Right basal bronchial fistula due to amebic infection: a case report.

BACKGROUND: Pleuropulmonary amebiasis is the second most common form of extraintestinal invasive amebiasis, but cases that include bronchopleural fistula are rare. CASE PRESENTATION: A 43-year-old male was referred to our hospital for liver abscess, right pleural effusion, and body weight loss. He was diagnosed with a bronchopleural fistula caused by invasive pleuropulmonary amebiasis and human immunodeficiency virus (HIV) infection. After initial medical treatment for HIV infection and invasive amebiasis, he underwent pulmonary resection of the invaded lobe. Intraoperative inspection revealed a fistula of the right basal bronchus in the perforated lung abscess cavity, but the diaphragm was intact. The patient was discharged on postoperative day 3 and was in good condition at the 1-year follow-up. CONCLUSIONS: Clinicians should be aware that pleuropulmonary amebiasis can cause a bronchopleural fistula although it is very rare.

[Lung Cancer Cases with Spontaneous Regression].

Case 1 was a 79-year-old man. Computed tomography (CT) showed a nodule in the left upper lobe. Surgery was planned, but the regression of the nodule was noted and the surgery was postponed. Six months later, the nodule shadow increased again, and was surgically resected. Pathological diagnosis was adenocarcinoma. Case 2 was an 82-year-old man. CT showed a nodule in the right lower lobe and surgery was planned, but the nodule regressed. Three months later, it increased and was resected. It was pathological diagnosed as squamous cell carcinoma. Although spontaneous regression of lung cancer is rare, careful follow up of the regressed nodules shadow is required because of possible regrowth after the regression.

[Uniportal versus Multiportal Video-assisted Thoracic Surgery for Primary Lung Cancer].

OBJECTIVES: This study aimed to consider the safety and feasibility of uniportal video-assisted thoracic surgery( VATS)[ u-VATS] compared with multiportal VATS( m-VATS). METHODS: Sixty-two patients underwent anatomical lung resection for primary lung cancer via u-VATS between February 2019 and May 2020 at our institution. We performed propensity score matching of these cases versus anatomical lung resection cases under m-VATS performed from January 2017 to December 2019, and compared the perioperative results. RESULTS: In the u-VATS group, operation time( 142 minutes vs. 178 minutes, p<0.01) and postoperative drainage days( 1.6 days vs. 2.4 days, p=0.01) were significantly shorter. There were no differences in intraoperative blood loss, vascular damage, conversion rate, number of lymph nodes dissected, postoperative complications, and postoperative hospital stay. The number of pain complaints and the number of analgesics (non-steroidal anti-inflammatory drugs:NSAIDs) prescribed at the first outpatient clinic after discharge were significantly lower in the u-VATS group( 10 vs. 22, p=0.03). CONCLUSIONS: U-VATS shortened the operation time and postoperative drainage period compared with conventional m-VATS, and significantly reduced the use of analgesics. U-VATS is considered to be safe and less invasive surgical procedure based on the present study.

[Video-assisted Thoracoscopic Total Pleural Adhesiolysis:Tips and Pitfalls].

PURPOSES: Here, we present the tips and pitfalls of video-assisted thoracoscopic( VATS) total pleural adhesiolysis( TPA), determined on an empirical basis. PATIENTS AND METHODS: From 2012 to 2020, VATS-TPA was performed in 33 patients undergoing pulmonary anatomic lung resection at our institute. The basic procedure was as follows:after peeling off the area of pleural adhesion surrounding the surgical ports using the fingers, the thoracoscope was inserted into the thorax and the adhesions in other areas were peeled off under thoracoscopic guidance. RESULTS: The adhesiolysis group had a longer operating time, greater blood loss, and higher rate of conversion to thoracotomy compared to the non-adhesiolysis group. However, the results were acceptable considering the extra manipulation for adhesiolysis. CONCLUSIONS: VATS-TPA is a necessary component of the standard surgical procedure for general thoracic surgeons in cases of total pleural adhesion.

[Erlotinib plus Bevacizumab Therapy for Postoperative Recurrence of Adenosquamous Cell Carcinoma Harboring EGFR Mutation-A Case Report].

A 59-year-old man clinically diagnosed with primary lung cancer underwent left lower lobectomy and lymph node dissection( ND2a-2). The postoperative pathological stage was ⅠB(pT2aN0M0), and the lesion was positive for epidermal growth factor receptor(EGFR)exon 21 L858R mutation. Thirty months after surgery, the patient developed pleural dissemination and effusion in the left pleural cavity. Carboplatin(AUC=6, day 1, every 3 weeks)and nab-paclitaxel(100 mg/m2, day 1 and day 8, every 3 weeks)were administered as first-line therapy. Progressive disease was evident 10 months after 4 courses of first-line therapy. Pembrolizumab(200 mg, day 1, every 3 weeks)was then administered as second-line therapy. After 7 months(9 courses of therapy), the lung cancer had metastasized to the left third intercostal muscle, and the pleural nodules regrew. The former lesion was treated with radiotherapy owing to the development of pain in the chest. Erlotinib (150 mg once daily)and bevacizumab(15 mg/kg, day 1, every 3 weeks)were initiated as third-line therapy, resulting in complete response at 14 months(67 months after surgery, 37 months after postoperative recurrence). The prognosis of patients with EGFR-positive pulmonary adenosquamous carcinoma and undergoing treatment with EGFR-tyrosine kinase inhibitors(TKI)is reportedly poor. Herein, we report a rare case of adenosquamous carcinoma with EGFR mutation presenting complete response following treatment with EGFR-TKI.

[Alectinib for an Octogenarian Patient with Poor Performance Status and ALK Fusion Gene-Positive Lung Cancer-A Case Report].

An 89-year-old female who had been clinically diagnosed with primary lung cancer underwent right upper lobectomy and lymph node dissection(ND2a-2). Postoperative pathological staging revealed a stage ⅡA(pT1bN1M0)adenocarcinoma that was negative for an EGFR mutation. Nineteen months after surgery, the patient developed a mediastinal lymph node metastasis, and radiotherapy was prescribed. Thirty-eight months later, she developed new mediastinal/hilar lymph node metastases and was prescribed pemetrexed(500 mg on day 1 of each of 3 weeks)as the first-line therapy. A complete response was evident after 10 courses. However, she developed grade 3 nausea, and pemetrexed was discontinued. During 10 months of follow-up, no new lesion appeared; therefore, follow-up was discontinued. Ninety-three months after surgery, she was referred to our hospital because an abnormal shadow was apparent on chest roentgenography. A thorough examination revealed pleural dissemination, pulmonary metastases, mediastinal/hilar lymph node metastases, an adrenal metastasis, and bone metastases. Although her performance status(PS)was poor(grade 4), as the diagnosis was ALK fusion gene-positive adenocarcinoma, alectinib(600 mg once daily)was commenced as the second-line therapy. Complete response was achieved 14 months later(ie, 108 months after surgery and 89 months after postoperative recurrence). Thus, an octogenarian patient with poor PS and ALK fusion gene-positive adenocarcinoma exhibited a complete response after treatment with alectinib.

[Postoperative Recurrence of ROS1‒Positive Pulmonary Adenocarcinoma after 19 Years].

A 73‒year‒old woman underwent right lower lobectomy for Stage ⅠA(pathological Stage T1N0M0)pulmonary adenocarcinoma. After 19 years, she complained of dyspnea on exertion. Computed tomography revealed metastatic lesions in the bilateral supraclavicular, mediastinal, and hilar lymph nodes. Thoracoscopic lymph node biopsy showed recurrence of the adenocarcinoma, and immunohistochemical staining confirmed that the metastases were ROS1‒positive. The patient responded well to crizotinib therapy. The prognosis of non‒small‒cell lung cancer is considered favorable when it does not recur within 5 years, postoperation. However, few studies have reported the recurrence of ROS1‒positive pulmonary adenocarcinoma after a long disease‒free interval. Long‒term postoperative follow‒up is essential for patients with ROS1‒positive pulmonary adenocarcinomas.

[Docetaxel and Ramucirumab Combination Chemotherapy after Nivolumab Treatment for Pretreated Pulmonary Squamous Cell Carcinoma-A Successful Case].

For immune checkpoint inhibitor(ICI)-pretreated patients, docetaxel and ramucirumab(DTX plus RAM)combination therapy can be more effective than no treatment. Herein, we present the case of a patient who had been treated with ICIs and was thereafter successfully treated with DTX plus RAM. A 62-year-old man with primary pulmonary squamous cell carcinoma( PDL-1 tumor proportion score<1%)at clinical stage ⅠA2(cT1bN0M0)was treated as follows: 1)right upper lobectomy ND2a-2(pT1bN0M0, stage ⅠA2); 2)surgery for a solitary pleural metastasis 20 months later; 3)cisplatin plus vinorelbine for multiple pleural metastases as a first-line treatment 24 months after the initial surgery; and 4)nivolumab as a second-line treatment. However, progressive disease and an adverse event occurred after 5 courses of nivolumab, and DTX plus RAM were introduced as a third-line treatment. A complete response to 12 courses of combination therapy(41 months after surgery/29 months after recurrence)was determined. Unfortunately, the DTX plus RAM regimen had to be withdrawn because the patient developed drug-induced acute pneumonitis. The patient has been in remission since drug discontinuation and is receiving steroid and home-oxygen therapy.

[Malignant Solitary Fibrous Tumor of the Pleura;Report of a Case].

We report a rare case of a malignant solitary fibrous tumor of the pleura(SFTP). The patient was a 66-year-old man, who had an asymptomatic 25 mm nodule in the left upper lung field. We performed a wedge resection of the left lung by video-assisted thoracic surgery, and the tumor was diagnosed as a malignant SFTP. Although the recurrence has not been found for 26 months, long-term clinical follow-up is thought to be necessary because of the potential adverse biological behavior of this tumor.

[Late-Onset Acute Pneumonitis Caused by Pembrolizumab Used to Treat Postoperative Recurrence of Squamous Cell Carcinoma-A Case Report].

We present an unusual case of late-onset acute pneumonitis developing 21 months after pembrolizumab monotherapy. An 80-year-old male with primary, pulmonary, squamous cell carcinoma underwent right lower lobectomy and lymph node dissection(ND2a-2); the postoperative pathological stage was ⅢA(pT2bN2M0)and the PD-L1 tumor proportion score 70%. Six months after surgery, he developed mediastinal lymph node(#2R), bilateral pulmonary, and hepatic metastases; pembrolizumab was administered every 3 weeks as a first-line treatment. A partial response was evident after 3 courses; we thus continued the monotherapy. However, after 28 courses(21 months)of pembrolizumab, we discontinued the regimen because acute pneumonitis(Grade 3)developed; we prescribed prednisolone at 50 mg/day. The acute pneumonitis shadow improved and prednisolone was tapered over 2 months. The patient exhibited no new lesion and no progressive disease 6 months after pembrolizumab was discontinued.

[Pulmonary Adenocarcinoma Responding to Fourth-Line S-1 Monotherapy-A Case Report].

Herein, we report a case of unresectable lung cancer in which S-1 monotherapy contributed to an improvement in the patient's quality of life and to prolonged survival. A 44-year-old man with primary pulmonary adenocarcinoma(negative driver mutation and a PD-L1 tumor proportion score of 1-24%)of clinical stage ⅢA(cT4N0M0)underwent multidisciplinary treatment as follows: 1 ) weekly carboplatin and paclitaxel plus radiotherapy as induction chemoradiotherapy, 2 ) surgery that revealed that the lesion was unresectable, 3 ) cisplatin plus pemetrexed as second-line treatment, and 4 ) pembrolizumab as third-line treatment. However, the disease progressed after 19 courses of pembrolizumab, and the patient developed cachexia due to esophageal stenosis caused by tumor enlargement. He underwent percutaneous gastrostomy and was fed via a gastrostomy tube. S-1 monotherapy(2-week administration every 3 weeks)was introduced as fourth-line treatment. After 3 courses of S-1 monotherapy, the patient complained of regurgitation of stomach fluid. Computed tomography( CT)revealed that the primary tumor had decreased in size, and he developed the ability to drink water. After 6 courses of S-1, CT revealed progressive disease, so atezolizumab was administered as fifth-line treatment. However, after 2 courses, mediastinitis due to esophageal penetration into the mediastinum occurred. The patient died 28 months after the initial treatment.

[Wedge Resection as an Alternative Procedure for Primary Pulmonary Carcinoma in Poor-risk Patients].

BACKGROUND: We present wedge resection as an alternative procedure for primary pulmonary carcinoma in poor-risk patients. PATIENTS AND METHODS: We examined the overall survival of 94 patients who underwent wedge resection for pN0M0 primary pulmonary carcinoma over the last 20 years because of their intolerance of lobectomy. RESULTS: In the wedge resection group, the postoperative 5-year survival in all causes of death was 59.6%, indicating significantly better prognoses in patients with adenocarcinoma aged less than 75 years old. The 5-year survival in the lobectomy group was 77.5%, while the 5-year survival in terms of primary causes of death in the wedge resection and lobectomy groups was 89.3% and 88.0%, respectively. There was a significant difference between wedge resection and lobectomy in all causes of death, but not between groups in primary causes of death. CONCLUSION: Because there were many non-primary deaths in the wedge resection group, care should be taken to follow comorbidities that cause limited lung resection. Survival in the wedge resection group was not inferior to that in the lobectomy group in analyses of the primary causes of death. We suggest that wedge resection should be a favorable procedure for primary pulmonary carcinoma in poor-risk patients to obtain a large enough sample volume of tumor cells.

[Successful Treatment of a Mechanically Ventilated Patient with an Oncological Emergency Caused by Recurrence of Pulmonary Adenocarcinoma].

We successfully treated a mechanically ventilated patient with severe respiratory failure caused by airway stenosis; she recovered after radiotherapy and gefitinib administration. A 68-year-old female with a pulmonary adenocarcinoma underwent a radical operation(right middle-lower sleeve lobectomy and lymph node dissection). Forty-four months later, she was admitted to our hospital with severe dyspnea, and was placed on mechanical ventilation after tracheal intubation. Postoperative cancer recurrence was evident in the bronchial mucosa and the site of carinal stenosis. Pathological examination revealed an epidermal growth factor receptor-positive adenocarcinoma. After radiotherapy(a total of 30 Gy), gefitinib(250mg/day) was commenced. Respiratory function improved gradually, and ventilator weaning was successful 3 weeks after tracheal intubation. Computed tomography revealed a partial response; her recovery from the emergency oncological situation was remarkable. She was discharged 4 months after hospitalization. Although she took gefitinib every 2-to-7 days, she refused all examinations and possible treatments for 25 months after recurrence. Finally, she died of respiratory failure 29 months after recurrence and 73 months after the initial operation.

Direct S0 → Tn Transition under Visible Light Irradiation Enabling Synthesis of a Pseudoindoxyl Scaffold.

Pseudoindoxyl is a partial skeleton found in various natural products. Its light-absorption properties make it useful for the design of functional molecules. However, versatile synthesis methods have not yet been reported. In this report, we present a versatile synthetic method for pseudoindoxyls using the direct S0 → Tn transition under visible light irradiation. We also discuss the application of pseudoindoxyls as photocatalysts.

Prognosis of non-small cell lung cancer with postoperative regional lymph node recurrence.

BACKGROUND: Regional lymph node recurrence after radical surgery for non-small cell lung cancer (NSCLC) is an oligo-recurrent disease; however, no treatment strategy has been established. In the present study we aimed to determine the clinical outcomes of postoperative regional lymph node recurrence and identify prognostic predictors in the era of molecular-targeted therapy. METHODS: We retrospectively analyzed data on clinical characteristics and outcomes of patients with regional lymph node recurrence after surgery who underwent treatment for NSCLC between 2002 and 2022. RESULTS: A total of 53 patients were included in this study. The median time between surgery and detection of recurrence was 1.21 years. Radiotherapy (RT) alone and chemoradiotherapy (CRT) were performed in 38 and six patients, respectively. Driver gene alterations were detected in eight patients (EGFR: 6, ROS1:1, and BRAF: 1) and programmed death-ligand 1 (PD-L1) expression was examined in 22 patients after 2016. Median progression-free survival (PFS) and overall survival (OS) after lymph node recurrences were 1.32 and 4.34 years, respectively. Multiple lymph node recurrence was an independent prognostic factor for PFS, whereas driver gene alteration was the only prognostic factor for OS. There was no significant difference in the OS between patients stratified according to the initial treatment modality for lymph node recurrence. CONCLUSION: Our results suggest that the number of tumor recurrences may correlate with PFS, while detection of driver gene alterations could guide decision-making for the appropriate molecular-targeted therapy to achieve longer OS.

Risk factors for late-onset pulmonary fistula after pulmonary segmentectomy.

Background: Late-onset pulmonary fistula (LOPF) is a well-described complication after segmentectomy, but the precise incidence and risk factors are still unclear. We aimed to determine the incidence of, and risk factors for, LOPF development after segmentectomy. Methods: A single-institution retrospective study was performed. A total of 396 patients who underwent segmentectomy were enrolled. Perioperative data were analyzed to identify the risk factors for LOPF requiring readmission according to univariate and multivariate analyses. Results: The overall morbidity rate was 19.4%. The incidence rates of prolonged air leak (PAL) in the early phase and LOPF in the late phase were 6.3% (25/396) and 4.5% (18/396), respectively. The most common surgical procedures with LOPF development were segmentectomy of the upper-division (n=6) and S6 (n=5). With a univariate analysis, presence of smoking-related diseases did not affect LOPF development (P=0.139). Conversely, segmentectomy with cranial side free space (CSFS) in the intersegmental plane and use of electrocautery to divide the intersegmental plane were associated with a high risk of LOPF development (P=0.006 and 0.009, respectively). A multivariate logistic regression analysis showed that segmentectomy with CSFS in the intersegmental plane and use of electrocautery were independent risk factors for LOPF development. Approximately 80% of patients who developed LOPF recovered by prompt drainage and pleurodesis without reoperation, whereas the remaining patients developed empyema due to delayed drainage. Conclusions: Segmentectomy with CSFS is an independent risk factor for LOPF development. Careful postoperative follow up and rapid treatment are necessary to avoid empyema.

Clinicopathological features and surgical outcomes of lobectomy combined with segmentectomy: a cohort study.

Background: Segmentectomy is a standard procedure, and there is considerable data on routine segmentectomies. However, there are only few reports on lobectomy performed in combination with segmentectomy (lobectomy + segmentectomy). Thus, we aimed to clarify the clinicopathological features and surgical outcomes of lobectomy + segmentectomy. Methods: We reviewed patients who underwent lobectomy + segmentectomy between January 2010 and July 2021 at Gunma University Hospital, Japan. We comparatively analyzed clinicopathological data of patients who underwent lobectomy + segmentectomy and those who underwent lobectomy in combination with wedge resection (lobectomy + wedge resection). Results: We collected data from 22 patients who underwent lobectomy + segmentectomy and 72 who underwent lobectomy + wedge resection. Lobectomy + segmentectomy was mainly performed to treat lung cancer, and the median number of resected segments was 4.5 and the median number of lesions was 2. Lobectomy + segmentectomy was associated with a higher rate of thoracotomy and a longer operation time. Incidence of overall complications, including pulmonary fistula and pneumonia was higher in the lobectomy + segmentectomy group. However, there were no significant differences in the length of drainage, major complications, and mortality. For lobectomy + segmentectomy, the only left-sided procedure was a left lower lobectomy + lingulectomy, whereas procedures were diverse on the right side, mostly combining a right upper or middle lobectomy with atypical segmentectomies. Conclusions: Lobectomy + segmentectomy was performed for (I) multiple lung lesions, (II) lesions invading an adjacent lobe, or (III) lesions with a metastatic lymph node invading the bronchial bifurcation. Although lobectomy + segmentectomy is a lung-preserving procedure that can benefit patients with multiple or advanced diseases involving two lobes, this procedure should still be performed following a careful patient selection process.

Autoimmune alopecia areata due to thymoma without myasthenia gravis: a case report.

BACKGROUND: Thymoma is associated with autoimmune diseases. Myasthenia gravis is frequently associated with thymoma, but cases of thymoma complicated by alopecia areata are very rare. In this report, we present a case of thymoma associated with alopecia areata, but without Myasthenia gravis. CASE PRESENTATION: A 60-year-old woman had a complaint of rapid progression of alopecia areata. A hair follicular biopsy was performed, which showed the infiltration of CD8-positive lymphocytes. She was prescribed topical steroids for 2 months prior to surgery, but her hair loss was not improved. Screening computed tomography showed a mass in the anterior mediastinum, which was suspected to be a thymoma. Myasthenia gravis was ruled out because she had no relevant symptoms or physical findings, and no anti-acetylcholine receptor antibodies were detected in serum. We performed a transsternal extended thymectomy based on a diagnosis of thymoma Masaoka stage I, without myasthenia gravis. Pathological examination showed Type AB thymoma, Masaoka stage II. The chest drainage tube was removed on postoperative day 1, and the patient was discharged on postoperative day 6. The patient has continued topical steroids and showed improvement 2 months postoperatively. CONCLUSIONS: Although alopecia areata is a rare complication in thymoma cases without myasthenia gravis, thoracic surgeons need to keep this condition in mind because alopecia reduces the patient's quality of life.

Differentiation between staple line granuloma and recurrence after sublobar resection for primary lung cancer.

BACKGROUND: The use of sublobar resection for early-stage lung cancer or frail cases that cannot tolerate radical surgery for primary lung cancer has been increasing. This study aimed to identify the frequency, shape, and course of staple line thickening and granuloma formation after sublobar resection for primary lung cancer, and to identify factors that help distinguish them from recurrent cancer cases. METHODS: The medical records of 64 patients who underwent sublobar resection for primary lung cancer from January 2012 to December 2017 at our institution were retrospectively reviewed. Computed tomography (CT) images taken every 6 months for at least 3 years after surgery were reviewed, and the postoperative course was examined. RESULTS: Staple line thickening at the time of the first CT scan after surgery was observed in 43 cases (67.2%). Of them, linear thickening was seen in 31 cases (72.1%), and nodular thickening was seen in 12 cases (27.9%). Of these 43 cases, 25 cases were decreased, 8 cases were unchanged and 10 cases showed a tendency to progress during the follow-up period. Of the 64 cases, 7 (10.9%) had staple line recurrence. Staple line recurrence was significantly correlated with vascular invasion (P=0.015), surgical margin (P=0.013), nodular thickening (P<0.001) and a tendency to show progressive thickening (P<0.001). CONCLUSIONS: Staple line thickening was observed in many cases of sublobar resection, and most of them were linear thickening. Staple line recurrence should be suspected if nodular thickening appears and shows a tendency to progress.

Application of "suction-guided stapling" during uniportal thoracoscopic major lung resection.

Uniportal thoracoscopic major pulmonary resection is used worldwide as a minimally invasive surgery. Occasionally, it is difficult to insert a stapler smoothly during uniportal thoracoscopic major pulmonary resection because of limited angulation. To address this challenge, we used "suction-guided stapling" to divide the bronchus or pulmonary vein. Here, we provide details of this technique, including division of the pulmonary veins or bronchus in a video. In addition, we validate this technique by showing perioperative results of uniportal thoracoscopic major pulmonary resections in our department.