Postoperative Lung Torsion With Retained Viability: The Presentation and Surgical Indications.

BACKGROUND: We review our experience with postoperative lung torsion with retained viability. METHODS: A total of 2165 patients underwent pulmonary resection (lobectomy or segmentectomy) at our institution between 1 January, 1986, and 31 March, 2017. Eight (0.3%, six males and two females: median age, 68 years) had lung torsion with retained viability. RESULTS: The right upper lobe was resected in seven patients, while the left upper segment was resected in one patient. The lung torsion with retained viability was the right middle lobe in seven patients and the left lingular segment in one patient. A bronchoscopic examination was performed in four patients to diagnose the pulmonary torsion; however, it demonstrated no specific findings. Subsequently, computed tomography (CT) was performed in all the patients, and lung torsion was diagnosed in all the patients based on the CT findings. None of the patients showed any symptoms when lung torsion was diagnosed in them. The diagnosis of pulmonary torsion was made at a median of 4 days (range, 1-22 days) after the initial surgery. Six patients underwent detorsion of the affected lung, while one patient had a lobectomy, and one patient received conservative management. The lungs of all patients in which detorsion was performed adequately re-expanded. Frequent pneumonia in the viable torsed lung was diagnosed as a cause of death in the one patient who received conservative management. CONCLUSION: The timely decision to follow a surgical approach for lung torsion with retained viability can lead to a satisfactory outcome.

[A case of adenoid cystic carcinoma of the thoracic esophagus after neoadjuvant chemotherapy].

A 60-year-old man was admitted to our hospital with a tumor in the thoracic esophagus, and squamous cell carcinoma was detected by endoscopic biopsy. On computed tomography, the tumor was suspected of having invaded adjacent organs by so the patient was given neoadjuvant chemotherapy consisting of low-dose CDDP and 5-FU. After 2 courses of chemotherapy, a subtotal esophagectomy was performed. The resected specimen showed no residual squamous cell carcinoma but another tumor was found in the submucosal layer which had a cribiform pattern in a solid nest. The tumor cells were positive for S-100 protein and an Alcian-blue-positive substance in the gland, so the tumor was diagnosed as an adenoid-cystic carcinoma.

Mucoepidermoid Carcinoma of Arising from a Bronchogenic Cyst of the Diaphragm.

INTRODUCTION: Bronchogenic cysts may rupture or become infected, and malignant degeneration may occur. Although various types of malignant degeneration have been described, only a few reports of mucoepidermoid carcinoma arising from a bronchogenic cyst have been published. We report such a case. CASE: A 77-year-old female was referred to our institution for evaluation of left chest pain. A computed tomography scan showed an enhancing 65 × 70 mm mass of the left diaphragm. Based on the intraoperative findings of an intradiaphragmatic tumor involving the lower lobe of the left lung, the resection of the tumor with the wedge resection of left lower lobe and partial resection of the left diaphragm was performed. Histopathologic examination revealed a mucoepidermoid carcinoma arising from a bronchogenic cyst of the diaphragm with the presence of fibrous adhesion to the lower lobe. CONCLUSION: We believe that complete resection of any bronchogenic cyst is justified.

Lingular segment torsion following a left upper division segmentectomy.

INTRODUCTION: Numerous publications regarding lung torsion have reported lobar torsion after lobectomy. On the other hand, torsion of the remaining segment after segmentectomy is extremely rare. We herein report a rare case of lingular segment torsion following a left upper division segmentectomy. CASE: A 68-year old female underwent thoracoscopic segmentectomy of the left upper division. She underwent chest radiography immediately after the initial surgery, which revealed complete expansion on the operated side. Routine chest radiograph findings on postoperative day 1 demonstrated atelectasis on the operated side, although she did not have any symptoms. Chest computed tomography was conducted because a follow-up chest radiograph on postoperative day 5 showed no improvement, and she was diagnosed with torsion of the lingular segment. We performed an exploratory thoracotomy. Based on intraoperative findings, the lingular segment was found to have a 90° clockwise torsion along the pedicle axis, although the segment was viable. We straightened the kinked lingular segment and affixed the lingular segment to the left lower lobe. The postoperative course was uneventful. CONCLUSION: Although lobectomy is the most common cause of lung torsion, physicians should check for lung segment torsion when performing segmentectomy.

The long-term prognosis of induction chemotherapy followed by surgery for N2 non-small cell lung cancer: A retrospective case series study.

INTRODUCTION: The long-term prognosis of induction chemotherapy followed by surgery for N2 non-small lung cell cancer (NSCLC) remains controversial. PATIENTS AND METHODS: We retrospectively reviewed the data and assessed the prognosis of 31 N2-NSCLC patients who underwent induction chemotherapy followed by surgery at our institution between January 1999 and December 2013. Potential prognostic factors, such as age, gender, tumor histology, tumor marker levels, tumor size, the number of N2 lymph nodes, the time from the last induction chemotherapy to the date of surgery, induction chemotherapy, RECIST response, downstaging status, pathological stage, adjuvant chemotherapy, and EF, were analyzed. RESULTS: The chemotherapy regimens of 30 of the 31 patients included a platinum agent. Complete resection was performed in 96.7% of the cases. Pathological downstaging was induced in 9 (29%) of the 31 patients. The median follow-up period was 7.89 years. The median DFI was 13.9 months. The recurrence rate was 74.2%. The 5-year OS was 56.9%. Univariate analyses revealed that none of the factors significantly affected OS, while the tumor histology had a significant effect on the DFI. CONCLUSION: Although the recurrence rate in our study was similar to previous studies, our survival data were much better than those of past reports. Although the tumor histology was the only factor that had a significant association with DFI in the current study, the possibility of bias exists.

A rare case of congenital bronchoesophageal fistula in an adult.

INTRODUCTION: When congenital bronchoesophageal fistulas exist without atresia of the esophagus, the diagnosis can be delayed, although symptoms may occur early following fistula development. Therefore, while they are usually found in infants, they can be extremely rarely found in adults. We herein report a rare case of bronchoesophageal fistula without atresia in an adult. CASE: An 69-year-old male presented to the outpatient clinic with a decades-long history of cough with expectoration immediately after taking food, especially liquids. Computed tomograph, esophagoscopy, and esophagography revealed the fistulous communication between the mid-esophagus and right lower lobe bronchus, with consolidation in the right lower lobe. We performed right lower lobectomy with the closure and excision of the fistula. The histopathology of the fistula revealed the mucosa to be lined by stratified squamous epithelium. There was no evidence of inflammation, granuloma, or carcinoma. CONCLUSION: In conclusion, despite the benign nature of this malformation, if left untreated, it can cause long-term debilitating respiratory symptoms associated with the fistula. Therefore, the diagnosis should be considered in the evaluation of recurrent lung infection.

Partial Anomalous Pulmonary Venous Connection Coexisting with Lung Cancer: A Case Report and Review of Relevant Cases from the Literature.

A 45-year-old man had an abnormal shadow in the right lung field on an annual screening chest X-ray. He was diagnosed with Stage IA (cT1bN0M0) lung cancer. Initially, we did not notice an anomalous vein on non-contrast computed tomography. However, we found that the right upper lobe bronchus branched from the lateral wall of the right main bronchial orifice, above the level of the common right upper lobe bronchus. Therefore, the bronchus was thought to be a tracheal bronchus. We carefully reevaluated the patient using three-dimensional computed tomography angiography. This technique showed that the anomalous right superior pulmonary vein drained into the azygos vein along the superior vena cava. These findings confirmed a partial anomalous pulmonary venous connection of the right upper lobe. We performed video-assisted thoracoscopic right upper lobectomy and mediastinal lymph node dissection for definitive treatment for lung cancer and partial anomalous pulmonary venous connection. No hemodynamic problems occurred in the postoperative course.

Giant pedunclated lipoma of the esophagus: A case report.

INTRODUCTION: Although Esophageal lipoma is extremely rare and pathologically benign, surgical excision of the lipoma is recommended when symptomatic or uncertain biological behavior. In general, some of the esophageal lipoma has a stalk. The pedunclated non-invasive tumor can be removed by stalk ligation, which is either endoscopic or surgical approache. Therefore, the preoperative evaluation is essential. We herein present a case of a huge esophageal lipoma. CASE REPORT: A 82-year-old man, with a wet cough and dyspnea for 6 months, who had the huge mass that almost completely occupied the esophageal lumen, was referred to our institution for the treatment.We diagnosed the mass as non-invasive tumor that has a stalk at the close to the esophageal orifice, by the CT image using air injection into esophageal lumen. We performed excision of the pedunclated huge mobile mass by esophagotomy via right thoracic approach with use of endoloop. Pathological examination showed a lipoma. CONCLUSION: In conclusion, an adequate preoperative evaluation to identify the correct origin of the stalk is mandatory for a successful treatment. In order to do the adequate preoperative evaluation and successful surgery, our diagnostic method of CT image can be effective.

Analysis of gastrointestinal metastasis of primary lung cancer: Clinical characteristics and prognosis.

The prevalence of gastrointestinal metastasis of lung cancer is low. The aim of the present study was to analyze the frequency and clinical characteristics of metastases to the gastrointestinal tract by retrospectively assessing the clinical records of 2,066 patients with lung cancer. A total of 7 patients (0.33%) were diagnosed with gastrointestinal metastasis, including 4 patients with adenocarcinoma, 1 patient with large cell carcinoma and 2 patients with pleomorphic carcinoma. Furthermore, 3 of the patients presented with small bowel metastases, 2 with gastric metastases, 1 with large bowel metastasis and 1 with metastasis of the appendix. The mean time between the diagnosis of the lung tumors and the identification of gastrointestinal metastasis was 13.5 months (range, 3-49 months). The mean time between the identification of the gastrointestinal metastasis and mortality was 100.6 days (range, 21-145 days). In conclusion, the prognosis of patients with recurrence in distant organs, including the gastrointestinal tract, may be worse than patients with recurrence in distant organs, excluding the gastrointestinal tract, particularly those with symptomatic gastrointestinal metastasis. Therefore, the presence of clinical gastrointestinal metastasis may be life threatening; comprehensive evaluations are required to detect and monitor gastrointestinal metastasis during follow-up.

Lung Cancer Detected 5 Years after Resection of Cancer of Unknown Primary in a Mediastinal Lymph Node: A Case Report and Review of Relevant Cases from the Literature.

We report the rare and interesting case of a primary lung cancer detected 5 years after cancer of unknown primary (CUP) of a mediastinal lymph node (LN) was resected. A 40-year-old male was diagnosed with adenocarcinoma of unknown primary in a mediastinal lymph node after resection of the mediastinal tumor. Five years after resection of the CUP in mediastinal LN, a small, abnormal nodular shadow in left upper lobe was detected by chest CT. This pulmonary tumor was diagnosed as a lung adenocarcinoma. The pathological and immunohistological findings of the resected pulmonary tumor resembled those of the LN resected 5 years before. We speculated that the pulmonary lesion represented primary lung cancer that enlarged later than the metastatic mediastinal LN. This case illustrates the importance of careful observation and long-term follow-up in patients treated for CUP of a thoracic LN.

Repeated Localized Treatment for Endobronchial Metastasis of Thymic Carcinoma.

BACKGROUND: Endobronchial metastases derived from nonpulmonary tumors are uncommon, although a variety of malignant tumors have been reported to be associated with endobronchial metastasis. We herein report a case of repeated bronchoscopic resection of endobronchial metastasis of a thymic carcinoma. CASE REPORT: A 59-year-old woman was diagnosed with primary thymic carcinoma, Masaoka stage IVA, in May 2009. In June 2013, she developed dyspnea. A chest CT scan revealed left upper lobe atelectasis, and a polypoid lesion was noted in the left upper bronchus on bronchoscopy. A pathological examination of the lesion revealed metastatic thymic carcinoma, and bronchoscopic resection was performed for symptom relief. However, the lesion was partially resected, based on the operative findings, which showed the peripheral part of B3 to be the origin of the polypoid lesion and bronchoscopy could not be used to reach this site. Although the patient underwent repeated partial bronchoscopic resection of the polypoid lesion due to the symptoms of dyspnea caused by regrowth of the polypoid metastatic thymic cancer in the left upper bronchus, she remains alive with an excellent performance status and no evidence of widespread or other metastases for more than 5 years after the initial diagnosis. CONCLUSIONS: We speculate that this case was successfully managed with repeated partial bronchoscopic resection because thymic cancer tends to be a slow-growing tumor. Therefore, it is worth resecting endobronchial metastatic thymic carcinoma repeatedly in such cases, even if the resection is partial.

Endobronchial electrocautery wire snare prior to wedge bronchoplastic lobectomy for central-type lung cancer: A case report.

INTRODUCTION: Occasionally, it is difficult to design an appropriate treatment plan for central-type lung cancer. We present the usefulness of combined treatment with a bronchoscopic electrocautery wire snare prior to wedge bronchoplastic lobectomy for patients with central-type lung cancer. PRESENTATION OF CASE: A 64-year-old man, who was a long-term corticosteroid user, complicated with left obstructive pneumonia. Chest CT scan showed total atelectasis of the left lung due to obstruction of the left main bronchus by an endobronchial tumor, which protruded from the left lower lobe. He was diagnosed with squamous cell carcinoma of c-T3N0M0 Stage IIB. Endobronchial tumor resection of the left main bronchus was initially performed, which resulted in an improvement of the patient's symptoms; the patient's pulmonary function was evaluated and bronchial extension of the tumor was also observed. He subsequently underwent elective bronchoplastic left lower lobectomy and lymphadenectomy, with no recurrence 2 years after surgery. DISCUSSION: A variety of therapeutic bronchoscopic intervention are available for the treatment of advanced central-type lung cancer. The effectiveness of endobronchial electrocautery using the snare wire has been reported for the treatment of respiratory tract tumors, which allowed planning of the following treatment procedure. CONCLUSION: The combination of a bronchoscopic electrocautery wire snare and bronchoplastic surgical procedure was useful for the treatment of central-type lung cancer such as in our case.

An analysis of and new risk factors for reexpansion pulmonary edema following spontaneous pneumothorax.

BACKGROUND: The major risk factor for reexpansion pulmonary edema (RPE) following the treatment of spontaneous pneumothorax is thought to be chronic lung collapse. However, a long-term collapsed lung does not always cause RPE. The purpose of this study was to define other risk factors for RPE among patients undergoing drainage for the treatment of spontaneous pneumothorax. METHODS: We retrospectively reviewed all the patients with spontaneous pneumothorax who had been treated at our hospital during a 5-year period. The duration of symptoms, location and size of the pneumothorax, size of the chest tube, and pleural effusion, which can occur coincidentally with pneumothorax, were compared in patients who did and did not experience RPE. RESULTS: Forty patients were underwent drainage for the treatment of a spontaneous pneumothorax between January 2007 and December 2012. RPE developed in 13 of the 40 (32.5%) patients. In the multivariate analysis, the presence of pleural effusion coincident with pneumothorax contributed to the risk for RPE [odds ratios (OR), 1.557; 95% confidence intervals (CI), 1.290-1.880]. The duration of symptoms, location and size of the pneumothorax and size of the chest tube were similar between the groups. Symptomatic RPE was associated with a larger pneumothorax size. CONCLUSIONS: The rate of RPE following spontaneous pneumothorax is higher than was previously reported. Our findings suggest the presence of pleural effusion coincidentally with pneumothorax may therefore be a new risk factor for RPE.

Salvage operation for late recurrence after stereotactic body radiotherapy for lung cancer: two patients with no viable cancer cells.

We report two patients who underwent salvage lung resection for suspected local recurrence on computed tomography image findings after stereotactic body radiotherapy; however, the pathologic findings indicated no viable tumor cells. Distinguishing between posttreatment changes and tumor recurrence after stereotactic body radiotherapy on the image findings is difficult; therefore, the determination of surgical indications requires comprehensive evaluations.

A case of synchronous double primary lung cancer presenting with pleomorphic carcinoma and adenocarcinoma.

BACKGROUND: Recently, synchronous multiple lung cancer (SMPLC) has sometimes been detected as a result of improved radiological imaging, although the occurrence of SPMLC is still rare. To the best of our knowledge, there have been no reported cases of with synchronous double primary lung cancer presenting with pleomorphic carcinoma and adenocarcinoma. We herein report such a case. CASE REPORT: A 64-year-old male was referred to our institution for an abnormal shadow in the apex of the left lung in April 2012. CT revealed 2 nodules that measured 15 mm in the left S(1+2b) and 20 mm in the left S3c. We suspected that the lesions were malignant, although the diagnosis could not be confirmed by transbronchial lung biopsy of the lesions. Therefore, we performed the left upper lobectomy. The results of the pathological examination of the nodule in S3c showed adenocarcinoma of pT1aN0M0, stage IA. The nodule in S(1+2b) was found to be pleomorphic carcinoma, pT1aN0M0, stage IA. In November 2012, the patient underwent an esophagogastroduodenoscopy because of anemia. The image findings showed a gastric ulcer on the greater curvature of his stomach. The pathological examination of the biopsy specimen from the ulcer revealed the metastatic cancer from pleomorphic carcinoma. In addition, abdominal CT revealed bilateral adrenal metastasis. Although the patient received chemotherapy, it was not effective. It was difficult to continue the chemotherapy because his performance status worsened. He died in May 2013. CONCLUSIONS: The present case was associated with a poor prognosis, even though the pathological stage of each tumor was stage IA. The prognosis of SMPLC may be associated with the histologic type, although the prognosis of SMPLC remains unclear due to its rarity.

Long-term survival after surgical treatment of metachronous bilateral adrenal metastases of non-small cell lung carcinoma.

Background Although resection of the metastases is the treatment of choice for unilateral solitary adrenal metastasis of non-small cell lung carcinoma (NSCLC), the surgical treatment for bilateral adrenal metastases is quite rare, likely due to the coexistence of multiple synchronous metastases at other sites and/or primary adrenal insufficiency following bilateral adrenalectomy. We herein report a rare case of asynchronous metastasis of NSCLC to the bilateral adrenal glands with long-term survival after bilateral adrenalectomy. Case Report A 70-year-old male underwent right upper lobectomy for lung adenocarcinomaT2aN2M0, stageIIIA following induction chemotherapy. Forty-four months later, right adrenalectomy of a right adrenal tumor was performed, which revealed metastatic lung carcinoma. Following the administration of adjuvant chemotherapy, a metastatic tumor was detected in the left adrenal gland. Although there were no other signs of distant metastasis on radiological examinations, he underwent the chemotherapy due to the risk of adrenal insufficiency. However, on follow-up CT the adrenal lesion was found to have enlarged; therefore, left adrenalectomy was performed. Three years and six months later, he was doing well, with no evidence of recurrence. Conclusions Selected patients with solitary adrenal metastases of NSCLC can benefit from an aggressive treatment approach, even if such metastases are bilateral.

Utility of the serum ProGRP level for follow-up of pulmonary carcinoid tumors.

PATIENT: Female, 67. FINAL DIAGNOSIS: Pulmonary carcinoid tumor. SYMPTOMS: Abnormal shadow on chest X-ray. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: Pulmonology. OBJECTIVE: Rare disease. BACKGROUND: Although pulmonary carcinoid tumors are generally considered to represent a low-grade malignancy, atypical carcinoids are more aggressive than typical carcinoids, metastasizing more commonly to both regional lymph nodes and distant sites. The treatment of choice for localized disease is surgery. In cases of advanced or metastatic disease, medical treatments, including chemotherapy, have not been proven to be very successful. Therefore, providing careful follow-up is extremely important. In general, tumor markers, such as the level of CYFLA21-1, are often useful for monitoring lung cancer. However, there are currently no sensitive tumor markers for carcinoid tumors. We herein report a rare case of an atypical carcinoid of the lung with the elevation of the serum ProGRP level. CASE REPORT: A 67-year-old female was referred to our hospital for an abnormal chest X-ray. CT revealed an 18×13 mm nodule in the right middle lobe with no significant mediastinal lymphadenopathy. The serum tumor marker, the ProGRP level, was significantly elevated (161 ng/ml). We performed a right middle lobectomy, because the pathological diagnosis of lung cancer was confirmed according to the results of a rapid frozen section biopsy of the lesion, although the pathological type could not be precisely determined by the frozen section alone. The final pathological diagnosis was atypical carcinoid. The level of ProGRP decreased (69 ng/ml) within 1 month after the surgery. CONCLUSIONS: The ProGRP level may be useful for monitoring carcinoid tumors, although no serum tumor markers are highly specific or sensitive for detecting recurrences and/or distant metastasis of pulmonary carcinoid tumors. In conclusion, ProGRP should be further evaluated as biomarker in a larger series of patients to determine whether it demonstrates any significant correlation with cancer recurrence.

Lung cancer mimicking lung abscess formation on CT images.

PATIENT: Male, 64 FINAL DIAGNOSIS: Lung pleomorphic carcinoma Symptoms: Cough • fever MEDICATION: - Clinical Procedure: - Specialty: Oncology. OBJECTIVE: Unusual clinical course. BACKGROUND: The diagnosis of lung cancer is often made based on computed tomography (CT) image findings if it cannot be confirmed on pathological examinations, such as bronchoscopy. However, the CT image findings of cancerous lesions are similar to those of abscesses.We herein report a case of lung cancer that resembled a lung abscess on CT. CASE REPORT: We herein describe the case of 64-year-old male who was diagnosed with lung cancer using surgery. In this case, it was quite difficult to distinguish between the lung cancer and a lung abscess on CT images, and a lung abscess was initially suspected due to symptoms, such as fever and coughing, contrast-enhanced CT image findings showing a ring-enhancing mass in the right upper lobe and the patient's laboratory test results. However, a pathological diagnosis of lung cancer was confirmed according to the results of a rapid frozen section biopsy of the lesion. CONCLUSIONS: This case suggests that physicians should not suspect both a lung abscesses and malignancy in cases involving masses presenting as ring-enhancing lesions on contrast-enhanced CT.

Right lower lobectomy with middle lobe preservation after right upper lobectomy in lung cancer of the right lower lobe.

A 73-year-old woman who underwent right upper lobectomy for tuberculosis 40 years earlier was diagnosed with adenocarcinoma, clinical stage IIA (T2bN0M0), in the right lower lobe of her lung. A lower lobectomy with preservation of the middle lobe was performed. The patient had an uneventful recovery. She is alive without signs of recurrence or requirement for additional oxygen support 6 years after the operation.