A case of concurrent follicular lymphoma and lung cancer requiring differentiation from lymph node metastasis.

Lung cancer complicated by follicular lymphoma has rarely been reported in the literature. A 69-year-old male with an abnormal shadow on a chest radiograph was referred to our hospital. A mass in the right lung was seen on chest computed tomography (CT). Positron emission tomography-CT showed fluorodeoxyglucose accumulation in the esophagus and multiple intra-abdominal lymph nodes, in addition to the right lung lesion. The lung lesion was diagnosed as a pulmonary adenocarcinoma after biopsy. Upper and lower gastrointestinal endoscopies did not reveal the presence of a tumor. Open lymph node biopsy was performed to determine the course of treatment, leading to a diagnosis of follicular lymphoma. The patient finally underwent radical resection for lung cancer; the follicular lymphoma was judged to be low-grade and was followed up. When complications involving other organs are detected during systemic examination of a patient with lung cancer, it is necessary to distinguish between metastasis to other organs and complications of other malignant diseases, as this will greatly influence the treatment strategy.

Usefulness of intraoperative nerve monitoring for giant type AB thymoma combined with an aberrant right subclavian artery: a case report.

BACKGROUND: Abnormal tumor vascularization and escalating tumor size represent two major impediments that make cancer surgery impossible or complicated. CASE PRESENTATION: Herein, we report the case of a giant thymoma (type AB) in a 58-year-old woman who presented with cough and yellow sputum. The thymoma grew extensively from the neck to the upper mediastinum. The patient exhibited an aberrant right subclavian artery and a non-recurrent inferior laryngeal nerve. Intraoperative nerve monitoring facilitated the identification and preservation of vital nerves spanning the neck and chest, including the non-recurrent inferior laryngeal nerve. Furthermore, the tumor was divided naturally along the constriction, and a good field of view was acquired to identify abnormal right subclavian arteries and nerves that ran deep in the tumor and surgical field. The tumor was safely removed without complications using intraoperative nerve monitoring, and the thymoma that grew extensively from the neck to the upper mediastinum and was associated with an aberrant right subclavian artery was resected. CONCLUSION: Intraoperative nerve monitoring was helpful in identifying the non-recurrent inferior laryngeal nerve and left recurrent laryngeal nerve.

An alternative posterior ascending pulmonary artery treatment in lobectomy with inflammatory lymph node infiltration.

BACKGROUND: Lobectomy may be a challenging treatment option in lung cancer with inflammatory lymph node infiltration. Moreover, the en-masse lobectomy technique, which involves the simultaneous ligation or stapling of pulmonary vessels and bronchi at the hilar area, is controversial. CASE PRESENTATION: We report the case of a 75-year-old woman who presented with lung cancer and lymph node infiltration from the posterior ascending pulmonary artery (A2) to the superior pulmonary artery (A6). A nodule was observed in her right upper lobe on chest computed tomography while treating her for a myocardial infarction 3 months prior; hence, a radical lobectomy was planned. Her main pulmonary artery could be constricted using surgical tape, but this was not possible in the peripheral pulmonary artery of the ascending A2 due to widespread lymph node infiltration. Intraoperative frozen sections confirmed the absence of metastases in the hilar lymph nodes. Pulmonary angioplasty was aborted because the cardiac function had not fully recovered from the previous procedure. The ascending A2 and upper lobe bronchus were collectively treated using an auto-stapler. Two months postoperatively, computed tomography showed no pulmonary artery aneurysm. CONCLUSIONS: This report highlights that the en-masse technique may be recommended as an alternative for A2 treatment during lobectomy in cases with inflammatory lymph node infiltration. Surgeons should consider switching to thoracotomy, in such cases, to avoid fatal intraoperative complications.

Robotic resection of ectopic mediastinal parathyroid adenoma with intraoperative parathyroid hormone monitoring: a case report.

BACKGROUND: Primary hyperparathyroidism is a disease caused by the secretion of excess parathyroid hormone (PTH) owing to the enlargement of the parathyroid gland. Ectopic parathyroid glands exist in the mediastinum in approximately 1-2% of cases, which is relatively rare. Intraoperative monitoring of serum PTH level is important to assess whether the source of hyperparathyroidism has been eliminated. CASE PRESENTATION: A 53-year-old asymptomatic woman was diagnosed with ectopic mediastinal parathyroid adenoma. A three-port robotic partial resection of the thymus containing the tumor was attempted, but bleeding from a swollen pericardial diaphragmatic vein led to the addition of an assist port along the way. The PTH level was measured intraoperatively. After confirming that the 15-min PTH level after removal of the tumor was less than 50% of the baseline value, the operation was completed. The tumor was positive for PTH and was diagnosed as an ectopic mediastinal parathyroid adenoma. Some small ectopic parathyroid gland tissues were observed in other parts of the thymic tissue. Serum calcium and PTH levels decreased and normalized. CONCLUSIONS: We report the usefulness of robotic resection for ectopic mediastinal parathyroid adenoma with PTH monitoring. However, histopathologically, small parathyroid gland tissues may remain in the surrounding thymus. Hence, we believe that a strict follow-up is required for parathyroid function in the future.

Genomics of Tumor Origin and Characteristics for Adenocarcinoma and Malignant Pleural Mesothelioma: A Case Report.

A female underwent a right middle lobectomy for a pulmonary adenocarcinoma (AD). She eventually died of a right malignant pleural mesothelioma (MPM; sarcomatoid type) 4 years and 7 months after the removal of the AD even though she did not have any history of asbestos exposure, smoking, or radiation exposure. Her chest CT revealed multiple pulmonary nodules and bilateral pleural effusion with a right pleural tumor directly invading into the abdominal cavity. The genomics of tumor origin and characteristics were examined for the AD and the MPM. As a result, 50 somatic variants were detected in the AD, and 29 somatic variants were detected in the MPM. The variants which were common in both the AD and the MPM were not present, which suggested that the AD and the MPM had occurred independently in different origins. The MPM had two driver oncogenes of TP53 and EP300, but the AD did not. Two driver oncogenes of TP53 and EP300 were hypothesized to make the MPM aggressive. The speed at which the MPM progressed without the patient having a history of asbestos exposure, smoking, or radiation exposure was alarming.

Analysis of risk factors for postoperative complications in non-small cell lung cancer: comparison with the Japanese National Clinical Database risk calculator.

BACKGROUND: Although the risk calculator of the National Clinical Database (RC-NCD) has been widely used to predict the occurrence of mortality and major morbidity in Japan, it has not been demonstrated whether a correlation between the calculated RC-NCD risk score and the actual occurrence of mortality and severe morbidity exists. METHODS: The clinical data of 585 patients who underwent pulmonary resection for non-small cell lung cancer were collected, and the risk factors for postoperative morbidity were analyzed to verify the validity of the RC-NCD. RESULTS: The coexistence of asthma (p = 0.02), nutrition lymphocyte ratio (p = 0.04), and pulmonary lobe (p < 0.01) were significant risk factors for postoperative morbidity in the present study, and the percent-predicted vital capacity (p < 0.01), pulmonary lobe (p = 0.03), and type of operative procedure (p = 0.01) were significant risk factors for severe postoperative morbidity. Furthermore, in patients received lobectomy, coexistence of asthma (p = 0.01) and pulmonary lobe (p < 0.01) were identified as significant risk factors for postoperative morbidity. Meanwhile, male sex (p = 0.01), high BMI (p < 0.01), low vital capacity (p = 0.04), and pulmonary lobe (p = 0.03) were identified as significant risk factors for severe postoperative morbidity. CONCLUSIONS: Given that the pulmonary lobe was a significant risk factor for postoperative morbidity in patients received pulmonary resection and for severe postoperative morbidity in patients received lobectomy, the RC-NCD for postoperative morbidity needs to be modified according to high-risk lobes. TRIAL REGISTRATION: The Institutional Review Board of Kanazawa Medical University approved the protocol of this retrospective study (approval number: I392), and written informed consent was obtained from all patients.

Is Overweight Related to the Prognosis of Octogenarians with Lung Cancer?

BACKGROUND: This study aimed to determine outcomes and prognostic factors associated with octogenarians who underwent pulmonary resection for lung cancer. METHODS: From 2009 to 2018, 76 octogenarians who underwent pulmonary surgery for lung cancer were enrolled in this study. We divided them into two groups, namely overweight and non-overweight, and investigated their clinicopathological characteristics and outcomes. Disease-specific survival (DSS) rates were determined using Kaplan-Meier curves. Univariate and multivariate analyses were performed to identify prognostic factors. RESULTS: Although perioperative morbidity and mortality in octogenarians were not significantly different between the two groups, the long-term prognosis of the overweight group was significantly worse than that of the non-overweight group. The 3-year DSS rate was 56.5%. The median observation period after surgery was 37.5 (8.9-112.3) months for the entire cohort postoperatively. Kaplan-Meier curves showed that being overweight (body mass index ≥ 25) was associated with worse survival rates in all pathological stages (0 to III) and stage 0/I (DSS, p = 0.036 and p = 0.003, respectively). Multivariate analysis identified overweight as an unfavorable prognostic factor for DSS in patients with stage 0/I lung cancer (hazard ratio 2.240, 95% confidence intervals 1.052-4.564, p = 0.037). CONCLUSIONS: Overweight is an independent risk factor, especially in pathological stage 0/I lung cancer. Indications for surgery should be carefully considered in elderly patients with obesity. However, owing to the limitations of this retrospective single-center study, future studies involving multiple institutions are required to confirm our findings.

Pulmonary Nodule and Mass: Superiority of MRI of Diffusion-Weighted Imaging and T2-Weighted Imaging to FDG-PET/CT.

The purpose of this retrospective study was to compare the diagnostic efficacy of FDG-PET/CT and MRI in discriminating malignant from benign pulmonary nodules and masses (PNMs). There were 278 lung cancers and 50 benign PNMs that were examined by FDG-PET/CT and MRI. The T2 contrast ratio (T2 CR) was designated as the ratio of T2 signal intensity of PNM divided by T2 signal intensity of the rhomboid muscle. The optimal cut-off values (OCVs) for differential diagnosis were 3.605 for maximum standardized uptake value (SUVmax), 1.459 × 10-3 mm2/s for apparent diffusion coefficient (ADC), and 2.46 for T2 CR. Areas under the receiver operating characteristics curves were 67.5% for SUVmax, 74.3% for ADC, and 72.4% for T2 CR, respectively. The sensitivity (0.658) of SUVmax was significantly lower than that (0.838) of ADC (p < 0.001) and that (0.871) of T2 CR (p < 0.001). The specificity (0.620) of SUVmax was that the same as (0.640) ADC and (0.640) of T2 CR. The accuracy (0.652) of SUVmax was significantly lower than that (0.808) of ADC (p < 0.001) and that (0.835) of T2 CR (p < 0.001). The sensitivity and accuracy of DWI and T2WI in MRI were significantly higher than those of FDG-PET/CT. Ultimately, MRI can replace FDG PET/CT for differential diagnosis of PNMs saving healthcare systems money while not sacrificing the quality of care.

Novel Insights of T2-Weighted Imaging: Significance for Discriminating Lung Cancer from Benign Pulmonary Nodules and Masses.

Diffusion-weighted imaging is useful for discriminating lung cancer from benign pulmonary nodules and masses (BPNMs), however the diagnostic capability is not perfect. The aim of this research was to clarify whether T2-weighted imaging (T2WI) is efficient in discriminating lung cancer from BPNMs, especially from pulmonary abscesses. A T2 contrast ratio (T2 CR) for a pulmonary nodule is defined as the ratio of T2 signal intensity of a pulmonary nodule divided by the T2 signal intensity of the rhomboid muscle. There were 52 lung cancers and 40 inflammatory BPNMs (mycobacteria disease 12, pneumonia 13, pulmonary abscess 9, other 6) and seven non-inflammatory BPNMs. The T2 CR (2.14 ± 0.63) of lung cancers was significantly lower than that (2.68 ± 1.04) of BPNMs (p = 0.0021). The T2 CR of lung cancers was significantly lower than that (2.93 ± 0.26) of pulmonary abscesses (p = 0.011). When the optical cutoff value of T2 CR was set as 2.44, the sensitivity was 0.827 (43/52), the specificity 0.596 (28/47), the accuracy 0.717 (71/99), the positive predictive value 0.694 (43/62), and the negative predictive value 0.757 (28/37). T2 CR of T2WI is useful in discriminating lung cancer from BPNMs. Pulmonary abscesses, which show strong restricted diffusion in DWI, can be differentiated from lung cancers using T2WI.

How to Discriminate Lung Cancer From Benign Pulmonary Nodules and Masses? Usefulness of Diffusion-Weighted Magnetic Resonance Imaging With Apparent Diffusion Coefficient and Inside/Wall Apparent Diffusion Coefficient Ratio.

BACKGROUND: Although diffusion-weighted imaging (DWI) is useful for differential diagnosis between lung cancers and benign pulmonary nodules and masses (BPNMs), it is difficult to differentiate pulmonary abscesses from lung cancers because pulmonary abscesses show restricted diffusion. With this research we will present how to assess the total apparent diffusion coefficient (ADC) and inside/wall ADC ratio for these pulmonary nodules and masses (PNMs). METHODS: The pulmonary lesions were divided into next 3 groups. There were 40 lung cancers, 41 inflammatory benign PNMs (mycobacteria disease 13, pneumonia 12, pulmonary abscess 10, other 6) and 7 noninflammatory benign PNMs. Definitions were as follows: wall ADC = ADC value in outer one-third of the lesion; inside ADC = ADC value in central two-thirds of the lesion: inside/wall ADC ratio = ratio of inside ADC/wall ADC. RESULTS: Mean total ADC (1.26 ± 0.32 × 10-3 mm2/s) of the lung cancers was remarkably lower than that (1.53 ± 0.53) of the BPNMs. The mean total ADC values were 1.26 ± 0.32 in lung cancer, 1.45 ± 0.47 in inflammatory BPNM and 2.04 ± 0.63 in noninflammatory BPNM, and there were significant differences among them. The mean inside ADC value (1.33 ± 0.32) of the lung cancers was remarkably higher than that (0.94 ± 0.42) of the pulmonary abscesses. The mean inside/wall ADC ratio (1.20 ± 0.28) of the lung cancers was remarkably higher than that (0.74 ± 0.14) of the pulmonary abscesses. CONCLUSIONS: Although ADC of DWI could differentiate lung cancer from BPNM, the inside/wall ADC ratio of DWI is efficient for differentiation between lung cancer and lung abscess. The inside/wall ADC ratio of DWI strengthens a weak point of DWI.

Whole-Lesion Apparent Diffusion Coefficient Histogram Analysis: Significance for Discriminating Lung Cancer from Pulmonary Abscess and Mycobacterial Infection.

Diffusion-weighted magnetic resonance imaging (DWI) can differentiate malignant from benign pulmonary nodules. However, it is difficult to differentiate pulmonary abscesses and mycobacterial infections (PAMIs) from lung cancers because PAMIs show restricted diffusion in DWI. The study purpose is to establish the role of ADC histogram for differentiating lung cancer from PAMI. There were 41 lung cancers (25 adenocarcinomas, 16 squamous cell carcinomas), and 19 PAMIs (9 pulmonary abscesses, 10 mycobacterial infections). Parameters more than 60% of the area under the ROC curve (AUC) were ADC, maximal ADC, mean ADC, median ADC, most frequency ADC, kurtosis of ADC, and volume of lesion. There were significant differences between lung cancer and PAMI in ADC, mean ADC, median ADC, and most frequency ADC. The ADC (1.19 ± 0.29 × 10-3 mm2/s) of lung cancer obtained from a single slice was significantly lower than that (1.44 ± 0.54) of PAMI (p = 0.0262). In contrast, mean, median, or most frequency ADC of lung cancer which was obtained in the ADC histogram was significantly higher than the value of each parameter of PAMI. ADC histogram could discriminate PAMIs from lung cancers by showing that AUCs of several parameters were more than 60%, and that several parameters of ADC of PAMI were significantly lower than those of lung cancer. ADC histogram has the potential to be a valuable tool to differentiate PAMI from lung cancer.

Risk factors of chest wall invasion in non-small cell lung cancer.

BACKGROUND: The risk factors for the development of chest wall invasion (CWI) in non-small cell lung cancer (NSCLC) patients are unclear. If the risk factors for the development of CWI can be clarified, surgical treatment might be able to be performed before CWI development, thus improving the prognosis. METHODS: In the present study, we enrolled patients who received surgery for NSCLC between January 2008 and December 2019 with available data on the maximum standardized uptake value (SUVmax) on positron emission tomography (PET) with lesions adjacent to the visceral pleura. Furthermore, the preoperative white blood cell (WBC) count, the preoperative neutrophil-to-lymphocyte ratio (NLR), platelet (Plt) count, levels of lactate dehydrogenase (LDH) and C-reactive protein (CRP) were analyzed as predictive factors of CWI. RESULTS: The relationships between CWI and clinicopathological variables were analyzed, and there were significant differences between patients with and without CWI in the age (P=0.02), maximum tumor diameter on computed tomography (CT) (P<0.01), diameter of tumors adjacent to the visceral pleura (Pmax) (P<0.01), SUVmax (P<0.01), maximum tumor diameter on a pathological examination (P<0.01), WBC count (P=0.03), Plt count (P=0.04), and levels of LDH (P<0.01) and CRP (P=0.01). Logistic regression analyses of the risk factors related to CWI showed that the age (P=0.02), Pmax (P=0.02), SUVmax (P=0.01), and LDH (P<0.01) were significant risk factors. CONCLUSIONS: The age, Pmax, SUVmax, and LDH levels might be associated with CWI.

Diffusion-weighted whole-body imaging with background suppression (DWIBS) is effective and economical for detection of metastasis or recurrence of lung cancer.

BACKGROUND: Diffusion-weighted whole-body imaging with background suppression (DWIBS) is used for the diagnosis and staging of cancers. The medical cost of an MR examination including DWIBS is $123, which is 80% less expensive than the cost ($798) of F18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) examination. METHODS: This study examined the efficacy of DWIBS for relapses after lung cancer resection. A total of 55 patients who had pulmonary resection of lung cancer, postoperative computed tomography (CT) every six months, and DWIBS and FDG-PET/CT (every year) were enrolled in this study. If a metastatic lesion was detected on CT scan, DWIBS and FDG-PET/CT were also used. RESULTS: A total of 55 patients who underwent pulmonary resections for lung cancer, and had CT, DWIBS and FDG-PET/CT examination during follow-up after pulmonary resection were enrolled in this study. Lung cancer in 32 patients relapsed. Postoperative radiographic examinations revealed pulmonary metastases in 17 patients, bone metastases in seven, liver metastases in five, lymph node metastases in five, pleural metastases in four, metastases to the chest wall in two, brain metastases in two, adrenal gland metastasis in one, and renal metastasis in one. The mean apparent diffusion coefficient (ADC) value of the relapse was 0.9 to 1.70 × 10-3 mm2 /s. The accuracy 0.98 (54/55) of DWIBS for detecting multiple metastatic lesions was likely to be higher than 0.94 (52/55) of CT or 0.94 (52/55) of FDG-PET/CT, but there were no significant differences. CONCLUSIONS: DWIBS can detect multiple metastatic lesions throughout the entire body and differentiate malignancy from benignity in only one examination. DWIBS has benefits of diagnostic accuracy and is less expensive in medical costs for the detection of a relapse. DWIBS could potentially replace FDG-PET/CT after lung cancer resection.

Unusual local and distant metastases after complete resection of roentgenographically occult squamous cell carcinoma.

Roentgenographically occult squamous cell carcinoma (ROSCC) was reported to have been cured after complete resection. We experienced unusual local and distant metastases after complete resection of a ROSCC of left B6 bronchus. During the operation due to the proximal bronchial stump being positive for squamous cell carcinoma (SCC), a left lower sleeve lobectomy was performed. Six years after the operation, a chest CT showed no abnormal shadows. 6 months later a PET-CT showed metastases on bilateral supraclavicular lymph nodes, mediastinal lymph nodes, and the right adrenal glands. A biopsy of the right supraclavicular lymph node revealed that it was a metastatic SCC. The possibility of recurrence from a second pulmonary SCC might still remain. A prolonged follow-up over many years is desirable for a heavy smoker with a ROSCC.

Congenital partial pericardial defect discovered incidentally during surgery for lung cancer: a case report and literature review.

BACKGROUND: Congenital pericardial defects are rare congenital anomalies, often asymptomatic and incidentally detected during thoracic surgery. CASE PRESENTATION: A 74-year-old man with primary lung cancer (cT1cN0M0, Stage IA3) underwent thoracoscopic radical lobectomy. At the time of thoracotomy, a pericardial defect was found on the ventral side of the hilar region, and the left atrial appendage was exposed. Due to concern that contact between the bronchial stump and the left atrial appendage may lead to postoperative bleeding and heart hernia, the pericardial defect was closed with an expanded polytetrafluoroethylene GoreTex® membrane. Preoperative computed tomography was reanalyzed with a 1 mm slice, congenital pericardial defect was detected as the pericardium had penetrated under the left atrial appendage. CONCLUSIONS: In congenital partial pericardial defect, contact between the left atrial appendage and bronchial stump, due to movement of the lung or heart, increases the risk of bleeding after lung resection. Therefore, closure of the defect should be considered. Although it is difficult to diagnose congenital partial pericardial defect preoperatively, computed tomography taken with a slice thickness of 1 mm is useful for diagnosis.

Differentiation between suture recurrence and suture granuloma after pulmonary resection for lung cancer by diffusion-weighted magnetic resonance imaging or FDG-PET / CT.

There has been no publication which supports the usefulness of DWI differentiating for suture recurrence and suture granuloma after resection for lung cancer. We presented efficacy of DWI or FDG-PET/CT for an assessment of suture lesions after resection for lung cancer. Thirteen suture recurrences and 15 suture granulomas were examined. There were 24 adenocarcinomas and 4 squamous cell carcinomas, and 26 partial resections and 2 segmentectomies. The period of time (907±907 days) between surgery and suture recurrence was not significantly longer than that (546±547 days) between surgery and suture granuloma. Diffusion detectability scores (a 5-point scale) of suture recurrences was significantly higher than that of suture granulomas. The ADC value (1.35±0.24 × 10-3mm2/sec) of suture recurrences was significantly lower than that (1.85±0.60 × 10-3mm2/sec) of suture granulomas. The SUVmax (6.1 ±â€¯5.0) of suture recurrences was not significantly higher than that (4.2 ±â€¯2.5) of suture granulmas. The sensitivity of 85% (11/13) with DWI was not significantly higher than 69% (9/13) with FDG-PET/CT for suture recurrences. The specificity of 73% (11/15) with DWI was not significantly higher than the 60% (9/15) with FDG-PET/CT for suture granulomas. The accuracy of 79% (22/28) with DWI was not significantly higher than that of 64% (18/28) with FDG-PET/CT for suture recurrences and granulomas. DWI can differentiate suture granuloma from suture recurrence after resection of lung cancer. DWI is more useful than FDG-PET/CT for the differentiation between suture recurrence and suture granuloma after resection for lung cancer.

Anterior mediastinal ectopic pancreatic cyst incidentally identified by pericarditis: a case report.

Ectopic pancreas often occurs in the gastrointestinal tract. However, the identification of a mediastinal ectopic pancreas is extremely rare. Herein, we report a case of ectopic pancreas of the anterior mediastinum, which was incidentally detected during treatment for pericarditis with widespread ST elevation on electrocardiogram. A 40-year-old woman complaining of chest pain was admitted with suspected pericarditis. A closer examination revealed a cystic mass in the anterior mediastinum, which was diagnosed as a pancreatic cyst of the anterior mediastinum on thoracoscopic tumor resection.

Clinical outcomes and survival following placement of self-expandable metallic stents for central airway stenosis and fistula.

BACKGROUND: Self-expandable metallic stent (SEMS) placement is an urgent procedure for patients with malignant central airway stenoses (CASs) and central airway fistulas (CAFs). The aim of this study was to determine the outcome and survival after SEMS placement in patients with malignant CASs and CAFs. METHODS: SEMSs were inserted into 20 patients with malignant CASs and four with malignant CAFs. Hospital records, the modified Medical Research Council dyspnea scale (mMRC) grade, performance status (PS), symptoms, procedure-related complications and survival after placement were retrospectively reviewed. RESULTS: Spiral Z stents were inserted in nine patients, covered Ultraflex stents in 14, and a bare Ultraflex in one patient. After SEMS placement, 20 patients (83.3%) showed improvement in mMRC grade, 19 (79.2%) showed improvement in PS, and 21 (87.5%) showed improvement in symptoms. There were three patients whose stents migrated out of place, but there were no patients with obstructive granulation, infection, or mucous plugs. Median survival days after stent insertion was 98 days for CAS and 103 days for CAF, and mean survival days was 383 ± 707 days for CAS and 93 ± 33 days for CAF. Two patients with CAS by malignant lymphoma and thymic cancer survived more than six years because they were also treated with efficient therapies. The five-year survival rate after stent insertion was 7.7%. CONCLUSIONS: SEMS placement for CAS and CAF is associated with improvement in mMRC grade, PS and symptoms in 87.5% of patients. Patients with a malignant CAS are usually terminal, but the possibility of increasing survival rate will become a reality with new efficient therapies. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Reasonable clinical outcomes and improved survival of patients following SEMS placement for thoracic malignancy with central airway stenosis and fistula. WHAT THIS STUDY ADDS: The possibility of increasing survival rate will become a reality with new efficient therapies.

Virtual thoracoscopic imaging-assisted pleural marking of pulmonary nodules.

BACKGROUND: Computed tomography (CT) is now able to detect small pulmonary nodules. Surgical resection for diagnosis of these nodules is widely performed with video-assisted thoracoscopic surgery (VATS). However, it is very difficult to localize a small tumor by palpation via a small access port. In this study, we aimed to describe a novel intraoperative method for marking the location of the pulmonary nodule. METHODS: In 46 cases, a virtual thoracoscopic image was reconstructed using the CT images of the chest using volume rendering software before surgery. During thoracoscopic surgery, a pleural marker was affixed to the parietal pleura, just above the tumor, by referring to the virtual thoracoscopic image. The pleural marker dye was then transferred to the point on the visceral pleura just above the nodule. The distance between the center of the marking and the visceral pleura closest to the tumor was measured to evaluate the accuracy of the marking. RESULTS: The mean distance between the center of the marking and the visceral pleura closest to the tumor was 10.2 mm. In 42 cases (92%), the tumor was within 30 mm of the marked point. All tumors were fully resected. No morbidity occurred intra- or postoperatively. CONCLUSIONS: Our pleural marking, using a virtual thoracoscopic image, identified the tumor location with high accuracy, may help surgeon to confirm whether the palpated nodule is the target one. This new procedure can assist in the localization of the pulmonary nodule with ease of application, safety, and accuracy.

Relationships and Qualitative Evaluation Between Diffusion-Weighted Imaging and Pathologic Findings of Resected Lung Cancers.

For detecting malignant tumors, diffusion-weighted magnetic resonance imaging (DWI) as well as fluoro-2-deoxy-glucose positron emission tomography/computed tomography (FDG-PET/CT) are available. It is not definitive how DWI correlates the pathological findings of lung cancer. The aim of this study is to evaluate the relationships between DWI findings and pathologic findings. In this study, 226 patients with resected lung cancers were enrolled. DWI was performed on each patient before surgery. There were 167 patients with adenocarcinoma, 44 patients with squamous cell carcinoma, and 15 patients with other cell types. Relationships between the apparent diffusion coefficient (ADC) of DWI and the pathology were analyzed. When the optimal cutoff value (OCV) of ADC for diagnosing malignancy was 1.70 × 10-3 mm2/s, the sensitivity of DWI was 92.0% (208/226). The sensitivity was 33.3% (3/9) in mucinous adenocarcinoma. The ADC value (1.31 ± 0.32 × 10-3 mm2/s) of adenocarcinoma was significantly higher than that (1.17 ± 0.29 × 10-3 mm2/s) of squamous cell carcinoma (p = 0.012), or (0.93 ± 0.14 × 10-3 mm2/s) of small cell carcinoma (p = 0.0095). The ADC value (1.91 ± 0.36 × 10-3 mm2/s) of mucinous adenocarcinoma was significantly higher than that (1.25 ± 0.25 × 10-3 mm2/s) of adenocarcinoma with mucin and that (1.24 ± 0.30 × 10-3 mm2/s) of other cell types. The ADC (1.11 ± 0.26 × 10-3 mm2/s) of lung cancer with necrosis was significantly lower than that (1.32 ± 0.33 × 10-3 mm2/s) of lung cancer without necrosis. The ADC of mucinous adenocarcinoma was significantly higher than those of adenocarcinoma of other cell types. The ADC of lung cancer was likely to decrease according to cell differentiation decreasing. The sensitivity of DWI for lung cancer was 92% and this result shows that DWI is valuable for the evaluation of lung cancer. Lung cancer could be evaluated qualitatively using DWI.