Sclerosing thymoma with numerous coarse calcifications.

This patient is the youngest among the previously reported sclerosing thymoma cases, and the resected mass contained numerous coarse calcifications due to dystrophic calcification. This is an unprecedented and extremely rare case.

Efficacy and safety of intraoperative partial spray of 50% glucose for patients with spontaneous pneumothorax.

OBJECTIVES: The management for pneumothorax patients involves surgical intervention, nevertheless postoperative recurrences are often encountered. To reduce the rates of recurrence, thoracic surgeons have experimented with various novel techniques, such as pleural abrasion, chemical pleurodesis, and staple line coverage with absorbable sheets, in addition to bullectomy. And in recent years, there have been reports of the effectiveness of the use of intraoperative glucose intrapleural spray (GIS) containing 50 ml of 50% glucose solution in addition to bullectomy. However, information on the effects and adverse events of GIS is limited. Current study was aimed to assess the efficacy and safety of GIS in preventing recurrence of pneumothorax. PATIENTS AND METHODS: We conducted a retrospective study with 74 cases of bullectomy with or without GIS between 2018 and 2021 at Okazaki City Hospital. Of these cases, 50 received GIS (GIS group) while 24 were treated conservatively (C group). RESULT: The GIS group consisted of 46 males and 4 females, whereas the C group consisted of 23 males and 1 female, with mean ages of 38.5 ± 5.7 years and 30.5 ± 6.7 years, respectively. The GIS group exhibited a mean increase in blood glucose of 23.8 mg/dL postoperatively, and postoperative infections were observed in 2 cases in the GIS group (4.0%) and 2 cases in the C group (8.3%). The NRS scores of the patients in the GIS group and the C group three hours postoperatively were 4.0 and 3.1, respectively (p = 0.28). No prolongation of postoperative drainage period by GIS was observed (1.2 days and 1.4 days in the GIS and C groups, respectively). Postoperative recurrence occurred in two patients from the C group. The postoperative total drainage volumes were 341.8 ± 25.2 ml and 74.2 ± 25.5 ml in the GIS and C groups, respectively, showing a significant increase in drainage volume (p < 0.01). None of them presented dehydration-related symptoms. CONCLUSIONS: The use of intraoperative glucose intrapleural spray is effective and safe in terms of preventing recurrences and postoperative complications.

A successful case of robot-assisted thoracic surgery for apical thoracic schwannoma.

The thoracic apex is a narrow and complicated area with nerves and vessels, making it difficult to secure a visual field and perform surgical operations. Robot-assisted surgery enabled good visibility and highly flexible forceps manipulation, we were able to perform minimally invasive and safe thoracic apical tumour resection.

A xiphisternal ulcer effectively treated with xiphoidectomy.

Xiphoid syndrome is a rare musculoskeletal disorder of the xiphoid process. The main symptom is precordial pain or xiphodynia. We experienced a case in which protrusion of the xiphoid process impaired blood flow to the skin, resulting in the formation of an ulcer and exposure of the xiphoid process. To the best of our knowledge, this is the first case of a xiphisternal ulcer secondary to a protruding xiphoid process. The patient was safely and effectively treated via xiphoidectomy using a T-saw.

Abnormal anastomosis of peripheral pulmonary arteries, initially suspected to be an arteriovenous fistula, in an adult with Williams syndrome.

Abnormal anastomosis of peripheral pulmonary arteries is rare and resembles a pulmonary arteriovenous fistula; thus, when the inflow or outflow route cannot be clearly identified in a suspected pulmonary arteriovenous fistula, the possibility of peripheral pulmonary artery anastomosis should be considered. However, the final diagnosis requires a catheterization study.

[Clinical Assessment of Spontaneous Hemopneumothorax].

We experienced 25 cases of spontaneous hemopneumothorax, in which 9 were defined as occult cases on chest X-ray at the time of visit. All 9 cases visited our hospital within 12 hours after the onset. Of these, 5 were done chest computed tomography (CT) and 3 could be diagnosed as hemopneumothorax. Emergency surgery were necessary in 4 of 9. Chest CT and careful observation is thought to be essential in case of suspiciously combined hemothorax in pneumothorax cases.

[Hepatoid Adenocarcinoma of the Lung with High Serum AFP and CEA Values;Report of a Case].

A 60-year-old man exhibited an abnormal shadow in the right upper lobe. He was diagnosed with lung cancer by percutaneous computed tomography-guided lung tumor biopsy. Preoperative blood test showed high serum alpha-fetoprotein(AFP) and carcinoembryonic antigen(CEA) values. Right upper lobectomy was performed and histlogical diagnosis was AFP producing hepatoid adenocarcinoma with immunohistochemically positive HEP-PAR1. After the surgery, AFP and CEA values decreased to normal range.

[Endobronchial Lipoma Treated Left Lower Lobectomy;Report of a Case].

Endobronchial lipoma is a rare benign tumor. Bronchoscopic intervention or surgical resection is reported for its treatment. A 63-year-old woman underwent chest X-ray and computed tomography (CT) scan for observation of her continuous wheezing. CT scan showed atelectasis in the left lower lobe and a tumor in the left lower lobe bronchus. Bronchoscopic examinations could not confirm the diagnosis. Although laser therapy was conducted, the tumor could not be resected due to the bleeding and the patient underwent left lower lobectomy. The pathological diagnosis was endobronchial lipoma. After the operation, her symptoms improved.

[Parathyroid Hormone-related Peptide (PTHrP) Producing Lung Cancer Presenting Hypercalcemia; Report of a Case].

An 82-year-old man was admitted to our hospital with hemoptysis and weight loss. Chest computed tomography(CT) showed a 90 mm mass with cavity formation in the right lower lobe adjacent to chest wall. Laboratory data revealed hypercalcemia and elevation of parathyroid hormone-related protein C (PTHrP). He was diagnosed as squamous cell carcinoma of lung by transbronchial lung biopsy (TBLB) [cT3aN1M0]. Nausea and anorexia due to hypercalcemia became worse and a right middle and lower lobectomy was performed because of difficult control of symptoms by medicine and worsening of his general condition. His symptoms were improved immediately after surgery.

[Pulmonary lymphoepithelioma-like carcinoma; report of a case].

A 66-year-old male was referred to our hospital due to an abnormal chest shadow in the left lung detected on a medical examination. Chest computed tomography(CT) revealed a round mass of 40 mm in diameter in the left S10. Positron emission tomography (PET) scan showed fluorodeoxy glucose (FDG) accumulation and surgical biopsy was done. The intraoperative frozen histopathological diagnosis was mucosal associated lymphoid tissue( MALT) lymphoma or pseudoinflammatory tumor. By postoperative pathology, the mass was finally diagnosis as lymphoepithelioma-like carcinoma (LELC) of the lung, pT2aN0M0 stage I B.After a month, left lower lobectomy with mediastinal lymph node dissection was performed. The association with Epstein-Barr virus was not demonstrated by EBER in situ hybridization. The patient was well without relapse at 24 months after surgery.

[Ectopic mediastinal parathyroid tumor resected by video-assisted thoracic surgery with intraoperative methylene blue infusion; report of a case].

We report a surgical case of ectopic mediastinal parathyroid tumor resected by video-assisted thoracic surgery with intraoperative methylene blue infusion. It is often difficult to detect ectopic mediastinal parathyroid tumor during the operation because the tumor is soft, small and buried under mediastinal tissue. After methylene blue 4 mg/kg intravenously administration, the tumor was gradually dyed blue and easily detected and resected by video-assisted thoracic surgery. It is useful of methylene blue for detection of ectopic mediastinal parathyroid tumor.

[Recurrence of inflammatory myofibroblastic tumor of chest wall after radical resection;report of a case].

A 61-year-old male presented with an asymptomatic left chest wall (the 7th rib) tumor detected by positron emission tomography(PET). The increase of tumor size was indicated by computed tomography(CT) scan and complete resection including the 6th to 8th rib was performed due to intraoperative rapid diagnosis as sarcoma. The diagnosis of inflammatory myofibroblastic tumor (IMT) was established by final pathological diagnosis. Three years later, he had a relapse of 2 tumors in left chest wall (the 9th, 10th rib), and surgical resection was performed without chest wall resection. Histological findings of a relapse tumor showed a large size tumor cell and a decrease in the number of plasma cell compared to the 1st tumor. These changes may be related to a clinical aggressive behavior.

[Mediastinal involvement of thyroid cancer with mediastinal lymph node metastasis; report of a case].

We report a surgical case of mediastinal involvement of papillary adenocacinoma of thyroid with mediastinal lymph node metastasis. A 58-year-old male was admitted to our hospital with laryngeal discomfort. The laryngeal fiber scopy showed left recurrent nerve palsy, although he hadn't noticed hoarseness before admission. An enhanced computed tomography(CT)scan revealed a heterogeneous 3×3 cm mass in the upper mediastinum. The 18F-fluorodeoxyglucose-positron emission tomography( FDG-PET)showed an accumulation of FDG in the mass and also in a mediastinal lymph node. The incisional biopsy on mediastinoscopy revealed a papillary adenocarcinoma of thyroid and a total thyroidectomy with resection of mediastinal lymph node through cervical and reverse-T upper mini-sternotomy approach was performed.

Late breast metastasis from resected lung cancer diagnosed by epidermal growth factor receptor gene mutation.

Primary lung cancer metastasizes to various organs, but rarely metastasizes to the breast. We report a case of breast metastasis from primary lung cancer, which was confirmed by the detection of the same epidermal growth factor receptor (EGFR) gene mutation.

Complete spontaneous regression of non-small cell lung cancer followed by adrenal relapse.

Spontaneous regression (SR) of cancer is a rare phenomenon. SR is recognized as complete or partial disappearance of the disease after inadequate or no treatment. Although reports of this phenomenon have been documented for several malignancies, it is rare in patients with lung cancer. In most documented cases, diagnoses of SR were made based on only the radiologic findings. We herein report a case of complete SR of non-small cell lung cancer (NSCLC) that was pathologically proven using a resected specimen. Moreover, despite the local complete SR, the patient subsequently experienced an adrenal metastasis after surgery. To the best of our knowledge, this is the first report of a patient with NSCLC in whom complete regression of the primary site was observed, but in whom a distant metastasis became apparent. Both phenomena were pathologically proven. Our report suggests that both SR and tumor progression can proceed simultaneously.

Can non-performance of radical systematic mediastinal lymphadenectomy be justified in elderly lung cancer patients? An evaluation using propensity-based survival analysis.

OBJECTIVES: The increasing age of the population has raised the importance of determining the minimally required surgical treatment for elderly lung cancer patients. Despite a number of previous studies, the therapeutic impact of a radical mediastinal lymphadenectomy (RLA) associated with a pulmonary resection for lung cancer remains controversial. Herein, we investigated the impact of lymph node dissection on the overall survival for elderly lung cancer patients and assessed whether the non-performance of an RLA could be justified in the surgical treatment for these elderly patients. METHODS: We analysed the data for 160 patients aged 70 years and older (113 males, 47 females) who underwent curative-intent surgery for non-small-cell lung cancer. They were divided into two groups, according to the method used for the intra-operative mediastinal lymph node dissection, the radical systematic lymphadenectomy (RLA, n=76) and the non-radical lymphadenectomy (NLA, n=94) groups. A Cox proportional hazards model and the Kaplan-Meier method were used for the survival analyses. Propensity-based analyses were also used to reduce the effect of non-randomisation and possible bias in indication of treatment between the two groups. RESULTS: RLAs had no protective effect on mortality; the hazard ratio for the RLA group in comparison to the NLA group was 0.97 (95% confidence interval (CI): 0.32-2.89) in the multivariate analysis and 1.43 (95% CI: 0.42-4.91) in the propensity-based stratifying analysis. The 3-year survival probability was 81.3% (95% CI: 67.1-89.8) for the NLA group, which was marginally better than that of the RLA group (77.5% (95% CI: 63.3-86.8)). There was no significant difference in the overall survival between the two groups (p=0.26). The 3-year survival probability of the NLA group at each quartile of the propensity score also tended to be better than that of the RLA group, which did not show any significant difference. CONCLUSIONS: There was no survival benefit shown for RLA associated with pulmonary resections in the present cohort, even in the propensity-based analyses. Although some reports recommend a systematic mediastinal lymphadenectomy for proper staging and better survival, a pulmonary resection with non-performance of radical lymphadenectomy could be an acceptable surgical treatment for the increasing number of elderly lung cancer patients.

Assessment of long-term postoperative pain in open thoracotomy patients: pain reduction by the edge closure technique.

BACKGROUND: Long-term postoperative pain in open thoracotomy patients could be related to injured intercostal nerves, and several methods have been devised to protect these nerves. METHODS: We retrospectively reviewed 184 consecutive patients who underwent posterolateral or anteroaxillary thoracotomy. Postoperative pain was routinely evaluated using an 11-point numerical pain rating scale (0 [no pain] to 10 [most severe pain]) at 1 to 2 weeks; 2 weeks to 1 month; and 1 to 2, 2 to 4, 4 to 6, 6 to 9, and 9 to 12 months after surgery. The following steps were considered to protect the intercostal nerves. During chest retraction, an intercostal muscle flap was harvested before using the retractor to prevent compression of the cranial intercostal nerve in posterolateral thoracotomy patients who needed buttressing of the bronchial stump. During closure, the thin space between the inferior edge of caudal rib and the intercostal neurovascular bundle was sutured to prevent strangulation of the intercostal nerve and vessels on the caudal side (edge closure technique). Subjects included 141 posterolateral and 43 anteroaxillary thoracotomies, 72 intercostal muscle flaps, and 87 conventional closures and 97 edge closures. RESULTS: During a year postoperatively, posterolateral thoracotomy patients experienced more pain (range, 1.2 to 4.6) than anteroaxillary thoracotomy patients (range, 1.1 to 3.7; p=0.038 for all periods). Patients with the intercostal muscle flap tended to experience less pain than those without the flap during the first month postoperatively. The scores of patients having edge closure (range, 0.9 to 3.8) were significantly lower than those of patients undergoing conventional closure (range, 1.6 to 5.1; p<0.001 for all periods). CONCLUSIONS: The edge closure technique, which preserved the caudal intercostal neurovascular bundle, successfully reduced pain.

Schwannoma of the sternum.

A primary sternal tumor is rare, and it is difficult to make an accurate diagnosis. We herein report a case of intraosseous schwannoma of the sternum, which was associated with various difficulties in regard to making an accurate preoperative diagnosis. A 38-year-old woman underwent a surgical resection for a sternal tumor. Preoperative radiologic images showed a well-defined, dumbbell-shaped and solid nodule in her sternum. However, a definitive diagnosis could not be obtained before the operation. The pathologic findings of the resected specimen revealed schwannoma, Antoni type A. No recurrence has been observed during her postoperative course.

Thymoma with spontaneous regression and disappearance of pleural effusion.

A 31-year-old woman was admitted to our hospital with sudden onset of chest pain. Chest radiography and computed tomography (CT) on admission showed an anterior mediastinal tumor with left pleural effusion, which was diagnosed as an inoperable malignant mediastinal tumor. However, 3 weeks after admission CT showed that the tumor was diminishing and the pleural effusion had disappeared without any treatment. CT-guided needle biopsy was performed, but diagnosis was impossible because most of the specimen was necrotic. A biopsy during video-assisted thoracic surgery was then performed. The intraoperative finding showed that the tumor was round, well mobilized, and did not invade adjacent structures. It was then assumed to be a benign teratoma that had been ruptured into the thoracic cavity. The operation was converted to a thoracotomy to resect it, but it could not be completely resected because of inflammatory adhesions to the mediastinum. Two months later, total thymectomy was performed through a median sternotomy because the tumor was pathologically diagnosed as a thymoma.

[A case of postoperative recurrent lung cancer with long survival due to gefitinib efficacy].

A 70-year-old woman underwent a right middle lobectomy and partial resection of right upper lobe for lung cancer. The pathological findings were well-differentiated adenocarcinoma, pT2N0M0, Stage IB. About 6 years after the operation, the serum CEA level increased and chest CT revealed right pleural dissemination and right pleural effusion. We diagnosed it as a recurrence of the lung cancer. Although we recommended chemotherapy, she hesitated and went without treatment for about 1 year. Then, 1 month after beginning gefitinib, her serum CEA level normalized and the recurrent lesion disappeared on chest CT. She has since a shown complete response with gefitinib for over 4 years and is still alive.