A case of renal cell carcinoma with microscopic pulmonary tumor embolism proven by surgical lung biopsy.

Pulmonary tumor embolism (PTE) is difficult to diagnose before death. We report the case of a 75-year-old man with microscopic PTE of renal cell carcinoma who was diagnosed by surgical lung biopsy. He visited our hospital because of dyspnea on exertion. Chest computed tomography (CT) showed multiple micronodules and ground glass opacities. Steroid therapy was started as therapeutic diagnosis for IgG4-related pulmonary disease. However, he was admitted our hospital due to progressive respiratory failure. Pathological findings of a lung biopsy obtained by video-assisted thoracic surgery showed PTE of renal cell carcinoma without embolization of large pulmonary arteries. He received palliative medicine and died four months after the surgical lung biopsy. In cases of multiple micronodules in chest CT findings and worsened respiratory symptoms, PTE should be considered in the differential diagnosis.

A case of bilateral uveitis associated with seminoma/germinoma in thymus and pineal glands, two primary lesions.

Purpose: To report a case of bilateral ocular paraneoplastic syndrome by seminoma/germinoma in thymus and pineal glands, two primary lesions. Observations: A 18-year-old male presented at a local clinic complaining of just floaters in left eye without any other clinical signs and symptoms. The treating ophthalmologist found bilateral uveitis, and referred to our hospital. Bilateral retinal periphlebitis and optic disc swelling were shown. Vitreous opacity was found in left eye. We started ocular and systemic examinations to identify the cause of the uveitis, and also initiated oral steroid therapy. The survey using aqueous humor and blood samples showed no specific results for his uveitis. Computer tomography (CT) and magnetic resonance imaging (MRI) detected tumors in thymus and pineal glands. Five months after his first visit, the tumor in his thymus was resected, and was diagnosed as a seminoma/germinoma by pathological examination. Three months later, the tumor in the pineal gland was diagnosed as a germinoma by biopsy followed by chemotherapy and focal radiotherapy. Finally no abnormal ocular finding but slight optic disc atrophy was ascertained. Conclusions and importance: This is a case of ocular paraneoplastic syndrome induced by seminoma/germinoma in thymus and pineal glands, two primary lesions. Systemic screening by CT and MRI enables prompt diagnosis, treatment and favorable clinical course for such pathogenesis.

A case of thymoma-associated multiorgan autoimmunity including polymyositis and myocarditis.

BACKGROUND: Polymyositis and myocarditis associated with thymoma are exceptionally rare conditions and usually accompanied by myasthenia gravis (MG) and have been recognized as critical conditions. Thymoma-associated multiorgan autoimmunity was reported recently with skin, liver, and intestinal manifestations similar to those seen in graft-versus-host disease. CASE PRESENTATION: A 77-year-old female presented to our department with exacerbation of ptosis and local recurrence of thymoma. Chest computed tomography revealed local recurrence of thymoma. Following 6 month observation, erythema on the extremities and body trunk suddenly appeared. Afterwards, the patient developed progressive muscle weakness and fatigue. We diagnosed as myocarditis and polymyositis. She was transferred to the intensive-care unit and received artificial ventilation. Steroid pulse therapy was induced immediately. The blood test findings were markedly improved, but the symptoms of MG and weakness of the muscles persisted. Various treatment including eculizumab was induced, and the symptoms of MG and weakness of the muscles were improved. On the 136th day of hospitalization, she was discharged. CONCLUSION: We were able to cure this patient, as we were able to start treatment immediately after the appearance of severe symptoms. An early diagnosis and treatment are important for curing such patients.

Surgical site infection at chest tube drainage site following pulmonary resection for malignant lesions.

BACKGROUND: We sometimes experience postoperative surgical site infection (SSI) at the chest tube drainage site (CDS) after thoracotomy. The incidence of and risk factors for SSI at the CDS have remained unclear. METHODS: We conducted a prospective study to determine the incidence and risk factors for SSI at the CDS. We analyzed 99 patients who underwent lobectomy or segmentectomy for pulmonary malignant lesions. RESULTS: There were 56 males and 43 females with an average age of 71 years. The postoperative drainage period was 2-15 days. Bacterial species were detected in secretions in 18 of 99 cases (18.2%). Older age was a risk factor for the detection of bacteria at the timing of chest tube removal. Eighteen cases (18.2%) were diagnosed with presence of SSI at the CDS at the timing of staple or suture removal. A pathological diagnosis of squamous cell carcinoma was regarded as a candidate risk factor for SSI. Eleven of 18 SSI patients showed delayed wound healing. A higher level of HbA1c was found in patients with delayed wound healing. Enterococcus faecalis infection may influence the development of complex SSI. CONCLUSIONS: We identified the bacterial profiles, incidence of and risk factors for SSI at the CDS. More intense preoperative glycemic control and an understanding of the bacterial profile and may be useful for reducing the incidence of SSI chest tube drainage sites (CDS).

Distribution of descending necrotizing mediastinitis and efficacy of distribution-specific drainage.

BACKGROUND: Descending necrotizing mediastinitis (DNM) resulting from oropharyngeal and cervical abscess is a life-threatening condition. This study attempted to improve our recognition of the extension and distribution of the abscess for ideal thoracic drainage. METHODS: We performed a retrospective clinical analysis of seven patients who underwent thoracic drainage for DNM with available clinical data. For mapping and classification of the distribution of the abscess, computed tomography and intraoperative findings were utilized. RESULTS: To cure patients, cervical drainage and thoracic drainage were performed 14 and 11 times, respectively. The operation time for thoracic drainage and intraoperative blood loss were 141±77 min and 103±103 g, respectively. The mean hospital stay was 66±41 days. All patients are alive without recurrence. We divided the abscess distribution into nine categories including the anterior thoracic wall, according to the computed tomography and intraoperative findings. The rate of abscess descended gradually toward the lower mediastinum. Abscesses were not necessarily continuous, and skipped lesions were occasionally noted. CONCLUSIONS: We were able to cure all seven patients with DNM. It might be helpful to recognize the exact distribution of the abscess and distribution-specific drainage using a new map and classification of thoracic abscess.

[Transition from Uniportal to Robot-assisted Surgery for Trans-subxiphoid Thymectomy;Merit and Demerit of Reduce Port Surgery].

The subxiphoid approach is useful in thymectomy, and its disadvantages can be ameliorated by the robot-assisted surgery( RAS). It was suggested that the increase in the number of ports due to RAS in the thymectomy with the trans-subxiphoid approach( RTts) would not be a disadvantage in any aspect other than cosmetology. RAS offers surgeons various technical advantages in thymectomy, however these are difficult to quantify. Therefore, it is difficult to objectively show the merits corresponding to expensive devices. It is necessary to conduct new clinical tests and collect data showing the superiority of RTts.

CCR4 Expression in Tumor-Infiltrating Regulatory T Cells in Patients with Squamous Cell Carcinoma of the Lung: A Prognostic Factor for Relapse and Survival.

To clarify the prognostic impact of tumor-infiltrating effector regulatory T cells (eTregs) in non-small cell lung cancer (NSCLC), eTregs were evaluated by immunohistochemical detection of CCR4 and Foxp3 in 108 consecutive surgical NSCLC tumors. Multivariate analysis showed that a high ratio of CCR4+ eTregs to total Tregs (≥40%) was the only independent risk factor for relapse-free survival (odds ratio [OR]: 6.54, 95% confidence interval: 1.67-25.7, p = .007) and overall survival (OR: 3.76, p = .037) in lung squamous cell carcinoma (SqCC). These results highlight the prognostic importance of the balance of tumor-infiltrating Tregs in resected lung SqCC.

Thoracoscopic Thymectomy for Large Thymic Cyst: Myasthenia Gravis With Thymoma Concealed by Thymic Cyst.

We herein report a case of myasthenia gravis (MG) in which thoracoscopic thymectomy was performed for a large thymic cystic lesion using a subxiphoid approach. We have previously suggested the usefulness of the subxiphoid approach in thymectomy. The indications of thoracoscopic thymectomy were recently expanded to include large thymic cystic lesions without intraoperative rupture of the lesions. The pathologic diagnosis of the lesion in the present case was multilocular thymic cyst with type A thymoma and micronodular thymoma. The postoperative complications were minimal without MG crisis. Thoracoscopic thymectomy using a subxiphoid approach seems to be an ideal procedure, even for large thymic cystic lesions. In addition, early-onset MG with a large thymic cystic lesion may suggest the presence of a small thymoma even if the lesion is not detected on a preoperative radiologic examination.

Reoperation for postoperative bleeding following pulmonary resection: a report of a single-center experience.

OBJECTIVE: The variety and incidence of postoperative complications seem to have changed with recent progress in thoracic surgery. This study attempted to improve our recognition of postoperative bleeding. METHODS: Among 1143 patients undergoing pulmonary resection for pulmonary nodules, ten underwent surgical treatment for postoperative bleeding. Clinical and pathologic data were analyzed. Additionally, the relationship between the bleeding point and an increased amount of drained bloody effusion before the second operation was analyzed. RESULTS: The bleeding point was recognized in eight cases: the intercostal artery (n = 4), the lung (n = 2), aberrant vessel of the apex of the lung (n = 1) and the bronchial artery (n = 1). The bleeding points were unknown in two cases in whom the decision to perform a second operation was delayed. Potential reasons or influential factors for bleeding were stapling complications (n = 4), low coagulation ability (n = 2) and intraoperative injury (n = 1). We experienced two cases in which intercostal arterial bleeding was induced by scratching the thoracic wall or the vertebra with the edge of the reinforced stapling line or the sharp edge of a broken staple at the first operation. We divided patients into three groups based on the interval between operations. Bleeding from the arteries seemed to show a higher rate of bleeding per hour than that from the lung parenchyma. CONCLUSION: The bleeding points and speculated reasons for bleeding varied among patients. We were able to cure all ten cases. It might be dependent on the rapid decision of reoperation in cases with arterial bleeding was suspected.

Nine cases of catamenial pneumothorax: a report of a single-center experience.

BACKGROUND: Catamenial pneumothorax (CP) is defined as repeated pneumothorax related to menses and thoracic endometriosis. We performed a retrospective analysis of nine patients with CP to determine the clinical features as well as the effects of treatment and recurrence rates. METHODS: A retrospective review was conducted of the clinical and pathologic data in all CP patients undergoing treatment at our institution. Nine patients underwent treatment for CP. Of these, six underwent surgical treatment 8 times. RESULTS: The median age was 36 years. Six patients had experienced delivery. The laterality of the pneumothorax was right in all patients. Pelvic endometriosis was diagnosed in five patients. Six patients underwent surgical treatment. Partial resection of the lung was performed in four patients and partial resection of the diaphragm in five. Of these, both resections were performed in four patients. A pathological diagnosis of endometriosis was achieved in only three patients. The observation period was 16.7 months. In the six patients with surgical resection, five experienced recurrence at various intervals. Onset of pneumothorax occurred pre- or menstrual period in most cases. CONCLUSIONS: The diagnosis and treatment of CP is not easy. A multidisciplinary approach and skillful management are required. Recurrence of CP is common following a temporary cure of pneumothorax by surgical treatment.

Thoracoscopic Thymectomy Using a Subxiphoid Approach for Anterior Mediastinal Tumors.

PURPOSE: Video-assisted thoracic surgery (VATS) techniques have been widely used for resection of mediastinal tumors. This study investigated the usefulness of the subxiphoid approach in thoracoscopic thymectomy. METHODS: In all, 36 patients with anterior mediastinal tumor underwent thymectomy using the subxiphoid approach in two Japanese institutions. These patients were retrospectively reviewed and analyzed. RESULTS: There were 16 females and 20 males with a mean age of 57 years. Five patients underwent partial thymectomy (PT), 27 underwent total or subtotal thymectomy, and 4 underwent thymectomy with combined resection (CR) of the surrounding organs or tissues. The mean maximum tumor diameter, amount of resected tissue, and blood loss were 4.1 cm, 72.5 g, and 20.6 g, respectively. More than half of tumors were diagnosed as thymoma (n = 19). The operation time was prolonged with a greater volume of thymectomy. The duration of chest tube drainage and postoperative stay were 1.7 ± 1.0 days and 5.9 ± 7.6 days, respectively. Four patients suffered intraoperative and postoperative complications, as follows: bleeding of the innominate vein, bleeding of the internal thoracic vein, crisis of myasthenia gravis (MG), pericarditis, and phrenic nerve paralysis. There were no mortalities after surgery. CONCLUSION: Subxiphoid thoracoscopic thymectomy might be a safe and useful approach for mediastinal tumors.

A pitfall of thoracoscopic thymectomy: a case with intraoperative and postoperative complications.

We have reported the usefulness of the subxiphoid approach in thymectomy. However, such a new operation method may have unknown complications that rarely occur. Surgeons cannot completely avoid intraoperative and postoperative complications. We report a case of intraoperative injury of the orifice of the left internal thoracic vein flowing to the left brachiocephalic vein and postoperative pericarditis following video-assisted thoracic surgery (VATS) thymectomy. The innominate vein has been considered to be the vessel that is most frequently injured especially at the orifice of the thymic veins. We also suggest that the orifice of the left internal thoracic vein is the second dangerous location that requires special care. In addition, postoperative pericarditis occurred in this patient. Pericardial drainage was necessary. No additional complications have been found in the 9 months since the operation. Though VATS thymectomy using the subxiphoid approach is a safe and less-invasive operation, intraoperative and postoperative complications were possible to be occurred.

The Subxiphoid Approach Leads to Less Invasive Thoracoscopic Thymectomy Than the Lateral Approach.

OBJECTIVE: Video-assisted thoracic surgery (VATS) is widely used in thoracic surgery. This study investigated the usefulness of the subxiphoid approach in thymectomy using VATS techniques. METHODS: Sixty operations were performed using the lateral approach (n = 46) and subxiphoid approach (n = 14). Using the lateral approach, 39 partial thymectomies (PT), 5 total or subtotal thymectomies (TT), and 2 total or subtotal thymectomies with combined resection of the surrounding organs (or tissues) (CR) were performed. Using the subxiphoid approach, 11 TT and 3 CR were performed. RESULTS: There were 33 females and 27 males, with a mean age of 55 years. The mean maximum tumor diameter was 4.0 cm. The operation time was prolonged according to the volume of thymectomy (PT: 119, TT: 234, CR: 347 min). Additionally, the intraoperative blood loss increased according to the volume of thymectomy (PT: 29, TT: 47, CR: 345 g). To compare the invasiveness of both approaches, we compared 16 TT operations. In the group using the subxiphoid approach, the operation time became shorter (158 vs. 392 min), and the blood loss decreased (5 vs. 135 g) compared with the lateral approach. Regarding laboratory data, white blood cell counts on postoperative day 1 (1POD) (8200 vs. 10,300/µl) and CRP on 1POD and 3POD (2.8 and 2.8 vs. 7.9 and 10.2 mg/dl, respectively) decreased in the subxiphoid approach compared with the lateral approach. CONCLUSIONS: The subxiphoid approach leads to a less invasive operation for anterior mediastinal tumors and extends the indications for VATS for invasive anterior mediastinal tumors.

Inhibition of NADPH oxidase 4 induces apoptosis in malignant mesothelioma: Role of reactive oxygen species.

Malignant pleural mesothelioma (MPM) is an aggressive tumor that is characterized by dysregulated growth and resistance to apoptosis. Reactive oxygen species (ROS)-generating NADPH oxidase (Nox) family enzymes have been suggested to be involved in neoplastic proliferation. Both the antioxidant N-acetylcysteine (NAC) and the inhibitor of flavoprotein-dependent oxidase, diphenylene iodonium (DPI), inhibited the cell viability of MPM cells in a dose-dependent manner. To examine whether Nox-mediated ROS generation confers antiapoptotic activity and thus a growth advantage to MPM cells, we analyzed the mRNA expression of Nox family members using quantitative RT-PCR in 7 MPM cell lines and a normal mesothelial cell line. Nox4 mRNA was expressed in all of the examined MPM cell lines, whereas little or no Nox2, Nox3 and Nox5 mRNA expression was detected. In 2 MPM cell lines, Nox4 mRNA expression was significantly higher than that in a normal mesothelial cell line. siRNAs targeting Nox4 suppressed ROS generation and cell viability in the MPM cell lines. In addition, DPI treatment and knockdown of Nox4 attenuated phosphorylation of AKT and ERK. Taken together, our results indicate that Nox4-mediated ROS, at least in part, transmit cell survival signals and their depletion leads to apoptosis, thus highlighting the Nox4-ROS-AKT signaling pathway as a potential therapeutic target for MPM treatment.

Metastatic embryonal carcinoma mimicking locally advanced non-small cell lung cancer.

A 50-year-old man with a history of smoking of 45 pack-years underwent right lower lobectomy after neoadjuvant chemoradiotherapy for locally advanced non-small cell lung cancer diagnosed on a bronchial biopsy and standard imaging examinations, including chest-abdominal contrast-enhanced computed tomography (CT) and whole-body F-18 fluorodeoxyglucose positron emission tomography/CT. Left orchiectomy was performed simultaneously to treat the slightly swollen left testis, which had remained unchanged for over five years. The thoracic tumor was proven to be in pathological complete remission and the testicular lesion was pathologically diagnosed as an embryonal carcinoma. Furthermore, a pathological reevaluation of the preoperative bronchial biopsy specimen revealed the lung tumor to be a metastatic embryonal carcinoma.

Complications of bronchial stapling in thoracic surgery.

OBJECTIVE: The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, complications of stapling are occasionally experienced. The aim of this retrospective study was to analyze complications of bronchial stapling. METHODS: A retrospective multi-institutional review was conducted by the Central Japan Lung Cancer Surgery Study Group, comprising 29 institutions. All instances of bronchial stapling in thoracic surgery were reviewed during the research period. RESULTS: Bronchial stapling was performed 2,030 times, using 36 kinds of staplers. The total number of complications related to stapling was 36 (1.8 %); 31 events occurred intraoperatively and five events occurred postoperatively. The intraoperative complications were air leakage (N = 20) and stapling failure (N = 11), which were caused by stapler-tissue thickness mismatch (N = 17), stapler defect (N = 3), tissue fragility (N = 2), and unknown reasons (N = 9). In all 31 cases, intraoperative complications were recovered intraoperatively with additional suturing, and no further complications were observed postoperatively. The postoperative complications were bronchopleural fistula (BPF) (N = 4) and bleeding from the chest wall (intercostal artery) (N = 1). The rate of BPF was 0.2 % (4 of 2,030). Two of four BPFs induced critical conditions. Postoperative bleeding was caused by the use of Duet TRS(TM). Both total complications and BPF occurred more frequently in the main bronchus than in the lobar or segmental bronchus. No relationship was seen between the incidence of complications and cartridge colors in lobar bronchial stapling. The compression types of staplers were associated with the incidence of complication. CONCLUSIONS: Intraoperative and postoperative complications of bronchial stapling were studied. Generally, bronchial stapling in recent thoracic surgery was safe, but rare postoperative complications may induce critical conditions. Knowledge of potential complications and causes of bronchial stapling may decrease the incidence of stapling complications.

Transcutaneous Electrical Nerve Stimulation on the PC-5 and PC-6 Points Alleviated Hypotension after Epidural Anaesthesia, Depending on the Stimulus Frequency.

Neuraxial blockade causes arterial hypotension. Transcutaneous electrical nerve stimulation (TENS) at the Neiguan (PC-6) and Jianshi (PC-5) reduces the severity of hypotension after spinal anaesthesia, but did not clarify the optimal stimulus frequency. We hypothesized that the stimulus frequency of TENS at the PC-6 and PC-5 points would influence the severity of hypotension after epidural anaesthesia. 65 ASA I or II male patients presenting for inguinal hernia repair were randomized to five groups: the control group received no treatment; the 2 Hz, 10 Hz, 20 Hz, and 40 Hz groups received TENS at a frequency of 2 Hz, 10 Hz, 20 Hz, and 40 Hz, respectively. The lowest SBP was significantly higher in the 40 Hz group [the control, 84 (74-110) mmHg; the 2 Hz, 96 (62-116) mmHg; the 10 Hz, 100 (68-110) mmHg; the 20 Hz, 96 (64-115) mmHg; the 40 Hz, 104 (75-140) mmHg: P = 0.004]. Significantly less patients experienced hypotension in the 40 Hz group [the control, 78%; the 2 Hz, 43%; the 10 Hz, 38%; the 20 Hz, 38%; the 40 Hz, 8%: P = 0.008]. TENS on the PC-6 and PC-5 points reduced the severity and incidence of hypotension after epidural anaesthesia, depending on the stimulus frequency.

18F-fluorodeoxyglucose uptake and apparent diffusion coefficient in lung schwannoma.

Intrapulmonary schwannoma is uncommon and preoperative radiological diagnosis is rare. Described is a schwannoma that developed as a pulmonary hilar nodule in a 38-year-old woman. The nodule showed strong (18)F-fluorodeoxyglucose uptake with a maximum standard uptake value of 5.98 on positron emission tomography and had a high apparent diffusion coefficient (2.5 × 10(3) mm(2)/s) on diffusion-weighted magnetic resonance imaging. Combination of these functional imaging techniques warrants further evaluation in radiological diagnosis of intrapulmonary schwannoma.

[Re-evaluation of effects of thymectomy on autoimmune myasthenia gravis].

In Japan, thymectomy for the treatment of autoimmune myasthenia gravis (MG) underwent about 300 cases every year. The number of the cases has most 2001 and is decreasing henceforth. Such reduction is considered because a steadfast proof that thymectomy is effective in the treatment of autoimmune MG is not shown. Thymectomy for autoimmune MG is considerably effective for patient with generalized, severe, female patients. The validity of thymectomy for the treatment of autoimmune MG should be confirmed in a randomized, controlled trial targeted on these types of autoimmune MG patients, with standardized surgical approach.

Pleuropulmonary blastoma in a 12-year-old boy presenting with pneumothorax.

Pleuropulmonary blastoma is a rare pulmonary neoplasm seen in the pediatric population. We report a purely cystic-type pleuropulmonary blastoma in a 12-year-old boy who presented with spontaneous pneumothorax. He underwent partial resection of the left lower lobe under video-assisted thoracoscopy.