We report a retrospective clinicopathological review of our experience with surgically excised atypical adenomatous hyperplasia (AAH). Between June 1999 and May 2002, 17 patients underwent surgical resection of AAH. There were 5 males and 12 females with a mean age of 64 years (range 44-83 years). The size of the tumor excised ranged from 4 to 20mm on HRCT (mean 9.2mm). Tumors≥5mm were present in 14 of 18 (77.8%) cases and in 8 of 18 (44.4%) of the cases the tumor was in fact≥10mm in diameter. In 2 patients there was no evidence of pure ground glass opacity. Single AAH was found in 15 patients, multiple AAH were seen in 1 patient and in 1 patient AAH was seen concomitantly with bronchioloalveolar carcinoma. This report is unique in that it describes outcome for AAH in isolation from primary lung cancer. It is likely that with mass screening programs with CT in the near future there will be increasing numbers of patients with isolated AAH. We believe that it is likely to be beneficial to identify these patients and offer minimal surgical resection of these lesions as it will have an impact on the activities of daily living and quality of life in these patients.
Video-assisted thoracic surgery (VATS) has been widely used in the treatment of pneumothorax, but the high incidence of recurrence from spontaneous pneumothorax after VATS is an important problem. We examined therefore the possibility of the recurrence of a spontaneous pneumothorax after VATS of younger ages from the intraoperative findings through the thoracoscope. Subjects were 42 patients (aged 16-24 years) who underwent VATS for primary spontaneous pneumothorax. We classified the groups into three categories (numbers, occupational patterns and properties about blebs) from the thoracoscopic observations. We disscussed whether or not there was reappearance of pneumothorax in the three categories from the thoracoscopic observations. In addition, we examinated whether adjunctive procedure contributes to recurrence of pneumothorax after operation or not. We concluded that the cases apical covering with absorbable material sheet and the use of fibrin glue spray were thought to be effective in preventing recurrence of pneumothorax in cases of skip lesions from the intraoperative findings through the thoracoscope.
We performed intraoperative Technetium (Tc) 99m sentinel lymph node (SN) mapping in patients with clinical T1N0M0 non-small cell lung cancer (NSCLC). METHODS: Twenty patients with clinical T1N0M0 NSCLC were enrolled. Before thoracotomy, the primary tumor was injected with 2 mCi Tc-99m. After dissection, scintigraphic readings of lymph nodes were obtained ex vivo with a handheld gamma counter. RESULTS: The migration of the Tc solution was considered successful if any node registered five times or more count comared with background values. If lymph nodes were found to have the highest or more than 50% of the highest counts and measurements were greater than five times the intrathoracic background, those nodes were classified as sentinel nodes. Four of the 20 patients did not have NSCLC and were excluded. Eleven patients (68.8%) had SNs identified. No inaccurately identified SNs were encountered. CONCLUSIONS: Intraoperative SN mapping with Tc-99m is an accurate way to identify the first site of potential nodal metastases of NSCLC. Several technical problems still remain unresolved in this method, however.
We reviewed ten patients with resected thymic carcinoma. The mean age was 55.0 years, ranging from 36 to 71 years, with five males and five females. The histological types were squamous cell carcinoma in 9 cases, and squamous cell carcinoma combined with small cell carcinoma in one case. One of the 10 patients was in stage I, 7 were in stage III, one was in stage IVa, and one was in stage IVb. Eight of the ten patients underwent complete resection, and induction chemotherapy was performed in one of the 8 cases, while induction chemoradiotherapy was performed in two of the 8 cases. Postoperative radiotherapy was performed in all cases (20-50Gy). In recurrence cases, operation was positively performed for resectable cases. The five-year and ten-year survival rates were 78.7%, 52.5%, respectively. We expect that patients with thymic carcinoma can be cured completely or survive for long periods with multimodal therapy and resection of recurrences.
We experienced a case of middle mediastinal lipoma originating from the aortic-pulmonary artery window (A-P window). A 64-year-old woman was admitted because of an abnormal shadow on chest X-ray, which was pointed out at a medical checkup.rCT scan showed a low density tumor with a little heterogeneous area at the A-P window. As the CT number of the tumor was about -50, it was diagnosed as a lipoma. Complete tumor extirpation was performed uneventfully. The tumor which measured 6×5.8×3.5cm in size, arose from the A-P window and was compressed by both the vagal nerve and recurrent nerve. The pathological diagnosis of the tumor was benign mature lipoma. This is the first report of a mediastinal lipoma arising from the A-P window in the Japanese literature as far as we have reviewed.
We report two cases of postoperative bronchial fistula successfully treated by endoscopic closure with coils and fibrin glue. Patient 1 was a 65-year-old man with diabetes and old myocardial infarction. He underwent right lower lobectomy for lung cancer (c-T2N0M0). On the 19th postoperative day, He was found to have a bronchial fistula, and it was treated twice by endoscopic closure with coils and fibrin glue. Two years after the treatment, he has no significant symptoms. Patient 2 was a 68-year-old man. He underwent operation and radiation for cholangiocellular carcinoma of the hepatic hilus, and right lower lobectomy for metastatic lung tumor. He was admitted to our hospital with fever. He had a postoperative bronchial fistula, and underwent drainage. Because of the persistent air leakage and deterioration of the patient's general condition, the bronchial fistula was treated by endscopic closure with coils and fibrin glue. Air leakage stopped following this treatment. He expired from duodenal bleeding secondary to a post-irradiation ulcer. Endoscopic closure of bronchial fistulas with metallic coils and fibrin glue is a useful treatment option, especially for poor surgical risk patients.
A 52-year-old man with the complaint of increasing weakness of leg muscular strength and difficulty of focusing was admitted to our institute for treatment. He had ptosis of the eyelids, but no dyspnea or dysphagia. The neurological first diagnosis was myasthenia gravis. Repetitive nerve stimulation showed a typical waning pattern at 3 Hz and 5Hz, but and acetylcholine receptor antibodies and anti muscle-specific receptor tyrosine kinase antibodies were both within normal limits. A chest CT showed paratracheal lymph node swelling, but, revealed no abnormal findings in the lung field. Pro-GRP in the blood was slightly high, while other tumor markers including NSE were within normal limits. The paratracheal lymph node was resected under VATS with thymic carcimona considered from the biopsy in the operation room. VATS was switched to a median sternotomy because of the biopsy results, and extensive thymectomy and resection of the mediastinal lymph nodes were performed. After the operation, immunohistopathological findings revealed lymph node small cell carcinoma with no apparent primary lesion. His postoperative course was uneventful. He left our institute 45 days after the operation. Anti voltage gated calcium channel antibodies in the blood were very high before and after the operation. At this time, he was diagnosed with Lambert-Eaton myasthenic syndrome. He became an outpatient for 3 months, with general fatigue and weakness of muscular strength gradually increasing. Pro-GRP increased again, and he was admitted to the hospital again for chemotherapy with CBDCA and irradiation therapy. Pro-GRP decreased to within normal limits after the treatment; however, he still complained of fatigue and reduced muscular strength. He must be followed up carefully, because primary lesions of small cell carcinoma will often appear.
A 50-year-old man was admitted to our hospital with abdominal pain due to urinary stone. High serum levels of Ca, intact PTH, and high-sensitivity PTH suggested hyper-parathyroidism. 99mTc-MIBI scintigram showed abnormal uptake in the upper mediastinum. CT with contrast enhancement and MRI showed a cystic mass measuring 3 cm. The diagnosis of functioning parathyroid ade-noma with cyst at upper mediastinum was made. Careful resection of the mediastinal tumor from the surrounding tissues was performed using a thoracoscopic technique alone. The postoperative course was uneventful. Serum Ca, intact PTH, and high-sensitivity PTH values were all normal following the surgery. Pathological study of the tumor confirmed the diagnosis of mediastinal intrathymic parathyroid adenoma with cyst. 99mTc-MIBI scintigram is a quite useful examination for localization of a functioning parathyroid adenoma. Because the frequency of malignancy in mediastinal parathyroid cysts is so low, thoracoscopic resection is an adequate procedure for the curative treatment.
We describe a case of bronchoesophageal fistula in a 58-year-old woman, who did not show the usual symptom of coughing after ingestion. Bloody sputum and hemoptysis had appeared at the age of 46, and repeated bouts of left-sided pneumonia had occurred from age 53. In June 2000, she was admitted with bilateral pneumonia. After antibiotic therapy, chest X-ray films, computed tomography of the chest, and pulmonary blood flow scintigraphy showed destruction of the left lower lung lobe. Surgery was carried out in July 2000. Because air transudation from the oral cavity continued after the start of mechanical ventilation, communication between the airway and the digestive tract was suspected. After left lower lobectomy, the esophageal surroundings were found to be desquamated, and a bronchoesophageal fistula connecting the esophagus with the left main bronchus was revealed. Because the fistula was short, it was transected and closed by suture and ligation. Intraoperative esophageal endoscopy showed that the fistula had no inflammatory changes in the mucosal surface. The patient's postoperative course was good. Coughing after ingestion is a characteristic symptom of bronchoesophageal fistula. Because this patient had not reported this symptom, preoperative diagnosis of the bronchoesophageal fistula was difficult.
A 55-year-old man was admitted to our hospital with an abnormal shadow on chest X-ray film. He had no subjective symptoms. Chest CT revealed a dumbbell-shaped mass in the right S7 region. We performed basal segmental resection. Histopathological examination showed a bronchogenic cyst. The postoperative course was uneventful.
We report a case of pulmonary metastasis from renal cell carcinoma, in which we suspected a mediastinal tumor rather than intrapulmonary tumor on preoperative image findings. A 72-year-old woman was admitted after a mediastinal tumor was detected on routine chest X-ray film. She underwent a left-side nephrectomy for renal cell carcinoma eight years ago. A smooth-surfaced and round mass projecting from azygoesophageal recess to the right thoracic cavity was demonstrated by preoperative chest CT and MM. Thoracotomy was performed under a diagnosis of mediastinal tumor. Unexpectedly, the tumor was located in the S7 segment in the lung. Partial pulmonary resection was performed. The tumor was diagnosed as a malignant tumor by frozen section. Therefore right lower lobectomy with lymph node dissection was performed. After examination of the permanent section, the malignant tumor was diagnosed as renal cell carcinoma in the lung. The patient was discharged on the 36th postoperative day and is doing well.
A 64-year-old female complained of cough, and was referred to our hospital. On admission, chest X-rays showed a mass and atelectasis of the left lower lobe. Chest computed tomography showed a mass shadow in the left lower lobe which obstructed the left main bronchus. Bronchoscopy revealed a whitish polypoid tumor which was obstructing the left main bronchus. We performed punch biopsy of the polypoid tumor, but the histological examination revealed normal bronchial mucosa. However, lung cancer was suspected and surgery was performed. Pneumonectomy of the left lung was performed. The resected specimen showed a tumor in the left lower lobe protruding into the left main bronchus without invading the bronchial mucosa. Histological findings showed adenocarcinoma comprised of spindle cell and giant cell components, so we finally diagnosed pleomorphic carcinoma of the lung.
A 59-year-old man with eventration of the left diaphragm since his teens. He was refferred to our hospital because of nausea and severe abdominal pain on July 9, 2001. A diagnosis of ileus was made, and the ileus was repaired immediately. Both chest and upper abdominal discomfort, however, continued after the operation, and thoracoscopic surgery for eventration of the diaphragm was performed on February 4, 2002. It was found that more than half of the thoracic cavity was occupied by abdominal organs, and the diaphragm appeared loose and reduced in thickness. After a small part of the diaphragm was resected to avoid injury of the abdominal organs, the remnant diaphragm was plicated and reinforced by Gore-Tex sheet ®. We concluded that this method can fix the diaphragm more firmly than the standard plication procedure, and can prevent reccurence.
The patient was a female infant weighing 1230g at birth, who was delivered by cesarean section. Despite cardiopulmonary arrest at birth, she was successfully resuscitated and received mechanical ventilation. A chest X-ray at 0 days of age showed grade III RDS. At 1 day of age the infant developed left tension pneumothorax, and a chest drain tube was inserted into the left pleural cavity. At 6 days old, the infant was removed from mechanical ventilation, and the chest drain tube was removed at 20 days of age. But from 21 days of age, chest X-ray films showed cystic changes in the lower area of the left lung, and the cystic lesions gradually enlarged. Considering the clinical presentation, congenital lobar emphysema or congenital cystic adenomatoid malformation (CCAM) was suspected. At first, we had planned elective surgery for when her weight exceeded 1.5 kilograms, but the cysts enlarged continuously and there was a risk of sudden respiratory deterioration. Therefore, at 52 days of age we performed an emergency left lower lobectomy. Pathological examination showed that the cystic lesion was not CCAM but pulmonary interstitial emphysema, which developed secondary to barotrauma caused by mechanical ventilation. The postoperative course of the patient was good. The patient is now out of hospital and growing properly.
A 58-year-old man was found to have an abnormal shadow on chest X-ray film and bronchoscopic examination revealed obstruction of the orifice of the right B2 by a polypoid tumor. A biopsied specimen of the tumor was diagnosed as squamous cell carcinoma and we carried out right upper lobectomy and mediastinal node dissection. Intraoperatively, we found an anomalous pulmonary vein arising from the dorsal part of the right upper lung lobe which emptied into the left atrium. We were able to perform lobectomy and mediastinal node dissection in safety, and the post operative course was uneventful. Retrospective review of the preoperative chest CT scan showed that the aberrant pulmonary vein (V2) descended dorsally to the right main bronchus and emptied into the left atrium. We should keep on mind the possibility of variation of pulmonary vessels when pulmonary surgery is planned, especially lobectomy with lymphnode dissection for lung cancer patients.