Lingular Division Research Articles

The Impact of Bronchiectasis on the Clinical Characteristics of Non-Severe Asthma.

Current literature primarily delves into the relationship between bronchiectasis and severe asthma, and only a few studies have evaluated the impact of bronchiectasis in patients with non-severe asthma. Therefore, this study investigated the clinical impact of bronchiectasis in patients with non-severe asthma. A prospective observational study of 140 non-severe asthmatic patients with (bronchiectasis group) and without bronchiectasis (control group) was conducted between September 2012 and February 2022. The bronchiectasis and control groups were compared in terms of demographics, lung function, asthma control test (ACT) results, exacerbation history, and respiratory medications. Among 140 non-severe asthmatic subjects, approximately 15.7% (n = 22) had bronchiectasis. The most common type of bronchiectasis was cylindrical type (90.7%). The left lingular division was the most frequently involved lung lobe (20.4%). There were no significant differences in the demographics (age, sex, body mass index, smoking history, and comorbidities) or ACT results between the 2 groups. The bronchiectasis group used inhaled corticosteroids/long-acting β2-agonists (P = 0.074) and mucolytics (P < 0.001) more frequently than the control group. Compared to the control group, the bronchiectasis group had lower forced expiratory volume in 1 second (FEV1) (L) (1.9 ± 0.7 L vs. 2.3 ± 0.9 L, P = 0.039) and FEV1%predicted (67.2 ± 22.2%predicted vs. 77.1 ± 20.0%predicted, P = 0.038). The rate of hospital admission to a general ward in the preceding year was significantly higher in the bronchiectasis group compared to those of the control group (23.8% vs. 3.5%, P = 0.005) with an adjusted odds ratio of 6.308 (95% confidence interval, 1.401-28.392). Patients with non-severe asthma and bronchiectasis had lower lung function and more frequent exacerbations requiring hospitalization than those without bronchiectasis. More attention is needed for asthmatic patients with bronchiectasis, even if the asthma is not severe.

Arteria Praebronchialis (AP) Found on MDCT: An Updated Incidence and Branching Patterns.

Preoperative detection of the arteria praebronchialis (AP), a rare variant mediastinal branch of the left pulmonary artery, can be crucial to a successful left-lung surgery; if the AP is overlooked and ligated during surgery, the blood supply to the remaining lobe may be compromised. The purpose of this study was to update the incidence and branching patterns of the AP. From 18 April 2012 to 31 December 2022, contrast-enhanced CT was screened by one radiologist for the presence of AP. Branching patterns of the AP were analyzed by three thoracic radiologists. The incidence of AP was updated to 0.068% (18/26,310) from the previously reported 0.03%; the incidence of AP for male and female patients was 0.110% and 0.017%, respectively. AP supplied only the LLL in 10 cases and both the lingular division of LUL and LLL in nine cases. Dual segmental supply by both the AP and the normal left descending pulmonary artery existed in 15 cases; exclusive segmental supply by either artery existed in four cases. The AP supplies either the LLL alone or both LLL and the lingular division of LUL, and its incidence is not negligible in the male population, necessitating routine surveillance prior to pulmonary resection.

The intersegmental pulmonary vein is not always located on the intersegmental plane of the lung: Evaluation with 3-dimensional volume-rendering image reconstruction.

To clarify whether intersegmental pulmonary veins are always located on the intersegmental plane and determine the division from which blood flows into them. We analyzed representative intersegmental veins located between the upper/lingular and superior/basal division of the lungs using preoperative chest computed tomography (CT) DICOM data from 22 patients who underwent lobectomy or segmentectomy during 2020. The location and blood flow of V3a+b andV6b+c were assessed using REVORAS (Ziosoft), a novel volume-rendering 3-dimensional (3D) image reconstruction software dedicated to lung segmentectomy. The V3a+b was in the upper division and on the intersegmental plane between the upper and lingular divisions of the left lung in 11 patients (50%) each. A main root of V3a+b was not found in the lingular division, but some peripheral flow in the V3a+b was derived from it in 14 patients (64%). The V6b+c was found in the superior division of the right lower lobe in 13 patients (59%) and the left lower lobe in 10 patients (45%), and on the intersegmental plane between the superior and basal division of the right lower lobe in 6 patients (27%) and the left lower lobe in 10 patients (45%). A main root of V6b+c was imperceptible in the basal division. Some peripheral blood flow was derived from the basal division in 6 patients (27%) with V6b+c veins located in the right lower lobe and in 8 patients (36%) with V6b+c veins located in the left lower lobe. Precise evaluation of intersegmental veins using preoperative volume-rendering 3D reconstructed CT images provides useful anatomic information for separating intersegmental pulmonary parenchyma.

Surgical outcomes of anatomical sublobar resections of left upper lobe and a technique of subsegmentectomy based on bronchovascular patterns

BackgroundAnatomical sublobar resection was widely performed for small-sized nodule located in the deep field of the lung. In this study, we compared surgical outcomes between anatomical sublobar resection in left upper lobe including segmentectomy and subsegmentectomy. We also applied a technique based on bronchovascular patterns for subsegmentectomy. Patients and methodsA hundred and fifty-one patients underwent anatomical sublobar resection of left upper lobe in our hospital in the period from January 2018 to December 2019 and they were retrospectively reviewed. Patients’ characteristics and surgical outcome of the subsegmentectomy group (n = 71) were analyzed and compared to those of patients of the segmentectomy group (n = 80). The bronchovascular patterns of left upper lobe in these patients were also classified, and a technique of subsegmentectomy was introduced by cases description. ResultsCompared to segmentectomy, the subsegmentectomy group had longer operative time [141min, interquartile range (IQR): 125–161 vs. 127.5 min, interquartile range (IQR): 114.75–148.25; P = 0.001] and more estimated blood loss [50 mL, IQR: 30–50 vs. 30 mL, IQR: 20–50; P = 0.02]. Branching pattern of bronchus was classified into 3 types in left upper division, and 2 types in lingular division. Branching pattern of pulmonary artery was classified into 7 types in left upper division and 2 types in lingular division. Branching pattern of pulmonary vein was classified into 3 types in left upper division and V3 b was classified into 4 types. ConclusionSubsegmentectomy is a safe procedure with surgical outcome comparable to the one of segmentectomy except operative time and estimated blood loss. Subsegmentectomy based on bronchovascular patterns in left upper lobe is feasible.

Pulmonary vessels and bronchus anatomy of the left upper lobe.

The bronchopulmonary vascular bifurcation patterns in the upper lobe of the left lung are diverse. Therefore, it is important for general thoracic surgeons to understand the detailed anatomy of the pulmonary segments when performing thoracoscopic anatomical pulmonary resection. This study aimed to analyze the bronchovascular patterns of the left upper lobe and summarize the anatomical information associated with pulmonary anatomical pulmonary resection. We reviewed the anatomical patterns of pulmonary vessels and the left lung bronchus of 539 patients using computed tomography imaging data including those obtained using three-dimensional computed tomography. We herein report the anatomic structure in the left upper lobe. Regarding the superior division bronchi, a pattern of trifurcation into B1+2, B3, lingular division bronchus was observed in nine patients (1.7%). A pattern of proximal bifurcation of B4 was found in eight patients (1.5%). Regarding the lingular veins (LV), patterns of LV drainage into the left lower pulmonary vein were observed in 22 patients (4.1%). Regarding the pulmonary artery, mediastinal lingular arteries (MLA) were found in 161 patients (29.9%). The bifurcation patterns of the bronchovascular region in the upper lobe of the left lung were clarified. These results should be carefully noted when performing anatomical pulmonary resection.

Comparison of stapler and electrocautery for division of the intersegmental plane in lung segmentectomy.

BackgroundWe retrospectively compared the use of a stapler and electrocautery for division of the intersegmental plane during pulmonary segmentectomy.MethodsWe enrolled 156 patients who underwent pulmonary segmentectomy in our department between March 2006 and August 2020. The patients were divided into electrocautery (n=62) and stapler (n=94) groups based on the device used to divide the intersegmental plane. Patient characteristics, perioperative outcomes, and ratios of actual (calculated using software) to predicted (calculated by counting the resected segments) lung volumes were compared between the two groups. Additionally, we used multivariate analysis to identify the factors that contributed to the incidence of postoperative air leakage after cut-off value was set by receiver operating characteristic (ROC) curve analysis. Moreover, a subset analysis was performed based on the type of segmentectomy (common or uncommon). Common segmentectomies included resection of the basilar or superior segment of the lower lobe, or lingular or upper division of the left upper lobe; all other segmentectomies were classified as uncommon.ResultsCompared to the electrocautery group, the stapler group had shorter operative times (P=0.0027), duration of postoperative drainage (P=0.00037), and duration of postoperative hospitalization (P=0.0021). Moreover, incidence of postoperative ≥3 days drainage was significantly reduced in the stapler group (P=0.003). There were no significant differences between the stapler and electrocautery groups in the actual:predicted lung volumes at 6 months (1.01 and 1.04, respectively; P=0.28) or 12 months (1.06 and 1.07, respectively; P=0.68) after surgery. Preoperative lung volume was significantly correlated with preoperative vital capacity (VC) (γ=0.69; P<0.001) and forced expiratory volume in 1 second (FEV1) (γ=0.48; P<0.001). The multivariate analysis indicated that the use of stapler for division of intersegmental plane was the only factor that contributed to reducing the incidence of postoperative ≥3 days drainage (P=0.0027, odds ratio: 0.23, 95% CI: 0.086–0.597). In a subset analysis of uncommon segmentectomy, there were no significant differences among the groups in most perioperative results.ConclusionsCompared to electrocautery, the use of a stapler for division of the intersegmental plane was associated with better perioperative outcomes, especially reduction of postoperative drainage time, and similar postoperative remnant lung volumes and function.

Analysis of bronchial and vascular patterns in left upper lobes to explore the genesis of mediastinal lingular artery and its influence on pulmonary anatomical variation

BackgroundFor thoracic surgeons, three-dimensional computed tomography bronchography and angiography (3-DCTBA) is a convenient way to analyze pulmonary variations before segmentectomy. Mediastinal lingular artery (MLA) is one of the representative variations.MethodsThe 3-DCTBA data of left upper lobe (LUL) were collected from patients who underwent pulmonary surgery from January 2018 to December 2019. We reviewed the patterns of bronchi and pulmonary vessels and grouped them according to different classifications.ResultsAmong all the 404 cases of 3-DCTBA, mediastinal lingular artery (MLA) was found in 107 cases (26.49%). The patterns of B3 and the vein in left upper division (LUD) are distinct between mediastinal (M-type) group and interlobar (IL-type) group. The patterns of bronchi and veins in lingular division, as well as the pattern of pulmonary artery in LUD, have no differences between M-type and IL-type groups.ConclusionsMediastinal lingular artery is speculated to originate from the variation of B3, and the MLA independently influences the venous pattern in LUD in turn.

Mediastinal pulmonary artery is associated with greater artery diameter and lingular division volume

Pulmonary vessels have numerous variation and aberrant branching patterns. Mediastinal lingular artery (MLA), the most common aberrant branch, might contribute to greater blood flow to lingular division. Hence, we investigated a correlation between lingular division volume and MLA using three-dimensional CT volumetry. We included 199 consecutive patients who underwent surveillance chest CT to detect possible malignancies in April 2015. We measured lingular division volume and cross-sectional area of lingular arteries using three-dimensional CT volumetry. MLA was identified in 58 cases (29.1%). The MLA group had significantly greater lingular division volume (median ± quartile deviation: 378.3 ± 75.5 mL vs. 330.0 ± 87.5 mL; p = 0.021) and percentage lingular division to left lung volume (19.0 ± 2.62% vs. 16.6 ± 2.39%; p < 0.001) than the non-MLA group. Total cross-sectional area of lingular arteries of the MLA group was significantly larger than that of the non-MLA group (46.1 ± 9.46 vs. 40.2 ± 5.76 mm2; p = 0.003). The total cross-sectional area of the lingular arteries strongly correlated to the percentage of lingular division to left lung volume (r = 0.689, p < 0.001). This is the first report demonstrating a positive correlation between branching pattern of pulmonary artery and lung volume.

Recurrent Tuberculous Fistular Granuloma During Antituberculous Drug Therapy, Managed With Repeated Bronchoscopy

SESSION TITLE: Tuberculosis Global Case Reports SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: In tuberculous (TB) lymphadenitis, caseous nodes attach to the bronchial wall and erode through it, leading to a fistulous tract and endobronchial granuloma. Drug therapy often has little impact on its progression. From 2007 to 2013, we experienced the cases of recurrent endobronchial TB granulomas associated with bronchial invasion of lymphadenitis. CASE PRESENTATION: Case 1. A 26-year-old woman was diagnosed with TB lymphadenitis via mediastinoscopic biopsy. No parenchymal lesions were observed. After 2 months of medication, cough worsened and two endobronchial granulomas of the proximal right intermediate bronchus were found on flexible bronchoscopy (FOB). One month later, wheezing developed and repeated FOB revealed a granuloma obstructing the proximal right main bronchus. Two months later, cough worsened again and granulomas were observed in the proximal left and right main bronchi. Four months later, tubular breathing sounds were noted; a granuloma also recurred in the proximal right main bronchus. AntiTB medication was administered for 18 months. Chest CT demonstrated improved lymphadenitis with no abnormal findings in the tracheobronchial tree. The patient refused follow-up bronchoscopy. Spirometric findings were normal. When she visited again because of throat trouble 38 months later, she had no respiratory symptoms and breath sounds were clear. Chest X-ray revealed no remarkable findings. Case 2. A 16-year-old boy was diagnosed with TB lymphadenitis via bronchoscopic biopsy of an endobronchial granuloma obstructing the apicoposterior segment of the left upper lobe, which developed from intraluminal invasion of mediastinal lymphadenitis. No parenchymal lesions were observed. After 1 month of medication, hemoptysis recurred and FOB revealed a granuloma in the distal left main bronchus. Follow-up FOB after 3 months confirmed the absence of residual lesions. AntiTB medication was administered for 18 months. Follow-up chest CT and spirometric findings were unremarkable. Case 3. A 31-year-old man was diagnosed with miliary TB, with lymphadenitis and bilateral pleural effusion. After 3 months of medication, dyspnea worsened and chest CT showed progression of lymphadenitis. FOB revealed several granulomas with obstruction or stenosis at all segments of the left upper lobe. Seven months later, chest CT scan demonstrated aggravated paraaortic lymphadenitis and FOB revealed a granuloma in the left main bronchus. After 2, 4, and 6 months, this granuloma developed repeatedly at the same site in the left main bronchus. Two months after that, the granuloma recurred at the lingular division of the left upper lobe. AntiTB medication was administered for 24 months. Follow-up chest CT scan showed well-healed lymphadenitis. FOB revealed residual obstruction and stenosis at 3 segments of the left upper lobe. FEV1 improved from 46 to 66% of the predicted normal, and FVC improved from 49 to 83%. DISCUSSION: The total number of recurrences was 10 in 3 cases. Six granulomas recurred at the same site and four recurred at a different site. Once an endobronchial granuloma was found, we removed as much as possible, via bronchoscopic procedures, to relieve bronchial stenosis. Follow-up FOB was performed in cases 1 and 2 if there were any findings suggestive of recurrence, and was performed after 2 months in case 3 because the risk of recurrence was high. Ultimately, significant stenosis remained in case 3, but this patient exhibited improved spirometric findings. Prolonging antiTB medication until lymphadenitis improves sufficiently is important even though drug therapy may not be entirely effective against progression of fistulous granulomas. CONCLUSIONS: In the case of TB lymphadenitis, particularly in cases of bronchus invasion, endobronchial granuloma can develop, and can recur even after almost complete removal because a fistulous tract has already formed. Aggressive bronchoscopic procedures should be considered to relieve significant bronchial stenosis. Therefore, if TB lymphadenitis is observed adjacent to the bronchus, close follow-up is advised even when drug therapy is administered. Reference #1: Polesky A, Grove W, Bhatia G. Peripheral Tuberculous Lymphadenitis; Epidemiology, Diagnosis, Treatment, and Outcome. Medicine 2005 ; 84 : 350-362 Reference #2: Gupta PR. Difficulties in managing lymph node tuberculosis. Lung India 2004; 21 : 50-53. Reference #3: Lincoln EM, Harris LC, Bovornkitti S, et al. Endobronchial tuberculosis in children. Am Rev Tuberc Pulm Dis 1958 ; 77 : 39-61 DISCLOSURE: The following authors have nothing to disclose: Hong Lyeol Lee, Jung Soo Kim No Product/Research Disclosure Information

Clinicopathological characteristics and lymph node metastasis pathway of non-small-cell lung cancer located in the left lingular division.

The purpose of this study is to assess the clinicopathological characteristics of non-small-cell lung cancer (NSCLC) occurring in the left lingular division (LLD) in association with a proposal of the LLD-specific regional lymph node stations. Medical records of patients, who underwent complete tumour resection with mediastinal lymph node dissection (MLND) for LLD-NSCLC from 2000 to 2009 in multiple institutions, were retrospectively examined. We analysed patient clinicopathological characteristics and obtained the LLD-specific regional lymph node stations, and then the validity of intraoperative navigation in lymphadenectomy for LLD-NSCLC was investigated. One hundred and eighty-four LLD-NSCLC patients (97 males and 87 females, and 128 adenocarcinomas and 56 non-adenocarcinomas) were studied. The 5-year overall survival (OS) and disease-free survival (DFS) rates for all LLD-NSCLC patients were 72.9 and 58.3%, respectively. We examined the lymph node metastasis patterns in 42 node-positive tumours. The frequent metastatic lymph node stations were #12u lobar node (n = 22), #5 subaortic node (n = 15) and #11 interlobar node (n = 13) in order. These three node stations were also single metastatic sites in some patients. Metastases to sub-carinal (#7) or inferior mediastinal nodes (#8) were rare. Thus, we assigned the three stations (#5, #11, #12u) as the regional lymph node stations for LLD-NSCLC. If these regional lymph node stations had been examined pathologically during surgery for a total of 160 LLD-NSCLC patients with c-T2N1M0 or lower stage disease, 125 p-N0 and 5 p-N1 patients diagnosed with no metastasis would have been subjected to selective MLND, while 14 p-N1 and all 16 p-N2 patients diagnosed with metastasis would have had complete MLND carried out. As a result, these regional lymph node stations could accurately predict the existence of p-N2 metastasis, and appropriately lead to a selective or complete MLND. An intraoperative pathological examination using our proposed LLD-specific regional lymph node stations may accurately diagnose the status of node metastasis, and appropriately lead to selective or complete MLND in LLD-NSCLC patients with c-T2N1M0 or lower stage disease.

Extended sleeve lobectomy after induction chemoradiotherapy for non-small cell lung cancer.

Extended sleeve lobectomy is a challenging surgery. While induction chemoradiotherapy (ChRT) followed by surgery is one of the therapeutic strategies used for locally advanced non-small cell lung cancer (NSCLC), ChRT can impair the anastomotic healing potential. We herein present our experience with cases who underwent an extended sleeve lobectomy after induction ChRT. The medical records of patients who underwent a surgery for NSCLC after ChRT were reviewed. Between December 2007 and January 2013, nine patients underwent an extended sleeve lobectomy; the left lingular division and lower lobe in four patients, the right upper lobe and trachea in one patient, the carina and trachea in one patient, the right middle and lower lobes in one patient, the right upper and middle lobes and carina in one patient and the right upper lobe and superior segment of the lower lobe in one patient. While no postoperative 90-day deaths occurred, one case developed a bronchopleural fistula on postoperative day (POD) 25 and one case developed a bronchovascular fistula on POD 163. No cases of local recurrence developed. Our experience suggests that an extended sleeve lobectomy after induction ChRT is feasible, but careful patient selection and perioperative management are mandatory.

Validity of using lobe-specific regional lymph node stations to assist navigation during lymph node dissection in early stage non-small cell lung cancer patients

The validity of our proposed lobe-specific regional lymph node stations (LSRLNS) was evaluated as a method for navigation during lymphadenectomy in patients with early stage non-small cell lung cancer (NSCLC). A total of 725 NSCLC patients with c-T2N1M0 or less extensive disease who had undergone a curative operation with complete mediastinal lymph node dissection (MLND) were studied. The LSRLNS were #2, #3, #4 and #10 for the right upper lobe, #11i, #11s, #7 and #8 for the right lower lobe, #4, #5 and #6 for the left superior division, #11, #5 and #7 for the left lingular division and #11, #7 and #8 for the left lower lobe. If the LSRLNS were used for pathological examinations during surgery, 599 p-N0 and 39 p-N1 patients diagnosed with no metastasis would have been subjected to a selective MLND, while 20 p-N1 and 65 p-N2 patients who had a diagnosis of metastasis would have been navigated to a complete MLND. Two p-N2 patients with a diagnosis of no metastasis would have inappropriately undergone a selective MLND, resulting in the false negative rate at 0.3 %. Intra-operative pathological examination using our LSRLNS may accurately reveal the status of metastasis, and appropriately lead to a selective or complete MLND in patients with c-T2N1M0 or less extensive disease.

Nontuberculous Mycobacterial Lung Disease Caused byMycobacterium chelonae: A Case Report

Mycobacterium chelonae lung disease is very rare. We report a case of lung disease caused by M. chelonae in a previously healthy woman. A 69-year-old woman was referred to our hospital because of hemoptysis. A computed tomography (CT) scan of the chest revealed bronchiolitis associated with bronchiectasis in the lingular division of the left upper lobe. Nontuberculous mycobacteria were isolated three times from sputum specimens. All isolates were identified as M. chelonae by various molecular methods that characterized rpoB and hsp65 gene sequences. Although some new lesions including bronchiolitis in the superior segment of the left lower lobe developed on the chest CT scan 35 months after diagnosis, she has been followed up without antibiotic therapy because of her mild symptoms. To the best of our knowledge, this is the first case of M. chelonae lung disease in Korea in which the etiologic organisms were confirmed using molecular techniques.

Nontuberculous Mycobacterial Lung Disease Caused byMycobacterium lentiflavumin a Patient with Bronchiectasis

We report a rare case of lung disease caused by Mycobacterium lentiflavum in a previously healthy woman. A 54-year-old woman was referred to our hospital due to chronic cough and sputum. A computed tomography scan of the chest revealed bilateral bronchiectasis with bronchiolitis in the right middle lobe and the lingular division of the left upper lobe. Nontuberculous mycobacteria were isolated twice from three expectorated sputum specimens. All isolates were identified as M. lentiflavum by multilocus sequence analysis based on rpoB, hsp65, and 16S rRNA fragments. To the best of our knowledge, this is the first documented case of M. lentiflavum lung disease in an immunocompetent adult in Korea.

Endobronchial Mycobacterium avium Infection in an Immunocompetent Patient.

Although Mycobacterium avium complex (MAC) is the most common pathogen in nontuberculous mycobacterial (NTM) pulmonary diseases, endobronchial lesions caused by MAC infections are very rare even in an immunocompromised host. Herein, we describe the case of a 59-year-old, HIV-negative and non-immunocompromised woman who developed multifocal pulmonary infiltrations with endobronchial lesion caused by M. avium. Bronchoscopic examination revealed white- and yellow-colored irregular mucosal lesions in the bronchus of the left lingular division. M. avium was identified using sputum culture and bronchial washing fluid culture. Following the recommendations of the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA), the patient was begun on treatment with antimycobacterial drugs. After treatment, pneumonic infiltration decreased.

Retrospective Analysis of Nodal Spread Patterns According to Tumor Location in Pathological N2 Non‐small Cell Lung Cancer

BackgroundThe purpose of the present study was to determine the nodal spread patterns of pN2 non-small cell lung cancer (NSCLC) according to tumor location, and to attempt to evaluate the possible indications of selective lymph node dissection (SLND).MethodsWe retrospectively analyzed nodal spread patterns in 207 patients with NSCLC of less than 5 cm with N2 involvement.ResultsThe tumor location was right upper lobe (RUL) in 79, middle lobe in 12, right lower lobe (RLL) in 40, left upper division (LUD) in 41, lingular division in 11, and left lower lobe (LLL) in 24. Both RUL and LUD tumors showed a higher incidence of upper mediastinal (UM) involvement (96 and 100 %, respectively) and a lower incidence of subcarinal involvement (15 and 10 %, respectively) than lower lobe tumors (UM; RLL 60 %, LLL 42 %; subcarinal: RLL 60 %, LLL 46 %, respectively). Among the patients with 24 right UM-positive RLL and 10 left UM-positive LLL tumors, 2 showed negative hilar, subcarinal, and lower mediastinal involvement, and cT1, suggesting that UM dissection may be unnecessary in lower lobe tumors with no metastasis to hilar, subcarinal, and lower mediastinal nodes on frozen sections according to the preoperative T status. Among the patients with 12 subcarinal-positive RUL and 4 subcarinal-positive LUD tumors, one showed negative hilar or UM involvement, suggesting that subcarinal dissection may be unnecessary in RUL or LUD tumors with no metastasis to hilar and UM nodes on frozen sections.ConclusionsThe present study appears to provide one of the supportive results regarding the treatment strategies for tumor location-specific SLND.

Bronchoplasty to adjust mismatches in the proximal and distal bronchial stumps during bronchial sleeve resection of the left lower lobe and lingular division

We treated two lung cancer patients with metastatic hilar lymph node at the left lower lobe, involving the bifurcation of the left upper- and lower lobar bronchi and the lingular pulmonary artery. After induction chemoradiotherapy, we performed a bronchial sleeve resection of the left lower lobe and lingular division. In these cases, anastomosis of the left superior divisional and main bronchial stumps was necessary, which required correction of an orifice size mismatch. For this purpose, we performed different procedures on each patient. In Procedure 1, we edged the larger superior divisional bronchial stump with the partially excised walls of the upper lobar and the lingular divisional bronchi. In Procedure 2, we reefed the membranous portion of the main bronchus with adjusting stitches. Our procedure is useful for adjusting mismatch of the bronchial stump in anastomosis in a bronchial sleeve resection of the left lower lobe and lingular division.

Sacrificing the pulmonary arterial branch to the spared lobe is a risk factor of bronchopleural fistula in sleeve lobectomy after chemoradiotherapy

A sleeve lobectomy is a widely accepted procedure for enabling the pulmonary parenchyma to be spared. Induction chemoradiotherapy (CRT) followed by surgery is one treatment option for locally advanced non-small cell lung cancer (NSCLC), but CRT is considered to have a negative effect on subsequent surgery, especially for anastomotic healing. In this study, we describe our experience performing sleeve lobectomies and the associated anastomotic complications after induction CRT. The medical records of NSCLC patients who underwent surgery after receiving CRT were reviewed. The relationships between anastomotic complications and clinicopathological factors were examined. Between December 1998 and October 2011, a total of 104 patients received CRT followed by surgery. Among them, 14 NSCLC patients underwent a bronchial sleeve resection: nine patients underwent a right upper lobe resection, two patients underwent a left lingular division and lower lobe resection and one patient each underwent a right lower lobe, a right upper and middle lobe and a right middle and lower lobe resection. A bronchopleural fistula at the anastomosis occurred in two patients. A pulmonary arterial (PA) branch to the spared lobe had been sacrificed in both of these patients because of tumour involvement. In contrast, the PA branches to the spared lobes were preserved in 11 of the 12 patients who did not exhibit anastomotic complications (P = 0.033). Our experience strongly suggests that the sacrifice of the PA branch to the spared lobe is a possible risk factor for anastomotic complications for a sleeve lobectomy after induction CRT.

Silicosis Caused by Chronic Inhalation of Snail Shell Powder

A 70-yr-old woman visited our hospital for shortness of breath. Chest CT showed ground glass opacity and traction bronchiectasis at right middle, lower lobe and left lingular division. Video-assisted thoracic surgical biopsy at right lower lobe and pathologic examination revealed mixed dust pneumoconiosis. Polarized optical microscopy showed lung lesions were consisted of silica and carbon materials. She was a housewife and never been exposed to silica dusts occupationally. She has taken freshwater snails as a health-promoting food for 40 yr and ground shell powder was piled up on her backyard where she spent day-time. Energy dispersive X-ray spectroscopy of snail shell and scanning electron microscopy with energy dispersive x-ray spectroscopy of lung lesion revealed that silica occupies important portion. Herein, we report the first known case of silicosis due to chronic inhalation of shell powder of freshwater snail.

Bronchiectasis with normal paranasal sinus roentgenogram

Bronchiectasis has come to be considered as a type of sinobronchial syndrome in Japan, but there exist some cases without chronic sinusitis. We studied the clinical features of 14 cases of bronchiectasis with definitely normal paranasal sinus roentgenogram, diagnosed during the past ten years. There were eleven middle-aged women and three men. Ten patients (71%) complained of hemoptysis, one (7%) of dry cough, one (7%) of productive cough, and the two (14%) had no complaint. In seven patients (50%) CT and bronchography showed localized cylindrical bronchiectasis in the right middle lobe and/or left upper lobe lingular division. They were considered to be middle lobe lingular syndrome. Three patients (22%) with localized varicose or cystic bronchiectasis had a history of pneumonia or pertussis in their infancy, so their bronchiectasis were considered secondary to infantile bronchopulmonary disease. Two patients (14%) had diffuse cystic bronchiectasis and were almost asymptomatic. They might be cases congenital bronchiectasis or Williams-Campbell syndrome. Pulmonary function tests were normal in most of the cases and sputum culture revealed no cases of persistent bacterial infection. These clinical features are quite different from those of bronchiectasis reported as sinobronchial syndrome, in which chronic productive cough, poor pulmonary function, persistent bacterial infection, etc. are significant. So we conclude that there are two distinct groups in bronchiectasis.