Dual-portal robotic-assisted thoracic surgery (DRATS) as a reduced port RATS: early experiences in three institutions in Japan

Background

Robotic-assisted thoracic surgery (RATS) has gained increasing interest in recent years, with most procedures performed using the conventional multiportal approach. Uniportal RATS (URATS) approaches have recently been reported in the pursuit of minimally invasive procedures. However, URATS requires specific skills. Herein, we introduce dual-portal RATS (DRATS) performed with two incisions.

Methods

Data of DRATS procedures performed from December 2022 to May 2023 were retrospectively reviewed. Twenty patients with lung cancer underwent anatomical lung resections via DRATS performed by our group at three institutes.

Results

Among 20 cases of planned DRATS for anatomical pulmonary resections, there were no conversions to thoracotomy and no need for extra ports. The mean surgery time was 121±60 minutes and mean console time was 91±47 minutes. The mean intraoperative blood loss volume was 9.6±12.1 g. The mean duration of chest tube drainage and hospital stay were 2±1 and 5±2 days, respectively. The mean numerical rating scale for pain was 2±1 on the first postoperative day, 1±1 on the third day, and 1±1 at discharge. There were no postoperative complications or mortalities.

Conclusions

Our primary experience shows that DRATS is safe and feasible for anatomical lung resection. We consider DRATS to be a very good preliminary step in the future transition to URATS.

[A Case Report of Metachronous Multiple Cancers Including Triple Lung Cancers, Gastric Cancer, and Double Urothelial Cancers]

A male patient in his 60s at the time of the first medical examination had a smoking history of 50 years with 25 cigarettes a day. He was diagnosed with double urothelial cancers. In 200a, total left pelvic ureterectomy(pT2N0M0, Stage Ⅱ)and transurethral bladder tumorectomy(pTisN0M0, Stage Ⅰ)were performed. For his gastric cancer with malignant pleural effusion(cT3N0M1, Stage Ⅳb), in 200a plus 2, downstaging was acquired after chemotherapy. In 200a plus 5, subtotal gastrectomy D1 dissection was performed(W/D adenocarcinoma, pT2N0M0, Stage ⅠA, Ef 1). For the first lung cancer, in 200a plus 5, thoracoscopic lung wedge resection of the left lower lobe was performed(P/D adenocarcinoma, pT1aN0M0, Stage ⅠA1, R0, Ef 1). For the second lung cancer, in 200a plus 13, thoracoscopic lung wedge resection of the right upper lobe was performed after chemotherapy(P/D adenocarcinoma, pT1bN0M0, Stage ⅠA2, R0). For the third lung cancer, in 200a plus 17, immunotherapy was performed for the left upper lobe lung cancer(P/D adenocarcinoma, cT3N1M1a, Stage ⅢA). All the cancers were diagnosed as primary lesions by immunohistological examination. For the metachronous multiple cancers, multidisciplinary treatment was necessary for each cancer considering the patient's physical condition. Moreover, strict follow-up was necessary because of the high risk of carcinogenesis.

Clinical and genetic features of 334 Asian patients with Birt-Hogg-Dubé syndrome (BHDS) who presented with pulmonary cysts with or without a history of pneumothorax, with special reference to BHDS-associated pneumothorax

BACKGROUND

The clinical pulmonary manifestations and genetic features of Birt-Hogg-Dubé syndrome (BHDS) in Asian patients remained unclear. We aimed to clarify the clinical features of BHDS-associated pneumothorax (PTX) and retrospectively investigate potential contributing factors in the largest Asian cohort to date.

METHODS

We reviewed the clinical and genetic data collected in 2006-2017, from the BHDS patients who were Asian and presented with pulmonary cysts with or without a history of PTX.

RESULTS

Data from 334 (41.3% males; 58.7% females) patients from 297 unrelated families were reviewed. Among them, 314 (94.0%) patients developed PTX. The median age at the first occurrence of PTX was 32 years, which was significantly lower in males (P = 0.003) and patients without notable skin manifestations (P < 0.001). Seventy-six (24.2%) patients experienced their first PTX episode before the age of 25 years. PTX simultaneously occurred in the bilateral lungs of 37 (11.8%) patients. Among 149 patients who had their first PTX episode at least 10 years before BHDS diagnosis, PTX occurred more frequently in males (P = 0.030) and light smokers than in nonsmokers (P = 0.014). The occurrence of PTX peaked in the early 30s and gradually decreased with age but remained high in females (P = 0.001). We identified 70 unique FLCN germline variants, including duplications (46.4%), substitutions (7.1%), insertions/deletions (30.0%), and variants affecting splicing (12.5%). Approximately 80% of Asian patients suspected of having BHDS could be genetically diagnosed by examining FLCN exons 7, 9, 11, 12, and 13. No apparent genotype-phenotype correlation regarding pulmonary manifestations was identified.

CONCLUSIONS

Our findings indicate that sex, smoking history, and skin manifestations at BHDS diagnosis significantly influence the clinical features of BHDS-associated PTX. These findings may contribute to the appropriate management and treatment of BHDS-associated PTX.

[Multiple Cysts Formation in Pulmonary Light Chain Deposition Disease(LCDD)-A Case Report]

AIM

To review the clinical features of the patient with cystic pulmonary light chain deposition disease(LCDD)and record high-resolution CT and histopathological findings.

PATIENT

A 60-year-old woman who diagnosed multiple myeloma was admitted. There were diffuse proliferation of plasma cells by the bone marrow puncture that she received. And multiple cystic pulmonary tumors found in CT. We analyzed the method and result of the diagnosis. CT showed multiple cystic pulmonary tumors in the both lung which vessels traversing the cysts with thin wall ranged 5 to 30 millimeters. There were no abnormality in the heart, kidney and liver. Right upper lobe wedge resection was performed via video-assisted thoracic surgery( VATS)to establish a definitive diagnosis. Thoracoscopic findings revealed multiple white oval formed tumors in the visceral pleura. Histological HE staining findings of the surgical specimen revealed amyloid-like acidophilic material, and the immunohistochemical Congo red staining revealed monoclonal IgG with a kappa component. According to the above results these tumors had a diagnosis of pulmonary LCDD.

CONCLUSION

VATS was effective to diagnose pulmonary LCDD in multiple cysts formation.

Quantitative Analysis of Cystic Lung Diseases by Use of Paired Inspiratory and Expiratory CT: Estimation of the Extent of Cyst-Airway Communication and Evaluation of Diagnostic Utility

PURPOSE

To establish a method for quantitatively estimating the extent of the communication between the cyst and the airway in cystic lung diseases (CLDs) and evaluate its diagnostic utility in differentiating among CLDs.

MATERIALS AND METHODS

Seventy-one patients (mean age, 49.9 years; age range, 25-79 years) with CLDs who underwent paired inspiratory and expiratory CT between July 2015 and July 2018 were enrolled in this prospective study. Participants were divided into three groups based on their diagnosis: Birt-Hogg-Dubé syndrome (BHDS) group (15 participants), lymphangioleiomyomatosis (LAM) group (43 participants), and other diseases (OT) group (13 participants). Total lung volume (TLV) and low-attenuation area volume (LAAV) were calculated at inspiration and expiration. The collapsibility of the LAAV was determined as the expiration-to-inspiration (E/I) ratio of LAAV (E/I ratio LAAV). The cyst-airway communicating index (CACI), the ratio of the LAAV change between inspiration and expiration to the TLV change between inspiration and expiration, was also determined. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic utility for differentiating diseases.

RESULTS

The E/I ratio LAAV was significantly higher in the BHDS group (0.69; 95% confidence interval [CI]: 0.61, 0.78) than in the LAM (0.33; 95% CI: 0.28, 0.38) (P < .001) and the OT (0.51; 95% CI: 0.38, 0.64) (P = .038) groups. The CACI was significantly lower in the BHDS group (0.89; 95% CI: 0.61, 1.17) than in the LAM (1.89; 95% CI: 1.76, 2.0) (P < .001) and the OT (1.539; 95% CI: 1.21, 1.86) (P = .003) groups. There was no significant difference in the area under the ROC curve of the CACI (0.881; 95% CI: 0.7749, 0.987) and the E/I ratio LAAV (0.877; 95% CI: 0.791, 0.963) for differentiating BHDS from other diseases.

CONCLUSION

Quantitative analysis using paired inspiratory and expiratory CT for estimating the extent of cyst-airway communication in CLDs is useful when distinguishing BHDS from other diseases.Supplemental material is available for this article.© RSNA, 2020See also the commentary by Chung in this issue.

A total pleural covering of absorbable cellulose mesh prevents pneumothorax recurrence in patients with Birt-Hogg-Dubé syndrome

Background

Birt-Hogg-Dubé syndrome (BHDS) is a recently recognized inherited multiple cystic lung disease causing recurrent pneumothoraces. Similarly to the lesions in patients with lymphangioleiomyomatosis (LAM), the pulmonary cysts are innumerable and widely dispersed and cannot all be removed. We recently described a total pleural covering (TPC) that covers the entire visceral pleura with oxidized regenerated cellulose (ORC) mesh. TPC successfully prevented the recurrence of pneumothorax in LAM patients. The purpose of this study was to evaluate the effect of an ORC pleural covering on pneumothorax recurrence in BHDS patients.

Results

This retrospective study enrolled a total of 81 pneumothorax patients with the diagnosis of BHDS who underwent 90 covering surgeries from January 2010 to August 2017 at Tamagawa Hospital. During the first half of the study period, a lower pleural covering (LPC) which covered the affected area with ORC mesh was mainly used to treat 38 pneumothoraces. During the second half of the study period, TPC was primarily performed for 52 pneumothoraces. All the thoracoscopic surgeries were successfully performed without serious complications (≥ Clavien-Dindo grade III). The median follow-up periods after LPC/TPC were 66/34 months, respectively. Pneumothorax recurrence rates after LPC at 2.5/5/7.5 years postoperatively were 5.4/12/42%, respectively; none of the patients who had underwent TPC developed postoperative pneumothorax recurrence (P = 0.032).

Conclusions

TPC might be an effective option for surgical treatment of intractable pneumothorax in patients with BHDS.

Electronic supplementary material

The online version of this article (10.1186/s13023-018-0790-x) contains supplementary material, which is available to authorized users.

Skin lesions of Birt-Hogg-Dubé syndrome: Clinical and histopathological findings in 31 Japanese patients who presented with pneumothorax and/or multiple lung cysts

BACKGROUND

Birt-Hogg-Dubé syndrome (BHDS) (OMIM #135150) is an autosomal dominant disease, characterized by fibrofolliculomas (FFs) of the skin, pulmonary cysts with/without pneumothorax, and renal tumors. The prevalence of skin manifestations reported for Japanese BHDS patients is lower (<30%) compared with that of Western countries (75∼90%), which appear to be underestimated.

OBJECTIVE

To precisely examine the prevalence of skin lesions with dermoscopy and histopathology with reference to genetic analyses.

METHODS

We studied 31 patients (47.0±13.2years old, range 15-71) consisting of 26 unrelated families consecutively from May 2013 to June 2015 specifically for skin-colored papules on their faces and cervicothoracic regions. Patients initially suspected of BHDS from multiple pulmonary cysts that resulted in pneumothorax (30/31; 96.8%) received dermoscopic examinations and skin biopsies if applicable. The diagnosis of BHDS was established by folliculin (FLCN) genetic testing, and the results were compared to the histopathological findings of FFs or trichodiscomas (TDs).

RESULTS

FLCN germline mutation was demonstrated in 25/26 (96.2%) unrelated families tested and 28/29 patients (96.6%) tested. Skin lesions were recognized in 26/31 patients (83.9%); skin biopsies were performed in 23 patients of whom FFs and/or TDs were histologically demonstrated in 17 (73.9%). Although our study population included patients whose skin manifestations were evaluated prior to or after FLCN genetic testing, skin lesions were clearly prevalent and recognizable irrespective of whether genetic testing was or wasn't done. When examined with dermoscopy, distinct FFs appeared as well-demarcated areas of pallor with central follicular openings in 13 of 15 FF-bearing patients (86.7%); however, those manifestations were not recognized for TD.

CONCLUSIONS

Skin lesions appear to be more prevalent than previously reported (<30% vs.73.9%) in Japanese BHDS patients. Dermoscopy is a useful diagnostic aid for finding FFs.

Oxidized regenerated cellulose induces pleural thickening in patients with pneumothorax: possible involvement of the mesothelial-mesenchymal transition

PURPOSE

The pleural covering technique, i.e., wrapping a part of or the entire surface of the lung with oxidized regenerative cellulose (ORC), reinforces visceral pleura through pleural thickening for patients with pneumothorax and cystic lung diseases. However, it remains undetermined how ORC induces pleural thickening.

METHODS

A histopathological examination was performed for lung specimens from patients who had recurrent pneumothoraces after pleural covering and re-operation (n = 5). To evaluate the influence of ORC on the pleura in vitro, we used MeT-5A cells (a human pleural mesothelial cell line).

RESULTS

Pleural thickening was confirmed in all lung specimens examined. Three months after covering, the thickened pleura showed inflammatory cell infiltration, proliferation of myofibroblasts, and expression of fibronectin and TGF-β. However, after 1 year, those findings virtually disappeared, and the thickened pleura was composed mainly of abundant collagen. When MeT-5A cells were cultured in ORC-immersed medium, their morphology changed from a cobblestone to spindle-shaped appearance. The expression of E-cadherin decreased, whereas that of N-cadherin, α-smooth muscle actin, and fibronectin increased, suggesting mesothelial-mesenchymal transition (Meso-MT).

CONCLUSIONS

Our results suggest that Meso-MT may be involved as a mechanism of pleural thickening induced by pleural covering with ORC.

Novel clinical scoring system to identify patients with pneumothorax with suspicion for Birt-Hogg-Dubé syndrome

BACKGROUND AND OBJECTIVE

Birt-Hogg-Dubé syndrome (BHDS) is a rare hereditary disease that presents with multiple lung cysts and pneumothorax (PTX). Although some reports propose that findings from chest computed tomography enable one to distinguish BHDS from primary spontaneous pneumothorax (PSP), it is still unclear whether clinical features are useful for identifying patients with suspicion of BHDS from those with PTX.

METHODS

We retrospectively reviewed the medical records of patients with PTX who underwent video-assisted thoracoscopic surgery at Nissan Tamagawa Hospital from January 2012 to December 2015.

RESULTS

We identified a total of 1141 patients with PTX, including 54 with BHDS and 517 with PSP. Among them, logistic regression analysis segregated five features that were significantly associated with BHDS: familial history of PTX, past history of bilateral PTX, age at the first episode of PTX (≥25 years old (y.o.)), body mass index (≥18.5) and gender (female). We assigned scores of 3, 3, 2, 2 and 1 to the five features, respectively, to establish a system with a calculated score from 0 to 11. The cut-off value of a calculated score ≥ 4 yielded the highest sensitivity of 93% and specificity of 86%. Receiver operating characteristic (ROC) analysis showed the area under the curve reflecting an accuracy of this diagnostic test as 0.953.

CONCLUSION

BHDS has several clinical features distinct from PSP. Our scoring system consists of only five clinical variables that are easily evaluated and efficiently separate BHDS patients from those who have PTX without relying on an imaging study. Further prospective study is needed to confirm our findings.

Haploinsufficiency of the folliculin gene leads to impaired functions of lung fibroblasts in patients with Birt-Hogg-Dubé syndrome

Birt–Hogg–Dubé syndrome (BHDS) is an autosomal dominant inherited disorder caused by germline mutations in the FLCN gene, and characterized by skin fibrofolliculomas, multiple lung cysts, spontaneous pneumothorax, and renal neoplasms. Pulmonary manifestations frequently develop earlier than other organ involvements, prompting a diagnosis of BHDS. However, the mechanism of lung cyst formation and pathogenesis of pneumothorax have not yet been clarified. Fibroblasts were isolated from lung tissues obtained from patients with BHDS (n = 12) and lung cancer (n = 10) as controls. The functional abilities of these lung fibroblasts were evaluated by the tests for chemotaxis to fibronectin and three‐dimensional (3‐D) gel contraction. Fibroblasts from BHDS patients showed diminished chemotaxis as compared with fibroblasts from controls. Expression of fibronectin and TGF‐β1 was significantly reduced in BHDS fibroblasts when assessed by qPCR. Addition of TGF‐β1 in culture medium of BHDS lung fibroblasts significantly restored these cells' abilities of chemotaxis and gel contraction. Human fetal lung fibroblasts (HFL‐1) exhibited reduced chemotaxis and 3‐D gel contraction when FLCN expression was knocked down. To the contrary, a significant increase in chemotactic activity toward to fibronectin was demonstrated when wild‐type FLCN was overexpressed, whereas transduction of mutant FLCN showed no effect on chemotaxis. Our results suggest that FLCN is associated with chemotaxis in lung fibroblasts. Together with reduced TGF‐β1 expression by BHDS lung fibroblasts, a state of FLCN haploinsufficiency may cause lung fibroblast dysfunction, thereby impairing tissue repair. These may reveal one mechanism of lung cyst formation and pneumothorax in BHDS patients.

A Total Pleural Covering for Lymphangioleiomyomatosis Prevents Pneumothorax Recurrence

Background

Spontaneous pneumothorax is a major and frequently recurrent complication of lymphangioleiomyomatosis (LAM). Despite the customary use of pleurodesis to manage pnenumothorax, the recurrence rate remains high, and accompanying pleural adhesions cause serious bleeding during subsequent lung transplantation. Therefore, we have developed a technique of total pleural covering (TPC) for LAM to wrap the entire visceral pleura with sheets of oxidized regenerated cellulose (ORC) mesh, thereby reinforcing the affected visceral pleura and preventing recurrence.

Methods

Since January 2003, TPC has been applied during video-assisted thoracoscopic surgery for the treatment of LAM. The medical records of LAM patients who had TPC since that time and until August 2014 are reviewed.

Results

TPC was performed in 43 LAM patients (54 hemithoraces), 11 of whom required TPC bilaterally. Pneumothorax recurred in 14 hemithoraces (25.9%) from 11 patients (25.6%) after TPC. Kaplan-Meier estimates of recurrence-free hemithorax were 80.8% at 2.5 years, 71.7% at 5 years, 71.7% at 7.5 years, and 61.4% at 9 years. The recurrence-free probability was significantly better when 10 or more sheets of ORC mesh were utilized for TPC (P = 0.0018). TPC significantly reduced the frequency of pneumothorax: 0.544 ± 0.606 episode/month (mean ± SD) before TPC vs. 0.008 ± 0.019 after TPC (P<0.0001). Grade IIIa postoperative complications were found in 13 TPC surgeries (24.1%).

Conclusions

TPC successfully prevented the recurrence of pneumothorax in LAM, was minimally invasive and rarely caused restrictive ventilatory impairment.

Left-Sided Catamenial Pneumothorax with Thoracic Endometriosis and Bullae in the Alveolar Wall

Catamenial pneumothorax (CP) is generally caused by intraperitoneal air leaking from the uterus into the thoracic cavity via a defect in the endometrial tissue of the diaphragm and is usually detected in the right thorax. We report a case of left-sided CP caused by endometriosis in the visceral pleura and with no abnormal findings in the diaphragm. A 33-year-old female patient presented at the end of a course of low-dose contraceptive pills for pelvic endometriosis, with spontaneous pneumothorax in the left chest. Chest CT revealed a bulla in the left upper lung lobe. The patient underwent partial resection of the lung. Immunohistochemistry confirmed the presence of endometrial stromal tissue in the visceral pleura and confirmed this as the cause of pneumothorax since there were no observable abnormalities in the diaphragm. This case suggests that immunohistochemical examination of patients with spontaneous pneumothorax can detect alternative endometrial lesions.

Isolation of individual cellular components from lung tissues of patients with lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare neoplastic disease entailing cystic destruction of the lungs and progressive respiratory failure. LAM lungs are histologically characterized by the proliferation of smooth muscle-like cells (LAM cells) and an abundance of lymphatic vessels. To elucidate the pathophysiological processes of LAM, cell-type-specific analyses are required. However, no method exists for isolating the individual types of cells in LAM lesions. Therefore, we established a fluorescence-activated cell sorting (FACS)-based method for the direct isolation of LAM cells and other various cellular components from LAM-affected lung tissue. We obtained LAM-affected lung tissue from resections or transplant recipients and prepared single-cell suspensions. FACS, immunohistochemical, and molecular analysis were used cooperatively to isolate HMB45-positive LAM cells with tuberous sclerosis complex (TSC) 2 loss of heterozygosity (LOH). Using a combination of antibodies against an epithelial cell adhesion molecule (EpCAM) and podoplanin, we fractionated CD45-negative lung cells into three groups: lymphatic endothelial cells (LEC) (EpCAM(-)/podoplanin(hi) subset), alveolar type II cells (EpCAM(hi)/podoplanin(-) subset), and mesenchymal cells (EpCAM(-)/podoplanin(-/low) subset). During subsequent analysis of HMB45 expression, as a LAM-specific marker, we clearly identified LAM cells in the mesenchymal cell population. We then discovered that CD90(+)/CD34(-) cells in the mesenchymal cell population are not only positive for HBM45 but also had TSC2 LOH. These isolated cells were viable and subsequently amenable to cell culture. This method enables us to isolate LAM cells and other cellular components, including LAM-associated LEC, from LAM-affected lung tissues, providing new research opportunities in this field.

Pleural Covering Application for Recurrent Pneumothorax in a Patient with Birt-Hogg-Dubé Syndrome

Birt-Hogg-Dubé syndrome (BHDS) is a rare hereditary disease that presents with multiple lung cysts and recurrent pneumothorax. These cysts occupy predominantly the lower-medial zone of the lung field adjacent to the interlobar fissure, and some of them abut peripheral pulmonary vessels. For the surgical management of pneumothorax with BHDS, the conventional approach of resecting all subpleural cysts and bullae is not feasible. Thus, after handling several bullae by using a stapler or performing ligation as a standardized treatment, we applied to a pleural covering technique to thicken the affected visceral pleura and then to prevent recurrence of pneumothorax. We herein report the successful application of a pleural covering technique via thoracoscopic surgery to treat the recurrent pneumothorax of a 30-year-old man with BHDS. This technique is promising for the management of intractable pneumothorax secondary to BHDS.

[Three cases of resected pulmonary metastasis from colorectal cancer after preoperative chemotherapy]

We describe three cases of resected pulmonary metastasis from postoperative colorectal cancer after preoperative 5-fluorouracil, Leucovorin, oxaliplatin (FOLFOX) chemotherapy. The first case is a 38-year-old man who underwent low anterior resection for rectal cancer in 2003. Subsequently, left lung metastasis occurred in February 2009. FOLFOX chemotherapy was administered, resulting in a partial response (PR) of tumor size. Post-chemotherapy, segmental resection of he S1+2 segments of the left lung was performed in May 2009. A pathological diagnosis of Grade 1b was made. The patient remained recurrence-free 5 years post-surgery. The second case is a 68-year-old man who underwent left half colon resection for descending colon cancer with left lung metastasis in March 2006. FOLFOX chemotherapy was administered, with a PR of lung metastasis size. Post-chemotherapy, a segmental resection of the S4 segment of the left lung was performed in September 2006. A pathological diagnosis of Grade 1b was made. The patient was alive 8 years post-surgery. The third case is a 64-year-old man who underwent low anterior resection for rectal cancer in November 2007. A year later, bilateral lung metastases were detected. FOLFOX+bevacizumab was administered, with a stable disease effect on tumor size. Post-chemotherapy, partial resection of both lungs was performed in March and April 2010. A pathological diagnosis of Grade 1a was made. The patient was recurrence-free at the 4-year follow up. We believe that preoperative FOLFOX chemotherapy may be effective in treating lung metastasis from colon cancer.

Thoracic endometriosis-related pneumothorax distinguished from primary spontaneous pneumothorax in females

PURPOSE

Thoracic endometriosis-related pneumothorax (TERP) is a secondary condition specific for females, but in a clinical setting, TERP often is difficult to distinguish from primary spontaneous pneumothorax (PSP) based on a relationship between the dates of pneumothorax and menstruation. The purpose of this study was to clarify the clinical features of TERP compared with PSP.

METHODS

We retrospectively reviewed the clinical and histopathological files of female patients with pneumothorax who underwent video-assisted thoracoscopic surgery in the Pneumothorax Research Center during the 6-year period from January 2005 to December 2010. We analyzed the clinical differences between TERP and PSP.

RESULTS

The study included a total of 393 female patients with spontaneous pneumothorax, of whom 92 (23.4 %) were diagnosed as having TERP and 33.6 % (132/393) as having PSP. We identified four factors (right-sided pneumothorax, history of pelvic endometriosis, age ≥31 years, and no smoking history) that were statistically significant for predicting TERP and assigned 6, 5, 4, and 3 points, respectively, to establish a scoring system with a calculated score from 0 to 18. The cutoff values of a calculated score ≥12 yielded the highest positive predictive value (86 %; 95 % confidence interval (CI) 81.5-90.5 %) for TERP and negative predictive value (95.2 %; 95 % CI 92.3-98 %) for PSP.

CONCLUSIONS

TERP has several distinct clinical features from PSP. Our scoring system consists of only four clinical variables that are easily obtainable and enables us to suspect TERP in female patients with pneumothorax.

[Clinicopathological analysis of 3 cases in which pulmonary metastasis from the urothelial carcinoma was resected]

We describe 3 cases in which the pulmonary metastasis from the urothelial carcinoma of the bladder and upper urinary tract was resected. The duration from the operation of the primary lesion to the occurrence of the pulmonary metastasis was 19, 11, and 4 years in each of the 3 cases. Repeated treatment of the local recurrence was performed in all the 3 cases. Local recurrence in the bladder membrane was observed in 1 case. In 2 cases, computed tomography( CT) scans revealed that the cavitation had penetrated the tumor. Histological findings of the surgical specimen obtained from the 3 cases revealed severe tumor necrosis. Immunostaining of the surgical specimen resulted in a definitive diagnosis of pulmonary metastasis from the urothelial carcinoma in 2 cases in which a differential diagnosis could not identify the primary lung cancer from the pulmonary metastasis. The prognoses in terms of survival in each of the 3 cases were shorter than 32, 19, and 6 months from the operation of the pulmonary metastasis. However, the prognoses could be improved by multidisciplinary treatment, including the resection of the pulmonary metastasis.

[Gallbladder carcinoma, progressed along cholecystoduodenal fistula--a case report]

A 75-year-old woman had an operation for gallstone ileus without cholecystectomy in other hospital and she was admitted to our hospital because of duodenal adenoma with severe atypia and small carcinoid in proximal duodenal wall. Distal gastrectomy and cholecystectomy were performed. Histological studies revealed the existence of cholecystoduodenal fistula and suggested the existence of gallbladder carcinoma progressed to the duodenal wall through the fistula. Cystic duct dissection and lymph nodes dissection were performed. It has been theorized that a cholecystoduodenal fistula may represent a significant risk factor in the development of gallbladder carcinoma because of the chronic reflux of duodenal contents which includes pancreatic juice. Our case may support this theory. In this case, we thought that the formation of gallbladder cancer could have been avoided if the cholecystectomy was performed in the first operation for gallstone ileus. It is very important that cholecystectomy should be performed when an existence of cholecystoduodenal fistula is highly suspected.

Delayed diagnosis of traumatic diaphragmatic rupture

We report a case of late presentation of traumatic rupture of the diaphragm discovered incidentally on chest radiography (CXR) during an annual medical checkup. A 60-year-old man suffered severe blunt trauma from heavy steel frames collapsing against his back, resulting in pelvic and femoral fractures as well as pulmonary contusions. The patient recovered, but 10 months later CXR performed for lung cancer surveillance during an annual medical checkup revealed a traumatic rupture of the diaphragm. Video-assisted thoracic surgery was performed with reduction of the intestine and primary closure of the diaphragmatic defect. The patient recovered uneventfully. This report serves as a useful reminder that a medical history of severe blunt trauma should provoke a high index of suspicion for diaphragmatic rupture during annual medical surveillance.

[Outpatient chemotherapy with home enteral nutrition for gastric cancer patients]

The jejunostomy catheters were placed with needle catheter jejunostomy (NCJ) kits at the time of gastrectomy for the gastric cancer patients. When the oral intake of the post-operative patient is insufficient, home enteral nutrition (HEN) was introduced to the patient. Forty seven cases out of the 278 gatrectomy patients with jejunostomy were applied to HEN (400-1,200 kcal/day in the night). Twenty nine HEN gastric cancer cases received the chemotherapy in the outpatient clinic. The mean age was 71 years old, the number of total gastrectomy and distal gastrectomy were 21 and 8, respectively, and the number of Stage III and IV were 21 and 8, respectively. The chemotherapy for these 29 cases was continued for a long period unevenly in the outpatient clinic, even though the oral intake of the cases was insufficient. HEN is a good arm for keeping the chemotherapy secure and efficient in the outpatient clinic.

[Study on adjuvant MTX-5-FU intraperitoneal chemotherapy for advanced gastric cancer]

The intraperitoneal administration of anti-cancer drug is a rationale route to adjuvant chemotherapy. We applied adjuvant MTX-5-FU intraperitoneal chemotherapy for 60 advanced gastric cancer cases which had undergone gastrectomy (Stage II 18, Stage III A 19, Stage IIIB 13, and Stage IV 10 cases). A 5-year survival rate of Stage II, III A, IIIB and IV was 66.2%, 60.7%, 46.5% and 18.8%, respectively. Five-year survival rates of both Stage III A and IIIB on this study were likely to be higher than the rates of Stage III A and IIIB of other institutions. The 24 out of 42 cases with the serosal surface exposure of cancer demonstrated a cancer recurrence. Seventy percent (17 cases) of the 24 recurred cases developed a peritoneal recurrence, which means that the intraperitoneal chemotherapy did not touch a pattern of the recurrence of the gastric cancer with the serosal surface exposure.