We performed an analysis of cases of simultaneous multiple cancers discovered by FDG-PET/CT performed as a part of preoperative evaluation in patients with resectable non-small cell lung cancer (NSCLC). We conducted a retrospective review of the data of 426 patients with NSCLC who underwent surgery from 2007 to 2014.
FDG-PET revealed uptake in areas other than that of the primary tumor and regional lymph nodes in 57 of the 426 patients (13.3%). Of these, 12 patients (2.8%) were diagnosed with simultaneous multiple cancers. The sites other than the lung involved in the simultaneous multiple cancers included cancers of the thyroid (4 cases), esophagus (1 case), stomach (1 case), liver (1 case), kidney (1 case), colon (1 case), prostate (1 case), and breast (2 cases). In all cases, the other cancer was also determined to be surgically resectable.
Preoperative FDG-PET/CT is not only useful for preoperative cancer staging, but also for the detection of multiple cancers.
Seven patients on hemodialysis (HD) with lung cancer underwent pulmonary resection in our hospital from 2010 to 2015. We retrospectively reviewed their surgical outcomes. Subjects included 4 males and the average age was 70.3 years. The underlying kidney disease was diabetic nephropathy in 3 patients, glomerulonephritis in 3, and SLE in 1. The median duration of HD before surgery was 9.6 years. Five patients underwent lobectomy, one segmental resection, and one wedge resection by video-assisted thoracoscopic surgery among all cases. The operative time was an average of 149 minutes (90-210). The amount of bleeding was an average of 281 mL (12-1,795) and blood transfusion was performed in one patient. Histological diagnoses included adenocarcinoma in 5 patients, squamous cell carcinoma in one, and pleomorphic carcinoma in one. The distribution of pathological staging was IA in four cases, IB in two, and IIA in one. There were no critical complications or in-hospital deaths. The period of hospitalization after surgery was an average of 13.8 days. Four of the 7 patients are alive and cancer-free. Two patients died of recurrence and one patient died of cerebral infarction.
These data indicate that pulmonary resection for lung cancer patients with HD requires careful operation and management during the perioperative period.
A 59-year-old man was referred to our hospital after an abnormal shadow was detected in his chest, which was suspected to be a primary lung tumor, during a regular physical checkup. Chest radiograph revealed dextrocardia and a 3.0 × 2.5 cm mass shadow in the left mid-lung zone. Thoracoabdominal computed tomography (CT) showed that he had bilateral bilobed lungs and the right and left bronchi and pulmonary artery morphologies were inverted. A right-sided aortic arch, dextrocardia, persistent left superior vena cava, polysplenia, inverted liver, abnormal rotation of the superior mesentery, and hypoplasia of the pancreatic tail were also observed. The radiographically visible mass was classified as a left middle lobe lung cancer of c-T2aN0M0 stage IB, arising in a patient with heterotaxy syndrome. After carefully assessing the topographical anatomy using imaging, including three-dimensional (3D) CT, we performed a thoracoscopic left middle lung lobe resection and lymph node dissection. However, because we were unable to intraoperatively identify the left recurrent laryngeal nerve, some of the mediastinal lymph nodes were only sampled.
Viscero-atrial heterotaxia often involves associated malformations, such as angiectopia or bronchiectopia. Therefore, it is important to comprehensively plan the surgical method and thoroughly evaluate the local anatomy preoperatively using 3D-CT and other appropriate imaging modalities.
A 68-year-old male was referred to our hospital due to an abnormal shadow on a radiograph in his medical checkup. Chest CT showed multiple masses in the right upper lobe, one of which was revealed to be squamous cell carcinoma by bronchoscopic biopsy. Right upper lobectomy with lymph node dissection was performed with video-assisted thoracic surgery. Pathological examination revealed adenosquamous carcinoma (pT3c (pl3) N1 M0 -IIIA) and large cell neuroendocrine carcinoma (pT3 (pm1) N0 M0 -IIB). Post-operative radiation therapy up to 58 Gy was performed for the chest wall invasion. No recurrence had been observed as of one year and 10 months after the surgery. Here, we report a rare surgical case of synchronous multiple lung cancer with various histopathologic features in a single lobe.
The patient was an asymptomatic 53-year-old female who had been referred to our facility after an abnormal finding on radiograph. Chest CT showed a tumor >5.6×3.2 cm in diameter with smooth margins in the left upper zone displacing the surrounding pulmonary vessels and trachea. Surgery was performed as a diagnostic and therapeutic measure. Based on a suspected diagnosis of sarcoma, an upper left lobectomy, as used in lung cancer, was performed under thoracoscopy. Pathological findings included spindle-shaped tumor cells dispersed within the lung tissue, and immunostaining was positive for epithelial membrane antigen and Ki-67. The break-apart signal in SYT-FISH analysis confirmed SYT translocation, and a diagnosis of biphasic synovial sarcoma was made. Synovial sarcomas are usually soft tissue tumors originating from the joints of the four limbs, and reported cases of primary tumors resected from the lungs are extremely rare.
An 82-year-old male had been receiving corticosteroid therapy for interstitial pneumonia and rheumatoid arthritis. Four years ago, he was referred to our hospital due to left pneumothorax. Because air leakage relapsed after three operations (partial resection and closure of the lung) and he showed chemical pleurodesis, we successfully performed pediculed serratus anterior muscle flap transposition to the fistula in the lingula. This time, he was again referred to our hospital due to the recurrence of left pneumothorax. After the failure of chemical pleurodesis, direct suture of the fistula in the lower lobe under VATS was performed. After the recurrence on postoperative day 7, air leakage from the same fistula was again noted on reoperation. The fistula was successfully covered with a latissimus dorsi pedicled muscle flap. Pneumothorax did not recur after the reoperation.
Chemical pleurodesis and repeated surgical intervention pose a risk for the acute exacerbation of interstitial pneumonia. Coverage with a pedicled muscle flap is an option for the treatment of intractable pneumothorax associated with interstitial pneumonia.
We report the case of a 44-year-old woman with a history of asbestos exposure who presented with bilateral pneumothorax. Computed tomography revealed no bulla, but partial pleural thickening of the apex on both sides of the lung and nodules on both sides of the diaphragm. The patient underwent an operation, which showed pleural nodules on the visceral and parietal pleura of both sides. We found a pinhole with air leakage on the upper lobe of the right lung, which was surrounded by small white nodules. There was no air leakage on the left side. Pleural biopsies revealed epithelioid mesothelioma. Further investigations by FDG PET-CT showed uptake in the right hilar and mediastinal lymph nodes. We considered that both sides occurred synchronously (IMIG stage right: stage III, left: stage Ib), or the primary tumor was initially on the right side and spread to the left side by lymphatic or hematogenous metastasis (IMIG stage IV). Chemotherapy is now being performed.
A 52-year-old man with cT2aN1M0 stage IIA lung adenocarcinoma underwent left lower lobectomy with wedge resection of the bronchus, pulmonary artery angioplasty, and lymph node dissection after two courses of induction chemotherapy with cisplatin and gemcitabine. The postoperative pathological stage was ypT2aN1M0 yp-Stage IIA, and the patient received two courses of adjuvant chemotherapy with carboplatin and paclitaxel. Fourteen months later, magnetic resonance imaging (MRI) revealed frontal lobe brain metastasis, and tumor resection was performed. Three years and eleven months after the first operation, fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) revealed paired cervical lymph nodes metastases. Although he was treated with radiation therapy (40 Gy), the metastatic lesions did not reduce in size. The resected lymph node specimen was found to be positive for the epidermal growth factor receptor mutation; therefore, we commenced erlotinib treatment. One month later, the lymph node lesions were undetectable on MRI, and four months later, FDG-PET/CT showed the regression of FDG uptake in the lesions. However, we discontinued erlotinib treatment due to air-space consolidations and ground glass opacities suggesting drug-induced pneumonitis on CT. Subsequently, there has been no recurrence of lung cancer to date, seven years and ten months after the discontinuation of erlotinib treatment.
The patient was a 66-year-old man who had been diagnosed with idiopathic pulmonary fibrosis in 2003. He was diagnosed with nontuberculous mycobacterial disease (Mycobacterial intracellulare) in September 2014, and began taking antibiotics. However, he refused to continue chemotherapy, and was subsequently observed from May 2015. He was referred to our hospital in May 2016 due to right chest pain with fever, and diagnosed with right pneumothorax with empyema caused by M.intracellulare infection. In spite of multidrug chemotherapy and thoracic drainage, the air leakage continued and inflammatory reaction did not improve. We therefore decided to perform surgery. Since a pulmonopleural fistula was detected in the right S6, we closed the fistula with a free fat graft and a pedicled flap, making use of the parietal pleura. Although expansion of the right lower lobe was observed immediately after the operation, pulmonary air leakage occurred on postoperative day 5. We performed a reoperation on the 14th day after surgery due to persistent right lower lobe collapse. At first, a pedicled intercostal muscle flap was prepared. Then, the careful decortication of the thickened visceral pleural peel covering the right lower lobe parenchyma was performed. Finally, the flap was sutured to the pulmonary fistula and fixed. After surgery, the full expansion of the right lung continued, the air leakage stopped, and the pleural cavity became sterile, enabling the removal of the chest tube. No recurrence of empyema was observed. The closure of the pulmonary fistula using a pedicled intercostal muscle flap after performing decortication was effective for treating pyopneumothorax complicated by a nontuberculous mycobacterial infection.
A 43-year-old man was injured by collision with a car when he was riding a motorcycle. He was transported to our emergency department. Computed tomography showed displaced fractures of the left 1st to 8th ribs, hemopneumothorax, and a large traumatic pulmonary pseudocyst in the left lower lung lobe. He was put on a ventilator because breathing on his own became difficult. On the second day after he was injured, a hemorrhage occurred from the pulmonary pseudocyst and was stopped by spraying thrombin. However, on the third day, a massive hemorrhage occurred again. Therefore, pulmonary lobectomy of the left lower lobe was performed. His postoperative course was favorable. A traumatic pulmonary pseudocyst is rare and generally treated using conservative methods. However, surgical intervention is necessary in some cases with severe complications such as refractory hemorrhage, secondary infection, and severe air leak. We should consider surgical intervention as a therapeutic option for a traumatic pulmonary pseudocyst with refractory hemorrhage.
A 68-year-old woman was radiologically followed after left upper lobectomy for lung adenocarcinoma. Her chest CT showed a ground glass nodule (GGN) in the right middle lobe that increased in size and density in the central region during follow-up. Laboratory examination before surgery showed high gamma-globulin. She underwent VATS middle lobectomy 5 years after lung cancer surgery. Pathological findings demonstrated the infiltration of plasma cells and lymphocytes to the lung interstitium, and she was diagnosed with plasma-cell type Castleman's disease based on the polyclonality of in situ hybridization. Multicentric Castleman's disease should be considered for patients with GGN and high gamma-globulin.
Cases of selected thoracoscopic surgery for mediastinal tumors have increased depending on each tumor.
In surgery for a tumor in the area of the lower thoracic vertebra, the operative field may be poor due to the diaphragm.
The patient, a woman in her 50s, had a posterior mediastinal tumor in the right posterior mediastinum at the 11th to 12th vertebral level.
Thoracoscopic surgery using CO2 insufflation in a prone position was performed, which has been increasingly employed for esophagectomy in recent years.
In addition to the collapse of the lungs, the diaphragm was also depressed to the caudal side because of gravity and CO2 insufflation. Thoracoscopic surgery for a posterior mediastinal tumor using CO2 insufflation in a prone position was able to secure a good operative field.
A 77-year-old woman was referred to our hospital with multiple ground-glass nodules on computed tomography. A large nodule was noted in the upper part of the left lung (S3), and a solid component was present in the nodule. It was thought that the nodule was early-stage lung cancer, and partial resection using video-assisted thoracoscopic surgery was performed. The nodule was histologically diagnosed as peribronchiolar metaplasia, with a co-existing adenocarcinoma in situ within the nodule. To the best of our knowledge, this is the first report of such a case.
The subject was a 55-year-old woman. Chest CT revealed an anterior mediastinal mass of 11.2×9.3 cm, which bordered the pericardium and the left side of the pulmonary arterial trunk and was accompanied by left pleural effusion. Contrast-enhanced MRI findings of the chest were suggestive of tumor invasion into the pericardium and pulmonary arterial trunk. CT-guided biopsy led to a diagnosis of thymoma with a WHO classification of type AB. Complete resection was determined to be difficult, and steroid pulse therapy was administered with the hope of inducing a cytoreductive effect. On steroid pulse therapy, the tumor shrunk to 8.5×6.2 cm, the border with the pulmonary arterial trunk became clear, and the left pleural effusion disappeared. On day 28 after initiating steroid pulse therapy, thymothymectomy by median sternotomy was performed. Intraoperative findings revealed tumor adhesion to the left upper pulmonary lobe and pericardium; however, complete resection was possible by the combined resection of the left lung and pericardium. Transient arrhythmia postoperatively developed but subsequently subsided. We encountered a case of thymoma in which preoperative steroid pulse therapy induced a marked cytoreductive effect and helped to determine the feasibility of complete resection. Steroid pulse therapy has fewer side effects than antitumor drugs, and in locally advanced thymoma, it can be a useful tool to determine the feasibility of complete resection.
We report a case of extensive asymptomatic thrombus developing from the resection stump of the pulmonary vein after left lower lobectomy, despite continuous anticoagulant therapy. A 67-year-old woman was taking warfarin after valve-replacement surgery. She was introduced to our institution with double cancer comprising cervical and lung cancer. Considering the cancer stages, lung cancer surgery preceded treatment for the cervical cancer. Left lower lobectomy under VATS (video-assisted thoracic surgery) (ND2a-2) was performed (pT1bN2M0), and the patient was discharged without complications. An extensive intraventricular thrombus was confirmed in the left lower pulmonary vein resection stump (with no embolic symptoms) on contrast-enhanced computed tomography of the chest and abdomen before cervical cancer treatment. The thrombus gradually disappeared after starting the continuous intravenous infusion of heparin. Although thrombus formation at the superior pulmonary vein stump has been widely reported after left upper lobectomy, few reports either domestically or abroad have described extensive thrombus formation after lower lobectomy. This case may be very rare, and it is therefore reported.
Background: Diaphragmatic metastasis of gastrointestinal stromal tumor (GIST) is rarely treated surgically. Resection of diaphragmatic metastases of GIST has thus not been studied in depth. We report a case of diaphragmatic metastases of GIST.
Case Report: A 64-year-old woman with a bulky intraperitoneal tumor was diagnosed with GIST by open abdominal biopsy. Two years and eight months after completing chemotherapy with imatinib and sunitinib, she underwent resection of the primary tumor in the duodenum and nearby organs (tail of the pancreas, spleen, left adrenal gland, small intestine, and transverse colon). As she declined postoperative chemotherapy, she took no medication. Three years and three months later, a right diaphragmatic tumor suspected to be GIST metastasis was identified at the right lower lobe of the lung or right diaphragm, and tumor resection was performed. The postoperative pathological diagnosis was diaphragmatic metastases of GIST. The mechanism of recurrence in this case was considered to be hematogenous metastasis to the right diaphragm or diaphragm penetration by peritoneal dissemination.
Conclusion: Surgery is not indicted for lung metastases of GIST because of the lack of clinical evidence for a sufficiently improved prognosis. However, surgical treatment in carefully selected cases of diaphragmatic metastasis of GIST might improve the prognosis.
We report the case of a 19-year-old man referred to our hospital with a complaint of severe dyspnea. Computed tomography demonstrated an anterior mediastinal tumor, of 130×95 mm, causing tracheal and bilateral bronchial stenosis.
The imaging along with a high serum level of alpha-fetoprotein (AFP) (2,643 ng/mL) facilitated the diagnosis of a malignant germ cell tumor. Chemotherapy (bleomycin, etoposide, and cisplatin: 4 courses) was administered immediately, with a significant reduction of the tumor size and normalization of AFP levels. We performed a combined resection of the mediastinal tumor, right atrium, and superior vena cava with graft reconstructions.
The postoperative course was favorable and he could return to college on postoperative day 22. He is currently alive with no evidence of recurrence at four years after surgery.
A 47-year-old woman was admitted to our hospital due to chest pain and a mediastinal mass on a chest radiograph. Chest computed tomography (CT) showed a 52×48-mm mass in the superior mediastinum. The mass adhered to the right mediastinal pleura and pericardium. Minimal pleural effusion was detected. Positron emission tomography (PET)-CT showed the accumulation of FDG (SUV max: 5.34) in the mass. Extended thymectomy was performed. The pathological diagnosis was large-cell neuroendocrine carcinoma of the thymus, and was classified as a stage I tumor based on Masaoka's classification. She survived without any sign of recurrence for 70 months after surgery.
We report a rare case of lung cancer with coronary artery to bronchial artery anastomosis (CBA). A 73-year-old woman was referred to our hospital because of a 7-mm part-solid nodule in the right lung detected by CT. Because this nodule grew gradually during an about one-year follow-up, we decided to resect it. Angina pectoris was suspected and she underwent coronary angiography and CT angiography at the age of 66. These showed communication between the conus branch of the right coronary artery and right bronchial artery. We started the operation by three-port VATS. Because the nodule was diagnosed as adenocarcinoma by intraoperative frozen section analysis, we decided to perform right S2 segmentectomy. We detected the aberrant networks of bronchial arteries at the hilum caused by CBA, and struggled to stop bleeding from these vessels. As a result, we converted to open thoracotomy and right upper lobectomy. No ischemic ECG change was detected throughout the perioperative period.
We report a case of pulmonary mucormycosis treated with segmentectomy of the right lung. A 78-year-old man developed a fever and was referred to our hospital. The laboratory data showed pancytopenia, and the patient was diagnosed with acute myeloid leukemia. He started receiving chemotherapy; however, he later developed febrile neutropenia and an abnormal shadow appeared in his right lung. Meropenem and micafungin injections did not yield a response. Consequently, the patient was diagnosed with pulmonary mucormycosis and started receiving amphotericin B. However, the shadow continued to worsen, and surgery was considered as a salvage treatment strategy. The shadow was located in segments 2, 6, and 8, with a smaller shadow in segment 4. We performed right S2+S6+S8a segmentectomy and a wedge resection of segment 4. The patient's postoperative course was uneventful. The chest drainage tube was removed on postoperative day 5, and the patient was discharged on postoperative day 17. Six months later, the patient experienced a recurrence of acute myeloid leukemia, and died 11 months after the operation. He had been receiving additional chemotherapy up until his death; however, he did not show recurrence of the pulmonary mucormycosis. When dealing with pulmonary infectious disease, care must be taken to ensure that the dead space after the operation is as small as possible. Lung segmentectomy is an appropriate option in these cases.
We report a case of pulmonary abscess accompanied by rib destruction. The patient was a 40-year-old male with relapsed leukemia. He received chemotherapy and cord blood stem cell transplantation, and achieved complete remission again. One month after, CT images showed an infiltrative shadow in the right upper lobe of the lung, and it was suspected to be caused by fungal infection. Despite the administration of anti-fungal drugs, the lesion was uncontrollable and a pulmonary abscess developed. Thereafter, the abscess infiltrated the chest wall with rib destruction, and then he complained of severe right chest pain. At the initial operation, when the scapula was peeled off from his chest wall, a large amount of pus was expelled from the abscess. Because adhesion between the chest wall and right upper lobe was marked, it was considered difficult to perform a right upper lobectomy, and an open window thoracostomy combined with resection of the chest wall was performed. After the cavity had been cleaned, several bronchial fistulas were occluded with EWSs, and the window was closed with a pedicled pectoralis major musclo-cutaneous flap. He recovered from the series of infection and pain.
Case: A 49-year-old woman visited a local hospital with a complaint of dry cough persisting for the past 3 weeks. A chest radiograph revealed an abnormal shadow in her right lower lung field, she was diagnosed with pneumonia, and started on antibiotic therapy. As the symptoms did not disappear and hemoptysis occurred, she was admitted to our hospital.
As contrast computed tomography (CT) revealed right lower and middle lobe pneumonia, lung abscess, and pulmonary arterial aneurysm in the right pulmonary artery (A8), trans-catheter arterial embolization (TAE) was performed. Hemoptysis disappeared temporarily, but massive hemoptysis occurred again five days after embolization. Bronchial artery angiography was performed, but the pulmonary arterial aneurysm could not be visualized. Contrast-enhanced CT revealed the enlargement of the aneurysm. Therefore, it was judged that the embolization had been ineffective, so right lower and middle bi-lobectomy was performed.
Pathologically, the patient was diagnosed with a pulmonary artery pseudoaneurysm. She was discharged on the 11th day after surgery without any complications, and her condition was favorable as of the two-year follow-up.
Conclusion: Surgical treatment should be considered for cases of pulmonary artery aneurysm, in which hemoptysis occurs again after TAE, the effect of TAE is deemed insufficient, and the general condition is unstable.
This study describes a case of superior mediastinal paraganglioma resected using a modified transmanubrial approach. A 42-year-old woman was referred to the authors' hospital for a mediastinal tumor that was found on examination of left mastopathy. Chest computed tomography revealed a 48×45-mm heterogeneous mass in the superior mediastinum.
Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed an abnormal uptake of FDG in the mass with a maximal standardized-uptake value (SUV max) of 8.52, which was suspected to be a malignant tumor. The left common carotid artery and left subclavian artery were running in the suspected tumor, which showed no invasion of the surrounding organs. The tumor was resected completely using a modified transmanubrial approach. Pathological examination confirmed the resected mass to be a paraganglioma. The modified transmanubrial approach was useful for resecting the superior mediastinal tumor, whose location is difficult to observe.