[Transition from Uniportal to Robot-assisted Surgery for Trans-subxiphoid Thymectomy;Merit and Demerit of Reduce Port Surgery].

The subxiphoid approach is useful in thymectomy, and its disadvantages can be ameliorated by the robot-assisted surgery( RAS). It was suggested that the increase in the number of ports due to RAS in the thymectomy with the trans-subxiphoid approach( RTts) would not be a disadvantage in any aspect other than cosmetology. RAS offers surgeons various technical advantages in thymectomy, however these are difficult to quantify. Therefore, it is difficult to objectively show the merits corresponding to expensive devices. It is necessary to conduct new clinical tests and collect data showing the superiority of RTts.

The Subxiphoid Approach Leads to Less Invasive Thoracoscopic Thymectomy Than the Lateral Approach.

OBJECTIVE: Video-assisted thoracic surgery (VATS) is widely used in thoracic surgery. This study investigated the usefulness of the subxiphoid approach in thymectomy using VATS techniques. METHODS: Sixty operations were performed using the lateral approach (n = 46) and subxiphoid approach (n = 14). Using the lateral approach, 39 partial thymectomies (PT), 5 total or subtotal thymectomies (TT), and 2 total or subtotal thymectomies with combined resection of the surrounding organs (or tissues) (CR) were performed. Using the subxiphoid approach, 11 TT and 3 CR were performed. RESULTS: There were 33 females and 27 males, with a mean age of 55 years. The mean maximum tumor diameter was 4.0 cm. The operation time was prolonged according to the volume of thymectomy (PT: 119, TT: 234, CR: 347 min). Additionally, the intraoperative blood loss increased according to the volume of thymectomy (PT: 29, TT: 47, CR: 345 g). To compare the invasiveness of both approaches, we compared 16 TT operations. In the group using the subxiphoid approach, the operation time became shorter (158 vs. 392 min), and the blood loss decreased (5 vs. 135 g) compared with the lateral approach. Regarding laboratory data, white blood cell counts on postoperative day 1 (1POD) (8200 vs. 10,300/µl) and CRP on 1POD and 3POD (2.8 and 2.8 vs. 7.9 and 10.2 mg/dl, respectively) decreased in the subxiphoid approach compared with the lateral approach. CONCLUSIONS: The subxiphoid approach leads to a less invasive operation for anterior mediastinal tumors and extends the indications for VATS for invasive anterior mediastinal tumors.

Small peripheral lung carcinomas with five-year post-surgical follow-up: assessment by semi-automated volumetric measurement of tumour size, CT value and growth rate on TSCT.

OBJECTIVES: To retrospectively assess the utility of semi-automated measurements by stratification of CT values of tumour size, CT value and doubling time (DT) using thin-section computed tomography (CT) images. The post-surgical outcomes of favourable and problematic tumours (more advanced p stage than IA, post-surgical recurrence or mortality from lung cancer) were compared using the measured values. The computed DTs were compared with manually measured values. METHODS: The study subjects comprised 85 patients (aged 33-80 years, 48 women, 37 men), followed-up for more than 5 years postoperatively, with 89 lung lesions, including 17 atypical adenomatous hyperplasias and 72 lung cancers. DTs were determined in 45 lesions. RESULTS: For problematic lesions, whole tumour diameter and density were >18 mm and >-400 HU, respectively. The respective values for the tumour core (with CT values of -350 to 150 HU) were >15 mm and >-70 HU. Analysis of tumour core DTs showed interval tumour progression even if little progress was seen by standard tumour volume DT (TVDT). CONCLUSION: Software-based volumetric measurements by stratification of CT values provide valuable information on tumour core and help estimate tumour aggressiveness and interval tumour progression better than standard manually measured 2D-VDTs.

A case of thymoma-associated multiorgan autoimmunity including polymyositis and myocarditis.

BACKGROUND: Polymyositis and myocarditis associated with thymoma are exceptionally rare conditions and usually accompanied by myasthenia gravis (MG) and have been recognized as critical conditions. Thymoma-associated multiorgan autoimmunity was reported recently with skin, liver, and intestinal manifestations similar to those seen in graft-versus-host disease. CASE PRESENTATION: A 77-year-old female presented to our department with exacerbation of ptosis and local recurrence of thymoma. Chest computed tomography revealed local recurrence of thymoma. Following 6 month observation, erythema on the extremities and body trunk suddenly appeared. Afterwards, the patient developed progressive muscle weakness and fatigue. We diagnosed as myocarditis and polymyositis. She was transferred to the intensive-care unit and received artificial ventilation. Steroid pulse therapy was induced immediately. The blood test findings were markedly improved, but the symptoms of MG and weakness of the muscles persisted. Various treatment including eculizumab was induced, and the symptoms of MG and weakness of the muscles were improved. On the 136th day of hospitalization, she was discharged. CONCLUSION: We were able to cure this patient, as we were able to start treatment immediately after the appearance of severe symptoms. An early diagnosis and treatment are important for curing such patients.

Surgical site infection at chest tube drainage site following pulmonary resection for malignant lesions.

BACKGROUND: We sometimes experience postoperative surgical site infection (SSI) at the chest tube drainage site (CDS) after thoracotomy. The incidence of and risk factors for SSI at the CDS have remained unclear. METHODS: We conducted a prospective study to determine the incidence and risk factors for SSI at the CDS. We analyzed 99 patients who underwent lobectomy or segmentectomy for pulmonary malignant lesions. RESULTS: There were 56 males and 43 females with an average age of 71 years. The postoperative drainage period was 2-15 days. Bacterial species were detected in secretions in 18 of 99 cases (18.2%). Older age was a risk factor for the detection of bacteria at the timing of chest tube removal. Eighteen cases (18.2%) were diagnosed with presence of SSI at the CDS at the timing of staple or suture removal. A pathological diagnosis of squamous cell carcinoma was regarded as a candidate risk factor for SSI. Eleven of 18 SSI patients showed delayed wound healing. A higher level of HbA1c was found in patients with delayed wound healing. Enterococcus faecalis infection may influence the development of complex SSI. CONCLUSIONS: We identified the bacterial profiles, incidence of and risk factors for SSI at the CDS. More intense preoperative glycemic control and an understanding of the bacterial profile and may be useful for reducing the incidence of SSI chest tube drainage sites (CDS).

Distribution of descending necrotizing mediastinitis and efficacy of distribution-specific drainage.

BACKGROUND: Descending necrotizing mediastinitis (DNM) resulting from oropharyngeal and cervical abscess is a life-threatening condition. This study attempted to improve our recognition of the extension and distribution of the abscess for ideal thoracic drainage. METHODS: We performed a retrospective clinical analysis of seven patients who underwent thoracic drainage for DNM with available clinical data. For mapping and classification of the distribution of the abscess, computed tomography and intraoperative findings were utilized. RESULTS: To cure patients, cervical drainage and thoracic drainage were performed 14 and 11 times, respectively. The operation time for thoracic drainage and intraoperative blood loss were 141±77 min and 103±103 g, respectively. The mean hospital stay was 66±41 days. All patients are alive without recurrence. We divided the abscess distribution into nine categories including the anterior thoracic wall, according to the computed tomography and intraoperative findings. The rate of abscess descended gradually toward the lower mediastinum. Abscesses were not necessarily continuous, and skipped lesions were occasionally noted. CONCLUSIONS: We were able to cure all seven patients with DNM. It might be helpful to recognize the exact distribution of the abscess and distribution-specific drainage using a new map and classification of thoracic abscess.

Reoperation for postoperative bleeding following pulmonary resection: a report of a single-center experience.

OBJECTIVE: The variety and incidence of postoperative complications seem to have changed with recent progress in thoracic surgery. This study attempted to improve our recognition of postoperative bleeding. METHODS: Among 1143 patients undergoing pulmonary resection for pulmonary nodules, ten underwent surgical treatment for postoperative bleeding. Clinical and pathologic data were analyzed. Additionally, the relationship between the bleeding point and an increased amount of drained bloody effusion before the second operation was analyzed. RESULTS: The bleeding point was recognized in eight cases: the intercostal artery (n = 4), the lung (n = 2), aberrant vessel of the apex of the lung (n = 1) and the bronchial artery (n = 1). The bleeding points were unknown in two cases in whom the decision to perform a second operation was delayed. Potential reasons or influential factors for bleeding were stapling complications (n = 4), low coagulation ability (n = 2) and intraoperative injury (n = 1). We experienced two cases in which intercostal arterial bleeding was induced by scratching the thoracic wall or the vertebra with the edge of the reinforced stapling line or the sharp edge of a broken staple at the first operation. We divided patients into three groups based on the interval between operations. Bleeding from the arteries seemed to show a higher rate of bleeding per hour than that from the lung parenchyma. CONCLUSION: The bleeding points and speculated reasons for bleeding varied among patients. We were able to cure all ten cases. It might be dependent on the rapid decision of reoperation in cases with arterial bleeding was suspected.

Thoracoscopic Thymectomy for Large Thymic Cyst: Myasthenia Gravis With Thymoma Concealed by Thymic Cyst.

We herein report a case of myasthenia gravis (MG) in which thoracoscopic thymectomy was performed for a large thymic cystic lesion using a subxiphoid approach. We have previously suggested the usefulness of the subxiphoid approach in thymectomy. The indications of thoracoscopic thymectomy were recently expanded to include large thymic cystic lesions without intraoperative rupture of the lesions. The pathologic diagnosis of the lesion in the present case was multilocular thymic cyst with type A thymoma and micronodular thymoma. The postoperative complications were minimal without MG crisis. Thoracoscopic thymectomy using a subxiphoid approach seems to be an ideal procedure, even for large thymic cystic lesions. In addition, early-onset MG with a large thymic cystic lesion may suggest the presence of a small thymoma even if the lesion is not detected on a preoperative radiologic examination.

[Re-evaluation of effects of thymectomy on autoimmune myasthenia gravis].

In Japan, thymectomy for the treatment of autoimmune myasthenia gravis (MG) underwent about 300 cases every year. The number of the cases has most 2001 and is decreasing henceforth. Such reduction is considered because a steadfast proof that thymectomy is effective in the treatment of autoimmune MG is not shown. Thymectomy for autoimmune MG is considerably effective for patient with generalized, severe, female patients. The validity of thymectomy for the treatment of autoimmune MG should be confirmed in a randomized, controlled trial targeted on these types of autoimmune MG patients, with standardized surgical approach.

Nine cases of catamenial pneumothorax: a report of a single-center experience.

BACKGROUND: Catamenial pneumothorax (CP) is defined as repeated pneumothorax related to menses and thoracic endometriosis. We performed a retrospective analysis of nine patients with CP to determine the clinical features as well as the effects of treatment and recurrence rates. METHODS: A retrospective review was conducted of the clinical and pathologic data in all CP patients undergoing treatment at our institution. Nine patients underwent treatment for CP. Of these, six underwent surgical treatment 8 times. RESULTS: The median age was 36 years. Six patients had experienced delivery. The laterality of the pneumothorax was right in all patients. Pelvic endometriosis was diagnosed in five patients. Six patients underwent surgical treatment. Partial resection of the lung was performed in four patients and partial resection of the diaphragm in five. Of these, both resections were performed in four patients. A pathological diagnosis of endometriosis was achieved in only three patients. The observation period was 16.7 months. In the six patients with surgical resection, five experienced recurrence at various intervals. Onset of pneumothorax occurred pre- or menstrual period in most cases. CONCLUSIONS: The diagnosis and treatment of CP is not easy. A multidisciplinary approach and skillful management are required. Recurrence of CP is common following a temporary cure of pneumothorax by surgical treatment.

Thoracoscopic Thymectomy Using a Subxiphoid Approach for Anterior Mediastinal Tumors.

PURPOSE: Video-assisted thoracic surgery (VATS) techniques have been widely used for resection of mediastinal tumors. This study investigated the usefulness of the subxiphoid approach in thoracoscopic thymectomy. METHODS: In all, 36 patients with anterior mediastinal tumor underwent thymectomy using the subxiphoid approach in two Japanese institutions. These patients were retrospectively reviewed and analyzed. RESULTS: There were 16 females and 20 males with a mean age of 57 years. Five patients underwent partial thymectomy (PT), 27 underwent total or subtotal thymectomy, and 4 underwent thymectomy with combined resection (CR) of the surrounding organs or tissues. The mean maximum tumor diameter, amount of resected tissue, and blood loss were 4.1 cm, 72.5 g, and 20.6 g, respectively. More than half of tumors were diagnosed as thymoma (n = 19). The operation time was prolonged with a greater volume of thymectomy. The duration of chest tube drainage and postoperative stay were 1.7 ± 1.0 days and 5.9 ± 7.6 days, respectively. Four patients suffered intraoperative and postoperative complications, as follows: bleeding of the innominate vein, bleeding of the internal thoracic vein, crisis of myasthenia gravis (MG), pericarditis, and phrenic nerve paralysis. There were no mortalities after surgery. CONCLUSION: Subxiphoid thoracoscopic thymectomy might be a safe and useful approach for mediastinal tumors.

Long-term follow-up study of a population-based 1996-1998 mass screening programme for lung cancer using mobile low-dose spiral computed tomography.

Early diagnosis and treatment are important for improvement of the low survival rate of patients with lung cancer. The objective of this study was to evaluate the long-term survival rate of patients identified to have lung cancer by our population-based baseline and annual repeat low-radiation dose computed tomography (low-dose CT) screenings, conducted in 1996-1998. A total of 13,037 CT scans were obtained from 5480 subjects (2969 men, 2511 women) aged 40-74 years at the initial CT screening. Lung cancer was detected in 63 subjects (57 were detected by CT scans and underwent surgery; 1 was detected by sputum cytology and underwent surgery; 3 rejected treatment; and 2 were interval cases that developed symptoms prior to the next annual repeat CT screening). Follow-up study included review of medical records. Death certificates were examined to check for any deceased interval case among participants. Postoperative follow-up of the 50 survived patients ranged from 70 to 117 (median, 101) months. Eight patients died during follow-up (6 due to lung cancer from 20 to 67 months after surgery and 2 deaths unrelated to lung cancer, each 7 and 60 months following surgery). Three patients who rejected treatment died 14 months to 6 years after positive screening CT scans, and the 2 interval cases died at each 17 and 30 months, respectively, following negative screening CT scans. Survival was analysed in 59 patients with lung cancer detected by low-dose CT screening (excluding two patients; one was detected by sputum cytology and the other had mass lesion already noted on the chest radiograph of the previous year). The 10-year survival calculated by the Kaplan-Meier method was 83.1% (95% CI: 0.735-0.927) for death from all causes and 86.2% (95% CI: 0.773-0.951) for death from lung cancer. The survival rate was excellent for never-smokers, patients with BAC and adenocarcinoma/mixed types with non-solid CT density pattern, associated with Noguchi's type A or B and pathologic stage IA. A poorer prognosis was noted in smokers with adenocarcinomas/mixed types, associated with part-solid or solid CT density pattern and Noguchi's type C or D. All patients with non-solid tumours measuring 6-13.5mm at presentation are alive, patients with part-solid tumours, measuring 17mm or more, or solid tumours, measuring 13mm or more at presentation were associated with increased risk of lung cancer-related morbidity or mortality. The estimated rate of possible over-diagnosis was 13% in total and we failed to cure 17% of patients encountered in the programme. Low-dose CT screening substantially improves the 10-year survival for lung cancer with minimal use of invasive treatment procedures.

CT findings of early-stage small cell lung cancer in a low-dose CT screening programme.

The survival of patients with small cell lung cancer (SCLC) is related to T, N, M components, and early diagnosis and treatment of limited stage SCLC may improve survival. The objective of this study was to review the initial and annual repeat screening computed tomography (CT) images of all five patients with SCLC, encountered in our 1996-1998 population-based screening for lung cancer, to clarify any subtle, characteristic CT findings of early-stage small cell lung cancer. The medical records of the patients were reviewed to examine demographic and clinical features. We identified characteristic CT features of SCLC in the lung periphery, which were related to gross pathologic findings with longitudinal spread along the bronchial wall: a small spindle-shaped or pyramidal lesion was found as a subtle CT finding of SCLC, and irregularly shaped nodular lesions (vermiform, pine-cone-like or tandem-like nodular lesions) appeared at a more advanced stage. Tumour volume doubling time of the cases ranged from 38 days to 217 days. All five patients were male smokers: four patients underwent surgery and adjuvant chemotherapy; three of them remain alive, while the remaining patient, an interval case, died of lung cancer. One patient refused treatment and died of a cause other than lung cancer. Annual repeat CT screening was useful for detecting SCLC cases mostly at a curable stage, and information about CT features, presented here, should help physicians identify SCLC at an earlier-stage and lead to a more successful treatment of the disease.

A pitfall of thoracoscopic thymectomy: a case with intraoperative and postoperative complications.

We have reported the usefulness of the subxiphoid approach in thymectomy. However, such a new operation method may have unknown complications that rarely occur. Surgeons cannot completely avoid intraoperative and postoperative complications. We report a case of intraoperative injury of the orifice of the left internal thoracic vein flowing to the left brachiocephalic vein and postoperative pericarditis following video-assisted thoracic surgery (VATS) thymectomy. The innominate vein has been considered to be the vessel that is most frequently injured especially at the orifice of the thymic veins. We also suggest that the orifice of the left internal thoracic vein is the second dangerous location that requires special care. In addition, postoperative pericarditis occurred in this patient. Pericardial drainage was necessary. No additional complications have been found in the 9 months since the operation. Though VATS thymectomy using the subxiphoid approach is a safe and less-invasive operation, intraoperative and postoperative complications were possible to be occurred.

Novel ATP-competitive Akt inhibitor afuresertib suppresses the proliferation of malignant pleural mesothelioma cells.

Malignant pleural mesothelioma (MPM), an asbestos-related occupational disease, is an aggressive and incurable tumor of the thoracic cavity. Despite recent advances in MPM treatment, overall survival of patients with MPM is very low. Recent studies have implicated that PI3K/Akt signaling is involved in MPM cell survival and development. To investigate the effects of Akt inhibitors on MPM cell survival, we examined the effects of nine selective Akt inhibitors, namely, afuresertib, Akti-1/2, AZD5363, GSK690693, ipatasertib, MK-2206, perifosine, PHT-427, and TIC10, on six MPM cell lines, namely, ACC-MESO-4, Y-MESO-8A, MSTO-211H, NCI-H28, NCI-H290, and NCI-H2052, and a normal mesothelial cell line MeT-5A. Comparison of IC50 values of the Akt inhibitors showed that afuresertib, an ATP-competitive specific Akt inhibitor, exerted tumor-specific effects on MPM cells. Afuresertib significantly increased caspase-3 and caspase-7 activities and apoptotic cell number among ACC-MESO-4 and MSTO-211H cells. Moreover, afuresertib strongly arrested the cell cycle in the G1 phase. Western blotting analysis showed that afuresertib increased the expression of p21WAF1/CIP1 and decreased the phosphorylation of Akt substrates, including GSK-3ß and FOXO family proteins. These results suggest that afuresertib-induced p21 expression promotes G1 phase arrest by inducing FOXO activity. Furthermore, afuresertib significantly enhanced cisplatin-induced cytotoxicity. Interestingly, results of gene set enrichment analysis showed that afuresertib modulated the expression E2F1 and MYC, which are associated with fibroblast core serum response. Together, these results suggest that afuresertib is a useful anticancer drug for treating patients with MPM.

Thoracoscopic Thymectomy with Tangential Partial Resection of the Innominate Vein.

We herein report a case in which thoracoscopic thymectomy with partial resection of the brachiocephalic vein was performed using a subxiphoid approach. We suggest the usefulness of the subxiphoid approach in thymectomy. We could extend the indications of thoracoscopic thymectomy for invasive tumors. Thoracoscopic thymectomy with the combined resection of part of the brachiocephalic vein was possible. The pathological diagnosis of the tumor was diffuse large cell B-cell lymphoma. Since the postoperative complications were minimal, postoperative adjuvant chemotherapy could be initiated without delay. This operation might be unnecessary. However, we could decrease the invasiveness of surgery using our procedures without sternotomy. Thoracoscopic thymectomy using subxiphid approach seems to be an ideal procedure for the surgical treatment of invasive lesions.

Rupture of a large cell neuroendocrine carcinoma, causing early local recurrence.

We present a case of large cell neuroendocrine carcinoma (LCNEC) requiring an urgent operation due to a rupture-induced shock. Primary lung cancers rarely rupture. This event could have spread malignant cells. Our patient died of pleural dissemination at day 81 after the operation. We had difficulty diagnosing the lesion before rupture despite various examinations including biopsy. In cases of a large, growing, cavitating mass, we should consider the possibility of malignant tumor, and a surgical approach to prevent rupture. A ruptured malignant tumor may also be treated by adjuvant therapy rather than resection.

Pleuropulmonary blastoma in a 12-year-old boy presenting with pneumothorax.

Pleuropulmonary blastoma is a rare pulmonary neoplasm seen in the pediatric population. We report a purely cystic-type pleuropulmonary blastoma in a 12-year-old boy who presented with spontaneous pneumothorax. He underwent partial resection of the left lower lobe under video-assisted thoracoscopy.

[Thymectomy for autoimmune myasthenia gravis].

Thymectomy has been performed as surgical treatment for autoimmune myasthenia gravis (MG) since the mid-1900s. Although it has been performed for more than half a century, there has been no report objectively confirming the validity of this treatment. Many groups have reported that surgery is effective in treating patients with MG, but the indications and type of surgery differ in each case. In addition, there has been no comparative trial of the results of surgery and natural progression of the disease. To resolve this situation, it would be desirable to standardize the indications for surgery in MG patients and to establish the surgical approach, as is being attempted by the Myasthenia Gravis Foundation of America although the results have not yet been announced. With recent advances in video-assisted surgery, the number of institutions in which thoracoscopic surgery is performed has increased. However, it appears that improvement in MG symptoms is dependent on the extent of resection in thymectomy. With the cervical or thorascopic approach, the extent of resection appears to be less than that using the transsternal or cervical plus transsternal approach. Before establishing a standard surgical approach, the validity of thymectomy for the treatment of MG should be confirmed in a randomized, controlled trial.

Myasthenia gravis with thymic epithelial tumour: a retrospective analysis of a Japanese database.

OBJECTIVES: Myasthenia gravis (MG) has been reported to correlate with earlier stage and Type B thymomas by the World Health Organization classification. We analysed a large database of clinical characteristics of patients with MG and thymic epithelial tumours to elucidate whether the severity of MG affected postoperative survival of those with thymic epithelial neoplasms. METHODS: We conducted a multi-institutional study on the patients who had undergone surgical treatment for thymic epithelial tumours between 1991 and 2010. We examined Masaoka stage, pathological type, serum titre of antiacetylcholine receptor antigen, severity of MG and postoperative prognosis of the patients with or without MG. RESULTS: Of the 2835 registered patients at 32 institutes belonging to the Japanese Association for Research on the Thymus, 2638 were eligible for the study. MG was present in 598 patients (23%). Patients with MG had thymic epithelial tumours with significantly earlier stage (P = 0.0082) and significantly smaller tumours (P = 0.000) than those without. Type A, Type AB thymomas and thymic carcinomas were less frequently observed in patients with MG. Three of 304 patients (1%) with thymic carcinomas had MG preoperatively. Serum titres of antiacetylcholine receptor antibodies were positive in 98% of patients with MG, and 23% of those without. Patients with generalized MG had significantly higher titres of antiacetylcholine receptor antibodies than those with ocular MG (P = 0.000). The postoperative 30-day mortality rate was 0.3%. Postoperative 5- and 10-year survival rates of thymoma patients with MG and those without MG were 94 and 96, and 89 and 89%, respectively. We found no statistical difference in the postoperative survival rate or recurrence-free rate between the two groups. We found no significant statistical differences of these rates by MGFA classification or surgical approach. CONCLUSIONS: We conclude that earlier stage, smaller size or Type B thymomas are more frequently associated with MG, and MG may have no impact on the overall survival of patients with thymoma. We suggest that postoperative survival time of the patients with MG and thymic epithelial tumours may be mainly affected by the tumours, not by MG.