Guide sheath breakage during endobronchial ultrasonography.

This report describes a case of guide sheath breakage during endobronchial ultrasonography. While steering the guide sheath in the direction of a peripheral lung nodule using a guiding device/curette, the radiopaque band (RB) attached to the head of the guide sheath dislodged and remained in the peripheral bronchus near the tumour. The band could not be removed endoscopically. As the tumour was diagnosed as a colon cancer metastasis, we performed a partial lung resection to remove the RB and nodule together four months after bronchoscopy.

Neo-generation of neogenetic bullae after surgery for spontaneous pneumothorax in young adults: a prospective study.

BACKGROUND: To investigate the development of neogenetic bullae or blebs on 1-year postoperative chest computed tomography after video-assisted thoracic surgery (VATS) in young patients with primary spontaneous pneumothorax (PSP). METHODS: In this prospective study, 10- to 20-year-old patients with PSP were treated via VATS with additional procedures (bullectomy, cold coagulation, coverage, pleural abrasion, or chemical pleurodesis). All patients underwent the additional procedures and computed tomography of the chest 1 year postoperatively for the assessment of neogenetic bullae. Postoperative PSP recurrence was monitored, and recurrence-free survival was evaluated using Kaplan-Meier analysis. RESULTS: Fifty-seven patients (66 cases) aged 17 ± 2 years underwent VATS for PSP and were followed up for 938 ± 496 days. Of the 36 cases at 1-year follow-up, 23 (63.9%) showed neogenetic bullae, which were adjacent to the staple lines in 16 cases (69.6%). The 1- and 2-year recurrence-free survival rates were 88.9 and 85.1%, respectively. Nine of the 66 cases (13.6%) showed recurrence after 869 ± 542 days. A history of contralateral PSP was significantly associated with recurrence. CONCLUSIONS: VATS, combined with additional procedures, provides acceptable long-term results in young patients with PSP. Additional procedures reduce the recurrence rate of PSP but do not prevent the occurrence of neogenetic bullae. A history of contralateral PSP is a potential risk factor for post-VATS recurrence in young patients.

Thymectomy during Myasthenic Crisis under Artificial Respiration.

A 34-year-old man was diagnosed with thymoma, which was evaluated preoperatively as stage II or III, with myasthenia gravis (MG). The size of the tumor was 70 × 44 × 80 mm. No invasion to neighboring organs was observed. Prednisolone was prescribed for stabilization of MG. However, a myasthenic crisis (MC) occurred, and intensive care, including emergent endobronchial intubation followed by artificial ventilation, pulse steroid therapy, high-dose intravenous immunoglobulin, and tacrolimus hydrate, was initiated. A chest computed tomography on day 6 revealed tumor reduction to 50 × 30 × 60 mm. An extended total thymectomy by median sternotomy was performed, and artificial ventilation was continued after that. Scheduled artificial ventilation and steroid therapy together can, therefore, enable complete resection of thymoma in patients undergoing treatment for MC. While ventilation helps avert a respiratory failure, the steroid therapy temporarily reduces the tumor size, making resection easier.

[Surgical Treatment for Synchronous Double Cancer of the Thoracic Esophagus and Lung].

We herein report 2 cases of radical operation for synchronous double cancer of the thoracic esophagus and each side of the lung. Case 1:A 71-year-old woman with synchronous double cancer of the thoracic esophagus (Mt, T3N2M0, Stage III) and right lung (M, T2aN0M0, Stage I B) underwent esophagectomy concomitantly with right middle lobectomy through right thoracotomy (single-stage operation) after 2 courses of systemic chemotherapy with docetaxel, cisplatin and 5-fluorouracil( DCF regimen). Case 2:A 72-year-old man with synchronous double cancer of the thoracic esophagus( MtLt, T3N2M0, Stage III) and left lung( U, T1aN0M0, Stage I A) underwent 2-stage operation after 2 courses of the DCF therapy. Esophagectomy through right thoracotomy was performed followed by left upper lobectomy through left thoracotomy 3 months later. Treatment strategy for synchronous double cancer of the thoracic esophagus and lung is discussed based on our experiences and previous reports.

Primary and Secondary Spontaneous Pneumothorax: Prevalence, Clinical Features, and In-Hospital Mortality.

Background. Optimal treatment practices and factors associated with in-hospital mortality in spontaneous pneumothorax (SP) are not fully understood. We evaluated prevalence, clinical characteristics, and in-hospital mortality among Japanese patients with primary or secondary SP (PSP/SSP). Methods. We retrospectively reviewed and stratified 938 instances of pneumothorax in 751 consecutive patients diagnosed with SP into the PSP and SSP groups. Factors associated with in-hospital mortality in SSP were identified by multiple logistic regression analysis. Results. In the SSP group (n = 327; 34.9%), patient age, requirement for emergency transport, and length of stay were greater (all, p < 0.001), while the prevalence of smoking (p = 0.023) and number of surgical interventions (p < 0.001) were lower compared to those in the PSP group (n = 611; 65.1%). Among the 16 in-hospital deceased patients, 12 (75.0%) received emergency transportation and 10 (62.5%) exhibited performance status (PS) of 3-4. In the SSP group, emergency transportation was an independent factor for in-hospital mortality (odds ratio 16.37; 95% confidence interval, 4.85-55.20; p < 0.001). Conclusions. The prevalence and clinical characteristics of PSP and SSP differ considerably. Patients with SSP receiving emergency transportation should receive careful attention.

[Displaced B1+2 Found at Video Assisted Thoracic Surgery for Lung Cancer of Left Upper Lobe].

We report the case of an 83-year-old woman who presented with an abnormal pulmonary nodule suspected to be lung cancer in the left S3 segment. Bronchoscopy showed that the left main bronchus branched off into the B1+2, B3 plus lingular bronchus, and lower bronchus. Video-assisted thoracic surgery was performed, and the nodule was pathologically diagnosed as a primary lung cancer. Subsequently, left upper lobectomy was performed, and an abnormal bronchus was observed behind the main pulmonary artery. Intraoperative bronchoscopy indicated that the bronchus was the displaced B1+2. The B3 plus lingular bronchus existed at the common place of the upper bronchus. The displaced B1+2 and the other upper bronchus were transected separately. No other abnormalities were observed in the pulmonary arteries, veins, or bronchi. Preoperative examination is the best way to detect this bronchial abnormality;identification with intraoperative bronchoscopy can play a crucial role in determining the perioperative strategy.

Invasive Thymoma with Pure Red Cell Aplasia and Amegakaryocytic Thrombocytopenia.

We here describe a case involving a 67-yearold female patient who was referred to our hospital due to severe anemia (hemoglobin, 5.0 g/dL), thrombocytopenia (platelet count, 0.6 × 104/µL), and a mediastinal shadow with calcification noted on X-ray. On admission, an anterior mediastinal tumor was detected, and bone marrow biopsy revealed few megakaryocytes and severely reduced numbers of erythroid cells. The diagnosis was thymoma with pure red cell aplasia (PRCA) and acquired amegakaryocytic thrombocytopenia (AAMT). On Day 8 of admission, the patient received immunosuppressive therapy together with cyclosporine for the 2 severe hematologic diseases, which were stabilized within 2 months. Subsequently, total thymectomy was performed. The diagnosis of the tumor invading the left lung was invasive thymoma, Masaokakoga stage III. The histological diagnosis was World Health Organization type AB. Thymoma accompanied with PRCA and AAMT is very rare, and, based on our case, immunotherapeutic therapy for the hematologic disorders should precede surgical intervention.

Myasthenia gravis with thymic epithelial tumour: a retrospective analysis of a Japanese database.

OBJECTIVES: Myasthenia gravis (MG) has been reported to correlate with earlier stage and Type B thymomas by the World Health Organization classification. We analysed a large database of clinical characteristics of patients with MG and thymic epithelial tumours to elucidate whether the severity of MG affected postoperative survival of those with thymic epithelial neoplasms. METHODS: We conducted a multi-institutional study on the patients who had undergone surgical treatment for thymic epithelial tumours between 1991 and 2010. We examined Masaoka stage, pathological type, serum titre of antiacetylcholine receptor antigen, severity of MG and postoperative prognosis of the patients with or without MG. RESULTS: Of the 2835 registered patients at 32 institutes belonging to the Japanese Association for Research on the Thymus, 2638 were eligible for the study. MG was present in 598 patients (23%). Patients with MG had thymic epithelial tumours with significantly earlier stage (P = 0.0082) and significantly smaller tumours (P = 0.000) than those without. Type A, Type AB thymomas and thymic carcinomas were less frequently observed in patients with MG. Three of 304 patients (1%) with thymic carcinomas had MG preoperatively. Serum titres of antiacetylcholine receptor antibodies were positive in 98% of patients with MG, and 23% of those without. Patients with generalized MG had significantly higher titres of antiacetylcholine receptor antibodies than those with ocular MG (P = 0.000). The postoperative 30-day mortality rate was 0.3%. Postoperative 5- and 10-year survival rates of thymoma patients with MG and those without MG were 94 and 96, and 89 and 89%, respectively. We found no statistical difference in the postoperative survival rate or recurrence-free rate between the two groups. We found no significant statistical differences of these rates by MGFA classification or surgical approach. CONCLUSIONS: We conclude that earlier stage, smaller size or Type B thymomas are more frequently associated with MG, and MG may have no impact on the overall survival of patients with thymoma. We suggest that postoperative survival time of the patients with MG and thymic epithelial tumours may be mainly affected by the tumours, not by MG.

Posterior mediastinal hematoma after a simple fall in a patient with normal coagulation.

Case: A 77-year-old woman presented with neck swelling and odynophagia following a fall from standing height. She had no history of antiplatelet or anticoagulant use. Computed tomography of the chest showed an isodense to hypodense soft tissue mass in the bilateral carotid space, retropharyngeal space, and posterior mediastinum. With no airway obstruction symptoms, the patient was placed on bed rest under close observation. Outcome: The mass decreased in size spontaneously over the 10 days following symptom onset, accompanied by overall clinical improvement. The patient was diagnosed with a posterior mediastinal hematoma. Conclusion: This is the first reported case of posterior mediastinal hematoma caused by a neck hyperextension injury secondary to a simple fall in a patient with normal coagulation. The outcome was good; however, emergency physicians should be aware that hematomas necessitating airway management may occur after a fall.

[Independent Occurrence of a Mediastinal Bronchogenic Cyst and an Intralobar Pulmonary Sequestration].

Here we describe a case of an 18-year-old boy who exhibited abnormal pulmonary parenchyma supplied by an aberrant artery from the descending aorta in the right lower lobe of the lung and a cystic tumor measuring 34×26×54 mm in the right upper mediastinum. Video-assisted thoracic surgery for resection of the 2 lesions showed that they were independent of each other. Final diagnosis of an intralobar pulmonary sequestration in the right lower lobe and a bronchogenic cyst in the upper mediastinum was made. In some reports, 2 lesions were described to be in close proximity to and connected with each other, but the present case is unique in that the 2 lesions were completely independent of each other.

Immunostaining for thyroid transcription factor 1, Napsin A, p40, and cytokeratin 5 aids in differential diagnosis of non-small cell lung carcinoma.

The present study aimed to examine the effectiveness of immunostaining of cytological specimens in discerning squamous from non-squamous cell carcinoma. Various combinations of six antibodies were examined in order to determine the optimal combination for use in differential diagnosis. Immunostaining was performed using tumor imprint smears obtained from 70 lung carcinoma cases. The results were scored based on positive area and intensity. For objective evaluation, scores for thyroid transcription factor 1 (TTF-1), napsin A, and CK CAM5.2 were expressed with positive values, while those for p40, cytokeratin (CK) 5/6 and CK5 were expressed with negative values. Histograms were produced to evaluate which combination was the most effective in differentiating squamous cell carcinoma from adenocarcinoma. The sensitivity for these molecules in adenocarcinoma was 88% for TTF-1, 85% for napsin A, and 100% for CAM5.2. In squamous cell carcinomas, sensitivity was determined to be 90% for p40, 86% for CK5, and 76% for CK5/6. The specificity for these molecules was calculated as 100%, 95%, 43%, 98%, 100% and 95%, respectively. Each combination was evaluated for scoring and the values were averaged. The most effective combination for mode and mean was TTF-1, napsin A, p40, and CK5, for which all adenocarcinomas had a score >1, and all squamous cell carcinomas scored <-2. Immunostaining scoring may therefore be useful for the differential diagnosis of these carcinomas when a limited number of tumor cells are present.

Acute onset of mediastinal cystic lymphangioma in the puerperium.

Lymphangioma is a benign congenital malformation developing from the prenatal lymphatic vessels. Lymphangiomas are typically slow-growing and asymptomatic, but can occur throughout the body; there are few documented cases of either mediastinal or rapid growing lymphangiomas. Here, we report a case of a 27-year-old female who experienced sudden-onset nocturnal dyspnea 1 month after delivery. Ultrasound and computed tomography revealed a cystic tumor (diameter, 8 cm), which posteriorly displaced the superior vena cava and trachea. Ultrasound-guided aspiration was performed and the tumor disappeared on chest X-ray, only to return on subsequent chest X-ray performed the following day. Therefore, thoracoscopic excision of the mediastinal tumor was performed, and pathological diagnosis confirmed mediastinal cystic lymphangioma. In this report, we discuss the rare nature of this case and the treatment of lymphangioma in pregnancy.

Mediastinitis of bronchogenic cyst caused by endobronchial ultrasound-guided transbronchial needle aspiration.

Here, we describe the case of a 56-year-old female patient who was diagnosed with an anterior mediastinal cyst measuring 26 × 16 mm in size. An endobronchial ultrasound-guided transbronchial needle aspiration was performed, and punctures occurred three times. The patient was then prescribed cefditoren pivoxil. Three days after the procedure, the patient developed infective mediastinitis. Panipenem/betamipron, clindamycin, and human immunoglobulin were administered, and her symptoms improved over 2 weeks. Five months after developing mediastinitis, surgical resection of the cyst was performed with inverted L-shaped mini-sternotomy. The cystic lesion strongly adhered to the surrounding tissues. The final pathological diagnosis was a bronchogenic cyst. Endobronchial ultrasound-guided transbronchial needle aspiration is not a completely sterile procedure and can lead to severe infective complications in the mediastinum. Although this procedure may not be contraindication for use with mediastinal cystic lesions, physicians must take into account the risk of severe infective complications.

Radiologically indeterminate pulmonary cysts in Birt-Hogg-Dubé syndrome.

Birt-Hogg-Dubé (BHD) syndrome is an inherited disease characterized by recurrent pneumothorax. We report some unusual clinicopathologic features of the lung in a Japanese family with this syndrome presenting with recurrent pneumothorax. Radiologic imaging did not show detectable lesions; however, at video-assisted thoracic surgery (VATS), multiple diffusely distributed microcysts were visible on the pleura. This characteristic morphologic feature was common to all affected family members. The proband underwent genetic testing and BHD syndrome was diagnosed. Although many patients with BHD syndrome with pneumothorax show obvious pulmonary cysts, this case suggests that radiologically indeterminate cysts have the potential to cause pneumothorax.

Intrapulmonary bronchogenic cyst in the thoracic cavity: a case report.

This case report presents an intrapulmonary bronchogenic cyst exhibiting a unique shape. The patient was a 19-year-old man who had been diagnosed with a posterior mediastinal tumor by computed tomography and magnetic resonance imaging, 2 years previously. The imaging revealed that the tumor was located on the left side of the posterior mediastinum and was 45 × 25 mm in size. As the size and shape of the tumor did not change in the 2 years after its detection, surgical extraction was planned. Preoperative diagnosis was, firstly, a neurogenic tumor originating in the posterior mediastinum.Surgical findings revealed that the tumor formed a bridge between the visceral pleura of the left lower lobe and the chest wall, and most of the tumor was located in the thoracic cavity. Pathological diagnosis was intrapulmonary bronchogenic cyst. An intrapulmonary bronchogenic cyst with a unique shape, as observed in this case, is very rare.Although preoperative imaging could predict the tumor size, it could not confirm where the tumor originated. Surgical resection of this type of tumor, which is diagnosed preoperatively as a posterior mediastinal tumor, is a superior strategy for precise diagnosis and treatment.

Spontaneous hemopneumothorax: epidemiological details and clinical features.

PURPOSES: Spontaneous hemopneumothorax (SHP) may cause life-threatening blood loss. The objective of this study was to elucidate the epidemiological and clinical features of SHP. METHODS: We reviewed the records of 26 patients who underwent surgery for SHP between 1989 and 2010. We evaluated their epidemiology and clinical features by comparing them with those of 681 patients with spontaneous pneumothorax treated during the same period. RESULTS: The proportion of smokers in the SHP group was higher than that in the spontaneous pneumothorax group (P < 0.01). Seventeen cases (65.4 %) of SHP occurred on the left side. The most frequent bleeding area was the superior thoracic aperture (STA:17 cases, 65.4 %), followed by the left superior mediastinum (six cases, 23.1 %). Ten cases had intrathoracic clots greater than 500 mL, which could not be drained preoperatively. The postoperative stay of patients treated with video-assisted thoracic surgery (VATS) was shorter than that of patients treated with open thoracotomy (21 versus five cases; P < 0.05). CONCLUSIONS: A higher proportion of smokers was revealed in the SHP patients. VATS shortened the hospital stay of the patients. The particular areas that should be observed intraoperatively are the STA and the left superior mediastinum.

Preoperative symptoms and postoperative sequelae of intrathoracic neurogenic tumors: a single institution's experience.

OBJECTIVE: Most intrathoracic neurogenic tumors are resected for therapeutic diagnosis; many adult tumors are benign. However, few studies have reported the preoperative symptoms, postoperative modalities, and sequelae of these tumors. We focused on and evaluated the diversity and postoperative prognosis of these tumors. METHODS: We assessed 31 consecutive cases of intrathoracic neurogenic tumors resected at Tsuchiura Kyodo General Hospital between 1988 and 2012. Two cases involved multiple tumors; therefore, complete resection or enucleation was performed only in the remaining 29 cases. The patients' clinical records were investigated retrospectively. RESULTS: All tumors were benign. Five cases (16.1 %) presented with preoperative symptoms; 2 cases with non-neurologic symptoms (dysphagia due to tumor oppression and a massive hemothorax with neurofibromatosis type 1) improved after surgery, but 3 others with neurologic symptoms (back pain, hand motor paralysis, and Horner's syndrome) did not. Ten cases (32.3 %) presented with postoperative modalities or sequelae. Eight cases presented with neurologic sequelae (Horner's syndrome, 4 cases; grip weakness, 3 cases; hypohidrosis, 3 cases; and hand numbness, 2 cases). All the patients presenting with neurologic sequelae had tumors proximal to the first or second thoracic vertebra; no tumors proximal to or under the third thoracic vertebra caused neurologic sequelae. Severe neurologic sequelae in daily life were observed in 2 cases, but they did not radically improve. CONCLUSIONS: While the non-neurologic symptoms caused by intrathoracic neurogenic tumors can be resolved by resection, the neurologic symptoms may not improve. Tumors proximal to the first or second thoracic vertebra can cause postoperative neurologic sequelae.

Early-stage thymic carcinoma: is adjuvant therapy required?

Although the prognosis of advanced thymic carconoma remains poor, previous reports have shown survival rates of 70% to 100% in patients with Masaoka stage I or stage II of the disease who were treated with surgery followed by adjuvant therapy. However, the role of adjuvant therapy in these stages is controversial. We retrospectively evaluated the outcome of 4 patients with Masaoka stage II thymic carcinoma who were treated with surgery alone between 1992 and 2008. No patient had stage I of the disease. Primary tumors were preoperatively evaluated by chest X-ray and computed tomography. Needle biopsy was not performed because the tumors were clinically diagnosed as noninvasive thymomas. The largest diameter of the primary tumor was 65 mm. Mediastinal lymphadenopathy was not detected by computed tomography. All patients underwent transsternal thymectomy. Mediastinal lymph node dissection was not performed. None of the patients received adjuvant chemotherapy and/or irradiation. Histopathologic examination revealed squamous cell carcinoma in 3 patients and undifferentiated carcinoma in one. Pathologic invasion to the adjacent organs or lymph node metastasis was not detected. All patients were alive and free from relapse at a follow-up of 72 months (range, 12-167 months). Radical resection without adjuvant therapy could be a treatment option for early Masaoka stage thymic carcinoma with low-grade histology.

Dual-phase FDG-PET imaging shows suspected malignancy that histological examination later confirmed as sclerosing mediastinitis: report of a case.

Sclerosing mediastinitis is a rare, benign disorder that is often indistinguishable from malignancy by conventional imaging techniques. The value of fluorodeoxyglucose positron emission tomography (FDG-PET) imaging in the diagnosis of this disorder has not been elucidated. Recently, a few studies have reported the use of dual-phase FDG-PET imaging in the diagnosis of malignancies. The dual phase contains early- and late- phase images. The maximum standard uptake value (SUVmax) of late phase images of malignant lesions tends to be higher than those of early phase images. The present case showed that early-phase SUVmax was 5.93, and late phase, 8.92. We strongly suspected malignancy from the results of this new imaging technique, though the histological examination of the surgical samples provided the definitive diagnosis of sclerosing mediastinitis, Flieder stage II. This report describes the uncommon use of dual-phase FDG-PET computed tomography in the preliminary diagnosis of sclerosing mediastinitis. It is thought that current imaging studies are insufficient for the diagnosis of sclerosing mediastinitis, and the rarity of this disorder may prevent the development of imaging techniques. Histological confirmation is still essential for the definitive diagnosis of this disorder.

Possible delayed cut-end recurrence after limited resection for ground-glass opacity adenocarcinoma, intraoperatively diagnosed as Noguchi type B, in three patients.

INTRODUCTION: In our limited resection trial of pulmonary peripheral ground-glass opacity (GGO) lesions from 1998 to 2002, limited resection of Noguchi type A and B carcinomas seemed to have a positive outcome. However, recently three of the 24 patients, with mixed GGO lesions intraoperatively diagnosed as type B, developed a solid lesion at the cut-end scar. METHODS: Medical records and radiology and pathology findings of the three patients were reviewed. We also analyzed epidermal growth factor receptor gene mutations when possible. RESULTS: Radiologically, these three second tumors were clearly cut-end scar area recurrences. However, other pathologic and mutation findings suggest metachronous primary cancers developed in Case 1, cut-end recurrence in Case 2, and needle biopsy implantation in Case 3. It is difficult to definitively conclude whether the second tumors were recurrences or metachronous primaries. CONCLUSIONS: These second tumors have convinced us that our initial caution in concluding GGO lesions can be cured by limited resection was very appropriate. The recurrences definitely indicate that continuing follow-up attention for more than 5 years is needed after limited resection even for GGO bronchioloalveolar carcinomas.