INTRODUCTION: Pulmonary sclerosing pneumocytoma (PSP) is a rare benign tumor classified as a pulmonary adenoma. It presents as a solitary pulmonary nodule without any specific findings, often posing a diagnostic challenge. We herein present a case of a PSP with a short volume doubling time (VDT) comparable to low-grade pulmonary malignancies. CASE PRESENTATION: A 27-year-old female presented to the emergency department with a fever that had persisted for the past two days. An incidental finding on chest screening computed tomography (CT) revealed a 9 mm pulmonary nodule with a round shape and smooth margin, suggestive of a benign etiology. Follow-up CT one year later revealed an enlarged nodule exhibiting a VDT of 249 days. A thoracoscopic lingulectomy was performed, and the histopathological examination revealed papillary and diffuse proliferation of epithelial-like cells. The epithelial cells were positive for cytokeratin (CKAE1/AE3) and thyroid transcription factor 1 (TTF1), whereas the stromal cells were positive for TTF1 but negative for CKAE1/AE3. Those results were consistent with the diagnosis of a PSP. DISCUSSION: PSPs typically present as incidental pulmonary nodules with no specific findings, often posing a diagnostic challenge. The radiographic features of PSPs have mainly been explored based on the morphological findings and metabolic activity, with limited research on their growth rate, represented by the VDT. CONCLUSION: PSPs may exhibit rapid growth, demonstrating a short VDT similar to that of low-grade pulmonary malignancies. Comprehensive diagnostic testing not based solely on the growth rate for this rare condition is essential.
INTRODUCTION: Inhalation of silicon dioxide causes silicosis, a condition that may occur in various industries and work settings. Radiologic findings typically show numerous nodular opacities, while solitary pulmonary nodules are atypical for silicosis. PRESENTATION OF CASE: A 68-year-old woman, a former glassblower, presented with a left solitary pulmonary nodule (13 mm) on chest computed tomography. The nodule enlarged to 23 mm over 6 months, exhibiting an irregular shape, spiculated margin, and rapid growth with a doubling time of 186.4 days. She underwent a left upper lobectomy with a suspicion of lung cancer. The histopathological findings revealed peribronchial lymphocytic infiltration and granulomatous-like structures containing multinucleated giant cells and phagocytic crystalline foreign bodies. These findings were consistent with a foreign body reaction to the glass fragments. DISCUSSION: Inhaled glass fragments may present as a solitary pulmonary nodule after the retirement of a glass blower. Its behavior and radiological features mimicked a primary lung adenocarcinoma. CONCLUSION: Solitary pulmonary nodules due to inhaled glass fragments may mimic a primary lung adenocarcinoma. A definitive diagnosis requires a histological examination in this rare condition.
INTRODUCTION AND IMPORTANCE: Mature mediastinal teratomas can rarely become symptomatic after a compression of surrounding organs and a rupture and are often treated with an emergency open approach such as median sternotomy. Clinical significance of thoracoscopic approach as elective setting is unknown. CASE PRESENTATION: A previously healthy 21-year-old man presented with worsening left-sided chest pain for one week. Chest computed tomography revealed a multilocular cystic mass with no evidence of great vessel invasion. A histopathological examination of the biopsy specimen revealed that the pancreatic glands and ductal elements were without any immature embryonic tissue, consistent with a mature teratoma. After the symptoms improved, he successfully underwent an elective video-assisted thoracic surgery as a substitute for an emergency median sternotomy. CLINICAL DISCUSSION: The ectopic pancreatic tissue itself may not imply an emergency surgery and a comprehensive workup is essential for an optimal treatment strategy. Elective surgery is worthy of consideration as a therapeutic option. CONCLUSION: Elective video-assisted thoracic surgery could be a feasible option even for a ruptured mature mediastinal teratoma in selected patients. Besides its maximum size, a large proportion of the cystic component and the absence of great vessel invasion may indicate the feasibility of a video-assisted thoracic surgery.
BACKGROUND: A solitary pulmonary nodule (SPN) poses a diagnostic challenge, which includes both a benign and malignant etiology. A size enlargement often indicates malignancy. We herein describe a case of a solitary pulmonary metastasis from a leiomyosarcoma that regressed transiently during follow-up. CASE PRESENTATION: A 47-year-old woman presented with an SPN detected by follow-up computed tomography 7 years after surgery for a left forearm high-grade leiomyosarcoma. The nodule regressed spontaneously after an additional 6 months, and therefore, an inflammatory change was the most likely diagnosis at that time. However, the nodule enlarged again over the next 5 years. The growth rate led us to suspect a malignancy. A trans-bronchial biopsy was undiagnostic and a video-assisted thoracic surgery was planned. She underwent a wedge resection of the right lung, and a histopathological examination found it was a metastatic leiomyosarcoma. CONCLUSIONS: A pulmonary metastasis from a leiomyosarcoma could emerge as an SPN and reveal a subsequent transient size reduction. An SPN in patients even with a remote history of a soft tissue tumor should raise the possibility of metastasis, and periodic follow-up is essential even after the size reduction.
Introduction: A bronchopleural fistula (BPF) after an anatomical lung resection commonly arises singly. We report a case of a metachronous BPF, which developed after omentoplasty of a preceding fistula and subsequently closed without any intervention. Case presentation: A 77-year-old patient underwent omentoplasty for a brochopleural fistula (BPF) following a right lower lobectomy. A sudden massive air leak developed from the novel BPF approximately 1 cm proximal to the preceding fistula 3 days later. The air leak resolved spontaneously without any intervention one week later. The corresponding fistula was found to be completely closed. Computed tomography showed the omental flap covered both fistulae. Conclusion: The present case suggested that a metachronous BPF could develop and a harvested omental flap might migrate even after being anchored.
BACKGROUND: Iatrogenic tracheal injury is a rare but potentially morbid condition and often poses a diagnostic challenge due to its rarity and the lack of specific clinical findings. Because a delayed diagnosis is associated with a higher mortality, a prompt diagnosis is essential. We report a case of an iatrogenic tracheal injury detected by subpleural emphysema as a rare initial manifestation. CASE PRESENTATION: A 75-year-old woman was diagnosed with stage IA2 right lung cancer. During the surgery, visceral subpleural emphysema developed along the lung surface up to the interlobar fissure followed by subcutaneous emphysema in the anterior neck. Suspecting a tracheal injury, we aborted the surgery. Fiberoptic bronchoscopy revealed a longitudinal laceration on the membranous part of the distal trachea without esophageal involvement, consistent with a level II injury. Conservative management was chosen and she had a successful recovery. CONCLUSIONS: Iatrogenic tracheal injury could initially manifest as visceral subpleural emphysema. Once subpleural emphysema is observed during surgery, a prompt diagnostic workup of the tracheal injury should be performed.
BACKGROUND: A hemothorax as the initial manifestation of bronchiectasis is extremely rare. We report a case of a sudden hemothorax due to exacerbation of clinically latent bronchiectasis under a direct oral anticoagulant. CASE PRESENTATION: A 77-year-old woman presented with chest pain and a fever noted since the day before. She had stage G3 chronic kidney disease and received edoxaban for paroxysmal atrial fibrillation. She had no history of trauma or respiratory symptoms. A chest computed tomography revealed a mass with a surrounding opacity in the right lower lobe with a pleural effusion. Conservative treatment was chosen because of the stable vital signs and her respiratory condition. Her oxygen saturation dropped 7 h later with progressive anemia. Repeated chest computed tomography showed a worsening pulmonary opacity and pleural effusion. She underwent a right lower lobectomy successfully. The histopathological findings suggested that the preceding infection of the subpleural focal bronchiectasis caused the bleeding. In addition, a steep caliber change between the subpleural focal bronchiectasis and proximal normal branch may have caused an intraluminal pressure gradient resulting in a peripheral discharge causing a pleural rupture with a hemothorax. CONCLUSION: The sudden hemothorax could have been the initial manifestation of bronchiectasis. Particular attention should be paid to peripherally localized bronchiectasis even if it is without any clinical symptoms, especially in patients with a comorbidity such as a susceptibility to infections and the use of direct oral anticoagulants.
INTRODUCTION AND IMPORTANCE: Spontaneous regression (SR) of cancer is extremely rare in non-small cell lung cancer and the exact pathogenesis is unclear. CASE PRESENTATIONS: A 69-year-old man underwent a right upper lobectomy for a squamous cell carcinoma histologically confirmed 8 weeks prior. A histopathological examination of the surgical specimen revealed no viable cancer. He remains disease free at 5 years after surgery. A 77-year-old man presented with a metastatic bone tumor compatible with a non-small cell lung cancer origin. He had undergone a surgical biopsy for a right lung nodule of which the histopathological examination revealed only scar tissue a year prior. He died of cancer 4 months after the diagnosis of a bone metastasis. CLINICAL DISCUSSION: The unknown etiology of an SR of cancer is still to be resolved. CONCLUSION: Patients with an SR of cancer may yield a variety of clinical outcomes and a meticulous observation is essential.
INTRODUCTION AND IMPORTANCE: Solitary fibrous tumors of the pleura (SFTPs) present a diagnostic challenge. We herein report a successful case mimicking a soft tissue sarcoma of the chest wall by a meticulous evaluation of the conventional images. CASE PRESENTATION: A 51-year-old woman presented with a left thoracic mass. The mass exhibited an extrapleural sign, which suggested a chest wall origin. However, the mass was found to be located more caudally by additional computed tomography. This positional change suggested that the mass was pedunculated from the visceral pleura, and an SFTP was suspected. The mass was found to originate from the visceral pleura of the left lower lobe and a pathological diagnosis of an SFTP was confirmed. CLINICAL DISCUSSION: Although a positional shift with a postural change or the respiratory phase is a well-known characteristic radiological finding, such an intentional imaging study is available only for suspicious cases of SFTPs. CONCLUSIONS: SFTPs pose a diagnostic challenge because of their rarity and the lack of specific radiological findings. Even conventional radiological images can be diagnostic by performing a meticulous evaluation regardless of any specific diagnosis being initially assumed.
INTRODUCTION: Isolated lung metastases from prostate cancer without any other organ involvement are rare. They are commonly in the form of diffuse or multiple lesions and rarely emerge as a solitary pulmonary nodule. PRESENTATION OF CASE: A 61-year-old man who had undergone a laparoscopic-assisted radical prostatectomy for prostate cancer 16 months prior presented with a growing solitary pulmonary nodule. Positron emission tomography/computed tomography showed an abnormal uptake in the nodule without any other organ involvement. A surgical specimen by a thoracoscopic wedge resection proved a diagnosis of a metastasis from prostate cancer. He is currently alive only with worsening pulmonary metastases at 7 years after the lung surgery. DISCUSSION: A rare entity of isolated pulmonary metastases could be a sole finding of metastatic prostate cancer over the years and its initial manifestation could emerge as a solitary pulmonary nodule. It poses a diagnostic challenge because primary lung cancer is the leading differential diagnosis of solitary pulmonary nodules and is also one of the most frequent second primary malignancies in prostate cancer survivors. CONCLUSION: An aggressive surgical biopsy is essential for definitive histopathological and immunohistochemical analyses of solitary pulmonary nodules to distinguish a rare form of an isolated pulmonary relapse from a second primary lung cancer in prostate cancer survivors.
BACKGROUND: Fissureless lobectomies are beneficial for preventing prolonged air leaks (PALs). Despite the widespread use of this technique in lobectomy cases, there have been no reports on fissureless bilobectomies to date. CASE PRESENTATION: A 73-year-old man with an 80-pack per year smoking history was diagnosed with a stage 1 primary squamous cell carcinoma in the right lower lobe. He developed a lung abscess inside the tumor 6 weeks after the cancer diagnosis and a surgical resection was planned. A middle and lower bilobectomy was mandatory because of the interlobar pulmonary artery involvement. We chose a fissureless technique to avoid any cancer dissemination and bacterial spillage. The thoracoscopic view revealed that the tumor volume was too large to flexibly mobilize. The minimally invasive open surgery (MIOS) approach was valuable in that it combined direct vision and a thoracoscopic maneuver for treating even a large, distended mass. He was discharged uneventfully 9 days after the operation. CONCLUSIONS: The fissureless bilobectomy, in addition to preventing PALs, was a feasible option for preventing cancer dissemination and bacterial spillage for a lung abscess. The MIOS was a safe and minimally invasive approach for even a giant abscess that inhibited the flexible mobilization of the lung.
INTRODUCTION AND IMPORTANCE: Mediastinal hemangiomas are a rare entity frequently developing in the anterior mediastinum. They may exhibit an infiltrating appearance into the surrounding tissue, and extensive surgery is often required despite its benign nature. We report a case of a mediastinal hemangioma mimicking an invasive tumor growth requiring a combined resection of the lung and diaphragm. CASE PRESENTATION: An asymptomatic 73 year-old-man presented with a 50 mm-sized mass on his chest radiography. A combined resection of the mediastinal mass with the part of the lower lobe of left lung and diaphragm not necessitating a patch repair was performed. The pathological findings were compatible with a diagnosis of a mediastinal hemangioma. Only fibrous adhesions were observed between the tumor and resected lung and diaphragm without any histological invasion. CLINICAL DISCUSSION: While imaging examinations play a key role in determining a preoperative diagnosis, mediastinal hemangiomas may pose a diagnostic challenge mainly due to its rarity. With a clinical suspicion of a hemangioma during the diagnostic work up, a dynamic CT might be helpful. CONCLUSIONS: In mediastinal hemangiomas, a preoperative diagnosis is essential in order to avoid extensive surgery. A hemangioma should be raised as a differential diagnosis for anterior mediastinal tumors, especially in cases with an infiltrative appearance that suggests the necessity for a combined resection of the surrounding organs.
Anomalous systemic arterial supply to the basal lung segments is relatively rare. A 39-year-old Japanese man was found to have high serum carbohydrate antigen 19-9 levels during a routine medical examination. He had no medical history and no symptoms. Although his serum carbohydrate antigen 19-9 level was high at 571 U/mL, his abdominal computed tomography (CT), gastrointestinal endoscopy, and abdominal ultrasonography findings were not abnormal. However, his chest CT scan revealed anomalous systemic arterial supply to the basal lung segment of the left lower lobe. He underwent partial resection of the left lung and stapling of the abnormal artery. After surgery, his serum carbohydrate antigen 19-9 level normalized. We consider that bronchiectasis of the basal left lung was involved in carbohydrate antigen 19-9 production and increase in its serum level. It is important to remain aware that various benign lung diseases can cause high serum carbohydrate antigen 19-9 levels.
A 65-year-old man was admitted to our hospital due to an abnormal shadow on chest radiographs. Chest computed tomography (CT) revealed a tumor (diameter: 38 mm × 27 mm) and another small nodule in the left upper lobe of the lung, which were accompanied by lymphangitis of the left upper lobe. The patient underwent a transbronchial lung biopsy, following which he was diagnosed with lung adenocarcinoma. Contrast-enhanced CT and ultrasound imaging revealed bilateral pulmonary artery thrombosis and multiple venous thromboses. He was thus diagnosed with stage IIB lung cancer complicated by Trousseau's syndrome. Chemotherapy was initiated using platinum doublets, while infusions of unfractionated heparin and Xa inhibitor were administered for anticoagulant therapy. Following chemotherapy, the main tumor had shrunk, and his lymphangitis, pulmonary artery thrombosis, and multiple venous thromboses had resolved. We then could perform a left upper lobectomy and lymph node dissection safely.
A 70-year-old man underwent right-sided pulmonary bilobectomy (removal of the middle and lower lobes) for stage IIIA non-small-cell lung carcinoma. Following the operation, there was minor air leakage through the intercostal drain from postoperative day 0 to 2, which stopped completely by postoperative day 3. The subsequent postoperative course was uneventful, and the patient was discharged on postoperative day 7 after removal of the chest tube. On postoperative day 9, the patient returned to the hospital with complaints of nasal speech and bulging of the skin over his right breast region. He was diagnosed with postoperative subcutaneous emphysema. A chest computed tomography (CT) scan revealed that the emphysema was not associated with a collapsed lung, and the patient's relatively small-sized thoracic cavity left limited space for the placement of a chest tube. We performed a CT-guided tube thoracostomy with proper insertion and placement of an intercostal drain at the site of the air leakage, within the compact thoracic cavity. The procedure was effective in draining the trapped air, thus resolving the subcutaneous emphysema successfully.
OBJECTIVE: This study aimed to construct a simple scoring system for predicting visceral pleural invasion of non-small cell lung cancer (NSCLC) from computed tomography (CT) findings and clinicopathological factors in lesions directly under the pleural membrane. METHODS: Among 376 cases of surgically treated NSCLC, cases in which the tumor was ≤ 7 cm in diameter and in contact with the pleura on the CT image were retrospectively extracted and examined. The CT findings and clinicopathological factors associated with the presence of pathological pleural invasion in each case were examined by Fisher's exact test. A score was then assigned based on the odds ratio obtained for each factor, and a risk scoring system for predicting pleural invasion was constructed. RESULT: In the 138 extracted cases, pathological visceral pleural invasion was found in 64 cases. The scoring system predicting pleural invasion could be defined as follows: pl risk score = 3 (tumor diameter in CT ≥ 24 mm) + 3 (tumor contact length with pleura in CT ≥ 16 mm) + 3 (smoking index ≥ 400) + 3 (clinically lymph node positive) + 2 (tumor with cavity in CT) + 2 (serum CEA level > 4.4 ng/mL). A score was calculated for each case and an ROC curve was created. The cutoff value was score 8 and the area under curve (AUC) was 0.68. CONCLUSION: Our findings suggest that visceral pleural invasion can be predicted using a score calculated from several simple CT findings and clinicopathologic factors.
Carcinoma, Non-Small-Cell Lung/diagnosis , Lung Neoplasms/diagnosis , Pleura/pathology , Propensity Score , Risk Assessment/methods , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Neoplasm Invasiveness , Neoplasm Staging/methods , ROC Curve , Retrospective Studies , Tomography, X-Ray Computed/methods
A 61-year-old man was admitted to the emergency room because of sudden right chest pain and dyspnea. A chest X-ray and chest computed tomography (CT) revealed severe right pneumothorax with massive pleural effusion. Chest drainage was performed and approximately 1.2 L of pleural fluid was removed. Hemothorax was suspected based on the imaging findings, but the pleural effusion was serous. Active air leakage continued for 4 days after chest drainage, thus we decided to surgically control the air leakage and performed video-assisted surgery. A thoracoscopic examination revealed a large number of nodule parietal pleural and epiphrenic pleural nodule lesions. A pathological examination of frozen sections of the nodules indicated malignant pleural mesothelioma (MPM). Continuous air leakage was observed from the pleural surface of the right lower lobe. The air leak developed from the visceral pleura and the point of visceral pleura had a normal macroscopic appearance. The patient was treated with wedge lung resection and pleurodesis.
A 76-year-old Japanese man underwent right upper lung lobectomy for lung cancer. He had a medical history of atrial fibrillation and myocardial infarction, and was treated with medications including apixaban (5 mg twice daily). His postoperative course was uneventful, and he left the hospital on the ninth day postoperatively. Apixaban was restarted on postoperative day (POD) 10. On POD18, he was evaluated as an outpatient. He complained of fatigue, and his hemoglobin level decreased from 13.5 to 8.5 mg/dL. Chest plain radiography showed massive fluid in the right thoracic cavity. His condition was thought to be a postoperative bleeding complication due to apixaban; thus, we stopped apixaban and performed red blood cell transfusion and thoracic drainage. Postoperative hemorrhage associated with apixaban use is rare.
BACKGROUND: To determine factors predicting indocyanine green (ICG) visualization during fluorescence imaging for segmental plane formation in thoracoscopic anatomical segmentectomy. METHODS: Intraoperatively, the intravenous ICG fluorescence imaging system during thoracoscopic anatomical segmentectomy obtained fluorescence emitted images of its surfaces during lung segmental plane formation after the administration of 5 mg/body weight of ICG. The subtraction of regularization scale for calculating the exciting peaks of ICG between the planned segments to resect and to remain was defined as ΔIntensity (ΔI). Variables such as the ratio of forced expiratory volume in 1 s to forced vital capacity (%FEV1.0), smoking index (SI), body mass index (BMI), and low attenuation area (LAA) on computed tomography (CT) took a leading part. RESULTS: The formation of the segmental plane was successfully accomplished in 98.6% segments and/or subsegments. SI and LAA significantly affected ΔI levels. The area under the receiver operating characteristic curve for the %FEV1.0, SI, and LAA was 0.56, 0.70, and 0.74, respectively. SI >800 and LAA >1.0% were strong predictors of unfavorable ICG visibility (P=0.04 and 0.01, respectively). CONCLUSIONS: Fluorescence imaging with ICG was a safe and effective method for segmental plane formation during thoracoscopic anatomical segmentectomy. In spite of its high success rate, unfavorable visibility may potentially occur in patients who are heavy smokers or those with a LAA (>1.0%) on CT.
