Clinical and pathological characteristics of spontaneous pneumothorax in women: a 25-year single-institutional experience.

OBJECTIVES: Accumulating evidence suggests that spontaneous pneumothorax (SP) in women, while relatively rare, has higher rates of post-treatment recurrence than in men. Our aim was to further elucidate the clinical and pathological characteristics of SP in women. METHODS: We retrospectively reviewed 59 female patients with no known underlying lung disease undergoing surgery for their SP from January 1990 to December 2015. We divided the study population into those older than or equal to 50 years and those younger than 50 years, the latter of which was further subdivided into catamenial and non-catamenial pneumothorax. RESULTS: Among the study population, 11 (18.6%) had catamenial pneumothorax, 40 (67.8%) had non-catamenial pneumothorax, and 8 (13.6%) were older than 50 years. Pathological diagnoses of catamenial pneumothorax were diaphragmatic endometriosis (n = 4), emphysematous bullae (n = 4), solitary pulmonary capillary hemangiomatosis (SPCH, n = 2), and hematoma (n = 1). By contrast, emphysematous blebs/bullae accounted for all but one case of non-catamenial pneumothorax and all cases in the ≥ 50 years age group. Catamenial pneumothorax showed a significantly higher postoperative recurrence rate compared to non-catamenial pneumothorax (p = 0.0043). The 2-year cumulative ipsilateral recurrence rates of catamenial, non-catamenial, and ≥ 50 years age group were 39.4, 13.8, and 14.3%, respectively. CONCLUSIONS: Catamenial pneumothorax affected approximately 20% of female patients undergoing surgery for spontaneous pneumothorax with no underlying lung disease and showed a significantly higher postoperative recurrence rate. Diaphragmatic endometriosis and subpleural blebs/bullae were common pathological findings in catamenial pneumothorax, but SPCH might be a possible pathological diagnosis of catamenial pneumothorax.

Combined small cell lung carcinoma and giant cell carcinoma: a case report.

BACKGROUND: Combined small cell lung carcinoma (SCLC) is defined as SCLC combined with elements of non-small cell lung carcinoma (NSCLC), accounting for approximately 30% of cases of SCLC. However, combined SCLC and giant cell carcinoma (GC) is very rare. CASE PRESENTATION: A 50-year-old woman with a 45 pack-year smoking history was referred to our hospital for further investigation of an abnormal left hilar shadow. Chest computed tomography (CT) revealed a 28-mm solid pulmonary nodule in the left lower lobe and an enlarged left hilar lymph node adjacent to the left main pulmonary artery. CT-guided biopsy of the pulmonary nodule led to the diagnosis of high-grade neuroendocrine carcinoma. The preoperative clinical stage was defined as cT1bN1M0. Thus, the patient underwent left lower lobectomy with ND2a-2 lymph node dissection via thoracotomy. Pathological investigation revealed a 22-mm tumor and dense sheet-like growth of small tumor cells with scant cytoplasm and finely granular nuclear chromatin. Moreover, there was a sheet-like growth of bizarre, highly pleomorphic mono- or occasionally multinucleated giant cells, accounting for approximately 40% of the tumor. Both the small and giant cell components were thyroid transcription factor-1-positive and p40-negative and exhibited neuroendocrine differentiation, as indicated by positivity for synaptophysin and CD56 and negativity for chromogranin A. While the small cell component was E-cadherin-positive and vimentin-negative, the giant cell component was E-cadherin-negative and vimentin-positive, indicating an epithelial-to-mesenchymal transition. Only the small cell component was found within the mediastinal and hilar lymph nodes. The final pathological diagnosis was combined SCLC and GC, pT1bN2M0, and pStage IIIA. The patient received adjuvant chemotherapy with 4 cycles of cisplatin and irinotecan. No sign of recurrence has been noted for 1 year after the surgery. CONCLUSIONS: This is the first detailed report of a unique case with combined SCLC and GC. The coexistence of SCLC and GC in the presented case might indicate several possibilities: (1) GC may arise from SCLC via epithelial-to-mesenchymal transition, (2) SCLC may arise from GC through phenotypic conversion, and (3) SCLC and GC may have derived from a common neuroendocrine origin. Further investigation is necessary to reveal the underlying pathological process.

The role of CD5 expression in thymic carcinoma: possible mechanism for interaction with CD5+ lymphoid stroma (microenvironment).

AIMS: Most thymic carcinomas express the lymphocyte marker CD5 aberrantly. This study was performed to examine the role of the self-reactive CD5 antigen in thymic carcinoma. METHODS AND RESULTS: We examined CD5 expression in thymic carcinoma in relation to the lymphoid stroma. All cases of thymic carcinoma examined expressed CD5. A number of CD5(+) lymphocytes were also present in the stroma of thymic carcinoma. The CD5(+) tumour areas were predominantly in contact with the lymphoid stroma, and the expression level was significantly lower in tumour cells than lymphocytes. Although p53 and Bcl-2 expression levels were significantly higher in thymic carcinoma than normal thymic epithelial cells (TECs), they did not differ between CD5(+) and CD5(-) areas. E-cadherin expression in thymic carcinoma was comparable with that of normal TECs, and it also did not differ between these areas. In contrast, both Ki-67 index and mitotic activity were significantly higher in thymic carcinoma than normal TECs, and they were significantly higher in CD5(+) than CD5(-) areas. CONCLUSIONS: CD5 may be induced by interaction with CD5(+) lymphoid stroma, and may be related to tumour proliferation. CD5 induction may also be a significant and/or specific effect of the tumour microenvironment of the thymus.

Efficacy and long-term clinical outcome of bronchial occlusion with endobronchial Watanabe spigots for persistent air leaks.

BACKGROUND: We reviewed our clinical experience and examined the efficacy and long-term outcome of bronchial occlusion with endobronchial Watanabe spigots (EWSs). METHODS: We retrospectively reviewed the clinical charts of patients who had undergone endoscopic bronchial occlusion with EWSs between July 2002 and July 2004. The affected bronchi were identified by chest computed tomography, pleurography, and balloon occlusion test. RESULTS: Of the 21 patients, 18 had underlying pulmonary complications, including chronic obstructive lung disease (n=14), cancer (n=4), pneumoconiosis (n=3), and pneumonia (n=1). Six (29%) achieved complete resolution and 12 (57%) experienced a reduction in air leaks after the first EWS insertion. Of the 12 patients with reduced air leaks, 10 subsequently underwent chemical pleurodesis and 5 (24%) achieved complete resolution after the procedure. A second EWS insertion procedure was performed for 8 patients: 2 achieved complete resolution and 5 achieved a further reduction in air leaks with complete resolution after chemical pleurodesis. Eighteen of the 21 patients were followed up at an outpatient clinic after discharge: 13 for more than 12 months and 4 for more than 84 months. During the follow-up period, most patients did not show any obvious pulmonary complications. CONCLUSIONS: We showed that bronchial occlusion with EWSs was effective in stopping or reducing air leaks and that 86% of our patients finally achieved complete resolution, some when the occlusion was combined with chemical pleurodesis. The rate of complications was acceptable, even after long-term placement.

A decrease in the size of ground glass nodules may indicate the optimal timing for curative surgery.

OBJECTIVES: Although ground glass nodules (GGNs) are generally considered to grow slowly to a large size, their natural progression remains unclear, and a decrease in tumor size has been reported in a few previous studies. The study aimed to retrospectively review the radiologic and pathological characteristics of resected ground glass nodules (GGNs) followed with chest computed tomography (CT) for at least a year before surgery to clarify the natural progression of GGNs. PATIENTS AND METHODS: The chest CT cans and clinical charts of 32 GGNs in 31 patients who underwent pulmonary resection between January 2006 and March 2013 were retrospectively reviewed. The definitions of pure GGNs and part-solid nodules were based on the tumor shadow disappearance rate. The tumor size was measured twice, and the mean size was used for evaluation. RESULTS: The mean GGN size before surgery was 15.2 mm, and the median follow-up period before surgery was 21 months. In the follow-up period, 15 (58%) of 26 pure GGNs at the initial CT remained pure GGNs at the last CT. However, a solid component appeared in the remaining 11 tumors (42%) of the 26 initial pure GGNs. Furthermore, 1 GGN of the 15 GGNs that remained pure and 10 of the 11 GGNs with solid component also showed a size decrease. In addition, 6 part-solid nodules were observed at the initial CT. Of these, 3 showed a decrease in size during follow-up. Overall, 47% of the GGNs showed a size reduction on follow-up chest CT. CONCLUSIONS: A size reduction was observed in nearly half of the GGNs and suggested the progression to an invasive adenocarcinoma. When a mild collapse of the GGNs is observed, a careful follow-up is necessary to identify a solid component. Tumor size decreases may represent the optimal timing of pulmonary resection for curative treatment.

Three-step management of pneumothorax: time for a re-think on initial management.

Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. There are some published guidelines for the management of spontaneous pneumothorax. However, they differ in some respects, particularly in initial management. In published trials, the objective of treatment has not been clarified and it is not possible to compare the treatment strategies between different trials because of inappropriate evaluations of the air leak. Therefore, there is a need to outline the optimal management strategy for pneumothorax. In this report, we systematically review published randomized controlled trials of the different treatments of primary spontaneous pneumothorax, point out controversial issues and finally propose a three-step strategy for the management of pneumothorax. There are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak, which is the obvious cause of the disease; frequent recurrence. These three characteristics correspond to the three steps. The central idea of the strategy is that the lung should not be expanded rapidly, unless absolutely necessary. The primary objective of both simple aspiration and chest drainage should be the recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. We believe that this management strategy is simple and clinically relevant and not dependent on the classification of pneumothorax.

Lesions in patients with multifocal adenocarcinoma are more frequently in the right upper lobes.

OBJECTIVES: Opportunities to treat multifocal lung cancers, mostly adenocarcinoma, are increasing due to the development of imaging technologies. The optimal therapy modality to treat multifocally growing lung cancers remains obscure. To determine the features of multifocal lung cancers, we retrospectively reviewed patients with multiple lung lesions. METHODS: Clinical, pathological and genetic characteristics of 31 patients with multifocal lesions were compared with those of patients who had had radical lung resection for solitary lung cancer. Gene mutation analyses for EGFR, KRAS and P53 were performed on three tumours of each of the patients who had four or more lesions. RESULTS: Of the 31 patients, 17 had double tumours, 4 had triple tumours and 10 had 4 or more lesions. Patients with four or more lesions were significantly more likely to be females and never smokers. All of the histologically confirmed tumours of the cases with four or more lesions were adenocarcinoma in situ or lepidic predominant adenocarcinoma. The number of lesions in the right upper lobes when compared with the right lower lobes was significantly higher in patients with four or more lesions than in patients with double or triple lesions (P = 0.013). Five of the 12 tumours were positive for the EGFR mutation L858R in exon 21. No KRAS mutation was found. CONCLUSIONS: Lesions in patients with multifocal adenocarcinoma are more frequently in the right upper lobes. Genetic analysis suggested that the specific EGFR mutation L858R in exon 21 might be the main factor contributing to lung carcinogenesis in multiple lung cancers. Further investigation of the right upper lobe in those patients compared with the lower lobes might provide more insights into lung carcinogenesis.

Impact of previous gastrectomy on postoperative pneumonia after pulmonary resection in lung cancer patients.

Postoperative pneumonia is a serious complication following pulmonary resection. Aspiration of oesophageal reflux contents is known to cause pulmonary complications in patients with a history of gastrectomy. In this study, we compared the incidence of postoperative pneumonia in patients with or without previous gastrectomy. A retrospective review was conducted of clinical charts for patients who underwent radical pulmonary resection for non-small cell lung cancer from January 2006 to December 2010. Pneumonia was diagnosed with chest computed tomography findings in all cases. A total of 333 patients underwent pulmonary resections during the study period. Twenty-seven patients (8.1%) had a history of gastrectomy. Eight patients (2.2%) had postoperative pneumonia. All eight patients who developed postoperative pneumonia did not have pneumonia before pulmonary resection. Of the aforementioned 27 patients, five (18.5%) developed pneumonia postoperatively, whereas only three of 325 patients who did not have a history of gastrectomy (0.9%) had pneumonia (P < 0.001). In multivariate analysis, a history of gastrectomy had the highest impact on the odds ratio (8.81) for postoperative pneumonia. A significantly higher incidence of postoperative pneumonia was found in patients with a history of gastrectomy. Prophylactic treatment, such as premedication with ranitidine, should be considered in those patients.

The covering with forceps-assisted polymeric biodegradable sheet and endostapling method: a simplified technique for wide coverage and reinforcement of staple-line in video-assisted thoracoscopic bullectomy for spontaneous pneumothorax.

Primary spontaneous pneumothorax is one of the most common diseases. To prevent recurrent pneumothorax after video-assisted thoracoscopic surgery, various methods of pleural covering with biodegradable polymers have been devised. In addition, using fibrin sealant should be avoided as far as possible because of its infectious aspect. Thus, we devised the covering with forceps-assisted polymeric biodegradable sheet and endostapling method in response to these demands. With this novel technique, we used non-woven polyglycolic acid (PGA) NEOVEIL® sheet (Gunze, Ayabe, Japan). A 5-mm cut was made in the center of the PGA sheet, which was then guided over the apical bulla with a lung forceps. The bulla was then pulled through the cut hole with the lung forceps, in a manner similar to the way a cape is worn through the head. To avoid stapling failure caused by wrinkling of the PGA sheet, we moistened the sheet with a few drops of saline before endostapling. The diseased lung tissue was resected by endostapling across the PGA sheet. After firing the endostapler, we could perform a sealing test by inflating the lung to detect persistent air leaks. This is a simple and reliable technique of staple-line reinforcement without fibrin glue.

Chest wall bleeding with giant intrathoracic meningocele in neurofibromatosis type 1.

We report the case of a 66-year-old woman with neurofibromatosis type 1 who developed chest wall bleeding with severe scoliosis and a giant intrathoracic meningocele. She was brought to the emergency department with acute-onset of left-sided chest pain and clinical signs of hypovolemia. Bleeding control was difficult in the first operation because the tissue was friable and there were multiple subcutaneous bleeding points. During the first operation, the patient developed disseminated intravascular coagulation, which required immediate management; therefore, the surgery was aborted and a repeat surgery was performed later to stop the bleeding. The major cause of bleeding was presumed to be the mechanical stretching of the intercostal arteries and branches of the internal thoracic artery secondary to the severe deformity of the thoracic vertebra and ribs. The massive bleeding remained as a hematoma and did not lead to development of hemothorax. This was believed to be because the giant intrathoracic meningocele supported the expansion of the hematoma and prevented the perforation of the visceral pleura. After the second operation, the hematoma shrunk gradually; however, the patient required ventilatory support because the decrease in the size of the hematoma was accompanied by the expansion of the meningocele.

[Approaches and results in video-assisted thoracic surgery lobectomy for the patient with primary lung cancer].

Video-assisted thoracic surgery (VATS) lobectomy is defined as a video-assisted procedure using anatomic dissection with individual ligation of the vessels and bronchi. VATS lobectomy can offer several advantages, including decreased pain, and decreased inflammatory response. The patient is placed in the lateral decubitus position. A 12-mm port is inserted in the 7th intercostal space at the midaxillary line. A 8-cm utility incision is created in the axilla at the 4th intercostal space for upper or middle lobectomy. For lower lobectomy, a 8-cm utility incision is created in the auscultatory triangle at the 5th intercostal space. A 12-mm incision is frequently placed near the utility incision in the 6th intercostal space, particularly when using retraction for improved exposure or for insertion of added instrumentation. We performed the hilar vessel ligation using endoscopic ligation forceps SAITO model (Japan patent no. 4148324). We reported approaches and techniques in our hospital for the patients who underwent VATS lobectomy based on the surgical databases from the Division of Thoracic Surgery at the Kansai Medical University Hirakata Hospital during the period from January 5, 2006 through August 31, 2008.

Appearance of bronchioloalveolar carcinoma and the rapid progression into invasive papillary adenocarcinoma.

The prognostic importance of bronchioloalveolar carcinoma in comparison to the invasive subtypes needs to be studied, although the natural history of a pure bronchioloalveolar carcinoma is still unclear. We report the appearance of a pure ground-glass opacity that demonstrates rapid progression into a solid component in the central area, pathologically revealing a minimally invasive papillary adenocarcinoma. Considering the findings of previous reports, as well as our case, we need to pay careful attention to the follow-up of a patient who has even a pure ground-glass opacity when the patient had a history of an invasive lung cancer. We need also to perform curative surgery with optimal timing.

Novel mutation (L157X) in the succinate dehydrogenase B gene (SDHB) in a Japanese family with abdominal paraganglioma following lung metastasis.

Recently, nuclear genes encoding two mitochondrial complex II subunit proteins, SDHD and SDHB, have been found to be associated with the development of familial pheochromocytomas and paragangliomas (hereditary pheochromocytoma/paraganglioma syndrome: HPPS). Growing evidence suggests that the mutation of SDHB is highly associated with abdominal paraganglioma and the following distant metastasis (malignant paraganglioma). In the present study, we report the case of a novel SDHB mutation (L157X) in a Japanese patient with abdominal paraganglioma following malignant lung metastasis. In addition, we identified an asymptomatic carrier of the SDHB mutation in this family.

Management of a complicated pulmonary fistula caused by lung cancer using a fibrin glue-soaked polyglycolic acid sheet covered with an intercostal muscle flap.

Pulmonary fistulas caused by tumours are very fragile and difficult to suture directly. It is impossible to close pulmonary fistulas with tissue sealants when massive air leakage occurs in the low pressure of the respiratory tract. A 73-year-old man with a pneumothorax caused by lung cancer had suffered a persistent massive air leakage for more than one month. We used a fibrin glue-soaked polyglycolic acid (PGA) sheet for sealing the complicated fistula. In addition, the visceral pleura of the fistula was wrapped with the pedicle of an intercostal muscle (ICM) flap to prevent massive air leakage. The pneumothorax did not reappear after surgery. Thus, a fibrin glue-soaked PGA sheet covered with an ICM flap was effective for sealing an intractable air-leaking fistula caused by lung cancer.

Evaluation of chest computed tomography in patients after pneumonectomy to predict contralateral pneumothorax.

PURPOSE: Contralateral pneumothorax is a severe complication after pneumonectomy. We evaluated the mediastinal shift and the residual lung in patients who had undergone pneumonectomy to predict the incidence of contralateral pneumothorax. METHODS: We evaluated 21 cases of pneumonectomy performed from 1996 to 2006. For this study, we excluded patients with recurrent neoplasm, empyema, or hemothorax. We reviewed the computed tomography (CT) results of 13 patients who had undergone pneumonectomy to compare the bullae in the residual lungs, carina shifts, and herniation of the residual lungs before and after pneumonectomy. When evaluating the degree of herniation 4-6 cm below the carina, the anterior and posterior pulmonary hernias were classified as grade A, B, or C. We also investigated the preoperative respiratory function in all 13 patients. Results. Two patients suffered contralateral pneumothorax after left pneumonectomy. Both patients who suffered contralateral pneumothorax after pneumonectomy had bullae. The percentage forced expiratory volume in 1 s (FEV(1.0%)) was <70% in these two patients. Carina shifts and lung herniation were found to be greater after left pneumonectomy than after right pneumonectomy. CONCLUSION: The bullae in the lung and obstructive pulmonary disease are associated not only with spontaneous pneumothorax but also with contralateral pneumothorax after pneumonectomy. Lung herniation and mediastinal shift are greater after left pneumonectomy than after right pneumonectomy, which may be related to contralateral pneumothorax after pneumonectomy.

Ossification does not cause any complication when a bronchial stump is reinforced with an intercostal muscle flap.

OBJECTIVE: An intercostal muscle (ICM) flap is used to buttress the bronchial stump or bronchial anastomosis during thoracic surgery for airway reconstruction. Such flaps sometimes show ossification after surgery. Previous reports have suggested that such ossification requires a functional periosteum and good vascularization. We examined the background of ICM flap ossification and its relationship with complications and pain after surgery. METHODS: We surveyed the clinical records of 47 patients who underwent bronchial stump reinforcement with an ICM flap during thoracic surgery at Kansai Medical University Hospital between January 2003 and December 2005. We reviewed the post-surgical chest computed tomography (CT) scans of 42 patients, and examined the degree of ICM ossification. We classified patients into two groups: those with ossification of the ICM flap (O group) and those without (non-O group). We compared the two groups for age, gender, the site of ICM flap placement, disease, type of lymph node dissection, and pretreatment. We also compared the two groups for pain levels and complications after surgery. Eight (19%) of the 42 patients showed ossification of the ICM after surgery. There were statistically significant differences between the O and non-O groups in gender (p=0.029), lymph node dissection (p=0.024) and pain levels after surgery (p=0.034). There were no complications attributable to ICM ossification in this series. CONCLUSION: Ossification of an ICM flap may be related to gender, lymph node dissection and pain after surgery. Ossification does not cause any complication after surgery when an ICM is used to reinforce bronchial stumps.

Preoperative steroid therapy stabilizes postoperative respiratory conditions in myasthenia gravis.

OBJECTIVE: We reviewed our experience from 1990 to 2005 to examine whether control of myasthenia gravis (MG) with steroid therapy before surgery could stabilize postoperative respiratory conditions, compared with the nonsteroid treatment. METHODS: Records of 43 consecutive patients with MG who underwent extended thymectomy at Kansai Medical University Hospital were retrospectively reviewed. Two groups, a steroid group (n = 28) and a nonsteroid group (n = 15) were compared. RESULTS: In the steroid group, steroid doses ranged from 10 to 100 mg every other day, or 40-60 mg daily. The patients showed significantly less thymus hyperplasia in the pathological findings (P = 0.023). Whereas 3 of 28 (7%) in the steroid group suffered respiratory insufficiency within 3 days of surgery, 5 of 15 (33%) in the nonsteroid group exhibited the same problem (P = 0.030). Univariate analysis showed that steroid treatment was the only significant factor (P = 0.041) affecting respiratory insufficiency. Patients in the steroid group achieved palliation of MG more quickly after surgery than patients in the nonsteroid group (86% vs. 57% within 6 months, P = 0.059; 84% vs. 42% within 1 year, P = 0.042). CONCLUSION: The control of myasthenia gravis with steroid therapy before surgery seems to stabilize postoperative respiratory status without having adverse effects on surgical infection.

Early postoperative mobilization with walking at 4 hours after lobectomy in lung cancer patients.

OBJECTIVES: The aim of this study was to determine whether walking at 4 h after surgery as a more aggressive way to proceed with early mobilization could be a safe approach compared with the patients who walked the day after surgery. METHODS: We encouraged patients who had lobectomy for non-small-cell lung cancer at Kansai Medical University Hospital to walk at 4 h after surgery and start pulmonary rehabilitation between January 2003 and June 2005. A group of 36 patients walked at 4 h after surgery. We retrospectively reviewed the postoperative courses of the patients and compared them with 50 patients who walked the next day during the same period. RESULTS: No patient had major trouble with chest drainage tube, and no patients fell when walking at 4 h. Amount of drainage, changing rates of the heart load during the walking, and pain scores after walking did not show significant differences in patients walking at 4 h and those walking the next day. Although four patients who walked the next day had an arterial oxygen partial pressure/inspired oxygen concentration ratio of <300 on day 3, none in the patients walking at 4 h had a ratio below this level. Among the patients walking at 4 h, 24 (67%) needed oxygenation for less than 2 days compared with 17 (34%) of the patients walking the next day. CONCLUSION: Walking at 4 h after lobectomy in patients with non-small-cell lung cancers is a safe approach to starting pulmonary rehabilitation after surgery.