To improve the response rates for anticancer agents of lung cancer, we applied the histoculture drug response assay (HDRA). Nine drugs, including CDDP, FU, ADM, MMC, DOC, VP16, CPT-11, GEM, and PAC, are now available for HDRA. Endoscopic surgery, consisting of 27 mediastinoscopic biopsies and 6 thoracoscopic biopsy, was performed to obtain specimens for HDRA in 33 lung cancer patients. HDRA data were obtained for 26 patients. An average of 5 (2-9) drugs were tested. HDRA revealed that there was no sensitive dug in 4 of the patients. Chemotherapy using HDRA-sensitive agents was administered to 20 patients. Clinical response was evaluated in 17 patients, and the response rate was 88%. HDRA may contribute to the improvement of the response to chemotherapy for lung cancer. Endoscopic surgery appeared to be a useful technique for obtaining specimens for HDRA.
We devised a new way to seal intractable air leakage after pulmonary resection using parietal pleura, and have obtained good results. Autologous parietal pleura is obtained, affixed to the raw surface of the lung with fibrin glue, and fixed to the lung by several mattress sutures. From 1998 to 2003, 35 lung cancer patients with large pleural defects due to adhesion lysis or incomplete lobule management and refractory intraoperative air leakage were treated using our new method. In all patients, the air leakage ceased completely intraoperatively, and postoperative air leakage ceased within the first 24 h after pulmonary resection.
Atrial fibrillation (af) is a common complication after lung resection. We examined the relationship between the frequency of af and some risk factors, including low serum potassium levels, in 134 patients who did not have af before undergoing lung resection. Postoperatively, 19 (14.2%) experienced af, and their mean age was higher than that of the 115 patients who did not develop af (70.5 years vs. 62.4 years, p=0.02). Men were more likely to develop af: The male to female ratio was 3.8 to 1 in the group of patients with af, compared with 1 to 1 in the group of patients without af (p=0.03). The mean perioperative fluid balance was +1389ml in the group of patients with af, compared with +960ml in the group of patients without af (p=0.002). The incidence of af in the patients who underwent pneumonectomy or lobectomy was significantly higher than that in the patients who underwent segmentectomy or wedge resection (16 of 71: 22.5% vs. 3 of 63: 4.8%, p=0.005). There was no significant difference (p=0.37) in serum potassium level between the patients with and without af, suggesting that a low serum potassium level does not contribute to the incidence of af after lung resection.
A 32-year-old woman developed spontaneous pneumothorax of the right lung at the 34th gestational week. A thoracic catheter was placed after admission, but air leakage persisted. At the 37th gestational week, video-assisted thoracoscopic bullectomy was performed. The postoperative course was uneventful, and she was discharged on the 4th operative day. At the 40th gestational week, she delivered a healthy normal female infant weighing 2898g and had no recurrence of pneumothorax. Treatment of spontaneous pneumothorax in pregnancy has been considered difficult, but we speculated that we could perform the operation safely with careful monitoring of the mother and infant during the peri-operative period.
We experienced two cases of solitary fibrous tumor of the pleura (SFTP) with different clinical courses. Case 1: A 54-year-old man had a nodule (30×15mm) in the lower lung field that has not changed for 3years. Thoracoscopic surgery was performed, and a smooth pedunculated tumor was removed. Case 2: A 56-year-old woman had a 62×40mm mass in the middle lung field, which was diagnosed as SFTP. Surgery was not performed, but 4 years later the mass had enlarged to 95×70mm. Thoracoscopic resection with mini-thoracotomy was performed, and a smooth pedunculated tumor was removed. Histologically, Cases 1 and 2 were both benign SFTP arising from the visceral pleura. SFTP should be resected, because tumor behavior cannot be predicted from histological findings. Thoracoscopic surgery is suitable for such pedunculated tumors because it is easy to achieve resection with an adequate surgical margin.
A 48-year-old female was admitted with complaints of cough and yellowish sputum. She had had pulmonary tuberculosis at the age of 11 and had an abnormal shadow noted in a chest X-ray about 15 years before admission. Chest X-ray showed an oval-shaped cavity infiltrate in the right middle lung field. Chest CT showed an intracavity mass lesion in the right lower lobe S6, suspected to be primary pulmonary aspergilloma. Transbronchial and CT-guided lung biopsies were performed, but the specimens were not histologically diagnosed as aspergilloma. A right lower segmentectomy (S6) was performed. Histopathologically, part of the necrotic specimen showed fungal hyphae with broad, irregular branching at right angles, so we diagnosed pulmonary mucormycosis in an apparently normal host. She has remained in good health since the surgical treatment.
A 54-year-old man had chest pain during walking and an abnormal shadow on chest X-ray film. He also had stenosis of the coronary arteries and received PTCA, which failed. As lung cancer was suspected, the patient was scheduled to undergo surgery of both the heart and lung in a one-stage operation. First, Coronary Artery Bypass Graft was performed under cardiopulmonary bypass, and left pneumonectomy with lymph node dissection was performed. The postoperative course was uneventful except for hemorrhage, which was controlled by transfusion. Histopathologic examination revealed adenocarcinoma with lymph node metastasis. Lung cancer and ischemic heart disease can be surgically treated simultaneously, benefitting for selected patients.
The patient was a 57-year-old woman. She had a checkup for chief complaints of pharynx pain and headache, and showed an abnormal chest shadow, in January 2003. On chest CT, an aggregation of minute nodules was recognized in the range of 2 cm in the right middle lobe of the lung, S4. Sclerosing hemangioma was suspected on bronchoscopy, but the diagnosis was not made. We performed a middle lobectomy by thoracoscopic surgery. The pathological diagnosis was multiple sclerosing hemangioma and tumorlet. The postoperative course was good and the patient left the hospital on the fourth postoperative day. Because multiple sclerosing hemangioma with tumorlet is rare, we report it.
The patient was a 62-year-old man who was admitted to our hospital because of a severe cough and arthralgia in both wrists. The laboratory examination showed leukocytosis (13,100/mm3) without any evidence of infection. A high concentration of G-CSF (98pg/ml) in the serum was revealed by enzyme immunoassay. A chest roentgenogram and computed tomography scans showed a tumorous shadow in the right lung. Cytology from a bronchoscopic examination revealed lung cancer (moderately differentiated adenocarcinoma, stage IIB). A right lower lobectomy with mediastinal lymph node dissection was then performed. Both the white blood cell count and the serum level of G-CSF decreased to normal levels and the arthritis improved soon after the surgery. Although the resected specimen of the main tumor was stained negatively with anti-recombinant human G-CSF monoclonal antibodies, the clinical course indicated that the lung cancer was producing G-CSF in the serum. The patient has done well without any sign of recurrence for 9 months after the surgery.
A 32 year-old man complained of fever and stomachache and was admitted to our hospital for further examination. Chest-abdominal CT showed a large mass of liver and liver abscess was susupected. Also pulmonary abscess was found and had a continuity with liver abscess. Percutaneous liver abscess drainage was performed and we drainaged “anchovy paste”-like pus from the abscess. Consequently we performed cavity enhancement and the contrast medium flowed into right lung and bronchus, and the diagnosis was hepatobronchial fistula. With the elevation of antibody against ameba, we diagnosed amebic liver abscess. After antibiotic treatment, we performed operation to resect the abscess and close the fistula. We made anetro-axial thoracotomy at the fifth intercostal space. The adhesion was not so strong, and middle lobectomy was performed. The fistula was already closed because of fibrosis due to the inflammation, so we covered there with pericardial fat pad. The patient recovered uneventfully after the operation. Hepatobronchial fistula is rarely seen in japan, and we report a case and review of the literature.
A 65-year-old woman had been diagnosed with pulmonary arteriovenous fistula in the right S10 by chest helical CT. She was admitted and an operation was performed. The fistula was enucleated under totally Video-Assisted Thoracoscopic Surgery, and the feeding artery and drainage vein were stapled with Endo-GIA II™. This operative method is an effective treatment for pulmonary arteriovenous fistula in the periphery of the lung.
A 66-year-old man, who had been treated surgically for “Dukes A” rectal cancer 56 months previously, was referred for evaluation of pulmonary nodule on chest rentgenogram. He had been complaining of intermittent nonproductive cough for a period of one month. Chest CT showed a solitary nodule, about 25 mm in diameter in the middle lobe. Bronchoscopy revealed a polypoid tumor, visualized at the entrance of the middle lobe bronchus, separate from a peripheral invisible tumor in the middle lobe. Biopsy specimens from both the pulmonary tumor and bronchial tumor were shown to be adenocarcinoma and were strongly suspected to be metastasis from the rectal cancer. Middle wedge lobectomy was performed. No lymph node metastasis was identified around the bronchus. The resected specimens showed no connection between the lung metastasis and the tumor at the entrance of the middle lobe bronchus, with no residual tumor existing. Although endobronchial metastasis is not still clearly defined, it is generally considered that localized endobronchial metastasis is rare, and resectable cases are also rare. Bronchofiberscopy should be performed to decide the therapeutic principle in a patient with metastatic lung tumor, even if the patient has no respiratory symptoms.
We report a case of empyema with ipsilateral recurrence of spontaneous pneumothorax after two uses of VATS. A 22-year-old man with complaints of high fever and right chest pain came to the hospital. He had undergone right bullectomy by VATS for spontaneous pneumothorax when he was 16 and 21 years old. Chest X-ray and chest CT showed right pneumothorax with thick visceral pleura. Chest tube drainage was performed, and the discharge culture showed Staphylococcus aureus. We inserted another chest tube and started irrigation. After 2 weeks of irrigation, decortication was performed. The endoscopic linear staples at the right lung apex were not removed. The patient left the hospital 47 days after the operation.
A 72-year-old woman, who had received artificial pneumothorax as a treatment for tuberculosis 53 years earlier, became aware of a left chest wall tumor. Three months later, chest CT and MRI revealed a heterogeneous mass growing from the left thoracic cavity, compressing the abdominal viscera and protruding beyond the lateral thoracic wall. Culture of thoracentesis and needle biopsy showed no evidence of infectious or malignant disease. Under a clinical diagnosis of chronic expanding hematoma of the thorax, the patient underwent a left thoracotomy. The intrathoracic hematoma with a tough capsule had expanded to the retroperitoneum, and was removed completely. It measured 24×20×12 cm and weighed 3000g. The diaphragm was reconstructed with polypropylene mesh. The postoperative course was uneventful, and the patient has been well for more than 10 months.
A 70-year-old woman was admitted to our hospital for further examination of an abnormal chest X-ray shadow. Chest CT showed a tumor with ground-glass opacity and pleural indentation in segment4 (S4) of the left lung. Lung cancer was suspected according to the radiological findings, but a definitive diagnosis was not obtained by bronchoscopic examination. Under a provisional diagnosis of lung cancer, the patient underwent partial resection of left S4 by video-assisted thoracic surgery (VATS). Intraoperative histopathological examination revealed BALT lymphoma. The chest wound was closed without lobectomy. The patient recovered uneventfully, and there has been no sign of recurrence for 9 months since the surgery. BALT lymphoma should be considered if lung cancer is suspected on the basis of imaging study alone.
Endobronchial hamartoma is rare compared with hamartomas located within the lung parenchyma. We reported a case of endobronchial hamartoma resected by longitudinal bronchoplasty, after which squamous cell carcinoma distal to that bronchus was detected 5 months later. We could not avoid pneumonectomy to resect the squamous cell carcinoma because of adhesion caused by the bronchoplasty. This is the fourth reported case of endobronchial hamartoma associated with lung cancer.