The surgical Apgar score predicts postoperative complications and the survival in lung cancer patients.

PURPOSE: The surgical Apgar score (SAS)-calculated using the intraoperative variables estimated blood loss, lowest heart rate, and lowest mean systolic pressure-is associated with mortality in cancer surgery. We investigated the utility of the SAS in patients with lung cancer undergoing surgery. METHODS: We retrospectively analyzed the data of 691 patients who underwent surgery for primary lung cancer between 2015 and 2019 in a single institute and analyzed the impact of the SAS. RESULTS: Of the 691 patients, 138 (20%), 57 (8.2%), and 7 (1.0%) had postoperative complications of all grades, grades ≥ III, and grade V, respectively, according to the Clavien-Dindo classification. The C-index for postoperative complications of grades ≥ III was 0.605. A lower score (0-5 points) (odds ratio 3.09 against 8-10 points, P = 0.04) and a lower percentage of vital capacity (odds ratio 0.97, P = 0.04) were independent negative risk factors for major postoperative complications. Patients with a lower score (0-5 points) had poor 5-year overall and cancer-specific survival rates (60.1% and 72.3%, respectively; P < 0.05 for both). CONCLUSIONS: The surgical Apgar score predicted postoperative complications and the long-term survival. Surgeons may improve surgical results using the SAS.

[Radiofrequency Ablation for Pulmonary Metastasis of Ovarian Cancer Caused Iatrogenic Pneumothorax, Leading to Empyema].

A female patient in her 40s who underwent surgery for recurrent right lung metastasis from resected ovarian cancer was referred to our department because of the right pneumothorax due to radiofrequency ablation for multiple lung metastases. Methicillin-resistant Staphylococcus epidermidis( MRSE) was detected from the tip of the drainage catheter indicated persistent pulmonary fistula with right empyema, and surgical treatment was performed. A white coat of the whole lung surface and air leakage were observed at radiofrequency ablation (RFA) treated lesion and partial resection of the right lung, debridement, and irrigation were performed. A pathological examination revealed residual viable ovarian cancer cells and pleural fistula.

[Giant Bullae Misdiagnosed as Pneumothorax:Report of a Case].

A 46-year-old man was taken to a hospital by ambulance because of sudden onset of dyspnea, and was inserted chest drainage tube with a diagnosis of right-sided tension pneumothorax on chest X-ray. Since the chest drainage was not effective, he was transferred to our institute. Based on chest computed tomography (CT) findings, a diagnosis of giant bullae of the right lung was made, and surgical treatment was performed. Postoperatively, the improvement of respiratory function was confirmed.

[Multiple Metastatic Lung Tumors in the Left Upper Lobe Complicated with Hypoplasia and Chronic Atelectasis of the Left Lower Lobe:Report of a Case].

An 80-year-old man with surgical history of colon cancer was referred to our department for surgical treatment for multiple metastatic lung tumors in the left upper lobe. The patient had been showing complete atelectasis of the left lower lung lobe one year prior to the consultation. Six months after wedge resections for the pulmonary metastases, the left lower lobe was re-expanded, showing bronchiectasis with rudimentary pulmonary artery branches. Further, the ventilation-perfusion scintigraphy showed decreased uptake in the left lower lobe. These findings indicated that the patient had the hypoplasia of the left lower lobe.

[Left Upper Lung Cancer with Mediastinal Inferior Lober Branch of Pulmonary Artery].

We herein report a rare case of an antero-basal pulmonary artery that was noticed during left upper lung lobectomy. A 61-year-old man underwent surgery and radiation for a brain tumor, which was diagnosed as a solitary metastasis of the primary lung cancer in the upper lobe of the left lung. He underwent left upper lobectomy for the lung cancer. During the operation, the left A4+5 and A8b+9+10 was found to be diverged from the main left pulmonary artery as the first branch, which descended between the left upper pulmonary vein and the left upper bronchus. The left upper lobe was successfully resected with preserving the A8b+9+10. This variation was not recognized preoperatively. Careful dissection along the pulmonary vessels is essential to prevent cutting off the unexpected aberrant anatomy.

[Pulmonary Nontuberculous Mycobacteriosis Difficult to Differentiate from Local Recurrence of the Metastatic Lung Tumor of the Uterine Cervix Cancer at the Staple-line:Report of a Case].

A 70-year-old woman underwent right S6 segmentectomy and left S6 partial resection for lung metastasis of uterine cervix cancer. Although she received adjuvant chemotherapy, chest computed tomography revealed a new pulmonary nodule on the staple stump of the right lung. We diagnosed the tumor as local recurrence at the stump and planned to continue chemotherapy. However, the size of the tumor increased, and we performed right middle and lower lobectomy. Based on the pathological and bacteriological examinations, an epithelioid cell granuloma infected by Mycobacterium avium was established.

[Pulmonary Benign Metastasizing Leiomyoma Found as Multiple Bilateral Lung Nodules 11 Years after Hysterectomy;Report of a Case].

Pulmonary benign metastasizing leiomyoma (PBML) is a rare entity. We herein report a case of PBML found as multiple bilateral lung nodules 11 years after total hysterectomy. The patient was a 53-year-old woman with past surgical history of abdominal total hysterectomy for a uterine leiomyoma at the age of 42. She was referred to our department for further evaluation of multiple pulmonary nodules detected by a chest radiography. A chest computed tomography revealed multiple bilateral small lung nodules less than 10 mm in diameter. 18-fluorodeoxyglucose (FDG) positron emission tomography showed no significant FDG accumulation to these nodules. The patient finally underwent video assisted thoracoscopic wedge resection of the lower lobe of the right lung for surgical biopsy. The final pathological diagnosis was PBML, based on the comparative evaluation of the surgical specimens from the lung and the uterus. No evidence of enlargement in the remaining pulmonary nodules was noted for 9 months after surgical lung biopsy.

Epithelial cell death markers in bronchoalveolar lavage correlate with chronic lung allograft dysfunction subtypes and survival in lung transplant recipients-a single-center retrospective cohort study.

Chronic lung allograft dysfunction (CLAD) remains the leading cause of late death after lung transplantation. Epithelial injury is thought to be a key event in the pathogenesis of CLAD. M30 and M65 are fragments of cytokeratin-18 released specifically during epithelial cell apoptosis and total cell death, respectively. We investigated whether M30 and M65 levels in bronchoalveolar lavage (BAL) correlate with CLAD subtypes: restrictive allograft syndrome (RAS) versus bronchiolitis obliterans syndrome (BOS). BALs were obtained from 26 patients with established CLAD (10 RAS, 16 BOS) and 19 long-term CLAD-free controls. Samples with concurrent infection or acute rejection were excluded. Protein levels were measured by ELISA. Variables were compared using Kruskal-Wallis, Mann-Whitney U test and Chi-squared tests. Association of M30 and M65 levels with post-CLAD survival was assessed using a Cox PH models. M65 levels were significantly higher in RAS compared to BOS and long-term CLAD-free controls and correlated with worse post-CLAD survival. Lung epithelial cell death is enhanced in patients with RAS. Detection of BAL M65 may be used to differentiate CLAD subtypes and as a prognostic marker in patients with established CLAD. Understanding the role of epithelial cell death in CLAD pathogenesis may help identify new therapeutic targets to improve outcome.

[Outcome of Limited Resection for Early Stage Non-small Cell Lung Cancer].

OBJECTIVES: Recent advancement in detection of small-sized early-stage lung cancer has made limited lung resection with curative intent a practical and vital option. In this retrospective study, we investigated the validity of choice of procedures at our institute with examining the survival outcomes of lung cancer patients who underwent surgery. METHODS: Data from consecutive patients with cTanyN0M0 lung cancer who underwent surgery between January 2006 and December 2012 were extracted by chart review, and the overall and recurrence-free survivals of the patients operated by wedge resection, by segmentectomy and by lobectomy were compared using the univariate and multivariate Cox proportional hazard model. A stepwise backward elimination method with a probability level of 0.15 was used to select the most powerful sets of outcome predictors. For all analyses, a p-value<0.05 was considered statistically significant. RESULTS: Limited lung resection (wedge resection and segmentectomy) were selected for higher age patients, for lower respiratory function patients and for smaller size tumor than lobectomy group. By univariate and multivariate analysis, surgical procedure was not identified as independent risk factor for overall and recurrence-free survival. CONCLUSION: In this study cohort, mode of surgical procedure did not affect the relapse risk and prognosis. The choice of procedures at our institute in this study period seemed to be appropriate.

[Multilocular Thymic Cyst with Calcification;Report of a Case].

A female in her 40s was admitted with an abnormal shadow on chest X-ray. A chest computed tomography (CT) revealed an anterior mediastinal cystic mass with calcification. We suspected the tumor to be a teratoma, and surgery was performed. The tumor was connected with the thymus, and did not infiltrate to the surrounding tissues. Macroscopically, the cyst was multiloculated with fibrous walls. Microscopically, thymic tissue was noted in the cyst wall, with neither thymic epithelial tumor nor teratoma. The cyst wall contained collagen fibers, cholesterol clefts, and calcification. Based on these findings, the tumor was diagnosed as multilocular thymic cyst with calcification.

Quantitative chest CT for subtyping chronic lung allograft dysfunction and its association with survival.

Chronic lung allograft dysfunction (CLAD) is a major cause of mortality in lung transplant recipients. CLAD can be sub-divided into at least 2 subtypes with distinct mortality risk characteristics: restrictive allograft syndrome (RAS), which demonstrates increased overall computed tomography (CT) lung density in contrast with bronchiolitis obliterans syndrome (BOS), which demonstrates reduced overall CT lung density. This study aimed to evaluate a reader-independent quantitative density metric (QDM) derived from CT histograms to associate with CLAD survival. A retrospective study evaluated CT scans corresponding to CLAD onset using pulmonary function tests in 74 patients (23 RAS, 51 BOS). Two different QDM values (QDM1 and QDM2) were calculated using CT lung density histograms. Calculation of QDM1 includes the extreme edges of the histogram. Calculation of QDM2 includes the central region of the histogram. Kaplan-Meier analysis and Cox regression analysis were used for CLAD prognosis. Higher QDM values were significantly associated with decreased survival. The hazard ratio for death was 3.2 times higher at the 75th percentile compared to the 25th percentile using QDM1 in a univariate model. QDM may associate with CLAD patient prognosis.

The role of biomechanical anatomical modeling via computed tomography for identification of restrictive allograft syndrome.

Chronic lung allograft dysfunction (CLAD) reduces long-term graft survival. It is important to distinguish CLAD subtypes: bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS) as RAS has a worse prognosis and accurate subtyping could facilitate targeted treatments. However, the current diagnosis of CLAD subtypes is based on pulmonary function test (PFT) results that reflect global estimates of lung function; anatomical modeling based on computed tomography (CT) has the potential to provide detailed analysis of global and regional lung function. The purpose of this study is to evaluate the utility of CT-based anatomical modeling for the identification of RAS. This retrospective study included 51 patients (CLAD: 17 BOS and 17 RAS, control: 17 No-CLAD). CT data were assessed using a biomechanical model-based platform (MORFEUS) to characterize changes in lung deformation between baseline and disease onset. Lung deformation demonstrated high sensitivity and specificity (>80%) in differentiating RAS from BOS (P<.0001) and No-CLAD (P<.0001). There were matching radiological reading and inward deformation abnormalities in 79% of lung sections in patients with RAS. Anatomical modeling is complementary to conventional assessment in the diagnosis of RAS and potentially provides quantitative data that can help in the characterization and detailed assessment of heterogeneous lung parenchymal disease.

[Postoperative Chylotholax;Intraoperative Prevention and Postoperative Management].

Postoperative chylothorax is a relatively rare but potentially fatal complication caused by iatrogenic injury to thoracic duct system, with an incidence ranging from 2 to 4% after major lung surgery or esophagectomy. The pathophysiologic features of chylothorax include dehydration, loss of nutrients and immunological components. Intraopreative prevention is the first step for the management, and treatment options include conservative therapy, percutaneous intervention, and redo-operation. Although the treatment algorithm has not been standardized, chylothorax which is refractory to conservative treatment, or that with high output greater than 1,000 ml/day should be treated aggressively with thoracic duct embolization or redo-operation in a timely fashion. We herein review the anatomy and physiology of thoracic duct system and describe the overview of prevention and each theapeutic options of postoperative chylothorax.

[Development of Personalized and Targeted Preventive Therapies for Chronic Lung Allograft Dysfunction Subtypes;A Novel Strategy].

Chronic lung allograft dysfunction (CLAD) is a major limitation to long-term success of lung transplantation. Restrictive allograft syndrome (RAS) is a recently discovered subtype of CLAD, showing distinct clinical, pathological and radiological features compared with the major CLAD subtype, bronchiolitis obliterans syndrome (BOS). Introduction of the novel CLAD classification system that differentiates CLAD into BOS and RAS has stimulated research activities aiming delineation of the underlying pathological mechanism in the 2 CLAD subtypes. Accumulating evidences suggest that BOS and RAS could be biologically distinct, indicating that optimal therapeutic strategy could be different. Further efforts in refinements in biologic profiling of BOS and RAS will lead to a better understanding of CLAD, as well as the development of personalized and targeted preventive therapies for underlying CLAD subtypes.

Protein expression profiling predicts graft performance in clinical ex vivo lung perfusion.

OBJECTIVES: To study the impact of ex vivo lung perfusion (EVLP) on cytokines, chemokines, and growth factors and their correlation with graft performance either during perfusion or after transplantation. BACKGROUND: EVLP is a modern technique that preserves lungs on normothermia in a metabolically active state. The identification of biomarkers during clinical EVLP can contribute to the safe expansion of the donor pool. METHODS: High-risk brain death donors and donors after cardiac death underwent 4 to 6 hours EVLP. Using a multiplex magnetic bead array assay, we evaluated analytes in perfusate samples collected at 1 hour and 4 hours of EVLP. Donor lungs were divided into 3 groups: (I) Control: bilateral transplantation with good early outcome [absence of primary graft dysfunction- (PGD) grade 3]; (II) PGD3: bilateral transplantation with PGD grade 3 anytime within 72 hours; (III) Declined: lungs unsuitable for transplantation after EVLP. RESULTS: Of 50 cases included in this study, 27 were in Control group, 7 in PGD3, and 16 in Declined. From a total of 51 analytes, 34 were measurable in perfusates. The best marker to differentiate declined lungs from control lungs was stem cell growth factor -ß [P < 0.001, AUC (area under the curve) = 0.86] at 1 hour. The best markers to differentiate PGD3 cases from controls were interleukin-8 (P < 0.001, AUC = 0.93) and growth-regulated oncogene-α (P = 0.001, AUC = 0.89) at 4 hours of EVLP. CONCLUSIONS: Perfusate protein expression during EVLP can differentiate lungs with good outcome from lungs PGD3 after transplantation. These perfusate biomarkers can be potentially used for more precise donor lung selection improving the outcomes of transplantation.

Re-appraisal of bronchus-first right upper lobectomy as an alternative routine procedure.

OBJECTIVES: Postoperative air leakage is a major complication of lung resection, particularly right upper lobectomy. However, various surgical procedures can reduce postoperative complications and shorten the drainage period. The current study aimed to analyse the utility of bronchus-first right upper lobectomy as an alternative routine procedure. METHODS: We retrospectively analysed the data of 225 (53.7%) patients who underwent bronchus-first right upper lobectomy and 194 (46.3%) patients who underwent the conventional bronchus-last right upper lobectomy at our institution from 2015 to 2022. In patients with incomplete fissures who underwent bronchus-first right upper lobectomy, the bronchus was dissected 1st, followed by the pulmonary artery and vein, and then, the interlobar fissure was divided. We compared the outcomes of 2 procedures and analysed the surgical utility of bronchus-first right upper lobectomy. RESULTS: The surgical outcomes and postoperative morbidity comparing bronchus-first and bronchus-last procedure were as follows: median operation time (min) 103/126 (P < 0.001), median bleeding amount (ml) 28/55 (P = 0.003), incomplete lobulation rate (%) 35.1/24.2 (P = 0.02), incidence of prolonged air leakage (%) 2.2/3.1 (P = 0.76) and rate of fellow surgeon's operation (%) 28.0/4.6 (P < 0.001). The procedure was associated with a decreased incidence of prolonged air leakage. The 4-year overall survival rates did not significantly differ between the 2 groups (P = 0.24). CONCLUSIONS: Bronchus-first right upper lobectomy can prevent postoperative air leakage in patients with incomplete fissure. Additionally, as an alternative routine procedure, it is associated with a shorter surgical duration and a lower volume of blood loss regardless of interlobar fissure and operator's experience.

Emergency right lower lobectomy for severe pulmonary abscess in a pregnant woman at the 25th week of gestation: a case report.

BACKGROUND: Pulmonary abscess is a severe infection commonly seen in patients with chronic obstructive pulmonary disease, interstitial pneumonia, immune deficiency disease, drug-induced immunocompromised state, and congenital pulmonary disease. The treatment strategy in pregnant women with a pulmonary abscess is considered challenging since adverse effects on the fetus must be avoided to ensure safe delivery. CASE PRESENTATION: A 34-year-old female patient at 24 weeks of gestation (G2P1) was admitted to the Department of Obstetrics and Gynecology due to sudden right chest pain. The patient had no significant medical history, including congenital anomalies, and no history of drug addiction or smoking. Laboratory data indicated high levels of inflammation (white blood cell 12,000/µL, C-reactive protein 16.0 mg/dL), and computed tomography demonstrated a large intrapulmonary cyst located in the middle of the right lower lobe, with some fluid collection. As the patient had no medical history of congenital pulmonary anomalies, she was initially diagnosed with a pulmonary cyst infection and treated with intravenous antibiotics. However, the infection did not resolve for over a week, and a spike in fever developed after admission. There was no definitive evidence concerning the risk of preterm delivery and fetal abortion during non-obstetric surgery. However, to control the severely infected pulmonary abscess that was refractory to antibiotics and obtain a pathological diagnosis while saving the life of both the mother and fetus, we elected to perform an emergent right lower lobectomy by open thoracotomy with a fissureless maneuver after receiving informed consent. Postoperatively, the infection gradually improved, and the patient was discharged on the 16th postoperative day without any major complications in the mother or fetus. Although she later experienced coronavirus disease-19 at 29 weeks of gestation, a boy was born at 40th weeks of gestation without any complications. Pathologically, no infectious agents, malignancies, or congenital anomalies other than lung abscesses associated with the pulmonary infarction were observed. The mother and child were healthy 1 year postoperatively. CONCLUSIONS: We experienced a rare case of a pulmonary abscess in a pregnant woman who needed an emergent right lower lobectomy to control the severe infection and obtain a correct pathological diagnosis. Under cooperation from an obstetrician and anesthesiologist, emergency pulmonary resection can be performed safely for serious abscess formation even for pregnant women who have several months left until delivery.

Alveolar adenoma with a single cyst: A case report.

Alveolar adenoma is a rare and benign pulmonary tumor, which originates from type II pneumocytes and is often incidentally identified on radiographic images. Alveolar adenoma presents as a peripleural, solitary and cystic nodule in the lung and may mimic other types of lung tumors, thus rendering its differential diagnosis difficult. Alveolar adenoma is diagnosed based on histopathological and immunohistochemical analyses. The present study describes the case of a 50-year-old male patient with alveolar adenoma. He visited a local doctor ~3 years prior due to left chest pain. A chest computed tomography scan revealed a cystic lesion in segment 8 of the left lung. A nodular shadow appeared in the cyst and gradually increased in size; the patient was thus referred to the authors' hospital. The nodule was well-defined, solitary and solid; thus, lung cancer or aspergilloma were suspected. Thoracoscopic wedge resection was performed as diagnostic therapy. The frozen sections were non-diagnostic, and a pathological examination revealed an alveolar adenoma with no evidence of malignancy and a negative culture. The patient had a good post-operative course, with no sign of recurrence at the follow-up evaluation 46 months later. On the whole, alveolar adenoma is a rare, benign pulmonary tumor that is difficult to diagnose pre-operatively.

Restrictive allograft syndrome post lung transplantation is characterized by pleuroparenchymal fibroelastosis.

We previously described restrictive allograft syndrome as a form of chronic lung allograft dysfunction, demonstrating restrictive pulmonary function decline. However, the histopathological correlates of restrictive allograft syndrome have yet to be satisfactorily described. We hypothesized that pulmonary pleuroparenchymal fibroelastosis, as has recently been described in bone marrow transplant recipients, may also be present in the lungs of patients with restrictive allograft syndrome. Retrospective review of 493 patients who underwent lung transplantation between 1 January 1996 and 30 June 2009, was conducted. Out of 47 patients with clinical features of restrictive allograft syndrome, 16 had wedge biopsy, re-transplant lung explant, or autopsy lung specimens available for review. All lungs showed varying degrees of pleural fibrosis. Fifteen of 16 showed parenchymal fibroelastosis, characterized by hypocellular collagen deposition with preservation and thickening of the underlying alveolar septal elastic network. The fibroelastosis was predominantly subpleural in distribution, with some cases also showing centrilobular and paraseptal distribution. A sharp demarcation was often seen between areas of fibroelastosis and unaffected lung parenchyma, with fibroblastic foci often present at this interface. Concurrent features of obliterative bronchiolitis were present in 14 cases. Another common finding was the presence of diffuse alveolar damage (13 cases), usually in specimens obtained <1 year after clinical onset of restrictive allograft syndrome. The single specimen in which fibroelastosis was not identified was obtained before the clinical onset of chronic lung allograft dysfunction, and showed features of diffuse alveolar damage. In conclusion, pleuroparenchymal fibroelastosis is a major histopathologic correlate of restrictive allograft syndrome, and was often found concurrently with diffuse alveolar damage. Our findings support a temporal sequence of diffuse alveolar damage followed by the development of pleuroparenchymal fibroelastosis in the histopathologic evolution of restrictive allograft syndrome.

The pulmonary surgical Apgar score for lung cancer surgery predicts postoperative complications and long-term survival.

OBJECTIVES: The surgical Apgar score, calculated using 3 intraoperative variables (blood loss, lowest mean arterial pressure and lowest heart rate), is associated with mortality in cancer surgery. The original score has less applicability in lung cancer surgery; therefore, we innovated the modified pulmonary surgical Apgar score with additional intraoperative oxygen saturation representing pulmonary parenchymal damage and cardiopulmonary dynamics. METHODS: We retrospectively analysed the data of 691 patients who underwent surgery for primary lung cancer between 2015 and 2019 at a single institute. We analysed the utility of the pulmonary surgical Apgar score compared with the original surgical Apgar score. RESULTS: Postoperative complications were observed in 57 (8.2%) and 7 (1.0%) of the 691 patients who were stratified as grade ≥III and V, respectively, according to the Clavien-Dindo classification. We compared the fitness of the score in predicting postoperative complications; the calculated c-index (0.622) was slightly higher than the original c-index (0.604; P = 0.398). Patients were categorized into 3 groups based on their scores as follows: 0-6 points (n = 59), 7-9 points (n = 420) and 10-12 points (n = 212). Univariable and multivariable analyses demonstrated that a lower score was an independent negative risk factor for postoperative complications (odds ratio 3.53; P = 0.02). Patients with lower scores had a considerably poor 5-year overall survival (64.6%) (P = 0.07). CONCLUSIONS: The pulmonary surgical Apgar score predicts postoperative complications and long-term survival in patients with lung cancer undergoing surgery and may be utilized for postoperative management.