Rapid progressive spontaneous hemothorax caused by carcinoma of unknown primary: A very rare case.

We present a very rare case of spontaneous hemothorax which was caused by carcinoma of unknown primary. To the best of our knowledge, there are no other such cases reported worldwide. The patient was 72-year-old male who was referred to our department for massive hemothorax. We undertook surgical treatment for haemostasis, and found multiple tumours which led to the diagnosis of carcinoma of unknown primary as the cause of haemorrhage. The tumours increased and grew rapidly after surgery and hemothorax progressed despite our treatment. The patient died from disseminated intravascular coagulation caused by continuous bleeding on postoperative day 19.

Intraoperative control of air leak using a sutureless free pericardial fat pad covering method in lung cancer resection.

Here, we introduce a new method for intraoperative control of air leak using a free pericardial fat pad covering to lung damage with sutureless fixation. We covered the damaged lung tissue with a free pericardial fat pad with a polyglycol acid sheet and fibrin glue fixation. This method provides a good air leak controlling effect with the use of a free pericardial fat pad and relatively short operative time with sutureless fixation.

Positive outcome of diaphragm covering and total pleural covering techniques for catamenial pneumothorax.

Catamenial pneumothorax (CP) is reported to be caused by the endometriosis of diaphragm, lung and parietal pleura. Therefore, the resection of endometriotic lesion in these organs is reported as effective surgical treatment. Overlooking of endometrial tissues during the operation is believed to be the cause of recurrence after surgical treatment. To address this problem, we underwent total diaphragm covering (TDC) and total pleural covering with sheets of oxidized regenerated cellulose mesh. This report described two CP cases that underwent total diaphragm covering (TDC) and total pleural covering. Both patients were followed up for 1 year without recurrence.

Intrathoracic lipoma of chest wall misdiagnosed as liposarcoma with malignant features based on radiological image and intraoperative findings.

Lipomas are common benign tumors, which are usually located in the subcutaneous tissue. It is relatively rare for lipoma to occur in the intrathoracic cavity, and it is clinically difficult to distinguish it from liposarcoma. We present the case of a 72-year-old man with a chest wall tumor preoperatively diagnosed as liposarcoma, with tumor enlargement with radiological image change to heterogenous and 18F-fluorodeoxyglucose positron emission tomography uptake. The tumor was resected along the chest wall, lung and diaphragm because of dense adhesions. The tumor was diagnosed as lipoma with fat necrosis and inflammatory changes.

Thoracoscopic resection of pulmonary sequestration with carbon dioxide insufflation and indocyanine green.

We encountered a rare case of pulmonary sequestration supplied from the right renal artery, which was resected by video-assisted thoracic surgery with carbon dioxide insufflation and indocyanine green-guided technique. A 41-year-old woman with intralobar pulmonary sequestration supplied from the right renal artery was referred to our department. At the time of surgery, we used carbon dioxide insufflation to improve the manoeuvrable workspace for shutting off aberrant arteries and indocyanine green fluorescence guidance to differentiate the boundary of the sequestered lung from the normal lung. These procedures helped in the efficient resection of the lesion.

Preoperative prediction of the localization of a solitary fibrous tumor using four-dimensional computed tomography: a case report.

Solitary fibrous tumors of the pleura (SFTP) are relatively rare primary pleural tumors. Four-dimensional computed tomography (4D-CT) is reportedly useful in assessing parietal pleural invasion and adhesion in patients with lung cancer. We report a case in which 4D-CT was performed to evaluate SFTP localization and parietal pleural invasion and adhesions. A 62-year-old female presented with an abnormality on a chest radiograph. Chest CT revealed a well-demarcated solid nodule in the left lower lobe adjacent to the pleura. We considered that the tumor was intrapulmonary or arose from the visceral pleura, without adhesion or invasion to the chest wall based on 4D-CT. Primary lung cancer was suspected, and the tumor was resected. Pathological diagnosis revealed an SFTP. This case suggests that 4D-CT is useful in predicting the localization of SFTP and other thoracic tumors, assessing chest wall adhesion and invasion, and making surgical strategies.

Primary posterior mediastinal angiolipoma: a case report.

An angiolipoma is a benign tumor, and a primary mediastinal angiolipoma is extremely rare. Herein, we describe the presentation and management of a posterior mediastinal angiolipoma in a woman with loss of consciousness. Chest computed tomography (CT) revealed a contrast-enhancing mass in the right posterior mediastinum, with intercostal arterial blood supply identified on three-dimensional reconstruction CT (3D-CT). Magnetic resonance imaging revealed a fatty component. Pre-operative embolization of the supplying intercostal artery was performed to reduce intraoperative bleeding. Mass resection was performed using video-assisted thoracic surgery. Histopathology confirmed angiolipoma diagnosis. Although rare, a posterior mediastinum angiolipoma should be considered a possibility; 3D-CT and pre-operative embolization may be useful in the surgical treatment of hypervascular mediastinal tumors, such as angiolipomas.

Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial.

BACKGROUND: Ipsilateral shoulder pain (ISP) is a common problem after pulmonary surgery. We hypothesized that phrenic nerve block (PNB) at the azygos vein level, near the location of the surgical operation, would be effective for reducing ISP. Our primary aim was to assess the effect of PNB on postoperative ISP, following video-assisted thoracic surgery (VATS). METHODS: This prospective, randomized, patient-blinded, single-institution trial was registered at the University Hospital Medical Information Network (UMIN000030464). Enrolled patients had been scheduled for VATS under general anesthesia with epidural analgesia. Patients were randomly allocated to receive infiltration of the ipsilateral phrenic nerve at the azygos vein level with either 10 mL of 0.375% ropivacaine (PNB group) or 0.9% saline (control group) before chest closure. Postoperative ISP was assessed using a numerical rating scale (NRS, 0-10) at rest at 2, 4, 8, 16, and 24 hours. The incidence of ISP was defined as the proportion of patients who reported an NRS score of ≥1 at least once within 24 hours after surgery. In the primary analysis, the proportion of patients with ISP was compared between PNB and control groups using the χ2 test. NRS values of ISP and postoperative incision pain within 24 hours were investigated, as was the frequency of postoperative analgesic use. Incision pain was assessed using an NRS at the time of ISP assessment. Finally, the incidence of postoperative nausea and vomiting and shoulder movement disorders were also evaluated. RESULTS: Eighty-five patients were included, and their data were analyzed. These patients were randomly assigned to either PNB group (n = 42) or control group (n = 43). There were no clinically relevant differences in demographic and surgical profiles between the groups. There was no significant difference in the incidence of ISP (the control group 20/43 [46.5%] versus the PNB group 14/42 [33.3%]; P = .215). The severity of ISP was lower in the PNB group than in the control group (linear mixed-effects model, the main effect of treatment [groups]: P < .001). There were no significant differences between groups in terms of postoperative incision pain. The frequency of postoperative analgesic use was significantly higher in the control group (Wilcoxon rank sum test, P < .001). Postoperative nausea and vomiting did not significantly differ between the 2 groups. There were no changes in the range of shoulder joint movement. CONCLUSIONS: Azygos vein level PNB did not significantly affect the incidence of ISP after VATS.

Pulmonary metastasis with coexisting pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma 20 years after endometrioid adenocarcinoma surgery: A case report.

Late pulmonary metastasis from endometrioid adenocarcinoma (EA) is rare, and occurrence after >20 years is extremely rare. Here, we report a case of pulmonary metastasis with coexisting pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma that occurred 20 years after surgery for EA. A 60-year-old Japanese woman had previously undergone surgery for primary EA, and 20 years later presented with an abnormality that was detected on chest radiography. Chest computed tomography (CT) revealed two nodules in the right lower lung lobe, which were suspected to be primary lung cancer. Wedge resection was performed, and the intraoperative pathological diagnosis was that of adenocarcinoma with MALT lymphoma; this prompted additional right lower lobectomy. The final pathological diagnosis was pulmonary metastasis from EA with coexisting MALT lymphoma. This is probably the first report on late pulmonary metastasis coexisting with MALT lymphoma 20 years after surgery for EA. Surgeons should be aware of the possibility of late pulmonary recurrence of EA after more than 20 years and should consider aggressive resection. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Although extremely rare, pulmonary metastasis can occur more than 20 years after surgery for endometrioid adenocarcinoma. Furthermore, pulmonary metastasis from endometrioid adenocarcinoma may coexist with mucosa-associated lymphoid tissue lymphoma. WHAT THIS STUDY ADDS: Endometrioid adenocarcinoma requires long-term postoperative follow-up to detect recurrence, even in early-stage cases. Video-assisted thoracoscopic surgery (VATS) is useful for resecting pulmonary metastasis from endometrioid adenocarcinoma.

Surgical resection of a middle mediastinal paraganglioma that caused diabetes.

BACKGROUND: Paragangliomas are rare neuroendocrine tumors originating from chromaffin cells of extra-adrenal origin. Ninety percent of adrenergic tumors originate in the adrenal medulla and are known as pheochromocytomas; the remaining 10% are extra-adrenal and are called paragangliomas. Mediastinum paragangliomas is rare and commonly originate from the posterior mediastinum, while those originating from the middle posterior are quite rare. Some paragangliomas secrete catecholamines, leading to symptoms such as hypertension, tachycardia, and diabetes. CASE PRESENTATION: A 76-year-old woman visited our hospital for the treatment and further evaluation of diabetes. Her hemoglobin A1c levels had risen to 11.0%. To investigate the cause of her diabetes, a contrast-enhanced chest computed tomography scan was performed, revealing a ring-enhancing tumor (30 × 30 mm) in the middle mediastinum. The surgical resection was performed via video-assisted thoracic surgery. Surgery was performed using a vessel-sealing device; however, bleeding was persistent from the surrounding tissue. Total bleeding was 400 g. Blood pressure fluctuations and arrhythmia did not occur during the operation. The patient's uncontrolled diabetes was cured after the surgery, and the tumor was diagnosed as a functional paraganglioma. CONCLUSIONS: We encountered a rare case of functional paraganglioma located in the middle mediastinum. Functional paragangliomas should be considered as a potential cause of uncontrolled diabetes, and a whole-body CT scan should be performed to investigate this possible cause.

Atraumatic bleeding of the subclavian artery 20 years after surgical treatment of pneumothorax.

BACKGROUND: Bleeding of the subclavian artery is a fatal condition. Adhesion between the pleura and staple line may develop after surgical treatment of pneumothorax, and collateral arteries often develop from the subclavian artery toward the adhesion at the lung apex; however, atraumatic tearing and bleeding of these collateral arteries into the extrapleural and intrathoracic cavities is rare. CASE PRESENTATION: A 70-year-old man visited the hospital for evaluation of left chest pain. Contrast-enhanced chest computed tomography showed a huge tumor in the left apex of the lung. It was suspected to be an extrapleural huge hematoma, and it ruptured into the thoracic cavity. Bleeding from the left subclavian artery was suspected; therefore, emergency angiography was performed. Angiography showed some collateral circulation from the left subclavian artery to the apex of the left lung. Distal and proximal bleeding points were identified. The distal bleeding point was embolized using coils. The proximal bleeding point was blown out, and stents were placed in the left subclavian artery. He had undergone pneumothorax surgery 20 years previously, and the present bleeding episode was strongly suspected to be associated with that surgery. The collateral circulation from the subclavian artery could have developed because of post-pneumothorax inflammation, eventually rupturing and bleeding into the extrapleural space. CONCLUSIONS: This report described an important case of atraumatic subclavian artery bleeding considered to have been caused by surgical treatment of pneumothorax 20 years previously. Emergency angiography and percutaneous stent placement or coil embolization should be considered first in such cases.

Solid component tumor doubling time is a prognostic factor in non-small cell lung cancer patients.

BACKGROUND: Recently, several reports investigating tumor doubling times (TDTs) in lung cancer have demonstrated that lung cancer patients with shorter TDTs have poor prognoses. Although data have shown that the solid component of a tumor is clinically more important, relationships between solid component TDTs and lung cancer prognoses remain unclear. METHODS: To evaluate relationships between TDT and survival, we retrospectively evaluated 231 patients who underwent surgical resection for non-small cell lung cancer. The TDTs of whole and solid components were calculated using preoperative thin-slice chest computed tomography scans with a cut-off of 400 d between scans. RESULTS: Patients with short TDTs (< 400 d) both in the solid and whole components had poor prognoses. Among pathological stage I patients (n = 176), short solid component TDT (< 400 d) significantly influenced prognosis only in pathological stage IB patients. Moreover, we found that patients with shorter solid component TDTs had significantly worse prognosis compared with patients who showed shorter whole component TDTs. CONCLUSIONS: Short solid component TDTs (< 400 d) could be a poor prognostic indicator for non-small cell lung cancer patients undergoing surgical resection; furthermore, clinicians should pay particularly close attention to cases with rapid growth of the solid tumor component.

Pulmonary mucormycosis developed during acute myelogenous leukemia and successfully treated by surgical resection before blood stem cell transplantation.

Pulmonary mucormycosis is relatively rare and occurs in immunosuppressed patients, for example, individuals with hematologic malignancies such as leukemia. As pulmonary mucormycosis increases rapidly and is often fatal, appropriate treatment including surgical resection is necessary. We report a patient with pulmonary mucormycosis and acute myelogenous leukemia for which antifungal drugs were invalid. After rapid surgical resection, the patient was administered a peripheral blood stem cell transplantation. In conclusion, we emphasize that patients with pulmonary mucormycosis undergoing leukemia treatment should be considered for rapid surgical treatment if the infected lesion is limited, as overcoming this acute infection increases their chance to undergo hematopoietic stem cell transplantation and potential for long-term survival.

Mediastinal mature teratoma with rupture into pleural cavity due to blunt trauma.

We report a rare case of mediastinal mature teratoma with rupture due to blunt trauma. A 15-year-old boy had received a strong head-butt in the left upper chest wall and was admitted with the sudden onset of left-sided severe chest pain and dyspnea. Chest computed tomography (CT) scan on admission revealed a heterogeneous mass lesion in the anterior mediastinum. The contrast-enhanced CT scans obtained 2 days after admission showed not only mediastinal mass lesion but also left pleural effusion. On the radiologic finding at 5 months later, the lesion became larger and was thought to be a typical mediastinal mature teratoma. The patient underwent extirpation of the tumor. Microscopically, the tumor was typically composed of adult-type tissues and was confirmed to be mature teratoma.

Localized nodular amyloidosis of the lung.

Pulmonary localized nodular amyloidosis is a rare disorder and is not associated with primary systemic amyloidosis. We herein report a patient with a growing lung nodule who underwent thoracic surgery and was diagnosed with this condition. This case study suggests that localized nodular amyloidosis should be considered during a differential diagnosis of growing lung nodules and that a histological examination should be performed to distinguish this disorder from lung malignancies.

Occurrence of a simultaneous bilateral spontaneous pneumothorax due to a pleuro-pleural communication.

Herein we present a case of a simultaneous bilateral spontaneous pneumothorax caused by a pleuro-pleural communication. A 70-year-old man with a history of esophagectomy presented with dyspnea. A chest roentgenogram revealed a bilateral pneumothorax and bilateral chest drainage procedures were performed. A left bullectomy was also performed 3 days later due to persistent air leakage on the left side. During surgery, a small fistula was detected in the anterior mediastinal pleura and was found to be in communication with the bilateral pleural spaces.

Clinical features of lung cancer in smokers with light and mild chronic obstructive pulmonary disease: a retrospective analysis of Japanese surgical cases.

OBJECTIVES: We estimated the influence of chronic obstructive pulmonary disease (COPD) upon the clinicopathological characteristics of lung cancer (LC) in Japanese surgical cases by comparing LC cases in non-COPD smokers. METHOD: A consecutive cohort comprising 157 COPD patients (78 in Global Initiative for Obstructive Lung Disease-1 (GOLD-1) and 79 in GOLD-2) and 374 non-COPD smoker-LC patients were enrolled in this study. Comparative analyses of the clinicopathological features of these two groups, including clinical outcomes, were performed. RESULTS: By analyzing all cases, we found that LC patients with COPD were older on average, more likely to be male, and heavier smokers than LC patients without COPD. In sub-analysis involving matched patient backgrounds, histological differentiation grade of LC in smokers with COPD was lower than in LC smokers without COPD, although distribution of clinical stages and histological types of LCs did not differ between smokers with and without COPD. The 5-year-survival rate in COPD patients was poorer than in non-COPD smokers in terms of both overall (38% vs 54%) and cancer-related mortality (45% vs 63%). By single-variant risk analysis, COPD became a prognostic factor. CONCLUSION: We concluded from our analysis that COPD-related LC may have a higher malignant potential than LC in non-COPD smokers, as the histological differentiation grade and clinical outcomes were poorer.

Multiple schwannomas of the bilateral mediastinal vagus nerves.

Multiple schwannomas arising from the mediastinal vagus nerve are very rare, but herein we report a case with such lesions involving the bilateral intrathoracic vagus nerves. A 43-year-old man presented with multiple mediastinal tumors during a check-up. A chest computed tomographic scan revealed multiple lesions that appeared strung together like beads along the right vagus nerve. Three small tumors were also evident on the left side of the esophagus. We performed a complete resection of the bilateral mediastinal tumors through right thoracoscopic surgery. The pathologic diagnosis for each of these tumors was a schwannoma without malignant components.

A mediastinal somatic-type germ cell tumor with hepatic metastasis successfully treated by multiple modalities.

Rhabdomyosarcoma in the mediastinum coexisting with metastatic non-seminomatous germ cell tumor, so-called somatic-type malignancy, is a rare carcinoma and has poor survival. This study reports a case of diffuse and huge hepatic metastasis of non-seminomatous germ cell tumor associated with coexisting embryonal rhabdomyosarcoma in the mediastinum. A 31-year-old man presented with abdominal pain and was found to have multiple abnormal hepatic masses on abdominal computed tomography (CT). Concomitantly, an anterior mediastinal mass was found on chest CT. Chemotherapy was initiated because the hepatic lesion was diagnosed as choriocarcinoma, based on histological findings and the elevation of chorionic gonadotropin ß-subunit and α-fetoprotein. After six cycles of bleomycin, etoposide and cisplatin chemotherapy the metastatic liver tumors showed complete response. The remaining mediastinal tumor was completely and successfully resected. The histological findings revealed mature teratoma with embryonal rhabdomyosarcoma. The patient has remained well for over six years after the treatment without any signs of disease recurrence.