Masaya Aoki

Pulmonary Metastasectomy 31 Years After Surgery for Renal Cell Carcinoma

An 82-year-old man underwent a left upper lobectomy for a solitary tumor on suspicion of lung cancer. Histopathologic findings of the resected specimen showed clear cell renal cell carcinoma, which was diagnosed as a metastasis from kidney cancer concealed for 31 years after nephrectomy. The Ki-67 labeling index of the metastatic tumor was high (36.1%). A few cases of recurrent renal cell carcinoma after a long interval from initial diagnosis have been seen. However, pulmonary metastasectomy more than 30 years after radical nephrectomy for renal cell carcinoma has not been reported. This remarkable case provides new and valuable clinical insights into metastatic renal cell carcinoma.

Potentially overlooked branches of the left pulmonary artery

Background During pulmonary resection, we sometimes encounter “pitfall branches” of the pulmonary artery, which could cause serious vessel injury. Current computed tomography and computer-processing technology can identify the pulmonary artery along the peripheral bronchus, thereby revealing the true rates of different pulmonary artery branching patterns. Knowledge of these branching patterns allows safe and definitive surgery. Methods In 186 cases of left lung resection performed at our institution from January 2006 to September 2011, two general thoracic surgeons and one radiologist independently reviewed computed tomography images and examined the branches of the pulmonary artery arising from the pars mediastinalis. Results Branching patterns of the lingular artery included 17 (9.2%) cases with mediastinal origin, 50 (26.9%) with interlobar and mediastinal origin, and 119 (63.9%) with interlobar origin. The 2 types of lingular artery of mediastinal origin, which were potentially overlooked during surgery, were observed in 36.1% of cases. This was a higher rate than previously reported. Moreover, a mediastinal basal pulmonary artery (A5+8+10 abnormal branching) was seen in one case. Conclusion Potentially overlooked branches of the left pulmonary artery arising from the pars mediastinalis are much more frequent than we expected. It is crucial to understand the branching pattern of the pulmonary artery by preoperative computed tomography assessment.

A Case of Nontuberculous Mycobacteria Highly Suspected as Lung Cancer Invading the Aortic Arch.

1118 Journal of Thoracic Oncology ® • Volume 10, Number 7, July 2015 CASE PRESENTATION A 65-year-old man presented with cough and hoarseness for 3 months and was admitted to our hospital. Chest computed tomography revealed tumor around the aortic arch. Fluorodeoxyglucose positron emission tomography showed an accumulation in the same area of maximum standardized uptake value of 10.8 (Figs. 1, 2). Although endobronchial ultrasound-guided transbronchial needle aspiration failed to obtain a histological diagnosis, mediastinal type lung cancer with aortic invasion was strongly suspected. Therefore, videoassisted thoracoscopic surgery was conducted. Because of lung adhesions, both the aortic arch and left main pulmonary artery were difficult to identify. Therefore, to avoid aortic injury, biopsy sites were restricted. We obtained two puncture biopsies, but could not obtain a histological diagnosis. Moreover, we could not obtain a diagnosis by permanent specimen. However, polymerase chain reaction using a biopsy specimen revealed the presence of Mycobacterium intracellulare deoxyribonucleic acid. Mycobacterial culture also showed the same result. Thus, we started to treat the patient for nontuberculous mycobacteria (NTM) with clarithromycin 800 mg, rifampicin 450 mg, and ethambutol 750 mg on a daily basis. As shown in Figure 3, the abnormal shadow was significantly improved. Mycobacterium intracellulare is one cause of NTM. Polymerase chain reaction can lead to a rapid confirmation of the pathogen. NTM is an atypical mycobacterial infection that can occur in both immunocompromised and immunocompetent patients. The prevalence of NTM in Japan is 5.7 people for a population of 100,000 people. Every year approximately 1000 human deaths are reported, and the NTM is the disease that we usually see in Japan. As Maekawa et al. already reported, soil exposure is one of the environmental risk factors in immunocompetent patients. As a therapeutic drug for NTM, unlike tuberculosis, multidrug therapy containing clarithromycin or azithromycin, ethambutol and rifamycin is used without using isoniazid. The sputum conversion rate in clarythromycin and azithromycin were 68 and 56%, respectively, and the efficacy is more restrictive than tuberculosis. We experienced a case that was highly suspected as mediastinal type lung cancer invading the aortic arch based on computed tomography images but turned out to be NTM. Not only malignancy but

Detection of alternative subpleural lymph flow pathways using indocyanine green fluorescence

PurposePulmonary lymphatic fluid predominately flows along the bronchi. However, there are reports suggesting that an alternative lymphatic pathway exist, which may result in skip metastases. The aim of this study was to evaluate the subpleural lymph flow in vivo using indocyanine green (ICG) fluorescence.MethodsOne hundred cases were enrolled. ICG was injected into the macroscopically healthy subpleural space. Intraoperative fluorescence images were then observed in real time.ResultsICG fluorescence was observed moving through subpleural channels in 58/100 cases. ICG flowed into adjacent lobes over interlobar lines in 18 cases and flowed from the visceral pleura directly into the mediastinum in 5 cases. The frequency of mediastinal detection without hilar lymph node detection was significantly higher in the left lung compared to the right (p < 0.05). The subpleural lymph flow detection rates were significantly lower in patients with smoking pack-years ≥ 40 than those with < 40 (p < 0.05).ConclusionsThe flow of lymphatic fluid directly into the mediastinum suggests one mechanism of skip metastasis. In addition, the reduction of the subpleural lymph flows in smokers with ≥ 40 pack-years suggests that smoking might modify lymph flow patterns. These findings may assist in selecting the optimal therapy for patients with possible skip metastasis.

P2.01-08 Conversion Surgery for Locally Advanced Lung Adenocarcinoma Harboring Driver Gene Mutation After TKI Followed by Cytotoxic Agent

was conducted to compare gender-based post diagnosis survival and disease progression. Statistical significance was 95% confidence level (p < 0.05). Result: Among 7738 lung cancer patients, 95.6% (3743/ 7738) were NSCLC: 52% male and 48% female. Significant genderbased differences were observed in histology (p1⁄40.00). SCC and ADC were the most frequent histology in both genders. However, ADC was commoner in women (49% vs 41%), while SCC was commoner in men (27% vs 17%). Relative changes of ADC rate over 15 years have increased significantly among women compared to men (58% vs 32%, P<0.02). The risk of developing NSCLC was greatly elevated with cigarette consumption in both genders; however, ADC in never smokers was higher in women (18%) compared to men (8%). Among ADC, smoking history and gender both showed a significant effect on survival, where mOS for never-smokers females exceeded that of neversmokers males [20 months vs 14 months, 95%CI, P1⁄40.00]. The same trend was also seen in smokers [13 months vs 7 months, 95%CI, P1⁄40.021]. In addition, the OS among male ADC cases was significantly lower than women of all tumor stages (P1⁄40.00), but these disparities were insignificant across genders with SCC (P1⁄40.46). Conclusion: Similar to what we observed in our systematic review, gender influences the clinical course of NSCLC regardless of smoking history or stage in Southern Alberta. Identifying the cause of the increase in ADC rate over 15 years in women and higher prevalence of NSCLC in never smoking women warrants aggressive research strategies.

Coil Intrabronchial Migration in an Arteriovenous Malformation Patient Treated 10 Years Ago

A 56-year-old male who had received transcatheter coil deposition 10 years ago for an arteriovenous malformation (AVM) was admitted to our hospital because of persistent hemosputum. Chest radiograph and bronchoscopy revealed straightened coil bundles in his air way. Recently, less invasive transcatheter intervention has been performed more frequently for treatment of AVM than surgical resection. In our case, however, chest radiography and bronchoscopy showed that the coils might migrate from the deposited site to the airway. Then, right lower lobectomy was undertaken. In AVM patient who received coil deposition, a long-term follow-up is recommended, and surgical resection should be carried out if necessary.

Lung abscess mimicking lung cancer developed around staples in a patient with permanent tracheostoma

Abstract A 68-year-old male with a tracheostoma due to hypopharyngeal cancer was admitted because his chest computed tomography (CT) showed a small nodule in the right middle lobe. Following a partial resection of the right middle lobe, histopathological diagnosis of the resected sample was that of organizing pneumonia. Eleven months later, chest CT showed a mass with pleural indentation and spiculation in the right middle lobe. 18-Fluorodeoxyglucose-positron emission tomography showed significant accumulation in the middle lobe tumor mass shadow. The abnormal chest shadow that had developed around surgical staples suggested inadequate resection and tumor recurrence. As the abnormal radiological shadow was enlarging, middle lobectomy was carried out. Histological examination revealed that the tumor was a lung abscess without malignant features. This is a unique case of lung abscess mimicking lung cancer which developed around staples used during partial resection of the lung.

Successful closure of a tracheocutaneous fistula after tracheostomy using two skin flaps: a case report.

A tracheocutaneous fistula may develop when a tracheostomy orifice epithelializes during a prolonged course of healing or undernutrition. Various techniques for closing such fistulae have been reported. However, a standard procedure has not yet been established. We, herein, present a case involving a 35-year-old woman who developed a tracheocutaneous fistula after tracheostomy. We closed the fistula using two skin flaps to cover the tracheal lumen and skin defect, respectively. The advantage of this technique is that it allows the tracheal lumen to be covered by inversed skin epithelium and ensures that the suture line of the skin does not match up with that of the subcutaneous tissue.

A case of resected plasma cell type castleman's disease with intramediastinal lymph nodes spread.

We report a case of resected plasma cell (PC) type Castlemans disease (CD) in a 21-year-old female who had an anterior mediastinal mass with additional surrounding nodules. She was aware of low-grade fever and fatigue for several years. From hematological and biochemical examinations, elevated inflammatory responses and levels of serum IgG (2908 mg/dL) and IL-6 (22.2 pg/mL) were observed. She was diagnosed with PC type CD by needle biopsy under computed tomography (CT) guidance. It was thought that the lesion was localized in the mediastinum. Then, mediastinal adipose tissue including the tumor, additional nodules and thymus were removed. The histological findings of PC type CD were found not only in the main tumor but also in surrounding swollen lymph nodes. Her symptoms improved and inflammatory responses decreased after the operation. No recurrence has been observed for 5 years after the operation.