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Purposes Delayed chest closure (DCC) is a widely accepted procedure in the context of lung transplantation (LTx); yet there are few reports detailing its long-term survival and clinical outcomes. Methods We reviewed the medical records of recipients who underwent deceased-donor lung transplantation (LTx) at Tohoku University Hospital. Long-term survival, including overall survival, freedom from chronic lung allograft dysfunction (CLAD), and CLAD-free survival and the clinical outcomes of graft function and physical performance and constitution were reviewed in recipients with DCC. Results Between 2009 and 2022, 116 patients underwent LTx, 33 of whom (28.4%) required DCC. The intra—and post-operative courses of the recipients who required DCC were more complicated than those of the recipients who underwent primary chest closure (PCC), with frequent volume reduction surgery and longer periods of invasive mechanical ventilation. Pulmonary vascular disease was considered a risk factor for these complications and DCC. Nonetheless, long-term survival and graft functions were comparable between the DCC and PCC groups. The physical performance and constitution of recipients who required DCC continued to improve, and by 2 years after transplantation, exhibited almost no difference from those who underwent PCC. Conclusions In view of the profoundly complicated intra- and post-operative courses, DCC should be performed cautiously and only when clinically indicated, despite which it can result in equivalent long-term survival and acceptable outcomes to PCC.

Purpose To investigate the surgical outcomes and postoperative survival prognostic factors of intractable secondary spontaneous pneumothorax. Methods A total of 95 patients who underwent thoracoscopic surgery for intractable secondary spontaneous pneumothorax between April 2010 and March 2020 were included in this study. These patients were classified into interstitial pneumonia and non-interstitial pneumonia groups, and a comparative study was performed on surgical outcomes and postoperative survival prognostic factors. Results There was no difference in the 1-year overall survival rate between the two groups. However, the 3-year overall survival rate was significantly lower in the interstitial pneumonia group than in the non-interstitial pneumonia group. The differences in short-term surgical outcomes (persistent air leakage, postoperative complications, etc.) were not significant between the two groups. Univariate analysis revealed that the drainage period, the development of postoperative complications, and recurrence were significant independent postoperative survival prognostic factors for all cases. Postoperative complications were the only associated postoperative survival prognostic factor for interstitial pneumonia pneumothorax in the multivariate analysis. Conclusion The development of postoperative complications can cause poor postoperative survival prognosis of intractable secondary spontaneous pneumothorax due to interstitial pneumonia.

PurposeThe purpose of this study was to assess the usefulness of positron emission tomography/computed tomography (PET/CT) in the differential diagnosis of anterior mediastinal tumors.MethodsA total of 94 patients with anterior mediastinal masses or nodules (male, n = 41; female, n = 53; age, 17–84 years) were retrospectively evaluated. All patients were evaluated by PET/CT and the masses or nodules were histologically diagnosed in our institution.ResultsAnterior mediastinal masses and nodules were classified into two disease categories: Low (thymic hyperplasia, thymoma, mature teratoma, and MALT lymphoma) and High (thymic carcinoid, thymic cancer, diffuse large B-cell lymphoma, T-cell lymphoblastic lymphoma, Hodgkin’s lymphoma, and malignant germ cell tumors) groups. The sensitivity and specificity of maximum standardized uptake value (SUVmax) 7.5 for the detection of High group were 77% and 100%, respectively. The SUVmax distributions of the WHO histological thymoma types and Masaoka stage thymomas extensively overlapped. Masaoka stage III thymomas had significantly higher SUVmax than Masaoka stage I thymomas. Regarding the TNM classification, the SUVmax of T3 and T1b thymomas was higher than T1a thymoma.ConclusionAlthough the SUVmax of each disease overlapped, PET/CT findings provided useful information for the differential diagnosis of anterior mediastinal masses.

INTRODUCTION: Myelolipoma is a benign tumor composed of mature adipose tissue and hematopoietic elements that typically arises in the adrenal glands, and involvement of the anterior abdominal region is extremely uncommon. We report a rare case of myelolipoma arising in the subxiphoid preperitoneal region adjacent to the site where a sternum-lifting device had been placed during previous surgery.CASE PRESENTATION: A 62-year-old man had undergone extended thymectomy for thymoma associated with myasthenia gravis at the age of 39. The procedure was performed via bilateral video-assisted thoracoscopic surgery using a sternum-lifting technique. The tumor was classified as Masaoka stage III, and postoperative radiotherapy was administered. No recurrence was observed during 13 years of follow-up. Ten years after completion of follow-up, CT performed for an unrelated condition incidentally revealed a slowly enlarging 65 × 40-mm mass in the preperitoneal space, adjacent to the previous surgical site where a sternum-lifting device had been placed. MRI demonstrated a fat-containing component within the lesion, and the differential diagnosis included liposarcoma and teratoma. Complete surgical resection was therefore planned. A midline incision extending caudally from the xiphoid process was made, and en bloc resection of the tumor with the involved peritoneum was performed via laparotomy. Histopathological examination revealed mature adipose tissue admixed with hematopoietic elements, confirming the diagnosis of myelolipoma.CONCLUSIONS: This unique case of extra-adrenal myelolipoma highlights the importance of MRI-based qualitative assessment for tumors arising at unusual sites and underscores the need to include extra-adrenal myelolipoma in the differential diagnosis of fat-containing lesions occurring at previous surgical sites.

PurposeMesenchymal stem cells (MSCs) suppress inflammation and immune responses. We conducted this study to find out if MSCs attenuate ischemia–reperfusion injury in a mouse model of lung transplantation.MethodsC57BL/6J mouse lungs perfused with low-potassium dextran glucose solution were preserved at 4 °C for 18 h. Human MSCs were slowly injected into the left pulmonary artery of the lung grafts, and orthotopic left lung transplantation was then performed. The lung isografts were reperfused for 6 h, and bronchoalveolar lavage fluid (BALF) from the left lung graft was collected. We measured the protein concentration, cell count, and proinflammatory cytokine concentrations in the BALF.ResultsThe protein concentration and cell count in the BALF were significantly lower in the MSC-administered grafts than in the PBS-administered controls. Concentrations of proinflammatory cytokines, including IL-1β, IL-17A, and TNF-α, in BALF tended to be lower in the MSC-administered grafts than in the controls, but the difference was not significant.ConclusionThe pre-transplant administration of MSCs via the pulmonary artery of the lung graft attenuated ischemia–reperfusion injury after prolonged cold ischemia in this mouse model of lung transplantation.

PurposeUsing a rat model of allograft lung transplantation, we investigated the effectiveness of mesenchymal stromal cells (MSCs) as prophylactic and therapeutic agents against the acute rejection of lung grafts.MethodsLung grafts were harvested from donor rats and transplanted orthotopically into major histocompatibility complex-mismatched rats. MSCs were administered to the recipients once (on day 0) or twice (on days 0 and 3) after transplantation. The grade of acute rejection was evaluated both macroscopically and microscopically 6 days after transplantation. To elucidate the related mechanism, mRNA levels of inflammatory cytokines and immunomodulatory receptors in the transplanted grafts were measured using quantitative RT-PCR.ResultsThe lung graft tissue from the rats that received MSCs post-surgically was protected from acute rejection significantly better than that from the untreated controls. Notably, the rats administered MSCs twice after surgery exhibited the least signs of rejection, with a markedly upregulated mRNA level of PD-L1 and a downregulated mRNA level of IL-17A.ConclusionThis study assessed MSC protection of lung allografts from acute rejection by modulating T cell activity via enforced expression of PD-L1 in transplants and downregulation of IL-17A.

PurposeTo compare the outcomes and efficacy of awake video-assisted thoracic surgery (VATS) with those of chemical pleurodesis for intractable secondary spontaneous pneumothorax (SSP).MethodsWe analyzed, retrospectively, 60 consecutive patients who underwent awake VATS (n = 22) or chemical pleurodesis (n = 38) for SSP. Using propensity score matching, we identified comparable patient groups (n = 12 each): the awake VATS group and the chemical pleurodesis group. We compared hematologic data on postoperative day 1, postoperative complications including respiratory complications, and the maximum score on the verbal rating scale (VRS) between the groups. Next, we identified comparable patient groups (n = 8 each) for those with controlled air leak after treatment, but not for those with a prolonged air leak. We analyzed data about the day of air leak control, intra-thoracic drainage, and hospital stay to compare awake VATS vs. chemical pleurodesis.ResultsAfter propensity score matching, the rates of recurrent pneumothorax and prolonged air leaks after conservative or surgical treatment were not significantly different. The C-reactive protein level and the VRS score were significantly lower in the awake VATS group. The duration of prolonged air leak, and drainage after treatment were significantly shorter in the awake VATS group. The postoperative hospital stay and the incidence of postoperative complications did not differ between the groups.ConclusionsWe advocate that awake VATS, performed by a skilled thoracic surgeon, is a more feasible surgical option than chemical pleurodesis for patients with intractable SSP.

Purpose This single-institution retrospective cohort study was conducted to assess the prognostic significance of perioperative changes in the prognostic nutritional index (PNI) in patients who underwent surgery for non-small cell lung cancer (NSCLC). Methods Clinicopathological data were collected from 441 patients who underwent lobectomy for NSCLC between 2010 and 2016.The PNI ratio (postoperative PNI/preoperative PNI) was used as an indicator of perioperative PNI changes. Prognostic differences were investigated based on PNI ratios. Results The optimal cut-off value of the PNI ratio for overall survival (OS) was set at 0.88 using a receiver operating characteristic curve. The PNI ratio was inversely related to a high smoking index, interstitial lung disease, and postoperative pulmonary complications. The 5-year OS rates for the high vs. low PNI ratio groups were 88.2% vs. 68.5%, respectively (hazard ratio [HR]: 3.04, 95% confidence interval [CI]: 1.90–4.86). Multivariable analysis revealed that a low PNI ratio was significantly associated with poor prognosis (HR: 2.94, 95% CI: 1.77–4.87). The PNI ratio was a more sensitive indicator than postoperative PNI status alone for identifying patients at high risk of mortality, particularly those with non-lung cancer causes. Conclusion The perioperative PNI change is a significant prognostic factor for patients with NSCLC.

Purpose Nutritional scores have been reported to be useful prognostic factors for various cancers. This study evaluated the usefulness of the preoperative controlling nutritional status (CONUT) score as a predictor of recurrence of non-small cell lung cancer (NSCLC). Methods The present study included 422 patients with stage I–IIIA NSCLC who underwent complete resection at Tohoku University Hospital between January 2010 and December 2016. The patients were divided into the low-CONUT and high-CONUT groups based on their CONUT scores. Overall survival (OS), recurrence-free survival (RFS), and cumulative recurrence rates in the low- and high-CONUT groups were evaluated retrospectively. Results One hundred forty-seven patients (34.8%) were assigned to the high-CONUT group. The high-CONUT group had a significantly worse performance status, pleural invasion, vascular invasion, and lung metastasis. In the whole cohort, the low-CONUT group showed better overall survival, recurrence-free survival, and a low cumulative recurrence rate in comparison to the high-CONUT group. There was no significant difference in prognosis or recurrence between the low- and high-CONUT groups after propensity score matching. Conclusion Patients with a high CONUT score may be at high risk of recurrence because of the high frequency of pleural invasion, vascular invasion, and lung metastasis.

Whole lung engineering and the transplantation of its products is an ambitious goal and ultimately a viable solution for alleviating the donor-shortage crisis for lung transplants. There are several limitations currently impeding progress in the field with a major obstacle being efficient revascularization of decellularized scaffolds, which requires an extremely large number of cells when using larger pre-clinical animal models. Here, we developed a simple but effective experimental pulmonary bioengineering platform by utilizing the lung as a scaffold. Revascularization of pulmonary vasculature using human umbilical cord vein endothelial cells was feasible using a novel in-house developed perfusion-based bioreactor. The endothelial lumens formed in the peripheral alveolar area were confirmed using a transmission electron microscope. The quality of engineered lung vasculature was evaluated using box-counting analysis of histological images. The engineered mouse lungs were successfully transplanted into the orthotopic thoracic cavity. The engineered vasculature in the lung scaffold showed blood perfusion after transplantation without significant hemorrhage. The mouse-based lung bioengineering system can be utilized as an efficient ex-vivo screening platform for lung tissue engineering.