[Considerations for Perioperative Management of Patients with Complicated Respiratory Dysfunction].

This article describes the perioperative complications, perioperative risk assessment, and perioperative management of patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease, especially idiopathic pulmonary fibrosis( IPF), which are the leading diseases in respiratory dysfunction. In COPD, testing for forced expiratory volume during the first second and pulmonary diffusing capacity is important and an algorithm for testing has been presented by the Japanese Association for Chest Surgery. Acute exacerbation of IPF is the leading cause of postoperative mortality in Japan, and risk factors are being analyzed. To reduce the occurrence of postoperative complications, it is important to carry out a risk assessment, select appropriate surgical strategy, and implement a well-planned perioperative management.

[Robot-assisted Minimally Invasive Surgery for Mediastinal Tumors].

The subxiphoid approach in thymectomy provides better visibility around the left brachiocephalic vein than the lateral thoracic approach. Robot-assisted thoracoscopic surgery is easier to parform than video- assisted thoracoscopic surgery for surgery of the upper mediastinum, because the forceps can be moved with many joints. Robot-assisted thymectomy using the subxiphoid approach may be less traumatic and less invasive than median sternotomy. We must continue to devise surgical procedures to make oncologically curative surgery more minimally invasive.

Clinical significance of bifocal treatment for synchronous brain metastasis in T1-2 non-small-cell lung cancers: JNETS0301.

OBJECTIVES: The treatment of patients with brain metastases associated with non-small-cell lung cancer (NSCLC) is frequently challenging. Starting in 2003, we conducted a phase II study of surgery for patients with clinical T1-2N0-1 NSCLC with oligometastasis. The aim of this subset study was to assess the clinical significance of bifocal treatment for synchronous brain metastases in T1-2N0-1 NSCLC using prospectively collected data. METHODS: In this phase II study of clinical T1-2N0-1 NSCLC patients with oligometastasis, 47 patients were enrolled from December 2003 to December 2016. Among them, 18 NSCLC patients with synchronous brain metastases were investigated in this subset analysis. RESULTS: Fourteen patients underwent complete resection, and 4 underwent incomplete resection of the primary lung cancer. The number of synchronous brain metastases was one in 14 and multiple in 4 patients. After surgery for the primary lung cancer, 12 of 18 patients underwent treatment for their brain lesions, including stereotactic radiosurgery (SRS) in 10, surgical resection in 1, and SRS followed by surgical resection in 1. In 5 of the 18 patients (28%), the brain lesion was diagnosed as benign on follow-up radiological imaging. The 5-year overall survival rate after enrollment was 31.8% for all 18 patients and 35.2% for the 13 patients with brain metastases. Univariate analysis showed that having multiple brain lesions was a significant factor related to a worse prognosis. CONCLUSION: For patients with suspected brain metastases associated with NSCLC, bifocal local treatment could be an acceptable therapeutic strategy, especially for solitary brain metastasis.

Resecting a giant malignant lung tumor in a patient with unilateral acute interstitial pneumonitis.

Acute interstitial pneumonia is a rare and fulminant form of idiopathic interstitial lung disease. Here, we report a case of a giant malignant sarcomatoid tumor of the left lung with unilateral lung infiltration. The tumor was resected under venovenous extracorporeal membrane oxygenation support. Right middle lung lobe biopsy revealed alveolar epithelial hyperplasia, mild interstitial fibrosis, and interstitial edema. The patient was diagnosed with acute interstitial pneumonitis, and effectively treated with steroid pulse therapy followed by prednisolone. In this case, the contralateral lung expansion accomplished with tumor resection, definitive diagnosis based on lung biopsy, and corticosteroid treatment possibly improved the outcome.

Validation of the Proposed cN2 Subclassification in the Eighth Edition of the IASLC Staging System: A Prospective Phase II Multicenter Study.

INTRODUCTION: Surgery for N2 stage IIIA NSCLC is not recommended in major guidelines. Nevertheless, it has been noted that single-station N2 may have a better prognosis than multistation N2 and that surgery can be performed as the main therapeutic option. METHODS: We conducted a prospective phase II study for single-station clinical N2 (cN2) NSCLC to evaluate the efficacy and safety of surgical resection without induction therapy. Complete resection with lobectomy, bilobectomy, or pneumonectomy followed by ipsilateral mediastinal lymphadenectomy was performed in 32 of 34 enrolled patients, whereas the remaining two patients underwent incomplete resection. Three-quarters of the patients underwent subsequent adjuvant chemotherapy. RESULTS: The 5-year overall survival rate was 58.5% (95% confidence interval: 41.9-75.4) for all 34 patients, and eight patients (23.5%) with pN0 or pN1 seemed to have been enrolled. The 5-year overall survival rates for single-station cN2 without and with hilar node enlargement were 81.3% and 37.5%, respectively (p = 0.025). Surgical mortality was 0% for all, and no considerable perioperative complications were noted; however, two patients died of interstitial pneumonia and unknown cause within 3 months after surgical resection. CONCLUSIONS: This is the very first prospective study on the surgical approach for cN2 NSCLC, and our result partially validated the proposed classification of the N descriptor in the new staging system. The treatment for single-station cN2 without hilar node enlargement would better if it were similar to that for cN1 disease. Induction chemotherapy or chemoradiotherapy may not be needed for such an entity.

[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.

Resection of primary malignant lung melanoma: a case report.

A 74-year-old man presented with chest pain and high-grade fever. Chest radiography revealed a consolidation in the right lower lung lobe, and computed tomography demonstrated atelectasis and infiltration of the right lower lobe, with pleural effusion. Bronchoscopy revealed a tumor occluding the inlet of the lateral/posterior basal segmental bronchus of the right lung, but bronchoscopic biopsy did not lead to a definitive diagnosis. Considering the possibility of obstructive pneumonia and pleuritis, we performed a right lower lobectomy, decortication, and pleuroclysis. Pathological examination revealed a malignant melanoma. The clinical and pathological findings suggested primary malignant melanoma of the lung.

[Successful Combined Modality Therapy for an Advanced Malignant Mediastinal Non-seminomatous Germ Cell Tumor in an Elderly Female].

A 69-year-old woman was diagnosed with a germ cell tumor in the anterior mediastinum. Following 3 years follow-up, she experienced chest pain and an enlarging of the anterior mediastinal tumor and bilateral lung metastases were detected by chest X-ray. The tumor was diagnosed as a primary malignant mediastinal non-seminomatous germ cell tumor by needle biopsy. After initial radiotherapy (12 Gy/4 Fr), she was subsequently treated with EP chemotherapy which achieved a partial response. Complete resection of the residual tumors in the mediastinum and right lung was performed. No recurrence has been noted for 5 years post-operatively.

[Hepatic-portal Venous Gas after Lung Cancer Surgery].

An 80-year-old man who was treated by pancreaticoduodenectomy and total gastrectomy for bile duct carcinoma 24 years ago, underwent right upper lobectomy for lung squamous carcinoma. Four days after surgery, he complained of fever and decrease of blood pressure without peritoneal irritation sign. Computed tomography showed hepatic-portal gas with mild pneumatosis intestinalis. He was treated by conservative therapy and recovered.

[Alpha Fetoprotein-producing Lung Adenocarcinoma].

We report a case of alpha fetoprotein (AFP) -producing lung adenocarcinoma. A 53-year-old man was referred to our hospital due to right pneumothorax. Computed tomography showed right moderate pneumothorax, a solid tumor in the upper lobe (S3) and mediastinal lymph node swelling. The serum AFP level was as high as 223.0 ng/ml. Frozen examination revealed a low-differentiated adenocarcinoma. Based on the pathological and immunohistochemical findings, the tumor was diagnosed as AFP-producing lung adenocarcinoma.

[Intrapulmonary Solitary Fibrous Tumor].

We report a case of intrapulmonary solitary fibrous tumor( SFT). A 34-year-old woman was referred to our hospital due to an abnormal shadow on a chest roentgenogram without symptom. Computed tomography showed a circumscribed intrapulmonary tumor with mild uptake on fluorodeoxyglucose (FDG)-positron emission tomography( PET) in the left lower lobe( S6). Frozen examination revealed a mesenchymal tumor. Based on the pathological and immunohistochemical findings, the tumor was diagnosed as intrapulmonary SFT.

[Long-term survival with complete response by gefitinib treatment followed by noncurative operation for lung cancer].

A 54-year-old man was referred to our hospital because of an abnormal shadow on chest X-ray. A computed tomography( CT) scan of the chest revealed a 6.5 cm tumor in the right upper lobe suspected of superior vena cava (SVC) infiltration. He was diagnosed as lung cancer(adenocarcinoma), and the right upper lobectomy with partial resection of SVC was performed. But the pathology confirmed the surgery to be non-curative. Nine months after operation, carcinomatous pleuritis was detected on chest X-ray. Since deoxyribonucleic acid (DNA)analysis revealed a mutation of epidermal growth factor receptor (EGFR) gene in exon 21, gefitinib treatment was started. Nine months later, pleural effusion regressed and his cerum carcinoembrionic antigen( CEA) level was normalized. 4 years later, gefitinib was discontinued by patient's request, however, he is alive without any signs of relapse 9 years after the operation.

[Typical bronchial carcinoid with repeated recurrence observed for 17 years after radical operation].

A 68-years-old male patient had been diagnosed as having bronchial carcinoid in B2 and right upper lobectomy with systematic hiler and mediastinal lymphadenectomy had been performed in 1996. Pathological diagnosis was a typical carcinoid (pT1aN0M0, stage I A). In 2004, 4 tumors were found in the trachea, right bronchial stump, right main bronchi and right B6 orfice. These were diagnosed as typical carcinoids by pathology. In 2005 argon plasma coagration was performed.In 2013, a localized recurrence was found in the right S6 by chest computed tomography (CT). The segmentectomy of the right S6 was performed. Even after radical operation for typical carcinoids, we should conduct long-term observation.

Remission of newly diagnosed immune thrombocytopenia after lung cancer resection.

Secondary immune thrombocytopenia is a rare paraneoplastic syndrome of lung cancer. We report a case of pulmonary pleomorphic carcinoma with newly diagnosed secondary immune thrombocytopenia. On referral, the patient's complete blood cell count was normal; however, it showed marked thrombocytopenia after 1 month. Blood biochemistry and bone marrow puncture showed normal findings. We speculated that he had immune thrombocytopenia associated with the lung cancer and planned lung resection. Sleeve middle and lower lobectomy was successfully performed with preoperative intravenous immunoglobulin and intraoperative platelet transfusion. His platelet count was restored and maintained a normal level at 8 months after the operation.

Benefits of rib head resection via costotransverse ligament release method for T3 lung cancer in the paravertebral space.

OBJECTIVE: Lung cancer located in the paravertebral region occasionally invades the rib head (T3) and not the spine (T4). In such cases, a costotransverse ligament release (CTLR) method may be useful for complete resection without performing a vertebrectomy. METHODS: Eighteen patients with lung cancer underwent chest wall resection between 2001 and 2009 at our institutions. Of those, 7 who underwent chest wall removal with rib head resection via a CTLR method (group A) and 11 without rib head resection(conventional distal rib resection, group B) were retrospectively analyzed. RESULTS: Three patients in group A underwent induction chemoradiotherapy. All rib head resections were performed via a CTLR approach without postoperative complications. There were no deaths within 30 day in group A and 1 in group B. The mean number of resected rib heads was 2.1 in group A, while 2.0 ribs were removed in group B. There was no significant difference for operation time between groups A and B(332±112 vs. 287±114 mins, p = 0.449). Local recurrence was seen in 0 patients in group A and 3 in group B(p = 0.13). The median survival time was 1489 and 727 day, respectively, while 5-year survival rates were 0.48 and 0.41, respectively. CONCLUSION: A rib head resection via a CTLR method is an effective procedure for T3 lung cancer infiltrating the rib head.

[Appropriate surgical approach to cystic thymic lesions].

We retrospectively analyzed surgical approach to cystic thymic lesions based on 25 cases. We classified to 4 groups as follows, 12 thin-wall solitary cysts with low uniform density, 7 solitary cysts with ununiform density, 5 cysts with tumor lesions and 1 multiple cysts. Preoperative image diagnoses were 10 thymic cysts, 7 cystic thymomas, 4 mature teratomas, and 1 each of multilocular thymic cyst and thymic lymphoma. Twenty cases were indicated to video-assisted thoracic surgery( VATS), the other 5 cases were operated by sternotomy. The reasons for thoracotomy were adherence with left brachiocephalic vein(LBCV)3, huge cyst compressing superior vena cava (SVC) 1, diffuse multiple cysts and tumors in hypertrophic thymus 1. Three cases were converted to open thracotomy from VATS because of dense adhesions around LBCV and malignant diagnosis. Final diagnosis are 16 congenital cysts, 3 thymomas, and one each multilocular thymic cyst, mature teratoma, thymic cancer, thymolipoma, venous hemangioma and mucosal associated lymphoid tissue( MALT) lymphoma. Thin-wall solitary cysts with low uniform density are able to diagnosed congenital thymic cysts by computed tomography( CT)/magnetic resonance imaging (MRI) appearances. On the contrary un-uniform density cysts or cysts with tumor lesions are difficult to achieve correct diagnoses by images. These lesions may contain thymoma or thymic cancer, so that rapid pathological examination should be prepared during surgical operation. Cysts adhering to LBCV should be operated by thoracotomy to avoid accidents of massive bleeding.

Pulmonary artery injury during mediastinoscopy controlled without gauze packing.

The most serious complication that can occur during mediastinoscopy is hemorrhage from large vessels in the mediastinum, whereas there are few articles relating to injury to major vessels. We describe a case of 77-year-old male with mediastinal lymphadenopathy, who underwent a mediastinoscopy procedure. When the pretracheal lymph nodes adjoining the right pulmonary artery were biopsied, a massive amount of bleeding spilled out through the scope. Immediately, the scope was removed from the body and the bleeding was controlled with digital compression at the skin incision. Then we closed the incision in a three-layer manner without any gauze packing in the mediastinum. Although some reports recommended gauze packing for massive bleeding during mediastinoscopy, we believe not all cases need gauze packing because bleeding from a low-pressure circulation system component into closed compartment, such as mediastinum, would cease without resulting in a large hematoma or pseudoaneurysm.

[Thymic cancer with cyst 10 years after esophagectomy].

A 65-year-old male, who had undergone an esophagectomy for esophageal cancer at the age of 53, presented a mediastinal growthing thymic cyst. The computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a cystic and thick wall in the anterosuperior mediastinum, and fluorodeoxyglucose-positron emission tomography (FDG-PET) showed strongly positive finding. Operation was performed and histological examination demonstrated thymic squamous carcinoma arising from thymic cyst. He underwent postoperative radiotherapy and survives 5 years after operation. As thymic cancer with thymic cyst is very rare, we presented this case with a review of the literature.

[Reversal of pulmonary hypertrophic osteoarthropathy in surgically treated lung cancer].

A 61-year-old man was admitted for evaluation of an abnormal chest abnormal with progressive swelling in both hands, clubbing of all fingers and toes, and polyarthroceles. He was given a diagnosis of pulmonary hypertrophic osteoarthropathy (PHO) associated with primary lung cancer, and underwent an upper left lobectomy. Histopathological analysis revealed stage IIB adenocarcinoma of the lung with K-ras mutation, but with no evidence of epidermal growth factor receptor (EGFR). Postoperatively, his symptoms rapidly improved, and the preoperatively observed high levels of serum vascular endothelial growth factor (VEGF) and interleukin 6 (IL-6) decreased to normal levels after just 1 month. VEGF and IL-6 caused by the genetic mutation of K-ras might play a role in the pathogenesis of PHO with lung cancer.