Comparison of the prognosis of symptomatic cerebral infarction and pulmonary embolism in patients with advanced non-small cell lung cancer

BACKGROUND

Lung cancer patients face a high risk of thromboembolism (TE), which is considered to be a poor prognostic factor. However, the impact of symptomatic cerebral infarction (CI) and pulmonary embolism (PE) on the prognosis of advanced non-small cell lung cancer (NSCLC) patients is not fully understood.

METHODS

We retrospectively identified 46 patients with advanced NSCLC who developed symptomatic CI or PE at five hospitals in Japan between January 2010 and December 2019. Prognosis and biomarker levels after incident CI and PE were investigated.

RESULTS

Of the 46 patients, 36 developed symptomatic CI, and 10 developed symptomatic PE. The median follow-up duration after incident CI and PE was 18.2 months. Although the proportion of Common Terminology Criteria for Adverse Events grade 4 tended to be higher in patients with PE than in those with CI (30% vs. 11%, p = 0.16), the overall survival (OS) after incident TE tended to be worse in patients with CI than in those with PE (median 2.3 months vs. 9.1 months, log-rank test p = 0.17). Multivariate analysis showed that OS after CI was worse in patients with high D-dimer (DD) levels than in those with low DD levels at the time of incident CI (median 1.3 months vs. 8.3 months, log-rank p < 0.001).

CONCLUSIONS

This retrospective study demonstrated that the prognosis of patients tended to be poorer after CI than after PE. The DD levels at the time of incident CI might be a promising predictor of clinical outcomes in advanced NSCLC patients who develop CI.

Non-small Cell Lung Cancer With Proto-Oncogene B-Raf V600E Presenting a Distinctive Clinical Course: A Case Report

Cases of proto-oncogene B-Raf (BRAF) V600E mutation are rare, accounting for 1%-4% of non-small cell lung cancers (NSCLCs), and its clinical features remain unclear. Here, we report a case of BRAF mutation-positive lung adenocarcinoma with an atypical clinical course and long-term survival. The patient was a 63-year-old female nonsmoker who was diagnosed with stage IA adenocarcinoma after surgical resection. Five years after the surgery, cancer recurred and was treated with various cytotoxic anticancer agents. During the course of treatment, the patient was found to be BRAF V600E mutation-positive and was treated with molecular-targeted drugs. Although multiple brain, subcutaneous, and tonsillar metastases appeared, the progression was significantly slower, and the patient survived for 14 years and three months after the diagnosis. There have been few case reports of long-term survival in BRAF-positive lung cancer, and more cases need to be accumulated in the future to gather more information. Based on this case, we speculate that sensitivity to cytotoxic anticancer agents such as pemetrexed (PEM) and maintenance of performance status (PS), in addition to molecular-targeted agents, are important for long-term survival.

Hepatocellular carcinoma with a sarcomatous appearance: report of a case

A 59-year-old man was admitted with general fatigue, an epigastric mass, and remittent fever. Radiological examinations disclosed a huge solid-to-cystic mass in the right lobe of the liver, and the mass severely compressed the right diaphragm, the inferior vena cava, and the right atrium. In addition, the patient suffered from chronic hepatitis; however, the serum alpha-fetoprotein, carcinoembryonic antigen, and PIVKA II levels were all within the normal ranges. The serum C-reactive protein level was 7.71mg/dl. With a clinical diagnosis of a malignant hepatic tumor invading the right diaphragm, surgery was performed. The tumor originated from segments IV and VII of the liver, was well defined, and grew extrahepatically. The tumor was resected using an ultrasonic cavitational aspirator together with the infiltrated right diaphragm. The resected tumor measured 23 x 13 x 23cm in size and weighed 3,700 g. Histologically, the tumor was found to consist of hepatocellular carcinomatous component and sarcomatous component. In the sarcomatous component, spindle-shaped cells which were positive for the immunohistochemical localization of vimentin, alpha-smooth muscle actin, and keratin were identified. The postoperative course was uneventful. The value of the serum C-reactive protein returned to within the normal range, and the patient became afebrile. The patient received a postoperative combination chemotherapy (etoposide, epirubicin, and cisplatin), and remains well with no signs of recurrence 12 months after the operation.

Management of cholelithiasis in combination with cardiovascular surgery

A retrospective review of the perioperative management of patients with cardiovascular surgical disorders and cholelithiasis was conducted, and the surgical strategies employed are discussed. Between 1988 and 1998, 18 patients having cardiovascular surgical disorders underwent cholecystectomy. These patients were divided into three groups: group I, given a one-stage operation (n = 9); group II, given a two-stage operation (n = 3); and group III, given cholecystectomy during follow-up after cardiovascular surgery (n = 6). In group I, a median laparotomy was adopted for patients with an abdominal aortic aneurysm (AAA) to allow both disorders to be treated through the same incision, whereas a right subcostal approach was employed to separate the incisions for patients who underwent cardiac operations. In group II, one patient underwent cholecystectomy before cardiac surgery, and two patients underwent cholecystectomy for postoperative cholecystitis after cardiovascular operations. One patient from group II and all from group III were on preoperative anticoagulant therapy, two of whom underwent laparoscopic cholecystectomy. No fatal complications such as prosthetic infection, intraperitoneal hemorrhage, or cerebral attack were encountered. In conclusion, we consider that performing cholecystectomy during AAA repair may be safe and prevents the risk of postoperative cholecystitis; it is preferable to treat cholelithiasis coexisting with cardiac disorders concomitantly with or before cardiac operations; and laparoscopic cholecystectomy can be safely performed under anticoagulant therapy.

Transabdominal inguinal hernioplasty combined with abdominal aortic aneurysm repair

The number of patients being encountered with abdominal aortic aneurysm (AAA) and inguinal hernia is increasing. We describe herein a technique of performing a concomitant one-stage operation for both disorder. After conventional transperitoneal AAA repair, transabdominal preperitoneal hernia repair is carried out through the same incision using a prosthesis made from the same material as the graft used for AAA. The maneuver is similar to that of laparoscopic hernioplasty. We employed this technique in the treatment of four patients, none of whom developed any complications such as infection or recurrence of the inguinal hernia. Thus, we conclude that this one-stage operation for AAA and inguinal hernia may bring physical and economic benefits to patients who have both diseases concomitantly.

Intraabdominal nonvascular operations combined with abdominal aortic aneurysm repair

The therapeutic approach to a patient who has an abdominal aortic aneurysm (AAA) and an intraabdominal nonvascular surgical disorder simultaneously remains controversial. To establish guidelines for the management of those patients, a retrospective review of patients who had concomitant AAA and intraabdominal nonvascular surgical disorders was undertaken. During the period January 1988 to December 1997 a series of 162 patients underwent surgical repairs of AAA in our hospital. Among them 16 patients (9.9%) had several kinds of intraabdominal nonvascular surgical disorders, and 13 underwent one-stage operation for both diseases. That is, cholelithiasis coexisted in five patients, inguinal hernia in four, gastric cancer in two, and retroperitoneal tumor and renal tumor in one each. All AAAs were the infrarenal type, and there were no inflammatory or ruptured aneurysms. In cases of cholelithiasis coexistent with AAA, aneurysmectomy was performed first. After tight closure of the retroperitoneum, cholecystectomy was done. In cases of cholelithiasis coexistent with AAA, aneurysmectomy was performed first. After tight closure of the retroperitoneum, cholecystectomy was done. In cases of inguinal hernia coexistent with AAA, the AAA was first replaced with a prosthetic vascular graft and a residual piece of the graft was used as a patch for hernioplasty. This procedure was similar to laparoscopic hernioplasty. In two cases of gastric cancer concomitant with AAA, the AAA was first replaced. Subtotal gastrectomy with D2 lymphatic dissection was done after tight closure of the retroperitoneum. A drain was inserted into the epiploic foramen to detect anastomotic leakage. A retroperitoneal tumor coexisting with AAA was dissected and resected en bloc with the aneurysmal wall because the tumor firmly adhered to the aneurysm. The abdominal aorta was then replaced with a prosthetic graft. In a case of renal tumor concomitant with AAA, nephrectomy was done first to perform a complete lymphatic dissection around the renal artery. Then AAA repair was performed with a conventional procedure. There were no fatal complications, such as pneumonitis, hemorrhage, anastomotic leakage, or graft infection. All 13 patients were discharged from our hospital and are currently free from recurrence of malignancy or hernia. In summary, properly selected one-stage operations for intraabdominal nonvascular surgical disorders and AAA may be safe and bring physical and economic benefit to the patient.

Complete caudate lobectomy: its definition, indications, and surgical approaches

There are three ways to approach and resect the caudate lobe of the liver, that is; and isolated caudate lobectomy, a combined resection of the liver overlying the caudate lobe, and a transhepatic anterior approach by splitting parenchyma of the liver. We had two patients with neoplasms originating in the caudate lobe who underwent a complete caudate lobectomy. Both patients have been doing well without liver dysfunction. Although after the transhepatic anterior approach we anticipated an adverse effect from splitting the parenchyma of the liver, the postoperative course was uneventful and similar to that of the right side approach.

Efficacy of applied cardiovascular surgery techniques for extended resection in hepato-biliary-pancreatic malignancies

The application of extracorporeal circulation (ECC) and vascular surgery techniques provide the possibility to resect severely advanced hepato-biliary-pancreatic (HBP) malignancies that had been adjudged unresectable hitherto. In this paper, recent two successful cases are reported for the purpose of indicating the efficacy of ECC and vascular surgery techniques in HBP surgery. Two patients had a cholangiocellular carcinoma and a carcinoma of the pancreatic head, those metastatic lymph nodes invaded to the portal veins and the hepatic arteries. These tumors could be resected en bloc with these Glissonian vessels using a centrifugal pump through veno-venous bypass. Reconstruction of these portal veins was performed with autologous external iliac vein graft. Postoperative angiographies showed no anastomotic leakage or occlusion on vascular anastomotic sites in both cases, and they have gone on uneventful postoperative courses. Application of cardiovascular techniques in the field of HBP surgery might expand surgical indication for advanced malignancies.

Hepatectomy of right superior portion (segment VII and VIII) combined with right hepatic vein reconstruction: a case report

A 63-year-old man was admitted for the surgical treatment of hepatocellular carcinoma in the segment VIII. The tumor was 4 cm in size, and the major trunk of the right hepatic vein and a branch of the middle hepatic vein were compressed by the tumor on preoperative hepatic venogram. To preserve the remnant liver function, resection of segments VII and VIII combined with right hepatic vein reconstruction was attempted. Right hepatic vein was reconstructed using an autologous external iliac vein graft after resection of segments VII and VIII with the reason that the inferior right hepatic vein was small in this case and the congestive change was recognized on the surface of segment V and VI after temporary clamp of the right hepatic vein. The postoperative course was uneventful, and the grafted portion was patent on postoperative hepatic venogram. Postoperative pathological examination revealed that poorly differentiated hepatocellular carcinoma of 4 cm x 3.5 cm in size existed in the segment VIII, and directly infiltrated to the main trunk of the right hepatic vein. This is uncommon operative method, but may be useful for preservation of the remnant liver function.

[Hepatobronchial fistula caused by intrahepatic bile duct carcinoma]

A 49-year-old female was complaining of persistent cough. CT-scan revealed abscess in the right hepatic lobe. Diagnostic percutaneous trans-hepatic abscessography disclosed hepatobronchial fistula, and biopsy of the lesion revealed intrahepatic bile duct carcinoma. She underwent right hepatic lobectomy, right pulmonary lower lobectomy and partial resection of the diaphragm, with removal of the fistulous tract. After operation, cough disappeared, but she died of intraabdominal hemorrhage, 40 days after operation.

A two-stage operation successfully performed for giant leiomyosarcoma of the esophagus with hepatic metastasis

Leiomyosarcoma of the esophagus is a rare neoplasm, with only 95 cases having been reported in the literature. Dysphagia is the most commonly noted symptom, however, because of its location in the submucosal layer, the tumor has usually grown to a considerable size by the time this presents. We report herein a case of a 39-year-old man who had no symptoms other than a 7 month history of a cough. After several investigations, the patient underwent resection of the thoracic and abdominal esophagus with lower lobectomy of the right lung through a right and left thoracotomy. The tumor measured 18 x 15 x 8 cm in length and weighed 1,500 g, being the biggest such tumor ever reported. Forty days after the first operation, an extended right hepatic lobectomy of the liver was performed for hepatic metastasis. He was discharged from the hospital 20 days after the second operation and is now doing well. The clinical features and surgical treatment of leiomyosarcoma of the esophagus are discussed herein.

[Surgical treatment for the association of cardiovascular disease and cholelithiasis]

Six cases of the association of cardiovascular disease and cholelithiasis were treated in our surgical ward. Simultaneous operation was carried out for four of them, and two-stage operation was performed in the remaining two cases. As the time of the simultaneous operation, reconstruction of the abdominal aorta and cardiac surgery was firstly done, and cholecystectomy was secondly performed after closing the retroperitoneum or the median sternotomy. All of these cases were discharged from hospital uneventful. In conclusion, cholecystectomy could be safely performed at the same time of the aortic reconstruction and cardiac surgery without any high risk for the patients.

[Extensive surgical treatment of advanced or recurrent carcinoma of the thyroid gland: report of three cases]

Three advanced or recurrent thyroid carcinomas invading the adjacent surrounding organs such as trachea, great vessels or anterior mediastinum were reviewed. In one patient, resection of subtotal thyroid combined with trachea including a part of cricoid cartilage was performed, and followed with end to end anastomosis. In the other two patients with SVC syndrome, a trans-sternal surgical approach was applied in order to resect a large tumor extending into the anterior mediastinum. Replacement of SVC with ringed PTFE graft and chest wall resection was performed in one patient. With these extended surgical intervention, more operative radicality, prolonged surviving time and better quality of life were expected.

[Primary malignant fibrous histiocytoma of the gallbladder: a case report]

A 75-year-old female patient was admitted to our department because of fever and right hypochondraligia. A giant tumor of the gallbladder was confirmed by CT scanning, ultrasonography and PTC. She underwent complete removal of the main tumor and right hemicolectomy. The extirpated tumor was solid, but partially occupied by coagulated and necrotic tissue, 13 X 11 X 9cm in size, and 900g in weight. On the basis of the histologic features of the tumor, MFH (pleomorphic type) originated from the gallbladder was clearly diagnosed. Her postoperative course was uneventful, but she died of cachexia due to recurrence on 79 days after operation. Malignant fibrous histiocytoma (MFH) is a soft tissue sarcoma, usually developing in the extremities, less commonly in the retroperitoneal and the abdominal cavity. MFH originated from the gallbladder is very rare, and only 3 cases were reported in Japan so far. This is the fourth reported case in Japan.