Radiological features and surgical management of lung abscess directly extending into the chest wall: A case report.

INTRODUCTION AND IMPORTANCE: We presented an extremely rare case of lung abscess following bronchoscopy associated with lung cancer that extended directly into the chest wall. CASE PRESENTATION: A 49-year-old man with adenocarcinoma underwent bronchoscopy. Eight days after the biopsy, the patient presented with chills and anterior chest wall pain. Chest computed tomography (CT) scan revealed a gas-containing lung abscess, measuring 10 cm in the left upper lobe and subcutaneous emphysema. The coronal view of the CT indicated a continuous passage of air from the lung abscess to the subcutaneous emphysema beneath the pectoralis muscle. Surgical debridement of the subcutaneous abscess was performed, resulting in drainage of a large volume of purulent material. We confirmed that the lung abscess had directly extended to the chest wall, leading to a decision to perform segmentectomy of the upper division of the left lung. CLINICAL DISCUSSION: Lung abscess associated with lung cancer is a rare, life-threatening complication, which may lead to significant delays in the commencement of oncological treatment and potentially worsen long-term outcomes. In the present case, surgical findings confirmed a lung abscess extending directly to the chest wall. Surgical therapy is the treatment of choice for this rare condition, providing rapid focus control. Therefore, prompt initiation of surgical therapy is essential when conservative measures prove ineffective. CONCLUSION: Lung abscesses may extend into the chest wall during differential diagnosis of infectious diseases of the chest wall. Successful treatment of this rare condition depends on prompt surgical intervention.

Intrapulmonary solitary fibrous tumor coexisting with lung adenocarcinomas.

BACKGROUND: Solitary fibrous tumor (SFT) is a rare tumor of mesenchymal origin and accounts for < 2% of all soft tissue masses. Although SFT has been identified in multiple anatomic locations and can grow anywhere in the body, intrapulmonary SFT are rare. CASE PRESENTATION: In this report, we presented a rare case of intrapulmonary solitary fibrous tumor (SFT) coexisting with lung adenocarcinoma in a 74-year-old man. Chest computed tomography showed a well-defined nodule with punctate calcification and measuring 2.3 × 2.1 cm and two ground-grass nodules with solid component. To obtain a definitive diagnosis and achieve complete resection, surgery was performed. The postoperative diagnosis was intrapulmonary SFT coexisting with lung adenocarcinoma. After surgery, he survived for 6 months without any signs of recurrence. CONCLUSION: Complete resection may be the best treatment for intrapulmonary SFT. Careful follow-up of the postoperative course is important, because differentiating between benignity and malignancy is difficult by histologic findings alone.

Hepatocyte Growth Factor Enhances Antineoplastic Effect of 5-Fluorouracil by Increasing UPP1 Expression in HepG2 Cells.

Aberrant activation of hepatocyte growth factor (HGF) and its receptor c-Met axis promotes tumor growth. Therefore, many clinical trials have been conducted. A phase 3 trial investigating a monoclonal antibody targeting HGF in combination with fluoropyrimidine-based chemotherapy had to be terminated prematurely; however, the reason behind the failure remains poorly defined. In this study, we investigated the influence of HGF on the antineoplastic effects of 5-fluorouracil (5-FU), a fluoropyrimidine, in HepG2 cells. HGF suppressed the proliferative activity of cells concomitantly treated with 5-FU more robustly as compared to that of cells treated with 5-FU alone, and markedly increased the expression of uridine phosphorylase 1 (UPP1). Intracellular concentration of 5-fluorouridine, an initial anabolite of 5-FU catalyzed by UPP1, was increased by HGF. Interestingly, erlotinib enhanced HGF-induced increase in UPP1 mRNA; in contrast, gefitinib suppressed it. Furthermore, erlotinib suppressed HGF-increased phosphorylation of the epidermal growth factor receptor at the Tyr1173 site involved in downregulation of extracellular signal-regulated kinase (Erk) activation, and enhanced the HGF-increased phosphorylation of Erk. Collectively, these findings suggest that inhibition of the HGF/c-Met axis diminishes the effects of fluoropyrimidine through downregulation of UPP1 expression. Therefore, extreme caution must be exercised in terms of patient safety while offering chemotherapy comprising fluoropyrimidine concomitantly with inhibitors of the HGF/c-Met axis.

A spontaneous reduction in tumor size of a thymic carcinoma: a case report.

BACKGROUND: Spontaneous regression of thymic carcinoma is extremely rare. We report a case of a resected thymic carcinoma with preoperative spontaneous regression in a 67-year-old woman. CASE PRESENTATION: The patient presented with low-grade fever and anterior chest pain. Chest computed tomography (CT) showed a 55 × 43 mm exophytic heterogeneously enhancing mass showing some areas of necrosis. Chest CT done one day preoperatively revealed that the tumor had rapidly shrunk for one month. Surgical resection was performed to obtain a definitive diagnosis and achieve complete resection, yielding a postoperative diagnosis of thymic carcinoma. The patient survived without signs of recurrence for 12 months postoperatively. CONCLUSIONS: Mediastinal tumors with necrosis demonstrating spontaneous regression should include thymic carcinomas in the differential diagnosis.

Primary mucinous adenocarcinoma of the thymus: A case report.

Primary thymic mucinous adenocarcinoma is extremely rare; to our knowledge, only 16 cases have been reported to date. A 68-year-old man presented to a previous hospital due to massive pericardial effusion. Cytological examination of the pericardial effusion revealed the presence of adenocarcinoma, and computed tomography showed an anterior mediastinal mass lesion invading the pericardium. Because systemic examination failed to detect other lesions, except for liver metastasis, mediastinal lymph node swelling, and pleural dissemination, a thoracoscopic biopsy of the mediastinal and pleural tumor was performed. The pathological diagnosis was thymic mucinous adenocarcinoma. Although he received chemotherapy, he died due to cancer 6 months after the biopsy.

Recurrent solitary fibrous tumor of the pleura with malignant transformation: a case report.

We report a rare case of recurrent solitary fibrous tumor (SFT) of the pleura with suspicious malignant transformation. A 78-year-old man had undergone prior surgical resection of the primary and recurrent SFT tumors at 11 and 2 years before the current presentation. Although his primary tumor had a round shape and did not show invasive growth, the current recurrent tumor extended through the neural foramen and had an osteoclastic progression into the thoracic spine. A computed tomography (CT) guided needle biopsy was performed and the pathological diagnosis of the tumor was confirmed as the recurrence of SFT. Immunohistochemically, the MIB-1 proliferation index (Ki-67) of the primary tumor and the current tumor was 1.74 and 30.00%, respectively. These clinical and immunohistochemical findings were strongly suspected the malignant transformation of SFT from benign. He was treated with radiotherapy, and a response was observed.

Pulmonary torsion after resuscitative thoracotomy: a case report.

We report a rare case of pulmonary torsion after nonpulmonary thoracotomy. A 38-year-old woman with schizophrenia committed suicide by a self-infliction of sharp force into the chest and abdomen. During emergent abdominal damage control surgery, a left-sided resuscitative thoracostomy was also performed due to hemorrhagic shock. Although abnormal shadow was detected on postoperative chest roentgenogram and computed tomography, the diagnosis of pulmonary torsion was delayed. Seven days after initial surgery, pulmonary torsion was diagnosed and managed by left upper lobectomy. To our knowledge, this is the first report of pulmonary torsion after resuscitative thoracotomy.

Prognostic Impact of a Novel Tumor Marker and Inflammation Index for Patients With Non-small-cell Lung Cancer.

BACKGROUND/AIM: Different tumor markers and systemic inflammation have been linked with cancer development and poor outcome. We aimed to establish a novel non-invasive prognostic index for patients with resectable non-small cell lung cancer (NSCLC) based on serum carcinoembryonic antigen (CEA) and C-reactive protein (CRP). PATIENTS AND METHODS: Four hundred and sixty-two patients curatively resected for NSCLC between 2008 and 2014 were included. All patients with a follow-up period of less than 5 years were omitted. The geometric mean of the normalized serum CEA and CRP levels was used as a novel tumor marker and inflammation index (TMII). The cut-off value of TMII was determined by receiver operating characteristic (ROC) curve analysis. Univariate and multivariate analyses were used to identify the relative risk factors for survival. RESULTS: ROC curve analysis revealed a TMII cut-off value of 0.46. The group with high TMII displayed more adverse clinical characteristics. Furthermore, compared to patients with low TMII, the group with high TMII had significantly poorer survival. On multivariate analysis, TMII was independently associated with survival. CONCLUSION: We established a novel prognostic index (TMII) based on serum CEA and CRP. Preoperative TMII may predict poor outcomes in patients with NSCLC.

[Preoperative Spontaneous Regression of Thymoma].

We report a case of preoperative spontaneous regression of thymoma in a 66-year-old woman who presented chest pain. Chest computed tomography revealed a well-defined tumor in the anterior mediastinum. The long axis of the tumor decreased from 25 to 18 mm during 1 month preoperatively. Video-assisted thoracoscopic thymothymectomy was performed for definitive diagnosis and treatment. Histopathologically, the tumor mainly comprised necrotic components with partially viable cells, and was diagnosed as a thymoma. The occlusion of the feeding artery by organized thrombus was found by pathology and it was considered to be the cause of coagulative necrosis.

The Prognostic Values of a Novel Preoperative Inflammation-Based Score in Japanese Patients With Non-Small Cell Lung Cancer.

BACKGROUND: Several previous researchers have investigated the prognostic value of the combinations of systemic inflammatory markers. However, the prognostic power of these systemic inflammatory markers is not identical. We aimed to establish a novel prognostic score based on systemic inflammatory markers. METHODS: Four hundred non-small cell lung cancer (NSCLC) patients who underwent surgery and were followed more than 5 years were included. Univariate and multivariate analyses were calculated by the Cox proportional hazards regression model. RESULTS: Among systemic inflammatory markers which were used for the previously reported indexes, preoperative serum C-reactive protein (CRP) and body mass index (BMI) were independent prognostic markers in multivariate analysis, while serum albumin level, neutrophil to lymphocyte ratio and platelet to lymphocyte ratio were not. Based on this result, a novel score was established. Patients with both normal CRP (< 0.13 ng/dL) and high BMI (> 20.6 kg/m2) were allocated a score of 0. Patients in whom only one of these abnormalities was present were allocated a score of 1, whilst those with both high CRP and low BMI were given a score of 2. Patients with score 0 had 84.44% of 5-year cancer-specific survival, while patients with score 1 - 2 had a 61.88%. On multivariate analysis, this novel score was an independent prognostic factor. CONCLUSION: This novel score based on CRP and BMI might serve as an efficient prognostic indicator in resected NSCLC.

Resected thymic large cell neuroendocrine carcinoma: A case report and review of the literature.

INTRODUCTION: Large cell neuroendocrine carcinoma (LCNEC) of the thymus is an extremely rare neoplasm. PRESENTATION OF CASE: We report a rare case of LCNEC of the thymus in a 55-year-old woman. Her chest roentgenogram during a routine checkup revealed an abnormal shadow in the mediastinal left upper lung field. Chest computed tomography showed an anterior mediastinal mass measuring 4.8 × 4.0 cm. Positron emission tomography with 18F-fluorodeoxyglucose (FDG) showed high FDG accumulation at the lesion. To obtain a definitive diagnosis and achieve complete resection, a surgery was performed. The postoperative diagnosis was thymic LCNEC; it was classified as a Masaoka stage III tumor due to the invasion of tumor cells into the left lung. Postoperatively, the patient received adjuvant chemotherapy and survived without any signs of recurrence for 30 months after surgery. DISCUSSION/CONCLUSION: The detailed clinical features of thymic LCNEC remain unknown because of its rarity. In total, 20 cases of resection for LCNEC, including the present case, have been reported in the English language literature; we have presented a review of these cases and discussed the optimal therapy for this rare and virulent tumor of the thymus.

Serum Carcinoembryonic Antigen Level Predicts Cancer-Specific Outcomes of Resected Non-Small Cell Lung Cancer With Interstitial Pneumonia.

BACKGROUND: It has been well accepted that the prognosis of non-small cell lung cancer (NSCLC) patients with interstitial pneumonia (IP) is significantly poor. However, there are only a few studies that indicated the prognostic factors, especially tumor markers, among NSCLC patients with IP. METHODS: Forty-one NSCLC patients with IP who underwent surgery at our institution were included. Patients died of other diseases including postoperative acute exacerbation (AE) of IP were excluded. Univariate and multivariate analyses were calculated by the Cox proportional hazards regression model. RESULTS: The 5-year cancer-specific survival of overall and stage I patients were 37.4% and 39.2%, respectively. The 5-year cancer-specific survival of patients with high serum carcinoembryonic antigen (CEA) level was 9.4%, while that with normal serum CEA level was 55.6%. However, serum cytokeratin-19 fragment (CYFRA 21-1) and squamous cell carcinoma-related antigen (SCC) levels were not associated with patients' survival. Furthermore, serum CEA level was significantly associated with poorer cancer-specific survival in univariate and multivariate analyses. CONCLUSIONS: This study demonstrated that serum CEA level might serve as an efficient prognostic indicator after surgery in NSCLC with IP.

The Inflammatory Prognostic Index Predicts Cancer-Specific Outcomes of Patients with Resected Non-Small Cell Lung Cancer

Background: Previous study developed a new inflammatory prognostic index (IPI) and found the prognostic value of IPI for all stage non-small cell lung cancer (NSCLC). To the best of our knowledge, however, no studies regarding IPI in patients with resected NSCLC are available. Methods: Three hundred forty-one NSCLC patients who underwent surgery at our institution were included. The IPI was calculated as C-reactive protein × neutrophil-to-lymphocyte ratio (NLR)/serum albumin. The optimal cut-off value was calculated by the Cutoff Finder. Univariate and multivariate analyses were calculated by the Cox proportional hazards regression model. Results: The optimal cut-off value was 5.237 for IPI. The IPI was associated with age, gender, smoking status, histology, pT status and serum CYFRA21-1 level, but not pStage, pN status and serum carcinoembryonic antigen level. The 5-year cancer-specific survival of patients with low IPI was significantly better than that with high IPI (84.8% vs. 57.9%, p< 0.001). Furthermore, low IPI was significantly associated with favorable cancer-specific survival in univariate (HR =0.326, 95% CI =0.212-0.494; p<0.001) and multivariate (HR =0.438, 95% CI =0.276-0.690; p=0.001) analyses. Conclusion: This is the first study to demonstrate that IPI might serve as an efficient prognostic indicator in resected NSCLC.

A case of spontaneous hemopneumothorax in which the condition worsened after chest drainage.

A 45-year-old woman was referred to our hospital with sudden chest pain. She came on foot with normal vital signs. Computed tomography (CT) revealed right mild pneumothorax with niveau level. We suspected spontaneous hemopneumothorax (SHP) and inserted a thoracic drain. After 800 ml of blood and air was evacuated immediately, the outflow from the drain stopped. However, despite the outflow of blood from the drainage tube having stopped, she developed hemorrhage shock 2 h after drainage. Contrast-enhanced CT revealed extra-vascular signs at the top of the right pleural cavity. Emergency video-assisted thoracic surgery (VATS) was performed. We identified the chest drain as being obstructed by blood clot. Continuous bleeding from a small aberrant vessel at the top of the thoracic cavity was identified, and we stanched it easily by clipping. The present experience suggests that routine enhanced CT and aggressive emergent VATS should be performed in cases of SHP.

Comparison of Inflammation-Based Prognostic Scores in Patients undergoing Curative Resection for Non-small Cell Lung Cancer.

BACKGROUND: Inflammation-based prognostic scores, including Glasgow prognostic score (GPS), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), prognostic nutritional index (PNI), systemic immune-inflammation index (SII) and advance lung cancer inflammation index (ALI) are reported to be associated with survival in patients with non-small cell lung cancer (NSCLC). However, at present, there are no studies that compared these scoring systems for resectable NSCLC. METHODS: Three hundred forty-one NSCLC patients who underwent surgery at our institution were included. The optimal cut-off values of SII and ALI were calculated by the Cutoff Finder. The area under the receiver operating characteristics curve (AUC) was calculated to compare the predictive ability of each of the scoring systems. Univariate and multivariate analyses were performed to identify the clinicopathological variables associated with overall survival. RESULTS: The optimal cut-off value of SII and ALI were 471.2 × 109/L and 37.66, respectively. All scores were significantly related to the 5-year cancer-specific survival. The ALI consistently had a higher AUC value in comparison with other inflammation-based prognostic scores. A multivariate analysis showed that GPS and ALI were independently associated with overall cancer-specific survival. CONCLUSION: To the best of our knowledge, this is the first study to demonstrate that GPS and ALI appear to be superior to other inflammation-based prognostic scores in patients undergoing potentially curative resection for NSCLC.

Intrathoracic scapular dislocation following lung cancer resection.

A 64-year-old man underwent right upper lobectomy combined resection with third-fifth rib for lung cancer and reconstruction of chest wall using Dual Mesh. Six days after surgery, he experienced acute severe pain in the right shoulder. The purulent drainage through the drainage tube was also found. Chest CT showed that the inferior angle of the scapula protruded into the right intrathoracic cavity. We performed a removal of Mesh. Although we did not want to use synthetic materials because of infection, we performed titanium plate fifth rib fixation to avoid the recurrent dislocation of the scapula. After the redo surgery, continuous lavages with physiologic saline of the thoracic cavity was also performed. Patient is now doing well without recurrences of cancer, infection and scapular dislocation, 14 months after the redo surgery.

Systemic Immune-inflammation Index Predicts Survival of Patients After Curative Resection for Non-small Cell Lung Cancer.

BACKGROUND: The systemic immune-inflammation index (SII) is reported to be associated with clinical outcomes and has been proven to be a promising prognostic indicator in several solid tumor types. To the best of our knowledge, however, no studies regarding SII in patients with resectable non-small cell lung cancer (NSCLC) are available. MATERIALS AND METHODS: Three hundred forty-one patients with NSCLC who underwent surgery at our Institution between 2008 and 2012 were included. The SII was calculated using the formula: platelet count × neutrophil/lymphocyte count. The optimal cut-off value was calculated using the Cutoff Finder (http://molpath.charite.de/cutoff). Univariate and multivariate analyses were calculated by the Cox proportional hazards regression model. RESULTS: The optimal cut-off value was 471.2×109/l for SII. A low SII was associated with female gender, never smoking status, adenocarcinoma histology, higher pathological TNM stage and low level of serum C-reactive protein, but not age, serum carcinoembryonic antigen or cytokeratin 19 fragment level. Patients of the low SII group had a significantly better 5-year overall survival than those with high SII (83.61% vs. 60.39%, p<0.001). Multivariate analysis revealed that the SII was a significant independent predictive indicator for cancer-specific survival (p=0.007). CONCLUSION: This is the first study to demonstrate that the SII could represent an independent prognostic factor for patients with resectable NSCLC.

The advanced lung cancer inflammation index is an independent prognostic factor after surgical resection in patients with non-small-cell lung cancer.

OBJECTIVES: The usefulness of a recently developed advanced lung cancer inflammation index (ALI) has been reported in advanced non-small-cell lung cancer (NSCLC) and small-cell lung cancer. However, no previous studies have examined the prognostic significance of ALI in patients with operable NSCLC. Therefore, the aim of this study was to explore the relationship between ALI and the prognosis of resected NSCLC. METHODS: Three hundred and forty-three patients with NSCLC who underwent surgery at our institution between 2008 and 2012 were included. The ALI score was calculated as body mass index × serum albumin/neutrophil to lymphocyte ratio. A Web-based software programme [Cutoff Finder (http://molpath.charite.de/cutoff/)] was used to determine the optimal cut-off value for ALI. The Kaplan-Meier methods and a multivariable Cox proportional hazards model were used to evaluate the potential prognostic factors. RESULTS: The optimal cut-off value of ALI was defined as 37.66. The low-ALI group (ALI < 37.66) displayed more adverse clinical characteristics. Furthermore, compared with patients in the high-ALI group (ALI > 37.66), those in the low-ALI group had significantly poorer survival rates. On multivariable analysis, gender, histological diagnosis, pN status, serum carcinoembryonic antigen level, serum C-reactive protein level and ALI were associated independently with cancer-specific survival. CONCLUSIONS: This study is the first to investigate whether ALI is useful for predicting postoperative survival in patients with NSCLC. Preoperative ALI might serve as a potentially clinically valuable marker of the prognosis for patients with operable NSCLC.

Fluorodeoxyglucose Positron Emission Tomography Can Provide Useful Information for Differentiating Thymic Epithelial Tumors.

BACKGROUND: We examined the usefulness of fluorodeoxyglucose (FDG) positron emission tomography (PET) in predicting the World Health Organization (WHO) histologic type and Masaoka stage of thymic epithelial tumors. METHODS: A total of 73 patients with thymic epithelial tumors who underwent preoperative FDG-PET were included. Relationships between the maximum standardized uptake value (SUVmax) and WHO histologic type and the Masaoka stage of the tumor were examined. Differences in SUVmax between the various groups were calculated. To avoid the effect of the tumor size on SUVmax, the ratio of SUVmax to tumor size (SUVmax/T) was also examined. RESULTS: There was a significant relationship between SUVmax and WHO histologic type. SUVmax of high-risk thymomas (types B2 and B3) was significantly higher than that of low-risk thymomas (types A, AB, and B1). SUVmax of thymic carcinomas was also significantly higher than those of the low-risk and high-risk groups. The relationship between the SUVmax/T and WHO histologic type showed more significant results. SUVmax and SUVmax/T showed higher values in patients with advanced Masaoka stage disease than in those with early-stage disease. CONCLUSIONS: FDG-PET can provide useful information for differentiating thymic epithelial tumors. The SUVmax/T is more useful than the SUVmax for differentiating between low-risk and high-risk thymomas.

Low Body Mass Index Is an Independent Predictive Factor after Surgical Resection in Patients with Non-Small Cell Lung Cancer

Background: The effect of body mass index (BMI) on postoperative survival in non-small cell lung cancer (NSCLC) has been controversial. We retrospectively analysed the effect of preoperative BMI on postoperative outcomes of NSCLC surgery. Methods: Consecutive 384 NSCLC patients were enrolled. Patients were subdivided into 3 groups: low BMI group (BMI<18.5 kg/m2), normal BMI group (BMI=18.5-24.0 kg/m2) and high BMI group (BMI>24.0 kg/m2). The prognostic significance of BMI was examined retrospectively. Results: The 5-year survival of patients with low, normal and high BMI groups were 46.3%, 74.3% and 84.3%, respectively. The low BMI group had a poorer prognosis than the other groups (p<0.001). The survival of high BMI group had a more favorable trend than that of normal BMI group, but this did not reach statistical significance (p=0.057). On multivariate analysis, significant risk factors for cancer-specific survival were male gender (p=0.0061), non-adenocarcinoma histology (p=0.0003), pN1-2 status (p=0.0007), high serum CEA level (p<0.0001) and low BMI (low vs. others: p <0.0001). Conclusions: Preoperative BMI is an independent prognostic factor for NSCLC patients after surgical resection, with low BMI patients having an unfavorable prognosis.