal classification of lung cancer.

Type AB thymoma with brain metastasis: Report of a case.

Type AB thymomas are considered to be nonaggressive tumors, and the great majority are classified as Masaoka stage I or II. This report presents a case with Masaoka stage I and type AB thymoma, which metastasized to the brain 2 years 5 months after removal of the primary tumor. The original mediastinal lesion was adhesive but not invasive to the lung. The patient is now alive with multiple tiny pulmonary metastases 3 years after complete resection of the brain metastasis. Some reports of recurrent thymomas have suggested that the presence of peritumoral adherence to the adjacent structures might be a risk factor for recurrence in patients with such noninvasive thymomas. During the development of fibrosis which thus causes adhesion, the tumor may have an increased chance to metastasize because of the increased vessels and lymphatics.

Azygos flap as a novel method for superior vena cava reconstruction.

In the surgical treatment of lung cancers invading the superior vena cava (SVC), primary closure is preferred for reconstruction when the resected area is small, but the repaired vessel can become constricted. A novel method for SVC repair with azygos flap, which is a longitudinally opened azygos arch, is a facile and effective treatment, and may prevent a reduction in the lumen if the area of tumor invasion is small and close to the azygos arch. When the azygos arch is not invaded by the tumor, this procedure should therefore be considered as one alternative method for SVC reconstruction.

Thymoma concomitant with a right aortic arch.

A 63-year-old woman was referred to our hospital because screening had detected an anterior mediastinal tumor with a right aortic arch. She underwent typical total thymectomy via a median sternotomy but developed left recurrent laryngeal nerve (RLN) palsy postoperatively. The pathology examination revealed that the tumor was a stage I thymoma. This is the first report of a thymoma with a right aortic arch. The left RLN goes around the left ductus arteriosus, which connects the origin of the left subclavian artery to the left pulmonary artery. The RLN was likely to be injured in the neighborhood of the left ductus arteriosus when the tumor and thymus were dissected over the pulmonary artery. During operations for an anterior mediastinal tumor with a right aortic arch, we should be attentive to the location of the tumor, the left ductus arteriosus, and the left RLN.

Acute occlusion of left coronary ostium associated with congenital quadricuspid aortic valve.

A 10-year-old girl suffered from chest discomfort during exercise. She experienced an acute myocardial infarction accompanied by an obstruction in an orifice to the left coronary artery. An emergency operation revealed that the aortic valve was quadricuspid, and a left-sided small cusp had adhered to the aortic wall resulting in an unusual sac with a tiny slit. Resection of the sac disclosed the ostium to left coronary artery. Blood toward the left coronary artery passed through the tiny slit. The mechanisms of obstruction in the coronary artery were uncertain. She recovered well after the aortic valve replacement with resection of the aortic cusps.