Multidisciplinary treatment of thoracic fistulous empyema caused by pulmonary infection: a retrospective study.

Background: In cases of thoracic empyema, the presence of a fistula is known to be difficult to treat and associated with a poor prognosis. Few reports have described the management of fistulous empyema caused by lung parenchymal infection. The aim of this study was to describe the outcomes of multidisciplinary management of fistulous empyema caused by pneumonia or lung abscess due to common bacteria and mycobacteria. Methods: Among 108 cases of empyema surgically treated at Kanagawa Hospital over a 10-year period, 14 patients with fistulous empyema due to common bacteria (CBFE) or fistulous empyema due to mycobacteria (MFE) were analyzed. Fistulous empyema due to lung resection was excluded. Results: Eight out of the 9 patients with CBFE and 4 out of the 5 patients with MFE were male. Patients with CBFE were more likely to be >65 years of age (p=0.052) and to have a poor performance status (p=0.078). The time from onset to first surgical treatment was significantly longer in MFE (median, 5 months; p=0.004). Five patients with CBFE and two patients with MFE underwent open window thoracostomy, while three patients with CBFE and four patients with MFE underwent endobronchial occlusion (EBO). Six patients (66%) with CBFE and 3 patients (60%) with MFE achieved fistula closure. Of the patients who underwent EBO, fistula closure was achieved in 3 (100%) of the patients with CBFE and in 2 (50%) of the patients with MFE. Fistula closure was not achieved in any case with non-tuberculous mycobacteria. Conclusions: Fistulous empyema caused by common bacteria or Mycobacterium tuberculosis could be cured by surgical treatment and endobronchial intervention with adequate antimicrobial therapy, but fistulous empyema caused by non-tuberculous mycobacteria proved to be intractable. The challenge in the treatment of fistulous empyema due to non-tuberculous mycobacteria is the achievement of bacterial negativity.

Successful management of postoperative tracheal metastasis in small cell lung cancer with radiotherapy and durvalumab: A case report.

The patient in this report was a 73-year-old male who was diagnosed with small cell lung cancer (T3N0M0 stage IIB) after presenting with a 5.5 cm tumor detected in the right lower lobe of the lung by radiography. After right lower lobectomy and lymphadenectomy, postoperative adjuvant chemotherapy was administered with cisplatin and etoposide. At 27 months after surgery, the patient complained of wheezing. Tracheal metastasis was identified through computed tomography and bronchoscopy. Biopsy confirmed metastasis of small cell lung cancer. Radiotherapy (60 Gy) was administered to the mediastinal lymph nodes, including the supraclavicular region. The patient then underwent four cycles of carboplatin-etoposide-durvalumab, followed by durvalumab maintenance therapy. At 49 months after surgery, the patient complained of discomfort while speaking, leading to the discovery of a nodule in the subglottic space, which confirmed small cell lung cancer metastasis. Radiotherapy (30 Gy) was administered to the larynx and mediastinum, and the patient continued with durvalumab monotherapy. As of 61 months after surgery, he remains recurrence-free after the second course of radiotherapy. Our favorable outcome could be explained by the synergy between immunotherapy and radiotherapy. Here, we report a rare case of postoperative tracheal metastasis in small cell lung cancer successfully managed with radiotherapy and durvalumab. This shows promise in achieving local disease control and extending survival in postoperative metastatic lesions, highlighting a potential therapeutic approach.

An independent prognostic factor in surgical cases of pleural empyema caused by common bacteria is the presence of a fistula.

OBJECTIVES: Some surgical cases of pleural empyema lead to death despite multidisciplinary treatment. The purpose of this study was to identify prognostic factors in cases treated surgically for pneumonia-associated pleural effusions and empyema caused by common bacteria. METHODS: We conducted a retrospective cohort study of 108 surgical patients of empyema who encountered at our hospital between 2011 and 2021. Patients were divided into surviving and non-surviving cases. Factors on admission (age, sex, body mass index, presence of fistula, performance status, pleural fluid culture results, HbA1c, albumin, leukocytes, hemoglobin, body temperature, heart rate, respiratory rate, systolic blood pressure, prognostic nutritional index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and RAPID score) were compared between the two groups. RESULTS: There were 87 cases of pleural empyema caused by pneumonia due to common bacteria. Variables that differed significantly in univariate analysis between the surviving and non-surviving cases in patients' characteristics on admission were fistula (p value < 0.001, odds ratio 20.000, 95% confidence interval 3.478-115.022), positive pleural fluid culture (0.016, 6.591, 1.190-36.502), body mass index < 18.5 (0.001, 16.857, 1.915-148.349), performance status 0-1 (0.007, 11.778, 1.349-102.858), and hemoglobin (0.024, 1.768, 1.077-2.904). Multivariate analysis showed significant differences in the presence of fistula (p = 0.036, CI 1.174-125.825). The odds ratio was 12.154. The mortality rate was 3.8% for non-fistulous empyema and 44.4% for fistulous empyema. In 6 of 9 cases of fistulous empyema, the fistula could be closed. CONCLUSION: Fistula was a significant independent prognostic factor for pneumonia-associated pleural effusions and empyema caused by common bacteria.

Right pneumothorax with congenital pericardial defect showed right atrium mimicking bulla in surgery.

BACKGROUND: Congenital pericardial defect (CPD) is found incidentally in cases of pneumothorax. CPD is seen in left side rather than right side and it is not generally known among thoracic surgeons how the inside of the pericardial space can be seen from the thoracic cavity in cases of pericardial defect. CASE PRESENTATION: A 52-year-old man with dyspnea was referred to our hospital because of the diagnosis of right pneumothorax. Chest radiography showed a right lung collapse and a pneumopericardium on the left side. Despite insertion of a chest tube, air leakage prolonged, bullectomy at the apex of the right lung was performed under thoracoscopy. During surgery, thoracoscope showed that the right atrium seemed as if it had been a non-pedunculated bulla or cardiac cyst. Heart beating, continuity with the heart, and the absence of respiratory motion could distinguish the right atrium from a bulla, and pericardial defect was confirmed. Preoperatively, the patient had no cardiac symptoms related to the CPD, and therefore, it was determined that a procedure to close the CPD was not necessary. Any complication and recurrence did not occur 6 months after surgery. CONCLUSIONS: Right pneumothorax with CPD showed right atrium mimicking bulla in surgery. It is important to consider correction of CPD if there are cardiac symptoms at the onset of pneumothorax, and not to misinterpret the right atrium as a bulla.

Partial anomalous pulmonary venous connection and a tracheal bronchus associated with lung cancer in the same lobe: classification of partial anomalous pulmonary venous connection in lung resection.

A 73-year-old man with primary lung adenocarcinoma (StageIA3), which was solid nodule in the posterior segment, was simultaneously diagnosed as having partial anomalous pulmonary venous connection (PAPVC) and a tracheal bronchus in the same lobe on preoperative chest computed tomography. Right upper lobectomy was performed as the definitive treatment for both the lung cancer and the PAPVC. The superior pulmonary vein connected to the proximal superior vena cava and the pulmonary artery to the apical segment diverged at the proximal portion of the right pulmonary artery trunk along with the tracheal bronchus. The patient's pulmonary arterial pressure improved after lobectomy. The patient is living well without recurrence of lung cancer 6 months after surgery. In conclusion, it is important to confirm the presence of anomalous pulmonary vein drainage to prevent the lethal change of pulmonary-systemic blood flow. Based on the classification of PAPVC proposed, surgical plan should be considered carefully.

Postpneumonectomy syndrome related to the thickness of the fat tissue in the anterior mediastinum: a retrospective observational study.

BACKGROUND: Postpneumonectomy syndrome (PPS) is a life-threatening condition characterized by the extrinsic compression of the mainstem bronchus after pneumonectomy, causing rapidly progressive dyspnea. Information regarding the predictive factors of this condition is limited. Thus, the current study aimed to identify the predictive findings that can help prepare the treatment of PPS in advance. METHODS: The present study is a retrospective observational study. We reviewed the medical records of 12 consecutive patients who underwent pneumonectomy for lung cancer or tuberculosis between 2009 and 2020. The anatomical findings evaluated via computed tomography scan, nutritional status assessed using laboratory data, respiratory function, intraoperative variables between PPS and non-postpneumonectomy-syndrome patients were compared. RESULTS: There were two female patients who presented with left PPS (PPS 1 and PPS 2 aged 73 and 55 years, respectively). The median age of 10 non-postpneumonectomy-syndrome patients (n=6, men and n=4 women) was 66 (range, 54-76 years). Four and six patients underwent right and left pneumonectomy, respectively. The fat tissue thickness in the anterior mediastinum was significantly thinner in PPS than in non-postpneumonectomy-syndrome patients. However, the body mass index (BMI) and other nutritional parameters did not differ between PPS and non-postpneumonectomy-syndrome patients. The median vital capacity was higher in PPS than in non-postpneumonectomy-syndrome patients. The decrement of respiratory function and body weight after pneumonectomy did not differ between two groups. The intraoperative variables did not also differ between two groups. CONCLUSIONS: The fat tissue in the anterior mediastinum between the bilateral lungs is an anchor that can help maintain the normal position of the mediastinum after pneumonectomy. Thus, the fat tissue thickness between the bilateral lungs can be a predictive factor for the occurrence of PPS before surgery.

[Acute Necrotizing Esophagitis Occurred after Lung Resection for Lung Cancer].

The patient was a 78-year-old man who had undergone left lung segmentectomy (S6) with lymph node dissection for lung adenocarcinoma. One year and 5 months later, lung partial resection was performed for the lung cancer recurrence and the hematemesis was noted on the next day of surgery. Upper gastrointestinal endoscopy revealed extensive black necrosis on the mucosa of the esophagus, which was diagnosed as acute necrotizing esophagitis. To treat the bleeding, the exposed esophageal vessels were clipped via endoscopy several times. The endoscopy on the 64th post-operative day showed the mucosa recovered and he could be discharged on the 85th day. The exact etiology of acute necrotizing esophagitis is unknown in most cases.

The Incidence of Hemorrhagic Complications Was Lower With the Guide Sheath Than With the Conventional Forceps Biopsy Method: Results of Bronchoscopy in the 2016 Nationwide Survey by the Japan Society for Respiratory Endoscopy.

BACKGROUND: The Japan Society for Respiratory Endoscopy performed a nationwide survey to evaluate the current status and complications of bronchoscopy. Data on deaths due to bronchoscopy, complications after bronchoscopy, and particularly, complications of forceps biopsy were surveyed. METHODS: The survey form was mailed to 532 facilities accredited by the society. The numbers of procedures, complications, and deaths were investigated. RESULTS: The response rate was 79.1% (421 facilities). Deaths attributable to diagnostic bronchoscopy occurred in 11 (0.011%) of 98,497 cases.In regards to forceps biopsy, the guide sheath method was applied in 23,916 cases and the conventional method in 31,419 cases was done with conventional method. Complications of forceps biopsy developed in 1019 cases in total, with an incidence rate of 1.84%. The most frequent complication was pneumothorax (0.70%), followed by pneumonia/pleurisy (0.46%) and hemorrhage (0.45%). The incidence of hemorrhagic complication was significantly lower in the guide sheath group than in the non-guide sheath group (0.29% vs. 0.58%; P<0.001). The overall incidence of complications (1.63% vs. 2.00%; P=0.002) and the mortality rate (0% vs. 0.02%; P=0.04) were significantly lower in the guide sheath group. CONCLUSION: The incidence of hemorrhagic complications in forceps biopsy of peripheral pulmonary lesions was lower when the guide sheath method was applied. It is necessary to increase the awareness for safety control in diagnostic bronchoscopy for new procedures.

Current status of diagnostic and therapeutic bronchoscopy in Japan: 2016 national survey of bronchoscopy.

BACKGROUND: The safety management committee of the Japan Society for Respiratory Endoscopy (JSRE) conducted national surveys to clarify the state of diagnostic and therapeutic bronchoscopy in 2016. METHODS: Questionnaire forms were mailed to 532 JSRE-accredited facilities throughout Japan. We surveyed the actual condition of clinical practice and cases of bronchoscopy during 2016. RESULTS: Four hundred and thirty-three facilities responded giving a response rate of 81.4%; 67.6% held more than 400 beds. The average number of board accredited senior Fellows and Fellows per facility was 1.9 and 3.2, respectively. Diagnostic bronchoscopy was performed in a hospitalized setting in 74.6% of all facilities. The radial type ultrasound probe was operated in 51.7% of all facilities. The number of facilities has markedly increased compared with that reported in the 2010 survey (19.6%). The bronchoscopic navigation system had been in operation in 41.7% of all facilities. Antithrombotic drugs were adjusted before biopsy in 96.8% of all facilities. For intravenous sedation, midazolam was the first choice in 76.9% of all facilities. Endobronchial ultrasound guided transbronchial lymph node needle aspiration (EBUS-TBNA) has become popular over the decade (19.6% in 2010 to 68.1% in 2016). The mean number of the board accredited senior Fellows and board accredited Fellows increased in comparison with that in 2010. As a new technique, radial type ultrasound-guided peripheral approach has become popular. CONCLUSIONS: Through this survey, the advanced safety of bronchoscopic examination has been secured in many facilities. A continuous monitoring of bronchoscopic practices with respect to safety management is recommended.

An entire clinical course of mediastinal myxofibrosarcoma treated by surgery and radiation.

A woman in her 70s with an 8.6-cm tumor in the anterior mediastinum underwent tumor excision by median sternotomy, which combined resection of the fifth and sixth ribs. The pathological diagnosis was myxofibrosarcoma, and pathologically curative resection was accomplished. Local recurrence was detected at 10, 19, 23 and 28 months after the initial surgery. After repeated surgical resection, radiation therapy for the fourth unresectable recurrence resulted in failure. She died 34 months after the initial surgery. There have been 3 case reports of mediastinal myxofibrosarcoma. With regard to prognosis, control over local recurrence by surgical resection might be essential to achieve a long survival. However, the clinical course of mediastinal myxofibrosarcoma has not been reported in detail. This is the first description on the entire clinical course of mediastinal myxofibrosarcoma.

A giant mediastinal liposarcoma weighing 3500g resected with clam shell approach, a case report with review of literature.

INTRODUCTION: Liposarcoma is rare in the mediastinum and is less than 1% of all mediastinal tumors. In the present report, we demonstrated our case and summarized the principal treatment of the mediastinal liposarcoma with literature review. PRESENTATION OF CASE: A 50-year-old man presented at our hospital with complain of dyspnea. Chest radiography showed remarkable cardiomegaly. Computed tomography revealed an anterior mediastinal tumor from the level of the cephalic vein to the diaphragm of bilateral thoracic cavity with fat component. Using clam shell approach, complete en bloc resection of the tumor was performed. The weight of the tumor was 3500g. The pathological findings were 0that size of adipocyte and lipoblast were different, and the nuclei of atypical stromal cell were misshapen. Immune-histologic examination was negative for MDM2 and cyclin-dependent kinase 4. The diagnosis was liposarcoma, well-differentiated type. He could discharge 10days after surgery. Without adjuvant therapy, disease free survival for three years has passed. DISCUSSION: From 1990-2016 in Japan, 60 cases of the mediastinal liposarcoma were reported. In analysis of the 61 cases including the present case, adjuvant therapy was performed in 14 cases, subsequently, and recurrence was recognized in 5 cases. Adjuvant therapy did not significantly suppress the recurrence. CONCLUSION: Mediastinal liposarcoma weighing 3500g could be resected using calm shell approach, and no recurrence interval for 3 years has been achieved without adjuvant therapy. Complete resection is the only means to achieve the favorable outcome in mediastinal liposarcoma.

[Psoriasis and Psoriatic Arthritis Induced by Nivolumab in a Patient with Advanced Non-Small-Cell Lung Cancer].

BACKGROUND: Immune checkpoint-blocking antibodies may induce specific side effects known as immune-relatedad verse events. CASE PRESENTATION: A 66-year-oldman without any history of autoimmune disease was referredto our hospital for treatment of lung cancer in the right upper lobe. The tumor was diagnosed as Stage III A non-small-cell lung cancer by using bronchoscopic biopsy, computedtomography, andFDG -PET. After a single course of cisplatin andpemetrexed , the tumor size increasedremarkably andthe regimen was changedto nivolumab(3mg/kg every 2 weeks). Psoriasis andpsoriatic arthritis were observed after 4 courses of nivolumab. Nivolumab treatment continued, and the oral administration of predni- solone(20mg/day)couldimprove psoriasis andpsoriatic arthritis. However, the lung cancer showedprogressive disease after the 11th course of nivolumab. CONCLUSION: Psoriasis andpsoriatic arthritis were inducedby nivolumab in the patient without any history of autoimmune disease. It is unclear how prednisolone affected nivolumab for the treatment of lung cancer.

The first rib hypoplasia and the aberrant pulmonary artery branch detected by three-dimensional computed tomography in a surgical case with apical lung cancer, a case report.

BACKGROUND: The complete resection is one of the most crucial requirements to achieve favorable outcomes in oncologic surgery. The apex of the lung is surrounded complicatedly by the clavicle, the first rib, the subclavian artery and vein, and the brachial plexus. Therefore, the image information especially about the infiltration of adjacent anatomic structures, facilitates the surgery in the apical lung cancer. CASE PRESENTATION: A 70-year-old man presented at our hospital with a computed tomography (CT) scan showing a tumor at the left lung apex that infiltrated the chest wall. Two anatomical anomalies were found, which were the first rib hypoplasia and the aberrant pulmonary artery branch. The three-dimensional (3D) CT enhanced with using bolus tracking method, simultaneously revealed that the subclavian vessels existed between the clavicle and the second rib, and the left lingual pulmonary artery and the ventrobasal pulmonary artery diverged from the left main pulmonary artery as the first branch. We diagnosed the tumor as a primary lung squamous cell carcinoma that infiltrated the second rib, because sputum cytology suggested squamous cell carcinoma. Left lung upper lobectomy with lymph node dissection and chest wall resection (the second and third ribs) were performed with caution for the anatomical anomalies. The pathological diagnosis was pleomorphic carcinoma (5.0 × 3.0 × 1.9 cm) that invaded the second costal bone, and the pathological stage was confirmed to be pT3N0M0. Pathologically curative resection was accomplished. The patient was discharged from the hospital on 10 days after surgery. CONCLUSION: The 3D-CT precisely detected the anomalous structure consisted with the clavicle, the second rib, the subclavian artery and vein, the aberrant pulmonary artery branch. In the present case with the apical lung cancer, the evaluation of the anatomical structure via 3D-CT facilitated to achieve a pathological complete resection.

[Complete Remission after Weekly Intravenous Nanoparticle Albumin-Bound Paclitaxel in Elderly Patients with Non-Small-Cell Lung Cancer].

Case 1: An 86-year-old man was diagnosed with large cell or squamous cell lung cancer of clinical Stage II A.He was administered nanoparticle albumin-bound paclitaxel(nab-PTX)as fourth-line chemotherapy after monochemotherapy with docetaxel, vinorelbine, and S-1.The patient continues to show complete remission at the 15 courses of nab-PTX.Case 2: A 79-year-old man underwent partial resection of the right lower lung, and the pathological diagnosis was large cell lung cancer of pStage I A.However, recurrence in the right lung and multiple lymph node metastases were identified 3 years after the surgery.He was administered nab-PTX as second-line chemotherapy after vinorelbine monotherapy, and he has shown complete remission for a year.Weekly intravenous nab-PTX may be useful in elderly patients with non-small-cell lung cancer.

[Acquired Bronchial Atresia due to Endobronchial Tuberculosis].

A 37-year-old woman was re-admitted to our hospital because the recurrence of endobronchial tuberclosis was suspected. Mycobacterium tuberculosis was not detected by culture of sputum and gastric fluid, and computed tomography revealed a left superior segmental bronchus obstruction and pneumonia. Her pneumonia improved by administration of antibiotics, but the strong cough persisted. Bronchoscopic examination revealed that the left superior segmental bronchus was blind. Mycobacterium tuberculosis was not detected from a biopsy of the blind bronchus wall. We diagnosed that her obstructive pneumonia was due to acquired atresia after endobronchial tuberculosis. Because a persistent cough even after the treatment of pneumonia indicated the possibility of recurrent obstructive pneumonia, surgical resection was performed. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. The atresia of the superior segmental bronchus was histologically considered to be acquired atresia due to the inflammation from tuberculosis.

Intratumoral gene expression of 5-fluorouracil pharmacokinetics-related enzymes in stage I and II non-small cell lung cancer patients treated with uracil-tegafur after surgery: a prospective multi-institutional study in Japan.

OBJECTIVES: This investigation was conducted to assess the use of the intratumoral mRNA expression levels of nucleic acid-metabolizing enzymes as biomarkers of adjuvant chemotherapy for non-small cell lung cancer (NSCLC) using uracil-tegafur in a multi-institutional prospective study. MATERIALS AND METHODS: 236 patients with a completely resected NSCLC (adenocarcinoma and squamous cell carcinoma) of pathological stage IA (maximum tumor diameter of 2 cm or greater), IB, and II tumors were given a dose of 250 mg of uracil-tegafur per square meter of body surface area per day orally for two years after surgery. Intratumoral mRNA levels of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyltransferase (OPRT), and thymidine phosphorylase (TP) genes relative to an internal standard, ß-actin, were determined using laser-capture microdissection and fluorescence-based real time PCR detection systems. RESULTS AND CONCLUSION: Among 5-FU target enzymes, TS was the only one that showed a significant difference in the level of gene expression between the high and low gene expression groups, for both disease-free survival (DFS) and overall survival (OS), when patients were divided according to median values; 5-year DFS rates in high/low TS gene expression were 60.4% and 72.6%, respectively (p=0.050), 5-year OS rates were 78.1% and 88.6%, respectively (p=0.011). Cox's proportional hazard model indicated that the pathological stage and TS gene expression level were independent values for predicting DFS. The TS gene expression level was shown to be an independent predictive factor for DFS in stage I and II NSCLC patients who were treated with uracil-tegafur following surgery.

Benign myoepithelioma in the intrathoracic trachea.

A 67-year-old woman who was followed as a patient with bronchial asthma for 1.5 years visited our hospital with progressive dyspnea. Although the chest radiography findings were normal, a chest computed tomography scan revealed a mass obliterating the intrathoracic tracheal lumen. The patient's symptoms disappeared immediately after tumor excision, and no recurrence was observed during a 1.5-year follow-up period. Microscopically, the tumor was composed of densely packed polygonal-, oval- and spindle-shaped cells that were positive for pan-cytokeratin, α-smooth muscle actin and p63. These pathological findings confirmed the diagnosis of benign myoepithelioma. Chest physicians should recognize that benign myoepithelioma can develop in the trachea, although it is very rare.

[Mediastinal lymph node carcinoma of unknown primary site; report of a case].

We experienced a rare case of a 38-year-old man with mediastinal lymph node carcinoma of unknown primary site. He had an abnormal shadow of upper mediastinal mass in a health check, and he was referred to our hospital. Chest computed tomography( CT) showed only one swollen mediastinal lymph node, and positron emission tomography(PET) revealed an accumulation of fluorodeoxyglucose in the nodule. Serum levels of neuron specific enolase (NSE) were found to be elevated. Preoperative examination did not detect the primary lesion. She underwent a mediastinal lymphadenectomy. The pathological diagnosis of the lesion was large cell neuroendocrine carcinoma. He was given platinum-based combined chemotherapy and radiotherapy as adjuvant therapy. He has been well without any sign of recurrence for 1 year after surgery. Surgical resection of mediastinal lymph node carcinoma of unknown primary site has the possibility of a good prognosis.

[Giant hemangioma of the rib].

We experienced a rare case of a 73-year-old woman with giant hemangioma of the left 8th rib. She had an abnormal shadow of left lower lung field in a health check and was referred to our hospital. Preoperative examination suggested malignant rib tumor because of tumor growth beyond the disrupted bony cortex. She underwent resection of the left 8th rib with the 7th rib and the 7th intercostal muscles and reconstruction of the chest wall defect. The pathological diagnosis of the lesion was cavernous hemangioma. She was discharged after an uneventful postoperative course. She has been well without any sign of recurrence for 3 year after surgery.