[The Basic Theory and Strategy for the Pleural Adhesiolysis Procedure].

Medical imaging and a patient's medical history are great resource for predicting the degree of adhesions developing in the thoracic cavity. However, we would encounter a strong, total adhesion unexpectedly. Although the degree of adhesions varies in each, individual case, there are common theories and techniques to apply for the total adhesion. We hope this article would be helpful to minimize any risk, such as the amount of blood loss, the surgery duration, the degree of lung injury, and postoperative complications, if you encounter the total adhesiolysis.

A case report of aspergillosis accompanied by saccular bronchodilation after bronchial thermoplasty in a 19-year-old woman.

BACKGROUND: Fungal infections are rarely reported as a complication of bronchial thermoplasty (BT) in patients without immunosuppressive comorbidity. CASE PRESENTATION: A 19-year-old woman college student was admitted to our hospital owing to uncontrolled severe asthma despite using the maximum dose of steroid inhalation. She experienced asthmatic attacks more frequently while cheerleading, which is an extracurricular activity. She received BT because she wanted to continue cheerleading. After the second BT session, she developed more sputum and cough. During the third session, white secretion and saccular bronchodilation appeared in the left lower bronchus. Aspergillus fumigatus was detected in the culture of the bronchial lavage sample, and saccular bronchodilation in the affected bronchus was observed on computed tomography (CT). Five months after the start of oral itraconazole, her subjective symptoms as well as her CT findings improved. Her asthma condition improved enough for the patient to continue cheerleading without exacerbation. CONCLUSIONS: It is necessary to consider the possibility of respiratory tract infections including fungal infections after BT. Detailed observations of the entire bronchus and sample collection for microbial culture are highly recommended.

A case of congenital bronchial atresia patient with subclinical infection who underwent lung resection.

Congenital bronchial atresia, CBA, is rare and has often asymptomatic benign condition. The CBA condition usually arose during the formation of bronchi, but the CBA patients are able to live well into adulthood. This case highlights a potential surgical intervention for a CBA patient with subclinical infection. A 55-year-old Japanese male had abnormal findings on his chest X-ray at an annual health check-up in March 2018. His chest computed tomography (CT) revealed bronchial stenosis and infiltrative shadow in the right inferior lobe. He was referred to our hospital for further investigation and was diagnosed CBA after a variety of examinations including bronchoscopy. His dilated bronchi were filled with mucus, the end of one of the bronchi had obstructive pneumonia, and subclinical infection in the CBA lesion was suspected. Also, the result of bronchoscopy disclosed intrabronchial infection with Gram-positive bacteria so we performed lobectomy onto the lower lobe. Although no protocol had been established, a surgical intervention would be necessary for this case.

The first case of micropapillary adenocarcinoma associated with cystic airspace in a non-smoking man.

Lung cancers associated with cystic airspaces are attracting increasing attention because of delayed diagnosis. The cancers that usually occur in smokers comprise lepidic, papillary, and/or acinar adenocarcinoma, but a micropapillary type has not been described to date. Pulmonary micropapillary adenocarcinoma was added to the 2015 World Health Organization (WHO) classification system as a new subtype with a notably poor prognosis. We describe the first micropapillary adenocarcinoma of the lung associated with cystic airspaces in a 79-year-old non-smoking man.

Azygos vein aneurysm resection concomitant with heart valve repair via right thoracotomy.

Azygos vein aneurysm is very rare and is usually found incidentally because of its clinical silence. We report a case of recurrent pleural effusion caused by an azygos vein aneurysm in a patient with moderate mitral valve regurgitation (MR) and tricuspid valve regurgitation (TR). Since valve disease is considered a significant precipitating factor for both dyspnoea and pleural effusion, we decided to study the aetiologies of these conditions concomitantly. Azygos vein aneurysm resection in combination with tricuspid and mitral valve repair using cardiopulmonary bypass was performed successfully through a right anterior thoracotomy. The postoperative course was uneventful, and the patient reported improved exercise capacity.

Recurrent thymoma with stiff-person syndrome and pure red blood cell aplasia.

Stiff-person syndrome (formerly known as stiff-man syndrome) is a very rare autoimmune and neurogenic disorder, thought to present as a paraneoplastic variant in association with thymoma. Pure red blood cell aplasia is also a paraneoplastic disorder associated with thymoma. Although separate cases of stiff-person syndrome and pure red blood cell aplasia have been reported, we describe here what is to our knowledge the first case of recurrent thymoma with both stiff-person syndrome and pure red blood cell aplasia. We describe the successful treatment of the neurogenic symptoms of stiff-person syndrome and the progressive anemia associated with pure red blood cell aplasia by tumor excision.

[Strategy for marginally resectable lung cancer].

Lung cancer accounts for the largest number of new cases of cancer deaths annually. The treatment of locally advanced non-small-cell lung cancer(NSCLC)will continue to be a problem for many years. In particular, the border-zone subset of stage III A(N2)patients, which lies between the generally resectable stage I and II tumors and the unresectable stage III B patients, has been the subject of a wide variety of clinical trials incorporating various combinations of chemotherapy, radiotherapy, and surgery.What is the ideal therapy for stage III A(N2)patients ? is a controversial question, and the role of surgery is not clearly defined because of its heterogeneous nature. Most importantly, treatment decisions for these patients should be dictated by the stage of the patients' disease and the patients' performance status, medical comorbidities, and preferences. At our hospital, therefore, all of these patients' data are discussed at our cancer-board conference, incorporating the options of thoracic surgeons, medical oncologists, and radiation oncologists to determine the optimal prospective treatment strategies for the patients. We focused on a treatment strategy for the patients with the so called marginally resectable' lung cancer in this article.

Ectopic hamartomatous thymoma--a truly rare neoplasm: report of a case.

An ectopic hamartomatous thymoma is an extremely rare benign neoplasm that commonly occurs in the lower neck region. It has distinctive pathological features that include haphazardly arranged spindle cells, epithelial cells, and mature fat tissue. Its histogenesis is still controversial. This report presents a case of a 26-year-old man with ectopic hamartomatous thymoma in the left supraclavicular region, and discusses the current knowledge regarding this type of lesion. Clinicians as well as pathologists should be aware of the existence of this disease so that it can be identified correctly.

Repeat FDG-PET for predicting pathological tumor response and prognosis after neoadjuvant treatment in nonsmall cell lung cancer: comparison with computed tomography.

BACKGROUND: The efficacy of fluorodeoxyglucose-positron emission tomography (FDG-PET) for predicting pathological tumor response and prognosis after neoadjuvant chemoradiotherapy followed by surgery in locally advanced nonsmall cell lung cancer (NSCLC) was compared to the predictive value of tumor size as determined by computed tomography (CT). METHODS: Thirty-seven consecutive NSCLC patients who received FDG-PET and CT scans both before and after neoadjuvant chemoradiotherapy were enrolled in this study. The percentage point changes in maximum standard uptake value (SUV) on PET and tumor size on CT after neoadjuvant treatment were defined as the SUV ratio and the size ratio, respectively, and were compared with pathological tumor response and prognosis after surgery. A major pathological response was defined as residual viable tumor cells corresponding to less than one-third the size of the original tumor. RESULTS: Nineteen and 18 patients showed major and minor pathological responses, respectively, after neoadjuvant treatment. The optimal cutoff values for predicting a major pathological response were 0.6 for the SUV ratio and 0.79 for the size ratio. The SUV ratio predicted the pathological tumor response with higher accuracy than the size ratio did (P = 0.04). Neither the SUV ratio nor the size ratio predicted prognosis after surgery. CONCLUSION: For predicting the pathological tumor response after neoadjuvant chemoradiotherapy, the SUV ratio on FDG-PET is superior to the size ratio on CT in patients with NSCLC. However, neither the SUV ratio nor the size ratio could predict prognosis.

11C-acetate for positron emission tomography imaging of clinical stage IA lung adenocarcinoma: comparison with 18F-fluorodeoxyglucose for imaging and evaluation of tumor aggressiveness.

BACKGROUND: To determine the usefulness of positron emission tomography (PET) with (11)C-acetate (AC) for imaging lung adenocarcinoma and evaluating its tumor aggressiveness, AC- and (18)F-fluorodeoxyglucose (FDG)-PET were compared. METHODS: One hundred and sixty-nine adenocarcinomas with clinical stage IA and 53 benign nodules were examined by both AC- and FDG-PET before surgery. The sensitivity and specificity for discriminating benign/adenocarcinoma were compared between AC- and FDG-PET. The AC and FDG uptakes were examined to determine the relationship with tumor aggressiveness, i.e., pathological tumor stage, lymphatic, vascular, or pleural involvement, and proliferative activity determined by Ki-67 staining score. RESULTS: While the sensitivity of AC-PET was significantly higher than FDG-PET for bronchioloalveolar carcinoma (BAC) and well-differentiated (W/D) adenocarcinoma (p < 0.001 and 0.006, respectively), there was no significant difference for moderately or poorly differentiated adenocarcinoma. The specificity was not different between them. While FDG uptakes were significantly higher in tumors with pathological advanced stages or those with lymphatic, vascular and/or pleural involvements than in tumors with pathological stage IA or those without these tumor involvements (p = 0.04 to p < 0.001), AC uptake did not show significant differences between the respective sub-groups except according to the tumor stage. While both AC and FDG uptakes showed a significant correlation with Ki-67 staining scores (p = 0.03 and p < 0.001, respectively), the correlation coefficient of former was lower than that of latter (p = 0.07). CONCLUSIONS: While AC-PET can image BAC and W/D adenocarcinoma with a higher sensitivity than FDG-PET, it cannot evaluate tumor aggressiveness of clinical stage IA lung adenocarcinoma as well as FDG-PET.

[Is video-assisted thoracic surgery lobectomy better than minimally invasive open thoracotomy?].

This article reviews our experiences of the current video-assisted thoracic surgery (VATS) lobectomy and minimally invasive open thoracotomy for resection of lung cancer. Between August 1999 and April 2007 at Saiseikai Central Hospital, Tokyo, Japan, we performed VATS lobectomy in 243 patients with clinical stage I lung cancer. It is certain that VATS lobectomy is acceptable in view of its low invasiveness, mortality, morbidity. And from an oncological viewpoint, VATS lobectomy is not inferior to conventional lobectomy. Therefore, we consider VATS lobectomy to be one of the therapeutic options in patients with clinical stage I lung cancer. However, what is most important is to achieve an anatomic lobectomy and complete mediastinal lymph node dissection. It may be that it is not important for differences of approach methods.

18F-fluorodeoxyglucose and 11C-acetate positron emission tomography are useful modalities for diagnosing the histologic type of thymoma.

BACKGROUND: The objective of this study was to clarify the usefulness of positron emission tomography (PET) using(18)F-fluorodeoxyglucose (FDG) and carbon 11-labeled acetate (AC) for predicting the histologic types and tumor invasiveness of thymoma in a multicenter study. METHODS: Forty thymomas were examined using both FDG-PET and AC-PET before surgery. The histologic types were type A in 1 thymoma, type AB in 12 thymomas, type B1 in 11 thymomas, type B2 in 7 thymomas, type B3 in 6 thymomas, and type C in 3 thymomas. Tumor invasiveness was assessed by pathologic tumor stage and was identified as stage I in 17 tumors, stage II in 17 tumors, stage III in 4 tumors, and stage IV in 2 tumors. FDG and AC uptake was measured as the maximum standard uptake value (SUV). RESULTS: The FDG-SUV in type C thymomas was significantly higher than that in the other types (A-B3; P = .001 - P = .048). The AC-SUV in type A/AB thymomas was significantly higher than that in the other tumor types (B1-C; P < .001 - P = .002). All 3 type C tumors had an FDG-SUV >or=6.3, and all 13 type A/AB tumors had an FDG-SUV <6.3 and an AC-SUV >or=5.7. All 17 thymomas that had an FDG-SUV <6.3 and an AC-SUV <5.7 were type B1, B2, or B3. Neither the FDG-SUV nor the AC-SUV differed significantly between the stages I/II tumors and stage III/IV tumors. CONCLUSIONS: Although neither the FDG-SUV nor the AC-SUV can predict the invasiveness of thymomas assessed by tumor stage, they are useful for predicting histologic types of thymoma. Thymomas with an FDG-SUV <6.3 and an AC-SUV >or=5.7 almost certainly are types A/AB, which is of considerable prognostic and management significance.

Thymoma of the middle mediastinum: 11C-acetate positron emission tomography imaging.

Thymomas arising outside the anterior mediastinum are very rare. Their occurrence is likely to be related to ectopic thymus tissue. We report a case of thymoma in the middle mediastinum, right paratracheal region. There have been few reports of middle mediastinal thymoma. In the present case, (11)C-acetate positron emission tomography (PET) was useful for a preoperative suggestive diagnosis. Recently, (11)C-acetate has been reported to be a more sensitive PET tracer than (18)F-fluorodeoxyglucose and may be a promising tracer for complementing the deficiency of (18)F-fluorodeoxyglucose in PET imaging.

11C-Acetate can be used in place of 18F-fluorodeoxyglucose for positron emission tomography imaging of non-small cell lung cancer with higher sensitivity for well-differentiated adenocarcinoma.

OBJECTIVES: Although positron emission tomography (PET) using F-fluorodeoxy-glucose (FDG) frequently gives false-negative results for slow-growing tumors, C-acetate (AC)-PET has been reported to be able to detect them. To determine the usefulness of AC-PET for imaging non-small cell lung cancers (NSCLCs), the sensitivity and specificity were compared between the AC-PET and FDG-PET with a multicenter study. MATERIALS AND METHODS: A total of 284 pulmonary lesions (227 NSCLCs and 57 benign lesions) were examined using both AC-PET and FDG-PET before surgery at seven Japanese institutes. The AC- or FDG-uptake in each lesion were quantitatively measured using the contrast ratio of the standard uptake value between the lesions and the contralateral lung. RESULTS: The sensitivity of AC-PET for diagnosing NSCLC was 0.71, which was significantly higher than the value of 0.57 obtained by FDG-PET (p < 0.001). No significant difference in the specificity was seen between AC- and FDG-PET. For the 146 well-differentiated adenocarcinomas, the sensitivity of AC-PET was 0.62, which was significantly higher than the value of 0.37 obtained by FDG-PET (p < 0.001). Of the 51 moderately- or poorly-differentiated adenocarcinomas and 30 nonadenocarcinomas, there was no significant difference of sensitivity between AC- and FDG-PET. CONCLUSIONS: AC-PET could be used in place of FDG-PET for imaging NSCLC, with higher sensitivity for well-differentiated adenocarcinoma compared with FDG-PET.

Intrapulmonary localized fibrous tumor of the lung: a very unusual presentation.

Most localized fibrous tumors arise from the visceral pleura on a stalk and project into the pleural cavity in a pedunculated manner. The origin of the tumors is now believed not to be mesothelial but rather submesothelial, based on studies using conventional histology, immunohistochemistry, and ultrastructural analysis. While inward tumor growth into the lung parenchyma with attachment to the pleura is uncommon, the tumor with an entirely pulmonary location is extremely rare. We present here a rare case of entirely intrapulmonary localized fibrous tumor (ie, localized fibrous tumor of the lung), and we review the pertinent literature.

Intrathoracic lipomas: their clinicopathological behaviors are not as straightforward as expected.

BACKGROUND: Lipomas are a common type of benign tumor, and may involve numerous sites. They are common in the subcutaneous region of the upper back, neck, and shoulder, but are rarely seen in the thoracic cavity. Intrathoracic lipomas are a type of deep-seated lipoma, unlike subcutaneous lipomas. Due to the rarity of intrathoracic lipomas, little is known about their clinicopathological features. METHODS: We conducted a retrospective review of the clinicopathological records of 10 patients who had undergone surgical resection for intrathoracic lipomas during a 16-year period (1991 to 2006). RESULTS: There were 9 men and 1 woman with a mean age of 57.9 years. The number of lesions was one in 9 patients and two in 1 patient. Symptoms caused by the tumor were seen in only one patient. Radiographically, the tumors showed well-defined, homogeneous, and fatty density masses/nodules. Intrathoracic lipomas were most frequently seen in the parietal pleura. The resected tumor size ranged from 1.0 to 6.0 cm. Pathologically, three lesions showed an infiltrating type in which mature fat cells were seen between and within muscle or nerve fascicles. One of these three ended in an incomplete resection because the tumor infiltrated the brachial plexus. One patient had a recurrent tumor arising from a resected margin. CONCLUSIONS: Intrathoracic lipomas should be surgically resected if they are detected, because the possibility of liposarcoma or infiltrating development of the tumor cannot be excluded preoperatively. We think that surgical resection of the tumor, rather than conservative management by close observation alone, is a safer treatment.

11C-acetate and 18F-fluorodeoxyglucose positron emission tomography of pulmonary adenocarcinoma.

Positron emission tomography (PET) with 11C-acetate has been recently reported in detection of slow-growing tumors, such as well-differentiated adenocarcinomas of the lung, which are often negative with 18F-fluorodeoxyglucose (FDG) PET. Here we present findings of acetate-PET and FDG-PET in a case of adenocarcinoma that was comprised of peripheral ground glass opacity and solid central components, and was histologically comprised of both a well-differentiated and a moderately-differentiated adenocarcinoma, respectively. Acetate-PET was positive in both components, whereas FDG-PET was only positive in the solid central component. The present case demonstrates the figurative findings of acetate-PET and FDG-PET in lung adenocarcinoma.

Prognostic significance of [(18)F]fluorodeoxyglucose uptake on positron emission tomography in patients with pathologic stage I lung adenocarcinoma.

BACKGROUND: [(18)F]Fluoro-2-deoxyglucose uptake on positron emission tomography (FDG-PET) has been frequently used for diagnosis and staging of lung cancer. The prognostic significance of FDG uptake on PET was evaluated in patients with pathologic Stage I lung adenocarcinoma (tumor stages were based on the TNM classification of the International Union Against Cancer). METHODS: Disease-free survival of 98 patients with pathologic Stage I lung adenocarcinoma who were treated by curative resection was examined in relation to sex, age, histologic grade of differentiation, surgical procedure, tumor stage, and FDG uptake measured as the maximum standardized uptake value (SUV). RESULTS: Sixty-three patients were had Stage IA disease and 35 patients had Stage IB disease. Six patients each with Stage IA and Stage IB disease developed disease recurrence after a mean postsurgical follow-up period of 31 months. Ten (23%) of the 43 patients with SUV > or = 3.3 developed a recurrence compared with 2 (4%) of the 55 patients with SUV < 3.3 (P = .020). Ten (20%) of the 51 patients with moderately or poorly differentiated adenocarcinoma developed disease recurrence, compared with 2 (4%) of the 47 patients with well-differentiated adenocarcinoma (P = .056). Multivariate analysis demonstrated that histologic grade of differentiation was not correlated with the frequency of tumor recurrence (P = .286), whereas SUV was found to be marginally correlated (P = .079). CONCLUSIONS: FDG uptake appears to be predictive of disease-free survival in patients with Stage I lung adenocarcinoma. FDG uptake could yield important information for determining the likely value of postoperative adjuvant chemotherapy in such patients.

Obstructive subglottic granuloma after removal of a minitracheostomy tube.

We report herein a patient with subglottic granuloma after removal of a minitracheostomy tube (Minitrach II, SIMS Portex Inc., Hythe, Kent, UK). The patient underwent pulmonary resection for lung cancer followed by insertion of the minitracheostomy tube for prevention of sputum retention. The tube was removed 4 days after insertion. Twelve weeks later, the patient developed severe dyspnea and stridor. Bronchoscopy showed an obstructive subglottic granuloma arising from the anterior wall. The granuloma was removed by coring out using a conventional tracheal tube, followed by local injection of methylprednisolone acetate. The patient is now asymptomatic without regrowth of the granulation tissue 12 weeks after the treatment. With complication in mind, attention should be paid to patients suffering dyspnea or stridor after removal of a minitracheostomy tube.