We developed a clinical pathway (CP) for patients with lung cancer who underwent pulmonary resection and applied it to 103 consecutive cases. In this study, we reviewed these patients to identify cases not suitable for this pathway. According to this CP, patients were discharged the day after removal of the chest tube when they could walk without oxygen. We defined variance cases as those with a postoperative hospital stay longer than 10 days. We analyzed causes of prolonged hospital stay. There were 27 variances (26.2%). The major causes of variances were pneumonia and prolonged chest drainage. Significant differences between the variance and non-variance group were found in gender (p<0.001), vital capacity (p=0.049), FEV1.0% (p=0.040), %FEV1.0 (p=0.005), clinical stage (p<0.001), extended operation (p=0.002), and tracheobronchoplasty (p<0.001). On multivariate analysis of these 7 factors, only tracheobronchoplasty (p=0.018) were significant. In our CP, the patient's discharge was planned within 10 days post operation. This pathway was valid for elderly patients and those with poor pulmonary function, but not valid for those with tracheobronchoplasty.
Between 1989 and 2004, 9 patients infected with non-tuberculous mycobacteria underwent pulmonary resections. Mycobacterium avium complex was detected in 8 patients, and M. scrofulaceum in another 1 patient. Patients ages ranged from 44 to 74, and 88.9% were men. Surgical procedures were 7 lobectomies (including one completion pneumonectomy) and 2 partial resections. Two patients with negative preoperative sputum smear underwent thoracoscopic wedge resection to exclude lung cancer. There were no perioperative complications or deaths. However, there have been 2 late deaths from respiratory failure at 4 years and 6 years postoperatively. Each of these patients had underlying diffuse lung disease, and one patient continued to show positive sputum findings after the left completion pneumonectomy. Seven patients are alive with negative- sputum findings. Results of pulmonary resection for localized non-tuberculous mycobacterial lung disease were very good. However, we should carefully determine the extent of lung resection in bilateral and disseminated pulmonary disease, especially when performing pneumonectomy, considering postoperative lung function and the possibility of becoming negative-sputum findings.
A 57-year-old man had received the tumor resection and radiation therapy for naso-pharyngeal cancer in 1995. After the operation, several metastases were treated; the resection of left 7th rib and tumor in the left parietal pleura, and radiation therapy for thoracic veretbrae (Th7, 8), left femur and upper abodominal para-aortic area. He developed left lateral chest pain and chest CT revealed a mass shadow attached to the left 7th rib and irregular thickness of parietal pleura, which exists in the left 8th rib from left 7th intercostals space of the paravertebral sulcus. Chest MRI and thin slice CT showed the tumor extended into the thoracic spinal canal through the left intervertebral foramen of Th7-8. The operation for the dumbbell tumor was performed with left hemi-laminectomy of Th7-8 and thoracotomy. A histopathological examination revealed the tumors to be metastases of naso-pharyngeal cancer. Generally, most dumbbell tumors are neurogenic tumors. However, in the case of chest wall tumors beside vertebrae, examination for intervertebral foramen should be performed with MRI and thin sliced CT.
A 71-year-old female was admitted to our hospital because of cough and sputum. Her chest X-ray film and chest CT showed a mass in the left lower lobe (S9), which was diagnosis as adenocarcinoma by CT-guided tumor biopsy. Laboratory data on admission showed thrombocytopenia (13,000 per cu. mm.), and the results of bone marrow aspiration were compatible with idiopathic thrombocytopenic purpura. Pre-operative high dose intravenous gamma-globulin therapy (400mg/kg/day for five days) and platelet transfusion allowed surgery, lower lobectomy and removal of regional lymphnodes, to be performed successfully. Pre-operative high dose intravenous gamma-globulin therapy is thought to be a very useful method of preventing hemorrhagic tendency post operatively.
A 50-year-old woman was admitted to our hospital after a routine chest x-ray showed an abnormal shadow in the left hilum. A benign pulmonary tumor, 3.5cm×3.5cm, had been found 7 years earlier and recommended for observation. Chest X-ray and computed tomography (CT) on admission showed a round mass in the same lesion, which had increased to 7.0cm×6.0cm. The tumor was diagnosed as a pulmonary hamartoma by CT-guided biopsy. Enucleation of the tumor was performed under video-assisted thoracic surgery, because the mass was continuing to grow. The pathological diagnosis was chondral hamartoma. Pulmonary hamartoma is associated with an increased risk of lung cancer, so long-term follow-up is necessary.
A 33-year old woman had cough, chest pain, and fever. Chest CT scanning showed a cystic mass located just beneath the bifurcation of the trachea and caused pulmonary arterial occlusion. Lung perfusion scintigraphy showed no perfusion of the right lung. The cystic mass was excised completely and found histopathologically to be a bronchogenic cyst. Immediately after the cyst was excised, the right lung was not reperfused. However, 6 hours after the operation reperfusion lung injury occurred. Three months after the operation, lung perfusion scintigraphy showed reestablishment of perfusion of the right lung.
In October 2002, an abnormal shadow on a chest radiograph of a 63-year-old man was found. He underwent partial resection of the right upper lobe for pulmonary Aspergilloma. Postoperative empyema occurred and he underwent a pedicled latissimus dorsi muscle flap, with which fistulas were covered, for the treatment of empyema in December 2002. But empyema recurred and non-operative therapy was performed. Although it was continued for three months, empyema was still not cured. We were consulted about his disease in May 2003 and he was admitted to our hospital for the treatment of empyema with fistulas. Chest radiograph and chest CT on the day of admission showed an air-fluid level in the right upper thoracic cavity. Exploratory thoracoscopy showed the air space of empyema, three bronchopleural fistulas and a destroyed latissimus dorsi muscle nap. MRSA in pleural effusion and Aspergillus in the destroyed latissmmus dorsi muscle were confirmed. We performed a fenestration. In the empyema cavity, three bronchopleural fistulas were identified. We kept the empyema cavity clean for three months. We transposed a free omental flap to the empyema cavity and sealed the fistulas with it. Then the empyema cavity was closed by the pedicled major pectoral muscle. Clinical course after the reoperation was satisfactory and there was no recurrence of empyema for 22 months. We propose that a transposed free omental flap may be an effective management for bronchopleural fistulas and chronic empyema.
A 61-year-old woman was admitted to our hospital with pneumonia on chest X-ray. Chest CT demonstrated a pulmonary abscess with cavity in the lt. S6. Furthermore, a mass shadow in the lt. S10, and hilar lymph nodes adenopathy were also indicated. TBLB and lung biopsy under CT guidance were performed, however diagnosis was not confirmed. After treatment of the pulmonary abscess, the patient underwent surgery. During the operation, a mass in the lt. S10, and Botallo's and subcarinal lymp nodes were sampled for diagnosis. Frozen section examination indicated pulmonary infarction for the mass in lt. S10, poorly differentiated carcinoma for Botallo's lymph node and moderately differentiated adenocarcinoma for the subcarinal lymph node. The patient underwent concurrent chemoradiotherapy and is well after surgery. This case was difficult to diagnose as hilar and mediastinal lymph node metastases from an unknown primary site, with the cause of pulmonary abscess and pulmonary infarction.
A 51-year-old female was referred to our hospital because of left upper extremity swelling and slight fever. Chest CT showed a ill-defined and diffuse infiltration at the superior mediastinum with an obstruction of the left brachiochephalic vein, the left subclavian vein and the left internal juglar vein. Because inflammatory change was seen and radiological findings showed only thickening of the soft tissue in the mediastinum, but no mass formation, it was suspected to be caused by inflammatory change. An operation was performed to exclude malignancy, and a diagnosis of sclerosing mediastinitis was made histopathologically. If the mediastinal mass displays the compression or occlusion of the vital mediastinal structures, sclerosing mediastinitis should be considered.
We report two cases with mediastinal cystic lymphangioma. A-70-year-old male complained chest compression and discomfort during swallowing caused by a cystic mass surrounding bilaterally vital structures, such as SVC, trachea and carina, and esophagus the middle mediastinum. It was suggested as a lymphangioma with unclear margin by CT scan ad MRI. We resected a part of the cystic lesion through a right thoracotomy to relieve symptom as much as possible, and divided the thoracic duct to prevent post-operative cylothorax. His symptoms disappeared, and no complication due to division of the thoracic duct occurred after surgery. A-64-year-female was referred to us by a cystic mass with clear margin in the middle mediastinum that was found incidentally, and underwent complete resection of the tumor by VATS. The two cystic lesions were diagnosed as cystic lymphangioma by histopathological exmanination.
A case of solitary bronchial squamous papilloma Masayasu Aikawa, Kozo NakanishiDepartment of Thoracic Surgery, Aso Iizuka Hospital A 50-year-old woman was consulted our hospital because of abnormal shadow on chest X ray. Chest CT demonstrated a 1cm mass lesion with a smooth margin in the left upper division of the lung. On 6-month follow up, the lesion did not change in size or shape. We preformed segmental resection of the left upper division. The tumor was elastic hard, 8×8×5mm, not invasive, and diagnosed as papilloma by intraoperative pathologic examination. On showing postoperative pathologic examination, the tumor was diagnosed as squamous papilloma, showing squamous cells without atypical cells covered by fibrous stroma in a dilated bronchiolus. There was no relapse during the 2 years follow-up after surgery. Solitary bronchial squamous papilloma is rare, about 50 cases reported in the literature. We must consider treatment with or without surgery because it is difficult to diagnose the lesion as benign or malignant on preoperative examination, Furthermore, it is necessary to follow patients strictly, especially high risk patients such as smokers.
Our patient was a 53 year-old male, who consulted an ophthalmologist, complaining of visual disturbance. Since the patient had uveitis, sarcoidosis was suspected and a chest X-ray was taken to investigate the lungs. His chest X-ray incidentally demonstrated a foreign body in the mediastinum and the patient was referred to our hospital. His chest CT confirmed a needle-like shadow in the mediastinum close to A-P window. Although VATS was applied to the extirpation under radiological guidance, it was difficult to find the foreign body, which was finally removed through axillary thoracotomy. The patient did not have any history of trauma, surgery or psycogenic disease. Therefore, the entry site of the foreign body was not determined. The entry site was also unknown in more than half of those cases reported in literature. Only 2 cases including our case were reported to have a foreign body in the mediastinum.
A 57-year-old male was referred to our hospital with an abnormal shadow on his chest X ray film. The chest X ray film showed a mass displacing the trachea to the left at the level of the thoracic inlet, and chest CT and MRI showed an upper mediastinal tumor in the lower pole on the right lobe of the thyroid. We performed a tumor resection by cervical collar skin incision, and intraoperative frozen section examination of the tumor revealed thymoma. Therefore, we performed thymus resection by sternum medical incision. Because the thymus originates in the third bronchial pouch and descends into the anterior mediastinum, thymic tissue can occasionally be found in a cervical as well as a mediastinal location. However, thymoma occurring in ectopic thymic tissue is rare. We report a case of ectopic cervical thymoma that was difficult to diagnose. Fine needle aspiration biopsy with flow cytometry and MRI may be helpful in diagnosing ectopic cervical thymoma before operation.
Here we present a case of xanthoma in the rib. A 59-year-old man was admitted to our hospital for the treatment of a chest wall tumor detected by routine chest X-ray. His chest CT scan revealed a well defined, radiolucent lesion with marginal sclerosis in the right fourth rib. Since the possibility of neoplastic lesion including metastatic maligmant diseases could not be ruled out, surgical resection of the tumor was performed. The area of the resection was determined under thoracoscopic guidance, and the tumor along with a part of the fourth rib was then directly resected through a small skin incision. Histopathological examination of the resected specimen revealed degenerated bone tissue and aggregation of foamy histiocytes with low atypism. The diagnosis of the tumor was xanthoma of the rib. Although xanthoma arising from the rib is a rare benign entity, differential diagnosis with other neoplastic diseases including bone metastasis is very important.
An 81-year-old male, who had undergone coronary artery bypass graft and replacement of an abdominal aortic aneurysm 10 months previously, presented with a small peripheral nodule lesion (0.5cm in diameter) in the left upper lobe on chest CT scan. Follow-up on the patient 6 months later, demonstrated an increase in the peripheral nodule lesion, from 0.5cm to 1.0cm in diameter. Chest CT demonstrated an irregular and heterogeneous shadow in the apico-posterior segment of the left lung (S1+2). The shadow was strongly suspected to be adenocarcinoma, but previous inflammatory changes could not discounted. CT-guided marking and resection of the small peripheral nodule lesion were performed on the same day. However, the small peripheral nodule lesion ultimately revealed smooth muscle hyperplasia in the wall of the peripheral bronchiole, between the terminal bronchiole and respiratory bronchiole. We reviewed the literature regarding smooth muscle hyperplasia of the peripheral bronchiole.
We reported a rare case of multiple ganglioneuromas, together with a review of the literature. At an annual examination, a 15-year-old boy exhibited an abnormal shadow on a chest roentgenogram. The chest-abdominal CT and MRI films demonstrated a well-defined, gourd-shaped left thoracic paraspinal shadow. An isolated left retroperitoneal nodule was also seen. The masses were suspected to be neurogenic tumors. Thoracolaparotomy, via a small left lateral incision with a thoracoscope, was performed. We found three well-capsulated tumors along the sympathetic chain in the thorax and an isolated tumor in the retroperitoneum. All tumors were extirpated and histologically diagnosed as ganglioneuromas.
Intrapulmonary bronchogenic cyst results from congenital disorders, and has been infrequently reported. In this report, we present a 66-year-old man who was referred to our institution due to an abnormal shadow on chest roentogenogram. Chest computed tomography (CT) scan demonstrated a round mass with homogenous high density in the right upper lobe. Video-assisted thoracoscopic lobectomy was performed as a diagnostic and therapeutic measure. Histopathological examination showed a bronchogenic cyst. Because complications such as infection and neoplasm are common, surgical resection might be recommended for all suspected bronchogenic cysts.
The patient was a 56-year-old female, who was referred to our clinic for hemoptysis. She had a history of cerebral hemorrhage eight years earlier. Since then, she had been repeatedly admitted to a hospital because of recurring pneumonia. Chest X-ray film and CT scan showed telecasts and destroyed parenchyma in the right lower lobe and a calcified nodule adjacent to the basal bronchus. The patient was diagnosed with broncholithiasis. Thoracoscopic and video-assisted right lower lobotomy was performed. A tooth was found in the granular tissues of the basal bronchus. The episode of aspiration was unknown. We supposed that she had aspirated a tooth when all teeth were extracted 8 years ago. Histologically, actinomycosis was detected in the resected lobe.