Results of surgical treatment of primary lung cancer with synchronous brain metastases.

INTRODUCTION: The surgical treatment of non-small cell lung cancer (NSCLC) with synchronous brain matastases is more effective than other therapeutic options, but this management is still controversial. THE AIM OF THE STUDY: The aim of the study was to evaluate the survival of patients after pulmonary resection NSCLC preceded by resection of brain metastases. MATERIAL AND METHODS: From 2007 to 2012, 645 patients underwent pulmonary resection for NSCLC at our department. In 25 of them (3.87%) thoracic surgery was preceded by resection of a single brain metastasis of NSCLC and a PET CT scan. No signs of nodal involvement or distant metastases were detected. RESULTS: The group consisted of 18 men (72%) and 7 women (28%). Average age was 57.62 years (46-70). In all cases, whole brain radiotherapy (5 × 4 Gy) was performed. The average interval between excision of brain metastasis and lung resection was 31.4 days (27-41). Pneumonectomy was performed in 1, lobectomy/bilobectomy in 17 and wedge resection in 7 cases. Pathological stage N0 was diagnosed in 17, N1 in 5 and N2 in 3 patients. Average survival was 18.68 months (4-74). Survival at 1, 2 and 5 years was 64%, 28% and 28% respectively. Average disease-free survival was 17.52 months. Histological type (p = 0.57) and G (p = 0.82) have no influence on survival. All the patients with hilar lymph node involvement died within 26 months and with mediastinal one within 12 months. CONCLUSIONS: Surgical treatment of patients with NSCLC with synchronous brain metastases may prove beneficial in selected patients after excluding other distant metastases and lymph node involvement.

Measurement of primary tumor volume by PET-CT to evaluate risk of mediastinal nodal involvement in NSCLC patients with clinically negative N2 lymph nodes.

AIM: The study aimed to determine a prognostic value of primary tumor volume measured on the basis of integrated positron emission tomography-computerized tomography (PET-CT) in terms of mediastinal nodal metastases (N2) prediction in non-small-cell lung cancer (NSCLC) patients with PET-CT N2 negative lymph nodes. METHODS: The records of 70 potentially operable NSCLC patients treated with surgical resection were analyzed. All patients underwent diagnostic, preoperative PET-CT, which was the basis for tumor volume calculations as well as the evaluation of N2 nodes status. The logistic regression analysis was employed to determine correlation between mediastinal nodal involvement and volume of primary tumor (izoSUV2.5 volume), that is the volume of primary tumor inside SUV 2.5 line, tumor histology, location (peripheral vs. central), hilar node status. RESULTS: A statistically significant correlation between mediastinal node involvement and izoSUV2.5 volume, tumor histology, locations peripheral vs. central and hilar node status was found. The risk of mediastinal lymph node metastasis is 24% for tumor volume of 100 cm(3) and increases up to 40% for tumor volume of 360 cm(3). An increase of tumor volume by 1 cm(3) increases the risk of lymph node disease by 0.3%. Tumor histology adenocarcinoma vs. squamous cell carcinoma increases the risk of mediastinal lymph node involvement by 195%, location central vs. peripheral by 68% and hilar node involvement by 166%. CONCLUSIONS: The study demonstrates that izoSUV2.5 volume of primary tumor may be considered as a prognostic factor in NSCLC patients, since it strongly correlates with mediastinal lymph node pathological status. This correlation is modified by primary tumor location, histology and hilar node involvement.

Quantitative analysis of free-circulating DNA in plasma of patients with resectable NSCLC.

OBJECTIVE: Minute amounts of free-circulating DNA are present in plasma of healthy individuals, whereas its increased concentration was observed in patients with malignant tumors including non-small cell lung cancer (NSCLC). This study aimed at demonstrating the potential usefulness of plasma DNA concentration monitoring in NSCLC patients for therapy effectiveness assessment throughout the treatment and follow-up period. METHODS: Plasma DNA concentration was assessed in 50 NSCLC patients (stage I - IIIA) prior and following the radical treatment using real-time quantitative PCR method. 10 orthopedic patient undergoing hip joint surgery and 40 healthy volunteers comprised control groups. RESULTS: NSCLC patients (8.02 ng/ml) demonstrated significantly higher mean plasma DNA concentration with respect to healthy controls (2.27 ng/ml; p < 0.0000). Drastic increase in plasma DNA levels up to mean 68.74 ng/ml was detected a week after primary tumor resection. Still, similar phenomenon was observed in patients subjected to orthopedic surgical treatment (from 3.00 to 28.38 ng/ml, p < 0.0015). Most resected NSCLC patients with no disease recurrence during 3- to 6-month follow-up demonstrated reduced plasma DNA levels (mean 2.77 ng/ml) with respect to their presurgical values, whereas in relapsed subjects plasma DNA levels were significant higher. CONCLUSION: Free-circulating DNA concentration in plasma was significantly higher in NSCLC patients versus healthy controls. Its drastic increase following radical NSCLC treatment was most likely due to the surgical trauma. Importantly, the kinetics of plasma free-circulating DNA seems to be a promising marker of long-term effects of radical surgery in NSCLC.

Time-dependent changes of plasma concentrations of angiopoietins, vascular endothelial growth factor, and soluble forms of their receptors in nonsmall cell lung cancer patients following surgical resection.

Even when patients with nonsmall cell lung cancer undergo surgical resection at an early stage, recurrent disease often impairs the clinical outcome. There are numerous causes potentially responsible for a relapse of the disease, one of them being extensive angiogenesis. The balance of at least two systems, VEGF VEGFR and Ang Tie, regulates vessel formation. The aim of this study was to determine the impact of surgery on the plasma levels of the main angiogenic factors during the first month after surgery in nonsmall cell lung cancer patients. The study group consisted of 37 patients with stage I nonsmall cell lung cancer. Plasma concentrations of Ang1, Ang2, sTie2, VEGF, and sVEGF R1 were evaluated by ELISA three times: before surgical resection and on postoperative days 7 and 30. The median of Ang2 and VEGF concentrations increased on postoperative day 7 and decreased on day 30. On the other hand, the concentration of sTie2 decreased on the 7th day after resection and did not change statistically later on. The concentrations of Ang1 and sVEGF R1 did not change after the surgery. Lung cancer resection results in proangiogenic plasma protein changes that may stimulate tumor recurrences and metastases after early resection.

Pneumonectomy due to lung cancer results in a more pronounced activation of coagulation system than lobectomy.

UNLABELLED: Surgical treatment of lung cancer is associated with an elevated risk of thrombo-embolic complications. The question is whether the extent of pulmonary resection influences the concentration of serum coagulation system proteins. OBJECTIVE: This study aims to compare the blood coagulation activation parameters among patients undergoing pneumonectomy and lobectomy due to primary lung cancer. METHODS: A prospective study was carried out in 40 patients. Of whom, 30 underwent lobectomy and 10 treated with pneumonectomy. Serum concentrations of tissue factor (TF), tissue factor pathway inhibitor (TFPI), tissue factor pathway inhibitor-activated factor X complex (TFPI/Xa), thrombin-antithrombin complex (TAT), L-selectin, E-selectin and P-selectin were measured on the first and seventh postoperative days. RESULTS: On the first postoperative day, the results of selected proteins concentrations were similar in both groups. However, on the seventh postoperative day, significantly higher concentrations of TF, TAT complex and E-selectin were found in patients who underwent pneumonectomy (median values: TF: 182.4 pg ml(-1) vs 116.6 pg ml(-1), P=0.031; TAT: 6.2 mg ml(-1) vs 3.9 mg ml(-1), P=0.048; E-selectin 40.24 ng ml(-1) vs 26.54 ng ml(-1), P=0.049). CONCLUSIONS: Pneumonectomy was associated with significantly higher activation of coagulation system on the seventh postoperative day than lobectomy. TAT complex, TF and E-selectin are promising markers of extensive postoperative activation of coagulation and efficacy of antithrombotic prophylaxis.

[Bronchial bacterial colonization in patients with lung cancer]. / Bakteryjna kolonizacja drzewa oskrzelowego u chorych na raka pluca.

INTRODUCTION: Infections are a part of the natural course of lung cancer but few studies have looked at the clinical and microbiological documentation of infections in these patients. The aim of this study is to analyze the profile of potentially pathogenic bacteria that colonize the bronchial tree in patients with primary lung cancer. MATERIAL AND METHODS: The study was conducted from January 2006 to August 2007. It included 44 consecutive patients (34 males and 10 females) with primary lung cancer aged from 38 to 77 (mean age of 57.9 years). In all patients, bronchoalveolar lavage (BAL) was performed during bronchofiberoscopy. Obtained BAL fluid was subjected to microbiological examination. The number of bacteria present in 1 ml of fluid was estimated by quantitative culture. A diagnostic level was set on >or= 104 cfu/ml. RESULTS: In 26 (59.1%) of 44 patients physiologic bacterial flora was found in the bronchial tree. In three cases (6.8%), potentially pathological bacteria were cultured but their number was < 104 cfu/ml. In 15 (34.1%) cases, the colonization of potentially pathogenic bacteria was >or= 104 cfu/ml. Both Gram-positive and Gram-negative bacteria were isolated. The most frequently isolated bacterium in the first group was Streptococcus pneumoniae (n = 7), and in the second group Haemophilus influenzae (n = 3). Multibacterial colonization was found in five patients (11.4%). In four cases (9.1%), the bronchial tree was colonized simultaneously by two and in one case [2.3%] by three types of micro-organism. Multi-drug-resistant strains were not found in the examined materials but among Streptococcus pneumoniae the constitutive MLSB phenotype was observed. CONCLUSIONS: 1. Approximately 30% of patients with lung cancer had a respiratory tract colonized by micro-organisms whose number was higher than the assumed diagnostic level. 2. Among micro-organisms colonizing the lower respiratory tract, Gram-positive cocci such as Streptococcus pneumoniae and Staphylococcus aureus were dominant. 3. The analysis of antibiotic-resistance did not detect multi-drug-resistant micro-organisms but some strains of Streptococcus pneumoniae exhibited resistance to macrolide, lincosamide and streptogramin B.

[The estimation of serum concentration of vascular endothelial growth factor in patients with non-small cell lung cancer]. / Ocena stezenia naczyniowo-sródblonkowego czynnika wzrostu w surowicy u chorych na niedrobnokomórkowego raka pluca.

UNLABELLED: Vascular endothelial growth factor (VEGF) is main angiogenic factor, which stimulates endothelial cells migration and proliferation. The extensive angiogenesis plays important role in tumor growth and metastasis. AIM OF THE STUDY: Analysis of serum concentrations of vascular endothelial growth factor in patients with non-small cell lung cancer depending on clinicopathologic findings. MATERIAL AND METHODS: The study group consisted of 50 patients with non-small cell lung cancer (16 females and 34 males) ranging in age from 47 - 80 years (mean age 63 +/- 8.2). Serum VEGF concentration was evaluated by ELISA. RESULTS: VEGF concentrations in serum did not differ significantly between groups of patients with different T-, N- and M-factor. Patients with inoperable tumor (IIIB and IV) had significantly higher serum VEGF concentrations compared with resected tumor (I-IlIA) and locally advanced cancer (IIIA). CONCLUSIONS: Serum VEGF may be a marker of tumor progression in non-small cell lung cancer.

[The serum concentration of metalloproteinase 9 and 2 in non-small cell lung cancer patients]. / Stezenie metaloproteinazy 9 i 2 w surowicy chorych na niedrobnokomórkowego raka pluca.

UNLABELLED: Matrix metalloproteinases are responsible for the proteolytic degradation of the basement membrane and extracellular matrix. Elevated expression levels of MMP-9 and MMP-2 have been associated with tumor invasion and metastasis. THE AIM OF THIS STUDY: To determine serum concentrations of metalloproteinases 9 and 2 in non-small cell lung cancer patients depending on tumor stage. MATERIAL AND METHODS: The study group consisted of 50 patients with non-small cell lung cancer (16 females and 34 males) ranging in age from 47 - 80 years (mean age 63 +/- 8.2). MMP-9 and MMP-2 concentrations in serum were evaluated by ELISA. RESULTS: MMP-9 and MMP-2 concentrations in serum did not differ significantly between group with different T- and N-factor. Serum level of MMP-9 was significantly higher in patients with metastases than those without them. Patients with inoperable tumor (IIIB - IV) had significantly higher serum MMP-9 concentrations compared with resected tumor (I - IlIA). CONCLUSIONS: Serum MMP-9 may be a marker of metastasis in non-small cell lung cancer.

[The influence of application of resorbable fibrinogen-collagen patches on the costs of selected procedures in thoracic surgery]. / Wplyw stosowania wchlanialnych opatrunków kolagenowo-fibrynowych na koszty wybranych operacji torakochirurgicznych.

UNLABELLED: The application of fibrinogen-collagen patch to air tight closure of the lung parenchyma after pulmonary surgery is profitable for the patients but relatively high price of this product may cause a surgeons' hesitation before using it. THE AIM OF THE STUDY: To compare the total costs of treatment of two subgroups of patients in whom, during the same surgical procedure, the fibrinogen-collagen patches were applicated or not to achieve air tight closure of the lung surface. MATERIAL AND METHODS: A total costs of treatment of 122 patients were analyzed. The operations performed were as follows: bullectomy in pulmonary emphysema (n=31), decortication and empyemectomy (n= 16), partial pulmonary resection with coexisting diffuse pleural adhesions (n=75). In 58 patients the surface of the lung was sutured manually or by staplers but in 64 cases fibrinogen-collagen patches were used additionally. RESULTS: The costs of the surgical procedure were higher in the sub-group of patients in whom fibrinogen-collagen patches were applicated. However, in these patients the hospital stay was shorter and the costs of laboratory tests and x-ray examinations performed after surgery were lower in comparison with patients operated on in traditional way. CONCLUSION: Application of a relatively expensive product - fibrinogen-collagen patch to seal the lung parenchyma does not cause the increase of the total cost of the treatment.

[Bacteriological and mycological analysis of material taken from lower respiratory tract in patients with malignancy]. / Analiza bakteriologiczna i mikologiczna materialu pobranego z dolnych dróg oddechowych u chorych na nowotwór zlosliwy.

UNLABELLED: The immunosuppression and incorrect function of the natural protection mechanisms are conducive to lower respiratory tract infections. The patients with malignancy, especially with lung cancer, belong to the group at higher risk to develop an infection due to accumulation of numerous risk factors. OBJECTIVE: The aim of this study was to assess the occurrence of bacteria and fungi in materials taken from lower respiratory tract from the patients treated in Thoracic Surgery and Clinical Department of Thoracic Surgery and Tumours from 2000 to 2004. The frequency of occurrence of alert-pathogens was also analyzed. MATERIAL AND METHODS: The retrospective analysis was carried out among 102 positive samples (sputum--68, bronchial secretion--32 and bronchoalveolar lavage--2). The material was obtained from patients treated due to lung cancer (n=84), pulmonary metastases (n=6), primary neoplasms of the chest wall (n=2), lymphoma of the mediastinum (n=3), mesothelioma (n=1) and other malignancies (n=6). The examinations were conducted in compliance with the current procedures, generally accepted in microbiological laboratories. RESULTS: Seventy examined patients (68.63%) had bronchial colonization with bacteria being the potential etiologic agents of lower respiratory tract infections. The presence of yeast-like fungi was confirmed in 62 patients (60.78%). The most frequent strains isolated were: Enterobacteriaceae (40.86%), followed by Staphylococcus aureus (21.51%), Haemophilus influenzae (16.13%) and Streptococcus pneumoniae (7.53%). The nonfermenting gram-negative rods Pseudomonas spp. and Acinetobacter spp. occurred as follows: 6.45% and 3.23%. Among yeast-like fungi the most common species isolated was Candida albicans (63.77%) which occurred more frequently in sputum than in bronchial secretion (p < 0.0004). The strains of Enterobacteriaceae and nonfermenting gram-negative bacillus producing extended-spectrum beta lactamase (ESBL) were not discovered like MBL (metallo- beta lactamase) positive strains. All of the Staphylococcus aureus strains were sensitive to the methicillin. Haemophilus influenzae did not show ampicillin resistance. We observed two strains Streptococcus pneumoniae which were penicillin intermediate but susceptible to the third-generation cephalosporins. CONCLUSIONS: Identification of the potential etiological agents of lower respiratory tract infections can be useful in the rational management of the antibiotics policy in the patients with maliganacy.

[Morgagni's hernia--still a difficult diagnostic problem]. / Przepuklina przeponowa morgagniego--trudny problem diagnostyczny.

Morgagni's hernia due to its non-specific symptoms and signs along with difficulties to detect it by x-ray imaging is still a disease difficult to diagnose. Patients suffering from this hernia are often treated unsuccessfully because of false diagnosis of other illnesses of the abdomen or thorax. It is only detailed diagnostics that can lead to a proper diagnosis. The authors present the current status of knowledge of Morgagni's hernia, its most common signs and symptoms and available diagnostic and therapeutic methods.

[Bone marrow isolated micrometastases of non-small cell lung cancer]. / Mikroprzerzuty niedrobnokomórkowego raka pluca do szpiku.

UNLABELLED: The ability to detect occult systemic metastases in patients with operable NSCLC could have a significant impact on the management of the disease. The aim of the study was to detect occult micrometastatic tumor cells in bone marrow in patients with resectable NSCLC. MATERIAL AND METHODS: A total of 35 patients (29 men, 6 women), age between 47 and 78 (mean 61.6) were included in the study. In each of the patients bone marrow aspirates from the ribs were sampled during surgery. Both the tumor and the bone marrow aspirate were examined histologically and immunocytochemically with the cytokeratin: AE1/AE3, CAM 5,2, CK-7, CK-18. The presence of grow factors CD 31 and CD 34 were examined as well. RESULTS: No evidence of micrometastases or tumor cells in bone marrow was found in histological examination. Cytokeratin positive (CAM 5,2 +) cells were detected in 33 cases (94.23%) of the tumors and in 21 cases (60.00%) of bone marrow samples. The statistically significant correlation between the presence of CAM 5,2 in tumors and bone marrow was found (p = 0.049). Cytokeratin positive cells were detected in all the 35 tumors (AE1/AE3), in 20 tumors--57.14% (CK-7) and in 23 tumors--65.71% (CK-18). Cytokeratin positive cells (CK-7) were detected in bone marrow sample in one patient only. CONCLUSIONS: Immunocytochemical examination with the use of cytokeratin CAM 5,2 is of use to detect occult micrometastatic tumor cells in bone marrow in NSCLC patients. However, no correlations were found between the presence of cytokeratin CAM 5,2 in bone marrow or tumor and patients' age, sex and the histological type of NSCLC its degree of malignancy and stage.

[Magnetic resonance imaging in the diagnosis of retrosternal anterior diaphragmatic hernia in an adult man]. / Zastosowanie techniki rezonansu magnetycznego do diagnostyki wrodzonej przepukliny przeponowej u doroslego mezczyzny.

The study presents a case report of a retrosternal anterior diaphragmatic hernia in a 46-year-old man presented with abdominal pain, nausea, dyspnoea and treated previously as for chronic pancreatitis. A strong suspicion of the diaphragmatic hernia was generated after chest radiograph. However, the exact diagnosis of the Morgagni hernia was established by magnetic resonance imaging. The hernia was repaired through thoracic incision. The postoperative course proved uneventful: the patient was discharged from the hospital 10 days after surgical intervention.

Factors associated with perioperative complications after pneumonectomy for primary carcinoma of the lung.

According to the literature patient's age, nutrition and smoking status, cardiopulmonary comorbidity and surgeon's experience are the main factors associated with perioperative complications after pulmonary resection. The purpose of the study was to identify the correlation between pre- and intraoperative risk factors and complications after pneumonectomy for primary carcinoma of the lung. Between Sept. 11th 1999 and Dec. 20th 2003 121 standard pneumonectomies were performed in patients with non small-cell lung cancer. Sixteen risk factors noted in the patients before surgery were correlated with complications occurred after pneumonectomy. Overall mortality and morbidity rates were 3.3% and 30.6%, respectively. Twenty patients (16.5%) experienced cardiac rhythm disturbances, six (4.9%)--pleural haematomas, five (4.1%)--main bronchus stump fistulas, four (3.3%)--acute respiratory failure. Chronic obstructive pulmonary disease was correlated with broncho-pleural fistulas and acute respiratory failure after surgery. Chronic coronary disease was associated with postoperative cardiac arrhythmias, whereas postoperative bleeding was correlated with the overweight of the patients. Chronic obstructive pulmonary disease, chronic coronary disease and overweight are the risk factors associated with complications after pneumonectomy.

[Procedure in case of exposure of hospital's workers to HBV, HCV and HIV]. / Postepowanie w przypadku ekspozycji pracowników szpitala na HBV, HCV i HIV.

The aim of this study was to show our own experiences in the treatment our hospital's workers after the exposition of potentially infectious material. The register of the occupational exposition was established on 1st January 2001. 43 cases of occupational exposition to potentially infectious material were noted down, since the beginning of the observation to 31st October 2004. The persons who were injured, represented different professional groups: 9 physicians, 19 section nurses, 13 operative nurses and 3 maintenance workers. The exposition was caused by needle pricks during blood collection or injections (34 cases), as a result of a scalpel or other surgical instrument cut (2 cases), a splash of infectious material on the skin and conjunctivae (4 cases) and in the singular cases as a result of a bite by a stimulated patient, a medical waste cut in a rubbish bag or the hospital equipment. It was determined in the immunological examinations that among patients being the source of infection were: 1 person HBsAg(+), 5 persons anti-HCV(+), 37 persons HbsAg (-), 33 persons anti-HCV(-) and 5 persons HBsAg(?) and HCV(?). One medical unvaccinated worker was exposed to the HBsAg(+) blood. The specific treatment was administered by the application of 1 dose of anti-HBs immunoglobulin and realization of a series of protective vaccinations against HBV. 4 persons are being observed due to an exposition to HCV(+) blood. In all cases until now the treatment has been finished without a diagnosis of the occupational infection.

[Fine-needle aspiration biopsy under CT-guidance--usefulness in diagnosis of malignant lung tumors]. / Znaczenie biopsji aspiracyjnej cienkoiglowej wykonywanej pod kontrola tomografii komputerowej w diagnostyce zlosliwych nowotworów pluca.

UNLABELLED: Aim of the study was to evaluate the usefulness of fine-needle aspiration biopsy (FNAB) in diagnosis of malignant lung tumors. MATERIAL AND METHODS: The results of 438 CT guided FNAB of lung lesions performed between Sep. 1st 1999 and Feb. 20th 2004 were evaluated. RESULTS: In 295 cases (67.35%) the cytological diagnosis of lung tumours were established by FNAB. The most common type of the tumours were: non-small cell lung cancer: 222 (50.69%) and small cell lung cancer: 49 (11.19%). 104 of these results were histologically verified and two false positive results were detected. In 143 cases (32.65%) however, the results established by FNAB were non-diagnostic. 63 of the lesions were verified and in 36 cases (57.1%) the malignant tumours were proved. The specificity of the method regarding malignant lesions reached 93.10%, and its sensitivity for patients with malignancy was 73.91%. The average diameter of the malignant tumour was 5.4+/-1.3 cm whereas in case of non-diagnostic results the diameter of the tumour was 4.1+/-1.6 cm. However, there was no significant difference between the two groups. The most common complication of FNAB was pneumothorax, which occurred in 22 patients (5.02%) and in 13 cases (2.97%) required drainage of the chest cavity. CONCLUSION: FNAB is a safe diagnostic method with high specificity and moderate sensitivity in detecting of malignant lung lesions.

[Long-term results after resection of IIIA-N2 non-small cell lung cancer and complementary mediastinal irradiation]. / Odlegle wyniki leczenia operacyjnego chorych na niedrobnokomórkowego raka pluca w stadium IIIA-N2 poddanych uzupelniajacej radioterapii sródpiersia.

The authors present a retrospective evaluation of long-term results of treatment of patients with IIIA-N2 non-small cell lung cancer (NSCLC), operated and subjected to complementary irradiation of mediastinum in the years 1987-1990. 60 patients were observed: 10 women and 50 men, aged 37-74 years (mean age 56). In all patients a radical resection of lung parenchyma with the primary tumour and mediastinal lymphadenectomy were performed. The one-year survival was 63% (38 patients), three-year survival--15% (9 patients) and five-year survival 13% (8 patients). It was found that the five year-survival in patients with IIIA-N2 NSCLC, in whom a combined therapy was applied (surgery and irradiation), was low, and the most common cause of death in the first three years of follow-up were distant metastases. Moreover it was observed that the number of mediastinal lymph node groups had a great influence on the time of survival.

[Unsuccessful treatment of pneumothorax which was associated with hilar tumor]. / Nieskutecznosc leczenia odmy jamy oplucnej przy wspólistniejacym guzie wneki pluca.

The authors present a case of unsuccessful treatment of pneumothorax which was associated with hilar tumor. A typical underwater-seal system was installed in a 79-year-old patient, but the lung was still collapsed. Because of prolonged air leak, the patient was operated on. During the surgical procedure several bullae in the lung and the inoperable hilar carcinoma were diagnosed. Despite the absence of air leak, the failure of the lung to re-expand was noted postoperatively. However, recurrent air leak, subcutaneous emphysema and respiratory failure caused the patient's death.