Preoperative state anxiety predicts postoperative health-related quality of life: A prospective observational study on patients undergoing lung cancer surgery.

Objective: Improving quality of life (QOL) after surgery is very important. Recently, preoperative anxiety has been suggested to predict postoperative health-related (HR) QOL, however the accuracy of anxiety measurement remains problematic. We examined the relationship between preoperative anxiety level and postoperative HRQOL using qualitative and quantitative assessment of anxiety. Method: We used a detailed anxiety assessment to quantitatively investigate preoperative anxiety as a predictor of postoperative HRQOL in lung cancer patients. Fifty one patients who underwent surgery for lung cancer were included. They were assessed four times: on admission, on discharge, 1 month after surgery, and 3 months after surgery. Anxiety was measured separately as "state anxiety" and "trait anxiety" using the State-Trait Anxiety Inventory, and HRQOL was measured using the EuroQol 5 dimension 5-level. Results: The HRQOL decreased at discharge and gradually recovered over time, reaching the same level at 3 months after surgery as at admission. HRQOL score was lower at discharge than at pre-surgery and 3 months after the surgery (p < 0.0001 each), and the score at 1 month after the surgery was lower than at pre-surgery (p = 0.007). In addition, multiple regression analysis showed that HRQOL at discharge was associated with "state anxiety" rather than "trait anxiety" at admission (p = 0.004). Conclusion: This study identifies the types of anxiety that affect postoperative HRQOL. We suggest that postoperative HRQOL on discharge may be improved by interventions such as psychological or medication treatment for preoperative state anxiety if identified preoperative state anxiety can be managed appropriately.

[Tracheobronchial Injury].

Tracheobronchial injurie( TBI) is rare but potentially life threatening. Blunt trauma of the chest and post-intubation injury are the most common cause of TBI. Clinical findings of TBI are subcutaneous emphysema, pneumomediastinum, and pneumothorax. Chest computed tomography (CT) and bronchoscopy are important examination for TBI to evaluate of injured site and condition. Most traumatic or iatrogenic TBIs occurred within 2.5 cm of the carina and/or main bronchus. Early diagnosis and early treatment are important to improve the long-term results of TBI. In principle, blunt traumatic TBI excluded membranous minor laceration should be operated immediately, if possible. Surgical procedures are usually selected single closure or end to end anastomosis with or without débridement. Right thoracotomy is often suitable for repair of carina or main bronchus in closed trauma. Recently transcervical repair of iatrogenic distal membranous tracheal laceration is reported. Conservative treatment of iatrogenic TBI cause by single lumen tube may be a save option in patients with stable spontaneous breathing, no other injury( such as esophagus), and small to moderate rupture. Left main bronchial rupture caused by double lumen tube during right thoracic surgery is critical situation. Throughout the operation expert cooperation between surgeon and anesthetist is important.

Evaluation of age-related thymic changes using computed tomography images: A retrospective observational study.

We aimed to investigate if Computed tomography (CT) attenuation values can help improve the identification of age-related changes in the thymus. We assessed CT images of 405 patients aged 0 to 80 years. We measured the area of the anterior mediastinum at the level of the carina and its average CT attenuation value. We evaluated the thymic area, the ratio of the thymus area to the total thoracic area, and the CT attenuation value. Additionally, we evaluated changes in the thymus area in the 0 to 13-year age group. The area of the thymus decreased from birth to the middle 20s. After the middle 20s, the area tended to increase and plateau till after 50 years of age. The ratio of the thymic area to the thoracic area decreased from age 0 to 20 years, but remained stable after 20 years of age. The CT attenuation values were stable from birth to puberty, decreased after puberty, and were stable again in the late 50s and beyond. The thymus of children showed mass formation, but the shape changed with age. No significant differences in the CT attenuation value were found across underlying conditions for the 0 to 13-year age group. The decrease in the CT attenuation values, observed with advancing age, reflects adipose degeneration of the thymus, indicating that by the late 50s, thymic tissue is replaced completely by adipose tissue. Our data suggest that adipose degeneration of the thymus begins after puberty and advances with age.

Pulmonary lymphoepithelial cyst with no prior HIV infection: A case report.

Most lymphoepithelial cysts (LECs) occur in the salivary glands and are considered one of the autoimmune syndromes caused by the human immunodeficiency virus (HIV). In this report, we present a case of pulmonary LEC without prior HIV infection, paying special attention to radiographic features. A chest radiograph revealed an oval mass with a smooth surface, localized in the left lower lung field, which was in direct contact with the diaphragm. Computed tomography showed an oval homogenous mass with a smooth surface in the lower left lobe. Further, magnetic resonance imaging demonstrated that the mass was a homogeneous internal structure with a smooth surface and a slightly high signal in T2-weighted images and a slightly low signal in T1-weighted images. Surgical resection was performed, and pathological examination confirmed the diagnosis of a pulmonary LEC. To the best of our knowledge, no cases of pulmonary LECs without prior HIV infection have been reported in the literature to date, therefore, the case presented here is considered very rare and informative.

Impact of the first surge of the coronavirus disease pandemic on general thoracic surgery practices in Kanagawa: a questionnaire survey by the Kanagawa General Thoracic Surgical Study Group.

OBJECTIVES: The first surge in severe acute respiratory syndrome coronavirus 2 infection had a significant impact on health care institutions. Understanding how the pandemic affected general thoracic surgery would provide valuable data for establishing a health care protocol for upcoming surges. METHODS: A questionnaire survey on coronavirus disease-related patient statistics and health care was conducted between February 2020 and June 2020 across 14 facilities affiliated with the Kanagawa General Thoracic Surgery Study Group. RESULTS: The average number of newly referred patients from February to June 2020 was 65% of that during the same period in 2019. Six facilities placed restrictions on medical care services, among which four restricted surgeries. At all institutions and those placed on surgical restriction, the total number of surgeries under general anesthesia was 92% and 78%, the total number of primary lung cancers was 94% and 86%, and the total number of surgeries for pneumothorax was 71% and 77% of that in the preceding year, respectively. Infection control and insufficient resources of the medical material were the most influential factors impacting the medical institutions' decision to restrict the services provided. CONCLUSIONS: Restrictions on surgery had a significant impact on the care provided by general thoracic surgery departments. To avoid patient inconvenience, establishing a collaborative system that refers patients to operational medical institutions in case of medical treatment restrictions may be useful.

A case of epithelioid cell granulomas arising at the margin of lung resection, with high accumulation on 18F-fluorodeoxyglucose-positron emission tomography.

It is important to distinguish tumour recurrence from other conditions that could show high accumulation on 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET). We describe the case of a 78-year-old woman who underwent partial resection of the left lower lung lobe for carcinoid treatment 20 years previously. Five years earlier, chest radiography revealed an abnormal shadow, and chest computed tomography (CT) showed partial atelectasis in the left S8. Periodical CT showed that the atelectasis had developed into a mass. The patient was referred to our hospital. A mass of 45 mm diameter was detected on CT and it had a maximum standardized uptake value of 8.91 on FDG-PET. We suspected recurrence and performed surgery. Pathological examination revealed epithelioid cell granuloma (maximum diameter, 25 mm) with necrosis. Tissue culture showed no evidence of Mycobacterium tuberculosis. However, serum anti-MAC antibody level was elevated, suggesting epithelioid cell granuloma caused by non-tuberculous Mycobacterium infection.

Acceptability and feasibility of S-1 plus cisplatin adjuvant chemotherapy for completely resected non-small cell lung cancer: an open-label, single arm, multicenter, phase 2 trial.

BACKGROUND: Although platinum-based chemotherapy is accepted as adjuvant chemotherapy for resectable advanced non-small cell lung cancer (NSCLC), its completion rate is low due to severe adverse events. S-1 plus cisplatin is associated with relatively low toxicity and an unimpaired quality of life, and has been used for unresectable advanced lung cancer. We investigated the acceptability and feasibility of combination therapy with S-1 plus cisplatin as postoperative adjuvant chemotherapy following complete resection of pathological stage II-IIIA NSCLC. METHODS: Enrolled patients received oral S-1 at a dose depending on their body weight twice daily for 21 days with intravenous cisplatin 60 mg/m2 on day 8, with 1 cycle comprising 5 weeks and 4 cycles. Patients received standard precautions against adverse events and received standard treatment when adverse events occurred. The primary endpoint was completion rate; secondary endpoints included safety, status of drug administration, disease-free survival (DFS), and overall survival (OS). RESULTS: A total of 19 patients [14 men, 5 women; mean age, 59.1 years; mean body surface area, 1.688 m2; 17 with an Eastern Cooperative Oncology Group performance status (PS) of 0 and 2 with a PS of 1; 7 (36.8%) with stage II disease and 12 (63.2%) with stage IIIA disease] were enrolled. The rate of completion of 4 cycles was 68.4%. Grade 3 adverse events that occurred in ≥10% of patients included neutropenia (21.1%), nausea (21.1%), and anorexia (15.8%). No grade 4 adverse events, febrile neutropenia, or treatment-related deaths occurred. The mean relative dose intensity (RDI) was 79% for S-1 and 80% for cisplatin. The 2-year DFS rate was 42.1%, and 2-year OS rate was 83.3%. CONCLUSIONS: This study demonstrated the acceptability and feasibility of using S-1 plus cisplatin as adjuvant chemotherapy. TRIAL REGISTRATION: This study was registered on the UMIN clinical study registration site (protocol ID: UMIN000016191) on December 1, 2015.

A case report of idiopathic pleuroparenchymal fibroelastosis with severe respiratory failure in pregnancy.

BACKGROUND: Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare lung disease that manifests as parenchymal fibrosis of the upper lung lobe and pleura. There have been no reports of IPPFE complicating pregnancy. Here, we report a case of IPPFE that deteriorated rapidly during pregnancy. CASE PRESENTATION: A 29-year-old woman presented with dyspnea and dry cough at 19 weeks of gestation. IPPFE with acute exacerbation was suspected on chest computed tomography (CT). Despite steroid treatment, her condition progressed. A cesarean section was performed at 28 weeks of gestation. On postoperative day 26, she underwent living-donor lung transplantation. She was discharged a year after transplantation. CONCLUSION: Our experience suggested that when pregnancy is complicated by PPFE, the disease may deteriorate rapidly. In this case, even though IPPFE with acute exacerbation was diagnosed during pregnancy, live birth was achieved, and the mother survived after lung transplantation. Lung transplantation should be considered in these patients because, once advanced, pulmonary lesions may be irreversible.

The Usefulness of Positron-Emission Tomography Findings in the Management of Anterior Mediastinal Tumors.

PURPOSE: We performed a retrospective analysis to evaluate the usefulness of positron-emission tomography/computed tomography (PET/CT) findings in the classification and management of anterior mediastinal tumors. METHODS: Between 2006 and 2015, 105 patients with anterior mediastinal tumor received PET/CT. 18F-fluorodeoxyglucose (18F-FDG)-PET images were obtained 60 minutes after the injection of 18F-FDG. RESULTS: The histological classifications were as follows: thymoma (n = 49), thymic carcinoma (TC) (n = 19), malignant lymphoma (ML) (n = 8), teratoma (n = 7), thymic cyst (n = 14), and others (n = 8). Upon visual inspection (SUV max: >2.0), all of the malignant tumors showed 18F-FDG accumulation (with the exception of one type A thymoma). Two of the 14 thymic cysts and three of the seven teratomas showed slight 18F-FDG accumulation. The SUV max values of the low-grade thymomas, high-grade thymomas, TCs and MLs were 3.14 ± 0.73, 4.34 ± 1.49, 8.59 ± 3.05, and 10.08 ± 2.53, respectively, with significant differences between the low- and high-grade thymomas, and between TCs and MLs. The sensitivity, specificity and accuracy of 18F-FDG in the detection of low-grade thymomas and thymomas with a maximum diameter of ≤50 mm and an SUV max of ≤3.4 were 85%, 48%, and 60%, respectively. CONCLUSION: FDG-PET/CT is an objective and useful modality in the differential diagnosis and management of anterior mediastinal tumors.

Expression of PTEN and its pseudogene PTENP1, and promoter methylation of PTEN in non-tumourous thymus and thymic tumours.

AIMS: Mutation or promoter methylation of the phosphatase tensin homologue deleted on chromosome 10 tumour suppressor gene (PTEN) promotes some cancers. Moreover, PTENP1 (PTEN pseudogene) transcript regulates PTEN expression and is thought to be associated with tumourigenesis in some cancers. Here, we investigated PTEN expression in thymic epithelium and thymic epithelial tumours. METHODS: Immunohistochemical analysis of PTEN was performed on two non-tumourous thymus (NT) samples, 33 thymomas (three type A, eight type AB, 11 type B1, six type B2, and five type B3), and four thymic carcinomas (TCs). In 16 cases (two NT, three A, five B1, two B2, one B3 and three TC), analyses of mutations, promoter methylation and comparisons of PTEN mRNA and PTENP1 transcripts were undertaken using PCR-direct sequencing, methylation-specific PCR, and reverse-transcription real-time PCR after target cell collection with laser microdissection. RESULTS: PTEN protein was not immunohistochemically detected in NT epithelium or types B1 or B2 thymoma cells, but was expressed in type A thymoma and carcinoma cells. Neither PTEN mutations nor promoter methylation were detected in any samples. Statistical analysis revealed that PTEN mRNA expression was highest in NT epithelium and lowest in type A thymoma cells. PTENP1 transcript expression did not significantly differ among NT, thymoma and TC samples. CONCLUSIONS: We speculated that NT epithelium and types B1/B2 thymoma cells have a mechanism of PTEN translation repression and/or acceleration of protein degradation, whereas type A thymoma cells exhibit transcriptional repression of PTEN mRNA and accelerated translation and/or protein accumulation.

Correlation between histological invasiveness and the computed tomography value in pure ground-glass nodules.

PURPOSE: The purpose of this study was to evaluate the correlation between histological invasiveness and the computed tomography (CT) value and size in pure ground-glass nodules (GGNs) to determine optimal "follow-up or resection" strategies. METHODS: Between 2001 and 2014, 78 resected, pure GGNs were retrospectively evaluated. The maximum diameter and CT value of pure GGNs were measured using a computer graphics support system. RESULTS: All GGNs with a maximum diameter ≤10 mm and CT value ≤-600 Hounsfield units (HU) were considered to be noninvasive lesions, while 21 of 26 (81 %) with a maximum diameter >10 mm and CT value >-600 HU were considered to be invasive lesions. With respect to the correlation between each histological type and pure GGN with a maximum diameter ≤10 mm and CT value ≤-600 HU, the specificity was 90 % and the sensitivity and negative predictive value were both 100 % in atypical adenomatous hyperplasia (AAH), while the specificity was 58 % and the sensitivity and positive predictive value were 0 % in minimally invasive and invasive adenocarcinoma. CONCLUSION: Pure GGNs with a maximum diameter of ≤10 mm and CT value of ≤-600 HU are nearly always pre-invasive lesions; therefore, surgery should be carefully selected in such patients.

A Surgical Case of Bronchial Artery Aneurysm Directory Connecting with Pulmonary Artery.

We present a surgical case of bronchial artery aneurysm (BAA) connecting pulmonary artery accompanied with racemose hemangioma. This is a third surgical case report of BAA directly connecting pulmonary artery in the English literature. A 63-year-old female was found a BAA, 2 cm in diameter, connecting right A4 pulmonary artery. The patient underwent two attempts for embolization. However, due to extensive collaterals, there was persistent flow in the aneurysm. Standard lateral thoracotomy was performed. A BAA was located between A4 and A5 PA. A small branch of A4 PA was separated, and the small vessel connecting to the BAA could be ligated. A5 PA was separated similarly, however BAA was ruptured not to identify the other small vessel connecting to the BAA. After a clamp of the BAA, middle lobe lobectomy was performed. We removed the aneurysm with dilated bronchial artery connecting to the aneurysm. The postoperative course was uneventful.

Difference in distribution profiles between CD163+ tumor-associated macrophages and S100+ dendritic cells in thymic epithelial tumors.

BACKGROUND: In a number of human malignancies, tumor-associated macrophages (TAMs) are closely involved in tumor progression. On the other hand, dendritic cells (DCs) that infiltrate tumor tissues are involved in tumor suppression. However, there have been very few reports on the distribution profiles of TAMs and DCs in thymic epithelial tumors. We examined the difference in the distribution profiles between TAMs and DCs in thymoma and thymic carcinoma. METHODS: We examined 69 samples of surgically resected thymic epithelial tumors, namely, 16 thymic carcinomas and 53 thymomas, in which we immunohistochemically evaluated the presence of TAMs using CD68 and CD163 as markers and DCs using S100 as the marker in tumor tissue samples in comparison with normal thymic tissues. RESULTS: The percentage of samples with a large number of CD68+ TAMs was not significantly different between thymic carcinoma and thymoma (7/16 versus 16/53, p = 0.904). However, the percentage of sample with a large number of CD163+ TAMs was significantly higher in thymic carcinoma than in thymoma (15/16 versus 34/53, p = 0.024). In contrast, the percentage of samples with a large number of S100+ DCs was significantly lower in thymic carcinoma than in thymoma (2/16 versus 23/53, p = 0.021). CONCLUSIONS: To the best of our knowledge, we are the first to show a high percentage of CD163+ TAMs and a low percentage of S100+ DCs in thymic carcinoma samples, and our findings may provide an idea for future targeted therapeutic strategies for thymic carcinoma using antibodies that inhibit monocyte differentiation to TAMs, thereby skewing TAMs differentiation toward DCs. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/13000_2014_215.

Cyclin-dependent kinase inhibitors, p16 and p27, demonstrate different expression patterns in thymoma and thymic carcinoma.

OBJECTIVES: The role of cell cycle inhibitors in tumorigenesis has been proven in various neoplasms; however, their roles in thymic tumors are still unclear. We examined the expression of cell cycle inhibitors such as those of the Cip/Kip family (p21, p27, and p57) and the INK-4/ARF family (p16 and p14) in thymoma and thymic carcinoma. METHODS: Samples from 41 thymoma and 14 thymic carcinoma patients, and 34 normal thymic tissue samples were prepared for the study. Immunohistochemical analysis using antibodies to p21, p27, p57, p16, and p14 was carried out, and the positivity for these inhibitors in each group was estimated in terms of their subcellular location and percentage of cells showing positive staining. RESULTS: Nuclear p27 showed a stepwise decrease (p < 0.0001), and the cytoplasmic p27 showed a stepwise increase (p < 0.0001) in expression level with the increase in malignancy. p16 in both the nucleus and cytoplasm showed a stepwise increase (p < 0.0001) in expression level with the increase in malignancy. However, as for p21, p57, and p14, there was almost no nuclear or cytoplasmic expression in each group. CONCLUSIONS: Our findings suggest that low nuclear and high cytoplasmic p27 expression levels, and high nuclear and cytoplasmic p16 expression levels may correlate with the increase in thymic malignancy.

Immunohistochemical analysis of thymic carcinoma focusing on the possibility of molecular targeted and hormonal therapies.

OBJECTIVE: Thymic carcinoma is a rare mediastinal malignant tumor, and in many patients, the tumor is detected in an inoperable advanced stage. Even when chemotherapy is administered to such patients, the patients show a poor response. We investigated new biomarkers of therapeutic molecular targets. METHODS: This study included 44 patients diagnosed and treated for primary thymic epithelial tumors at Showa University Northern Yokohama Hospital, Showa University Hospital, and Showa University Fujigaoka Hospital from 2003 to 2011. We investigated new biomarkers of therapeutic molecular targets, such as the peroxisome proliferator-activated receptor γ (PPARγ), insulin-like growth factor 1 receptor (IGF1R), epidermal growth factor receptor (EGFR), estrogen receptor (ER), progesterone receptor (PgR), androgen receptor (AR), human epidermal growth factor type 2 (HER2)/neu, CD44, and L-type amino acid transporter 1 (LAT1), in thymic tumors. RESULT: Immunohistochemical analysis showed that the PPARγ positivity rate in thymic carcinoma was 32 %, which was significantly higher than that in thymoma (4 %). The IGF1R positivity rate in thymic carcinoma was 73 %, which was significantly higher than that in thymoma (27 %). CONCLUSION: Therefore, by examining the expressions of PPARγ and IGF1R, it would be possible to identify therapy-responsive patients and to improve results of thymic carcinoma treatment.

One-dimensional mean computed tomography value evaluation of ground-glass opacity on high-resolution images.

OBJECTIVE: Differentiation of atypical adenomatous hyperplasia (AAH), bronchioloalveolar carcinoma (BAC), and invasive carcinoma on computed tomography (CT) is useful for determining "follow-up or resection" strategies for lesions displaying ground-glass opacity (GGO). The purpose of this study is to evaluate one-dimensional quantitative CT values of GGO on high-resolution CT (HRCT) images using computer-aided diagnosis. METHODS: Between April 2001 and March 2010, a total of 44 nodules in 42 patients with pure or mixed GGOs ≤2 cm were retrospectively evaluated. Maximum diameter and one-dimensional mean CT (m-CT) value of the diameter were measured using a computer graphics support system (HOPE/DrABLE-EX, Fujitsu, Tokyo, Japan) that displays a CT density profile across the tumor. RESULTS: m-CT values were -682 ± 64 HU (range) for AAH lesions, -544 ± 179 (range) for Type A lesions, -496 ± 147 (range) for Type B lesions, and -371 ± 142 (range) for invasive lesions. AAH lesions had a significantly lower m-CT value than Type B lesions. AAH, Type A, and Type B lesions had significantly lower m-CT values than invasive lesions (p < 0.05). All seven GGO lesions with a maximum diameter ≤1 cm and m-CT value ≤-600 HU were pre-invasive lesions, while 16 of 22 (73 %) cases with maximum diameter >1 cm and m-CT value >-600 HU were invasive lesions. CONCLUSION: Observation may be indicated for GGO lesions with a maximum diameter ≤1 cm and m-CT value ≤-600 HU.

[Case of acute respiratory distress syndrome treated with direct hemoperfusion using a polymyxin B immobilized fiber colum].

During a 54-year-old woman's visit to a hot-spring resort, she suffered a fever and became dizzy and unable to speak clearly. She was admitted to our hospital due to serious pneumonia and respiratory failure type I. She was treated with antibiotics, but her condition became worse and developed into acute respiratory distress syndrome (ARDS). She was intubated and received artificial ventilation. Her blood pressure gradually decreased and she suffered septic shock probably due to endotoxin with gram negative coccus infection. Subsequently, she was treated with a direct hemoperfusion using a polymyxin B immobilized fiber column (PMX-DHP), which resulted in an improvement of oxygenation. However, her pneumonia led to the development of septic shock with gram negative coccus infection, and PMX-DHP treatment was resumed. After PMX-DHP re-treatment, she recovered gradually in intensive care including prone positioning ventilation.

Mediastinal lung herniation associated with pulmonary sequestration.

Mediastinal lung herniation is a rare condition characterized by protrusion of 1 lower lung through behind the heart into the opposite side of the chest, usually from right to left. We present a case of mediastinal lung herniation associated with pulmonary sequestration, which was confirmed both surgically and pathologically in a 13-year-old girl initially admitted with a diagnosis of pneumonia. Contrast-enhanced computed tomographic images using a multidetector-row computed tomography clearly demonstrated the right lung herniation toward the left and 2 aberrant systemic arteries supplying the sequestered lung mass. These arteries run through the herniated lung from right to left. Additionally, on the basis of pleural anatomy, we discuss herein the difference between a mediastinal lung herniation and horseshoe lung.

Thymoma with intracystic dissemination arising in a unilocular thymic cyst.

A 33-year-old asymptomatic woman was referred to our hospital for evaluation of an abnormal shadow on a chest radiograph. A chest-computed tomogram revealed a cystic, partially solid tumor in the right inferior mediastinum. Following an initial diagnosis of cystic teratoma, surgery was performed. The tumor, a well-encapsulated, thin-walled cyst located within the right inferior lobe of the thymus, was extirpated by partial resection of the thymus. The cut surface revealed a unilocular cyst containing multiple grayish-white tumors on the inner cyst walls. Some tumors detached from the wall owing to loose connections. Microscopic findings revealed that the cyst was lined with squamous epithelium. The tumor on the cyst wall was diagnosed to be a type B1 thymoma. Based on these findings, we diagnosed this case as a thymoma originating from the wall of a thymic cyst, accompanied by intracystic dissemination from the tumor.