Clinical outcomes after tracheostomy in patients with coronavirus disease 2019: a single-center experience in Japan.

PURPOSE: Many patients with coronavirus disease 2019 require mechanical ventilation and tracheostomy. However, the timing and indications for tracheostomy are controversial. This study assessed 11 patients with coronavirus disease 2019 who underwent tracheostomy with clinical information and retrospective analyses. METHODS: A single-center retrospective observational study was performed on patients with coronavirus disease 2019 who underwent tracheostomy between 2020 and 2021. RESULTS: Failure to wean was the most common indication for tracheostomy, followed by extracorporeal membrane oxygenation decannulation and the need for secretion management. After tracheostomy, six patients (54.5%) were liberated from the ventilator. The time from intubation to tracheostomy (21.1 ± 9.14 days) was correlated with the duration of ventilator dependency (36.83 ± 20.45 days, r2 = 0.792, p = 0.018). The mean Acute Physiological and Chronic Health Evaluation II score was significantly lower in the ventilator-liberated group (23 ± 2.77) than in the non-ventilator-liberated group (31 ± 6.13, p = 0.0292). Furthermore, patients with Acute Physiological and Chronic Health Evaluation II scores of < 27 points achieved ventilator liberation and a long-term survival (p = 0.0006). CONCLUSIONS: This study describes the outcomes of a cohort of patients who underwent tracheostomy after intubation for coronavirus disease 2019. The Acute Physiological and Chronic Health Evaluation II score predicted whether or not the patient could achieve ventilator liberation.

Loss of GSTO2 contributes to cell growth and mitochondria function via the p38 signaling in lung squamous cell carcinoma.

Glutathione S-transferase omega 2 (GSTO2) lacks any appreciable GST activity, but it exhibits thioltransferase activity. The significance of GSTO2 in lung function has been reported; however, the precise expression and molecular function of GSTO2 in the lungs remain unclear. In the present study, we found that GSTO2 is expressed in airway basal cells, non-ciliated, columnar Clara cells, and type II alveolar cells, which have self-renewal capacity in the lungs. Contrastingly, no GSTO2 expression was observed in 94 lung squamous cell carcinoma (LSCC) samples. When human LSCC cell lines were treated with 5-aza-2'-deoxycytidine, a DNA-methyltransferase inhibitor, GSTO2 transcription was induced, suggesting that aberrant GSTO2 hypermethylation in LSCC is the cause of its downregulation. Forced GSTO2 expression in LSCC cell lines inhibited cell growth and colony formation in vitro. In a subcutaneous xenograft model, GSTO2-transfected cells formed smaller tumors in nude mice than mock-transfected cells. Upon intravenous injection into nude mice, the incidence of liver metastasis was lower in mice injected with GSTO2-transfected cells than in those injected with mock-transfected cells. In addition, GSTO2 induction suppressed the expression of ß-catenin and the oxygen consumption rate, but it did not affect the extracellular acidification rate. Furthermore, GSTO2-transfected cells displayed lower mitochondrial membrane potential than mock-transfected cells. When GSTO2-transfected cells were treated with a p38 inhibitor, ß-catenin expression and mitochondrial membrane potential were recovered. Our study indicated that the loss of GSTO2 via DNA hypermethylation contributes to the growth and progression of LSCC, probably by modulating cancer metabolism via the p38/ß-catenin signaling pathway.

Cessation of methotrexate and a small intestinal resection provide a good clinical course for a patient with a jejunum perforation induced by a methotrexate-associated lymphoproliferative disorder: a case report.

BACKGROUND: Methotrexate (MTX) is a frequently used drug in the treatment of rheumatoid arthritis (RA), but occurrences of lymphoproliferative disorders (LPD) have been reported in patients undergoing an MTX regimen. Almost half of the patients with methotrexate-associated lymphoproliferative disorders (MTX-LPD) have extranodal lesions; moreover, although extremely rare, digestive tract perforations resulting from the extranodal lesions of MTX-LPD have also been reported. CASE PRESENTATION: We describe the case of an 81-year-old woman with RA who had been prescribed MTX at 6 mg per week for the past 11 years. She was admitted to our hospital with occasional abdominal pain and was first diagnosed with enteritis. Her abdominal pain did not improve, and a computed tomography scan showed abdominal effusion and free air in the abdominal cavity. She was diagnosed with a digestive tract perforation and underwent emergency surgery. The perforation site was identified in the jejunum, and she underwent small intestinal resection around the perforated region. The pathological findings showed an ulcer in the jejunum and infiltration of large atypical lymphocytes around the perforated region. An immunohistochemical examination revealed the expression of a cluster of differentiation 20 and latent membrane protein 1. Considering the patient's history of RA treated with MTX, she was diagnosed as having Epstein-Barr virus (EBV)-related MTX-LPD with a histological diagnosis of EBVMCU. MTX was discontinued after the surgery, and her soluble interleukin-2 receptor (sIL-2R) levels had returned to normal 1 year later. She has had a good course for the 2 years since surgery and remains asymptomatic with no recurrence of MTX-LPD, as confirmed by the sIL-2R levels. CONCLUSION: We experienced a rare case of the jejunum perforation induced by MTX-LPD. Since only a few cases have been reported of a patient with small intestinal perforation induced by MTX-LPD, further research is necessary to evaluate the clinicopathological features of MTX-LPD. The patient had disease remission after surgery and by discontinuing MTX treatment; our case did not require chemotherapy. EBV-positive patients, especially those with a pathological presentation of EBVMCU, could have a higher likelihood of remission, which could have been a factor in the present case.

Clear cell neuroendocrine tumor in the gallbladder diagnosed as a benign polyp preoperatively: a case report.

BACKGROUND: Gallbladder neuroendocrine neoplasm is a rare disease that is divided into neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs). Clear cell NETs of the gallbladder are extremely rare. We report the case of a patient with polypoid clear cell NET G1 of the gallbladder who underwent laparoscopic cholecystectomy. CASE PRESENTATION: A 10-mm pedunculated polyp in the gallbladder neck was detected on a follow-up abdominal ultrasound in a 60-year-old man with chronic hepatitis and hepatitis B without medication. Six months later, an abdominal ultrasound revealed that the tumor had enlarged to 12 mm in size. He was asymptomatic and had no abnormalities in other laboratory examinations, including the tumor markers, carcinoembryonic antigen and CA19-9. Abdominal ultrasound showed a 12-mm polyp in the neck of the gallbladder with perfusion and focal thickening of the gallbladder wall. A gallbladder stone was also seen in the fundus. An enhanced computed tomography scan and magnetic resonance imaging revealed a polypoid lesion and gallbladder stone located at the neck of the gallbladder and the fundus, respectively. Malignancy could not be excluded, and hence, a laparoscopic cholecystectomy was performed. Pathologically, a pedunculated polyp (14 × 11 × 15 mm) was observed in the neck of the gallbladder, and the polypoid lesion comprised nests or trabecular growths of clear NET cells in the lamina propria (ENETS: T1N0M0; AJCC: T1aN0M0). Immunohistochemical staining with synaptophysin, chromogranin A, and CD56 was confined to the tumor. The pathological diagnosis was clear cell NET G1 of the gallbladder. Although clear cell NET is often described as a distinct manifestation of von Hippel-Lindau disease (VHL), the patient had no past medical or family history of VHL. Until his one-and-a-half-year follow-up, the patient was doing well and without any signs of recurrence. CONCLUSION: We report an extremely rare case of gallbladder clear cell NET G1. When NET G1 is incidentally identified in a gallbladder surgical specimen, clinical information and pathological findings should be considered as references.

Free superficial circumflex iliac artery perforator fascial flap for reconstruction of upper abdominal wall with extensive infected herniation: A case report.

Complex abdominal wall reconstruction is challenging, and vascularized fascia is preferred for active infection cases. Pedicled tensor fascia lata flap is commonly used for lower abdominal wall reconstruction, and free vascularized fascial flap based on the lateral circumflex femoral artery (LCFA) is used for upper abdominal wall reconstruction. However, LCFA-based flap transfer requires invasive and time-consuming muscle dissection and a large recipient vessel. The purpose of this report was to present a new application of superficial circumflex iliac artery (SCIA) perforator (SCIP)-based fascial flap for upper abdominal wall reconstruction. A 70-year-old male suffered from a long-lasting extensive abdominal wall herniation complicated with mesh infection and cutaneous fistulae following multiple herniation repair with synthetic mesh. After complete debridement of infected tissues, there was a 29 x 26 cm full-thickness abdominal wall defect. Components separation was performed to minimize the defect size, after which 12 x 7 cm defect remained in the upper abdominal wall. A 20 x 10 cm SCIP deep fascial flap was elevated based on the deep branch of the SCIA. The SCIP flap was transferred to the defect to reconstruct the upper abdominal wall. The SCIP was anastomosed to the deep inferior epigastric artery perforator with supermicrosurgical perforator-to-perforator anastomosis. Postoperative course was uneventful with good functional and esthetic results of the donor and recipient sites 11 months after the surgery. Although further studies are required, SCIP fascial flap may be an option for upper abdominal wall reconstruction.

Multilocular thymic cyst detected during COVID­19 treatment in an HIV­positive adult man: A case report and literature review.

A multilocular thymic cyst (MTC) is a rare mediastinal tumor with multiloculated cyst-like structures in the anterior mediastinum. This tumfor is associated with inflammatory diseases, including human immunodeficiency virus (HIV) infection. The present study reports a case of MTC detected during coronavirus disease 2019 (COVID-19) treatment in an adult who was tested HIV positive. An anterior mediastinal tumor was incidentally detected on computed tomography in a 52-year-old man with a 20-year history of HIV infection on the 9th day of COVID-19. The patient was asymptomatic with no notable physical findings. Magnetic resonance imaging revealed a 28-mm bilocular cyst. Robot-assisted thoracoscopic tumor resection was performed. Pathological examination showed that the cyst was lined with squamous or cuboidal epithelium, and the cystic lesion wall was mainly composed of thymic tissue with follicular hyperplasia. Based on these findings, the patient was diagnosed with MTC. To date, only 15 MTC cases have been reported in patients with HIV, and the majority of cases showed HIV infection-related symptoms such as lymphoid interstitial pneumonia and parotid gland enlargement. The present case was atypical for an HIV-related MTC because it did not involve HIV infection-related symptoms, suggesting the possibility for an alternative etiology such as COVID-19. Further reports on MTC development in patients with COVID-19 are required to elucidate the relationship between MTC and COVID-19.

Kallikrein-related peptidase 13 expression and clinicopathological features in lung squamous cell carcinoma.

Lung squamous cell carcinoma (LSCC) is associated with poor prognosis. Molecular targeting drugs have been demonstrated to be effective for lung adenocarcinoma; however, they are often not effective for LSCC. Kallikrein-related peptidase 13 (KLK13) expression enhances the malignancy of lung adenocarcinoma; however, its expression and crucial role in LSCC remain largely unknown. The present study examined the relationship between the KLK13 expression and clinicopathological features of LSCC. A total of 94 patients diagnosed with LSCC who underwent lobectomy, segmentectomy or wedge resection were selected. KLK13 expression was evaluated through immunostaining of formalin-fixed paraffin-embedded sections of surgical specimens. Of the 94 LSCC samples, 70 exhibited no KLK13 expression, while the remaining 24 exhibited ectopic expression. KLK13 expression in tumors was focal and restricted to the cytoplasm of keratinized cells. LSCC cases were classified into KLK13-negative and KLK13-positive groups, and KLK13 expression was positively associated with E-cadherin expression (P=0.0143). Associations between KLK13 expression and keratinization (P=0.0052) or absence of lymphatic vessel invasion (P=0.0603) were observed; however, these trends did not reach statistical significance. The present findings indicated that KLK13 expression in keratinized LSCC may have a protective role in lymphatic vessel invasion of LSCC, which suggests its significance for therapeutic applications against LSCC.

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

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

Pulmonary leiomyoma with iceberg tumor growth pattern: A case report.

Pulmonary leiomyoma is a rare disease, accounting for ~2% of cases of benign lung tumors. Pulmonary leiomyomas can be classified as tracheobronchial or pulmonary parenchymal, or as having an iceberg growth pattern, wherein the tumor extends into both the bronchial and pulmonary cavities. In the present report, a 41-year-old man complaining of sputum and discomfort during swallowing was referred to the National Center for Global Health and Medicine, because of an abnormal shadow on chest radiography and computed tomography (CT). Since the follow-up CT showed that the tumor in the third right lung segment had increased and progressed along the intra-bronchus over time, thoracoscopic right upper lobectomy was performed and leiomyoma was pathologically diagnosed. After resection, the symptoms of airway irritation improved. Since respiratory symptoms and radiographical findings are nonspecific with tracheobronchial and pulmonary parenchymal types of pulmonary leiomyoma, the identification of symptoms and determination of the extent of the lesion are necessary for treatment. In cases of iceberg growth pattern, in which the tumor extends into both the bronchial and pulmonary cavities, surgical resection should be considered.

Solitary pleural tuberculoma diagnosed by thoracoscopic surgical resection.

Tuberculoma is a manifestation of pleural tuberculosis. Although the clinical manifestation of tuberculoma has been widely reported, the pathogenesis of this condition still remains unclear. An abnormal shadow was detected on the chest radiograph of a 44-year-old man with a history of pulmonary tuberculosis. Computed tomography revealed a well-defined, elliptical 44 mm nodule located in the right posterior thoracic cavity. Thoracoscopic surgery was performed to rule out malignant tumors. Although loose adhesions were observed throughout the thoracic cavity, a nodule was found between the visceral pleura and parietal pleura. En bloc resection was performed, and the patient was pathologically diagnosed with tuberculoma. An acid-fast bacterium culture was negative, and the patient's recovery was uneventful without chemotherapy. Surgical resection should be considered to rule out malignancy, because tuberculomas are difficult to distinguish from malignant pleural tumors.

Complete thoracoscopic surgery for extensive emphysema in the right upper and middle lobes caused by right B5 bronchial atresia.

Bronchial atresia is a rare congenital condition that may lead to infectious complications. Almost all patients with this condition are diagnosed early in life with normal lungs, making them particularly suitable candidates for thoracoscopic surgery. A 30-year-old man was referred to our hospital due to an abnormal shadow on chest radiography taken 7 years prior. Despite being diagnosed with B5 bronchial atresia, he refused to undergo surgical resection. Seven years later, he developed right chest pain. Computed tomography showed B5 bronchial occlusion, mucoid impaction and emphysematous changes. Treatment with thoracoscopic right middle lobectomy and S3 partial resection using four ports resulted in good lung expansion after discharge. This study highlights that thoracoscopic surgical resection should be considered in patients with bronchial atresia.

Ectopic intrapulmonary follicular adenoma diagnosed by surgical resection.

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

Prolonged survival of a patient with aortogastric fistula treated with combined surgery and endovascular stent placement: A case report.

INTRODUCTION: Aortogastric tube fistula is a rare and fatal complication of esophagectomy. The treatment for aortogastric tube fistula with active infection is challenging, wherein a contamination around the fistula can cause a high risk of aneurysm and recurrence of bleeding, even if large amount of bleeding is controlled immediately. PRESENTATION OF CASE: We present a case of a 54-year-old male patient who underwent lower esophagectomy for esophageal squamous cell carcinoma 22 years ago. He developed aortogastric tube fistula on postoperative day 46. The patient underwent two surgeries and stenting for aortogastric tube fistula and pseudoaneurysm between days 46 and 120 following the first surgery, and digestive reconstruction was performed 6 months after the first surgery. Computed tomography and esophagogastroduodenoscopy were performed periodically, and the postoperative course was uneventful for 22 years. However, the patient died from pneumonia at the age of 76 years. Autopsy findings revealed no recurrence of esophageal cancer, anastomotic complications, or stent issues. The fistula between the aorta and gastric tube was closed with a stent and connective tissue. Intrathoracic findings revealed that the cause of death was severe bilateral pneumonia. DISCUSSION: Immediate hemodynamics stabilization and interval infection control enabled successful disease management. CONCLUSION: Tenting for aneurysm was performed under aseptic conditions, and the patient did not experience recurrence of esophageal cancer and stent issues, which contributed to the long-term survival of 22 years.

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

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

Seventeen primary malignant neoplasms involving the skin, ovary, esophagus, colon, oral cavity, and ear canal: a case report and review of the literature.

Multiple primary malignant neoplasm (MPMN) is a rare disease with two or more malignant neoplasms in one patient. In less than 0.1% of cancer patients, four or more occur. MPMN is frequently associated with hereditary cancer syndrome, although in rare cases, it is not. A female patient developed 17 MPMNs. Although they were successfully treated with surgery, radiation, and adjuvant chemotherapy, the patient died from the recurrence of ovarian cancer. To explore genetic susceptibility to MPMN, immunohistochemical analysis, microsatellite instability analysis, germ line exome sequencing, and unscheduled DNA synthesis assays were performed. However, the results of immunohistochemical analysis and microsatellite instability indicated that there were no known hereditary cancer syndromes, and exome sequencing with 88 representative genes associated with hereditary cancer syndrome revealed no variants. An unscheduled DNA synthesis assay to rule out xeroderma pigmentosum was also performed, but the result was negative. While the presence of multiple neoplasms is rare, the present case represents 17 primary neoplasms with no associations with hereditary cancer syndrome. Although the cause of MPMN was not detected in this patient, careful follow-up and deliberate cancer screening enabled successful disease management over 17 years from the appearance of the first neoplasm.