Practical methods to differentiate thymic malignancies by positron-emission tomography and tumor markers.

PURPOSE: An accurate diagnosis of thymic malignancies is important, but challenging due to the broad range of differential diagnoses. This study aims to evaluate the efficacy of PET/CT and tumor markers for diagnosing thymic malignancies. METHODS: Patients admitted to our department between January 2012 and December 2021 with primary anterior mediastinal tumors were retrospectively evaluated. We evaluated the relationship between the maximum standardized uptake value (SUVmax), tumor markers, and pathological diagnosis in four groups: thymic carcinoma, thymoma, lymphoma, and others. RESULTS: In total, 139 patients were included in this study. The SUVmax was significantly higher in lymphoma, thymic carcinoma, and thymoma, in that order. The cytokeratin 19 fragment (CYFRA 21-1) was significantly higher in thymic carcinoma than in the other groups. An ROC curve analysis indicated that the optimal cut-off values of SUVmax for thymic carcinoma plus lymphoma and CYFRA 21-1 for thymic carcinoma were 7.97 (AUC = 0.934) and 2.95 (AUC = 0.768), respectively. Using a combination of cut-off values (SUVmax = 8, CYFRA 21-1 = 3), the accuracy rate for diagnosing thymic carcinoma was 91.4%. CONCLUSIONS: The SUVmax and CYFRA 21-1 levels are significant indicators for the diagnosis of thymic carcinoma. Combining these indicators resulted in a more accurate diagnosis of thymic malignancies, which could facilitate the decision-making process for determining the optimal treatment strategies.

Pulmonary artery sarcoma and severe valvular diseases in late-septuagenarian women: was 2-stage surgery an appropriate strategy? A case report.

BACKGROUND: Pulmonary artery sarcomas (PASs) are rare, and complete tumor resection is often difficult at the time of detection. We encountered a case of PAS that was thought to be resectable; however, the patient had severe symptomatic valvular disease. We faced a difficult decision regarding the surgical strategy. CASE PRESENTATION: A 76-year-old female presented with a history of polysurgery for multiple primary cancers. She was referred to our department with a calcified mass in the right pulmonary artery (PA) and severe symptomatic valvular disease. After a discussion with the cardiovascular surgeon, we decided to perform a two-stage surgery. She underwent valvuloplasty through a median sternotomy, resulting in an improvement in her exertional dyspnea. The tumor was removed three months later with a right upper lobectomy and PA patch reconstruction through a posterolateral thoracotomy. When the PA was opened, the edge of the tumor was entrapped by vascular clamp forceps because of insufficient dissection of the adhesions between the superior vena cava and the right main PA resulting from the first operation. The patient underwent proton therapy twice for chest wall metastases which recurred three months after surgery, and local recurrence in the PA was diagnosed five months after surgery. The patient was alive with stable disease 25 months after surgery. CONCLUSION: Two-stage surgery for PAS and valvular disease resulted in incomplete resection of the PAS in the right PA. It is important not to underestimate surgical adhesions due to the initial surgery and to consider and implement measures to prevent adhesions of critical vessels during the second operation.

Sex-specific emphysematous changes evaluated by a three-dimensional computed tomography volumetric analysis among patients with smoking histories who underwent resection for lung cancer.

PURPOSE: The present study evaluated the sex-specific susceptibility to the development of emphysema in patients with smoking histories who underwent lung cancer surgeries. METHODS: Lung cancer patients with smoking histories who underwent lung resection at the University of Tsukuba Hospital, Japan, were enrolled. Radiologic emphysematous changes were analyzed using three-dimensional computed tomography (3D-CT). The volume proportion of emphysematous lung per unit of smoking and the relationship between emphysematous change and clinicopathologic factors were evaluated. RESULTS: Radiologic emphysematous changes analyzed using 3D-CT per pack-year smoked, defined as the Smoking-Emphysema Index (SEI), were greater in females than males. The difference was more profound in adenocarcinoma patients than in non-adenocarcinoma patients (0.70 ± 2.30 vs. 0.21 ± 0.28, P = 0.037). CONCLUSION: Female lung cancer patients are more susceptible to smoking-induced emphysema than males. The SEI may be an effective indicator for evaluating smoking-induced emphysema.

Relationship between changes in pulmonary function and patient-reported outcomes of lung cancer surgery.

PURPOSE: To investigate the relationship between changes in pulmonary function (PF) and patient-reported outcomes (PROs) of lung cancer surgery. METHODS: We recruited 262 patients who underwent lung resection for lung cancer, to evaluate the PROs, using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30 and the Lung Cancer 13-question supplement (LC13). The patients underwent PF tests and PRO assessments preoperatively (Pre) and 1 year after surgery (Y1). Changes were calculated by subtracting the value at Pre from the value at Y1. We set two cohorts: patients under the ongoing protocol (Cohort 1) and patients who were eligible for lobectomy with clinical stage I lung cancer (Cohort 2). RESULTS: Cohorts 1 and 2 comprised 206 and 149 patients, respectively. In addition to dyspnea, changes in PF were also correlated with scores for global health status, physical and role function scores, fatigue, nausea and vomiting, pain, and financial difficulties. Absolute correlation coefficient values ranged from 0.149 to 0.311. Improvement of emotional and social function scores was independent of PF. Sublobar resection preserved PF more than lobectomy did. Wedge resection mitigated dyspnea in both cohorts. CONCLUSION: The correlation between PF and PROs was found to be weak; therefore, further studies are needed to improve the patient's postoperative experience.

Three-dimensional analysis reveals a high incidence of lung adenocarcinoma in the upper region.

PURPOSE: The lung is a unique organ with a ventilation-perfusion mismatch, which can cause inhomogeneous incidence rates of lung cancer depending on the location in the lung. We aimed to evaluate the incidence of lung adenocarcinoma in each lobe by analyzing the incidence per unit volume, to evaluate the incidence without being affected by differences in the size of each lobe or in the size of the lungs between individuals. METHODS: The number of adenocarcinomas in each lobe was counted. Lung volumes were measured using a three-dimensional computer workstation. The tumor incidence per unit volume was analyzed based on the number of tumors in each lobe. RESULTS: The number of tumors per unit volume was 0.467 in the right upper lobe (RUL), 0.182 in the right middle lobe, 0.209 in the right lower lobe, 0.306 in the left upper segment (LUS), 0.083 in the left lingular segment, and 0.169 in the left lower lobe. The tumor incidence rate of RUL + LUS was 2.269 times that of the other lobes, a value that was significantly higher when using the bootstrap method (p < 0.001). CONCLUSIONS: The incidence of adenocarcinoma per unit volume in both upper lobes was higher than that in other lobes.

[Perioperative Management for Air Leakage, Atelectasis, and Pneumonia in Patients Undergoing Lung Resection].

Thoracic surgeons often encounter postoperative air leakage, atelectasis, and pneumonia as common complications of lung resection. Mostly, those are managed and treated properly, which results in avoiding serious outcomes. However, some clinical conditions manifesting initially as common complications could become severe unless an early correct differential diagnosis is made. Regarding air leakage, we summarized intraoperative techniques for pulmonary fistula and pleurodesis as postoperative treatment. Concerning atelectasis, in addition to management for obstructive atelectasis due to bronchial secretion, we described the adaptive displacement of the middle lobe after right upper lobectomy and tips for diagnosis and management of bronchial kinking and/or lobar torsion of the middle lobe. Regarding postoperative pneumonia, we emphasized smoking cessation and overviewed standard management for chronic obstructive pulmonary disease by bronchodilator as preoperative management. Moreover, we summarized standard treatment for hospital-acquired pneumonia and emphasized the importance of differential diagnosis if the initial empiric antibiotic therapy failed because some interstitial pulmonary diseases, such as organizing pneumonia and drug-induced lung injury, may mimic bacterial pneumonia.

Sphericity of lymph nodes using 3D-CT predicts metastasis in lung cancer patients.

BACKGROUND: The presence of mediastinal lymph node metastasis is important because it is related to the treatment and prognosis of lung cancer. Although prevalently used, evaluation of lymph nodes is not always reliable. We introduced sphericity as a criterion for evaluating morphologic differences between metastatic and nonmetastatic nodes. METHODS: We reviewed the cases of 66 patients with N2 disease and of 68 patients with N0-1 disease who underwent lobectomy with mediastinal dissection between January 2012 and December 2021. The sphericity of the dissected station lymph nodes, which represents how close the node is to being a true sphere, was evaluated along with the diameter and volume. Each parameter was obtained and evaluated for ability to predict metastasis. RESULTS: Metastatic lymph nodes had a larger short-axis diameter (average: 8.2 mm vs. 5.4 mm, p < 0.001) and sphericity (average: 0.72 vs. 0.60, p < 0.001) than those of nonmetastatic lymph nodes. Short-axis diameter ≥ 6 mm and sphericity ≥ 0.60 identified metastasis with 76.2% sensitivity and 70.2% specificity (AUC = 0.78, p < 0.001) and 92.1% sensitivity and 53.9% specificity (AUC = 0.78, p < 0.001), respectively. For lymph nodes with a short-axis diameter ≥ 5 mm, sphericity ≥ 0.60 identified metastasis with 84.1% sensitivity and 89.3% specificity. CONCLUSION: By using 3D-CT analysis to examine sphericity, we showed that metastatic lymph nodes became spherical. Our method for predicting lymph node metastasis based on sphericity of lymph nodes with a short-axis diameter ≥ 5 mm could do so with higher sensitivity than the conventional method, and with acceptable specificity.

Successful long-term management for postoperative sternal infection with multiple disseminated lymphadenitis caused by Mycobacterium abscessus.

BACKGROUND: Postoperative sternal infection caused by Mycobacterium abscessus (M. abscessus) is rare, but associated with a high 2-year mortality rate of 40%. Decision-making around treatment strategy is challenging. Here, we present a successfully treated case of postoperative M. abscessus sternal infection with multiple disseminated lymphadenitis. CASE PRESENTATION: The patient, an 80-year-old woman with anterior mediastinal tumor and myasthenia gravis, underwent extended thymectomy under median sternotomy. Redness appeared around the scar two months after the operation. Sternal wires were removed, debridement was performed, and the wound was kept open. Mycobacterium abscessus was isolated from the wound culture. The disseminated lesions in the right axillary, parasternal, and bilateral supraclavicular lymph nodes, rendered surgical options for infection control difficult; therefore, she was treated conservatively with antibiotics and negative pressure wound therapy (NPWT). The wound diminished but infectious granulation tissue remained after NPWT. Two disseminated lesions were percutaneously punctured and drained of pus, which resulted in negative cultures. Additional debridement and wound closure were performed. She was discharged after switching to oral antibiotics. No recurrence was observed five months after the antibiotics were completed (total sensitive antibiotics use: 366 days). CONCLUSIONS: Repeated culture assessment of disseminated lesions is recommended to facilitate the development of appropriate therapeutic strategies. Localized procedures may be an option for patients with controlled disseminated lesions evidenced by negative cultures.

Retrospective single-arm cohort study of video-assisted thoracic surgery for treatment of idiopathic peripherally located simple type pulmonary arteriovenous malformation in 23 consecutive patients.

BACKGROUND: Although case reports of video-assisted thoracic surgery (VATS) for pulmonary arteriovenous malformation (PAVM) have been published, studies analyzing more than 10 cases were limited. A retrospective single-arm cohort study was performed to investigate the efficacy of VATS in 23 consecutive patients with idiopathic peripherally located simple type PAVM. METHODS: VATS was performed for wedge resection of 24 PAVMs in 23 patients, which included 4 males and 19 females with an age range of 25 to 80 years (mean: 59.6 ± 13.0). Two patients underwent simultaneous resection of lung carcinoma, one by wedge resection and another by lobectomy. Each medical record was analyzed according to the resected specimen, bleeding volume, postsurgical hospital stay length, duration of chest tube placement, and VATS time. The distance between pleural surface/fissure and PAVM was measured on CT, and the influence of this distance on identification of PAVM was investigated. RESULTS: In all 23 patients, VATS was successfully performed, and the venous sac was included in each resected specimen. Bleeding volume was less than 10mL in all but one with 1900 mL bleeding volume due to simultaneous lobectomy for carcinoma, not wedge resection of PAVM. Postsurgical hospital stay length, duration of chest tube placement, and VATS time were 5.0 ± 1.4 days, 2.7 ± 0.7 days, and 49.3 ± 39.9 min, respectively. In 21 PAVMs with a distance of 1 mm or less, purple vessel or pleural bulge of PAVM was identified soon after insertion of a thoracoscope. In the remaining 3 PAVMs with a distance of 2.5 mm or more, additional efforts were needed for identification. CONCLUSION: VATS was found to be a safe and effective to treatment for idiopathic peripherally located simple type PAVM. When the distance between pleural surface/fissure and PAVM was 2.5 mm or more, a plan and strategy for identification of PAVM should be prepared before VATS.

A novel approach to the lung apex avoiding dissection of severe pleural adhesions.

A 70-year-old man was incidentally diagnosed with left pneumothorax. Primary surgery via the caudal thoracic cavity found severe pleural adhesions causing narrowing of the tunnel leading to the lung apex. The point of air leakage was located at the lung apex beyond the tunnel. To stop the air leakage, fibrin glue was injected to the apex via the tunnel; however, leakage reoccurred postoperatively. Considering the lung injury, a novel approach for lung apex without adhesion dissection was chosen for secondary surgery. An axillary skin incision was made at the 2nd intercostal space, and extrapleural dissection proceeded toward the apex. After the pleural space was confirmed by the movement of pleural effusion, the parietal pleura was incised, and a bulla was exposed and resected. The presented procedure to reach the apex of the lung without adhesion dissection could be an option in cases with dense and extensive pleural adhesions.

Progression of Smoking-Induced Emphysema in a Case with Indium Lung.

Recently, it has become clear that inhaled indium-tin oxide causes emphysematous as well as interstitial changes in the lung. Here, we present a 59-year-old male ex-smoker, quitting smoking at the age of 55. He had been engaged in indium-tin oxide processing from 27 to 37 years of age, with 22 years having passed since the final exposure to indium. He was found to have a high serum indium concentration and Krebs von den Lungen-6 (KL-6). Furthermore, bilateral centrilobular emphysema was recognized in high-resolution computed tomography (HRCT). After transferring jobs to a non-indium-tin oxide section, KL-6 returned to a normal level within 4 years, whereas neither serum indium concentration nor emphysema had decreased to normal despite 22 years having passed since the exposure ended. At the age of 59, a thoracoscopic lung biopsy was performed to assess the contribution of smoking and that of indium to the lung destruction. The pathological findings demonstrated cholesterol granulomas with the accumulation of macrophages and multinucleated giant cells that had phagocytosed particles. Together with the typical findings of indium lung, fibrotic and emphysematous changes were observed. The elemental analysis of the biopsied specimens revealed excessive deposition of indium throughout the airways, interstitial spaces and alveoli. The pathological findings of this case may be the result of two kinds of pulmonary damage, i.e., smoking and indium. This report indicates that occupationally-inhaled indium could remain in the lung for as long as 22 years and continue to insult the lung tissue with inflammation caused by smoking.

Alaska pollock gelatin sealant shows long-term efficacy and safety in a pulmonary air leakage rat model.

OBJECTIVES: Postoperative prolonged air leakage is a frequent complication following lung resection. We have shown the high adhesive quality of a newly developed sealant based on a hydrophobically modified Alaska pollock-derived gelatin (ApGltn) sealant in acute in vivo settings. The purpose of this study was to investigate the long-term efficacy and safety of ApGltn sealant using rats as a preclinical model. METHODS: An air leakage rat model with a 5-mm pleural defect was created, to which ApGltn sealant or fibrin sealant was applied. In both groups, the rats were evaluated on days 1, 7, 14 and 28. In the ApGltn sealant group, days 56 and 84 were added to evaluate absorption as sealant was still present on day 28. The number of rats in each subgroup was 4 (for a total of 40). Lung specimens and blood samples were obtained for histological and haematological assessment. RESULTS: No findings suggesting infection or air leakage were observed. ApGltn sealant was absorbed from day 56 to day 84. Histologically, although neutrophil and lymphocyte infiltrations on the lung side did not differ between groups, those on the sealant side were significantly less in the ApGltn sealant group. Blood sample tests revealed no significant findings suggesting inflammation or organ damage in either group. CONCLUSIONS: ApGltn sealant showed long-term sealing efficacy and safety with mild inflammation in a pulmonary air leakage rat model. ApGltn sealant is expected to be a safe and effective sealant for clinical applications.

[Emergency Surgical Management of Mediastinal Tumors].

Mediastinal tumors rarely lead to acute symptomatic manifestations due to spontaneous rupture and perforation, intra-tumoral hemorrhage, and bacterial contamination. Moreover, giant mediastinal tumors can compress and infiltrate surrounding mediastinal structures, such as the trachea, bronchus, cardiac sac, and superior vena cava, at the first visit. In addition, mediastinal mature teratomas include various ectopic tissues such as digestive glands and sebaceous glands that can cause specific pathological conditions. To address and properly manage patients with these rare conditions, prior learning must be emphasized to facilitate in clinical decision-making. In this article, we classified four pathological conditions of emergency due to mediastinal tumors. These include the clinical conditions resulting from the compression of anatomical structures by the tumor, those resulting from infiltration and extension into the surrounding mediastinal structures by the tumor, the specific conditions attributable to mature teratomas, and the occurrence of hemothorax due to spontaneous rupturing of the tumor. Based on the review of our cases and other recently reported cases, we summarize and discuss practical pitfalls and pearls in the emergency surgical management of these rare but life-threatening clinical situations.

Impacts of pleural adhesions on lobectomies for malignant lung tumors.

OBJECTIVES: Pleural adhesions are sometimes troublesome in lung lobectomies, and how they affect such surgeries depends on the degree of the adhesion. Herein, pleural adhesions were categorized according to density, tenacity, and coverage, and the impact of each category on lung lobectomy was investigated. METHODS: The cases of 510 patients who consecutively underwent lobectomies were retrospectively reviewed. Pleural adhesions were classified into two classes (non-dense and dense) in the category of "Density," 3 classes (loose, firm, and very-strong) in that of "Tenacity," and 3 classes (1-10%, 10-50%, 50-100%) in that of "Coverage." The perioperative findings for each class were compared with those of patients without pleural adhesions. RESULTS: The 50-100% group in the Coverage category was the most affected by pleural adhesions, and the very-strong group in the Tenacity category was the next. In these 2 groups, when compared with the no-adhesion group, significant differences were found in operative time (336, 326 vs 231 min), amount of bleeding (187.5, 80 vs 20 g), and frequency of prolonged air leakage (20%, 22% vs 3%), respectively. The dense group, firm group, and 10-50% group also significantly affected the perioperative course. As for postoperative complications, prolonged air leakage was the most problematic. CONCLUSIONS: The impact of pleural adhesions on lobectomy would be greater if the pleural adhesion is dense, firm, or very-strong and has a coverage of 10% or more. Careful and patient pleural dissection is required, even if this entails a longer operative time, to minimize postoperative complications.

Rapid enlargement of pulmonary benign metastasizing leiomyoma with fluid-containing cystic change: a case report.

BACKGROUND: Pulmonary benign metastasizing leiomyoma (PBML) is a rare disease that can occur in women with a history of uterine leiomyoma. Despite its benign histological features, like a malignancy, leiomyomas can on rare occasion spread to the lung. Typically, PBML presents with asymptomatic multiple solid lung nodules with slow tumor progression, following hysterectomy. Here, we present an atypical case with rapid enlargement of PBML with fluid-containing cystic change. CASE PRESENTATION: We experienced a case of a 49-year-old woman with bilateral lung nodules following hysterectomy. Two nodules in the right lung had cystic change with fluid in the tumors. Hormone therapy was initiated after surgical biopsy of the left lung confirmed a diagnosis of PBML. However, the cystic component of right upper lobe lesion enlarged rapidly over the following 7 months, and, considering the risk of malignant transformation or tumor rupture, right upper lobectomy was performed. Pathologically, the fluid-containing tumor was diagnosed as PBML. CONCLUSION: Given the risk of rapid progression, we should carefully consider the surgical indications of fluid-containing PBML.

Prognostic Implication of PD-L1 Expression on Osimertinib Treatment for EGFR-mutated Non-small Cell Lung Cancer.

BACKGROUND/AIM: Real-world data on the clinical outcomes of first-line osimertinib treatment for non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations is lacking. This study aimed to reveal the treatment outcomes and prognostic factors of osimertinib as first-line therapy in clinical practice settings. PATIENTS AND METHODS: We retrospectively evaluated clinical outcomes of patients with EGFR-mutated NSCLC treated with osimertinib as first-line therapy across 12 institutions in Japan between August 2018 and March 2020. RESULTS: Among 158 enrolled patients, the objective response rate (ORR) was 68%, and the estimated median progression-free survival (PFS) was 17.1 months [95% confidence interval (CI)=14.5-19.7]. Subgroup analysis showed that PFS in the group with high programmed death-ligand 1 (PD-L1) expression was significantly shorter than that in groups with low or no PD-L1 expression (10.1 vs. 16.1 vs. 19.0 months; p=0.03). Univariate and multivariate analyses demonstrated that high PD-L1 expression was the only independent adverse prognostic factor of osimertinib outcome related to PFS (hazard ratio=2.71; 95%CI=1.26-5.84; p=0.01). In terms of anti-tumor response, there was no statistically significant correlation between PD-L1 expression and the ORR (67% vs. 76% vs. 65%; p=0.51). No significant correlation was also found between PD-L1 and the incidence of de novo resistance to osimertinib (p=0.39). CONCLUSION: Although PD-L1 expression was not associated with either the ORR or frequency of de novo resistance, high PD-L1 expression could be an independent adverse prognostic factor related to PFS in osimertinib treatment.

Efficacy of Alaska Pollock Gelatin Sealant for Pulmonary Air Leakage in Porcine Models.

BACKGROUND: Postoperative prolonged air leakage is a frequent complication after lung resection. We have developed a new sealant based on a hydrophobically modified Alaska pollock-derived gelatin (ApGltn) sealant. The purpose of this study was to evaluate the adhesive strength of the ApGltn sealant in comparison with a fibrin sealant using a new spray system in ex vivo and in vivo models. METHODS: Pleural defects in ex vivo and in vivo porcine models were created, to which the ApGltn sealant or the fibrin sealant was applied. The pressure resistance was assessed with a stepwise increase in airway pressure to confirm air leakage from the sealing site. Tissue samples covered with each sealant were obtained for histologic assessment. RESULTS: In the ex vivo experiment, the leak pressures of the ApGltn sealant were significantly greater than those of the fibrin sealant (102.94 ± 15.6 cm H2O and 28.37 ± 5.1 cm H2O, respectively) (P < .01). In the in vivo experiment, the leak pressures of the ApGltn sealant were also significantly greater than those of the fibrin sealant (68.82 ± 18.04 cm H2O and 43.33 ± 7.13 cm H2O, respectively) (P = .043). The histologic examination confirmed that the ApGltn sealant adhered tightly to both the pleura and the surface of the pleural defect. CONCLUSIONS: The ApGltn sealant has sufficiently high adhesive quality in ex vivo and in vivo porcine lungs, which could be considered suitable and effective for use in the prevention of air leakage from the lungs.

Comparison of Postoperative Quality of Life and Pain with and without a Metal Rib Spreader in Patients Undergoing Lobectomy through Axillary Mini-Thoracotomy for Stage I Lung Cancer.

PURPOSE: To evaluate postoperative patient-reported quality of life (QOL) and pain with and without a metal rib spreader (MRS) in patients with stage I lung cancer who underwent lobectomy through axillary mini-thoracotomy (AMT). METHODS: This single-institution prospective observational study enrolled patients between January 2015 and April 2018. Their QOL and pain were evaluated using the EQ-5D and the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire 30 items (QLQ-C30). The EQ-5D was completed preoperatively (Pre) and on days 1/3/5/7 (D1/3/5/7), at 1 month (M1), and at 1 year postoperatively (Y1). The EORTC QLQ-C30 was completed at Pre, M1, and Y1. RESULTS: The data of 140 patients were analyzed (video-assisted without MRS: VA/noMRS: 67, AMT with MRS: AMT/MRS: 73). Although the AMT/MRS group had more preoperative comorbidities, longer operative times, and more blood loss than the VA/noMRS group, the EQ-5D visual analog scale scores were not significantly different at any assessment point (Pre/D1/D3/D5/D7/M1/Y1) (VA/noMRS: 82/48/60/67/73/77/85, AMT/MRS: 80/46/60/66/73/76/85). Postoperative pain in the EQ-5D descriptive system and the EORTC QLQ-C30 was comparable between the groups. CONCLUSION: VA/noMRS and AMT/MRS showed similar postoperative QOL and pain scores, indicating that MRS negligibly impacts the postoperative QOL and pain.

Thymoma with a feeding vessel from coincident coronary-pulmonary artery fistulas.

We report a rare case of a 68-year-old man with thymoma and coronary-pulmonary artery fistulas. The thymoma was 66 × 51 × 88 mm in size and accompanied by a feeding vessel originating from the coronary-pulmonary artery fistulas. We performed total thymectomy and resection of coronary-pulmonary artery fistulas at the same time, which has not been reported in the literature. The fistulas along with the left main trunk were successfully resected while temporarily transecting the main pulmonary artery. This strategy was a useful option for obtaining a good field of vision around the left main trunk behind the main pulmonary artery.

Predicting Respiratory Complications Following Lobectomy Using Quantitative CT Measures of Emphysema.

PURPOSE: In performing surgery for lung cancer, emphysema is a risk factor related to postoperative respiratory complications (PRC). However, few studies have addressed the risk of radiological emphysematous volume affecting PRC. The aim of this study was to investigate the relationship between emphysematous volume as measured on 3-dimensional computed tomography and PRC. PATIENTS AND METHODS: We reviewed 342 lung cancer patients undergoing lobectomy between 2013 and 2018. The percentage of low attenuation area (LAA%) was defined as the percentage of the lung area showing attenuation of -950 Hounsfield units or lower. Preoperative factors including age, sex, body mass index, smoking index, respiratory function, tumour histology, and LAA% were evaluated. PRC included pneumonia, atelectasis, prolonged air leakage, empyema, hypoxia, ischemic bronchitis, bronchopleural fistula, and exacerbation of interstitial pneumonia. Uni- and multivariable analyses were performed to investigate the relationship between independent clinical variables and postoperative adverse events. RESULTS: Median LAA% was 5.0% (range, 0-40%) and PRC was observed in 50 patients (14.6%). Patients who presented with PRC showed significantly high LAA% compared to those without complications (median: 8.1% vs 3.8%; p < 0.001). Based on univariable analysis, age, sex, smoking index, percentage of forced expiratory volume in 1 s (FEV1.0%), histology, and LAA% were significant predictors for PRC. Multivariable analysis revealed higher LAA% as a significant risk factor for PRC (odds ratio = 1.040; 95% confidence interval, 1.001-1.080; p = 0.046). CONCLUSION: In addition to respiratory function with spirometry, LAA% can be used as a predictor of PRC.