We report a case of pulmonary pleomorphic carcinoma that showed rapid progression with 4-year remission after the first operation. On CT examination, the tumor showed a ground glass appearance in the first operation, but the recurrent tumor was solid.
A 74-year-old man was referred to our department for a 3-cm GGN in the upper lobe of the right lung on a medical examination. We performed an upper lobectomy of the right lung with lymph node dissection. Histopathology of the resected specimen revealed mixed adenocarcinoma, with a pathological stage of IA (pT1bN0M0). A regimen of carboplatin (CBDCA) +irinotecan (CPT-11) was administered, because the multiple new GGNs occurred 2 years after the first operation. The GGNs after the chemotherapy were classed as stable disease.
A new solid nodule appeared in the right lower lobe 4 years after the first operation. The solid tumor was evaluated as newly developed primary lung cancer and was resected. Histopathology of the tumor showed pleomorphic carcinoma with spindle cells, papillary adenocarcinoma, and bronchioloalveolar cell carcinoma. The patient died of the cancer 3 months after the second operation, with rapidly growing multiple metastases. Re-examination of the specimen showed pleomorphic carcinoma with 10% of the area showing spindle cell carcinoma. The ratio of spindle cells may be associated with this prognosis.
Micronodular thymoma with lymphoid stroma is a rare tissue subtype among thymomas and its biological characteristics have yet to be clarified. We report herein a resected case of micronodular thymoma with lymphoid stroma. A 67-year-old woman visited our hospital after plain CT of the chest for screening purposes in another hospital revealed a mass in the anterior mediastinum. Contrast-enhanced CT of the chest in our hospital showed a multi-nodular tumor with clear boundaries measuring 80×60×30 mm in the anterior mediastinum. FDG-PET showed multiple accumulations in the anterior mediastinum. Surgery was performed because tumorous lesions could not be ruled out from the imaging findings. Surgery was started in a supine position under general anesthesia. Thymectomy was performed with a bilateral thoracic approach. The histopathological diagnosis was micronodular thymoma with lymphoid stroma. The patient was discharged on postoperative day 7.
A 71-year-old man was found to have an incidental right S6 lesion. Transbronchial biopsy and the intraoperative pathological diagnosis confirmed no malignancy, but lung cancer was strongly suspected. We performed right S6 segmentectomy. The final pathological diagnosis was collision tumor, comprising both squamous cell carcinoma and an inflammatory myofibroblastic tumor. This case calls attention to this possibility.
Lung cancer can arise from an emphysematous bulla. Here, we report a case of squamous cell carcinoma in the wall of an emphysematous pulmonary bulla in a patient who developed pneumothorax during follow-up for the bulla. This case illustrates that follow-up of patients with a pulmonary bulla is important in accordance with their characteristics. The patient was a 91-year-old man with a 136 pack-year smoking history. A left pulmonary bulla had been diagnosed approximately 4 years earlier, and follow-up CT showed slight and gradual increases in the size of the bulla; partial thickening of the bulla wall was also observed. Left-sided pneumothorax occurred. Video-assisted thoracoscopic bullectomy was performed and subsequent histopathologic examination revealed that the thickened pulmonary bulla wall on CT was a squamous cell carcinoma arising from the emphysematous bulla wall.
We report a case of pulmonary thromboembolism with cardiac arrest after surgery for lung cancer successfully treated with catheter-assisted thrombus removal. Patient, a 78-year-old woman who underwent thoracoscopic left upper lobectomy for lung cancer fainted and developed cardiac arrest on her first walk after surgery. Cardiopulmonary resuscitation was started immediately, echocardiography showed flattening of the interventricular septum, and pulmonary thromboembolism was suspected. After cardiopulmonary resuscitation for about 40 minutes, she showed return of spontaneous circulation and underwent catheter-assisted thrombus removal without cardiopulmonary support. Pulmonary angiography showed multiple bilateral thrombuses mainly in the truncus anterior of the right pulmonary artery, and a massive thrombus was collected by fragmentation and aspiration. Hemodynamics of the patient improved immediately. She was discharged without neurological disorder on postoperative day 25. Although pulmonary thromboembolism with collapse or cardiac arrest is associated with a high mortality rate, we could save the patient due to immediate cardiopulmonary resuscitation and catheter-assisted thrombus removal.
A 61-year-old male with lung cancer of the right upper lobe was referred to our hospital. The patient underwent video-assisted thoracic surgery with right upper lobectomy+ND2a-1 and wedge resection of the right lower lobe. The drain effusion volume on postoperative day 1 (POD 1) reached 1000 mL, and the patient was diagnosed with chylothorax due to the milky drain effusion on POD 2. Conservative treatments including drainage, fasting, and total parenteral nutrition were unsuccessful, and intranodal lymphangiography (INL) was performed. Chylous discharge stopped completely on POD 10.
Postoperative chylothorax is a rare complication that can usually be treated conservatively; however, surgical intervention or another approach is required in a few cases. Since the patient had chronic obstructive pulmonary disease along with postoperative dyspnea, surgical intervention for chylothorax was not considered initially as it could have led to worsening of postoperative dyspnea. Therefore, he underwent INL, which was useful fot resolving chylothorax with a minimally invasive technique.
A 56-year-old woman was referred to our hospital with left shoulder pain and an abdominal shadow noted on chest computed tomography (CT). CT revealed a 45-mm mass in the carina and atelectasis of the left lung. Bronchoscopy revealed a tumor in the inlet of the left main bronchus, and swelling of the bronchial mucosa was detected in the right main bronchus. She was diagnosed with adenoid cystic carcinoma (cT4N0M0 c-Stage IIIA), and surgical resection was planned. The intraoperative procedure was considered to involve the risk of aggravating circulatory insufficiency due to the size of the tumor; therefore, we decided to perform median sternotomy for tumor resection and prepared her for cardiopulmonary bypass (CPB). Circulatory insufficiency due to retraction of the ascending aorta and right main pulmonary artery occurred, and CPB was performed (dranage of the right atrium and perfusion of the ascending aorta). After CPB, the hemodynamic status stabilized and the tumor was resected with the carina and left lung. The trachea and right main bronchus were anastomosed, and a free pericardial fat pad was used to cover the suture line. Twenty months after surgery, the patient was well without tumor relapse. We report the case of a patient who underwent left sleeve pneumonectomy safely using CPB.
A 38-year-old man was referred to our hospital complaining of dry cough and an abnormal shadow on a chest radiograph. Chest CT showed a 4.7-cm tumor mass with a high concentration of SUV, 5.53, by fluorodeoxyglucose-positron emission tomography (FDG-PET). Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed twice, but the diagnosis could not be confirmed. Right middle and lower lobectomy was performed considering the possibility of a malignant tumor. Histopathologically, this tumor was diagnosed as intrapulmonary schwannoma. We report an intrapulmonary schwannoma with high accumulation on PET, which was difficult to distinguish from malignant tumors.
Pulmonary vein stump thrombosis after lobectomy may cause thrombotic emboli of vital organs. Spinal cord infarction is rare as a postoperative complication except for in spine and vascular surgery. We report a patient who underwent left upper lobectomy for lung cancer and developed spinal cord infarction on postoperative day 3 and pulmonary vein stump thrombosis simultaneously. A 65-year-old man developed sudden paraplegia and sensory disorder of the lower limbs at 3 days after left upper lobectomy for lung cancer. Magnetic resonance imaging revealed a spinal cord infarction at Th2/3. An enhanced computed tomography revealed pulmonary vein stump thrombosis. Anticoagulant therapy was started. Rehabilitation for paraplegia of the lower limbs was also started and symptoms improved. At 5 postoperative months, although the sensory disorder weakly remained, the motor paralysis had disappeared. The patient recovered enough to walk and drive a car without difficulty. Considering the existence of pulmonary vein stump thrombosis and course of spinal cord infarction, we suspect that pulmonary vein stump thrombosis was the cause of spinal cord infarction.
A man in his 60s consulted our hospital because of cervical swelling and hoarseness persisting for one month. CT showed a huge mass that encompassed the posterior wall of the pharynx to posterior mediastinum. The mass consisted of fat on MRI, but it showed no FDG accumulation on PET-CT. We diagnosed it as a cervicomediastinal lipoma or liposarcoma, and decided to operate.
At first, the patient was placed in a left lateral decubitus position. We performed thoracoscopic surgery under carbon dioxide insufflation. Blunt dissection toward the cranial side was performed as far as possible. Thereafter, the patient was placed in a supine position, followed by a cervical operation using a cervical collar incision and en bloc tumor resection. The pathological diagnosis was a well-differentiated liposarcoma. This surgical approach enabled us to obtain a good view through the carbon dioxide insufflation and safely perform the operation.
Angiolipoma is a rare histological variant of lipoma and is considered to be a benign tumor. Angiolipoma commonly occurs in subcutaneous tissues of the upper extremity and trunk; its occurrence in the chest wall is extremely rare. Only a few cases of angiolipoma involving infiltration of surrounding tissues have been reported; therefore, it is usually difficult to distinguish angiolipoma from other diseases, including malignancies. Herein, we describe a case of non-infiltrating angiolipoma of the chest wall that mimicked radiological infiltration of the rib. A 68-year-old woman was referred to our institute for further examination of an abnormal shadow that was incidentally detected on a chest radiograph. Computed tomography showed a soft tissue mass in her right chest wall as well as characteristics of bone resorbability in her eighth rib. On magnetic resonance imaging (MRI), the lesion showed a low signal on T1-weighted imaging (T1WI), high signal on T2-weighted imaging (T2WI), and homogeneous enhancement. MRI also showed continuity of the tumor with intercostal vessels. All findings except osteoclastic features of the rib suggested hemangioma. As malignancy could not be ruled out, surgical excision was performed for both diagnostic and therapeutic purposes. Histological examination of the tumor showed mature adipose tissue and capillary hyperplasia, which were consistent with angiolipoma. Infiltration of the rib was absent, but bone resorption due to tumor compression was revealed. Finally, we diagnosed it as non-infiltrating angiolipoma. She had an uneventful recovery and did not show recurrence until 35 months post-surgery.
A 65-year-old man was referred to our hospital due to a mediastinal tumor, because chest CT revealed growth of the tumor in comparison with two years previously. CT showed a 57-mm lobulated tumor in the anterior mediastinum. Inside the tumor were cystic and marginal parts and it showed thickness of the wall with enhancement. It also showed enlargement to the surroundings and adipose tissues, but no invasion to great vessels or dissemination. FDG-PET and MRI showed similar findings. We suspected invasive thymoma or thymic cancer and performed an operation. The tumor invaded the left upper lobe and pericardium, and combined resection was performed. The pathological diagnosis was primary mediastinal choriocarcinoma. We planned adjuvant chemotherapy, but one month after surgery, chest Xp and CT showed multiple lung metastases and β-HCG was 18.67 ng/mL (<0.10). We diagnosed it as postoperative recurrence of primary mediastinal choriocarcinoma.
BEP treatment (Bleomycin, Etoposide, and Cisplatin) was given, and the tumor shrank. However, he developed drug-induced interstitial pneumonia and died despire the treatment.
A 50-year-old man, with a three-year history of diarrhea after eating, runny nose, and cough, consulted another hospital and was diagnosed with chronic sinusitis. At the time, chest computed tomography incidentally showed an anterior mediastinal tumor and bilateral centrilobular nodular opacities. Consequently, he was referred to our hospital. We suspected immunodeficiency because he had some persistent infectious symptoms. Laboratory test results indicated hypogammaglobulinemia. We performed thymothymectomy, and pathological examination revealed that the tumor was a type AB thymoma; he was finally diagnosed with Good syndrome. We aimed to prevent perioperative infectious complications by administering intravenous immunoglobulin before surgery. Fortunately, he had an uneventful postoperative course. He received intravenous immunoglobulin every four weeks; one year post-surgery, all of the patient's symptoms showed improvement. Good syndrome has been reported to be associated with a poor prognosis and no established treatment strategies are currently available. Therefore, we think that this case report is valuable as it outlines the clinical course of this condition.
Traumatic diaphragmatic rupture is a relatively rare entity that is caused by major blunt or penetrating trauma. It can result in ileus, respiratory distress, and cardiac insufficiency, and, therefore, should be repaired as soon as possible after diagnosis. However, diagnosis is occasionally difficult in the absence of diaphragmatic hernia. Here, we report a case of traumatic diaphragmatic rupture that was difficult to diagnose. A 76-year-old man who fell from a stepladder, hitting the left side of his chest on the floor, was diagnosed with multiple left rib fractures and left traumatic hemopneumothorax, and advised to rest. However, his hemopneumothorax worsened, and anemia observed on the fourth day after the trauma. A chest drainage tube was placed after he was transferred to our hospital, and he recovered. However, he developed abdominal pain and vomiting in the evening of the same day. He was diagnosed with left diaphragmatic hernia after re-examination with chest computed tomography (CT). Thus, emergency surgery was performed. His diaphragm was repaired after returning the abdominal organs to the abdominal cavity. We reviewed the chest CT scan obtained before placement of the chest drainage tube. We found a pre-existing diaphragmatic rupture and mild herniation on the coronal section of the CT scan, and considered that the diaphragmatic hernia could be attributed to the chest tube placement and thoracic drainage. The diagnosis of traumatic diaphragmatic hernia is occasionally difficult in mild cases, and the coronal section of CT is useful for the early detection of traumatic diaphragmatic hernia.
Three-dimensional computed tomography (3D-CT) of the pulmonary blood vasculature helps perform safe navigation during video-assisted thoracic surgery (VATS), which anatomically involves a variety of blood vessels. Generally, 3D-CT is reconstructed from contrast-enhanced CT data using a workstation semi-automatically. However, some patients are allergic to contrast mediums, have poor renal functions, or are receiving biguanide medications; the utmost care is required to perform contrast-enhanced CT in such cases. In recent years, virtual bronchoscopy is reconstructed from plain CT using air surrounding the bronchus as negative contrast medium. From this point of view, air surrounding the pulmonary blood vasculature also becomes negative contrast medium, and we can obtain 3D-CT of the pulmonary blood vasculature from plain CT. In some cases, 3D-CT of the pulmonary blood vasculature from plain CT helps in VATS just as contrast-enhanced CT.