Background: Currently, surgery for primary spontaneous pneumothorax (PSP) is performed by bullectomy using a stapler with complete video-assisted thoracic surgery (cVATS). However, the postoperative recurrence rate (RR) of PSP is high in young men. The factors of postoperative PSP recurrence are the formation of postoperative bulla neogenesis (POBN) around the staple line, pleural injury caused by forceps for VATS, and bulla overlooked with a thoracoscope. We attempted nonstapling bullectomy with one-port-one-window (1p-1w) by using hybrid VATS (hVATS) to reduce postoperative RR. This study aimed to evaluate nonstapling bullectomy by manual suturing for young male patients with PSP compared with bullectomy by cVATS. Methods: From January 2012 to December 2022, we retrospectively reviewed the medical records of 259 male patients aged <= 25 years who underwent initial surgery for PSP and compared them between two groups, with staple use (S+) or by manual suturing without staple use (S-). RR, operative time, blood loss, and postoperative hospitalization period were examined in both groups. Results: The median operative time was 81 and 63 min in the S- and S+ groups, respectively (P<0.001), with the S- group tending to be statistically significantly longer. The mean intraoperative blood loss was 1.61 and 2.11 mL in the S- and S+ groups, respectively (P=0.003). The median postoperative hospitalization period was 4 days in both groups (P=0.32). Recurrences occurred in 8 (7.1%) and 14 patients (12.2%) in the S- and S+ groups, respectively [odds ratio (OR) =0.55; 95% confidence interval (CI): 0.22-1.37; P=0.19]. In patients aged <20 years, 5 (6.6%) and 10 (14.1%) patients had a recurrence in the S- and S+ groups, respectively (OR =0.42; 95% CI: 0.13-1.32; P=0.13). Conclusions: Compared with stapling bullectomy, nonstapling bullectomy with small thoracotomy for young male patients with PSP had lesser RR. This procedure is beneficial in reducing postoperative recurrence and is one of the surgical choices for young male patients with PSP.

Background Granulosa cell tumors (GCTs) are uncommon sex cord-stromal ovarian neoplasms. We report a case of GCT presenting in the chest, 18 years after oophorectomy for ovarian cystadenocarcinoma. Case presentation A 63-year-old female was admitted to our hospital for evaluation of a right hilar lesion. Subsequent abdominal and pelvic computed tomography and brain magnetic resonance imaging were unremarkable. Eighteen years earlier, the patient had undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy at another institution for a uterine myoma, with the pathological findings indicating a uterine myoma, dermoid cyst of the right ovary, and serous cystadenocarcinoma and endometrioid adenoacanthofibroma around hemorrhagic cyst of the left ovary. No indication of a granulosa cell tumor (GCT) was present in either ovary. As such, diagnostic video-assisted thoracoscopic surgery was performed, revealing a well encapsulated tumor located next to the inferior pulmonary vein and small, disseminated lesions on the chest wall and diaphragm. Thereafter, we performed resection of the main tumor in its entirety and the disseminated lesions to the extent possible. Pathological examination of the resected specimens revealed a neoplasm characterized by sheets and islands of closely packed tumor cells exhibiting small follicles (Call-Exner bodies) surrounded by cells with pale, uniform nuclei, typically observed in the microfollicular pattern of adult GCT. Although the etiology of occurrence of intrathoracic granulosa cell tumor is unknown, we assumed that the neoplasm oriented from radiologically undetectable peritoneal seeding at the time of her previous surgery, with subsequent migration through the diaphragm. Over the next 10 years, she received chemotherapy with cyclophosphamide, adriamycin, and cisplatin; other combination chemotherapy; single-agent chemotherapy; and palliative radiotherapy. She died from malignant pleuritis and peritonitis 10 years after thoracoscopic surgery. Conclusions We have reported a case of a 63-year-old female with a history of ovarian cystadenocarcinoma who underwent resection of a pleural neoplasm, which turned out to be a granulosa cell tumor. This possibility resulted from dissemination of a previous abdominal lesion.

ObjectiveImproving quality of life (QOL) after surgery is very important. Recently, preoperative anxiety has been suggested to predict postoperative health-related (HR) QOL, however the accuracy of anxiety measurement remains problematic. We examined the relationship between preoperative anxiety level and postoperative HRQOL using qualitative and quantitative assessment of anxiety.MethodWe used a detailed anxiety assessment to quantitatively investigate preoperative anxiety as a predictor of postoperative HRQOL in lung cancer patients. Fifty one patients who underwent surgery for lung cancer were included. They were assessed four times: on admission, on discharge, 1 month after surgery, and 3 months after surgery. Anxiety was measured separately as “state anxiety” and “trait anxiety” using the State–Trait Anxiety Inventory, and HRQOL was measured using the EuroQol 5 dimension 5-level.ResultsThe HRQOL decreased at discharge and gradually recovered over time, reaching the same level at 3 months after surgery as at admission. HRQOL score was lower at discharge than at pre-surgery and 3 months after the surgery (p < 0.0001 each), and the score at 1 month after the surgery was lower than at pre-surgery (p = 0.007). In addition, multiple regression analysis showed that HRQOL at discharge was associated with “state anxiety” rather than “trait anxiety” at admission (p = 0.004).ConclusionThis study identifies the types of anxiety that affect postoperative HRQOL. We suggest that postoperative HRQOL on discharge may be improved by interventions such as psychological or medication treatment for preoperative state anxiety if identified preoperative state anxiety can be managed appropriately.

Tracheobronchial injurie( TBI) is rare but potentially life threatening. Blunt trauma of the chest and post-intubation injury are the most common cause of TBI. Clinical findings of TBI are subcutaneous emphysema, pneumomediastinum, and pneumothorax. Chest computed tomography (CT) and bronchoscopy are important examination for TBI to evaluate of injured site and condition. Most traumatic or iatrogenic TBIs occurred within 2.5 cm of the carina and/or main bronchus. Early diagnosis and early treatment are important to improve the long-term results of TBI. In principle, blunt traumatic TBI excluded membranous minor laceration should be operated immediately, if possible. Surgical procedures are usually selected single closure or end to end anastomosis with or without débridement. Right thoracotomy is often suitable for repair of carina or main bronchus in closed trauma. Recently transcervical repair of iatrogenic distal membranous tracheal laceration is reported. Conservative treatment of iatrogenic TBI cause by single lumen tube may be a save option in patients with stable spontaneous breathing, no other injury( such as esophagus), and small to moderate rupture. Left main bronchial rupture caused by double lumen tube during right thoracic surgery is critical situation. Throughout the operation expert cooperation between surgeon and anesthetist is important.

We aimed to investigate if Computed tomography (CT) attenuation values can help improve the identification of age-related changes in the thymus. We assessed CT images of 405 patients aged 0 to 80 years. We measured the area of the anterior mediastinum at the level of the carina and its average CT attenuation value. We evaluated the thymic area, the ratio of the thymus area to the total thoracic area, and the CT attenuation value. Additionally, we evaluated changes in the thymus area in the 0 to 13-year age group. The area of the thymus decreased from birth to the middle 20s. After the middle 20s, the area tended to increase and plateau till after 50 years of age. The ratio of the thymic area to the thoracic area decreased from age 0 to 20 years, but remained stable after 20 years of age. The CT attenuation values were stable from birth to puberty, decreased after puberty, and were stable again in the late 50s and beyond. The thymus of children showed mass formation, but the shape changed with age. No significant differences in the CT attenuation value were found across underlying conditions for the 0 to 13-year age group. The decrease in the CT attenuation values, observed with advancing age, reflects adipose degeneration of the thymus, indicating that by the late 50s, thymic tissue is replaced completely by adipose tissue. Our data suggest that adipose degeneration of the thymus begins after puberty and advances with age.

症例は60歳代の女性．前縦隔腫瘍精査目的で紹介となった．画像上非浸潤性の胸腺腫を疑ったが，好中球数の減少を認め，CTガイド下生検を施行した．病理診断は胸腺腫typeB1であった．赤血球数，血小板数は正常値であり，骨髄穿刺でも顆粒球の減少は認めなかったが，好中球数は300/μl前後で推移していた．G-CSFによる好中球の増加が確認されたので，術直前に投与したのちに拡大胸腺摘出術を施行した．最終病理診断はtype B1の胸腺腫で正岡分類II期であった．術後は感染症の合併はなく経過し，第10病日に退院となった．好中球数は術後1ヵ月で術前と同レベルの300/μlまで低下した．同時期の血液検査で抗好中球抗体の陽性を確認した．術後2年後に朝のこわばり等関節症状を認め，再度内科的精査を行ったが膠原病の確定診断には至らなかった．好中球単独での血球減少を伴う胸腺腫は極めて稀であるので報告する．

背景．Nuclear protein in testis（NUT）carcinomaはNUT midline carcinoma family member 1（NUTM1）遺伝子の転座により形成される融合遺伝子を認め，近年報告が散見される．症例．26歳男性．血痰，胸部痛の精査で，最大径約6 cmの前縦隔腫瘍を認めた．CTガイド下針生検で胸腺扁平上皮癌の診断に至りCBDCA＋PTXを4コース施行した．原発巣は縮小したが，縦隔リンパ節が増大し，姑息的放射線治療を行ったが，胸膜播種，肝転移，後腹膜転移が出現し，初診より7か月で死亡した．剖検所見は，両肺，肝臓，リンパ節（肺門，縦隔，腹腔），胸膜，横隔膜，後腹膜に病巣を認め，組織学的には未分化な成分と高分化な扁平上皮癌様成分が混在し，免疫組織学的検査でNUT，p63陽性であり，NUT carcinomaと診断された．結論．NUT carcinomaは若年者にも発症する予後不良な悪性腫瘍であり，本症例は病理解剖で診断に至った．若年者の胸部扁平上皮癌と診断された症例にNUT carcinomaが含まれる可能性が示唆された．

Most lymphoepithelial cysts (LECs) occur in the salivary glands and are considered one of the autoimmune syndromes caused by the human immunodeficiency virus (HIV). In this report, we present a case of pulmonary LEC without prior HIV infection, paying special attention to radiographic features. A chest radiograph revealed an oval mass with a smooth surface, localized in the left lower lung field, which was in direct contact with the diaphragm. Computed tomography showed an oval homogenous mass with a smooth surface in the lower left lobe. Further, magnetic resonance imaging demonstrated that the mass was a homogeneous internal structure with a smooth surface and a slightly high signal in T2-weighted images and a slightly low signal in T1-weighted images. Surgical resection was performed, and pathological examination confirmed the diagnosis of a pulmonary LEC. To the best of our knowledge, no cases of pulmonary LECs without prior HIV infection have been reported in the literature to date, therefore, the case presented here is considered very rare and informative.

Background and Aims: Myeloid-derived suppressor cells (MDSCs) play the pivotal role in the induction of immune tolerance in cancer, which limits the benefits of immune checkpoint blockade.Recent studies demonstrated that several chemotherapeutic agents, such as 5-fluorouracil (5-FU), gemcitabine, decreased MDSCs in digestive cancer, thymoma cancer.However, the impact of chemotherapeutic agents on MDSCs has been still unclear in thoracic cancers.Therefore, we aimed to determine the effects of chemotherapeutic agents those are approved for the patients with thoracic cancer on the tumor-associated MDSCs in murine models.Methods: Mice were subcutaneously injected with murine mesothelioma cells, namely AB1-HA cells, followed by administration of several chemotherapeutic agents and antiprogrammed cell death 1 (anti-PD-1) antibody.MDSCs, defined as CD11b+Gr-1+ cells, were evaluated by flow cytometry in the tumor tissues and spleens.Results: The administration of 5-FU and its oral formulation S-1 effectively reduced the number of MDSCs in tumor microenvironment (TME), while several chemotherapeutic agents such as pemetrexed (PEM), carboplatin (CBDCA) and cisplatin failed to suppress the accumulation of MDSCs in vivo.Additionally, S-1 also enhanced CD8+ T cell infiltration into TME.The combination of CBDCA and S-1 was significantly more effective than that of CBDCA and PEM to inhibit MDSCs and tumor progression.Consequently, these chemotherapeutic agents improved the anti-tumor effect of anti-PD-1 antibody in vivo.

AbstractIt is important to distinguish tumour recurrence from other conditions that could show high accumulation on 18F‐fluorodeoxyglucose‐positron emission tomography (FDG‐PET). We describe the case of a 78‐year‐old woman who underwent partial resection of the left lower lung lobe for carcinoid treatment 20 years previously. Five years earlier, chest radiography revealed an abnormal shadow, and chest computed tomography (CT) showed partial atelectasis in the left S8. Periodical CT showed that the atelectasis had developed into a mass. The patient was referred to our hospital. A mass of 45 mm diameter was detected on CT and it had a maximum standardized uptake value of 8.91 on FDG‐PET. We suspected recurrence and performed surgery. Pathological examination revealed epithelioid cell granuloma (maximum diameter, 25 mm) with necrosis. Tissue culture showed no evidence of Mycobacterium tuberculosis. However, serum anti‐MAC antibody level was elevated, suggesting epithelioid cell granuloma caused by non‐tuberculous Mycobacterium infection.

OBJECTIVES:The first surge in severe acute respiratory syndrome coronavirus 2 infection had a significant impact on health care institutions. Understanding how the pandemic affected general thoracic surgery would provide valuable data for establishing a health care protocol for upcoming surges.METHODS:A questionnaire survey on coronavirus disease-related patient statistics and health care was conducted between February 2020 and June 2020 across 14 facilities affiliated with the Kanagawa General Thoracic Surgery Study Group.RESULTS:The average number of newly referred patients from February to June 2020 was 65% of that during the same period in 2019. Six facilities placed restrictions on medical care services, among which four restricted surgeries. At all institutions and those placed on surgical restriction, the total number of surgeries under general anesthesia was 92% and 78%, the total number of primary lung cancers was 94% and 86%, and the total number of surgeries for pneumothorax was 71% and 77% of that in the preceding year, respectively. Infection control and insufficient resources of the medical material were the most influential factors impacting the medical institutions' decision to restrict the services provided.CONCLUSIONS:Restrictions on surgery had a significant impact on the care provided by general thoracic surgery departments. To avoid patient inconvenience, establishing a collaborative system that refers patients to operational medical institutions in case of medical treatment restrictions may be useful.

Background: Although platinum-based chemotherapy is accepted as adjuvant chemotherapy for resectable advanced non-small cell lung cancer (NSCLC), its completion rate is low due to severe adverse events. S-1 plus cisplatin is associated with relatively low toxicity and an unimpaired quality of life, and has been used for unresectable advanced lung cancer. We investigated the acceptability and feasibility of combination therapy with S-1 plus cisplatin as postoperative adjuvant chemotherapy following complete resection of pathological stage II-IIIA NSCLC.Methods: Enrolled patients received oral S-1 at a dose depending on their body weight twice daily for 21 days with intravenous cisplatin 60 mg/m2 on day 8, with 1 cycle comprising 5 weeks and 4 cycles. Patients received standard precautions against adverse events and received standard treatment when adverse events occurred. The primary endpoint was completion rate; secondary endpoints included safety, status of drug administration, disease-free survival (DFS), and overall survival (OS).Results: A total of 19 patients [14 men, 5 women; mean age, 59.1 years; mean body surface area, 1.688 m2; 17 with an Eastern Cooperative Oncology Group performance status (PS) of 0 and 2 with a PS of 1; 7 (36.8%) with stage II disease and 12 (63.2%) with stage IIIA disease] were enrolled. The rate of completion of 4 cycles was 68.4%. Grade 3 adverse events that occurred in ≥10% of patients included neutropenia (21.1%), nausea (21.1%), and anorexia (15.8%). No grade 4 adverse events, febrile neutropenia, or treatment-related deaths occurred. The mean relative dose intensity (RDI) was 79% for S-1 and 80% for cisplatin. The 2-year DFS rate was 42.1%, and 2-year OS rate was 83.3%.Conclusions: This study demonstrated the acceptability and feasibility of using S-1 plus cisplatin as adjuvant chemotherapy.Trial registration: This study was registered on the UMIN clinical study registration site (protocol ID: UMIN000016191) on December 1, 2015.

Thymic mucinous adenocarcinoma is an extremely rare and aggressive subtype of thymic carcinoma, and there is no effective treatment for this disease except complete resection. Moreover, it is necessary to determine the efficacy and safety of multimodal treatments, including molecular targeted drugs and immunotherapy. Although a case of a thymic mucinous adenocarcinoma with KRAS gene mutation has been reported, there are no reports describing any other gene mutations in thymic mucinous adenocarcinomas. We herein present the first case of STK11/LKB1 mutationpositive primary thymic mucinous adenocarcinoma. The findings of the current clinical case are expected to further the evaluations of gene mutations and aid in the development of therapeutic methods for primary thymic mucinous adenocarcinomas. (C) 2020 Elsevier Inc. All rights reserved.

Background Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare lung disease that manifests as parenchymal fibrosis of the upper lung lobe and pleura. There have been no reports of IPPFE complicating pregnancy. Here, we report a case of IPPFE that deteriorated rapidly during pregnancy. Case presentation A 29-year-old woman presented with dyspnea and dry cough at 19 weeks of gestation. IPPFE with acute exacerbation was suspected on chest computed tomography (CT). Despite steroid treatment, her condition progressed. A cesarean section was performed at 28 weeks of gestation. On postoperative day 26, she underwent living-donor lung transplantation. She was discharged a year after transplantation. Conclusion Our experience suggested that when pregnancy is complicated by PPFE, the disease may deteriorate rapidly. In this case, even though IPPFE with acute exacerbation was diagnosed during pregnancy, live birth was achieved, and the mother survived after lung transplantation. Lung transplantation should be considered in these patients because, once advanced, pulmonary lesions may be irreversible.

PURPOSEWe performed a retrospective analysis to evaluate the usefulness of positron-emission tomography/computed tomography (PET/CT) findings in the classification and management of anterior mediastinal tumors.METHODSBetween 2006 and 2015, 105 patients with anterior mediastinal tumor received PET/CT. 18F-fluorodeoxyglucose (18F-FDG)-PET images were obtained 60 minutes after the injection of 18F-FDG.RESULTSThe histological classifications were as follows: thymoma (n = 49), thymic carcinoma (TC) (n = 19), malignant lymphoma (ML) (n = 8), teratoma (n = 7), thymic cyst (n = 14), and others (n = 8). Upon visual inspection (SUV max: >2.0), all of the malignant tumors showed 18F-FDG accumulation (with the exception of one type A thymoma). Two of the 14 thymic cysts and three of the seven teratomas showed slight 18F-FDG accumulation. The SUV max values of the low-grade thymomas, high-grade thymomas, TCs and MLs were 3.14 ± 0.73, 4.34 ± 1.49, 8.59 ± 3.05, and 10.08 ± 2.53, respectively, with significant differences between the low- and high-grade thymomas, and between TCs and MLs. The sensitivity, specificity and accuracy of 18F-FDG in the detection of low-grade thymomas and thymomas with a maximum diameter of ≤50 mm and an SUV max of ≤3.4 were 85%, 48%, and 60%, respectively.CONCLUSIONFDG-PET/CT is an objective and useful modality in the differential diagnosis and management of anterior mediastinal tumors.

AIMS:Mutation or promoter methylation of the phosphatase tensin homologue deleted on chromosome 10 tumour suppressor gene (PTEN) promotes some cancers. Moreover, PTENP1 (PTEN pseudogene) transcript regulates PTEN expression and is thought to be associated with tumourigenesis in some cancers. Here, we investigated PTEN expression in thymic epithelium and thymic epithelial tumours.METHODS:Immunohistochemical analysis of PTEN was performed on two non-tumourous thymus (NT) samples, 33 thymomas (three type A, eight type AB, 11 type B1, six type B2, and five type B3), and four thymic carcinomas (TCs). In 16 cases (two NT, three A, five B1, two B2, one B3 and three TC), analyses of mutations, promoter methylation and comparisons of PTEN mRNA and PTENP1 transcripts were undertaken using PCR-direct sequencing, methylation-specific PCR, and reverse-transcription real-time PCR after target cell collection with laser microdissection.RESULTS:PTEN protein was not immunohistochemically detected in NT epithelium or types B1 or B2 thymoma cells, but was expressed in type A thymoma and carcinoma cells. Neither PTEN mutations nor promoter methylation were detected in any samples. Statistical analysis revealed that PTEN mRNA expression was highest in NT epithelium and lowest in type A thymoma cells. PTENP1 transcript expression did not significantly differ among NT, thymoma and TC samples.CONCLUSIONS:We speculated that NT epithelium and types B1/B2 thymoma cells have a mechanism of PTEN translation repression and/or acceleration of protein degradation, whereas type A thymoma cells exhibit transcriptional repression of PTEN mRNA and accelerated translation and/or protein accumulation.

Herein we report on the long-term survival of a surgical case of typical carcinoid tumor and supraclavicular lymph node metastasis at initial diagnosis. The present study is a follow-up to a previously published case report. Initially, a 73-year-old man was admitted to hospital for evaluation of an enlarged lymph node in his right supraclavicular fossa. Serum progastrin-releasing peptide (ProGRP) concentrations were markedly elevated, and carcinoid was diagnosed by histopathological examination of the excised supraclavicular lymph node. The patient underwent right upper lobectomy and mediastinal lymph node dissection via median sternotomy. The final diagnosis was Stage IIIB (pT1aN3M0) typical carcinoid. Serum ProGRP concentrations decreased to within the normal range, and follow-up computed tomography, performed approximately 10 years after surgery, showed no recurrence. For this patient, radical resection of metastatic lymph nodes was an effective treatment for his typical lung carcinoid.

BackgroundThymidylate synthase (TS) is an essential enzyme for de novo DNA synthesis.TS expression is associated with the proliferative activity of cancer cells, and low TS expression is associated with favorable outcomes in nonsmall-cell lung cancer patients treated with TS-targeted drugs．The aim of the present study was to assess the association between TS expression in lung cancer and smoking status. MethodsWe studied 113 patients who underwent surgical resection for lung cancer.78 were smokers and 35 were non-smokers.We manually microdissected tumor specimens and used RT-PCR to assess intratumoral TS mRNA expression levels.We analyzed the relationship between patient TS levels and the cumulative lifetime smoking dose, expressed as pack-years. ResultsAmong smokers, the median smoking dose was 45 pack-years in patients with adenocarcinoma (Ad) and 50 pack-years in patients with squamous cell carcinoma (Sq) .TS mRNA expression was signi cantly higher in patients with Sq compared with patients with Ad (P＝ 0.03) .Among smokers with Ad, TS mRNA expression was higher in patients with a smoking status of ≥ 45 pack-years compared with those with a smoking status of ＜ 45 pack-years (P ＝ 0.02) .We observed no difference in TS mRNA expression levels between non-smokers and smokers with Ad.In addition, no difference in TS mRNA expression levels was observed between smoking doses in smokers with Sq. ConclusionOur results indicate that it may be possible to predict high TS levels in patients with Ad by considering the patientʼs cumulative smoking dose.