The Usefulness of a Simple Classification for Bronchoscopic Findings for Diagnosis of Peripheral Pulmonary Tumour.

BACKGROUND: Normal bronchial epithelium has been described in terms of transparency and smoothness. No studies have compared bronchoscopic and pathological findings in the identification of bronchial epithelium. OBJECTIVES: This study aimed to classify bronchoscopic findings for peripheral pulmonary tumour (PPT) for accurate bronchoscopic diagnosis accounting for the presences of bronchial epithelium and bronchial stenosis using an ultrathin bronchoscope. METHODS: We performed endocytoscopy using narrow-band imaging (NBI) of specimens immediately after lobectomy to investigate the normal bronchial epithelium under the physiological saline injection technique (PSIT) prior to classification of PPT. A retrospective study to classify bronchoscopic findings included 46 patients diagnosed with malignancy by bronchoscopy for PPT. RESULTS: We recognized a "light blue line" (LBL) with NBI under PSIT, corresponding to strong reflection of short-wavelength light by cilia on the epithelial surface in an ex vivo endocytoscopic study. Bronchoscopic findings of PPT were classified morphologically into stenotic type (ST) and non-stenotic type (NonST). Tumours were also classified as exposed type (ET) and non-exposed type (NonET) based on the presence of epithelium. Most ST and NonET lesions (74%) were adenocarcinoma. Among squamous cell carcinoma, 55% were categorized as ST and ET. All NonST and NonET cases were adenocarcinoma. A significant difference in the presence of LBL was seen between ET and NonET. CONCLUSIONS: Our simple classification based on the appearance of stenosis and LBL in PPT may facilitate pathological diagnosis.

[A Case of Ileus Due to Colon Cancer with Non-Occlusive Mesenteric Ischemia].

Abdominal computed tomography(CT)revealed ileus due to sigmoid colon cancer in a 68-year-old man with abdominal pain, and endoscopic decompression using a transanal ileus tube was attempted. The blood test on the following day showed a marked increase in CRP 46.13mg/dL. Abdominal contrast CT was performed, and mesenteric ischemia was confirmed. Emergency surgery was performed on the same day. The ileum, and ascending, transverse, and descending colon appeared mottled and necrotic and were excised. A specialized diet started on the 5th postoperative day, and parenteral nutrition was used for a long period of time, due to the possibility of short bowel syndrome. The ileostomy and colostomy was closed 57 days after the operation. The patient finished parenteral nutrition on the 88th postoperative day without obvious nutritional absorption disorder and was discharged on the 94th postoperative day as oral intake only. We reported a case of ileus due to colon cancer with non-occlusive mesenteric ischemia(NOMI).

[A Case in Which the ICG Fluorography Was Useful for Detecting Minute Peritoneal Disseminations].

A 65-year-old man was emergently brought to our hospital because of rupture of 10 cm hepatocellular carcinoma(HCC) at left lobe in September 2019. He underwent selective transcatheter arterial embolization(TAE)for hemostasis. Enhanced computed tomography(CT)revealed one more 26 mm HCC at segment 8(S8)in addition to the ruptured HCC. Transcatheter arterial chemoembolization(TACE)was performed for both tumors. HCC at left lobe was resistant to TACE, hence we performed left hepatectomy. During the surgery we searched for peritoneal dissemination by using indocyanine green(ICG) fluorography and found 4 nodules with ICG accumulation in the omentum. All the nodules were pathologically diagnosed as peritoneal dissemination. We reported a case in which the ICG fluorography was very useful for detecting small peritoneal disseminations.

A case report: Feasibility of a near infrared ray vision system (Photo dynamic eye®) for the postoperative ischemic complication of gallbladder carcinoma.

INTRODUCTION: Radical resection with or without preserving extra-hepatic bile duct has shown similar prognoses for gallbladder carcinoma (GB ca), although aggressive resection is essential. In preserving bile duct, ischemic complications are serious, life-threatening serious problems. Correct evaluation of the blood flow to the biliary tract is crucial. CASE PRESENTATION: A case of gallbladder ca in a 62-year-old man was reported. The patient was diagnosed with stage Ⅱ GB ca (T2, N0, M0) by ultrasonography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography. Cholecystectomy and intraoperative frozen section examination were planned. After recognition of invasion to subserosa and negative cystic duct margin, radical dissection of the lymph nodes in the hepatoduodenal ligament with preserving biliary tract was performed. Three days after the operation, biliary peritonitis was revealed. Emergency laparotomy showed ischemic bile leakage. Proper blood flow of the biliary system was realized by a near-infrared ray vision system (Photo Dynamic Eye®: HAMAMATSU Photonics) using indocyanine green. Primary suture of the extra-hepatic biliary duct and T-tube drainage were selected. No stricture of the bile system nor recurrence was recognized for two years after surgery. DISCUSSION: In the case of ischemic biliary complications, whether to preserve the extrahepatic bile duct is a critical issue for the surgeons. In this case study, the feasibility of authentic indocyanine green near-infrared imaging was shown for postoperative ischemic biliary situations. CONCLUSIONS: Authentic indocyanine green near-infrared imaging was feasible for the estimation of the blood flow to the postoperative ischemic biliary complication.

Case: Authentic multimodal therapy and liver resection for an initially unresectable intrahepatic cholangiocarcinoma.

INTRODUCTION: Although curative resection is an outstanding prognostic factor of intrahepatic cholangiocarcinoma (ICC), certain segments remain unresectable. The standard therapy for initially unresectable ICC is uncertain. In this case report, we reported the feasibility of multimodal chemotherapy and curative resection. CASE: A 59-year-old Asian woman with back pain was referred to the hospital by her family physician regarding liver mass visible on ultrasonography. At admission, the carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were high, and images showed characteristic signs of ICC with intrahepatic metastases and invasions to on the right Glisson's sheath. Multimodal therapy was applied to the ICC, which could not be resected at first. The therapy comprised hepatic arterial chemoembolization with drug-eluting beads (DEB-TACE), angiographic subsegmentectomy (AS), and systemic chemotherapy. Downstaging of the ICC, which results in curative resection, was planned due to non-normalization of the tumor markers, and pathological analysis revealed complete remission. At 34 months after the surgery, the patient was alive without relapse. DISCUSSION: Recently, chemotherapy and/or an interventional approach were reported to be feasible, although unresectable advanced ICC has a poor prognosis. Some studies have reported that multimodal chemotherapy and R0 resection of initially unresectable ICC can prolong survival time. However, some reports have shown high morbidity and mortality associated with initially unresectable ICC treated with multimodal chemotherapy and R0 resection. Our study resulted in complete remission without complications. CONCLUSION: Multimodal chemotherapy and hepatic curative resection on locally advanced ICC are feasible treatment approaches for initially unresectable ICC.

[A Case Report of Appendiceal Cancer Complicated Appendicitis Treated with Single-Incision Laparoscopic Ileocecal Resection].

We report a case of appendicitis with an abscess that was treated with single-incision laparoscopic ileocecal resection with D2 lymphadenectomy because of intraoperative suspicion of appendiceal cancer. A 73-year-old woman was admitted to the hospital because of right lower abdominal pain. She was diagnosed with appendicitis with an abscess. Although single-incision laparoscopic appendectomy was planned, appendiceal cancer was suspected from intraoperative findings. Therefore, we performed single-incision laparoscopic ileocecal resection with D2 lymphadenectomy. The pathological result was moderately differentiated adenocarcinoma in the appendix. Because of the high risk of fStage II appendiceal cancer, adjuvant chemotherapy was administered. Neither recurrence nor metastasis have been detected 7 months after surgery.

[A Case of Gastric GIST with Pathological Complete Response Achieved by Long-Term Chemotherapy with Imatinib Mesylate].

A 78-year-old woman was diagnosed with a gastrointestinal stromal tumor(GIST)of the stomach, gradually increasing from 5 years prior. The tumor was suspected to invade the pancreatic body tail and spleen, as observed with computed tomography. Because the patient refused to undergo resection, we administered imatinib mesylate for 6 years. Since early rectal cancer was revealed, the patient was referred for resection and underwent laparoscopic low anterior resection and partial gastrectomy. Histopathologically, the tumor was replaced by tissues with myxomatous changes, and no viable tumor cells were detected. This was a rare case of GIST, resected after long-term chemotherapy by imatinib mesylate, and pathological complete response was achieved.

[Metachronous Bilateral Hemothorax Due to Reverse Chance Type Thoracic Fracture].

Metachronous bilateral hemothorax due to reverse Chance type thoracic fracture is very rare. In this case, we experienced a case of metachronous bilateral hemothorax, triggered by a thoracic fracture in which the anterior component of the spine collapsed, so-called reverse Chance type thoracic fracture. An 83-year-old woman with spinal kyphosis traumatically injured thoracic spine burst fracture, and bone fragments appeared on both sides of the destroyed vertebra. After injury, the left hemothorax also appeared, followed by the right hemothorax causing hemorrhagic shock. In thoracic destructive anterior fracture, we should consider the possibility of metachronous bilateral hemothorax.

[A Case of Small Bowel Adenocarcinoma That Was Diagnosed and Treated using Laparoscopic Surgery].

A 40-year-old man presented to our department with chief complaints of nausea and abdominal pain, and was diagnosed with small intestine ileus. After hospitalization, he underwent intestinal tract decompression using an ileus tube. A small bowel tumor was suspected as the cause of the intestinal obstruction. We then performed laparoscopic surgery for diagnosis and resection. In the intraoperative findings, stenosis near the small intestine tumor could be confirmed. The patient therefore underwent laparoscopic resection of a segment of the small intestine. Following rapid intraoperative pathological examination, the tumor was identified as well-differentiated adenocarcinoma with metastasis of the intermediate mesenteric lymph nodes. We then performed dissection of the main lymph nodes using small laparotomy incisions. Adjuvant chemotherapy with XELOX(130mg/m2 L-OHP on day 1 and 2,000 mg/m2 capecitabine on days 1-14)was administered for 6 months. Currently the patient is in relapse-free survival.

Ultrathin Bronchoscopy with Multimodal Devices for Peripheral Pulmonary Lesions. A Randomized Trial.

RATIONALE: The combination of an ultrathin bronchoscope, navigational technology, and endobronchial ultrasound (EBUS) seems to combine the best of mutual abilities for evaluating peripheral pulmonary lesions, but ultrathin bronchoscopes that allow the use of EBUS have not been developed so far. OBJECTIVES: To compare the diagnostic yield of transbronchial biopsy under EBUS, fluoroscopy, and virtual bronchoscopic navigation guidance using a novel ultrathin bronchoscope with that using a thin bronchoscope with a guide sheath for peripheral pulmonary lesions. METHODS: In four centers, patients with suspected peripheral pulmonary lesions less than or equal to 30 mm in the longest diameter were included and randomized to undergo transbronchial biopsy with EBUS, fluoroscopy, and virtual bronchoscopic navigation guidance using a 3.0-mm ultrathin bronchoscope (UTB group) or a 4.0-mm thin bronchoscope with a guide sheath (TB-GS group). MEASUREMENTS AND MAIN RESULTS: A total of 310 patients were enrolled and randomized, among whom 305 patients (150, UTB group; 155, TB-GS group) were analyzed. The ultrathin bronchoscope could reach more distal bronchi than the thin bronchoscope (median fifth- vs. fourth-generation bronchi; P < 0.001). Diagnostic histologic specimens were obtained in 74% (42% for benign and 81% for malignant lesions) of the UTB group and 59% (36% for benign and 70% for malignant lesions) of the TB-GS group (P = 0.044, Mantel-Haenszel test). Complications including pneumothorax, bleeding, chest pain, and pneumonia occurred in 3% and 5% in the respective groups. CONCLUSIONS: The diagnostic yield of the UTB method is higher than that of the TB-GS method. Clinical trial registered with www.umin.ac.jp/ctr/ (UMIN 000003177).

[A Case of Rectal Villous Tumor Detected with Heart Failure and Electrolyte Imbalance].

A 74-year-old woman presented to our emergency department with a chief complaint of appetite loss, and already diagnosed dehydration and heart failure. After hospitalization, the signs of heart failure were improved with liquid supplementation and electrolyte revision. At admission, computed tomography incidentally detected a rectal tumor. She underwent colonography, which revealed a huge villous tumor in the rectum. Based on the result of the initial biopsy, it was classified as a group 4 tumor, but additional biopsy of specimens obtained from 6 places led to a diagnosis of group 5 tumor. Then, we performed laparoscopic super-low anterior resection and made an ileal stoma. The electrolyte imbalance was improved and did not recur after the operation. In this case, the electrolyte imbalance caused by the huge villous tumor was electrolyte depletion syndrome (EDS).

Primary pulmonary mucinous (colloid) adenocarcinoma with postoperative bone metastasis.

We describe rare primary pulmonary mucinous (colloid) adenocarcinoma in an 80-year-old man. Chest computed tomography revealed a lobulated, well-defined nodule with a diameter of 3.2 cm in the right middle lobe. Transbronchial biopsy via endobronchial ultrasound with a guide sheath did not uncover malignancy. Right middle lobectomy proceeded because the tumor was located close to the pulmonary hilum. Macroscopically, the cut surface of the nodule comprised a well demarcated area of somewhat transparent granular aggregates and a yellow-white gelatinous substance. Computed tomography findings of a solitary metastatic lesion in the left fifth costal head 28 months thereafter were consistent with those of a mucin-rich tumor, which was effectively treated by radiotherapy.

The usefulness of endobronchial ultrasonography-guided transbronchial needle aspiration at the lobar, segmental, or subsegmental bronchus smaller than a convex-type bronchoscope.

BACKGROUND: Endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) is a standard procedure for approaching the lesion adjacent to extrapulmonary bronchus. We started to use wedge insertion of a convex endobronchial ultrasound bronchoscope into bronchi narrower than the diameter of the bronchoscope itself to perform EBUS-TBNA. Our objective was to investigate the bronchus in which EBUS-TBNA was possible and safe. METHODS: In this prospective study, we examined 15 lesions that were adjacent to lobar, segmental, or subsegmental bronchi narrower than the 6.9 mm external diameter of the convex scope. The cross-sectional area and maximum, minimum, and mean internal diameters of the airway lumen adjacent to the lesion were calculated using the measurement software. We investigated the airway branch in which EBUS-TBNA was possible, the narrowest airway diameter adjacent to the lesion for which insertion and diagnosis could be performed, the feasibility of puncture, and techniques for ensuring procedural success. RESULTS: The mean cross-sectional area of the lumen for the 13 lesions that could be punctured was ≥ 15.9 mm2 and the mean internal diameter was ≥ 4.5 mm. Cytologic or histologic diagnosis by EBUS-TBNA was possible in 11 of the 15 cases. In 2 of the 4 undiagnosed lesions, the mean internal diameter was <4.5 mm, and the convex scope was unable to reach the lesion. There was no occurrence of complications in any case. CONCLUSIONS: EBUS-TBNA can be performed by inserting a 6.9 mm EBUS bronchoscope into airways with a mean diameter ≥ 4.5 mm as measured on computed tomography before bronchoscopy.

[Two cases of retroperitoneal liposarcoma].

We report 2 cases of retroperitoneal liposarcoma. Case 1: A 53-year-old woman with severe abdominal distension and dyspnea was admitted to our hospital. Abdominal computed tomography(CT) and magnetic resonance imaging(MRI) revealed a large mass that occupied almost the entire abdominal cavity. She underwent surgery under the diagnosis of retroperitoneal liposarcoma. The tumor originated from the left lower pelvis. The tumor weighed 18 kg, and the histopathological diagnosis was well-differentiated liposarcoma. Seven years after the operation, local recurrence was found without any complaints. The operation was performed again. The tumor weighed 750 g, and it originated from the same area as observed in the first operation. The histopathological diagnosis was well-differentiated liposarcoma. Case 2: An 82-year-old woman complained of abdominal distension. A new dumbbell-like solid tumor was identified as retroperitoneal liposarcoma by CT and MRI findings, and it was growing rapidly. The tumor was removed with the cecum and right kidney in a curative operation. The tumor weighed 2.6 kg, and the histopathological diagnosis was dedifferentiated liposarcoma. The best treatment for retroperitoneal liposarcoma is curative resection. However, dedifferentiation occasionally occurs over time and in recurrent cases. It is important to follow-up strictly for retroperitoneal liposarcoma.

[A case of acute mediastinitis after endobronchial needle aspiration].

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become widespread, but reports of complications are rare. CASE: An enlarged mediastinal lymph node (4R) was detected in a 67-year-old man 33 months after surgery for rectal cancer, and we performed EBUS-TBNA to confirm the diagnosis. He was then admitted to hospital 13 days after the procedure, with cough, a swollen mediastinal fatty area around the 4R lymph node, and elevated WBC and CRP levels. After a diagnosis of acute mediastinitis was confirmed we gave him antibiotics, which improved his symptoms, the mediastinal fatty area and his WBC and CRP levels. CONCLUSION: We have to be aware of the possibility of acute mediastinitis after EBUS-TBNA of necrotic lymph nodes.

Female gender is an independent prognostic factor in non-small-cell lung cancer: a meta-analysis.

PURPOSE: It is not clear whether women with non-small-cell lung cancer (NSCLC) live significantly longer than men. Thus, we conducted a meta-analysis of published studies to quantitatively compare NSCLC survival data between genders. MATERIALS AND METHODS: A MEDLINE Web search for computer-archived bibliographic data regarding overall survival differences between genders was performed. DerSimonian-Laird random effects analysis was used to estimate the pooled hazard ratio (HR). RESULTS: We selected 39 articles as appropriate data sources, involving 86 800 patients including 32 701 women and 54 099 men. Combined HRs for women vs. men in studies using univariate and multivariate analyses respectively were 0.79 (p <0.0001) and 0.78 (p <0.0001). Pooled HRs for 3 study subgroups having (1) fewer than 30% stage I cases, (2) fewer than 50% adenocarcinoma cases, and (3) statistical adjustment for smoking status all indicated the survival advantage of women. CONCLUSION: This meta-analysis of published data concerning NSCLC patients indicated significantly better survival for women.

Pleuroperitoneal shunt for chylothorax and chylopericardium in lung cancer: a case report.

A 70-year-old man with T1N3M1 stage IV squamous cell carcinoma in the right upper lobe of the lung developed chylothorax and chylopericardium as rare simultaneous complications. Intravenous hyperalimentation, repeated pleurodesis, and ligation of the thoracic duct were all ineffective. A pleuroperitoneal shunt was inserted into the right pleural cavity from the fifth intercostal space, and a peritoneal catheter was placed in the abdominal cavity. Chylothorax was markedly improved, and the quality of life of the patient increased. This case indicates that a pleuroperitoneal shunt can be used for lung cancer-related chylothorax, as well as for malignant pleural effusion.

[Pulmonary alveolar proteinosis detected by a nodular lesion on chest computed tomography].

A 74-year-old woman was admitted to our hospital for further examination of chest X-ray abnormality. The chest computed tomography (CT) revealed a nodular lesion (1.0 cm in diameter) in right lung. Bronchoscopic biopsy showed no malignant cells and bronchoalveolar lavage fluid was not milky white. We performed video-assisted thoracic surgery and a tumor was resected. Histologically, dilated alveolar areas was filled with eosinophilic materials. This finding was compatible with pulmonary alveolar proteinosis (PAP). The characteristic CT finding of PAP is ground glass opacities in both lungs with thickened alveolar septa (so-called crazy-paving appearance). The CT findings of this case (unilateral, single nodular lesion) are very rare, so we report this case with references to the literatures.