[Giant Pericardial Cyst with Left Ventricular Compression on Echocardiography:Report of a Case].

We report a very rare case of giant pericardial cyst with left ventricular compression on echocardiography. A 61-year-old man visited our hospital with a feeling of chest tightness. A cardiologist ruled out cardiac diseases of the patients and he was referred to us for examination and treatment of an abnormal left lung field shadow on chest x-ray. Chest computed tomography (CT) showed a 16×7.5 cm cystic mass in connect with the heart and diaphragm. Echocardiography showed that the cystic mass was compressing the left ventricle. Surgical resection was attempted by video-assisted thoracoscopic surgery (VATS). We aspirated serous liquid contents in the cyst and partially resected the cyst wall excepting cardiac side. After confirming the cyst was not a pericardial diverticulum, we completely resected its residual wall. His postoperative course was uncomplicated. The cyst was pathologically diagnosed as a pericardial cyst.

[Pulmonary Epithelioid Hemangioendothelioma:Report of a Case].

A 54-year-old woman with a lung tumor was admitted to our hospital for surgical treatment. Chest computed tomography (CT) showed a 16×14×10 mm nodule in left upper lobe. Flurodeoxyglucose (FDG)-positron emission tomography (PET)/CT revealed increased uptake in the nodule. We diagnosed the tumor as lung cancer preoperatively, and performed surgery. Frozen section diagnosis after partial lung resection was lung cancer and we performed left upper lobectomy. The tumor was histopathologically diagnosed as pulmonary epithelioid hemangioendothelioma( PEH).

[Primary Pulmonary Paraganglioma:Report of a Case].

A 60-year-old woman with a lung tumor was admitted to our hospital for surgical treatment. Chest computed tomography (CT) showed a 23×21×20 mm nodule in the right lower lobe. Although the lung nodule was thought to be benign due to CT image findings, its size was apparently larger than that of CT image at four years ago. So, we decided to resect the nodule and performed a partial lung resection under video-assisted thoracic surgery. The tumor was histopathologically diagnosed as a paraganglioma and scored 0 point in pheochromocytoma of the adrenal gland score( PASS). Since no abnormal uptake that indicates primary site was not found on fluorodeoxyglucose-positron emission tomography (FDGPET) performed after surgery, we diagnosed this tumor as a primary pulmonary paraganglioma. She is still alive without recurrence.

[Rare Case of Thymic Epidermoid Cyst;Report of a Case].

A 68-year-old man with a mediastinal tumor was admitted to our hospital for surgical treatment. Chest computed tomography (CT) showed a 33×20×20 mm mass in anterior mediastinum. Magnetic resonance imaging (MRI) showed a heterogeneous structure in the cystic component of the mass. We diagnosed the tumor as thymic cyst preoperatively, and thymectomy was performed. The tumor was histopathologically diagnosed as thymic epidermoid cyst.

[Two-staged Operation for Bilateral Giant Bullae Successfully Performed with Veno-venous Extracorporeal Membrane Oxygenation( V-V ECMO) for First Surgery].

57-year-old man with bilateral giant lung bullae was admitted to our hospital for dyspnea on exertion as his chief complaint. The size and shape of right lung bullae were bigger and more complicated than those of left lung bullae. He underwent 2-staged bullectomy by video-assisted thoracoscopic surgery (VATS). Left lung bullectomy was expected to be more safely done, and was performed with veno-venous extracorporeal membrane oxygenation( V-V ECMO) prior to right side without any complications. The right lung bullectomy was performed 6 months after 1st operation without V-V ECMO. These reoperations were necessary due to postoperative air leak, however, his respiratory condition was well maintained by his left lung which had already been remarkably improved.

[Wedge Bronchoplastic Left Upper Lobectomy for Lung Cancer Patient with Abnormal Mediastinal Left Basal Pulmonary Artery].

A 65-year-old man with left lung squamous cell carcinoma was admitted to our hospital for operation. His tumor was located left upper lobe and invaded to the orifice of left upper bronchus. We diagnosed the tumor as cT2aN0M0 and intended to perform radical operation. Preoperative three-dimensional computed tomography (3D-CT) revealed that A9+10 which descended along lower bronchus was arisen from the left main pulmonary artery as a 1st branch of it. A wedge bronchoplastic left upper lobectomy was safely done with preserving the branch. Although this abnormal branching of left pulmonary artery is very rare, we should pay more attention this type of anomaly because unintended injury of the branch causes massive bleeding or ischemia of left lower lobe. Preoperative 3D-CT is useful for detecting the anomaly of pulmonary vessels.

The influence of comorbidity on the postoperative survival in elderly (≥ 75 years old) with lung cancer.

OBJECTIVES: We conducted a multi-institutional prospective observational study of elderly patients (≥ 75 years-old) with resected non-small cell lung cancer. In this report, we have followed the cohorts for 2 years after surgery and examined both the influence of preoperative comorbidity [Adult Comorbidity Evaluation-27 (ACE-27) index] on the postoperative survival and the change in the Karnofsky Performance Status (KPS). METHODS: From March 2014 to April 2015, 264 patients were prospectively registered from 22 hospitals affiliated with the National Hospital Organization. The mean age at the time of surgery was 79.3 years (range 75-90 years), and 41% of the patients were ≥ 80 years of age. A total of 26% underwent sublobar resection. The study endpoints were the postoperative overall survival (OS), its prognostic factors, and the changes in the postoperative KPS. RESULTS: The 2-year OS was 85.3% (95% confidence interval 80.4-89.1%). Male gender, age ≥ 80, a smoking history, grade 2 of ACE-27, and an advanced disease stage were significantly poor prognostic factors for the OS in the univariate risk analysis. The multivariate analysis showed that male gender, age ≥ 80, an advanced disease stage and sublobar resection were significantly poor prognostic factors for the OS. In comparison with the preoperative KPS, no marked decline was observed in the postoperative chorological change of KPS. CONCLUSIONS: In the surgical treatment of elderly patients, the comorbidity as assessed by the ACE-27 index might affect the postoperative survival, and therefore should be taken into accounts in the preoperative evaluation of the surgical indications.

[Immunohistochemical Analysis of Krebs von den Lungen-6 (KL-6) Expression in Lung Tissue in Primary Lung Cancer Patients with High Serum KL-6 Levels].

We investigated sialylated carbohydrate antigen( Krebs von den Lungen-6:KL-6) expression in lung tissue and correlation between the expression and serum KL-6 level in the patients with primary lung cancer. Thirty-four primary lung cancer patients with high serum KL-6 levels( >500 U/ml) were evaluated. A coexistence of interstitial pneumonia (IP) was histopathologically evaluated and an immunohistochemical staining using a mouse anti-human KL-6 antibody (mKL-6) was performed. A multiple regression analysis was also caluculated using a serum KL-6 level as a target variable and the histopathological and immunohistochemical factors (KL-6 expression in cancer tissue and IP tissue, coexistence of IP, tumor size, pathological staging) as descriptive variables. Twenty-two patients (64.7%) were histopathologically concomitant with IP. Cancer tissues were positively stained by mKL-6 in 32 patients (94.1%). Among them, 20 patients were concomitant with IP and all of their cancer tissues were more strongly stained by mKL-6 than IP tissues. Although considerable high rate of lung cancer patients might express the KL-6 in the cancer tissue, we could not reveal the relationship between the expression and serum KL-6 level by a multiple regression analysis. For revealing the mechanism of elevating serum KL-6 level in the patients with lung cancer, more detailed and powerful study is thought to be needed.

[Pulmonary blood flow measurement using magnetic resonance imaging (MRI) without contrast medium;comparison of phase contrast MRI and perfusion-ventilation scintigraphy].

To define the accuracy of pulmonary arterial blood flow (PA-flow) measured by phase contrast magnetic resonance imaging (PC-MRI), we compared the PA-flow data of PC-MRI with the data of perfusion-ventilation lung scintigraphy. Eighteen patients who preoperatively underwent PA-flow measurement using PC-MRI and perfusion-ventilation lung scintigraphy were evaluated. The PA-flow (cm3/sec) of MRI was calculated by multiplying maximum velocity (cm/sec) by region of interest (ROI) area (cm2) of measured main pulmonary artery using phase contrast method. The left to right ratio (R/L ratio) of PA-flow measured by PC-MRI was compared with the R/L ratios of the date of perfusion-ventilation lung scintigraphy. The R/L ratios of PC-MRI and perfusion lung scintigraphy were 1.43 ± 1.07 and 1.35 ± 0.82, respectively. Both ratios showed excellent correlation( y=-0.50+1.30x, r=0.99,p<0.001). The R/L ratios of PC-MRI also approximated to those of perfusion lung scintigraphy in the patients with a past history of lung resection, even if their R/L ratios of perfusion lung scintigraphy differed from those of ventilation lung scintigraphy. These results revealed that the PA-flow could be accurately measured by PC-MRI without contrast medium and nuclear medicine instruments.

Feasibility of adjuvant chemotherapy with S-1 consisting of a 4-week administration and a two-week rest period in patients with completely resected non-small cell lung cancer.

The efficacy of adjuvant chemotherapy with S-1 in patients with completely resected non-small cell lung cancer (NSCLC) has yet to be clarified, and the appropriate schedule for the adjuvant chemotherapy with S-1 remains unknown. A phase II study was conducted to evaluate the feasibility and efficacy of adjuvant chemotherapy with S-1. Patients enrolled in this study were 20-75 years old, had pathological stage IB-IIIA NSCLC, and had received complete resection of NSCLC. S-1 (80 mg/m2) was administered orally to the patients for four weeks followed by a two-week rest period (conventional schedule), for a maximum of eight cycles. The primary endpoint was relative dose intensity (RDI), while the secondary endpoints were safety and 1 year of disease-free survival (1y-DFS). Between May 2007 and October 2009, 28 patients were enrolled. The RDI was 63.1% (95% CI, 48.6-77.7). No grade 3 or worse hematological toxicity was observed. Grade 3 non-hematological toxicities were observed in four patients. No grade 4 or worse hematological toxicity was detected. The probability of 1y-DFS was 85.7% (95% CI, 72.8-98.6). In the subgroup analysis, the median RDI of patients over 65 years old was lower compared to the other patients (44.8 vs. 100%; P=0.013; Mann-Whitney U test). Creatinine clearance (CCr) was lower in the older group, with more grade 2 or 3 non-hematological toxicities in the elderly patients. These results suggest that the conventional schedule of adjuvant chemotherapy with S-1 is not likely to be feasible in older patients with completely resected NSCLC.

[Intraoperative thracoscopic needle biopsy for the diagnosis of indeterminate pulmonary tumor].

To define the usefulness of intraoperative thracoscopic needle biopsy( ITNB), we compared the background and operative outcomes of the patients underwent ITNB with those of the patients underwent partial lung resection(PLR)using auto-suture devices. Between 2002 and 2009, 78 patients were diagnosed as lung carcinoma by intraoperative pathological examination (IPE) and subsequently performed curative surgery. In these 78 patients, 31 underwent ITNB (NB group)first and 47 underwent PLR (PR group) first. The tumor size, distance between tumor and pleura, number of required auto-suture devices and duration time of surgery in NB group were 34.5±15.6 mm, 9.2±8.6 mm, 4.2±1.5 and 276±47 minutes, respectively. Those in PR group were 27.8±14.2 mm, 7.1±6.8 mm, 5.5±2.0 and 286±61 min utes, respectively. The number of required auto-suture devices in NB group was significantly fewer than that in PR group (p<0.01).The accuracy of IPE was 93.5% and local recurrences weren't observed in NB group. ITNB prior to PLR for the patients with indeterminate lung tumor economizes the auto-suture devices and time required for PLR, so this method might contribute to save the operative cost and duration.

[Pulmonary squamous papilloma].

We report a rare case of pulmonary squamous papilloma. A 42-year-old woman was referred to our hospital complaining of dry cough. A chest computed tomography (CT) showed a mass shadow in the lower lobe of left lung. Serum concentrations of carcinoembryonic antigen (CEA) and squamous cell carcinoma-related antigen (SCC) were elevated to 13.0 ng/ml and 11.8 ng/ml, respectively. The mass was positron emission tomography( PET)-positive, with a maximum standard uptake value( SUVmax) of 11.55, suggesting a malignant neoplasm. Under the guidance of video-assisted thoracoscopy, left basal segmentectomy was performed. Intra-operative diagnosis was a squamous papilloma and no malignancy. Her postoperative course was uneventful. She is currently alive without any sign of recurrence.

[Posterior mediastinal paraganglioma].

We report a case of 26-year-old man with a posterior mediastinal paraganglioma. Although he was asymptomatic, chest abnormal shadow was pointed out by the regular medical screening with chest X-rays. A chest computed tomography (CT) showed a left posterior mediastinal tumor with strong enhancement. He was referred to our hospital for surgery. We tried a video-assisted thoracic surgery (VATS) for resection of the tumor, but additional small thoracoscopy was necessary for control of bleeding. The patient's vital sign was stable at perioperative course. The histopathological examination revealed no evidence of malignancy, and a final diagnosis of paraganglioma was made. His postoperative course was uneventful, and is currently doing well without sign of recurrence. Because metastasis and/or local recurrence of paragangliomas is difficult to predict accurately only by histopathological finding, long-term follow-up is thought to be essential after surgery.

[Surgical results of a video-assisted lung resection for lung cancer; does surgical approach affect patient's satisfaction of surgery?].

Ninety five patients with lung cancer who underwent a single lobectomy were studied. In these patients, 42 were underwent a video-assisted thoracic surgery (VATS) lobectomy with minithoracotomy (Va group), 43 were operated under a muscle sparing thoracotomy (Ms group) and 10 were operated under a posterolateral thoracotomy (P1 group). White blood cell (WBC) numbers, C-reactive protein (CRP) levels and visual analogue scale (VAS) scores in Va group were significantly lower than those in P1 group until 3 or 7 postoperative day (POD). However, at 14 POD, there were no significant differences in these dates between these 2 groups. There were no significant differences in WBC numbers, CRP levels and VAS scores between Va and Ms groups. There were no significant differences in changing ratios of vital capacity and patient's satisfaction of surgery among these 3 groups. VATS lobectomy had several advantages over the conventional open surgery. However, those differences disappeared shortly and patient's satisfaction of surgery was not affected by surgical approaches.

[Bronchioloalveolar carcinoma illustrating difficulties in diagnosis and determination of operative management; report of a case].

A 56-year-old male was admitted to our hospital to treat for an abnormal lung shadow. Computed tomography (CT) revealed the shadow with ground-glass opacity that was 30 mm in diameter at left S6 lesion. Although transbronchial lung biopsy had been performed, histological diagnosis could not be made. We had expected the tumor could not be resected completely with a partial lung resection. Additionally, he refused being done a lower lobectomy without a histological diagnosis. So we performed a S6+S* segmentectomy with No. 7-12 lymph node dissection. Although the intraoperative frozen section diagnosis was an atypical adenomatous hyperplasia, the tumor was finally diagnosed as bronchioloalveolar carcinoma (BAC) because of its nuclear atypia. We did not resect the residual part of left lower lobe because he refused the additional operation and might have histopathologically no residual tumor and lymph node metastasis. At present, he is alive without any evidence of recurrence.

[Thoracoscopic segmentectomy of the left upper division in a patient with endobronchial hamartoma; report of a case].

A 71-year-old man was admitted to our hospital for treatment of an endobronchial tumor. Although he was asymptomatic and chest radiography showed no tumor shadow, bronchoscopic findings demonstrated an endobronchial tumor with a villous surface occluding the bronchus of the left upper division. Endobronchial resection was abandoned because we could not directly observe the cervix with a bronchoscope. In addition, because we could not diagnose the tumor histologically as benign by biopsy specimens, we elected to perform a segmentectomy of the left upper division. To reduce surgical stress, the operation was carried out using thoracoscopy. The tumor was finally diagnosed as endobronchial chondromatous hamartoma. The patient's postoperative course was uneventful. When endobronchial resection is not feasible, a less invasive surgical approach and method should be taken in patients with suspected endobronchial hamartoma.

[A case of thymic cyst with thymic hyperplasia].

A 70-year-old man was admitted to our hospital for treatment of an anterior mediastinal tumor. Although he was asymptomatic, an abnormal shadow was visible on chest radiography. CT revealed a heterogeneous tumor located in the anterior mediastinum. On MRI, the tumor demonstrated low signal intensity in T1-weighted images and high signal intensity in T2-weighted images. Laboratory data, including tumor markers, were mostly within the reference ranges. Although a CT-guided needle biopsy was performed, histologic diagnosis could not be confirmed. We resected the tumor with the thymus by median sternotomy. Histopathological examination demonstrated that the tumor was a multilocular thymic cyst with thymic hyperplasia and numerous lymphocytes. The lining epithelial cells gave positive reactions to immunohistochemical staining for carbohydrate antigen 19-9. Carcinoembryonic antigen and squamous cell carcinoma antigen levels in the cystic fluid were elevated. This case appeared to be an acquired thymic cyst with thymic hyperplasia. There are few reports of such cysts.

Cyclic strain stimulates early growth response gene product 1-mediated expression of membrane type 1 matrix metalloproteinase in endothelium.

SUMMARY: Matrix metalloproteinases (MMPs) are hypothesized to be involved in the processes of endothelial cell (EC) migration and matrix remodeling during angiogenesis. Although hemodynamic forces (such as blood pressure, wall tension, and shear stress) are considered to be strong stimuli for angiogenesis, the role of hemodynamic forces on the regulation of MMPs including membrane type 1 matrix metalloproteinase (MT1-MMP) has not been fully elucidated. To study this, rat microvascular EC were exposed to 60 cycles/minute of 24% maximum strain for up to 24 hours. MT1-MMP mRNA and protein increased in a time-dependent manner through 24 hours of exposure to cyclic strain. Cyclic strain induced early growth response gene product (Egr-1) mRNA and protein within 1 hour. A specific nucleoprotein complex was formed when an oligonucleotide containing binding sites for Sp1 and Egr-1 was incubated with nuclear extracts from EC exposed to 1 hour of cyclic strain. Antibodies to Egr-1 completely supershifted this complex. Increased binding of Egr-1 by cyclic strain to the MT1-MMP promoter correlated with enhanced transcriptional activity. These results suggest that cyclic strain up-regulates the Egr-1-mediated expression of MT1-MMP in rat microvascular EC, emphasizing the importance of hemodynamic forces in the regulation of MT1-MMP in vivo.