[Organizing Pneumonia with Difficult Differentiation from Lung Cancer:Report of a Case].

A 72-year-old woman underwent a close examination because of chest computed tomography (CT) scan revealed a nodule in the left lower lobe of the lung. Positron emission tomography( PET) showed strong accumulation of fluorodeoxyglucose (FDG) in the lesion. Since lung cancer was strongly suspected, video-assisted thoracoscopic lung biopsy was performed. The lesion was diagnosed as organizing pneumonia by pathology. PET is widely used to distinguish between benign and malignant lung nodules, but FDG accumulation can also be seen in benign diseases such as inflammatory lesions. Abnormal accumulation can also be seen in organizing pneumonia, but strong FDG accumulation such as in this case is relatively rare, and it was difficult to distinguish it from lung cancer.

[Pneumothorax with Birt-Hogg-Dubé Syndrome Diagnosed by Family History:Report of a Case].

Birt-Hogg-Dubé (BHD) syndrome is a rare autosomal and predominantly inherited disorder. A 43 year-old woman was admitted to our hospital for right spontaneous pneumothorax and the thoracoscopic pulumonary wedge resection was performed. A chest computed tomography (CT) scan before surgery showed multiple bilatetal thin walled pulmonary cysts predominant to the lower mediastinum side of the lung field. Since her brother had history of pneumothorax with BHD syndrome. Diagnosed by deoxyribonucleic acid (DNA) sequence analysis of his BHD gene, she was diagnosed as BHD syndrome.

[Pulmonary Tumorlet Associated with Atypical Mycobacterium].

A 55-year-old woman was referred to our department for further examination for chest abnormal shadow in the right lower lobe. Chest computed tomography (CT) showed two nodules in the right lower lobe and positron emission tomography( PET)-CT showed abnormal accumulation of fluorodeoxyglucose (FDG) only in the main lesion. Because of lung cancer could not be denied, she underwent a partial resection of the right lower lobe. The main lesion was diagnosed as granuloma and the other was tumorlet by pathology. Although pulmonary tumorlet is considered a proliferation of neuroendocrine cells rather than a neoplastic lesion, it is sometimes difficult to distinguish it from a neoplastic lesion because its histologic morphology resembles carcinoid or small cell carcinoma.

[Postoperative Recurrent Lung Cancer Successfully Treated with Alternate Day Administration of Gefitinib].

A 57-year-old man was referred to our department for further examination for chest abnormal shadow in the right upper lobe. Positron emission tomography (PET)-computed tomography (CT) showed abnormal accumulation of fluorodeoxyglucose (FDG). Because of lung cancer could not be denied, he underwent right upper lobectomy and the nodule was diagnosed as adenocarcinoma by pathology. A chest CT performed one and a half years after surgery showed multiple lung nodules and was diagnosed as recurrence. Since the deletion mutation of exon19 was confirmed in the epidermal growth factor receptor( EGFR) gene mutation analysis, gefitinib( 250 mg/day) daily administration was started. Multiple lung nodules were almost banished promptly, but severe skin rash developed, so gefitinib administration was reduced to 250 mg/every second day and the skin rush disappeared. In spite of reduced dose antitumor effect was maintained for two years without recurrence of skin rash.

[Rheumatoid Lung Nodule could be Diagnosed by Pulmonary Biopsy:Report of a Case].

A 60-year-old woman was referred to our department for further examination for chest abnormal shadow in the right upper lobe. She had a past history of rheumatoid arthritis. Positron emission tomography-computed tomography (PET-CT) showed mild abnormal accumulation of fluorodeoxyglucose (FDG). Because of lung cancer could not be denied, she underwent partial resection of the right upper lobe and the nodule was diagnosed as a rheumatoid nodule by pathology.

[Surgical Treatment for Thymoma with Good's Syndrome;Report of a Case].

A 50-year-old man was admitted to our hospital for severe pneumonia. An anterior mediastinum tumor and the hypogammaglobulinaemia were detected during treatment of pneumonia, and Good's syndrome was diagnosed. The clinical characteristics of Good's syndrome are increased susceptibility to bacterial infections and opportunistic viral and fungal infections. We planned thymectomy with the perioperative supplementation of immunoganmmagloblin to prevent perioperative infectious complications after pneumonia recovered completely. Extended thymo-thymectomy was performed. Pathological examination revealed type AB thymoma. The hypogammaglobulinaemia did not improved following thymectomy, and the patient had to be treated by immunoglobulin supplementation to maintain adequate trough immunoglobulin G( IgG) values.

[Successful surgical treatment for catamenial pneumothorax at the time of menstruation].

A 39-year-old female was referred to our hospital due to repeated right pneumothorax. Each episode was related to the onset of menstruation, suggesting catamenial pneumothorax. Thoracoscopy showed multiple blue berry spots on the diaphragm. Partial resection of the diaphragm including these lesions were performed. But she had a recurrent right pneumothorax. Treatment with a gonadotropin-releasing hormone analogue was started, resulting in failure to introduce menopose and the pneumothorax repeatedly appeared again. Reoperation was intentionally done at the time of menstruation enable to find the lesion. Patient is free from pneumothorax more than 6 years after surgery.

[Pulmonary sclerosing hemangioma with lymph node metastasis].

Sclerosing hemangioma is unusual pulmonary tumor. During a routine care evaluation, an abnormal shadow was detected in the chest X-ray films of a 38-year-old woman. Chest computed tomography scanning showed a nodule, 3.9 cm in diameter, in the left S6 pulmonary segment. Bronchoscopy performed before the operation could not establish the diagnosis. Since low-grade malignant tumor wassuggested by frozen section analysis at surgery, segmentectomy of left S6 and sampling of interlober lymph node were performed. The tumor was diagnosed as a plmonary sclerosing hemangioma. Metastatic leasion in the interlober lymph node was pathologically confirmed.

Adjuvant surgical treatment of nontuberculous mycobacterial lung disease.

BACKGROUND: According to the 2007 American Thoracic Society/Infectious Diseases Society of America statement on nontuberculous mycobacterial diseases, more evidence for the benefits of adjuvant nontuberculous mycobacterial lung disease surgical intervention is needed before its wide application can be recommended. METHODS: A retrospective review was conducted of 60 consecutive patients who met American Thoracic Society/Infectious Diseases Society of America diagnostic criteria and underwent pulmonary resection for localized nontuberculous mycobacterial lung disease between January 2007 and December 2011. All patients were receiving chemotherapy before resection. RESULTS: Included were 41 women (68%) and 19 men (32%), with a median age of 50 years (range, 20 to 72 years). Of these, 55 patients (92%) had Mycobacterium avium complex disease. Bronchiectatic disease was noted in 29 patients, cavitary disease in 25, both in 4, and nodular disease in 2. The indications for resection were a poor response to drug therapy in 52 patients, hemoptysis in 6, and a secondary infection in 2. Sixty-five pulmonary resections were performed: 1 pneumonectomy, 3 bilobectomies, 39 lobectomies, 17 segmentectomies, 3 lobectomies plus segmentectomies, and 2 wedge resections. There were no operative deaths, and all patients attained sputum-negative status postoperatively. Eleven postoperative complications occurred in 8 patients (12%); relapse was observed in only 2 (3%). CONCLUSIONS: Pulmonary resection combined with chemotherapy is safe, with favorable treatment outcomes, for patients with localized nontuberculous mycobacterial lung disease. Our results support the liberal use of operations for nontuberculous mycobacterial lung disease whenever indicated.

[Remarkable improvement in dyspnea following bronchofiberscopic ethanol injection therapy -a case report].

A 69-year-old man with squamous cell carcinoma( SCC) of the left lower lobe of the lung underwent lobectomy. One year later, radiography performed during check-up revealed pneumonia. After 1 week, he was admitted to the hospital because of dyspnea. Three tumors in his trachea and bronchus had narrowed the respiratory tract, and these were diagnosed as recurrence of SCC. The patient was treated with radiation and bronchofiberscopic ethanol injection (BEI) therapy, following which the tumors reduced remarkably in size; he recovered from respiratory insufficiency and was able to go home. He stayed home for 2 months; however, tumor enlargement was detected subsequently and the patient was at risk of suffocation. This time, the patient received combination therapy that included radiation, TS-1, and BEI. Subsequently, his respiratory airway reopened. BEI offers a quick and safe treatment option and has a rapid effect; therefore, we consider it useful for the treatment of malignant tracheobronchial stenosis.

Risk factors that affect the surgical outcome in the management of focal bronchiectasis in a developed country.

BACKGROUND: The purpose of this study was to demonstrate our surgical experience for focal bronchiectasis in the setting of modern diagnostic modalities and state-of-the-art medical treatment in a developed country. METHODS: Thirty-one patients undergoing 33 lung resections for the treatment of focal bronchiectasis from 1991 to 2009 were reviewed. The mean age was 54 years. Twenty-nine patients (94%) were female; 21 patients (68%) had nontuberculous mycobacterial infection; and 22 patients (71%) received preoperative multiple-drug regimens containing clarithromycin. Five patients (16%) were in an immunocompromised status. All were diagnosed by chest computed tomography scan, and either the right middle lobe or left lingula were involved in 29 (94%). The curve for relapse-free interval was estimated by Kaplan-Meier methods. The factors that affected this curve were examined using Cox's regression analysis. RESULTS: Operative morbidity and mortality were 18% and 0%, respectively. All patients became asymptomatic postoperatively. During the median follow-up of 48 months (11 to 216), 8 patients (26%) experienced recurrence, and the mean relapse-free interval was 34 months (3 to 216). By univariate analysis, an immunocompromised status (p=0.017), Pseudomonas aeruginosa infection (p=0.040), the preoperative extent of bronchiectatic lesion (p=0.013), and the extent of residual bronchiectasis after surgery (p=0.003) were significantly associated with the shorter relapse-free interval. By multivariate analysis, an immunocompromised status (p=0.039), Pseudomonas aeruginosa infection (p=0.033), and the extent of residual bronchiectasis (p=0.009) were independent and significant factors. CONCLUSIONS: Complete resection of bronchiectasis while the disease is localized and is free from Pseudomonas aeruginosa infection is the key for a success. Also, immunocompromised status was suggested to be a risk factor.

Does postoperative serum interleukin-6 influence early recurrence after curative pulmonary resection of lung cancer?

PURPOSE: We examined the influence of inflammatory cytokine levels on postoperative early recurrence in patients who underwent curative lung cancer surgery. METHODS: In 107 patients who underwent curative pulmonary resections for non-small cell lung cancer (NSCLC) from November 2007 to June 2008, we measured serum interleukin-6 (IL-6) levels preoperatively, and on postoperative day (POD) 0, 1, and 2. Between July 2009 and August 2009, 1 year after the date of enrollment of the last patient, we investigated survival status of each patient and identified a group with recurrence. RESULTS: Among 107 patients, 29 patients developed recurrence with a mean follow-up of 18.1 months (range 14 to 21). P-stage was significantly more advanced in the recurrence group than in the non-recurrence group (p = 0.005). Serum IL-6 levels on POD 1 were significantly higher in the recurrence group than in the non-recurrence group (p = 0.007). In Cox's proportional hazards regression, P-stage and serum IL-6 levels on POD 1 were significant independent predicting factors for postoperative early recurrence (p = 0.006, p = 0.003). CONCLUSIONS: The higher the serum IL-6 levels on POD 1, the higher the risk of early postoperative recurrence, even when curative pulmonary resection can be accomplished in lung cancer patients.

Different morbidity after pneumonectomy: multidrug-resistant tuberculosis versus non-tuberculous mycobacterial infection.

To assess whether there is any difference in postoperative morbidity and mortality after pneumonectomy between patients with multidrug-resistant tuberculosis (MDR-TB) and patients with non-tuberculous mycobacterial (NTM) infections. Between January 2000 and December 2007, 61 patients with MDR-TB and 60 patients with NTM infections underwent 66 and 64 pulmonary resections, respectively. Of these, 33 patients were analyzed who underwent a pneumonectomy, including 22 patients with MDR-TB (seven right, 15 left) and 11 patients with NTM infections (seven right, four left). All bronchial stumps were covered with the latissimus dorsi. Patients with NTM infections were predominantly more female, older, thinner, and presented with a higher frequency of culture-positive sputum at operation than patients with MDR-TB. Operative mortality was zero. Morbidities were bronchial stump dehiscence (n=1) and mycobacterial empyema (n=1) for patients with MDR-TB, and acute respiratory failure (n=1), bronchial stump dehiscence (n=5) and mycobacterial empyema (n=2) for patients with NTM infections. Prevalence of bronchial stump dehiscence was significantly higher in patients with NTM infections (P=0.010). Five of six dehiscences occurred after right pneumonectomy. The optimal management of the bronchial stump in the setting of pneumonectomy for NTM infections needs further investigation.

Aggressive surgical treatment of multidrug-resistant tuberculosis.

OBJECTIVE: Because extensively drug-resistant tuberculosis has emerged, adequate control of drug-resistant tuberculosis has become increasingly important. We report on our experience using liberal adjuvant resectional surgery as part of aggressive treatment for multidrug-resistant tuberculosis. METHODS: We retrospectively reviewed the records of 56 consecutive patients who underwent pulmonary resections for multidrug-resistant tuberculosis between January 2000 and June 2007. There were 42 males and 14 females (mean age, 46 years; range, 22-64 years). Isolates were resistant to a mean of 5.6 drugs (range, 2-10 drugs). Multi-drug regimens employing 3 to 7 drugs (mean, 4.6 drugs) were initiated in all patients. Indications for surgery were a high risk of relapse for 37 patients, persistent positive sputum for 18, and 1 with associated empyema. RESULTS: The 56 patients underwent 61 pulmonary resections (3 completion pneumonectomies, 19 pneumonectomies, 33 lobectomies, and 6 segmentectomies). Bronchial stumps were reinforced with muscle flaps in 54 resections. Operative mortality and morbidity rates were 0% and 16%, respectively. All patients attained postoperative sputum-negative status. Relapse occurred in 5 patients; 3 were converted by a second resection, and 1 responded to augmentation of chemotherapy. Late death occurred for 2 patients without evidence of relapse. Among 54 survivors, 53 (98%) were considered cured. CONCLUSION: Surgical treatment that complements medical treatment has proved safe and efficacious for patients with multidrug-resistant tuberculosis. In an era with extensively drug-resistant tuberculosis, an aggressive treatment approach to multidrug-resistant tuberculosis continues to be justified until a panacea for this refractory disease is available.

Experience with pulmonary resection for extensively drug-resistant tuberculosis.

Extensively drug-resistant tuberculosis is becoming a global threat. It is a relatively new phenomenon, and its optimal management remains undetermined. We report our experience in using pulmonary resection for treating patients with this disease. Records were reviewed of 54 consecutive patients undergoing a pulmonary resection for multidrug-resistant tuberculosis at Fukujuji Hospital between 2000 and 2006. These patients were identified using the definition approved by the World Health Organization Global Task Force on extensively drug-resistant tuberculosis in October 2006. Five (9%) patients (3 men and 2 women) aged 31-60 years met the definition. None of the patients was HIV-positive. Although the best available multidrug regimens were initiated, no patient could achieve sputum conversion. Adjuvant resectional surgery was considered because the patients had localized disease. Procedures performed included pneumonectomy (2) and upper lobectomy (3). There was no operative mortality or morbidity. All patients attained sputum-negative status after the operation, and they were maintained on multidrug regimens for 12-25 months postoperatively. All patients remained free from disease at the time of follow-up. Pulmonary resection under cover of state-of-the-art chemotherapy is safe and effective for patients with localized extensively drug-resistant tuberculosis.

[Case of tuberculous psoas abscess successfully treated with surgery during antituberculosis therapy for miliary tuberculosis].

A case of tuberculous psoas abscess complicated during antituberculosis therapy for miliary tuberculosis and successfully treated with surgery was reported. A 20-year-old man visited our hospital because of fever lasting for 3 months. Chest radiography showed miliary nodules in both lungs and transbronchial lung biopsy revealed granuloma. Magnetic resonance imaging of the head showed small lesions in the brain. Computed tomography of the abdomen showed an enlarged paraaortic lymph node and a nodule in the spleen. Needle biopsy of the lymph node revealed necrotic tissue. Mycobacterium tuberculosis was not isolated; however, miliary tuberculosis was highly suspected based on clinical and radiographic findings. Once antituberculosis therapy was initiated with isoniazid, rifampicin, streptomycin, and pyrazinamide, the fever subsided. In spite of improvement of general radiographic findings, a new abscess was found in the right psoas major muscle after 8 months of therapy by computed tomography. A sample of the abscess showed a positive smear, negative culture, and positive PCR test for M. tuberculosis. Although antituberculosis therapy continued for another 6 months, the abscess enlarged to 7 cm and new retroperitoneal lymph nodes also appeared. Surgical drainage and curettage of the abscess was performed. Intra- and post-operative specimens were negative for bacteria, fungi, and M. tuberculosis. The patient was treated with isoniazid, rifampicin, and ethambutol for one year postoperatively. The disease disappeared without any evidence of relapse for 2.5 years after surgery.