Malignant lymphoma is one of the differential diagnoses of a mediastinal tumor. Although we need to obtain an adequate specimen for diagnosis, with subsequent sub-typing and grading of malignant lymphoma, diagnosis is often difficult due to an insufficient specimen and crush. We analyzed 27 patients who underwent surgical biopsy for mediastinal malignant lymphoma from 2006 to March 2018. There were 12 males and 15 females, and their median age was 43.3 years. Sixteen patients underwent computed tomography-guided biopsy or bronchoscopy before surgical biopsy. Surgical biopsy was performed in the following manners: thoracoscopic biopsy 14, parasternal approach 10, mediastinoscopy-based biopsy 2, subxiphoid approach 1. Many cases required repeat biopsies until diagnosis, and Hodgkin's lymphoma required more specimens until diagnosis than other histological subtypes. We suggest that surgical biopsy of malignant lymphoma is useful to collect sufficient tissue from the center of a tumor and for an accurate diagnosis.
Patients with refractory nontuberculous mycobacterial pulmonary disease (NTMPD) are subject to adjunctive pulmonary resection. Ideal surgical candidates are patients whose disease is predominantly localized to one lung. However, we may encounter NTMPD patients who have bilateral airway destructive lesions. Between January 2010 and December 2017, we operated on 184 patients with Mycobacterium avium complex pulmonary disease. Of these, seven patients who underwent two-stage bilateral pulmonary resection were analyzed in this study. All patients were female and had bronchiectatic lesions both in the right middle lobe and left lingular segment. Two of them also had cavitary lesions in the other lobes. The duration of preoperative chemotherapy prior to the first operation was 44.7±70.4 months. The right side was operated on first in five patients and the left side was operated on first in the remaining two. The interval between the first and second surgeries was 8.0±4.1 months. The duration of postoperative chemotherapy after the second operation was 28.6±21.7 months. All patients have been free from relapse/recurrence with an average follow-up of 38.7±27.9 months.
It is well-known that renal cell carcinoma has a tendency to undergo hematogenous metastasis, particularly pulmonary metastasis. We retrospectively assessed outcomes and prognostic factors in 23 patients who underwent pulmonary resection of metastases that originated from renal cell carcinoma between September 2002 and March 2015 at the Shizuoka Cancer Center Hospital after radical nephrectomy. Although the 5-year disease-free survival rate was 38.4%, the 5-year overall survival (OS) rate was 91.3%. The 5-year OS rate in patients with segmentectomy/wedge resection was 100.0%, as compared with 60.0% in patients with lobectomy (P=0.01). The 5-year OS rate was 100.0 and 77.8% for patients with peripheral tumors and those with tumors in a central location, respectively (P=0.10). The patients with DFI (disease-free interval) ≥24 months also tended to have a good prognosis (5-year OS for DFI < 24 vs. ≥24 months: 81.3 vs. 100.0%, respectively, P=0.11). Non-surgical treatment for pulmonary metastasis from renal cell carcinoma is not radical, and long-term survival can be expected with pulmonary metastasectomy. In some cases of surgical resection, survival without recurrence is expected. Moreover, surgical treatment may contribute to prolong disease-free survival. Thus, pulmonary metastasectomy may be an effective treatment strategy.
In recent years, some empyema patients treated with negative-pressure wound therapy have been reported. We report the treatment of two empyema patients using negative-pressure wound therapy after open window thoracotomy and muscle flap filling in one operation. This therapeutic strategy enables surgeons to shorten the duration of negative-pressure wound therapy compared with treatment whereby the patient undergoes open window thoracotomy first, and after the resolution of infection using negative-pressure wound therapy, a second operation is carried out to close the wound. Thus, because two-stage operations are unnecessary, our procedure may promote both short hospitalization and reduced stress of both patients and medical staff.
A 63-year-old man was referred to our hospital due to a growing chest wall tumor. Computed tomography (CT) showed a well-defined and well-circumscribed tumor, and magnetic resonance imaging showed a high signal intensity in both T1- and T2-weighted images and a low signal intensity with fat suppression. CT-guided biopsy showed an atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDLPS), and surgery was performed. The tumor did not infiltrate the chest wall but adhered to the lung; we resected the tumor and a part of the lung without additional resection of the chest wall. The pathological diagnosis was chest wall lipoma with inflammation, and the absence of invasion to the lung was confirmed. The patient was doing well and free from recurrence at 14 months after surgery. Surgeons should recognize that it is difficult to distinguish ALT/WDLPS from lipoma based on pre-operative findings of clinical imaging. Marginal resection may be a reasonable operative procedure for chest wall lipoma or ALT/WDLPS, and adjuvant treatment might be considered if needed.
We report the case of a 72-year-old male with intrathoracic extramedullary hematopoiesis. During treatment for a cough, CT incidentally revealed bilateral posterior mediastinal tumors of 32 mm at the right Th9 level and 33 mm at the left Th11 level. He underwent extirpation of the right tumor under video-assisted thoracic surgery (VATS) for a preoperatively suspected neurogenic tumor. The tumor was dark red and so soft and fragile that it was prone to hemorrhage. Pathological findings revealed hypercellular marrow with granulocytes, megakaryocytes, and erythrocytes, and the patient was diagnosed with extramedullary hematopoiesis. Postoperative biopsy of bone marrow showed hypocellular marrow; however, we did not detect abnormal cells or hematological abnormalities. We performed postoperative bone marrow scintigraphy with 111In to evaluate the contralateral tumor, and found the accumulation of 111In in the left tumor. The patient recovered well without recurrence of the right mass or growth of the left tumor for 12 months post-surgery. Our case demonstrates that if bilateral posterior mediastinal tumors are detected on CT, then extramedullary hematopoiesis should be considered and evaluated by hematological testing.
Case 1: A 65-year-old man was tentatively diagnosed with multiple lung cancer in the right upper lobe and right middle lobe based on preoperative examination for esophageal cancer. After preoperative chemotherapy for esophageal cancer, subtotal esophagectomy, mediastinal lymphadenectomy, right upper and middle lobectomy, and esophagostomy were performed. Twenty days after the first surgery, gastric tube reconstruction through a subcutaneous route was performed as the second surgery. No recurrence has been observed for one year.
Case 2: A 72-year-old man was diagnosed with esophageal cancer on examination for dysphagia and suspected to have lung cancer in the right lower lobe based on a preoperative work-up for esophageal cancer. Wedge resection of the right lower lobe, subtotal esophagectomy, mediastinal lymphadenectomy, esophagostomy, and tracheotomy were performed. Subcutaneous gastric tube reconstruction was performed as the second surgery 32 days after the first surgery. No recurrence has been observed for eight months. Here, we report two cases of two-staged surgery for synchronous double cancer of the right lung and esophagus with a review of the literature.
A 46-year-old female showed a nodule with spiculations on computed tomography (CT). The preoperative diagnosis was malignant lung cancer [cT2a (PL1) N0M0, Stage IB] and lobectomy was planned. However, intraoperative pathology suggested a meningioma and only wedge resection was performed. As no lesions were found in the central nervous system, she was diagnosed with primary pulmonary meningioma. Including the present case, we summarized 28 cases reported in the English literature of primary pulmonary meningioma, with a description of the prognosis, since the first report in 1982. Of the 17 patients who underwent CT, most showed well-defined round nodules, and 2 had spiculations. Pulmonary spiculation on CT usually indicates malignancy; however, in the present patient, spiculation was pathologically derived from lymphocyte infiltration. Consequently, its correlation with malignancy was unproven. The collected patients mostly showed recurrence-free survival of more than 1 year, although 2 cases with malignant pathological findings had postoperative metastasis. Primary pulmonary meningioma, difficult to diagnose preoperatively because of its rarity, is usually benign and wedge resection is generally performed. Careful observation is necessary for patients in whom the postoperative pathology indicates malignancy.
A 67-year-old man underwent preoperative computed tomography (CT) owing to the presence of a thoracic aortic aneurysm. CT showed a ground-glass nodule in the left lower lobe of the lung. We performed video-assisted thoracoscopic surgery (VATS) wedge resection of the nodule. The pathological diagnosis was lepidic pattern-based lung adenocarcinoma, pT1miN0M0-IA1 (UICC 8th). Two years and five months later, he came to the hospital complaining of dyspnea, and a chest radiograph showed mass pleural effusion in the left lung field. We performed VATS pleural biopsy of the left lung base where the pleural thickening was observed. The pathological diagnosis was poorly differentiated adenocarcinoma.
Pathologically differentiating metastasis from metachronous lung adenocarcinoma was difficult; therefore, we performed examinations using a comprehensive cancer panel, which revealed an EGFR p.R521K mutation in both tumors. Further, somatic mutations were observed in approximately 90% of the cells in both tumors. These results facilitated a diagnosis of metastasis. The patient has been undergoing chemotherapy with cisplatin and pemetrexed.
The patient was a 74-year-old woman with intestinal obstruction. Upon admission to our hospital, a plain chest radiograph showed a right upper-lobe mass of 47 mm, so the patient was referred to the Department of Chest Surgery. After discharge from the department, we performed bronchoscopy, and cytology revealed cytological class V findings. Thoracic computed tomography (CT) and positron emission tomography-CT were performed, and the patient was diagnosed with T2bN0M0 cStage IIA. In addition, three-dimensional (3D) CT showed abnormal reflux from the superior pulmonary vein (V1-3) into the superior vena cava (V4, 5 shared a common trunk with the inferior pulmonary vein), so the patient was diagnosed with lung cancer complicated by partial anomalous pulmonary venous return (PAPVR). The risk of postoperative cardiac failure was determined to be low due to an anomalous venous connection in the lobe scheduled for resection, so video-assisted thoracoscopic right upper lobectomy was performed. PAPVR is rare and the preoperative diagnosis is challenging, although diagnosis is often confirmed at surgery. The PAPVR in this patient was identified on preoperative 3D CT, and appropriate surgical planning was thus possible.
While undertaking outdoor work, a 42-year-old man was hit on the back of his neck by a large log. At the time of admission to the hospital, he showed dyspnea, stridor, deep cervical emphysema, and swelling, in addition to an invagination of the cervical skin overlying the respiratory tract. Computed tomography identified complete disruption of the cervical trachea but no cervical cord injury. Using a flexible bronchoscope, a distal bronchial stump was identified; subsequently, bronchoscopy-guided endotracheal intubation and tracheal reconstruction were performed.
The trachea was completely disrupted at the level of the manubrium sterni, but the degree of detrition was slight. End-to-end anastomosis was performed without trimming.
On the 8th day after the operation, tracheotomy was performed due to recurrent nerve paralysis. After rehabilitation, the tracheal cannula was removed on the 32nd day.
We present a case of postoperative recurrent malignant solitary fibrous tumor of the pleura in a young patient that was successfully resected. The patient was a 22-year-old female who (initially) presented with chest pain. CT revealed a mass of 11 cm in diameter in the right lower thoracic cavity. Although CT-guided needle biopsy failed to provide a definitive diagnosis, the mass was suspected to be a solitary fibrous tumor of the pleura based on radiological features. We performed thoracotomy and resection with curative intent. The intrathoracic mass was extirpated in combination with partial resection of the diaphragm, lung, and parietal pleura. The pathological diagnosis was malignant solitary fibrous tumor of the pleura. One year after surgery, the tumor relapsed on the right chest wall, and we resected the recurrent mass including the 10th and 11th ribs. There has been no evidence of recurrence for seven years since the second operation. Surgical resection was useful for controlling postoperative local recurrence of the malignant solitary fibrous tumor. We have also reviewed the Japanese literature on postoperative recurrent solitary fibrous tumors, including those with a benign pathology, and paid attention to the time to recurrence after surgery.
A 57-year-old female was referred to our hospital due to an abnormal sputum cytology on an annual medical check-up. Bronchoscopy and subsequent biopsy revealed a squamous cell carcinoma in the tracheal carina. The tumor extended to four right main bronchial rings and two left main bronchial rings. Carinal resection was performed with a right upper sleeve lobectomy, followed by carinal reconstruction using a modified double-barrel method. Firstly, two thirds of the circumference of the trachea and the left main bronchus were end-to-end anastomosed. Next, the remaining part of the circumference was end-to-side anastomosed to the right intermediate bronchus after trimming. Neither a severe ischemic finding nor significant stenosis was postoperatively identified. This patient has survived without relapse for two and half years since the surgery.
Carinal reconstruction using a modified double-barrel method could minimize the tension of the anastomotic site, and maintain sufficient blood flow to the anastomosis. This procedure is considered effective, especially for cases requiring extensive carinal resection.
Case: A 58-year-old woman underwent percutaneous radiofrequency ablation (RFA) for liver metastasis of sigmoid colon cancer. She was readmitted with fever and bilious pleural effusion 28 days after the RFA. Drainage of pleural effusion and endoscopic nasobiliary drainage were started following the diagnosis of biliopleural fistula. Chest drainage was required for 30 days until the bile excretion was controlled.
Biliopleural fistula after RFA is a rare but severe complication. Immediate interventions with transthoracical and transabdominal drainage are required.
A 37-year-old man was referred to our hospital because of an abnormal shadow on a screening chest radiograph. Chest computed tomography demonstrated a middle mediastinal tumor with fluid density, which extended from the carina to left main bronchus. We performed fine needle aspiration under bronchoscopy and obtained a milky material, so the tumor was diagnosed as a bronchogenic cyst. Although it remained asymptomatic, the size of the tumor gradually increased after the first diagnosis and caused compression of the left main bronchus. Therefore, surgery was performed. Considering the tumor location, mediastinoscopoy was selected as the approach. We alternately performed sharp dissection and exfoliation of the tumor through mediastinosocpy. The tumor showed severe adhesion to the trachea, so we performed subtotal resection with destruction of the lining mucosa by electric cauterization. The patient was discharged without complications, and there has been no recurrence in the 4 years since surgery.
A 57-year-old man presented with a 36-mm mass lesion in the anterior mediastinum detected by chest computed tomography during follow-up for a thoracic aortic aneurysm. Invasive thymoma was suspected and extended thymectomy was performed through median sternotomy. Intraoperatively, the local pericardium putatively affected by tumor invasion was excised and the pericardial defect site was reconstructed with a Gore-Tex sheet. High fever, pericardial effusion, and ST elevation on electrocardiography were observed on the 8th day after surgery (diagnosed as post-pericardiotomy syndrome) but colchicine and NSAID administration resulted in renal impairment. An increase in pericardial effusion accompanied by marked growth of the septal wall was treated with thoracoscopic pericardial fenestration on the 15th day after surgery. Post-surgically, steroid administration was started and pericardial effusion was reduced, the fever went down, and the white blood cell count and CRP value normalized. Post-pericardiotomy syndrome is a relatively well-known complication after cardiac surgery, but it should be considered as a possibility even after mediastinal tumor surgery requiring pericardiotomy.
An 80-year-old woman was admitted with an abnormal shadow in the right upper zone on chest radiograph. Chest CT revealed a comparatively small nodule with a clear margin in the periphery of the right upper lung. The preoperative diagnosis was c-T1aN0M0 stageIA squamous cell carcinoma based on CT-guided lung biopsy. She underwent right upper lobectomy and the resected specimens revealed meningioma. We diagnosed her with primary pulmonary meningioma because no tumor was detected in the central nervous system. She has remained relapse-free for 30 months.
Injury of the pulmonary artery is a severe incident that sometimes occurs during pulmonary lobectomy. The action taken in response to it is left to the discretion of each surgeon and has not been standardized. A survey was performed on the method of transecting pulmonary arteries (PA) and response to PA injury involving 719 active members of the Japanese Association of Chest Surgery (JACS), and 418 (58.1%) provided viable responses. Eighty-two percent of the responders chose video-assisted thoracic surgery for pulmonary lobectomy. At the time of transection of the right A1+3 (approximately 9 mm in diameter), 92.6% used automatic stapling devices. For the left A3 (approximately 6 mm in diameter), 83.3% used automatic stapling devices and 8.4% favored double ligatures. For the right A2b (approximately 3 mm in diameter), 65.6% used single ligation and an energy device (or surgical clip) and 21.3% favored double ligatures. The majority of the responders had encountered blood loss of more than 500 mL, a half had considered conversion from VATS to thoracotomy when blood loss exceeded 500 mL, and one fourth had introduced cardiopulmonary bypass during hemostatic procedures in patients with PA injury. The common method of PA transection and response to PA injury were shown in this questionnaire survey.