Objectives: We examined the feasibility of the diagnostic method for metastasis by measurement of carcinoembryonic antigen (CEA) extracted from regional lymph nodes of CEA producing lung cancer. Methods: CEA extracted from 109 regional lymph node stations of 16 CEA producing lung cancer patients, who received lobectomy with lymph nodes dissection, were examined. Lymph nodes were simply immersed in 10ml saline for 30min. and then were histologically examined. CEA protein in the saline was measured by immunoradiometric assay. Results: The amount of CEA protein from 8 histological positive lymph node stations was significantly higher than that from 101 histological negative lymph node stations (49.9±119.0 vs. 0.41±1.22ng/ml, P<0.05). Among 101 histological negative lymph node stations, high concentration of CEA was detected in one lymph node station, which suggested the presence of micrometastases missed by histological examination. Conclusions: These results implied that the CEA extraction method may be used in addition to histological examination to diagnose lymph node metastasis of CEA producing lung cancer.
During the past five years, 21 patients with thymoma have been treated by endoscopic surgical procedures in our department (infrasternal approach: 17, unilateral video-assisted thoracic surgery (VATS): 4). All tumors were preoperatively diagnosed as non-invasive thymomas, although pleuropericardial dissemination was revealed in 1 case at the time of surgery (stage I: 16, stage II: 4, stage IVa: 1). Extended thymectomy by infrasternal approach was performed for 17 cases, including 11 cases complicated by myasthenia gravis, while subtotal or partial thymectomy was performed for 4 cases by VATS. Infrasternal approach was converted to sternotomy in 2 cases, based on intraoperative findings on the clinical stage (including a case with dissemination), and complicating injury of the thymic vein in 1 case. The mean operation time and intraoperative bleeding were 213minutes and 129ml, respectively, in the cases treated by infrasternal approach, and 178minutes and 233ml, respectively, in the cases by VATS. Resection of thymoma was macroscopically complete, and neither prolonged hospital stay nor evidence of recurrence was detected in all cases. Our results suggest that endoscopic surgery for extirpation of non-invasive thymoma is acceptable as an appropriate surgical approach. Surgeons should improve the safety, reliability, and cost-effectiveness of endoscopic surgical procedures for patients with thymoma, and should employ the best procedure for each case.
In recent years video-assisted thoracoscopic surgery has gained popularity in the treatment of chylothorax. The usage of VATS in the treatment of chylothorax is an attractive option because of its easy manageability. From January 1996 to December 2003, five patients developed chylothorax after surgical treatment for lung tumor in our institution. Of the five patients, four patients received thoracoscopic treatment for chylothorax 2nd to 5th days postoperatively. The sites of the thoracic duct laceration were identified and treat with VATS in all patients. Earlier use of VATS in the treatment of postoperative chylothorax shortens the duration of chest drainage.
We report two cases of malignant mesothelioma detected during treatment of pneumothorax. In Case 1, an 80-year-old man underwent an operation by VATS for left pneumothorax. During the operation, no abnormal findings were found on the pleural surface, and a bulla was resected. Based on postoperative pathological findings, malignant mesothelioma was diagnosed. After the operation, he had been suffered from pneumothorax several times and died of mesothelioma about two years later. In Case 2, a 45-year-old man with right pneumothorax was operated on by VATS. A large bulla with white, small nodules on its surface was resected. Pathological findings of the nodules indicated epithelial-type malignant mesothelioma. Chest CT showed no pleural effusion or nodules. This patient also suffered from recurrent pneumothorax after the operation. Later, right extrapleural pneumonectomy was performed. The IMIG staging was T1b, N0, M0, stage 1b. He was well without recurrence 30 months after the operation. We suggest that malignant mesothelioma be included in the differential diagnosis of elderly recurrent pneumothorax even though in patients who have no nodules or pleural effusion in the thoracic cavity.
Adamantinoma in long bone is a rare malignant bone tumor in Japan. And more, few lung metastases were reported. A 33-year-old male was admitted for cystic tumors on left lung observed on a chest CT examination. He had left tibial amputation for adamantinoma 5 years ago. As the lung metastasis was suspected, he underwent open lung biopsy of left lower lobe. Histological finding showed metastatic tumors of adamantinoma. One year after operation, chest CT examination did not show any recurrence on lungs, although, in 10 months after the examination, he complained of bloody sputum. Chest CT examination demonstrated tumor mass on his left lower lobe. On bronchoscopy, a tumor was detected in B 10. The patient underwent left lower lobectomy. On pathological examination, the metastatic tumor demonstrated abundant mitoses and mib-1 positive cells. These features were more prominent in the second metastatie tumor than in the prior metastatic tumor. Therefore, the secondary metastatic tumor represented rapid growth. This finding suggests that patients require careful observation for several years after the resection of metastatic tumors of adamantinoma in lung.
A 45-year-old woman with dyspnea and shoulder pain was admitted to our center. She had developed the symptoms at the time of menstruation, suggesting catamenial pneumothorax. She was treated with GnRH analogue and discharged with a good response. She had recurrent right pneumothorax three months later, although she had been taking GnRH analogue and didn't experience regular menstruation. A right thoracoscopy was performed. There were two fenestrations and some thin parts in the right diaphragm. Partial resection of the diaphragm was performed under VATS. Microscopic examination revealed endometriosis in the resected diaphragm. She has had no pneumothorax for 14 months since the operation, without treatment by GnRH analogue. We studied 45 Japanese reports of catamenial pneumothorax since 2000. Almost catamenial pneumothorax have diaphragmatic lesions and therefore must relate to them. Left diaphragmatic lesion may be expected spontaneous closure for adhesion of omentum and treated with hormonal therapy at first, whereas right diaphragmatic lesion can't be expected spontaneous closure and should be performed VATS for first choice.
We report a rare case of successful treatment of solitary lung metastasis from pancreatic carcinoma. A 76-year-old female patient who had previously undergone surgical resection of pancreatic carcinoma was admitted. Chest radiography on admission revealed a solitary tumor shadow in the left lower lung field. A chest CT scan revealed an isolated nodule with a diameter of 2.3cm in the left S10 in contact with the descending aorta. Microscopic findings of the transcutaneous CT-guided needle biopsy specimen revealed adenocarcinoma. Left lower lobectomy with ND2a lymph node dissection was performed. Histologically, the tumor was revealed to be adenocarcinoma. Immunohistochemical staining for CK7 was positive but those for TTF-1 and SP-A were entirely negative in both the lung tumor and the pancreatic cancer. These results strongly suggest that the pulmonary tumor was a metastasis of adenocarcinoma of the pancreas.
The patient, a 51-year-old male, had undergone a left lower segmentectomy 30 years earlier, and a right middle lobectomy 20 years earlier, for pulmonary arteriovenous (A-V) fistula. He was admitted to our hospital with an abnormal shadow on chest X-ray, and pulmonary angiography showed a large A-V fistula with a 3-cm diameter, attached to the right basal pulmonary arteries. The supplied pulmonary arteries were not clear, therefore, we performed the surgical option. Because of the severe adhesion of the interlobal side of the right basal pulmonary artery, we approached from the posterior side via splitting the segmental bronchus between the B6 and basal bronchi for the dissection and cutting of the basal artery. After the resection of the basal segment, the B6 bronchus was reanastomosed to the intermedius bronchus with “double-barreled” bronchoplasty. Although postoperatively right side cardiac failure was found temporally, the patient had a good recovery and was discharged uneventfully. He is now well without recurrence.
The 59-year-old woman was referred to our hospital with complaint of a mass, 39 mm on the long axis, on her right anterior chest wall. She had undergone thymomectomy followed by 50-Gy radiation therapy 12 years before. Further examinations revealed that this mass was a spindle cell sarcoma arising from the soft tissue around the right sternoclavicular joint. The chest wall, including the tumor, was widely resected and reconstructed with polypropylene mesh, titanium mesh and a bilateral muscle flap. The tumor was histopathogically diagnosed as fibrosarcoma. The resected margin was free from tumor cells. She was discharged on the 34th postoperative day. Eight months later, she had a subcutaneous mass on her left back area. It was resected and diagnosed as a metastatic fibrosarcoma. She underwent two series of chemotherapy using ifosfamide, and to the present day there has been no sign of obvious recurrence. Radiationinduced sarcoma is a rare disease which arises in an irradiated area several years after radiation therapy. Aggressive surgical resection greatly influences life expectancy in patients diagnosed with fibrosarcoma, given that chemotherapy alone is not sufficient for curing the disease and prolonging survival. Regardless, the high recurrence rate of this tumor results in an overall poor prognosis. Further studies should explore the possibility of the use of aggressive surgery combined with chemotherapy in an attempt to improve patient outcome.
We describe the resection of pulmonary pleomorphic carcinoma with hamartoma. A 63-year-old man was admitted to our hospital complaining of back pain and hemosputum. Chest X-ray showed an abnormal shadow in the left lower lung field and chest CT showed abnormal mass shadows in the S9, 10 field and the S6 field. Bronchoscopic biopsy demonstrated pleomorphic carcinoma in the tumor detected in the S9, 10 field. Left lower lobectomy and lymph node resection was performed. On histological examination, the main tumor in the left lobe (S9, 10) was diagnosed as pleomorphic caricinoma, while the other tumor was diagnosed as hamartoma. We reported this rare case of coexisting pulmonary pleomorphic carcinoma and hamartoma.
Anatomical VATS segentectomy of the left upper division of the lung was performed as positive limited surgery in a 75-year-old woman with small peripheral adenocarcinoma in left S1+2. The upper division and lingular segment were separated in accordance with anatomical structures such as the location of the pulmonary vein, using an Ultrasonically Activated Scalpel (Harmonic Scalpel). Fibrin glue and PGA felt were used to treat cut surfaces of the residual lung. No air leakage was observed immediately postoperatively, so the chest drainage catheter was renived on postoperative day (POD) 1, and she was discharged from hospital on POD 7. Pathological examination revealed a 12×10×7mm Noguchi Type B adenocarcinoma. The pathological classification was T1N0M0, stage IA. Preservation of the respiratory muscles was achieved using VATS, and the detachmentof the segments using the Ultrasonically Activated Scalpel, without a surgical stapler, resulted in good expansion and preservation of the residual lung volume, This operative method prevented postoperative air leakage and contributed to improved postoperative QOL, and appears to be useful as a limited surgery for small peripheral lung cancer cases.
We report a case of ACTH-producing thymic carcinoid. A 52-year-old man was admitted because of polyposia and fatigue. Endocrinological examination revealed high plasma ACTH and serum cortisol level, and secretion of cortisol was not inhibited in an 8-mg dexamethazone suppression test. On CT scan, an anterior mediastinal tumor was detected. We diagnosed ectopic ACTH-producing tumor, and performed resection of the thymus. Histologically, the tumor consisted of atypical thymic carcinoid with ACTH production. After resection, the ACTH and cortisol levels normalized and the clinical symptoms disappeared. The patient received adjuvant radiotherapy, and was well without recurrence after surgery.
A 61-year-old asymptomatic male was admitted to Shiga Medical Center for Adults for abnormal chest x-ray opacity at the apex of the left lung field. Computed tomographic scan demonstrated an 8×3cm left paravertebral tumor at the level of Th3, which had invaginated the spinal canal via the intervertebral foramen. Magnetic resonance imaging study demonstrated a well-defined tumor contour with extradural cord compression. A dumbbell-type neurilemmoma was suspected, and surgery was performed. Under general anesthesia, the patient was initially placed in a prone position and the entire intraspinal and foraminal tumor was removed through a Th2-Th4 laminectomy and Th3-Th4 facetectomy by the neurosurgeon. There was no intradural extension detected. Then, with the right decubitous position, the paravertebral part of the tumor was completely removed by video-assisted thoracoscopic surgery (VATS). The tumor was a neurilemmoma derived from the third intercostal nerve, which was sacrificed and excised with the tumor. Successful removal of the tumor was completed in a one-stage operation. The patient was discharged home seven days later without any major complications, and there has not been any sign of recurrence noted about six months after the resection. The recent surgical modality for a dumbbell-type mediastinal tumor has been one-stage operation combining posterior microneurosurgical and transthoracic approaches. Although thoracotomy has usually been used, this case demonstrated that VATS could be a standard method for transthoracic approach with sufficient safety and minimal invasiveness. Furthermore, due to the characteristic anatomical shape and location of this tumor, close collaboration between the thoracic surgeon and neurosurgeon or orthopedic surgeon is considered important for the successful treatment for a tumor of this kind.
A 18-year-old man consulted his home doctor with complaints of hemosputum, fever, and dyspnea. Although these symptoms improved after treatment with antibiotics, his chest CT demonstrated a tumor-like shadow in the right lower lobe (RLL), pleural effusion, and an anomalous vessel arising from the descending thoracic aorta and coursing posteriorly into the RLL. He was referred to our hospital for surgical treatment. Aortography showed this anomalous vessel in the early phase and the inferior pulmonary vein in the late phase. Intralobar sequestration was diagnosed and right thoracotomy was performed. Massive bloody effusion was present in the pleural cavity. The basal segment had multiple cysts filled with blood clots, one of which had ruptured. The high pressure in the cyst produced by the bleeding was considered to have caused the rupture, which resulted in the massive hemothorax. A review of the literature revealed that massive hemothorax is a rare but sometimes life-threatening complication associated with pulmonary sequestration.
Abstract-Background. Central bronchial squamous cell carcinomas occasionally form endobronchial masses, and also tend to be difficult to resect completely because of their invasive growth with severe local extension in the advanced stages. Case. A 58-year-old man was admitted to our hospital with an abnormal mass shadow in the right lung discovered upon routine check-up. Bronchoscopy demonstrated an endobronchial tumor, that obstructed the right upper trunk. The tumor was diagnosed as squamous cell carcinoma by transbronchial biopsy and right upper lobectomy was performed. Intraoperative frozen section demonstrated a residual in situ carcinoma on the bronchial stump, and complete resection could be performed by additional bronchial resection. The tumor extended along the bronchial wall with intraepithelial spreading at its invasive front, and also showed exophytic growth forming an arborescent mass measuring 4.5cm, which filled the bronchial lumen. Histologically, the tumor was well differentiated squamous cell carcinoma proliferating in a papillary pattern with fibrovascular stroma. Despite being large, the extrabronchial invasive tendency was low and most of the tumor remained within the bronchial wall and lumina. Conclusion. Since papillary bronchial squamous cell carcinoma of the hilum, which shows endobronchial exophytic growth, occasionally accompanies intraepithelial spreading at the front of invasive growth along the bronchial wall, intraoperative frozen section should be examined to determine the bronchial surgical margin.
We report a case of pneumothorax with lymphangioleiomyomatosis undergoing pleurodesis using absorbable polyglycolic acid mesh. A 46-year-old woman was admitted to our hospital because of right pneumothorax. Chest CT demonstrated multiple bullae in the both lungs. She successfully underwent whole pleural enforcement using absorbable mesh fixed on the lung with absorbable sutures for pleurodesis. Pathological examination demonstrated pulmonary lymphangioleiomyomatosis. Pleurodesis using absorbable mesh is effective for pneumothorax with multiple bullae resulting from lymphangioleiomyomatosis.