Alveolar adenoma with a single cyst: A case report.

Alveolar adenoma is a rare and benign pulmonary tumor, which originates from type II pneumocytes and is often incidentally identified on radiographic images. Alveolar adenoma presents as a peripleural, solitary and cystic nodule in the lung and may mimic other types of lung tumors, thus rendering its differential diagnosis difficult. Alveolar adenoma is diagnosed based on histopathological and immunohistochemical analyses. The present study describes the case of a 50-year-old male patient with alveolar adenoma. He visited a local doctor ~3 years prior due to left chest pain. A chest computed tomography scan revealed a cystic lesion in segment 8 of the left lung. A nodular shadow appeared in the cyst and gradually increased in size; the patient was thus referred to the authors' hospital. The nodule was well-defined, solitary and solid; thus, lung cancer or aspergilloma were suspected. Thoracoscopic wedge resection was performed as diagnostic therapy. The frozen sections were non-diagnostic, and a pathological examination revealed an alveolar adenoma with no evidence of malignancy and a negative culture. The patient had a good post-operative course, with no sign of recurrence at the follow-up evaluation 46 months later. On the whole, alveolar adenoma is a rare, benign pulmonary tumor that is difficult to diagnose pre-operatively.

[Multiple Metastatic Lung Tumors in the Left Upper Lobe Complicated with Hypoplasia and Chronic Atelectasis of the Left Lower Lobe:Report of a Case].

An 80-year-old man with surgical history of colon cancer was referred to our department for surgical treatment for multiple metastatic lung tumors in the left upper lobe. The patient had been showing complete atelectasis of the left lower lung lobe one year prior to the consultation. Six months after wedge resections for the pulmonary metastases, the left lower lobe was re-expanded, showing bronchiectasis with rudimentary pulmonary artery branches. Further, the ventilation-perfusion scintigraphy showed decreased uptake in the left lower lobe. These findings indicated that the patient had the hypoplasia of the left lower lobe.

[Radiofrequency Ablation for Pulmonary Metastasis of Ovarian Cancer Caused Iatrogenic Pneumothorax, Leading to Empyema].

A female patient in her 40s who underwent surgery for recurrent right lung metastasis from resected ovarian cancer was referred to our department because of the right pneumothorax due to radiofrequency ablation for multiple lung metastases. Methicillin-resistant Staphylococcus epidermidis( MRSE) was detected from the tip of the drainage catheter indicated persistent pulmonary fistula with right empyema, and surgical treatment was performed. A white coat of the whole lung surface and air leakage were observed at radiofrequency ablation (RFA) treated lesion and partial resection of the right lung, debridement, and irrigation were performed. A pathological examination revealed residual viable ovarian cancer cells and pleural fistula.

Risk factors for postoperative cerebral infarction in Lung Cancer patients: a retrospective study.

BACKGROUND: Postoperative cerebral infarction is a rare but serious complication after lung cancer surgery. We aimed to investigate the risk factors and evaluate the efficiency of our devised surgical procedure to prevent cerebral infarction. METHODS: We retrospectively examined 1,189 patients who underwent a single lobectomy for lung cancer at our institution. We identified the risk factors for cerebral infarction and investigated the preventive effects of performing resection of the pulmonary vein as the last step of the surgical procedure during left upper lobectomy. RESULTS: Among the 1,189 patients, we identified 5 male patients (0.4%) with postoperative cerebral infarction. All five underwent left-sided lobectomy including three upper and two lower lobectomies. Left-sided lobectomy, a lower forced expiratory volume in 1 s, and lower body mass index were associated with postoperative cerebral infarction (Ps < 0.05). The 274 patients who underwent left upper lobectomy were stratified by two procedures: lobectomy with resection of the pulmonary vein as the last step of the surgical procedure (n = 120) and the standard procedure (n = 154). The former procedure significantly shortened the length of the pulmonary vein stump when compared with the standard procedure (mean stump length: 15.1 vs. 18.6 mm, P < 0.01), and the shorter pulmonary vein might possibly prevent postoperative cerebral infarction (frequency: 0.8% vs. 1.3%, Odds ratio: 0.19, P = 0.31). CONCLUSIONS: Resecting the pulmonary vein as the last step during the left upper lobectomy enabled the length of the pulmonary stump to be significantly shorter, which may contribute to preventing cerebral infarction.

Rapid imaging of thymoma and thymic carcinoma with a fluorogenic probe targeting γ-glutamyltranspeptidase.

In recent years, thoracoscopic and robotic surgical procedures have increasingly replaced median sternotomy for thymoma and thymic carcinoma. In cases of partial thymectomy, the prognosis is greatly improved by ensuring a sufficient margin from the tumor, and therefore intraoperative fluorescent imaging of the tumor is especially valuable in thoracoscopic and robotic surgery, where tactile information is not available. γ-Glutamyl hydroxymethyl rhodamine green (gGlu-HMRG) has been applied for fluorescence imaging of some types of tumors in the resected tissues, and here we aimed to examine its validity for the imaging of thymoma and thymic carcinoma. 22 patients with thymoma or thymic carcinoma who underwent surgery between February 2013 and January 2021 were included in the study. Ex vivo imaging of specimens was performed, and the sensitivity and specificity of gGlu-HMRG were 77.3% and 100%, respectively. Immunohistochemistry (IHC) staining was performed to confirm expression of gGlu-HMRG's target enzyme, γ-glutamyltranspeptidase (GGT). IHC revealed high GGT expression in thymoma and thymic carcinoma in contrast to absent or low expression in normal thymic parenchyma and fat tissue. These results suggest the utility of gGlu-HMRG as a fluorescence probe for intraoperative visualization of thymomas and thymic carcinomas.

[Giant Bullae Misdiagnosed as Pneumothorax:Report of a Case].

A 46-year-old man was taken to a hospital by ambulance because of sudden onset of dyspnea, and was inserted chest drainage tube with a diagnosis of right-sided tension pneumothorax on chest X-ray. Since the chest drainage was not effective, he was transferred to our institute. Based on chest computed tomography (CT) findings, a diagnosis of giant bullae of the right lung was made, and surgical treatment was performed. Postoperatively, the improvement of respiratory function was confirmed.

The surgical Apgar score predicts postoperative complications and the survival in lung cancer patients.

PURPOSE: The surgical Apgar score (SAS)-calculated using the intraoperative variables estimated blood loss, lowest heart rate, and lowest mean systolic pressure-is associated with mortality in cancer surgery. We investigated the utility of the SAS in patients with lung cancer undergoing surgery. METHODS: We retrospectively analyzed the data of 691 patients who underwent surgery for primary lung cancer between 2015 and 2019 in a single institute and analyzed the impact of the SAS. RESULTS: Of the 691 patients, 138 (20%), 57 (8.2%), and 7 (1.0%) had postoperative complications of all grades, grades ≥ III, and grade V, respectively, according to the Clavien-Dindo classification. The C-index for postoperative complications of grades ≥ III was 0.605. A lower score (0-5 points) (odds ratio 3.09 against 8-10 points, P = 0.04) and a lower percentage of vital capacity (odds ratio 0.97, P = 0.04) were independent negative risk factors for major postoperative complications. Patients with a lower score (0-5 points) had poor 5-year overall and cancer-specific survival rates (60.1% and 72.3%, respectively; P < 0.05 for both). CONCLUSIONS: The surgical Apgar score predicted postoperative complications and the long-term survival. Surgeons may improve surgical results using the SAS.

The pulmonary surgical Apgar score for lung cancer surgery predicts postoperative complications and long-term survival.

OBJECTIVES: The surgical Apgar score, calculated using 3 intraoperative variables (blood loss, lowest mean arterial pressure and lowest heart rate), is associated with mortality in cancer surgery. The original score has less applicability in lung cancer surgery; therefore, we innovated the modified pulmonary surgical Apgar score with additional intraoperative oxygen saturation representing pulmonary parenchymal damage and cardiopulmonary dynamics. METHODS: We retrospectively analysed the data of 691 patients who underwent surgery for primary lung cancer between 2015 and 2019 at a single institute. We analysed the utility of the pulmonary surgical Apgar score compared with the original surgical Apgar score. RESULTS: Postoperative complications were observed in 57 (8.2%) and 7 (1.0%) of the 691 patients who were stratified as grade ≥III and V, respectively, according to the Clavien-Dindo classification. We compared the fitness of the score in predicting postoperative complications; the calculated c-index (0.622) was slightly higher than the original c-index (0.604; P = 0.398). Patients were categorized into 3 groups based on their scores as follows: 0-6 points (n = 59), 7-9 points (n = 420) and 10-12 points (n = 212). Univariable and multivariable analyses demonstrated that a lower score was an independent negative risk factor for postoperative complications (odds ratio 3.53; P = 0.02). Patients with lower scores had a considerably poor 5-year overall survival (64.6%) (P = 0.07). CONCLUSIONS: The pulmonary surgical Apgar score predicts postoperative complications and long-term survival in patients with lung cancer undergoing surgery and may be utilized for postoperative management.

Symptom severity trajectories and distresses in patients undergoing video-assisted thoracoscopic lung resection from surgery to the first post-discharge clinic visit.

This study aimed to characterize patients' symptom severity trajectories and distresses from video-assisted thoracoscopic lung resection to the first post-discharge clinic visit. Seventy-five patients undergoing thoracoscopic lung resection for diagnosed or suspected pulmonary malignancy prospectively recorded daily symptom severity on a 0-10 numeric scale using the MD Anderson Symptom Inventory until the first post-discharge clinic visit. The causes of postoperative distresses were surveyed, and symptom severity trajectories were analyzed using joinpoint regression. A rebound was defined as a statistically significant positive slope after a statistically significant negative slope. Symptom recovery was defined as symptom severity of ≤3 in two contiguous measurements. The accuracy of pain severity on days 1-5 for predicting pain recovery was determined using area under the receiver operating characteristic curves. We applied Cox proportional hazards models for multivariate analyses of the potential predictors of early pain recovery. The median age was 70 years, and females accounted for 48%. The median interval from surgery to the first post-discharge clinic visit was 20 days. Trajectories of several core symptoms including pain showed a rebound from day 3 or 4. Specifically, pain severity in patients with unrecovered pain had been higher than those with recovered pain since day 4. Pain severity on day 4 showed the highest area under the curve of 0.723 for predicting pain recovery (P = 0.001). Multivariate analysis identified pain severity of ≤1 on day 4 as an independent predictor of early pain recovery (hazard ratio, 2.86; P = 0.0027). Duration of symptom was the leading cause of postoperative distress. Several core symptoms after thoracoscopic lung resection showed a rebound in the trajectory. Specifically, a rebound in pain trajectory may be associated with unrecovered pain; pain severity on day 4 may predict early pain recovery. Further clarification of symptom severity trajectories is essential for patient-centered care.

Bronchogenic cyst with atypical imaging findings and repeated ruptures in a short period of time: A case report.

Bronchogenic cysts are the most common primary cysts of the mediastinum. Although most are asymptomatic, some bronchogenic cysts cause symptoms such as chest pain and dyspnea. Here, we report a case of bronchogenic cyst that ruptured twice in a short period of time in a patient who presented with sudden back pain. The lesion was apparent on computed tomography (CT) as a mass lesion with heterogeneous and high attenuation in the posterior mediastinal region. CT-guided puncture performed for diagnostic purposes revealed the contents as bloody fluid. The patient suffered chest pain approximately 3 months after the first presentation, and re-growth and re-rupture of the mass was suspected. The lesion was surgically resected and pathologically diagnosed as a bronchogenic cyst. Spontaneous rupture is a very rare complication of bronchogenic cyst, usually into the trachea, pleural cavity, or pericardial cavity. However, there are no reports of multiple ruptures. This case highlights the importance of recognizing the atypical imaging findings of bronchogenic cyst and the rare complication of rupture.

Rapid imaging of lung cancer using a red fluorescent probe to detect dipeptidyl peptidase 4 and puromycin-sensitive aminopeptidase activities.

Rapid identification of lung-cancer micro-lesions is becoming increasingly important to improve the outcome of surgery by accurately defining the tumor/normal tissue margins and detecting tiny tumors, especially for patients with low lung function and early-stage cancer. The purpose of this study is to select and validate the best red fluorescent probe for rapid diagnosis of lung cancer by screening a library of 400 red fluorescent probes based on 2-methyl silicon rhodamine (2MeSiR) as the fluorescent scaffold, as well as to identify the target enzymes that activate the selected probe, and to confirm their expression in cancer cells. The selected probe, glutamine-alanine-2-methyl silicon rhodamine (QA-2MeSiR), showed 96.3% sensitivity and 85.2% specificity for visualization of lung cancer in surgically resected specimens within 10 min. In order to further reduce the background fluorescence while retaining the same side-chain structure, we modified QA-2MeSiR to obtain glutamine-alanine-2-methoxy silicon rhodamine (QA-2OMeSiR). This probe rapidly visualized even borderline lesions. Dipeptidyl peptidase 4 and puromycin-sensitive aminopeptidase were identified as enzymes mediating the cleavage and consequent fluorescence activation of QA-2OMeSiR, and it was confirmed that both enzymes are expressed in lung cancer. QA-2OMeSiR is a promising candidate for clinical application.

Development of a fluorescent probe library enabling efficient screening of tumour-imaging probes based on discovery of biomarker enzymatic activities.

Fluorescent probes that can selectively detect tumour lesions have great potential for fluorescence imaging-guided surgery. Here, we established a library-based approach for efficient screening of probes for tumour-selective imaging based on discovery of biomarker enzymes. We constructed a combinatorial fluorescent probe library for aminopeptidases and proteases, which is composed of 380 probes with various substrate moieties. Using this probe library, we performed lysate-based in vitro screening and/or direct imaging-based ex vivo screening of freshly resected clinical specimens from lung or gastric cancer patients, and found promising probes for tumour-selective visualization. Further, we identified two target enzymes as novel biomarker enzymes for discriminating between tumour and non-tumour tissues. This library-based approach is expected to be an efficient tool to develop tumour-imaging probes and to discover new biomarker enzyme activities for various tumours and other diseases.

Results of emergency salvage lung resection after chemo- and/or radiotherapy among patients with lung cancer.

OBJECTIVES: This study aimed to elucidate the outcomes of emergency salvage surgery following life-threatening events (serious haemorrhage and/or infections) among patients with lung cancer who had undergone chemo- and/or radiotherapy. MATERIALS AND METHODS: We analysed the data of patient from 2015 to 2020, retrospectively. The clinical characteristics, including preoperative treatment, perioperative outcomes and survival time, were analysed. RESULTS: Of the 862 patients who underwent primary lung cancer surgeries, 10 (1.2%) underwent emergency surgeries. The preoperative clinical characteristics were: median age, 63.7 years [interquartile range (IQR) 55-70.5]; sex (male/female), 9/1; clinical staging before initial treatment (I/II/III/IV), 1/1/3/5; initial treatment (chemoradiotherapy/chemotherapy/proton beam therapy), 5/4/1; and indications for emergency surgery (lung abscess/lung abscess with haemoptysis/haemoptysis/empyema), 5/3/1/1. The selected procedures and results were as follows: lobectomy/bilobectomy/pneumonectomy, 8/1/1 (all open thoracotomies); median operation time, 191.0 min (IQR 151-279); median blood loss, 1071.5 ml (IQR 540-1691.5); postoperative severe complications, 3 (30%); hospital mortality, none; median postoperative hospital stay, 37 days (12-125); control of infection and/or haemoptysis, all the cases; final outcome (alive/dead), 3/7 (all the cancer deaths); median postoperative survival, 9.4 months (IQR 4.3-20.4); and median survival from initial treatment, 19.4 months (IQR 8.0-66.9). CONCLUSIONS: Emergency salvage lung resection is a technically challenging procedure; however, the results were feasible and acceptable when the surgical indication, procedure and optimal timing were considered carefully by a multidisciplinary team. Although the aim was palliation, some patients who received additional chemotherapy afterwards and, thus, had additional survival time.

Solitary pulmonary metastasis after meningioma surgery of the head: a case report.

BACKGROUND: Meningioma is the most common type of benign primary brain tumor that is rarely associated with distant metastasis. No established treatment strategy for metastatic meningiomas exists to date. Herein, we report a case of solitary pulmonary metastasis of meningioma detected 2 years after neurosurgical resection of the primary tumor. CASE PRESENTATION: A 75-year-old male patient underwent neurosurgical resection of a convexity meningioma (World Health Organization grade II atypical meningioma), followed by postoperative radiotherapy for the residual tumor. Two postoperative years later, a solitary 10-mm pulmonary nodule in the left lower lung lobe was detected on chest computed tomography. The patient underwent video-assisted thoracoscopic left lower lobectomy for suspected pulmonary metastasis of meningioma. The pathological diagnosis was solitary pulmonary metastasis of meningioma. No sign of further recurrence was noted at 8 months postoperatively. CONCLUSIONS: We present a rare and unique surgical case of solitary pulmonary metastasis of meningioma. Further investigation is necessary to establish the standardized treatment strategy for metastatic meningiomas.

Right Epipericardial Fat Necrosis After Thymectomy.

A 62-year-old male patient underwent median sternotomy and thymectomy for thymoma (World Health Organization classification type B1+B3, Masaoka classification stage II). A 10-month follow-up postoperative computed tomography showed a 22-mm nodule in the anterior mediastinal lipid tissue just above the right diaphragm. The patient was followed for 8 years, and the nodule's capsule eventually became calcified. Considering the possibility of postoperative recurrence of thymoma, we excised the nodule. The pathologic diagnosis was epipericardial fat necrosis. In some cases, fat necrosis is difficult to distinguish from malignancy by imaging only; surgical resection has diagnostic significance and should be considered.

[Pulmonary Nontuberculous Mycobacteriosis Difficult to Differentiate from Local Recurrence of the Metastatic Lung Tumor of the Uterine Cervix Cancer at the Staple-line:Report of a Case].

A 70-year-old woman underwent right S6 segmentectomy and left S6 partial resection for lung metastasis of uterine cervix cancer. Although she received adjuvant chemotherapy, chest computed tomography revealed a new pulmonary nodule on the staple stump of the right lung. We diagnosed the tumor as local recurrence at the stump and planned to continue chemotherapy. However, the size of the tumor increased, and we performed right middle and lower lobectomy. Based on the pathological and bacteriological examinations, an epithelioid cell granuloma infected by Mycobacterium avium was established.

[Left Upper Lung Cancer with Mediastinal Inferior Lober Branch of Pulmonary Artery].

We herein report a rare case of an antero-basal pulmonary artery that was noticed during left upper lung lobectomy. A 61-year-old man underwent surgery and radiation for a brain tumor, which was diagnosed as a solitary metastasis of the primary lung cancer in the upper lobe of the left lung. He underwent left upper lobectomy for the lung cancer. During the operation, the left A4+5 and A8b+9+10 was found to be diverged from the main left pulmonary artery as the first branch, which descended between the left upper pulmonary vein and the left upper bronchus. The left upper lobe was successfully resected with preserving the A8b+9+10. This variation was not recognized preoperatively. Careful dissection along the pulmonary vessels is essential to prevent cutting off the unexpected aberrant anatomy.

Prognostic effect of preoperative red cell distribution width on the survival of patients who have undergone surgery for non-small cell lung cancer.

Red cell distribution width (RDW) is a prognostic factor for various malignancies, including colorectal, breast and lung cancer. The effect of preoperative RDW on the prognosis of patients who have undergone surgery for non-small cell lung cancer (NSCLC) was investigated in the present study. This retrospective, single-institution study included consecutive patients who had undergone complete NSCLC resection between January 2006 and December 2013 at the Department of Thoracic Surgery of Kansai Medical University Hospital (Hirakata, Japan). The overall and recurrence-free survival rates were compared using univariate and multivariate Cox proportional hazard models. A stepwise backward elimination method with a probability level of 0.15 was performed to select the most powerful outcome predictor sets. A total of 338 cases with NSCLC were analyzed. Of these, 25 had high RDWs (≥50 fl) and 313 had low RDWs (<50 fl). The 5-year overall survival rates in patients with high and low RDWs were 0.40 [95% confidence interval (CI): 0.21-0.58] and 0.80 (95% CI: 0.76-0.84), respectively, and the recurrence-free survival rates were 0.48 (95% CI: 0.25-0.68) and 0.70 (95% CI: 0.64-0.75), respectively. High RDW was identified as an independent prognostic factor for overall survival [hazard ratio (HR)=2.29; 95% CI: 1.3-4.01; P=0.004) but not for recurrence-free survival (HR=1.70; 95% CI: 0.93-3.12; P=0.085) by univariate and multivariate analysis. A high preoperative RDW was an independent predictor of poor prognosis in patients who had undergone radical resection of NSCLC. Therefore, patients with high RDW should be carefully monitored postoperatively, regardless of the disease stage.

Emergent salvage surgery for massive hemoptysis after proton beam therapy for lung cancer: a case report.

BACKGROUND: Salvage surgery is an effective therapeutic option for patients experiencing relapses after chemoradiotherapy for advanced-stage lung cancer or after high-dose radiotherapy for early-stage lung cancer. We report a case involving an emergent salvage surgery for a patient with massive hemoptysis who developed lung cancer recurrence after undergoing proton beam therapy 7 years prior to presentation. CASE PRESENTATION: A 70-year-old male patient was emergently admitted due to massive hemoptysis. He had undergone proton beam therapy for a stage I adenocarcinoma of the left upper lobe 7 years ago, and was receiving chemotherapy for local recurrence. We performed an emergent salvage pulmonary resection to achieve hemostasis. During the operation, we confirmed the presence of a left broncho-pulmonary arterial fistula, which was considered as the origin of the massive hemoptysis. We repaired the fistula between the pulmonary artery and left upper bronchus without incident; an orifice of the fistula at the left pulmonary artery was sutured using a non-absorbable monofilament, and the central portion of the orifice of the fistula at the left upper bronchus was closed with a mechanical stapling device. The postoperative diagnosis was of an adenocarcinoma-ypT3(pm1) N0M1a (dissemination)-IVA, ef1b. The patient has survived for over a year with the cancer in almost complete remission following the administration of an epidermal growth factor receptor tyrosine kinase inhibitor. CONCLUSIONS: Emergent salvage surgery demands high skill levels with optimal timing and correct patient selection. Our case suggested that the procedure played an important role in controlling serious bleeding and/or infectious conditions. Consequently, he could receive chemotherapy again and survive for over a year.