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In recent years, there has been a shift from extrapleural pneumonectomy (EPP) toward pleurectomy/decortication (P/D) as the preferred surgical technique. However, we occasionally encounter difficult cases wherein visceral pleurectomy requires conversion to EPP from P/D. We sought to clarify the preoperative risk factors and clinical outcomes associated with conversion to EPP. We compared and analyzed conversion to EPP and P/D between September 2012 and December 2019. Conversion to EPP was decided in case of diffuse tumor invasion to the pulmonary parenchyma or due to failure of decortication. Univariable regression analysis was performed to determine the association of preoperative variables with conversion to EPP. Survival was analyzed by the Kaplan-Meier method and log-rank test. Of the 181 patients who underwent intended P/D, 145 (80.1%) patients underwent P/D and 18 (9.9%) patients underwent conversion to EPP. The sum of 3-level pleural thickness (P0.001), maximum of 3-level pleural thickness (P = 0.006), and clinical T stage (P0.001) demonstrated association with conversion to EPP. Overall survival and progression-free survival were significantly worse in the conversion to EPP group (median overall survival, 29.2 months vs 57.0 months [P = 0.008]; median progression-free survival, 15.3 months vs 23.2 months [P = 0.005]. Our data show that approximately 1 of every 10 patients with P/D intention converted to EPP. Preoperative pleural thickness and clinical T stage may be risk factors associated with conversion to EPP. The survival rate of conversion to EPP was worse than that of P/D.

Objective: Our aim was to validate the prognostic relevance in NSCLC of potential residual tumor (R) descriptors, including the proposed International Association for the Study of Lung Cancer definition for uncertain resection, referred to as R(un). Methods: A total of 14,712 patients undergoing resection with full R status and survival were analyzed. The following were also evaluated: whether fewer than three N2 stations were explored, lobe-specific nodal dissection, extracapsular extension, highest lymph node station status, carcinoma in situ at the bronchial resection margin, and pleural lavage cytologic examination result. Revised categories of R0, R(un), R1, and R2 were tested for survival impact. Results: In all, 14,293 cases were R0, 263 were R1, and 156 were R2 (median survivals not reached, 33 months, and 29 months, respectively). R status correlated with T and N categories. A total of 9290 cases (63%) had three or more N2 stations explored and 6641 cases (45%) had lobespecific nodal dissection, correlated with increasing pN2. Extracapsular extension was present in 62 of 364 cases with available data (17%). The highest station was positive in 942 cases (6.4%). The pleural lavage cytologic examination result was positive in 59 of 1705 cases (3.5%): 13 had carcinoma in situ at the bronchial resection margin. After reassignment because of inadequate nodal staging in 56% of cases, 6070 cases were R0, 8185 were R(un), 301 were R1, and 156 were R2. In node-positive cases, the median survival times were 70, 50, and 30 months for RO, R(un) (p < 0.0001), and R1 (p < 0.001), respectively, with no significant difference between RO and R(un) in pN0 cases. Conclusions: R descriptors have prognostic relevance, with R(un) survival stratifying between R0 and R1. Therefore, a detailed evaluation of R factor is of particular importance in the design and analyses of clinical trials of adjuvant therapies. (C) 2019 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

To investigate the incidence and risk factors of chest wall metastasis (CWM) at biopsy sites in patients with malignant pleural mesothelioma (MPM). This retrospective cohort study was conducted in 262 consecutive MPM patients who underwent multimodal treatment in which including neoadjuvant chemotherapy (NAC) and curative-intent surgery, from August 2009 to March 2021. CWM was evaluated radiologically (r-CWM) and pathologically (p-CWM). We also investigated the risk factors of p-CWM and the consistency between r-CWM and p-CWM. Of 262 patients, 25 patients were excluded from analysis due to missing data or impossibility of evaluation. Of the eligible 237 patients, pleural biopsy was performed via video-assisted thoracoscopic surgery in 197 (83.1%) and medical thoracoscopy in 40 (16.9%). Pleurodesis was performed after pleural biopsy in 74 patients (31.2%). All patients received NAC followed by curative-intent surgery. Radiological examination showed r-CWM in 43 patients (18.1%), while pathological examination showed p-CWM in 135 patients (57.0%). The incidence of p-CWM was significantly higher in the patients who received pleurodesis after pleural biopsy (77.0% vs. 47.9%

A 74-year-old woman was referred for a right lower lobe consolidation (maximum diameter, 73 mm) pathologically diagnosed as invasive mucinous adenocarcinoma (c-T4 N0 M0, c-stage IIIA). Computed tomography revealed an aberrant mediastinal inferior lobar branch (A6 and common basal artery [A7 to A10]) from the right main pulmonary artery (PA). Right lower lobectomy and lymph node dissection were performed. A mediastinal inferior lobar branch is extremely rare, and this patient with lung cancer underwent right lower lobectomy for all inferior PA branches (A6 and A7 to A10) arising from the main PA into the lower lobe.

We compared less invasive surgery with conventional surgery for malignant pleural mesothelioma (MPM). We retrospectively reviewed consecutive patients with MPM who received surgery at Hyogo College of Medicine between July 2004 and April 2016. Patients underwent multimodal treatment comprising chemotherapy (neoadjuvant and/or adjuvant) and surgery with or without 54 Gy hemithoracic radiotherapy. Patients were grouped into 3 groups according to the surgery intended: Conventional extrapleural pneumonectomy was intended in Group 1 (until August 2009); less invasive extrapleural pneumonectomy was intended in Group 2 (after September 2009); pleurectomy/decortication was intended in Group 3 (after September 2012). We included 152 patients (median age 64 [37-71] years; 131 men, 21 women), mostly with epithelioid subtypes (91.4%). Of them, 149 (98.0%) underwent neoadjuvant chemotherapy and 117 (77.0%) underwent surgery (60 had extrapleural pneumonectomy and 57 had pleurectomy/decortication). Macroscopic complete resection was achieved in 94.9% (111/117), and the mortality rates at 30 and 90 days were 1.7% (2/117) and 3.4% (4/117), respectively. The overall median survival time and progression-free survival for all 152 patients were 34.9 and 17.4 months. The overall median survival time for Groups 1, 2, and 3 were 18.5, 41.9, and 43.4 months, respectively. The progression-free survival for Groups 1, 2, and 3 were 12.0, 24.5, and 21.8 months, respectively. Compared with conventional surgical techniques, less invasive surgery for MPM yielded lower surgical risks and comparable or improved survival.

Efficient monitoring of tumor responsiveness to chemotherapy is essential to mitigate high mortality risks and cytotoxic effects of chemotherapeutics. However, there is no consensus on the most suitable diagnostic technique/parameters for assessing response to chemotherapy in malignant pleural mesothelioma (MPM). We compared the tumor responsiveness of MPM patients as assessed using modified RECIST (mRECIST) criteria and integrated 18F-FDG-PET/CT.Histologically confirmed MPM patients (N=82) who were treated with three cycles of cisplatin and pemetrexed, or carboplatin and pemetrexed, were included. mRECIST and integrated 18F-FDG-PET/CT were used to evaluate MPM tumor response to chemotherapy. Metabolic non-responders were defined as those with a 25% or greater increase in SUVmax compared with the previous value. Time to progression (TTP) and overall survival (OS) were compared between metabolic-responders and non-responders.After three cycles of chemotherapy, 62(75.6%) of the patients were classified as having SD, 15 (18%) with partial remission (PR), and 5 (6%) with progressive disease (PD), based on mRECIST criteria. The cumulative median OS was 728.0days (95% confidence interval [CI]: 545.9-910.1) and cumulative median TTP was 365.0days (95% CI: 296.9-433.1). For the 82 patients, the disease control rate was 93.9%, whereas the metabolic response rate was only 71.9% (p0.001). All PD and PR patients were found to be metabolic responders on 18F-FDG-PET/CT; however, among the 62mRECIST SD patients, 18 (29%) were classified as metabolic non-responders. The median TTP for metabolic responders was 13.7 months, while it was 10.0 months for non-responders(p0.001). Metabolic responders had a trend toward longer OS, although the difference did not reach statistical significance (metabolic responders:33.9 months; non-responders: 21.6 months; p0.05).Several mRECIST-confirmed SD MPM patients may be classified as metabolic non-responders on18F-FDGPET/CT. Metabolic response is significantly correlated with the median TTP, suggesting it should be included in the evaluation of the response to chemotherapy in MPM patients classified as mRECIST SD, to identify non-responders.

Purpose To investigate the relationships between pretreatment volume-based quantitative 18 F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) parameters and overall survival (OS) in patients with malignant pleural mesothelioma (MPM). Materials and methods We retrospectively reviewed data from 201 MPM patients, of whom 38 underwent surgical resection, and calculated the maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG), including primary tumors and nodal or distant metastatic lesions, on pretreatment 18 F-FDG PET/CT. Relationships between clinicopathological factors (age, sex, performance status, European Organization for Research and Treatment of Cancer [EORTC] score, histological subtype, TNM stage, and treatment strategy), volume-based quantitative PET/CT parameters, and OS were evaluated using a Cox proportional hazards model and log-rank test. Results The median follow-up was 15 months (range, 1–96 months; median, 17 months). In a univariate analysis of all patients, older age (p Conclusions Pretreatment volume-based quantitative 18 F-FDG PET/CT parameters, especially TLG, could serve as potential surrogate markers for MPM prognosis.

A 55-year-old man with malignant pleural mesothelioma underwent multimodality treatment comprising induction chemotherapy followed by extrapleural pneumonectomy and radiation therapy. After 2.5 years, focal recurrence occurred, with computed tomography revealing a tumor in the left cardiophrenic angle. Surgery was considered a problem for the patient because of the previous extrapleural pneumonectomy and difficult tumor location. Radiofrequency ablation was therefore performed; the course was uneventful, and there was no recurrence. Radiofrequency ablation should be considered an option to treat recurrence of malignant pleural mesothelioma.

Introduction Patients with lung cancer who harbor multiple pulmonary sites of disease have been challenging to classify; a subcommittee of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee was charged with developing proposals for the eighth edition of the tumor, node, and metastasis (TNM) classification to address this issue. Methods A systematic literature review and analysis of the International Association for the Study of Lung Cancer database was performed to develop proposals for revision in an iterative process involving multispecialty international input and review. Results Details of the evidence base are summarized in other articles. Four patterns of disease are recognized; the clinical presentation, pathologic correlates, and biologic behavior of these suggest specific applications of the TNM classification rules. First, it is proposed that second primary lung cancers be designated with a T, N, and M category for each tumor. Second, tumors with a separate tumor nodule of the same histologic type (either suspected or proved) should be classified according to the location of the separate nodule relative to the index tumor—T3 for a same-lobe, T4 for a same-side (different lobe), and M1a for an other-side location—with a single N and M category. Third, multiple tumors with prominent ground glass (imaging) or lepidic (histologic) features should be designated by the T category of the highest T lesion, the number or m in parentheses (#/m) to indicate the multiplicity, and a collective N and M category for all. Finally, it is proposed that diffuse pneumonic-type lung cancers be designated by size (or T3) if in one lobe, T4 if involving multiple same-side lobes, and M1a if involving both lungs with a single N and M category for all areas of involvement. Conclusion We propose to tailor TNM classification of multiple pulmonary sites of lung cancer to reflect the unique aspects of four different patterns of presentation. We hope that this will lead to more consistent classification and clarity in communication and facilitate further research in the nature and optimal treatment of these entities.

Enumeration of circulating tumor cells (CTCs) may be valuable for prognostic assessment in lung cancer patients. In this study, we report the clinical significance of CTCs in small cell lung cancer (SCLC).In total, 51 consecutive patients newly diagnosed as having SCLC and starting chemotherapy or chemoradiotherapy were prospectively enrolled. Blood samples were drawn at the baseline, after chemotherapy, and at relapse. CTCs were isolated using the CellSearch System (Veridex LLC). Thresholds of 1 to 100 cells at the baseline were systematically correlated with the overall survival. The optimal cutoff was determined by comparing the Cox proportional hazard ratios (HRs).Two or more CTCs were detected at baseline in 35 patients (68.6%; 95% confidence interval, 55.0-79.7). The HR signifying the difference between the unfavorable (more than or equal to threshold) and favorable (less than threshold) groups was maximal at the threshold of 8 CTCs (HR, 3.50; 95% confidence interval, 1.45-8.60). Patients with ≥8 CTCs had worse survival than those with8 CTCs at baseline (p = 0.0014). Patients with ≥8 CTCs posttreatment or at relapse also showed worse survival than those with8 CTCs (p = 0.0096 and0.0001). Patients whose baseline and posttreatment CTC levels remained8 tended to show better survival than those whose CTC level converted from ≥8 to8 cells (p = 0.0288) or whose posttreatment CTC level was ≥8 cells (p = 0.0047).CTCs were highly detectable in SCLC, and higher CTC levels were strongly associated with worse survival. Consistently favorable CTC levels were associated with favorable outcomes.

Malignant pleural mesothelioma is a refractory tumor with poor prognosis associated with asbestos exposure. Pleural effusion is frequently observed in patients with malignant pleural mesothelioma, and cytological analysis is effective to detect malignant pleural mesothelioma. However, cytological discrimination between malignant pleural mesothelioma and reactive mesothelium is often difficult. Increased expression of CD146, a cell adhesion molecule, has been reported to be closely associated with an advanced stage of malignant melanoma, prostate cancer, and ovarian cancer. In this study, to evaluate the diagnostic utility of CD146 for discrimination between malignant pleural mesothelioma and reactive mesothelium, we examined immunocytochemical expression of CD146 in malignant pleural mesothelioma and reactive mesothelium using two clones of CD146 antibody, OJ79 and EPR3208, on smear specimens of effusion fluids. Immunocytochemical stains were semiquantitatively scored on the basis of immunostaining intensity (0, negative; 1, weak positive; 2, moderate positive; and 3, strong positive). CD146 expression was detected in 15 of 16 malignant pleural mesothelioma with median immunostaining score of 3 by OJ79, and in 19 of 21 malignant pleural mesothelioma with median immunostaining score of 2 by EPR3208. Strong immunoreactivity of CD146 was observed at the apposing surfaces of cell-cell interactions on the plasma membrane of mesothelioma cells. In addition, one OJ79-negative case of malignant pleural mesothelioma was positive for CD146 by EPR3208 and two EPR3208-negative cases of malignant pleural mesothelioma were CD146 positive by OJ79, showing that all 23 malignant pleural mesothelioma cases were positive for CD146 by either OJ79 or EPR3208. On the other hand, CD146 expression was undetectable in all reactive mesothelium cases by OJ79 and EPR3208. The sensitivity of OJ79 and EPR3208 was 94 and 90%, respectively, and the specificity was 100% for both clones. We propose that CD146 is a sensitive and specific immunocytochemical marker enabling differential diagnosis of malignant pleural mesothelioma from reactive mesothelium.

Well-differentiated papillary mesothelioma (WDPM) is an uncommon tumor with a papillary architecture, bland cytologic features, a tendency toward superficial spread without invasion, and good prognosis with prolonged survival. WDPM occurs primarily in the peritoneum of women, but also rarely in the pleura. We here report a case of 48-year-old woman who developed WDPM in the pleura with no history of asbestos exposure. Tumors were multifocal and widespread with a velvety appearance on the surface of parietal and visceral pleurae resected by extrapleural pneumonectomy (EPP). Tumors showed papillary structures with fibrovascular cores and lined by epithelioid cells. Immunohistochemically, these epithelioid tumor cells were positive for epithelial membrane antigen (EMA), a marker of malignant mesothelioma, with more than 50% positive for p53. Tumor cells microinvaded into subpleural parenchyma of the lung and minimally spread to adipose tissues of the mediastinal lesion. In addition, tumor cells invaded into the chest wall with a trabecular or glandular architecture. Based on these findings, this case is pathologically considered as WDPM of the pleura with malignant potential.

Background Circulating tumor cells in peripheral blood (CTC) is a potential surrogate of distant metastasis, which is the critical factor influencing decision making regarding therapy and prognosis of primary lung cancer patients. After our preliminary study showing that CTCs were detected in peripheral blood in 29.4% of resectable lung cancer patients, we conducted a prospective study on CTC in pulmonary vein (PV) blood because tumor cells apart from the primary tumor may circulate after passing through the drainage PV. Methods A total of 30 consecutive lung cancer patients who underwent thoracotomy were included. The CTCs in peripheral blood and in PV blood from the primary tumor site were quantitatively examined with the CellSearch system, and the numbers of CTCs per 7.5 mL peripheral and PV blood in each patient were represented as periCTC count and pvCTC count, respectively. Results Circulating tumor cell was detected in peripheral blood in 5 patients (16.7%; the periCTC count was 1 in 2 patients; and 2, 3, and 16 in 1 patient each), and the incidence of positive periCTC was higher in squamous carcinoma patients than in adenocarcinoma patients (p = 0.028). Circulating tumor cell was detected in PV blood in most patients (29 of 30, 96.7%), and the mean and median pvCTC counts were 1,195 and 81, respectively (range, 0 to 10,034). There was no significant correlation between pvCTC count and any other patient characteristic, including periCTC count. Conclusions In resectable lung cancer, CTC was positive in peripheral blood of some patients and in PV blood of most patients. A long-term follow-up study to clarify the clinical significance of pvCTC status is warranted.

The shortage of lung donors and ischemia-reperfusion injury following transplantation have been grave problems in lung transplantation (LTx). One of the most important strategies to solve these problems is the development of effective and highly reliable methods for lung preservation. Therefore, we developed a new organ preservation solution, namely, the extracellular-type trehalose-containing Kyoto (ET-Kyoto) solution. Here we report the first experience of clinical application of ET-Kyoto solution for cadaveric LTx. The recipient was a 38-year-old man with pulmonary emphysema. The donor was a 51-year-old male current smoker with a smoking history of 62 pack-years. The ventilated donor's PaO(2) was 340 Torr (FiO(2) = 1.0). The pulmonary vasculature was flushed with ET-Kyoto solution supplemented with nitroglycerine and dibutyryl cAMP. The recipient underwent bilateral sequential LTx on cardiopulmonary bypass. The ischemic time was 544 and 613 minutes for the left and right lung, respectively. PaO(2) (FiO(2) = 1.0) was 385 Torr immediately after reperfusion. The donor lung was so large that bilateral partial resections were performed at 413 minutes (right) and 348 minutes (left) after reperfusion. On histopathologic examination of the resected transplanted lungs the structure was almost normal. Postoperatively, PaO(2) (FiO(2) = 1.0) was over 400 Torr with or maximum of 526 Torr. The clinical course was almost uneventful. In conclusion, ET-Kyoto solution may be safely applied in clinical cadaveric LTx with extended donor lungs and relatively long ischemic times. Functional and histopathological efficiency of ET-Kyoto solution was confirmed. Longer preservation times with preserved quality using ET-Kyoto solution would increase the donor pool and enable semielective LTx.

The diagnosis of multiple primary lung cancer is sometimes difficult when multiple lung tumors with the same histologic type are identified. We now present a case of synchronous double primary lung adenocarcinomas (one in the right upper lobe and another in the right middle lobe) diagnosed based on mutational analysis of the epidermal growth factor receptor (EGFR) gene, although clinico-pathological findings suggested the diagnosis of intrapulmonary metastasis. After complete resection, pathological sections revealed the similar pathological features of two adenocarcinomas and unexpected subcarinal nodal metastasis. As the L858R mutation within exon 21 of the EGFR gene was identified in the middle-lobe tumor and the subcarinal node but not in the upper-lobe tumor, we diagnosed as double primary cancers. Local mediastinal recurrence after operation has been well-controlled with administration of gefitinib, a EGFR-tyrosine kinase inhibitor, and mutational analysis of the EGFR gene provided important information not only in the diagnosis of double primary cancers but also in decision-making of selection of chemotherapeutic agent.

During a routine health care evaluation, an abnormal shadow was detected in the chest roentgenogram of a 35-year-old man. Chest computed tomography scanning showed a nodule, approximately 3 cm in diameter, in the left S6 pulmonary segment with surrounding infiltration. Bronchoscopy revealed obstruction of the left B6c bronchus by a tumor, for which biopsy was done but no definitive histologic diagnosis could be made. Then, left lower lobectomy was performed, and the tumor was diagnosed as a pulmonary sclerosing hemangioma. A mediastinal lymph node (no. 7) showed some metastatic tumor cells. As lymph node metastasis from pulmonary sclerosing hemangioma is very rare, we herein report the details of our case.

Flexible fiberoptic bronchoscopy (FFB) is of great importance for diagnostic and therapeutic purposes in pediatric respiratory management. However, lack of a built-in channel in commercially available ultrathin fiberscopes has limited its usefulness in neonates and infants. Bronchoscopic procedures, including suctioning, BAL, bronchography, and selective drug injection have instead been performed by temporary extubation followed by mask ventilation. However, such techniques are not suitable for repeated FFB and are open to considerable risks, especially in critically ill patients. In this context, we developed a directable ultrathin fiberscope with an external diameter of 2.7 mm and a 0.8-mm internal diameter built-in channel. This prototype fiberscope, the XPF27, is useful during spontaneous ventilation and can be inserted through a 3.5-mm or larger endotracheal tube. The XPF27 was utilized for 55 FFB procedures and allowed suctioning, BAL, bronchial toileting, and bronchography in 16 critically ill children without complications. We conclude that XPF27 is useful for pediatric FFB despite its limited flexibility, visual field, and resolution.

We previously reported that trehalose, a reduced disaccharide, was effective in the preservation of lungs. In this study, we investigated the possibility of prolonged cryopreservation of tracheas in a preservative solution containing trehalose. Five rings of cervical trachea were removed and immersed in the preservative solution. The harvested tracheas were then cryopreserved and stored in a deep freezer at -85° C. One month later, five rings of mediastinal trachea were removed. The cryopreserved cervical tracheas were thawed and autotransplanted in place of the excised mediastinal trachea ( n = 6). The anastomotic site and graft were then covered with an omental pedicle. All six animals survived for more than 6 months. All grafts survived without any evidence of atrophy or stenosis. Microscopic examination of the grafts showed that the integrity of the tracheal tissues was maintained. Our findings show that consistent cryopreservation of the trachea for 1 month is possible in a preservative solution containing trehalose. (J THORAC CARDIOVASC SURG 1995;110:382-5)

The capillary filtration coefficient (K f ) is one of the most accurate measures of change in pulmonary vascular permeability and has been used in various models of acute lung injury. To evaluate the isolated effects of ischemia on K f , we have developed an ex vivo rabbit lung model in which the influences of reperfusion are eliminated. The current study was designed to validate this model by determining the effect of cold flushing with low-potassium-dextran solution containing 1% glucose (LPDG), ischemic time, temperature, and inspired oxygen fraction on K f . On completion of the ischemic period, the ventilated lungs, with the heart still attached, were suspended from a strain-gauge force transducer. After the lungs were flushed with 50 mL hetastarch solution (6% hetastarch solution with physiologic saline solution), the left atrial drainage cannula was occluded and the pulmonary artery pressure was incrementally increased by elevation of the reservoir. The K f was calculated as the slope of the line relating the weight gain rate and pulmonary capillary pressure. Our study demonstrated the following: (1) K f was not altered by flushing the lungs with LPDG at either 1 °C or 10 °C; (2) preservation at 37 °C, even for only 2 hours, demonstrated severe deterioration in K f ; (3) although hypothermia during ischemia suppressed the deterioration of K f , there were no significant differences in K f between 1 °C and 10 °C when ischemic time was less than 24 hours; (4) when preservation lasted less than 8 hours, change in K f was not influenced by the differences in inspired oxygen fraction during the ischemic period; (5) during 24-hour preservation, K f increased less when the lungs were inflated with room air than when they were inflated with either 100% oxygen or 100% nitrogen. These results indicate that injury occurs primarily during ischemia and increases with ischemic lime even in lungs flushed with LPDG and kept at 1 °C or 10 °C. Inflation with 100% oxygen may cause injury of the pulmonary vascular endothelium during 24-hour preservation, although oxygen supply from airway is essential. This isolated, ex vivo rabbit model examining pulmonary vascular permeability provides a sensitive and reliable means for evaluation of ischemic injury of the preserved lung.

We report a case of epithelioid hemangioendothelioma arising from the left brachiocephalic vein in the anterior superior mediastinum of a 41-year-old man. The tumor was resected by local excision using a novel approach, the "hemi-plastron window" technique. The patient had an uneventful postoperative course and no recurrence of tumor 28 months after surgical treatment. We describe this surgical approach and discuss its advantage for cervicothoracic tumors.

To determine the endurable radiation dose before bronchial anastomosis, the bronchial circulation of mongrel dogs was assessed after bronchoplastic surgery conducted after various single doses of radiation. Plastic surgery of the right main bronchus was carried out 1 week after cobalt 60 irradiation to the right hilar region. Bronchial blood flow was measured with laser Doppler velocimetry 7, 14, and 30 days after operation. Animals were killed 30 days after operation and the region of the bronchial anastomosis was examined histologically. The animals were divided into five groups: group A (control group without irradiation), group B (8 Gy irradiation), group C (16 Gy), group D (19 Gy), and group E (24 Gy). Wound healing of the anastomosed bronchus was excellent in groups A and B. In group A, bronchial blood flow did not drop below 80% of the preoperative level throughout the postoperative observation period. In group B, bronchial blood flow on day 7 after operation was only 65% of the preoperative level, but blood flow had returned to the preoperative level by day 30. In groups C, D, and E, bronchial blood flow was less than 60% of the preoperative level on day 30. There was a high prevalence of radiation-induced morbidity in the region of anastomosis in groups C, D, and E. Postoperative recovery of bronchial blood flow and wound healing of the anastomosed bronchus were thus delayed in dogs that had received high doses of radiation before operation. We conclude that the safe dose of preoperative radiation in clinically used fractionation is 36 Gy or less (corresponding to a single dose of 16 Gy or less in dogs). ( J Thorac Cardiovasc Surg 1993;106:1059-64)

A 17-year-old man, who had received a diagnosis of juvenile polymyositis (PM) at the age of 1 year, developed recurrent spontaneous pneumothoraces and underwent surgical treatment by means of video-assisted thoracic surgery. Intraoperative observation and microscopic studies demonstrated numerous bleb-like lesions below the visceral pleura. To our knowledge, this is the first article that describes a case of spontaneous pneumothorax associated with PM. Our observation should lead to broadening of the spectrum of pleuropulmonary manifestations of PM.

A 29-year-old woman with an unusual form of pulmonary metastasis from epithelioid sarcoma of the right forearm is presented. Since she manifested left pneumothorax due to metastatic pulmonary cyst 7 years ago, the only metastatic manifestation has been the presence of bilateral multiple thin-walled pulmonary cysts; no other types of pulmonary lesions, such as nodules, cavitary lesions with thick or irregular walls, or extrapulmonary metastases, have been found. Pathologic studies revealed metastatic proliferation of sarcoma cells in the wall of the pulmonary cysts and infiltration of malignant cells inside the microscopic cavitary metastases surrounded by normal lung parenchyma.

Aim: It is believed that additional chemotherapy is infrequently feasible in patients with recurrent malignant pleural mesothelioma (MPM) after extrapleural pneumonectomy (EPP) due to deteriorated cardiopulmonary reserve. We examined the feasibility and efficacy of additional chemotherapy in patients with recurrent MPM after EPP. Methods: A retrospective review was conducted on 56 consecutive patients who underwent bi-/tri-modality treatment with induction chemotherapy, EPP, and with/without radiation therapy during July 2004 and November 2013 at Hyogo College of Medicine. Results: Of 56 patients, 31 (M/F=25/6, right/left=11/20, p-stage I/II/III/IV=1/5/22/3, bi-/tri-modality=12/19) relapsed at median age of 60 years (37-70). Median time to recurrence after EPP was 8.9 months. Of 31 relapsed patients, 10 received best supportive care (BSC) alone, 4 started but discontinued chemotherapy and had BSC, and the remaining 17 (55%) completed>3 cycles of intravenous chemotherapy. Median survival time after recurrence was significantly longer in 17 patients who received additional chemotherapy than that in 14 patients who did not (20 months vs. 3.1 months, p=0.001). Overrall(n=56) Relapsed(n=31) BSC(n=14) additional chemo(n=17) M/F 48/8 12/2 14/3 Right/left 26/30 5/9 6/11 Age at recurrence 62(37-71) 63(37-70) 61(44-68) Time to rucurrence after EPP NA 5.2 mo 24 mo MST after recurrence NA 3.1 mo 20 mo MST after EPP 34 mo 9.4 mo 39 mo Conclusions: Additional systemic chemotherapy was successfully administered in approximately 60% of relapsed patients after bi-/trimodality treatment including EPP, which resulted in a longer survival in comparison with BSC alone. Disclosure: All authors have declared no conflicts of interest.

We have developed a new organ preservation solution called extracellular-type trehalose-containing Kyoto (ET-Kyoto) solution. ET-Kyoto solution has been applied in clinical lung transplantation. The patient was a 49-year-old woman with diffuse panbronchiolitis. She underwent bilateral lobar lung transplantation from living donors. Each lobe was flushed with ET-Kyoto solution. After reperfusion, Pao 2 with inhalation of 100% oxygen was more than 500 Torr. Posttransplantation course was uneventful. Despite the relatively short ischemic time of this case report, ET-Kyoto solution may be feasible and safely applied in clinical lung transplantation.

J Thorac Cardiovasc Surg 2002;124:635-6

The use of video-assisted thoracoscopic surgery (VATS) sometimes leads to additional and unnecessary risks compared with thoracotomy. We report a troubling case of VATS lung biopsy in a 43-year-old woman with mild pulmonary hypertension. A progressive elevation of pulmonary artery pressure (PAP) was noted after the commencement of right unilateral ventilation. When the systolic PAP reached 90 mm Hg (390 min after induction of anesthesia), a massive blood discharge through the chest drain occurred. At repeat thoracotomy, continuous blood spouting was seen from > 10 of the surgical sites. It was supposed that the endoscopic staplers were unable to maintain hemostasis with such a high PAP.