Obstructive Shock Due to a Crushed Left Atrium and Pulmonary Vein by Pulmonary Artery Intimal Sarcoma Successfully Treated with Pulmonary Vein Stenting.

A 46-year-old patient who had undergone right pneumonectomy for pulmonary artery intimal sarcoma presented with hypoxemia. The recurrent sarcoma in the mediastinum revealed external compression to the left pulmonary veins (PVs), leading to obstructive shock and cardiac arrest. Venous artery extracorporeal membrane oxygenation (VA-ECMO) was initiated; however, withdrawal was difficult, and the patient's survival seemed hopeless. However, the patient's condition improved with stenting for the compressed PV; therefore, VA-ECMO was discontinued, and he was discharged on foot. This is the first case report of obstructive shock due to critical PV stenosis caused by compression of a malignant tumor that responded to PV stenting.

Thoracoscopic and laparoscopic approach for pleuroperitoneal communication under peritoneal dialysis: a report of four cases.

BACKGROUND: Pleuroperitoneal communication (PPC) is a rare complication of continuous ambulatory peritoneal dialysis (CAPD) and often forces patients to switch to hemodialysis. Some efficiencies of video-assisted thoracic surgery (VATS) for PPC have been reported recently; however, there is no standard approach for these complications. In this case series, we present a combined thoracoscopic and laparoscopic approach for PPC in four patients to better assess its feasibility and efficiency. CASE PRESENTATION: Clinical characteristics, perioperative findings, surgical procedures, and clinical outcomes were retrospectively analyzed. We combined VATS with a laparoscopic approach to detect and repair the diaphragmatic lesions responsible for PPC. We first performed pneumoperitoneum in all patients following thoracoscopic exploration. In two cases, we found bubbles gushing out of a small pore in the central tendon of the diaphragm. The lesions were closed with 4-0 non-absorbable monofilament sutures, covered with a sheet of absorbable polyglycolic acid (PGA) felt, and sprayed with fibrin glue. In the other two cases without bubbles, a laparoscope was inserted, and we observed the diaphragm from the abdominal side. In one of the two cases, two pores were detected on the abdominal side. The lesions were closed using sutures and reinforced using the same procedure. In one case, we failed to detect a pore using VATS combined with the laparoscopic approach. Therefore, we covered the diaphragm with only a sheet of PGA felt and fibrin glue. There was no recurrence of PPC, and CAPD was resumed at an average of 11.3 days. CONCLUSIONS: The combined thoracoscopic and laparoscopic approach is an effective treatment for detecting and repairing the lesions responsible for PPC.

A Case of Intractable Lung Abscess Following Dropped Gallstone-Induced Subphrenic Abscess: A Rare Postoperative Complication Caused by Dropped Gallstone During Laparoscopic Cholecystectomy.

Dropped gallstones into the abdominal cavity due to perforation of the gallbladder occasionally occur during laparoscopic cholecystectomy. Abscess formation caused by residual gallstones is one of the late postoperative complications after laparoscopic cholecystectomy. Most of them are intra-abdominal abscesses; however formation of intra-thoracic abscesses, in particular, lung abscess, is less described, and surgery for an intra-thoracic abscess is rarely performed. We describe a case of intractable lung abscess following dropped gallstone-induced subphrenic abscess caused by a residual gallstone after laparoscopic cholecystectomy.

A case of pleuroperitoneal communication in which establishing a laparoscopic pneumoperitoneum was useful for the detection of a fistula.

BACKGROUND: Pleuroperitoneal communication (PPC) is rarely observed, accounting for 1.6% of all patients who undergo continuous ambulatory peritoneal dialysis (CAPD). Although there have been several reports concerning the management of this condition, we have encountered several cases in which control failed. We herein report a valuable case of PPC in which laparoscopic pneumoperitoneum with video-assisted thoracic surgery (VATS) was useful for supporting the diagnosis and treatment. CASE PRESENTATION: The patient was a 58-year-old woman with chronic renal failure due to chronic renal inflammation who was referred to a nephrologist in our hospital to undergo an operation for the induction of CAPD. Post-operatively, she had respiratory failure, and chest X-ray and computed tomography (CT) showed right-sided hydrothorax that decreased when the injection of peritoneal dialysate was interrupted. Therefore, PPC was suspected, and she was referred to our department for surgical repair. We planned surgical treatment via video-assisted thoracic surgery. During the surgery, we failed to detect any lesions with thoracoscopy alone; we therefore added a laparoscopic port at her right-sided abdomen near the navel and infused CO2 gas into the abdominal cavity. On thoracoscopy, bubbles were observed emanating from a small pore at the central tendon of the diaphragm, which was considered to be the lesion responsible for the PPC. We closed it by suturing directly. CONCLUSIONS: VATS with laparoscopic pneumoperitoneum should be considered as an effective method for inspecting tiny pores of the diaphragm, especially when the lesions responsible for PPC are difficult to detect.

Cardiac herniation after extrapleural pneumonectomy.

Cardiac herniation is a fatal complication in patients undergoing pneumonectomy with pericardial resection. A 53-year-old man underwent right-sided extrapleural pneumonectomy for malignant pleural mesothelioma. He underwent right-sided pericardial resection and reconstruction with an expanded polytetrafluoroethylene sheet. Routine chest radiography performed 18 h postoperatively revealed cardiac herniation into the right-sided thoracic cavity. The patient was immediately transferred to the operating room, and the defect was repaired. He died of tumor progression. However, cardiac herniation did not recur over 2 years postoperatively.

[Coexistence of Schwannomatosis from Vagal Nerve and Intercostal Nerve;Report of a Case].

Schwannomatosis with mediastinal vagal schwannoma is rare. A 71-year-old man presented with multiple mediastinal tumors by a regular check-up. A chest computed tomography showed well-defined round tumors along with the 3rd intercostal nerve and in the left upper mediastinal area. A percutaneous biopsy specimen of the tumor suggested benign tumor, however surgical excision was performed for a definitive diagnosis and treatment. The histological diagnosis was schwannoma. Since the tumor originated from the mediastinal vagal nerve proximal to the recurrent laryngeal nerve and was suggested to be benign, it was not resected to preserve the function of the recurrent laryngeal nerve.

Anterior mediastinal tumor as a solitary lymph node metastasis of occult thyroid carcinoma.

Solitary metastasis of occult thyroid carcinoma to the anterior mediastinum is very rare. A 65-year-old woman was examined for anterior mediastinal tumor based on the FDG accumulation on PET. We resected the tumor by video-assisted thoracic surgery. A pathological examination revealed that the tumor was lymph node metastasis of papillary thyroid carcinoma. The postoperative examination showed that the tumor was a solitary lymph node metastasis of occult thyroid carcinoma. Primary thyroid carcinoma has not appeared in 2 years since the surgery, and careful follow-up has been continued.

Modified risk scoring system for acute exacerbation of interstitial lung disease.

BACKGROUND: Lung cancer patients with interstitial lung disease often develop acute exacerbation of their interstitial lung disease after lung resection. Special care is needed in selection of the surgical procedure to reduce acute exacerbation and provide long-term survival. METHODS: The Japanese Association for Chest Surgery devised a risk scoring system based on 7 risk factors to predict the probability of postoperative acute exacerbation. We excluded surgical procedures and used a modified system categorizing 4 groups: group A (risk score 0-6), group B (risk score 7-10), group C (risk score 11-14), and group D (risk score 15-18). We retrospectively examined 60 lung cancer patients with interstitial lung disease to determine whether the modified risk scoring system is useful for selecting the optimal surgical procedure in anticipation of curability and risk of postoperative acute exacerbation. RESULTS: Eight (13.3%) patients experienced postoperative acute exacerbation. In group A ( n = 20), there was no difference in the incidence of acute exacerbation between wedge (0%) and anatomic resection (6.3%, p = 0.800). In group B ( n = 40), the incidence was significantly higher after anatomic resection (5.0% vs. 30.0%, p = 0.046). Thus group A had high-quality outcomes with anatomic resection, and in group B, the incidence of postoperative acute exacerbation can be reduced if wedge resection is performed. CONCLUSIONS: Our modified risk scoring can be useful for selecting the optimal surgical procedure in anticipation of curability and the risk of acute exacerbation of interstitial lung disease after lung cancer surgery.

Management of Airway Obstruction due to Diffuse Idiopathic Skeletal Hyperostosis in the Cervical Spine: A Case Report and Literature Review.

Diffuse idiopathic skeletal hyperostosis (DISH) is a relatively common progressive noninflammatory entheses disease. Patients are often asymptomatic or are undiagnosed due to minor chronic symptoms. We herein report a rare case in which the primary symptom was sudden-onset upper airway obstruction due to exuberant osteophytosis in the cervical spine. Treatment was successful with careful airway management and surgical osteophyectomy. Most DISH cases in the literature with airway obstruction have been managed with tracheotomy. However, the safety and necessity of this approach remain questionable. We herein discuss the possibility of conservative management as a choice of airway control. Airway obstruction due to DISH may be underrecognized. This highlights the importance of including DISH in the differential diagnosis of airway obstruction. In addition, a detailed evaluation and personalized care for each individual case is essential.

Idiopathic spontaneous pulmonary torsion of the lingula: A case report.

INTRODUCTION: Spontaneous pulmonary torsion is an extremely rare event and is known to occur as a complication of thoracic surgery and traumatic injuries. PRESENTATION OF CASE: An 18-year-old man presented to our hospital with pain in the left back region. Clinical examination, computed tomography and bronchoscopy are crucial for diagnosis of pulmonary torsion. During thoracotomy, the lingula segment was observed to be bent on the head side and turned 180° counterclockwise; subsequently, lingulectomy was performed. DISCUSSION: Spontaneous pulmonary torsion may occur in pulmonary conditions such as pneumothorax, atelectasis, infection, pleural effusion, congenital defect, or tumor. Furthermore, it can be speculated that torsion of the segment is possible only in the patients with an accessory fissure or those who have undergone a segmentectomy. CONCLUSION: We have reported an extremely rare case with respect to the fact that the pulmonary torsion occurred spontaneously in an unseparated segment, and that the etiological factor could not be identified.

Video-assisted thoracic surgery lobectomy for right lung cancer in a patient with right aortic arch: report of a case.

A 57-year-old man with an anomalous right aortic arch presented with cancer of the right lung. The right recurrent laryngeal nerve was found to be hooked around the right aortic arch. Right lower lobectomy with systematic mediastinal lymph node dissection was successfully performed using video-assisted thoracic surgery to provide close intraoperative attention to the branching of recurrent laryngeal nerve.

[Clinical significance of micrometastases in the lymph nodes of patients with resectable lung cancer].

Clinical evaluation of micrometastases in the lymph nodes of lung cancer patients is not currently recommended in guidelines because of several different results concerning their prevalence and prognostic implications. However, a recent large, prospective, multicenter clinical study has shown a significant prognostic impact of micrometasteses in the lymph nodes of patients with resectable lung cancer; therefore, the clinical significance of micrometastases as predictive markers of recurrence and prognosis has begun to be clarified. From the viewpoint of surgery for lung cancer, sentinel node navigation surgery, segmentectomy, and individualized therapies such as adjuvant chemotherapy are expected to be developed. In the near future, standardization and improvement of the efficiency of diagnostic procedures will be necessary in common clinical practice. Recently, minimal residual cancer cell research, such as circulating tumor cells in the peripheral blood and disseminated tumor cells in the bone marrow, has made good progress. As research in this field continues, it is expected that the mechanism of metastasis and novel therapeutic strategies targeting minimal residual cancer cells will become better understood.

Cytochrome P450 in non-small cell lung cancer related to exogenous chemical metabolism.

The occurrence of lung cancer is associated with smoking, which exposes smokers to a series of carcinogenic chemicals. CYP (cytochrome P450) usually metabolizes carcinogens to their inactive derivatives, but occasionally convert the chemicals to more potent carcinogens. In addition to the metabolism of carcinogenic compounds, CYP also participates in the activation and/or inactivation of anti-carcinogenic agents, suggesting that the local CYP expression in lung cancer and surrounding tissues could be an important determinant of efficacy of anticancer drugs. Furthermore, CYP19 (aromatase), estrogen synthase P450, expressed in more than 80 percent of non-small cell lung cancers. It suggests an association between estrogens and cancer development, which makes aromatase an attractive therapeutic target for the treatment of lung cancer. 1alpha,25-Dihydroxyvitamin D3 has an inhibitory effect on the proliferation of cancer tissues, and is converted to its inactive 24-hydroxylated derivatives by CYP24, which is frequently expressed in lung cancer tissues. Therefore, understanding the CYP expression in tumor tissues is important in developing better therapies for lung cancer, and may lead us to standardized, tailor-made therapies for individuals.

Spindle cell carcinoma of the lung.

We report a rare case of spindle cell carcinoma in the lung. A 73-year-old woman was admitted because of a lung tumor, which was indicated during a group examination. Chest computed tomography revealed a tumor located in the right lung accompanied by spiculation. Right upper lobectomy with lymph nodal dissection was performed. Histological findings revealed only spindle-shaped tumor cells, and immunohistochemical stain showed that they were cytokeratin-positive. We diagnosed it as a pulmonary spindle cell carcinoma.

A randomized phase II trial of adjuvant chemotherapy with bi-weekly carboplatin plus paclitaxel versus carboplatin plus gemcitabine in patients with completely resected non-small cell lung cancer.

BACKGROUND: The benefits of adjuvant chemotherapy for completely resected non-small cell lung cancer (NSCLC) have been demonstrated using mainly cisplatin (CDDP)-based chemotherapeutic regimens. However, treatment-related deaths sometimes occur. Therefore, the development of a safer regimen is necessary. PATIENTS AND METHODS: The patients were randomized to either carboplatin (CBDCA) area under the curve (AUC) 3 and paclitaxel (PTX) 90 mg/m(2) (PCb arm) or CBDCA (AUC3) plus gemcitabine (GEM) (1000 mg/m(2)) (GCb arm) every 2 weeks for 8 cycles after surgery. The primary endpoint was the compliance with the regimen, while the secondary endpoints were safety and toxicity. RESULTS: A total of 75 patients were enrolled in a multi-institutional study. Twenty-one out of 39 patients (54%) in the PCb arm and 25 of 36 patients (69%) in the GCb arm completed 8 cycles, and 59% in the PCb arm and 81% in the GCb arm completed ≥6 cycles. The predominant toxicity was neutropenia. Non-hematological adverse effects were infrequent and no treatment-related death was registered. The estimated disease-free survival and overall survival at 2 years were 70.8% and 66.3% in the PCb and 91.4% and 79.1% in the GCb arm, respectively. CONCLUSION: This adjuvant bi-weekly scheduled chemotherapy resulted in good compliance in both arms, and the regimen was feasible, with acceptable levels of toxicity in completely resected Japanese NSCLC patients. Therefore, these regimens represent a new treatment option suitable for outpatients with completely resected NSCLC.

Unique extralobar sequestration with atypical location and aberrant vessels.

We report a unique extralobar pulmonary sequestration in the upper thoracic region with 3 aberrant vessels connecting to the right subclavian artery, right superior pulmonary vein, and right pulmonary artery in a 20-year-old man. The sequestered lung was completely excised using a video-assisted thoracoscopic approach.

[Plasmacytoma of chest wall].

We report a 70-year-old man who suffered from right anterior chest wall tumor. Physical examination revealed an elastic hard mass at the right 4th rib measured 6 cm in diameter. Chest X-ray and computed tomography (CT) revealed enhanced mass and destruction of the 4th rib. As needle aspiration cytology did not define the diagnosis, we performed a chest wall resection and reconstruction. Histological diagnosis of the tumor was plasmacytoma (IgG lambda type). Five months after the operation, the tumor recurred at the right anterior chest wall. Radiotherapy was performed with dose of 50 Gy. Fourteen months after the operation, the tumor recurred at the lower sternum, and the chemotherapy was performed using ranimustine, vincristine, melpharan and dexamethasone. He is doing well 2 years and 9 months after surgery without signs of progressive disease or conversion to myeloma

Huge mediastinal cystic tumor penetrating the sternum.

We report a very rare case of a huge anterior mediastinal tumor penetrating the sternum that was diagnosed in a 59-year-old woman. The tumor was completely resected en bloc with the manubrium sterni, and the chest wall defect was closed with a pectoralis major muscle flap. Histologic examination of the cystic mass revealed the diagnosis of a benign mediastinal cystic tumor, most likely a benign cystic mature teratoma.

Thymoma with Lambert-Eaton myasthenic syndrome.

We describe a rare case of thymoma with Lambert-Eaton myasthenic syndrome. A 62-year-old woman reporting weakness in her legs and arms was found to have an anterior mediastinal mass on computed tomography. Electromyography showed incremental response to repeated stimulations, and thymoma with Lambert-Eaton myasthenic syndrome was diagnosed. The patient was successfully treated with video-assisted thoracoscopic extended thymectomy.

Thoracic empyema and lung abscess resulting from gastropulmonary fistula as a complication of esophagectomy.

A benign fistula between the gastric tube and the airway resulting from esophagectomy is a rare complication, but it is a potentially life-threatening status. We present a 59-year-old man with thoracic empyema and lung abscess resulting from a benign gastric tube-to-pulmonary fistula caused by a penetration of the peptic ulcer in the gastric tube four years after an esophagectomy for esophageal cancer. After a thorough conservative management of infection and nutrition, the fistula was successfully repaired surgically with direct closure. The postoperative course was uneventful. Two years and nine months later, the patient retains satisfactory oral feeding status and is in good general condition.