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.

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.

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.

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.

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.

[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.

Response to pembrolizumab in a patient with primary lung adenocarcinoma originated from indium lung.

BACKGROUND: Indium is a metal used as a compound called indium-tin oxide for liquid crystal display. Its inhalation causes lung toxicity, resulting in a new occupational lung disease called indium lung. Although the carcinogenicity of indium has been reported in an animal model, its carcinogenicity in humans is unknown. CASE PRESENTATION: This is the first reported case of a primary lung cancer originating from indium lung. In this report, we describe a 46-year-old man with interstitial pneumonia-type indium lung diagnosed 16 years ago. The initial symptom was left chest pain, and computed tomography showed a mass adjacent to the aorta with left pleural effusion. Specimens collected using video-assisted thoracoscopy revealed an adenocarcinoma with a high expression of programmed cell death-ligand 1 (cT4N0M1a stage IVA). Although the lesions showed a remarkable aggressive nature, the patient benefited from pembrolizumab, a monoclonal antibody against programmed cell death 1, which was used as second-line therapy for 2 years. CONCLUSIONS: It is important for clinicians to be aware of lung cancer development in indium-exposed workers or in patients with indium lung, as this could have an aggressive behavior. Treatment with immune checkpoint inhibitors is an option even in patients with interstitial pneumonia-type indium lung.

Consolidation volume and integration of computed tomography values on three-dimensional computed tomography may predict pathological invasiveness in early lung adenocarcinoma.

PURPOSE: To investigate the relationship between three-dimensional computed tomography (3D-CT) findings and pathological invasiveness in lung adenocarcinoma. METHODS: We retrospectively evaluated 95 patients who underwent surgical resection of lung adenocarcinoma of ≤ 20 mm. The diameters, volumes, and CT values of tumor consolidation were analyzed. We defined the modified CT value by setting air as 0 and water as 1000 and assumed a correlation with pathological invasiveness. Pre-invasive lesions and minimally invasive adenocarcinomas were classified as non-invasive adenocarcinoma. We compared the clinico-radiological features with pathological invasiveness. Receiver operator characteristic (ROC) curves and recurrence-free survival curves were constructed. RESULTS: Twenty-six non-invasive adenocarcinomas and 69 invasive adenocarcinomas were evaluated. The multivariate analysis revealed that the consolidation volume and the integration of modified CT values were the most important predictors of pathological invasion. The area under the ROC curve and the cut-off values of the consolidation volume were 0.868 and 75 mm3, respectively. The area under the ROC curve and the cut-off values of the integration of modified CT values were 0.871 and 80,000, respectively. There was no recurrence in cases with values below the cut-off across all parameters. CONCLUSION: The consolidation volume and integration of modified CT values were shown to be highly predictive of pathological invasiveness.

Factors related to physical and mental components of quality of life in the community-dwelling frail older persons.

[Purpose] The aim of this study was to investigate factors associated with changes in both the physical and mental components of quality of life (QOL) in of community-dwelling frail older persons in long-term care and to clarify which aspects are important to maintaining physical and mental components of QOL. [Participants and Methods] In this 1 year follow-up cohort study, participants were older persons from a single day care rehabilitation center in Japan. The Medical Outcome Study 8-Item Short-Form Health Survey (MOS-SF8), which gives both physical component summary (PCS) and mental component summary (MCS) scores, was used as the main QOL assessment. Participants were divided according to their level of QOL maintenance according to changes in PCS and MCS scores over the study period, and the variables were compared between the groups. [Results] PCS domain was significantly associated with forced vital capacity and the MCS domain was significantly associated with the Geriatric Depression Scale and Dysphagia Risk Assessment for the Community-Dwelling Elderly Test. [Conclusion] Depression, reduced pulmonary function, and reduced deglutition ability were independently related to low QOL. Assessment of these factors could be beneficial for maintaining the physical and mental components of QOL in community-dwelling frail older persons in long-term care.

A population-based cohort study to evaluate the effectiveness of lung cancer screening using low-dose CT in Hitachi city, Japan.

OBJECTIVES: To evaluate the effectiveness of lung cancer screening using low-dose computed tomography for the general population, we conducted a retrospective cohort study of screening for participants among Hitachi residents. MATERIALS AND METHODS: Citizens aged 50-74 who underwent low-dose computed tomography screening at least once during 1998-2006 were defined as the computed tomography group, and those who underwent X-ray screening at least once during the same period, but did not receive low-dose computed tomography screening throughout the follow-up period, were defined as the XP group. We investigated the lung cancer incidence rate, mortality rate and all-cause mortality rate for both groups from the first lung cancer screening to the end of 2012. RESULTS: In the computed tomography group (17 935 residents; 9790 males and 8145 females), 273 cases of lung cancer (1.5%), 72 cases of lung cancer death (0.4%), and 885 cases of all-cause death (4.9%) were observed. On the other hand, 164 cases (1.1%) of lung cancer, 80 cases (0.5%) of lung cancer death and 1188 cases (7.6%) of all-cause death were observed in the XP group (15 548 residents; 6526 males and 9022 females). The hazard ratios of the computed tomography group to the XP group adjusted for gender, age and smoking history were 1.23 for lung cancer incidence rate, 0.49 for lung cancer mortality rate and 0.57 for all-cause mortality rate. Non-smokers and light smokers (<30 pack-years) had a significantly lower lung cancer mortality (0.41 and 0.21, respectively). CONCLUSION: low-dose computed tomography screening for a population including non-smokers and light smokers may be effective.

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.

[Spontaneous tension hemothorax due to rupture of a solitary fibrous tumor of the posterior mediastinum].

A 37-year-old man was transported by ambulance to our hospital due to abrupt chest pain. The pain began when he was practicing a combative-type sport. He denied any impact or blunt trauma. A chest radiograph revealed massive left pleural effusion with a mediastinal shift. Thoracentesis revealed a hemothorax;therefore, we performed an emergency thoracotomy. The intraoperative findings revealed a rupture of a posterior mediastinal tumor itself located between the descending aorta and the thoracic vertebra. After we identified the artery of Adamkiewicz that originates away from the tumor and evaluated the degree of tumor extension into the inter-vertebral foramen, we safely performed an elective tumor resection 1 month after the initial emergency operation. In patients with a hemothorax caused by rupture of the tumor itself, an elective tumor resection after detailed investigation should be considered if hemostasis can be achieved in the emergency thoracotomy.

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.

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.

Comparison of patient-reported outcomes and clinical outcomes between pleurectomy and pleural covering added to thoracoscopic bullectomy for primary spontaneous pneumothorax.

Background: An optimal surgical procedure for primary spontaneous pneumothorax (PSP) has not yet been established. The study aimed to compare patient-reported outcomes (PROs) and clinical outcomes between parietal pleurectomy (pleurectomy) and visceral pleural covering with absorbable prosthesis (covering) added to thoracoscopic bullectomy in patients with PSP. Methods: From January 2015 to April 2018, PROs were prospectively evaluated using EuroQOL-5 dimensions-5 levels (EQ5D). Questionnaires were administered preoperatively and at 1, 3, and 5 days and 1 month postoperatively. The perioperative outcomes were compared retrospectively. Recurrences and postoperative symptoms in the distant period were investigated cross-sectionally by telephone and mail surveys in February 2020. Results: In total, 26 and 29 patients underwent covering and pleurectomy, respectively. The visual analog scale score of the EQ5D on postoperative day 1 was significantly better in the pleurectomy group than in the covering group. There was no significant difference in the frequency of PROs in the EQ5D including pain. Perioperative outcomes, such as postoperative chest tube placement, and hospital stay, were comparable between the groups, except for the operative time. There was no significant difference in the recurrence rate and frequency of residual symptoms, e.g., chest discomfort in the long-term outcomes. Conclusions: PROs and clinical outcomes were comparable between the two procedures. Further studies are required to determine the optimal treatment procedure.

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.

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.

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.