Robot-assisted thoracoscopic right upper lobectomy with displaced B3 and absence of minor fissure: a case report.

INTRODUCTION: B3 downward-shifting is a rare bronchial anomaly characterized by abnormal pulmonary arteries associated with downward displacement of B3 and complete fusion between the right upper and middle lobes. CASE PRESENTATION: We report a case of robot-assisted thoracoscopic right upper lobectomy in a patient with lung cancer with B3 downward-shifting. An 81-year-old male was diagnosed with non-small cell lung cancer in S3 of the right upper lung. Preoperative three-dimensional computed tomography angiography revealed a B3 bronchus derived from the middle lobe bronchus and an anterior segmental pulmonary artery variation. Robot-assisted thoracoscopic surgery right upper lobectomy with ND2a-1 was performed via four-port incisions and an assist incision. No interlobar fissure was observed between the right upper and middle lobes. After dissecting B1+2, the displaced B3 root was dissected. The displaced A3a was difficult to dissect because of an extremely severe complete fissure. Therefore, we dissected the bronchus preceding from the cranial side. To confirm a minor fissure, indocyanine green was administered intravenously, and the interlobar boundary was identified as the line separating the dark and green lung parenchyma. The boundary was divided using mechanical staples. No surgical complications occurred. CONCLUSIONS: Using three-dimensional reconstruction imaging and systemic indocyanine green administration, we successfully performed a right upper lobectomy through robot-assisted thoracic surgery.

[Case of Unresectable Gastric Mixed Neuroendocrine Neoplasm(MiNEN)Treated with Chemotherapy].

A 68-year-old man diagnosed with gastric mixed neuroendocrine-non-neuroendocrine neoplasia(MiNEN)concomitant with liver metastasis received chemotherapy using ramucirumab and paclitaxel. A decrease in tumor marker levels and size of the metastatic liver lesions was observed after 3 courses of treatment. However, the patient developed progressive disease after 9 courses of chemotherapy; hence, nivolumab chemotherapy was initiated. Although liver metastases were reduced after 2 courses of nivolumab, the patient developed new liver lesions after 18 courses of treatment; irinotecan, S-1 and oxaliplatin, and trifluridine/tipiracil were then administered. Liver metastases progressed despite changing the regimen, and the patient died 25 months after the initiation of chemotherapy. Gastric MiNEN usually shows poor prognosis, and there is lack of consensus regarding optimal treatment. Ramucirumab and nivolumab are relatively well-tolerated and may be effective for chemotherapy.

Assessment of intrathoracic lymph nodes by FDG PET/CT in patients with asbestos-related lung cancer.

BACKGROUND: This study explored the assessment of intrathoracic lymph node metastasis by 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography computed tomography (PET/CT) in patients with asbestos-related lung cancer (ARLC). METHODS: We retrospectively reviewed the data on 35 patients with ARLC who underwent preoperative FDG-PET/CT and surgical resection between January 2012 and December 2018. We collected medical information from medical records and imaging systems and examined the FDG uptake in each lymph nodal region resected by surgery and the presence or absence of pathological lymph node metastasis. RESULTS: Pathological lymph node metastases were detected in 14 (8.70%) of 161 nodal stations. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FDG-PET/CT were 71.4% (10/14), 87.8% (129/147), 35.7% (10/28), 97.0% (129/133), and 86.3% (139/161), respectively. Six of the eight false-positive patients had bilateral accumulations, whereas all six true-positive patients had unilateral accumulation (P=0.006). On histopathological examination, the false-positive nodes showed disruption of lymphoid follicles in the cortex, infiltration of histiocyte-like cells in the medulla, fibrous micronodules, and severe anthracosis. CONCLUSIONS: PET/CT scans of patients with ARLC showed comparable sensitivity and specificity to those of PET/CT scans of patients with conventional lung cancer reported in the literature. Many false-positive cases also showed bilateral symmetric accumulation. This method can be used to evaluate lymph node involvement in lung cancer.

A rare case of chest wall tuberculosis: Tuberculous scapulothoracic bursitis.

Chest wall tuberculosis is a relatively rare extrapulmonary tuberculosis, and is often difficult to diagnose and treat because of the lack of symptoms. The scapulothoracic joint is a special joint that does not have a joint capsule, cartilage, or synovial membrane but consists of muscle and bursa. Tuberculosis infection of the scapulothoracic joint is an extremely rare musculoskeletal tuberculosis of the chest wall. Herein, we present the diagnosis and treatment strategy for tuberculous scapulothoracic bursitis in an 82-year-old man who was successfully treated.

Primary omental torsion diagnosed and treated laparoscopically: a case report.

Omental torsion, a rare cause of acute abdomen in children and adults, is difficult to correctly diagnose before surgery because it mimics the common causes of acute surgical abdomen. We present a case of greater omental torsion that was diagnosed by laparoscopy. A 37-year-old man presented with right lower abdominal pain and was suspected to have appendicitis. Blood tests revealed elevated C-reactive protein and white blood cell count, whereas computed tomography revealed a nodular mass and high-density lesions in the fat tissue. As the patient's abdominal symptoms were severe and a clear diagnosis could not be made, we performed exploratory laparoscopy. Laparoscopy revealed omental torsion, and an omentectomy was performed. The patient's pain had significantly reduced post-surgery, and post-operative recovery was uneventful. Thus, laparoscopic examination is useful for accurately diagnosing omental torsion and is less invasive than surgery.

[Change in Therapy for Malignant Pleural Mesothelioma at Our Hospital].

When molecular target drug began to be used for chemotherapy to treat malignant pleural mesothelioma in 2014, we introduced this treatment strategy for 61 patients who were diagnosed and were being treated in our hospital. Chemotherapy was performed on 37 patients, while 12 patients underwent surgical remedy and best supportive care was provided to another 12 patients. Molecular target drug was used as the primary chemotherapy treatment in 14 cases, while it was the secondary treatment in 22 others. Pleural decortication was performed as the operative method for all the 12 cases requiring surgical remedy, and 2 of these cases were shifted to extrapleural pneumonectomy. By the chemotherapy, there were many cases of PS≥2, non‒epithelial type, advanced stage, LMR<2.74 of the biomarker. When we compared surgical remedy with the chemotherapy clinicopathologically. In the prognostic examination, in median survival time of all cases, as for 23 months, the chemotherapy, 31 months, the surgical remedy was not reached. Prognostic improvement of stage ⅢA was determined according to the stage of the chemotherapy. A multivariate variable analysis revealed that only a non‒sarcomatous type was a good prognostic factor, and surgery remedy was not.

Catamenial pneumothorax due to heterotopic endometriosis in the pericardium.

A 46-year-old woman presented with a right pneumothorax at a regular medical examination during menstruation. The pneumothorax resolved without intervention; however, 6 months later, she was referred to our hospital due to chest pain and dyspnoea. A chest X-ray showed grade III pneumothorax and surgery was performed. During surgery, the patient was found to have pleural adhesions around the right upper lung, pores in the diaphragm and a blueberry spot in the pericardium. The margins of the upper lobe and diaphragm were covered with a polyglycolic acid sheet at the operation. Eight days after surgery, she was referred to our hospital again due to massive haemothorax. The reoperation suggested that the aforementioned blueberry spot in the pericardium was the source of bleeding. The spot was resected and shown to be oestrogen and progesterone receptor-positive, providing evidence of heterotopic endometriosis.

[A Case of Intraductal Apocrine Carcinoma of the Breast].

A female in her 60s who complained of nipple discharge in her left breast for 1 year. A soft mass ill-defined margin in the border of AB area was observed. Mammography showed a focal asymmetric density. Ultrasonography disclosed an irregular heterogenous low echoic lesion in the AB area of her left breast. MRI image showed an enhanced lesion in the inner area. The pathological diagnosis by core needle biopsy was non-invasive ductal carcinoma with apocrine metaplasia. Mastectomy with sentinel lymph node biopsy of the left breast was performed. Post operative histopathological examination revealed intraductal apocrine carcinoma without lymph node metastasis. Estrogen and progesterone receptors were negative. Three years after operation without any adjuvant treatment, she has no recurrence of lesion.

[A Case of Metastatic Pancreatic Ductal Adenocarcinoma Successfully Treated with Modified FOLFIRINOX and Concurrent Radiotherapy].

A 70-year-old man with metastatic pancreatic ductal adenocarcinoma(cT4N1bM1, cStage Ⅳ)underwent chemotherapy with modified FOLFIRINOX without any severe adverse event to 20 cycles. In the middle of that, concurrent irradiation toward primary lesion(total dose, 43.2 Gy)was administered. Grade 1 adverse events include anemia, thrombocytopenia, hypoalbuminemia, hypokalemia, alkaline phosphatase increased, hypertension, peripheral sensory neuropathy, fatigue, anorexia and nausea. The relative dose intensities of oxaliplatin, irinotecan and fluorouracil at 6 months after beginning of treatment were 77.6, 84.0 and 88.3 percent, respectively. The total dose of administered oxaliplatin was 825 mg to the square meter. The primary lesion had been stable for the 20 cycles, although peritoneal dissemination had progressively increased in size. For 17 months, opioid was not necessary for the control of abdominal or back pain to the end of third-line treatment. Though safety or clinical benefits of modified FOLFIRINOX plus concurrent radiotherapy for metastatic pancreatic ductal adenocarcinoma have not been reported, in this case, such treatment might contribute to prolong prognosis or prevent developing abdominal or back pain.

[A Case of Malignant Thyroid Lymphoma That Was Difficult to Differentiate from Methotrexate-Associated Lymphoproliferative Disorders(MTX-LPD)].

A female patient in her 60s was going to get treatment for rheumatoid arthritis(RA). Considering the possibility of using biologics, CT examination was performed for screening of malignant diseases. A mass shadow in the left lobe of the thyroid gland was detected. The patient was followed up, and ultrasonography did not reveal any malignant findings. She was treated with methotrexate(MTX), and 1 year later, the thyroid mass was enlarged on CT. Ultrasonography revealed an enlarged hypoechoic region. Fine needle aspiration cytology revealed malignant lymphoma. Excisional biopsy was performed to determine the treatment plan. The pathological diagnosis was follicular lymphoma, and the possibility of methotrexate- associated lymphoproliferative disorders(MTX-LPD)persisted. It was difficult to discontinue MTX because of the high activity of RA. She was treated with rituximab for malignant lymphoma and concurrently with MTX for RA. The thyroid tumor disappeared for 3 months. Four years later, there is no sign of tumor recurrence.

[Two Cases of Stage â £ Occult Breast Cancer].

The first case is a 62-year-old female who complained of painful left axillary lymph node swelling. Six months later, a CT scan revealed multiple lung nodules. Biopsies of the axillary lymph node and lung showed metastatic carcinoma from breast cancer. However, no breast tumor was found. She was diagnosed with occult breast cancer with metastasis to the axillary lymph node and lung. ER(+), PgR(±), HER2(1+). Letrozole was administered, and effective control was achieved for 20 months. The second case is a 62-year-old female who presented with back pain. A CT scan revealed left axillary lymph node swelling and multiple osteolytic changes in the thoracolumbar spine and rib. Biopsies of the axillary lymph node and thoracic spine showed metastatic carcinoma from breast cancer. However, no breast tumor was found. She was diagnosed with occult breast cancer with metastasis to the axillary lymph nodule and bone. ER(+), PgR(+), HER2(1+). Fulvestrant and denosumab were administered. However, after 6 months, she discontinued the treatment. Our results suggested that effective control could be achieved through systemic therapy and local therapy was not necessary for Stage Ⅳ occult breast cancer.

[A Case of Unresectable Intrahepatic Cholangiocarcinoma Successfully Treated with Chemoradiotherapy].

A 69-year-old woman with unresectable intrahepatic cholangiocarcinoma(T3N1M1, Stage Ⅳ)underwent chemoradiotherapy with gemcitabine, cisplatin and irradiation toward primary lesion(total dose, 36 Gy). Grade 3 or 4 adverse events include leukopenia, neutropenia, and anemia. The relative dose intensities at 6 months after beginning of treatment were 58.9%(gemcitabine)and 80.2%(cisplatin), respectively. The total dose of administered cisplatin was 525 mg to the square meter. Partial response was obtained, and after that, the representative lesions have been stable with continuous administration of gemcitabine. As some studies have reported clinical benefits of chemoradiotherapy for unresectable intrahepatic cholangiocarcinoma, further clinical investigations are expected.

Negative pressure wound therapy with instillation without open-window thoracostomy for empyema.

Treatment of empyema is very challenging. The use of negative pressure wound therapy (NPWT), and NPWT with instillation and dwell time (NPWTi-d) for wound closure have attracted attention. However, they are both limited to use after open-window thoracostomy (OWT) performed to control infection. In some patients with poor general conditions, who cannot undergo surgery, no treatment for empyema is available. Therefore, we devised a new treatment for such patients with NPWTi-d without OWT (non-OWT NPWTi-d). Here we present the cases of two patients with refractory empyema after intrathoracic irrigation and drainage, who underwent non-OWT NPWTi-d using the fistula of the thoracic drain. Both the patients recovered. The first patient was treated for 31 days. As the empyema persisted, he underwent a repeat intrathoracic drainage after which the wound healed. The second patient was treated for 20 days. Non-OWT NPWTi-d may be a new option to treat empyema.

[A Case of Breast Metastasis of Gastric Cancer after an Eight Year Latency Period].

A 66-year-old woman underwent distal gastrectomy because of gastric cancer(stage ⅠB)and received no adjuvant chemotherapy. Eight years after the operation, computed tomography showed a small nodule in the right breast. Mammography did not reveal any abnormalities. Ultrasound sonography showed a diffuse and gradual non-mass-like low echoic lesion. Core needle biopsy indicated a malignancy. Partial resection of the right breast was performed to obtain a diagnosis. On postoperative histopathological examination, signet-ring cells were found in the tumor, and immunohistochemical analysis showed that both the breast tumor and the gastric carcinoma were MUC5AC-positive and MUC1-negative. We diagnosed this breast tumor as metastasis from gastric cancer. The patient has received chemotherapy with no subsequent metastatic tumors, and good control has been achieved for 21 months after the detection of the breast metastasis.

Rebiopsy with Thoracoscopy under Local Anesthesia for the Detection of EGFR T790M Mutation.

A 70-year-old woman underwent right upper lobectomy for adenocarcinoma of the lung (pT1bN2M0 stage IIIA). Five years after the surgery, lymph node recurrence was detected. Gefitinib was administered because epidermal growth factor (EGFR) exon 19 deletion mutation was detected in the previously resected surgical specimen. After a treatment of first-generation EGFR tyrosine kinase inhibitors, an FDG-PET/CT scan demonstrated abnormal FDG uptake in the pleura indicating pleural dissemination. Pleurocentesis revealed tumor cells in the pleural fluid; however, EGFR mutation testing failed due to inadequate tumor cellularity. Thoracoscopy under local anesthesia revealed multiple nodules on the parietal pleura. A biopsy specimen confirmed the diagnosis of lung adenocarcinoma with pleural dissemination and revealed EGFR exon 20-T790M mutation.

[A Case of Long-Term Survival after Para-Aortic Lymph Node Recurrence Following the Curative Resection of Gastric Cancer Treated Using Multimodality Therapy Including Salvage Surgery].

This case was observed in a man in his 70s. Although symptomatic treatment was performed for epigastralgia, endoscopic examination revealed a type 3 tumor on the fornix of the stomach to the lesser curvature of the body just above the esophagogastric junction, and the patient was diagnosed with moderately differentiated tubular adenocarcinoma(cT4bN3aM0, cStage ⅣA). As esophageal and diaphragmatic invasion was suspected based on CT findings, S-1 plus CDDP was started as preoperative chemotherapy. Although the primary lesion and lymph node metastasis decreased in size, chemotherapy was discontinued after one course due to stenosis symptoms, and total gastrectomy and D2 dissection were performed. Postoperative adjuvant chemotherapy with S-1 was started. However, 6 months after starting the treatment, para-aortic lymph node recurrence was observed, and the treatment strategy was changed to weekly PTX. After 5 courses of weekly PTX, the lymph nodes continued to increase in size, and chemotherapy was discontinued per the patient's request. The patient was followed up with CT and PET-CT; however, no new recurrent lesions were found in other sites for approximately 1 year. Therefore, para-aortic lymph node dissection was performed as the salvage surgery. Pathological findings showed that gastric cancer metastasis was present in 1 swollen lymph node only, as confirmed by PET. At present, 6 years have passed since the first operation, and there has been no recurrence. In general, para-aortic lymph node metastasis is considered to result in poor prognosis in gastric cancer. However, in the absence of other noncurative factors, a good prognosis may be obtained with combined therapeutic modalities.

Video-assisted thoracoscopic surgery for bilateral intralobar pulmonary sequestration.

INTRODUCTION: Intralobar pulmonary sequestration (ILS) is a rare congenital malformation, and is supplied by an aberrant systemic artery. The conventional surgical resection for ILS is lobectomy through an open thoracotomy. However, lobectomy might lead to a significantly compromised pulmonary function. There have been some reports on the feasibility or advantages of the VATS approach in recent years. We report a rare case where we performed a two staged segmentectomy and wedge resection of the affected lesions using a VATS approach for bilateral ILS, and achieved a successful outcome. CASE PRESENTATION: A 30-year-old woman was diagnosed with pneumonia. Chest CT showed multiple cystic masses containing fluid, in the posterobasal segment of the right lung and a hyper infiltrated area in the identical segment of the left lung. 3D CT angiography showed that the area of the right sided lesion received its blood supply from the left gastric artery and the area of the left sided lesion from the proximal celiac artery. The patient was diagnosed with bilateral ILS, and a staged, sequential lung resection was planned using the VATS approach. Anatomical basilar segmentectomy with VATS minithoracotomy for the right ILS, and resection of only the sequestrated lung by VATS for the left ILS were performed. CONCLUSIONS: It is important to plan the surgical treatment strategy for bilateral ILS for the preservation of respiratory function. Limited resection using the VATS approach for bilateral ILS can be performed safely and might be useful as a minimally invasive surgery.

[A Case of Primary Spinddle Cell Carcinoma of the Breast].

A 76-year-old female underwent breast-conserving surgery of the right breast and sentinel lymph node biopsy for primary breast cancer. Three years later, mammography and ultrasonography showed a small nodule in the right breast. There was nothing abnormal in the left breast. Three months later, she complained of a huge and rapid growing mass in the left breast. Malignant cells were obtained on fine needle aspiration biopsy in the right breast tumor. But it was not possible to diagnose whether the left breast tumor was benign or malignant on fine needle aspiration biopsy and needle biopsy. Bilateral mastectomy and sentinel lymph node biopsy of the right side were performed. Pathological diagnosis were squamous cell carcinoma of the right breast and spindle cell carcinoma of the left breast. Although the patient was treated with adjuvant chemotherapy, she had an early relapse with pleural, lung and bone metastases. The patient died approximately 8 months after operation. Spindle cell carcinoma presents many problems about therapy and prognosis. Further accumulation analysis is necessary.

Clinical features of secondary spontaneous pneumothorax complicated with silicosis.

BACKGROUND: Few studies have focused on the management of secondary spontaneous pneumothorax (SSP) as a complication of pneumoconiosis. The aim of this study was to investigate the clinical features and therapeutic course of SSP associated with silicosis. METHODS: Between April 2005 and March 2015, 17 patients with silicosis underwent chest tube drainage for SSP in our institution. We retrospectively analyzed patient characteristics, type of treatment, clinical course, rate of recurrence, and survival time, and compared them with those of 30 patients diagnosed with chronic obstructive pulmonary disease (COPD) during the same period. RESULTS: Fourteen patients with silicosis had performance status score ≥ 2 and modified Medical Research Council Grade ≥ 2; these were significantly different from those in patients with COPD (P = 0.047, P = 0.026). Patients with silicosis had a significantly longer duration of chest tube placement and hospital stay. Recurrent pneumothorax occurred in 47.1% of patients with silicosis, which was not significantly different from the proportion of patients with COPD (40.9%, P = 0.843). However, in the silicosis group, patients treated with chest tube drainage alone tended to have a higher rate of ipsilateral recurrence than those who had pleurodesis, although this was not statistically significant. The median overall survival time of patients with silicosis was 82.6 months, while that of patients with COPD was 104.1 months. CONCLUSIONS: Patients with silicosis had worse physical status and respiratory functions at the time of occurrence of pneumothorax than those with COPD. Pleurodesis could be an effective treatment for SSP complicating silicosis.

Visualization of bronchial circulation at bronchial anastomotic site using bronchial fluorescein angiography technique.

OBJECTIVES: Successful bronchial healing after a bronchoplastic procedure mainly depends on bronchial circulation at the anastomostic site. We developed a bronchial fluorescein angiography (B-FAG) technique for visualizing circulation on the bronchial surface. The technique was evaluated in animals. METHODS: Fluorescein was used as a contrast agent and an autofluorescence imaging (AFI) bronchoscope as a detector. The left main pulmonary artery (PA) and main bronchus of 10 pigs were isolated. After transection of the left main bronchus and bronchial arteries and re-anastomosis of the bronchus, the pigs were randomly divided into two groups: the PA- group (n = 5), in which the pulmonary artery was transected; and the PA+ group (n = 5), in which the pulmonary artery was preserved. Following intravenous injection of fluorescein, the distal anastomotic site was observed for 30 min with autofluorescence imaging bronchoscopy. Bronchial specimens sampled 2 days after the surgical intervention were histologically evaluated. RESULTS: In the PA- group, there was no fluorescein enhancement in the distal bronchus throughout the observation time. However, enhancement, which turned the bronchial surface from magenta to bright green, was clearly observed in less than 207 ± 102.5 s in the PA+ group. The enhancement status detected by bronchial fluorescein angiography was related to the extent of tissue damage, as was proven histologically in the acute healing stage. CONCLUSIONS: Bronchial fluorescein angiography clearly visualized the circulatory status promptly after the anastomosis procedure at the central bronchus. This technique is a potentially practical approach to predict ischaemic airway complications following bronchial anastomosis.