Extended operation for non-small-cell lung cancer invading into the liver.

Direct invasion of a lung cancer into the liver is rare. Here we report a case with a non-small-cell lung cancer invading through the diaphragm into the liver. A 77-year-old woman was admitted to our hospital with a complaint of right chest pain. Chest X-ray showed a 10-cm shadow in the right lower lung field. Chest CT demonstrated a large heterogeneous tumor located in the right lower lobe of the lung. Chest MRI revealed the tumor directly invading through the diaphragm into the liver. Bronchoscopic biopsy revealed squamous cell carcinoma. Surgical resection was performed to prevent intrapulmonary rupture of the necrotic contents. A right lower lobectomy was performed with partial resection of the diaphragm, liver and chest wall. Marlex mesh was used to reconstruct the diaphragm and chest wall. The patient was discharged on the 23rd postoperative day without complications, but died 4 months later from bilateral pulmonary metastases. Invasion to the diaphragm and liver may increase the risk for hematological spread. Although there are limited reports on treatment options, combined resection of the liver should be considered in the case of non-small-cell lung cancer invading the liver, particularly in c-N0M0 case.     

Combined thoracoscopic and open chest approach of lobectomy with inferior chest wall resection for advanced lung cancer

Patients with advanced non-small cell lung cancer invading a chest wall are surgical candidates if complete resection is possible. When a primary tumor locating the lower lobe invades an inferior chest wall, either a wide skin incision or double skin incisions to secure surgical views both for dissection of hilum and mediastinum and for inferior chest wall resection is necessary. Wider incision causes higher rate of wound necrosis and infection. We describe a combined approach of thoracoscopic and open chest surgery for lobectomy and inferior chest wall resection, respectively. Patient was a 68-year-old man with an advanced non-small cell lung cancer. Video-assisted thoracoscopic middle and lower lobectomies and mediastinal nodal dissection was completed via 5 ports. Chest wall resection including the posterior portion of the 9th and 10th ribs and the transverse process followed inferior postero-lateral thoracotomy. Postoperative course was uneventful. The present surgical approach can avoid a wide thoracotomy for an advanced lung cancer invading an inferior chest wall.     

Combined hepatic resection with the inferior vena cava and diaphragm and reconstruction using an equine pericardial patch: Report of a case

We herein report a case of combined hepatic resection with inferior vena cava (IVC) and diaphragm resection, and reconstruction using an equine pericardial patch. A 54-year-old woman showed hepatic cancer recurrence on radiological imaging, with invasion to the caudate lobe of the liver, IVC, diaphragm, and adrenal gland. We resected 10 × 5 cm of the diaphragm. After dissecting the hepatic parenchyma, the caudate lobe was connected only to the IVC. Clamping of the IVC was performed between the IVC below the confluence of the hepatic vein and the suprarenal IVC. A 6 × 3-cm segment of the IVC was then resected. The IVC and diaphragm were reconstructed using an equine pericardial patch, as both defects were too large to repair without a patch. The equine pericardium represents a suitable graft material for repairing both the IVC and diaphragm. Further investigation is needed to determine the durability and anti-infection properties of equine pericardial grafts.     

Thymoma with synchronous pulmonary metastasis; report of a case

We report a resected case of thymoma with a solitary pulmonary metastasis. A 63-year-old woman had pointed out a solitary nodule in right lung field on chest X-ray. Computed tomography (CT) scan showed an anterior mediastinal tumor and a solitary lung nodule in the right lower lobe. Extended thymectomy and partial resection of right lung was performed. Pathological diagnosis showed an invasive thymoma (type B3) and a pulmonary metastasis. Post operative radiotherapy was administered and she is doing well 19 months following the resection. Thymoma with a solitary synclonous pulmonary metastasis is rare and is classified into Masaoka stage IVb. Generally, thymoma cases with distant metastasis are not indication for operation. But, if radical resection is possible, operation is recommended for good prognosis.     

Extension incision for renal carcinoma including invaded vena cava and right lobe of liver.

We report on a thirty-five-year-old woman with renal cell carcinoma who successfully underwent right radical nephrectomy and extended right hepatic lobectomy with resection and reconstruction of inferior vena cava (IVC). A temporary bypass was placed between the infrarenal IVC and right atrium using a heparin-coated synthetic tube. The tumor was resected en bloc including right kidney, adrenal gland, hepatic lobe, and IVC. The IVC was reconstructed using an expanded polytetrafluoroethylene (EPTFE) graft. Her postoperative course was uneventful with no signs of recurrence four years after surgery.     

Mediastinal hemangioma mimicking an invasive tumor growth: A case report

Introduction and importanceMediastinal hemangiomas are a rare entity frequently developing in the anterior mediastinum. They may exhibit an infiltrating appearance into the surrounding tissue, and extensive surgery is often required despite its benign nature. We report a case of a mediastinal hemangioma mimicking an invasive tumor growth requiring a combined resection of the lung and diaphragm.Case presentationAn asymptomatic 73 year-old-man presented with a 50 mm-sized mass on his chest radiography. A combined resection of the mediastinal mass with the part of the lower lobe of left lung and diaphragm not necessitating a patch repair was performed. The pathological findings were compatible with a diagnosis of a mediastinal hemangioma. Only fibrous adhesions were observed between the tumor and resected lung and diaphragm without any histological invasion.Clinical discussionWhile imaging examinations play a key role in determining a preoperative diagnosis, mediastinal hemangiomas may pose a diagnostic challenge mainly due to its rarity. With a clinical suspicion of a hemangioma during the diagnostic work up, a dynamic CT might be helpful.ConclusionsIn mediastinal hemangiomas, a preoperative diagnosis is essential in order to avoid extensive surgery. A hemangioma should be raised as a differential diagnosis for anterior mediastinal tumors, especially in cases with an infiltrative appearance that suggests the necessity for a combined resection of the surrounding organs.     

Classification for predicting mediastinal lymph node metastases in patients with T1 or T2 lung cancer

The aim of this study is to classify patients into risk groups for mediastinal lymph node metastases. Three hundred and thirty-seven patients underwent lung resection for lung cancer. The nodal status was pN0 in 181 patients, pN1 in 62 and pN2 in 94. The presence of the involvement of one mediastinal compartment (superior or inferior) or two mediastinal compartments (superior and inferior) was considered to be the main end point. One mediastinal compartment was involved in 65 patients and two mediastinal compartments in 29 patients. Two variables (visceral pleural invasion and the primary tumor location) were retained in the model. The regression tree analysis categorized patients into 3 risk groups for the involvement of two mediastinal compartments. The low-risk group included 118 patients with a tumor located in the left side and no visceral pleural invasion. The intermediate-risk group included 160 patients with a tumor located in the right side and no visceral pleural invasion. The high-risk group included 59 patients with visceral pleural invasion and a tumor located in the right side or left lower lobe. A practical, easy-to-use risk grouping system is proposed to aid the decision making and to simplify mediastinal lymphadenectomy procedure.     

Combined resection of a tumor and the inferior vena cava: report of two cases

Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.     

Surgical repair of scimitar syndrome by direct anastomosis between right pulmonary vein and left atrium

A surgical case of 8-year-old boy with scimitar syndrome is presented. The patient was admitted to the hospital because of exertional dyspnea and underdevelopment. Cardiac catheterization revealed a large amount of left to right shunt and O2 step up at the level of the inferior vena cava below the diaphragm. Angiography showed that the pulmonary vein draining the right lower lobe pierced the diaphragm and emptied into IVC. At operation the right pleural cavity was entered and a large anomalous pulmonary vein trunk was found which headed downward and medially and eventually entered in the diaphragm. A direct anastomosis between the scimitar vein and left atrium was made. To avoid kinking or stenosis of this vein, the parenchyma of the right lung (S7) was divided to create a passway of the vein. Anastomosis was performed without excessive tension or kinking on it. We conclude that the method applied in this case might be a procedure of choice for the repair of scimitar syndrome especially when there is no associating atrial septal defect or scimitar vein drains into IVC at the level lower than hepatic vein.     

Successful outcome after resection of lung, liver and diaphragm for locally advanced lung cancer.

A 63-year-old man presented with a 2 month history of intermittent right subcostal and shoulder tip pain. Preoperative imaging confirmed a locally advanced right lower lobe lung tumour involving the diaphragm and liver. Bronchoscopic biopsy confirmed squamous cell carcinoma and mediastinoscopy was negative. The patient underwent a right bilobectomy with resection of the right hemi-diaphragm and a right hemi-hepatectomy. His postoperative recovery was satisfactory and he remains well 18 months after the surgery. We believe that in selected cases, patients with locally advanced lung tumours invading the liver may have a survival advantage following resection.     

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.     

Renal cell carcinoma with an infrarenal vena caval tumor thrombus

Extension of renal cell carcinoma (RCC) along venous drainage pathways is a well-recognized entity. All previously reported cases of inferior vena cava (IVC) involvement by RCC have been with tumor thrombus in the suprarenal IVC. We report a 45-year-old man who had RCC arising from the lower pole of the right kidney with a tumor thrombus totally occluding the infrarenal IVC. The patient underwent radical nephrectomy with successful ligation and resection of the infrarenal IVC.     

Thymic carcinoma with combined resection of the hemisternum

We report a case of partial resection of the hemisternum of a thymic carcinoma invading the right anterior chest wall. A computed tomographic scan of the chest and positron emission tomography showed a mass invading the right anterior chest wall in the anterior mediastinum with high 18F-fluorodeoxyglucose accumulation. An operation was performed to obtain a definitive diagnosis and achieve complete resection. First, we assessed the boundaries of gross disease using left-sided video-assisted thoracoscopy. After delineating the margins of the lesion invading the anterior chest wall, a median sternotomy was added and the tumor was resected with the right half of the sternum, parts of the right third and fourth costal cartilages, part of the right upper lung lobe, and pericardium. Histopathological evaluation revealed a squamous cell carcinoma of the thymus with direct invasion to the right lung, pericardium, and the right third costal cartilages.     

Indication of limited pulmonary resection for small-sized lung cancer based on preoperative clinical data

Limited pulmonary resection is performed mostly based on the size of lung cancer and ground-glass opacity (GGO). It has been proposed to determine the indication of segmentectomy according to hilar lymph node involvement. There is a potential risk of underestimation for lymph node involvement since there may be a skip mediastinal lymph node metastasis without hilar involvement. We propose to use standardized uptake value( SUV) max of primary lung cancer as an indicator of non-invasive lung cancer. None of 44 small-sized lung cancers with SUVmax lower than 1 had lymph node metastasis or vessel invasion. A small-sized lung cancer ≤ 2 cm with SUVmax ≤ 1 is indicated wedge resection if GGO area is greater than 75% of tumor. Segmentectomy is indicated if the GGO area is less than 75%. We also propose selective lymphadenectomy for small-sized lung cancer. The lower mediastinal lymphadenectomy may be omitted if a small-sized tumor is located in the right upper lobe or the left upper segment. The upper mediastinal lymphadenectomy may be omitted if a small-sized lung cancer is located in the lower lobe and if the lower mediastinal lymph node involvement is excluded.     

Pulmonary pleomorphic carcinoma

Pleomorphic carcinoma is a rare primary pulmonary malignancy. We report 2 surgical cases of pulmonary pleomorphic carcinoma. The first case was a 71-year-old male. Chest computed tomography (CT) showed a rapidly growing tumor with irregular density. Transbronchial lung biopsy revealed the tumor to be malignant. Left lower lobectomy was performed. Pathological diagnosis was pleomorphic carcinoma (pT2N2M0, stage IIIA). He died 8 months after surgery due to brain metastasis and mediastinal lymph node metastasis. The second case was a 74-year-old male who complained of bloody sputum. Chest CT showed a tumor with cavity in the right middle lobe. Brushing cytology under bronchofiberscopy revealed atypical cell. Right middle lobectomy and partial resection of the right lower lobe were performed. Pathological diagnosis was also pleomorphic carcinoma (pT2N0M0, stage IB). He has no findings of recurrence nor metastasis 15 months after the operation.     

Segmentectomy for multiple adenocarcinoma presenting as ground-glass opacities after lung cancer surgery

During follow-up of patients after primary lung cancer resections, small nodules or ground-glass opacities (GGOs) are sometimes detected on chest computed tomography. We report a case with multiple GGOs that were noted after primary lung cancer resection. A 76-year-old woman, who had undergone right upper lobectomy, middle lobe partial resection, and mediastinal lymph node dissection 3 years earlier, was admitted owing to five GGOs in the right lower lobe that had been increasing in size or density. A right S6+10 segmentectomy was performed. On histology, one adenocarcinoma and four bronchioloalveolar carcinomas (BACs), as well as two additional BACs that had not been detected preoperatively, were identified. No complications occurred postoperatively. Three years 4 months later, no tumor recurrence or new lesions have been found. Given the high possibility of malignancy, the appearance of new GGOs in patients with a history of lung cancer requires appropriate investigation.     

Torsion of the middle lobe after right upper lobectomy of the lung; report of a case and the review of the Japanese literatures

We report a case of torsion of the residual right middle lobe of the lung, following right upper lobectomy for lung cancer. A 71-year-old man who had medical treatment for emphysema was admitted with a lung tumor on chest computed tomography. The tumor was diagnosed as pulmonary adenocarcinoma by transbronchial biopsy. Right upper lobectomy with mediastinal lymph node dissection, and partial resection of the right lower lobe were performed. On the following day, chest X-ray showed an opacification in the right upper lung field, which gradually increased. Bronchoscopic examination revealed a stenotic middle lobe bronchus. Torsion of the middle lobe was suspected, and rethoracotomy was performed on the second postoperative day. The middle lobe was torsed 90-degree counterclockwise around its bronchovascular pedicle. A middle lobectomy was performed secondary to severe congestion. The patient was discharged in good condition on the 11th postoperative day. In reviewing the literatures including this case, 13 of 16 torsions occurred after right upper lobectomy of the lung. Thirteen patients had rethoracotomy, 10 of them underwent resection of the rotated lung. Simple detorsion was carried out in 3 patients, and 1 of them developed cerebral infarction. Lung torsion was reported to be potentially life-threatening. Therefore, fixation of a remaining lobe should be performed. Exploratory thoracotomy should be performed without delay, if lung torsion is suspected.     

Huge localized mesothelioma of the diaphragm in a 17-year-old Female — a case report with calculated tumor volume doubling time —

An operative case of localized mesothelioma of the pleura developed in a 17-year-old female was reported. She was admitted to our hospital complaining of right chest pain. A chest X-ray film showed a huge mass in the right lower field of the lung. After the embolization of the right inferior phrenic artery, which was the main feeder to the tumor, it was then successfully resected combined with the right diaphragm and the right lower lobe of the lung. Histologicaly, the tumor was diagnosed as benign localized mesothelioma (solitary fibrous tumor of the pleura). Further histological and immunohistochemical study revealed that it had developed from the connective tissue under the parietal mesothelium of the diaphragm. As chest roentgenograms had been undertaken during past two years, the tumor volume doubling time was calculated at 153 days. Despite the short tumor volume doubling time as like primary lung cancer, she is alive without recurrence 5 years after the operation.     

Tumor thrombectomy for endometrial stromal sarcoma extending into the inferior vena cava and the right atrium from the uterus

We report an extremely rare case of endometrial stromal sarcoma (ESS) extending into the inferior vena cava and the right atrium. A 65-year-old woman was admitted to our hospital due to lower-extremity edema. The chest-abdominal computed tomography (CT) showed tumor thrombus invading the inferior vena cava and right atrium with multiple lung metastasis. To prevent sudden death from pulmonary embolism, she underwent surgical removal the tumor thrombus with the use of cardiopulmonary bypass and deep hypothermic circulatory arrest. The pathological diagnosis of the tumor thrombus was low-grade ESS originating from the uterus. After thrombectomy, she underwent chemotherapy with carboplatin and paclitaxel. Surgical resection and chemotherapy to low-grade ESS achieved favourable prognosis.     

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.