In situ follicular neoplasm discovered as an enlarging pulmonary nodule complicated by pulmonary aspergillosis.

In situ follicular B cell neoplasm, previously known as follicular lymphoma in situ, is a neoplastic proliferation of follicular lymphoma-like B cells confined to the germinal centers. Herein, we report a case of a woman in her 70s who initially presented with several enlarged abdominal lymph nodes. Seven months later during follow-up, a solitary pulmonary nodule was detected. As it was close to the hilum, lobectomy was performed. The intraoperative frozen section showed fibrosis and a collection of lymphocytes and macrophages. Therefore, the lymph nodes were sampled. Station 4 and 10 lymph nodes exhibited similar tumor cells and were immunohistochemically positive for CD10 and BCL2. Thus, the patient was diagnosed with in situ follicular neoplasm and is currently under observation. In situ follicular neoplasm is typically a slowly progressive neoplasm; however, it can present as a rapidly enlarging pulmonary nodule complicated by pulmonary aspergillosis.

Prognostic evaluation of preoperative serum tumor marker-negative cases in non-small cell lung cancer: A retrospective study.

BACKGROUND: The role of various serum tumor markers (TMs) has been reported in non-small cell lung cancer (NSCLC). However, the prognosis of patients with multiple TM-negative NSCLC remain unclear. AIMS: This study aimed to describe the characteristics and outcomes of patients with NSCLC undergoing surgery and to investigate their prognostic association with preoperative serum TM-negative cases. METHODS AND RESULTS: We retrospectively evaluated 442 patients who underwent complete resection of stage I NSCLC between January 2004 and December 2019. These 442 patients were classified into a group whose preoperative serum levels of carcinoembryonic antigen (CEA), cytokeratin-19 fragment (CYFRA21-1), carbohydrate antigen 19-9 (CA19-9), and squamous cell carcinoma antigen (SCC Ag) were all negative (TM-negative group; n = 249, 56%) and a group with at least one positive marker (TM-positive group; n = 193, 44%). Among all patients, the TM-negative group showed higher 5-year recurrence-free survival (RFS) (92.6% vs. 79.1%; p < .01), and overall survival (OS) rates (86.3% vs. 68.6%; p < .01). After propensity score matching, patients in the TM-negative group still exhibited good 5-year RFS (92.1% vs. 81.4%; p = .01) and OS rates (87.6% vs. 72.6%; p < .01). CONCLUSION: Our study suggests that NSCLC patients who are preoperatively negative for all serum TMs, such as CEA, CYFRA21-1, CA19-9, and SCC Ag, represent a subgroup with a particularly good prognosis.

Rapidly growing proliferative pulmonary chondroma: A case report.

INTRODUCTION: Pulmonary chondroma, a component of Carney's triad, is commonly unilateral and multiple, and progresses slowly. Herein, we report a case of a chondrogenic tumour that grew and proliferated during follow-up. PRESENTATION OF CASE: A female patient in her 20s presenting with a cough was found to have a 1.4-cm nodule in the left lung on computed tomography (CT). After 18 months' follow-up, CT revealed that the original nodule had increased to 2.2 cm, and a new 1.3-cm nodule had appeared. She was then referred to our hospital and underwent a robot-assisted lower lobectomy of the left lung. The tumour was diagnosed as a chondrogenic tumour. She had no problems after the surgery or during follow-up; other signs of the Carney's triad were ruled out. Twenty-six months postoperatively, there was no evidence of recurrence. DISCUSSION: One report suggests that the growth of pulmonary chondroma is slow, but the present case showed an increase in both the size and number of tumours within 2 years without any symptoms. The chondroma did not recur after the surgery, though her pulmonary tumours had grown and proliferated rapidly. Furthermore, it has been reported that an average of 8.4 years is needed for another sign of Carney's triad to appear; therefore, careful follow-up should be continued. CONCLUSION: This report suggests that pulmonary chondroma can grow and proliferate rapidly and asymptomatically, and can be controlled by complete resection.

Lepidic growth component as a favorable prognostic factor in non-small cell lung cancer of ≤3 cm.

BACKGROUND: Many non-small cell lung cancer (NSCLC) tumors present complex histology with various components. The effects of the lepidic growth component (LGC) on the prognosis of NSCLC have not been investigated. Here, we investigated whether an LGC is a relevant prognostic factor for NSCLC. METHODS: This study retrospectively investigated the clinicopathologic characteristics of 379 patients with NSCLC ≤3 cm who underwent complete surgical resection between 2004 and 2016 at the University of Yamanashi Hospital. The histologic subtypes were classified into NSCLC with or without an LGC. We evaluated the effect of an LGC on the clinicopathologic features and 5-year overall survival of patients with NSCLC. RESULTS: On final pathology, 214 (56%) of 379 patients had an LGC, and 165 (44%) did not. Sex, smoking history, ground-glass opacity component, pathologic invasive size, lymph node metastasis, pleural invasion, vessel invasion, pathologic stage, and histologic type were significantly different between the groups. Multivariate analysis of 5-year overall survival, identified age (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.035-1.105; p < 0.001), pathologic invasive size (HR, 1.548; 95% CI, 1.088-2.202; p = 0.015) and LGC (HR, 2.11; 95% CI, 1.099-4.051; p = 0.025) as independent prognostic factors. When the pathologic invasive size was matched, the 5-year overall survival of the LGC and non-LGC groups was 93% and 77%, respectively (p = 0.006). CONCLUSIONS: LGC is a significantly favorable prognostic factor for NSCLC with a pathologic invasive size of ≤3 cm.

Liver herniation mimicking a thoracic tumor with restoration of the liver surface structure on closure of the hernia orifice under thoracoscopic surgery.

Non-congenital, non-traumatic spontaneous diaphragmatic liver hernia in adults is extremely rare and sometimes misdiagnosed as a thoracic tumor. Almost all previous reports with a definitive diagnosis reported preservation; thus, differential diagnosis is extremely important for planning optimal management of such clinical conditions. An abnormal shadow in the right lower lung field was detected on chest radiography in a 61-year-old woman. Further imaging study revealed a 33-mm diameter mass adjacent to the right diaphragm. Thoracoscopic surgery was performed as diagnostic treatment. We found a pale hemispherical herniated liver on the central tendon of the diaphragm. After repositioning the herniated liver, the orifice was closed with a non-absorbable suture, and the surface of the liver returned to being a perfectly smooth surface. With this result, we believe that repair of diaphragmatic liver hernia through a minimally invasive procedure has great benefits for patients.

Ectopic intrapulmonary follicular adenoma diagnosed by surgical resection.

Ectopic intrapulmonary thyroid tissue is extremely rare and considerably difficult to diagnose without surgery. Ectopic thyroid tissue, described as a mediastinal tumor, and intrapulmonary lesions are infrequent. An abnormal shadow was detected upon chest X-ray in a 60-year old woman with a history of benign thyroid goiter. A computed tomography scan revealed a solitary nodule measuring 27 mm in diameter in the left lower lobe, the diameter of which had increased by 5 mm since initial observation eight years ago. A thoracoscopic wedge resection was performed and the lesion was determined to be a non-invasive, soft-tissue tumor. It was pathologically diagnosed as an ectopic thyroid follicular adenoma. The course of the tumor was uneventful. A diagnosis of ectopic intrapulmonary thyroid should be made cautiously and only after ruling out metastasis of a follicular adenoma or thyroid carcinoma. This diagnosis of ectopic thyroid tissue was made possible by the surgical approach.

Video-assisted thoracoscopic right upper lobectomy in a patient with a displaced bronchus and vascular abnormalities.

Bronchial abnormalities are rare, and they are infrequently associated with pulmonary vascular abnormalities. It is important to identify such abnormal anatomical structures before lobectomy of the lung under thoracoscopy. There have been only three reports on video-assisted thoracoscopic lobectomy in patients with anomalous bronchi and vascular abnormalities to date. Here, we present a report of video-assisted thoracoscopic right upper lobectomy performed in a patient with bronchial and vascular abnormalities. Both preoperative imaging and intraoperative findings revealed a displaced anomalous B2 bronchus arising from the bronchus intermedius, as well as abnormal distribution of the aberrant vein V2 draining into vein V6 . It is critical to understand the precise anatomical structures preoperatively to perform video-assisted thoracoscopic pulmonary lobectomy safely.

Thoracoscopic right middle lobectomy for Mycobacterium abscessus in a young patient suspected of having congenital immunodeficiency.

Mycobacterium abscessus (M. abscessus) infection is resistant to multi-antibacterial treatment, and surgical resection is often recommended. We report a case of M. abscessus infection in a young patient suspected of having a GATA2 mutation. A 19-year-old woman with a medical history of severe sinusitis and a family history of non-tuberculous mycobacteriosis presented at our hospital. M. abscessus was confirmed by sputum culture. The patient received multidrug therapy, including clarithromycin. CT scan demonstrated bronchodilation and capacity decrease due to non-obstructive atelectasis in the middle lobe. We performed thoracoscopic resection without complications. Congenital immunodeficiency was suspected given the patient's past medical and family history. The result of lymphocyte subset analysis revealed a GATA2 mutation, but no genetic mutation was detected by a next-generation sequencer. The patient followed a good clinical course. This paper reports the successful treatment of an M. abscessus infection and the importance of checking the genetic background of young patients.

Detecting tumor-infiltrating Forkhead box P3-positive T cells in the prognosis of lung adenocarcinoma: Possible role of clustering tumor interleukin-12 subunit alpha and transforming growth factor beta 1 expression.

BACKGROUND: While regulatory T cells (Tregs) are a poor prognostic factor for lung cancer, they may be detected as Forkhead box P3+ (FOXP3+) and cluster of differentiation (-CD) 4+ T cells by classifying FOXP3+CD4+ T cells into different subpopulations of CD4 cells. OBJECTIVES: To classify clusters of tumor-infiltrating Tregs in lung adenocarcinoma based on the mRNA expression levels of interleukin-12 subunit alpha (IL12A) and transforming growth factor beta 1 (TGFB1) in tumor specimens. MATERIAL AND METHODS: Seventy-nine patients with lung adenocarcinoma were evaluated in this study. Clinical data were obtained from the patients' medical records, while tumor tissue samples were preserved as formalin-fixed paraffin-embedded (FFPE) tissue specimens. Immunohistochemical staining for CD4, CD8 and FOXP3 was performed and stained cell counts were obtained under 5 high-power fields. cDNA was synthesized from total RNA extracted from FFPE tissue specimens and amplified with Taqman probes for FOXP3, IL12A, TGFB1, and the glyceraldehyde-3-phosphate dehydrogenase gene. RESULTS: Two clusters were identified: IL12AlowTGFB1low (Cluster 1: n = 44) and IL12AhighTGFB1high (Cluster 2: n = 39). Although no significant difference in the FOXP3+ cell/CD4+ cell ratio was observed between the 2 clusters (p = 0.921), the high FOXP3+/CD4+ cell ratio group showed a significantly poorer relapse-free survival rate than the low FOXP3+/CD4+ cell ratio group in Cluster 1 (p = 0.031). CONCLUSIONS: Although the results revealed no direct association between Tregs and prognosis according to each subtype, these results suggest that if a lung cancer specimen contains low levels of IL12A and TGFB1, the FOXP3+/CD4+ cell ratio is useful for predicting the prognosis of lung cancer.

Case of Rapid Formation of Intraoperative Pulmonary Pneumatocele After Lobectomy.

Pulmonary pneumatocele that forms immediately after pulmonary resection is extremely rare. This report describes a case of pneumatocele that formed rapidly in the left lower lobe immediately after left upper lobectomy in a patient with lung cancer and emphysema. Massive and persistent air leakage through a chest tube was noted immediately after chest closure. Therefore, the chest was reopened, and the cyst wall was incised. The air leakage point was cauterized and covered with a polyglycolic acid sheet and fibrin glue. Herein, we report a rare case of newly developed pneumatocele immediately after lobectomy.

Ciliated muconodular papillary tumor of the lung presenting with polymyalgia rheumatica-like symptoms: a case report.

Ciliated muconodular papillary tumors (CMPTs) of the lung have been recently characterized as low-grade malignant tumors and may be indistinguishable from adenocarcinoma in situ (AIS) because they are both abundant in mucous and spread along the alveolar walls. Herein, we report a case of CMPT with polymyalgia rheumatica (PMR)-like symptoms, which resolved after resection. After the surgery, antinuclear antibody tests were performed, but no abnormalities were noted. Furthermore, the lung tumor could not be distinguished from AIS, as revealed by a pathological examination. This case demonstrates two key points: the paraneoplastic symptoms of CMPT can indicate PMR, and it is difficult to diagnose peripheral lung tumors as CMPT unless there is a completely resected specimen available. The possibility exists that an increased number of older patients will be diagnosed with CMPT because of the increasing frequency of computed tomography performed in this population. Therefore, it is important for clinicians to obtain completely resected specimens to ensure accurate diagnosis and management of CMPT.

[Thyroid Transcription Factor-1 is Useful for Identifying Primary Tumors].

A 67-year-old man had underwent liver resection 3 years previously. The pathological diagnosis was intrahepatic cholangiocarcinoma. However, a follow-up computed tomography(CT) scan revealed gradual enlargement of the pulmonary nodule left S1+2 and he was performed surgery. Because the metastasis of intrahepatic cholangiocarcinoma was demonstrated for lymph node (LN) #3 by intraoperative rapid pathology, only the left upper lobe was resected. Finally, the postoperative pathological diagnosis by thyroid transcription factor-1 (TTF-1) staining was primary lung cancer. Liver lesion was also diagnosed as liver metastases of the lung cancer by TTF-1 staining.

Spontaneous regression of a carcinoid tumor that required resection owing to its reappearance and subsequent enlargement after 2 years: a case report.

We present a rare case of spontaneous regression in a typical lung carcinoid. A 20-year-old woman with an abnormal shadow on a chest radiograph was admitted to our hospital. Computed tomography revealed a smooth nodule in the left S1 + 2 segment. At the 6-month follow-up, the nodule had regressed without treatment. At the 2-year follow-up, the tumor reappeared in the same place as before. We performed left upper lobectomy via 4-port thoracoscopic surgery. A pathological examination revealed a typical carcinoid. Lung carcinoids can spontaneously regress; long-term follow-up is important for timely detection of tumor reappearance.

Mesothelial cyst derived from chest wall pleura growing after thoracic surgery: a case report.

BACKGROUND: Intrathoracic mesothelial cysts almost always arise in the mediastinum, and extramediastinal mesothelial cysts are extremely rare. Here we describe a case of mesothelial cyst derived from the chest wall pleura growing after thoracic surgery. CASE PRESENTATION: A 63-year-old Japanese woman was referred to our department. She had undergone total hysterectomy for cervical carcinoma and two lung wedge resections for metastatic lung cancer on the upper and lower lobes of her right lung and lower lobe of her left lung. After the thoracic surgery, an intrathoracic chest wall mass was found, which grew gradually. Computed tomography demonstrated a 2.0 × 1.8 cm low-density mass without contrast effect. Magnetic resonance imaging demonstrated a low-intensity mass in T1-weighted imaging and a high-intensity mass in T2-weighted imaging. Thoracoscopic excision of the mass was performed. The cystic mass was thought to be derived from her chest wall and was pathologically diagnosed as mesothelial cyst. Five years after the surgery, she has no evidence of recurrence of the cyst or cervical carcinoma. CONCLUSIONS: The genesis of extramediastinal mesothelial cysts may be related to inflammation. From this perspective, extramediastinal mesothelial cysts may have different characteristics from pericardial cysts and resemble peritoneal inclusion cysts. Although, extramediastinal mesothelial cysts are not established, their characteristics resemble peritoneal inclusion cysts; therefore, such interesting intrathoracic cysts should be carefully resected considering the risk.

Mediastinal mature teratoma perforating the right lung that was successfully resected with complete thoracoscopic surgery: A case report.

INTRODUCTION: A perforating mediastinal mature teratoma can cause severe inflammation and adhesion; therefore, open surgery is usually performed. Asymptomatic perforation involving a teratoma is very rare. Complete thoracoscopic surgery is often difficult because of inflammation associated with perforation and the frequently large size of a mediastinal mature teratoma. We report a rare case of an asymptomatic perforating mediastinal mature teratoma successfully treated with complete thoracoscopic surgery. PRESENTATION OF CASE: The patient was a 15-year-old girl with an abnormal shadow at the mediastinum seen on chest radiography at a health examination performed at her junior high school; an asymptomatic mediastinal tumour was suspected. Enhanced computed tomography revealed a 6.5 × 3.5-cm tumour associated with the right upper lobe. Thoracoscopic surgery was performed using 4 access ports. Although there were inflammatory changes, hemi-thymectomy and right upper lobectomy were achieved with complete thoracoscopic surgery. The tumour included the skin, sebaceous glands, hair, and pancreatic tissue and was diagnosed as a mature teratoma perforating the right upper lobe. DISCUSSION: There might be limited inflammatory changes if the patient has few or no symptoms, as in our case. In such cases, the tumour may be excised even if it is large. CONCLUSION: We report a rare case of an asymptomatic perforating mediastinal mature teratoma that was successfully treated with complete thoracoscopic surgery. Although infection, inflammatory adhesion, large tumour size, and the need for radical cure are concerns, complete thoracoscopic surgery might be helpful. In cases of few or no symptoms, thoracoscopic surgery is worth challenging.

Intractable pneumothorax complicated with interstitial pneumonitis treated with the Tachosuture technique: A case report.

It has been proven that the Tachosuture technique is effective for preventing prolonged air leaks caused by pulmonary resection. We successfully used the Tachosuture technique to treat intractable pneumothorax with interstitial pneumonia. This technique avoids pulmonary resection and contributes to acute exacerbations of interstitial pneumonia.

Remitting seronegative symmetrical synovitis with pitting edema syndrome complicated with primary lung cancer.

Remitting seronegative symmetrical synovitis with pitting edema syndrome has been reported to be associated with malignant tumors. However, few cases occurring with lung cancer have been reported. We here report a case of remitting seronegative symmetrical synovitis with pitting edema syndrome complicated with lung cancer. A 77-year-old man presented with poly arthritis (both shoulders, knees, and hands), swelling of the hands, and an elevated C-reactive protein level. As the patient's rheumatoid factor was negative, he was diagnosed with remitting seronegative symmetrical synovitis with pitting edema syndrome. At the same time, computed tomography revealed a nodule suspicious of lung carcinoma in the right lower lobe. Right lower lobe lobectomy was performed, and the nodule was diagnosed as adenocarcinoma. Pathologically, pleural invasion and visceral pleural dissemination were detected, and the tumor was diagnosed as a primary lung carcinoma, p-T2aN0M1a, stage IV. During the preoperative interval, the remitting seronegative symmetrical synovitis with pitting edema syndrome had been successfully treated with prednisolone 20 mg/day, which was later reduced to 6 mg/day. Eighteen months after surgery, the patient's carcinoembryonic antigen levels increased, and the same symptoms recurred, this time more severely. We performed cranial magnetic resonance imaging and whole body positron emission tomography, but we did not detect any cancer recurrence. To treat the recurred remitting seronegative symmetrical synovitis with pitting edema syndrome, the patient has required not only prednisolone, but also azathioprine; however, the symptoms have not been controlled effectively. In our case, matrix metalloproteinase-3 levels were elevated, as shown in the tumor cells by immunohistochemistry. If higher matrix metalloproteinase-3 levels cause the symptoms, in our case, then remitting seronegative symmetrical synovitis syndrome might be considered a paraneoplastic syndrome. However, we could not conclusively determine if the subsequent reduction in matrix metalloproteinase-3 levels was the result of the surgery or the prednisolone treatment. Furthermore, based on the patient's progress following surgery, it is still not clear if the remitting seronegative symmetrical synovitis with pitting edema syndrome complicated with primary lung cancer in this case may be a paraneoplastic syndrome.