[Lung Transplantation at a Low Volume Center].

The number of lung transplantation performed in Japan is extremely low compared to other countries, whereas we have 10 facilities certified as cadaveric lung transplantation in Japan, meaning that there are low volume centers. By August 2021, we performed lung transplantation in 21 cases for 12 years, therefore, our facility should be considered as low volume center. Surgical outcomes at low volume centers are generally considered poor. However, the overall five-year survival rate of total cases was 84.8%, and that of cadaveric cases was 94.4% in our hospital. It was better than the average of about 73% of all facilities in Japan. These data suggested that the accreditation system in Japan is functioning well. On the other hand, there may be a disparity between facilities. At our facility, we are actively performing inverted lung transplantation so as not to lose the opportunity for transplantation, and we have performed it in three cases so far and have achieved good results.

[Structural Deterioration of a Bovine Pericardial Valve in a Tricuspid Position 14 Years Postoperatively;Report of a Case].

Although nonstructural dysfunction of a bioprosthesis caused by pannus formation or native valve attachment has been well described, structural valve deterioration( SVD) caused by calcification or tear of a bioprosthesis, especially a bovine pericardial valve, is very rare in the tricuspid position. We report a case of redo tricuspid valve surgery for SVD 14 years after tricuspid valve replacement( TVR) using a Carpentier-Edwards Perimount (CEP) pericardial valve. A 71-year-old woman was referred to our hospital because of exertional dyspnea and pre-syncope. She had undergone mitral valve replacement with a St. Jude Medical mechanical valve and TVR with a CEP pericardial valve 14 years previously. Transthoracic echocardiography revealed tricuspid valve stenosis with a mean trans-tricuspid valve pressure gradient (TVPG) of 7.3 mmHg. Redo TVR using a CEP Magna Mitral Ease valve was performed under cardiac arrest. Severe calcification was observed on the ventricular side of the leaflets of the explanted valve. The mean TVPG decreased to 3.2 mmHg after surgery, and the patient's postoperative course was uneventful.

[Salvage Surgery Following Chemoradiotherapy for Thymic Basaloid Cell Carcinoma].

We performed salvage surgery after chemoradiotherapy(CRT) in a patient with thymic basaloid cell carcinoma. A 46-year-old man with an abnormal chest shadow on X-ray findings was referred to our hospital. Computed tomography revealed a partially solid tumor along with a multilocular cyst in the anterior mediastinum with mediastinal lymph node swelling infiltrating to the superior vena cava(SVC). Positron emission tomography revealed FDG accumulation (SUVmax 7.94)in the tumor. Pathological findings of a tumor biopsy specimen obtained by thoracoscopy led to a diagnosis of thymic basaloid cell carcinoma. Following CRT (ADOC+RT:60 Gy), a complete resection (R0)with replacement of the SVC was performed. The postoperative course was uneventful, and the patient was alive at 20 months after surgery with metastasis to the cervical lymph nodes and bone.

[Spindle Cell Sarcoma Originated in the Anterior Mediastinum;Report of a Case].

An anterior mediastinal sarcoma is a very rare type of mediastinal tumor. A 45-year-old female visited our hospital with swelling in the right anterior chest wall. Radiographically, the tumor was found to originate from the thymus and to infiltrate to the major pectoral muscle through the 1st intercostal space. Positron emission tomography revealed fluorodeoxyglucose accumulation at a standardized uptake maximum value of 16.1. Percutaneous needle biopsy showed the pathological findings of sarcoma. The tumor was resected along with the thymus and chest wall tissues including the right hemi-manubrium of the sternum, clavicle head, 1st and second ribs, and major pectoral muscle. After 4 months, tumor relapse occurred at the site of needle biopsy and additional resection was performed. At 10 months after the 2nd surgery, the patient was free from disease. From histologic and immunohistochemical findings, the tumor was diagnosed as spindle cell sarcoma.

[Radical resection following to concurrent chemoradiotherapy for eighty-five year-old patient with superior sulcus tumor].

An 85-year-old male with superior sulcus tumor was referred to our hospital complaining right brachial pain and omalgia. Chest computed tomography showed right apical lung tumor involving the 1st rib, and bronchoscopy established a diagnosis of squamous cell carcinoma, cT3NOM0. After concurrent chemoradiotherapy [cisplatin (CDDP) + 60 Gy], functional examination indicated him to be tolerable to lobectomy, and he underwent right upper lobectomy + chest wall resection (1st-3rd ribs) + lymph-node dissection. Pathological examination revealed that the effect of chemoradiotherapy was Ef. 3. The postoperative course was uneventful. He is free from recurrence for 7 years after the surgery.

[Diaphragmatic metastasis from uterine corpus cancer].

We report a case of metastatic diaphragm tumor from uterine corpus cancer. A 72-year-old female had a tumor on right diaphragm 4-years after operation for uterine corpus cancer. After chemotherapy, tumor resection was performed by right lung basal segmentectomy, partial liver resection, and partial diaphragm resection. The pathological examination revealed adenocarcinoma, compatible with uterine corpus cancer, metastasizing in diaphragm and involving lung and liver. After the operation, a local recurrence occurred at parasternal lymph node, which is considered to be present on the efferent route of lymph flow from diaphragm.

Comparison of 5-fluorouracil-related gene expression levels between adenocarcinomas and squamous cell carcinomas of the lung.

BACKGROUND: A recent meta-analysis study showed that post-operative adjuvant chemotherapy with UFT, an oral combination drug composed of tegafur [prodrug of 5-fluorouracil (5-FU)] and uracil [inhibitor of dihydropyrimidine dehydrogenase (DPD)] was associated with improved survival in patients with lung adenocarcinomas, but not in those with lung squamous cell carcinomas. METHODS: We investigated the 5-FU-related gene expression levels of thymidylate synthase (TS), DPD, thymidine phosphorylase (TP) and orotate phosphoribosyl transferase (OPRT) in resected tumor specimens from 51 patients with adenocarcinomas and 47 with squamous cell carcinomas using quantitative reverse transcription-PCR, and compared those levels between the two histological types. RESULTS: The relative gene expression values of TS, TP and OPRT were significantly lower in adenocarcinomas compared with squamous cell carcinomas, 1.60 +/- 0.86 versus 4.33 +/- 3.40 (P < 0.001), 0.84 +/- 0.52 versus 2.27 +/- 1.16 (P = 0.006) and 9.59 +/- 6.30 versus 16.94 +/- 12.04 (P < 0.001), respectively. The relative gene expression value of DPD was significantly greater in adenocarcinomas than those in squamous cell carcinomas, 2.33 +/- 1.22 versus 1.50 +/- 1.20 (P = 0.01). Lower expressions of TS and TP were observed more in adenocarcinomas (89.8%) than in squamous cell carcinomas (48.9%) (P < 0.001). CONCLUSION: These data may explain that post-operative adjuvant chemotherapy with UFT was associated with improved survival in stage I patients with adenocarcinoma, but less with squamous cell carcinoma.

Molecular biological analysis in a patient with multiple lung adenocarcinomas.

The utility of molecular biological analysis in lung adenocarcinoma has been demonstrated. Herein we report a rare case presenting as multiple lung adenocarcinomas with four different EGFR gene mutations detected in three lung tumors. After opacification was detected by routine chest X-ray, the patient, a 64-year-old woman, underwent chest computed tomography which revealed a right lung segment S4 ground-glass nodule (GGN). Follow-up computed tomography revealed a 42 mm GGN nodule with a 26 mm nodule (S6) and a 20 mm GGN (S10). Histopathology of resected specimens from the right middle and lower lobes revealed all three nodules were adenocarcinomas. Four EGFR mutations were detected; no three tumors had the same mutations. Molecular biological analysis is a promising tool for the diagnosis of primary tumors in patients with multiple lung carcinomas of the same histotype, enabling appropriate treatment.

Prognostic significance of p21 protein expression in patients with pulmonary squamous cell carcinoma following induction chemotherapy.

BACKGROUND: The prognostic value of p21 protein expression in lung cancer patients has been assessed. However, its significance in those with pulmonary squamous cell carcinoma following induction chemotherapy (IC) remains unclear. We studied on patients who did or did not undergo IC (NIC) to elucidate the prognostic value of p21 protein expression. MATERIALS AND METHODS: p21 protein expression was assessed immunohistochemically and samples with greater than 10% positive tumor cells were considered positive. We then analyzed clinical-pathological features, including p53 protein expression and prognosis, in 43 patients who underwent IC group and 40 who did not IC (NIC) group. RESULTS: Positive nuclear p21 samples were obtained from 17 (41.5%) patients in the in IC group and 22 (55.0%) in the NIC group. In the IC group, there was no significant correlation between the histological effectiveness of chemotherapy and p53 protein expression, whereas a significant correlation was observed between that and p21 protein expression (p=0.048). Further, the prognosis for p21-positive patients tended to be better (p=0.0506) than for p21-negative patients, and was significant (p=0.048) in patients with pathological stage (p-stage) II or III disease. CONCLUSION: Our findings suggest that p21 protein expression is a prognostic factor for primary patients with pulmonary squamous cell carcinoma following IC.

Juvenile catamenial pneumothorax: institutional report and review.

BACKGROUND: Catamenial pneumothorax (CP) is a type of spontaneous pneumothorax due to thoracic endometriosis occurring in reproductive women, and usually involves the right side of the thorax showing diaphragm lesions. For the present study, we defined juvenile CP (JCP) as patients with CP who were 19 years old and younger. Institutional findings and a systematic literature review are presented. METHODS: We retrospectively enrolled all patients with CP treated at our institutions from January 2002 to June 2013. In addition, we conducted a search of medical literature published using the PubMed and Japanese Ichushi databases with "catamenial pneumothorax" as the search term. RESULTS: Thirteen female patients with CP, 1 on the left side, were treated at our institutions. The patient with left-side CP was classified as JCP, while that was also identified in 29 of 451 CPs reported in our literature review. Pneumothorax occurred more frequently on the left side in JCP as compared to usual CP (p<0.01). There was a significantly lower ratio of JCP cases with diaphragm lesions as compared to usual CP (p<0.01). CONCLUSION: Significant laterality was not seen in JCP patients and fewer had diaphragm lesions as compared to usual CP. JCP may be a new entity of CP.

Needlescopic operation for partial lung resection.

Needlescopic operation using instruments with a diameter of 2 mm has not been applied to partial lung resection because of the difficulty in grasping the lung firmly or the possibility of injuring the lung easily with 2-mm forceps. We have developed a technique using a mini-loop retractor and successfully performed partial lung resection in 35 patients with pneumothorax, small lung tumor, or interstitial pneumonia.

One-step nucleic acid amplification for detection of lymph node metastasis in lung cancer.

OBJECTIVE: Intraoperative diagnosis of lymph node (LN) metastasis is critical in lung cancer patients. The one-step nucleic acid amplification (OSNA) assay is a novel technique using a loop-mediated isothermal amplification method of gene amplification. The objective of this study was to investigate whether the OSNA assay provides sufficient diagnosis of LN metastasis in lung cancer patients. METHODS: A total of 40 LN stations were dissected from the 20 patients, who had curative lobectomy for lung cancer. The cut halves of LNs were used for pathological diagnosis, and other halves were for the OSNA assay. The OSNA assay used cytokeratin (CK) 19 mRNA as a marker. The CK19 mRNA copy number was detected using RD-100i (Sysmex Corp., Hyogo, Japan). One formalin-fixed section with the largest cutting surface of the other halves of LNs was used for pathological examination. When discordance was observed between OSNA assay and usual pathological examination, an additional examination using 1-mm interval sections was performed. RESULTS: In the forty LN stations, three stations were diagnosed as LN metastasis positive pathologically. In these three, the OSNA assays showed extremely high numbers of CK19 mRNA copies. When the cutoff value was set to 250 copies/µl, 4 stations with relatively low copy numbers were found to be discordant. Of the 4 discordant cases, one was shown to be micro-metastasis positive in the additional pathological assessment. The sensitivity of the OSNA assay was 100.0%, and its specificity was 91.7%. CONCLUSIONS: This method could be applied to intraoperative assessment LNs metastasis.

Unexpected rapid growth of estrogen receptor positive lung cancer during pregnancy.

We report a case with lung cancer during pregnancy, which has a very poor prognosis.A 34-year old female at 30 weeks of pregnancy came to us with a cough and right lower chest pain. Chest computed tomography revealed a mass in the right lower lung lobe and the diagnosis of adenocarcinoma cT2aN1M0 was made. We performed a right sleeve pneumonectomy, as the tumor had progressed to the right main bronchus near carina. Histological sections of the specimens revealed a poorly differentiated adenocarcinoma that infiltrated surrounding structures. The pathological stage of lung cancer was T4N2M0 stage IIIB. Immunohistochemistry findings for estrogen receptor ß were positive in the nuclei of the adenocarcinoma. She had a rapid recurrence in spite of chemotherapy, and she died 7.5 months after operation. The positive estrogen receptor and hormonal condition during pregnancy might promote cancer and result in her poor prognosis.

Intractable pneumothorax with empyema in a patient with interstitial pneumonia.

Secondary pneumothorax occurring in interstitial lung disease cases is a refractory and life-threatening condition, because of compromised lung function. A 70-year-old woman with interstitial pneumonia was referred to our hospital after treatment failure for pneumothorax associated with empyema. An open window thoracostomy was created, and mechanical irrigation and dressing changes of the pleural cavity were performed. Then, the lung was widely covered with the latissimus dorsi and serratus anterior muscles because there were multiple fistulae on the lung surface. After the covering muscles were completely adhered to the lung surface and stopped air leaking, the chest was successfully closed. The wide covering technique of the lung with chest wall muscles is effective for intractable pneumothorax with multiple fistulae.

Incidence of acute exacerbation of interstitial pneumonia in operated lung cancer: institutional report and review.

PURPOSE: Several small studies have reported that acute exacerbation (AE) of idiopathic interstitial pneumonia (IIP) can occur after lung resection for patients with non-small cell lung cancer, though the incidence rate is unclear. METHODS: We examined our institutional data and performed a search of the MEDLINE database for publications regarding AE of IIP following surgery for lung cancer. Studies reporting the incidence rates of IIP and AE were included. RESULTS: Eleven studies including our institutional data were determined to be eligible. Seven studies designated the incidence of IIP. Of 4749 patients (from 7 studies) who underwent lung resection for NSCLC, 277 had IIP, for an incidence rate of 5.8% (range 1.1%-11.7%). Eleven studies designated the incidence of AE from IIP patient, 67 (15.8%) of 424 IIP patients (from 11 studies) developed AE after surgery, of whom 38 (56.7%) died during the postoperative course. CONCLUSION: Coexistent IIP in patients with lung cancer increases the risk of lung cancer surgery. Furthermore, AE of IIP may be a major cause of operation-related death.

Efficacy of functional operability algorithm for octogenarians with primary lung cancer.

PURPOSE: The number of lung cancer patients is increasing in association with the aging of society, and age is associated with the risk of undergoing a thoracotomy procedure. We prospectively investigated the efficacy of a functional operability algorithm that included pulmonary function and exercise test results for determining the indication for surgery in octogenarians. METHODS: From April 2001 to October 2008, surgical indications for a total of 45 octogenarians were assessed using our algorithm, including forced expiratory volume in 1 s/forced vital capacity ratio, predicted postoperative percent of forced expiratory volume in 1 s, Hugh-Jones dyspneic index, and empirical anaerobic threshold obtained during an exercise test. Then the surgical results were reviewed. RESULTS: Thoracotomy was contraindicated in one patient; the remaining 44 patients underwent surgery. Axilloanterior thoracotomy (75%), lobectomy (84%), and mediastinal lymph node dissection (73%) were the major procedures. Altogether, 37 postthoracotomy complica-Received: 13 February 2011 / Accepted: 30 May 2011 © The Japanese Association for Thoracic Surgery 2012 tions occurred in 29 (65.9%) patients. The 30-day and hospital mortality rates were 2.3% and 4.5%, respectively, and overall and disease-specific 5-year survival rates for the 42 patients were 54.5% and 79.6%, respectively. CONCLUSION: Following careful selection with our functional operability algorithm, octogenarians were able to tolerate a standard lung resection for primary lung cancer with acceptable morbidity and mortality. Their survival was consistent with that of younger cancer patients.

Lung transplantation for aspiration-induced silicosis of the lung.

Silicosis, a slowly progressing chronic disease, is rare in lung transplantation patients. Herein, we report a case of single lung transplantation in a 35-year-old man for acute and accelerated silicosis, without a history of inhalation of silicium. A pathology examination of the explanted lung revealed that aspiration of a scouring powder was the cause of lung silicosis. Aspiration-induced lung silicosis is rare.

Sarcoidosis development during induction chemotherapy for lung cancer mimicked progressive disease.

We report a rare case of sarcoidosis that developed during induction chemotherapy for primary lung cancer, mimicking progressive disease. A 63-year-old man had an abnormal shadow in the right upper lung, and a bronchoscopic examination revealed a squamous cell carcinoma. Swelling of a pretracheal lymph node was also noted. Thus, we gave induction chemotherapy consisting of paclitaxel (days 1, 8) + carboplatin (days 1, 8) for two cycles under clinical staging of T2N2M0. After induction chemotherapy, (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed positive accumulation of FDG in mediastinal and bilateral hilar lymph nodes that had been negative in a previous FDG-PET examination, which led us to suspect disease progression. Transbronchial lymph node biopsy results showed sarcoid granulomas in the specimens. Following complete resection of the lung cancer, sarcoid granulomas were revealed in both nonneoplastic lung tissue and lymph nodes, which resulted in a diagnosis of lung cancer accompanied with sarcoidosis.

Tracheal chondrosarcoma.

Tracheal chondrosarcomas are rare, with only 14 cases previously documented. We report a case of chondrosarcoma of the trachea and review other published cases. Our patient was a 34-year-old man who began to feel shortness of breath 8 months after initial hemoptysis. Transverse and coronal computed tomography demonstrated a tumor that was obstructing nearly 80% of the tracheal lumen at the thoracic inlet. A bronchoscopic biopsy specimen led to an initial diagnosis of chondroma. Five tracheal rings from the third to the seventh including the tumor were completely resected, and an end-to-end anastomosis was performed. The histological diagnosis of the surgical specimen showed it to be a chondrosarcoma. The patient was alive without recurrence at 6 years 4 months after surgery. Because recurrence after incomplete resection and malignant transformation can occur with chondromas, radical resection of the trachea is recommended for all cartilaginous tumors of the trachea.

Cytologically malignant margin without continuous pulmonary tumor lesion: cases of wedge resection, segmentectomy and lobectomy.

The surgical margin is usually investigated during the operation using a pathological method, though cytological methods are also used to identify remaining malignant cells. We reviewed cases of pulmonary resection for a malignant tumor. At our institution, an on-site surgical margin examination using a cytological method is mandated for cases of wedge resection and segmentectomy, and an option in lobectomy cases. We examined 21 wedge resection (3 primary lung cancer, 18 metastasis), 17 segmentectomy (13 primary lung cancer, 4 metastasis), and 4 lobectomy (all primarily lung cancer) cases. Six cases showed malignant cells in the surgical margin, of which one had a microscopic skip lesion pattern and five an 'occult' pattern (positive cytology, negative pathology). Cytological malignancy occurred even in cases of wedge resection of a tiny (4 mm in diameter) lesion metastasized from colon cancer, as well as segmentectomy with a sufficient gross margin containing microscopic skip lesions and right middle lobectomy with an additional right upper lobectomy due to two previous cytological malignancies in a residual lobe. Surgical margin cytology revealed remaining malignancy in the residual lobe, which provided important information for deciding additional procedures during surgery.