A case of a shrunken multilocular mediastinal cyst that developed into thymic carcinoma with lung metastases 13 years later.

Multilocular thymic cysts (MTC) are acquired multilocular cysts caused by inflammation. The rarity of such lesions and a lack of recognition make diagnosis and treatment difficult. Herein, we present our experience with a multilocular mediastinal cyst that resulted in the development of thymic cancer with metastasis over a period of 13 years. Computed tomography findings revealed an anterior mediastinal mass that was suspected to be an MTC in a 49-year-old man. The mass shrank gradually over a period of 7 years; however, growth was observed at 10 years after initial detection. At 13 years after detection, thymic carcinoma with multiple lung metastases was diagnosed. Resection was recommended during the follow-up period, but the patient refused treatment. A multilocular wall and location are factors that indicate MTC. However, even if a definitive diagnosis is not made, resection of multilocular anterior mediastinal cysts should be considered as determining the preoperative diagnosis is difficult. Nevertheless, our case suggests that the coexistence of tumors with cysts is possible, and the potential for malignant tumor development exists.

Pulmonary arterial pseudoaneurysm as an unusual complication of pulmonary actinomycosis: Two case reports.

We report 2 cases of pulmonary actinomycosis complicated by a pseudoaneurysm. In Case 1, a 67-year-old man visited a hospital 7 months ago because of hemoptysis. CT revealed a suspected lung abscess in the left lingular segment; however, no diagnosis was confirmed by bronchoscopy. A CT scan taken after heavy hemoptysis showed a pseudoaneurysm within the consolidation of the same segment. On the same day, embolization of the left bronchial and intercostal arteries was performed. Left lingulectomy was performed 5 days later, and pulmonary actinomycosis was diagnosed histologically. Case 2 was a 51-year-old man with a 2-year history of cough and intermittent hemoptysis. CT showed a lesion with a cavity suggesting an abscess 3 months previously, and antibiotic treatment was started. After the appearance of massive hemoptysis, embolization was performed for a pseudoaneurysm seen on bronchial arteriography. Four days later, a left lower lobectomy was performed, and pulmonary actinomycosis was histologically diagnosed. Pseudoaneurysms are commonly associated with tuberculosis; however, only one report of pseudoaneurysms has been associated with pulmonary actinomycosis. Appropriate treatment should be selected according to the type of pseudoaneurysm and the risk of recurrent hemoptysis. Angiography and embolization are essential tools in diagnosing and treating pulmonary arterial pseudoaneurysms; however, surgical intervention may also be an option in some cases to ensure a good long-term outcome.

Stereotactic Body Radiotherapy for Stage I Lung Cancer With a New Real-time Tumor Tracking System.

BACKGROUND/AIM: Suppression of respiratory movement is crucial for safe and effective stereotactic body radiotherapy (SBRT). SyncTraX FX4 is a novel device for synchronous respiratory irradiation. The purpose of this study was to evaluate the efficacy and toxicity of SBRT using SyncTraX FX4 for patients with lung cancer. PATIENTS AND METHODS: Patients treated with SBRT using SyncTraX FX4 between November 2017 and August 2020 were included. In all cases, fiducial markers were inserted into the lung, and the total dose administered was 55 or 60 Gy, depending on the distance from the central region of the lung. Acute and late toxicities were reported, and local control, progression-free survival, cancer-specific survival, and overall survival were analyzed. RESULTS: We evaluated 16 patients and 17 sites. The median follow-up period was 14.4 months. In both the acute and late phases, one patient experienced grade 3 radiation pneumonitis; however, grade 4 or higher toxicities were not observed. There was no local recurrence during the observation period, and the overall survival, cancer-specific survival, and progression-free survival at 2 years were 54.6%, 85.1%, and 33.7%, respectively. CONCLUSION: SBRT with SyncTraX FX4 can provide safe and effective treatment for lung cancer patients in poor condition.

Clinical Outcomes of Postoperative Adjuvant Chemotherapy for Surgically Resected High-Grade Pulmonary Neuroendocrine Carcinoma.

INTRODUCTION: Data on the clinical outcomes of patients receiving adjuvant chemotherapy for surgically resected high-grade pulmonary neuroendocrine carcinoma (HGNEC) (large-cell neuroendocrine carcinoma and small-cell lung cancer) are limited. This study aimed to evaluate the prognostic significance of adjuvant chemotherapy in patients with HGNEC. METHODS: We retrospectively analyzed patients with surgically resected HGNEC at five institutions in Japan between January 2006 and May 2016. RESULTS: A total of 143 patients were enrolled. Among them, 65 received adjuvant chemotherapy. Four patients who participated in clinical trials were excluded; the remaining 61 patients were included in the study. Fifty-six patients received adjuvant small-cell lung cancer-based chemotherapy. Twenty-five of 29 patients who relapsed after postoperative adjuvant chemotherapy received chemotherapy. The most commonly administered chemotherapy agent was amrubicin. The 3-year relapse-free and overall survival rates were 55.2% and 66.8%, respectively. The median relapse-free and overall survival times for the 25 patients who received chemotherapy after relapse were 12.9 and 27.5 months, respectively. Among them, 22 relapsed within 2 years. Patients who received platinum-doublet chemotherapy after relapse tended to have better time to progression disease and overall survival than those who received single-agent chemotherapy. CONCLUSIONS: Most patients with HGNEC received small-cell lung cancer-based regimens as postoperative adjuvant chemotherapy. Those who relapsed after adjuvant chemotherapy were mainly treated with amrubicin. Our findings suggest that platinum-doublet chemotherapy tends to improve the time to progression disease and overall survival in patients who relapse after postoperative adjuvant chemotherapy.

Risk of stroke even after dissipation of a thrombus in the pulmonary vein stump after lobectomy: A case report.

INTRODUCTION AND IMPORTANCE: Thrombosis in the pulmonary vein stump (PVS) after lung resection has been reported as a cause of cerebral infarction (CI). However, there is limited research focusing on thrombosis in the PVS. Although anticoagulant therapy is performed in clinical settings, the optimal duration of anticoagulant therapy is not established. In addition, no case leading to CI after withdrawal of the anticoagulant therapy has been reported. CASE PRESENTATION: An 81-year-old woman with lung cancer underwent left lower lobectomy. Since a thrombus was detected in the PVS 6 months after the operation, anticoagulant therapy was started. The thrombus disappeared 1 month later, and the medication was discontinued. However, only 23 days after discontinuation, the patient developed CI. CLINICAL DISCUSSION: This case was considered as cardiogenic CI due to a thrombus in the PVS because of the presence of the past thrombus, the distribution of infarction, and the absence of atrial fibrillation. The length of PVS in this case was longer than that reported previously, which could have caused turbulence and congestion leading to thrombogenesis. As long as patients have a long neck PVS, there might be a potential risk of thrombosis. CONCLUSION: We must recognize the risks associated with the discontinuation of anticoagulant therapy for thrombosis in PVS even after thrombus dissipation.

A population-based study of outcomes in patients with surgically resected non-small cell lung cancer with anaplastic lymphoma kinase-rearranged mutations: A matched-pair study.

The present study aimed to evaluate clinical outcomes in patients with surgically resected non-small cell lung cancer (NSCLC) with anaplastic lymphoma kinase (ALK)-rearranged mutations. A matched-pair analysis in completely resected ALK-rearranged NSLC patients and those with neither ALK nor epidermal growth factor receptor (EGFR) mutations diagnosed at 11 institutes was performed between April 2008 and March 2019. A total of 51 patients with surgically resected ALK-rearranged NSCLC were included. Women constituted 68.6%, and smokers 29.4%. The median age was 65 years. In matched-pair analysis, disease-free survival and overall survival did not differ between patients with ALK-rearranged mutations and those without mutations. Post-recurrence survival in patients with ALK mutations was longer than that of patients with neither ALK nor epidermal growth factor receptor mutations. ALK genetic testing should be performed, even in elderly patients with NSCLC. Favorable prognosis might be expected after appropriate treatment for patients with recurrent ALK-mutated disease.

Delayed postoperative bleeding following lobectomy caused by the sharp tip of a suture: a case report.

BACKGROUND: Postoperative bleeding is a rare but serious complication occasionally caused by hard surgical materials, such as staples. Postoperative hemorrhage caused by sutures is very rare. CASE PRESENTATION: A 75-year-old man with lung cancer underwent right lower lobectomy. Eleven days after surgery, he developed a haemothorax. Emergency thoracotomy revealed arterial bleeding from a pinhole injury in the parietal pleura caused by a monofilament non-absorbable suture tip used during the initial surgery. CONCLUSIONS: Postoperative bleeding is a serious complication, and as sutures are often used in surgery, it is important to be cautious while using this material.

Treatment of Patients With Non-small-cell Lung Cancer With Uncommon EGFR Mutations in Clinical Practice.

BACKGROUND/AIM: To describe real clinical outcomes in patients with non-small cell lung cancer who have uncommon epidermal growth factor receptor (EGFR) mutations. MATERIALS AND METHODS: We performed a retrospective chart review from 15 medical institutes that cover a population of three million people from April 2008 to March 2019. RESULTS: There were 102 patients with uncommon EGFR mutation. Progression-free survival (PFS) tended to be longer in patients receiving afatinib compared with first-generation EGFR tyrosine kinase inhibitors. PFS in patients treated with afatinib or osimertinib was significantly longer than in patients treated with gefitinib or erlotinib (p=0.030). Multivariate analysis also revealed the contribution of afatinib or osimertinib to increased survival. In patients with exon 20 insertions, chemotherapy was efficacious. CONCLUSION: In treating patients with uncommon EGFR mutations, our results indicate longer-term survival might be achieved with second-generation or later TKIs and cytotoxic chemotherapeutic drugs.

Treatment of an Aberrant Arterial Aneurysm with Intralobar Pulmonary Sequestration: A Case Report.

An aberrant arterial aneurysm with pulmonary sequestration is rare. Here, we report about a 35-year-old man who had no symptoms related to pulmonary sequestration. Computed tomography revealed an aberrant arterial aneurysm with an 18 mm in diameter with intralobar pulmonary sequestration, which gradually increased in size to 27 mm over 5 years. The patient underwent thoracic endovascular aortic repair with coil embolization for the aneurysmal distal branches to prevent aneurysm rupture. The postoperative course was unremarkable without a need for lobectomy. During a 1-month follow-up period, the aneurysm shrunk with no endoleaks. Stent-graft placement and coil embolization represent an effective and less invasive treatment option to completely block systemic arterial flow and unexpected retrograde backflow and control the expansion of the aneurysm.

Real Clinical Practice in ALK-rearranged NSCLC Patients: A Retrospective Observational Study.

BACKGROUND/AIM: To describe real clinical outcomes when using systemic therapy to treat non-small cell lung cancer (NSCLC) patients who have anaplastic lymphoma kinase (ALK) fusion gene mutation. PATIENTS AND METHODS: We performed a retrospective chart review from April 2008 to March 2019 sourced from 16 medical institutes that cover a population of three million people. RESULTS: There were 129 ALK rearranged NSCLC patients. Among them, 103 patients including 40 recurrent disease cases received ALK-tyrosine kinase inhibitors (TKI) and chemotherapy. Our treatment results were comparable to previously reported clinical trials and clinical practice studies. First-line alectinib, treatment sequence of ALK-TKI followed by another ALK-TKI, and pemetrexed-containing chemotherapy contributed to the outcome of treatment. CONCLUSION: By arrangement of treatment such as treatment sequence of ALK-TKI and chemotherapy regimen, it might be possible to obtain a treatment outcome almost equivalent to those of clinical trials even in real clinical practice.

Acquired EGFR T790M Mutation After Relapse Following EGFR-TKI Therapy: A Population-based Multi-institutional Study.

AIM: To describe the prevalence and determinants of acquired epidermal growth factor receptor (EGFR) T790M gene mutation in a clinical practice setting. MATERIALS AND METHODS: We performed a retrospective chart review study between January 2013 and November 2017 across multiple institutes, covering a population of 3 million people. RESULTS: We reviewed the charts of 233 patients non-small cell lung cancer with EGFR mutations. Of them, 99 (42.5%) patients had acquired T790M mutations in EGFR. Patients ≥75 years old and patients with an exon 19 deletion had higher rates of acquired T790M mutation than did younger patients and those with an exon 21 L858R mutation. In 75 patients treated with afatinib, 34 (45.3%) patients had acquired T790M mutation. The sensitivity of T790M mutation detection was lower in plasma specimens than in biopsy specimens. CONCLUSION: This population-based study confirms previous studies and highlights potential determinants of acquired T790M mutation to be considered in clinical practice.

Epithelioid hemangioendothelioma originating from the chest wall with rib metastases.

An asymptomatic 39-year-old woman was referred to us for an abnormal nodular opacity detected on the chest X-ray. Histopathological and further examinations revealed findings consistent with epithelioid hemangioendothelioma (EHE) originating from the chest wall with metastases to the ribs. Complete excision was performed; however, adjuvant chemotherapy was not administered because of the patient's mental disorder. There are very few reports of EHE arising from the chest wall; therefore, we present this case report with the clinicopathological features of EHE and discuss the therapeutic aspects.

Long-term outcomes after surgical resection of pulmonary metastases from colorectal cancer.

BACKGROUND: Surgical resection has been widely performed on patients with pulmonary metastases from colorectal cancer with favorable outcomes. However, there are currently no standard surgical indications for pulmonary metastases. METHODS: We reviewed 94 patients who underwent complete resection of pulmonary metastases from colorectal cancer between November 1991 and April 2013. The cumulative survival rate after pulmonary metastasectomy was calculated, and prognostic factors for long-term survival were analyzed. RESULTS: There were 60 men and 34 women, and their median age was 66 years. The 5-year survival rate was 45.5% after pulmonary metastasectomy. The 5-year survival of patients with colon and rectal cancers was 62.4% and 33.8%, respectively (p = 0.030), and the 5-year survival of those with normal and high carcinoembryonic antigen (CEA) levels before pulmonary resection was 57.0% and 30.9%, respectively (p = 0.038). Multivariate analysis revealed the preoperative CEA level was an independent prognostic factor. Recurrence was identified in 65 of the 94 patients (69.1%) after pulmonary metastasectomy, and the patients who underwent surgical resection for recurrent lesions in the liver or lungs, or both, had better survival than those who received other treatments or palliative care. CONCLUSIONS: Surgical resection offers a chance to prolong survival in colorectal cancer patients with resectable pulmonary metastases. Owing to the high recurrence rate, careful postoperative follow-up for early detection is recommended, and even for recurrence, surgical resection should be considered for better survival if the lesions are limited to the liver or lungs, or both.

Resection of an azygos vein aneurysm that formed a thrombus during a 6-year follow-up period.

We report a resection of an azygos vein aneurysm that formed a thrombus during a 6-year follow-up period. An azygos vein aneurysm is commonly detected as an asymptomatic mediastinal mass. A thrombus could suddenly form without enlarging the aneurysm. Therefore we suggest that even asymptomatic azygos vein aneurysms causing blood stagnation should be resected before they can form a thrombus and cause a pulmonary embolism.

Usefulness of FDG-PET/CT in the detection of pancreatic metastases from lung cancer.

OBJECTIVE: The objective of this study was to assess the ability to detect pancreatic metastasis of lung cancer and to clarify the degree of fluorodeoxyglucose (FDG) accumulation and computed tomography (CT) characteristics of pancreatic metastasis from lung cancer. METHODS: A total of 573 patients (415 men and 158 women) with lung cancer were retrospectively evaluated. All patients underwent FDG-positron emission tomography (PET)/CT with contrast-enhanced CT for first=stage (313 patients; initial study group) or follow-up study (260 patients; follow-up study group). A lesion was regarded as positive for metastasis on the basis of visual judgment of the degree of increased metabolism by two experienced and independent interpreters, supported by semiquantitative evaluation on the basis of calculation of the maximum standardized uptake value (SUV(max)). RESULTS: Abnormal accumulations in the pancreas were detected in 5 of 313 patients (1.60%) in the initial study group, and 6 of 260 patients (2.31%) in the follow-up study group. Seven of these patients had adenocarcinoma, three had small cell carcinoma, and the rest had large cell endocrine carcinoma. Tumor sizes (longitudinal diameter), measured by CT, of these 11 patients ranged from 6 mm to 52 mm (mean +/- SD 8.3 mm +/- 11.9 mm), and SUV(max) for 1 h ranged from 3.37 to 11.1 (mean +/- SD 6.12 +/- 2.43). Three of these pancreatic lesions were difficult to determine by routine transaxial images, and detection was obvious only by thin-slice images or multiplanar reconstruction images. Contrast-enhanced CT showed gradual fill-in from the peripheral portion to the center. In addition, 10 of 11 cases did not show main pancreatic duct dilatation even if the tumor size was large. CONCLUSIONS: Metastases to the pancreas in lung cancer patients are not so rare and radiologists first have an important role to detect the pancreatic mass and then suggest to metastasis as the likely diagnosis. For this purpose, FDG-PET/CT has an advantage in depicting unsuspected pancreatic metastasis from lung cancer, particularly that which is not detected by CT alone.

A logistic regression predictive model and the outcome of patients with resected lung adenocarcinoma of 2 cm or less in size.

Diagnostic criteria to identify small lung adenocarcinomas that relapse after resection have yet to be established. For this purpose, we developed a mathematical logistic model in the present study. We collected data for patients with lung adenocarcinoma of 2 cm or less in size: the original cohort comprised 28 men and 25 women and the validation cohort comprised 11 men. By entering five clinicopathological factors (vascular invasion, lymphatic permeation, histological subtype, papillary carcinoma component, and smoking status) into the logistic model, we calculated a predictive function for relapse after surgery. The obtained predictive function accurately classified the patients into a recurrence or non-recurrence group: the overall accuracy of the predictive model for recurrence established from the male patients in the original cohort was 86%. Our predictive model is, however, currently limited to male patients only, because the original cohort included only one female patient with relapse. By applying the logistic model to the validation cohort, six patients were classified into a recurrence group and the other five into a non-recurrence group: four of the six patients in a recurrence group had relapsed, while all five patients in the non-recurrence group were well during their follow-up periods. Although the predictive ability of the logistic model did not reach a statistical significance (P=0.0606), nine of the 11 (82%) patients in the validation cohort were correctly classified. Consequently, using a logistic predictive model consisting of the five clinicopathological factors might enable us to predict the recurrence of resected small-sized lung adenocarcinomas in male patients.

Long-term survival after repeat resections of metastases in liver, lung, and stomach from sigmoid colon cancer: report of a case.

A 74-year-old female patient underwent a simultaneous colectomy and hepatectomy for sigmoid colon cancer and its hepatic metastases. Six months later she underwent a hepatectomy for recurrent hepatic metastases; then 10 months later, a pulmonary resection for pulmonary metastasis; and 24 months later, a partial gastrectomy for gastric metastasis. As of December 2005, at 7 years 6 months after the first surgery and at 4 years after the last surgery, the patient is still alive with a good quality of life and no sign of recurrence.

Pulmonary artery stenting for recurrent lung cancer after left pneumonectomy.

We present a case of a patient with stenosis of the pulmonary artery which was successfully treated by implantation of a vascular endoprosthesis. A 50-year-old man underwent left pneumonectomy for lung cancer. Eleven months later, a computed tomographic scan revealed a soft tissue mass in the mediastinum and there was severe stenosis of the remaining right main pulmonary artery. A self-expandable vascular endoprosthesis was implanted in the stenotic portion. We used percutaneous cardiopulmonary support (PCPS) during the procedure. We recommend the technique of pulmonary artery stenting using PCPS as efficacious and safe.