[Surgical Procedure and Perioperative Outcomes of Three-port Video-assisted Thoracoscopic Surgery Thymectomy for Thymoma, Including en-bloc Resection of Adjacent Organs].

This report discusses the treatment and outcomes of three-port video-assisted thoracoscopic surgery (VATS) thymectomy for thymoma. We reviewed perioperative results of 159 thymoma cases( excluding thymic carcinoma) over 16 years. Thoracoscopic surgery was indicated for Masaoka stagesⅠ to Ⅲ, tumor diameter up to 12 cm, and resection of surrounding organs up to the lung, pericardium+reconstruction, internal thoracic artery and vein, left brachiocephalic vein, and phrenic nerve+reconstruction. The mean age of patients was 56.9±12.7, with 71 males and 88 females. The surgical approach was right-sided in 110 cases, left-sided in 47 cases, and bilateral in 2 cases. Total thymectomy was performed in 141 cases, with total thymectomy plus combined resection of other organs (lungs, pericardium, and phrenic nerve) ±reconstruction in 18 cases. The World Health Organization( WHO) classification( 5th edition) was type A/AB/B1/B2/B3/micronodular thymoma with lymphoid stroma (MNTLS) = 20/49/32/45/11/2, and Masaoka classification was stageⅠ/Ⅱ/Ⅲ=69/86/4. The three-port VATS technique offers several advantages, including its applicability to other surgeries, avoidance of contralateral thoracic cavity opening, safety in thymectomy without open conversion, and a mean postoperative hospital stay of 3 days.

Loss of YAP1 defines neuroendocrine differentiation of lung tumors.

YAP1, the main Hippo pathway effector, is a potent oncogene and is overexpressed in non-small-cell lung cancer (NSCLC); however, the YAP1 expression pattern in small-cell lung cancer (SCLC) has not yet been elucidated in detail. We report that the loss of YAP1 is a special feature of high-grade neuroendocrine lung tumors. A hierarchical cluster analysis of 15 high-grade neuroendocrine tumor cell lines containing 14 SCLC cell lines that depended on the genes of Hippo pathway molecules and neuroendocrine markers clearly classified these lines into two groups: the YAP1-negative and neuroendocrine marker-positive group (n = 11), and the YAP1-positive and neuroendocrine marker-negative group (n = 4). Among the 41 NSCLC cell lines examined, the loss of YAP1 was only observed in one cell line showing the strong expression of neuroendocrine markers. Immunostaining for YAP1, using the sections of 189 NSCLC, 41 SCLC, and 30 large cell neuroendocrine carcinoma (LCNEC) cases, revealed that the loss of YAP1 was common in SCLC (40/41, 98%) and LCNEC (18/30, 60%), but was rare in NSCLC (6/189, 3%). Among the SCLC and LCNEC cases tested, the loss of YAP1 correlated with the expression of neuroendocrine markers, and a survival analysis revealed that YAP1-negative cases were more chemosensitive than YAP1-positive cases. Chemosensitivity test for cisplatin using YAP1-positive/YAP1-negative SCLC cell lines also showed compatible results. YAP1-sh-mediated knockdown induced the neuroendocrine marker RAB3a, which suggested the possible involvement of YAP1 in the regulation of neuroendocrine differentiation. Thus, we showed that the loss of YAP1 has potential as a clinical marker for predicting neuroendocrine features and chemosensitivity.

Outpatient Treatment of Pneumothorax with a Thoracic Vent: Economic Benefit.

BACKGROUND: Since rising medical costs currently represent a growing problem worldwide, finding cost-effective treatment options is important. In our hospital, outpatient treatment of pneumothorax using a thoracic vent began in December 2012. OBJECTIVES: We aimed to test our hypothesis that outpatient treatment of pneumothorax with a thoracic vent can reduce medical expenses. METHODS: Patients were classified into four groups based on treatment: thoracic vent with or without surgery or conventional intercostal chest tube drainage with or without surgery. We compared mean medical expenses, duration of hospitalization and number of physician visits among these four groups. RESULTS: During a 2-year period, 65 patients were treated with a thoracic vent (36 patients) or conventional intercostal chest tube drainage (29 patients). Patients treated with a thoracic vent who underwent surgery had a shorter mean duration of hospitalization (5.0 ± 1.3 vs. 10.3 ± 3.4 days; p < 0.0001) and lower overall cost, at JPY 971,830.00 ± 81,291.80 (USD 10,400.40 ± 1,464.90) versus JPY 1,179,791.10 ± 198,383.10 (USD 13,888.90 ± 1,965.30; p < 0.0001) compared with conventional intercostal chest tube drainage. Nonsurgical patients treated with a thoracic vent had lower overall costs, at JPY 79,960.00 ± 25,643.60 (USD 890.10 ± 352.30) versus JPY 268,588.80 ± 94,636.50 (USD 2,932.80 ± 903.50; p < 0.0001) compared with conventional intercostal chest tube drainage. No serious complications were observed. CONCLUSIONS: Outpatient thoracic vent treatment can significantly reduce medical expenses and thereby have a major economic impact.

Outcomes of combined modality therapy for patients with stage III or IV mediastinal malignant germ cell tumors.

PURPOSE: The treatment of primary mediastinal germ cell tumors with cisplatin-based chemotherapy followed by surgery is an established practice; however, the prognosis has remained poor. This study reviews the survival outcomes of patients with primary mediastinal germ cell tumors to evaluate the efficacy of our treatment. METHODS: We retrospectively reviewed 11 consecutive patients with primary mediastinal germ cell tumors. RESULTS: We had treated four patients with seminomas and seven patients with non-seminomas. Ten patients had undergone cisplatin-based chemotherapy. All patients underwent complete resection. Two patients showed a failure of first-line chemotherapy and thus received salvage chemotherapies, including paclitaxel plus ifosfamide followed by high-dose carboplatin plus etoposide (TI-CE) with stem cell transplantation. One of them died of relapse 29 months later; while the other patient remained disease-free for 56 months postoperatively. The postoperative overall 3-year survival rates of the patients with non-seminomas and seminomas were 83 and 100%, respectively. CONCLUSION: Complete resection after establishing normalized or decreased at a low-level serum tumor markers plateau plays a crucial role in the management of patients with primary mediastinal malignant germ cell tumors.

[Video-assisted thoracoscopic surgery for pleuroperitoneal communications as a complication of continuous ambulatory peritoneal dialysis( CAPD)].

A 54-year-old female who was started on continuous ambulatory peritoneal dialysis( CAPD) for endstage renal disease secondary to focal developed 2 pleuroperitoneal communications. At first, she developed chest pain and cough on the day following introduction. A 99m-technetium-macroaggregated albumin (99mTc-MAA) radionuclide scan showed a communication between the abdomen and the right pleural cavity. We diagnosed a right pleuroperitoneal communication. Four months later, she developed similar symptoms and was diagnosed with a left pleuroperitoneal communication. Video-assisted thoracoscopic surgery was performed for each lesion. However, the communications were detected using different methods. During the 1st surgery, the communication was detected using peritoneal dialysis fluid containing indigocarmine introduced through a CAPD catheter. During the 2nd surgery, the communication was detected by pneumoperitoneum. With regards to diaphragmatic pressure regulation, pneumoperitoneum was more rapid and convenient, so pneumoperitoneum was considered more effective for the identification and treatment of pleuroperitoneal communications. Diaphragmatic plication and pleurodesis with polyglycolic acid felt and fibrin glue on both sides were performed. No recurrence of hydrothorax was detected after treatment.

[Pulmonary thromboembolism that developed 16 days after surgery for lung cancer].

An 79-year-old man underwent right upper lobectomy with mediastinal lymph node dissection for lung cancer. He was discharged without complications on postoperative day( POD) 8. However, on POD 16 he become dyspneic at home and was transported to a hospital by ambulance. Pulmonary thromboembolism (PTE) was detected by contrast-enhanced computed tomography. Anticoagulant therapy was initiated and inferior vena cava filter placement was performed.Due to its many possible clinical manifestations, early detection of postoperative PTE is difficult. Therefore prevention of PTE is thought to be more important. Intermittent application of pneumatic compression stockings and preventive anticoagulant therapy may help prevent PTE after surgery.

[Anomalous systemic arterial supply to the basal segment of the right lung with patent ductus arteriosus; report of a case].

A 38-year-old woman was referred to our hospital because she presented with an abnormal shadow on a chest radiograph. A through examination showed an aberrant artery arising from the abdominal aorta and supplying the right basal segment and patent ductus arteriosus(PDA).Moreover the sequestrated lung was not recognized. Based on these findings we diagnosed the patient with anomalous systemic arterial supply to the basal segment of the right lung with PDA. Her pulmonary-to-systemic blood flow ratio was 1.10. Therefore we planned to treat the PDA someday afterwards. Right basal segmentectomy and transection of the aberrant artery by using only autosuturing device were performed. Five months later, three-dimensional computed tomography showed no aneurysm of the cut end of the abnormal vessel.

Dendriform Pulmonary Ossification: Findings from Eight Years of Observation.

Dendriform pulmonary ossification is a rare condition characterized by branching bony spicules. A 33-year-old man was clinically considered to have sarcoidosis. At 53 years old, another attending physician performed a detailed evaluation. Computed tomography (CT) showed a fine nodular pattern with foci of calcifications and pulmonary function testing showed peripheral airway obstruction. We performed a surgical biopsy. A histological examination revealed dendriform pulmonary ossification. After surgery, CT showed progression of some lesions; the pulmonary function had also decreased slightly. Since dendriform pulmonary ossification might be a progressive disease, we should perform long-term follow-up.

Peribronchiolar Metaplasia of the Lung Incidentally Detected During a Surgery for Pneumothorax: A Case Report.

BACKGROUND: Peribronchiolar metaplasia (PBM) is a lesion characterized by an abnormal connection between the terminal bronchiole and parabronchiole via the Lambert's canals. We report a rare case of PBM incidentally detected during a surgery for pneumothorax. CASE PRESENTATION: At 38-year-old man was admitted to our hospital with chest pain. He was diagnosed with pneumothorax and treated using a thoracic drain 12 years ago. Chest computed tomography revealed a cyst in the right upper lobe and ground glass lesion with a solid component in the right lower lobe of the lung. Hence, we performed a surgery for pneumothorax management, which revealed a cyst in the right upper lobe and induration with angiogenesis in the right lower lobe. We performed partial resection of the right upper and lower lobes. Pathological examination of the lower lobe nodule revealed small airways with lymphocytic inflammation and bronchiolar metaplasia. Pathological diagnosis of the nodule was PBM. CONCLUSION: Although PBM is considered a lesion with good prognosis, there have been cases associated with early-stage lung cancer. Hence, care should be taken to distinguish PBM from other neoplasms. However, preoperative diagnosis is difficult in most cases so complete surgical resection is recommended, if feasible.

Anaphylactic Shock Caused by Talc Pleurodesis Performed for Postoperative Air Leakage.

Chemical pleurodesis, including talc pleurodesis, has been commonly used to prevent malignant pleural effusions and pneumothorax. This report describes a case of anaphylactic shock caused by talc pleurodesis. A 69-year-old woman who had prolonged air leakage after lobectomy underwent talc pleurodesis. Just after the talc administration, she went into shock. We immediately treated her for anaphylactic shock and simultaneously removed talc from the thoracic cavity through a thoracic tube. She subsequently recovered from shock. She had no further symptoms and was discharged 10 days after pleurodesis. Talc pleurodesis rarely causes severe complications, but it is necessary to treat these appropriately when they occur.

Micronodular Thymoma with Lymphoid Stroma: A Case Report.

BACKGROUND: Micronodular thymoma with lymphoid stroma (MNT) is a rare subtype of thymic neoplasms. Therefore, clinical guidelines, histopathological diagnostic criteria, prognostic factors, and therapeutic regimens have not been established. CASE PRESENTATION: A 69-year-old woman was admitted to our hospital because of an abnormal shadow detected by chest radiography. Further imaging revealed an anterior mediastinal tumor measuring 65×28×15 mm. We performed thymectomy for diagnosis and treatment. Histopathological examination revealed spindle cells comprised multiple micronodules separated by abundant interstitial lymphocytes and lymphoid follicles. Immunohistochemical staining showed that the tumor was positive for cell adhesion molecule (CAM), cytokeratin (CK) 5/6, and terminal deoxynucleotidyl transferase. The histopathological diagnosis was MNT and the stage was I by the World Health Organization classification. The patient remained free of recurrence for seven years after surgery. CONCLUSION: When the lesion is completely resected, MNT has a good prognosis. Therefore, MNT is considered to be a borderline tumor with good prognosis and no reports of recurrences, distant metastasis, or tumor-related deaths exist thus far. However, preoperative diagnosis is difficult in most cases. Hence, complete surgical resection is recommended for suspicious mediastinal masses, if feasible, for both accurate diagnosis and to ensure long-term survival.

Bronchial Foreign Body Aspiration Due to Polycarbophil Calcium.

Polycarbophil calcium (Polyful®; Mylan, Tokyo, Japan) is a stool stabilizer that absorbs liquid and swells to form a soft, bulky mass. A 75-year-old woman experienced sore throat and difficulty breathing immediately after taking the drug. Chest computed tomography showed a foreign body in the right intermediate bronchus. Bronchoscopy showed a white mass blocking the right intermediate bronchus. Since the mass was very fragile, we performed suctioning while breaking up the mass with a suction tube. The mass consisted of polycarbophil calcium. Since aspirated polycarbophil calcium swells and can obstruct bronchi, complete removal is crucial.

Paraneoplastic Dermatomyositis as a Potential Precursor to Thymic Carcinoma.

A red rash developed on both hands of a 54-year-old man. At age 56, he was admitted to our hospital because of an abnormal shadow detected by chest roentgenogram. A detailed examination revealed an anterior mediastinal tumor and dermatomyositis. Thymectomy was performed, and pathologic examination revealed thymic carcinoma. After the surgery, the dermatomyositis symptoms improved. Although dermatomyositis associated with thymic carcinoma is extremely rare, we should account for the possibility of thymic carcinoma-associated dermatomyositis. This will allow for early identification and treatment of malignant tumors, and symptom severity may reflect the degree disease control.

Pulmonary inflammatory myofibroblastic tumor: a case report.

Pulmonary inflammatory myofibroblastic tumor is a rare disease. Computed tomography in a 54-year-old woman showed a mass compressing the segmental bronchus of the left lung. Bronchoscopy indicated a mesenchymal tumor, hamartoma, or inflammatory myofibroblastic tumor. Because an inflammatory myofibroblastic tumor can potentially clog the segmental bronchus, we performed a left upper division segmentectomy. Pathologic examination revealed an inflammatory myofibroblastic tumor. In most cases, preoperative diagnosis is difficult because of the varied radiologic manifestations, and it can also be difficult to distinguish from malignancy in small tissue samples.

Outpatient drainage for patients with spontaneous pneumothorax over 50 years of age.

INTRODUCTION: The British Thoracic Society has reported a lower success rate for aspiration of spontaneous pneumothorax in patients over 50 years of age. Outpatient drainage therapy is used to manage spontaneous pneumothorax at some institutions. We examined the effect of age on outpatient drainage therapy outcomes. MATERIALS AND METHODS: We reviewed the records of 68 patients who underwent outpatient drainage therapy with a thoracic vent between December 2012 and April 2015, which included 11 patients over 50 years of age. Indications for outpatient drainage therapy included pneumothorax with no circulatory or respiratory failure and no pleural effusion. RESULTS: Of the 11 patients over 50 years of age, 5 had chronic obstructive pulmonary disease (COPD), one had interstitial pneumonia, one had a history of pulmonary tuberculosis, and one has lung tumors (LTs). Among the 57 younger patients, 2 patients had COPD, and one had LTs. Unexpected hospital admission occurred in 2 patients over 50 years of age and one patient aged 50 years or less (P = 0.0658, Fisher's exact test). Six of the 11 patients over 50 years of age underwent surgery for prolonged air leakage, compared to 8 of the 57 younger patients (P = 0.00695, Fisher's exact test). CONCLUSIONS: Outpatient drainage therapy is useful for patients with spontaneous pneumothorax over 50 years of age, because outpatient drainage therapy alone was successful in 4 of 11 patients and admission for drainage was avoided in 9 of 11 patients. However, prolonged air leakage occurs more frequently in this age group.

Thoracoscopic surgery for multiple peripheral pulmonary arteriovenous fistulas.

A 37-year-old woman with dyspnea was referred to our department with the diagnosis of multiple bilateral pulmonary arteriovenous fistulas. Computed tomography of the chest showed nine fistulas in the right lung and four in the left lung. Because the fistulas were small and located peripherally, we chose thoracoscopic surgery instead of transcatheter pulmonary artery embolization. Intraoperatively, we identified four additional fistulas in the left lung. We resected 15 abnormal vessels and ligated two vessels during thoracoscopic surgery. Postoperatively, her dyspnea decreased and arterial blood oxygenation improved. Thoracoscopic surgery is a good treatment option for multiple small peripheral pulmonary arteriovenous fistulas.

Significance of the Glasgow Prognostic Score as a prognostic indicator for lung cancer surgery.

OBJECTIVES: The Glasgow Prognostic Score (GPS), which is calculated with C-reactive protein (CRP) and albumin (Alb) values, is a prognostic indicator for various types of cancers. However, its role in lung cancer still remains unclear, and its optimal cut-off values are controversial. Here, we evaluated the significance of the GPS and adjusted GPS (a-GPS) using our institution's cut-off values in patients undergoing resection for primary lung cancer. METHODS: We analysed 1043 lung cancer patients who underwent resection between 1998 and 2012. The overall survival (OS) probabilities of the GPS subgroups were estimated using the Kaplan-Meier method and were compared using the log-rank test. The prognostic significance of the GPS and the a-GPS was assessed by the Cox proportional hazards model with clinicopathological variables and inflammation markers, such as the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR). The GPS was calculated based on cut-off values of 1.0 mg/dl for CRP and 3.5 g/dl for Alb, as previously reported. The a-GPS was calculated based on cut-off values 0.3 mg/dl for CRP and 3.9 g/dl for Alb, which are the standard thresholds used by our institution. RESULTS: The GPS and the a-GPS were correlated with preoperative factors, such as age, sex, smoking status, the NLR and the PLR, and oncological factors, including the pathological stage, histological type and level of lymphovascular invasion. The 5-year OS rates were 82, 55 and 55% with GPS 0, 1 and 2 (1 vs 0: P < 0.01; 2 vs 1: P = 0.66), respectively, and 88, 67 and 59% with a-GPS 0, 1 and 2 (1 vs 0: P < 0.01; 2 vs 1: P = 0.04), respectively. Multivariable analysis revealed that the GPS [1 vs 0, hazard ratio (HR): 1.63, 2 vs 0, HR: 1.44] and the a-GPS (1 vs 0, HR: 2.00, 2 vs 0, HR: 2.10) were independent prognostic factors. The a-GPS classification showed a clearer prognostic distribution than the GPS classification. CONCLUSIONS: The GPS is a useful prognostic indicator of the OS in lung cancer surgery. The optimal cut-off values for GPS estimation may need to be re-evaluated.

Virtual Bronchoscopy Using OsiriX.

BACKGROUND: Although the utility of virtual bronchoscopy has been reported, the software for virtual bronchoscopy has not been popular because of the high cost. OsiriX is a reasonably priced software that is available to reconstruct virtual endoscopic images. Herein, we present the ability of OsiriX to enable virtual bronchoscopy. METHODS: Computed tomography of the chest was performed using a 16-row multidetector. Data in 2 mm slices from one lung were obtained from 10 patients with a lung nodule. Virtual bronchoscopic images were established by OsiriX version 5.5 (32-bit). To examine the ability to visualize small bronchi, we tried to visualize the distal bronchus if possible. We selected B and B for the right lung and B and B for the left lung. In addition, to predict whether a pathologic diagnosis can successfully be made by transbronchial lung biopsy, we reconstructed virtual bronchoscopic images toward the lung nodule. RESULTS: Bronchoscopic images were successfully reconstructed for all patients. The third to the seventh bronchi were visualized except in one patient whose right B was occluded by a tumor. In all patients, the virtual bronchoscopic path reached the lung nodule, and 5 lung nodules were successfully diagnosed by transbronchial biopsy. CONCLUSIONS: OsiriX is practicable for virtual bronchoscopy at a low cost.

Outpatient Drainage Therapy with a Thoracic Vent for Traumatic Pneumothorax due to Bull Attack.

Outpatient drainage therapy is generally indicated for spontaneous pneumothoraces. A 63-year-old man, who had been attacked by a bull sustaining injuries on the right side of his chest, was referred to the emergency room with dyspnea. His chest X-ray showed a small pneumothorax. The next day, a chest X-ray demonstrated that his pneumothorax had worsened, although no hemothorax was identified. Outpatient drainage therapy with a thoracic vent was initiated. The air leak stopped on the third day and the thoracic vent was removed on the sixth day. Thoracic vents can be a useful modality for treating traumatic pneumothorax without hemothorax.

Resection of solitary pulmonary lesion is beneficial to patients with a history of malignancy.

BACKGROUND: Solitary pulmonary lesion poses a diagnostic challenge, especially in patients with a history of malignancy. The purpose of this study was to evaluate the characteristics of solitary pulmonary lesions and the outcome of surgical resection. METHODS: We retrospectively analyzed 243 patients with a history of cancer who underwent surgery for new-found solitary pulmonary lesion between January 1998 and December 2007. RESULTS: The diagnosis was primary lung cancer in 92 patients, metastasis in 133, and benign lesions in 18. The 5-year survival rate was 67.9% in all patients, 74.6% in those with primary lung cancer, 62.8% in those with metastasis, and 79.9% in those with benign lesions (p = 0.56). In metastasis patients, history of extrapulmonary recurrence and larger diameter lesion were risk factors for recurrence by multivariate analysis. History of cancers other than colorectal and bone and soft tissue sarcoma and shorter disease-free interval were indicators of poor prognosis. Pathologic stage was the only indicator of prognosis for primary lung cancer, and none of the factors concerning antecedent cancer influenced prognosis. CONCLUSIONS: Surgical resection of solitary pulmonary lesion is essential in patients with a history of cancer because substantial numbers of benign lesions are included. In the case of malignancy, metastasectomy had a life-prolonging effect for selected patients, and prognosis of primary lung cancer was no worse than for the general population if treated appropriately. It is important not to hesitate to take a surgical approach for a diagnosis and to treat with standard therapy for primary lung cancer.