[Synovial cyst of chest wall; report of a case].

A 55-year-old male taxi driver visited our hospital because of a left dorsal tumor. The tumor was palpated at the inferior angle of the left scapula with tenderness. Computed tomography (CT) revealed a homogeneous 5-cm mass with capsule between the latissimus dorsi muscle and rib. T2-weighted magnetic resonance imaging( MRI) demonstrated the tumor with high intensity. The latissimus dorsi muscle was divided and separated off from the tumor and the lower layer;then, an applied wound retractor (Alexis) was placed under the lower layer of the latissimus dorsi muscle and the operative field was developed. Next, the anterior serratus and greater rhomboid muscles were separated off from the tumor and the lower layer, the Alexis was placed under the lower layer of those muscles. All muscles were preserved and the tumor was removed. The tumor was 56×32 mm in size. The histological diagnosis was synovial cyst.

Sentinel node navigation surgery by thoracoscopic fluorescence imaging system and molecular examination in non-small cell lung cancer.

PURPOSE: The application of sentinel node navigation surgery in non-small cell lung cancer (NSCLC) is not popular because of the difficulty of sentinel node identification and the low incidence of complications after systemic lymph node dissection. We report the intraoperative assessment of sentinel node metastasis by thoracoscopic ICG fluorescence imaging system and real-time reverse transcription-polymerase chain reaction (RT-PCR). METHODS: Sixty-one patients who underwent surgery between January 2009 and December 2010 were investigated for sentinel node biopsy. ICG fluorescence imaging was applied by an infrared light CCD system, and sentinel nodes were identified and dissected. Intraoperative real-time quantitative RT-PCR to determine the expression of cytokeratin 19 (CK-19) was performed for evaluation of metastasis and finally histologic examination of hematoxylin and eosin-stained, paraffin-embedded sections. RESULTS: Sixteen (80%) of 20 patients with segmentectomy and 33 (80.5%) of 41 with lobectomy were identified for sentinel lymph nodes. The total identification rate was 80.3% (49 of 61). The false-negative rate was 2.1% (1 of 49). The overall accuracy rate was 78.7% (48 of 61 patients). Disease of four of these patients was upstaged to stage IIA by RT-PCR for CK-19 expression, which was positive for sentinel nodes and micrometastases. CONCLUSIONS: These results demonstrated that thoracoscopic ICG fluorescence imaging-guided surgery and real-time quantitative RT-PCR were useful for sentinel node biopsy and might be a powerful tool for more focused pathologic or molecular evaluation for staging.

Clinical impact of segmentectomy compared with lobectomy under complete video-assisted thoracic surgery in the treatment of stage I non-small cell lung cancer.

BACKGROUND: Segmentectomy for small or early stage non-small cell lung cancer (NSCLC) has been controversial. Further, video-assisted thoracic surgery (VATS) for lung cancer was accepted during the past decade. We here compared the outcome between VATS segmentectomy and VATS lobectomy for stage I NSCLC. METHODS: In the retrospective study, 109 consecutive patients in stage I underwent surgery at Oita University Hospital (Oita, Japan) between September 2003 and October 2008. VATS segmentectomy was performed in 38 patients and VATS lobectomy with systemic lymphadenectomy was performed in 71 patients. After clinicopathologic factors were compared in both groups, local recurrence rates and survivals were compared. RESULTS: Five of 38 VATS segmentectomy and eight of 71 VATS lobectomy patients relapsed during the follow-up period (median 27.5 mo). In the relapsed patients after VATS segmentectomy, three (7.9%) were local recurrences and two (5.3%) were distant metastases. On the other hand, four (5.6%) were local recurrence and four (5.6%) were distant metastases in the VATS lobectomy group. There was no significant difference between the two groups. Furthermore, there was no difference in recurrence-free and overall survival between segmentectomy and lobectomy. CONCLUSIONS: Although the sample size is small, VATS segmentectomy is one of the appropriate procedures for stage I NSCLC.

Resection and postoperative radiation therapy for desmoid fibromatosis of the chest wall in a young woman.

BACKGROUND: Surgery is an effective treatment for desmoid fibromatosis, but it may be difficult, depending on the location or local spread of the tumor, and the decision to perform surgery must be made carefully. We herein report a case of desmoid fibromatosis of the chest wall in a young woman suspected of having invasion to the 1st, 2nd and 3rd ribs. CASE PRESENTATION: A 35-year-old woman had been aware of dry cough and right chest pain, so she was referred to our hospital. Chest computed tomography showed a localized pleural tumor mainly at the first rib. Magnetic resonance imaging revealed a 75 × 65 × 27-mm tumor with a smooth surface, with partial contact from the first rib to third rib and partial extension to the 1st intercostal space. The tumor showed growth in the two months after the first visit, so resection was performed. The tumor was completely resected, and adjuvant radiation therapy (50 Gy) was performed for the small margin. The pathological diagnosis was desmoid fibromatosis. The postoperative course has been uneventful, without recurrence at 14 months after surgery. CONCLUSIONS: In chest wall tumors located ventral of the pulmonary apex, we suggest that a combination of the Grunenwald method and Masaoka anterior approach may be a useful option. In cases where margin is not enough, adjuvant radiation therapy should be considered.

Thymoma-associated myasthenia gravis coexisting with myotonic dystrophy: a case report.

BACKGROUND: Myotonic dystrophy (dystrophia myotonica [DM]) is an autosomal-dominant inheritance, and myasthenia gravis (MG) is an autoimmune disease characterized by weakness of skeletal muscles. Cases of both DM and MG are extremely rare and distinguishing DM and MG symptoms is challenging. CASE PRESENTATION: We herein report a 49-year-old woman presenting with subacute dyspnea and muscle weakness. She had previously been diagnosed with DM 24 years earlier. Computed tomography (CT) revealed an anterior mediastinal 32-mm solid mass that was suspected of being thymoma. The clinical features and neurological examination findings confirmed the diagnosis of thymoma-associated MG coexisting with DM. Intensive treatment for MG, including surgery, resulted in an improvement in some of her neurological symptoms. CONCLUSIONS: The symptoms of DM usually progress slowly, so the sudden exacerbation of symptoms indicates the involvement of other factors. It is important to be aware of these associations, as an early diagnosis with proper treatment will result in a better outcome.

Evaluating the Platelet Distribution Width-to-Plateletcrit Ratio as a Prognostic Marker for Patients With Breast Cancer.

AIM: This study aimed to evaluate plateletcrit (PCT) and platelet distribution width-to-PCT ratio (PDW/PCT) as potential prognostic biomarkers in patients with breast cancer. PATIENTS AND METHODS: Information of 337 patients was retrospectively reviewed. The Cox regression proportional hazards model was used to evaluate the prognostic value of PCT and PDW/PCT compared to the platelet distribution width-to-platelet count ratio (PDW/P) and red cell distribution width-to-platelet count ratio (RDW/P). RESULTS: Large tumor size (p<0.01), lymph node involvement, and increased PDW/P, RDW/P, and PDW/PCT (p<0.05) were significantly associated with inferior disease-free survival (DFS) according to the univariate analysis. The multivariate analysis showed that large tumor size (p<0.01) and increased PDW/PCT (p<0.05) were significant prognostic factors for poor DFS. CONCLUSION: To our knowledge, this is the first report to show that PDW/PCT is a significant prognostic factor for patients with breast cancer. Therefore, it might be an attractive biomarker providing additional prognostic information for these patients.

Branching patterns of segmental bronchi and arteries in the medial basal segment.

BACKGROUND: We investigated the branching patterns of B7 and A7 on computed tomography. METHODS: The study population was 2150 patients. The branching patterns were classified into 5 types. RESULTS: Pattern 1 [the entire S7 segment was ventral to the inferior pulmonary vein (IPV), and A7 branched from the basal segmental artery (Aba) and ran on the ventral side of the basal bronchus (Bba)] was found in 1373 patients, pattern 2 (B7 showed double branching into the dorsal and ventral sides of the IPV. A7 flowed into the lung on the dorsal side of the IPV and ran on the dorsal side of the Bba after branching from the Aba) in 226, pattern 3 (B7 showed double branching into the dorsal and ventral sides of the IPV. A7 ran on the ventral side of the Bba after branching from the Aba) in 170, pattern 4 (the entire S7 was dorsal to the IPV, and A7 ran on the dorsal side of the Bba after branching from the Aba) in 99, and pattern 5 (although the entire S7 was dorsal to the IPV, A7 either ran on the dorsal side of the Bba after branching from the Aba or ran on the ventral side of the Bba after branching from the Aba) in 24. CONCLUSIONS: Because segmentectomy of the basal segment is anticipated to become more frequent, the results of this study may serve as useful reference data.

Successful use of mediastinal repositioning employing PTFE sheet for right-sided post-pneumonectomy syndrome.

Post-pneumonectomy syndrome (PPS) is a rare late complication of pneumonectomy, and diverse treatments have been employed. We herein present a useful technique for right-sided PPS. The patient was a 53-year-old female who underwent a right pneumonectomy for locally advanced squamous cell lung cancer (pT2N2M0). Mild dyspnea and stridor developed and progressed 1 year after surgery. A chest roentgenogram and computed tomography (CT) scan showed a right-sided mediastinal shift. Under local anesthesia, a chest tube with a balloon was inserted into the right thoracic cavity, and the balloon was inflated with air. Dyspnea and stridor improved and disappeared as the balloon expanded. Then, mediastinal fixation was performed under general anesthesia. Mediastinal fixation involved a PTFE (polytetrafluoroethylene) sheet which was sewn on the sternum and costal cartilage anteriorly, on the vertebra posteriorly, and covered the azygos vein level superiorly and two thirds of the pericardium inferiorly using nonabsorbable sutures. A post-operative chest roentgenogram and CT scan showed improvement of the right-sided mediastinal shift. The post-operative course was uneventful, and dyspnea and stridor were improved and became stable. In conclusion, the presented method is a useful procedure for right-sided PPS.

Basal cell carcinoma of the nipple in male patients with gastric cancer recurrence: report of a case.

Although basal cell carcinoma (BCC) is the most common dermatological malignancy arising from sun exposed skin, BCC of the nipple is extremely rare. To our knowledge only 34 cases have been reported. We report a 78-year-old man who was undergoing chemotherapy for liver metastasis of gastric cancer 1 year after surgery. The chief complaint was exudation and oozing from the nipple. A mass lesion was palpable and detected on mammography and enhanced computed tomography, and atypical cells were detected on cytological examination. Simple resection was performed because histopathological diagnosis of an intraoperative frozen section revealed BCC. Final pathological diagnosis was also BCC. The authors report this case and review the previous reports, and discuss the clinicopathologic characteristics and adequate treatment for this disease.

Contralateral mediastinal lymph node micrometastases assessed by video-assisted thoracoscopic surgery in stage I non-small cell left lung cancer.

OBJECTIVES: Survival of patients with left-sided stage I non-small cell lung cancer (NSCLC) is unsatisfactory, probably because of the high incidence of contralateral mediastinal node involvement. In this study, occult micrometastases to the right upper mediastinal nodes were retrospectively investigated in patients with left-sided stage I NSCLC. METHODS: Nineteen patients with clinical stage I NSCLC underwent video-assisted thoracoscopic lobectomy and bilateral mediastinal node dissection (BMD). Clinical data and survival of patients with BMD were compared with those of 25 left-unilateral mediastinal node dissection (UMD) patients. Occult micrometastases were detected using the cytokeratin 19 mRNA reverse transcription-polymerase chain reaction method. RESULTS: Pathological N2 disease was found in 1 patient, and 18 had pN0 disease. The operative time, blood loss, duration of chest tube drainage and duration of postoperative hospital stay were not different between BMD and UMD patients. Nodal micrometastases were detected in 11/19 (57.8%) patients. Skip micrometastases to the level N3 nodes without N1 and N2 node involvement were observed in 8/11 (72.7%) patients. Patients with BMD are all alive and have had no recurrence during the median follow-up period of 21.4 months. Overall 3-year survival and disease-free 3-year survival were not significantly different between the two groups. CONCLUSION: In this preliminary study, occult micrometastases to the level N3 nodes occurred frequently in patients with left-sided clinical N0 stage I NSCLC. Postoperative survival of patients with occult micrometastases to the level N3 node does not appear to be poor. Further follow-up and work are needed.

Successful application of subcutaneous adipose tissue with fibrin glue in conservative treatment of tracheobronchial rupture.

An 84-year-old woman underwent aortic and mitral valve replacement. After weaning from cardiopulmonary bypass, hemorrhage was observed in the endobronchial tube. The bleeding bronchus was isolated to protect the airway using the blocker cuff of a Univent tube (Fuji Systems Corp, Tokyo, Japan). Computed tomography showed a pulmonary pseudoaneurysm in the left upper lobe. She underwent selective pulmonary angiography and embolization of the pseudoaneurysm. Bronchoscopy revealed a 5-mm bronchial rupture at the left upper lobe bronchus. The laceration was filled with adipose tissue and fibrin glue. Bronchoscopy showed a completely reepithelialized membrane, and she was discharged 38 days postoperatively.

Thoracoscopic segmentectomy with intraoperative evaluation of sentinel nodes for stage I non-small cell lung cancer.

OBJECTIVES: Segmentectomy is the treatment of choice for small-sized non-small cell lung cancer (NSCLC); however, it is difficult to decide the surgical procedure because accurate evaluation of hilar lymph node metastasis remains unclear. We here report the outcome of video-assisted thoracic surgery (VATS) segmentectomy with and without the assessment of sentinel nodes. MATERIALS AND METHODS: Eighty-three patients with stage IA NSCLC underwent VATS segmentectomy between January 2003 and December 2010. Twenty patients underwent indocyanine green fluorescence imaging for sentinel node biopsy (SNB) and 63 did not. Intraoperative real-time quantitative RT-PCR to determine the expression of CK-19 was used for evaluation of metastasis. Perioperative outcome, local recurrence rates and survival were compared in both groups. RESULTS: Sentinel lymph nodes were identified in 16 of 20 patients (80%) with segmentectomy in the SNB group. The false negative rate was 0%. By RT-PCR for CK-19 expression, only one of these patients showed positive sentinel nodes, which indicated isolated tumor cells; however, segmentectomy was not converted to lobectomy. Seven of 63 patients with VATS segementectomy without SNB and none of the SNB group relapsed. In the relapsed patients without SNB, 4 (6.3%) were local recurrences and 3 (4.7%) were distant metastases. Recurrence-free survival rates in both groups were not significantly different because of the short follow-up period of the SNB group. CONCLUSIONS: Our study demonstrated that VATS segmentectomy with SNB was useful for deciding intraoperatively to perform segmentectomy with an accurate lymph node status.

Thoracoscopic segmentectomy for T1 classification of non-small cell lung cancer: a single center experience.

OBJECTIVES: Segmentectomy is one of the treatment options for small-sized non-small cell lung cancer (NSCLC). Although growing results support the feasibility and efficacy, it still remains unclear in segmentectomy. The International Association for the Study of Lung Cancer recommended a revised classification of TNM staging in 2009 (the seventh edition) and multidisciplinary classification of adenocarcinoma. We report here the outcome of totally thoracoscopic segmentectomy and lobectomy for T factor and adenocarcinoma. METHODS: Ninety patients with Stage IA NSCLC underwent thoracoscopic segmentectomy between September 2003 and June 2011. A total of 124 patients were referred as a control group to compare the peri-operative outcome, local recurrence rate and survival. These survivals were analysed using the Kaplan-Meier method with the log-rank test and propensity score analyses. RESULTS: The peri-operative outcome, including operative time, blood loss, duration of chest tube drainage and length of hospital stay, was not significantly different between groups. The number of dissected lymph nodes with segmentectomy was less than that with lobectomy. Morbidity and mortality were not significantly different between groups. Seven patients relapsed in each group and propensity score analysis in disease-free and overall survivals showed no differences between two groups in Stage IA. Subclass analyses revealed that disease-free and overall survivals in T1a and T1b were not significantly different between the two groups. CONCLUSIONS: Our study demonstrated that thoracoscopic segmentectomy was feasible with regard to peri-operative and oncological outcomes for Stage IA NSCLC, especially T1a and carefully selected T1b descriptor.

Video-assisted thoracoscopic indocyanine green fluorescence imaging system shows sentinel lymph nodes in non-small-cell lung cancer.

OBJECTIVE: The primary objective was to assess the feasibility and accuracy of intraoperative sentinel lymph node mapping by using a video-assisted thoracoscopic indocyanine green fluorescence imaging system in patients with clinical stage I non-small-cell lung cancer. METHODS: Thirty-one patients who underwent operation between January 2009 and September 2009 were investigated for sentinel node biopsy. Indocyanine green fluorescence imaging was applied by an infrared light charge-coupled device, and sentinel nodes were identified intraoperatively and dissected. Histologic examination by hematoxylin-eosin staining was used to evaluate metastases. RESULTS: Sentinel lymph nodes were identified by segmentectomy in 11 of 14 patients (78.5%) and by lobectomy in 14 of 17 patients (82.4%). The total identification rate was 80.7% (25/31 patients), the false-negative rate was 0% (0/24 patients), and the overall accuracy rate was 80.7% (25/31 patients). CONCLUSION: Video-assisted thoracoscopic indocyanine green fluorescence image-guided surgery is feasible for sentinel node biopsy and may be a powerful tool to eliminate unnecessary lymph node dissection in patients with lung cancer.

Combination of p53AIP1 and survivin expression is a powerful prognostic marker in non-small cell lung cancer.

BACKGROUND: p53AIP1 is a potential mediator of apoptosis depending on p53, which is mutated in many kinds of carcinoma. High survivin expression in non-small cell lung cancer is related with poor prognosis. To investigate the role of these genes in non-small cell lung cancer, we compared the relationship between p53AIP1 or survivin gene expression and the clinicopathological status of lung cancer. MATERIALS AND METHODS: Forty-seven samples from non-small cell lung cancer patients were obtained between 1997 and 2003. For quantitative evaluation of RNA expression by PCR, we used Taqman PCR methods. RESULTS: Although no correlation between p53AIP1 or survivin gene expression and clinicopathological factors was found, the relationship between survivin gene expression and nodal status was significant (p = 0.03). Overall survival in the p53AIP1-negative group was significantly worse than in the positive group (p = 0.04); however, although survivin expression was not a prognostic factor, the combination of p53AIP1 and survivin was a significant prognostic predictor (p = 0.04). In the multivariate cox proportional hazard model, the combination was an independent predictor of overall survival (p53AIP1 (+) survivin (+), HR 0.21, 95%CI = [0.01-1.66]; p53AIP1 (+) survivin (-), HR 0.01, 95%CI = [0.002-0.28]; p53AIP1 (-) survivin (-), HR 0.01, 95%CI = [0.002-3.1], against p53AIP1 (-) survivin (+), p = 0.03). CONCLUSION: These data suggest that the combination of p53AIP1 and survivin gene expression may be a powerful tool to stratify subgroups with better or worse prognosis from the variable non-small cell lung cancer population.

Expression of dual-specificity tyrosine-(Y)-phosphorylation-regulated kinase 2 (DYRK2) can be a favorable prognostic marker in pulmonary adenocarcinoma.

OBJECTIVES: We investigated the possibility of DYRK2, a dual-specificity tyrosine-(Y)-phosphorylation-regulated kinase gene, to predict survival for patients with pulmonary adenocarcinoma. PATIENTS AND METHODS: One hundred forty-four patients with pulmonary adenocarcinoma underwent surgery in our institute from 2000 to 2008. We used immunohistochemical analysis and real-time reverse-transcriptase polymerase chain reaction to determine the expression of DYRK2 and compared this with the clinicopathologic factors and survival. RESULTS: We found no correlation between DYRK2 expression by immunohistochemical and clinicopathologic factors; however, a negative nodal status and negative lymphatic invasion were significantly associated with DYRK2 expression by reverse-transcriptase polymerase chain reaction. Five-year disease-free survival in the DYRK2-positive group (75.4%) was significantly different from that in the negative group (55.4%; P = .03) by immunohistochemical analysis. The 5-year overall survival of 89.2% in the DYRK2-positive group was better than the 66.3% survival of the DYRK2-negative group (P = .01). Quantitative real-time reverse-transcriptase polymerase chain reaction analyses showed a significant difference between positive and negative expressions for disease-free survival (P = .003) and overall survival (P = .007). In multivariate Cox regression analysis, negative DYRK2 protein and messenger RNA expression showed a worse prognostic value of survival (hazard ratio [HR] = 4.7, 95% confidence intervals [CI] = 1.5-14.5, P=.007; HR = 2.5, 95% CI = 1.1-6.1, P = .04, respectively). When we analyzed adenocarcinoma cases except for bronchioloalveolar carcinoma, we found a close correlation between DYRK2 expression by immunohistochemical analysis and nodal status (P = .03). Furthermore, disease-free survivals between positive and negative groups of DYRK2 expression by immunohistochemistry (P = .03) and reverse-transcriptase polymerase chain reaction (P = .02) without bronchioloalveolar carcinoma were significantly different. Overall survivals in both groups showed significant differences by immunohistochemistry (P = .02) but not by reverse-transcriptase polymerase chain reaction (P = .08). CONCLUSIONS: These data showed that DYRK2 expression is associated with a favorable prognosis.

DYRK2 expression may be a predictive marker for chemotherapy in non-small cell lung cancer.

BACKGROUND: The possibility of a dual-specificity tyrosine-(Y)-phosphorylation-regulated kinase gene, DYRK2, predicting benefit from chemotherapy for patients with recurrent non-small cell lung cancer (NSCLC) was investigated. MATERIALS AND METHODS: Forty patients with recurrent disease after surgery received several combinations of platinum-based chemotherapy. The chemotherapy effectiveness was evaluated according to RECIST (response evaluation criteria in solid tumors). Immunohistochemical (IHC) analysis was used to determine the expression of DYRK2. RESULTS: Although the response rates between the two groups did not show statistical differences, the disease control rate of the DYRK2-positive group (15 out of 17, 88%) was significantly different from the DYRK2-negative group (8 out of 23, 35%, p=0.001). The median time to the progression (TTP) of disease was significantly different between the two groups (310 days in the positive group, 120 days in the negative, HR=2.12, 95% CI=[1.1-4.09], p=0.024). Multivariate analysis showed that negative DYRK2 expression was a strong predictor of disease progression (HR=3.01, 95% CI=[1.45-6.26], p=0.003). CONCLUSION: Patients with high DYRK2 expression could be good candidates for chemotherapy.