Feasibility of thoracoscopic pulmonary bullectomy using a transareolar approach for treatment of primary spontaneous pneumothorax

Background

Primary spontaneous pneumothorax (PSP) is a common disease among young patients, particularly men. While the most common thoracoscopic approach is triportal, the transareolar approach is rare. In this study, we prospectively investigated the feasibility of thoracoscopic pulmonary bullectomy using a transareolar approach for treatment of PSP.

Methods

Ten patients with PSP who underwent thoracoscopic transareolar pulmonary bullectomy were prospectively enrolled in this study between September 2017 and March 2018. For all 10 patients, we evaluated the perioperative outcomes, postoperative complications, recurrence, wound-related pain, and cosmetic satisfaction regarding the surgical wound.

Results

The mean patient age was 18.9±4.2 years; three patients were affected on the right side and seven patients were affected on the left side. Bullae and blebs were localized at the apex of the affected lung in all patients. All procedures were completed using a transareolar approach without additional ports or conversion to thoracotomy in any patient. The mean operative time was 39.8±8.6 min. The mean volume of blood lost during surgery was extremely small in all patients. The duration of postoperative drainage was 1 day, while the length of postoperative hospital stay was 2 days in all patients. No morbidities or recurrence of PSP occurred during the study period. The mean cosmetic satisfaction scores of the surgical wound were 3.3 and 3.2 on postoperative day (POD) 7 and at postoperative month (POM) 12. The mean NRS score was 1.5 on POD 7. All patients were pain-free at POM 12.

Conclusions

Transareolar thoracoscopic pulmonary bullectomy for treatment of PSP is feasible and safe, with a high degree of satisfaction for postoperative pain and cosmetics. This new approach could be a novel option for surgical treatment of PSP.

En bloc lymphadenectomy of the right thorax via a uniportal thoracoscopic approach

The uniportal approach to an en bloc complete lymphadenectomy is significantly more challenging than a multiportal approach or a thoracotomy because of the limited angulation available to the surgeon and the limited number of usable surgical instruments. Because of these limitations, it is very important to completely master the specific surgical steps in order to achieve success. Additionally, it is important to make sure the lymph nodes remain structurally intact, taking care not to cause damage by grasping them during lymphadenectomy, in order to prevent the dissemination of malignant cells into the thorax. In this video tutorial, we demonstrate our surgical technique for lymphadenectomy in the right upper (2R/4R) or lower (7/8/9) mediastinal zone, which is suitable for a uniportal approach, and explain the nuances of performing it.

Dorsal (S2) segmentectomy of right upper lobe via a uniportal approach using near infrared imaging and indocyanine green administration

Uniportal video-assisted thoracic surgery is becoming more common worldwide, but the limited angle of approach of inserted surgical instruments makes it challenging. Because of this, segmentectomy via a uniportal approach is more difficult technically than a multiportal approach. In addition, the inflation/deflation technique, which is a standard method for identifying the intersegmental plane, is often less useful because it can be difficult to get a good surgical view. To resolve this problem, a technique using near infrared imaging and indocyanine green  administration technique  can be very helpful in performing a uniportal segmentectomy. In this video tutorial, we demonstrate a uniportal thoracoscopic dorsal segmentectomy of the right upper lobe of a patient with primary lung cancer, using a near infrared imaging/indocyanine green technique. We explain the nuances of the procedure and how to perform it, and we discuss our successful results.

Uniportal thoracoscopic lateral and posterior basal (S9+10) segmentectomy

Among uncommon pulmonary segmentectomies, the lateral and posterior basal (S9+10) segmentectomy is one of the most challenging because it requires exposure and recognition of common basal pulmonary vein branches located deep in lung parenchyma. In order to achieve an optimal thoracoscopic S9+10 via a uniportal approach the surgeon must first select the most suitable uniportal method, because the angulation of surgical instruments is limited in this minimally invasive approach and this makes it especially difficult to perform.  In this video tutorial, we demonstrate our technique for a uniportal thoracoscopic S9+10 segmentectomy; we discuss our successful results, and explain the nuances of performing the procedure.

[Late-Onset Acute Pneumonitis Caused by Pembrolizumab Used to Treat Postoperative Recurrence of Squamous Cell Carcinoma-A Case Report]

We present an unusual case of late-onset acute pneumonitis developing 21 months after pembrolizumab monotherapy. An 80-year-old male with primary, pulmonary, squamous cell carcinoma underwent right lower lobectomy and lymph node dissection(ND2a-2); the postoperative pathological stage was ⅢA(pT2bN2M0)and the PD-L1 tumor proportion score 70%. Six months after surgery, he developed mediastinal lymph node(#2R), bilateral pulmonary, and hepatic metastases; pembrolizumab was administered every 3 weeks as a first-line treatment. A partial response was evident after 3 courses; we thus continued the monotherapy. However, after 28 courses(21 months)of pembrolizumab, we discontinued the regimen because acute pneumonitis(Grade 3)developed; we prescribed prednisolone at 50 mg/day. The acute pneumonitis shadow improved and prednisolone was tapered over 2 months. The patient exhibited no new lesion and no progressive disease 6 months after pembrolizumab was discontinued.

Removal of an endobronchial lipoma via uniportal thoracoscopic right basal segmentectomy

Background

Endobronchial lipoma is a rare benign tumor. The standard treatment is bronchoscopic intervention or surgical resection. Here, we present a case of endobronchial lipoma treated by right basal segmentectomy via a uniportal thoracoscopic approach.

Case presentation

A 66-year-old female presented with a persistent cough and recurring high-grade fever 4 months in duration. Chest X-ray revealed an abnormal infiltration shadow in the right lower lung field. Chest computed tomography revealed a tumor that occluded the lateral segmental bronchus of the right lower lobe. Surgical resection was planned because we failed to diagnose the tumor via bronchoscopic biopsy. Finally, uniportal, thoracoscopic right basal segmentectomy, which is less invasive than lobectomy and allows preservation of the apical segment of the lower lobe, was successfully performed. The pathological diagnosis was of endobronchial lipoma. The cough and recurrent pneumonia improved after surgery.

Conclusions

Segmentectomy via a uniportal thoracoscopic approach could be a novel treatment option for endobronchial lipoma.

Uniportal anterior segmentectomy (S3) of the left upper lobe

As the rate of detection of pulmonary lesions such as small ground glass opacities and partial solid nodules has increased, so has the necessity for thoracic surgeons to perform previously uncommon pulmonary segmentectomies. Compared to common types of segmentectomy, such as upper division segmentectomy of the left upper lobe, lingual segmentectomy, superior segmentectomy of the lower lobe, and basilar segmentectomy of the lower lobe, uncommon segmentectomies present a number of technical challenges . In addition, an uncommon segmentectomy can be more difficult to perform  via a uniportal approach than via a multiportal thoracoscopic or thoracotomy approach.  Among the uncommon segmentectomies, we have achieved a thoracoscopic anterior segmentectomy of the left upper lobe via a uniportal approach for a patient with primary lung cancer. In this video tutorial, we demonstrate some tips and tricks for successfully   performing this procedure.

The effect of bilateral cardiac sympathetic denervation for refractory ventricular tachycardia in ischemic cardiomyopathy

Recent studies have shown that cardiac sympathetic denervation (CSD) is effective in the treatment of refractory ventricular tachyarrhythmia in patients with structural heart disease. This case report aimed to highlight the effect of bilateral CSD in suppressing treatment‐resistant ventricular tachycardia in patients with ischemic cardiomyopathy.

Uniportal thoracoscopic upper division segmentectomy of left upper lobe using a unidirectional anterior approach

Thoracoscopic major pulmonary resection via a uniportal approach is becoming more common worldwide as the adoption of minimally invasive surgical procedures increases. With a uniportal approach, 3 or 4 surgical instruments, including a thoracoscope, are simultaneously inserted via an approximately 4-cm access port. The surgeon must master the surgical techniques required to perform a major pulmonary resection safely using the uniportal method, specifically the challenge of dissecting the tissue and inserting staplers unidirectionally, due to the limited angle of approach.  In this video tutorial, we demonstrate a uniportal thoracoscopic upper division segmentectomy of the left upper lobe of a patient with primary lung cancer, using a unidirectional anterior approach without dissection of the fissure. We explain the nuances of the procedure and how to perform it, and we discuss our successful results.

[Malignant Solitary Fibrous Tumor of the Pleura;Report of a Case]

We report a rare case of a malignant solitary fibrous tumor of the pleura(SFTP). The patient was a 66-year-old man, who had an asymptomatic 25 mm nodule in the left upper lung field. We performed a wedge resection of the left lung by video-assisted thoracic surgery, and the tumor was diagnosed as a malignant SFTP. Although the recurrence has not been found for 26 months, long-term clinical follow-up is thought to be necessary because of the potential adverse biological behavior of this tumor.

[Pulmonary Adenocarcinoma Responding to Fourth-Line S-1 Monotherapy-A Case Report]

Herein, we report a case of unresectable lung cancer in which S-1 monotherapy contributed to an improvement in the patient's quality of life and to prolonged survival. A 44-year-old man with primary pulmonary adenocarcinoma(negative driver mutation and a PD-L1 tumor proportion score of 1-24%)of clinical stage ⅢA(cT4N0M0)underwent multidisciplinary treatment as follows: 1 ) weekly carboplatin and paclitaxel plus radiotherapy as induction chemoradiotherapy, 2 ) surgery that revealed that the lesion was unresectable, 3 ) cisplatin plus pemetrexed as second-line treatment, and 4 ) pembrolizumab as third-line treatment. However, the disease progressed after 19 courses of pembrolizumab, and the patient developed cachexia due to esophageal stenosis caused by tumor enlargement. He underwent percutaneous gastrostomy and was fed via a gastrostomy tube. S-1 monotherapy(2-week administration every 3 weeks)was introduced as fourth-line treatment. After 3 courses of S-1 monotherapy, the patient complained of regurgitation of stomach fluid. Computed tomography( CT)revealed that the primary tumor had decreased in size, and he developed the ability to drink water. After 6 courses of S-1, CT revealed progressive disease, so atezolizumab was administered as fifth-line treatment. However, after 2 courses, mediastinitis due to esophageal penetration into the mediastinum occurred. The patient died 28 months after the initial treatment.

Prognostic Significance of Glucose Metabolism as GLUT1 in Patients with Pulmonary Pleomorphic Carcinoma

Glucose metabolism is necessary for tumor progression, metastasis, and survival in various human cancers. Glucose transporter 1 (GLUT1), in particular, plays an important role in the mechanism of ¹⁸F-FDG (2-[¹⁸F]-fluoro-2-deoxy-d-glucose) within tumor cells. However, little is known about the clinicopathological significance of GLUT1 in patients with pulmonary pleomorphic carcinoma (PPC). Adenocarcinoma, squamous cell carcinoma, adenosquamous cell carcinoma, poorly differentiated carcinoma, large cell carcinoma, and others were identified as epithelial components, and spindle-cell type, giant-cell type, and both spindle- and giant-cell types were identified as sarcomatous components. This study was performed to determine the prognostic impact of GLUT1 expression in PPC. Patients with surgically resected PPC (n = 104) were evaluated by immunohistochemistry analysis to detect GLUT1 expression and determine the Ki-67 labeling index using specimens of the resected tumors. GLUT1 was highly expressed in 48% (50/104) of all patients, 42% (20/48) of the patients with an adenocarcinoma component, and 53% (30/56) of the patients with a nonadenocarcinoma component. High expression of GLUT1 was significantly associated with advanced stage, vascular invasion, pleural invasion, and tumor cell proliferation as determined by Ki-67 labeling. GLUT1 expression and tumor cell proliferation were significantly correlated according to the Ki-67 labeling in all patients (Spearman’s rank; r = 0.25, p < 0.01). In multivariate analysis, GLUT1 was identified as a significant independent marker for predicting a poor prognosis. GLUT1 is an independent prognostic factor for predicting the poor prognosis of patients with surgically resected PPC.

Prognostic Significance of Tumor Immunity in Surgically Resected Pulmonary Pleomorphic Carcinoma

BACKGROUND

Pulmonary pleomorphic carcinoma (PPC) is a rare aggressive neoplasm, with dismal prognosis. Whether tumor immunity is associated with the progressive biological behavior of PPC remains unclear. The purpose of this study was to examine the prognostic significance of tumor immunity-related markers such as programmed death-1 ligand (PD-L1) and CD4⁺ or CD8⁺ tumor-infiltrating lymphocytes (TILs) in patients with surgically resected PPC.

PATIENTS AND METHODS

Ninety-nine patients with surgically resected PPC were assessed by immunohistochemistry. The expression of PD-L1, CD4, and CD8 was examined in specimens of the resected tumors.

RESULTS

PD-L1 was highly expressed in 61% (60/99) of lesions and high expression of CD4 and CD8 was identified in 42% (42/99) and 51% (51/99) of lesions, respectively. There was no relationship between the expression PD-L1 and the numbers of CD4⁺ or CD8⁺ TILs. The expression of PD-L1 was not identified as a significant prognostic marker; however, a low number of CD4⁺ TILs was identified as an independent marker for predicting a worse outcome after surgical resection of PPC, especially in patients with an epithelial component of adenocarcinoma or early stage of disease. By univariate analysis, a low number of CD8⁺ TILs was found to be a significant prognostic marker linked to poor overall survival in patients with non-adenocarcinoma components.

CONCLUSION

A low number of CD4⁺ TILs is an independent marker for predicting a favorable prognosis after surgical resection in patients with PPC, especially in patients with adenocarcinoma components or early stage of disease.

Algorithm-based troubleshooting to manage bleeding during thoracoscopic anatomic pulmonary resection

Background

Few studies have reported on the effects of intraoperative complications, such as vessel injury, during thoracoscopic anatomic pulmonary resection. We evaluated intraoperative vessel injury and assessed troubleshooting methods for thoracoscopic anatomic pulmonary resection.

Methods

A total of 378 patients underwent thoracoscopic anatomic pulmonary resection between April 2012 and March 2018, 40 of whom were identified as having an intraoperative vessel injury. In our department, we treat significant bleeding based on the algorithm shown in Figure 1. We analyzed the injured vessels and hemostatic procedures employed and compared perioperative outcomes in patients with (n=40) or without (n=338) a vessel injury. Additionally, we examined the data on a year-by-year basis from April 2012, and perioperative results were compared in each year.

Results

The vessel injured was a branch of the pulmonary artery in 22 cases (55%). Hemostasis was achieved by applying a thrombostatic sealant in 26 cases (65%). Although patients without a vessel injury had a shorter operation time, less intraoperative blood loss, and shorter duration of chest tube drainage, no significant differences in the length of postoperative hospitalization or morbidity were observed. The occurrence rate of significant intraoperative bleeding in the last year measured was similar to that in the first year measured.

Conclusions

Thoracoscopic anatomic pulmonary resection is feasible and safe if the surgeon performs appropriate hemostasis, although vascular hazards might be inherent during thoracoscopic anatomic pulmonary resection, regardless of the surgeon's experience.

Uniportal thoracoscopic fissureless right lower lobectomy using the suction device trick

The fissureless technique for lobectomy is considered one of the most useful and effective techniques for patients who have a fused fissure because it offers a relatively low risk of prolonged postoperative air leakage. In the fissureless technique, we use "unidirectional dissection" or "unidirectional stapling" because of the limited angle of approach necessitated by thoracoscopic surgery. Uniportal thoracoscopic surgery has even more access angle limitations than a typical multiportal approach and can be very challenging. When performing fissureless lobectomies, especially lower lobectomies, we have to insert a stapler to divide the bronchus behind which the pulmonary arteries run. It is critically important to avoid injury to the pulmonary arteries as this might cause catastrophic bleeding. We use the "suction device trick" to protect the pulmonary arteries: The suction device is inserted between the lower bronchus and the pulmonary artery, which runs behind it, when stapling, and this ensures that stapling can safely be done without any risk of injury to the pulmonary artery.  In this video tutorial we demonstrate our technique for a uniportal thoracoscopic fissureless right lower lobectomy in a patient with a dense fissure, using the suction device trick, and we explain the nuances of performing it.

Is salvage surgery for patients with lung cancer after carbon ion radiotherapy easy or difficult?

Carbon ion radiotherapy (CIRT) shows higher local control rates and minimal damage to normal lung parenchyma compared with conventional radiotherapy; however, some patients experience local recurrence. The efficacy and safety of salvage surgery after CIRT for non-small-cell lung cancer are unclear. We reviewed clinical, surgical, pathological and prognostic data of 6 patients who underwent salvage surgery after CIRT between 2010 and 2015. All patients were men with a smoking history, and their median age was 67 years. The time from CIRT to surgery was 18 (range 12-24) months. All patients underwent at least lobectomy with mediastinal node dissection. Viable tumour cells were confirmed pathologically in all cases. Five patients required combined resection or extra procedure because of strong adhesions and the possibility of tumour extension; however, none of the patients had a tumour invasion to the adjacent organ. None of the patients had severe complications, perioperative death and local recurrence, and 3 patients are alive without recurrence (range 28-84 months). Salvage surgery appears to be safe and effective. Even though the tumours did not invade the adjacent organs, combined resection was required because of severe adhesion.

[Successful Treatment of a Mechanically Ventilated Patient with an Oncological Emergency Caused by Recurrence of Pulmonary Adenocarcinoma]

We successfully treated a mechanically ventilated patient with severe respiratory failure caused by airway stenosis; she recovered after radiotherapy and gefitinib administration. A 68-year-old female with a pulmonary adenocarcinoma underwent a radical operation(right middle-lower sleeve lobectomy and lymph node dissection). Forty-four months later, she was admitted to our hospital with severe dyspnea, and was placed on mechanical ventilation after tracheal intubation. Postoperative cancer recurrence was evident in the bronchial mucosa and the site of carinal stenosis. Pathological examination revealed an epidermal growth factor receptor-positive adenocarcinoma. After radiotherapy(a total of 30 Gy), gefitinib(250mg/day) was commenced. Respiratory function improved gradually, and ventilator weaning was successful 3 weeks after tracheal intubation. Computed tomography revealed a partial response; her recovery from the emergency oncological situation was remarkable. She was discharged 4 months after hospitalization. Although she took gefitinib every 2-to-7 days, she refused all examinations and possible treatments for 25 months after recurrence. Finally, she died of respiratory failure 29 months after recurrence and 73 months after the initial operation.

Thoracoscopic fissureless left upper lobectomy for the patient with a dense fissure

The fissureless technique is a useful procedure for the treatment of patients with dense fissures because it reduces the risk of prolonged postoperative air leakage, which can lengthen postoperative hospitalization and increase medical costs. This technique is frequently utilized in right upper lobectomies because dense fissures are most commonly detected between the right upper and middle lobe, and consequently, there are multiple reports describing the efficacy of the fissureless technique in right upper lobectomy. However, there are relatively few reports discussing the efficacy of fissureless left upper lobectomy, and we have not found any reports or videos demonstrating the actual technique. We aim to fill this void here, with a demonstration of a thoracoscopic left upper lobectomy in a patient with dense fissures, and we also explain the nuances of performing this procedure.

The safety and feasibility of thoracoscopic uncommon pulmonary segmentectomy

Backgrounds

Opportunities to treat patients requiring uncommon pulmonary segmentectomy are increasing because small pulmonary nodules are being incidentally detected more often. Uncommon segmentectomy is frequently performed via thoracotomy because uncommon pulmonary segmentectomies are associated with various technical difficulties compared to common segmentectomies. In this study, we investigated the safety and feasibility of thoracoscopic uncommon segmentectomy.

Methods

A total of 105 patients underwent thoracoscopic anatomic pulmonary segmentectomy in our department between March 2006 and September 2018. Among them, 37 received an uncommon segmentectomy and 68 received a common segmentectomy. Uncommon segmentectomy was defined as any segmentectomy, except for segmentectomies of the lingual, basilar, or superior segment of the lower lobe, or upper division of the left upper lobe. We retrospectively compared characteristics and perioperative outcomes between patients receiving uncommon versus common segmentectomy.

Results

Uncommon segmentectomies were performed in the left S¹⁺² in nine patients, S³ in three, S⁹⁺¹⁰ in one, others including the sub-segment area in one, right S¹ in four, S² in six, S³ in two, S⁷⁺⁸ in two, S⁹⁺¹⁰ in six, and others including the sub-segment area in three. No significant differences were observed in patient characteristics between the two groups, or in perioperative results, including operative time, blood loss, postoperative drainage, hospitalization, morbidity, mortality, rate of conversion to thoracotomy, or rate of significant bleeding. No local recurrence was detected on the intersegmental plane in either group.

Conclusions

Thoracoscopic uncommon segmentectomy is feasible and safe. It also helps ensure an oncological safety margin by division of the appropriate intersegmental plane.

Prognostic Impact of β2 Adrenergic Receptor Expression in Surgically Resected Pulmonary Pleomorphic Carcinoma

BACKGROUND/AIM

The β2-adrenergic receptor (β2AR) is highly expressed in various human cancers and has been linked to tumor growth and metastases. Although β2AR is considered a novel therapeutic target of human neoplasms, the clinicopathological significance of β2AR expression in patients with pulmonary pleomorphic carcinoma (PPC) remains unclear. The aim of this study was to clarify the prognostic impact of β2AR in PPC.

PATIENTS AND METHODS

One hundred and five Japanese patients with surgically resected PPC were included in the study. The expression levels of β2AR were assessed by immunohistochemistry in specimens from the resected tumors, and their association with patient survival, as well as with tumor characteristics was investigated.

RESULTS

β2AR was highly expressed in 63% of all patients, irrespective of adenocarcinoma components present. The β2AR expression was significantly associated with lymph node metastasis, lymphatic permeation and tumor cell proliferation in PPC patients with early-stage disease (stage I or II). A high β2AR expression was identified as a significant predictor of worse prognosis for PPC patients during early stages of the disease. Multivariate analysis confirmed that β2AR expression was an independent factor for predicting the overall survival of PPC patients.

CONCLUSION

β2AR can serve as a significant predictor of tumor aggressiveness and poor survival for PPC patients, especially those with early-stage disease.