Significance of Body Mass Index for Postoperative Outcomes after Lung Cancer Surgery in Elderly Patients.

BACKGROUND: Although the frequency of elderly patients undergoing surgery for lung cancer has been increasing, indications for surgery in elderly patients are still controversial. Low body mass index is a significant predictor of poor prognosis in elderly patients with various medical conditions. Then, we examined the long-term outcome of elderly patients who had undergone thoracic surgery for lung cancer, focusing especially on body mass index. PATIENTS AND METHODS: Between January 2004 and March 2011, 1673 patients with lung cancer underwent surgical resection at our institution. Among these patients, we retrospectively examined 158 patients aged 80 years or older. RESULTS: Perioperative morbidity and mortality rates were 41.8 and 1.3%, respectively. Among 149 patients who were completely followed up, 80 patients (53.7%) died. The overall postoperative survival rates at 3 and 5 years were 66.9 and 49.9%, respectively. Univariate analysis demonstrated that sex (female), smoking index (pack-years <20), histology (non-squamous cell carcinoma), pathological stage (stage I) and BMI (within normal BMI) were statistically significant factors associated with better outcome. Multivariate analysis revealed that patients with a low (<18.5 kg/m2) or high (≥25 kg/m2) body mass index had a significantly and poorer prognosis than patients with a normal body mass index. CONCLUSION: Body mass index is a more useful prognostic factor than other clinical factors including pathological stage in elderly patients. Because elderly patients with low and high body mass index have a significant poor prognosis, surgeons and pulmonologist should take this into account when consider surgical indication for such elderly patients.

[Organizing Pneumonia with High Radiotracer Concentration on Fluorodeoxyglucose-positron Emission Tomography, Mimicking Pleural Dissemination of Lung Cancer;Report of a Case].

A 68-year-old man was referred to our hospital because of an abnormal shadow in the chest roentgenogram. Chest computed tomography (CT) showed the nodule in the right upper lobe (S3), 17 mm in size. One month later, fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT scanning revealed positive reaction in the right upper lobe lesion and new lesion close to another lobe. In addition, interloblar small nodules were detected, 5 mm and 7 mm in size. A transbronchial brush cytology by bronchoscopy was performed, and the microscopic findings demonstrated the presence of atypical cells, suspected adenocarcinoma. The video-assisted thoracoscopic surgery was performed to establish a diagnosis and a treatment. Histopathological examination showed no malignancy and organizing pneumonia with inflammation. In case of the PET-positive solitary nodule increasing in size, organizing pneumonia should be included in the differential diagnosis.

[Interlobar neurinoma with a cystic formation derived from the vagal pulmonary branches].

A 60-year-old woman was referred to our hospital because of an abnormal shadow in the chest roentgenogram. Chest computed tomography (CT) showed the mass with heterogeneous low attenuation in the right lower lobe (S6), 40 mm in size. Fluorodeoxyglucose-positron emission tomography (FDGPET)/CT scanning revealed slight positive reaction in the right lower lobe lesion. The video-assisted thoracoscopic surgery (VATS) was performed to establish diagnosis and treat. Intraoperative finding showed the tumor was located between the left upper lobe and the left lower lobe, and the inflow of the vagal pulmonary branches. Histopathological examination showed no malignancy and neurinoma with a cystic formation derived from the vagus nerve.

Solitary Splenic Metastasis of Lung Cancer Presenting as Benign Cystic Disease.

Solitary splenic metastasis from primary lung cancer is extremely rare. Here, we demonstrated a solitary splenic metastasis of primary lung cancer that was difficult to distinguish from benign cystic disease. A 69-year-old-female was diagnosed as middle lobe lung cancer. Although preoperative abdominal computed tomography (CT) demonstrated a low-density splenic nodule, fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed no fluorodeoxyglucose uptake in the splenic nodule. Therefore, the nodule was diagnosed as benign cystic disease and middle lobe lobectomy was performed. Postoperative pathologic examination demonstrated papillary-predominant adenocarcinoma with mucin, and the tumor was diagnosed as primary lung cancer. However, the splenic nodule continued to increase postoperatively. Splenectomy was undergone 30 months after the pulmonary resection and the splenic tumor was diagnosed as the splenic metastasis of lung cancer. In the 24 months since the splenectomy, no recurrence has been observed in the absence of treatment. Splenectomy was an effective treatment for solitary splenic metastasis of lung cancer in this case. FDG uptake in the splenic tumor was not evident due to marked mucus production.

Delayed bronchial perforation after bulla cauterization with soft coagulation system.

BACKGROUND: Soft coagulation is widely used for hemostasis because of its significant advantage in inducing tissue coagulation and denaturation without carbonization. However, a few cases of airway damage have been reported at the site, where soft coagulation was directly applied. CASE PRESENTATION: We encountered an unusual case of delayed perforation of the intermediate bronchial trunk observed on 24 days after cauterization of the right S6 bulla adjacent to the bronchus. Chest computed tomography revealed a large fistula between the intermediate bronchial trunk and the cauterized bulla in the right S6. Bronchoscopy showed a large fistula at the membranous portion of the intermediate bronchial trunk. We presumed that the bronchial perforation resulted from thermal damage to the intermediate bronchial trunk during bulla cauterization and the bronchial perforation induced infection in the bulla. Resection of the infectious bulla and the intermediate bronchial trunk, followed by end-to-end bronchial anastomosis and a pedicled intercostal muscle flap coverage, was performed. CONCLUSIONS: The severe airway damage resulting in perforation developed even without direct contact between the electrode tip and the bronchial wall, provoking the need for special attention to the duration of cauterization and location, where it is used.

Case report of thoracoscopic resection for broncholithiasis with severe obstructive pneumonia.

Broncholithiasis is a rare disease characterized by bronchial erosion or distortion due to hilar or parenchymatous calcification. When a broncholith has no mobility and there is a risk of major bleeding if removal is attempted, surgical intervention is required. Most operations for broncholithiasis are performed via a thoracotomy, and bronchial lithotripsy under complete video-assisted thoracoscopic surgery has been reported only rarely. We have experienced a case of broncholithiasis with severe obstructive pneumonia that was treated successfully by video-assisted thoracoscopic surgery. Thoracoscopic surgery is an effective treatment for broncholithiasis because it is minimally invasive and aids smooth recovery after surgery. When the adhesion between the pulmonary artery and the bronchus is highly advanced, it is advocated to cut them together using an endostapler.

Contralateral tension pneumothorax during video-assisted thoracic surgery for lung cancer in a patient with obesity and rib fractures: a case report and review of the literature.

BACKGROUND: Intraoperative contralateral pneumothorax during one-lung ventilation is a rare but life-threatening complication. Although the exact incidence is unknown, only 14 cases with this complication have been reported until now. CASE PRESENTATION: A 67-year-old Japanese man with a weight of 80 kg, height of 162.2 cm, and body mass index of 30.4 kg/m2 underwent three-port video-assisted thoracic surgery for lung cancer with one-lung ventilation. He had suffered from traumatic right rib fractures 6 weeks before the referral. Fifteen minutes before the end of the surgery, the systolic blood pressure suddenly dropped to about 50 mmHg, which was immediately recovered by intravenous injection of phenylephrine. This episode occurred during chest closure after the completion of the left upper lobectomy, and one-lung ventilation was soon switched to two-lung ventilation. Contralateral tension pneumothorax was noted by the postoperative chest x-ray. As the patient was complicated with obesity and a past history of rib fractures, increased airway pressure during one-lung ventilation related to obesity together with the persistent compression of the visceral pleura by the fractured ends of the ribs was considered to be the factors responsible for this critical complication. CONCLUSIONS: Patient backgrounds such as obesity and past history of rib fractures should be noted carefully as risk factors for intraoperative contralateral pneumothorax during one-lung ventilation. We present the clinical course and discuss the mechanism of development of this potentially life-threatening complication in the present case with a review of the literature.

Pulmonary lymphangiectasis presenting as solitary pulmonary coin lesion.

Pulmonary lymphangiectasis is a rare anomaly of infancy characterized by dilatation of pulmonary lymphatic vessels. It is considered to occur exclusively in young children and neonates, and pulmonary lymphangiectasis in asymptomatic adults is rare. Moreover, because chest radiography usually demonstrated the generalized congestive pattern of increased pulmonary vascularity or a reticulonodular pattern, it is extremely unusual for pulmonary lymphangiectasis to be demonstrated as a solitary nodular lesion. There were only two case reports of lymphangiectasis that developed as a nodular shadow in asymptomatic adults in English and Japanese literature. Here, we describe two cases of pulmonary lymphangiectasis that were demonstrated as solitary coin lesions in asymptomatic adults without any extrapulmonary manifestations. An 84-year-old male and a 48-year-old male were found to have a gradually increasing round pulmonary nodule. Chest computed tomography (CT) demonstrated a smooth round nodule on the lung surface, and video-assisted thoracoscopic wedge resection was performed. The nodule was a thin-walled cyst containing yellowish liquid. Histological examination of the resected lung demonstrated lymphangiectasis in the subpleural and interlobular connective tissue and no abnormal cell proliferation. Therefore, we considered that the pulmonary nodule had been formed as a result of local fluid collection in pulmonary lymphangiectasis.

Nodule around the staple line after pulmonary resection: benign granuloma or cancer recurrence?

PURPOSE: When a mass develops around the staple line after lung cancer surgery, differential diagnosis between lung cancer recurrence and benign granuloma can be clinically problematic. Therefore, we investigated the clinical characteristics of benign granuloma and cancer recurrence around the staple line to determine clinical factors that can distinguish staple line granuloma and cancer recurrence. METHODS: We retrospectively investigated the clinical records of 25 patients who developed a nodule around the staple line after pulmonary resection for lung cancer and conducted a comparative study of staple line granuloma and cancer recurrence. RESULTS: Among 25 patients, the nodule was diagnosed as benign granuloma in 9, recurrence of primary lung cancer in 8, and recurrence of metastatic lung cancer in 8. Among these three groups, there were no significant differences in age, maximum standardized uptake value of fluoro-deoxyglucose, laboratory data, or radiological findings. However, in comparison with the cancer recurrence cases, the proportion of patients who had undergone segmentectomy as initial surgery was significantly higher in the granuloma group. Moreover, in five patients in the granuloma group, mycobacterium was detected. CONCLUSION: It seemed difficult to differentiate between cancer recurrence and granuloma on the basis of radiological examination and laboratory findings. However, if a mass shadow around the staple line appeared after segmentectomy, the mass is likely to be a granuloma. Mycobacterial infection may be an important factor for development of granuloma on the staple line.

Preoperative Smoking Cessation Period Is Not Related to Postoperative Respiratory Complications in Patients Undergoing Lung Cancer Surgery.

PURPOSE: Smoking is reported to be a risk factor for postoperative complications. However, there is no consensus regarding the length of time for which patients need to give up smoking. Therefore, we examined the relationship between preoperative smoking status and postoperative complications in patients who underwent lobectomy for treatment of lung cancer. METHODS: Between January 2009 and December 2014, 1380 patients underwent lobectomy for lung cancer at our institution. After excluding patients who had undergone induction therapy, 1248 patients were enrolled in this study. We examined the relationship between postoperative complications and preoperative smoking habitation. RESULTS: Among the enrolled patients, 1210 (97%) underwent video-assisted thoracoscopic lobectomy and 38 (3%) underwent lobectomy via open thoracotomy. The incidence of postoperative complications was higher in smokers than in nonsmokers, and the frequency of respiratory-related complications increased along with the number of pack-years. However, there was no relationship between the length of the preoperative smoking cessation period and the frequency of postoperative complications. CONCLUSION: The risk of postoperative complications does not increase even if smoking is continued within 2 weeks before surgery. It seems unnecessary to delay the timing of surgery to allow patients to cease smoking, especially those scheduled for thoracoscopic surgery.

Mycobacterial granuloma on the staple line after pulmonary resection.

Objective It has been reported previously that granulomas can occur around nonabsorbable sutures, but that granuloma formation around the staple line is very rare. However, the increased use of thoracoscopic surgery is creating more opportunities to use automatic mechanical suturing equipment for pulmonary surgery, and it is expected that the incidence of granuloma around the staple line will increase. Methods We retrospectively investigated the clinical records of 6 patients who developed nontuberculous mycobacterial granuloma on the staple line after pulmonary resection. We investigated their clinical characteristics and compared them with data in 16 cases of cancer recurrence. Results Fluorodeoxyglucose uptake was detected in all 6 patients. Laboratory data including white blood cell counts and C-reactive protein levels were within normal ranges in all patients. There was no evident tendency in terms of age, sex, maximal standardized uptake value, or radiological findings. However, compared to cancer recurrence, mycobacterial granuloma around the staple line appeared after a longer period of time, and the proportion of patients who had a segmentectomy as the initial surgery was significantly higher. Conclusion When growing shadows are observed near the staple line, it is difficult to differentiate between cancer recurrence and nontuberculous mycobacterial granuloma from computed tomography and laboratory findings. However, if a mass shadow around the staple line appears 2, 3, or more years after segmentectomy, it could be considered likely to be a granuloma. "Post-segmentectomy" and "late occurrence" are important attributes for distinguishing staple line granuloma from cancer recurrence.

Mediastinal parathyroid cyst resected via a cervical incision using video-mediastinoscopy.

Parathyroid cysts are rare, benign, cystic lesions usually located in the neck region, and those located in the mediastinum are extremely unusual. Traditionally, thoracotomy or sternotomy has been used to resect mediastinal parathyroid cysts, and recently, video-assisted thoracoscopic surgery has also been employed. Here, we describe a case of non-functional mediastinal parathyroid cyst that was successfully resected via a cervical incision using video-mediastinoscopy.

Video-assisted thoracoscopic surgery for lung cancer after induction therapy.

Background Although thoracoscopic surgery is widely performed for early-stage lung cancer, only a few small studies have evaluated the role of video-assisted thoracoscopic surgery in patients with locally advanced lung cancer who had received preoperative chemotherapy. Methods Among 1655 patients who underwent anatomical lung resection for lung cancer between January 2009 and December 2014 in our institution, we retrospectively examined the short- and long-term outcomes of 110 (6.6%) who had undergone induction therapy. Thoracoscopic surgery was performed in 79 of these patients and thoracotomy in 31. Results In the thoracoscopic group, conversion to a thoracotomy was required in 4 patients. More combined resections were included in the thoracotomy group, and combined resection of large vessels or the carina was carried out only via a thoracotomy. Postoperative complications of grade 3 or above were found in 15 (13.6%) patients, and there was no significant difference in the incidence of postoperative complications between the 2 groups. The 3- and 5-year survival rates for the patients overall were 58.6% and 50.3%, respectively. Although there was no significant difference in overall outcome between the 2 groups, the patients with postoperative ypN2 status in the thoracoscopic group had a significantly better outcome than those in the thoracotomy group. Conclusion Although video-assisted thoracoscopic surgery was not suitable for central advanced lung cancer requiring angioplasty or carinal resection, it seems to be useful for patients with locally advanced lung cancer who had undergone induction therapy, especially patients with peripheral lung cancer and mediastinal lymph node metastasis.

The outcomes of anatomical lung resection for nontuberculous mycobacterial lung disease.

BACKGROUND: The number of cases of nontuberculous mycobacterial (NTM) lung disease has been increasing in recent years, and the efficacy of surgical treatment has been recognized. We investigated the clinical characteristics and behavior of NTM lung disease and analyzed the outcomes of surgery. METHODS: The data of 25 patients who underwent anatomical resection for NTM lung disease in our institution between January 2004 and December 2014 were retrospectively examined. RESULTS: The patients included 10 men and 15 women (mean age, 63.1 years). Twenty patients had Mycobacterium avium, and 5 had Mycobacterium intracellular. The indications for lung resection in 20 definitively diagnosed patients included a remaining or worsening lesion despite medical treatment (n=16), massive hemoptysis or bloody sputum (n=5), and prolonged smear positivity (n=1); multiple reasons were allowed. In five cases without a definitive diagnosis, surgery was performed due to the suspicion of lung cancer. The surgical procedures included pneumonectomy, n=4; lobectomy, n=13; and segmentectomy, n=8. Complete resection was achieved in 10 cases (40.0%). Video-assisted thoracoscopic surgery (VATS) was performed in 17 cases (68.0%), especially in 6 of 8 cases (75.0%) that underwent segmentectomy and in 10 of 11 cases (90.9%) that received simple lobectomy. There was one case of hospital mortality. Among the 22 patients who were followed at our institution, relapse occurred in 4 patients, and new infection occurred in 1 patient. NTM lung disease was controlled in 17 patients (77.3%). In the four cases that relapsed, the median relapse-free interval was 29.5 months. CONCLUSIONS: Surgical resection was a feasible treatment for NTM lung disease and was associated with favorable outcomes, although there was 1 case of hospital mortality. VATS procedures were considered adequate for the treatment of NTM lung disease; however, the surgical indications must be carefully considered.

Prognostic value of carcinoembryonic antigen and CYFRA21-1 in patients with pathological stage I non-small cell lung cancer.

BACKGROUND: The aim of this retrospective study was to assess the prognostic value of serum tumor markers (carcinoembryonic antigen (CEA) and CYFRA21-1) in patients with pathologic (p-) stage I non-small cell lung cancer (NSCLC) undergoing complete resection. METHODS: Two hundred and seventy-five patients (163 males, 112 females, mean age 67.1 years) with p-stage I NSCLC who underwent complete resection at our institution between April 1999 and October 2004 were examined. Patients who had received preoperative chemotherapy or radiotherapy were excluded, as were patients who had multiple malignancies including multiple lung cancer. The serum levels of tumor markers were measured using commercially available immunoassays within 1 month before surgical resection. Serum levels of CEA and CYFRA21-1 higher than 5.0 and 2.8 ng/ml, respectively, were considered as positive according to the manufacture's instructions. RESULTS: The histological classification was adenocarcinoma in 193 patients, squamous cell carcinoma in 71, large cell carcinoma in 5, and other histological type in 6. One hundred and fifty-seven patients had T1 disease and 118 patients had T2 disease. The positive ratio of CEA and CYFRA21-1 was 25.7% and 13.7%, respectively, and in relation to histological type was 27.8% and 7.8% in adenocarcinoma, and 20.6% and 28.4% in squamous cell carcinoma. The overall 5-year survival rate was 79.3%. With a median follow-up of 35.5 month for surviving patients, those with initial CYFRA21-1 serum levels higher than 2.8 ng/ml had a significantly worse prognosis (p=0.0041). Patients with an elevated preoperative CEA level exceeding 5.0 ng/ml had a shorter disease-free survival period (p=0.0003). In patients with adenocarcinoma, a CEA level above 5.0 ng/ml was associated with shorter survival and early recurrence, whereas CYFRA21-1 showed no such association. In patients with squamous cell carcinoma, elevated preoperative CEA was not related to survival and recurrence. In these patients, preoperative CYFRA21-1 level exceeding 2.8 ng/ml was associated with a poorer outcome, whereas preoperative CYFRA21-1 level was not associated with cancer recurrence. CONCLUSION: The patients with p-stage I adenocarcinoma whose preoperative CEA level was high might be considered as good candidates for adjuvant chemotherapy. The prognostic value of CYFRA21-1 could not be confirmed for stage I NSCLC, and preoperative CYFRA21-1 level was not useful in selecting the candidates for adjuvant chemotherapy.

Costal chondrosarcoma requiring differential diagnosis from metastatic tumor.

Although chondrosarcoma is a common malignant bone tumor, cases arising in the rib are relatively rare. We experienced a case of chondrosarcoma arising in the right 10th rib during follow-up after lung cancer surgery. Although the finding of an osteolytic mass suggested a metastatic bone tumor, 18F-fluorodeoxyglucose positron-emission tomography demonstrated low fluorodeoxyglucose uptake, and a primary bone tumor was suspected. The bone tumor was resected and diagnosed as chondrosarcoma. Four years after resection, there has been no recurrence or metastasis. Positron-emission tomography was useful for differential diagnosis between a chondrosarcoma and a metastatic bone tumor.

Phrenic Nerve Reconstruction and Bilateral Diaphragm Plication After Lobectomy.

A 49-year-old man with left phrenic nerve paralysis caused by mediastinal tumor resection 28 years earlier was found to have a nodule in the right upper lobe. The right phrenic nerve was severed during right upper lobectomy but was reconstructed along with bilateral plication of the diaphragm. The patient was weaned from the ventilator during the daytime on postoperative day 13 and was discharged home on postoperative day 48. Three months postoperatively, chest fluoroscopic imaging showed recovery of movement of the right diaphragm. Nerve conduction studies showed improvement of function of the reconstructed right phrenic nerve.

Mycobacterium avium infection complicating congenital bronchial atresia.

Bronchial atresia is a rare congenital malformation that is often complicated by infectious disease; however, mycobacterial infection is rare. Here we report a case of Mycobacterium avium infection complicating congenital bronchial atresia. A 50-year-old woman consulted our institution for further investigation of a nodular lesion in an emphysematous lung due to congenital bronchial atresia. Because we were unable to rule out malignant disease, we performed video-assisted thoracoscopic surgery. After left S8 segmentectomy, the nodular lesion were diagnosed as Mycobacterial avium infection. Three years after surgery, there has been no recurrence of mycobacterium infection in the absence of medication.

Ectopic thymic carcinoma presenting as an intrathoracic mass.

An asymptomatic 83-year-old man was found to have a right intrathoracic tumor. Computed tomography demonstrated a soft-tissue density mass measuring 55 × 25 × 22 mm adjacent to the right anterior chest wall. At surgery, the tumor was found to adhere to the diaphragm and right lung, contiguous with the mediastinal fat tissue. Histology of the resected specimen demonstrated proliferation of spindle and sarcomatous cells with multinucleated giant cells. Thus the tumor was diagnosed as undifferentiated thymic carcinoma and was considered to have arisen from ectopic thymic tissue. At 2 years postoperatively, the patient had no evidence of recurrence.