Clinicopathological features of immunoglobulin G4-related pleural lesions and diagnostic utility of pleural effusion cytology.

OBJECTIVE: Immunoglobulin (Ig)G4-related disease is a recently described systemic immune-mediated fibro-inflammatory disease that frequently occurs in tumorous form. Herein, we elucidated the clinicopathological and cytological characteristics of IgG4-related pleural lesions (PLs). PATIENTS AND METHODS: Among 22 patients with fibro-inflammatory PLs of idiopathic aetiology, eight cases were diagnosed as IgG4-PL and the remaining 14 as non-IgG4-PL according to comprehensive diagnostic criteria for IgG4-related disease. Cell block examination of pleural effusion (CBPE) was performed in five patients with IgG4-PL and in six with non-IgG4-PL. Both groups were compared in terms of clinical presentation, laboratory data, histopathological features of resected pleura, and cytological features of pleural effusion (PE). RESULTS: PE was the most common (six patients, 75%) clinical presentation of IgG4-PL. IgG4-PL comparatively showed significantly more frequent concomitant allergic disease (P = .021), higher serum IgE levels (P = .012), higher adenosine deaminase levels in pleural fluid (P = .005), and rare spontaneous recovery without treatment (P = .046). The IgG4-PL group was histologically characterised by thicker fibrous pleura, storiform fibrosis, and infiltration of regulatory T cells, eosinophils and basophils. Using CBPE, IgG4-PL was cytologically distinct with numerous IgG4+ cells and eosinophils. The cytology of CBPE positively correlated with the histology of pleural tissue in the number of IgG4+ cells and eosinophils (R = .769 and .803, respectively). CONCLUSION: IgG4-PL frequently presents with PE and is histologically and cytologically characterised by abundant infiltration of IgG4+ cells and eosinophils. We believe that CBPE with immunohistochemistry/special staining could assist in the auxiliary diagnosis of IgG4-PL.

Chitosan tubes can restore the function of resected phrenic nerves.

OBJECTIVES: We previously reported that the phrenic nerve could be morphologically repaired by implantation of a chitosan nanofibre tube (C-tube). In the current study, we investigated whether implantation of C-tubes could improve the function of an injured phrenic nerve using a beagle dog model. METHODS: Seven beagle dogs underwent right thoracotomy under general anaesthesia. An approximately 5 mm length of the right phrenic nerve was resected. Five dogs had a C-tube implantation (C-tube group) and other two dogs did not have the C-tube implantation (control group). Diaphragm movements were longitudinally measured by X-ray fluoroscopy before surgery, immediately after the surgery, and 3, 6 and 12 months after the surgery. The diaphragm movement was determined by diaphragm levels at inspiration and expiration phases, and the excursion difference between them was calculated. At 12 months after the surgery, rethoracotomy was performed to examine electrical phrenic nerve conduction. The C-tube and phrenic nerve were then excised for histological assessment of nerve regeneration. RESULTS: Three of the five animals of the C-tube group showed improvement of diaphragm movement with time. In these three animals, slow phrenic nerve conduction was observed. Histological assessment showed that the injured nerve was connected by newly regenerating nerve fibres surrounded by granulation tissue within the C-tube. On the other hand, the animals in the control group and two animals of the C-tube group showed neither improved diaphragm movement, nor electrical conduction to the diaphragm. No nerve fibre regeneration was found by histology. CONCLUSIONS: Our results suggest that, in addition to morphological improvement, C-tube implantation can functionally improve the injured phrenic nerve by promoting phrenic nerve regeneration.

Needlescopic video-assisted wedge resection combined with the subcostal trans-diaphragmatic approach for undetermined peripheral pulmonary nodules.

BACKGROUND: Reduced mortality from lung cancer by computed tomography (CT) screening facilitates the use of video-assisted thoracic surgery (VATS) lung wedge resection to obtain a definite diagnosis and to treat tiny nodules. The authors evaluated their initial experience using novel needlescopic VATS wedge resection combined with the subcostal trans-diaphragmatic (SCTD) approach for managing undetermined peripheral pulmonary nodules. METHODS: Between 2009 and 2012, 35 patients who had 36 operations underwent needlescopic VATS wedge pulmonary resection with the SCTD approach. Preoperative percutaneous CT-guided marking of the nodule was performed. Two 3-mm miniports were placed in the thorax for the thoracoscopic camera and minigrasper. Just anterior to the 10th rib, a 2-cm subcostal incision was made, and a 12- or 15-mm port was placed trans-diaphragmatically into the chest cavity. Wedge resection of the lung was performed with endostaplers introduced through a subcostal port. RESULTS: The median tumor size was 1.1 cm. Localization of the tumor was widely distributed. The mean operation time was 51 min, and the mean blood loss was 4.2 mL. No patients required conversion to thoracotomy, and one patient required conversion to conventional VATS. Additional thoracic ports were placed in five patients, and the needlescopic incision was extended to 15 mm in one patient. The median duration of chest drainage was 1 day. Additional analgesia was not required for 22 patients and was used for less than 1 day for three patients, less than 2 days for seven patients, and less than 3 days for seven patients. The pathologic diagnosis of the nodules was malignant for 28 patients and benign for 8 patients. On postoperative day 7 or at admission, 34 patients were free of postoperative neuralgia. CONCLUSIONS: Needlescopic VATS wedge pulmonary resection combined with the SCTD approach is both safe and feasible and offers the specific advantages of minimal invasiveness and good cosmetic outcomes.

A novel fluorescence technique for identification of the pulmonary segments by using the photodynamic diagnosis endoscope system: an experimental study in ex vivo porcine lung.

OBJECTIVE: Photodynamic diagnosis is a technique that has been proposed to enhance tumor detection and resection. We modified this technique to identify pulmonary segments and examine the feasibility of this technique in ex vivo porcine lungs. METHODS: The photodynamic diagnosis endoscope system consisted of the D-Light system as the excitation light source and a TRICAM camera as the fluorescence sensing endoscope (Karl Storz GmbH & Co, Tuttlingen, Germany). Vitamin B2 was used as the fluorescence substance. Two kinds of segmentectomy were performed in right porcine lung. After identification of the segmental bronchus, the fluorescent substance was injected transbronchially. The fluorescent segment was observed using the photodynamic diagnosis endoscope system, and the identified intersegmental plane was cut using scissors. The operative data collected were the success rate of accurately identifying the pulmonary segments. The duration and light intensity of fluorescence of the target segment were recorded to provide an objective measurement of success. The same parameters were also measured for the adjacent segment. RESULTS: Overall, 20 segmentectomies were performed, 10 of each kind--cranial segmentectomy and L2 segmentectomy. In all procedures, it was possible to identify the target segment by its yellow-green fluorescence. No unexpected injuries of the major segmental bronchi and vessels nor incorrect recognition of target segments occurred. The success rate of accurately identifying pulmonary segments was 100%. The duration and light intensity of this fluorescence technique was enough to perform pulmonary segmentectomy. CONCLUSIONS: This florescence technique using vitamin B2 and the photodynamic diagnosis endoscope system is useful to identify the target pulmonary segment easily and clearly in ex vivo porcine lung.