Masahito Naito

Report of a rare case: occult hemothorax due to blunt trauma without obvious injury to other organs.

Traumatic hemothorax commonly occurs accompanied by organ damage, such as rib fractures, lung injury and diaphragm rupture. Our reported patient was a 61-year-old man who fell down from a stepladder about 1 meter in height, resulting in a heavy blow to the left abdomen. He consulted a clinic because of left chest pain the next day and was transported to the emergency center of our hospital on diagnosis of hemothorax with hemorrhagic shock.On computed tomography scanning with contrast medium, left hemothorax without rib fracture, diaphragm rupture or obvious organ injury was evident. We found only bleeding to the thoracic space from a branch of the left inferior phrenic artery without involvement of the abdomen. The patient underwent percutaneous angiography and embolization for hemostasis, and subsequently thoracotomy in order to check the active bleeding and remove the hematoma to improve respiratory. As thoracotomy findings, we found damage of a branch of the left inferior phrenic artery to the thoracic space without diaphragm rupture, and sutured the lesion. Such active intervention followed by surgical procedures was effective and should be considered for rare occurrences like the present case. We must consider not only traumatic diaphragm rupture, but also vascular damage by pressure trauma as etiological factors for hemothorax.

Microenvironmental changes in the progression from adenocarcinoma in situ to minimally invasive adenocarcinoma and invasive lepidic predominant adenocarcinoma of the lung

OBJECTIVES Invasive lepidic predominant adenocarcinoma (LPA) of the lung is thought to progress in a stepwise fashion from adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA). The aim of this study was to investigate the microenvironmental changes during the development from AIS to LPA. MATERIALS AND METHODS Clinicopathological characteristics of AIS (n=51), MIA (n=59), LPA smaller than 3cm (LPA-S, n=113), and LPA larger than 3cm (LPA-L, n=47) were analyzed. We then evaluated the expression levels of epithelial-mesenchymal transition (EMT)-related molecules (E-cadherin, S100A4), invasion-related molecules (laminin-5, ezrin), stem-cell-related molecules (ALDH-1), and growth factor receptors (c-Met, EGFR) in cancer cells of each group (n=20). The number of tumor-promoting stromal cells, including podoplanin-positive cancer-associated fibroblasts (PDPN+ CAFs), CD204-positive tumor-associated macrophages (CD204+ TAMs), and CD34+ microvessel cells, were also analyzed. RESULTS No significant difference in these characteristics was found between LPA-S and LPA-L. Laminin-5 expression in the non-invasive carcinoma component of MIA was significantly higher than that of AIS (p<0.001). During the progression from MIA to LPA-S, the expression level of laminin-5 in the invasive carcinoma component was significantly elevated (p<0.01). Moreover, tumor-promoting stromal cells were more frequently recruited in the invasive area of LPA-S (PDPN+ CAFs; p<0.05, CD204+ TAMs; p<0.001, CD34+ microvessel; p<0.05). Ezrin expression in the invasive carcinoma component of LPA-L was significantly increased (p<0.05) compared to LPA-S; however, the number of tumor-promoting stromal cells were not different between these two groups. CONCLUSION Our current results indicated that microenvironmental molecular changes occur during the progression from MIA to LPA-S and suggested that this process may play an important role in disease progression from AIS to LPA.

Effect of adjuvant chemotherapy after pulmonary metastasectomy on the prognosis of colorectal cancer

Background Adjuvant chemotherapy after resection of colorectal cancer (CRC) lung metastases may reduce recurrences and improve survival. We investigated the effects of adjuvant chemotherapy after curative resection of lung CRC metastases on prognosis. Methods We retrospectively reviewed records of our patients undergoing pulmonary metastasectomy from CRC between January 2000–March 2014. Data were analyzed with Kaplan-Meier survival analysis and Cox proportional hazards models. Results One-hundred (56 men; median age, 66 years) of 128 consecutive patients who underwent complete resection for first lung colorectal metastases were analyzed. Postoperative 5-year rates of overall survival (OS) and relapse-free survival (RFS) were 76% and 41%, respectively. Adjuvant chemotherapy strongly affected RFS and OS by multivariable analysis compared to surgery alone (RFS: HR, 0.49; 95% CI, 0.27–0.88; P = 0.016 and OS: HR, 0.35; 95% CI, 0.14–0.81; P = 0.014). Similar effects of adjuvant chemotherapy occurred in subgroups respectively classified according to number of lung metastases and preoperative serum carcinoembryonic antigen (CEA) level. Conclusions Adjuvant chemotherapy after curative resection of lung metastases might strongly affect the prognosis of metastatic CRC patients. Even patients with single metastatic lesions and normal preoperative CEA level appeared to receive benefits from such chemotherapy. Narrowing of suitable candidates by predicting the effects of systemic chemotherapy and prospective randomized studies are needed.

Pulmonary torsion after open esophagectomy for esophageal cancer: a case report and review

Pulmonary torsion (PT) is an extremely uncommon event (1-4). Although PT is known to occur only rarely after lung resection, we now know that it can also occur after other thoracic procedures such as cardiac, esophageal, and chest trauma surgery and, spontaneously, after chest trauma itself (3-11). A delay in diagnosis and/or an improper treatment strategy can lead to serious complications (3,4,10-15). In this report, we describe a case of PT, discuss what we learned about methods of early diagnosis and appropriate treatment strategies from our experience, and review the literature.

Feasible and promising modified trans-subxiphoid thoracoscopic extended thymectomy for patients with myasthenia gravis

Background We have used a promising, minimally invasive thoracoscopic technique of extended thymectomy for patients with myasthenia gravis (MG). The aim of this study was to report our promising technique, a modified single-port trans-subxiphoid approach (MTXA) and to compare perioperative outcomes and effects on MG between our approach and sternotomy. Methods We retrospectively reviewed records of all patients undergoing extended thymectomy for MG and/or thymoma between January 1, 2010 and December 31, 2016. The patients were divided into the MTXA group and Sternotomy group. Results Of the 50 consecutive patients undergoing extended thymectomy for MG, finally, 13 patients undergoing our MTXA extended thymectomy technique were compared with 20 patients undergoing extended thymectomy via sternotomy. Intraoperative blood loss, postoperative length of stay, and C-reactive protein value on postoperative day 1 were significantly more favorable in the MTXA group than the Sternotomy group (P<0.0001, P=0.0040 and P=0.0073, respectively). Furthermore, no significant differences in the frequency of patients with improvement of their Quantitative Myasthenia Gravis score and/or MG-Activities of Daily Living scale, decrease in the serum level of acetylcholine receptor antibody, and dose reduction of oral prednisone were seen between the two groups. Conclusions Our approach to extended thymectomy might be more favorable than sternotomy in patients with MG.

Molecular alterations in a new cell line (KU-Lu-MPPt3) established from a human lung adenocarcinoma with a micropapillary pattern

PurposeLung adenocarcinomas with a micropapillary pattern (MPP) are characterized by more frequent and pronounced vascular invasion, higher incidence and more advanced lymph node involvement and poorer prognosis than papillary adenocarcinomas without an MPP. Here we established a new lung cancer cell line featuring micropapillary structure.MethodsA 73-year-old never-smoker Japanese female, presenting with an abnormal chest shadow, was diagnosed with a clinical T2aN0M0 Stage IB lung adenocarcinoma and underwent left upper lobectomy with mediastinal lymph node dissection. Pathological study demonstrated a T2aN2M0 Stage IIIA micropapillary adenocarcinoma. Tumor cells were obtained from freshly resected lung material and used to establish the KU-Lu-MPPt3 cell line.ResultsThe KU-Lu-MPPt3 cells featured adherent monolayers, adherent tufts, and suspended tufts without adhesion under the same culture conditions. The cells were positive for cytokeratin, epithelial cell-adhesion molecules, E-cadherin, mucin-1, thyroid transcription factor-1, vimentin, and anti-programmed death ligand 1. Xenograft tumors clearly demonstrated micropapillary structures. Sequencing and fragment analysis of the epidermal growth factor receptor in the primary tumor tissue and KU-Lu-MPPt3 cells revealed an in-frame deletion E746-A750 in exon 19.ConclusionsThis cell line represents a new model system for molecular studies of lung adenocarcinoma which may be suitable for investigation of cancer spread and also for development of molecular-targeting and immunotherapies, both in vitro and in vivo.

Lung metastases of a uterine tumor resembling ovarian sex‐cord tumor: Report of a rare case

Uterine tumor resembling an ovarian sex‐cord tumor (UTROSCT) is a rare type of uterine neoplasm. We present an extremely rare case of lung metastases from a UTROSCT focusing on the cytologic features. A 69‐year‐old Japanese woman was admitted to our hospital for further examination and treatment for abnormal shadows in the right lung field. She had a history of total hysterectomy for UTROSCT. Moreover, she underwent wedge resection of the right middle lobe for lung metastasis of UTROSCT in 2011. Enhanced chest computed tomography scan revealed a solid nodule 8 mm in diameter in the right upper lobe and a well‐demarcated 33‐mm mass or nodule in the lower lobe. Under the diagnosis of metastatic tumors from UTROSCT, she underwent wedge resection of the right upper lobe and segmentectomy of the right S8. Cytologically, the stump smear from the resected tumors revealed round to short spindle‐shaped neoplastic small cells arranged in sheets with poor cohesion and no cluster formation. The nuclei were irregular in shape, and the chromatin was finely granular, uniform, and increased. Mitotic figures were not observed. Necrosis was absent in the background. Histologically, the final diagnosis was UTROSCT group II. This is an unusual case of metastatic UTROSCT to the lung in which the cytologic features are described.

Prognostic impact of uncertain parietal pleural invasion at adhesion sites in non-small cell lung cancer patients

OBJECTIVES Pleural invasion has been recognized as an important negative prognostic factor in non-small cell lung cancer (NSCLC), and therefore, accurate evaluation is required. However, when the visceral pleura adheres to the parietal pleura around a tumor and parietal pleural structures are destroyed and unrecognizable as a result of inflammation, it is often difficult to accurately evaluate pleural invasion, and classification of the T stage is unclear. To aid in categorization, we defined this status as pl1-3 and investigated the prognostic impact of the pl1-3 status on NSCLC. MATERIALS AND METHODS We retrospectively examined the clinicopathological characteristics and prognoses of 929 NSCLC patients who underwent curative surgical resection. The pl1-3 status was defined as invasion beyond the elastic layer of the visceral pleura (pl1 or higher) but showing unclear parietal pleural invasion. We compared the prognoses of pl1-3 status NSCLC patients with that of patients with other pleural invasion statuses. RESULTS Thirty-one patients (3%) had a pl1-3 status. The 5-year overall survival rate for pl1-3 patients was 58.9%, and the prognosis was significantly worse than pl1 (p=0.04). In pN0 cohort, pl1-3 disease had a significantly worse prognosis than pl1 and pl2 diseases (p=0.01 and 0.04, respectively) and a similar prognosis to pl3 disease. Furthermore, similar relationships were also observed after adjusting for other prognostic factors in multivariate analysis. Among the pl1-3 and pN0 patients, 11 (46%) developed recurrences (9 patients had distant metastasis, one had local recurrence, and one had both). Although the proportion of pl1-3 patients who underwent adjuvant therapy was similar to that of T3 patients, more individuals received oral tegafur-uracil treatment than intravenous chemotherapy. CONCLUSION These results indicate that pl1-3 patients can be managed in the same manner as patients with T3 and pl3 disease. These results may be informative for treatment decisions during postoperative chemotherapy.

Spontaneous non-traumatic mediastinal hematoma associated with oral anticoagulant therapy: A case report and literature review

Highlights • Spontaneous mediastinal hematoma is rare but can occur in patients taking anticoagulants.• Diagnosis in an early state is difficult, unless clinicians recognize and suspect this condition.• Although conservative therapy is often effective, active surgical intervention is occasionally needed.• We should be aware of this entity as a potential complication of anticoagulant therapy for prompt and proper management.