Kesato Iguchi

Limited thymectomy for stage I or II thymomas

BACKGROUND Once an anterior mediastinal tumor has been diagnosed as a thymoma, complete excision including the thymic gland and perithymic fat is currently the procedure of choice. However, little is known about the clinical outcome of grossly encapsulated thymomas excised only with the surrounding tissue while leaving a part of the thymic gland. METHODS A retrospective historical comparative study was conducted on 79 patients who had received surgery for stage I (n=25) or stage II (n=54) thymomas. Total thymectomy was performed in 61 patients (Total Thymectomy Group), whereas resection of tumors with only the surrounding tissue was carried out in 18 (Limited Thymectomy Group). The follow-up interval was longer in the Limited Thymectomy Group because these patients were treated longer ago (104.2+/-58.1 months vs 67.3+/-54.8 months, p<0.05). RESULTS One case in the Limited Thymectomy Group showed postoperative myasthenia gravis (5.6%). Two patients with multiple thymomas (2.5%) were treated with total thymectomy. One case in the Limited Thymectomy Group, which had been diagnosed as Masaoka stage II and WHO type B3 at initial surgery, recurred. None died of tumor progression in this study. Disease free survival rates at 10 years did not differ between the Limited Thymectomy and Total Thymectomy Groups (85.7% and 82.0%, respectively). There were no statistical differences in the incidence of postoperative myasthenia gravis and disease free survival between the two groups. CONCLUSION Resection of thymomas with surrounding tissue instead of total thymectomy can be indicated for stage I or II thymomas in light of disease free and overall survival, post-operative onset of MG, and the incidence of multiple lesions.

Video-Assisted Thoracoscopic Conservative Repair of Postoperative Lobar Torsion

Postoperative lobar torsion is a rare and life-threatening complication. Several previous cases have been treated with completion lobectomy. We report successful surgical repair of middle lobar torsion after upper lobectomy. On postoperative day 4, the middle lobe was rotated approximately 150 degrees counterclockwise. The surface of the middle lobe appeared congestive, but its surface color, elasticity, and compliance improved 1 h after detorsion. We preserved the middle lobar function and prescribed warfarin for pulmonary vein thrombosis. When preserving a twisted lobe, it is important to consider the damage to the twisted lung, risk of thrombosis, and residual pulmonary function.

Early-stage thymic carcinoma: is adjuvant therapy required?

Although the prognosis of advanced thymic carconoma remains poor, previous reports have shown survival rates of 70% to 100% in patients with Masaoka stage I or stage II of the disease who were treated with surgery followed by adjuvant therapy. However, the role of adjuvant therapy in these stages is controversial. We retrospectively evaluated the outcome of 4 patients with Masaoka stage II thymic carcinoma who were treated with surgery alone between 1992 and 2008. No patient had stage I of the disease. Primary tumors were preoperatively evaluated by chest X-ray and computed tomography. Needle biopsy was not performed because the tumors were clinically diagnosed as noninvasive thymomas. The largest diameter of the primary tumor was 65 mm. Mediastinal lymphadenopathy was not detected by computed tomography. All patients underwent transsternal thymectomy. Mediastinal lymph node dissection was not performed. None of the patients received adjuvant chemotherapy and/or irradiation. Histopathologic examination revealed squamous cell carcinoma in 3 patients and undifferentiated carcinoma in one. Pathologic invasion to the adjacent organs or lymph node metastasis was not detected. All patients were alive and free from relapse at a follow-up of 72 months (range, 12-167 months). Radical resection without adjuvant therapy could be a treatment option for early Masaoka stage thymic carcinoma with low-grade histology.

Mediastinal Mass in a Patient with IgG4-Related Disease

Introduction: IgG4-related disease is now considered to result from an imbalance in the regulatory immune system, and it is diagnosed on the basis of clinical and histopathologic evidence such as the presence of lymphoplasmacytic infiltrates, especially increased IgG4-positive plasma cells and fibrotic sclerosing tissue. Case report: We report herein a 45-year-old male patient with mediastinal mass with IgG4-related disease. IgG4-related disease can involve any organ but the most frequently involved sites include pancreato-hepatobiliary tract, salivary glands, and kidneys, generally manifesting as a mass in one or more sites mimicking a neoplasia. In the thoracic region, IgG4-related disease manifests as interstitial lung disease and fibrosing mediastinitis. Mediastinal lesion in our patient was quite resemble to mediastinal tumor derived from anterior mediastinum. This is the first case with mediastinal mass in a patient with this disease. Conclusion: Although very rare, we should rule out this disease as differential diagnosis in patients with anterior homogeneous density mediastinal mass simulating mediastinal tumor.

Chronic expanding hematoma in the chest: A case report

Chronic expanding hematoma (CEH) is a rare disease that is usually present as a large solitary pulmonary nodule. CEHs are slow growing, but processes underlying their development remain unknown. The present study herein reports the case of a 76-year-old male patient with CEH and discusses a number of CEH cases published in the literature. The majority of these previously described patients were Asians. The CEH in the present case was not a successfully resected one, but the patients clinical course provided information concerning the natural history of the disease. During the clinical course, the patient underwent several chest computed tomography scans. For the present case report, the doubling time and volume change of the mass was calculated, which revealed that the lesion had an inconstant growth rate and that its onset was between 8.2-11.0 years before the patient succumbed to this disease. Accumulation of knowledge about this rare disease will help to elucidate it further.

VATS and Intrapleural Fibrinolytic Therapy for Parapneumonic Empyema

With great interest, we read the article by Samancilar et al. on the efficacy of video-assisted thoracoscopic (VATS) and intrapleural fibrinolytic (IPFib) therapy in parapneumonic empyema treatment (February issue, Ann Thorac Cardiovasc Surg, 2018).1) We would like to ask four questions. First, the authors described the postoperative length of hospital stay.1) However, there is no description of required condition to discharge hospital. We suppose that disappearance of drainage and removal of chest tube must be requited before the discharge of hospital. However, one patient discharged with Heimlich valve.1) Please let us know the condition and timing. Second, the authors reported that the total blood count and coagulation parameters of the patients were checked before every IPFib therapy.1) Based on your experience, we would like to hear from the authors what are other tests than them to be done before performing of VATS deloculation (VATS-D) and IPFib? Is there a need to investigate the properties of pleural fluid by exploratory puncture? How about confirming coagulation and VATS and Intrapleural Fibrinolytic Therapy for Parapneumonic Empyema

Pulmonary metastasis from uterine leiomyosarcoma in a patient with limited cutaneous systemic scleroderma

A 51‐year‐old woman, who was diagnosed as having limited cutaneous systemic scleroderma, presented with pulmonary nodules incidentally detected in a chest radiograph. The patient had surgical biopsy of the nodules. In microscopic examination of the specimens, proliferation, mitotic activity, and cellular anaplasia of spindle cells were present. Fluorodeoxyglucose‐positron emission tomography showed tumors in lungs as well as uterus. The diagnosis of the tumor was pulmonary metastases from uterine leiomyosarcoma. We should be on alert the possibility of developing malignant disease in patient with this autoimmune disease. If it is certain that there is metastasis, we believe that therapy for the primary lesion will be preceded by biopsy and surgery for the metastatic lesions.