Short-term outcomes of robotic subxiphoid-optical thymectomy.

PURPOSE: To evaluate the usefulness of robotic subxiphoid-optical thymectomy (RST). METHODS: Thirty-seven procedures (thymoma, n = 19; thymic carcinoma, n = 1; myasthenia gravis, n = 3; and others, n = 14) performed between October 2020 and December 2023 were included. The right and left 6th intercostal midclavicular lines and subxiphoid, with an assistant port placed in the right third intercostal anterior axillary line, were adapted. Postoperative pain was assessed using a numerical rating scale (NRS). RESULTS: A good view of the surgical field is obtained. The median console time was 113 min and the time to roll-in was 30 min. The body mass index (BMI) was 21.6. One patient with thymic carcinoma required combined resection of the left phrenic nerve and left brachiocephalic vein without conversion to thoracotomy, and 1 patient had post-pericardiotomy syndrome with bilateral pleural effusion. There was a correlation between the prolonged time to roll-in and BMI (ρ = 0.439; p = 0.007). Pain was controlled with oral medication on postoperative day 1 and significantly decreased at discharge and at the first outpatient visit without epidural anesthesia (median NRS scores: 4, 1, and 1, respectively). CONCLUSION: RST is a safe procedure that provides surgeons with a sufficient view of the anterior mediastinum and causes minimal postoperative pain.

Inter-prefectural and urban-rural regional disparities in lung cancer surgery: a Japanese nationwide population-based cohort study from 2017 to 2019.

PURPOSE: To investigate regional disparities in lung cancer surgery in Japan. METHODS: The annual incidence of lung cancer, lung cancer surgery, and the number of board-certified thoracic surgeons in Japan during 2014-2019 were investigated using a national open database. Lung cancer surgeries were categorized by procedure (wedge resection, segmentectomy, lobectomy, pneumonectomy) and approach (open, thoracoscopic). Disparities in 47 prefectures and urban-rural disparities during 2017-2019 were evaluated using the Gini coefficient and an unpaired t-test. Correlation was assessed using Pearson's correlation method. RESULTS: The national annual average incidences of lung cancer and lung cancer surgery were 121,106 and 50,959, respectively, in 2014-2019. The use of the thoracoscopic approach increased over time in all procedures, except pneumonectomies. The Gini coefficients of lung cancer, thoracoscopic surgery, and board-certified thoracic surgeons indicated low inequality across prefectures; however, those of open surgery indicated high inequality. Open surgery was more common in urban areas than in rural areas. The number of thoracoscopic surgeries and board-certified thoracic surgeons by prefecture were moderately correlated. CONCLUSION: The thoracoscopic approach is becoming more common in lung cancer surgery, with little inter-prefectural regional disparity in the incidence of lung cancer, thoracoscopic surgeries, or the number of board-certified thoracic surgeons.

Characteristic differences in the abundance of tumor-infiltrating lymphocytes and intratumoral developing T cells in thymoma, with special reference to PD-1 expression.

PURPOSE: Though programmed cell death-1 (PD-1) inhibitors mainly target tumor-infiltrating lymphocytes (TILs) expressing PD-1, developing T cells in thymus also express PD-1 in their process of maturation. To predict the therapeutic effect of PD-1 inhibitors for thymoma, it is necessary to clarify the proportions of TILs and intratumoral developing T cells. METHODS: The expressions of CD4, CD8, and PD-1 on T cells were analyzed by flow cytometry in 31 thymomas. The amount of T cell receptor excision circles (TRECs), which can be detected in newly formed naïve T cells in the thymus, was evaluated using sorted lymphocytes from thymomas by quantitative PCR. The expressions of granzyme B (GZMB) and lymphocyte activation gene-3 (LAG-3) in PD-1 + CD8 T cells were analyzed by image cytometry using multiplex immunohistochemistry. RESULTS: The PD-1 + rate in both CD4 and CD8 T cells was significantly higher in type AB/B1/B2 than in type A/B3 thymomas. The amounts of TRECs in CD4 and CD8 T cells were significantly higher in type AB/B1/B2 than in type A/B3 thymomas and comparable to normal thymus. PD-1 expression at each stage of T cell development of type AB/B1/B2 thymomas was comparable to that of normal thymus. Both the percentages and cell densities of PD-1 + CD8 T cells expressing GZMB or LAG-3, which are known to contain tumor-reactive T cells, were significantly lower in type AB/B1/B2 thymomas. CONCLUSION: Most PD-1 + T cells in type AB/B1/B2 thymomas are intratumoral developing T cells and are not TILs.

Proteomic analysis identifies argininosuccinate synthetase 1 and special AT-rich sequence binding protein 1 as reliable markers for the immunohistochemical distinction between WHO types A and B3 thymomas.

AIMS: The reliable classification of type A versus type B3 thymomas has prognostic and therapeutic relevance, but can be problematic due to considerably overlapping morphology. No immunohistochemical markers aiding in this distinction have been published so far. METHODS AND RESULTS: We identified and quantified numerous differentially expressed proteins using an unbiased proteomic screen by mass spectrometry in pooled protein lysates from three type A and three type B3 thymomas. From these, candidates were validated in a larger series of paraffin-embedded type A and B3 thymomas. We identified argininosuccinate synthetase 1 (ASS1) and special AT-rich sequence binding protein 1 (SATB1) as highly discriminatory between 34 type A and 20 type B3 thymomas (94% sensitivity, 98% specificity and 96% accuracy). Although not the focus of this study, the same markers also proved helpful in the diagnosis of type AB (n = 14), B1 (n = 4) and B2 thymomas (n = 10). CONCLUSIONS: Mutually exclusive epithelial expression of ASS1 in 100% of type B3 thymomas and ectopic nuclear expression of SATB1 in 92% of type A thymomas support the distinction between type A and type B3 thymomas with 94% sensitivity, 98% specificity and 96% accuracy.

Usefulness of free pericardial fat pads as pledgets for air leaks in pulmonary resection.

PURPOSE: Intraoperative control of air leaks is important for preventing prolonged air leaks after surgery. The usefulness of suturing free pericardial fat pads (FPFPs) as pledgets for repairing air leaks was investigated. METHODS: A total of 111 patients who underwent anatomical lung resection and required suture repair for intraoperative air leaks were retrospectively reviewed. Mattress sutures were performed using polyglycolic acid (PGA) sheets (PGA group; n = 60) in the early period (April 2014 to March 2018) and FPFPs (FPFP group; n = 51) in the late period (April 2018 to March 2021) as pledgets. RESULTS: More patients had a history of smoking in the FPFP group than in the PGA group. The duration of air leakage was significantly shorter (mean 1.2 vs. 3.5 days, p = 0.002) and prolonged air leakage (> 5 days) was less frequently observed (23.3% vs. 5.9%, p = 0.016) in the FPFP group than in the PGA group. The FPFP group had fewer cases requiring pleurodesis and with recurrent air leaks than in the PGA group. In one case in the FPFP group, fat necrosis with fibrosis and fibrous adhesion to the visceral pleura was found on a pathological examination. CONCLUSION: Parenchymal repair using FPFPs as pledgets can reduce prolonged air leaks after surgery.

Prognostic Impact of Using Combined Plasma Fibrinogen Level and Neutrophil-to-Lymphocyte Ratio in Resectable Non-small Cell Lung Cancer.

BACKGROUND: Both plasma fibrinogen level and neutrophil-to-lymphocyte ratio (NLR) are associated with malignant potential in different cancer types. The current study evaluated the use of combined plasma fibrinogen level and NLR (F-NLR) as a prognostic predictor in patients with non-small cell lung cancer (NSCLC). METHODS: Data collected from 279 patients with resectable NSCLC were retrospectively reviewed. Patients were divided into three groups based on the F-NLR score: score 2, high fibrinogen level (≥350 mg/dL) and high NLR (≥2.5); score 1, either high fibrinogen level or high NLR; and score 0, neither abnormal. Overall survival (OS) and relapse-free survival (RFS) were evaluated using the Kaplan-Meier method and log-rank test. Cox proportional hazard model was used to assess prognostic factors. RESULTS: Numbers of patients with F-NLR score of 0, 1, and 2 were 122 (43.7%), 105 (37.6%), and 52 (18.6%), respectively. The F-NLR was found to be significantly associated with age, male sex, heavy smoking history, high pT status and pathological stage, and nonadenocarcinoma. Moreover, the OS and RFS significantly differed according to the F-NLR score (P < 0.001, P = 0.003). A multivariate analysis revealed that a high F-NLR score (≥1) was an independent poor prognostic factor for OS (P = 0.027). In subgroup analyses, an adverse prognostic impact of the F-NLR score on OS was identified regardless of nodal involvement or pathological stage. CONCLUSIONS: The F-NLR score, which is based on histological inflammation and coagulability, could be a potential prognostic indicator in patients with resectable NSCLC.

High Neutrophil Count as a Negative Prognostic Factor for Relapse in Patients with Thymic Epithelial Tumor.

PURPOSE: Preoperative neutrophil count is reportedly associated with poor prognosis in cancer patients. This study aimed to investigate the clinical significance of pre-treatment peripheral blood cell counts in patients with thymic epithelial tumors (TETs). METHODS: A retrospective review of 71 patients with completely resected TETs [64 thymoma, 6 thymic carcinoma, and 1 thymic neuroendocrine tumor] between 2000 and 2018 was conducted. Associations between tumor recurrence and pre-treatment peripheral blood cell counts of leukocytes (WBC), neutrophils (Neut), lymphocytes (Lymph), monocytes (Mono), and platelets (Plt) were analyzed. Optimal cut-off points were selected using receiver operating characteristic curve analysis to predict tumor recurrence. RESULTS: High WBC (≥ 7000), Neut (≥ 4450), and Plt (≥ 226 × 103) counts had significantly poor relapse-free survival (RFS), but high Lymph (≥ 1950) and Mono (≥ 400) did not. High Neut had the strongest correlation with recurrence (area under curve, 0.800); we focused on the analysis between high-Neut and low-Neut groups. High Neut count significantly correlated with smoking history, pre-treatment C-reactive protein level, and advanced stage; high Neut count and aggressive histology tended to show correlations. RFS was significantly poorer in the high-Neut group than in the low-Neut group (p = 0.003), with 5-year RFS rates of 63.8% and 96.8%, respectively. High Neut count was a significant adverse predictor for RFS and cumulative incidence of recurrence (p = 0.005 and p < 0.001, respectively). The risk scoring system comprising high Neut count, advanced stage, and aggressive histology demonstrated better prognostic ability than any prognostic factors alone. CONCLUSIONS: High Neut count significantly correlated with TET recurrence, suggesting a negative prognostic effect of latent inflammation in TET patients.

Prediction models for the viability of pulmonary metastatic lesions after chemotherapy in nonseminomatous germ cell tumors.

OBJECTIVES: To analyze predictors associated with viable cells in pulmonary residual lesions after chemotherapy for metastatic testicular nonseminomatous germ cell tumors and to develop models to prioritize pulmonary resection. METHODS: Between 2008 and 2017, 40 patients underwent pulmonary metastasectomy after chemotherapy for nonseminomatous germ cell tumors. We evaluated these patients, and 326 pulmonary residual lesions were confirmed using computed tomography and pathological evaluations. Relationships with outcomes were analyzed using logistic regression analyses. Risk prediction models were developed, and predictive probabilities for the risk of viable cells were estimated. RESULTS: Histological examinations showed that 73 (22%) pulmonary residual lesions contained viable cells: teratomas, 46 (14%); and cancer cells, 37 (11%). Multivariate analyses showed that the predictors associated with cancer cells in the residual lesions were elevated tumor marker levels, multiregimen chemotherapy, increased tumor size 6 months before surgery and the histological composition of the primary lesion, including yolk sac tumors. Additional predictors associated with teratomas were aspect ratio and histological composition of the primary lesion, including teratomas. CONCLUSIONS: Intratumoral heterogeneity contributes to nonseminomatous germ cell tumor chemoresistance, and primary lesion site yolk sac tumors and teratomas are associated with greater risks of viable cells. Increased residual lesion size during chemotherapy could also be a predictor. Our simple model can predict the presence of viable cells in residual lesions after chemotherapy, and it might assist in decision-making and prioritizing pulmonary residual lesion resection.

Long-Term Prognostic Impact of Severe Postoperative Complications After Lung Cancer Surgery.

BACKGROUND: Postoperative complications are reportedly related to poor prognosis following lung cancer surgery; however, the difference in the prognostic impact according to immune-nutritional status is unknown. METHODS: In 411 patients with completely resected non-small cell lung cancer, the relationship between severe postoperative complications (SPCs; Clavien-Dindo grade III or higher) and survival was retrospectively analyzed, with special reference to preoperative immune-nutritional status based on the prognostic nutritional index (PNI), which was calculated using serum albumin level and total lymphocyte count. RESULTS: A total of 52 (12.7%) patients had SPCs. The most common SPC was air leak (n = 39), atelectasis/sputum (n = 4), pneumonia (n = 2), pyothorax (n = 2), and bleeding (n = 2). The 5-year overall survival (OS) rates in patients with and without SPCs were 63.8% and 80.1%, respectively (p = 0.007). A multivariate Cox proportional hazard model revealed SPCs had a negative prognostic impact on patients with preserved immune-nutritional status (PNI ≥ 48.3; first to third quartile), but not on those with poor immune-nutritional status (PNI < 48.3; fourth quartile), with statistically significant interaction. Further analysis focused on 309 patients with preserved immune-nutritional status. The OS and relapse-free survival (RFS) rates were significantly worse in patients with SPCs than in those without (p < 0.001). After controlling for potential confounders, SPCs remained significantly associated with worse OS (adjusted hazard ratio [HR] 2.49, 95% confidence interval [CI] 1.21-4.83; p = 0.015) and RFS (adjusted HR 2.02, 95% CI 1.10-3.53; p = 0.025). CONCLUSION: Severe complications following lung cancer surgery could negatively impact prognosis, particularly in patients with preserved immune-nutritional status.

Effects of Zoledronate on Local and Systemic Production of IL-1ß, IL-18, and TNF-α in Mice and Augmentation by Lipopolysaccharide.

Bisphosphonates (BPs) containing nitrogen (N-BPs) exhibit far stronger anti-bone-resorptive effects than non-N-BPs. However, repeated administration of N-BPs causes osteonecrosis selectively in jawbones. As BPs accumulate in large amounts within inflamed bones, any N-BP released from the pool accumulated within jawbones might directly act on cells in the surrounding soft-tissues and induce inflammation or necrosis. Here, we examined the local and systemic effects of zoledronate (the most potent N-BP with the highest incidence of jawbone-necrosis) on inflammatory cytokines in mice. Locally within ear-pinnas: (i) zoledronate induced long-lasting accumulation of interleuikin-1ß (IL-1ß) and IL-18, but not tumor necrosis factor-α (TNF-α), (ii) zoledronate and lipopolysaccharide (LPS, a cell-wall component of Gram-negative bacteria) mutually augmented the productions of IL-1ß, IL-18, and TNF-α, and (iii) oxidronate (a toxic non-N-BP) by itself produced not only IL-1ß and IL-18, but also TNF-α. In systemic experiments using intraperitoneal injection of zoledronate and/or LPS, (i) zoledronate by itself increased none of the above cytokines in serum, and (ii) in mice pretreated (3 d before) with zoledronate, the LPS-induced increases in serum IL-1ß and IL-18 were greatly augmented with a delayed slight TNF-α augmentation. These results, together with previous ones, suggest that (a) pro-IL-1ß and pro-IL-18 accumulate within cells in soft-tissues exposed to N-BPs, and infection may augment not only their production, but also the release of their mature forms, (b) IL-1ß and IL-18 (possibly together with TNF-α) may play important roles in N-BP-induced inflammation and/or necrosis, and (c) mechanisms underlying the cytotoxic effects of BPs may differ between N-BPs and non-N-BPs.

Suppressive Effects of Aspirin for Postthoracotomy Pleural Adhesion in Rats.

BACKGROUND: Postoperative adhesion is one of major concerns at re-thoracotomy. Aspirin has both the anti-platelet and anti-inflammatory effects, and decreases several cytokines production. OBJECTIVE: We investigated that aspirin could reduce postoperative adhesion formation in a rat model. METHODS: We cauterised the lung visceral pleural to make postoperative adhesion in rats. The animals were allocated to a control group and an aspirin administration group (100 mg/kg/day for 14 days). We performed re-thoracotomy and evaluated the adhesion lengths on day 14. We also investigated the cytokine expression in the adhesion region and the peripheral tissue with platelet-derived growth factor (PDGF), platelet-derived growth factor receptor (PDGFR), alpha smooth muscle actin (α-SMA), transforming growth factor beta 1 (TGF-ß1), and vascular endothelial growth factor-A (VEGF-A), sequentially. RESULTS: The adhesion lengths were significantly shorter in the aspirin group than that in the control group (8.7±2.0 mm vs 11.2±1.1 mm, p=0.024). The expressions of PDGF and PDGFR were lower in the aspirin group than that in the control group on day 3. The expression of α-SMA on fibroblasts decreased in the aspirin group on day 3. There was no significant difference in the expressions of TGF-ß1 and VEGF-A with administration of aspirin. CONCLUSIONS: Aspirin could reduce postoperative pleural adhesion by inhibiting the expression of PDGF.

Risk Stratification According to the Prognostic Nutritional Index for Predicting Postoperative Complications After Lung Cancer Surgery.

BACKGROUND: The prognostic nutritional index (PNI), an immune nutritional marker based on serum albumin levels and total lymphocyte count, predicts postoperative complications in various types of malignancies. However, the clinical significance of the PNI for postoperative complications following lung cancer surgery is uncertain. METHODS: Patients with resected non-small cell lung cancer (n = 515) were retrospectively analyzed and the relationship between the preoperative PNI and postoperative complications was evaluated. RESULTS: Multivariate logistic regression analysis revealed that a preoperative low PNI was a significant independent predictor of postoperative complications of Clavien-Dindo Grade ≥ II (odds ratio: 1.06 per unit decrease, 95.0% confidence interval 1.01-1.11). Patients were divided into three groups according to the preoperative PNI: normal (≥ 50; n = 324), mildly low (< 50, ≥ 45; n = 134), and severely low (< 45; n = 57). The incidence of postoperative complications of Grade ≥ II and Grade ≥ III in the normal, mildly low, and severely low PNI groups was 22.2, 39.6, and 42.1% and 7.1, 16.4, and 22.8%, respectively. The incidence of postoperative complications of Grade ≥ II and Grade ≥ III was significantly higher in the mildly low and severely low PNI groups than in the normal PNI group (p < 0.001 and p < 0.001, respectively). The incidence of air leak, pneumonia, and extrapulmonary infection, but not arrhythmia, was significantly higher in the mildly low and severely low PNI groups than in the normal PNI group. CONCLUSIONS: The PNI could be a useful marker to predict the risk of postoperative complications after lung cancer surgery.

Surface-processing technology of a microgrooving and water-repellent coating improves the fusion potential of an ultrasonic energy device.

BACKGROUND: Ultrasonic energy devices are essential for effective hemostasis during endoscopic surgery. Ultrasonic tissue transection occurs as a result of mechanical friction between the oscillating blade and the tissue. We hypothesized that blade surface structures and characteristics would affect tissue transection and sealing. The aim of this study was to clarify the efficacy of blade surface structures and characteristics in vessel sealing with an ultrasonic vibration. METHODS: We developed an ultrasonic energy device with 50-kHz vibration frequency and 50 µm amplitude. We manufactured four types of blade surface of the ultrasonic device using microprocessing technology: (1) a non-coated blade without microgrooves, (2) a non-coated blade with microgrooves, (3) a water-repellent-coated blade without microgrooves, and (4) a water-repellent-coated blade with microgrooves. We compared the performance of the four devices and a commercially available ultrasonic device with a non-coated blade without microgrooves in an ex vivo vessel-sealing experiment. We sealed porcine carotid arteries (3-5 mm diameter) using each device 20 times. RESULTS: The cutting time of the water-repellent-coated blade with microgrooves was the shortest (11.0 ± 3.4 s); however, it did not differ significantly from that of the commercial ultrasonic device (12.9 ± 2.9 s, p = 0.73). The burst pressure of the water-repellent-coated blade without microgrooves (1456 ± 425 mmHg) was significantly higher than that of the commercial ultrasonic device (966 ± 559 mmHg, p = 0.04). The sealing failure rate of the water-repellent blade with microgrooves was the lowest of all devices (0 %). Instrumental sticking of tissue decreased in the water-repellent devices. The sealing width was not significantly different. CONCLUSION: The surface-processing of microgrooves and water-repellent coatings will improve the potential of ultrasonic devices with a fast transection and a high sealing reliability.

Prolonged air leak following lobectomy can be predicted in lung cancer patients.

PURPOSE: The purpose of this study was to identify the factors associated with prolonged air leak (PAL) following pulmonary lobectomy for lung cancer. METHODS: The data of 146 patients who underwent pulmonary lobectomy for lung cancer between August 2010 and July 2015 were retrospectively reviewed. Air leaks were assessed daily by a visual evaluation and were categorized as follows: forced expiratory only (Grade 1), expiratory only (Grade 2), or continuous (Grade 3). Logistic regression analyses were performed to identify the predictors of PAL (>5 days). RESULTS: PAL occurred in 23 patients (16%). An air leak at rest (Grade ≥ 2) was detected on postoperative day (POD) 1 in 48% of the patients with PAL and 7% of the patients without PAL. A univariate analysis demonstrated that PAL was significantly associated with male sex, a smoking history of ≥ 40 pack years, a serum albumin level of ≤4.0 mg/dL, and an air leak on POD1 (Grade ≥ 2). A multivariate analysis demonstrated that a serum albumin level of ≤4.0 mg/dL (p = 0.027) and an air leak on POD1 (p = 0.006) were independent predictors of PAL. PAL occurred in 75% of the patients with these two risk factors. CONCLUSIONS: The preoperative serum albumin level and the presence of a visually evaluated air leak on POD1 may be useful indicators for the perioperative management of air leaks.

Phosphonocarboxylates Can Protect Mice against the Inflammatory and Necrotic Side Effects of Nitrogen-Containing Bisphosphonates by Inhibiting Their Entry into Cells via Phosphate Transporters.

Bisphosphonates (BPs) are used against diseases involving increased bone-resorption. Among BPs, nitrogen-containing BPs (N-BPs) have much stronger anti-bone-resorptive effects than non-nitrogen-containing BPs (non-N-BPs). However, N-BPs carry the risk of inflammatory/necrotic effects, including osteonecrosis of jawbones. When injected into mouse ear-pinnas, N-BPs induce inflammatory/necrotic effects within the ear-pinna. We previously found that (a) the non-N-BPs clodronate and etidronate can reduce such side effects of N-BPs, and (b) phosphonoformate (an inhibitor of the phosphate transporters SLC20 and SLC34) can reduce the inflammatory/necrotic effects of zoledronate (the N-BP with the highest reported risk of side effects). However, it is not clear (i) whether phosphonoformate can reduce the side effects of other N-BPs, too, and (ii) whether other phosphonocarboxylates have such inhibitory effects. Here, using the mouse ear-pinna model, we compared the effects of etidronate, clodronate, and four phosphonocarboxylates on the inflammatory/necrotic effects of N-BPs of the alkyl type (alendronate) or cyclic type (zoledronate and minodronate). Like phosphonoformate, the other three phosphonocarboxylates protected against the inflammatory/necrotic effects of all the N-BPs. The protective potencies were clodronate>etidronate>phosphonoacetate>phosphonoformate>phosphonopropionate>phosphonobutyrate. With a similar order of potencies, these agents reduced the amount of (3)H-alendronate retained within the ear-pinna after its injection therein. The mRNAs of SLC20 and SLC34 were detected in untreated ear-pinnas. These findings suggest that the inhibition of phosphate transporters by phosphonocarboxylates, as well as by etidronate and clodronate, might be a useful preventive strategy against the side effects of both alkyl- and cyclic-type N-BPs.

Atypical presentation of tight filum terminale with thoracic disc herniation: a case report.

BACKGROUND: Tight filum terminale is a rare and challenging condition to diagnose because it presents with nonspecific symptoms and unclear imaging findings. This report documents an atypical case of tight filum terminale. CASE PRESENTATION: The patient was a previously healthy Asian 18-year-old male presenting with recurrent upper extremity and back pain, initially treated as nonspecific musculoskeletal pain. Notably, the patient's symptoms were inconsistent with the dermatome, showing no correlation with his skin's sensory innervation areas. In contrast to typical tight filum terminale presentations focused on lower extremity and lumbar region disturbances, this patient experienced pain and weakness predominantly in the upper extremities and back, hypothesized to result from traction myelopathy exacerbated by thoracic disc herniation. Investigations including blood and nerve function tests were inconclusive. However, a magnetic resonance imaging scan revealed a combination of tight filum terminale and tiny thoracic disc herniation. A diagnosis of tethered spinal cord syndrome was confirmed following further tests and imaging. The filum terminale was surgically removed, resolving the symptoms at a 7-month follow-up. CONCLUSIONS: This case underlines the importance of including tight filum terminale as a differential diagnosis in cases of unexplained upper or lower extremity pain. Primary care practitioners, particularly those managing undefined symptoms, should consider tight filum terminale in their diagnostic approach.

Supraglottic myxoedema successfully treated orally.

Summary: Myxoedema coma is a severe form of hypothyroidism with multiple organ dysfunction, characterised by an altered state of consciousness and hypothermia. Intravenous thyroid hormone replacement therapy is the preferred treatment for myxoedema. The mortality rate associated with this disease is high, and early detection and intervention are essential. Supraglottal myxoedema is a rare form of periglottic oedema and can be fatal. A previously healthy 66-year-old man presented with impaired consciousness, hypothermia, and nonpitting oedema. Blood tests revealed the presence of hypothyroidism and respiratory acidosis. He was intubated for type 2 respiratory failure; however, severe laryngeal oedema made the procedure difficult to perform. Oral thyroid hormone therapy was initiated under the diagnosis of myxoedema coma. Tracheostomy was performed because of prolonged type 2 respiratory failure and laryngeal oedema. Three weeks after admission, the patient was weaned off the ventilator. Approximately a week later, laryngeal oedema improved, and the tracheostomy tube was removed. The patient was discharged and remained stable for 3 months. This case report describes a patient with comatose myxoedema and supraglottic oedema who was successfully treated with oral medication alone. This case shows that supraglottic oedema should be considered even in the absence of wheezing or other signs of upper airway obstruction. Learning points: Myxoedema coma is a differential diagnosis of respiratory acidosis. In myxoedematous coma, the possibility of difficult intubation due to supraglottic oedema should be considered. Tracheostomy should be considered for supraglottic myxoedema, which often results in prolonged ventilator use. Supraglottic myxoedema can be treated with oral medications.