[Malignant Solitary Fibrous Tumor Compressing the Right Ventricle].

An 84-year-old woman was referred to our department with an abnormal mass detected on a chest computed tomography (CT) scan. The CT scan revealed a tumor between the sternum and the right ventricle, fed by the left internal thoracic artery. Multiple hepatic nodules were also observed. An ultrasound-guided biopsy was performed on the liver nodule, which was diagnosed as a solitary fibrous tumor. The tumor was compressing the heart, and the patient was at risk of sudden death, therefore, a decision was made to resect tumor. Preoperative embolization of the left internal thoracic artery was performed to prevent massive intraoperative bleeding. The tumor was resected via a median sternotomy approach. Intraoperatively, feeding vessels entering the tumor from the diaphragm were also identified. Total blood loss was 70 ml. The postoperative course was uneventful.

A case report of a gastrobronchial fistula and lung abscess caused by leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer.

BACKGROUND: Gastrobronchial fistulas are rare, but life-threatening, complications of esophagectomy. They are caused by anastomotic leakage and mainly occur around anastomotic sites. In the present paper, we report a rare case of leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer, which was successfully treated using an intercostal muscle flap and lung resection. CASE PRESENTATION: A 61-year-old male underwent subtotal esophagectomy with regional lymphadenectomy for esophageal cancer. The sutures along the staple line of the gastric tube failed 11 days after surgery, and a pulmonary abscess was also found on imaging. The abscess did not heal after conservative treatment; therefore, right lower lobectomy, gastrobronchial fistula resection, primary closure, and patching of the leaking portion of the gastric tube with an intercostal muscle flap were performed 9 months after the first operation. The patient's postoperative course was uneventful, and he was discharged on the 354th day. CONCLUSIONS: We experienced a case involving a gastrobronchial fistula caused by leakage from the staple line of a gastric tube and successfully treated it by performing right lower lobectomy and patching the leak with an intercostal muscle flap.

Parahiatal Hernia Sac Tumor of Localized Malignant Peritoneal Mesothelioma.

We describe an extremely rare case of a parahiatal hernia sac tumor. A computed tomography scan showed a solitary mass located adjacent to the diaphragm and esophagus in a 72-year-old woman. Thoracoscopic surgery revealed that a tumor protruded through a diaphragmatic defect lateral to the crus and adhered to the perigastric fat in the gastric fundus. Radical resection of the tumor and herniorrhaphy of the diaphragmatic defect were performed. Pathologic and clinical findings indicated this was a parahiatal hernia sac tumor of localized malignant peritoneal mesothelioma. No recurrence was observed without adjuvant therapy 10 months after surgery.

[High-grade Fetal Lung Adenocarcinoma with Hepatoid Adenocarcinoma Component].

A 71-year-old man with a history of smoking 1 pack of cigarettes per day for the past 53 years visited our department with chest pain, and was diagnosed as spontaneous pneumothorax. A chest computed tomography scan revealed a nodular shadow in the upper portion of the left lobe of the lung, which was found to be adenocarcinoma by transbronchial lung biopsy. A left upper lobectomy and lymphadenectomy were performed. The pathological diagnosis was a high-grade fetal lung adenocarcinoma (H-FLAC) with a hepatoid adenocarcinoma component (pT2aN0M0, pStage I B). H-FLAC comprises at least 50% fetal lung-like cells, while hepatoid adenocarcinoma comprises hepatocellular carcinoma-like cells. Following the diagnosis, adjuvant chemotherapy with uracil-tegafur was started. Although both these neoplasms are known to have a poor prognosis, no recurrences were observed at 11 months postsurgery.

[Giant Solitary Fibrous Tumor of Pleura Metastasizing Contralateral Lung Following Two Times of Surgery for Ipsilateral Pleural Disseminations].

We report a case of giant solitary fibrous tumor (SFT) of pleura metastatising contralateral lung following 2 times of surgery for ipsilateral pleural disseminations. A 70-year-old woman was carried to our hospital by ambulance because of hypoglycemic attack. A chest X-ray film showed a huge mass in the right lung field. A computed tomography guided biopsy revealed a SFT producing IGF-Ⅱ, which caused hypoglycemic attack. After surgery, she was relieved of hypoglycemic attack and discharged from the hospital 14 days following the surgery. SFT repeatedly relapsed in the ipsilateral pleura. In the follow-up period, 2 times of resection of disseminated nodules were carried out. Finally, SFT developed ipsilateral pleural disseminations and contralateral pulmonary metastases, accompanying hypoglycemic attack. She died 76 months after the initial surgery.

[Metaplastic Thymoma;Report of a Case].

A 76-year-old man was referred to our division because of an abnormal shadow on chest computed tomography (CT). CT revealed a 20 mm nodule in the anterior mediastinum. Non-ivasive thymoma was suspected and thymomectomy and resection of right thymus was performed. The resected tumor was 25×25×13 mm in size. Pathologically the tumor was composed with polygonal cell components and spindle cell components, partially invading surrounding tissue. Cytokeratin AE1/3 and epithelial membrane antigen (EMA) were strongly positive, and the pathological diagnosis was biphasic, metaplastic thymoma.

[Solitary Pulmonary Metastasis from Carcinoma of the Ampulla of Vater after Pancreatoduodenectomy;Report of a Case].

A 74-year-old woman had underwent pancreatoduodenectomy for a carcinoma of the ampulla of Vater. After 3 years of the operation, chest computed tomography (CT) scan showed a solitary nodule in the right posterior segment (S2). Under the diagnosis of solitary pulmonary metastasis, we performed wedge resection for the right S2 lesion under video-assisted thoracic surgery (VATS). Pathological diagnosis was the metastasis of carcinoma of the ampulla of Vater. One year later, chest CT scan showed another solitary lesion in right superior segment (S6). Wedge resection was performed again for the right S6 nodule, which was also diagnosed as a metastasis.

[Pulmonary Enteric Adenocarcinoma;Report of a Case].

A 73-year-old man was referred to our hospital because of an abnormal shadow on a chest radiography. Chest computed tomography(CT) revealed a 3 cm nodule in the right lower lung lobe, fluorodeoxyglucose-positron emission tomography (FDG-PET) showed abnormal uptake in the tumor with a maximal standardized uptake value (SUV) max of 5.8. Bronchoscopy revealed adenocarcinoma cells. A right lower lobectomy and upper lobe partial resection and ND2a-1 were performed. Histological analysis revealed lung cancer comprising tall columnar cells. Immunohistochemical staining was positive in CDX2, CK20 and CK7. Any primary tumor was not found by postoperative screening. We diagnosed as a pulmonary enteric adenocarcinoma. After 6 months from operation, multiple recurrence was found and the patient died 8 months after operation.

[Pulmonary Metastasis of Gastric Cancer as Carcinomatous Lymphangiosis at Five and Half Years after Surgery;Report of a Case].

A 51-year-old woman underwent radical operation for a gastric cancer and adjuvant chemotherapy with tegafur, gimeracil, and oteracil potassium. Five and a half years later, screening chest computed tomography(CT)scan showed slight ground glass opacity(GGO)of the both lungs and they were regarded as inflammatory change. Several months later, she experienced a dry cough. CT scan showed aggravation of GGO, and she was refered to our hospital to investigate these lesions 6 years after operation. We performed a wedge resection of right middle lobe. A postoperative pathology revealed metastatic carcinomatous lymphangiosis of gastric cancer. Chemotherapy using capecitabine and oxaliplatin, and then docetaxel was performed and talc pleurodesis was done for the malignant pleural effusion. These treatments did not improve condition, and she died 7 months after lung operation. In conclusion, we need to consider GGO as the possibility of carcinomatous lymphangiosis in case of patient with gastric cancer.

[Synchronous Triple Primary Lung Adenocarcinomas, One of which Showing a Thin-walled Cavity Nodule;Report of a Case].

A 74-year-old woman was referred to our hospital to investigate a right apical segment (S1)nodule which was increasing gradually. Chest computed tomography (CT) scan showed three lesions in right S1, posterior segment(S2) and superior segment(S6). S6 lesion was a thin-walled cavity enlarging gradually with same appearance. The S1 nodule was diagnosed as adenocarcinoma by CT guided biopsy. Since the possibility of lung cancer couldn't be denied for S6 lesion, right upper lobectomy and S6 segmentectomy with mediastinal lymph node dissection was performed. A postoperative pathology revealed all of 3 tumors as lung adenocarcinoma and confirmed as synchronous triple primary lung adenocarcinomas.

[Surgical Removal of a Metallic Staple in Right Lower Bronchus, Aspirated a Year Before].

A 77-year-old man was referred to our hospital, due to an intrabronchial foreign body. He had aspirated a metallic staple during carpentry work a year before. A bronchoscopic examination revealed a fixed metallic staple at the entrance of right lower bronchus surrounded by granulation tissue, causing a marked bronchial stenosis. In addition, a sharp edge of the staple stabbed the membranous portion of intermediate bronchus. Endoscopic removal was thought to have a risk of tracheal laceration or bleeding. Then we successfully removed it surgically through transpleural bronchotomy.

Cellulose aerogel regenerated from ionic liquid solution for immobilized metal affinity adsorption.

Surface morphology of cellulosic adsorbents is expected to influence the adsorption behavior of biomacromolecules. In the present study, cellulose aerogel regenerated from ionic liquid solution was prepared for use as a polymer support for protein adsorption. Iminodiacetic acid groups were introduced to the aerogel for immobilized metal affinity adsorption of proteins. A Cu(II)-immobilized iminodiacetic acid cellulose aerogel (Cu(II)-IDA-CA), which has a large specific surface area, showed a higher adsorption capacity than Cu(II)-immobilized iminodiacetic acid bacterial cellulose (Cu(II)-IDA-BC) and Cu(II)-immobilized iminodiacetic acid plant cellulose (Cu(II)-IDA-PC). In contrast, the Cu(II)-immobilized cellulosic adsorbents showed similar adsorption capacities for smaller amino acid and peptides. The results show that cellulose aerogels are useful as polymer supports with high protein adsorption capacities.

[Primary lung cancer with pulmonary hypertrophic osteoarthropathy mimicking bone metastasis; report of a case].

A 64-year-old man visited our hospital, due to right shoulder pain and fever. Chest X-ray revealed a well-defined tumor in the upper field of the left lung, and the histological diagnosis was adenocarcinoma. Bone scintigraphy demonstrated abnormal accumulation localized in the right shoulder joints. Although bone metastasis was highly suspected, pulmonary resection was performed to remove infected pulmonary tumor. A week after pulmonary resection, his shoulder pain dramatically improved, and abnormal accumulation in bone scan decreased definitely 1 month later. In conclusions, this is an atypical case of hypertrophic osteoarthropathy accompanying lung cancer.

Bronchoplasty for bronchial carcinoid tumor without removing lung parenchyma.

A 15-year-old boy was admitted with a pneumothorax of the left lung. Computed tomographic scans demonstrated a tumor 20 mm in diameter situated on the left main to upper lobar bronchus that eventually was proved to be a typical carcinoid tumor by transbronchial biopsy. We performed bronchial resection with atypical bronchoplasty, which preserves lung parenchyma in cases of s-T1N0M0 disease. The patient has had no evidence of recurrence 7 years after surgery.

Selective mediastinal lymphadenectomy for clinico-surgical stage I non-small cell lung cancer.

BACKGROUND: Improved radiologic imaging provides earlier detection of non-small cell lung cancer, but controversy exists regarding the need for complete lymph node dissection. This study was designed to evaluate the possibility of lesser mediastinal dissection for early-stage lung cancer. METHODS: Selective mediastinal dissection is defined as follows: Dissection of the upper mediastinum for upper-lobe tumors is performed but it is not needed for lower-lobe tumors with intact hilar and lower mediastinal nodes. Also, dissection of the lower mediastinum for an upper-lobe tumor is not routinely required when the nodes in the hilum and upper mediastinum are negative. From 1997 through 2002, 377 patients with clinico-surgical stage I non-small cell lung cancer underwent curative-intent surgery with selective dissection (group S). In addition, 358 patients with the same-stage disease who underwent complete lymphadenectomy by the same surgical team served as historic controls (group C). RESULTS: The characteristics of the two groups were well balanced. There was no significant difference in disease-free survival (p = 0.376) or overall survival (p = 0.060). Multivariate analysis showed that the dissection mode did not significantly influence either disease-free survival (p = 0.636) or overall survival (p = 0.119). The postoperative morbidity rates were 17.3% and 10.1% for group C and group S, respectively (p = 0.005). One operative death occurred in each group (0.3%). The rates of distant metastasis and local recurrence were similar in the two groups. CONCLUSIONS: Selective mediastinal dissection for clinico-surgical stage I non-small cell lung cancer proved to be as effective as complete dissection, and although large multicenter trials are warranted, it might be considered as an alternative for curative surgery in this era of minimally invasive surgery.

Functional advantage after radical segmentectomy versus lobectomy for lung cancer.

BACKGROUND: Although several reports have recently demonstrated that segmentectomy for small-sized N0 lung cancer leads to recurrence and survival rates equivalent to those associated with lobectomy, controversy regarding the postoperative functional advantage in the former over the latter still persists. The purpose of this study was to evaluate the degree of postoperative functional loss in patients undergoing segmentectomy or lobectomy for lung cancer. METHODS: We analyzed patients able to tolerate lobectomy, who underwent radical segmentectomy (n = 38) or lobectomy (n = 45) for non-small-cell lung cancer. Functional testing included forced vital capacity, forced expiratory volume in 1 second, and anaerobic threshold measured preoperatively and at 2 and 6 months after surgery. RESULTS: Preoperative function tests showed no differences between segmentectomy and lobectomy patients. A positive and significant correlation was found between the number of resected segments versus loss of forced vital capacity (r = 0.518, p < 0.0001 at 2 months; r = 0.604, p < 0.0001 at 6 months) and loss of forced expiratory volume in 1 second (r = 0.492, p < 0.0001 at 2 months; r = 0.512, p < 0.0001 at 6 months). The postoperative reduction of forced vital capacity (p = 0.0006) and forced expiratory volume in 1 second (p = 0.0007) was significantly less in the segmentectomy group; however, a marginally significant benefit was observed in this group for anaerobic threshold (p = 0.0616). CONCLUSIONS: The extent of removed lung parenchyma directly affected that of postoperative functional loss even at 6 months after surgery, and segmentectomy offered significantly better functional preservation compared with lobectomy. These results indicate the importance of segmentectomy for early staged lung cancer.

Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery.

STUDY OBJECTIVES: Controversy regarding the most suitable surgical approach for treating malignancies of the lung is a matter of continuous discussions. "Complete" video-assisted thoracic surgery (VATS) that is performed using only the vision of a monitor is generally limited to lung resections of minimal difficulty. With the great interest in minimally invasive techniques for treating various pathologies, we have widely applied an integrated surgical approach that combines muscle-sparing minithoracotomy (incision, 4 to 10 cm) and video assistance using mainly direct visualization of the lung resection, which we have called hybrid VATS. The aim of this study is to evaluate the usefulness of hybrid VATS. DESIGN: Retrospective single-center study. INTERVENTIONS: From January 1998 to October 2004, 405 of 678 lobectomies (60%) and 165 of 226 segmentectomies (73%) were performed for primary lung cancer using hybrid VATS. RESULTS: Bronchoplasty was performed in 93 of the 678 patients (14%) who underwent lobectomy and in 11 of the 226 patients (5%) who underwent segmentectomy. Hybrid VATS was utilized in 33% of sleeve lobectomy procedures and in 27% of sleeve segmentectomy procedures. The mean (+/- SD) surgical time using hybrid VATS was 164 +/- 48 min for lobectomy and 158 +/- 35 min for segmentectomy, and the mean blood loss was 166 +/- 120 and 109 +/- 80 mL, respectively. There was one operative mortality (0.2%) secondary to cardiogenic shock. Postoperative complications developed in 11% of patients with p-stage IA disease after undergoing hybrid VATS, in contrast to 19% of patients after undergoing open thoracotomy. The prognosis of patients treated by hybrid VATS was equivalent to that obtained with open thoracotomy. CONCLUSIONS: Minithoracotomy combined with video support that is performed predominantly via direct visualization is a secure, integrated, minimally invasive approach to performing major resection for lung cancer, including atypical procedures such as bronchoplasty. This hybrid VATS can be an acceptable and satisfactory option whenever the performance of complete VATS is considered to be challenging.

Complications and outcomes after pulmonary resection for cancer in patients 80 to 89 years of age.

OBJECTIVE: Patients 80 years or older often present with potentially resectable cases of non-small cell lung cancer. Whether such patients should undergo surgical treatment is becoming increasingly important in this rapidly aging society. METHODS: From April 1997 through March 2004, 40 consecutive patients with non-small cell lung cancer who were 80-88 years of age underwent complete resection of their tumors, as confirmed pathologically. We reviewed preoperative data including gender, age, history of smoking, pulmonary function, co-morbidity, and induction/adjuvant therapy. Perioperative data consisted of surgical procedure, operative morbidity and mortality, histopathologic type, pathologic stage, and outcome. RESULTS: The procedures comprised 16 lobectomies (40%), 12 segmentectomies (30%), and 12 wedge resections (30%). The histopathologic diagnosis was adenocarcinoma in 22 patients, squamous cell carcinomas in 11, large cell carcinomas in 4, adenosquamous cell carcinomas in 2, and neuro-endocrine cell carcinoma in 1. The disease stage was IA in 21 patients, IB in 14, IIB in 3, and IIIA in 2. There was no perioperative mortality. Eight patients had non-lethal complications (20%), including five with cardiopulmonary complications (parenchymal air leaks persisting for more than 7 days in two patients, interstitial pneumonia in one, bacterial pneumonia in one, and moderate arrhythmias in one) and three with minor complications (depression or confusion). The actuarial survival rates of the 40 patients, including deaths from all causes, were 92.4, 71.6, and 56.9% at 1, 3, and 5 years, respectively. In patients with stage I disease, the respective survival rates were 94.3, 74.3, and 57.3%. CONCLUSIONS: Advanced age is not a contraindication to curative resection in patients 80-89 years of age with stage I non-small cell lung cancer.

Border between N1 and N2 stations in lung carcinoma: lessons from lymph node metastatic patterns of lower lobe tumors.

OBJECTIVE: Distinction of lymph node stations is one of the most crucial topics still not entirely resolved by many lung cancer surgeons. The nodes around the junction of the hilum and mediastinum are key points at issue. We examined the spread pattern of lymph node metastases, investigated the prognosis according to the level of the involved nodes, and conclusively analyzed the border between N1 and N2 stations. METHODS: We reviewed the records of 604 consecutive patients who underwent complete resection for non-small cell lung carcinoma of the lower lobe. RESULTS: There were 390 patients (64.6%) with N0 disease, 127 (21.0%) with N1, and 87 (14.4%) with N2. Whereas 11.3% of patients with right N2 disease had skip metastases limited to the subcarinal nodes, 32.6% of patients with left N2 disease had skip metastases, of which 64.2% had involvement of N2 station nodes, except the subcarinal ones. The overall 5-year survivals of patients with N0, N1, and N2 disease were 71.0%, 50.8%, and 16.7%, respectively (N0 vs N1 P = .0001, N1 vs N2, P < .0001). Although there were no significant differences in survival according to the side of the tumor among patients with N0 or N1 disease, patients with a left N2 tumor had a worse prognosis than those with a right N2 tumor (P = .0387). The overall 5-year survivals of patients with N0, intralobar N1, hilar N1, lower mediastinal N2, and upper mediastinal N2 disease were 71.0%, 60.1%, 38.8%, 24.8%, and 0%, respectively. Significant differences were observed between intralobar N1 and hilar N1 disease ( P = .0489), hilar N1 and lower mediastinal N2 disease (P = .0158), and lower and upper mediastinal N2 disease (P = .0446). Also, the 5-year survivals of patients with involvement up to station 11, up to station 10, and up to station 7 were 41.4%, 37.9% and 37.7%, respectively (difference not significant). CONCLUSIONS: N1 and N2 diseases appeared as a combination of subgroups: intralobar N1 disease, hilar N1 disease, lower mediastinal N2 disease, and upper mediastinal N2 disease. Interestingly, the survivals of patients with involvement up to interlobar nodes (station 11), main bronchus nodes (station 10), and subcarinal nodes (station 7) were identical. These data constitute the basis for a larger investigation to develop a lymph node map in lung cancer.

Effect of tumor size on prognosis in patients with non-small cell lung cancer: the role of segmentectomy as a type of lesser resection.

OBJECTIVE: As a result of increasing discovery of small-sized lung cancer in clinical practice, tumor size has come to be considered an important variable affecting planning of treatment. Nevertheless, there have been no reports including large numbers of patients and focusing on tumor size, and controversy remains concerning the surgical management of small-sized tumors. Therefore, we investigated the relationships between tumor dimension and clinical and follow-up data, as well as surgical procedure in particular. METHODS: We reviewed the records of 1272 consecutive patients who underwent complete resection for non-small cell carcinoma of the lung. RESULTS: Fifty patients had tumors of 10 mm or less, 273 had tumors of 11 to 20 mm, 368 had tumors of 21 to 30 mm, and 581 had tumors of greater than 30 mm in diameter. The cancer-specific 5-year survivals of patients in these 4 groups were 100%, 83.5%, 76.5%, and 57.9%, respectively. For patients with pathologic stage I disease, they were 100%, 92.6%, 84.1%, and 76.4%, respectively. Multivariate analysis demonstrated that male sex, older age, larger tumor, and advanced pathologic stage adversely affected survival. Lesser resection was performed in 167 (52%) of 323 patients with a tumor of 20 mm or less in diameter but in 156 (16%) of 949 patients with a tumor of greater than 20 mm in diameter. The percentages of lesser resection among all procedures performed were 79%, 56%, 30%, and 15% in patients with pathologic stage I disease with a tumor of 10 mm or less, 11 to 20 mm, 21 to 30 mm, and greater than 30 mm in diameter, respectively. The 5-year cancer-specific survivals of patients with pathologic stage I disease with tumors of 20 mm or less and 21 to 30 mm in diameter were 92.4% and 87.4% after lobectomy, 96.7% and 84.6% after segmentectomy, and 85.7% and 39.4% after wedge resection, respectively. On the other hand, with a tumor of greater than 30 mm in diameter, survivals were 81.3% after lobectomy, 62.9% after segmentectomy, and 0% after wedge resection, respectively. CONCLUSIONS: Tumor size is an independent and significant prognostic factor and important for planning of surgical treatment. Although lobectomy should be chosen for patients with a tumor of greater than 30 mm in diameter, further investigation is required for tumors of 21 to 30 mm in diameter. Segmentectomy should, as a lesser anatomic resection, be distinguished from wedge resection and might be acceptable for patients with a tumor of 20 mm or less in diameter without nodal involvement.