[Segmental Bronchoalveolar Lavage Provided a Favorable Clinical Course in a Case of Autoimmune Pulmonary Alveolar Proteinosis].

A 49-year-old man was diagnosed with autoimmune pulmonary alveolar proteinosis. Chest computed tomography (CT) showed typical CT findings of pulmonary alveolar proteinosis: thickening of septa with ground-glass opacities in both lung fields. The diagnosis of autoimmune pulmonary alveolar proteinosis (PAP) was based on findings of bronchoalveolar lavage (BAL) fluid with milky appearance and elevated serum titer of anti-granulocyte-macrophage colony-stimulating factor antibody. We decided to perform segmental BAL via bronchoscopy. The surgery was performed under a general anesthesia since the patient had severe hypoxemia and strong cough reflex. Following 3 repeated courses of therapy, his respiratory condition and the ground-glass opacity in both lung fields improved remarkably, with no recurrence in 3 years. There are only a few published case reports in the world of the usefulness of segmental BAL under general anesthesia for PAP. We consider that segmental BAL is a useful therapeutic method for PAP in cases with severe hypoxemia, such as the present patient.

Unusual giant multilocular thymic cyst with mature teratoma including a carcinoid component in the mediastinum.

BACKGROUND: Teratoma is the second most common mediastinal neoplasm, but malignant transformation in mature teratomas is uncommon, and cases of carcinoid tumor with teratoma are described in only a few studies. In addition, multilocular thymic cyst associated with mature mediastinal teratoma is also a rare entity. There have been no reports of case with the coexistence of these three pathological lesions. CASE PRESENTATION: The patient was a 24-year-old man who was referred to our hospital due to a 2-day history of left shoulder pain, a feeling of severe chest tightness and high fever. Pre-operative computed tomography (CT) showed a large, fluid-filled and well-demarcated multilocular cyst in the anterior to superior mediastinum measuring up to 12 cm in size. Contrast-enhanced CT also revealed that the tumor contained a solid component with slight contrast enhancement and spotty wall-thickening septation. Therefore, cystic thymoma, thymic cyst, cystic teratoma, or germ cell tumor with an inflammatory reaction were considered as differential diagnoses. The patient underwent tumor extirpation under median sternotomy. The pathological diagnosis was multilocular thymic cyst with mature teratoma including carcinoid tumor (Grade 2) in the mediastinum. CONCLUSIONS: The relationship between thymic cyst, teratoma and carcinoid tumor is unclear at present; therefore, further research is needed to clarify the relationship between these entities. In this report, we present a case of multilocular thymic cyst with mature teratoma including a carcinoid component in the mediastinum that was detected by complete surgical resection.

Three Cases of Resection of Late Recurrence of Breast Cancer that Required Differential Diagnosis of Primary Lung Cancer.

We report 3 cases of surgical resection for lung metastasis more than 15 years after initial surgery for breast cancer. Case 1: A 77-year-old woman was referred to our hospital because of a lung nodule in the left lower lobe detected in a computed tomography (CT) scan. She had undergone breast preservation therapy for breast cancer 15 years before the first visit. Left lower lobectomy was performed via video-assisted thoracoscopic surgery (VATS). The pathological diagnosis was lung metastasis of breast cancer, based on positive immunohistochemical staining of estrogen receptor (ER) and gross cystic disease fluid protein 15 (GCDFP-15). Case 2: An 88-year-old woman had undergone a mastectomy for breast cancer 23 years previously. A CT scan revealed a nodule in the upper lobe of the left lung. A wedge resection of the left upper lobe was performed. Because immunostainings for progesterone receptor (PgR) and GCDFP-15 were positive, the pathological diagnosis was metastasis of breast cancer. Case 3: A 78-year-old woman had undergone right mastectomy for the breast cancer 29 years previously. The patient was referred to our hospital because of a nodule in the right lung in a CT scan. Thoracoscopic right upper lobectomy was performed. The pathological diagnosis was lung metastasis of the breast cancer, with immunohistochemical positivity to ER, PgR, and focally to GCDFP-15. A differential diagnosis between primary lung cancer and metastasis of breast cancer on the basis of the findings of a CT scan is often difficult. It is important to obtain the previous clinical information about the breast cancer before VATS, even in patients with a long disease-free interval of more than 15 years.

Chronic obstructive pulmonary disease severity in middle-aged and older men with osteoporosis associates with decreased bone formation.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) is a risk factor for osteoporosis. Nevertheless, much remains unclear regarding the bone metabolism dynamics associated with COPD. The present study focuses on the associations between the COPD severity and serum bone metabolism biomarkers. METHODS: We enrolled 40 patients who visited the orthopedics departments at our institutions and underwent dual-energy X-ray absorptiometry between September 2015 and December 2017. Only male osteoporosis patients over 45 years of age were included, and 5 patients were excluded due to disease or use of internal medicines affecting bone metabolism. All subjects underwent lung function testing, spine radiography, and blood tests. We measured percent forced expiratory volume in 1 second (%FEV1), which reflects COPD severity, and we examined the relationships between %FEV1 and serum levels of bone metabolism biomarkers. RESULTS: All subjects were diagnosed with osteoporosis based on T-scores. %FEV1 correlated with body weight, body mass index (BMI), and Z-score/T-scores. %FEV1 moderately correlated with serum levels of alkaline phosphatase (ALP), procollagen type 1 N-terminal propeptide (P1NP), and tartrate-resistant acid phosphatase 5b in the partial correlation analysis adjusted for BMI or T-score in the lumbar vertebrae. We performed a hierarchical multiple regression analysis to identify that serum ALP and P1NP were the independent explanatory variables to %FEV1 independent of other factors. CONCLUSIONS: The data suggest that the COPD severity in middle-aged and older men with osteoporosis associates with decreased bone formation. COPD patients may exhibit bone metabolism dynamics characterized by low bone turnover with osteogenesis dysfunction as COPD becomes severe.

Aspiration of a drug in a blister pack.

We report a rare case of aspiration of a drug in a press-through package (PTP) treated by not just pulling it but using a unique technique. A 73-year-old woman was referred to our department because of a persistent cough resulting from aspiration of a PTP. Flexible bronchoscopy identified the PTP in the trachea immediately above the carina. Just pulling the centre of the PTP edge with biopsy forceps could not move it, and we then rotated it by pulling the corner of the PTP edge to directly below the vocal cord. Passing over the vocal cord was difficult, which made us remove the bronchoscope and urge the patient to cough. These rotation techniques and voluntary coughing successfully removed the foreign body. This unique procedure may aid in the removal of a similar foreign body using a flexible bronchoscope forceps with insufficient grasping force.

[Two Resected Cases of Primary Pulmonary Mucosa-Associated Lymphoid Tissue Lymphoma, Differently Diagnosed in Chest Tomography Scan].

Case 1: A 81-year-old man was admitted to our hospital because of a mass shadow on chest x-ray examination. Chest computed tomography (CT) showed a 1.5 cm nodule in the middle lobe of the right lung. We suspected a primary lung cancer and performed video-assisted right middle lobectomy. Histopathological examination showed a white, elastic, hard and solid 30 × 10 × 10 mm nodule with infiltration of small-to-medium-sized lymphocytes that were positive for CD20 and CD79a, and negative for CD10 and Cyclin D1 in immunohistochemical staining. We diagnosed mucosa-associated lymphoid tissue (MALT) lymphoma. Case 2: A 67-year-old woman was admitted to our hospital because of a mass shadow in the right upper lobe on chest x-ray and chest CT. As the lesion had not grow in 1 year, the patient strongly wanted it resected, therefore we performed wedge resetion of the right upper lobe via video-assisted thoracic surgery. Histopathological examination showed a white, elastic, hard and solid 25 × 25 × 16 mm nodule with infiltration of small-to-medium-sized lymphocytes that had positive staining of CD20 and CD79a, and negative staining of CD10 and Cyclin D1. We diagnosed MALT lymphoma. Primary lung MALT lymphoma shows a variety of shadows on chest CT, similar to lung cancer and other inflammatory diseases. Local therapies such as surgery and radiation therapy are effective against early stage MALT lymphoma, but there is no consensus of a standard surgery.

Prognostic value of preoperative exercise capacity in patients undergoing thoracoscopic lobectomy for non-small cell lung cancer.

OBJECTIVES: Whether or not the preoperative exercise capacity, as assessed by 6-min walk test, influences the survival of patients undergoing thoracoscopic lobectomy for lung cancer is unclear. We therefore investigated the prognostic value of the 6-min walk distance in this population. MATERIALS AND METHODS: This prospective cohort study was conducted between 2005 and 2013. We studied 224 consecutive subjects with stage I-II non-small cell lung cancer who underwent thoracoscopic lobectomy. Survival was calculated by the Kaplan-Meier method. The log-rank test was used to assess the survival rate. Cox proportional hazards models were used to estimate the risk of 5-year all-cause mortality based on the preoperative 6-min walk distance with adjustment for other prognostic factors, including the age, performance status, postoperative cardiopulmonary complication, and pathological stage. RESULTS: The median follow-up period was 60.8 months. During this period, 38 deaths were recorded. The 5-year overall survival rate of the subjects with a preoperative 6-min walk distance of <400 m were significantly lower than those with a 6-min walk distance of ≥400 m (65.3% vs. 88.0%; p < 0.001). A multivariate analysis showed that the 6-min walk distance was significantly associated with the overall survival after adjusting for the age and pathologic stage (hazard ratio, 2.40; 95% confidence interval, 1.20-4.79), but it did not provide additional prognostic value beyond the performance status. CONCLUSION: The preoperative 6-min walk distance may be useful as an additional prognostic factor for patients at an increased risk of mortality after thoracoscopic lobectomy for stage I-II non-small cell lung cancer.

Primary epithelial-myoepithelial carcinoma of the lung with cavitary lesion: A case report.

Epithelial-myoepithelial carcinoma (EMC) typically arises in the salivary glands, whereas EMC of the lung is an extremely rare histological form that originates from the bronchial glands. Although cavitation in primary lung cancer is not uncommon, to the best of our knowledge, a case of EMC with a cavitary lesion has not been reported to date. We herein describe a case of cavity-forming pulmonary EMC. A 72-year-old man was referred to our department due to a thickened cystic wall discovered in the upper lobe of the left lung and underwent thoracoscopic left upper lobectomy. Microscopically, the tumor was characterized by biphasic architecture, with glands surrounded by myoepithelial cells. The pathological diagnosis was EMC. The patient has remained in good health for 2 years postoperatively, without any evidence of recurrence. As regards the mechanism of cavity formation, it was hypothesized that the bronchial gland in the primary cystic lesion had been present 3 years prior to the development of the EMC, and grew to become a cavitary lesion. Therefore, although the mechanism of cavity formation remains to be elucidated, EMC of the lung may include a cavitary lesion.

Malignant Melanoma of the Nipple: A Case Report.

Malignant melanoma rarely originates from the female nipple. Tumors that develop on the skin of the breast are often subject to a delayed diagnosis. Cytologic examination provides excellent diagnostic capabilities and is a safe procedure with a lower risk of local implantation, compared to needle or incisional biopsy. We herein report a patient who underwent surgical resection of a primary malignant melanoma of the nipple. An elastic soft nodule was observed on the left nipple, and no abnormal lesions were identified in the breast. Eventually, a malignant melanoma was diagnosed from the clinical and cytological evaluation findings. This bulky tumor was classified as a stage IIIC nodular melanoma, with a thickness of 12 mm. The patient received adjuvant chemotherapy and exhibits no evidence of recurrence 7 years after surgery.

Prognostic impact of programmed death-ligand 1 expression in correlation with human leukocyte antigen class I expression status in stage I adenocarcinoma of the lung.

OBJECTIVE: The study objective was to investigate the prognostic impact of programmed death-ligand 1 expression in correlation with human leukocyte antigen class I expression on tumor cells in early-stage adenocarcinoma of the lung, because both programmed death-ligand 1 and human leukocyte antigen class I molecules play important roles in cancer immunity. METHODS: Ninety-four patients with completely resected pathologic stage I lung adenocarcinoma were retrospectively reviewed. Programmed death-ligand 1 expression on tumor cells was evaluated with immunohistochemistry in correlation with several clinicopathologic and molecular features, including human leukocyte antigen class I expression on tumor cells. RESULTS: Fifteen patients (16.0%) had tumor with positive programmed death-ligand 1 expression (percentage of tumor cells expressing programmed death-ligand 1, ≥5%), and the incidence was significantly higher in poorly differentiated tumors. There was no significant correlation between human leukocyte antigen class I expression and programmed death-ligand 1 expression. Programmed death-ligand 1 positivity was a significant factor to predict a poor survival (5-year survival, 66.7% vs 85.9%; P = .049), which was enhanced in tumors with normal human leukocyte antigen class I expression (P = .029) but was not evident in tumors with reduced human leukocyte antigen class I expression (P = .552). CONCLUSIONS: The prognostic impact of programmed death-ligand 1 expression on tumor cells in early-stage lung adenocarcinoma may be distinct according to concurrent human leukocyte antigen class I expression.

[A Successful Case of Tracheal Segmental Resection and Reconstruction for Cicatricial Tracheal Stenosis].

A 45-year-old man had consciousness disorder due to fall trauma had received ventilation support and tracheostomy. Two months later, the tracheostomy tube was removed. One year later, he suffered from severe cicatricial tracheal stenosis. Under a diagnosis of post-intubation tracheal stenosis, he underwent circumferential resection and end-to-end anastomosis of the trachea. The central part of the resected trachea of 3 cartilage rings showed a stenosis like a pin hole. The post operative course was uneventful, and there was no stenosis or sutural insufficiency on examination by bronchoscopy. Tracheal resection and reconstruction is rare but effective for refractory tracheal stenosis.

Contralateral thoracoscopic lobectomy in postlobectomy patients.

BACKGROUND: It is difficult to perform thoracoscopic lobectomy in patients with a history of contralateral lobectomy, as stable oxygenation is not always maintained under conditions of one-lung ventilation during surgery. METHODS: This study evaluated 14 patients who underwent thoracoscopic lobectomy after previously undergoing contralateral lobectomy at a single institution between 2008 and 2015. RESULTS: Among 14 patients who had previously received contralateral lobectomy, 4 were unable to maintain sufficient perioperative oxygenation with usual one-lung ventilation. The predicted pulmonary function before surgery in these patients was as follows: both (I) predicted postoperative forced expiratory volume in 1 second <800 mL/m2; and (II) ≤5 contralateral residual segments for ventilation. Regarding special oxygenation techniques, two underwent selective ventilation using lobe-selective bronchial blockade, one underwent intermittent positive airway pressure for operative side lung, and one underwent high-frequency jet ventilation for operative residual lobe. CONCLUSIONS: When performing thoracoscopic lobectomy in patients with a history of contralateral lobectomy, a careful evaluation of the preoperative pulmonary function is needed.

Simple covering technique in thoracoscopic bullectomy for spontaneous pneumothorax.

Reduced-port thoracoscopic surgery for pneumothorax has been well reported. However, the optimum method for preventing postoperative recurrence in reduced-port thoracoscopic bullectomy remains unclear. We investigated ways to improve the covering technique with reduced-port thoracoscopic bullectomy for spontaneous pneumothorax. From April to December 2016, we performed a simple covering technique with reduced-port thoracoscopic bullectomy on six patients and evaluated the surgical results and patient outcomes. All of the patients were successfully treated with the simple covering technique, and none had a postoperative ipsilateral recurrence of pneumothorax. Our method is a simple and easy technique involving the wide reinforcement of the staple line and may be effective in reducing the risk of postoperative recurrence in reduced-port thoracoscopic bullectomy.

Immunohistochemical Expression and Serum Levels of CD44 as Prognostic Indicators in Patients with Non-Small Cell Lung Cancer.

BACKGROUND/OBJECTIVES: CD44 is often expressed in various types of tumor cells and involved in a number of biological behaviors of malignancy. The present study focused on the clinical significance of the expression of CD44st and CD44v6 in non-small cell lung cancer (NSCLC). METHODS: The cohort consisted of 261 consecutive patients who had undergone complete resection of NSCLC. CD44 expression was evaluated in surgical specimens by immunohistochemical staining. Serum CD44 levels were determined using a sandwich ELISA (enzyme-linked immunosorbent assay). RESULTS: In the immunohistochemical analysis, significant correlations were observed between CD44 expression and clinicopathological factors such as the T factor, N factor, pathological stage, and histological type. The 5-year survival rates according to CD44v6 expression were 65.8 and 80.6% in the higher and lower expression groups, respectively (p = 0.0053). According to ELISA, the group with higher expression of serum CD44v6 also showed a significantly more unfavorable prognosis than the lower expression group (p = 0.014). According to multivariate analysis using these significant variables, serum CD44v6 level was found to be an independent prognostic factor (p = 0.048). CONCLUSIONS: CD44v6 overexpression and higher serum CD44v6 levels were found to be significantly unfavorable prognostic factors.

Primary Adenoid Cystic Carcinoma of the Peripheral Lungs.

We herein report a very rare case of adenoid cystic carcinoma of the peripheral lungs. A 77-year-old female visited a family physician for aortitis syndrome, diabetes mellitus and hyperlipidemia. A follow-up chest computed tomography scan for aortitis syndrome revealed a nodule in the middle lobe of the right lung. Although a transbronchial lung biopsy was attempted, a definitive diagnosis could not be made. Because the possibility of lung malignancy could not be ruled out, thoracoscopic wedge resection of the middle lobe was performed. The intraoperative pathological diagnosis revealed carcinoma of the lungs and we performed middle lobectomy under complete video-assisted thoracoscopic surgery. A histopathological examination demonstrated an adenoid cystic carcinoma with a characteristic cribriform structure.

Regulatory T-cells and micrometastasis in lymph nodes of stage I NSCLC.

BACKGROUND: Regulatory T-cells (Tregs) have a pivotal role not only in abrogating autoimmune disease, but also in tumor immune escape. The purpose of the present study was to evaluate the clinical significance of the relative expression of forkhead/winged helix transcription factor (FOXP3) and micrometastasis in the regional lymph nodes (RLNs) of patients with stage I non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: The RLNs in 131 patients who underwent complete surgical resection for stage I NSCLC were collected at the time of surgery. The relative expression levels of FOXP3 and cytokeratin 19 (CK19) in RLNs were determined by quantitative RT-PCR. RESULTS: The pathological stage was diagnosed as stage IA in 97 patients (74.0%) and stage IB in 34 patients (26.0%). The relative expression levels of FOXP3 and CK19 in the RLNs were 0.062±0.0083% and 0.025±0.056%, respectively. The relative expression of FOXP3 tended to increase with increasing relative expression of CK19. The five-year overall survival rate of the patients with low expression of FOXP3 was better (90.3%) than that of patients with high expression (79.3%) (p=0.0419). A multivariate analysis using the significant variables (gender, age, histology and FOXP3 expression) showed that the FOXP3 expression in RLNs was a significant independent prognostic factor. CONCLUSION: The expression of CK19 tended to be positively correlated with the expression of FOXP3. High expression of FOXP3 in RLNs was a significant unfavorable prognostic factor in patients with stage I NSCLC.

Discrepancy between the Clinical Image and Pathological Findings of Non-Small Cell Lung Cancer Harboring an Epidermal Growth Factor Receptor Gene Mutation That Was Surgically Resected after Gefitinib Treatment.

We herein describe a discrepancy between the clinical image and pathological findings in a non-small cell lung cancer patient with an epidermal growth factor receptor (EGFR) mutation who underwent surgical resection after gefitinib treatment. The patient was a 66-year-old female with c-stage IIIA lung adenocarcinoma harboring an EGFR gene mutation; she was surgically treated after receiving gefitinib. The pathological examination revealed adenocarcinoma, and the pathologically therapeutic effect was considered to be slight or of no response. EGFR T790M mutation and MET amplification were not present. The pathologically therapeutic effect is generally well correlated with the response rate after induction therapy. In this case, there was a discrepancy between the clinical image and pathological findings. Our findings, therefore, raise questions about the role of surgery after EGFR-tyrosine kinase inhibitor treatment.

Evaluation of undiagnosed solitary lung nodules according to the probability of malignancy in the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines.

BACKGROUND: This study retrospectively investigated the clinical significance of undiagnosed solitary lung nodules removed by surgical resection. PATIENTS AND METHODS: We retrospectively collected data on the age, smoking, cancer history, nodule size, location and spiculation of 241 patients who had nodules measuring 7 mm to 30 mm and a final diagnosis established by histopathology. We compared the final diagnosis of each patient with the probability of malignancy (POM) which was proposed by the American College of Chest Physicians (ACCP) guidelines. RESULTS: Of the 241 patients, 203 patients were diagnosed to have a malignant lung tumor, while 38 patients were diagnosed with benign disease. There were significant differences in the patients with malignant and benign disease in terms of their age, smoking history, nodule size and spiculation. The mean value and the standard deviation of the POM in patients with malignant tumors were 51.7 + 26.1%, and that of patients with benign lesions was 34.6 + 26.7%. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.67. The best cut-off value provided from the ROC curve was 22.6. When the cut-off value was set at 22.6, the sensitivity was 83%, specificity 52%, positive predictive value 90%, negative predictive value 36% and accuracy 77%, respectively. CONCLUSIONS: The clinical prediction model proposed in the ACCP guidelines showed unsatisfactory results in terms of the differential diagnosis between malignant disease and benign disease of solitary lung nodules in our study, because the specificity, negative predictive value and AUC were relatively low.

Factors predicting the surgical outcome in patients with T3/4 lung cancer.

PURPOSE: Locally advanced lung cancer, such as T3/4 tumors, is considered to have a significantly worse prognosis than lower-stage disease, and the treatment of these tumors is difficult. Nevertheless, the information regarding the optimal treatment of T3/4 lung cancers after an operation is still limited. This study evaluated the prognostic factors for the postoperative outcome in patients with T3/4 lung cancers. METHODS: The results of the surgical treatments were retrospectively analyzed for 212 patients with pathological T3 and 197 patients with T4 disease. RESULTS: The global 5-year survival rate was 30.7% in this series. The 5-year overall survival (OS) rate in patients with T3 disease was 36.1%, while that in patients with T4 disease was 24.8%. The prognosis in females, those with N0-1 disease and those who underwent a complete resection was better than that of the other patients in both the T3 and T4 subgroups. The examination of the OS according to a time series showed that the rate was higher in more recent versus less recent years. From the standpoint of pulmonary metastasis (PM), the 5-year OS rates in T4 patients with PM and without PM were 38.6 and 17.4%, respectively. Multivariate analyses demonstrated that female gender, T3 disease, N0-1 disease and postoperative treatment were significant favorable prognostic predictors for OS. CONCLUSIONS: These findings suggest that surgical resection remains an important treatment option, especially in cases having the aforementioned factors.

Clinical Characteristics of Resected T3 Non-small Cell Lung Cancer Characterized by Parietal Pleural Invasion or Chest Wall Invasion.

This study investigated the clinicopathological characteristics and the surgical outcome in patients with non-small cell carcinoma (NSCLC) with parietal pleura invasion or chest wall invasion (p3/T3). This study clinicopathologically evaluated 760 patients who had undergone a resection for NSCLC between 1999 and 2008. There were 43 (5.7 %) patients with p3/T3 NSCLC. The patients included 37 males and 6 females. The histological types included 23 squamous cell carcinomas, 13 adenocarcinomas, 3 large cell carcinomas, 3 pleomorphic carcinomas, and 1 spindle cell carcinoma. Pneumonectomy was performed in 2 patients, bilobectomy in 1, lobectomy in 31, segmentectomy in 3, and partial resection of the lung in 6. The combined resection regions were parietal pleural in 23, ribs in 16, pericardium in 2, and diaphragm in 2 patients. Major complications included empyema in 1, chylothorax in 1, and postoperative bleeding in 1 patient. The first recurrence sites in 16 patients with recurrent disease were the lung in 5 patients, brain in 3, bone in 2, adrenal gland in 2, skin in 2, liver in 1, mesenterium in 1, mediastinal lymph node in 1, axillary lymph node in 1, and carcinomatous pleuritis in 1. The overall 5-year survival rate after surgery was 50.6 %. An en bloc resection for p3/T3 NSCLC provides a modestly favorable prognosis. Local recurrence was observed in a minority of case, and recurrence by distant metastasis was observed in most cases, suggesting a greater need for postoperative chemotherapy.