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Renfang Wang, Chao-Xiu (Melanie) He
Published: 1 October 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.09.156

Siying Yan, Vivian Kong
Published: 1 October 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.09.150

Abstract:
The ancient Greek aphorism “ know thyself ” engraved on the forecourt of the Temple of Apollo epitomizes the human desire for the exploration into the unknown. In fact, never has mankind dragged their feet in understanding themselves, as in the achievements scientists have made all these years in the studies of disease and pathology.
, Shintaro Chiba, Igor Brichkov, Danny Sherwinter
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.08.48

Abstract:
Peritoneopericardial diaphragmatic hernia is a rare entity involving herniation of abdominal viscera through the diaphragm into the pericardial sac. It is most often seen after blunt abdominal trauma, but can occur following any trans-diaphragmatic intervention. We report on a 56-year-old female with peritoneopericardial diaphragmatic hernia secondary to a convergent procedure for the treatment of atrial fibrillation, who underwent a laparoscopic repair. An anterior abdominal wall laparoscopic approach was employed. Transverse colon and greater omentum were within the hernia sac. The defect measuring 3 cm × 3 cm was repaired using a composite hernia mesh. The total operative time was 78 minutes. No intra-operative and no post-operative complications were observed. Patient remained asymptomatic at a 6-month follow-up. Laparoscopic mesh repair of peritoneopericardial diaphragmatic hernia is safe, feasible and is the procedure of choice for treating these complex hernias.
, Elisa Nardecchia, Lorenzo Dominioni, , Sebastiano Spampatti, Giancarlo Feliciotti, Nicola Rotolo
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3222-3231; https://doi.org/10.21037/jtd.2017.08.122

Abstract:
Background: To assess incidence and risk factors of surgical site infections (SSI) (wound infection, pneumonia, empyema) in a monocentric series of patients undergoing lung resection over a decade. Methods: All patients undergoing lung resection at our institution in 2006–2015 [wedge resection, n=579; lobectomy, n=472 (12% after chemo/radiotherapy); pneumonectomy, n=40 (47% after chemo/radiotherapy)], were prospectively enrolled. Perioperative SSI risk factors were recorded: age, gender, blood haemoglobin, lymphocyte count, serum albumin, forced expiratory volume in 1 second percentage (FEV1%) of predicted, antibiotic prophylaxis, length of stay, diabetes, malignancy, steroid therapy, induction chemo/radiotherapy, resection in 2006–2010/2011–2015, urgent/elective procedure, videothoracoscopic/open approach, resection type, operative time. SSIs diagnosed within 30 days from surgery were prospectively recorded and association with risk factors was evaluated. Results: Of the 1,091 resected patients [median age, 65 (range, 13–91) years; male, 74%; malignancy, 65%], 124 (11.4%) developed one or more SSI. Wound infection, pneumonia and empyema rates were respectively 3.2%, 8.3% and 1.9%, stable through the decade. Overall infection rates after wedge resection, lobectomy and pneumonectomy were 4.8%, 17.4% and 35.0%, respectively. Thirty-day postoperative mortality was 0.6%; of the 7 deaths, 4 were causally related with SSI. Multivariable analysis showed that male gender, diabetes, preoperative steroids, induction chemo/radiotherapy, missed antibiotic prophylaxis and resection type were independent risk factors for overall SSI. Conclusions: SSI rates after lung resection were stable over the decade. The observed 11.4% frequency of SSI indicates that postoperative infections remain a relevant issue and a predominant cause of mortality after lung surgery. Focusing on SSI risk factors that are perioperatively modifiable may improve surgical results.
Chen-Sung Lin, Chao-Yu Liu, Chih-Tao Cheng, Yu-Chen Tsai, Lun-Wei Chiou, Ming-Yuan Lee, Chia-Chuan Liu, Chih-Hsun Shih
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3193-3207; https://doi.org/10.21037/jtd.2017.08.108

Abstract:
Background: The objective of this study was to appraise the prognostic role of initial pan-endoscopic tumor length at diagnosis within or between operable esophageal squamous cell carcinoma (ESCC) undergoing upfront esophagectomy or neoadjuvant concurrent chemoradiotherapy (nCCRT) followed by esophagectomy. Methods: Between Jan 2001 and Dec 2013 in Koo-Foundation Sun Yat-sen Cancer Center in Taiwan, 101 ESCC patients who underwent upfront esophagectomy (surgery group) and 128 nCCRT followed by esophagectomy (nCCRT-surgery group) were retrospectively collected. Prognostic variables, including initial pan-endoscopic tumor length at diagnosis (sub-grouped ≤3, 3–5 and >5 cm), status of circumferential resection margin (CRM), and pathological T/N/M-status and cancer stage, were appraised within or between surgery and nCCRT-surgery groups. Results: Within surgery group, longer initial pan-endoscopic tumor length at diagnosis (≤3, 3–5 and >5 cm; HR =1.000, 1.688 and 4.165; P=0.007) was an independent prognostic factor that correlated with advanced T/N/M-status, late cancer stage, and CRM invasion (all’s P5 cm, nCCRT-surgery group had a poorer (P=0.039), similar (P=0.447) and better (P5 cm, nCCRT-surgery group had more percentage of T0/N0-status and stage 0 (all’s P<0.05), and fewer rate of CRM invasion (P=0.036) than did surgery group. Conclusions: Initial pan-endoscopic tumor length at diagnosis could be a criterion to select proper ESCC cases for nCCRT followed by esophagectomy to improve survival and reduce CRM invasion.
Tiange Luo, Jie Han, Xu Meng
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3138-3147; https://doi.org/10.21037/jtd.2017.08.121

Abstract:
Background: We aimed to assess the pathological characteristics of rheumatic mitral valve disease in Chinese patients and formulate a pathological grading system to identify cases suitable for rheumatic mitral valve repair (rMVP). Methods: Nearly 5 years of follow-up data on patients who underwent rMVP were analysed. A Kaplan-Meier survival curve for freedom from reoperation and valve failure was constructed. A pathological grading system of rheumatic mitral valve lesions (PGSRMVL) was developed based on the pathological characteristics of rheumatic mitral valve disease and tested by receiver operating characteristics (ROCs) curve analysis. Predictors of endpoints for rheumatic repair were analysed. Results: From January 2012 to June 2016, 179 patients underwent rMVP in our centre. The mean follow-up duration was 24±14 months. A left atrial anterior and posterior diameter >60 mm was an independent predictor for the 16 endpoints [hazard ratio (HR) =3.884, P=0.029]. Between 2015 and 2016, 126 consecutive pathological characteristics of rheumatic mitral valve were evaluated (61 and 65 repair and replacement cases, respectively). The ROCs area under the curve was 0.891 for the correlation between the pathological score and successful repair (cut-off point, 17.5; sensitivity, 78%; specificity, 85.2%). Seven lesions had higher ratios in the replacement group than the repair group. Commissural fusion/calcification and main chordae tendineae fusion/calcification were the most common severe pathological lesions. Conclusions: The main pathological characteristics of rheumatic mitral valve disease in Chinese patients are commissure and sub-valvular apparatus lesions. Most patients can be appropriately treated via commissurotomy and leaflet thinning. Severe calcification of the commissure and sub-valvular apparatus can considerably decrease the odds of a successful repair. The median follow-up results of rheumatic mitral repair are considered satisfactory for the pathological characteristics in Chinese patients.
Pierpaolo Pastina, , Stefania Croci, Giuseppe Battaglia, Francesca Vanni, , , Veronica Ricci, , , et al.
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3123-3131; https://doi.org/10.21037/jtd.2017.08.68

Abstract:
Background: Results from the BEVA2007 trial, suggest that the metronomic chemotherapy regimen with dose-fractioned cisplatin and oral etoposide (mPE) +/− bevacizumab, a monoclonal antibody to the vascular endothelial growth factor (VEGF), shows anti-angiogenic and immunological effects and is a safe and active treatment for metastatic non-small cell lung cancer (mNSCLC) patients. We carried out a retrospective analysis aimed to evaluate the antitumor effects of this treatment in a subset of patients with squamous histology. Methods: Retrospective analysis was carried out in a subset of 31 patients with squamous histology enrolled in the study between September 2007 and September 2015. All of the patients received chemotherapy with cisplatin (30 mg/sqm, days 1–3q21) and oral etoposide (50 mg, days 1–15q21) (mPE) and 14 of them also received bevacizumab 5 mg/kg on the day 3q21 (mPEBev regimen). Results: This treatment showed a disease control rate of 71% with a mean progression free survival (PFS) and overall survival (OS) of 13.6 and 17 months respectively. After 4 treatment courses, 6 patients showing a remarkable tumor shrinkage, underwent to radical surgery, attaining a significant advantage in term of survival (P=0.048). Kaplan-Meier and log-rank test identified the longest survival in patients presenting low baseline levels in neutrophil-to-lymphocyte ratio (NLR) (P=0.05), interleukin (IL) 17A (P=0.036), regulatory-T-cells (Tregs) (P=0.020), and activated CD83+ dendritic cells (DCs) (P=0.03). Conclusions: These results suggest that the mPE +/− bevacizumab regimen is feasible and should be tested in comparative trials in advanced squamous-NSCLC (sqNSCLC). Moreover, its immune-biological effects strongly suggest the investigation in sequential combinations with immune check-point inhibitors.
, Huan Ma, Wenzhao Zhong, Xiaoting Wang, Yan Wu, Tiehe Qin, Shouhong Wang,
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3177-3186; https://doi.org/10.21037/jtd.2017.08.16

Abstract:
Background: Ultrasonography (US) is a non-invasive and commonly available bedside diagnostic tool. The aim of this study was to assess the utility of M-mode US on ventilator weaning outcomes in elderly patients. Methods: This was a single center, prospective, observational study in patients aged 80 years or older who were in the medical intensive care unit, had undergone mechanical ventilation for >48 hours, and met the criteria for a spontaneous breathing trial (SBT). For 30 minutes at the start of SBT, each hemi-diaphragmatic movement and the velocity of contraction were evaluated by M-mode US. The the area under the receiver operating characteristic curve (AUROC) was calculated to determine the ability for measured variables to predict successful ventilator weaning. Results: Forty patients were enrolled and assessed, grouped by those who had US-diagnosed diaphragm dysfunction (DD; 30/40; 75%) and those who did not (10/40; 25%). Patients with DD had a significantly longer total mechanical ventilation duration (536.4±377.05 vs. 250±109.02 hours, P=0.02) and weaning time (425.9±268.31 vs. 216.0±134.22 hours, P=0.002) than patients without DD. Patients with DD also had a higher incidence of weaning failure than patients without DD (24/30 vs. 4/10, P=0.017). Analysis of the receiver operating characteristic (ROC) curve (ROC) curve showed that the optimal cut-off values to predict weaning success were >10.7 mm for the right diaphragmatic movement, and >21.32 mm/s for the right diaphragmatic velocity of contraction; AUROC were 0.839 (95% CI, 0.689–0.936) and 0.833 (95% CI, 0.682–0.932), respectively. The sensitivity, specificity, positive and negative likelihood ratios for predicting weaning success were 83.33% vs. 66.67%, 75.00% vs. 92.86%, 3.33 vs. 9.33, and 0.22 vs. 0.36, for right diaphragmatic movement and diaphragmatic contraction velocity, respectively. Conclusions: When assessed by M-mode US, DD appeared to be common in ventilated patients aged 80 years or older and was associated with a higher incidence of weaning failure. Larger right diaphragmatic movements or faster right diaphragmatic contraction velocity appeared to be good predictors of mechanical ventilation weaning success in elderly patients.
Xufeng Pan, , Rui Wang, Heng Zhao, Jun Yang,
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3062-3068; https://doi.org/10.21037/jtd.2017.08.99

Abstract:
Background: To review our experience of transmanubrial osteomuscular sparing approach (TMA) for resection of various lesions involving the thoracic inlet and to prove the feasibility and safety of the approach. Methods: Retrospective review of 58 consecutive cases, from April 2007 to January 2016, with surgical resection of cervico-thoracic lesions via TMA. Results: There were 22 neurogenic tumors, 21 bronchogenic tumors, and 15 other cases in the study. There was no intraoperative or postoperative mortality. Mean postoperative stay was 10.5 days (3–33 days). Mean operation time was 179.0 mins (57–328 mins) and the mean volume of blood loss for bronchogenic tumors was 900 mL, which was similar to non-bronchogenic tumors (474 mL, P=0.103). Moreover, patients with malignant tumors had more intraoperative blood loss than patients with benign diseases did (847 versus 194 mL, P=0.001). R0 resection was achieved in 28 of 33 (84.8%) malignant cases. Tumor size was related to incomplete resection (8.19 vs. 5.72 cm, P=0.023) in malignancy. Five (8.6%) cases were complicated with chylothorax and all occurred in patients with left incision. All of 21 cases (100%) with brachial plexus compression symptom were relieved after surgery and 3 of 4 (75%) cases with Horner’s syndrome were ameliorated postoperatively. Conclusions: TMA can be carried out safely in treating various cervico-thoracic lesions with good resection rate. Left side procedure should be cautious of thoracic duct injury.
Guofei Zhang, Zhijun Wu, Yimin Wu, Gang Shen, Ying Chai
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3280-3284; https://doi.org/10.21037/jtd.2017.07.67

Abstract:
Uniportal video-assisted thoracoscopic surgery (VATS) has now evolved into a sophisticated technique that can be used in some of the most complex thoracic procedures; however, this approach to segmentectomy is not standardized, and the surgical procedure varies between surgeons. Here, we describe the use of our uniportal VATS procedure during right upper posterior segmentectomy in a patient with a nodule in the right upper lobe. Subsequent mediastinal lymphadenectomy was performed. The patient has recovered well after surgery. We believe that uniportal VATS segmentectomy is a technically safe and feasible alternative approach to conventional thoracoscopic techniques for treating lung cancer.
Bing Xia, Shirong Zhang,
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3385-3393; https://doi.org/10.21037/jtd.2017.09.67

Abstract:
In recent years, the treatment of advanced non-small cell lung cancer (NSCLC) was greatly promoted by the discovery of oncogenic drivers and the development of targeted therapies specific for these drivers. Somatic mutations in epidermal growth factor receptor (EGFR) are the most common type in patients with NSCLC. Small-molecule tyrosine kinase inhibitor (TKI) targeting EGFR produced relatively high response rate and long duration with acceptable toxicity profile. Also, the life expectancy in patients with active EGFR mutation has been significantly prolonged than the past. Additionally, evolution of advanced imaging and radiation techniques has expanded the indications for radiotherapy in complex clinical situation. All of those factors contributed to the widely use of radiotherapy for advanced NSCLC treated with TKI therapy. In this review, we will discuss how to integrate radiotherapy into the comprehensive treatment of patients with TKI therapy in order to maximize the therapeutics effect.
Jia-Tao Zhang, Song Dong, Xue-Ning Yang, , Wen-Zhao Zhong
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 3272-3274; https://doi.org/10.21037/jtd.2017.07.66

Abstract:
Here we introduce a manual tunnel approach to remove the mediastinal lymph nodes and highlight the conception of non-clamping during dissection. We describe two cases of pulmonary malignancy performing a strategic lobectomy and systemic dissection of mediastinal lymph nodes via single port. The technique of tunnel dissection without clamping ensure to satisfy the requirement of oncology and clinical criteria. By efficiently specifying surgery procedure and improving dissection thoroughness, our approach should be implemented.
Jennifer L. Philip, Nilto C. De Oliveira, Shahab A. Akhter, Brooks L. Rademacher, Christopher B. Goodavish, Paul D. DiMusto,
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9, pp 2966-2973; https://doi.org/10.21037/jtd.2017.08.06

Abstract:
Background: Whether primary tear size impacts extent of type A dissection is unclear. Using statistical groupings based on dissection morphology, we examined its relationship to primary tear area. Methods: We retrospectively reviewed 108 patients who underwent acute ascending dissection repair from 2000–2016. Dissection morphology was characterized using 3-dimensional (3D) reconstructions of computed tomography (CT) scan images. Two-step cluster analysis was performed to group the dissections by examining the true lumen area as a fraction of the total aortic area at various levels. Results: Cluster analysis defined two distinct categories. This first grouping corresponds to DeBakey type I (n=71, 65.7%) with a dissection extending from the ascending aorta to the aortic bifurcation. The second grouping conforms more closely to DeBakey type II dissection (n=37, 34.3%). It differs however from the classic type II definition as the dissection may extend up to the distal arch from the ascending aorta. Compared to type I, this “extended” DeBakey type II had no malperfusion (P<0.05), a larger primary tear area (6.6 vs. 3.7 cm2, P=0.009), and a greater burden of atherosclerotic coronary artery disease (P<0.05). A smaller aortic valve annulus (P=0.025) and a smaller root false lumen area (P=0.017) may explain less aortic valve insufficiency (P<0.05) in extended type II dissections. No differences in complications or survival were seen. Conclusions: In this series, limited distal extension of DeBakey type II dissections appears to be related to a larger primary tear area and greater atherosclerotic disease burden. It is also associated with less malperfusion and aortic valve insufficiency.
Katherine Khvilivitzky, Puja N. Trivedi,
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.08.104

Abstract:
A case of tracheobronchial stenosis due to tuberculosis in a young woman is presented. Compromised pulmonary function due to near-total obstruction of the proximal left main bronchus was diagnosed. Treatment options included surgical resection, endobronchial dilation or stenting, and argon photocoagulation. An approach was chosen to address symptoms without aggressive resection or commitment to stenting. She remains monitored and, while possibly committed to future intervention, no bridges have been burned with respect to more definitive and invasive therapies. We propose this “less is more” initial approach in all patients when possible. Reserving the more aggressive alternatives for high-risk surgical candidates and those that have been unresponsive to lesser procedures.
Chun Wang, Yuan Ma, Xin Zhao, Pei-Li Sun, Ying-Ming Zhang, Mao Huang, Yan Zhu, Shu-Xian Jin
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.08.54

Abstract:
Glomus tumors (GTs) of the trachea are very rare neoplasms that usually arise from the distal portion of the respiratory tree. The origin of these tumors is modified smooth muscle cells of glomus bodies. In this study, we describe two cases of GT of the trachea, as well as the histologic features of these tumors and their treatments. One tumor was diagnosed via bronchoscopic biopsy, and the other tumor was diagnosed via surgery. Clinical follow-up showed that the two patients are alive and well after 8 and 15 months post-treatment, respectively. We also review the literature regarding GTs and discuss the clinical presentation, histologic features, differential diagnosis, treatment and prognosis of these tumors.
Po-Jen Yun, Hsu-Kai Huang, Hung Chang, Shih-Chun Lee, Tsai-Wang Huang
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.08.14

Abstract:
Killian-Jamieson diverticulum (KJD) is a rarely encountered esophageal diverticulum which attributes to several symptoms. Clinically, KJD should be differentiated from the most common type of esophageal herniation, i.e., Zenker’s diverticulum (ZD). The two diverticula may present in a similar fashion, and treatments have evolved from transcervical to a minimally invasive endoscopic approach in recent years. We present a case of an 88-year-old male with symptomatic esophageal diverticulum. Barium swallow esophagogram and flexible esophagoscopy demonstrated a large KJD with food debris retention. Endoscopic diverticulotomy using a stapler was performed successfully without injury to the recurrent laryngeal nerve (RLN). A literature review and discussion concerning etiology, clinical presentations, and radiographic characteristics of KJD was conducted, and comparison between open and endoscopic method for esophageal diverticulum was also carried out.
Keng Peng Cheng, , , Kein Seong Mun
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.08.74

Abstract:
Hemangiopericytomas (HPCs) are uncommon tumours. We present the case of a 41-year-old female with multiple resections at different sites over the course of 11 years. The approach considerations, as well as treatment options and prognosis are discussed. A 41-year-old female with two previous resections for intracranial meningeal HPC in 2004 and 2008, as well as adjuvant radiotherapy, presented in 2015 with left intrathoracic and left hip recurrence confirmed by positron emission tomography/computed tomography (PET/CT). She underwent left proximal femur resection/reconstruction and video-assisted thoracoscopic surgery (VATS) resection of the intrathoracic tumour was attempted. She was discharged home on her 4th post-operative day with minimal pain. There were no neurosensory or motor deficits. Any patient who has been diagnosed with HPC in the past who develops new symptoms should be worked up for recurrence, regardless of the length of disease-free interval, as our case study suggested. There has yet to be a standardized follow-up regime due to the rarity of these tumours. HPC remains a rare soft tissue sarcoma with high recurrence rate. Planned VATS evaluation and resection is possible provided complete resection with clear surgical margins can be achieved, as clear surgical margins offer the best chance of survival.
Takaki Akamine, , Kenichi Kohashi, Taichi Matsubara, Yuka Kozuma, Naoki Haratake, Shinkichi Takamori, Masakazu Katsura, Kazuki Takada, Fumihiro Shoji, et al.
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.07.94

Abstract:
A tracheal metastasis (TM) from non-pulmonary malignancy is extremely rare, and there are very few reports regarding TM. Here, we report a case of the successful tracheal resection of TM of colorectal cancer. A 36-year-old man underwent a surgical resection for the rectal cancer. Approximately 5 years after the surgical resection of the primary rectal cancer, an isolated TM was identified. The patient was successfully treated with a tracheal resection. In conclusion, the current case suggested that the best treatment of the isolated TM might be a surgical resection.
, Isaac Pascual, , , Ruben Alvarez, Rocio Díaz, Beatriz Díaz, María Martín, Amelia Carro, Guillermo Muñiz, et al.
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.08.164

Abstract:
Post-infarction ventricular septal defect (VSD) is a rare but potentially lethal complication of acute myocardial infarction. Medical management is usually futile, so definitive surgery remains the treatment of choice but the risk surgery is very high and the optimal timing for surgery is still under debate. A 55-year-old man with no previous medical history attended the emergency-room for 12 h evolution of oppressive chest pain and strong anginal pain 7 days ago. On physical examination, blood pressure was 96/70 mmHg, pansystolic murmur over left sternal border without pulmonary crackles. An electrocardiogram revealed sinus rhythm 110 bpm, elevation ST and Q in inferior-posterior leads. Transthoracic echocardiogram showed inferoposterior akinesia, posterior-basal septal rupture (2 cm × 2 cm) with left-right shunt. Suspecting VSD in inferior-posterior acute myocardial infarction evolved, we performed emergency coronarography with 3-vessels disease and complete subacute occlusion of the mid segment of the right coronary artery. Left ventriculography demonstrated shunting of contrast from the left ventricule to the right ventricule. He was rejected for heart transplantation because of his age. Considering the high surgical risk to early surgery and his hemodynamic and clinical stability, delayed surgical treatment is decided, and 4 days after admission the patient suffered hemodynamic instability so venoarterial extracorporeal membrane oxygenation system (ECMO) is implanted as a bridge to reparative surgery. The 9th day after admission double bypass, interventricular defect repair with pericardial two-patch exclusion technique, and ECMO decannulation were performed. The patient’s postoperative course was free of complications and was discharged 10 days post VSD repair surgery. Follow-up 3-month later revealed the patient to be in good functional status and good image outcome with intact interventricular septal patch without shunt. ECMO as a bridge to reparative surgery in postinfarction VSD is an adequate option to stabilize patients until surgery.
Yi-Jhih Huang, Kuan-Hsun Lin, Tai-Kuang Chao, Tsai-Wang Huang, Hsu-Kai Huang
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.08.51

Abstract:
Langerhans cell histiocytosis (LCH) is a rare disease with uncertain etiology that is more prevalent in children. LCH typically invades skeletal systems, but in rare cases, it has been reported in the ribs or sternum. Optimal treatment choices for single-site, skeletal LCH are still undefined. We report a case of adult-onset LCH of the sternum. The range of surrounding soft tissue invasion was confirmed by three-dimensional fusion and reconstruction of chest computed tomography and magnetic resonance images. Our patient was successfully treated by local surgical curettage and adjuvant radiation therapy. We concluded that postoperative adjuvant radiation therapy may be advantageous for single-site LCH of bones with soft tissue invasion.
, Yoshitane Tsukamoto, Shohei Matsuo, Toru Nakamichi, Nobuyuki Kondo, Seiki Hasegawa
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.07.109

Abstract:
A 35-year-old woman had undergone extensive thymothymectomy for type A thymoma several years ago. However, two small lung nodules were found 4 and 5 years after surgery. After a partial lung resection to remove these nodules, pathology revealed that they were metastases of the type A thymoma. A pathological re-evaluation confirmed that the primary tumor had in fact been an atypical type A thymoma variant, a subset added to the WHO classification in 2015. Pathology should be re-evaluated in all patients diagnosed with type A thymoma before 2015 since they may have the more aggressive atypical type A thymoma variant.
Yu Okubo, Yuji Matsumoto, Toshiyuki Nakai, , , , Shun-Ichi Watanabe
Published: 1 September 2017
Journal of Thoracic Disease, Volume 9; https://doi.org/10.21037/jtd.2017.08.103

Abstract:
Endobronchial ultrasound-guided needle aspiration (EBUS-TBNA) is a well-established procedure with high diagnostic yield and safety. However, the standard 22 gauge needles sometimes cause major bleeding particularly in hypervascular tumors like metastatic lung tumors from renal cell carcinoma (RCC). The 25 gauge needles are already introduced to endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), and are considered as one of the standard devices due to their comparable diagnostic outcome, lower complication risk, and the better manipulability. Recently, the new 25 gauge needles have been applied to EBUS-TBNA. In present case, we were able to obtain a definitive diagnosis of the metastatic RCC by EBUS-TBNA using the 25 gauge needle. The new thin needle might be a better option for hypervascular tumors of the lung.
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