Assessment of pleural air leakage using digital chest drainage system after surgical pulmonary resection: Comparison of visible alveolar air leakage with the digital value measured by a digital chest drainage system.

BACKGROUND: The sensitivity of postoperative pleural air leakage (PAL) after pulmonary resection is evaluated by a simple subjective grading method in clinical practice. A new electronic digital chest drainage evaluation system (DCS) recently became clinically available. This study was designed to evaluate the clinical application of the DCS in monitoring the airflow volume and managing postoperative PAL. METHODS: We prospectively enrolled 25 patients who underwent pulmonary resection. Postoperative PAL was evaluated using both conventional PAL grading based on the physician's visual judgment (analog chest drainage evaluation system [ACS]: Level 0 = no leakage to 4 = continuous leakage) and the DCS. The DCS digital measurement was recorded as the flow volume (ml/min), which was taken once daily from postoperative day 1 to the day of chest drainage tube removal. RESULTS: In total, 45 measurements were performed on 25 patients during the evaluation period. Postoperative PAL was observed in five patients (20.0%) and judged as ACS Level >1. The mean DCS values corresponding to ACS Levels 0, 1, 2, and 3 were 2.42 (0.0-11.3), 48.6 (35.4-67.9), 95.6 (79.7-111.5), and 405.3 (150.3-715.6), respectively. The Spearman correlation test showed a significant positive correlation between the ACS PAL level and DCS flow volume (R = 0.8477, p < 0.001). CONCLUSIONS: A relationship between the visual PAL level by the ACS and the digital value by the DCS was identified in this study. The numeric volume obtained by the DCS has been successful in information-sharing with all staff. The digital PAL value evaluated by the DCS is appropriate, and the use of the DCS is promising in the treatment of postoperative PAL after pulmonary resection.

Primary intrapulmonary thymoma.

Primary intrapulmonary thymoma (PIT), which is an intrapulmonary tumor without an associated mediastinal component, is rare. We herein report a resected case of PIT in a 55-year-old female who presented with a 2.5 × 2.4 cm mass in the left upper lobe. We also summarize the clinicopathological features and discuss the diagnosis, pathogenesis, and treatment of PIT.

A case of middle mediastinal cavernous hemangioma.

A 51-year-old female was referred to our clinic for investigation of abnormal chest X-ray findings during a routine health examination. Chest computed tomography showed a middle mediastinal tumor, and she was admitted to hospital for surgical treatment. The tumor was removed using thoracoscopic surgery, without significant blood loss. Pathological examination showed that the tumor was composed of blood vessels with relatively thick vascular walls containing smooth muscle. Immunohistochemical staining was positive for CD34 and Factor VIII, and negative for D2-40. Based on these findings, the tumor was diagnosed as a cavernous hemangioma. We herein present this very rare case of middle mediastinal cavernous hemangioma.

[A case of long-term survival following combined modality therapy for peritoneal disseminated recurrence of duodenal cancer].

A 65-year-old man was diagnosed with primary duodenal cancer and he underwent pancreaticoduodenectomy in June 2006. S-1 was administered as the postoperative adjuvant chemotherapy. A peritoneal disseminated recurrence was diagnosed together with a right reniportal node and right hydronephrosis in February 2007. A ureteral stent was inserted. DOC +S-1 combination therapy was administered from March 2007. Following progression of the recurrence, CDDP+S-1 combination therapy was administered from August 2007. Temporal diminution of the recurrence was achieved with radiotherapy from May to June 2009. Following re-progression of the recurrence, biweekly CPT-11 therapy was administered from February 2010. Weekly PTX therapy was administered from January 2011. The patient died due to progression of the recurrence in June 2011, 5 years after the operation. Our patient maintained a good quality of life and achieved long-term survival by combined modality therapy for peritoneal disseminated recurrence of duodenal cancer.

[A case successfully treated with abdominoperineal resection after preoperative chemoradiation therapy for anal cancer].

A 46-year-old female was diagnosed with anal squamous cell carcinoma. Chemoradiation therapy was administered for a first-line therapy. Two courses of enforced 5-FU/MMC combination therapy were administered along with radiotherapy (60 Gy). This chemoradiation therapy had complete response. However, three months after, anal cancer had a local recurrence. Since there was no distant metastasis, abdoninoperineal resection was performed. No complications were observed after the operation. We conclude that abdominoperineal resection may be effective in the treatment of anal cancer in cases which the local recurrence was observed after chemoradiation therapy.

[A case of long-term survival by combined modality therapy for liver and pulmonary metastasis of rectal cancer].

We report a case of rectal cancer diagnosed in 2001, which enforced a rectal low anterior resection. Then, metastatic liver cancer and metastatic lung cancer recurred and we enforced an operation for both. Furthermore, metastatic lung cancer recurred again and enforced chemotherapy with radiation and systemic chemotherapy for approximately seven years. The metastatic lung cancer was reduced now in 2011, so that the chemotherapy has not been used since then. In our case, we mainly performed a surgical and radiation therapy for a local recurrent site therapy in the first half because we did not have much choice for a systemic chemotherapy like we have now. In the later half, we mainly performed a systemic chemotherapy to control the local recurrent site. A treatment policy for colon cancer recommends a surgical treatment by the guidelines, or even though chemotherapy has been developed at present, if a local therapy is practical. There were many cases where metastases had occurred right after surgery so a local site therapy by excision was good at all unconditionally. However, as a result of our case in a local site therapy combined with whole body chemotherapy, we report here that a long- term survival was obtainable. We also include a brief literature review.

[Two cases, of pulmonary sclerosing hemangioma, and peripheral lung carcinoid, in which the diagnoses were difficult by intraoperative frozen section examinations].

Case 1: A 38-year-old man was referred to our hospital because of a chest nodular shadow found on a medical check-up. Chest CT showed a mass about 2 cm in diameter with a sharp margin in the right S6 segment. Right lower lobectomy was performed by video-assisted thoracoscopic surgery, because the mass was thought to be a peripheral lung carcinoid by intraoperative frozen section examination. However, the postoperative histopathological diagnosis was pulmonary sclerosing hemangioma with lymph node metastasis. Case 2: An 81-year-old woman was referred to our hospital because of a chest nodular shadow found on a medical check-up. Chest CT showed a mass about 1.5 cm in diameter with a sharp margin in the right S. Partial lung resection was performed by video-assisted thoracoscopic surgery, because the mass was thought to be an inflammatory lymph node on intraoperative frozen section examination. However, the postoperative histopathological diagnosis was peripheral lung carcinoid. Then, a right middle lobectomy was performed. These cases suggest that it may be difficult to diagnose peripheral lung carcinoid or pulmonary sclerosing hemangioma by intraoperative frozen section examination because of their pathological diversity.

[A case successfully treated with subtotal esophagectomy after preoperative second-line chemotherapy for cT4 esophageal cancer].

A 69-year-old male was diagnosed with type 2 advanced esophageal cancer in the upper and middle thoracic esophagus which invaded the left main bronchus and the aorta. Radio-chemotherapy was administered since a radical resection could not be performed due to the invasion. Two courses of enforced FP combination therapy (5-FU and CDDP) were administered along with radiotherapy. Although this radio-chemotherapy was effective to some degree in tumor reduction, a radical resection still could not be performed due to the invasion of the left main bronchus and the aorta. Thus, we administered four more courses of DCF combination therapy (docetaxel, CDDP and 5-FU). This chemotherapy reduced the esophageal cancer mass significantly, and subtotal esophagectomy was performed. No complications were observed after the operation. We conclude that DCF combination therapy may be effective in the treatment of esophageal cancer in cases which the desired effect cannot be achieved by FP combination therapy alone.

[A case of elderly advanced gastric cancer patient with multiple liver metastases effectively treated by hepatic arterial infusion chemotherapy].

An 85 years old man was performed systemic chemotherapy after the palliative gastrectomy for unresectable gastric cancer with multiple liver metastases. The response evaluation revealed a progressive disease after 4 courses of first-line S-1 therapy and 3 courses of second-line paclitaxel therapy. At this point, metastatic lesions were still localized in the liver, so hepatic arterial infusion chemotherapy (HAI) was introduced as third-line therapy. Despite the marked reduction of all target lesions and reduced tumor marker level after 25 weeks of HAI without any adverse event, novel multiple metastatic lesions had appeared in the lung and celiac LNs, resulted in the cessation of HAI. Then he had suffered grade 3 mucositis oral and anorexia throughout 2 courses of fourth-line S-1 + CDDP therapy and fifth-line docetaxel therapy. Considering that the goal of treatment for unresectable gastric cancer patients is to delay developing symptoms and to prolong their life with the least adverse event, HAI could be an effective therapy.

[A long-term survival after hepatectomy combined with hepatic arterial infusion chemotherapy for hepatic metastasis of colon cancer].

We report on a patient who presented in 2000 with multiple hepatic metastasis of sigmoid colon cancer. We chose the hepatic arterial infusion chemotherapy for this case since there was no effective chemotherapy at that time. After the intermittent chemotherapy for one and half years, we recognized that the tumor became smaller, though it couldn't cure completely. Therefore, two years after the first medical examination, we underwent a hepatic left lobectomy and S8 hepatectomy. No recurrence has been observed until now. As a recent treatment of the hepatic metastasis of colon cancer, there is a tendency to choose chemotherapy before operation. However, there are some cases in which chemotherapy isn't acceptable because of its side effect. Besides chemotherapy, we report another treatment (the hepatic arterial infusion chemotherapy) which has a similar effectiveness with fewer side effects for the hepatic metastasis of colon cancer.

[A case of duodenal penetration by indwelling catheter during hepatic arterial infusion chemotherapy].

We report a patient with hepatic metastasis of descending colon cancer who underwent hepatic arterial infusion chemotherapy using 5-fluorouracil (5-FU) and CDDP, with an indwelling catheter and port system by GDA coil method. Since the tumor became smaller after five months, we decided to follow her up as an outpatient. Considering the possibility of its recurrence, the catheter-port system remained in her. Two and half years later, the recurrent hepatic metastasis was recognised and the hepatic arterial infusion chemotherapy was fulfilled again. The tumor obviously reduced and the same treatment was continued. However, he was hospitalized with a complaint of hematemesis. Upper gastrointestinal endoscopy revealed a projection around the splitting catheter in the duodenal bulb. Therefore, we embolized with coil under angiographic guidance in order not to bleed from the artery and removed the port. With this experience, special attention for the catheter port system must be taken if one considers a long-term treatment. Thereby, we report on the complications of the catheter-port system.

The use of a water seal to manage air leaks after a pulmonary lobectomy: a retrospective study.

BACKGROUND: The methods for managing chest drainage tubes during the postoperative period differ among thoracic surgeons and, as a result, the optimal method remains controversial. PATIENTS AND METHODS: We reviewed 170 consecutive patients undergoing a pulmonary lobectomy for either primary lung cancer or metastatic lung cancer from January 1998 to December 2002. After the operation, the chest drainage tube was placed on a suction pump with a negative pressure of -10 cmH(2)O in 120 patients before 2001, while such drainage tubes were kept on water seal in 47 cases mainly since 2001. RESULTS: Regarding the preoperative and postoperative variables, postoperative air leak as well as the video-assisted thoracic surgery (VATS) procedure were more frequently observed in the water seal group than in the suction group (p=0.01580, p<0.001, respectively). In comparing these different populations, each Kaplan-Meier curve, which presented the duration of the postoperative air leak seemed to be similar between the two methods. CONCLUSION: These observations suggest that applying chest tubes on water seal seems to be an effective method for preventing postoperative air leak in clinical practice. However, a prospective randomized trial using a larger series of patients is warranted for this subject.

Multimodal treatment for resectable epithelial type malignant pleural mesothelioma.

BACKGROUND: Malignant pleural mesothelioma is a rare malignancy. The outcome remains poor despite complete surgical resection. PATIENTS AND METHODS: Eleven patients with histologicaly proven epithelial type malignant pleural mesothelioma undergoing extrapleural pneumonectomy with systemic chemotherapy and/or radiotherapy before and after surgical resection were retrospectively reviewed. RESULTS: Ten out of 11 patients underwent complete surgical resection, of these 7 patients had stage I disease. Of these 7 patients, 5 are alive without any recurrence, a 2-year survival rate of 80% was observed in this group. There was no operative mortality or morbidity. CONCLUSION: Extrapleural pneumonectomy with perioperative adjuvant treatment is safe and effective procedure for epithelial type malignant pleural mesothelioma.

Induction chemoradiotherapy and surgical resection for selected stage IIIB non-small-cell lung cancer.

BACKGROUND: Combination chemotherapy using an oral combination of uracil and tegafur (UFT) plus cisplatin and concurrent thoracic radiotherapy is reported to have a high response rate and less toxicity for locally advanced non-small-cell lung cancer (NSCLC) patients. We performed a phase II trial using this chemoradiotherapy as an induction treatment. METHODS: Patients with marginally resectable stage IIIB NSCLC, an age younger than 70 years, a performance status of 0 or 1, and good organ function were eligible. The UFT (400 mg/m(2)) was administered orally on days 1 through 14 and 22 through 35 and cisplatin (80 mg/m(2)) was injected intravenously on days 8 and 29. Radiotherapy with a total dose of 40 Gy was delivered in 20 fractions from day 1. A surgical resection was performed from 3 to 6 weeks after completing the induction treatment. RESULTS: Twenty-seven patients, 18 male and 9 female with a median age of 56 years and ranging from 36 to 69 years, were entered into the phase II trial. Clinical T4 and N3 cancers were observed in 22 and 7 patients, respectively. Twenty-five (93%) achieved a partial response. The most frequently observed adverse event was grade 3 leukopenia in 26%. Of 25 patients who underwent a thoracotomy, 22 had a tumor resection. In all 22 patients a complex resection including a resection of the superior vena cava, carina, and vertebrae was required. Operative morbidity and mortality rates were 36% and 4% respectively. The calculated 1-year and 3-year survival rates of all 27 patients were 73% and 56% respectively. CONCLUSIONS: Chemotherapy using UFT plus cisplatin and concurrent radiotherapy as induction treatment and a surgical resection for patients with marginally resectable stage IIIB NSCLC is feasible and promising. However it is difficult to conduct multi-institutional trials even for selected stage IIIB disease as a complex resection in almost all patients is necessary.

[A case of preoperative concurrent chemoradiotherapy and curative resection for locally advanced non-small-cell lung cancer].

We report the case of a 58-year-old man who underwent complete resection for locally advanced non-small-cell lung cancer (cT4N2M0). The patient received UFT (400 mg/m2 orally on days 1-14 and 22-35) and cisplatin (80 mg/m2 intravenously on days 8, 29) with a total 40 Gy, delivered in 20 fractions on days 1-26. The tumor reduction rate was 76%, and no remarkable toxicities were observed. The patient underwent complete resection and a pathologic complete response was observed. This induction concurrent chemoradiotherapy (followed by surgery) is considered to be effective and safe.

Treatment outcome of resected and nonresected primary adenoid cystic carcinoma of the lung.

BACKGROUND AND OBJECTIVE: The incidence of primary adenoid cystic carcinoma of the lung is relatively rare and the optimal treatment strategy is still unclear. METHODS: Sixteen adenoid cystic carcinoma patients were treated at our institute from 1972 to 1998 and their clinical features, treatments and survivals were reviewed. RESULTS: Half of all patients were female and the median age was 46 ranging from 30 to 64. All primary lesions were located in the central bronchial tree and 80% of the patients had some symptoms. Eleven patients underwent a resection of the tumor with/without plasty of the trachea or bronchus. Although 6 (55%) of 11 patients had a microscopic residual tumor after resection, 5 patients who received postoperative radiotherapy survived without recurrence from 3 to 17 years. Five patients received radiotherapy as their initial treatment and all tumors responded well to the treatment. The 5-year and 10-year survival rates were 91 and 76% without local recurrence in the resected group and 40 and 0% in the nonresected group, respectively. CONCLUSION: These observations suggest that surgical resection should be selected first whenever possible, and, in addition, adenoid cystic carcinoma is sensitive to radiotherapy.