Recovery of respiratory muscle strength, physical function, and dyspnoea after lobectomy in lung cancer patients undergoing pulmonary rehabilitation: A retrospective study.

OBJECTIVE: To characterise changes in respiratory muscle strength, physical function, and dyspnoea in patients who underwent pre- and post-operative exercise intervention following lobectomy for non-small-cell lung cancer (NSCLC). METHODS: This retrospective study included NSCLC patients who underwent lobectomy via video-assisted thoracoscopic surgery (VATS) or posterolateral thoracotomy (PLT) and pre- and post-operative exercise intervention consisting of breathing, flexibility, resistance, aerobic exercises, coughing/huffing techniques, and early mobilisation. Maximum mouth inspiratory (Pimax) and expiratory pressures (Pemax), 6-min walk distance (6MWD), quadriceps force (QF), and modified Medical Research Council (mMRC) dyspnoea scale were evaluated preoperatively, at hospital discharge, and post-lobectomy 1 and 3 months. RESULTS: Data from 41 patients were analysed. At hospital discharge, the Pimax, Pemax, 6MWD, and mMRC dyspnoea scores were lower than pre-operatively; QF remained unchanged; Pimax and 6MWD recovered to pre-operative values at post-lobectomy 1 month; and Pemax and mMRC dyspnoea scores recovered at 3 months. During sub-analysis, Pimax and mMRC dyspnoea scores in the VATS (n = 24) and PLT groups (n = 17) recovered to pre-operative values at post-lobectomy 1 and 3 months. CONCLUSION: After lobectomy, respiratory muscle strength, physical function, and dyspnoea in patients who underwent exercise intervention returned to pre-operative values at post-lobectomy 3 months.

Liposome-encapsulated hemoglobin accelerates bronchial healing after pneumonectomy in the rat with or without preoperative radiotherapy.

Liposome-encapsulated hemoglobin (LEH) has been reported to accelerate wound healing in the stomach and skin in an experimental setting. LEH was tested in bronchial anastomotic healing after radiation and pneumonectomy in the rat. Sprague-Dawley rats (n = 61) received preoperative radiation (20 Gy) to the chest and underwent left pneumonectomy with bronchial stump closure using the Sweet method 4 days later, when they were randomized to receive intravenous infusion of LEH with high O2 affinity (P50 O2 = 17 mm Hg, 10 mL/kg, n = 32) or saline (n = 29). Additional rats (n = 18) were treated in the same way without preoperative radiation. Bronchial anastomotic healing was evaluated 2 days after surgery by determining the bursting pressure and infiltration of neutrophils, monocytes, and macrophages. Bronchial bursting pressure was elevated in the rats receiving LEH both in the unirradiated group (LEH 212 ± 78 vs. saline 135 ± 63 mm Hg, P < 0.05) and in rats with preoperative radiation (LEH 162 ± 48 vs. saline 116 ± 56 mm Hg, P < 0.01). Moreover, the percentage of rats with bursting pressure <100 mm Hg tended to be smaller in the unirradiated group (LEH 1/9 [11.1%] vs. saline 4/9 [44.4%], NS) and was significantly reduced in irradiated animals (LEH 3/32 [9.4%] vs. saline 11/29 [38%], P < 0.05). There were no morphological differences except for macrophage infiltration to the anastomotic area, which was significantly prominent in the LEH-treated rats (P < 0.05) regardless of the presence or absence of preoperative irradiation (IR). The results suggest that LEH with high O2 affinity may improve mechanical strength and morphological findings in bronchial anastomosis in rats regardless of the presence or absence of preoperative IR. The irradiated rats later treated with LEH had equivalent or better bronchial healing than that of saline-treated naïve animals undergoing pneumonectomy alone.

[The relation between the frequency of exercise oxygen desaturation following major lung resection and the predictions of postoperative pulmonary function].

The predictors of oxygen desaturation during exercise in patients submitted to major pulmonary resection for lung cancer are to be determined. We analyzed retrospectively the relation between the oxygen saturation by pulse oxymetry (Spo2) during exercise and the predictions of postoperative pulmonary function. A hundred twenty-two patients with lung cancer who underwent lung resection from January 1999 to May 2004 were included (79 men, 43 women, average age 66.9 +/- 9.2). A fall over 5% in Spo2 during exercise was termed 'desaturation'. Twenty-eight patients developed desaturation [group D(+)] and 94 patients did not [group D(-)]. We compared the predictions of postoperative pulmonary function (%ppoVC, %ppoFEV1.0, %ppoDLco) between these 2 groups. As a result, only %ppoDLco was significantly different between 2 groups [D(+) 68.7 +/- 19.1%, D(-) 83.8 +/- 24.9%]. Patients with poor %ppoDLco are at increased risk to develop a postoperative exercise oxygen desaturation.

A Case of Mediastinal Lymph Node Carcinoma of Unknown Primary Site.

A 63-year-old man was pointed out with a mediastinal tumor on chest computed tomography (CT). On positron emission tomography-CT, fluorodeoxyglucose accumulation with a maximum standardized uptake value of 12.70 was seen in this tumor. Scar-like nodule was found in the apex of the right lung, but no abnormal accumulation was observed in this nodule. The level of carcinoembryonic antigen was abnormally elevated. We performed mediastinal tumorectomy under thoracoscopic surgery. Since arterial oxygen saturation fell during intraoperative one-lung ventilation, we finished the surgery without resection of right apex nodule. Histologically, mediastinal tumor was diagnosed as metastatic adenocarcinoma in lymph node. Because immunohistochemical staining suggested lung adenocarcinoma as the primary site, the right apex nodule was resected. Pathological diagnosis of this nodule was scar fibrosis. No other malignant lesions were detected, and therefore we finally diagnosed this tumor as mediastinal lymph node carcinoma of unknown primary site. The patient was given adjuvant chemotherapy, and at present, 37 months after surgery, the patient remains free of the disease.

Video-assisted segmental resection of an intrapulmonary bronchogenic cyst mimicking a middle mediastinal cystic tumor.

We report a case of an intrapulmonary bronchogenic cyst that radiologically mimicked a cystic tumor of the middle mediastinum. During video-assisted thoracoscopic surgery, the lesion was confirmed to be in the lung parenchyma rather than in the mediastinum. A video-assisted thoracoscopic anterior basal segmentectomy was eventually performed, and an intrapulmonary bronchogenic cyst was the diagnosis based on histology.

Compromised video-assisted thoracoscopic segmental resection for high-risk patients with stage I lung cancer near the lung hilum.

We performed a video-assisted thoracoscopic segmental resection without doing a mini-thoracotomy in two patients (one octogenarian and one with poor lung function) with early stage (T1-2N0) lung cancer located at the lung hilum who required preservation of their cardiopulmonary function. After 2 years of follow-up, both patients are alive without recurrence. We describe the cases and the method used for the video-assisted thoracoscopic segmental resection using an endoscopic stapler.

L-shaped mini-sternotomy combined with videoscopic approach for thymoma with invasion of major veins.

It might be possible to remove thymic tumors with minimal invasion of the left brachiocephalic vein (BCV) using an advanced videoscopic technique; simple resection of this vessel can be achieved via such an approach. However, tumor invasion of the superior vena cava or right  BCV requires angioplasty or reconstruction, both of which are difficult to perform in videoscopic procedures. We report a case of invasive thymoma with localized invasion of the great vessels at the junction of the left BCV and superior vena cava. An L-shaped mini-sternotomy combined with a videoscopic approach allowed thymectomy with safe vesselplasty of the involved vessels.

Recurrence in regional pulmonary lymph nodes after surgery for isolated pulmonary metastasis from hepatocellular carcinoma.

Hepatocellular carcinoma occasionally metastasizes to extrahepatic organs, rarely to the mediastinal lymph nodes. We present the case of a 64-year-old man who presented with nodules in the upper and right lower lobes of the lung 4 years after undergoing resection of a hepatocellular carcinoma. We performed wedge resection of both lesions. Pathological examination showed that the lesion in the right upper lobe was non-small cell lung cancer and that in the right lower lobe hepatocellular carcinoma. We accordingly performed right upper lobectomy with lymph node dissection. Nine months later, enlarged subcarinal and segmental lymph nodes were detected and mediastinal lymph node metastases from the hepatocellular carcinoma diagnosed by transbronchial needle aspiration.

Spontaneous pneumothorax and a coexistent azygos lobe.

We present a primary spontaneous pneumothorax involving a possible diagnostic and surgical pitfall. A 25-year-old man with a previously identified azygos lobe was admitted to our hospital because of right primary spontaneous pneumothorax. A preoperative chest X-ray at the onset of the pneumothorax as well as after resolution by tube drainage showed an azygos fissure but no azygos vein. Chest computed tomography revealed the dislocated azygos vein external to the azygos fissure on the mediastinal side of the reexpanded upper lobe. Thoracoscopic bullectomies were uneventfully performed. The azygos arch was found dangling in the free inferior border of the mesoazygos. An azygos vein located in this position can be a potential surgical hazard especially in video-assisted thoracic surgery. This case suggests that the presence of an azygos lobe can be missed on chest X-ray when a pneumothorax occurs in a patient with an azygos lobe.

Delayed hemothorax superimposed on extrapleural hematoma after blunt chest injury: a case report.

We report a case showing delayed hemothorax superimposed on extrapleural hematoma after blunt chest injury. The patient was a 56-year-old man with a medical history of alcoholic hepatopathy who presented with a chief complaint of dyspnea on exertion. One month prior to presentation, he had sustained a fall that had resulted in left simple rib fracture. A chest radiograph taken at the time of injury showed notable reduction in the permeability of the left lung field along with high pulmonary collapse as well as rightward deviation of the shadow of the inferior mediastinum. Chest CT images showed a region of low absorption in the thoracic cavity with septi. Thoracic drainage was performed (1,300 mL total) and hemothorax was diagnosed. Thoracoscopic examination was then performed. When the inside of the thorax was observed, what had been presumed to be the septi of a multilocular fluid collection was found to be actually the parietal pleura, and a hematoma was confirmed inside the extrapleural cavity. The hematoma inside the extrapleural cavity was managed with lavage and drainage, and drainage tubes were placed inside both the thoracic cavity and extrapleural cavity at the end of the procedure. The patient's postoperative course was uneventful, and he was discharged on postoperative day 4.

Tumor budding is a significant indicator of a poor prognosis in lung squamous cell carcinoma patients.

Lung cancer is a leading cause of cancer mortality worldwide and patients occasionally develop local recurrence or distant metastasis soon after curative resection. Reports of new therapeutic strategies for lung squamous cell carcinoma (SqCC) are extremely rare, while selective anticancer therapy has been reported for lung adenocarcinoma. The aim of this study was to identify clinicopathological prognostic factors for SqCC. We analyzed tumor budding and infiltrative patterns (INF) in 103 cases of surgically-resected SqCC. Tumor infiltrative patterns were classified into three groups (INFa, b and c) and INFc was infiltrative growth at the tumor invasive front. The cases with an INFc component [INFc(+)]were significantly associated with venous invasion (P=0.014) and the scirrhous stromal type (P<0.001). The overall survival rate of patients with INFc(+) was significantly lower than that of patients without the INFc component [INFc(-); P=0.003]. Tumor budding was defined as a single cancer cell or a small nest of up to four cancer cells within stromal tissue. The cases with tumor budding [Bud(+)] were significantly associated with lymph node metastasis (P=0.001), lymphatic invasion (P=0.002), INFc(+) (P<0.001) and the scirrhous stromal type (P=0.014). Patients with the Bud(+) type had a lower overall survival rate than patients with the Bud(-) type (P<0.001). Multivariate analysis demonstrated that tumor budding [hazard ratio (HR), 2.766; 95% confidence interval (CI), 1.497-5.109] and lymph node metastasis (HR, 1.937; 95% CI, 1.097-3.419) were independent predictors of mortality. In conclusion, tumor budding is a significant indicator of a high malignant potential and poor prognosis in SqCC of the lung.

A case of an elderly patient treated for descending necrotizing mediastinitis.

We report a case of descending necrotizing mediastinitis (DNM). DNM is a serious infection, and preventing death requires early diagnosis and draining of the infection focus. An 84-year-old man was admitted to our hospital complaining of a swollen neck and pain when swallowing. He had had a tooth extracted at a neighboring dental clinic 2 days previously. Cervicothoracic computed tomography (CT) scan demonstrated gas bubbles and unencapsulated abscesses in the cervical spaces and anterosuperior and posterior mediastinum, extending below the carina. He was diagnosed as DNM caused by odontogenic infection. Cervical drainage was performed, in addition to mediastinal drainage using video-assisted thoracic surgery (VATS). Complications were sepsis, disseminated intravascular coagulation (DIC), and heart failure after surgery, but he recovered following intensive care. This was a lifesaving case of DNM for which mediastinal drainage was performed with VATS.

Life-saving treatment by fluid resuscitation and a thoracotomy in a case of deep pulmonary laceration.

CASE: A 41-year-old man survived deep pulmonary and hepatic lacerations by treatment with fluid resuscitation, blood transfusion, thoracotomy, and transcatheter hepatic artery embolization. The patient was transferred to our hospital 46 minutes after his motorbike struck a station wagon from behind. Hemorrhagic shock with systolic blood pressure of 68 mmHg was observed. He showed nonresponse to 20-minute intravenous infusion of 1,500 mL of lactated Ringer's solution. The initial plain chest radiograph showed mediastinal deviation to the left, radio-opacity of the right lower lobe, and decreased radiolucency of the right thorax. Rapid drainage of 800 mL of blood through a right chest tube led to a diagnosis of a deep pulmonary laceration of the right lower lobe. Abdominal computed tomography revealed another deep laceration affecting 40% of the liver. A right lower lobectomy of the lung was performed at 169 minutes after arrival. After the thoracotomy,transcatheter arterial embolization of the right hepatic artery was performed. The patient was discharged on hospital day 57. CONCLUSION: Prompt diagnosis and appropriate treatment are necessary to save patients with multiple, severe blunt injuries. Advanced Trauma Life Support (ATLS) guidelines should be adhered to for appropriate early treatment of patients with severe trauma.