[Probable Immunoglobulin G4 (IgG4)-related Periaortitis Requiring Differentiation from Mediastinal Tumor].

A 42-year-old man with a history of suspected of Behcet's disease underwent oral steroid treatment. During follow-up, chest X-ray revealed an abnormal shadow of the mediastinum. Chest computed tomography(CT) showed a circumferential tumor around the descending thoracic aorta. Enhanced CT showed a lowly and uniformly enhanced tumor at delay phase. A mediastinal tumor was suspected, which prompted a biopsy of the periaortic tumor by video-assisted thoracic surgery (VATS). Histopathological diagnosis showed numerous immunogloblin G4 (IgG4)-positive plasma cells suggesting the possibility of IgG4-related periaortitis. However, based on the diagnostic criteria, the case was comprehensively diagnosed as probable IgG4-related periaortitis, steroid treatment may have affected blood IgG4-positive cells and tissues.

Pulmonary metastasectomy is associated with prolonged survival among patients with bone and soft tissue sarcoma.

The aim of the present study was to evaluate the survival impact of surgical resection among patients with pulmonary metastases from bone and soft tissue sarcomas. A total of 34 consecutive patients with ≤5 pulmonary metastases from bone and soft tissue sarcomas were retrospectively reviewed. The patients included 19 men and 15 women, with a median age of 64.0 years and a median follow-up of 14.5 months. The oncological outcome was compared between patients who underwent surgical and non-surgical treatment. A total of 22 patients underwent surgery and 12 patients did not undergo surgery. The surgery group had 3- and 5 year overall survival rates of 62 and 53%, respectively. None of the patients in the non-surgery group survived to 3 years. Compared with the non-surgery group, surgery achieved significantly better 3- and 5 year overall survival rates. Pulmonary metastasectomy was associated with significantly improved survival among patients who were aged <64 years (P=0.0155), as well as those who were aged ≥64 years (P=0.0444), which indicated that age was not associated with a difference in survival between the two groups. Therefore, pulmonary metastasectomy may improve the prognosis of patients with pulmonary metastases from bone and soft tissue sarcomas.

[Paraffinoma with Spinal Paralysis 40 Years After Pleural Plombage for Tuberculosis].

Paraffin had been used for pleural plombage in the treatment of tuberculosis. However, paraffin use has been reported to cause late postoperative complications. A 79-year-old man was presented with an extramedullary tumor and spinal paralysis. Forty-seven years ago, he had undergone pleural plombage using paraffin for the treatment of pulmonary tuberculosis. Since the extramedullary tumor was found to be paraffinoma, paraffin in the vertebral canal and thoracic cavity was removed surgically. All the paraffin in the vertebral canal and thoracic cavity was removed. After surgery, the patient remains well, without spinal paralysis.

Outcomes of completion lobectomy long after segmentectomy.

BACKGROUND: Completion lobectomy long after segmentectomy in the same lobe is extremely difficult because of severe adhesions around hilar structures, especially in cases involving video-assisted thoracoscopic surgery (VATS) completion lobectomy. We report and compare the surgical outcomes of patients who underwent VATS or thoracotomy completion lobectomy long after radical segmentectomy for lung cancer. METHODS: We retrospectively evaluated the surgical outcomes of completion lobectomies performed at our institute long after radical segmentectomies for lung cancer in the same lobe. The efficacy and safety of VATS completion lobectomy was compared to that of thoracotomy completion lobectomy. RESULTS: Ten of 228 patients who underwent radical segmentectomy for lung cancer between 2009 and 2018 underwent completion lobectomy at least a month after segmentectomy; five patients underwent VATS completion lobectomy. None of the patients underwent VATS left upper completion lobectomy, and conversion to thoracotomy was required in one patient. There were no significant differences between VATS and thoracotomy completion lobectomies in the median operative times (VATS 295 min, thoracotomy 339 min, p = 0.55), intraoperative blood loss volumes (VATS 350 mL, thoracotomy 500 mL, p = 0.84), intervals between initial segmentectomy and completion lobectomy (VATS 40 months, thoracotomy 48 months, p = 0.55), and number of patients with pulmonary artery injury (VATS 1, thoracotomy 2, p = 0.49). There was no operation-related mortality. CONCLUSIONS: VATS completion lobectomy long after segmentectomy for lung cancer could be performed without fatal complications unless severe adhesions are observed around each main pulmonary artery.

Quality assessment using EQ-5D-5L after lung surgery for non-small cell lung cancer (NSCLC) patients.

OBJECTIVES: Aim of this study was to elucidate an alteration of quality of life (QOL) score before and after video-assisted thoracoscopic surgery (VATS) for non-small cell lung cancer (NSCLC) patients using the 5-level EuroQol-5D questionnaire (EQ-5D-5L). We also investigated how the preoperative QOL scores affected the postoperative clinical outcome prospectively. METHODS: Between July 2018 and December 2018, 24 consecutive NSCLC patients who underwent VATS were recruited. The EQ-5D-5L for Japanese was used with face-to-face interviews to estimate the utility values of QOL. RESULTS: QOL scores were significantly declined after surgery (0.81 ± 0.19 vs. 0.74 ± 0.11: P = 0.049). The levels of EQ-5D-5L questionnaire were not significantly different before and after surgery except Q4 (pain control). The levels of Q4 were significantly worsened after surgery (1.33 ± 0.56 vs. 1.88 ± 0.61, P < 0.001). Operation time and bleeding in the preoperative low-QOL score group (N = 13) was longer (215.4 ± 52.3 min. vs. 173.5 ± 42.3 min., respectively: P = 0.045) and more (116.2 ± 152.7 ml vs. 22.7 ± 20.1 ml, respectively: P = 0.049) than those in the high-QOL score group (N = 11). CONCLUSIONS: QOL survey for lung cancer patients using EQ-5D-5L is simple and useful to identify the issue facing at the medical team. Preoperative low QOL score could be a predicting factor for the longer operation time and more bleeding.

[Surgical Treatment for Pneumopyothorax Secondary to Pancreatic Fistula].

A 46-year-old woman with cervical cancer with multiorgan metastasis visited our hospital. She underwent a total gastrectomy, splenectomy, distal pancreatectomy, left adrenalectomy, and left partial diaphragmatic resection. Postoperatively, she developed pleural effusion with high level of amylase secondary to a pancreatic fistula, consequently causing left-sided empyema. She developed acute respiratory distress syndrome. Urgent surgical treatment was scheduled, and left lower lobectomy, with diaphragmatic partial resection were performed under the venovenous extracorporeal membrane oxygenation. After surgery, intensive care for 45 days was necessary and she was discharged home 6 months post operatively.

Thoracoscopic Right Basilar Segmentectomy After Right Upper Lobectomy.

This report describes a case of thoracoscopic right basilar segmentectomy after upper lobectomy. A 76-year-old man who underwent right upper lobectomy for lung tuberculosis 50 years earlier had a diagnosis of squamous cell carcinoma, stage IB (T2a N0 M0), in the right lower lobe and underwent right basilar segmentectomy for limited resection. The postoperative course was uneventful. The patient showed no recurrence clinically, and the 1-year postoperative chest computed tomographic scan showed adequate volume of the middle and residual right lower lobe without emphysematous changes.

Left upper pulmonary vein connected to the persistent left superior vena cava and the left atrium.

Persistent left superior vena cava (PLSVC) is the most common anomalous thoracic venous drainage. A PLSVC usually drains into the right atrium through a dilated coronary sinus. It is rare that a PLSVC flows directly into the left atrium, and even rarer that it connects to the left upper pulmonary vein (LUPV). We report a case, wherein the LUPV connected to both the PLSVC and the left atrium.

Thoracoscopic one-stage lobectomy and diaphragmatic plication for T3 lung cancer.

BACKGROUND: Combined resection of a phrenic nerve is occasionally required in T3 primary lung carcinomas invading the phrenic nerve to completely remove a malignant tumour, resulting in diaphragmatic paralysis. We describe the first case of thoracoscopic lobectomy and diaphragmatic plication as a one-stage surgery for lung cancer invading the phrenic nerve. CASE PRESENTATION: A 56-year-old woman with a T3N0M0 primary adenosquamous carcinoma in the left upper lobe presented with suspicious invasion to the anterior mediastinal fat tissue and left phrenic nerve and underwent left upper lobectomy, node dissection, and partial resection of the anterior mediastinal fat tissue with the left phrenic nerve. Furthermore, thoracoscopic diaphragmatic plication was performed as a concomitant procedure. The patient's postoperative course was favourable, without any complications, and respiratory function was preserved for 1 year postoperatively. CONCLUSIONS: Thoracoscopic one-stage lobectomy and diaphragmatic plication for T3 lung cancer invading the phrenic nerve is effective for preservation of postoperative pulmonary function.

Relationship between onset of spontaneous pneumothorax and weather conditions.

OBJECTIVES: Spontaneous pneumothorax (SP) results from the rupture of blebs or bullae. It has been suggested that changes in weather conditions may trigger the onset of SP. Our aim was to examine the association between the onset of primary SP with weather changes in the general population in Sapporo, Japan. METHODS: From January 2008 through September 2013, 345 consecutive cases with a diagnosis of primary SP were reviewed. All cases of primary SP developed in the area within 40 km from the Sapporo District Meteorological Observatory. Climatic measurements were obtained from the Observatory, which included 1-h readings of weather conditions. Logistic regression model was used to obtain predicted risks for the onset of SP with respect to weather conditions. RESULTS: SP occurred significantly when the atmospheric pressure decreased by - 18 hPa or less during 96 h before the survey date (odds ratio = 1.379, P = 0.026), when the pressure increased by 15 hPa or more during 72 h before the survey date (odds ratio = 1.095, P = 0.007) and when maximum fluctuation in atmospheric pressure over 22 hPa was observed during 96 h before the survey date (odds ratio = 1.519, P = 0.001). Other weather conditions, including the presence of thunderstorms, were not significantly correlated with the onset of pneumothorax. CONCLUSIONS: Changes in atmospheric pressure influence the onset of SP. Future studies on the relationship between the onset of SP and weather conditions on days other than before the onset and with large number of patients may enable us to predict the onset of SP in various regions and weather conditions.

[Management of Pulmonary Thromboembolism].

Pulmonary thromboembolism is a fatal perioperative complication in general thoracic surgery. There is a report on its incidence of 2.68 cases out of 10,000 general thoracic surgeries. To prevent pulmonary thromboembolism, risk evaluation of an individual case and steady implementation of recommended preventive techiques are required. Because of the prevalence of guidelines for prevention, the incidence of pulmonary thromboembolism in the perioperative period is reducing. However, maximum prevention of deep vein thrombosis(DVT), which can lead to pulmonary thromboembolism, is impossible even if preventive measures are strictly implemented in the perioperative period. Mindful of potential DVT postoperatively, it is crucial to speculate perioperative acute pulmonary thromboembolism when sudden sensation of postoperative dyspnea occurs. For lifesaving measures, treatment along with diagnosis is necessary. In the presence of shock, pulmonary endarterectomy is recommended with percutaneous cardiopulmonary support, while in the absence of shock, treatment depends on a patient's condition.

Video-assisted thoracoscopic surgery node dissection for lung cancer treatment.

PURPOSE: Mediastinal node dissection (MND) is an integral component of the surgical treatment for non-small cell lung cancer (NSCLC). Although video-assisted thoracoscopic surgery (VATS) has been used increasingly for lung cancer treatment, the accuracy of by VATS MND still remains controversial. We reviewed the surgical results of VATS MND for NSCLC. METHODS: A systematic review of literature was performed, and articles that fully described the surgical procedure, devices, and results of VATS MND were selected to compare the efficacy of MND by VATS and thoracotomy. RESULTS: Various techniques and equipments have been shown to perform adequate MND, but there is an argument as to the method of estimation of the accuracy of MND. Most of the recent studies showed that the nodal upstaging and number of dissected nodes are significantly lower by VATS than after thoracotomy. Oppositely, some studies showed VATS noninferiority in these issues. Complications such as chylothorax, pleural effusion, bleeding, and nerve damage were similar in both groups. CONCLUSIONS: Although ND by VATS remains controversial, VATS MND is becoming easier and more feasible owing to the development of more advanced endoscopic cameras and equipments. We should learn further to become more adept at performing adequate ND by VATS.

Fibroblastic foci, covered with alveolar epithelia exhibiting epithelial-mesenchymal transition, destroy alveolar septa by disrupting blood flow in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive interstitial lung disease of unknown cause. IPF has a distinct histopathological pattern of usual interstitial pneumonia in which fibroblastic foci (FF) represent the leading edge of fibrotic destruction of the lung. Currently there are three major hypotheses for how FF are generated: (1) from resident fibroblasts, (2) from bone marrow-derived progenitors of fibroblasts, and (3) from alveolar epithelial cells that have undergone epithelial-mesenchymal transition (EMT). We found that FF dissociated capillary vessels from the alveolar epithelia, the basement membranes of which are fused in normal physiological conditions, and pushed the capillaries and elastic fibers down ~100 µm below the alveolar epithelia. Furthermore, the alveolar epithelial cells covering the FF exhibited a partial EMT phenotype. In addition, normal human alveolar epithelial cells in vitro underwent dynamic EMT in response to transforming growth factor-ß signaling within 72 h. Because it seems that resident fibroblasts or bone marrow-derived cells cannot easily infiltrate and form FF between the alveolar epithelia and capillaries in tight contact with each other, FF are more likely to be derived from the epithelial-to-mesenchymal transitioned alveolar epithelia located over them. Moreover, histology and immunohistochemistry suggested that the FF formed in the lung parenchyma disrupt blood flow to the alveolar septa, thus destroying them. Consequently, collapse of the alveolar septa is likely to be the first step toward honeycombing in the lung during late stage IPF. On the basis of these findings, inhibition of transforming growth factor-ß signaling, which can suppress EMT of the alveolar epithelial cells in vitro, is a potential strategy for treating IPF.

[Pulmonary Carcinoid Tumor with Cushing's Syndrome in a Patient who Underwent Pulmonary Resection by Video-Assisted Thoracic Surgery;Report of a Case].

Pulmonary carcinoid tumor with Cushing's syndrome is comparatively rare disease. It is difficult to make an early diagnosis due to small size lesion in its early stage. We report a case of pulmonary carcinoid tumor with Cushing's syndrome successfully localised by positron emission tomography/computed tomography and was resected in the early stage. The levels of serum cortisol and adrenocorticotropic hormone( ACTH) decreased immediately after surgery, and the symptoms of Cushing's syndrome were relieved.

Spontaneous thymic hemorrhage in an adult.

Spontaneous thymic hemorrhage in a normal thymus in neonates and infants has been reported in the literature. Only one case of spontaneous thymic hemorrhage in an adult has been reported to our knowledge. We herein report the case of an adult who had a cardiac operation 26 years previously and who was on anticoagulation. He experienced acute hemorrhage in a normal thymus, and this was not thought to be attributable to an accidental cause such as trauma or to hypertension.

[Evaluation of long-term results in patients who underwent reconstruction of thoracic wall with curved metal plates].

Between 1992 and 2011, 22 patients underwent surgery of reconstruction of thoracic wall with curved metal plates for multiple rib fracture and resection of thoracic wall tumor. They were divided into 2 groups according to original disorders. Twelve cases of group A accepted surgical stabilization of traumatic multiple rib fractures with the metal plates fixed on the fractured ribs as an external brace. Ten patients of group B were suffered from thoracic wall tumors, including 1 fibrous dysplagia, 1 chondroma, 5 invasive lung cancer, 2 rib metastases and 1 primary chest wall cancer. After the resection of tumors, an average of 3.2 ribs were removed, the defects of full thickness chest wall were reconstructed using a combination of a polypropylene mesh and the metal plates. In both groups, there were no displacement of the plates and allergic reaction. Only 2 patients needed removal of the fixed plates due to pyothorax caused by pneumonia after crushing thoracic injuries. The long metal reconstruction plates with many perforations were very useful for reconstruction of chest wall because they were long enough to cover the whole length of widely resected chest defects and moderately soft enough to be appropriately bent or twist by hand at the time of operation. Moreover long-term result of the reconstructed chest wall was safe and satisfactory without severe complication.

[Henoch-Schönlein Purpura with lung abscess].

A 72-year-old man had underwent left lower lobectomy for squamous cell carcinoma in our hospital in 2008. Postoperative stage was I A (T1N0M0). In 2010, follow-up chest computed tomography (CT) images showed similar cavitary nodules in segments 2 and 8 of the right lung with positive uptake on fluorodeoxyglucose-positron emission tomography (FDG-PET) images. Physical examination, blood tests, and levels of serum tumor markers showed no abnormality. Transbronchial lung biopsy revealed the absence of malignant cells. Segment 8 of the right lower lobe with the nodule was partially resected, and pathological examination demonstrated lung abscess. He was discharged but was hospitalized in another hospital for purpuric rash, fever, and arthralgia. Microscopic albuminuria was noted, and renal biopsy revealed nephritis with immunoglobulin A( IgA)deposition. He was made a diagnosis of Henoch-Schönlein purpura. Oral steroid therapy( prednisolone 60 mg/d) was initiated, resulting in the improvement of symptoms and disapearance of the cavitary nodule in the right lung segment 2.