Durvalumab maintenance therapy following chemoradiotherapy is the standard treatment for patients with unresectable stage III non-small-cell lung cancer. Immune checkpoint inhibitors can alter host immunity, potentially amplifying inflammatory responses during opportunistic infections. We report a rare case of rapidly progressive destroyed lung caused by invasive pulmonary aspergillosis during durvalumab therapy, which was successfully managed with salvage pneumonectomy. A 53-year-old man with locoregionally recurrent lung adenocarcinoma received chemoradiotherapy followed by durvalumab treatment. Invasive pulmonary aspergillosis developed on day 74. Despite intensive antifungal therapy and corticosteroid administration, the right lung developed extensive liquefactive necrosis beyond the irradiated field within 5 weeks. Given the risk of fatal hemoptysis and sepsis, an emergency right pneumonectomy was performed. The frozen hilum required intrapericardial vascular control and reinforcement of the bronchial stump. Recovery was uneventful, and pathological examination confirmed aspergillosis without residual malignancy. Prompt recognition of medical refractoriness and timely surgery are critical for survival.

INTRODUCTION: Empyema associated with parapneumonic pleural effusion can cause respiratory failure requiring surgical intervention. However, some cases remain difficult to manage even after surgery. Patients with Down syndrome are particularly susceptible to respiratory infections and tend to develop more severe symptoms. Few studies have addressed the management of postoperative respiratory failure in acute empyema. CASE PRESENTATION: A 12-year-old girl with Down syndrome developed acute empyema following right-sided parapneumonic pleural effusion and underwent thoracoscopic empyema cavity debridement. Surgical intervention alone was not sufficient to resolve postoperative respiratory failure. She was managed with adjunctive therapies including inhaled nitric oxide (iNO), intrapulmonary percussive ventilation (IPV), and prone positioning therapy. These therapies resulted in marked improvements in postoperative atelectasis and respiratory failure, enabling successful weaning from mechanical ventilation. CONCLUSIONS: The combined use of iNO, IPV, and prone positioning therapy may be an effective management strategy for severe respiratory failure after acute empyema surgery in patients with Down syndrome. These adjunctive therapies could contribute to recovery of respiratory function in patients with postoperative atelectasis.

Background Krabbe disease is a rare autosomal recessive lysosomal disorder caused by a deficiency of galactocerebrosidase, leading to progressive demyelination and severe neurological impairment.The infantile-onset form has a particularly poor prognosis. Early hematopoietic stem cell transplantation can improve survival, but longterm survival into adolescence is exceedingly rare. Here, we report a case of an adolescent with infantile Krabbe disease who survived long-term after unrelated cord blood transplantation and underwent thoracic surgery for spontaneous pneumothorax. Case presentation A 16-year-old male with infantile Krabbe disease, diagnosed at birth, underwent unrelated cord blood transplantation at 41 days of age. At age 14, he developed a left spontaneous pneumothorax, which initially improved with conservative management. He later presented with recurrent left pneumothorax, unresponsive to two weeks of chest tube drainage. Computed tomography revealed a bulla at the apex of the left lung. Surgery was performed under general anesthesia with one-lung ventilation. Left lung wedge resection was conducted using a stapler, with reinforcement of the staple line using a polyglycolic acid sheet and autologous blood. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 4. No recurrence was observed during six months of follow-up. Pathology revealed a bullous lesion covered by pleura with fibrous thickening and reactive mesothelial hyperplasia. Conclusions This case represents the first reported thoracic surgical intervention for spontaneous pneumothorax in a patient with Krabbe disease who achieved long-term survival following unrelated cord blood transplantation. The favorable surgical outcome suggests that conventional surgical principles may be applicable in selected patients, with appropriate modifications based on individual clinical conditions.The relationship between Krabbe disease and the development of pneumothorax remains unclear, and further accumulation of cases is needed to guide perioperative management in this rare population.

BackgroundPulmonary wedge resection is a lung-sparing procedure, with mechanical staplers enhancing surgical safety. Staple line reinforcement reduces air leakage; however, its effect on preventing mechanical vascular injury remains unclear. Staple-related vascular injuries rarely cause life-threatening complications. Here, we report a rare case of hemorrhagic shock caused by intercostal artery perforation from a protruding staple leg following thoracoscopic wedge resection with a reinforced stapler, which was likely triggered by lung collapse and re-expansion.Case presentationA 76-year-old man underwent thoracoscopic wedge resection of right segment 6 for suspected metachronous lung adenocarcinoma using a reinforced stapler with a gold cartridge. The surgery was uneventful. On postoperative day (POD) 1, accidental chest drain removal caused lung collapse. After drain reinsertion and lung re-expansion on POD 2, the patient developed hemorrhagic shock on POD 3. Emergency thoracotomy revealed massive intrathoracic hemorrhage from the eighth intercostal artery due to a staple leg protruding through the reinforcement and perforating the artery during lung inflation. Hemostasis was achieved using electrocautery and artery ligation, followed by removal of the protruding staple and additional staple line reinforcement. The postoperative course was uneventful, and the patient was discharged on POD 10.ConclusionsMechanical vascular injury due to staple protrusion can occur despite reinforced staplers. Lung collapse and re-expansion may alter the spatial relationship between the staple line and adjacent chest wall vessels, thereby increasing arterial injury risk. Careful staple line inspection, appropriate cartridge selection based on tissue thickness, and chest drain management are essential for preventing this rare complication.

Surgical resection is the primary treatment for giant mediastinal liposarcoma. However, aggressive R0 resection involving major nerves can lead to fatal functional loss. Clinicians must balance oncological radicality with functional preservation, as early diagnosis remains the most critical factor for avoiding highly morbid, extensive surgeries.

ABSTRACTBackgroundImpairment of the visceral pleura following thoracic surgery often leads to air leaks and intrathoracic adhesions. For preventing such complications, mesothelial cell proliferation at the pleural defects can be effective. To develop new materials for pleural defects restoration, we constructed a hybrid artificial pleural tissue (H‐APLT) combining polyglycolic acid (PGA) nanofiber sheets with a three‐dimensional culture of mesothelial cells and fibroblasts and evaluated its therapeutic efficacy in a rat pleural defect model.MethodsAfter rat lungs were harvested, pleural mesothelial cells and lung fibroblasts were cultured separately. To construct H‐APLT, the cells were then coated with multiple layers of fibronectin and gelatin, followed by a single layer of mesothelial cells on top of multiple layers of fibroblasts accumulated onto a collagen‐coated PGA nanofiber sheet. Left lateral thoracotomy was performed, and H‐APLTs were transplanted into a rat model with pleural defects (N = 8). After 2–12 weeks of transplantation, lung resection and histological analyses were performed.ResultsH‐APLTs exhibited a pleural structure with a highly integrated mesothelial layer in vitro. After transplantation, all eight rats survived until sacrifice. At 12 weeks post‐transplantation, the mesothelial layer on the lung surface was observed to be without defects with no intrathoracic adhesions detected.ConclusionSuccessful isogenic engraftment of H‐APLTs was achieved in a rat model of pleural defects. The combination of accumulated fibroblasts and collagen‐coated PGA nanofiber sheets contributed to the maintenance of the mesothelial layer's structure and function, potentially preventing air leaks and intrathoracic adhesions.

A 74-year-old male was admitted with acute cholecystitis, during which computed tomography( CT) revealed a 20 cm anterior mediastinal tumor. He developed septic shock requiring tracheostomy and mechanical ventilation, and was referred to our institution. Biopsy under local anesthesia excluded malignant lymphoma and germ cell tumor, leading to planned surgical resection. Due to the tumor's extensive bilateral spread and proximity to the tracheostomy site, clamshell thoracotomy with lower partial sternotomy was performed instead of median full sternotomy. The final diagnosis was well-differentiated liposarcoma. The sternum was closed with wires and plates, and prophylactic negative pressure wound therapy was applied. Postoperatively, there were no sternal complications. Laparoscopic cholecystectomy was later performed, and the tracheostomy cannula was removed successfully. In surgical resection of giant mediastinal tumors, the approach should be selected based on the tumor's location and its extent of invasion into surrounding tissues.

INTRODUCTION:Neurogenic tumors commonly develop in the posterior mediastinum in both pediatric and adult patients. In patients with neurofibromatosis type 1, distinguishing benign schwannomas from malignant peripheral nerve sheath tumors is challenging. In this study, we aimed to present the surgical management of a giant schwannoma that required differentiation from a malignant peripheral nerve sheath tumor. CASE PRESENTATION:A 15-year-old boy presented with a large right mediastinal mass discovered on chest radiography at high school admission. Subsequent contrast-enhanced CT of the chest showed the development of a large tumor (16.0 × 12.5 × 11.8 cm) occupying approximately two-thirds of the right thoracic cavity, with atelectasis of the lower lobe of the right lung. The patient was histopathologically diagnosed with a benign schwannoma associated with neurofibromatosis type 1 through a thoracoscopic biopsy of the tumor and had received oral selumetinib at 50-70 mg/day for 11 months. Surgical excision was performed because of tumor progression and suspected malignant transformation. Right posterolateral thoracotomy with the opening of the 6th intercostal space was performed by extending the anterior skin incision along the abdominal rectus muscle and separating the 6th costal cartilage and diaphragmatic margin along the chest wall. The tumor was completely removed by resecting numerous adhesions between the tumor and the surrounding tissues and coagulating several nutrient vessels that flowed into the tumor, while resecting the lower lobe of the lung. The postoperative course was uneventful. The pathological examination revealed no malignancy. Subsequent contrast-enhanced CT of the chest revealed no residual tumors. CONCLUSIONS:Posterolateral thoracotomy with the separation of the costal cartilage and diaphragmatic margin along the chest wall could achieve safe surgery for a giant mediastinal schwannoma.

A 33-year-old woman, who had a 6 pack-year smoking history, presented with cyclical hemoptysis for 4 months. Although she was treated for suspected pneumonia due to the opacity in posterior basal segment of the right lower lobe (Fig 1A), her symptom recurred concurrently with menstruation. She had a history of an induced abortion and a spontaneous abortion in her late 20s.

AIM:The study aimed to evaluate the reliability and usability of the CARE-Radiology checklist in assessing radiological case reports and provide a basis for its broader adoption and optimization. METHODS:Ten randomly selected radiological case reports published in scientific journals in 2020 were evaluated using the CARE-Radiology checklist. Twenty-six experts from 10 countries were invited to independently assess all ten reports. The reliability of the checklist was measured using Fleiss' Kappa, and Cronbach's alpha coefficient. Usability was evaluated by recording the time taken to complete the assessments and requesting the evaluators to rate each item on a Likert scale for its easiness of use. RESULTS:The median time for evaluating one radiological case report was 15 min. The overall agreement among evaluators showed moderate reliability with a Kappa value of 0.47 and a Cronbach's alpha of 0.51. The mean compliance rate for the items of CARE-Radiology was 61.8%, with some items exceeding 90% compliance. Items related to abstracts and keywords had the lowest compliance rates. The evaluators found most items easy to understand, with a few exceptions. CONCLUSIONS:The CARE-Radiology checklist is relatively easy for researchers to use and understand. Continuous feedback is necessary for future revisions and updates, to enhance the effectiveness of the checklist, and to improve user experience.

Background and Objective:Giant anterior mediastinal tumors sometimes may cause circulatory collapse and respiratory failure, known as mediastinal mass syndrome (MMS). The prediction and prevention of MMS is challenging. The aim of this study is to summarize the evaluation methods for MMS and formulate treatment strategies for giant anterior mediastinal tumors.Methods:We performed a thorough analysis of recent international literature on giant anterior mediastinal tumors (>10 cm in diameter) and MMS published in the PubMed database. The search spanned the duration of the preceding 10 years from August 19, 2023, and only studies published in English were included.Key Content and Findings:Mature teratomas and liposarcomas are the most common giant anterior mediastinal tumors and MMS develops most frequently in case of malignant lymphomas. Here, we propose a new treatment strategy for giant anterior mediastinal tumors. Based on imaging findings, giant anterior mediastinal tumors can be classified as cystic or solid and further blood investigation data are useful for a definitive diagnosis. When malignant lymphoma or malignant germ cell tumor is highly suspected, the first choice of treatment is not surgery but chemotherapy and radiotherapy. Moreover, image-guided drainage may be effective if giant cystic anterior tumors develop into MMS. The risk classification of MMS is important for treating giant anterior mediastinal tumors. If the MMS risk classification is 'unsafe' or 'uncertain', the intraoperative management deserves special attention. The surgical approach should however be based on tumor localization and invasion of surrounding tissues. Multidisciplinary team coordination is indispensable in the treatment of giant anterior mediastinal tumors.Conclusions:When giant anterior mediastinal tumors are encountered, it is important to follow the appropriate treatment strategy, focusing on the development of MMS based on imaging findings and symptoms.

Background Cerebral infarction after pulmonary resection is a minor but critical complication. We report a rare case of postoperative complication of Wallenberg syndrome caused by cerebral infarction in the posterior inferior cerebral artery after the left upper lobectomy. Case presentation A 72-year-old man developed cerebral infarction 2 days after a left upper lobectomy for lung cancer. Magnetic resonance imaging indicated right vertebral artery occlusion following an early ischemic area on the right lateral side of the medulla oblongata and cerebellum. Contrast-enhanced computed tomography revealed no thrombus in the left superior pulmonary vein stump. The patient was diagnosed with Wallenberg syndrome, and prompt anticoagulation therapy was initiated. The patient was discharged and transferred to another hospital for rehabilitation on postoperative day 16. Conclusions We present a rare case of Wallenberg syndrome occurring in the posterior inferior cerebral artery area due to vertebral artery occlusion after lobectomy. Because cerebral infarction of the posterior circulation has many similar symptoms due to the side effects of anesthetic drugs, careful physical examination is required to determine Wallenberg syndrome.

BACKGROUND:Giant mediastinal mature teratomas may cause airway obstruction or decreased venous return due to the mass effect. Preoperative stabilization of the respiratory and circulatory systems is important for perioperative management to safely perform surgery, including general anesthesia. However, to the best of our knowledge, there are only a few reports regarding the preoperative computed tomography (CT)-guided drainage of mediastinal tumors.CASE PRESENTATION:A 30-year-old woman was admitted to the emergency room with sudden dyspnea. CT findings revealed a giant cystic mass in the anterior mediastinum compressing the trachea and the right main bronchus. The patient was intubated and CT-guided drainage of the fluid content of the cyst was performed to decompress the airway obstruction. Thereafter, the mediastinal tumor was resected during elective surgery and pathologically diagnosed as a mature teratoma.CONCLUSIONS:Rescue preoperative CT-guided drainage of a giant mediastinal mature teratoma allowed safe general anesthesia and surgery by releasing the airway obstruction.

PURPOSE:To investigate the incidence of postoperative cerebral infarction after curative lobectomy, its association with the type of lobectomy, and how postoperative new-onset arrhythmia contributes to postoperative cerebral infarction.METHODS:The subjects of this analysis were 77,060 patients who underwent curative lobectomy for lung cancer between 2016 and 2018 according to the National Clinical Database. Incidences of postoperative cerebral infarction and postoperative new-onset arrhythmia were analyzed. Moreover, mediation analysis was performed to evaluate the causal pathway between postoperative new-onset arrhythmia and postoperative cerebral infarction.RESULTS:Postoperative cerebral infarction occurred in 110 (0.7%) patients after left upper lobectomy and in 85 (0.7%) patients after left lower lobectomy. Left upper lobectomy and left lower lobectomy were associated with a higher likelihood of postoperative cerebral infarction than right lower lobectomy. Left upper lobectomy was the strongest independent predictor of postoperative new-onset arrhythmia. However, in the mediation analysis, the odds ratio for cerebral infarction did not change after the addition of the factor of postoperative new-onset arrhythmia.CONCLUSION:Cerebral infarction occurred significantly more often not only after left upper lobectomy, but also after left lower lobectomy. Postoperative new-onset arrhythmia was less likely to be related to cerebral infarction after left upper lobectomy.

Background Thrombosis in the pulmonary vein stump (PVS) is not a well-known complication after pulmonary lobectomy, but it has the potential to cause embolism to vital organs. The aim of this study was to evaluate the risk factors for thrombosis in the PVS after pulmonary lobectomy. Methods A total of 439 patients who underwent pulmonary lobectomy from 2008 to 2017 were retrospectively reviewed, and 412 patients were further analyzed. The state of the PVS was evaluated by chest contrast-enhanced computed tomography (CECT). Univariate analysis was performed to evaluate the potential risk factors for thrombosis in the PVS. Results Thrombosis in the PVS was detected in 6 of 412 (1.5%) patients, and 5 of them underwent left upper lobectomy (LUL) (5/100, 5.0%) ( P = 0.004). In the analyses of the LUL group, postoperative chest radiotherapy was identified as a risk factor for thrombosis in the PVS ( P = 0.024), and postoperative atrial fibrillation showed a tendency to be a risk factor for thrombosis ( P = 0.058). Conclusions Chest radiotherapy after LUL is a possible risk factor for thrombosis in the PVS. Periodic chest CECT is recommended after postoperative chest radiotherapy for patients after LUL.

症例は79歳の男性.検診で胸部異常陰影を指摘され,当院紹介となった.胸部CTで右上葉に結節影を認め,経気管支鏡下肺生検で腺癌と診断された.気管支鏡検査で気管右壁から発生する異常気管支を認め,右上葉気管支は通常通りに分岐していたため過剰気管気管支と判断した.原発性肺腺癌cT1bN0M0,Stage IA2と診断し,右上葉切除術を施行した.過剰気管支は奇静脈弓よりわずかに頭側のレベルで気管右壁から分岐し,奇静脈弓の尾側を通過して右上葉縦隔側へ走行していた.分岐部の視野を確保するため奇静脈を先に切離した上で,過剰気管支を処理した.過剰気管支を有する肺癌手術症例の報告は少なく,過剰気管気管支についてはこれまで本邦からの報告はない.3D-CTは気管支分岐異常の検索やそれに伴う肺血管走行異常の確認,位置関係の把握に有用であった.

A pleuroperitoneal communication is a serious complication for patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Video-assisted thoracoscopic surgery is performed using indocyanine green adsorbed to human serum albumin fluorescence to identify the communication because human serum albumin reinforces fluorescence images. A patient diagnosed with a pleuroperitoneal communication was referred to our department and underwent surgery. To detect the communication, a dialysate mixture that contained indocyanine green and human serum albumin was injected from the CAPD catheter. Real-time fluorescence images were able to clearly show a bleb-like lesion with a near-infrared spectroscopy camera, and the site was repaired. The patient had no recurrence at one-year follow-up. This method might be good method for pleuroperitoneal communication surgery.

Abstract Background Adjuvant chemotherapy with platinum‐based regimens for completely resected early‐stage non‐small cell lung cancer (NSCLC) provides overall survival benefit in several clinical trials. Objectives We conducted this prospective study to evaluate the efficacy and safety of adjuvant chemotherapy with carboplatin and S‐1 for patients with completely resected stage II to IIIA NSCLC. Methods Patients with completely resected stage IIA to IIIA NSCLC were treated with four cycles of carboplatin with area under the concentration time curve of 5 mg/mL/min on day 1 plus S‐1 at 80–120 mg/bodyweight per day for two weeks, followed by one‐week rest as adjuvant chemotherapy. The primary endpoint was the completion rate of three cycles of the treatment. The secondary endpoints were safety and two‐year survival rate. Results A total of 19 patients were enrolled, until the study was terminated prematurely because of fatal pulmonary embolism in two patients. The median number of treatment cycles was three (range: 1–4). The completion rate of three cycles was 78.9% (95% confidence interval [CI]: 56.6–91.4%). Two‐year disease‐free survival rate was 57.8%. Grade 3 or 4 hematological toxicities included neutropenia (26.2%), anemia (5.2%), and thrombocytopenia (15.7%). Grade 3 or 4 nonhematological toxicities were anorexia (10.5%) and nausea (10.5%). Febrile neutropenia developed in 5.2%. In two patients (10.5%), grade five pulmonary embolism was observed, and the causal relationship with treatment could not be denied. Conclusions Carboplatin and oral S‐1 had modest survival benefit, but this regimen was not tolerable in an adjuvant setting because fatal pulmonary embolism occurred in two patients. Key points Carboplatin and oral S‐1 had modest survival benefit but this regimen was not tolerable. Fatal pulmonary embolism occurred in this regimen.