Objective: To evaluate the efficacy of perioperative oral management to prevent postoperative pneumonia after lung cancer surgery. Method: A total of 100 consecutive patients who underwent thoracoscopic lobectomy for primary lung cancer from April 2013 and March 2015 in our institute were examined. We compared 50 cases each before and after introduction of perioperative oral management about postoperative course retrospectively. Results: There were no significant differences in the patients' backgrounds, tumors, or operative conditions. Postoperative complications occurred in 5 patients (10.0%) in the oral management group and 16 patients (32.0%) in the no management group, and postoperative pneumonia occurred in 6 patients (12.0%) in the no management group but in no patient in the oral management group. Fever after surgery developed in fewer patients in the oral management group and the average CRP level at 7 POD tended to lower in the oral management group. The length of the postoperative hospital stay was shorter in the oral management group compared with no management group. Conclusion: Perioperative oral management may have an effect to prevent postoperative pneumonia, and it should be introduced universally.
Hepatitis virus B and C cause not only hepatocellular carcinoma (HCC) but also chronic hepatitis. Chronic hepatitis causes liver damage and often complicates surgery for HCC. Recently, the therapy for hepatitis virus has been improving; therefore, the number of patients who can undergo surgery for HCC may increase and therapy for HCC recurrence will become an issue. This study aimed to investigate the relationship with the prognosis and inflammatory markers such as the neutrophil to lymphocyte ratio and Glasgow prognostic score (known as prognostic factors for primary HCC).
This study retrospectively reviewed 10 patients who underwent pulmonary metastasectomy for HCC metastasis at the University of Yamanashi Hospital between 2001 and 2011.
Nine patients underwent partial pulmonary resection and one patient underwent lobectomy. No patient experienced any complications. Seven patients relapsed and six patients died. There was no local recurrence and 4 of the deaths were cancer-related.
Multivariate analysis revealed a significant difference between NLR>2.31 patients and NLR≤2.31 patients regarding the disease-free survival (hazard ratio: 10.28, P=0.043) and between single metastasis and multiple metastases concerning overall survival (hazard ratio: 2.347, P=0.04) after metastasectomy.
In this study, three of the relapsed patients, who underwent a second surgery for the recurrence, showed a significantly longer overall survival after recurrence than the four other patients (median: 98.6 vs. 12.2 months, respectively; P=0.01).
Although patients with NLR>2.31 have a high risk of recurrence, if the recurrence is limited to the lung or liver, repeated surgery will be useful to prolong the survival.
Objective: We retrospectively analyzed reconstructive procedures, kinds of grafts used, antithrombotic therapy, and graft patency in patients with thoracic malignancies and resection of the superior vena cava (SVC) and brachiocephalic veins (BCVs).
Methods: From 2005 to 2014, 15 patients underwent resection and reconstruction of SVC and/or BCVs. We collected and reviewed their clinical data, surgical procedures, postoperative graft status, and perioperative antithrombotic therapy.
Results: The subjective tumors were thymic epithelial tumor in 11 patients, germ cell tumor in two, and lung cancer and malignant lymphoma in one each. SVC was reconstructed in 13 patients, right BCV in 12 patients, and left BCV in 14 patients. In all patients, the adopted graft diameter was ≥10 mm and antithrombotic therapy was performed. Although occlusion of the reconstructed veins was observed in six patients, the associated symptoms were rarely observed in patients whose left and right brachiocephalic pathways were maintained.
Conclusion: Procedures that require the resection of great vessels remain challenging. We did not observe perioperative deaths nor early graft occlusions in this study. In the case of graft occlusion, follow-up is possible in the absence of severe symptoms.
A 35-year-old pregnant woman developed right spontaneous pneumothorax at 29 weeks of gestation during the management of imminent abortion. She was admitted to our hospital, and chest tube drainage was performed. The air leak stopped, and the collapsed lung re-expanded the day after drainage. However, a massive air leak occurred 4 days after admission, and chest radiograph revealed that the lung had recollapsed. Further, her symptoms of imminent abortion were in remission. Therefore, video-assisted thoracoscopic surgery was planned and performed 7 days after admission. Fetal heart rate monitoring was used to monitor the fetus during the surgery. Neither the mother nor fetus showed any perioperative complications. The chest tube was removed 4 days after the surgery, and she was admitted to the Department of Obstetrics the next day. Thereafter, she experienced no recurrence of pneumothorax and delivered a healthy baby at 39 weeks of gestation. Thus, we suggest that surgery can and should be considered when treating a pregnant woman with spontaneous pneumothorax.
Pulmonary pleomorphic carcinoma is a rare lung tumor, and it is sometimes associated with granulocyte colony-stimulating factor (G-CSF) production or infection. Herein, we report a case of G-CSF-producing pulmonary pleomorphic carcinoma associated with lung abscess and empyema. A 42-year-old man was referred to our hospital for further examination of high fever and a mass shadow in the right upper lung field. Antibiotics failed to reduce the fever, and right upper lobectomy and lymph node dissection were performed. Pathological examination revealed pleomorphic carcinoma associated with lung abscess and empyema. Three months after the operation, the carcinoma metastasized to the pleura, and three months after that he died of liver metastasis. Even though rare, it is important to keep the possibility of G-CSF-producing pulmonary pleomorphic carcinoma associated with infection in mind.
We present a rare case of acute on chronic pancreatitis with a pseudocyst extending up to the neck.
A 56-year-old man with acute on chronic pancreatitis was transferred to our hospital because of neck swelling and hoarseness, diagnosed as descending necrotizing mediastinitis. The patient had a medical history of multiple hospital admissions because of recurrent alcoholic pancreatitis. In the previous hospital, computed tomography-guided drainage of the pancreatic pseudocyst was performed. CT from the previous hospital showed no pancreatic pseudocyst in the abdomen. Initially during the data collection process, we had considered the possibility that the fluid accumulation was descending necrotizing mediastinitis. Contrast-enhanced CT revealed a low-density area in the prevertebral space extending from the mediastinum and communicating with the tail of the pancreas via the esophageal hiatus. Additionally, the swelling of the patient's neck disappeared without any intervention. From the data and clinical findings, the patient was diagnosed with a paraesophageal abscess. Abscess drainage under video-assisted thoracic surgery was carried out, and the fluid specimen showed a markedly high value of amylase (100.000 IU/L). Internal fistulization of the pancreatic pseudocyst was performed endoscopically. Thereafter, the patient recovered and was discharged. There are few reports of chronic pancreatitis with this kind of severe complication. Although a pseudocyst is a common complication of chronic pancreatitis, its extension up to the neck is extremely rare, and so we report this case.
Epithelioid hemangioendothelioma (EHE) arising from the chest wall is extremely rare. We report a case of rapidly growing EHE that originated from the chest wall. A 29-year-old woman with back pain that developed after delivery was admitted to our hospital for further examination of erosion of the right rib on a chest roentgenogram. Chest CT revealed a mass in the chest wall measuring 5 cm in diameter involving the right 7th rib and a nodule measuring 2 cm in diameter in the lower lobe of the left lung. It was difficult to definitively diagnose her by transbronchial lung biopsy of the left lung nodule. The patient underwent resection of the chest wall tumor with reconstruction of the chest wall and partial resection of the left lower lobe under thoracoscopic surgery. Because intraoperative findings demonstrated some subpleural nodules in the bilateral lungs, we also resected all nodules. The chest wall tumor and pulmonary nodules were diagnosed pathologically as EHE; therefore, we diagnosed the patient with EHE originating from the chest wall and bilateral lung metastases. Although radiotherapy and systemic chemotherapy were performed after the operation, she died 12 months after the operation due to the development of multiple metastases and malignant pericardial and pleural effusion.
Initial surgery consisting of a right upper lobectomy and lymphadenectomy was performed for a 49-year-old woman with a well-differentiated adenocarcinoma (pT1N0M0). A small nodule was identified on computed tomography (CT) in the left lower lobe 3 years and 6 months after the initial operation. Nine years after the surgery, the nodule had enlarged and another three nodules in the same lobe and a nodule in the right lower lobe were identified. These five nodules were resected in a wedge-shaped manner using video-assisted thoracic surgery. Histological findings verified that all five nodules were metastatic lesions from the lung cancer operated on previously. The patient is currently alive without any recurrence 3 years and 3 months after the second operation. Because the prognosis of patients with bilateral multiple metastases is poor, this case may be very rare. The long interval from the initial operation to the second operation and slow growth of the recurrent tumor in this case might be characteristics suggesting a good prognosis. Because of the rearrangements in the anaplastic lymphoma kinase (ALK) gene detected in the resected lesion, an ALK inhibitor could have been selected for treatment after detection of the rearrangements in the ALK gene in a sample obtained by CT-guided needle biopsy. However, surgery was thought to be more beneficial in this case because the patient has survived without any significant loss of respiratory function or any adverse effects or costs of chemotherapy.
A 72-year-old woman was evaluated following an abnormal CT scan of the chest. The scan showed a 10-mm-diameter nodule in the right lower lobe. Bronchoscopic biopsy revealed a typical carcinoid. Pre-operative CT showed a significant reduction in size of the nodule, to 3 mm. The patient underwent a right lower lobectomy. Inside the nodule, tumor cells had disappeared histologically and were replaced by lymphocytes, foam cells, and fibrotic tissues.
A 73-year-old man was admitted to the hospital because of bloody sputum. Chest computed tomography (CT) showed a 70-mm mass shadow in S6 of the left lung. We planned surgical resection because the patient was diagnosed with squamous cell carcinoma based on bronchoscopy findings. The tumor invaded S1+2 of the left lung, the pulmonary artery between the upper and lower lobes, and the superior lobar bronchus, so we decided to perform left pneumonectomy. Furthermore, we planned to resect the aortic wall, as we suspected that the tumor had invaded the descending aorta based on chest CT findings. The patient required thoracic endovascular aortic treatment before left pneumonectomy, and we decided to place two thoracic endovascular stents to reinforce the strength of the aorta. First, the patient underwent thoracic endovascular aortic stenting in the supine position. After moving the patient to the right lateral decubitus position, he underwent left pneumonectomy with en bloc resection of the infiltrated area of the aortic adventitia via a posterolateral thoracotomy. His postoperative course was uneventful. Pathology findings confirmed a pleomorphic carcinoma invading the aortic adventitia. The patient did not receive adjuvant chemotherapy. He has been doing well, and at the 12-month follow-up, he showed no evidence of recurrent disease or any complications related to the endovascular stents. Therefore, we suggest using a thoracic endovascular stent for patients in whom lung cancer has invaded the aorta, because it enabled us to perform minimally invasive and safe en bloc resection of a tumor invading the aortic wall in the present case.
Colon metastases from primary lung cancers are rare. A 69-year-old man underwent a right upper lobectomy for primary lung cancer (acinar adenocarcinoma, pT1aN0M0 pStageIA) 2 years previously. Follow-up chest-abdominal contrast-enhanced computed tomography (CT) showed left hilar and pericecal lymphadenopathies. Positron emission tomography (PET) showed high fluorodeoxyglucose accumulation in the cecum and lymph nodes. Colonoscopic examination showed a type-3 tumor in the cecum. A biopsy specimen revealed adenocarcinoma. We diagnosed the patient with colon cancer and performed laparoscopic ileocecal resection and D3 lymphadenectomy. The histopathological diagnosis was cecum metastasis from primary lung cancer, which was not suspected until the follow-up PET-CT. This experience indicates that PET-CT is useful to assess postoperative lung cancer patients.
We encountered two cases of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) associated with the resection of pulmonary adenocarcinoma. Case 1 was a 71-year-old female and case 2 was an 82-year-old female. Their tumors were diagnosed as pulmonary adenocarcinomas. In these cases, hyponatremia was observed after surgery, and they were diagnosed with SIADH. Serum sodium levels normalized following water restriction and the administration of 3% hypertonic saline. As a result, these patients' symptoms and electrolyte abnormalities resolved.
Chemical shift MRI can identify intracellular lipids, which leads to diagnoses such as adrenal adenomas. Radiologically, it is well-known that intranodular lipids are characteristic of pulmonary hamartoma.
A 66-year-old man was found to have an abnormal shadow on a chest radiograph. The patient was followed up after being diagnosed with a benign tumor. Six years later, the tumor became enlarged, and was thought to be a candidate for surgical resection. Chemical shift MRI revealed intranodular lipids in the tumor. A pulmonary hamartoma was strongly suspected based on the radiologic diagnosis. Tumor enucleation was carried out without minimum loss of lung parenchyma.
Our case showed the potential usefulness of chemical shift MRI for the diagnosis of pulmonary hamartomas. It also facilitates less invasive lung resection such as tumor enucleation.
Since the number of lung cancer cases among elderly patients has been markedly increasing in Japan, the number of surgeries for lung cancer patients aged over 80 years old has also been increasing. Recently, there were some reports of lung resection for very elderly patients aged over 85 years old. An 89-year-old woman consulted a local medical doctor because of pyrexia. Since chest radiograph and CT showed a tumor with pneumonia in the left lower lobe of the lung, she was referred to our hospital. We diagnosed her with locally advanced lung cancer (cT3 (chest wall) N0M0) based on a chest radiograph, CT, and PET-CT. She had diabetes mellitus, hyperlipidemia, hypertension, angina pectoris, hyperuricemia, and bladder cancer; however, her performance status (PS) was 1. Because her respiratory function was normal, we judged that she could tolerate lung resection under general anesthesia. We performed surgery without induction chemoradiotherapy. Left lower lobectomy with chest wall resection was performed (operative time: 2 hrs and 6 min, blood loss: 133 mL). The pathological diagnosis was squamous cell carcinoma (pT3N0M0 stage IIB). The postoperative course was favorable and she could be discharged seven days after the operation, maintaining the preoperative performance status. Therefore, we report a second-half octogenarian case of safe radical surgery for locally advanced primary lung cancer.
We report a rare case of primary pulmonary meningioma. A 68-year-old man was referred to our hospital because of a nodule in the left lung detected by chest-radiograph. CT showed a 12×10-mm round tumor in the left S9. Because this nodule grew gradually during an about one-year follow-up, we decided to resect it. We performed wedge resection of the left lower lobe by three-port complete VATS. Histological examination revealed that the tumor has broad sheets or medium-sized lobules of fairly uniform cells with round or oval nuclei, abundant light-pink cytoplasm, and indistinct cytoplasmic borders. Immunohistochemical staining showed negative results for EMA, CD34, and S-100, and a positive results for Vimentin. We diagnosed this patient with a primary pulmonary meningioma because neither brain nor spinal cord MRI detected a neoplastic lesion.
A 38-year-old female suddenly developed left chest pain while taking a walk, and was emergently transported to a local hospital. Chest radiograph and CT showed pleural effusion occupying 2/3 of the left chest. A drain was inserted into the left thoracic cavity, and hemothorax was observed. Contrast-enhanced CT suggested the rupture of a left pulmonary arteriovenous malformation. Due to suspected persistent bleeding, she was transferred to our hospital the next day and underwent emergent surgery. A dark-red blood vessel-like lesion (about 2.5 cm) was present in the peripheral area of S5 in the left lung, and S5 including the lesion was resected by video-assisted thoracoscopic surgery. A histological diagnosis of left pulmonary arteriovenous malformation was made. Rupture of a pulmonary arteriovenous malformation is relatively rare. When this malformation is in contact with the pleura, active treatment should be considered, with the possibility of rupture being kept in mind.
We report a case of pulmonary metastasis from an extremely rare carcinoma of the external auditory canal. A 46-year-old woman was referred to our head and neck surgery department for resection of the residual tumor after cyberknife therapy for a primary carcinoma of the right external auditory canal in another hospital in August 2013. In January 2014, we performed subtotal resection of the right lateral temporal bone, radical neck lymph node dissection on the right, and reconstruction with a free rectus abdominis musculocutaneous flap. In November 2014, a new tumor appeared in the right cervical region, which was resected and diagnosed as local recurrence. In May 2015, computed tomography (CT) and magnetic resonance imaging revealed a second recurrent tumor in the right lateral oropharyngeal wall, para-hyoid area, and middle deep cervical lymph nodes, which was resected along with reconstruction with a free radial forearm flap. In December 2015, chest radiograph and CT showed a nodule in the lower lobe of the right lung, suggesting pulmonary metastasis. Therefore, she was referred to the Department of General Thoracic surgery. Thoracoscopic wedge resection of the right lower lobe was performed. Histological examination revealed squamous cell carcinoma similar to the primary carcinoma of the external auditory canal. She was discharged on day 3, and no recurrence and metastasis had occurred at 12 months after pulmonary metastasectomy (38 months after initial treatment). Resection of pulmonary metastasis from carcinoma of the external auditory canal can improve the prognosis, as in other pulmonary metastases from head and neck carcinomas. Therefore, surgery is recommended for pulmonary metastasis from carcinoma of the external auditory canal, and wedge resection is appropriate to ensure a safe resection margin.
A 49-year-old woman was pointed out as showing deviation to the right of the trachea on a screening chest radiograph. Chest computed tomography showed a 4.9-cm anterior mediastinal mass extending from the suprasternal notch over the aortic arch. The mass with microcalcifications showed the same density as the thyroid gland, but no succession was seen in the mass to the thyroid gland. Aberrant mediastinal goiter was suspected, and surgery was conducted. A half median sternotomy was added to cervical collar incision for the extirpation of the anterior mediastinal mass. The mass was not continuous with the thyroid gland and was completely encapsulated; it was diagnosed as adenomatous goiter on pathological examination. Aberrant mediastinal goiters are rare, and many different approaches are considered appropriate depending on the tumor location and size.
An 18-year-old man was referred to our hospital after visiting a doctor's office for left-sided chest discomfort. In our hospital, he was diagnosed with spontaneous left pneumothorax, and admitted for treatment. Thereafter, he underwent video-assisted thoracoscopic (VATS) bullectomy. A 2-mm-diameter tumor was detected on the staple line, and a specimen was harvested for histopathological examination. He was diagnosed with left spontaneous pneumothorax with primary lung adenocarcinoma (pT1a). Because the surgical margin was positive, we performed an additional VATS partial resection 1 month after the initial diagnosis. The new specimen did not show signs of residual adenocarcinoma, and the patient has been disease-free for 26 months. It is important to analyze computed tomography scans of the chest carefully because tiny pulmonary nodules may be found adjacent to a predicted surgical margin even in young patients presenting with a benign condition, such as pneumothorax.
Round atelectasis (RA) is a non-malignant disease usually related to asbestos pleural plaque and pleural fluid accumulation, but it could be related to pneumothorax. Typical CT findings include a pulmonary mass with a "comet tail sign". In such cases, RA shows chronic enlargement. It may be difficult to rule out lung malignancies. A 65-year-old woman presented with an enlarging mass in the apical region of the right lung 2 years after the first operation for pneumothorax. She underwent a right upper lobectomy to rule out malignancy. Pathological findings of the resected RUL showed no evidence of malignancy, and it was diagnosed as RA. We report a case of enlarging RA related to chronic pneumothorax.
A 19-year-old man presented at a nearby hospital with right chest pain and dyspnea. He was diagnosed with right spontaneous pneumothorax and treated with pleural drainage. However, the pneumothorax did not improve, and he was transferred to our hospital for surgery. After the induction of anesthesia, we observed 70% oxygen saturation with one-lung ventilation on the left side. We confirmed that the intubation tube had been placed in the proper position, that no bronchial obstruction had been caused by sputum retention, and that there were no abnormal breathing sounds. Therefore, we considered ventilation-perfusion imbalance to be the cause of desaturation, and continued the operation with additional continuous positive pressure ventilation of the right lung. However, oxygen levels did not improve after the operation. Following a detailed examination, we diagnosed him with pulmonary thromboembolism, since the D-dimer level was elevated and CT showed thrombi in the left main pulmonary artery. We treated the patient with anticoagulation therapy and implanted a temporary inferior vena cava filter. Furthermore, antithrombin III deficiency was suspected following an examination for a potential thrombotic predisposition. This case illustrates the need to consider the risk of pulmonary thromboembolism even in younger patients.
We report a case of neurofibroma arising from the right first intercostal nerve resected via subclavicular incision and thoracoscopy. The case was a 15-year-old female who had a family history of neurofibromatosis type 1. She had multiple cafe-au-lait spots on the trunk. She was referred to our hospital because of an abnormal shadow in the right lung on a chest radiograph at a school physical examination. Chest computed tomography showed a 5-cm mass in the right first intercostal space and right pleural effusion. Contrast-enhanced magnetic resonance imaging showed a heterogeneously enhanced mass abutting the right subclavian vein.
Tumor resection was successfully performed via an approximately 6-cm subclavicular incision and 3 ports for a thoracoscopic approach without clavicectomy and/or sternotomy. The tumor was fixed to the first rib and resected with a part of the first rib. Pathological examination showed neurofibroma. The combination of the thoracoscopic approach and direct approach through subclavicular incision was useful for safe resection of the tumor with clear visualization of the surgical field.
A 79-year-old woman presented with pain on the right side of the chest. A right anterior chest wall tumor was palpable and the patient was referred to our hospital. Chest enhanced computed tomography showed a lobulated tumor of approximately 9 cm in the right anterior chest wall, which involved the right 3rd rib and right upper lobe of the lung. The tumor was diagnosed as a solitary fibrous tumor by percutaneous needle biopsy, and surgery was performed with thoracoscopic assistance. Firstly, wedge resection of the invaded right upper lobe of the lung was performed using a stapling device. The lateral margin of the invaded 3rd rib was resected using a pneumatic high-speed power drill with a thoracoscopic view. The 4th rib was partially resected using the drill and 2nd and 4th intercostal muscle was resected around the tumor to maintain a safe surgical margin. The sternal side of the 3rd rib was resected with a direct view through an additional parasternal incision and the tumor was removed. The chest wall resection was less invasively achievable using the drill.
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