In situ follicular neoplasm discovered as an enlarging pulmonary nodule complicated by pulmonary aspergillosis

In situ follicular B cell neoplasm, previously known as follicular lymphoma in situ, is a neoplastic proliferation of follicular lymphoma-like B cells confined to the germinal centers. Herein, we report a case of a woman in her 70s who initially presented with several enlarged abdominal lymph nodes. Seven months later during follow-up, a solitary pulmonary nodule was detected. As it was close to the hilum, lobectomy was performed. The intraoperative frozen section showed fibrosis and a collection of lymphocytes and macrophages. Therefore, the lymph nodes were sampled. Station 4 and 10 lymph nodes exhibited similar tumor cells and were immunohistochemically positive for CD10 and BCL2. Thus, the patient was diagnosed with in situ follicular neoplasm and is currently under observation. In situ follicular neoplasm is typically a slowly progressive neoplasm; however, it can present as a rapidly enlarging pulmonary nodule complicated by pulmonary aspergillosis.

Prognostic evaluation of preoperative serum tumor marker-negative cases in non-small cell lung cancer: A retrospective study

BACKGROUND

The role of various serum tumor markers (TMs) has been reported in non-small cell lung cancer (NSCLC). However, the prognosis of patients with multiple TM-negative NSCLC remain unclear.

AIMS

This study aimed to describe the characteristics and outcomes of patients with NSCLC undergoing surgery and to investigate their prognostic association with preoperative serum TM-negative cases.

METHODS AND RESULTS

We retrospectively evaluated 442 patients who underwent complete resection of stage I NSCLC between January 2004 and December 2019. These 442 patients were classified into a group whose preoperative serum levels of carcinoembryonic antigen (CEA), cytokeratin-19 fragment (CYFRA21-1), carbohydrate antigen 19-9 (CA19-9), and squamous cell carcinoma antigen (SCC Ag) were all negative (TM-negative group; n = 249, 56%) and a group with at least one positive marker (TM-positive group; n = 193, 44%). Among all patients, the TM-negative group showed higher 5-year recurrence-free survival (RFS) (92.6% vs. 79.1%; p < .01), and overall survival (OS) rates (86.3% vs. 68.6%; p < .01). After propensity score matching, patients in the TM-negative group still exhibited good 5-year RFS (92.1% vs. 81.4%; p = .01) and OS rates (87.6% vs. 72.6%; p < .01).

CONCLUSION

Our study suggests that NSCLC patients who are preoperatively negative for all serum TMs, such as CEA, CYFRA21-1, CA19-9, and SCC Ag, represent a subgroup with a particularly good prognosis.

Long-term survival of a patient with lung cancer treated with pembrolizumab after recurrent cardiac tamponade

A 69-year-old man with non-small cell lung cancer presenting with pericardial effusion and rapid progression of dyspnea achieved long-term disease stabilization after radiation therapy and immunotherapy. This case shows that pembrolizumab may improve prognosis in advanced lung cancer, even when complicated by cardiac tamponade.

Lepidic growth component as a favorable prognostic factor in non-small cell lung cancer of ≤3 cm

BACKGROUND

Many non-small cell lung cancer (NSCLC) tumors present complex histology with various components. The effects of the lepidic growth component (LGC) on the prognosis of NSCLC have not been investigated. Here, we investigated whether an LGC is a relevant prognostic factor for NSCLC.

METHODS

This study retrospectively investigated the clinicopathologic characteristics of 379 patients with NSCLC ≤3 cm who underwent complete surgical resection between 2004 and 2016 at the University of Yamanashi Hospital. The histologic subtypes were classified into NSCLC with or without an LGC. We evaluated the effect of an LGC on the clinicopathologic features and 5-year overall survival of patients with NSCLC.

RESULTS

On final pathology, 214 (56%) of 379 patients had an LGC, and 165 (44%) did not. Sex, smoking history, ground-glass opacity component, pathologic invasive size, lymph node metastasis, pleural invasion, vessel invasion, pathologic stage, and histologic type were significantly different between the groups. Multivariate analysis of 5-year overall survival, identified age (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.035-1.105; p < 0.001), pathologic invasive size (HR, 1.548; 95% CI, 1.088-2.202; p = 0.015) and LGC (HR, 2.11; 95% CI, 1.099-4.051; p = 0.025) as independent prognostic factors. When the pathologic invasive size was matched, the 5-year overall survival of the LGC and non-LGC groups was 93% and 77%, respectively (p = 0.006).

CONCLUSIONS

LGC is a significantly favorable prognostic factor for NSCLC with a pathologic invasive size of ≤3 cm.

Rapidly growing proliferative pulmonary chondroma: A case report

INTRODUCTION

Pulmonary chondroma, a component of Carney's triad, is commonly unilateral and multiple, and progresses slowly. Herein, we report a case of a chondrogenic tumour that grew and proliferated during follow-up.

PRESENTATION OF CASE

A female patient in her 20s presenting with a cough was found to have a 1.4-cm nodule in the left lung on computed tomography (CT). After 18 months' follow-up, CT revealed that the original nodule had increased to 2.2 cm, and a new 1.3-cm nodule had appeared. She was then referred to our hospital and underwent a robot-assisted lower lobectomy of the left lung. The tumour was diagnosed as a chondrogenic tumour. She had no problems after the surgery or during follow-up; other signs of the Carney's triad were ruled out. Twenty-six months postoperatively, there was no evidence of recurrence.

DISCUSSION

One report suggests that the growth of pulmonary chondroma is slow, but the present case showed an increase in both the size and number of tumours within 2 years without any symptoms. The chondroma did not recur after the surgery, though her pulmonary tumours had grown and proliferated rapidly. Furthermore, it has been reported that an average of 8.4 years is needed for another sign of Carney's triad to appear; therefore, careful follow-up should be continued.

CONCLUSION

This report suggests that pulmonary chondroma can grow and proliferate rapidly and asymptomatically, and can be controlled by complete resection.

Determinants for residual symptoms in chronic thromboembolic pulmonary hypertension patients with mean pulmonary arterial pressure &lt;25 mmHg after balloon pulmonary angioplasty

Background

Balloon pulmonary angioplasty (BPA) improves hemodynamics and exercise capacity in inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some symptoms, such as dyspnea on exertion, had remained in more than half of the patients even after BPA could decrease mean pulmonary artery pressure (PAP) &lt;25 mmHg in a Japanese multicenter registry. In addition, previous report indicated that impaired exercise capacity was observed in about half of the patients with CTEPH who achieved mean PAP &lt;25 mmHg at rest after BPA. Lowering mean PAP alone would not be sufficient as a treatment goal of BPA to eliminate residual symptoms in the patients.

Purpose

The purpose of this study was to elucidate the determinants of residual symptom in patients who had achieved mean PAP &lt;25 mmHg after BPA.

Methods

Among 310 CTEPH patients who received BPA in our center, 217 patients (70.0%) could achieve mean PAP &lt;25mmHg at six months after the final BPA were enrolled in this study. The patients were divided into two groups based on the necessity of additional BPA due to residual symptoms; additional BPA group and non-additional BPA group. Clinical parameters including resting hemodynamics at 6 months follow up were retrospectively investigated between the two groups.

Results

Additional BPA had been underwent in 67 patients (30.9%). No significant differences in mean PAP were identified between the additional and non-additional BPA groups (20.4±2.5 mmHg vs. 19.7±2.7 mmHg, p=0.106). In additional BPA group, cardiac index (CI), heart rate (HR) and percutaneous oxygen saturation (SpO2) was lower than non-additional BPA group, and pulmonary vascular resistance (PVR) was higher than non-additional BPA group (CI, 2.51±0.41 L/min/m2 vs. 2.72±0.56 L/min/m2, p=0.016, HR, 62.9±9.7 bpm vs. 67.8±10.8 bpm, p=0.003, SpO2, 94.3±3.7% vs. 95.9±3.5%, p&lt;0.001, PVR, 3.67±1.18 W.U. vs. 3.11±1.09 W.U. p=0.001). In a multivariate analysis, CI, SpO2 and PVR were associated with residual symptoms requiring additional treatment in patients with mean PAP &lt;25mmHg after BPA (95% confidence interval: CI; 0.221–0.900, SpO2; 0.825–0.976, PVR; 1.000–1.785).

Conclusion

Low CI and SpO2 and High PVR were determinants for residual symptoms in CTEPH patients who could achieve mean PAP &lt;25 mmHg after BPA. To eliminate the residual symptoms, treatment goals of BPA in inoperable CTEPH patients should be increasing CI and SpO2 and lowering PVR in addition to normalizing mean PAP.

Funding Acknowledgement

Type of funding sources: None.

Age-related differences in the effect of balloon pulmonary angioplasty on cardiac output in chronic thromboembolic pulmonary hypertension

Background

Balloon pulmonary angioplasty (BPA) has been accepted as an alternative for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). Although BPA improves most of the hemodynamic parameters, the improvement of cardiac output (CO) after BPA cannot be obtained in all the patients.

Purpose

This study was aimed to clarify whether BPA could improve CO or not. We also investigated the determinants for the improvement of CO after BPA.

Methods

We enrolled in consecutive 317 CTEPH patients treated with BPA in our hospital. All the patients were divided into three groups by generations (Younger group; age &lt;60 years old, n=103, Middle-aged group; 60 ≤ age &lt; 70 years old, n=100, Elderly group; 70 ≤ age, n=114). We retrospectively investigated the change of CO after BPA, including its determinants as heart rate (HR) and stroke volume (SV) among the three groups.

Results

Baseline mean pulmonary arterial pressure and six minutes-walk distance in the elderly group were lower than those in the younger group. Baseline CO was almost similar among the three groups. All the hemodynamic parameters, excluding CO, were improved after BPA in overall patients' analyses. The significant improvement in CO after BPA was identified only in the younger patients. Whereas HR decreased after BPA in all age groups, the improvement of CO and SV depended on each patient's generation, as shown in Figure 1.

Conclusions

It would be challenging to improve CO after BPA in all the populations, especially in elderly CTEPH patients. Adjuvant medical treatment in addition to BPA would be required in elderly patients.

Funding Acknowledgement

Type of funding sources: None.

High incidence of pulmonary artery thrombosis after balloon pulmonary angioplasty in CTEPH patients receiving direct oral anticoagulants

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) requires life-long anticoagulant therapy, whereas limited data exist on the safety and efficacy of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) along with balloon pulmonary angioplasty (BPA).

Objectives

To evaluate outcomes and complications in CTEPH following BPA for individuals receiving DOACs or VKAs.

Methods

Consecutive CTEPH patients underwent BPA from September 2014 to August 2021 were included in a retrospective analysis. Complications during BPA, post-BPA hemodynamics and bleeding events were obtained from patient's medical records. Our routine follow-up “selective” pulmonary angiography, to evaluate all segmental pulmonary arteries one by one at six months and every year after final BPA session, was performed to elucidate the incidence of in-situ fresh floating thrombus.

Results

Of total 250 individuals, 104 were treated with DOACs and 146 with VKAs following BPA. Mean observation period was 905 (SD ± 660) days. Total 1278 BPA sessions were performed among the period in which 409 sessions were treated with DOACs and 869 sessions with VKAs. Significant improvements in hemodynamics and functional status were observed in both groups following BPA. There was no significant difference of hemoptysis during BPA between DOACs and VKAs (7.1% vs 10.1%, P=0.131). Major bleeding events during observation period were equivalent in those treated with DOACs and VKAs. No significant re-elevation of pulmonary artery pressure was observed in both groups after BPA. Follow-up selective pulmonary angiography identified in-situ fresh floating thrombus in pulmonary artery in 22 cases of total 769 follow-up sessions. The occurrence of fresh thrombus was significantly higher in those receiving DOACs than VKAs in therapeutic range of PT-INR &gt;1.8 (3.9% vs 1.2%, P=0.023) whereas no significant difference between DOACs and overall VKAs (3.9% vs 2.4%, P=0.177)

Conclusions

Post-BPA hemodynamic outcomes and bleeding events appear unaffected by choice of anticoagulant. However, the incidence of in-situ pulmonary thrombosis detected by selective pulmonary angiography was significantly higher in those receiving DOACs than VKAs in therapeutic range, suggesting inadequate anticoagulation under current dose of DOACs. Our study provides a rationale for further examination to evaluate the efficacy of DOACs in CTEPH.

Funding Acknowledgement

Type of funding sources: None.

Thymoma-associated anti-LGI1 encephalitis and myasthenia gravis: A unique combination with autoantibodies

We report a 77-year-old woman with a thymoma, anti-LGI1antibody associated encephalitis (LGI1 encephalitis), and MG accompanied by positive anti-acetylcholine receptor antibodies (AchR Ab) and anti-titin antibodies (titin Ab). She was treated with thymomectomy followed by immunosuppressive therapy, which resulted in immediate amelioration of motor weakness and gradual improvement of cognitive impairment over the next two years. LGI1 Ab were positive at two months after thymomectomy, followed by negative conversion demonstrated on 1 year examination. The AchR Ab level had gradually decreased but titin Ab was positive on re-examination after two years, although the cognition and motor impairment symptoms had been alleviated. In patients with suspected autoimmune encephalitis, the detection of several autoantibodies including LGI1 and thymomas provides useful information for making an accurate diagnosis.

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A rare case complicated with a thymoma, anti-LGI1antibody associated encephalitis, and myasthenia gravis.

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Accompanied by positive anti-acetylcholine receptor antibodies and anti-titin antibodies.

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The symptoms of encephalitis had improved with thymomectomy and immunosuppressive therapy.

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These unique combinations of the disease and autoantibodies will help us to diagnose and treat autoimmune encephalitis.

Metastatic pulmonary nodule after a seventeen-year disease-free interval resected through thoracoscopic subsegmentectomy: A case report

The lung is the most common site of metastasis in patients with renal cell carcinoma (RCC). Metastatic RCCs, even those classified as stage I, can recur after >10 years. Therefore, it is critical to completely resect metastatic nodules. Here, we report the case of a 74‐year‐old man who underwent a nephrectomy for RCC and was diagnosed with lung metastasis 17 years later. The metastatic nodule was resected through complete thoracoscopic subsegmentectomy. He had previously undergone partial nephrectomy for clear cell renal carcinoma pT1bN0M0. During his annual follow‐up, a computed tomography scan revealed a pulmonary nodule. The intraoperative frozen section revealed a metastatic clear cell RCC. Thus, additional lobectomy was not performed. The postoperative course was uneventful with no complications. This case demonstrates that even early stage metastatic clear cell renal carcinoma can recur after over 17 years. Thoracoscopic segmentectomy is less invasive and can preserve pulmonary function.

Effects of an elemental diet to reduce adverse events in patients with esophageal cancer receiving docetaxel/cisplatin/5-fluorouracil: a phase III randomized controlled trial-EPOC 2 (JFMC49-1601-C5)

Background

Oral mucositis (OM) is an unpleasant adverse event in patients receiving chemotherapy. A prospective feasibility study showed that elemental diet (ED), an oral supplement that does not require digestion, may prevent OM. Based on this, we established a central review system for oral cavity assessment by dental oncology specialists blinded to background data. We used this system to elucidate the preventive effect of an ED against OM in patients with esophageal cancer receiving docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy.

Patients and methods

In this phase III, multicenter, parallel-group, controlled trial, patients consuming a normal diet orally were randomly assigned (1 : 1) to receive two cycles of DCF with (group A) or without (group B) an ED (Elental® 160 g/day). We assessed the incidence of grade ≥2 OM evaluated by two reviewers, changes in body weight, prealbumin, C-reactive protein, and DCF completion rate based on ED compliance.

Results

Of the 117 patients randomly assigned to treatment, four failed to start treatment and were excluded from the primary analysis; thus, groups A and B comprised 55 and 58 patients, respectively. There were no significant differences in background characteristics. Grade ≥2 OM was observed in eight (15%) and 20 (34%) patients in groups A and B, respectively (P = 0.0141). Changes in body weight and prealbumin during the two DCF cycles were significantly higher in group A than B (P = 0.0022 and 0.0203, respectively). During the first cycle, changes in C-reactive protein were significantly lower in group A than B (P = 0.0338). In group A (receiving ED), the DCF completion rate was 100% in patients with 100% ED compliance and 70% in patients failing ED completion (P = 0.0046).

Conclusions

The study findings demonstrate that an ED can prevent OM in patients with esophageal cancer receiving chemotherapy.

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Patients receiving docetaxel, cisplatin, and 5-fluorouracil (DCF) chemotherapy commonly develop oral mucositis (OM).

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An elemental diet (ED) was able to prevent OM in patients with esophageal cancer receiving DCF.

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Grade ≥2 OM was observed in 15% of patients receiving the ED versus 34% of those not receiving the ED (P = 0.0141).

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Body weight was maintained in the ED group, and hematologic toxicities were lower, compared with the non-ED group.

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The DCF completion rate significantly correlated with ED compliance (P = 0.0046).

Congenital communicating bronchopulmonary foregut malformation including ectopic pancreatic tissue in an infant

Background

Several reports have documented that the pulmonary sequestration is in communication with the gastrointestinal tract and the concept of bronchopulmonary foregut malformation (BPFM) has become more widespread. However, there are few reports of the sequestration associated with the pancreas derived from the foregut. We describe the history and pathophysiology of BPFM including pancreatic tissue in a male infant with respiratory distress.

Case presentation

A male patient was born at 38 weeks of gestation and weighed 2752 g at birth. He developed pneumonia and was hospitalized at 3 months of age. Chest radiographs and CT scans led to the diagnosis of a lung abscess in the left lower intralobar pulmonary sequestration with aberrant arteries from the abdominal cavity. At 4 months of age, when the abscess had resolved, left lower lobectomy and the resection of the intralobar sequestration were performed. The pulmonary sequestration was conjoined with the esophagus. A fistula was found between the lower esophageal wall and the pulmonary sequestration. An additional small segment of the esophageal wall was excised. Histologically, the mediastinal surface of the sequestration tissue contained pancreatic tissue. Furthermore, esophageal and gastric tissue, cartilage tissue, and ciliated epithelium were confirmed. A definitive diagnosis of BPFM was made.

Conclusions

We postulated the rare case of a communicating BPFM with intrapulmonary sequestration on one end and the esophagus on the other forming a mass lesion, which included ectopic pancreatic tissue in a male infant.

Mediastinal mature teratoma with chest pain onset and subsequent perforation: A case report

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Ruptured mediastinal teratomas (RMTs) may lead to mediastinitis.

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RMTs may also cause the rupture of adjacent tissues.

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Immediate resection of RMTs should be performed once perforation is confirmed.

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Radiography and MRI may provide useful information for RMT diagnosis.

Introduction

Mediastinal mature teratomas are often benign, asymptomatic, and incidentally detected during routine chest roentgenography. Enzymes secreted by intestinal or pancreatic tissue in teratomas may lead to mediastinitis or the rupture of adjacent tissues. Herein, we present a case of a patient who experienced sudden onset of chest pain followed by the perforation of a mediastinal teratoma.

Presentation of case

A 10-year-old boy presented with chest pain 2 days before admittance to the hospital. Chest radiography showed an anomalous mass shadow, and computed tomography showed an anterior mediastinal mass. Radiography revealed an increase in the mass shadow size and dullness of the left costal phrenic angle. Magnetic resonance imaging revealed pleural effusion and intratumoral haemorrhage, indicating perforation of the tumour. Emergency excision and thymectomy via sternotomy were performed. Pathology confirmed that the mediastinal tumour presented no immature or malignant elements.

Discussion

In the present case, the onset of chest pain occurred 2 days before admission, and the initial computed tomography did not reveal tumour perforation. Subsequent chest radiography and magnetic resonance imaging indicated that the tumour had perforated. Surgical tumour excision was planned at the time of admission; however, once perforation was confirmed, emergency surgery was performed. The pleural effusion had high cancer antigen 19-9 levels, and this was expected as the pleural effusion contained pancreatic digestive enzymes.

Conclusion

The perforation of a mediastinal mature teratoma cannot be predicted based on the symptoms, tumour size, or onset of pain alone. Once perforation is confirmed, surgical excision should be performed immediately.

Efficacy of measuring the invasive diameter of lung adenocarcinoma using mediastinal window settings: A retrospective study

The recently published 8th edition of the tumor node and metastasis Classification of Lung Cancer proposes using the maximum dimension of the solid component of a ground glass nodule (GGN) for the T categorization. However, few studies have investigated the collection of this information when using mediastinal window settings. In this study, we evaluated tumor measurement data obtained from computed tomography (CT) scans when using mediastinal window settings.This study included 202 selected patients with persistent, partly solid GGNs detected on thin-slice CT after surgical treatment between 2004 and 2013. We compared the differences in tumor diameters measured by 2 different radiologists using a repeated-measures analysis of variance. We divided the patients into 2 groups based on the clinical T stage (T1a+T1b vs T1c) and estimated the probability of overall survival (OS) and disease-free survival (DFS) using Kaplan-Meier curves.The study included 94 male and 108 female patients. The inter-reviewer differences between tumor diameters were significantly smaller when the consolidation to maximum tumor diameter ratio was ≤0.5. The 2 clinical groups classified by clinical T stage differed significantly with respect to DFS when using the mediastinal window settings. However, no significant differences in OS or DFS were observed when using the lung window setting.Our study yielded 2 major findings. First, the diameters of GGNs could be measured more accurately using the mediastinal window setting. Second, measurements obtained using the mediastinal window setting more clearly depicted the effect of clinical T stage on DFS.

Detecting tumor-infiltrating Forkhead box P3-positive T cells in the prognosis of lung adenocarcinoma: Possible role of clustering tumor interleukin-12 subunit alpha and transforming growth factor beta 1 expression

BACKGROUND

While regulatory T cells (Tregs) are a poor prognostic factor for lung cancer, they may be detected as Forkhead box P3+ (FOXP3+) and cluster of differentiation (-CD) 4+ T cells by classifying FOXP3+CD4+ T cells into different subpopulations of CD4 cells.

OBJECTIVES

To classify clusters of tumor-infiltrating Tregs in lung adenocarcinoma based on the mRNA expression levels of interleukin-12 subunit alpha (IL12A) and transforming growth factor beta 1 (TGFB1) in tumor specimens.

MATERIAL AND METHODS

Seventy-nine patients with lung adenocarcinoma were evaluated in this study. Clinical data were obtained from the patients' medical records, while tumor tissue samples were preserved as formalin-fixed paraffin-embedded (FFPE) tissue specimens. Immunohistochemical staining for CD4, CD8 and FOXP3 was performed and stained cell counts were obtained under 5 high-power fields. cDNA was synthesized from total RNA extracted from FFPE tissue specimens and amplified with Taqman probes for FOXP3, IL12A, TGFB1, and the glyceraldehyde-3-phosphate dehydrogenase gene.

RESULTS

Two clusters were identified: IL12AlowTGFB1low (Cluster 1: n = 44) and IL12AhighTGFB1high (Cluster 2: n = 39). Although no significant difference in the FOXP3+ cell/CD4+ cell ratio was observed between the 2 clusters (p = 0.921), the high FOXP3+/CD4+ cell ratio group showed a significantly poorer relapse-free survival rate than the low FOXP3+/CD4+ cell ratio group in Cluster 1 (p = 0.031).

CONCLUSIONS

Although the results revealed no direct association between Tregs and prognosis according to each subtype, these results suggest that if a lung cancer specimen contains low levels of IL12A and TGFB1, the FOXP3+/CD4+ cell ratio is useful for predicting the prognosis of lung cancer.

How Different is the Core of ^{25}F from ^{24}O_{g.s.} ?

The structure of a neutron-rich ^{25}F nucleus is investigated by a quasifree (p,2p) knockout reaction at 270A  MeV in inverse kinematics. The sum of spectroscopic factors of π0d_{5/2} orbital is found to be 1.0±0.3. However, the spectroscopic factor with residual ^{24}O nucleus being in the ground state is found to be only 0.36±0.13, while those in the excited state is 0.65±0.25. The result shows that the ^{24}O core of ^{25}F nucleus significantly differs from a free ^{24}O nucleus, and the core consists of ∼35% ^{24}O_{g.s.}. and ∼65% excited ^{24}O. The result may infer that the addition of the 0d_{5/2} proton considerably changes neutron structure in ^{25}F from that in ^{24}O, which could be a possible mechanism responsible for the oxygen dripline anomaly.

Ciliated muconodular papillary tumor of the lung presenting with polymyalgia rheumatica-like symptoms: a case report

Ciliated muconodular papillary tumors (CMPTs) of the lung have been recently characterized as low-grade malignant tumors and may be indistinguishable from adenocarcinoma in situ (AIS) because they are both abundant in mucous and spread along the alveolar walls. Herein, we report a case of CMPT with polymyalgia rheumatica (PMR)-like symptoms, which resolved after resection. After the surgery, antinuclear antibody tests were performed, but no abnormalities were noted. Furthermore, the lung tumor could not be distinguished from AIS, as revealed by a pathological examination. This case demonstrates two key points: the paraneoplastic symptoms of CMPT can indicate PMR, and it is difficult to diagnose peripheral lung tumors as CMPT unless there is a completely resected specimen available. The possibility exists that an increased number of older patients will be diagnosed with CMPT because of the increasing frequency of computed tomography performed in this population. Therefore, it is important for clinicians to obtain completely resected specimens to ensure accurate diagnosis and management of CMPT.

P4678The hemodynamic improvement with balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension depends on the lesion location

Background

Pulmonary endarterectomy (PEA) is a treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Patients with proximal pulmonary artery disease are considered to be good candidates for PEA because of their generally excellent outcomes. However, not all patients can be operated because of patients' advanced age, comorbidities and poor general condition. Balloon pulmonary angioplasty (BPA) has become an alternative treatment for CTEPH patients especially whose lesions locate in the distal site. The effectiveness of BPA in patients who have lesions in the proximal pulmonary arteries but cannot be a candidate for PEA remains unclear.

Purpose

The aim of this study was to investigate the outcome of BPA in CTEPH patients whose lesions appears operable but ineligible for PEA.

Methods

A total of 370 patients who underwent BPA in our institute from November 2004 to January 2018 were enrolled. All the patients were divided into operable group and inoperable group according to the difference of lesion location based on the findings of perfusion scintigraphy, computed tomography and pulmonary angiography. Hemodynamic effects of BPA in both groups were investigated. We also conducted survival analyses using the Kaplan-Meier method with the log-rank test.

Results

Among 370 patients, 90 patients deemed operable. The main reasons why not operated in the PEA operable group were patient's refusal (44%), advanced age (14%), and comorbidities (27%). There were no baseline characteristic differences between two groups except for the history of acute pulmonary embolism. Mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) equally improved after BPA in both groups (operable: 38.2±10.8 mmHg to 21.5±4.7mmHg, inoperable: 42.4±11.3 mmHg to 21.8±4.8 mmHg, p<0.001, operable: 8.0±4.2 wood unit to 3.5±1.5 wood unit, inoperable: 9.1±4.6 wood unit to 3.4±1.3 wood unit, p<0.001). Furthermore, five-year cumulative survival rates were not different between two groups (inoperable vs. operable: 93% vs. 88%, p=0.23, median follow-up period was 23.0 months (range: 5–136 months)). Meanwhile, the absolute change of mPAP and PVR in inoperable group were greater than those in operable group (inoperable: 20.7±11.2 mmHg, operable: 16.6±11.0 mmHg, p=0.010, inoperable: 5.6±4.4 wood unit, operable: 4.5±3.9 wood unit, p=0.015).

Conclusions

Although the outcome of BPA for CTEPH patients with operable lesions appears acceptable, absolute change in hemodynamics was lower than that of the patients with inoperable lesions. CTEPH with proximal lesions should be treated with PEA rather than BPA.

P4675The utility of additional balloon pulmonary angioplasty for residual hypoxemia in normohemodynamic chronic thromboembolic pulmonary hypertension patients after invasive treatments

Background

Balloon pulmonary angioplasty (BPA) improves hemodynamics, symptoms and exercise capacity in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are ineligible for pulmonary endarterectomy (PEA). However, certain patients still have hypoxemia after BPA or PEA despite normalization of hemodynamics. In CTEPH, hypoxemia is related increased dead space ventilation caused by vascular obstruction.

Purpose

This study was aimed to clarify whether additional BPA can improve hypoxemia of CTEPH patients after normalization of hemodynamics.

Methods

A total of 335 patients who underwent initial series of BPA in our institute were followed up. Sixty-four patients with mean pulmonary artery pressure (mPAP) <30mmHg and percutaneous oxygen saturation (SpO2) <95% without oxygen inhalation at more than 6 months after the initial series of BPA and of patients who could reevaluate hemodynamics and oxygenation after additional BPA were enrolled. These patients were divided into two groups with or without additional BPA procedures. Change of hemodynamics and SpO2 were retrospectively investigated.

Results

Thirty-three of 64 patients underwent additional BPA procedures. Patients' age was older in BPA group than those in non-BPA group (71.3±10.4 vs. 66.5±9.4 years old, p=0.02). mPAP and pulmonary vascular resistance (PVR) was significantly higher in BPA group (mPAP: 23.9±3.2 vs. 20.7±3.8 mmHg, p=0.001, PVR: 4.2±1.2 vs. 3.5±1.4 wood unit, p=0.03, respectively). Among the 1.8±1.4 BPA procedures per person, total 6.6±3.8 segmental pulmonary arteries per person were treated. While no obvious improvements were observed in non-BPA group, PVR and SpO2 in BPA group were significantly improved (4.2±1.2 to 3.7±1.3 wood unit, p=0.002, 90.7±3.1% to 94.1±3.6%, p<0.001, respectively). In the multivariate logistic regression analysis, additional BPA procedures were associated with further improvement of SpO2 (hazard ratio, 3.7; 95% confidence interval, 1.2–11.5; P=0.02).

Conclusions

Additional BPA procedure was associated with improvement of hypoxemia in CTEPH patients after normalization of hemodynamics. Treating as many lesions as possible in BPA might relieve the patients' residual dyspnea.

[Thyroid Transcription Factor-1 is Useful for Identifying Primary Tumors]

A 67-year-old man had underwent liver resection 3 years previously. The pathological diagnosis was intrahepatic cholangiocarcinoma. However, a follow-up computed tomography(CT) scan revealed gradual enlargement of the pulmonary nodule left S1+2 and he was performed surgery. Because the metastasis of intrahepatic cholangiocarcinoma was demonstrated for lymph node (LN) #3 by intraoperative rapid pathology, only the left upper lobe was resected. Finally, the postoperative pathological diagnosis by thyroid transcription factor-1 (TTF-1) staining was primary lung cancer. Liver lesion was also diagnosed as liver metastases of the lung cancer by TTF-1 staining.

Spontaneous regression of a carcinoid tumor that required resection owing to its reappearance and subsequent enlargement after 2 years: a case report

We present a rare case of spontaneous regression in a typical lung carcinoid. A 20-year-old woman with an abnormal shadow on a chest radiograph was admitted to our hospital. Computed tomography revealed a smooth nodule in the left S1 + 2 segment. At the 6-month follow-up, the nodule had regressed without treatment. At the 2-year follow-up, the tumor reappeared in the same place as before. We performed left upper lobectomy via 4-port thoracoscopic surgery. A pathological examination revealed a typical carcinoid. Lung carcinoids can spontaneously regress; long-term follow-up is important for timely detection of tumor reappearance.

Mesothelial cyst derived from chest wall pleura growing after thoracic surgery: a case report

Background

Intrathoracic mesothelial cysts almost always arise in the mediastinum, and extramediastinal mesothelial cysts are extremely rare. Here we describe a case of mesothelial cyst derived from the chest wall pleura growing after thoracic surgery.

Case presentation

A 63-year-old Japanese woman was referred to our department. She had undergone total hysterectomy for cervical carcinoma and two lung wedge resections for metastatic lung cancer on the upper and lower lobes of her right lung and lower lobe of her left lung. After the thoracic surgery, an intrathoracic chest wall mass was found, which grew gradually. Computed tomography demonstrated a 2.0 × 1.8 cm low-density mass without contrast effect. Magnetic resonance imaging demonstrated a low-intensity mass in T1-weighted imaging and a high-intensity mass in T2-weighted imaging. Thoracoscopic excision of the mass was performed. The cystic mass was thought to be derived from her chest wall and was pathologically diagnosed as mesothelial cyst. Five years after the surgery, she has no evidence of recurrence of the cyst or cervical carcinoma.

Conclusions

The genesis of extramediastinal mesothelial cysts may be related to inflammation. From this perspective, extramediastinal mesothelial cysts may have different characteristics from pericardial cysts and resemble peritoneal inclusion cysts. Although, extramediastinal mesothelial cysts are not established, their characteristics resemble peritoneal inclusion cysts; therefore, such interesting intrathoracic cysts should be carefully resected considering the risk.

Mediastinal mature teratoma perforating the right lung that was successfully resected with complete thoracoscopic surgery: A case report

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Open surgery is usually performed for a perforating mediastinal mature teratoma.

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Asymptomatic perforation involving a teratoma is very rare.

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Complete thoracoscopic surgery was successfully used in this case.

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Complete thoracoscopic surgery might be meaningful in cases of few or no symptoms.

Introduction

A perforating mediastinal mature teratoma can cause severe inflammation and adhesion; therefore, open surgery is usually performed. Asymptomatic perforation involving a teratoma is very rare. Complete thoracoscopic surgery is often difficult because of inflammation associated with perforation and the frequently large size of a mediastinal mature teratoma. We report a rare case of an asymptomatic perforating mediastinal mature teratoma successfully treated with complete thoracoscopic surgery.

Presentation of case

The patient was a 15-year-old girl with an abnormal shadow at the mediastinum seen on chest radiography at a health examination performed at her junior high school; an asymptomatic mediastinal tumour was suspected. Enhanced computed tomography revealed a 6.5 × 3.5-cm tumour associated with the right upper lobe. Thoracoscopic surgery was performed using 4 access ports. Although there were inflammatory changes, hemi-thymectomy and right upper lobectomy were achieved with complete thoracoscopic surgery. The tumour included the skin, sebaceous glands, hair, and pancreatic tissue and was diagnosed as a mature teratoma perforating the right upper lobe.

Discussion

There might be limited inflammatory changes if the patient has few or no symptoms, as in our case. In such cases, the tumour may be excised even if it is large.

Conclusion

We report a rare case of an asymptomatic perforating mediastinal mature teratoma that was successfully treated with complete thoracoscopic surgery. Although infection, inflammatory adhesion, large tumour size, and the need for radical cure are concerns, complete thoracoscopic surgery might be helpful. In cases of few or no symptoms, thoracoscopic surgery is worth challenging.

Intractable pneumothorax complicated with interstitial pneumonitis treated with the Tachosuture technique: A case report

It has been proven that the Tachosuture technique is effective for preventing prolonged air leaks caused by pulmonary resection. We successfully used the Tachosuture technique to treat intractable pneumothorax with interstitial pneumonia. This technique avoids pulmonary resection and contributes to acute exacerbations of interstitial pneumonia.

Video-assisted thoracoscopic surgery can help enable the complete resection of a mediastinal tumor caused by immunoglobulin G4-related disease and avoid the need for postoperative medication: A case report

Immunoglobulin (Ig) G4-related disease has various clinical signs and symptoms, and steroidal therapy with corticosteroids has been found to be effective for treatment. Few cases of IgG4-related disease associated with paravertebral tumor have been reported, and there have been no reports on complete resection of such a tumor. Here, we report a case of IgG4-related disease associated with a paravertebral tumor that was successfully resected without the need for postoperative medication. An 84-year-old woman was admitted to our hospital with a paravertebral tumor. She underwent thoracoscopic surgery, and pathological examination of the tumor specimen revealed that the tumor resulted from IgG4-related disease. After resection, there was no need for postoperative medication. Our case indicates the rare possibility of a paravertebral tumor associated with IgG4-related disease and the potential for complete resection as a treatment for such a tumor.

Excitation of the Isovector Spin Monopole Resonance via the Exothermic ^{90}Zr(^{12}N,^{12}C) Reaction at 175 MeV/u

The (^{12}N, ^{12}C) charge-exchange reaction at 175  MeV/u was developed as a novel probe for studying the isovector spin giant monopole resonance (IVSMR), whose properties are important for better understanding the bulk properties of nuclei and asymmetric nuclear matter. This probe, now available through the production of ^{12}N as a secondary rare-isotope beam, is exothermic, is strongly absorbed at the surface of the target nucleus, and provides selectivity for spin-transfer excitations. All three properties enhance the excitation of the IVSMR compared to other, primarily light-ion, probes, which have been used to study the IVSMR thus far. The ^{90}Zr(^{12}N,^{12}C) reaction was measured and the excitation energy spectra up to about 70 MeV for both the spin-transfer and non-spin-transfer channels were deduced separately by tagging the decay by γ emission from the ^{12}C ejectile. Besides the well-known Gamow-Teller and isobaric analog transitions, a clear signature of the IVSMR was identified. By comparing with the results from light-ion reactions on the same target nucleus and theoretical predictions, the suitability of this new probe for studying the IVSMR was confirmed.

Reappraisal of classification of distal cholangiocarcinoma based on tumour depth

Background

In the eighth edition of the AJCC cancer staging classification, the T system for distal cholangiocarcinoma (DCC) has been revised from a layer-based to a depth-based approach. The aim of this study was to propose an optimal T classification using a measured depth in resectable DCC.

Methods

Patients who underwent pancreatoduodenectomy for DCC at 32 hospitals between 2001 and 2010 were included. The distance between the level of the naive bile duct and the deepest cancer cells was measured as depth of invasion (DOI). Invasive cancer foci were measured as invasive tumour thickness (ITT). Log rank χ2 scores were used to determine the cut-off points, and concordance index (C-index) to assess the survival discrimination of each T system.

Results

Among 404 patients, DOI was measurable in 182 (45·0 per cent) and ITT was measurable in all patients, with median values of 2·3 and 5·6 mm respectively. ITT showed a positive correlation with DOI (rs = 0·854, P &lt; 0·001), and the cut-off points for prognosis were 1, 5 and 10 mm. Median survival time was shorter with increased ITT: 12·4 years for ITT below 1 mm, 5·2 years for ITT at least 1 mm but less than 5 mm, 3·0 years for ITT at least 5 mm but less than 10 mm, and 1·5 years for ITT 10 mm or more (P &lt; 0·001). This classification exhibited more favourable prognostic discrimination than the T systems of the seventh and eighth editions of the AJCC (C-index 0·646, 0·622 and 0·624 respectively).

Conclusion

ITT is an accurate approach for depth assessment in DCC. The four-tier ITT classification with cut-off points of 1, 5 and 10 mm seems to be a better T system than those in the seventh and eighth editions of the AJCC classification.

Spectroscopy of Pionic Atoms in ^{122}Sn(d,^{3}He) Reaction and Angular Dependence of the Formation Cross Sections

We observed the atomic 1s and 2p states of π^{-} bound to ^{121}Sn nuclei as distinct peak structures in the missing mass spectra of the ^{122}Sn(d,^{3}He) nuclear reaction. A very intense deuteron beam and a spectrometer with a large angular acceptance let us achieve a potential of discovery, which includes the capability of determining the angle-dependent cross sections with high statistics. The 2p state in a Sn nucleus was observed for the first time. The binding energies and widths of the pionic states are determined and found to be consistent with previous experimental results of other Sn isotopes. The spectrum is measured at finite reaction angles for the first time. The formation cross sections at the reaction angles between 0° and 2° are determined. The observed reaction-angle dependence of each state is reproduced by theoretical calculations. However, the quantitative comparison with our high-precision data reveals a significant discrepancy between the measured and calculated formation cross sections of the pionic 1s state.

Low-dose hyperthermia enhances the antitumor effects of chemotherapy in squamous cell carcinoma

Esophageal squamous cell carcinoma is a highly aggressive neoplasm and the sixth leading cause of global cancer-related death; the 5-year survival rate for esophageal cancer is only about 20%-25% for all stages. Therefore, improving the therapeutic effect is important. This study assessed whether low-dose hyperthermia (LDH) enhances the antitumor effects of chemotherapy. The antitumor effect of chemotherapy with/without LDH in the squamous cell carcinoma cell line SCCVII was evaluated. A comprehensive analysis was performed with real-time polymerase chain reaction (PCR) to study the hyperthermia-induced changes in the gene expression of SCCVII cell lines. In addition, the cytotoxic and apoptotic changes in the cells treated with LDH combined with/without 5-fluorouracil (5-FU) were measured. LDH combined with 5-FU (10 nM) strongly inhibited the cell growth of SCCVII, with flow cytometry showing an increased population of apoptotic cells. PCR showed that LDH promoted a 25.22-fold increase of p53 mRNA and 18.08-fold increase of Bax mRNA in vitro. MDR1 expression was decreased to 28.7% after LDH. This treatment can result in much higher efficacy of antitumor drugs. After LDH, the expressions of TS decreased to 12.06%, OPRT increased by 4.17-fold, and DPD did not change (1.03-fold). This transformations will induce susceptibility to 5-FU. LDH may be a useful enhancer of chemotherapy drugs for squamous cell carcinoma.

Electric Dipole Polarizability of ^{48}Ca and Implications for the Neutron Skin

The electric dipole strength distribution in ^{48}Ca between 5 and 25 MeV has been determined at RCNP, Osaka from proton inelastic scattering experiments at forward angles. Combined with photoabsorption data at higher excitation energy, this enables the first extraction of the electric dipole polarizability α_{D}(^{48}Ca)=2.07(22)  fm^{3}. Remarkably, the dipole response of ^{48}Ca is found to be very similar to that of ^{40}Ca, consistent with a small neutron skin in ^{48}Ca. The experimental results are in good agreement with ab initio calculations based on chiral effective field theory interactions and with state-of-the-art density-functional calculations, implying a neutron skin in ^{48}Ca of 0.14-0.20 fm.

Predicting difficulty in extending the ileal pouch to the anus in restorative proctocolectomy: investigation of a simple predictive method using computed tomography

AIM

This study aimed to assess the ability of preoperative axial computed tomography (CT) to predict surgical difficulty in bringing the ileal pouch to the level of the anus during restorative proctocolectomy (RPC).

METHOD

Patients who underwent RPC with an ileal pouch-anal anastomosis (or ileal pouch-anal canal anastomosis) in our institution between January 2008 and April 2014 were enrolled. The patients were divided into two groups, including those in whom CT indicated potential difficulty in extending the pouch downwards (extension difficult (ED) group) and patients with no CT evidence of potential difficulty (normal group). The groups were compared for clinical factors and the thickness of the slices of CT showing the root of the superior mesenteric artery, the point of communication of the ileocaecal artery with the marginal artery (tICA) and the anal verge (AV). Receiver-operating characteristic analysis was performed, and a cut-off value was calculated for predicting the degree of difficulty in bringing the ileal pouch down to the anal canal.

RESULTS

Thirty-four patients were entered in the study. The ED group included significantly taller patients and more with familial adenomatous polyposis than the normal group. The distance between tICA and AV was significantly longer in the ED group, with a cut-off of 21 cm giving a sensitivity of 100% and a specificity of 83.3%.

CONCLUSION

The distance between tICA and AV measured by axial CT can be a useful predictor for the difficulty in bringing the ileal pouch down to the anus during RPC.

Impact of hospital volume on risk-adjusted mortality following oesophagectomy in Japan

Background

Previous studies have reported that patients undergoing oesophagectomy in high-volume hospitals experience lower mortality rates. However, there has been ongoing discussion regarding the validity of evidence for this association. The purpose of this study was to investigate the relationship between hospital volume and risk-adjusted mortality following oesophagectomy in Japan, using a nationwide web-based database.

Methods

The study included patients registered in the database as having undergone oesophagectomy with reconstruction between 2011 and 2013. Outcome measures were 30-day and operative mortality rates. Logistic regression analysis was used to adjust for hospital volume, surgeon volume and risk factors for mortality after oesophagectomy.

Results

A total of 16 556 oesophagectomies at 988 hospitals were included; the overall unadjusted 30-day and operative mortality rates were 1·1 and 3·0 per cent respectively. The unadjusted operative mortality rate in hospitals performing fewer than ten procedures per year (5·1 per cent) was more than three times higher than that in hospitals conducting 30 or more procedures annually (1·5 per cent). Multivariable models indicated that hospital volume had a significant effect on 30-day (odds ratio 0·88 per 10-patient increase; P = 0·012) and operative (odds ratio 0·86 per 10-patient increase; P &lt; 0·001) mortality.

Conclusion

In Japan, high-volume hospitals had lower risk-adjusted 30-day and operative mortality rates following oesophagectomy compared with low-volume hospitals.

Candidate Resonant Tetraneutron State Populated by the ^{4}He(^{8}He,^{8}Be) Reaction

A candidate resonant tetraneutron state is found in the missing-mass spectrum obtained in the double-charge-exchange reaction ^{4}He(^{8}He,^{8}Be) at 186  MeV/u. The energy of the state is 0.83±0.65(stat)±1.25(syst)  MeV above the threshold of four-neutron decay with a significance level of 4.9σ. Utilizing the large positive Q value of the (^{8}He,^{8}Be) reaction, an almost recoilless condition of the four-neutron system was achieved so as to obtain a weakly interacting four-neutron system efficiently.

A novel screening test for detecting graft thrombosis after pancreatic transplantation using contrast-enhanced ultrasonography with sonazoid

Pancreatic graft thrombosis is the primary cause of nonimmunologic graft loss, with an incidence ranging from 5% to 15%. Therefore, developing a screening test to detect graft thrombosis after pancreatic transplantation is important. We created a screening test to assess graft thrombosis after pancreatic transplantation using contrast-enhanced ultrasonography (CEUS) with Sonazoid in addition to Doppler ultrasonography. A total of seven patients were examined using CEUS after undergoing pancreatic transplantation. All patients were observed to have a clear blood flow from the horizontal region to the peripheral region of the splenic vein in the pancreatic graft, and only one of the seven patients exhibited a blood flow in the horizontal portion of the splenic vein on Doppler ultrasonography performed immediately after pancreatic transplantation. Results from CEUS with Sonazoid showed the blood flow in the splenic vein and parenchyma of the pancreatic graft in detail, despite the slow and lateral blood flow in the splenic vein of the pancreatic graft immediately after transplantation.

Nonquenched Isoscalar Spin-M1 Excitations in sd-Shell Nuclei

Differential cross sections of isoscalar and isovector spin-M1 (0(+)→1(+)) transitions are measured using high-energy-resolution proton inelastic scattering at E(p)=295  MeV on (24)Mg, (28)Si, (32)S, and (36)Ar at 0°-14°. The squared spin-M1 nuclear transition matrix elements are deduced from the measured differential cross sections by applying empirically determined unit cross sections based on the assumption of isospin symmetry. The ratios of the squared nuclear matrix elements accumulated up to E(x)=16  MeV compared to a shell-model prediction are 1.01(9) for isoscalar and 0.61(6) for isovector spin-M1 transitions, respectively. Thus, no quenching is observed for isoscalar spin-M1 transitions, while the matrix elements for isovector spin-M1 transitions are quenched by an amount comparable with the analogous Gamow-Teller transitions on those target nuclei.

Objective assessment in digital images of skin erythema caused by radiotherapy

PURPOSE

Skin toxicity caused by radiotherapy has been visually classified into discrete grades. The present study proposes an objective and continuous assessment method of skin erythema in digital images taken under arbitrary lighting conditions, which is the case for most clinical environments. The purpose of this paper is to show the feasibility of the proposed method.

METHODS

Clinical data were gathered from six patients who received carbon beam therapy for lung cancer. Skin condition was recorded using an ordinary compact digital camera under unfixed lighting conditions; a laser Doppler flowmeter was used to measure blood flow in the skin. The photos and measurements were taken at 3 h, 30, and 90 days after irradiation. Images were decomposed into hemoglobin and melanin colors using independent component analysis. Pixel values in hemoglobin color images were compared with skin dose and skin blood flow. The uncertainty of the practical photographic method was also studied in nonclinical experiments.

RESULTS

The clinical data showed good linearity between skin dose, skin blood flow, and pixel value in the hemoglobin color images; their correlation coefficients were larger than 0.7. It was deduced from the nonclinical that the uncertainty due to the proposed method with photography was 15%; such an uncertainty was not critical for assessment of skin erythema in practical use.

CONCLUSIONS

Feasibility of the proposed method for assessment of skin erythema using digital images was demonstrated. The numerical relationship obtained helped to predict skin erythema by artificial processing of skin images. Although the proposed method using photographs taken under unfixed lighting conditions increased the uncertainty of skin information in the images, it was shown to be powerful for the assessment of skin conditions because of its flexibility and adaptability.