[Preoperative Virtual Reality Simulation Regarding the Appropriate Port Location for Thoracoscopic Surgery for the Mediastinal or Chest Wall Lesions].

In thoracoscopic surgery for mediastinal or chest wall lesions the suitable position of ports( trocars) are required depending on the position of a target lesion in a particular patient. We have therefore developed a virtual reality (VR) simulation system using the specific data of each individual patient. The model data generation system, PASS-GEN, is customized for thoracic surgery. The chest wall and organs around the tumor are extracted from DICOM image data of computed tomography (CT) scan, and three-dimensional (3D) virtual images are constructed. Rehearsal of ports insertion is carried out by locating the scope and the forceps anywhere on the chest wall on PC monitor. The constructed VR images clearly show three dimensional relationships between the target and surrounding structures. This system also simulates circumstances where on the chest wall a thoracoscope and tools should be inserted for the better view and more comfortable manipulation. Particularly in mediastinal or chest wall surgery VR simulation is more practical because those structures would be less transformed during operation.

[Outcomes of FOLFIRINOX as First-Line Treatment for Recurrent or Unresectable Pancreatic Cancer].

We retrospectively analyzed adverse effects(AEs), overall survival(OS), and progression-free survival(PFS)in 15 consecutive patients treated with FOLFIRINOX as the first-line treatment for recurrent or unresectable pancreatic ductal adenocarcinoma( PDAC)between February 2014 and December 2017 in our hospital. Eleven patients were treated for unresectable PDAC with distant metastases(UR-M), and 4 were treated for locally advanced unresectable PDAC(UR-LA). The median age was 56(range: 40-75)years. Nine patients were male, and 6 were female. The performance status was 0 or 1 in all patients. Tumors were located in the pancreas head in 8 cases and in the body-tail in 7 cases. Grade 5 AEs were observed in 1 case in which liver abscess causing sepsis resulted in mortality. The response rate was 20.0%, and the disease control rate was 66.7%. Two patients underwent conversion surgery after FOLFIRINOX treatment. Seven patients received a nab-paclitaxel plus gemcitabine regimen as second-line treatment. The median OS and PFS were 17.0 and 8.4 months, respectively, and the 1-year survival rate was 66.7%. FOLFIRINOX for recurrent and unresectable PDAC showed relatively good tumor control. However, strict attention is required for severe AEs. Conversion surgery might be effective in patients who are good responders even if they have metastatic disease.

A Phase II Study of Partial and Subtotal Thymectomy for Thymoma (JART02).

BACKGROUND: We believe the merit of preservation of a part of the thymus following surgery for thymoma. We evaluated the efficacy of partial or subtotal thymectomy for early-stage thymoma in the prospective study. METHODS: The Japanese Association for Research on the Thymus conducted a multiple institutional study of thymectomy for thymoma localized in the thymus without total thymectomy. Patients without autoimmune disease who had an anterior mediastinal tumor that had been clinically diagnosed as an early-stage thymoma were enrolled in the study. Patients who were positive for anti-acetylcholine receptor antibodies were excluded. RESULTS: Sixty-three patients were enrolled preoperatively; 27 patients were judged as being inappropriate based on the other thymic pathologies or tumor invasion. The remaining 36 cases were diagnosed as early-staged thymoma and analyzed. The mean age of the patients was 61 years. The mean maximal tumor diameter in the resected specimens was 3.6 cm. The most common pathological types of thymoma were AB (n = 10) and B1 (n = 10). The Masaoka stages were classified as stage I (n = 22) and II (n = 14). The mean observation period was 63 months. Two patients died due to respiratory dysfunction, which was not related to thymoma. One hundred percent of the patients remained recurrence-free. CONCLUSIONS: This prospective study suggested the efficacy of partial or subtotal thymectomy for early-stage thymoma in patients without any apparent evidence of autoimmune disease. We can preserve a part of the thymus even following surgery for thymoma to prepare the possible second malignancies or diseases in future.

Single-step enrichment of basophils from human peripheral blood by a novel method using a Percoll density gradient.

We have developed a novel continuous flow-through cell separation method using a Percoll density gradient. This method can continuously separate a large number of cells into five fractions according to their densities. To apply this method to the separation of basophils, Percoll density gradients were modified to improve basophil enrichment. When a set of Percoll density gradients was prepared (1.071, 1.075, 1.080, 1.084, and 1.090 g/mL) the basophils in a healthy volunteer were enriched by an average of 23.1 and 63.5% at Percoll densities of 1.075 (fraction 3) and 1.080 g/mL (fraction 4), respectively. On average, the yield of basophils was 1.66 × 10(5) cells in fraction 3 and 1.61 × 10(5) cells in fraction 4 from 9 mL of peripheral blood. The expression of CD203c (cluster of differentiation 203c) on separated basophils was upregulated by anti-immunoglobulin E stimulation similar to basophils in whole blood. Histamine release induced by calcium ionophore was also observed in the separated basophils. The present method will be useful for basophil enrichment since it preserves their function without using counterflow elutriation and immunological reagents, and this method will be effective as a preparative separation for cell purification by flow cytometry.

Improved procedures and comparative results for video-assisted thoracoscopic extended thymectomy for myasthenia gravis.

INTRODUCTION: We previously introduced video-assisted thoracoscopic ET (VATS-ET) as a therapeutic option for MG with acceptable results. We have conducted further investigations to improve the procedure without deterioration of operative results, including myasthenia gravis (MG) remission rate and palliation rate. Here, we report the details of our current procedure, as well as surgical results and patient outcomes as compared with the original VATS-ET procedure. MATERIAL AND METHODS: From January 2002 to September 2013, we performed a VATS-ET procedure with an anterior chest wall lifting method for 77 patients who had MG with or without a thymoma. During that period, we investigated the appropriate indications and improved the procedure. RESULTS: Our current indication for this procedure is MG with the anti-acetylcholine receptor antibody or sero-negative type, or MG with a thymoma <5 cm in diameter without invasion to adjacent organs. With our procedure, the thymus and surrounding tissue are sufficiently resected using a bilateral thoracoscopic surgical method without neck incision. Remission and palliation rates were found to be equivalent to those obtained with the original VATS-ET procedure. CONCLUSION: VATS-ET is suitable for select patients with MG with or without a thymoma. In addition, our current method has shown to be effective while also offering cosmetic advantages as compared with the original, neck incision needed, VATS-ET method.

Lung metastasis from an ovarian granulosa cell tumor 36 years after the initial diagnosis: report of a case.

This report presents the case of a late relapse of an ovarian granulosa cell tumor (GCT) that metastasized to the lung 36 years after the initial diagnosis. A 72-year-old female demonstrated multiple nodules with extrapleural signs on chest computed tomography. Positron emission tomography with (18)F-fluorodeoxyglucose ([(18)F]FDG-PET) showed that the nodules had no FDG avidity. The nodules, which appeared as polypoid lesions of the visceral pleura on thoracoscopy, were resected and diagnosed as pulmonary metastases from the GCT. This case report indicates that thorough thoracoscopic exploration of the pleural cavity is essential when intrathoracic nodules are seen on postoperative imaging examinations in GCT patients, even when the [(18)F]FDG-PET results are negative.

[Invasive thymoma with extensive growth in the superior vena cava;report of a case].

An anterior mediastinal tumor was incidentally found in a 58-year-old asymptomatic woman on a medical checkup. Computed tomography (CT) demonstrated a large tumor plugging the almost entire lumen of the superior vena cava (SVC), and 3 nodules in the bilateral lungs. The tumor seemed most likely an advanced thymoma or thymic carcinoma extending into the SVC and presenting with lung metastases. The patient underwent a combined resection of the invasive tumor and the SVC under cardiopulmonary bypass (CPB), and lung wedge resection for the nodules. The bilateral brachiocephalic veins were reconstructed with the separate grafts. The invasive tumor and the lung nodules were histologically confirmed as thymoma. Resection and reconstruction of the SVC was successfully performed under CPB for extirpation of an invasive thymoma with extensive intracaval growth. Combination chemotherapy for the relapsing lung metastases finally achieved complete response 41 months after surgery.

Anterior chest wall lifting methods for mediastinal approach-literature review.

Background and Objective: For the purpose of facilitating a wide view and working space during surgery such as a thymectomy procedure, as well as that for treatment of anterior mediastinal lesions, anterior chest wall lifting began to be employed. In this article, previous reports of various kinds of chest wall lifting methods are reviewed. Methods: The present study focused on procedures used for anterior chest wall lifting in a review of related studies primarily available in English. A search of the PubMed database was conducted in 1st March 2016. The first description about lifting method was reported in 1988. Key Comments and Findings: Although objective evaluation regarding the effectiveness of lifting is difficult, in view of a balance among safety, reliability, and minimal invasiveness, surgeons may consider chest wall lifting as an optional method. Conclusions: Anterior chest wall lifting began to be employed for enlarging the working space long before the advent of endoscopic surgery. Some originally developed retractors were used in transcervical thymectomy procedures. After general acceptance of transsternal extended thymectomy for myasthenia gravis, these transcervical approaches remained an important option along with anterior chest wall lifting. Thoracoscopic surgery for the treatment of anterior mediastinal lesions was introduced in the 1990s. Particularly in cases of surgery in the supine position, various creative methods and devices of lifting the sternum body, the anterior part of the rib, or the xiphoid process were reported.

Pulmonary metastasectomy in patients with renal cell carcinoma: a single-institution experience.

BACKGROUND: Pulmonary metastasectomy in patients with renal cell carcinoma (RCC) remains controversial. The purpose of our analysis was to explore the outcome of patients with RCC who underwent pulmonary metastasectomy at our institution. METHODS: We reviewed data on 25 patients who underwent resection of lung metastasis from 1998 to 2008 at our institution. RESULTS: All patients were treated by radical nephrectomy for primary RCC. Progression-free survival (PFS) ranged from 0.3 to 198.8 months (median 7.4 months), and overall survival (OS) ranged from 2.4 to 198.8 months (median 33.9 months). The 5-year PFS rate was 24.9%, and the OS rate was 35.5%. Although differences in the resectability of the metastasectomy and OS were not significant in univariate or multivariate analyses, the relationship between PFS and the radicality of pulmonary metastasectomy was significant in both the univariate and multivariate analyses (P = 0.004, 0.012, respectively). CONCLUSIONS: The results of pulmonary metastasectomy for patients with RCC at our institution indicate that pulmonary metastasectomy should be performed only when the pulmonary metastasis can be completely resected. Additional studies are therefore necessary to evaluate the prognostic factors and to determine the selection criteria for pulmonary metastasectomy in the new era of molecular-targeted agents.

Medical teleconference about thoracic surgery using free Internet software.

Surgical teleconferences using advanced academic networks are becoming common; however, reports regarding Internet teleconferencing using free software packages such as Skype, USTREAM, and Dropbox are very rare. Teleconferences concerning mainly surgical techniques were held five times between Fukuoka University Hospital and other institutions from April to September 2010. These teleconferences used Skype and USTREAM as videophones to establish communication. Both PowerPoint presentations and surgical videos were made. These presentation files were previously sent to all stations via mail, e-mail, or Dropbox, and shared. A slide-show was simultaneously performed following the presenter's cue in each station. All teleconferences were successfully completed, even though there were minor instances of the Skype link being broken for unknown reasons during the telecommunication. Internet surgical teleconferences using ordinary software are therefore considered to be sufficiently feasible. This method will become more convenient and common as the Internet environments advance.

[Recent advancement in the basic and clinical studies in myasthenia gravis].

Myasthenia gravis (MG) is an autoimmune disease characterized by fatigable muscle weakness, and autoantibodies to nicotinic acetylcholine receptor (AchR) have been thought to play the key role in the pathogenesis. The recent great progress in the basic research is identification of a novel autoantibody to muscle-specific kinase (MuSK). This discovery led to elucidation of difference in pathogenesis between AchR antibody (+) and MuSK antibody (+) diseases. The recent progress in the clinical practice for MG is introduction of video-assisted thoracic surgery. Less invasive surgery is expected to improve the outcome of thymectomy. At the same time, several immunosuppressants have been shown to be effective for MG. Further progresses in the basic as well as clinical researches are expected to improve the treatment for MG.

SS-A52 antigen expression in thymic carcinoma accompanied with Sjögren syndrome: A case report.

RATIONALE: The relationship between thymic tumors and Sjögren syndrome (SjS) is unknown, and surgical resection has not been optimized. Especially, thymic carcinoma with autoimmune disease is rare. Analysis of SS-A52, germinal centers, plasma cells, and Foxp3+ Treg in thymic carcinoma has never been reported, and their pathological roles in causing SjS have not been studied. PATIENT CONCERNS: A 78-year-old man presented with sputum production and xerostomia while asleep. Chest computed tomography showed a homogeneous and hypodense mass in the anterosuperior mediastinum. Serum levels of the antinuclear antibody, antibody to SS-A, and antibody to SS-B were positive. DIAGNOSES: Thymic carcinoma (squamous cell carcinoma) and SjS. INTERVENTIONS: Video-assisted thoracoscopic resection of the mediastinal tumor and postoperative radiation therapy was performed. OUTCOMES: The histological diagnosis was thymic squamous cell carcinoma. Histologically, the squamous carcinomatous cells were arranged in nests and cords in the fibrohyaline stroma with capsular invasion. In the stroma, dense lymphoid tissues containing large reactive germinal centers and many plasma cells were also noted. In the involuted thymus, CD20-positive mature lymphocytes infiltrated, and germinal centers were noted. Double immunohistochemical staining revealed that SS-A52 antigen was positive in both the carcinoma component and CD20-positive mature B cells. Postoperatively, the xerostomia persisted, and serum SS-A and SS-B remained positive. No evidence of carcinoma recurrence with chest computed tomography scan was observed at 18-months follow-up. LESSONS: In the surgical treatment of thymic tumors with SjS, extended thymectomy might be worth considering to stop the progressive destruction of the targets of SjS-specific autoantibodies. However, the postoperative symptoms may not dramatically improve because the target organs might have changed irreversibly, and memory B cells might persist. This is the first report that demonstrated the SS-A52 antigen presentation in a thymic tumor to the best of our knowledge.

Efficacy of pleural coverage with polyglycolic acid sheet after bullectomy for postoperative recurrence of spontaneous pneumothorax in young patients: a multi-institutional cohort study.

OBJECTIVE: Various surgical procedures have been performed to decrease the recurrence of primary spontaneous pneumothorax after video-assisted thoracic surgery. This study aimed to examine the efficiency of pleural coverage for the prevention of postoperative recurrence in relatively young patients. METHODS: Between January 2008 and December 2012, a total of 357 cases of 345 patients (age 15-29 years) with primary spontaneous pneumothorax who underwent bullectomy at 13 institutions were enrolled in this multi-institutional retrospective cohort study. A concurrent bilateral operation was counted as two cases. Polyglycolic acid sheets were used in 238 cases, and oxidized regenerated cellulose sheets were used in 37 cases to cover the visceral pleura, with no pleural coverage in 82 cases. The average observation period was 4.2 ± 2.0 years. RESULTS: Postoperative recurrence was observed in 50 cases (14.0%) after video-assisted thoracic surgery. Twenty-six cases (10.9%) in the polyglycolic acid group, eight (21.6%) in the oxidized regenerated cellulose group, and sixteen (19.5%) in the non-coverage group experienced postoperative recurrence. Kaplan-Meier analysis revealed that the rate of freedom from postoperative recurrence in the polyglycolic acid group was significantly higher than that in the non-coverage group. Multivariate analysis showed that age ≥ 20 years and coverage with polyglycolic acid sheets were associated with reduced risk factors for postoperative recurrence. CONCLUSION: Pleural coverage with a polyglycolic acid sheet is suggested to be effective in preventing postoperative recurrence of pneumothorax compared with non-coverage in relatively young patients.

Analysis of pulmonary nodules caused by nontuberculous mycobacteriosis in 101 resected cases: multi-center retrospective study.

BACKGROUND: Solitary pulmonary nodules caused by nontuberculous mycobacteriosis are included as a category of pulmonary nontuberculous mycobacterium disease. Clinical characteristics, treatments and prognosis are not fully known because there are a few related reports. METHODS: This was a multi-center retrospective study of 101 cases diagnosed as solitary nodular type of nontuberculous mycobacteriosis from January 2000 to March 2017 that underwent resection at 9 related facilities belonging to the Thoracic Surgery Study Group of Osaka. RESULTS: The most common pathogen was Mycobacterium avium complex (n=77, 87.5%), followed by Mycobacterium kansasii (n=8, 9.1%). Chest computed tomography results showed subpleural locations that were difficult to distinguish from lung cancer. Fluorodeoxyglucose positron emission tomography/computed tomography was performed in 58 cases and positive results were obtained in 35 (60.3%), with an average maximum standardized uptake value of 3.87. The purpose of resection in most cases was for diagnosis. The surgical procedure was wedge resection in 87, segmentectomy in 3, and lobectomy in 11, while 77 underwent thoracoscopic surgery. Postoperative complications occurred in 7 cases, though no infections caused by nontuberculous mycobacteriosis were noted. The median observation period was 27 months. A worsened condition occurred in 10 (9.9%) with Mycobacterium avium complex, though none had local recurrence. CONCLUSIONS: Solitary pulmonary nodules due to nontuberculous mycobacteriosis is difficult to diagnose based on preoperative examination results or distinguish from lung cancer. Among the present cases, none had local complications or recurrence, even in those that underwent a wedge resection, thus postoperative chemotherapy was not considered necessary if a complete resection was performed. On the other hand, some cases showed reinfection after a long period following resection, thus patients should be informed of that future possibility.

Biological implications of thymectomy for myasthenia gravis.

Myasthenia gravis (MG) is an autoimmune disease mediated by autoantibodies to the striated muscle tissue. It is often treated by thymectomy. We review recent studies to investigate the biological implications of thymectomy. In anti-acetylcholine receptor antibody (anti-AchR Ab)-positive patients without a thymoma, abnormal germinal center formation in the thymus seems to play an essential role in the pathogenesis of MG. Specific differentiation of B cells producing anti-AchR Ab takes place uniquely in the thymus, and thymectomy is thought to assist in terminating the provision of high-affinity anti-AchR antibody-producing cells to peripheral organs. Thymectomy is not indicated for anti-AchR Ab-negative MG patients who are antimuscle specific kinase antibody (anti-MuSK Ab)-positive, although some anti-MuSK Ab-negative patients may benefit from the procedure. A thymoma can be considered as an acquired thymus with insufficient function of negative selection. The resection of a thymoma is thought to terminate the production of self-reactive T cells. Thus, the biological implications of thymectomy for MG have been partially revealed. Nevertheless, additional studies are needed to elucidate the ontogeny of T cells that recognize AchR and the mechanism of the activation of anti-AchR antibodies producing B cells.

Winged scapula following axillary thoracotomy with long thoracic nerve preservation.

Winged scapula is a rare condition caused by injuries to the long thoracic nerve (LTN) and accessory nerves. A 69-year-old man underwent surgery for right lung cancer. Video-assisted thoracic surgery was converted to axillary thoracotomy at the fourth intercostal space. The latissimus dorsi was protected, and the serratus anterior was divided on the side anterior to the LTN. Two months after discharge, he presented with difficulty in elevating his right arm and protrusion of the scapula from his back. Active forward flexion of the right shoulder was limited to 110° and abduction to 130°. He was diagnosed with winged scapula. After 6 months of occupational therapy, the symptoms improved. The LTN may have been overstretched or damaged by the electric scalpel. We recommend an increased awareness of the LTN, and to divide the serratus anterior at a site as far as possible from the LTN to avoid postoperative winged scapula.

Lung Cancer Surgery for Patients on Hemodialysis: A Decade of Experience at Multicenter Institutions.

BACKGROUND: The clinical outcome of patients undergoing hemodialysis (HD) has not yet been clarified in lung cancer surgery. The aims of this study were to assess the clinical features, outcomes, and main cause of death after lung cancer surgery in patients undergoing HD and to evaluate the risk factors for postoperative complications. METHODS: The study identified 39 patients undergoing HD who had lung cancer surgery in 9 institutions under the Thoracic Surgery Study Group of Osaka University in Japan between 2007 and 2016. Study investigators retrospectively analyzed the surgical outcomes of these patients. RESULTS: Most patients were male and were smokers. Diabetes mellitus was the most common cause of primary renal disease. Lobectomy with systemic lymph node dissection was performed in 16 patients, and an extended operation was performed in 6 patients. Most patients had a diagnosis of pathologic stage IA (69.2%) lung cancer. The overall complication and mortality rates were 30.8% and 7.7%, respectively. Pneumonia was the most frequently observed complication. Extended operation was significantly associated with complications (P = .04). The 5-year overall survival rate was 57.9%, and the most common cause of death was not primary lung cancer but was a disease related to HD. CONCLUSIONS: Lung cancer surgery for patients undergoing HD provides favorable long-term outcomes despite higher postoperative mortality and morbidity rates. Because an extended operation is significantly associated with postoperative complications, thoracic surgeons should carefully select the type of resection on the basis of a balance between therapeutic benefit and invasiveness in these patients.

(18)F-FDG PET for the evaluation of thymic epithelial tumors: Correlation with the World Health Organization classification in addition to dual-time-point imaging.

PURPOSE: Our aim was to determine dual-phase (18)F-FDG PET imaging features for various subtypes of thymic epithelial tumors based on the World Health Organization classification. METHODS: Forty-six patients with histologically verified thymic epithelial tumors [23 with low-risk tumors (4 with type A, 16 with AB, and 3 with B1) and 23 with high-risk tumors (7 with B2, 5 with B3, and 11 with thymic carcinoma] were enrolled in this study. All patients were injected with (18)F-FDG.; after 1 h, they underwent scanning; after 3 h, 23 patients underwent an additional scanning. The maximum standard uptake value (SUV(max)) and the retention index (RI%) of the lesions were determined. RESULTS: The early and delayed SUV(max) values in the patients with high-risk tumors [early SUV(max) (mean: 6.0) and delayed SUV(max) (mean: 7.4)] were both significantly larger than those in patients with low-risk tumors [early SUV(max) (mean: 3.2) and delayed SUV(max) (mean: 3.4)] (P < 0.05). Early SUV(max) values of greater than 7.1 differentiated thymic carcinomas from other types of tumors. For the histological differentiation between high-risk tumors and low-risk tumors, an early SUV(max) value of 4.5 was used as the cutoff. The sensitivity, specificity, and accuracy were 78.3, 91.3, and 84.8%, respectively. CONCLUSION: High SUV values (early SUV > 4.5) suggest the presence of high-risk tumors. A very high SUV value (early SUV > 7.1) is useful for the differentiation of thymic carcinomas from other types of tumors. The delayed SUV values were higher than the early SUV values in all types of tumors.

Eosinophilic Pneumonia Putatively Induced by Vancomycin: A Case Report.

BACKGROUND Herein, we describe a case of eosinophilic pneumonia that was likely to have been induced by vancomycin. CASE REPORT A 65-year-old man on maintenance hemodialysis presented with chest pain and dyspnea. He subsequently developed methicillin-resistant Staphylococcus aureus-positive acute pleural empyema in an evacuated right-sided pneumothorax. Surgical thoracoscopic curettage was ultimately performed, but dyspnea recurred postoperatively. Computed tomography depicted widespread reticular shadowing of the left lung, and peripheral eosinophilia was detected. The proportion of eosinophils found in bronchoalveolar lavage fluid was also remarkable (43%). All symptoms and the results of laboratory tests immediately improved after the discontinuation of vancomycin and initiation of prednisolone therapy. CONCLUSIONS We attribute this case of eosinophilic pneumonia to vancomycin, because all other candidate causes were ruled out, and only vancomycin fulfilled the criteria of both drug-induced eosinophilic pneumonia and drug-induced lung injury. If confirmed, this constitutes the first reported case of vancomycin-induced eosinophilic pneumonia.