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.