[Anaphylaxis Induced by Fibrin Glue During Surgery for Pneumothorax].

We report here our experience with a case of anaphylactic shock caused by fibrin glue. A 51-year-old male underwent a thoracoscopic surgery for refractory pneumothorax under local anesthesia. Bullae were revealed, and subsequently covered with fibrin glue and a polyglycolic acid sheet. Twenty-minutes after application of the fibrin glue, sudden drop of blood pressure less than 80 mmHg and a skin rash appeared. Since the patient was not administered any other drugs prior to the reduction in blood pressure, anaphylactic shock was considered to be caused by fibrin glue. The patient recovered after the treatment by dopamine and steroid.

CD271 is a negative prognostic factor and essential for cell proliferation in lung squamous cell carcinoma.

Squamous cell carcinoma is a major type of cancer in the lung. While several therapeutic target molecules for lung adenocarcinoma have been identified, little is known about lung squamous cell carcinoma (LSCC). We recently reported that CD271 (p75 neurotrophin receptor) serves as a marker for tumor initiation and is a key regulator of cell proliferation in hypopharyngeal squamous cell carcinoma. In this study, we found that CD271 was also expressed in squamous cell carcinoma, but not in adenocarcinoma, of several tissues, including the lung, and the expression of CD271 was associated with a poor prognosis in LSCC. To examine CD271's role in LSCC, we established xenograft cell lines from LSCC patients. Within the sorted live LSCC cell population, the CD271high cells were primarily cycling through the G2/M phase, while the CD271low cells were mostly in the G0 phase. CD271 knockdown in the LSCC cells completely suppressed their proliferation and tumor-formation capability, and increased their cell-cycle arrest in the G0 phase. In the CD271-knockdown cells, ERK-phosphorylation was decreased, while no change was observed in the IκBα-phosphorylation, p65-phosphorylation, or Akt-phosphorylation. Treatment with the MEK inhibitor U0126 decreased the LSCC cells' proliferation capability. Microarray analysis revealed that CD271 knockdown attenuated the RAS-related pathways. The knockdown of TrkB, which forms a heterodimer with CD271 and accelerates its downstream signaling, partially inhibited the LSCC cell proliferation. These results indicated that LSCC exclusively depends on CD271 for cell proliferation, in part through ERK-signaling activation, and CD271 is a promising target for LSCC therapy.

Periostin is a negative prognostic factor and promotes cancer cell proliferation in non-small cell lung cancer.

Periostin is a matricellular protein that is secreted by fibroblasts and interacts with various cell-surface integrin molecules. Although periostin is known to support tumor development in human malignancies, little is known about its effect on lung-cancer progression. We here demonstrate that periostin is a negative prognostic factor that increases tumor proliferation through ERK signaling in non-small cell lung carcinoma. We classified 189 clinical specimens from patients with non-small cell lung-cancer according to high or low periostin expression, and found a better prognosis for patients with low rather than high periostin, even in cases of advanced-stage cancer. In a syngenic implantation model, murine Ex3LL lung-cancer cells formed smaller tumor nodules in periostin-/- mice than in periostin+/+ mice, both at the primary site and at metastatic lung sites. An in vitro proliferation assay showed that stimulation with recombinant periostin increased Ex3LL-cell proliferation. We also found that periostin promotes ERK phosphorylation, but not Akt or FAK activation. These findings suggest that periostin represents a potential target in lung-cancer tumor progression.

Preoperative bronchoscopic cancer confirmation does not increase risk of recurrence in stage1A non-small cell lung cancer.

OBJECTIVE: This study was conducted to evaluate the risk of recurrence possibly caused by preoperative bronchoscopic cancer confirmation in stage1A non-small cell lung cancer. METHODS: One hundred and seventy-nine cases of peripheral non-small cell lung cancer (including 151 adenocarcinoma) with no more than 3 cm in their tumor longer diameter were selected. All patients underwent preoperative diagnostic bronchoscopy followed by lobectomy, and were demonstrated to have pathologically free of lymph node involvement and pleural involvement. Radiological and pathological low-grade adenocarcinomas were excluded. Of 179 cases, 95 were confirmed lung cancer by bronchoscope (Group 1) and rest 84 had failed cancer confirmation by bronchoscope before surgery (Group 2). Forty-eight pairs for non-small cell lung cancer and 41 pairs for adenocarcinoma were identified from each group by propensity caliper matching. Kaplan-Meier method and log-rank test were performed on matched groups, and Cox proportional hazard model analysis was performed on whole matched cases. RESULTS: Log-rank test revealed no significant inferiority of recurrence-free survival of Group 1 in both all-NSCLC and adenocarcinoma subset. Cox proportional hazard model analysis also revealed that the 'presence of preoperative bronchoscopic cancer confirmation' dose not increase risk of recurrence in both NSCLC and adenocarcinoma subset. CONCLUSIONS: It is unlikely that preoperative bronchoscopic cancer confirmation would increase recurrence risk in stage1A non-small cell lung cancer; however, a future prospective study with larger cohorts would be warranted to validate the results.

Nivolumab-Induced Severe Akathisia in an Advanced Lung Cancer Patient.

BACKGROUND Nivolumab is an anti-PD-1 immune checkpoint inhibitor that was recently developed for cancer immunotherapy. In the clinical trials of nivolumab, its adverse effects were reported to be less likely than those of conventional anti-cancer agents; however, after practical clinical distribution, it has come to be known that nivolumab induces various immune-related adverse events. CASE REPORT A 58-year-old male with a recurrence of lung adenocarcinoma was treated with nivolumab. Only four days after the initial administration of nivolumab, the patient presented with unbearable restlessness and distress that was resistant to all therapeutic agents used, and it gradually became worse. He finally came to need deep sedation despite his cancer status being stable during the course. Clinical tests including magnetic resonance imaging, cerebrospinal fluid cytology, and antibodies of paraneoplastic syndrome exhibited no signs of encephalitis or another possible cause of the neuropathy. The diagnosis of akathisia could be made only by his somatoform presentation. It was uncertain whether or not this complication was correlated with the activation of his immune system. CONCLUSIONS Anti-immune check point inhibitors may induce many unknown adverse events. Severe akathisia induced by nivolumab, as in our case, has not been reported yet. Collecting every adverse event of nivolumab may be important to make a better algorithm to manage its huge variety of complications.

Mixed squamous cell and glandular papilloma of the lung resembling early adenocarcinoma: A case report.

INTRODUCTION: An extremely rare case of mixed squamous cell and glandular papilloma of the lung is reported. The correlation between the radiological and the pathological features as well as the clinical pitfall in making a diagnosis is discussed. PRESENTATION OF CASE: An asymptomatic 68-year-old female with a cigarette smoking habit presented with a small nodule in her peripheral lung. A wedge resection was performed though it failed on-site diagnosis which was instead obtained following pathological scrutiny. The postsurgical course was excellent with no recurrence of disease. DISCUSSION: A small ground glass nodule gradually enlarged and transformed to a partially solid nodule a year and a half later. This transformation falsely made us suspect an early adenocarcinoma development. Eventually, the extremely rare subtype of pulmonary papilloma, with biphasic glandular and squamous cells, had been demonstrated to obstruct the peripheral bronchiole; and the adjoining alveoli had filled with a large volume of mucus. These pathological features seemed to have constituted the inner solid portion and the marginal ground glass portion respectively in the CT images, mimicking invasive lepidic adenocarcinoma. CONCLUSION: Both pre- and intra-operative diagnoses are difficult mainly because of the rareness of the disease, however, mixed squamous cell and glandular papilloma may be considered in case the presence of primary adenocarcinoma is not validated.

Fatal broncho-pulmonary artery fistula after lobectomy for lung cancer†.

A broncho-pulmonary artery fistula is one of the most fatal complications of lung cancer surgery. This article discusses the case of a patient who died of massive hemoptysis after a left upper lobectomy. There were no previous signs of broncho-pleural fistula except for an obstinate dry cough and slightly elevated serum C-reactive protein levels after surgery. An autopsy revealed that a fistula had formed between the bronchial stump and the pulmonary artery, leading to prolonged inflammation and ultimately a broncho-pulmonary artery fistula. The left lobectomy and right upper sleeve resection are the procedures most affected by this complication, according to the reviewed literature. The median period from the surgery to the events is 4 weeks. Abrupt onset of recurrent hemoptysis in that period is the most critical sign that should not be ignored.

Preoperative saline-filled computed tomography thoracography for awake video-assisted thoracic surgery: report of three cases.

Awake video-assisted thoracic surgery (VATS) is a therapeutic option for patients with intractable secondary spontaneous pneumothorax (SSP) complicated by impaired pulmonary function. The preoperative identification of air leak points is one of the keys to the success of this procedure. We describe how we performed saline-filled computed tomography (CT) thoracography to detect pleural fistulae in three patients with intractable SSP. Saline-filled CT thoracography showed bubble signs in two patients and an air-water level in bulla in one patient. The preoperative identification of air leak points resulted in successful awake VATS for all three patients. Our experience demonstrates that saline-filled CT thoracography is a useful diagnostic tool for SSP, especially when used in preparation for awake VATS when minimally invasive procedures are desirable.

[Management of a lung tumor accompanied by aortic dissection; report of a case].

During an annual health check-up, a 75-year-old man was admitted to our hospital due to an abnormal shadow in the left upper lung field. A computed tomography (CT) scan taken at his 1st hospital visit showed a calcified nodule in the left upper lobe and Stanford type A aortic dissection. We could not perform bronchofiberscopy due to the risk associated with the aortic dissection and could not make a diagnosis prior to surgery. Because of the possibility of lung cancer, surgery for the lung tumor and aortic dissection was performed. The pathological diagnosis of the lung tumor was a hematoma. In a case of suspicion of lung cancer along with cardiovascular disease, a surgical diagnosis might be considered.

Positron emission tomography for predicting recurrence in stage I lung adenocarcinoma: standardized uptake value corrected by mean liver standardized uptake value.

OBJECTIVE: F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has become an important staging tool for patients with lung cancer, and determination of the standardized uptake value (SUV) is probably the most widely used method for evaluating patients. Although SUV is recognized as a powerful surrogate marker for lung cancer outcomes, SUV standardization and reproducibility in clinical practice remain major concerns. The aim of this study was to evaluate the corrected SUV as a universal marker for lung cancer recurrence. METHODS: We conducted a case-control study in our institute. From May 2004 to February 2010, 141 patients with pathological stage IA and IB adenocarcinomas underwent PET-computed tomography scanning and SUV determination. The corrected SUV was defined as the SUV index, which was calculated as the ratio of tumor SUV(max) to liver SUV(mean). We examined the association between disease-free survival and several clinicopathological factors, including the SUV index. RESULTS: The 3-year overall survival rate after surgery was 94.3% and the 3-year disease-free survival rate was 90.4%. Univariate analysis showed that male gender (p=0.04), smoking (p=0.02), and SUV index (p<0.01) were independent predictive factors for recurrence. Multivariate analysis showed that the SUV index was significantly associated with a high risk for recurrence (p=0.03). No patient with an SUV index <1.0 experienced a recurrence. CONCLUSIONS: The SUV index is a significantly predictive and reproducible factor for recurrence in pathological stage I lung cancers. Patients with an SUV index <1.0 were more likely to have a good prognosis. Additional multi-institutional studies are needed to confirm these study results.

[Evaluation of diagnostic imagings of liver metastases].

With the advent of various therapeutic modalities for the management of metastatic liver tumor, the task of pretreatment imaging has become more demanding. US and CT are non-invasive, and the most widely used techniques for pretreatment imaging, but they are far from optimal. Recently, the most sensitive pretreatment imaging modality for the depiction of focal liver lesions is CT during arterial portography (CTAP); however, it is an invasive procedure with an established risk of false-positive results. CT and MRI are the sensitivities of these techniques have recently been improved with the development of multidetector CT, contrast agents for MRI that specifically accumulate in the liver, and other advances. Superparamagnetic iron oxide (Feridex) has been developed as a liver-specific particulate MRI contrast agent that is taken up by the Kupffer cells of the liver. Rational selection of appropriate modalities for a given purpose requires familiarity with the characteristics of each modality. The aim of the present study was to evaluate the sensitivities of diagnostic modalities in the pre- and post-treatment periods of metastatic liver tumor. Feridex-enhanced MRI (Ferumoxide MRI) is more sensitive than enhanced CT and MRI in the depiction of metastatic liver tumor. In terms of the ability to visualize residual tumor after MCT, dynamic MRI was superior to enhanced CT and Ferumoxide MRI. In conclusion, combined Ferumoxide MRI and dynamic MRI is a noninvasive method and clinically useful since it can change the therapeutic approach.