Tracheal and main bronchial tumors are relatively rare diseases. Primary or metastatic malignant tumors and benign tumors are also found. Even benign tumors can obstruct the airways and may require urgent treatment. We report three cases of endoscopic snare resection.

Introduction:In the phase 3 study entitled ALK in Lung cancer Trial of brigAtinib in 1st Line (ALTA-1L), which is a study of brigatinib in ALK inhibitor-naive advanced ALKpositive NSCLC, brigatinib exhibited superior progressionfree survival (PFS) versus crizotinib in the two planned interim analyses.Here, we report the final efficacy, safety, and exploratory results.

The treatment of lung cancer has advanced in recent years, and the postoperative survival period has been extended. As a result, the incidence of multiple lung cancer tends to increase. At the time of second surgery, it is necessary to examine the extent of resection in more detail.

Before lung resection, it is necessary to perform various preoperative examinations to determine the indication for surgery. In our department, lung blood flow scintigraphy is performed on all cases scheduled for lung resection, and predicted post operation (ppo)%FEV1 and ppo%DLCO, are calculated based on lung function tests and scheduled surgery. Both have a cut-off value of 40%, and if the case has less than 40%, change to surgery with less lung volume loss. However, the large number of cases have no difference between left and right lung blood flow ratios. Even if the difference is large, almost all cases have organic lung abnormalities which are detected by CT easily. In addition, even if there is a large dissociation in the left-right difference in pulmonary blood flow, it is very rare that the predicted value after surgery is less than 40% in normal respiratory function patients. In recent years, most institutions do not perform pulmonary blood flow scintigraphy as preoperative examination, and it may be necessary to examine the significance of lung blood flow scintigraphy as preoperative examination. Of the cases in which lung blood flow scintigraphy was performed as a preoperative examination for lung resection in our department from January 2010 to December 2018, we selected the cases who has the blood flow ratio between the left and right lungs has more than doubled difference and doesn’t have detectable organic abnormality and history of lung resection. Nineteen out of 1570 cases were extracted. The blood flow of the right lung was more than twice that of the left lung in 18 cases. 19 cases have 12 men and the average age is 73.6 ± 6.9. There were 13 cases undergoing planned surgery, 3 cases that could not be resected due to the progress of the tumor, 1 case refusing the operation, and only 2 cases changed treatment based on the result of scintigraphy. One case treated by radiation therapy and another was treated by PDT. It is suggested that lung blood flow scintigraphy may not be necessary in cases who have normal pulmonary function and have no organic abnormalities.

Lung cancer is the leading cause of cancer death worldwide. A large part of lung cancer is diagnosed at an advanced stage, but the number of lung cancer diagnosed at an early stage are increasing due to improved diagnostic imaging techniques. In Japan, sputum cytology for mass screening provides chances to detect very early stage centrally located lung cancer which is good adaptation of PDT. Although PDT is less invasive therapy which enable us to treat the patients with poor pulmonary function or poor performance status. It is important to clarify the therapeutic outcome and the morbidity after PDT such as airway narrowing, pneumonia, and sunlight hypersensitivity. We analyzed 14 patients who received PDT in Tohoku University Hospital between January 2010 and April 2017 retrospectively and evaluated the therapeutic outcome of PDT. 14 cases were all male and the average age was 71. Nine cases were detected in cancer screening examinations and other 5 cases were detected accidentally while observing other diseases. Lung cancer existed in trachea 1, in segmental bronchi 4, in sub segmental bronchi 7, and more peripheral lesion 2. All 14 cases were pathologically squamous cell carcinoma. In 2 cases, we performed PDT twice. In 3 cases, we performed surgical resection after PDT. Within follow-up period after PDT, 5 cases developed metachronous lung cancer and were treated with surgical resection or radiation therapy. After these therapies 11 cases alive without recurrence, 1 case alive with recurrence, 1 case died from original disease, and 1 case died from other disease. Only one case suffered airway narrowing after PDT, but other 13 cases had no morbidity. We concluded PDT is a good treatment in early stage centrally located lung cancer with good outcomes and little morbidity rates.

Acute exacerbation could be life-threatening for idiopathic interstitial pneumonia (IIP) patients. It is often challenging to choose a surgical treatment for a patient with IIP associated with lung cancer because lung resection is one of the risk factors of acute exacerbation. The objective of this present study was to investigate the correlation between preoperative findings of 18F-FDG PET/CT and postoperative acute exacerbation in patients with IIP associated with lung cancer. We retrospectively reviewed the data of 450 patients who underwent lung resection for non-small cell lung cancer between November 2012 and October 2017. We excluded patients who had preoperative radiotherapy (25 patients) from the analysis. All these patients preoperatively underwent 18F-FDG PET/CT for staging lung cancer. The maximum standardized uptake value was obtained. CT findings of IIPs were found in 31 out of 425 patients (7.1%). Five out of 31 patients (16.1%) developed acute exacerbation after lung resection. These 5 patients had significantly higher SUVmax in the lesions of IIPs compared 26 patients without postoperative acute exacerbation. This study demonstrated that 18F-FDG PET/CT findings may predict postoperative acute exacerbation of IIP in lung cancer patients.

Background. Calcineurin inhibitors are a commonly used immunosuppressive drug and over 80% of lung transplant (LTx) recipients use tacrolimus. Sustained-release tacrolimus (SRT) was developed as a once-daily formulation, resulting in slower release and reduction in peak concentration compared with twice-daily immediate-release tacrolimus (IRT). Previous reports indicate that SRT may carry fewer side effects than IRT; however, the impact of SRT in bronchiolitis obliterans syndrome (BOS) after LTx is unclear. Objective. Our study objective was to evaluate the effect of SRT in BOS after LTx. Materials and methods. We investigated the effect of SRT for BOS among 75 LTx recipients who were alive in 2017 in our LTx program. All analyses were carried out using student t test or F test. Results. Thirty-five recipients took IRT, 32 recipients used SRT, 7 recipients used cyclosporine, and 1 patient who received bone marrow and a lung graft from the same donor did not use a calcineurin inhibitor. The most frequent reason for conversion of IRT to SRT was kidney dysfunction, followed by other IRT complications. Five recipients underwent conversion of IRT to SRT because of decline of forced expiratory volume in 1 second (FEV1) with fluctuation of the tacrolimus trough level. After induction of SRT, the fluctuation of the tacrolimus trough level was significantly reduced in 4 of 5 patients (P < .05). Before drug form conversion, the FEV1 in these 5 patients was significantly decreased; however, this exacerbation of FEV1 was attenuated after SRT induction (P < .05). Conclusion. SRT appeared to stabilize decline of FEV1 in patients with BOS possibly due to reducing the fluctuation of tacrolimus trough blood concentration.

It is not determined whether single lung transplantation (SLT) or double lung transplantation (DLT) is suitable for lymphangioleiomyomatosis (LAM). Because of extreme shortage of cadaveric donor, SLT has been preferably chosen for LAM in Japan. The purpose of this study is to evaluate the outcome of SLT for LAM in our institute. From March 2000 to April 2015, 28 patients with LAM underwent SLT and 4 patients with LAM underwent DLT in our institute. We collected data from medical records and retrospectively reviewed them. All patients who underwent SLT were women with a mean age of 44.5 (range, 24 - 61) years old. The median months of the waiting time form the listing to SLX was 39.9 (range, 6 - 111) months. LAM-related complications before SLT were as follows; pneumothorax: 11, chylothorax: 1, chyloptysis: 2, chylous ascities: 3. The mean ischemic time of the lung graft was 7.4 (range, 5.2 - 9.4) hours. The 30-day mortality was none and the 90-day mortality was 7.1% (2 patients). The cause of early death in the 2 patients was primary graft dysfunction. Five late deaths occurred and the causes were chronic lung allograft dysfunction in two patients, pulmonary thromboembolism in 1 patient, viral encephalitis in 1 patient, and cytomegalovirus pneumonia in 1 patient. There were no deaths in DLT patients. Recipients demonstrated functional improvement 1 year after SLT compared with the preoperative status at registration as shown by the increase in %FEV1 (34.5 to 57.1% to), %DLCO (26.4 to 81.8%) and 6-minute walk distance (243 to 434 m). Recurrent or new complications related to LAM after SLT were as follows; pneumothorax at native lung side: 7, chylothorax: 6, rupture of angiomyolipoma: 1. The Kaplan-Meier survival was 89.3 % at 1 year, 81.5% at 3 years, and 74.7% at 5 years. Satisfactory functional improvement and survival rate observed in this study indicate that SLT is a suitable option for patient with LAM although postoperative complications in the native lung side including pneumothorax should be paid attention and managed.

BACKGROUND:Bronchiolitis obliterans (BO) is a major cause of morbidity and mortality after lung transplantation. BO is pathologically characterized by neovascularized fibro-obliteration of the allograft airway. A recent study has shown that aberrant angiogenesis during fibro-obliteration contributes to the pathogenesis of BO. Vasohibin-1 (VASH1) has been isolated as a vascular endothelial growth factor-inducible gene in endothelial cells (ECs) that inhibits migration and proliferation of ECs and exhibits anti-angiogenic activity in vivo.PURPOSE:This study examines whether VASH1 inhibits fibro-obliteration of the allograft in a murine intrapulmonary tracheal transplantation model.METHOD:Tracheal allografts of BALB/c mouse were transplanted into the left lung of recipient C57BL/6J mouse. We performed gene transfer to the recipient lungs using an adenovirus vector encoding human VASH1 (Ad-VASH1) or beta- garactosidase (Ad-LacZ) as the control. Tracheal allografts were harvested and pathological on days 21 and 28.RESULT:Ad-VASH1 treatment reduced the vascular area on day 21 (4.6% versus 13.0%, P = .037) and day 28 (5.4% versus 13.4%, P = .022) compared with the control group. This was accompanied by significantly inhibited luminal obliteration of the tracheal allografts in the animals transferred with Ad-VASH1 compared with the control (69% versus 93%, P = .028) on day 21. We were not able to observe this effect on day 28 (92% versus 97%, P = .48).CONCLUSION:Transgene expression of VASH1 in the recipient lung significantly attenuated luminal obliteration of the tracheal allograft; this was associated with significantly reduced aberrant angiogenesis in the fibro-obliterative tissue in a murine model intrapulmonary tracheal transplantation.

The patient was a 68 year-old woman who had a history of treatment of pulmonary tuberculosis 35 years ago. She has experienced dyspnea and hemosputa since several years ago and has been followed up as having chronic empyema. She was admitted to our hospital due to recent exacerbation of symptoms. X-ray films and computed tomography scans of the chest showed the right thoracic cavity to be totally filled with a mass and the shift of mediastinum to the left side. After several days from admission, she needed mechanical ventilation support due to dyspnea exacerbation. Emergency decortication with right pneumonectomy through median sternotomy with anterolateral incision was performed. Postoperative course was uneventful. Pathlogical diagnosis was chronic expanding hematoma.

We report a case who had undergone operation of very early malignant pleural mesothelioma (MPM). A 58-year-old woman admitted to first visited hospital because of pleural effusion of the right side. She received a diagnosis of epithelial type MPM which had been confirmed from a pleural biopsy spacemen obtained by thoracoscopy under local anesthesia. An abnormal change of the pleura could not be detected on chest X-ray and thoracic computed tomography (CT) scan after chest drainage. She was referred to our hospital for surgery, and was undergone an extrapleural pneumonectomy followed by postoperative treatment with cisplatin puls gemcitabine. Pathologically, the disease was diagnosed as stage IA based on the classification of International Mesothelioma Interest Group (IMIG). There is a no evidence of the relapse 9 months after the operation. An early diagnosis of the MPM is very difficult. The thoracoscope with local anesthesia was very effective for early diagnose of a MPM.

A case of 42-year-old man with postintubation subglottic stenosis underwent primary thyrotracheal anastomosis. Since trachea had been incised longitudinally for previous tracheostomy, tracheal resection came to be longer. Therefore, we had to anastomose the incised trachea with thyroid cartilage even after the suprahyoid release. After the operation, he suffered from the tracheal collapse at the incised portion of the trachea One week after intubation, tracheal patency was achieved. We recommend horizontal incision for tracheostomy in patient with subglottic stenosis, when the following surgical approach is considered.

Both thyrotracheal anastomosis and carinoplasty are relative rare procedure in routine clinic. We reported each 2 cases of thyrotracheal anastomosis and carinoplasty in 51 cases of tracheobronchoplasty. Thyrotracheal anastomosis with partial cricoidectomy was performed in patients with subglottic stenosis for postintubation stenosis and thyroid cancer using suprahyoid release. Each case need re-intubation after surgery. Montage carinoplasty was performed in 2 patients with advanced lung cancer. Right upper lobe was end-to-side anastomosed to trachea in 1 case, and right basal segment was to left main bronchus in another. It was important both diameter in bronchus and mobilization of the residual lung for this procedure.