Between October 1998 and May 2004, 7 patients with malignant pleural mesothelioma received multimodality therapy. These patients were all men aged 50 ∼ 72 years (mean age: 60.6 ± 7.0 years). The left pleura was affected in 4 patients and the right side was involved in 3. The treatment consisted of extrapleural pneumonectomy, postoperative chemotherapy (ADM 60 mg/m2, CPA 600 mg/m2, and CDDP 70 mg/m2), and radiotherapy (54 ∼ 60 Gy to the entire hemithorax). The tumors were of the epithelial type in 5 patients and were sarcomatous in 2. The International Mesothelioma Interest Group (IMIG) clinical stage of the disease was stage III in 5 patients and stage IV in 2 patients. Macroscopically the tumor was resected completely in all patients. The only postoperative complication was heart failure in 3 patients. Grade 4 toxicity of chemotherapy was seen in 5 patients; neutropenia in 5, anemia in 1, thrombocytopenia in 1, and anorexia in 1. 5 patients completed the treatment, but 2 patients discontinued chemotherapy and/or radiotherapy because of decrease in the performance status or the general condition. The 2- and 5-year survival rates of the 7 patients were 68.6% and 45.7%, respectively, and the median survival was 29.0 months. Multimodality therapy is promising for improving the prognosis of malignant pleural mesothelioma.
Three-dimensional computed tomographic pulmonary angiography (3D-CTPA) was performed in 11 patients with primary lung cancer who were scheduled for anatomical pulmonary resection. The 3D-CTPA images were obtained by the multidetector row spiral computed tomography (MDCT) technique. Images of the branching pattern of the pulmonary artery (PA) were compared with intraoperative findings in each case. All branches of the right PA (31 of 31) and 97% of the left branches (34 of 35) were visualized on the pre-operative 3D-CTPA images. One branch that was not detected on the 3D-CTPA images was a small vessel, and it was difficult to distinguish between the PA and the pulmonary vein. No intraoperative bleeding or pulmonary vessel injury occurred. Thus, pre-operative 3D-CTPA by means of MDCT is very useful for ensuring a safe surgical procedure in anatomical pulmonary resection.
A 73-year-old woman complained of chest pain and a solid lesion was found in the right lower lung field on chest computed tomography (CT). She was admitted and right lower lobectomy was performed. After the operation, she could not walk because of chest pain and nausea. Four days after surgery, she fell into dyspnea and then shock just after returning from the restroom. After cardiopulmonary resuscitation, angiography was performed revealing pulmonary thromboembolism. Anticoagulation therapy was started immediately and she was successfully recovered. She was able to leave our hospital on postoperative day 18. Recently prophylaxis of thromboembolism has been considered important and we must make a guideline for prophylactic strategies regarding acute pulmonary thromboembolism.
The hyperimmunoglobulin-E (hyper-IgE) syndrome is a rare immunodeficiency characterized by recurrent infections of the skin and lungs with extremely elevated levels of IgE in the serum. We reported a case of surgical resection for pulmonary abscess from methicillin-resistant staphylococcus aureus (MRSA) due to the hyper-IgE syndrome. A 21-year-old man diagnosed with hyper-IgE syndrome at the age of 2 years was admitted because of fever and cough. On admission, the white blood cell count was 10100/mm3. The serum IgE level was extremely elevated at 21736IU/ml. MRSA was cultured from his sputum. Chest radiographs demonstrated pneumonia of the right upper lobe. Chest CT showed abscess formation in the right upper lobe. Although he was continuously treated with intravenous antibiotics, abscess formation appeared in the right lower lobe. We performed right upper lobectomy and partial resection of the S6 and S9+10 region in the right lower lobe. The postoperative course was uneventful and he was discharged on postoperative day 28. The first treatment for pulmonary infection due to the hyper-IgE syndrome is antibiotics therapy, but surgical resection should be performed for pulmonary abscess with nonfunctional space.
We report our experience with a patient who had a mediastinal cyst that was removed using a thoracoscope, and describe the results of the clinical diagnosis and classification based on a literature review. The patient was a male, aged 61, who visited a nearby doctor due to an abnormal shadow in the right posterior mediastinum that was found on a chest x-ray during a health screening. Retrospectively, a mass had been observed in that site 4 years before and had gradually increased in size at a rate of approximately 1mm per year. It was suspected to be a benign cystic lesion, and the patient was admitted to our hospital for surgery, partly because of the increasing size of the lesion, and partly because the patient requested a definite diagnosis. The results of CT, MRI and ultrasonic endoscopy suggested that the cystic lesion was connected to the internal orbicularis muscle of the esophagus and contained a viscous liquid. The lesion was, therefore, diagnosed as an esophageal cyst and the tumor was removed using a thoracoscope. Histologically, the lumen consisted of a pseudostratified ciliated columnar epithelium and was surrounded by connective, glandular and muscular tissues. It was difficult to distinguish the lesion from a bronchial cyst, but it was diagnosed as a foregut cyst, i.e., a cyst of foregut origin.
A 75-year-old man, who had undergone a decortication for tuberculous empyema a year earlier, was admitted to our hospital with the complaints of appetite loss and cough. A chest radiograph showed an air-fluid level in the left thoracic cavity and chest CT showed a pulmonary aspergilloma in the left apex. Aspergillus was isolated from his pleural effusion. Despite an open-window thoracostomy for empyema thoracis, aspergillus was repeatedly isolated from the sputum, and a cavernostomy, with the removal of the fungus ball, was performed three months later. After another three months of sterilization of both the thoracic cavity and the intrapulmonary cavity through the opened thoracostomy had achieved infection control, the patient successfully underwent a left pneumonectomy with omentoplasty. He has been well with no evidence of recurrence for twelve months. Staged thoracostomy and cavernostomy followed by pneumonectomy appear to have cured this combined pulmonary aspergilloma and aspergillus empyema, although this treatment strategy has not been seen in the literatures.
A 72-year-old woman was admitted to our hospital for surgical treatment of primary lung cancer of the right lower lobe. She had undergone a modified radical mastectomy for right breast cancer 12years earlier. Preoperative chest computed tomography showed multiple subpleural nodules in the same lobe. We performed a right lower lobectomy with lymph node dissection. Pathological examination revealed primary lung cancer (adenocarcinoma, pT1N0M0) and multiple pleural metastasis from the breast cancer in the right lower lobe. The patient had an uneventful postoperative course and is currently receiving hormonal therapy.
We encountered a case of pulmonary tumorlet associated with atypical mycobacterium. A 73-year-old woman was treated with anti-tuberculosis medication under a diagnosis of atypical mycobacterium. S6 segmentectomy was performed because a chest x-ray film showed enlargement of an abnormal shadow in the lower lobe of the left lung. Histopathological examination revealed immunoreactivity to chromogranin-A in the clusters of epithelial cells that existed beside the granuloma. Pulmonary tumorlet was diagnosed because of the minimal cytological atypia and chronic pulmonary damage around the lesion. Pulmonary tumorlet is clinically a rare lesion, but the diagnosis and treatment of tumor-like lesion should be done carefully, considering the existence or co-existence of tumorlet lesion.
We present a very rare case of congenital tracheoesophageal fistula in an adult, who underwent surgical treatment. A 39-year-old woman was admitted to our hospital because of an esophageal fistula incidentally detected by esophagoscopy in a medical health check. The fistula was detected on the anterior wall of the esophagus by esophagoscopy, and also on the membrane portion of the trachea by bronchoscopy. Chest computed tomography revealed the fistula communicating between the esophagus and the trachea. The patient, with known long-standing choking fits and a history of frequent pneumonia in her childhood, was diagnosed with congenital tracheo-esophageal fistula. Open thoracic surgery was performed for the resection and closure of the fistula. The patient has had no symptoms related to oral intake and there has been no sign of relapse one year after the surgery.
A 58-year-old female with von Recklinghausen's disease consulted her home doctor, complaining of sudden chest pain. Chest x-ray revealed pleural effusion in her left thoracic cavity and she was referred to our hospital. Bloody effusion was obtained by thoracocentesis, and enhanced chest CT and selective angiography demonstrated an aneurysm in the 8th intercostal artery. Rupture of the aneurysm was diagnosed and aneurysmectomy was performed. Fifty-seven cases of arterial aneurysm or laceration in association with von Recklinghausen's disease including our case have been reported in Japanese literature. Twenty-two patients had the lesions in the thoracic cavity and 8 of them died of bleeding. The mortality rate was the highest in lesions of the thorax. We should know that patients with von Recklinghausen's disease sometimes have vessel disease, which is rarely associated with life-threatening bleeding.
A 50-year-old man was admitted to our hospital because of blunt right chest injury due to falling down in July 2003. Twelve days after the injury he was diagnosed with right hemothorax and underwent chest drainage from the right 7th intercostal space on the middle axillary line. After chest drainage, computed tomography (CT) scan revealed many residual blood clots in the thoracic cavity. The patient underwent video-assisted thoracic surgery (VATS) to evacuate and treat the blood clots in the thoracic cavity 16 days after the injury. The initial port was approached from the route of the preoperatively inserted chest tube to avoid injuring the lung; however, the trocar was inserted into the abdominal cavity through the diaphragm, which was adhered to the chest wall. There was no organ injury in the abdominal cavity at the time of trocar entry. We approached from the 5th intercostal space of the dorsum, to which the lung was not adhered on CT scan, and could reach the pleural cavity appropriately. Then, blood clot evacuation, decortication and ablation were performed by VATS and the injured diaphragm was repaired by direct suturing with minithoracotomy. The patient had an uneventful postoperative recovery. In cases of lung adhesion in the thoracic cavity, the initial port for a VATS procedure should be approached through a position different from the preoperatively inserted chest tube, when there is the possibility of diaphragm injury.
A 46-year-old man who had developed Kugelberg-Welander disease at the age of 16 was admitted to our hospital with coughing in February 2003. Chest X-ray revealed right side pneumothorax and muscle atrophy of the body. Chest CT revealed multiple bullae of the right lung apex. A chest tube was inserted for two weeks, but right side pneumothorax recurred after a week. Partial resection of the right lung was performed by video-assisted thoracic surgery via small access thoracotomy under general anesthesia in March. Becuronium was used for muscle relaxation. Postoperative recovery was slightly delayed and volume loss of the left lung developed on the third postoperative day. Endotracheal suction with a bronchoscope was necessary. The patient was discharged from the hospital on the 15th postoperative day. Kugelberg-Welander disease had caused neurogenic muscle atrophy, but a mixture of myogenic atrophy by intercostal muscle biopsy was observed in this patient. For chest surgery in Kugelberg-Welander disease, reduction of muscular relaxant, preservation of respiratory muscle and postoperative respiratory care are essential.
The patient was a 39-year-old female. At the end of May, she noticed excessive menstrual bleeding and the development of numerous petechiae. She visited the outpatient clinic of our hospital on June 5. The peripheral blood showed many blasts, and a definite diagnosis of acute lymphocytic leukemia was made by examination of the bone marrow. Chemotherapy in accordance with the protocol of JALSG-ALL97 was started on June 11, and complete remission was achieved. During the course of chemotherapy, she had low-grade fever, and the chest X-ray film on July 3 showed an infiltrative shadow in the right lower lung field. Therefore, she received by turns several antibiotics and antifungal agents such as CZOP, MCFG, CFPM, MEPM and FCLZ, but the low-grade fever continued. On July 11, chest X-ray film and CT scan showed a cavitary lesion in the right lower lung field. Aspergillosis was suspected and ITCZ was administered from July 12. Although bronchoscopy was performed on July 22, a definite diagnosis could not be established. On July 31, right lower lobectomy was performed for the purpose of final diagnosis and treatment. The final pathological diagnosis was invasive mucormycosis. The postoperative course was good, and she received consolidation chemotherapy from August 20, continuing the administration of ITCZ.
A 71-year-old male was diagnosed with usual interstitial pneumonia (UIP) in 1998, and had been followed without treatment. In September 2003, chest CT revealed a mass, 4cm in size, in his left lung (S9). A transbronchial lung biopsy was performed but a dignosis could not be obtained. He underwent left lower lobectomy and lymph node dissection because malignant findings were found in the mass by surgical biopsy. Histologically, the tumor was composed of squamous and giant cell carcinoma and spindle cell formations, and there were also fibrogenic foci and infiltration of lymphocytes. Therefore, he was diagnosed with pleomorphic carcinoma and UIP. Pleomorphic carcinoma following UIP is rare, so we report this case with references to the literature regarding these two diseases.
A 62-year-old woman with von Recklinghausen's disease was admitted to our hospital because of sudden severe back pain. Chest CT revealed left hemothorax, and a chest drainage tube was inserted. She was asymptomatic for twelve hours after drainage, but then she suddenly suffered cardiopulmonary arrest due to re-bleeding. Cardiopulmonary resuscitation was immediately initiated and an emergency operation was performed. The origin of the bleeding was the left seventh intercostal artery. Her postoperative course was uneventful. There have been some cases which were treated conservatively or treated with endovascular embolization because the bleeding vessel was too fragile to suture. However, urgent thoracotomy is needed in many cases.
We encountered a case of pulmonary thromboembolism after left pnemonectomy for lung cancer. The patient was saved by urgent treatment with transvenous catheter pulmonary embolectomy and thrombolytic agents. Whole body CT revealed a left internal jugular vein thrombus, which was considered to be the cause of the pulmonary thromboembolism. The left internal jugular vein thrombus was possibly formed during the operation, since blood stasis induced by holding the innominate vein with tape for a long time could allow thrombus formation. Therefore, we must give special attention to such intraoperative manipulation. In this case, the hypercapnea was recognized, instead of the hypocapnea that is usually shown in pulmonary thromboembolism. The reason the hypercapnea was presented was considered to be that the gas-exchangeable pulmonary vessel was decreased excessively due to pulmonary thromboembolism. It is important that the hypercapnea may be evident in cases of pulmonary thromboembolism after pulmonary resection, whereas the hypocapnea is shown in usual pulmonary thromboembolism.