The standard treatment for resectable non-small cell lung cancer (NSCLC) located in the superior sulcus is neoadjuvant chemoradiotherapy followed by highly invasive resection. Based on the results of the CheckMate 816 trial, which showed a marked improvement in the efficacy of neoadjuvant chemo-immunotherapy, we report a case of minimally invasive resection after neoadjuvant nivolumab plus chemotherapy for superior sulcus NSCLC, resulting in a pathologic complete response. The patient was a 76-year-old man with a 65-mm right superior sulcus tumour diagnosed as squamous cell carcinoma with 95% PD-L1. After two courses of neoadjuvant nivolumab plus chemotherapy, the tumour was completely resected through an 11-cm right lateral thoracotomy with second rib resection and first rib preservation. No residual tumour cells were observed in the specimen, and the patient had a pathologic complete response. This report represents a new treatment option for superior sulcus tumours.
Objectives Descending necrotizing mediastinitis (DNM) is a poor prognosis disease. This study aims to examine the patient background and treatment of DNM and to identify more effective treatments for DNM. Methods The patient background and treatment of 11 patients who underwent surgery for DNM between November 2010 and June 2021 were studied. The patients were divided into six patients who underwent continuous saline irrigation (group I) and five patients who did not (group N). The differences in the drainage duration and length of hospital stay between the two groups were retrospectively investigated. Results Eleven patients were treated for DNM: six male and five female, with a median age of 61 years (35-79). Comorbidities included diabetes mellitus in three cases; one patient was administered steroids. The pathways of occurrence were anterior tracheal gap/vascular visceral gap/posterior visceral gap in group I (2/1/2) and group N (0/2/4). Progression was I/IIA/IIB according to Endo's classification in group I (1/1/4) and group N (3/1/1). The mean duration of irrigation was 9.0 ± 3.7 days, and the drainage duration in group I was 17.5 ± 8.2 days, which was significantly shorter than 31 ± 13.6 days in group N ( p < 0.048). The hospital stays in group I was 29.3 ± 8.4 days, which was significantly shorter than that in group N (68 ± 27.1 days; p < 0.015). Conclusions Irrigation therapy significantly shortened the drainage duration and hospital stay. Irrigation is a useful treatment for DNM.
A 72-year-old man was diagnosed with hypercalcaemia 13 years ago. He was diagnosed with hyperparathyroidism associated with a parathyroid tumour and surgery was performed. Postoperatively, his serum calcium levels, which had once normalized, rose again. Medical treatment for hypercalcaemia failed to control the condition. A chest computed tomography showed multiple pulmonary nodules which were diagnosed as pulmonary metastases of parathyroid carcinoma. The tumour was considered to be the cause of the hypercalcaemia and volume reduction surgery was performed. Immediately after surgery, the patient presented with hypocalcaemia and required calcium correction with Calcium Gluconate Hydrate. Since then, the serum calcium level has stabilized and the patient has progressed without medical treatment. Parathyroid carcinoma is rare. This is a valuable case in which the serum calcium level was controlled by surgery. The patient also developed post-operative hypocalcaemia, which should be reported.
PURPOSE: Atrial fibrillation (AF) frequently occurs after pulmonary resection and is commonly referred to as postoperative atrial fibrillation (POAF). This study explored whether or not POAF is related to the recurrence of AF in the chronic phase. METHODS: A total of 1311 consecutive patients without a history of AF who underwent lung resection based on a diagnosis of lung tumor were retrospectively analyzed. RESULTS: POAF occurred in 46 patients (3.5%), and a logistic regression analysis revealed that the age (p < 0.05), history of hyperthyroidism (p < 0.05), and major lung resection (p < 0.05) were independent predictors of POAF. AF events in the chronic phase were observed in 15 (32.6%) and 45 (3.6%) patients with and without POAF, respectively. A Cox regression analysis revealed that POAF was the only independent predictor of AF development in the chronic phase (p < 0.01). The Kaplan-Meier curve and log-rank test revealed that the cumulative incidence of AF in the chronic phase was significantly higher in patients with POAF than in those without POAF (p < 0.01). CONCLUSION: POAF was an independent predictor for AF in the chronic phase after lung resection. Further investigations including cases of catheter ablation and optimal medical therapy for patients with POAF after lung resection are needed.
Atrial Fibrillation , Humans , Atrial Fibrillation/epidemiology , Atrial Fibrillation/etiology , Retrospective Studies , Risk Factors , Lung , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/diagnosis
Pulmonary nocardiosis is a rare disease that is often difficult to cure because of its tendency to recur. Here, we report a case of refractory localized pulmonary nocardiosis caused by Nocardia mexicana. A 60-year-old Japanese woman had recurring pulmonary nocardiosis four times previously and each time she was treated with antibiotics for a sufficient duration; nevertheless, the disease continued to recur, probably because of resistance to antibiotics. As a fifth treatment, we performed middle lobe resection and pre- and post-operative antimicrobial therapy for 6 months. The combination of medication and surgery was useful for treating refractory localized pulmonary nocardiosis.
A 75-year-old female patient was referred to our hospital due to an abnormal shadow detected by chest X-ray. Computed tomography scans revealed a well-circumscribed nodule measuring 28 mm between B4 and B5 in the right middle lobe. Because the tumor was in the center of right middle lobe, a middle lobe resection was performed. The tumor was located within the lung and there were no obvious pleural surface changes. Postoperative histological findings showed 34-mm firm and round tumor, and well circumscribed without involving the visceral pleura. The pathologic examination revealed proliferating spindle-shaped cells with a random fascicular arrangement with continuity to the pulmonary interstitium. Not much cellular atypia was observed. Immunohistochemical staining indicated that the tumor was positive for STAT6, CD34. The final diagnosis was an intrapulmonary benign solitary fibrous tumor (SFT). Even benign intrapulmonary SFTs that have been completely resected may later become malignant and recur, and careful follow-up is necessary.
Our medical team observed a right upper lobe nodule in a 78-year-old man who was treated with warfarin for chronic atrial fibrillation. The nodule was diagnosed as adenocarcinoma via intraoperative frozen sectioning. We performed video-assisted right upper lobectomy and mediastinal lymph node dissection. Warfarin was discontinued in the perioperative period. However, unfractionated heparin was administered. Nonetheless, the patient developed acute arterial occlusion of the lower extremities on post-operative day 7. Contrast-enhanced computed tomography showed thrombosis in the right upper lobe pulmonary vein stump, which was considered to be the cause of the acute arterial occlusion. The patient underwent emergency thrombectomy following which his symptoms immediately improved. Herein, we report a rare case of pulmonary vein thrombosis occurring after a right upper lobectomy. Our findings may facilitate effective clinical decision-making.
A 71-year-old man, who was found to have a posterior mediastinal tumour, was referred to our hospital. Contrast-enhanced computed tomography (CT) showed a 15-cm soft tissue shadow in the posterior mediastinum, with many affected areas and a gradually increasing pattern. We also detected oligemic areas with poor contrast-filling. There was no invasion into the adjacent vertebral body and the blood vessels penetrating the interior were intact. Positron emission tomography-CT revealed a high maximum standardized uptake level of 4.53 in the mediastinal masses. We performed thoracoscopic surgery for the biopsy. Histological findings showed lymphoplasmacytic infiltration in the fibrous stroma as well as storiform fibrosis. Immunohistochemical examination revealed abundant infiltration of immunoglobulin G4 (IgG4)-positive plasma cells and 40% IgG4/IgG-positive plasma cells. Postoperative serum examinations showed a high serum IgG4 level (570 mg/dl). Accordingly, we diagnosed the patient with IgG4-related fibrosing mediastinitis, a rare manifestation of IgG4-related disease.
Descending necrotizing mediastinitis (DNM) is a severe, life-threatening disease and requires prompt treatment. The primary treatment for DNM is cervical and mediastinal drainage in addition to antibiotic treatment. However, the most appropriate drainage approach and the effectiveness of additional treatment remain unclear. In this study, we performed cervical and mediastinal drainage for three patients with type IIB DNM using the cervical approach alone. Continuous saline irrigation was administered as additional treatment. There is little evidence for the use of saline irrigation for DNM. We propose that this combination treatment may be more effective and has the potential to improve patient prognosis. In our report, the average drainage duration was 13 days, and the average hospital stay was 30 days. Furthermore, both drainage duration and hospital stay were shorter than those in previously reported cases. Our case series provides valuable insight into the use of combination treatment to treat DNM.
The occurrence of lipoma in the thoracic cavity is relatively rare, and it is clinically difficult to distinguish it from liposarcoma. We report a case of intrathoracic lipoma that was pathologically diagnosed and differentiated from liposarcoma after minimally invasive thoracoscopic tumour resection. A 35-year-old male patient without any symptoms was referred to our hospital due to an abnormal shadow on chest x-ray. Computed tomography showed a low-attenuated round-shaped mass of 3.6 cm × 2.3 cm in diameter in the left chest wall. On magnetic resonance imaging, the mass was displayed as a high, high and low signal mass on T1-weighted imaging (WI), T2WI and T2WI with fat suppression, respectively. We suspected a chest wall-type lipoma, but because it appeared in a relatively short period of time and we thought it could be liposarcoma, we performed minimally invasive thoracoscopic surgery for diagnosis and treatment. The tumour was a stalked tumour with a capsule, contiguous to the wall pleura with only a single cord-like structure. The majority of the tumour was found free in the pleural cavity. The tumour was diagnosed as a lipoma by histopathological examination.
Objective: With the increased frequency of small lung tumor detection, there has been a similar increase in limited surgery, such as wedge resection. To identify such small lung tumors, we use a computed tomography (CT)-guided intraoperative marking method using the O-arm Surgical Imaging System. We retrospectively investigated its usefulness. Methods: Of 1,043 cases of thoracic surgery performed at our department between May 2017 and June 2021, O-arm System marking was used in 30 cases (2.9%), totaling 39 lesions. Tumor location was predicted preoperatively based on 3-dimensional CT and anatomic positioning. Visceral pleura near the tumor was marked with a metal clip, and the O-arm System was brought to the surgical site. CT was taken after the tumor side lung was fully re-expanded and clamped. After confirming the tumor and the clip locations, the clip was repositioned as necessary and marked in the same way. If the marking was successful, the clips were used as markers when performing lung resection. Results: Marking was successful in all cases. The average number of targets was 1.3, the average number of O-arm insertions was 1.3, and the average total number of marking clips was 2.6. In all cases, we checked the specimens, and if the tumor was palpable, the resection margin was also checked. No intraoperative or postoperative complications were observed in any patients. Conclusions: If the O-arm System is available, this technique is a noninvasive, simple, and useful method that could be widely used in clinical practice with a low dose of radiation.
Lung Neoplasms , Surgery, Computer-Assisted , Humans , Imaging, Three-Dimensional , Lung Neoplasms/diagnostic imaging , Lung Neoplasms/pathology , Lung Neoplasms/surgery , Retrospective Studies , Surgery, Computer-Assisted/methods , Thoracic Surgery, Video-Assisted/methods , Tomography, X-Ray Computed/methods
A 63-year-old woman was diagnosed with tuberculous bronchial stenosis of the left main bronchus following recurrent pneumonia. She underwent airway dilatation and stenting for long and severe stenosis. Initially, a Dumon Y-stent was implanted, but repeated granulation occurred at the distal end of the stent. The granulation reappeared repeatedly despite cauterization and stent replacement. An attempt at stent removal led to worsening of scar stenosis; therefore, it was reinstalled. Finally, two self-expandable metallic stents were implanted sequentially, and she remained asymptomatic for 14 months. After this, she presented with fever and a computed tomography showed obstructive pneumonia due to associated granulation at the distal end of the stent. She was then started on tranilast to treat the granulation with the stent in situ. Granulation almost completely disappeared after 4 months and no recurrence was noted at 12 months since the start of tranilast.
Capillary haemangioma is a rare condition that is difficult to diagnose preoperatively because of its rarity and nonspecific imaging findings. In this report, we describe a case of capillary haemangioma diagnosed by robot-assisted thoracic surgery (RATS). A 72-year-old man was incidentally found to have an anterior mediastinal tumour on chest computed tomography. The preoperative imaging findings were indicative of thymoma, and surgical treatment by RATS was selected. The intraoperative findings suggested that the tumour was a haemangioma originating from the pericardiophrenic vein. The pathological findings revealed a well-defined tumour with capillaries in a vascular-like structure and some thrombus formation. The pathological diagnosis was capillary haemangioma. The patient was discharged unaided at 7 days postoperatively and no recurrence was observed at 16 months postoperatively.
A 72-year-old man was diagnosed as having myasthenia gravis (MG). He underwent computed tomography which revealed an anterior mediastinal tumour. Laboratory examination revealed elevated levels (106.3 U/ml) of carbohydrate antigen (CA) 19-9 in serum. However, no malignant disease was detected on fluorodeoxyglucose-positron emission tomography. A diagnosis of thymoma associated with MG was considered and an extended thymectomy was performed. Histopathologically, thymoma was categorized as stage I based on the Masaoka classification, and as type AB according to the World Health Organization classification. Immunohistochemistry was positive for CA 19-9. The serum levels returned to the normal range post-operatively (16.7 U/ml). Herein, we report an extremely rare case of thymoma with raised levels of CA 19-9.
Chest high-resolution computed tomography (HRCT) finding of part-solid nodule (PSN) is related to pulmonary adenocarcinoma (AC) with lepidic growth. We recently experienced a pulmonary squamous cell carcinoma (SCC) showing PSN pattern on HRCT. We present a 70-year-old man who had a small nodule with PSN pattern in the right lung field on HRCT. After clinical diagnosis of AC, lobectomy was performed. The tumour was pathologically diagnosed as SCC with lepidic growth. Histopathologically, the central area of the tumour showed keratinizing SCC, whereas the peripheral area revealed lepidic SCC cell growth between non-neoplastic type II pneumocytes and alveolar basement membrane. On the basis of the present case and five from the literature, SCC with lepidic growth had the following clinical characteristics: peripheral location, early stage detection, clinical misdiagnosis as AC, less progression, and favourable prognosis. This case may be a special type of SCC with less progression and favourable prognosis.
BACKGROUND: Upper-limb lymphedema is a well-known complication of breast cancer and its treatment. This retrospective cohort study aims to determine what risk factors affect breast cancer-related lymphedema in patients with breast cancer. METHODS: This retrospective study comprised patients diagnosed with breast cancer and who underwent surgery at Wakayama Medical University Hospital between January 1, 2012 and December 31, 2018. Assessed factors using univariate and multivariate analyses were patient-related factors (age, gender, and BMI), breast cancer-related factors (tumor size, nodal status, histology, tumor location, and intrinsic subtype), and treatment-related factors (type of surgery, application, timing and regimen of chemotherapy, and application of radiotherapy). RESULTS: This study included 1041 patients. BMI did not affect the onset of breast cancer-related lymphedema. There were only six sentinel lymph node biopsy cases in the breast cancer-related lymphedema group (6.6%). In cases of axillary lymph node dissection, adjuvant chemotherapy was marginally associated with increased risk of breast cancer-related lymphedema compared to no chemotherapy (HR 2.566; 95% CI 0.955-6.892; p = 0.0616). Among anti-cancer agents, docetaxel (HR 3.790; 95% CI 1.413-10.167; p = 0.0081) and anti-HER2 therapy (HR 2.507; 95% CI 1.083-5.803; p = 0.0318) were associated with increased risk of lymphedema according to multivariate analysis. Neo-adjuvant chemotherapy did not affect the onset of breast cancer-related lymphedema. Radiotherapy (HR 2.525; 95% CI 1.364-4.676; p = 0.0032) was an important risk factor for breast cancer-related lymphedema. CONCLUSIONS: Axillary lymph node dissection, radiotherapy and adjuvant chemotherapy, especially docetaxel, were risk factors for breast cancer-related lymphedema, but BMI and neo-adjuvant chemotherapy were not.
Breast Cancer Lymphedema/epidemiology , Breast Neoplasms, Male/therapy , Breast Neoplasms/therapy , Docetaxel/adverse effects , Mastectomy/adverse effects , Adult , Age Factors , Aged , Aged, 80 and over , Axilla , Body Mass Index , Breast Cancer Lymphedema/etiology , Chemoradiotherapy, Adjuvant/adverse effects , Chemoradiotherapy, Adjuvant/methods , Chemotherapy, Adjuvant/adverse effects , Chemotherapy, Adjuvant/methods , Female , Follow-Up Studies , Humans , Lymph Node Excision/adverse effects , Lymph Nodes/pathology , Lymph Nodes/surgery , Male , Mastectomy/methods , Middle Aged , Neoadjuvant Therapy/adverse effects , Neoadjuvant Therapy/methods , Retrospective Studies , Risk Factors , Sentinel Lymph Node Biopsy/adverse effects , Upper Extremity , Young Adult
PURPOSE: Hormesis is a phenomenon of growth stimulation at low doses and inhibition at higher doses. In cancer treatment, little is known about how hormesis affects cancer cell proliferation. We evaluated the hormetic dose-response relationship of paclitaxel using surgically resected breast cancer specimens on the basis of histoculture drug response assay (HDRA). METHODS: We used surgically resected fresh tumor specimens from 22 patients with breast cancer: 17 invasive ductal, 3 mucinous, and 2 other "special-type" cancers. All patients were female, ranging in age between 40 and 86 (median 60) years. Small pieces of viable cancer tissue were placed on collagen gel and cultured for 7 days with paclitaxel. Inhibition rates of paclitaxel at several concentrations were measured and fitted to a sigmoid dose-response curve. RESULTS: Hormesis was observed in 9 of the 22 cases; ED50 of cytotoxic effect was significantly higher (P = .0036) in hormesis (H) group (44.6 ± 4.2 µg/mL) than in nonhormesis (N) group (26.7 ± 3.5 µg/mL). CONCLUSION: We evaluated hormesis in breast cancer tissue using HDRA for the first time although previously confirmed in cultured cells. Hormesis seems to occur in patients undergoing treatment with anticancer agents, especially in a metastatic setting. Meanwhile, tumor growth may be stimulated in patients who are resistant to paclitaxel.
BACKGROUND: The benefits of continuing bevacizumab (BEV) beyond progressive disease (PD) in patients with non-small cell lung cancer (NSCLC) remain unclear. We present our experience of continuing chemotherapy with BEV in patients with recurrent NSCLC after surgery. PATIENTS: From January 2010 to December 2016, chemotherapy with BEV was continued beyond PD in 20 patients. These patients included 10 men and 10 women, and their mean age at surgery was 71±10 years. Recurrence was observed at 630±460 days after surgery. RESULTS: The average number of protocols with BEV was 3±1 (1-6). The presented side effects were acceptable. Eight patients died of cancer. The 5-year survival rates after surgery, recurrence, and initiation of BEV were 78.8%, 50.1%, and 34.3%, respectively, and the median survival times were 2,465, 2,017, and 1,120 days, respectively. CONCLUSION: The majority of patients with operable NSCLC had a good performance status. We could detect recurrence early on, before the symptoms appeared, by regular examination. Therefore, these patients had an advantage in that more chemotherapeutic regimens could be administered to them and their prognosis could be improved by the continuation of BEV beyond over PD.
Antineoplastic Agents, Immunological/therapeutic use , Bevacizumab/therapeutic use , Carcinoma, Non-Small-Cell Lung/drug therapy , Lung Neoplasms/drug therapy , Adult , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/surgery , Disease Progression , Female , Humans , Lung Neoplasms/pathology , Lung Neoplasms/surgery , Male , Middle Aged , Recurrence
INTRODUCTION: Lymphovascular invasion (LVI) is a known adverse prognostic factor for early-stage non-small-cell lung cancer (NSCLC). Nonetheless, the prognostic effect of LVI on TNM staging of stage I NSCLC remains inconclusive. We thus hypothesized that it might be better to upstage pathologic stage IA NSCLC with LVI to pathologic stage IB NSCLC. PATIENTS AND METHODS: Using a Cox proportional hazards model, we examined the effect of LVI on disease-specific survival (DSS) in stage IA versus stage IB disease in 660 consecutive patients with stage I NSCLC (598 with adenocarcinoma, 62 with squamous cell carcinoma) who had undergone complete resection. RESULTS: On univariable analysis of stage IA cases, vascular invasion (VI) was significantly associated with inferior DSS (univariable hazard ratio [HR], 3.39; 95% confidence interval [CI], 1.46-7.89; P = .005). In contrast, lymphatic invasion exhibited a tendency toward inferior DSS (univariable HR, 2.90; 95% CI, 0.97-8.66; P = .056). Multivariable analysis of DSS in stage IA cases identified VI as an independent significant prognostic factor (multivariable HR, 2.86; 95% CI, 1.58-5.18; P = .007). With VI, DSS was significantly poorer for stage IB than for stage IA patients without VI (univariable HR, 3.44; 95% CI, 1.67-7.09; P < .001). In contrast, no difference was observed between patients with stage IA and VI and stage IB patients (P = .97). CONCLUSION: The presence of VI independently and significantly affects DSS in patients with stage IA NSCLC. We found that stage IA with VI and stage IB disease had equivalent prognostic outcomes. Our results suggest that stage IA with VI should be upstaged to IB in the TNM classification of NSCLC.
Carcinoma, Non-Small-Cell Lung/diagnosis , Lung Neoplasms/diagnosis , Neoplasm Staging/methods , Aged , Carcinoma, Non-Small-Cell Lung/mortality , Carcinoma, Non-Small-Cell Lung/pathology , Chemotherapy, Adjuvant , Female , Follow-Up Studies , Humans , Lung Neoplasms/mortality , Lung Neoplasms/pathology , Lymphatic Metastasis , Male , Prognosis , Proportional Hazards Models , Recurrence , Retrospective Studies , Survival Analysis
