A case of diaphragmatic hemangioma completely resected by partial diaphragmatic resection.

Diaphragmatic hemangiomas are rare tumors and the preferred resection range in surgical procedures is considered on a case-by-case basis. We report a case of diaphragmatic hemangioma that was completely resected by partial diaphragmatic resection. An 81-year-old man was referred for the examination of right diaphragmatic mass. Computed tomography revealed two contrast-enhanced nodules (diameter: 17 and 10 mm, respectively) on the right diaphragm. The nodules were completely resected by partial resection of the diaphragm via video-assisted thoracic surgery using an ultrasonic coagulation and incision device. Resection was performed leaving part of the muscular layer of the diaphragm. Histopathology confirmed the nodule to be hemangioma originating from the diaphragm and no hemangiomatous lesions were noted in the normal connective tissue in the resected stump. Partial diaphragmatic resection is a less invasive treatment method and may be a useful surgical procedure for diaphragmatic hemangioma.

A case of spontaneous hemopneumothorax in which the condition worsened after chest drainage.

A 45-year-old woman was referred to our hospital with sudden chest pain. She came on foot with normal vital signs. Computed tomography (CT) revealed right mild pneumothorax with niveau level. We suspected spontaneous hemopneumothorax (SHP) and inserted a thoracic drain. After 800 ml of blood and air was evacuated immediately, the outflow from the drain stopped. However, despite the outflow of blood from the drainage tube having stopped, she developed hemorrhage shock 2 h after drainage. Contrast-enhanced CT revealed extra-vascular signs at the top of the right pleural cavity. Emergency video-assisted thoracic surgery (VATS) was performed. We identified the chest drain as being obstructed by blood clot. Continuous bleeding from a small aberrant vessel at the top of the thoracic cavity was identified, and we stanched it easily by clipping. The present experience suggests that routine enhanced CT and aggressive emergent VATS should be performed in cases of SHP.

Prognostic Significance of a Tumor Marker Index Based on Preoperative Serum Carcinoembryonic Antigen and Krebs von den Lungen-6 Levels in Non-Small Cell Lung Cancer

Background: We retrospectively analysed the prognostic significance of a tumor marker index (TMI) based on preoperative serum carcinoembryonic antigen (CEA) and Krebs von den Lungen-6 (KL-6) levels in nonsmall cell lung cancer (NSCLC) patients. Materials and Methods: We enrolled 176 NSCLC patients who had preoperative serum CEA and KL-6 level measurements and had undergone curative surgery between 2009 and 2011. Results: The 5-year disease-specific survival of patients with high serum CEA levels was significantly poorer compared with that of patients with normal levels. The value for patients with high serum KL-6 levels was also poor. Patients with both normal serum CEA and KL-6 levels had a favourable prognosis, whereas those with both high serum CEA and KL-6 levels had a poor outcome. The5-year disease-specific survival rate was 82.9% for patients in the low TMI group compared to 47.5% in the high TMI group (p<0.01). Both univariate and multivariate analyses revealed prognostic significance for TMI. Conclusions: TMI based on preoperative serum CEA and KL-6 levels might be useful for the prediction of the prognosis of NSCLC patients.

Port-site implantation of Type A Masaoka Stage I thymoma after video-assisted thoracic surgery: a case report.

A 60-year-old woman was referred to our hospital with an anterior mediastinal tumor measuring 3.5 cm in diameter on computed tomography (CT). We performed tumor resection by video-assisted thoracic surgery (VATS) with three ports. The final diagnosis was Type A Masaoka Stage I thymoma. On follow-up CT performed 36 months after the operation, two pleural tumors were detected at the port sites through which the forceps and ultrasonic scalpel had passed repeatedly during the operation. We therefore performed a second operation and enucleated the tumors while preserving the ribs. However, other tumor tissue was detected along the surgical marginal line during the pathological diagnosis after the operation. Surgeons should thus be aware that port-site recurrence can occur after VATS resection of Type A thymoma, despite its mild biological behavior. Wide resection of the chest wall is therefore recommended for operations of port-site recurrence after VATS thymectomy.

Prognostic significance of preoperative serum Krebs von den Lungen-6 level in non-small cell lung cancer.

OBJECTIVES: We retrospectively analyzed the prognostic significance of preoperative serum Krebs von den Lungen-6 (KL-6) level in non-small cell lung cancer (NSCLC) patients. METHODS: We enrolled 175 NSCLC patients who underwent curative surgery between 2009 and 2011. We subdivided the patients into 2 groups: with and without interstitial lung disease (ILD). Prognostic significance of serum KL-6 level was examined. RESULTS: The 5-year survival of patients with high serum KL-6 level was poor. Multivariate analysis also revealed the prognostic significance of serum KL-6 level. Serum KL-6 level was also a prognostic factor for patients without ILD. Although the number of patients with ILD was small, in patients with ILD, there was a trend towards an association between serum KL-6 level and patients' prognosis but this did not reach statistical significance. CONCLUSIONS: Serum KL-6 level is a prognostic factor for resected NSCLC patients, especially patients without ILD. There is a possibility that serum KL-6 level is a prognostic marker regardless of the presence of ILD.

Simultaneous bilateral decortications via video-assisted thoracic surgery for bilateral empyema.

INTRODUCTION: Bilateral empyema is a rare and life-threatening condition that is difficult to treat. We herein report a case of bilateral empyema that was treated with simultaneous bilateral decortications via video-assisted thoracic surgery (VATS). PRESENTATION OF CASE: A 38-year-old female complained of chest pain, dyspnea, and high grade fever lasting two weeks. Computed tomography revealed bilateral notching pleural effusion and pneumonia with atelectasis. Bilateral thoracic drainage was performed. From the right chest, white pus was drained, and Streptococcus anginosus was identified. The left drainage fluid was serous, and no bacteria were identified. We diagnosed the patient with right empyema and left para-pneumonic effusion consequent to pneumonia. Because conservative therapies could not resolve the inflammatory findings, simultaneous bilateral VATS decortications were performed. Both thoracic cavities had loculated pleural effusion. In contrast to the preoperative findings, white pus was found in not only the right, but also the left thoracic cavity. She had an uncomplicated postoperative course and recovered. DISCUSSION: Bilateral empyema that has developed to the fibrinopleural phase is difficult to treat with drains alone. Bilateral VATS decortications helped to make a definitive diagnosis and treat both sides simultaneously. CONCLUSION: Simultaneous bilateral VATS decortications should be considered as a feasible and effective procedure for bilateral empyema that is refractory to medical treatment.

The diagnosis of primary cardiac lymphoma was facilitated by computed tomographic coronary angiography.

Primary cardiac lymphoma (PCL) is a rare entity that leads to fatal symptoms such as serious arrhythmia. The present case was an 80-year-old female with severe dyspnea caused by 30 bpm bradycardia. Computed tomography revealed a tumor invading to the right inferior myocardium. A computed tomographic coronary angiography (CTCA) study revealed the right coronary artery penetrating the tumor with no invasion by the surrounding tumor. Because a percutaneous biopsy was unsuccessful, video-assisted thoracic surgery (VATS) was performed. The final pathological diagnosis was diffuse large B cell lymphoma. Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) chemotherapy reduced the size of the tumor, and the symptoms thereafter improved. An observation of the coronary artery penetrating the tumor without tumor invasion may be a characteristic finding of PCL. CTCA is useful to detect this finding. When a percutaneous biopsy is unavailable, VATS should be considered as a minimally invasive procedure to obtain a reliable diagnosis of PCL.

Subglottic granuloma after aortic replacement: resection via flexible bronchoscopy after an emergency tracheostomy.

A subglottic granuloma is one of the late-phase complications that can occur after intubation. It can cause a life-threatening airway obstruction; therefore, a rapid diagnosis and appropriate treatment plan is necessary. A 62-year-old male had undergone an emergency total arch replacement for acute aortic dissection. Postoperative ventilation support had been performed until the 15th postoperative day (POD). He was discharged from the hospital on POD 30. On POD 50, he was brought to our hospital by an ambulance with severe dyspnea. A large subglottic granuloma occupying the trachea was identified by flexible bronchoscopy. After an emergency tracheostomy, resection of the granuloma with argon plasma coagulation via flexible bronchoscopy was performed safely. Physicians should suspect a post-intubation subglottic granuloma when patients who have undergone intubation report feeling throat discomfort. Resection via flexible bronchoscopy after tracheostomy is a safe and feasible procedure that may shorten the duration of therapy and hospital stay.

Pulmonary dirofilariasis in a 59-year-old man.

We present a case of a human pulmonary dirofilariasis in a 59-year-old man. At the medical examination, a chest computed tomography (CT) revealed a mass, measuring 18 × 15 mm in diameter, with an irregular margin on the bottom of the right lower lobe. We could not neglect the possibility of a primary lung cancer, and therefore, a lung partial resection was performed under video-assisted thoracoscopic surgery. The intra-operative pathological findings revealed inflammatory granuloma with coagulation necrosis and no malignant cells. The permanent pathological examination showed occlusion of the peripheral pulmonary artery by worms and formation of a necrotic mass surrounded by reactive inflammation and hemorrhage. Human pulmonary dirofilariasis is an extremely rare zoonotic infection, and sometimes it is difficult to distinguish it from a primary lung cancer on radiographic findings.

Saccular aortic aneurysm that resembled a mediastinal neoplasm.

INTRODUCTION: Saccular aortic arch aneurysms in unusual sites may be misdiagnosed as a neoplasm. We present the case of a rare saccular aortic arch aneurysm between trachea and esophagus that resembled a mediastinal neoplasm in the preoperative findings. PRESENTATION OF CASE: A 63-year-old male with an abnormal mediastinal shadow on chest X-ray was referred to the hospital. An axial plain computed tomogram of the chest revealed mediastinal soft tissue next to the right side of the aortic arch resembling a neoplasm originating from the gap between the trachea and the esophagus. The coronal view constructed by enhanced 64-row multi detector computed tomography revealed the soft tissue was an aneurysm arising from the inner side of the aortic arch. An aortic arch replacement was performed via a median sternotomy. DISCUSSION: A thoracic aortic aneurysm sometimes behaves like a mediastinal neoplasm. The multiple cross-sectional image from multidetector computed tomography was useful for the correct diagnosis of such an aneurysm. CONCLUSION: The possibility of an aneurysm should be considered whenever a mass in contact with the aortic wall is identified.

[Chest wall reconstruction with rectus abdominis musculocutaneous flap for sternum osteomyelitis after radiation].

We report a case of reconstruction of radiation ulcer on the chest wall and sternum osteomyelitis using a rectus abdominis musculocutaneous flap. A case of 67-year-old woman, Halsted operation was performed for right breast cancer, 23 years ago. After 4 years, transcatheter arterial injection and radiation therapy was performed to treat recurrence of parasternal lymph nodes. Since then, she had been without recurrence of the tumor, but suffered from repeated scabbing of parasternal skin. In 2009, she suffered from pain, redness and purulent discharge of the wound, and diagnosed with sternum osteomyelitis. She was admitted to our hospital and underwent debridement of sternum, and the resection of surrounding skin. Sixteen days later, reconstruction using a rectus abdominis musculocutaneous flap was performed. Twenty months after the operation, she is well without any evidence of recurrence.

Detection of EGFR and K-ras mutations for diagnosis of multiple lung adenocarcinomas.

The incidence of multiple primary lung adenocarcinoma (MPLA) is increasing, and it is important to distinguish MPLA from intrapulmonary metastasis (IPM) in order to determine the therapeutic strategy. However, there is no reliable method to differentiate between the two. The purpose of this study was to distinguish MPLA from IPM based on the gene status of EGFR and K-ras and the morphological Noguchi classification system. Sixty-eight tumors from 34 cases of clinical MPLA were evaluated. Of them, 11 cases (32.4%) were diagnosed as biological MPLA (bMPLA) by EGFR/K-ras mutation analyses, and 12 cases (35.3%) by morphological analysis. In all, 23 of the 34 cases (67.6%) were diagnosed as bMPLA. The remaining 11 cases were diagnosed as biological IPM (bIPM). The 5-year survival rates of bMPLA and bIPM were 90.9% and 63.6%, respectively (p=0.04). These findings suggest that the combination method including gene mutation and morphological analysis can guide treatment decisions and that there is a need for systemic chemotherapy, and surveillance monitoring.

Expression of estrogen receptor beta predicts a clinical response and longer progression-free survival after treatment with EGFR-TKI for adenocarcinoma of the lung.

PURPOSE: Epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (EGFR-TKI) demonstrates a dramatic clinical response for the lung adenocarcinoma patients harboring a somatic mutation of EGFR. Such EGFR mutations are frequently found in adenocarcinoma with a strong expression of estrogen receptor (ER) beta, which has been shown to correlate with a favorable prognosis for the patients with EGFR mutations. The aim of this study is to elucidate the correlation between expression of ER beta and the therapeutic effect of EGFR-TKI in adenocarcinoma of the lung. PATIENTS AND METHODS: Forty-three patients who were treated with EGFR-TKI for adenocarcinoma of the lung were evaluated. The expression of ER beta and the EGFR mutation were evaluated by immunohistochemistry and the polymerase chain reaction, respectively. Patients divided into two groups by the nuclear expression of ER beta. The clinical response and survival data were compared between the two groups. RESULT: Strong (S) and weak (W) expression of ER beta was observed in 21 and 22 patients, respectively. EGFR mutations were detected in 30 (69.8%) cases. The S group had more frequent EGFR mutations than the W group (85.7%, 54.5%, p=0.045). The S group had better response rate (p=0.006) and longer progression-free survival (PFS; p=0.001) than the W group. Even in a limited analysis in the patients with EGFR mutations, the S group had tended to have a better response rate (77.8%, 41.7%, p=0.063), and significant longer PFS (p=0.012) than the W group. CONCLUSION: A strong expression of ER beta predicts a good clinical outcome for patients with adenocarcinoma of the lung after treatment with EGFR-TKI. This suggests that the expression status of ER beta can be a candidate surrogate marker for EGFR-TKI treatment of patients with adenocarcinoma of the lung. Further investigation will be necessary to identify biomarkers using a larger cohort of patients in a prospective study.

[Long-term survival after surgical resection of bone metastasis from lung cancer].

BACKGROUND: The prognosis of patients with bone metastasis from primary lung cancer is poor, and the effective treatment for bone metastasis had not been established. We report a case of more than 6 years survival after a surgical resection of rib metastasis. CASE: A 56-years-old woman underwent right lower lobectomy and mediastinal lymph node dissection for lung cancer (well differentiated adenocarcinoma, pT1N0M0, stage IA) in another hospital in July 1995. In May 2003, the patient suffered right lateral chest pain and the chest computed tomography (CT) showed an osteolytic mass of right 5th rib. Percutaneous ultrasound-guided fine-needle aspiration cytology revealed adenocarcinoma and the tumor was diagnosed as bone metastasis from primary lung cancer. A chest wall resection for bone metastasis of right 5th rib was carried out and she underwent adjuvant chemotherapy. She is presently alive and well without recurrence more than 6 years after chest wall resection. CONCLUSION: A resection of bone metastasis from lung cancer may offer the possibility of a long-term survival in selected patients.

Acquired resistance to gefitinib: the contribution of mechanisms other than the T790M, MET, and HGF status.

BACKGROUND: Some types of somatic mutation of the epidermal growth factor receptor (EGFR) gene in non-small cell lung cancer (NSCLC) are associated with a significant clinical response to a tyrosine kinase inhibitor (TKI). However, most of the patients with this type of sensitive mutations in their tumor show acquired resistance during the TKI treatment. METHODS: The mutations in exons 19-21 of the EGFR gene were examined in both the pre-treatment and the post-treatment gefitinib resistant tumors in 10 patients with lung adenocarcinoma. Eight patients were recurrent cases after surgery, and two patients were non-surgical cases whose tumor specimens were obtained from the metastatic lymph node and endobronchially invading tumor. RESULTS: In 10 patients, 5 patients had a deletion in exon 19 and another 5 did L858R mutation in exon 21 of EGFR in gefitinib pre-treatment tumors. The mutation status did not change in the gefitinib-resistant tumors. In 7 of 10 patients, the gefitinib-resistant tumors had a secondary T790M mutation, which was not detected in the gefitinib pre-treatment tumors. In one patient, only one of the 4 gefitinib-resistant tumors showed the T790M mutation. Neither other novel secondary mutations of EGFR nor the K-ras were observed in their gefitinib-resistant tumors. Neither MET gene amplification nor HGF were observed in their gefitinib-resistant tumors without T790M mutation. CONCLUSIONS: The T790M mutation in the EGFR is relatively common in the patients with acquired resistance to gefitinib. However, mechanisms other than T790M, MET, and HGF status are involved in resistance to gefitinib.

Gefitinib and a ventriculo-peritoneal shunt to manage carcinomatous meningitis from non-small-cell lung cancer: report of two cases.

The prognosis of patients with carcinomatous meningitis from non-small-cell lung cancer (NSCLC) remains poor, and the available treatment options for the lung cancer do not relieve the severe symptoms of this sequela. We report the successful treatment of two cases of carcinomatous meningitis caused by NSCLC, using gefitinib and a ventriculo-peritoneal (V-P) shunt. The first patient was a 43-year-old woman with pT1N0M0 adenocarcinoma. Multiple brain and vertebral metastases were found 13 months after surgery. She had undergone gamma-knife radiosurgery for the brain metastases, radiotherapy for the vertebral metastases, and two regimens of systemic chemotherapy, before carcinomatous meningitis was diagnosed. She was given gefitinib, and then a V-P shunt was placed. She continued to take gefitinib and was free of subjected symptoms for 5 months until she died. The second patient was a 64-year-old woman with cT4N0M0 adenocarcinoma. After local chemotherapy using cisplatin and OK-432 for carcinomatosis pleuritis and two regimens of systemic chemotherapy, carcinomatous meningitis was detected. A V-P shunt was placed, and she was sequentially given gefitinib. At her 15-month follow-up, she was free of symptoms of carcinomatous meningitis. No adverse effects or shunt problems were detected in either patient. This therapeutic modality may liberate carcinomatous meningitis patients with severe symptoms from hospitalization and improve their quality of life.

Association between estrogen receptor-beta expression and epidermal growth factor receptor mutation in the postoperative prognosis of adenocarcinoma of the lung.

PURPOSE: Adenocarcinoma of the lung unrelated to a smoking habit occurs more frequently in women than men, thus suggesting an association between female hormones and development of these tumors. The aim of this study was to elucidate the correlation between expression of estrogen receptor (ER) and clinicopathologic factors, including a mutation in the tyrosine kinase domain of epidermal growth factor receptor (EGFR), and prognosis in adenocarcinoma of the lung. PATIENTS AND METHODS: This study evaluated 447 resected primary lung adenocarcinoma specimens. The expression of ERalpha and ERbeta was evaluated with an immunohistochemical method. The EGFR mutation was evaluated with polymerase chain reaction. RESULTS: A strong cytoplasmic expression of ERalpha and nuclear expression of ERbeta were detected in 49.4% and 48.5% of all patients, respectively. A strong nuclear expression of ERbeta was independently associated with the EGFR mutations (odds ratio = 2.947; 95% CI, 1.97 to 4.57; P < .001) and good differentiation (odds ratio = 1.84; 95% CI, 1.21 to 2.80; P = .004) and was correlated with an increasing disease-free survival in patients with EGFR mutations (hazard ratio = 2.18; 95% CI, 1.18 to 4.06; P = .014). However, no prognostic significance was identified in patients without EGFR mutations. No clinicopathologic and/or prognostic significance of a strong expression of cytoplasmic ERalpha was found. CONCLUSION: A strong nuclear expression of ERbeta correlates with EGFR mutations, and its favorable prognostic significance was influenced by the EGFR mutations in adenocarcinoma of the lung.

Expression of cytochrome P450 in non-small cell lung cancer.

Lung cancer accounts for most of cancer-related deaths in both men and women. Lung cancer is also associated with cigarette smoking that exposes the individual to carcinogenic chemicals. Normally, CYP enzymes (cytochrome P450s) metabolize carcinogens to inactive derivatives, however, occasionally the action of CYP enzymes leads to development of more potent carcinogens. In addition to the metabolism of carcinogenic compounds, CYP enzymes are also involved in the activation and/or inactivation of agents, which are used in the treatment of lung cancer. Therefore, the local level of CYP enzymes in lung cancer and surrounding tissues could be an important determinant in the efficacy of anticancer drugs. Furthermore, the expression of CYP19 (aromatase), estrogen synthesis P450, was found in more than 80 percent of non-small cell lung cancers. Lung cancer was also found to frequently express CYP24A1 that converts 1 alpha, 25-dihydroxyvitamin D3 to its inactive 24-hydroxylated derivatives. The understanding of the local expression of CYP enzymes in tumor tissues is important in the development of better treatment for lung cancer and a standardized treatment, tailor-made, for individual patients.

Successful treatment of sclerosing mediastinitis with a high serum IgG4 level.

Sclerosing mediastinitis is not a common condition in the thoracic cavity and is difficult to cure. Several medications have been used; however, most of the cases do not achieve satisfactory results, and the most successful treatment is operative resection. We report the first case of IgG4-related sclerosing mediastinitis that showed IgG4-positive plasma cells infiltrated into the fibrous tissue and a high serum IgG4 level. The patient clearly showed remission of the symptoms after steroid therapy. Our findings suggest that the serum IgG4 level is a good selection indicator for steroid therapy in sclerosing mediastinitis.

Leiomyoma originating from the extrapleural tissue of the chest wall.

We describe a rare case of leiomyoma of the chest wall in a 55-year-old female. Computed tomography showed a well-circumscribed neoplasm with a diameter of 2 cm in the right chest wall. The tumor was excised with video-assisted thoracic surgery. Histopathology confirmed that the tumor was leiomyoma arising from the microvascular smooth muscle in the chest wall. We present the immunohistochemical profiles of the tumor in detail, critically reviewing the previously reported cases.