Pressure-volume curve of the remaining lung after lung resection

In order to evaluate ventilatory function of the remaining lung after lobectomy, using dogs, we measured the pressure-volume curve of the right lower lobe separately from the other lobes. The right lower lobe bronchus was surgically separated from the other bronchi and the expiratory volume of the right lower lobe was measured independently. The dogs were put in an airtight box. Transpulmonary pressure and expiratory volume in the right lower lobe were measured before lobectomy, after the left upper lobectomy and subsequently after the right upper and middle lobectomy. As a result, the esophageal pressure at endoexpiratory state became more subatmospheric following the lobectomies and the pressure-volume curves of right lower lobe shifted down to the right. Though the right lower lobe was intact after surgery, the pressure-volume curve shifted. This might be caused by the imbalanced postoperative volume of the lung and thoracic cage, and it is one of the problems remaining after lobectomy.     

Video-assisted thoracic surgery for left lung cancer in a patient with a right aortic arch

We report a rare case of left lung cancer in a patient with a right aortic arch. A 65-year-old woman was diagnosed to have an adenocarcinoma in the left upper lobe (S3) in addition to a right aortic arch (type II), with the left subclavian artery originating from the descending aorta. Left upper lobectomy and lymph node dissection was performed by video-assisted thoracic surgery (VATS). For the mediastinal dissection, the upper mediastinal lymph nodes were easily resected after verifying the location of the arterial ligament and the recurrent laryngeal nerve (RLN). This is the first report of using VATS to remove a lung cancer from a patient with a right aortic arch.     

Thoracoscopic right upper mediastinal dissection for left lung cancer

OBJECTIVE: In left lung cancer, left and right mediastinum lymphatic spread occur equally frequently. We evaluated the safety and effectiveness of thoracoscopic right upper mediastinal dissection, implemented prior to left lung resection for left lung cancer. METHODS: Between January 1999 and May 2000, 17 patients with left lung cancer underwent thoracoscopic right upper mediastinal dissection prior to resection of the left lung and left mediastinal dissection for left lung cancer. These patients had either enlarged left hilar or bilateral mediastinal nodes, or either a tumor at least 3 cm in diameter or tumor extension to the hilum, mediastinum, or chest wall. Tumor and lymph nodes were examined with hematoxylin and eosin and immunohistochemical staining of cytokeratin for micrometastasis. RESULTS: In 3 patients (17.6%), metastasis occurred in right paratracheal nodes. The 30-day mortality was 0% and morbidity 35.3% (6/17). Postoperative complications occurred in 3 of 4 patients (75%) undergoing induction chemotherapy, but none were lethal. CONCLUSION: Thoracoscopic right upper mediastinal dissection is safe and feasible in treating advanced left lung cancer.     

Extended operation for lung cancer invading the aortic arch and superior vena cava

Extended operation for lung cancer and mediastinal carcinoma involving the aortic arch or superior vena cava was performed in six patients. In three patients with lung cancer invading the right side of the mediastinum, sleeve pneumonectomy (two patients) or sleeve lobectomy was followed by resection and reconstruction of the superior vena cava with ringed polytetrafluoroethylene grafts. One patient with squamous cell carcinoma and T4 N1 M0 disease was alive and free of disease more than 34 months after the operation. The other patients with adenocarcinoma (T4 N1 M0) and adenosquamous cell carcinoma (T4 N2 M0) died 18 and 5 months after the operation of systemic metastases. In two patients with invasion of lung cancer into the left side of the mediastinum, resection and reconstruction of the aortic arch and left common carotid artery were performed by a femoro-femoral bypass. These patients had adenocarcinoma (T4 N2 M0) and large cell carcinoma (T4 N1 M0) and died of systemic metastases and bleeding during reoperation 12 and 4 months after the initial operation. In one patient with mediastinal squamous cell carcinoma, resection and reconstruction of the aortic arch and left subclavian artery were performed by application of a temporary bypass graft between the ascending and descending aorta. This patient was alive and free of disease more than 17 months after the operation.     

Synchronous primary intrapulmonary and mediastinal thymoma-A case report

We report an extremely rare case of Synchronous primary intrapulmonary and mediastinal thymoma in a Chinese patient. We describe the histological and radiological findings, which support the possibility of multicentric thymoma. Resection of the mass in the left anterior superior mediastinum and upper lobectomy of right lung were performed, with lymph Nodes clearance, superior vena cava, left and right brachiocephalic veins resection, reconstruction of left brachiocephalic vein to right auricle and reconstruction of right brachiocephalic vein to superior vena cava.     

Long-term survival following multimodality treatment of metachronous metastases (parotid gland, adrenal gland, brain and mediastinal lymph node) after resection of non-small cell lung cancer; report of a case

We describe a case of long-term survival following multimodality treatment of metachronous metastases (parotid gland, adrenal gland, brain and mediastinal lymph node) after resection of non-small cell lung cancer. A 72-year-old man had a past history of right upper lobectomy for pT3N0M0 tubular adenocarcinoma of the lung 12 years ago and left lower lobectomy for pT3N1M0 papillary adenocarcinoma of the lung 42 months ago, and left parotidectomy and irradiation to the neck for parotid metastasis 20 months ago. A progressive increase in serum CEA level during the follow-up period revealed a 5 cm left adrenal mass and small (1 cm or less) multiple brain metastases, and a 2 cm mediastinal lymph node. He underwent adrenalectomy and gamma knife surgery and received irradiation to the mediastinum, and was administered gefitinib as first-line chemotherapy for about a year. Brain metastases recurred despite 4 more rounds of gamma knife surgery and 4 cycles of docetaxel hydrate as second-line chemotherapy, and 1 cycle of vinorelbine ditartrate as third-line chemotherapy. He died of multiple brain metastases 65 months postoperatively. We confirm the possibility of long-term survival following multimodality treatment even though multiple organ metastases were found after resection of non-small cell lung cancer.     

Invasive thymoma in a child: a rare case report

Thymomas are neoplasms of the anterior mediastinum and generally occur between the fourth and sixth decades of life. In children, they are rare, with few reported cases. We describe a 9-year-old boy with invasive thymoma treated successfully by surgery alone. The patient was previously healthy and under treatment for a community-acquired pneumonia. A chest radiograph showed an opacity at the left lung base, and thoracic computed tomographic scan showed a mass with thick walls and liquid content situated in the lingula with no cleavage plane with the mediastinum. The patient underwent a left anterolateral thoracotomy, which showed a mass extending from the anterior mediastinum, infiltrating the left upper lobe of lung, phrenic nerve, and pericardium. A left upper lobectomy and resection of the mediastinal mass and lymph nodes were carried out. The pathologic analysis showed it to be a type B3 fusiform-cell thymoma, infiltrating the left upper lobe and 1 peribronchial lymph node. A multidisciplined tumor group decided to observe the patient and followed with thoracic computed tomographic scans every 3 months. After 2 years of follow-up, the patient has no evidence of recurrent disease.     

Radiographic Manifestations of Mediastinal Hemorrhage from Blunt Chest Trauma

The diagnosis of rupture of the thoracic aorta or its major branches depends largely on the recognition of mediastinal hemorrhage from the initial chest radiograph and subsequent thoracic aortography. This review discusses the radiographic manifestations of mediastinal hemorrhage, including widening of the mediastinum; a ratio of mediastinal width to chest width greater than 0.25; abnormalities of aortic contour; opacification of the aortopulmonary window; depression of the left main bronchus; deviation of the trachea to the right; deviation of the nasogastric tube to the right; the apical cap sign; widening of the paraspinal lines; widening of the right paratracheal stripe; and left hemothorax. The relationship of these manifestations to major thoracic arterial injury is examined. Pitfalls in the radiographic evaluation of mediastinal abnormalities are considered, and indications for computed tomography of the thorax and thoracic aortography in the severely injured patient are reviewed.     

Lung cancer associated with the right aortic arch; report of a case

We report a rare case of lung cancer associated with the right aortic arch. A 72-year-old male was admitted to our hospital for surgical treatment of squamous cell carcinoma arising from left B3. The patient had a right aortic arch with the type of mirror-image branching. He underwent a left upper lobectomy and lymph node dissection. We easily resected the lymph nodes in the left side of the upper mediastinum without rotating aortic arch because the aortic arch was positioned on the other side.     

Prognosis of completely resected pN2 non-small cell lung carcinomas: What is the significant node that affects survival?

OBJECTIVE: We analyzed the effect of the station of mediastinal metastasis with regard to the location of the primary tumor on the prognosis in patients with non-small cell lung cancer. METHODS: Of 956 consecutive patients who underwent operation for primary lung carcinoma between 1986 and 1996, 760 patients (79.5%) were diagnosed as having non- small cell carcinoma and were subjected to complete removal of hilar and mediastinal lymph nodes together with the primary tumor. RESULTS: The status of lymph node involvement was N0 in 480 patients (63.2%), N1 in 139 patients (18.3%), and N2 in 141 patients (18.6%). The 5- and 10-year survival of patients with N2 disease were 26% and 17%, respectively. Neither cell type nor the extent of procedure was a significant survival determinant. Patients having involvement of subcarinal nodes from upper-lobe tumors had a significantly worse prognosis than those patients with metastases only to the upper mediastinal or aortic nodes (P =.003). Patients with nodal involvement of the upper mediastinum from lower-lobe tumors had a significantly worse survival than those patients with metastases limited to the lower mediastinum (P =.039). Furthermore, patients with involvement of the aortic nodes alone from left upper-lobe tumors had a significantly better survival than those patients with metastasis to the upper or lower mediastinum beyond the aortic region (P =.044). CONCLUSIONS: When mediastinal metastasis is limited to upper nodes from upper-lobe tumor, to lower nodes from lower-lobe tumor, or to aortic nodes from left upper-lobe tumor, acceptable survival could be expected after radical resection.     

Gastropleural fistula due to gastric perforation after lobectomy for lung cancer

We report a case of acute gastropleural fistula due to gastric perforation after a left lower lobectomy for lung cancer. A 76-year-old male, who received a left hemicolectomy 20 years previously, came to our hospital for surgical treatment of lung cancer, which was performed uneventfully as a left lower lobectomy with combined resection of the diaphragm. On the postoperative day 2, acute dilatation of the stomach followed by gradual cardiopulmonary collapse, and then gastric perforation into the thorax occurred. The perforated stomach wall and diaphragm became paper-thin and necrotic, though the abdominal cavity was free of contamination. This life-threatening condition was treated by an emergency thoracotomy and partial gastrectomy through the thorax, as the left hemidiaphragm was remarkably elevated. An oeganoaxial torsion gastric volvulus caused by anatomic rotation following the lobectomy was speculated as the disease process, with loss of suspended tissue of the gastro-colic ligament from the left hemicolectomy being a possible predisposing factor. Such an episode is rare, however, it should be looked for during perioperative care following a lobectomy.     

A case of teratoma in both the mediastinum and the intrapulmonary system

A rare case of mature teratoma in both the mediastinum and the intrapulmonary system is presented. A 30-year-old male was admitted to our hospital due to tumor masses in the mediastinum and the left lung. We performed mediastinal tumor resection and left upper partial lobectomy. Neither tumor communicated with each other. Pathological findings revealed teratoma in the mediastinal lymph node and the intrapulmonary system including no malignant cells in either tumor. In this case, because metastasis and perforation were negative, we proposed that both tumors occurred at the same time in the early embryo.     

Mediastinal solitary fibrous tumor with right diaphragm invasion: Report of a case

Mediastinal solitary fibrous tumors (SFTs) are rarely found in adults and there are few reports describing primary mediastinal SFT invading the diaphragm. We report the case of a 47-year-old woman with a large right inferior mediastinal SFT. Magnetic resonance imaging showed the tumor invading the right lower lobe of the lung and the right hemidiaphragm, with displacement of the inferior vena cava (IVC) and right lobe of the liver. Angiogram showed IVC stenosis. To our knowledge, this is the first report of complete resection of the tumor combined with right lower lobectomy of the lung and partial resection and reconstruction of the right diaphragm with a Dacron flap.     

Thoracic stent-graft herniation through the aortic wall in a case of lung cancer

A 67-year-old man had left upper lung cancer with invasion into the descending aorta. He underwent pre-emptive thoracic endovascular aortic repair using a Valiant Navion followed by left lung upper lobectomy with resection of the aortic wall. Because of continuous bleeding, he underwent re-thoracotomy. Since the surgically resected aortic wall was largely cleaved, bleeding around the stent-graft that herniated into the left pleural cavity was observed. Re-thoracic endovascular aortic repair using a GORE TAG was immediately performed to prevent further stent-graft herniation and impending lethal haemorrhage. It may be necessary to consider reinforcement of the resected aortic wall to prevent thoracic endovascular aortic repair-related complications.     

肺叶、肺段淋巴结引流的解剖学特征

目的探讨肺叶、肺段淋巴结引流的解剖学特征。 方法对9具成人尸体采用解剖乳胶填充剂行胸部淋巴结灌注,然后游离标本的纵隔前、纵隔后及中纵隔淋巴结,同时游离并清扫右肺上、中、下肺叶和各个肺段,以及左肺上、下肺叶和各个肺段的肺内淋巴结、肺门淋巴结;观察淋巴结的分布、数目和淋巴回流状况。 结果在标本上共观察到212个纵隔淋巴结,平均每例23.5个;各区淋巴结的数目以隆突下淋巴结7区和右下气管旁4R最多,其次为右气管支气管旁(10R)、左支气管旁(10L)和主-肺动脉窗区(5区)淋巴结;纵隔各区以隆突下区(7区)淋巴结最大,其次是右气管支气管旁(10R)淋巴结,气管旁淋巴结自上而下直至隆突下淋巴结逐渐增大,并且右侧大于左侧,即下大于上,右大于左。左肺和右肺的肺内淋巴结一般按照亚段淋巴结→段淋巴结→叶淋巴结→叶间淋巴结/肺门淋巴结;右肺上叶、中叶及肺门淋巴结通常回流至上纵隔淋巴结及隆突下淋巴结,下叶回流至下纵隔淋巴结。而左肺上叶一般引流至主—肺动脉窗区淋巴结及隆突下淋巴结,下叶也引流至下纵隔淋巴结。 结论肺叶及纵隔淋巴回流具有一定的规律性,从而为肺叶特异性/系统性淋巴结清扫方式的选择提供了解剖学依据。     

Median approach for upper lobe lung cancer patients with suspected anterior mediastinal invasion

We report the usefulness of a median approach to the mediastinum for the treatment of lung cancer with possible mediastinal invasion. Patient was a 74-year-old man with left S3 squamous cell carcinoma suspected of anterior mediastinal invasion (cT4N0M0) because of hoarseness before surgery. A median sternotomy with partial collar incision was chosen for surgery. The tumor was widely adherent to the anterior mediastinum, invading the common carotid artery and the origin of the left subclavian artery. Left upper lobectomy with ND2a by incomplete resection of the invading portion followed by postoperative radiotherapy was performed. For upper lobe lung cancer with possible mediastinal invasion, a median approach seems to be useful, because it facilitates both easy approach to the anterior mediastinum and the management of invasion of large vessels.     

Descending necrotizing mediastinitis with sternocostoclavicular osteomyelitis and partial thoracic empyema: Report of a case

We present herein the case of a 50-year-old woman in whom descending necrotizing mediastinitis originating from an anterior neck abscess spread to the left upper bony thorax, resulting in osteomyelitis of the left sternocostoclavicular articulation and left partial thoracic empyema. Transcervical mediastinal irrigation and drainage was performed with aggressive antibiotic therapy, followed by resection of the left sternocostoclavicular joint and debridement of the anterior mediastinum. The patient had an uneventful postoperative course, and her left arm and shoulder mobility was well preserved.     

Long-term survival cases of lung cancer presented as solitary bone metastasis.

The prognosis of non-small cell lung carcinoma (NSCLC) with bone metastasis has been regarded as very poor. We report herein on two cases of NSCLC which presented as a solitary bone metastasis, were treated with surgical resection. Both these cases survived for over 5 years after their last operations. A 71-year-old-man was hospitalized with right crural pain. A diagnosis of squamous cell carcinoma of the left lower lobe with right fibula metastasis was made. A marginal resection of the right fibula was performed. After that, a left lower lobe lobectomy and systemic chemotherapy were carried out. He had a local recurrence in the right mediastinal lymph nodes eleven months after the operation. He received intraluminal and external radiation therapy and obtained complete remission. He has survived for 5 years without any other recurrence or metastasis. A 52-year-old-man was admitted to our hospital with left thigh pain. A diagnosis of adenocarcinoma of the right upper lobe with left thigh metastasis was made. A right upper lobe lobectomy and a resection of the left thigh tumor were performed. Three cycles of systemic chemotherapy were given after that. He has survived for 5 years since his last operation without any recurrence or metastasis.     

Recurrence in regional pulmonary lymph nodes after surgery for isolated pulmonary metastasis from hepatocellular carcinoma

Hepatocellular carcinoma occasionally metastasizes to extrahepatic organs, rarely to the mediastinal lymph nodes. We present the case of a 64-year-old man who presented with nodules in the upper and right lower lobes of the lung 4 years after undergoing resection of a hepatocellular carcinoma. We performed wedge resection of both lesions. Pathological examination showed that the lesion in the right upper lobe was non-small cell lung cancer and that in the right lower lobe hepatocellular carcinoma. We accordingly performed right upper lobectomy with lymph node dissection. Nine months later, enlarged subcarinal and segmental lymph nodes were detected and mediastinal lymph node metastases from the hepatocellular carcinoma diagnosed by transbronchial needle aspiration.     

Successful lingular segmentectomy using bronchoplasty in a patient with early hilar second primary lung carcinoma

A 71-year-old man was admitted to our hospital with a small protrusive lesion at the lingular orifice of the left upper bronchus. He had undergone a right lower lobectomy and mediastinal dissection for lung carcinoma (large cell carcinoma, pT1N0M0) 14 months earlier. Early hilar squamous cell carcinoma was diagnosed by chest radiograph, CT and transbronchial biopsy. We performed a lingular segmentectomy with wedge resection of the left upper bronchus and N 1 lymph node dissection. The tumor was histopathologically diagnosed as early hilar second primary lung carcinoma. The patient's postoperative course was uncomplicated. At present, he is alive with good respiratory condition and without any evidence of recurrence. Segmentectomy is appropriate for a patient with contralateral second primary lung carcinoma as well as a patient with early hilar lung carcinoma. Bronchoplasty seems to increase the likelihood that such a patient will be a candidate for segmentectomy.