Partial Lung Resection Research Articles

Robot-assisted laparoscopic hepatectomy for liver metastasis from clitoral malignant melanoma: a case report

IntroductionMalignant melanomas occur most commonly in the skin, mucous membranes, or choroid. Clitoral malignant melanomas are extremely rare. Stage IV malignant melanomas have a poor prognosis, and molecularly targeted agents or immune checkpoint inhibitors are recommended. However, surgical resection is reportedly a valid option for improving the prognosis of patients with oligometastases, defined as a small number of metastases that can be completely resected. In this report, we describe hepatic resection for a recurrent liver metastasis in a patient who had undergone removal of a clitoral malignant melanoma 9 years previously.Case presentationAn 82 year-old woman presented with a black nodule on her clitoris. Total resection of the nodule resulted in a diagnosis of clitoral malignant melanoma (pT4bN0M0, pStage IIC; UICC 8th edition). A follow-up computed tomography scan 4 years later revealed a single 5 mm mass in the lower lobe of the right lung, prompting partial resection of the right lung. Pathological examination of the operative specimen revealed a pulmonary metastasis of malignant melanoma. The patient was treated with pembrolizumab monotherapy as adjuvant chemotherapy for 1 year. A follow-up computed tomography scan 9 years after surgical removal of the primary lesion revealed an 18 mm mass in segment II of the liver, prompting robot-assisted laparoscopic left lateral sectionectomy. The provisional diagnosis of metastatic malignant melanoma in the liver was confirmed by histopathological examination of the operative specimen. The patient was treated with pembrolizumab monotherapy as postoperative adjuvant chemotherapy for 1 year. No further recurrence was detected at the 1.5 year follow-up.ConclusionWe performed hepatectomy for oligometastasis of clitoral malignant melanoma, an extremely rare entity. Surgery has the potential to prolong the prognosis of patients with oligometastasis.

Repercussions of SARS-CoV-2 infection on intrapulmonary shunt in patients undergoing one-lung ventilation

BackgroundHypoxic pulmonary vasoconstriction is the most important regulatory mechanism by which right-to-left shunts decrease during one-lung ventilation (OLV), but the effects of pulmonary microarterial thrombosis and impaired HPV after SARS-CoV-2 infection on intrapulmonary shunt during OLV remain unknown. The aim of this study was to observe the changes of intrapulmonary shunt in patients undergoing thoracoscopic partial pneumonectomy at different periods after SARS-CoV-2 infection compared with patients without SARS-CoV-2 infection history.MethodsA total of 80 patients who underwent elective thoracoscopic partial lung resection and were classified as American Society of Anaesthesiologists (ASA) grades I-II were selected and divided into 4 groups (n = 20 in each group): patients not infected with SARS-CoV-2 (Group A), patients infected with SARS-CoV-2 for 5–8 weeks (Group B), patients infected with SARS-CoV-2 for 9–12 weeks (Group C), and patients infected with SARS-CoV-2 for 13–16 weeks (Group D). For all patients, the same anaesthesia method was adopted, and anaesthesia was maintained with propofol, remifentanil, and cisatracurium. Radial artery and mixed venous blood gases were measured at 10 min of two-lung ventilation (TLV), 15 min of one-lung ventilation (OLV15), and 30 min of OLV (OLV30) in the lateral recumbent position to calculate the intrapulmonary shunt. Multiple linear regression analysis was employed to investigate the association between intrapulmonary shunt and SARS-CoV-2 infection.ResultsQs/Qt at TLV was significantly higher in Groups B and C than in Group A (P < 0.05), and PaO2 at TLV was significantly lower in Groups B and C than in Group A (P < 0.05). Qs/Qt values at OLV15 and OLV30 were significantly higher in Group B, C or D than in Group A (P < 0.05), and PaO2 values at OLV15 and OLV30 were significantly lower in Groups B, C or D than in Group A (P < 0.05). Multiple linear regression analysis revealed that SARS-CoV-2 infection (95%CI -4.245 to -0.679, P = 0.007) was an independent risk factor for increased intrapulmonary shunt during TLV, while SARS-CoV-2 infection (95%CI 0.124 to 3.661, P = 0.036), exacerbation of COVID-19 clinical classification (95%CI -5.203 to -1.139, P = 0.003), and persistent symptoms (95%CI -12.122 to -5.522, P < 0.001) were independent risk factors for increased intrapulmonary shunt during OLV after SARS-CoV-2 infection.ConclusionSARS-CoV-2 infection increased intrapulmonary shunt and reduced oxygenation. Although oxygenation improved at TLV after 13–16 weeks of infection, intrapulmonary shunt and oxygenation under OLV took longer to recover.Trial registrationChinese Clinical Trial Registry, Retrospectively registered, Full date of first registration: 17/05/2023, Registration number: ChiCTR2300071539.

A case of opioid-induced rigidity requiring naloxone administration at the time of anesthesia emergence

BackgroundOpioid-induced rigidity is typically observed during rapid administration of fentanyl. Herein, we present a case in which rigidity occurred after reversal of rocuronium during emergence from anesthesia.Case presentationA 73-year-old man underwent video-assisted partial lung resection. General anesthesia was induced with propofol, remimazolam, remifentanil, and rocuronium. Fentanyl was administered early during anesthesia. The surgery was completed without complications, and sugammadex sodium was administered for rocuronium reversal. The patient became agitated, but spontaneous breathing was maintained; therefore, the intratracheal tube was removed after the administration of flumazenil. The patient developed stiffness in the neck and jaw muscles along with remarkable skeletal muscle contractions. Dramatic improvement was observed immediately after administration of naloxone.ConclusionsEven as the simulated effect site concentration of fentanyl decreases during anesthesia emergence, opioid-induced rigidity may still occur. Rapid reversal of remimazolam by flumazenil might have contributed to the rigidity in this case.

Progress in the diagnose and treatment of pulmonary arterial thrombosis in situ

In situ pulmonary arterial thrombosis (ISPAT) refers to the formation of new blood clots in the pulmonary arterial system in the absence of pre-existing clots in the peripheral venous system. With the emergence and prevalence of COVID-19, ISPAT has become an increasingly important cause of pulmonary arterial thrombosis (PAT) alongside thromboembolism. Several factors such as hypoxia, inflammation, endothelial dysfunction, and hypercoagulable state can lead to ISPAT, which is associated with a number of conditions such as thoracic trauma, partial lung resection, pulmonary infectious disease, pulmonary vasculitis, connective tissue diseases, severe pulmonary hypertension, radiation pneumonitis, and acute chest syndrome in sickle cell disease. It is important to differentiate between pulmonary thromboembolism (PTE) and ISPAT for proper disease management and prognosis. In this review, we summarized the characteristics of ISPAT under different disease conditions, the methods to distinguish ISPAT from PTE, and the best treatment strategies. We hoped that this review could improve clinicians' understanding of this independent disease and provide guidance for the refined treatment of patients with PAT.

Navigating a complex case of Mycobacterium xenopi in a patient with blue rubber bleb nevus syndrome

Introduction: Blue rubber bleb nevus syndrome is a rare disorder of venous malformations, with around 200 cases reported. We present a case of Mycobacterium xenopi infection in a patient with blue rubber bleb nevus syndrome. Case Description: A 40-year-old female with blue rubber bleb nevus syndrome, asthma, and bronchiectasis came to the pulmonology clinic with shortness of breath and a cough. She was recently admitted for a bronchiectasis exacerbation but continued to have a worsening productive cough and fevers. The most recent CT scan of the chest showed interval stable right upper lobe fibrocavitary disease, demonstrating gradual progression over two years. She had occasional positive cultures for Mycobacterium Avium Complex and M. xenopi one year previously, assumed to be a colonizer and not treated. Most recent hospital cultures were negative for bacteria and an acid-fast bacilli smear. She was sent to the emergency department for bronchiectasis exacerbation and returned to the clinic six weeks later with two sputum cultures growing M. xenopi. It was decided to treat M. xenopi as this was likely the cause of her cavitary lung lesion and frequent infections. Azithromycin, rifampin, and sulfamethoxazole/trimethoprim were initiated. Intravenous amikacin was added later on. She finally had a right partial lung resection done after one year at an outside hospital. She was on and off antibiotics for M. xenopi for approximately three years with negative repeat cultures for non-tuberculous mycobacteria. Conclusion: Due to the high mortality of M. xenopi infections (which can be as high as 69%), treatment of at least twelve months is recommended. To our knowledge, this is the first reported case of M. xenopi in a patient with blue rubber bleb nevus syndrome.

Scoliosis After Resection of Primary Pediatric Chest Wall Tumors

BackgroundScoliosis is one of the long-term consequences of surgical resection of pediatric chest wall tumors. This study aimed to identify the risk factors associated with scoliosis development following the resection of chest wall tumors. MethodsRetrospective cohort study of 64 children who underwent resection of malignant chest wall tumors from 2009 to 2022. Univariate and multivariate analyses were used to investigate factors associated with scoliosis development. ResultsThe median age at the time of surgery was 7 years (range, 3–21), with 33 (51.6%) patients undergoing surgery before the age of 10 years. The most common histology was Ewing sarcoma (n = 57). A median of 3 (range, 1–5) contiguous ribs were resected. A total of 34 (53.1%) patients had anterior CWTs and 30 (46.9%) had posterior CWTs. Concomitant partial lung and diaphragmatic resection were performed in 12 patients (lung, n = 7; diaphragm, n = 5). Scoliosis convex towards the resection side developed in 21 (32.8%). The primary risk factors for scoliosis were resecting 3 or more ribs (OR 6.44) and resection of the posterior rib segment (OR 5.49). Patients with a tumor resection below 10 years old were not associated with a higher risk of scoliosis. ConclusionsScoliosis following resection of a primary malignant pediatric chest wall tumor is associated with resection involving three or more ribs and resection of the posterior rib sector. Type of StudyRetrospective observational. Level of EvidenceIV.

Regional ventilation distribution before and after laparoscopic lung parenchymal resection.

Objective.The aim of the present study was to evaluate the influence of one-sided pulmonary nodule and tumour on ventilation distribution pre- and post- partial lung resection.Approach.A total of 40 consecutive patients scheduled for laparoscopic lung parenchymal resection were included. Ventilation distribution was measured with electrical impedance tomography (EIT) in supine and surgery lateral positions 72 h before surgery (T1) and 48 h after extubation (T2). Left lung to global ventilation ratio (Fl), the global inhomogeneity index (GI), standard deviation of regional ventilation delay (RVDSD) and pendelluft amplitude (Apendelluft) were calculated to assess the spatial and temporal ventilation distribution.Main results.After surgery (T2), ventilation at the operated chest sides generally deteriorated compared to T1 as expected. For right-side resection, the differences were significant at both supine and left lateral positions (p< 0.001). The change of RVDSDwas in general more heterogeneous. For left-side resection, RVDSDwas worse at T2 compared to T1 at left lateral position (p= 0.002). The other EIT-based parameters showed no significant differences between the two time points. No significant differences were observed between supine and lateral positions for the same time points respectively.Significance.In the present study, we found that the surgery side influenced the ventilation distribution. When the resection was performed on the right lung, the postoperative ipsilateral ventilation was reduced and the right lung ratio fell significantly. When the resection was on the left lung, the ventilation delay was significantly increased.

IMPACT OF PARAVERTEBRAL BLOCKADE ON THE COURSE OF EARLY POSTOPERATIVE PERIOD FOLLOWING SURGICAL INTERVENTION FOR LUNG MALIGNANCIES UNDER INHALED SEVOFLURANE ANESTHESIA

The aim of the study is to investigate the impact of paravertebral blockade on the quality of anti-stress protection of general inhalation anaesthesia based on sevoflurane during operations in patients with lung malignancy. Material and methods. We examined 60 individuals of an average age 55±5.6 years, whose physical status was assessed as class II – III according to the ASA classification. The patients underwent open surgical procedures, including frontal or pneumonectomy, or partial lung resection. The patients were divided into 2 groups depending on the method of anaesthesia: SF group (sevoflurane) (n = 29) received inhaled anaesthesia with sevoflurane; SF+PVB group (n = 31) received the combination of inhaled anaesthesia with PVB. The following indicators were assessed: time of the first administration of the analgesic after surgery, pain intensity by the visual analogue scale (VAS), perfusion systemic pressure (PST), cardiac index (CI), oxygen content in arterial and venous blood, blood lactate levels, indicators of circulatory energy efficiency, cortisol, insulin and HOMA index levels. Indicators were recorded before the surgical operation, at the wake-up stage, on the 1st and 5th days following the operation. Results. In the SF+PVB group, the intensity of pain in the postoperative period was significantly lower than in the SF group. In the SF+PVB group, there was no necessity for administering narcotic analgesics on the first day, while in the SF group, the dose of morphine was 0.27±0.04 mg/kg∙day, the first administration was performed 65.5±10.3 minutes after surgery. CI during surgery and in a day was significantly higher in the SF+PVB group, and the arteriovenous difference in oxygen content was significantly lower. The energy efficiency of blood circulation at the same stages was significantly higher in the SF+PVB group. In the same group, there was a significantly lower concentration of markers of stress responses (cortisol levels and HOMA index). Conclusions. The use of paravertebral blockade under the general anaesthesia based on sevoflurane during operations in patients with lung malignancies contributes to a significant reduction in the pain intensity in the postoperative period; eliminates the need to use narcotic analgesics; provides significantly more stable hemodynamics and significantly more adequate oxygen supply during the operation and in the postoperative period; significantly reduces the intensity of stress reactions as well as significantly improves the energy efficiency of blood circulation.

T4 Lung Carcinoma with Infiltration of the Thoracic Aorta: Indication and Surgical Procedure.

Lung carcinomas infiltrate the aorta mostly on the left side and are altogether rare. As an initial step, complete staging is performed and the results are evaluated in an interdisciplinary tumor board. If the patient's general condition including cardiopulmonary reserves is sufficient, and if there is neither distant metastasis nor an N2 situation, surgical resection may be indicated. The option for neoadjuvant chemotherapy should always be taken into consideration. Depending on the anatomic tumor location, partial lung resection and resection of the affected aortic wall are performed employing a cardiopulmonary bypass. The resected aortic wall is replaced by a vascular prosthesis. In recent years, this proven procedure has partly been replaced by an alternative one, avoiding extracorporeal circulation. An endoaortic stent is implanted in the affected area followed by partial lung resection and resection of the diseased aortic wall. This new procedure has significantly reduced perioperative mortality and morbidity. With proper patient selection, long-term survival can be improved even in this complex malignoma.

Clinicopathological Impacts of Expression of Neuronal Markers in Lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is a tuberous sclerosis complex (TSC)-associated tumor, characterized by the expression of neural crest lineages including neuronal markers. Neural crest cells can differentiate into multiple cell types that contribute to tissues associated with TSC-related tumors, and TSC-related tumors could be specifically associated with distinct neural crest subtypes. This study aimed to clarify the clinicopathological effects of expression of neuronal markers in LAM. Lung tissues from 40 patients with LAM (of whom 13, 1, and 26 had undergone lung transplantation, lobectomy, and partial lung resection, respectively) were immunohistochemically analyzed. All patients were women, and their median age was 36 years (range: 24-62y). All patients who underwent lung transplantation or lobectomy were classified as LAM histologic score (LHS)-3, whereas those who underwent partial lung resection were classified as LHS-1. LAM cells expressed peripherin (65%), and neuron-specific βIII-tubulin (43%). A comparison of the early (LHS-1) and advanced (LHS-3) stages of LAM revealed that neuron-specific βIII-tubulin was significantly expressed in the early stage of LAM ( P = 0.0009). Neuron-specific βIII-tubulin-positive LAM was associated with younger age ( P < 0.0001), the coexistence of renal angiomyolipoma ( P = 0.027), and the absence of retroperitoneal LAM ( P = 0.045). Furthermore, based on the expression levels of immunohistochemical markers in LAM, 2 distinct clusters with different expression levels of neuronal markers were observed. Approximately 40% to 60% of patients with LAM expressed neuron-specific βIII-tubulin and peripherin. Neuronal expression may be associated with disease severity.

Lung protection effect of EIT-based individualized protective ventilation strategy in patients with partial pulmonary resection.

This study aimed to evaluate the lung protection effect of an individualized protective ventilation strategy based on lung impedance tomography (EIT) technology in patients with partial pulmonary resection. Eighty patients of any gender, American Society of Anesthesiologists (ASA) classification I-II, age 30-64 years and body mass index (BMI) 18-28 kg/m2 who underwent elective thoracoscopic partial lung resection were selected and divided into 2 groups (n=40) using the random number table method: [positive end-expiratory pressure (PEEP) by electrical impedance tomography (EIT)] PEEPEIT group (experimental group) and control group. The PEEPEIT group used volume-controlled ventilation after one-lung ventilation, setting a tidal volume of 6 ml/kg and titrating the optimal PEEP value by EIT. Group C used volume-controlled ventilation after one-lung ventilation, setting a tidal volume of 6 ml/kg and a PEEP of 5 cm H2O. Clinical data were collected and recorded at 5 min after double lung ventilation (T0), single lung ventilation, 30 min after PEEP setting (T1), 60 min after PEEP setting (T2), the end of surgery, 10 min after resumption of double lung ventilation (T3) and 10 min after removal of the tracheal tube (T4), and serum surface active substance-associated protein-A (SP-A) concentrations were measured at T0, T3 and 1 d after surgery (T5). PEEP values were higher in the PEEPEIT group than in the control group at T1 and T2 (p-value <0.05); oxygenation index (OI) was higher in the PEEPEIT group compared to the control group at T2 and T3 (p-value <0.05); pulmonary dynamic compliance (Cdyn) was higher in the PEEPEIT group compared to the control group at T1 and T2 (p-value <0.05); intrapulmonary shunt rate (Qs/Qt) was lower in the PEEPEIT group compared to the control group at T1, T2 and at T3, the intrapulmonary shunt rate (Qs/Qt) was reduced in the PEEPEIT group compared to group C (p-value <0.05); at T5, the SP-A protein was reduced in the PEEPEIT group compared to group C. There was no statistically significant difference in the incidence of postoperative pulmonary complications between the two groups (p-value >0.05). The EIT-guided individualized protective ventilation strategy has a lung-protective effect in patients undergoing thoracoscopic partial lung resection.

Delayed emergence from anesthesia caused by an intraoperative cerebral embolism of a malignant peripheral nerve sheath tumor in a neurofibromatosis type 1 patient: a case report

BackgroundMalignant peripheral nerve sheath tumors (MPNSTs) are aggressive soft tissue sarcomas which commonly arise from neurofibromatosis type 1. Lung metastases of the tumors are well-known, but intraoperative cerebral tumor embolisms of MPNSTs have not been reported in literature.Case presentationA 52-year-old female patient with neurofibromatosis type 1 underwent a right lung partial resection for lung tumors. She was extubated after adequate recovery of spontaneous breathing; however, she could not respond to verbal commands. In the intensive care unit, her neurological examination revealed conjugate eye deviation, right hemiparalysis, and aphasia. Magnetic resonance imaging revealed acute cerebral ischemia, so she underwent an endovascular thrombectomy. The histopathological diagnosis of emboli was a MPNST, which was identical with that of the resected lung tumor.ConclusionWe report the first case of delayed emergence caused by a cerebral tumor embolism of MPNST during partial lung resection.

Biomimetic scaffold-based stem cell transplantation promotes lung regeneration.

Therapeutic options are limited for severe lung injury and disease as the spontaneous regeneration of functional alveolar is terminated owing to the weakness of the inherent stem cells and the dyscrasia of the niche. Umbilical cord mesenchymal-derived stem cells (UC-MSCs) have been applied to clinical trials to promote lung repair through stem cell niche restruction. However, the application of UC-MSCs is hampered by the effectiveness of cell transplantation with few cells homing to the injury sites and poor retention, survival, and proliferation in vivo. In this study, we constructed an artificial three-dimensional (3D) biomimetic scaffold-based MSCs implant to establish a beneficial regeneration niche for endogenous stem cells in situ lung regeneration. The therapeutic potential of 3D biomimetic scaffold-based MSCs implants was evaluated by 3D culture in vitro. And RNA sequencing (RNA-Seq) was mapped to explore the gene expression involved in the niche improvement. Next, a model of partial lung resection was established in rats, and the implants were implanted into the operative region. Effects of the implants on rat resected lung injury repair were detected. The results revealed that UC-MSCs loaded on biomimetic scaffolds exerted strong paracrine effects and some UC-MSCs migrated to the lung from scaffolds and had long-term retention to suppress inflammation and fibrosis in residual lungs and promoted vascular endothelial cells and alveolar type II epithelial cells to enter the scaffolds. Then, under the guidance of the ECM-mimicking structures of scaffolds and the stimulation of the remaining UC-MSCs, vascular and alveolar-like structures were formed in the scaffold region. Moreover, the general morphology of the operative lung was also restored. Taken together, the artificial 3D biomimetic scaffold-based MSCs implants induce in situ lung regeneration and recovery after lung destruction, providing a promising direction for tissue engineering and stem cell strategies in lung regeneration.

Reverse partial pulmonary resection: a new surgical approach for pediatric pulmonary cysts

To evaluate the safety and efficacy of reverse partial lung resection for treatment of pediatric pulmonary cysts combined with lung abscesses or thoracic abscess. We retrospectively analyzed the clinical data of children undergoing reverse partial lung resection for complex pulmonary cysts in our hospital between June, 2020 and June, 2021.During the surgery, the patients lay in a lateral position, and a 3-5 cm intercostal incision was made at the center of the lesion, through which the pleura was incised and the fluid or necrotic tissues were removed.The anesthesiologist was instructed to aspirate the sputum in the trachea to prevent entry of the necrotic tissues in the trachea.The cystic lung tissue was separated till reaching normal lung tissue on the hilar side.The proximal end of the striated tissue in the lesion was first double ligated with No.4 silk thread, the distal end was disconnected, and the proximal end was reinforced with continuous sutures with 4-0 Prolene thread.The compromised lung tissues were separated, and the thoracic cavity was thoroughly flushed followed by pulmonary inflation, air leakage management and incision suture. Sixteen children aged from 3 day to 2 years underwent the surgery, including 3 with simple pulmonary cysts, 11 with pulmonary cysts combined with pulmonary or thoracic abscess, 1 with pulmonary cysts combined with tension pneumothorax and left upper lung bronchial defect, and 1 with pulmonary herpes combined with brain tissue heterotaxy.All the operations were completed smoothly, with a mean operation time of 129 min, an mean hospital stay of 11 days, and a mean drainage removal time of 7 days.All the children recovered well after the operation, and 11 of them had mild air leakage.None of the children had serious complications or residual lesions or experienced recurrence of infection after the operation. Reverse partial lung resection is safe and less invasive for treatment of complex pediatric pulmonary cysts complicated by infections.

A case report of Indium lung with progressive emphysema and fibrosis underwent lung unilateral transplantation 20 years after the end of the exposure

BackgroundIndium lung is characterized by interstitial pneumonia and/or emphysema which occurs in indium-tin oxide (ITO) workers. Indium lung is now known to progress after stopping exposure to ITO, but the long-term influences of ITO remain unclear.Case presentationForty seven years old, a never-smoker, who had been engaged in an ITO manufacturing process for 8 years. Emphysema was indicated by the medical check-up for ex-ITO workers, and he was diagnosed with indium lung. He underwent partial lung resections for pneumothorax two times, and obstructive pulmonary dysfunction had progressed through the years. He underwent right single lung transplant 20 years after ITO exposure. Pathologically, his lung showed severe distal acinar emphysema and honeycomb change. Fibrosis and destruction of the lung tissue significantly progressed compared to the previous partial resections. Scanning electron microscopy combined with energy dispersive spectroscopy revealed that the deposited particles contained indium and tin. After the transplantation, his respiratory function was improved.ConclusionsIn this case, ITO resided in the lung tissue for 20 years, and lung tissue destruction kept progressing. Careful medical follow-up is recommended for ITO-workers even if they are asymptomatic.

IgG4-related lung disease with recurrent pulmonary lesions during steroid therapy and difficulty in differentiating from malignancy: a case report

BackgroundImmunoglobulin G4-related disease (IgG4-RD) is characterized by the formation of inflammatory lesions with fibrosis and infiltration of IgG4-positive plasma cells and lymphocytes in various organs of the body. Since the first report of IgG4-related autoimmune pancreatitis, IgG4-RD affecting various organs has been reported; however, only a few reports of IgG4-related lung disease (IgG4-RLD) exist. In this report, we describe a case of IgG4-RLD that was difficult to differentiate from malignancy, and the usefulness of the surgical approach in determining the appropriate diagnosis and treatment plan.Case presentationA 61-year-old man was referred to our hospital after a chest radiograph revealed an abnormal chest shadow. At the time of his first visit, he had a slight fever and dyspnea on exertion. Chest computed tomography (CT) revealed a middle lobe hilar mass with irregular margins and swelling of the right hilar and mediastinal lymph nodes. These findings were not present on CT 1.5 years ago. 18F-fluorodeoxyglucose-positron emission tomography revealed a mass lesion with a maximum diameter of 5.5 cm, maximum standardized uptake value (SUVmax) of 11.0, and areas with high SUV in the hilar and mediastinal lymph nodes. We suspected lung cancer or malignant lymphoma and performed a thoracoscopic lung biopsy to confirm the diagnosis. Histopathological examination revealed no malignant findings, and IgG4-RLD was diagnosed. One month after treatment with prednisolone (PSL), the tumor had shrunk, but a CT scan during the third month of PSL treatment revealed multiple nodular shadows in both lungs. Considering the possibility of malignant complications and multiple lung metastases, we performed thoracoscopic partial lung resection of the new left lung nodules to determine the treatment strategy. Histopathological examination revealed no malignant findings in any of the lesions, and the patient was diagnosed with IgG4-RLD refractory to PSL monotherapy.ConclusionsIgG4-RLD refractory to PSL monotherapy showed changes from a solitary large mass (pseudotumor) to multiple nodules on chest CT. It was difficult to distinguish malignancy from IgG4-RLD based on imaging tests and blood samples alone, and the surgical approach was useful in determining the appropriate diagnosis and treatment plan.

Catheter Ablation of Atrial Fibrillation in Patients with Previous Lobectomy or Partial Lung Resection: Long-Term Results of an International Multicenter Study.

Introduction: Data regarding the efficacy of catheter ablation in patients with atrial fibrillation (AF) and patients’ previous history of pulmonary lobectomy/pneumonectomy are scanty. We sought to evaluate the efficacy and long-term follow-up of catheter ablation in this highly selected group of patients. Material and Methods: Twenty consecutive patients (8 females, 40%; median age 65.2 years old) with a history of pneumonectomy/lobectomy and paroxysmal or persistent AF, treated by means of pulmonary vein isolation (PVI) at ten participating centers were included. Procedural success, intra-procedural complications, and AF recurrences were considered. Results: Fifteen patients had a previous lobectomy and five patients had a complete pneumonectomy. A large proportion (65%) of PV stumps were electrically active and represented a source of firing in 20% of cases. PVI was performed by radiofrequency ablation in 13 patients (65%) and by cryoablation in the remaining 7 cases. Over a median follow up of 29.7 months, a total of 7 (33%) AF recurrences were recorded with neither a difference between patients treated with cryoablation or radiofrequency ablation or between the two genders. Conclusions: Catheter ablation by radiofrequency ablation or cryoablation in patients with pulmonary stumps is feasible and safe. Long-term outcomes are favorable, and a similar efficacy of catheter ablation has been noticed in both males and females.

Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes

Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes. We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing. Over 12months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p < 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities. Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.

A patient with diaphragmatic eventration and lung cancer who underwent partial lung resection and diaphragmatic plication and showed improved respiratory function

A patient with diaphragmatic eventration and lung cancer who underwent partial lung resection and diaphragmatic plication and showed improved respiratory function

Metastasiertes Plattenepithelkarzinom auf einem Ulkus bei Graft-versus-Host-Disease nach allogener Stammzelltransplantation

Wir berichten über einen 48-jährigen multimorbiden Patienten, der vor 26 Jahren eine allogene Knochenmarktransplantation aufgrund einer chronischen myeloischen Leukämie erhielt; 24 Jahre lang litt der Patient an einer sklerodermiformen chronischen Graft-versus-Host-Disease (GVHD) der Haut und der Lunge mit partieller Lungenresektion und immunsuppressiver Therapie. An den Unterschenkeln entwickelten sich rezidivierende Ulzerationen an den von der kutanen GVHD betroffenen Stellen. Der Patient stellte sich mit einem größenprogredienten Ulkus mit Therapieresistenz in unserer Klinik vor. Histologisch konnte ein Plattenepithelkarzinom diagnostiziert werden. Die Magnetresonanztomographie zeigte eine Knochenbeteiligung und eine kutane In-Transit-Metastase, und die Computertomographie ergab eine Metastase im Os sacrum. Bevor die Therapie eingeleitet wurde, verstarb der Patient plötzlich an den Folgen seiner Vorerkrankungen. Die Entwicklung einer kutanen GVHD ist häufig bei Patienten mit allogener Stammzelltransplantation. Hierbei ist das Risiko für die Entwicklung von Plattenepithelkarzinomen erhöht. Patienten sollten unter engmaschiger dermatologischer Kontrolle stehen. Bei Verdacht auf ein Plattenepithelkarzinom bei vorbestehender GVHD sollte zeitnah eine bioptische Sicherung erfolgen, um das Risiko einer Metastasierung zu senken.