Impact of pneumothorax-like pulmonary collapse caused by rapid bronchial obstruction: A case report of pneumothorax ex vacuo.

We report two cases of pulmonary collapse that simulated pneumothorax on computed tomographic images and were caused by rapid complete bronchial obstruction. One patient was a 77-year-old woman with sudden dyspnea, and the other was an 83-year-old woman with sudden dyspnea who was infected with influenza A virus. Chest computed tomography revealed lobular complete atelectasis with an almost complete expansion of the other lobes of the right lung. Some air space in the right pleural cavity was also observed. Both cases were diagnosed as "pneumothorax" by primary doctors. We noted the disappearance of air density in the lumen of the right bronchus in both cases. We performed bronchoscopy before thoracic drainage and removed the obstruction. Immediately, the obstructed pulmonary lobes expanded, and the air space in the pleural cavity disappeared without thoracic drainage. In the literature, this pneumothorax-like pulmonary collapse is called as "pneumothorax ex vacuo."

Increased carbohydrate antigen 19-9 expression in a thymic neuroendocrine tumor.

Here, we report a case of carbohydrate antigen (CA) 19-9-producing mediastinal neuroendocrine tumor (NET) (atypical carcinoid). A 54-year-old woman with no specific relevant medical history was referred to our hospital because of increased CA19-9 (95.3 U/ml) detected on health screening. Chest computed tomography (CT) revealed an anterior mediastinal mass without localized lymphadenopathy. Thoracic surgery was performed and the histopathological diagnosis was thymic CA19-9-positive NET. The patient developed mediastinal lymph node metastasis at 1 year (CA19-9: 413 U/ml) and multiple bone metastases 4 years (CA19-9: 2303 U/ml) after surgery. Increased CA19-9 levels paralleled the clinical courses of relapse. To our knowledge, this is the first report of CA19-9-producing thymic NET.

[Pulmonary Artery Replacement in a Patient with Pulmonary Artery Dissection Associated with Pulmonary Hypertension and Single Ventricle:Report of a Case].

A right-sided classical Blalock-Taussig shunt was created in a 3-year-old male infant with hypoplastic left ventricle, common atrioventricular valve, transposition of the great arteries, and pulmonary stenosis. He was diagnosed with near Eisenmenger pulmonary hypertension at the age of 6 years. Surgery to achieve right heart bypass circulation was not conducted. At 33 years of age, he experienced hemoptysis. Pulmonary artery dissection, a life-threatening condition, was detected upon computed tomography performed when the patient was 35 years of age. After three weeks, surgery with cardiopulmonary bypass requiring pulmonary artery replacement using composite prosthetic conduits, closure of the pulmonary valve, and banding of the previously created Blalock-Taussig shunt was performed. Six years after the surgery, the patient's physical activity is maintained. Although intracardiac repair or definitive palliation with cardiopulmonary bypass is contraindicated in such patients, life-saving surgery with cardiopulmonary bypass that does not worsen pulmonary hypertension can be performed.

The extracorporeal circulation with transdiaphragmatic approach in living-donor liver transplantation for HB with atrial extension of tumor thrombus: A case report.

Surgical intervention for HB with tumor thrombi extending into the IVC and the RA might requires careful planning of the surgical procedures, including vascular reconstruction and extracorporeal circulation. We herein report a successful case of LDLT for HB with atrial extension of a tumor thrombus by extracorporeal circulation with a transdiaphragmatic approach. The patient was a 5-year-old boy with PRETEXT IV HB with a tumor thrombus that extended into the IVC and the RA. After 4 cycles of chemotherapy and resection of bilateral lung metastases, the size of the primary HB tumor decreased. As the tumor extension from the LHV to the RA had decreased but was still present, we performed LDLT with tumor thrombectomy. The central part of the diaphragm was sagittally incised to expose the suprahepatic IVC and the RA. Venovenous bypass was achieved from the right femoral vein and IMV to the RA En bloc resection of the native liver with the tumor thrombus was then performed. HV anastomosis was made between the newly created orifice on the IVC and the graft LHV. The duration of LDLT was 10 hours and 44 minutes (extracorporeal circulation time: 78 minutes). Pediatric LT for HB with the extension of tumor thrombi into the RA under extracorporeal circulation is a feasible option and allows for the expansion of the indications for transplantation for children with unresectable liver tumors.

Extralobar sequestration with a pulmonary arterial feeding vessel.

Extralobar sequestrations are rare congenital malformations of the lung. They are usually located between the diaphragm and left lower lobe and receive their blood supply from the aorta. We report a case of extralobar sequestration in an atypical location with a pulmonary arterial feeding vessel. An 18-year-old woman presented with an abnormality on chest X-ray. Chest computed tomography revealed a lung field not communicating with the bronchus between the upper and lower right lung lobes. Three-dimensional reconstruction computed tomography demonstrated a feeding artery from the pulmonary artery draining into the pulmonary vein. We diagnosed her with extralobar sequestration and resected the sequestered lung using video-assisted thoracic surgery. Therefore, three-dimensional reconstruction computed tomography helped identify the abnormal blood vessels, and video-assisted thoracic surgery may be useful in the treatment of extralobar sequestration.

Successful Resection of a Giant Pulmonary Colloid Adenocarcinoma via Median Sternotomy.

We report on a giant pulmonary colloid adenocarcinoma successfully resected using a median sternotomy approach. A 69-year-old woman visited our hospital owing to a giant mass detected on chest radiography. A giant cystic mass measuring 115 × 90 mm was detected in the right upper lung using computed tomography. We suspected mucinous adenocarcinoma and performed right upper lobectomy and mediastinal lymph node dissection with median sternotomy. The surgical field of view for the tumor and superior vena cava was satisfactory, and compression but not invasion of the superior vena cava and chest wall by the tumor was observed. The tumor was pathologically diagnosed as a colloid adenocarcinoma of stage IIIA with pT4N0M0. The postoperative course was uneventful, with no signs of recurrence at one and a half years after operation. Thus, this case demonstrates that for giant lung tumor surgery, median sternotomy is useful and safe for improving the surgical field of view.

[Effect of Pharmacist Interview before Doctor's Examination for Breast Cancer Chemotherapy Patients].

Patients treated with anticancer drugs are likely to have serious physical and mental anxieties due to severe adverse events. Continuous information provision with the expertise of pharmacists will lead to the improvement of quality of life (QOL) of patients and efficient administration of chemotherapy. At Koyama Memorial Hospital, a pre-consultation service by pharmacists has been initiated to reduce adverse events in patients undergoing breast cancer chemotherapy. The service has allowed pharmacists to continuously intervene with treatment from the start and if necessary, suggest that physicians change supportive care or conduct additional tests. Pre-consultations were provided for 503 breast cancer patients who received outpatient chemotherapy between January 2016 and October 2017. For 68(13.5%)of the 503 cases, pharmacists suggested prescriptions or tests. In the 68 cases, the adoption rate of suggestions among physicians was 95.6%(65/68). As a result of the adopted suggestions, adverse events disappeared or were alleviated in 89.2%(58/65)of the patients. Therefore, in breast cancer patients undergoing chemotherapy, adverse events associated with chemotherapy may be alleviated early through pharmacist-led pre-consultation and provision of appropriate pharmaceutical interventions based on the preconsultations.

Metachronous Thin-Walled Cavity Lung Cancers Exhibiting Variable Histopathology.

We report a case of metachronous thin-walled cavity lung cancers exhibiting variable histopathology. A 70-year-old man visited our hospital because of a thin-walled cavity located in the right upper lobe, detected by chest computed tomography. Right upper lobectomy was performed and a histological diagnosis of squamous cell carcinoma was made. Computed tomography at 7 years posttreatment detected a new thin-walled cavity in the left lower lobe. Histopathology after video-assisted thoracic surgery left S6 segmentectomy revealed adenocarcinoma. Patients with primary lung carcinoma may present with thin-walled cavities; postoperative screening can aid early the detection of metachronous primary lung cancers of variable origin.

Empyema and pyogenic spondylitis caused by direct Streptococcus gordonii infection after a compression fracture: a case report.

BACKGROUND: Empyema and pyogenic spondylitis are common diseases that are often caused by oral pathogens in direct or hematogenous infection. However, there exists no report describing empyema and pyogenic spondylitis caused by oral pathogens after a compression fracture of the vertebral body. Herein, we report a case of empyema and pyogenic spondylitis caused by direct Streptococcus gordonii infection after a compression fracture of the vertebral body. CASE PRESENTATION: A 74-year-old man had back pain while working. At 1 week after experiencing back pain, he underwent periodontal debridement. At 3 weeks after periodontal debridement, he visited our hospital owing to the absence of improvement in back pain. He was admitted on the same day with a diagnosis of compression fracture of the 12th thoracic vertebral body. Magnetic resonance imaging (MRI) revealed a compression fracture of the 12th thoracic vertebral body and a hematoma anterior to the vertebral body. Computed tomography (CT) showed no findings suggestive of infection. After admission, antibiotic therapy was initiated, as the patient developed fever and his blood cultures grew S. gordonii. CT performed after antibiotic therapy revealed a right-sided pleural effusion, and drainage was performed. As the inflammation did not improve after thoracic drainage for empyema, surgical debridement through video-assisted thoracic surgery was performed. Intraoperative pleural effusion cultures also grew S. gordonii. Postoperative MRI showed low T1-weighted signals and high T2-weighted signals in the 12th thoracic vertebral body, and the signals spread to the upper and lower intervertebral disk space; hence, a diagnosis of empyema and pyogenic spondylitis due to direct infection spread was established. Intravenous antibiotic therapy was continued for 6 weeks and then was switched to oral antibiotic treatment. His C-reactive protein level and erythrocyte sedimentation rate gradually decreased and remained within normal limits. Neither empyema nor pyogenic spondylitis had recurred at 12 months after surgery. CONCLUSIONS: Compression fracture with dental procedures possibly results in the thoracic cavity and spinal infection caused by oral pathogens. We emphasize the importance of early imaging examinations, diagnosis, and appropriate treatment for patients with compression fractures who develop a fever.

Recurrent sternal thymoma after thymectomy by video-assisted thoracic surgery.

An 81-year-old man underwent thymectomy by video-assisted thoracic surgery for a mediastinal tumor. The pathological diagnosis was Masaoka stage II type B3 thymoma. Thirty-six months later, he presented with a growing mass on his anterior chest wall. Computed tomography showed a lobulated tumor in the sternum with bone destruction. Positron-emission tomography-computed tomography showed a maximal standardized uptake of 12.3 in the tumor. Core needle biopsy confirmed a metastatic sternal tumor from a type B3 thymoma. We partially resected the sternum and reconstructed the defect using an expanded polytetrafluoroethylene sheet. The patient has remained recurrence-free for 3 years after the second surgery.

Higher Tissue Levels of Thymidylate Synthase Determined by ELISA Are Associated with Poor Prognosis of Patients with Lung Cancer.

Thymidylate synthase (TS) is essential in thymidylate biosynthesis and DNA replication. Dihydropyrimidine dehydrogenase (DPD) is a rate-limiting enzyme in pyrimidine catabolism and is important in catabolism of 5-fluorouracil (5-FU). The significance of TS and DPD expressed in lung cancer remains controversial. Here we analyzed the relationship between TS and DPD expression and clinicopathological features of lung cancer. Enzyme-linked immunosorbent assays (ELISAs) were used to measure TS and DPD levels in paired tumor and non-tumor lung tissues obtained from 168 patients (107 adenocarcinomas, 39 squamous cell carcinomas, and 22 others), who had operations at the Shinshu University Hospital from 2004 to 2007 and were followed up for a median of 57.0 months. TS and DPD expression levels were higher in tumor tissues, and TS expression levels were significantly lower in adenocarcinomas than those in other subtypes. In addition, patients with low TS levels survived longer compared with patents with high TS levels. By contrast, DPD expression levels were not correlated with overall patient survival. Importantly, patients with low TS and DPD levels exhibited significantly prolonged survival than those with high TS and DPD. Among the 168 patients, 59 patients were treated with tegafur-uracil (UFT), a DPD-inhibitory fluoropyrimidine, and the UFT-treated patients with high TS and high DPD levels showed worst prognosis. Our study demonstrates a significant correlation between low TS expression levels and long-term prognosis of patients with lung cancer. Thus, ELISA is a clinically useful method to measure TS and DPD expression in lung cancer tissues.

Differential diagnosis of a rare papillary tumor and mucinous adenocarcinoma.

Ciliated muconodular papillary tumors are characterized as rare papillary tumors of the peripheral lung, and involve ciliated, goblet, and basal cell proliferation with mucin secretion. We report the case of a 76-year-old woman who had an irregular solid nodule in the lung on chest computed tomography during a health screening. A wedge resection was performed. Although the intraoperative cytological diagnosis was mucinous adenocarcinoma, the final histological diagnosis was ciliated muconodular papillary tumor. The postoperative course was uneventful, with no recurrence at 24 months after surgery. Cytological diagnosis of ciliated muconodular papillary tumor can be difficult because of its similarity to mucinous adenocarcinoma.

Breast metastasis of pulmonary pleomorphic carcinoma: a case report.

BACKGROUND: Lung cancer rarely metastasizes to the breast, and breast metastasis of pulmonary pleomorphic carcinoma has not been previously reported. CASE PRESENTATION: The patient was a 66-year-old woman who became aware of a mass in the right breast and visited a physician. She was referred to our department for close examination, upon which she was diagnosed with double cancer (right breast cancer and left lung cancer). Needle biopsy findings for the mammary tumor were similar to those for the lung biopsy specimen, but spindle cell or metaplastic carcinoma were possibilities. The initial diagnosis was primary breast cancer. Left upper lobectomy and lymph node dissection were performed for left lung cancer. Both the lung and mammary tumors grew rapidly during the wait for surgery. The white blood cell count was within the normal range at the first examination, but was markedly increased and remained at a high level after surgery for lung cancer. Preoperative chemotherapy was initially planned for the mammary tumor, but surgical treatment was selected in consideration of the clinical course, and right mastectomy and full thickness skin graft were performed. However, the disease rapidly aggravated and the patient died 5 months after the first examination. CONCLUSION: The final diagnosis was pulmonary pleomorphic carcinoma with metastasis to the breast on postoperative histopathological examination. We describe this case as the first reported example of breast metastasis of pulmonary pleomorphic carcinoma.

A New Suturing Device for Small Arteries.

Endoscope-assisted surgery and robot-assisted surgery are not common in cardiac surgery, particularly coronary artery bypass grafting, because of the complex nature of the procedures. We developed a new suturing device that allows for easy performance of such cardiac surgeries in comparison with conventional suturing methods. A total of 63 rabbits were used in this study. The right carotid artery was bypassed using the same side of the jugular vein under endoscopic guidance. Of these, 48 rabbits were operated on using the new devices and 15 rabbits were operated on using conventional polypropylene sutures. The proximal suturing time was 16.6 ± 5.3 minutes in the group that underwent surgery using the new device (group D) and 22.8 ± 7.6 minutes in the control group (group C; P < 0.05). The distal suture time was 16.3 ± 4.2 minutes in group D and 22.8 ± 6.0 minutes in group C (P < 0.05). The operation time was 113.0 ± 15.8 minutes in group D and 136.7 ± 20.6 minutes in group C (P < 0.05). Graft flow was 19.9 ± 12.8 mL/minute in group D and 12.1 ± 11.3 mL/minute in group C (P < 0.05). Thus, the operation time and the suture time differed significantly between the groups. This device provides advantages in endoscopic surgery compared to the conventional suture method.

Recurrence of juxtacortical chondrosarcoma arising on the rib.

Juxtacortical chondrosarcoma developing on the surface of a bone is quite rare. We report a case of juxtacortical chondrosarcoma arising on the fourth rib of a 76-year-old man. Intraregional tumor resection was performed, but local recurrence was detected after 6 months. The patient underwent wide resection including the ribs, and reconstruction of the thoracic wall. He was released with a good prognosis after a year. This case emphasizes the importance of biopsy analysis before surgery to carefully evaluate tumor spread in the cartilage and performing wide resection even if the tumor is easily separated from the bone.

Birt-Hogg-Dubé syndrome detected incidentally by asymptomatic bilateral pneumothorax in health screening: a case of a young Japanese woman.

Birt-Hogg-Dubé syndrome (BHD) is an autosomal dominant disease caused by mutations of germline folliculin (FCLN) mapped in the chromosome 17p11.2 region. BHD commonly accompanies renal tumors, fibrofolliculomas, multiple pulmonary cysts, and spontaneous pneumothorax. We report a case of a young Japanese woman in whom asymptomatic bilateral pneumothorax was found incidentally in a health screening, which led to the diagnosis of BHD. She had developed neither renal tumors nor fibrofolliculomas. However, her father, uncle, and aunt also experienced pneumothorax. In Japan, BHD is not yet well known because skin-related symptoms of fibrofolliculomas are sometimes absent unlike in most cases in Europe and the United States. On the basis of this case, we propose that BHD should be considered at the time of pneumothorax examination.

Computed tomography attenuation predicts the growth of pure ground-glass nodules.

OBJECTIVES: Cases of lung cancer with pure ground-glass nodules (GGNs) have been detected with increasing frequency since the advent of computed tomography (CT), and growth is sometimes noted during follow-up. The objective of this study was to evaluate the potential predictive factors for pure GGN growth. MATERIALS AND METHODS: We retrospectively examined 124 cases involving pure GGNs. Patients were monitored for > 2 years using high-resolution CT. After a median follow-up period of 57.0 months, GGNs showed growth in 64 of the 124 cases. We compared the patient characteristics and tumor properties of cases with and without growth. The predictive value of the mean CT attenuation for GGN growth was evaluated using receiver operating characteristic curve analysis. RESULTS: Univariate analysis revealed significant differences between mean CT attenuation values in patients with and without growth (-602.9 ± 90.7 Hounsfield units [HU] vs -705.7 ± 77.7HU, P < 0.0001). The final incidence of growth was estimated to be significantly higher for lesions with a mean CT attenuation value of ≥ -670HU (n = 62; 93.2%) than for lesions with values of < -670HU (n = 62; 31.6%; P < 0.0001). The sensitivity and specificity for predicting tumor growth using this cutoff value were 78.1% and 80.0%, respectively (area under the curve, 0.81). CONCLUSION: The mean CT attenuation value could be useful in predicting the growth of GGNs.

Lung re-expansion following one-lung ventilation induces neutrophil cytoskeletal rearrangements in rats.

PURPOSE: To investigate the morphological and functional behavior of neutrophils during and after one-lung ventilation (OLV). METHODS: We utilized an OLV rat model system and performed 3 hours of OLV followed by either re-expansion (RE) and 30 minutes of two-lung ventilation (TLV) (RE group), only two-lung ventilation (TLV group), or only OLV (OLV group). Cytoskeletal rearrangements of circulating neutrophils were assessed by determining the localization of filamentous actin (F-actin). In addition, the number of sequestered neutrophils in the lung capillary and the cytokine-induced neutrophil chemoattractant 1 (CINC-1) levels in the plasma were determined. RESULTS: The F-actin rimmed neutrophils in the RE group increased after RE, but did not increase in the other groups. In the RE group, the sequestered neutrophils in the ventilated lung were significantly more numerous, and the plasma CINC-1 levels were significantly higher than in the other groups. CONCLUSIONS: Lung RE following OLV induces cytoskeletal rearrangements in circulating neutrophils and would thereby promote their sequestration in the lung capillaries. The plasma CINC-1 elevation after RE can be involved in neutrophil recruitment.

Feasibility of using a vessel sealing system in a human pulmonary lobectomy: a retrospective comparison of this procedure with or without a vessel sealing system.

OBJECTIVE: Despite recent advances in video-assisted thoracoscopic lobectomy, some technical limitations still remain. Our current study purpose was to determine if the vessel sealing system (VSS) has utility in this procedure. METHOD: 112 patients who underwent an anatomic pulmonary lobectomy at our institute were evaluated retrospectively. The burst pressure of pulmonary vessels, which was divided into VSS (VSS group; n = 44) or manual ligature (ligature group; n = 53) groups, was measured experimentally in transected lungs. Perioperative clinical data was also retrospectively evaluated in patients treated with (VSS group) or without using VSS (n-VSS group). RESULTS: Burst pressures achieved adequate strength in both the VSS (600.0 ± 436.8 mmHg) and ligature (1057.4 ± 462.3 mmHg) groups. Compared with the n-VSS group, the VSS group patients showed lower intraoperative blood loss (115.4 ± 181.1 vs. 183.3 ± 159.1 ml), lower chest fluids by 3rd post-operative day (POD) (533.8 ± 264.8 vs. 705.3 ± 339.3 ml) and a shorter period of chest tube duration (4.1 ± 1.2 vs. 5.4 ± 2.4 days). No serious complications or perioperative (30 days) deaths occurred in either group. CONCLUSION: The VSS device has the advantage in pulmonary lobectomy procedures, especially those involving video-assisted thoracic surgery (VATS).

Complications of bronchial stapling in thoracic surgery.

OBJECTIVE: The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, complications of stapling are occasionally experienced. The aim of this retrospective study was to analyze complications of bronchial stapling. METHODS: A retrospective multi-institutional review was conducted by the Central Japan Lung Cancer Surgery Study Group, comprising 29 institutions. All instances of bronchial stapling in thoracic surgery were reviewed during the research period. RESULTS: Bronchial stapling was performed 2,030 times, using 36 kinds of staplers. The total number of complications related to stapling was 36 (1.8 %); 31 events occurred intraoperatively and five events occurred postoperatively. The intraoperative complications were air leakage (N = 20) and stapling failure (N = 11), which were caused by stapler-tissue thickness mismatch (N = 17), stapler defect (N = 3), tissue fragility (N = 2), and unknown reasons (N = 9). In all 31 cases, intraoperative complications were recovered intraoperatively with additional suturing, and no further complications were observed postoperatively. The postoperative complications were bronchopleural fistula (BPF) (N = 4) and bleeding from the chest wall (intercostal artery) (N = 1). The rate of BPF was 0.2 % (4 of 2,030). Two of four BPFs induced critical conditions. Postoperative bleeding was caused by the use of Duet TRS(TM). Both total complications and BPF occurred more frequently in the main bronchus than in the lobar or segmental bronchus. No relationship was seen between the incidence of complications and cartridge colors in lobar bronchial stapling. The compression types of staplers were associated with the incidence of complication. CONCLUSIONS: Intraoperative and postoperative complications of bronchial stapling were studied. Generally, bronchial stapling in recent thoracic surgery was safe, but rare postoperative complications may induce critical conditions. Knowledge of potential complications and causes of bronchial stapling may decrease the incidence of stapling complications.