A retrospective analysis of treatment selection and risk factors of treatment failure and recurrence in patients with spontaneous pneumothorax.

Background: Conservative observation with/without oxygen supplementation, aspiration, or tube drainage is selected as an initial treatment for spontaneous pneumothorax. In this study, we examined the efficacy of initial management for cessation of air leak and prevention of recurrence, with consideration of the degree of lung collapse. Methods: Spontaneous pneumothorax in patients who underwent initial management in our institute between January 2006 and December 2015 were included in this retrospective, single-institutional study. Multivariate analyses were conducted to identify risk factors related to the treatment failure after initial treatment and those related to ipsilateral recurrence after last treatment. Results: Of 668 episodes of 522 patients, 198 events were initially treated by observation, 22 by aspiration, and 448 by tube drainage. Successive outcome for cessation of air leak in initial treatment was achieved in 170 (85.9%), 18 (81.8%), and 289 (64.5%) events, respectively. In the multivariate analysis for predicting failure after first treatment, previous episode of ipsilateral pneumothorax [odds ratio (OR) 1.9; 95% confidence interval (CI): 1.3-2.9; P<0.01], high degree of lung collapse (OR 2.1; 95% CI: 1.1-4.2; P=0.032), and bulla formation (OR 2.6; 95% CI: 1.7-4.1; P<0.0001) were the significant risk factors for treatment failure. Recurrence of ipsilateral pneumothorax was observed in 126 (18.9%) cases: 18 of 153 cases (11.8%) in the observation group, 3 of 18 cases in the aspiration group (16.7%), 67 of 262 cases in the tube drainage group (25.6%), 15 of 63 cases in the pleurodesis group (23.8%), and 23 of 170 cases in the surgery group (13.5%). In the multivariate analysis for predicting recurrence, previous episode of ipsilateral pneumothorax was a significant risk factor [hazard ratio (HR) 1.8; 95% CI: 1.2-2.5; P<0.001]. Conclusions: Predictive factors for failure after initial treatment were recurrence of ipsilateral pneumothorax, high degree of lung collapse, and radiological evidence of bullae. The predictive factor for recurrence after the last treatment was the previous episode of ipsilateral pneumothorax. Observation was superior to tube drainage in success rate to cease air leak and recurrence rate, although this effect was not statistically significant.

Primary Pleural Angiosarcoma Treated with Nivolumab and Ipilimumab: A Case Report.

Primary pleural angiosarcoma (PPA) is a rare and clinically fatal pleural tumor originating from vascular endothelial cells. Herein, we presented the case of a 73-year-old man who was referred to our emergency room with complaints of right chest and back pain for a few days. Chest computed tomography revealed massive pleural effusion and a large mass in the right chest cavity. Thoracoscopic examination demonstrated a large hemorrhagic tumor on the parietal pleura whose pathological analysis indicated PPA. The patient received immunotherapy combined with nivolumab and ipilimumab. A cycle of nivolumab and ipilimumab improved his hemorrhagic anemia and reduced the pleural effusion and tumor size. This treatment outcome suggests that nivolumab and ipilimumab comprise a vital treatment option for PPA.

Preoperative lung surface localization for pulmonary wedge resection: a single-center experience.

BACKGROUND: Preoperative lung surface localization is effective in sublobar resection for small lung nodules. However, the efficacy may vary depending on the underlying conditions of the lung and tumor, as well as the technique. This study aimed to evaluate the efficacy and limitations of preoperative lung surface localization for wedge resection by analyzing the outcomes of computed tomography (CT)-guided percutaneous marking and virtual-assisted lung mapping (VAL-MAP). METHODS: We investigated 215 patients who underwent curative wedge resection for malignant tumors using CT-guided localization or VAL-MAP from 1998 to 2018 in our institute. Each resected nodule was assessed for successful resection, which was defined as complete resection with adequate margins. RESULTS: One-hundred-and-nineteen patients with 153 nodules were included. The overall successful resection rate was 87.6%. The successful resection rate was significantly lower for nodules with intraoperative adhesion than those without intraoperative adhesion (75.0% vs. 90.1%; P=0.034), and for tumors requiring deep resection margins (>31 mm) than those requiring shallow margins (≤31 mm) (76.7% vs. 94.6%; P=0.002). Although the successful resection rate for nodules resected using CT-guided localization was significantly lower in cases with versus without intraoperative adhesion (54.5% vs. 86.7%; P=0.048), the successful resection rate for nodules resected using VAL-MAP was not influenced by the presence or absence of adhesion (85.7% vs. 93.4%; P=0.491). CONCLUSIONS: A requirement for deeper resection and the presence of intraoperative adhesion were limitations of preoperative lung surface localization for curative pulmonary wedge resection.

Diagnosis and outcome of resected solitary pulmonary nodules after liver transplantation.

OBJECTIVE: Solitary pulmonary nodules after liver transplantation are challenging clinical problems. Herein, we report the causes and clinical courses of resected solitary pulmonary nodules in patients who underwent liver transplantation. METHODS: We retrospectively obtained medical records of 68 patients who underwent liver transplantation between March 2009 and June 2016. This study mainly focused on patients with solitary pulmonary nodules observed on computed tomography scans during follow-ups that were conducted until their deaths or February 2019. RESULTS: Computed tomography scans revealed solitary pulmonary nodules in 7 of the 68 patients. Definitive diagnoses were obtained using video-assisted lung resection in all seven patients. None experienced major postoperative complications. The final pathologic diagnoses were primary lung cancer in three patients, pulmonary metastases from hepatocellular carcinoma in one patient, invasive pulmonary aspergillosis in one patient, post-transplant lymphoproliferative disorder in one patient, and hemorrhagic infarction in one patient. The three patients with lung cancer were subsequently treated with standard curative resection. CONCLUSIONS: Solitary pulmonary nodules present in several serious but potentially curable diseases, such as early-stage lung cancer. Patients who present with solitary pulmonary nodules after liver transplantation should be evaluated by standard diagnostic procedures, including surgical biopsy if necessary.

Preoperative biopsy does not affect postoperative outcomes of resectable non-small cell lung cancer.

OBJECTIVES: Preoperative diagnostic interventions such as transbronchial biopsy and/or computed tomography-guided biopsy inevitably disrupt the lung structures and may disseminate tumour cells into the airway, vessels, or pleural cavity. Therefore, these procedures may affect the postoperative outcomes. Thus, we aimed to compare the survival outcomes in patients diagnosed by transbronchial biopsy vs computed tomography-guided biopsy vs lung resection. METHODS: In a single-institution retrospective analysis, data from consecutive patients with cTanyN0M0 lung cancer, who underwent surgery between January 2006 and December 2012, were extracted by chart review. The overall and recurrence-free survivals of patients diagnosed by transbronchial biopsy, computed tomography-guided biopsy, and lung resection were compared using the univariate and multivariate Cox proportional hazard models. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. RESULTS: Transbronchial biopsy and/or computed tomography-guided biopsy were performed for larger and more advanced tumours, than lung resection (intra- or postoperative-diagnosis group). At crude analysis, transbronchial biopsy group and computed tomography-guided biopsy group showed higher probability of pleural dissemination, and worse prognosis than the lung resection group. At multivariate analysis, the diagnostic methods were not identified as independent risk factors of pleural dissemination, overall survival, or recurrence-free survival. CONCLUSIONS: Preoperative diagnostic interventions did not affect the relapse risk and prognosis, in this study cohort. Thus, preoperative diagnostic intervention is recommended if deemed necessary.

Comparative study of programmed cell death ligand-1 immunohistochemistry assays using 22C3 and 28-8 antibodies for non-small cell lung cancer: Analysis of 420 surgical specimens from Japanese patients.

OBJECTIVES: Multiple programmed cell death ligand-1 (PD-L1) immunohistochemistry assays are currently used as companion or complementary diagnostic tools for anti-programmed cell death-1 immunotherapies. We aimed to characterize two PD-L1 immunohistochemistry assays (Dako 22C3 and 28-8) for non-small cell lung cancer (NSCLC) in clinical laboratories. MATERIALS AND METHODS: Surgical specimens from 420 patients with pathological stages IA to IIIA NSCLC were investigated. The archived samples were freshly cut into 5-µm-thick sections stained with antibodies 22C3 and 28-8, and tumoral PD-L1 expression was evaluated in two clinical laboratories, respectively. Overall, positive, and negative percent agreement (OPA, PPA, and NPA, respectively) at specified PD-L1 cutoffs were calculated to assess the concordance between 22C3 and 28-8 assays. RESULTS: Tumoral PD-L1 expression of ≥ 1% was detected by either 22C3 or 28-8 assays in 176 cases (41.9%), whereas 22C3 revealed a significantly higher tumoral PD-L1 expression compared to 28-8 (median 30% vs. 10%, p < 0.0001). OPA was 89.0, 90.2, and 91.9% at 1, 25, and 50% cutoff levels. When 22C3 was compared to a standard assay 28-8, the PPA was 85.5, 98.3, and 94.9%, whereas NPA was 91.0, 89.0, and 91.6% at 1, 25, and 50%. On the other hand, when 28-8 was compared to 22C3, PPA was 84.4% at 1%, but it decreased to 58.3 and 53.6% at 25 and 50%; whereas NPA remained high (91.7, 99.7, and 99.4% at 1, 25 and 50%, respectively). CONCLUSION: Our analysis revealed that, despite the high OPA, there was discordance in the PPA between 22C3 as a standard assay and 28-8 as a comparator assay at 25% and 50% PD-L1 cutoff levels, indicating that the results of 28-8 could be translated to those of 22C3 but not vice versa.

[Role of Perioperative Extracorporeal Membrane Oxygenation in Cardiothoracic Surgery].

Extracorporeal membrane oxygenation (ECMO) is a temporary mode of providing life support by totally/partially augmenting heart and lung function over a few days to weeks. More than 30,000 cases involving ECMO usage in adults have been reported worldwide since the introduction of this unique therapy, and its applications continue to evolve rapidly. In recent times, ECMO plays a key role not only in the domain of critical care in intensive care units, but is also useful in the field of cardiothoracic surgery;it provides cardiopulmonary support intra- and post-operatively, respiratory support for primary graft dysfunction after lung transplantation and serves as a bridge to lung transplantation. The purpose of this review is to analyze the indications, modes of application, and complications of ECMO use in the field of cardiothoracic surgery.

Cytological characteristics of meningeal solitary fibrous tumor metastatic to the lung: A case report with immunocytochemical analysis.

Solitary fibrous tumor (SFT) is a relatively uncommon mesenchymal tumor, and its occurrence in the meninges is rare. We herein report what is, to the best of our knowledge, the first cytological case of meningeal SFT metastatic to the lung with immunocytochemical analysis for signal transducer and activator of transcription 6 (STAT6), and compare the cytological characteristics to those of pleuropulmonary SFT. A 58-year-old Japanese male patient was found to have multiple nodules in the bilateral lungs after surgery for meningeal SFT. Partial resection of the nodules was performed, and touch smears were obtained. The Papanicolaou smear revealed cohesive hypercellular clusters of polygonal to elongated neoplastic cells with scant cytoplasm and oval to short spindle-shaped nuclei with nucleoli containing coarse chromatin. Mild-to-moderate nuclear pleomorphism was observed. No collagenous stroma was noted. Immunocytochemical analysis revealed that the neoplastic cells diffusely expressed STAT6. Histopathological and immunohistochemical studies confirmed the diagnosis of meningeal SFT metastatic to the lung. Moreover, reverse transcription-polymerase chain reaction analysis revealed that the lung tumor harbored NAB2ex6-STAT6ex16 fusion. Recent studies demonstrated that there is a clinicopathological difference among NAB2-STAT6 fusion variants in SFT. As reflected in fusion variants, meningeal SFT occasionally lacks collagenous stroma, as in the present case, although the most characteristic cytological feature of SFT is the presence of spindle-shaped neoplastic cells embedded in dense collagenous stroma. Thus, immunocytochemical analysis for STAT6 is very useful for diagnosing SFT.

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.

[Combined Anterior and Posterior Surgical Approaches for Resection of a 2nd-rib Chondrosarcoma Occupying the Superior Sulcus].

A 77-year-old man with right chest wall chondrosarcoma invading vertebral bodies underwent resection. Computed tomography (CT) showed that the tumor occupied the right superior sulcus, and was close to mediastinal organs including the trachea and esophagus. We adopted a combined anterior and posterior approaches that made safe and curative resection possible. In the anterior approach, we dissected and mobilized the neurovascular structures and neighboring organs from the tumor. A-4 cm gutter on the ventral side of the 1st, 2nd, and 3rd thoracic vertebral bodies was created for safe resection. By the subsequent posterior approach, successful resection was achieved without violating tumor margins.

Transformation to small-cell lung cancer as a mechanism of acquired resistance to crizotinib and alectinib.

A 56-year-old woman, a never-smoker, had postoperative recurrence of anaplastic lymphoma kinase rearranged lung cancer. She achieved a partial response to treatment with an anaplastic lymphoma kinase tyrosine kinase inhibitor, crizotinib. After the tumor regrowth, crizotinib was switched to alectinib; once again a partial response was observed. At the second recurrence, transbronchial needle aspiration of the right paratracheal node was performed, which revealed cytological findings of small-cell carcinoma. While treatment with cisplatin-irinotecan chemotherapy made reduction of some tumor shadows, including the biopsied mediastinal lymph nodes, new, small, nodular shadows, highly suggestive of pulmonary metastases, were detected in both lung fields. This case may show proof of the transformation to small-cell lung cancer as a mechanism of resistance to anaplastic lymphoma kinase tyrosine kinase inhibitors in anaplastic lymphoma kinase rearranged tumor. However, this transformation may also be only one part of the resistance mechanism of the heterogeneous tumor.