Robot-assisted distal gastrectomy and local resection for gastric cancer and gastrointestinal stromal tumor.

Gastrointestinal stromal tumors surrounding the esophagogastric junction are often challenging to resect, with no consensus regarding the optimal surgical technique. Here in, we present a case of concurrent gastric cancer in the antrum and gastrointestinal stromal tumors adjacent to the esophagogastric junction. The patient underwent simultaneous distal gastrectomy and local resection assisted by a surgical robot, avoiding the need for total gastrectomy. The utilization of robot-assisted surgery has become an increasingly popular technique, holding promise for simplifying complex surgical procedures across diverse medical settings.

Synchronous multiple lung cancers with hilar lymph node metastasis of small cell carcinoma: A case report.

BACKGROUND: Synchronous multiple lung cancers are rare and refer to the simultaneous presence of two or more primary lung tumors, which present significant challenges in terms of diagnosis and treatment. CASE SUMMARY: We report a case of multiple synchronous lung cancers with hilar lymph node metastasis of small cell carcinoma of unknown origin in a 73-year-old man. Transbronchial lung biopsy revealed squamous cell carcinoma. Although enlargement of lymph node 12u was detected, no distant metastases were observed. The patient was preoperatively diagnosed with T1cN0M0 and underwent thoracoscopic right upper lobectomy with nodal dissection (ND2a). Based on histopathological findings, the primary lesion was squamous cell carcinoma. A microinvasive adenocarcinoma was also observed on the cranial side of the primary lesion. Tumors were detected in two resected lymph nodes (#12u and #11s). Both tumors were pathologically diagnosed as small cell carcinomas. The primary lesion of the small cell carcinoma could not be identified even by whole-body imaging; however, chemotherapy was initiated for hilar lymph node metastasis of the small cell carcinoma of unknown origin. CONCLUSION: Multiple synchronous lung cancers can be accompanied by hilar lymph node metastasis of small cell carcinomas of unknown origin.

Primary Dedifferentiated Liposarcoma of the Posterior Mediastinum With a Positive Surgical Margin.

Liposarcoma often occurs in the extremities and retroperitoneum. Primary mediastinal liposarcoma is uncommon, and there is no settled opinion regarding adjuvant therapy after surgery. We have recently experienced a relatively rare case of primary dedifferentiated liposarcoma of the posterior mediastinum. The patient was a 76-year-old woman. An abnormal shadow was noted in the posterior mediastinum. Esophageal submucosal tumor and gastrointestinal stromal tumor were suspected; endoscopic ultrasound-guided fine needle aspiration was performed, but a definitive diagnosis could not be obtained. As the tumor tended to slowly grow, surgical resection was performed. Based on histopathological findings, the patient was diagnosed with primary dedifferentiated liposarcoma of the posterior mediastinum. Owing to the presence of a positive surgical margin, postoperative radiotherapy (60 Gy/24 fr/6 w) was administered. No recurrence was observed after three and a half years of follow-up. The prognosis of primary dedifferentiated liposarcoma of the posterior mediastinum with a positive surgical margin is poor, but postoperative radiotherapy may be useful.

Assessment of factors affecting flicker ERGs recorded with RETeval from data obtained from health checkup screening.

PURPOSE: To determine the factors significantly associated with the amplitudes and implicit times of the flicker electroretinograms (ERGs) recorded with the RETeval system by analyzing the comprehensive data obtained during a health checkup screening. METHODS: Flicker ERGs were recorded with the RETeval system from 373 individuals who had a normal fundus and optical coherence tomography images. The sex, age, anthropometric, ophthalmologic, and hematologic data were collected from all participants who were 40- to 89-years-of-age. Univariable and multivariable linear mixed effects regression analyses were performed to identify factors that were significantly associated with the implicit times and amplitudes of the RETeval flicker ERGs. RESULTS: Univariable linear mixed effects regression analysis showed significant correlations between the implicit times and the best-corrected visual acuity, the age, the axial length, the blood sugar level, and the blood urea nitrogen level. Analyses by multivariable linear mixed effects regression identified that the axial length (ß = 0.28), the age (ß = 0.24), and the blood sugar level (ß = 0.092) were three independent factors that were significantly correlated with the implicit times of the RETeval flicker ERGs. Univariable linear mixed effects regression analysis also showed significant correlations between the amplitudes of the RETeval flicker ERGs and the age, the platelet count, and the creatinine level. Multivariable linear mixed effects regression models identified the age (ß = -0.092), the platelet count (ß = 0.099), and the creatinine level (ß = -0.12) as three independent factors that were significantly correlated with the amplitudes of the RETeval flicker ERGs. However, the smoking habits, body mass index, and the blood pressure were not significantly correlated with either the implicit times or amplitudes of the RETeval flicker ERGs. CONCLUSIONS: Our results indicate that the age and some ophthalmologic and hematologic findings but not the anthropometric findings were significantly associated with the implicit times and amplitudes of the RETeval flicker ERGs. Thus, clinicians should remember these factors when analyzing the RETeval flicker ERGs.

A Case of Pneumothorax Ex Vacuo Associated with COVID-19.

Pneumothorax is a known complication of coronavirus disease 2019 (COVID-19). The concept of pneumothorax ex vacuo has also been proposed to describe pneumothorax that occurs after malignant pleural effusion drainage. Herein, we present the case of a 67-year-old woman who had abdominal distension for 2 months. A detailed examination led to the suspicion of an ovarian tumor and revealed an accumulation of pleural effusion and ascitic fluid. Thoracentesis was performed, raising the suspicion of metastasis of high-grade serous carcinoma arising from the ovary. An ovarian biopsy was scheduled to select subsequent pharmacotherapy, and a drain was inserted preoperatively into the left thoracic cavity. Thereafter, a polymerase chain reaction analysis revealed that the patient was positive for COVID-19. Thus, the surgery was postponed. After the thoracic cavity drain was removed, pneumothorax occurred, and mediastinal and subcutaneous emphysema was observed. Thoracic cavity drains were then placed again. The patient's condition was conservatively relieved without surgery. This patient may have developed pneumothorax ex vacuo during the course of a COVID-19 infection. Since chronic inflammation in the thoracic cavity is involved in the onset of pneumothorax ex vacuo, careful consideration is required for the thoracic cavity drainage of malignant pleural effusion and other fluid retention.

[Thymic Neuroendocrine Tumor Associated with Multiple Endocrine Neoplasia Type 1].

Multiple endocrine neoplasia (MEN) type 1 is a hereditary syndrome characterized by hyperplasia and adenoma of the parathyroid gland, pancreatic tumor, and pituitary tumor. We report a rare case of thymic neuroendocrine tumor diagnosed after removal of a thymic tumor following pancreatic and parathyroid surgery. A 35-year-old man was diagnosed with MEN type 1 by hypercalcemia and gastrinemia with a ureteral tone. Two well defined nodules in the anterior mediastinum on computed tomography (CT), and a high degree of accumulation on positron emission tomography (PET) was noted. Surgery was performed through a median sternotomy with anterior mediastinal tumor resection. Pathology showed thymic neuroendocrine tumor (NET). Immunostaining results were different from pancreatic NET and duodenal NET, and a diagnosis of primary thymic NET was made. Postoperative radiation therapy was completed as adjuvant therapy, and the patient is alive without reccurrence.

Expression of soluble CD27 in extranodal natural killer/T-cell lymphoma, nasal type: potential as a biomarker for diagnosis and CD27/CD70-targeted therapy.

The engagement of CD27 on lymphocytes with its ligand, CD70, on tumors is believed to mediate tumor immune evasion and the elevation of serum soluble CD27 (sCD27) levels in patients with CD70-positive malignancies. We previously showed that CD70 is expressed in extranodal natural killer/T-cell lymphoma, nasal type (ENKL), an Epstein-Barr virus (EBV)-related malignancy. However, little is known about serum sCD27 expression and its association with the clinical characteristics of, and the CD27/CD70 interaction in, ENKL. In the present study, we show that serum sCD27 is significantly elevated in the sera of patients with ENKL. The levels of serum sCD27 provided excellent diagnostic accuracy for discriminating patients with ENKL from healthy subjects, correlated positively with the levels of other diagnostic markers (lactate dehydrogenase, soluble interleukin-2 receptor, and EBV-DNA), and decreased significantly following treatment. Elevated serum sCD27 levels also correlated significantly with advanced clinical stage and tended to correspond with shorter survival, in patients with ENKL. Immunohistochemistry indicated that CD27-positive tumor-infiltrating immune cells exist adjacent to CD70-positive lymphoma cells. In addition, serum sCD27 levels in patients with CD70-positive ENKL were significantly higher than those in patients with CD70-negative ENKL, suggesting that the intra-tumoral CD27/CD70 interaction boosts the release of sCD27 in serum. Furthermore, the EBV-encoded oncoprotein latent membrane protein 1 upregulated CD70 expression in ENKL cells. Our results suggest that sCD27 may serve as a novel diagnostic biomarker and also may serve as a tool for evaluating the applicability of CD27/CD70-targeted therapies by predicting intra-tumoral CD70 expression and CD27/CD70 interaction in ENKL.

Celecoxib promotes the efficacy of STING-targeted therapy by increasing antitumor CD8+ T-cell functions via modulating glucose metabolism of CD11b+ Ly6G+ cells.

Recent studies have shown that activation of the cGAS-STING pathway is a key process in antitumor immune responses and various kinds of STING agonists have been developed for cancer immunotherapy. Despite promising preclinical studies, preliminary clinical results have shown only a modest effect of STING agonists. There is therefore a need to develop more effective treatment strategies. Based on previous observations that COX-2 is frequently overexpressed not only in a variety of cancers but also in tumor myeloid cells and that it suppresses antitumor immunity and promotes tumor survival by producing PGE2, we investigated the antitumor effects of combination therapy with a STING agonist cGAMP and the selective COX-2 inhibitor celecoxib in mouse models. Combination treatment with cGAMP and celecoxib inhibited tumor growth compared with either monotherapy, and the combination therapy induced both local and systemic antitumor immunity. cGAMP treatment decreased PD-1 expression on tumor-infiltrating T-cells and enhanced T-cell activation in tumor-draining lymph nodes regardless of the presence of celecoxib. Meanwhile, although celecoxib treatment did not alter the frequency of CD4+ CD25+ Foxp3+ regulatory T-cells, it enhanced the expression of costimulatory molecules and glycolysis-associated genes in tumor-infiltrating CD11b+ Ly6G+ cells. Moreover, we also found that celecoxib decreased lactate efflux and increased the frequency of IFN-γ- and TNF-α-producing CD8+ T-cells in the tumor microenvironment. Taken together, our findings suggest that combined treatment with celecoxib may be an effective strategy to improve the antitumor efficacy of STING agonists.

A tumor metastasis-associated molecule TWIST1 is a favorable target for cancer immunotherapy due to its immunogenicity.

Although neoantigens are one of the most favorable targets in cancer immunotherapy, it is less versatile and costly to apply neoantigen-derived cancer vaccines to patients due to individual variation. It is, therefore, important to find highly immunogenic antigens between tumor-specific or associated antigens that are shared among patients. Considering the cancer immunoediting theory, immunogenic tumor cells cannot survive in the early phase of tumor progression including two processes: elimination and equilibrium. We hypothesized that highly immunogenic molecules are allowed to be expressed in tumor cells after an immune suppressive tumor microenvironment was established, if these molecules contribute to tumor survival. In the current study, we focused on TWIST1 as a candidate for highly immunogenic antigens because it is upregulated in tumor cells under hypoxia and promotes tumor metastasis, which is observed in the late phase of tumor progression. We demonstrated that TWIST1 had an immunogenic peptide sequence TWIST1140-162 , which effectively activated TWIST1-specific CD4+ T-cells. In a short-term culture system, we detected more TWIST1-specific responses in breast cancer patients compared with in healthy donors. Vaccination with the TWIST1 peptide also showed efficient expansion of TWIST1-reactive HTLs in humanized mice. These findings indicate that TWIST1 is a highly immunogenic shared antigen and a favorable target for cancer immunotherapy.

Broad locations of antigenic regions for anti-TRPM1 autoantibodies in paraneoplastic retinopathy with retinal ON bipolar cell dysfunction.

PURPOSE: Cancer-associated retinal ON bipolar cell dysfunction (CARBD), which includes melanoma-associated retinopathy (MAR), has been reported to be caused by autoantibodies against the molecules expressed in ON bipolar cells, including TRPM1. The purpose of this study was to determine the antigenic regions of the autoantibodies against TRPM1 in the sera of CARBD patients, in whom we previously detected anti-TRPM1 autoantibodies. METHODS: The antigenic regions against TRPM1 in the sera of eight CARBD patients were examined by Western blots using HEK293T cells transfected with the plasmids expressing FLAG-tagged TRPM1 fragments. The clinical course of these patients was also documented. RESULTS: The clinical course differed among the patients. The electroretinograms (ERGs) and symptoms were improved in three patients, deteriorated in one patient, remained unchanged for a long time in one patient, and were not followable in three patients. Seven of the eight sera possessed multiple antigenic regions: two sera contained at least four antigen recognition regions, and three sera had at least three regions. The antigen regions were spread over the entire TRPM1 protein: five sera in the N-terminal intracellular domain, six sera in the transmembrane-containing region, and six sera in the C-terminal intracellular domain. No significant relationship was observed between the location of the antigen epitope and the patients' clinical course. CONCLUSIONS: The antigenic regions of anti-TRPM1 autoantibodies in CARBD patients were present not only in the N-terminal intracellular domain, which was reported in an earlier report, but also in the transmembrane-containing region and in the C-terminal intracellular domain. In addition, the antigenic regions for TRPM1 were found to vary among the CARBD patients examined, and most of the sera had multiple antigenic regions.

The feasibility of circulating tumor DNA analysis as a marker of recurrence in triple-negative breast cancer.

Triple-negative breast cancer (TNBC) has a poorer prognosis than other breast cancer subtypes; therefore, identifying markers of early recurrence is important. The present study aimed to establish a liquid biopsy protocol for droplet digital PCR-based detection of frequently mutated genes in patients with TNBC. Tumor DNA from 36 patients with TNBC who relapsed within 2 years after surgical resection was retrospectively analyzed. Somatic mutational profiles were evaluated using targeted sequencing to identify frequently mutated genes and genes associated with molecularly targeted therapies. The association between genetic alterations and associated protein phosphorylation was investigated using immunohistochemical analysis. Recurrent hot spot mutations in the plasma were monitored over time. Mutation-specific probes were used to successfully detect mutations in the blood samples of patients who were positive for PIK3CA H1047R and AKT1 E17K mutations. Somatic mutations in AKT1 (14.9%) and PIK3CA (25.5%) were frequently identified in the data. Robust phosphorylation of AKT and S6RP was more common in tumors with PIK3CA H1047R and AKT1 E17K mutational background than in tumors with wild-type PIK3CA and AKT1. In conclusion, the present study evaluated a high-sensitivity detection system for frequently mutated genes that was also applicable for cell-free DNA. The PI3K/AKT pathway was revealed to be activated in patients harboring PIK3CA H1047R and AKT1 E17K mutations; therefore, the PI3K/AKT pathway may be a promising candidate for targeted therapy in these patients.

Photodynamic Diagnosis for Pleural Disseminated Lesions of Lung Cancer Using a Combination of 5-Aminolevulinic Acid and Autofluorescence Observation System.

PURPOSE: We developed a diagnostic method for pleural disseminated lesions of lung cancer using a combination of 5-aminolevulinic acid (5ALA) and autofluorescence observation system. We utilized a phenomenon in which externally ingested 5ALA is metabolized to protoporphyrin IX, a precursor of heme, which remains inside malignant cells and emits red fluorescence of approximately 630 nm. The diagnosis was made employing an observation system based on autofluorescence emitted from normal tissues that we have investigated. METHODS: Between January 2017 and April 2019, we examined 82 lung cancer patients with suspected pleural invasion. We orally administered 5ALA (20 mg/m2) to the patients 4 hours before surgery, and malignant pleural lesions were thoracoscopically visualized using the autofluorescence observation system. RESULTS: (1) Pleural disseminated lesions were observed in six patients. Of these lesions, two were not detected by usual white light inspection, and the use of this method enabled the diagnosis of disseminated lesions. (2) Regarding the diagnosis of lung cancer pleural invasion to estimate the risk of pleural dissemination, if limited to adenocarcinoma, the sensitivity was 93.9%; specificity, 74.3%; positive predictive value, 60.8%; and negative predictive value, 96.2%. CONCLUSION: This method may facilitate the detection of minute disseminated lesions that are difficult to detect by usual inspection. In addition, the degree of pleural invasion may be diagnosed to evaluate the need for limited resection such as segmentectomy.

Spontaneous pneumothorax caused by an inflammatory myofibroblastic tumor-like lesion in a 14-year-old girl: a case report.

BACKGROUND: Spontaneous pneumothorax occurs more often in younger, slim, and shallow-chested men. Although less common, differential diagnoses for secondary pneumothorax in children are asthma, emphysematous blebs, catamenial pneumothorax, and others. We report a patient who presented with pneumothorax and was found to have an inflammatory myofibroblastic tumor (IMT)-like lesion, and present a review of the related literature. CASE PRESENTATION: A 14-year-old girl visited her physician for chest pain that developed while exercising. Although chest drainage was performed, the symptoms associated with a collapsed lung did not improve, and she was referred to our hospital. Computed tomography revealed the presence of a 19 × 17-mm cyst with a thick wall in the apex of the right lung. She was tested for infectious diseases, namely tuberculosis, but the results were not definitive. Catamenial pneumothorax was also suspected because she was menstruating when she presented to our hospital. As a therapeutic diagnosis, we performed a thoracoscopic partial resection of the right upper lobe of the lung. Three small openings were identified inside the cyst, suggesting connection with the bronchiole. The lesion was pathologically diagnosed as an IMT-like lesion. Considering the progress so far, we considered that the final diagnosis to be an IMT. The patient was discharged on postoperative day 3, and we have followed her for the past 6 months with no local recurrence or metastasis. CONCLUSIONS: IMT is not uncommon in children. Therefore, this lesion should be considered as a possible diagnosis if children and young adults develop spontaneous pneumothorax.

Solitary fibrous tumor of the trachea: a case report.

We experienced a surgical case of a rare primary tracheal tumor. A 77-year-old woman visited a local clinic with chief complaints of coughing, wheezing, and discomfort in the throat. Computed tomography revealed a mass measuring approximately 1.5 cm in the mediastinal trachea, extending from the membranous portion of the trachea to the esophagus. Bronchofibroscopy showed a flat, smooth-surfaced, round mass arising from the membranous portion. Surgery was performed because of the possibility of airway obstruction and suffocation. Sleeve resection of five tracheal rings was performed via median sternotomy and interrupted suture was performed using 3-0 absorbable suture material. The postoperative course was favorable and there has been no evidence of recurrence. The pathological diagnosis was solitary fibrous tumor. A primary solitary fibrous tumor of the trachea is extremely rare. Here, we report this disease with a literature review.

CLINICAL COURSE OF PARANEOPLASTIC RETINOPATHY WITH ANTI-TRPM1 AUTOANTIBODY IN JAPANESE COHORT.

PURPOSE: To report the clinical course of eyes with paraneoplastic retinopathy caused by an autoantibody against transient receptor potential cation channel, subfamily M, member 1 (TRPM1). METHODS: Ten paraneoplastic retinopathy patients with retinal ON-bipolar cell dysfunction, including six melanoma-associated retinopathy, from eight institutions in Japan were evaluated for the presence of an anti-TRPM1 antibody. The results of ophthalmic examinations and the presence of anti-TRPM1 antibody were analyzed. RESULTS: Five patients were positive for the anti-TRPM1 antibody. These patients had similar clinical findings in both eyes at the time of diagnosis; relatively preserved best-corrected visual acuity, absence of fundus and optical coherence tomography abnormalities, and specific abnormalities of the electroretinography (ERG); and negative-type ERGs with bright stimulus flashes. One patient whose retinal ON-bipolar cells remained dysfunctional for the entire testing period, although the anti-TRPM1 antibody had disappeared. On the other hand, the ERGs recovered in 2 cases within 2 years after the onset. One case progressed to additional impairment of the photoreceptors with deterioration of ERGs. One case died and the clinical course was unavailable. CONCLUSION: Paraneoplastic retinopathy patients with retinal ON-bipolar cell dysfunction possess autoantibodies against TRPM1 at the onset of the disease process; however, the clinical course of these eyes can be different.

INNER MACULAR CHANGES AFTER VITRECTOMY WITH INTERNAL LIMITING MEMBRANE PEELING FOR RHEGMATOGENOUS RETINAL DETACHMENT: Similarity With Alport Syndrome.

PURPOSE: The internal limiting membrane (ILM), the innermost basement membrane of the retina, is peeled occasionally during vitreous surgery. This study aimed to investigate the effect of ILM loss on the retina. METHODS: We used optical coherence tomography to retrospectively evaluate retinal changes in 26 eyes (11 ILM-peeled and 15 ILM-unpeeled eyes) of 26 patients after vitrectomy for retinal detachment. In addition, we studied six eyes of three patients with Alport syndrome, in which ILM is genetically impaired. RESULTS: We observed significant inner retinal displacement of the foveal pit toward the optic disk with inner retinal thickening in the nasal area (fellow, 191.9 ± 24.3 µm vs. affected, 210.3 ± 31.4 µm; P = 0.048), inner retinal thinning in the temporal area (fellow, 174.3 ± 18.3 µm vs. affected, 142.2 ± 23.6 µm; P < 0.001), foveal thickening (ILM-unpeeled, 217.0 ± 39.4 µm vs. ILM-peeled, 302.0 ± 86.2 µm; P = 0.006), inner retinal dimples predominantly in the temporal area, and deviation between the foveal pit and foveal bulge. Eyes with Alport syndrome exhibited similar findings. CONCLUSION: Internal limiting membrane loss seems to cause characteristic inner retinal changes of the macula in both congenital and acquired conditions.

Supernormal Flicker ERGs in Eyes With Central Retinal Vein Occlusion: Clinical Characteristics, Prognosis, and Effects of Anti-VEGF Agent.

Purpose: To determine the clinical characteristics, prognosis, and effect of anti-vascular endothelial growth factor (VEGF) agents on eyes with a central retinal vein occlusion (CRVO) with and without supernormal flicker ERG amplitudes. Methods: Forty-eight eyes of 48 patients with a CRVO were studied. Flicker ERGs were recorded from fully dilated eyes with the RETeval system. The amplitudes and implicit times of the fundamental component were analyzed. "Supernormal flicker ERGs" were defined as those whose amplitudes were ≥117% of the unaffected fellow eyes. Results: Ten of the 48 eyes (20.8%) with a CRVO showed supernormal flicker ERGs before the treatment. The difference in the implicit times of these 10 CRVO eyes and those of normal fellow eyes was <4 millisecond. There was a significant correlation between the implicit time delay and the relative amplitude in the 48 CRVO eyes. All 10 CRVO eyes with supernormal flicker ERGs had the nonischemic type of CRVO and tended to have better visual acuities than did the 28 nonischemic CRVO eyes without supernormal flicker ERGs at 12 months after the treatment (P = 0.058). The CRVO eyes with supernormal flicker ERGs had a significant amplitude reduction after a single injection of an anti-VEGF agent. Conclusions: These results indicated that the supernormal flicker ERGs can be a sign of a mild degree of ischemia, and these eyes have a better prognosis. The results also suggest that the supernormal flicker ERG may be caused by changes in the electrical activities of retinal cells following a mild increase in the VEGF levels in eyes with CRVO.

[Two-staged Operation for Bilateral Giant Bullae Successfully Performed with Veno-venous Extracorporeal Membrane Oxygenation( V-V ECMO) for First Surgery].

57-year-old man with bilateral giant lung bullae was admitted to our hospital for dyspnea on exertion as his chief complaint. The size and shape of right lung bullae were bigger and more complicated than those of left lung bullae. He underwent 2-staged bullectomy by video-assisted thoracoscopic surgery (VATS). Left lung bullectomy was expected to be more safely done, and was performed with veno-venous extracorporeal membrane oxygenation( V-V ECMO) prior to right side without any complications. The right lung bullectomy was performed 6 months after 1st operation without V-V ECMO. These reoperations were necessary due to postoperative air leak, however, his respiratory condition was well maintained by his left lung which had already been remarkably improved.

[Wedge Bronchoplastic Left Upper Lobectomy for Lung Cancer Patient with Abnormal Mediastinal Left Basal Pulmonary Artery].

A 65-year-old man with left lung squamous cell carcinoma was admitted to our hospital for operation. His tumor was located left upper lobe and invaded to the orifice of left upper bronchus. We diagnosed the tumor as cT2aN0M0 and intended to perform radical operation. Preoperative three-dimensional computed tomography (3D-CT) revealed that A9+10 which descended along lower bronchus was arisen from the left main pulmonary artery as a 1st branch of it. A wedge bronchoplastic left upper lobectomy was safely done with preserving the branch. Although this abnormal branching of left pulmonary artery is very rare, we should pay more attention this type of anomaly because unintended injury of the branch causes massive bleeding or ischemia of left lower lobe. Preoperative 3D-CT is useful for detecting the anomaly of pulmonary vessels.

BETTER PROGNOSIS FOR EYES WITH PRESERVED FOVEAL DEPRESSION AFTER INTRAVITREAL RANIBIZUMAB INJECTION FOR MACULAR EDEMA SECONDARY TO CENTRAL RETINAL VEIN OCCLUSION.

PURPOSE: To determine the prognosis of eyes with central retinal vein occlusion that had a preserved foveal depression at the baseline and were treated by intravitreal ranibizumab injections (IRIs). METHODS: The authors reviewed the medical records of 23 eyes of 23 consecutive treatment-naive patients who received IRIs to treat the macular edema due to central retinal vein occlusion. Eyes were classified by the pre-IRI presence or absence of a foveal depression. A foveal depression was defined as a central foveal thickness that was <50 µm thinner than the average thickness at 200 µm temporal and nasal to the central fovea. The characteristics of the two groups were compared. RESULTS: Seven of 23 eyes had a preserved foveal depression before the IRI. The mean number of injections within 12 months after the initial IRI was significantly fewer (P < 0.001) in eyes with foveal depression (1.6 ± 0.5) than in eyes without foveal depression (4.3 ± 1.3). The mean best-corrected visual acuity at 12 months after the initial IRI was significantly better (P = 0.003) in eyes with foveal depression (0.10 ± 0.17 logarithm of the minimum angle of resolution [logMAR] units; 20/25 Snellen units) than in eyes without foveal depression (0.77 ± 0.54 logMAR units; 20/118 Snellen units). CONCLUSION: These results indicate that the prognosis is better for eyes with a foveal depression before the IRI treatment for a macular edema secondary to central retinal vein occlusion.