Surgical outcomes of ipsilateral metachronous second primary lung cancer.

OBJECTIVES: The optimal surgical approach for metachronous second primary lung cancer (MSPLC), especially ipsilateral MSPLC, remains unclear. This study aimed to review postoperative complications and examine surgical outcomes based on the extent of resection after surgery for ipsilateral MSPLC. METHODS: Clinical data from 61 consecutive patients who underwent pulmonary resection for ipsilateral MSPLC according to the Martini-Melamed criteria between January 2005 and December 2017 in 3 institutes were retrospectively reviewed. RESULTS: Postoperative complications were identified in 12 patients (19.7%). Regarding the combination of initial and second surgery, intraoperative bleeding was significantly greater in patients with anatomic-anatomic resection than in others (P < 0.001). Operation time was significantly longer in patients with anatomic-anatomic resection than in others (P < 0.001). However, postoperative complications showed no significant differences based on the combination of surgeries. Five-year overall survival rates in patients with anatomic resection and wedge resection after second surgery were 75.8% and 75.8%, respectively (P = 0.738), and 5-year recurrence-free survival rates were 54.2% and 67.6%, respectively (P = 0.368). Cox multivariate analysis identified ever-smoker status (P = 0.029), poor performance status (P = 0.011) and tumour size >20 mm (P = 0.001) as independent predictors of poor overall survival, while ever-smoker status (P = 0.040) and tumour size >20 mm (P = 0.007) were considered independent predictors of poor recurrence-free survival. CONCLUSIONS: Regarding postoperative and long-term outcomes for patients with ipsilateral MSPLC, surgical intervention is safe and offers good long-term survival. Wedge resection is an acceptable provided tumours ≤2 cm and ground-glass opacity-predominant as a second surgery for early-stage ipsilateral MSPLC.

Salvage surgery to treat tumor regrowth after stereotactic body radiotherapy in primary non-small cell lung cancer.

BACKGROUND: Stereotactic body radiotherapy (SBRT) is considered to be an effective and safe treatment in patients with primary lung cancer. If local recurrence is confirmed following SBRT, surgical treatment is a possibility. The present study aimed to clarify the safety and survival outcomes of salvage surgery in primary lung cancer patients with local recurrence following SBRT. METHODS: All subjects were patients with primary lung cancer who underwent surgical treatment for local recurrence following SBRT during the period from July 2005 to July 2015. We evaluated the reason for SBRT selection, the surgical procedure, postoperative complications, and prognosis. RESULTS: Of 932 patients underwent SBRT as treatment for primary lung cancer, 48 patients (5.2%) had local recurrence alone and 19 patients (2.0%) underwent salvage surgery. SBRT was selected in eight medically operable patients who refused surgery, and in 11 patients considered medically inoperable by their pulmonologist. Lobectomy was performed in 15 patients. Postoperative complications were documented in 4 patients (21.1%). Incomplete resection was performed in 2 patients. Stage progression was confirmed in 7 patients (36.8%). The 5-year overall survival (OS) was 72.5% and the 5-year disease-free survival (DFS) was 65.2%. CONCLUSIONS: We evaluated patients who underwent salvage surgery due to local recurrence of lung cancer following SBRT. We found that salvage surgery could be performed safely without affecting SBRT outcomes. We further infer that cases of complete resection are likely to be associated with good prognosis, and that SBRT should be selected only after careful consideration because complete resection is not possible in all cases.

Temporal Changes of Inflammatory Cytokine Profiles in Epithelial Lining Fluid in a Canine Lung Transplant Model.

OBJECTIVES: Ischemia-reperfusion injury resulting in post-transplant lung dysfunction involves a complicated network of cytokines that has yet to be fully investigated. We analyzed temporal changes in cytokine levels in epithelial lining fluid (ELF) from the distal airways of a canine lung transplantation model. METHODS: Ischemic time was set to 18 hours to enhance lung injury in a left single-lung transplantation model. ELF was collected via bronchoscopic microsampling, a minimally-invasive technique allowing repeated sampling, hourly up to 5 hours after reperfusion started. We compared levels of pro-inflammatory cytokines in ELF with those at baseline (time zero), and with a sham-operated control group. RESULTS: Concentrations of tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) significantly increased immediately after the start of lung reperfusion in the transplant group relative to the sham group (P < 0.005 and P < 0.05, respectively); both were sustained through the 5 hours. Interferon gamma (IFN-γ levels were significantly reduced 3 h after reperfusion started (P < 0.05). CONCLUSIONS: We found time- and cytokine-dependent changes in TNF-α, IL-6, and IFN-γ in ELF from the lung transplantation model. These specific changes in the cytokine profile may relate to the mechanism underlying post-transplant lung dysfunction.

Sudden death of a 14-year-old girl with lymphangiomatosis.

A 14-year-old girl presented with progressively worsening intermittent orthopnea. Imaging studies showed cardiomegaly, extensive pericardial effusion, and a mediastinal tumor. By pericardial drainage, approximately 8,000-mL fluid was collected over 10 days. Left thoracoscopic pericardial fenestration and mediastinal tumor biopsy were performed, revealing lymphangiomatosis. Chylous pleural effusion developed post-surgery. Although control was attempted, her condition worsened. Eight months later, she died of sudden cardiopulmonary arrest. Autopsy revealed systemic spread of the primary lesion from the hyperplastic lymph ducts to the parietal pleura and mediastinum confirming systemic lymphangiomatosis.

[Pulmonary Resection for Malignant Tumor after Stereotactic Radiation Therapy].

We describe our experience with 14 patients who underwent surgery for a recurrent malignant lung tumor following stereotactic radiation therapy (SRT). The reasons for selecting SRT were patients'decision in 7 patients, advanced age in 3, reduced lung function in 3, and comorbidity in 1. Eight patients had primary lung cancer and 6 had metastatic lung cancer. Tumor recurrence was diagnosed by chest computed tomography in all patients except for one. The median period from SRT to surgery was 12.2 months. All 14 patients were deemed fit for surgery;5 patients underwent lobectomy, and 9 underwent limited resection. In 13 patients, complete resection was possible. In all 14 patients, lung resection was performed safely, and postoperative course was uneventful. No patients died of cancer during follow-up. Informed consent should be obtained from patients for post-recurrence treatment because tumor recurrence can occur after SRT.

Successful treatment of penetrating chest injury caused by a crossbow.

A 67-year-old man presented with a crossbow injury sustained in a suicide attempt during which he fixed the crossbow to a table. Although he retired to bed without treatment on the day of the initial injury, his pain increased the following day, and he was admitted to our hospital. On arrival, his vital signs were stable and a 10-mm diameter crossbow arrow that had penetrated the right anterior chest remained in place. Chest computed tomography revealed suspected damage to the right middle lobe, diaphragm, and liver. A right anterior thoracotomy was performed with partial resection of the middle lobe, diaphragm repair, and arrest of hepatic bleeding. There were no complications, and his postoperative course was uneventful. On day 12 after surgery, he was transferred to the psychiatry department of another hospital for treatment of his depression.

[Chest wall reconstruction after resection of chest wall tumors].

Between 1994 and 2012, chest wall resection and reconstruction were performed 15 patients (16 cases) with primary chest wall tumors, metastatic tumors. and chest wall recurrence of breast carcinoma. In all the patients, reconstruction of the chest wall was performed using layers of polypropylene Marlex mesh sheets. In 9 patients, only Marlex mesh sheets were used. The post-operative course was uneventful, and neither paradoxical respiration nor respiratory failure was observed. In 2 patients, reconstructions of the sternum was performed using a Marlex mesh sandwich. A full thickness chest wall defect was reconstructed using Marlex mesh and a pedicled latissimus dorsi musculocutaneous flap. Chest wall recurrence of breast cancer and primary leiomyosarcoma of the chest wall were observed in 4 and 1 patient, respectively. In conclusion, polypropylene Marlex mesh sheets arranged in a layered form appear to be a stable prosthetic material for chest wall reconstruction.

[Rectal tenesmus due to tumor invasion into the pelvic cavity responding favorably to antiarrhythmic drug therapy].

We experienced 3 patients(Cases 1, 3, and 4)with pelvic tumor-related rectal tenesmus showing favorable responses to antiarrhythmic drugs. Based on this experience, we administered antiarrhythmic drugs preferentially to 2 others with tumor derived rectal tenesmus(Cases 2 and 5), and again obtained favorable responses. These 5 patients(1 man, 4 women)were 28-89(mean 58)years of age. The primary lesion was cervical cancer in 3 patients, ovarian cancer in 1, and bladder cancer in 1. In the 3 with cervical cancer, the tumor had directly infiltrated the rectum and vulva. The patient with ovarian cancer had a residual tumor in the Douglas pouch postoperatively. The patient with bladder cancer had undergone total cystectomy and urinary diversion using an ileal conduit at another institution. All 5 patients complained of a frequent desire to defecate without feces(rectal tenesmus). Their rectal tenesmus was attributed to pelvic neurological dysfunction around the rectum. Drug therapy was initiated with oral mexiletine hydrochloride(Mexitil)150 mg in 3 divided doses in 4 patients and with continuous infusion of intravenous lidocaine 2%(Xylocaine)500mg/day in the other(Case 2). None had adverse reactions; all 5 experienced palliation of symptoms and improved quality of life.

Late diaphragmatic laceration detected as a result of spontaneous pneumothorax.

Injury to the right diaphragm is sometimes missed in the acute stage and is detected only when the rupture becomes more extensive, a diaphragmatic hernia develops, and dyspnea ensues. We report a case in which spontaneous right pneumothorax developed 46 months after blunt trauma due to a fall. Air had leaked into the right pleural cavity, passed through the injured right diaphragm, and entered the abdominal cavity; the patient presented with intraperitoneal emphysema.