Placement of self-expandable metallic stents for tracheal stenosis secondary to thyroid cancer.

The indications and suitable approaches for treating upper airway obstruction secondary to thyroid cancer are controversial. Patients with thyroid cancer generally have a good prognosis, but airway stenosis and vocal cord paralysis are not uncommon. Subglottic airway stenting may be challenging, due to stent migration, granulation tissue formation and supraglottic stenosis. In this study, we evaluated the application of covered self-expandable metallic stents to relieve upper airway obstruction. This was a retrospective study of 5 patients with airway stenosis due to thyroid cancer treated in 2009 and 2010. Immediate airway enlargement was achieved in 3 patients with stenosis at the middle mediastinum. Gradual enlargement over 2 months was observed in the remaining 2 patients with stenosis at the cervical level. The performance status was improved in all 5 patients, including a case with anaplastic carcinoma. The follow-up averaged 13 months (range, 8-27 months). Granulation tissue developed at both ends of the stent in 3 patients, sputum was retained in 2 cases and bacterial colonization was detected in all 5 cases. No stent migration was reported. Additional tracheostomy was required in 2 patients, due to proximal tumor growth or progressive bilateral vocal cord paralysis after 10 and 6 months, respectively. In conclusion, stenting for central airway stenosis secondary to thyroid cancer may be beneficial, even in patients with anaplastic carcinoma. Long-term regular bronchoscopic follow-up is required to monitor complications, as patients with thyroid cancer are at high risk of granulation tissue formation, sputum retention and bacterial colonization.

Transbronchoscopic oxygen insufflation-induced barotrauma during endobronchial silicon spigot removal.

While transbronchoscopic air insufflation has been described in refractory atelectasis as a therapy without any serious complications, 3 cases of gastric rupture during the same procedure have been reported when it was used to support tracheal intubation by employing the jet of oxygen from the wall pipeline. Here, we report a 66-year-old woman who underwent transbronchoscopic oxygen insufflation using a flexible fiberscope to clear away secretions during an endobronchial silicon spigot removal procedure. She suffered a sudden drop of blood pressure with pneumomediastinum, subpleural and subcutaneous emphysema, and bilateral pneumothorax. Blood pressure recovered rapidly when we stopped the insufflation. Tube thoracostomy was initiated, and she recovered well without systemic air embolism. We conclude that transbronchoscopic oxygen insufflation using the wall pipeline does carry a potential risk of serious barotrauma, and is not to be recommended except with the use of a pressure monitor or pop-off valve.

Complete response of 7 years' duration after chemoradiotherapy followed by gefitinib in a patient with intramedullary spinal cord metastasis from lung adenocarcinoma.

Intramedullary spinal cord metastasis is a rare but serious complication which causes rapid progression of neurological deficits. Here we report a 35-year-old man presenting with increasing leg pain and gait disturbance, 8 months after surgery for lung adenocarcinoma. Spinal magnetic resonance imaging revealed an intramedullary tumor at the Th7/8 level. Radiotherapy at 35 Gy resulted in transient symptomatic improvement, but during chemotherapy with vinorelbine and cisplatin, symptoms worsened again. Gefitinib was then administered; the patient improved after 2 weeks and has now maintained a complete response for 7 years.

Anterior mediastinal cystic seminoma.

Mediastinal cystic seminoma is uncommon; only 17 cases have been reported, most diagnosed postoperatively, without recurrence on follow-up, even without radiotherapy. Here, we report a mediastinal seminoma showing a unilocular cyst with enhancing thickened wall in computed tomography (CT) and septal structures in magnetic resonance imaging (MRI) in a 24-year-old man. Fluorodeoxyglucose (FDG) uptake was not significant. Histopathologically, seminoma cells were found scattered in the cyst wall. Twenty months after resection, the patient's quality of life is good, without chemotherapy or radiation. Cystic seminoma has a good prognosis and complete resection without adjuvant therapy might be sufficient for young patients of reproductive age.

Recovery of lung perfusion after sleeve resection for tuberculous bronchial stenosis.

Parenchyma-sparing main bronchial sleeve resection is a safe and effective procedure to restore impaired lung function. We present a case illustrating recovery of lung perfusion in a 24-year-old woman with dyspnea on exertion because of bronchial tuberculosis. Bronchoscopic examination revealed pin-hole stenosis of the left main bronchial orifice. 99mTc-macroaggregated albumin perfusion scanning revealed essentially absent left lung perfusion. Because of bronchomalacia in the distal portion, six rings of the left main bronchus were resected by carinoplasty. Symptoms abated and perfusion recovered to a large extent 2 months later. She became pregnant and delivered successfully 12 months postoperatively.

Pulmonary hamartoma diagnosed by convex probe endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

A 71-year-old man with a right hilar mass shadow was referred to our department. Chest computed tomography showed a small fatty area inside. Convex probe endobronchial ultrasound (CP-EBUS) images revealed a heterogeneous low-echoic mass, resembling a stone wall and showing a smooth sliding movement along the tracheal wall during respiration. Transbronchial needle aspiration (EBUS-TBNA) was performed and cartilage cells were identified, compatible with the presence of a hamartoma. The patient requested follow-up without surgical intervention. CP-EBUS images are easier to interpret than other methods for monitoring respiratory dynamics. We conclude that CP-EBUS is a useful addition to techniques both for non-invasive imaging as well as guiding pathological examination.

Late onset postoperative pulmonary fistula following a pulmonary segmentectomy using electrocautery or a harmonic scalpel.

PURPOSE: The purpose of this study is to retrospectively examine the postoperative pulmonary fistula as a complication after the use of either electrocautery or a harmonic scalpel without stapling devices. PATIENTS AND METHODS: The subjects of this study consisted of 28 patients who received a segmentectomy for a pulmonary malignant tumor, 25 cases of lung cancer and 3 of metastatic lung tumor. The electrocautery was used in 17 patients (EC group) and the harmonic scalpel in 11 (HS group). The levels of postoperative air leakage and postoperative complications were examined among the two groups retrospectively. The histological findings of the cut surface of the segmentectomy by electrocautery and harmonic scalpel were also examined. RESULTS: Hemostasis and air leakage both were well controlled during the operation, and the postoperative drainage period was short. No major postoperative complications occurred, and all patients began walking in the early postoperative days. However, 1 to 3 postoperative months after discharge, 8 patients showed late onset of a pulmonary fistula, 3 of the 17 (18%) in the EC group and 5 of the 11 (45%) in the HS group. The histological findings of the cut surface of the segmentectomy showed that most of the layer of coagulation necrosis by the harmonic scalpel measured 2 mm thick, and it was denser than that cut from electrocautery. The lumen of the bronchus markedly decreased in size, but it remained, as it also did under the effects of electrocautery. CONCLUSIONS: In the months following the operation, the incidence of the late onset of a pulmonary fistula was higher when the harmonic scalpel was used. It was believed that the small bronchial stump could not tolerate the airway pressure because the thick coagulation necrosis delayed healing of the postoperative wound. It was necessary to ligate the stump of a small bronchus, even though the stump had been temporally closed by coagulation necrosis with the electrocautery or harmonic scalpel during the operation.

Use of emergency rigid bronchoscopy to reduce tumour mass prior to surgical resection.

Two patients with lung adenocarcinoma developed acute respiratory failure as a result of unilateral lung collapse. They were successfully treated by tumour de-bulking using a rigid brochoscope and subsequent radical sleeve lobectomy. Case 1 was a 46-year-old man whose carcinoma was pathological stage IIIb (P-T4N2M0), and he remains tumour-free 39 months after the surgery. Case 2 was a 79-year-old man whose carcinoma was pathological stage IIb (P-T3N0M0). Following treatment, he was able to resume his daily activities, however, his tumour recurred and he died 5 months after the surgery. Debulking of tumours with a rigid bronchoscope was useful for improving patients' quality of life and for the subsequent multidisciplinary treatment of lung carcinoma.