Impact of accurate diagnosis of interstitial lung diseases on postoperative outcomes in lung cancer

OBJECTIVE

The prognostic impact of interstitial lung disease (ILD) subclassification based on both high-resolution computed tomography (HRCT) scan findings and histopathological findings is unknown.

METHODS

We retrospectively analyzed 104 patients who were diagnosed with clinical ILD according to HRCT scan findings and who underwent lung cancer surgery. Via an expert multidisciplinary discussion, we re-classified HRCT scan findings and validated the histopathological patterns of ILDs in lung specimens.

RESULTS

There were several mismatches between HRCT scan findings and histological patterns. Moreover, 87 (83.7%) and 6 (5.8%) patients were diagnosed with definitive ILD and pathological non-ILD, respectively. Finally, 82 patients with idiopathic interstitial pneumonias (IIPs) were divided into the idiopathic pulmonary fibrosis (IPF) (n = 61) group and the other group (n = 21). The 5-year overall survival rate of the IPF group was significantly lower than that of the other group (22.8% vs 67.9%; p = 0.011). Sub-classification of IIPs was found to be an independent prognostic factor for overall survival in patients with lung cancer.

CONCLUSION

An accurate diagnosis of IIPs/IPF according to both HRCT scan findings and histological patterns is important for providing an appropriate treatment among patients with lung cancer who presented with clinical ILD.

Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases

PURPOSE

Pheochromocytoma crisis is a life-threatening endocrine emergency that requires prompt diagnosis and treatment. Because of its rarity, sudden onset, and lack of internationally uniform and validated diagnostic criteria, pheochromocytoma crisis remains to be fully clarified. Therefore, we aimed to describe the clinical characteristics and outcomes of pheochromocytoma crisis through a literature review.

METHODS

We performed a systematic literature search of PubMed/MEDLINE database, Igaku-Chuo-Zasshi (Japanese database), and Google Scholar to identify case reports of pheochromocytoma crisis published until February 5, 2021. Information was extracted and analyzed from the literature that reported adequate individual patient data of pheochromocytoma crisis in English or Japanese. Cases were also termed as pheochromocytoma multisystem crisis (PMC) if patients had signs of hyperthermia, multiple organ failure, encephalopathy, and labile blood pressure.

RESULTS

In the 200 cases of pheochromocytoma crisis identified from 187 articles, the mean patient age was 43.8 ± 15.5 years. The most common symptom was headache (39.5%). The heart was the most commonly damaged organ resulting from a complication of a pheochromocytoma crisis (99.0%), followed by the lungs (44.0%) and the kidney (21.5%). PMC accounted for 19.0% of all pheochromocytoma crisis cases. After excluding 12 cases with unknown survival statuses, the mortality rate was 13.8% (26/188 cases). Multivariable logistic regression analysis revealed that nausea and vomiting were significantly associated with a higher mortality rate.

CONCLUSION

Pheochromocytoma can present with different symptomatology, affecting different organ systems. Clinicians should be aware that patients with nausea or vomiting are at a higher risk of death because of pheochromocytoma crisis.

Necessity of Multi-Step Surgical Treatment for Patients with Interstitial Lung Disease and a Pneumothorax

Purpose: A pneumothorax occurs in 3%–8% of patients with idiopathic pulmonary fibrosis. A pneumothorax may predict a poor outcome in patients with interstitial lung disease (ILD), and it is difficult to treat patients with ILD and a pneumothorax.

Patients and Methods: We retrospectively studied data from all 12 patients with ILD and a pneumothorax who underwent surgical treatment at Toho University Omori Medical Center Hospital between 2009 and 2021.

Results: Of the 12 patients, 2 had home oxygen therapy preoperatively and were classified with grade IV interstitial pneumonia (IP). Six patients had preoperative pleurodesis and two had postoperative one using auto-blood. Three patients (25%) had multi-step surgery ≥2, and 5 patients had surgical resection of bullae. No patients had postoperative acute exacerbations and all were discharged from the hospital in a stable condition. The 5-year overall survival rate for all patients was 70.0%. The median survival time was not reached. One patient with unclassified IP was doing well 116 months after surgery.

Conclusion: Patients with ILD and a pneumothorax were shown to require multi-step surgical treatment and can anticipate long-term survival.

Time to Incurable Recurrence for Patients Treated With Pulmonary Metastasectomy for Colorectal Cancer

BACKGROUND

Probability of cure is important for patients with lung metastasis who must decide whether to undergo metastasectomy. Although progression-free survival (PFS) is thought to reflect this, it does not include curative effects by repeat metastasectomy. Thus, the authors developed a new indicator, time to incurable recurrence (TTIR), in which only incurable recurrence was set as an event that included death, with incurable recurrence defined as recurrence not treated by definitive local therapy (DLT), recurrence treated by DLT but with PFS maintained less than 2 years, or recurrence followed by re-recurrence.

METHODS

This multi-institutional study included 339 patients who underwent lung metastasectomy for colorectal cancer between 1990 and 2008.

RESULTS

Among the 339 patients, 191 experienced recurrence, 77 received DLT for recurrence, 38 had a PFS of 2 years or longer after the treatment, and 33 had maintained a PFS at the last follow-up date. The patients had PFS ranging from 39 to 212 months (median, 101 months). The 5-year OS, PFS, and TTIR rates were respectively 63.4%, 42.2%, and 51.9%. The TTIR curve was similar to the OS curve 7 years after the initial metastasectomy. The difference between TTIR and PFS at 7 years was 9.7%, indicating probability of cure by repeat DLT. Multivariable analysis showed different prognostic factors among OS, PFS, and TTIR.

CONCLUSION

At the initial metastasectomy, TTIR may reflect probability of a cure, including cure by repeat DLT, and can be used to analyze prognostic factors associated with cure.

Multifocal locules including the anterior mediastinum side as a surgical indicator in pleural infection

Background

The indication for and the timing of surgery in patients with pleural infection remains unclear. Determining the need for surgery in patients with pleural infection may help in the early consultation of surgeons.

Methods

Data of 167 consecutive patients with pleural infection were retrospectively reviewed. To detect a surgical indicator, the variables of patients who required surgery were compared with those of patients who were cured by non-surgical therapy (n=94) and patients resistant to the non-surgical therapy (n=73; 62 underwent surgery, and 11 showed recurrence or disease-related death after non-surgical treatment). Prognosis and timing of surgery were analyzed by comparing three groups: patients who underwent surgery within 7 days of admission (n=33), patients who underwent surgery after 7 days of admission (n=29), and patients who underwent non-surgical therapy (n=105).

Results

The presence of multifocal locules, including a locule on the anterior mediastinum side (LAMS) was a significant indicator of resistance to initial non-surgical therapy, as compared to the absence of locules (P<0.0001), a single locule (P<0.0001), or multifocal locules without a LAMS (P=0.0041). Recurrence and mortality were not observed in the patients who underwent surgery within 7 days of admission, and the hospitalization period (P=0.0071) and duration of C-reactive protein (CRP) improvement (P<0.0001) were significantly shorter in these patients compared with those who that underwent surgery after 7 days.

Conclusions

In patients with pleural infection, the presence of multifocal locules, including a LAMS, was associated with resistance to non-surgical therapy. Early surgery should be considered for these patients to shorten the hospitalization period and improve the prognosis.

Surgical lung biopsy for interstitial lung diseases-a single center study of 129 patients

Background

According to guidelines for the diagnosis and treatment of interstitial lung diseases (ILDs), a diagnostic surgical lung biopsy should be used to obtain the differential diagnosis of an ILD in patients with ILDs, which are difficult to distinguish clinically. However, the risk of developing postoperative complications such as postoperative pulmonary fistula or acute exacerbation is a concern. The purpose of this study was to evaluate the safety of surgical lung biopsy for the differential diagnosis of ILDs.

Methods

From October 2007 to July 2019, 129 patients thought to have ILD underwent a surgical lung biopsy at Toho University Omori Medical Center. We conducted a retrospective study on the diagnosis and safety of surgical lung biopsy for patients with ILD.

Results

The 30- and 60-day mortality was 0%. Postoperative complications occurred in 13 of 129 (10.1%) patients. The complications included pneumothorax in 8 (6.2%) patients after removal of the chest tube, postoperative pneumonia in 2 (1.0%), and acute exacerbation in 1 (0.8%). Postoperative pneumothorax was observed in 4 of 13 patients (30.7%) who underwent a biopsy of the apex of the lung (right S1, left S1+2), which was a significantly higher rate of postoperative pneumothorax than seen for patients undergoing biopsy at other sites (P=0.0086).

Conclusions

Surgical lung biopsy for the differential diagnosis of an ILD was performed safely. However, biopsy sites for ILDs need to be carefully selected to avoid postoperative complications.

Adenocarcinoma in situ detected on a thin-walled lung cavity: a case report

BACKGROUND

Cavitary lesions pathologically diagnosed as adenocarcinoma in situ (AIS) have been rarely reported. The examination of these type of lesions is necessary for a better understanding of the mechanisms underlying their formation and development of more efficient diagnostic and treatment strategies. Here, we present the case of a patient with cavitary lung carcinoma, diagnosed as AIS, who underwent partial resection.

CASE PRESENTATION

A 72-year-old man presented with an abnormal shadow on chest radiography. Computed tomography findings showed a nodule in the right upper lobe, which was later diagnosed as an adenocarcinoma via transbronchial biopsy. A thin-walled cavity with partial thickening in the right lower lobe was also noted. We suspected that the thin-walled cavitary lesion was malignant, and performed wedge resection during a right upper lobectomy. AIS was diagnosed based on the histopathological findings of the thickened part of the thin-walled cavity.

CONCLUSIONS

This study highlights that, although rare, AIS may be observed in cavitary lung carcinoma cases, particularly in thin-walled lesions.

Combination of mean CT value and maximum CT value as a novel predictor of lepidic predominant lesions in small lung adenocarcinoma presenting as solid nodules

Lung adenocarcinomas presenting as solid nodules are occasionally diagnosed as lepidic predominant lesions. The aim of this study was to clarify the histological structure and to identify factors predictive of lepidic predominant lesions. We retrospectively reviewed 38 patients that underwent lobectomy for small (≤ 2 cm) adenocarcinoma presenting as solid nodules. Resected tumor slides were reviewed and histological components were evaluated. Clinical and radiological data were analyzed to identify factors predictive of lepidic predominant lesions. Of 38 solid nodules, 9 (23.7%) nodules were lepidic predominant lesions. Five-year disease-free survival (DFS) rates were 100% for lepidic predominant lesions (n = 9) and 74.6% for non-lepidic predominant lesions (n = 29). Mean CT values (p = 0.039) and maximum CT values (p = 0.015) were significantly lower in lepidic predominant lesions compared with non-lepidic predominant lesions. For the prediction of lepidic predominant lesions, the sensitivity and specificity of mean CT value (cutoff, - 150 HU) were 77.8% and 82.8%, respectively, and those of maximum CT value (cutoff, 320 HU) were 77.8% and 72.4%, respectively. A combination of mean and maximum CT values (cutoffs of - 150 HU and 380 HU for mean CT value and maximum CT value, respectively) more accurately predicted lepidic predominant lesions, with a sensitivity and specificity of 77.8% and 86.2%, respectively. The prognosis of lepidic predominant lesions was excellent, even for solid nodules. The combined use of mean and maximum CT values was useful for predicting lepidic predominant lesions, and may help predict prognosis.

Thoracoscopic resection of bilateral multiple superior mediastinal neurofibromas

Background

The indications for surgical resection concerning multiple bilateral neurofibromas in the superior mediastinum remain controversial, because vascular injury or development of postoperative Horne syndrome are concerned.

Case presentation

A 60-year-old woman presented with multiple nodules in her right neck and bilateral chest cavity tops which indicated neurofibromatosis. The thoracic masses grew slowly over 9 years, and she then underwent a 2-stage resection starting with the left to right side. Bilateral tumors were completely removed via video-assisted thoracic surgery. The patient’s postoperative course was uneventful, without postoperative Horner syndrome.

Conclusions

To the best of our knowledge, this is the first case of multiple bilateral superior mediastinal neurofibromas resected from the pulmonary apices via thoracoscopy. We selected a minimally invasive pure video-assisted thoracoscopic surgery approach and enucleated some tumors to avoid nerve injury. This approach may be safe and useful for multiple neurofibromas in patients with neurofibromatosis.

Bronchial Foreign Body Aspiration Due to Polycarbophil Calcium

Polycarbophil calcium (Polyful^®; Mylan, Tokyo, Japan) is a stool stabilizer that absorbs liquid and swells to form a soft, bulky mass. A 75-year-old woman experienced sore throat and difficulty breathing immediately after taking the drug. Chest computed tomography showed a foreign body in the right intermediate bronchus. Bronchoscopy showed a white mass blocking the right intermediate bronchus. Since the mass was very fragile, we performed suctioning while breaking up the mass with a suction tube. The mass consisted of polycarbophil calcium. Since aspirated polycarbophil calcium swells and can obstruct bronchi, complete removal is crucial.

Micronodular Thymoma with Lymphoid Stroma: A Case Report

BACKGROUND

Micronodular thymoma with lymphoid stroma (MNT) is a rare subtype of thymic neoplasms. Therefore, clinical guidelines, histopathological diagnostic criteria, prognostic factors, and therapeutic regimens have not been established.

CASE PRESENTATION

A 69-year-old woman was admitted to our hospital because of an abnormal shadow detected by chest radiography. Further imaging revealed an anterior mediastinal tumor measuring 65×28×15 mm. We performed thymectomy for diagnosis and treatment. Histopathological examination revealed spindle cells comprised multiple micronodules separated by abundant interstitial lymphocytes and lymphoid follicles. Immunohistochemical staining showed that the tumor was positive for cell adhesion molecule (CAM), cytokeratin (CK) 5/6, and terminal deoxynucleotidyl transferase. The histopathological diagnosis was MNT and the stage was I by the World Health Organization classification. The patient remained free of recurrence for seven years after surgery.

CONCLUSION

When the lesion is completely resected, MNT has a good prognosis. Therefore, MNT is considered to be a borderline tumor with good prognosis and no reports of recurrences, distant metastasis, or tumor-related deaths exist thus far. However, preoperative diagnosis is difficult in most cases. Hence, complete surgical resection is recommended for suspicious mediastinal masses, if feasible, for both accurate diagnosis and to ensure long-term survival.

Intraoperative argon-plasma coagulation treatment for patients with malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is often associated with asbestos exposure and carries an extremely poor prognosis. The present study assessed the effectiveness of argon plasma coagulation (APC) treatment in patients with MPM who underwent radical pleural decortication (PD). The clinical data from 11 patients who underwent radical PD treated with APC at Toho University Omori Medical Center from July 2015 to March 2020 were retrospectively analyzed. Clinical features, local recurrence, and clinical prognoses were evaluated. The median overall survival was 18.5 months, and the 1- and 2-year overall survival rates were 71.6 and 43.0%, respectively. One patient survived 5 years but had recurrent tumors. The median disease-free survival was 11.1 months. The 1- and 2-year disease-free survival rates were 49.9 and 12.5%, respectively. Three patients had no recurrences, two of whom were followed continuously (39.6 and 10.2 months). The present study revealed that APC treatment for MPM might be associated with good survival and prognosis. APC as an additional intraoperative treatment for patients with MPM may be further investigated with larger multi-center clinical trials to support its efficacy.

Contributions of Airway Stent for Long-term Outcome in Patients With Malignant Central Airway Stenosis or Obstruction

BACKGROUND

Although an airway stent is used for malignant central airway stenosis or obstruction, long-term outcomes are unknown. In this study, we retrospectively analyzed the clinical features of patients who required stenting for malignant central airway stenosis or obstruction.

PATIENTS AND METHODS

We retrospectively analyzed clinical data from 116 patients with stenting for central airway stenosis or obstruction who underwent treatment at Toho University Hospital from 1998 to 2018. We evaluated the clinical features, prognoses, and complications for stenting in these patients.

RESULTS

The distribution of the 116 patients was as follows: lung cancer, 53; esophageal cancer, 40; thyroid cancer, 8; and others, 15. Patients with thyroid cancer had a significantly higher rate of complications after stenting than patients with lung cancer (P=0.0062), esophageal cancer (P=0.0029), and others (P=0.0062). Patients with esophageal cancer had a significantly worse prognosis than patients with lung and thyroid cancer. In patients with lung cancer the prognosis was significantly different between patients who underwent additional treatment for lung cancer after stenting and patients with no treatment (P=0.0398), and patients who received chemoradiotherapy for lung cancer after stenting had a significantly better prognosis than patients with no treatment (P=0.0306).

CONCLUSION

Stenting for airway stenosis/obstruction may improve prognosis in patients with lung or thyroid cancer, especially if patients with lung cancer undergo additional treatments after stenting, although airway stenting for patients with esophageal cancer was palliative. New treatment strategies may be necessary for patients with esophageal cancer after stenting to improve prognosis.

Necessity of Thin Section CT in the Detection of Pulmonary Metastases: Comparison between 5 mm and 1 mm Sections of CT

Background: The aim of this study was to evaluate the difference in the ability of 1-mm and 5-mm section Computed Tomography(CT) to detect pulmonary metastases in patients with pulmonary metastases.

Methods: We retrospectively analyzed the CT findings of 106 patients with pulmonary metastases due to malignancies treated at Toho University Omori Medical Center between 2013 and 2020.

Results: Cases with only one nodule evaluated by 5-mm section CT had significantly lower discordance with 1-mm section CT than cases with two or more nodules detected by a 5 mm section (p = 0.0161). After reference to a 1 mm section, cases with only one nodule reevaluated by 5-mm section CT had significantly lower discordance than cases with two or more nodules reevaluated using 5-mm section CT. In cases with only one nodule, reevaluation using a 5 mm section was consistent with evaluation using a 1 mm section. However, this was not observed in cases with two or more nodules, with a significant difference between one nodule and two or more nodules.

Conclusions: If there are two or more nodules observed in 5-mm section CT it may be necessary to reevaluate using 1-mm section CT to determine the exact number of pulmonary metastases.

Prognostic and functional impact of perioperative LAMA/LABA inhaled therapy in patients with lung cancer and chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an important risk factor for postoperative complications and mortality. To determine the effects of perioperative combination therapy, using a long-acting muscarinic antagonist (LAMA) and a long-acting β₂ agonist (LABA), on preoperative lung function, postoperative morbidity and mortality, and long-term outcome in COPD patients.

METHODS

Between January 2005 and October 2019, 130 consecutive patients with newly diagnosed COPD underwent surgery for lung cancer. We conducted a retrospective review of their medical record to evaluate that LAMA/LABA might be an optimal regimen for patients with COPD undergoing surgery for lung cancer. All patients were received perioperative rehabilitation and divided into 3 groups according to the type of perioperative inhaled therapy and management: LAMA/LABA (n = 64), LAMA (n = 23) and rehabilitation only (no bronchodilator) (n = 43). We conducted a retrospective review of their medical records.

RESULTS

Patients who received preoperative LAMA/LABA therapy showed significant improvement in lung function before surgery (p < 0.001 for both forced expiratory volume in 1 s (FEV₁) and percentage of predicted forced expiratory volume in 1 s (FEV₁%pred). Compared with patients who received preoperative LAMA therapy, patients with LAMA/LABA therapy had significantly improved lung function (ΔFEV₁, LAMA/LABA 223.1 mL vs. LAMA 130.0 mL, ΔFEV₁%pred, LAMA/LABA 10.8% vs. LAMA 6.8%; both p < 0.05). Postoperative complications were lower frequent in the LAMA/LABA group than in the LAMA group (p = 0.007). In patients with moderate to severe air flow limitation (n = 61), those who received LAMA/LABA therapy had significantly longer overall survival and disease-free survival compared with the LAMA (p = 0.049, p = 0.026) and rehabilitation-only groups (p = 0.001, p < 0.001). Perioperative LAMA/LABA therapy was also associated with lower recurrence rates (vs. LAMA p = 0.006, vs. rehabilitation-only p = 0.008).

CONCLUSIONS

We believe this treatment combination is optimal for patients with lung cancer and COPD.

Long-term survival of airway silicone stents in patients with central airway stenosis or obstruction due to thoracic malignancy

OBJECTIVES

Silicone airway stents are used to manage central airway stenosis or obstruction, although their impact on long-term survival remains unknown in patients with central airway stenosis or obstruction due to thoracic malignancy. In this study, we retrospectively analyzed the impact of silicone stents on survival.

METHODS

We retrospectively analyzed clinical data of 106 patients with central airway stenosis or obstruction due to thoracic malignancy treated by stenting at Toho University Omori Medical Center between 1998 and 2018.

RESULTS

Patients treated with silicone stents had significantly higher survival rates than patients treated with metallic stents (p = 0.0173). Silicone stents patients also had significantly more additional treatments for thoracic malignancy after stenting than metallic stents patients (p = 0.0007). Notably, significantly more silicone stents patients underwent chemoradiotherapy or radiotherapy (p = 0.0268, p = 0.0300). During multivariate analyses, the additional treatment, including chemoradiotherapy or radiotherapy, was an independent optimal prognostic factor.

CONCLUSIONS

Silicone stents patients had significantly higher survival rates than metallic stents patients. Although stenting for airway stenosis or obstruction due to thoracic malignancy may be mainly palliative, additional treatments after stenting should be considered to improve the prognoses of patients with airway stenosis or obstruction due to thoracic malignancy.

Acceptability and feasibility of S-1 plus cisplatin adjuvant chemotherapy for completely resected non-small cell lung cancer: an open-label, single arm, multicenter, phase 2 trial

Background

Although platinum-based chemotherapy is accepted as adjuvant chemotherapy for resectable advanced non-small cell lung cancer (NSCLC), its completion rate is low due to severe adverse events. S-1 plus cisplatin is associated with relatively low toxicity and an unimpaired quality of life, and has been used for unresectable advanced lung cancer. We investigated the acceptability and feasibility of combination therapy with S-1 plus cisplatin as postoperative adjuvant chemotherapy following complete resection of pathological stage II-IIIA NSCLC.

Methods

Enrolled patients received oral S-1 at a dose depending on their body weight twice daily for 21 days with intravenous cisplatin 60 mg/m² on day 8, with 1 cycle comprising 5 weeks and 4 cycles. Patients received standard precautions against adverse events and received standard treatment when adverse events occurred. The primary endpoint was completion rate; secondary endpoints included safety, status of drug administration, disease-free survival (DFS), and overall survival (OS).

Results

A total of 19 patients [14 men, 5 women; mean age, 59.1 years; mean body surface area, 1.688 m²; 17 with an Eastern Cooperative Oncology Group performance status (PS) of 0 and 2 with a PS of 1; 7 (36.8%) with stage II disease and 12 (63.2%) with stage IIIA disease] were enrolled. The rate of completion of 4 cycles was 68.4%. Grade 3 adverse events that occurred in ≥10% of patients included neutropenia (21.1%), nausea (21.1%), and anorexia (15.8%). No grade 4 adverse events, febrile neutropenia, or treatment-related deaths occurred. The mean relative dose intensity (RDI) was 79% for S-1 and 80% for cisplatin. The 2-year DFS rate was 42.1%, and 2-year OS rate was 83.3%.

Conclusions

This study demonstrated the acceptability and feasibility of using S-1 plus cisplatin as adjuvant chemotherapy.

Trial registration

This study was registered on the UMIN clinical study registration site (protocol ID: UMIN000016191) on December 1, 2015.

Diaphragm reconstruction by GORE DUALMESH in patients undergoing resection for thoracic malignancies

Background

We used GORE DUALMESH for the reconstruction of diaphragms in patients with thoracic malignancies. Here, we report the results.

Methods

Between July 2015 and August 2017, diaphragm reconstruction using 2-mm GORE DUALMESH was performed in 7 patients undergoing surgical resection for thoracic malignancies. After resection of the diaphragm, the mesh was trimmed to the size of defect and placed with the smooth surface facing the chest cavity and the rough surface facing the abdomen. It was fixed with interrupted sutures consisting of synthetic monofilament nonabsorbable 1–0 to 2 threads.

Results

Indications for resection were malignant pleural mesothelioma and primary lung cancer in 5 and 2 patients, respectively. Patients with malignant pleural mesothelioma underwent pleurectomy with decortication; patients with primary lung cancer underwent lung lobectomy. Right and left diaphragm reconstruction was performed for 4 and 3 patients, respectively. Neither complications related to diaphragm reconstruction nor displacement of mesh occurred during a follow-up period ranging from 11 days to 37 months.

Conclusions

GORE DUALMESH is a good synthetic material for diaphragm reconstruction, because its smooth surface prevents adhesions to the lung and its rough surface allows adherence to abdominal tissue.

Streptococcus anginosus group infection as a predictor for the progression of descending necrotizing mediastinitis

BACKGROUND

The prognosis of descending necrotizing mediastinitis (DNM), especially that extending inferiorly to the carina, remains poor. The identification of additional prognostic factors may improve the prognosis.

METHODS

We retrospectively analyzed six patients who underwent thoracic surgery for DNM extending to the anterior and posterior mediastinum inferior to the carina (Endo classification type IIB) from 2014 to 2020. We reviewed their characteristics, clinical course, causative bacteria, and treatment to investigate their prognostic factors.

RESULTS

The median patient age was 62 years. Five patients were men and one patient was a woman. The causative disease in three of the patients was pharyngolaryngeal, and for the others, it was an odontogenic infection. Five patients had sepsis and four had disseminated intravascular coagulation (DIC) at surgery. Four patients had polymicrobial infections of aerobic and anaerobic bacteria, all of whom showed gas bubbles on a chest computed tomography scan and detection of Streptococcus anginosus group (SAG). All patients underwent cervicotomy, tracheostomy, and mediastinal drainage and debridement via a transthoracic approach. Three patients underwent additional surgery or drainage because an additional abscess appeared postoperatively. The median duration of hospitalization was 58 days and the mixed infections, including SAG, were all detected in the three cases of long-term hospitalization. No disease-associated death was observed during the follow-up period of 18 months.

CONCLUSIONS

Mixed infection, including SAG, may be a predictor for DNM aggravation and spread. Gas bubbles on a chest computed tomography scan suggest polymicrobial aerobic and anaerobic infections including SAG, which require broad-spectrum antibiotic therapy and aggressive drainage and surgery.

Preoperative undernutrition predicts postoperative complications of acute empyema

INTRODUCTION

Surgery for acute empyema is associated with postoperative complications and relapse. Establishing a predictor for postoperative complications may improve prognosis.

OBJECTIVES

To demonstrate undernutrition as a predictor of complications after surgery for acute empyema.

METHODS

We retrospectively analyzed 52 consecutive patients who underwent surgery for acute empyema from 2004 to 2019 and validated the correlation of undernutrition with serum albumin level, patient characteristics, hospital stay, and postoperative complications.

RESULTS

The median preoperative serum albumin level was 2.4 g/dL (range: 1.1-3.4). The levels in all patients were lower than the standard value (3.5 g/dL). Patients were divided into two groups based on the median serum albumin levels: the low serum albumin level group (group L, n = 28) and the high serum albumin level group (group H, n = 24). Group L patients were significantly older (64.5 vs 52.9 years, P = .002), had lower median body mass index (21.0 vs 24.2, P = .008), and significantly had Streptococcus anginosus group as the causative bacteria (50% vs 21%, P = .044). Their hospitalization duration was significantly longer (28.1 vs 14.8 days, P < .001), and postoperative complications were significant or tended to be more frequent (all incidence; 11 (39%) vs 2 (8%), P = .012, respiratory-related; 7 (25%) vs 1 (4%), P = .056) in group L. Further analyses revealed that other undernutrition indicators also correlated with postoperative complications.

CONCLUSIONS

Preoperative serum albumin level is a valid predictor of complications after surgery for acute empyema. Preoperative nutrition management for empyema patients may reduce the occurrence of postoperative complications.

Preoperative detection of pleural adhesions using pocket-sized ultrasound

BACKGROUND

Although preoperative detection of pleural adhesions is important in thoracic surgery, it is not widely performed. We report the availability of a pocket-sized ultrasound device for the preoperative detection of pleural adhesions.

METHODS

Between September 2019 and September 2020, pleural adhesions were assessed preoperatively using a pocket-sized ultrasound device in 62 patients who underwent thoracic surgery. Evaluations were performed using the Vscan Dual Probe on the wards or just before surgery in the operating theater. We used a linear probe to scan the chest wall where the incision was scheduled, and evaluated the sliding sign. We compared ultrasound results with intraoperative findings.

RESULTS

Of the 62 patients, the sliding sign was observed in 58 patients, 56 of whom demonstrated no pleural adhesions intraoperatively. The sensitivity was 96.6%. Four patients were negative for the sliding sign; of these, three had pleural adhesions and one did not. The specificity was 75.0%. Among all 62 patients, the diagnostic accuracy of ultrasound for pleural adhesions was 95.2%. False negatives were caused by loose adhesions. False positives were caused by the absence of vertical lines on ultrasound. Accuracy was not influenced by the timing of the test.

CONCLUSIONS

A pocket-sized ultrasound device was useful for the preoperative detection of pleural adhesions in thoracic surgery.

Perioperative Bypassing Agent Therapy for Pulmonary Pleomorphic Carcinoma with Acquired Hemophilia

A 74-year-old man was admitted with lung cancer, and preoperative blood test showed abnormal activated partial thromboplastin time (APTT). Coagulation factor screening and APTT mixing test achieved a diagnosis of acquired hemophilia A (AHA). Bypassing agent therapy was indicated and lobectomy was successfully performed without bleeding complications. APTT returned to normal after the operation without any additional treatment for AHA. The pathogenesis of AHA is still unknown and there is no evidence for hemostatic strategy for AHA patients requiring surgery. This study supports the importance of hemostatic therapy and suggests that malignancy might cause AHA.

A novel finding related to bulla and bleb formation in patients with primary spontaneous pneumothorax

BACKGROUND

Spontaneous pneumothorax is a common problem globally. Bullas and blebs have been implicated in this problem, but the etiology of their formation is unknown. We aim to show the relation between a novel clinical finding, the pulmonary delayed inflation (PDI) sign, and the etiology of bulla and bleb formation in young patients.

METHODS

We retrospectively analyzed data from 111 patients with pneumothorax and a control group of 27 patients. We evaluated the relation between the PDI sign and other clinical factors.

RESULTS

The PDI sign was observed in 78 patients. Of these, 75 exhibited the PDI sign in only the upper lobe. Regardless of smoking status, patients 34 years of age or younger had a significantly higher incidence of the PDI sign than, patients 55 years of age or older and control patients. The inflation time in patients 34 years of age or younger, regardless of smoking status, was significantly longer than in patients 55 years of age or older and patients in the control group. There was no significant association between inflation time and the presence of asthma.

CONCLUSIONS

The novel PDI sign is seen in patients 34 years of age or younger. Because this sign may indicate a peripheral bronchial abnormality and may be related to the formation of blebs and bullae in young patients with spontaneous pneumothorax, it is possible that it can be used to develop effective treatments for pneumothorax in young patients.

Mediastinal tumor resection in a patient with spinocerebellar degeneration

Background

In spinocerebellar degeneration (SCD) patients, general and regional anesthesia may cause postoperative dysfunction of respiratory, nerve and muscle systems. We present the surgical case of thymoma developed in patient with SCD.

Case presentation

A 47-year-old woman with spinocerebellar degeneration was admitted because of a well-defined mass measuring 48 × 31 mm in anterior mediastinum. She showed limb, truncal, ocular, and speech ataxia; hypotonia; areflexia; sensory disturbances; and muscle weakness. Her eastern cooperative oncology group performance status was 4. Surgical resection was performed via video-assisted thoracic surgery and under general anesthesia only without epidural analgesia. The mass was diagnosed as type B1 thymoma without capsular invasion (Masaoka stage I). The patients got a good postoperative course by cooperation with anesthesiologists and neurologists in perioperative managements. She has been well over 3 years of follow-up.

Conclusions

In conclusion, careful surgical and anesthesia management is essential for providing an uneventful postoperative course in patients with SCD. Especially, selection of minimal invasive approach and avoid diaphragmatic nerve damage are the most important points in surgical procedures.

Good syndrome with cytomegalovirus hepatitis: successful resection of Thymoma: a case report

BACKGROUND

Good syndrome is a rare condition, manifesting as immunodeficiency due to hypogammaglobulinemia associated with thymoma. Herein, we present a patient with Good syndrome whose thymoma was resected after treatment of cytomegalovirus hepatitis.

CASE PRESENTATION

The patient was a 45-year-old woman presenting with fever, cough, and nasal discharge, and was diagnosed with thymoma and hypogammaglobulinemia. She subsequently developed cytomegalovirus hepatitis that was treated by immunoglobulin. After resolution of the hepatitis, she underwent thymectomy through a left anterior thoracotomy. Her postoperative course was uneventful, and while receiving ongoing immunoglobulin therapy, she has been doing well without signs of infection.

CONCLUSIONS

Management of infections is important for patients with Good syndrome. To minimize the risk of perioperative infection, we should take care while planning the surgical approach and procedure.

Neuroendocrine tumors of the lung: clinicopathological and molecular features

In 1970, neuroendocrine tumors of the lung were classified into three categories: typical carcinoid (TC), atypical carcinoid (AC), and small cell lung carcinoma (SCLC). The third edition of the World Health Organization (WHO) classification in 1999 defined large cell neuroendocrine carcinoma (LCNEC) as a variant of large cell carcinomas, whereas the fourth edition of the WHO classification redefined LCNEC as a neuroendocrine tumor. Currently, neuroendocrine tumors of the lung are classified into four main categories: TC, AC, LCNEC, and SCLC. Although the treatments for TC, AC, and SCLC have not changed remarkably, the treatment strategy for LCNEC is not yet established because of its reclassification from a variant of "large cell carcinoma" to a new category of "neuroendocrine tumor". In this review article, we discuss the pathological findings, biological behavior, and treatment of neuroendocrine tumors of the lung.

Catamenial Pneumothorax With Pulmonary Fistula Identified During Surgery

A 41-year-old woman was admitted with a recurrent pneumothorax coincident with menstruation 2 months after a first occurrence. Video-assisted thoracic surgery was performed for definitive diagnosis and pneumothorax treatment. Bluish diaphragmatic spots and three lung bullae were noted. A lung fistula was observed in one of the bullae, and the diaphragmatic lesion and bullae were resected. The bulla with air leakage and the diaphragmatic lesion were diagnosed as endometrial tissue by pathology. This case is rare as a fistula from a bulla with endometriosis was identified intraoperatively, suggesting the check-valve mechanism might be one of the etiologies of catamenial pneumothorax.

Paraneoplastic Dermatomyositis as a Potential Precursor to Thymic Carcinoma

A red rash developed on both hands of a 54-year-old man. At age 56, he was admitted to our hospital because of an abnormal shadow detected by chest roentgenogram. A detailed examination revealed an anterior mediastinal tumor and dermatomyositis. Thymectomy was performed, and pathologic examination revealed thymic carcinoma. After the surgery, the dermatomyositis symptoms improved. Although dermatomyositis associated with thymic carcinoma is extremely rare, we should account for the possibility of thymic carcinoma-associated dermatomyositis. This will allow for early identification and treatment of malignant tumors, and symptom severity may reflect the degree disease control.

Single-port thoracoscopic wedge resection using the Endo GIA Radial Reload: outcome of 15 cases

Background

We previously described the technique for single-port thoracoscopic lung wedge resection using the Endo GIA^TM Radial Reload surgical stapler. The GIA Radial Reload has a curved cut line that is perpendicular to the direction of instrument insertion, facilitating the approach to the lung tissue behind the lesion. Herein, we report the outcomes of 15 cases using this procedure.

Methods

Between August 2016 and February 2018, 15 patients underwent single-port thoracoscopic wedge resection using the Endo GIA Radial Reload. Single-port thoracoscopic surgery was performed through 3-5-cm incisions. For the first stapler, we used a GIA Radial Reload cartridge. For the second and subsequent staplers, we used the GIA Radial Reload cartridge or a straight cartridge based on the direction of the cut.

Results

In one patient, we extended the incision up to 7 cm and performed video-assisted thoracotomy because the lesion was too small to find. In the other 14 patients, the procedure was completed through a 3-5-cm port. In one patient, we added a suture for air leakage detected intraoperatively. Postoperative air leakage occurred in two patients. These three patients had emphysema based on computed tomography. In the remaining 12 patients, no air leakage was found and the chest tube was removed on postoperative day 1.

Conclusions

This procedure is suitable for resecting small nodules, because palpation with two fingers is easy. The GIA Radial Reload cartridge may not be a good choice for emphysematous lung, because air leakage sometimes occurs.

Resection of a Superior Mediastinal Mature Teratoma Using Intraoperative Neural Monitoring

A 33-year-old woman presented with a right cervical mass. Contrast computed tomography showed a multilocular tumor with a clear border and heterogeneous contents including fat and calcification. The tumor was located adjacent to the vagus and recurrent nerves. To avoid injury of these nerves, we resected the tumor through a median sternotomy and right cervical lateral incision. Intraoperative neural monitoring was performed using an NIM TriVantage EMG tube (Medtronic, Minneapolis, MN). After the surgery, no neuropathy such as hoarseness was recognized. Pathological diagnosis showed a benign mature teratoma. Intraoperative neural monitoring is useful for superior mediastinal surgery around the vagus and recurrent nerves.

Risk factors for postoperative complications and long-term survival in lung cancer patients older than 80 years

OBJECTIVES

The number of octogenarian lung cancer patients undergoing radical surgery has been increasing recently. However, knowledge regarding the risk factors for postoperative complications and reliable predictive factors for long-term survival is limited. This study aimed to investigate the risk factors of postoperative complications, and reliable prognostic factors, in lung cancer patients older than 80 years.

METHODS

Lung cancer patients aged 80 years or older who underwent radical surgery were retrospectively studied; a multi-institutional analysis was conducted from January 1998 to December 2015. Preoperative and postoperative clinical data, including age, gender, smoking history, body mass index, respiratory function, Charlson Comorbidity Index, Glasgow Prognostic Score, surgical procedure, cancer histology, clinical and pathological stage, surgical result and survival time, were collected.

RESULTS

A total of 337 patients, comprising 216 (64.1%) men and 121 (35.9%) women were enrolled. The median age was 82 (range 80-92) years. Of the 337 patients, 205 (60.8%) had preoperative comorbidities. Postoperative complications were observed in 119 (35.3%) patients; postoperative mortalities occurred in 6 (1.8%) patients. Univariate and multivariate analyses showed that male gender (P = 0.01) and operation time (P = 0.047) were associated with postoperative complications; in contrast, pathological Stage III (P < 0.001), male gender (P = 0.01), Charlson Comorbidity Index ≥2 (P = 0.03) and Glasgow Prognostic Score = 1/2 (P = 0.04) were independent prognostic factors for overall survival.

CONCLUSIONS

The risk factors for postoperative complications (male gender and operation time) and the predictive factors affecting long-term survival (male gender, Charlson Comorbidity Index, Glasgow Prognostic Score and P-stage) should be taken into account for the effective management of patients older than 80 years with lung cancer, undergoing surgery.

Transient elevation of squamous cell carcinoma antigen levels with influenza virus infection

We report a case of squamous cell carcinoma antigen (SCCA) elevation due to influenza B infection. A 78-year-old male had undergone right middle lobectomy and lymphadenectomy for lung squamous cell carcinoma two years and four months previously. His SCCA level ranged from 0.8 ng/mL to 1.9 ng/mL after the surgery. He underwent blood testing, including SCCA, as part of a regular check-up three days after the diagnosis of the influenza B infection. His SCCA level was 17.1 ng/mL; no recurrences were found on computed tomography. One month later, his SCCA level had decreased to 1.6 ng/mL. We should keep in mind that influenza infection may cause transient elevations in SCCA levels.

Clinical study of asbestos-related lung cancer diagnosed by asbestos medical examination

AIM

People with occupational exposure to asbestos demonstrate a high incidence of lung cancer. Asbestos medical examination for those at risk was implemented as a national policy in Japan. This study aimed to characterize patients with asbestos-related lung cancer who were diagnosed by these examinations.

METHODS

We retrospectively investigated 120 individuals exposed to asbestos who were examined from 2008 to 2016 at our institution. Clinical data, including CT findings and time-related exposure variables, were evaluated. Each asbestos-related change was assigned 1 point if present, and the scores were compared between patients with and without asbestos-related lung cancer using the Mann-Whitney U test and Fisher's exact test.

RESULTS

Five patients were diagnosed with lung cancer, and four underwent surgical treatment. At the time of writing, three of four operated patients were alive without recurrence, with a similar prognosis to patients with lung cancer unrelated to asbestos. Average scores for asbestos-related findings on CT Scan were 1.8 (9/5) for patients with lung cancer and 0.79 (91/115) for those without lung cancer.

CONCLUSION

Patients with lung cancer had significantly more asbestos-related changes on CT scan than those without lung cancer. Concurrent calcified plaque and interstitial changes might be a predictor of lung cancer incidence. Although further investigation with a larger study group is needed, regular medical examination and CT scan every 6 months might contribute to the early detection of lung cancer with asbestos-related changes on CT.

Rib Radiography versus Chest Computed Tomography in the Diagnosis of Rib Fractures

Background The accurate diagnosis of rib fractures is important in chest trauma. Diagnostic images following chest trauma are usually obtained via chest X-ray, chest computed tomography, or rib radiography. This study evaluated the diagnostic characteristics of rib radiography and chest computed tomography.

Methods Seventy-five rib fracture patients who underwent both chest computed tomography and rib radiography between April 2008 and December 2013 were included. Rib radiographs, centered on the site of pain, were taken from two directions. Chest computed tomography was performed using a 16-row multidetector scanner with 5-mm slice-pitch without overlap, and axial images were visualized in a bone window.

Result In total, 217 rib fractures were diagnosed in 75 patients. Rib radiography missed 43 rib fractures in 24 patients. The causes were overlap with organs in 15 cases, trivial fractures in 21 cases, and injury outside the imaging range in 7 cases. Left lower rib fractures were often missed due to overlap with the heart, while middle and lower rib fractures were frequently not diagnosed due to overlap with abdominal organs. Computed tomography missed 21 rib fractures in 17 patients. The causes were horizontal fractures in 10 cases, trivial fractures in 9 cases, and insufficient breath holding in 1 case.

Conclusion In rib radiography, overlap with organs and fractures outside the imaging range were characteristic reasons for missed diagnoses. In chest computed tomography, horizontal rib fractures and insufficient breath holding were often responsible. We should take these challenges into account when diagnosing rib fractures.

Single-port thoracoscopic lung wedge resection using the Endo GIA Radial Reload

The GIA Radial Reload is a surgical stapler with a curved cut line that is perpendicular to the direction of instrument insertion. We used the GIA Radial Reload in three cases of single-port thoracoscopic lung wedge resection. The operations were performed through a 3.0-4.5-cm incision. For the first stapler, we selected the GIA Radial Reload. The orientation of this device's cut line enabled us to easily cut the lung behind the lesion during single-port thoracoscopic surgery.

Thoracoscopic Surgery for Pneumothorax Following Outpatient Drainage Therapy

PURPOSE

We investigated the outcomes of surgery for pneumothorax following outpatient drainage therapy.

METHODS

We reviewed the records of 34 patients who underwent operations following outpatient drainage therapy with the Thoracic Vent at our hospital between December 2012 and September 2016. Indications for outpatient drainage therapy were pneumothorax without circulatory or respiratory failure and pleural effusion. Indications for surgical treatment were persistent air leakage and patient preference for surgery to prevent or reduce the incidence of recurrent pneumothorax.

RESULTS

Intraoperatively, 9 of 34 cases showed loose adhesions around the Thoracic Vent, all of which were dissected bluntly. The preoperative drainage duration ranged from 5 to 13 days in patients with adhesions and from 3 to 19 days in those without adhesions, indicating no significant difference. The duration of preoperative drainage did not affect the incidence of adhesions. The operative duration ranged from 30 to 96 minutes in patients with adhesions and from 31 to 139 minutes in those without adhesions, also indicating no significant difference.

CONCLUSION

Outpatient drainage therapy with the Thoracic Vent was useful for spontaneous pneumothorax patients who underwent surgery, and drainage for less than 3 weeks did not affect intraoperative or postoperative outcomes.

Outpatient drainage for patients with spontaneous pneumothorax over 50 years of age

Introduction:

The British Thoracic Society has reported a lower success rate for aspiration of spontaneous pneumothorax in patients over 50 years of age. Outpatient drainage therapy is used to manage spontaneous pneumothorax at some institutions. We examined the effect of age on outpatient drainage therapy outcomes.

Materials and Methods:

We reviewed the records of 68 patients who underwent outpatient drainage therapy with a thoracic vent between December 2012 and April 2015, which included 11 patients over 50 years of age. Indications for outpatient drainage therapy included pneumothorax with no circulatory or respiratory failure and no pleural effusion.

Results:

Of the 11 patients over 50 years of age, 5 had chronic obstructive pulmonary disease (COPD), one had interstitial pneumonia, one had a history of pulmonary tuberculosis, and one has lung tumors (LTs). Among the 57 younger patients, 2 patients had COPD, and one had LTs. Unexpected hospital admission occurred in 2 patients over 50 years of age and one patient aged 50 years or less (P = 0.0658, Fisher's exact test). Six of the 11 patients over 50 years of age underwent surgery for prolonged air leakage, compared to 8 of the 57 younger patients (P = 0.00695, Fisher's exact test).

Conclusions:

Outpatient drainage therapy is useful for patients with spontaneous pneumothorax over 50 years of age, because outpatient drainage therapy alone was successful in 4 of 11 patients and admission for drainage was avoided in 9 of 11 patients. However, prolonged air leakage occurs more frequently in this age group.