[Primary Lung Cancer Associated with Dilated Phase of Hypertrophic Cardiomyopathy;Report of a Case].

A 66-year-old man diagnosed as dilated phase of hypertrophic cardiomyopathy (D-HCM) was pointed out an abnormal shadow on routine chest radiography. The patient had past medical history of hypertension, congestive heart failure and chronic obstructive pulmonary disease. The computed tomography showed a 3.8 cm-sized tumor in the left lower lobe of the lung, and histopathological examination revealed squamous cell carcinoma (cT2aN0-1M0, cStage I B-II A). Cardiosonography showed diffuse hypokinesis from basal to mid area, and ejection fraction was 36.3%. Sporadic ventricular premature contraction was seen by the Holter electrocardiogram. The patient underwent left lower lobectomy with node lymph node dissection (ND1b). The circulatory condition of the patient was stable during surgery. After surgery, careful management of electrolytes and fluid infusion, and the regular medication was started again on the next day of surgery.

[Tension Pneumothorax Developing Hemothorax after Chest Tube Drainage].

A 61-year-old man visited a physician complaining of progressive chest pain and dyspnea. The chest radiography showed complete collapse of the right lung suggesting tension pneumothorax. The patient was transferred to our hospital. A small amount of the right pleural effusion was also seen in addition to pulmonary collapse on the chest radiography. Chest drainage was performed, and continuous air leakage was seen. At 2 hours later, air leakage was disappeared but the bloody effusion was noted. The chest radiography revealed massive effusion and the enhanced computed tomography showed active bleeding. The emergency surgery was conducted. The bleeding point was a ruptured vessel between the apical parietal pleura and the pulmonary bulla. Hemostasis and the resection of the bullae was performed. Careful observation after chest drainage is necessary to prepare unexpected hemothorax in case of tension pneumothorax with pleural effusion.

[Results of non-rigid prosthetic reconstruction with expanded polytetrafluoro-ethylene( ePTFE) soft tissue patch following chest wall resection for malignant tumors].

Twenty patients underwent chest wall reconstruction using expanded polytetrafluoroethylene(ePTFE) soft tissue patch following resection between June 1996 and December 2012. The patients included 15 men and 5 women, aged 18 to 80 years. The indications for resection included 4 primary tumors, 8 metastatic tumors, and 8 infiltrating tumors. The lesions were located anteriorly in 10 patients, laterally in 5 patients and posteriorly in 5 patients. Skeletal resection involved an average of 2 ribs in 19 patients, and a partial sternectomy in 1 patient. The size of chest wall defects ranged from 20 to 210 cm2( mean, 69.8 cm2). Lung resection was performed in 7 patients included a wedge resection, 5 lobectomy, and a bilobectomy. Chest wall defects were closed primarily with ePTFE soft tissue patch. There were no critical complications or postoperative mortalities. The mean follow-up in all patients is 72.7 months. Recurrence of malignancy occurred in 10 patients included a local recurrence in 1 patient, and metastases in 9 patients. The overall postoperative 5-year survival rate is 61.0%. Non-rigid prosthetic reconstruction with ePTFE soft tissue patch provides satisfactory outcome. New prosthetic materials have to be examined whether they are superior to ePTFE soft tissue patch.

[Hemopneumothorax after thoracic sympathetic nerve block; report of a case].

A 72-year-old man, who had been treated pneumothorax 50 years ago, visited a physician complaining of dyspnea after thoracic sympathetic nerve block for postherpetic neuralgia. The patient was diagnosed as pneumothorax, and was consulted to our hospital. Clinical sign and the chest radiography suggested tension hemopneumothorax, and the chest drainage was immediately performed. Although bloody fluid of 1,100 ml was initially drained, no further increase was noted. The patient was discharged on the 21st hospital day.

[Elderly Bochdalek hernia found out by intestinal obstruction].

A 78-year-old man, who had been pointed out elevation of the diaphragm by chest radiography, visited local physician complaining of abdominal pain and vomiting. He was referred to our hospital and was diagnosed as intestinal obstruction. The patient had neither respiratory symptoms nor findings of peritonitis. The radiography revealed intestinal gas with neveau formation in the left thorax. The computed tomography showed dilatation of the stomach and small intestine, and a diaphragmatic hernia was suspected. Although conservative treatment was started, radiographic and laboratory findings got worse on the 5th hospital day. The patient underwent surgery for a left diaphragmatic hernia with the intestinal obstruction. Diagnosis of Bochdalek hernia with hernia sac was established. The content of hernia was the perforated small intestine. Postoperative course was almost uneventful, and the patient was discharged on the 35th postoperative day without pyothorax. In treatment of adult Bochdalek hernia, early surgery is important because patients with incarceration or perforation often experience severe postoperative complication.

Chest radiotherapy after left upper lobectomy may be a risk factor for thrombosis in the pulmonary vein stump.

BACKGROUND: Thrombosis in the pulmonary vein stump (PVS) is not a well-known complication after pulmonary lobectomy, but it has the potential to cause embolism to vital organs. The aim of this study was to evaluate the risk factors for thrombosis in the PVS after pulmonary lobectomy. METHODS: A total of 439 patients who underwent pulmonary lobectomy from 2008 to 2017 were retrospectively reviewed, and 412 patients were further analyzed. The state of the PVS was evaluated by chest contrast-enhanced computed tomography (CECT). Univariate analysis was performed to evaluate the potential risk factors for thrombosis in the PVS. RESULTS: Thrombosis in the PVS was detected in 6 of 412 (1.5%) patients, and 5 of them underwent left upper lobectomy (LUL) (5/100, 5.0%) (P = 0.004). In the analyses of the LUL group, postoperative chest radiotherapy was identified as a risk factor for thrombosis in the PVS (P = 0.024), and postoperative atrial fibrillation showed a tendency to be a risk factor for thrombosis (P = 0.058). CONCLUSIONS: Chest radiotherapy after LUL is a possible risk factor for thrombosis in the PVS. Periodic chest CECT is recommended after postoperative chest radiotherapy for patients after LUL.

[Bronchioloalveolar carcinoma producing CA19-9].

A 76-year-old man, who had underwent radiation for laryngeal cancer 5 years before, was pointed out abnormal pulmonary lesion on computed tomography. The 4.6 cm-sized lesion was seen in the upper lobe of the left lung. Endoscopic brushing cytology revealed adenocarcinoma. The patient was diagnosed as primary lung cancer of T2N0M0, clinical stage IB. Preoperative serum CA19-9 was elevated to 250 U/ml, although other tumor markers were within normal limits. The patient underwent left upper lobectomy with mediastinal lymph node dissection. Histologically, the lesion was diagnosed as well differentiated adenocarcinoma, mucinous subtype of bronchioloalveolar carcinoma (BAC) in World Health Organization (WHO) classification. Immunohistochemistry shows positive for CA19-9 and thyroid transcription factor-1 (TTF-1).

[Surgical treated pulmonary metastasis from prostatic cancer; report of a case].

A 74-year-old man who had been treated by endocrine therapy for prostatic cancer for 7 years was pointed out an abnormal shadow on the chest X-ray. Computed tomography showed solitary tumor in the lower lobe of the left lung. Transbronchial lung biopsy revealed pulmonary metastasis form prostatic cancer. Because no other metastatic lesions were detected, the patient underwent surgery for pulmonary lesion. The wedge resection of the left lung was performed. Microscopically, the diagnosis of pulmonary and multiple pleural metastases was established. The pulmonary metastasis without bone nor lymph node metastasis is rare. Pleural metastasis should be considered in case of pulmonary metastasis from prostatic cancer. Surgical indication for pulmonary metastasis from prostatic cancer has to be decided carefully.

[Multiple nodular pulmonary amyloidosis complicated with Sjögren syndrome].

A 67-year-old woman, who had been treated for Sjögren syndrome and rheumatoid arthritis for 10 years, was consulted for examination of multiple nodular pulmonary nodules. She has been pointed out multiple pulmonary nodules on chest computed tomography (CT) for 7 years, of which the number and the size gradually increased. When visuting our hospital, approximately 20 nodules up to 10 mm in size were noted. Thoracoscopic resection of the nodule was performed and histological diagnosis was amyloid, which was negative for A- and P- component and positive for transthyretin. Neither amyloid deposition in other organs nor abnormal protein in serum and urine was detected. The diagnosis of localized nodular pulmonary amyloidosis was established. As far as our knowledge, this is the 1st report of transthyretin amyloidosis with Sjögren syndrome.

[Assessment of meteorological conditions in relation to the onset of spontaneous pneumothorax in young adults].

Thirty-eight patients less than 30-year-old with spontaneous pneumothorax, of which onset date were known between January 2001 and December 2007, were included in this study. Meteorological factors such as temperature, humidity, atmospheric pressure, amount of rainfall and actual sunshine duration were assessed for the onset days of spontaneous pneumothorax (SP days) compared with days without pneumothorax (non-SP days) in the analyzed periods. The difference of those meteorological factors between the index day and one day before were also assessed. No significant difference was found in meteorological factors between SP and non-SP days. While, significant change in minimal temperature between SP days and non-SP days was found (+1.000 degrees C vs -0.015 degrees C, p=0.019). Meteorological factors may affect the onset of spontaneous pneumothorax in young adults. However, further assessment of accumulation of the patients is necessary including multi-institute study.

Left superior pulmonary vein stump thrombosis and right renal infarction after left upper lobectomy: case report and literature review.

Left upper lobectomy (LUL) has been considered to have a higher risk of thrombus formation in the pulmonary vein stump (PVS) than other lobectomies. A case of thrombus formation in the PVS and right renal infarction detected by contrast-enhanced computed tomography (CECT) 12 days after LUL is presented. The thrombus in the PVS was considered to be related to the renal infarction because of the lack of other potential explanations. After intravenous heparin treatment for 1 week and continuous oral anticoagulation, the thrombus in the PVS became smaller 3 months after the operation, and it basically disappeared after 1 year. Scar formation was detected in the area of renal infarction 3 months after the operation, and no specific change was detected from then on. One should consider performing postoperative chest and abdominal CECT routinely within 1 week after LUL, and, if thrombosis is found, antithrombotic therapy might then be given.

Novel approach for predicting occult lymph node metastasis in peripheral clinical stage I lung adenocarcinoma.

BACKGROUND: Occult nodal metastasis results in a poor prognosis for lung cancer patients. The aim of this study was to develop an efficient approach for predicting occult nodal metastasis in peripheral clinical stage I lung adenocarcinoma. METHODS: Data for 237 peripheral clinical stage I lung adenocarcinoma patients who underwent complete resection were retrospectively reviewed. Univariate and multivariate analyses were performed to investigate predictors of occult nodal metastasis. Kaplan-Meier analysis was performed for survival. RESULTS: Occult nodal metastasis was detected in 26/237 (11.0%) patients. Nodule type, tumor SUVmax, whole tumor size, solid tumor size, and preoperative serum carcinoembryonic antigen (CEA) were identified as preoperative predictors of occult nodal metastasis (all P<0.05). Solid tumor size (P<0.001) and preoperative serum CEA (P=0.004) were identified as independent predictors on multivariate analysis. A prediction model was established using the independent predictors. The occult nodal metastasis rate was 2.4% with solid tumor size ≤2.3 cm (low-risk group), 17.0% with solid tumor size >2.3 cm and CEA ≤5 ng/mL (moderate-risk group), and 56.0% with solid tumor size >2.3 cm and CEA >5 ng/mL (high-risk group). The occult nodal metastasis rate was significantly higher in papillary-predominant (11.0%) and solid-predominant subtypes (28.6%; P=0.001). Patients having a micropapillary component had a significantly higher occult nodal metastasis rate (24.2%) compared with no micropapillary component (P=0.007). Histological subtype with micropapillary component and all preoperative predictors were significant prognostic factors affecting disease-free survival (DFS) (all P<0.05). CONCLUSIONS: A novel approach to predict occult nodal metastasis was developed for peripheral clinical stage I lung adenocarcinoma. It would be helpful for selecting candidates for stereotactic ablative radiotherapy (SABR) or wedge resection and mediastinoscopy or endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA). Complete nodal dissection should be performed for moderate to high-risk patients or patients with poor histologic subtypes.

Management of acute ischemic stroke after pulmonary resection: incidence and efficacy of endovascular thrombus aspiration.

OBJECTIVE: We analyzed acute ischemic stroke by thromboembolism in the early period after lung cancer surgery. METHODS: A retrospective review of the clinical records of patients who underwent lung resection for primary lung cancer was performed. Patients who underwent lobectomy, bilobectomy, and pneumonectomy were included. The clinical characteristics of the patients, the incidence of atrial fibrillation (Af) after surgery, and the incidence of acute ischemic stroke were analyzed. The clinical courses of patients having acute ischemic stroke were also reviewed. RESULTS: In 4 (0.6%) of 696 patients, acute ischemic stroke occurred in the early period during hospitalization after lung cancer surgery. Acute ischemic stroke occurred within 4 days in three cases and after 4 days in one case. The resection site of the lung was the left side in all cases, and there were three cases of left upper lobectomy and one case of left lower lobectomy. As for the two recent patients, thrombus removal was performed by a neurosurgeon, and both cases achieved successful recanalization. The time between symptom detection and recanalization was 205 and 170 min, respectively. One patient was cured without any residual effect of disease, and the other patient's hemiplegia resolved and aphasia improved. CONCLUSION: Since cerebral infarction impairs the patient's quality of life, thrombus removal should be considered if possible.

[Treatment for oncogenic emergencies of the cardiovascular system].

Cardiac tamponade and superior vena cava(SVC)syndrome are important oncogenic emergencies of the cardiovascular system. Depending on the nature of the emergency, its severity, the progression of malignancies, general condition and proper treatment should be chosen in each patient. The treatment to be first considered for cardiac tamponade is percardiocentesis and tube pericardiotomy. It is important to improve cardiac function by prompt drainage after diagnosis with cardiac ultrasonography. To avoid recurrence of cardiac tamponade, pericardial fenestration and instillation of anticancer agents into the pericardium are sometimes added. In patients with SVC syndrome, treatment should be determined after enhanced computed tomography. Although surgery, chemotherapy and radiation are important treatments for malignances, stenting in obstruction of SVC is a safe and effective method to improve symptoms promptly.

Comparison of perioperative and oncological outcomes between video-assisted segmentectomy and lobectomy for patients with clinical stage IA non-small cell lung cancer: a propensity score matching study.

BACKGROUND: Segmentectomy for lung cancer remains controversial because of the complexity of the procedure and concern about an increased recurrence rate. It is important to compare perioperative and oncological outcomes between segmentectomy and lobectomy. METHODS: From January 2007 to December 2016, 41 segmentectomies by video-assisted thoracic surgery (VATS) and 122 VATS lobectomies for 163 patients with clinical stage IA non-small cell lung cancer (NSCLC) were performed. Clinicopathological factors, including recurrence rate and survival rate, were compared. In order to reduce biases of outcomes, clinicopathological factors were used for propensity score matching (PSM). Then, 41 VATS segmentectomies and 41 lobectomies were selected and further analyzed. RESULTS: No significant differences were seen between the two groups in age, pulmonary function, comorbidity, operative time, blood loss, chest tube duration days, postoperative stay days, complications, histological type, and multiple primary rate. Smoking index resected number of nodes, tumor size, lymph node metastasis rate, and pathological stage were higher in the lobectomy group than in the segmentectomy group (P<0.05). In the lobectomy group, 16 patients (13.1%) had recurrence, and 2 patients (1.6%) died because of cancer progression. There were no significant differences in the recurrence rate and prognosis between the two groups. In addition, Cox regression analysis suggested that sex, lymph node metastasis, and pathology stage were associated with recurrence (P<0.05), but no factor was an independent prognostic factor. After PSM, the two groups had similar clinicopathological factors, and the type of operation still had no relationship with the recurrence rate or the death rate. CONCLUSIONS: Perioperative and oncological outcomes of VATS segmentectomy are similar to those of VATS lobectomy for patients with clinical stage IA NSCLC. VATS segmentectomy can be considered one of the surgical procedures appropriate for patients with clinical stage IA NSCLC.

[Successfully treated case of cervical trachea injury caused by suicide].

A 52-year-old man stabbed in his neck and abdomen by a kitchen knife for the purpose of suicide. He was immediately transferred by ambulance car. Subcutaneous emphysema was not observed. Stabbed wounds were observed in the neck and the abdomen. Radiography and computed tomography showed subcutaneous and mediastinal emphysema. The patient was diagnosed as having trachea injury. After admission, emphysema progressed rapidly and respiratory distress appeared. The patient was orally intubated and emergency surgery was performed. The stabbed wound was found to extend to thyroid grand and cricotracheal ligament. After thyroidectomy, the injured trachea was repaired primarily. The course of the patient was almost uneventful, and was discharged on the 23th operative day. He was diagnosed as having alcoholism by a psychiatrist. The patient died due to suicide by hanging 16 months after surgery. Orotracheal intubation and primary suture were effective in a patient with trachea injury. Prevention of suicide is also important after leaving hospital in patients with history of suicide.

Successfully repaired traumatic tracheal disruption and cardiac rupture with cardiopulmonary support.

A 19-year-old man suffering from dyspnea associated with tracheal and cardiac rupture from a traffic accident was found by bronchoscopy to have a 7.5 cm longitudinal tear in the membranous portion of the trachea. Right posterolateral thoracotomy was conducted and open ventilation through the left main bronchus initiated with standby cardiopulmonary bypass cannulation of the right femoral artery and vein. When oxygenation was poor, extracorporeal circulation was initiated through the cannulated artery and vein. Under the cardiopulmonary bypass, we safely repaired the tracheal laceration and cardiac rupture.

A clinical study of the prognostic factors for postoperative early recurrence in patients who underwent complete resection for pulmonary adenocarcinoma.

PURPOSE: The 2-[F-18]-Fluoro-2-deoxy-D-glucose (FDG) uptake in positron emission tomography (PET) and serum neutrophil/lymphocyte ratio (NLR) are recently noteworthy prognostic factors. We studied the prognostic factor to predict early recurrence after curative resection for pulmonary adenocarcinoma including FDG uptake and NLR. METHODS: We performed a retrospective review of 23 patients who underwent a complete resection for pulmonary adenocarcinoma. The patients were divided into 2 groups: 19 patients in the disease-free group, and 4 patients in the recurrent group. Clinical and pathological factors concerning the recurrence within 1 year of surgery were analyzed between two groups. RESULTS: No significant differences between the recurrent group and disease-free group was seen in age, gender, CEA, NLR, CRP, pathological stage, pleural invasion, pathological grading, Ki-67 expression, venous invasion and lymphatic invasion. The SUVmax was significantly elevated in the recurrent group (12.5 ± 2.01 vs. 5.70 ± 3.97, p = 0.0094). Tumor size was significantly larger in the recurrent group (5.58 ± 0.71 vs. 3.62 ± 1.33 cm, p = 0.0058). The first, recurrent sites in 4 patients were brain, in 3 patients; and lung, in 1 patient. CONCLUSION: Both tumor size and SUVmax are possible predictors of early recurrence after curative resection in patients with pulmonary adenocarcinoma. Although it is impossible to determine the SUVmax as an independent prognostic factor, the SUVmax may be one of the predictors of early hematogenous recurrence in surgically treated pulmonary adenocarcinoma.

Pulmonary embolism and cerebral venous thrombosis after thoracoscopic surgery for benign pulmonary disease.

A-76-year-old woman consulted for open biopsy for a pulmonary mass. Thoracoscopic wedge resection was performed. The lesion was histologically diagnosed as nonspecific inflammation. On the first postoperative day (POD1), the patient lost consciousness transiently. Eleven hours after the first stroke, the patient experienced a second stroke together with hypoxia. Pulmonary perfusion scan on POD2 showed multiple perfusion defects, and the patient was diagnosed with pulmonary embolism (PE). Thrombolitic therapy was started. Neurological symptoms didn't improve, and cerebral angiography on POD3 showed delayed perfusion in superficial veins. The patient was diagnosed with cerebral venous thrombosis (CVT). Thrombolytic and anticoagulant therapy had been continued, and the patient was found to have hemorrhagic cerebral infarction on POD11. After persistent therapy, the patient was discharged on POD120. Although both PE and CVT are rare complications after thoracic surgery, we must consider these complications in patients undergoing thoracic operations including thoracoscopic surgery.

Bleeding Meckel diverticulum associated with a vitellointestinal artery aneurysm found on preoperative angiography: report of a case.

An 18-year-old man was admitted to a local hospital with abdominal pain and bloody stool. Upper and lower gastrointestinal endoscopy failed to show any bleeding sites; however, an angiography of the superior mesenteric artery done on hospital day 4 showed an abnormal artery with an aneurysm, branching from the ileal artery. This artery was thought to be the vitellointestinal artery, a feeding artery of Meckel diverticulum. After embolization, he was transferred to our hospital, where we performed emergency laparotomy with partial resection of the ileum, including a bleeding Meckel diverticulum. Pathological examination revealed ectopic gastric mucosa and peptic ulceration, which we assumed was the origin of the bleeding. The patient had an uneventful postoperative course. Visceral artery aneurysms are rare but important vascular lesions because of their potential for fatal rupture. Although a minimally invasive procedure can be performed for a vitellointestinal artery aneurysm in patients with asymptomatic Meckel diverticulum, we treated our patient surgically because he presented with hemorrhagic shock and had been unresponsive to an H(2)-receptor antagonist.