Successful resection of giant mediastinal tumor with growing teratoma syndrome by bilateral transmanubrial approach, clamshell and median sternotomy

A 25-year-old man was initially diagnosed with a giant mediastinal nonseminomatous germ cell tumor. Chemotherapy was administered and the tumor markers were normalized; however, the tumor grew in size (20 cm), invading the left brachiocephalic vein (BCV) and the superior vena cava (SVC). Bilateral transmanubrial approach with median sternotomy and bilateral clamshell thoracotomy was required for the complete resection of the giant tumor with the SVC reconstruction. Bilateral TMA provided the surgical field of view around the bilateral phrenic nerves and bilateral BCVs. Given the final pathological diagnosis of the mature teratoma, this was considered growing teratoma syndrome where surgery is the only treatment option.

Efficacy of three-dimensional computed tomography volumetry for recipients in downsizing oversized grafts in brain-dead donor lung transplantation

Objective

Brain-dead donor lung transplantation frequently requires reduction in the size of oversized lung grafts for patients with a small chest cavity. We focused on the role of three-dimensional computed tomography (3D-CT) volumetry for recipients on downsizing oversized lung grafts.

Methods

We performed 53 brain-dead donor bilateral lung transplantations, including 15 lobar lung transplants (Lobar group) and 38 standard lung transplants with full-sized grafts (Full group), between December 2010 and December 2018. Recipient chest volume before transplantation was measured using 3D-CT volumetry, and donor lung volume was evaluated by predicted total lung capacity. Post-transplant outcomes and pulmonary function were retrospectively compared between the groups.

Results

The ratio of the recipient chest volume to the donor lung volume was significantly lower in the Lobar group (0.42 ± 0.15) than in the Full group (0.77 ± 0.30, P < 0.01). The calculated size matching between the donor and recipient after downsizing the grafts was significantly correlated to the ratio of the recipient chest volume to the donor lung volume (Spearman r = 0.69; P < 0.01). Early post-transplant outcomes did not significantly differ between the groups. Although the Full group showed slightly better pulmonary function after transplantation, the 1-, 3-, and 5-year overall survival rates were similar to the Lobar group (100%, 93%, and 81% in the Lobar group vs. 92%, 78%, and 70% in the Full group; P = 0.50).

Conclusions

Brain-dead donor lobar lung transplantation showed favorable post-transplant outcomes. The assessment of recipient chest cavity volume using 3D-CT volumetry may help surgeons precisely downsize oversized lung grafts prior to transplantation.

Native lung complications after living-donor lobar lung transplantation

BACKGROUND

Living-donor lobar lung transplantation (LDLLT) is viable for critically ill patients in situations of donor shortage. Because it is sometimes difficult to find 2 ideal living donors with suitable graft sizes, we developed native lung-sparing procedures, including single LDLLT and native upper lobe-sparing LDLLT. This study aimed to investigate native lung complications (NLCs) in native lung-sparing LDLLT.

METHODS

Between April 2002 and March 2019, 92 LDLLTs and 124 cadaveric lung transplantations (CLTs) were performed at the Kyoto University Hospital. Our prospectively maintained database and clinical records were reviewed to compare NLCs among recipients who underwent native lung-sparing LDLLT (n = 21) with those among recipients who underwent single CLT (n = 61).

RESULTS

Among 21 recipients who underwent native lung-sparing LDLLT, 11 NLCs occurred in 8 recipients. No fatal NLC was noted; however, 2 required surgical intervention. Post-transplant survival was not significantly different between native lung-sparing LDLLT recipients with NLCs and those without NLCs. The incidence of NLCs was comparable between native lung-sparing LDLLT recipients and single CLT recipients (8/21 vs 26/61, p = 0.80); however, NLCs occurred significantly later in LDLLT recipients than in CLT recipients (median: 665 vs 181.5 days after transplantation, p = 0.014).

CONCLUSIONS

NLCs after native lung-sparing LDLLT had favorable outcomes. Therefore, native lung-sparing LDLLT is a useful treatment option for severely ill patients who cannot wait for CLT. However, it is important to recognize that NLCs may occur later in LDLLT than in CLT.

Prognostic significance of cribriform adenocarcinoma of the lung: validation analysis of 1,057 Japanese patients with resected lung adenocarcinoma and a review of the literature

Background

Cribriform-predominant adenocarcinoma of the lung (Cribri-ADC) is a recently described tumor growth pattern. However, its prognostic impact has not been clearly determined. We analyzed the data of a series of 1,057 Japanese patients with resected lung adenocarcinoma to identify the clinical significance of Cribri-ADC.

Methods

Cribriform pattern (Cribri-p) is defined as invasive back-to-back fused tumor glands with poorly formed glandular spaces or invasive tumor nests comprising tumors cells that produced glandular lumina. We investigated the correlations of Cribri-p and Cribri-ADC with clinicopathological factors as well as disease-free survival (DFS) and overall survival (OS).

Results

Cribri-p was present in 217 patients (20.5%) and Cribri-ADC was determined in 25 patients (2.4%). Cribri-p was associated with larger tumor size, pleural invasion, vascular invasion, lymphatic invasion, and spreading through air spaces (STAS) (all, P<0.0001). Cribri-ADC was associated with younger age (P=0.019), vascular invasion (P=0.0025), STAS (P<0.0001), and ALK rearrangement (P=0.012). The DFS curve of patients with Cribri-ADC was identical to that of patients with solid adenocarcinoma; however, the OS curve was located between that of patients with papillary and acinar adenocarcinoma. Of the 10 patients who had tumor recurrences, eight had EGFR mutations or ALK rearrangement, six of whom achieved relatively long survival (median, 64.6, range, 37.4–113 months) following treatment with tyrosine kinase inhibitors (TKIs). In multivariate analysis, Cribri-ADC was not an independent prognostic factor of either recurrence or death.

Conclusions

Cribri-ADC is associated with a higher risk of recurrence; however, most patients can be successfully treated with TKIs.

Postoperative outcomes of lung transplant recipients with preformed donor-specific antibodies

OBJECTIVES

Few studies have evaluated the outcomes of lung transplantation (LTx) in recipients with preformed donor-specific antibodies (DSAs). This study investigated the postoperative changes in preformed DSAs based on prospectively collected data of DSAs, and the influences of preformed DSAs on postoperative outcomes among LTx recipients.

METHODS

Between July 2010 and December 2019, 216 recipients underwent LTx (81 living-donor lobar lung transplants and 135 deceased-donor lung transplants). We reviewed 8 cases with preformed DSAs to determine postoperative changes in DSAs and compared postoperative outcomes between recipients with and without DSAs.

RESULTS

The preoperative mean fluorescence intensity of preformed DSAs ranged from 1141 to 14 695. Two recipients experienced antibody-mediated rejection within 2 weeks after LTx. DSAs disappeared in 7 recipients; however, 1 recipient experienced the relapse of DSAs and died from chronic lung allograft syndrome (CLAD), whereas 1 recipient had persisting DSAs within the study period and died from CLAD. Neither overall survival (OS) nor CLAD-free survival was significantly different between recipients with and without DSAs (P = 0.26 and P = 0.17, respectively). However, both OS and CLAD-free survival were significantly lower in recipients with DSAs against HLA class II than in those without these antibodies {5-year OS: 25.0% [95% confidence interval (CI): 0.9-66.5%] vs 72.1% (95% CI: 63.8-78.9%), P = 0.030 and 5-year CLAD-free survival: 26.7% (95% CI: 1.0-68.6%) vs 73.7% (95% CI: 66.5-79.5%), P = 0.002}.

CONCLUSIONS

Prognosis in recipients experiencing the relapse of preformed DSAs and those with persisting DSAs may be poor. The recipients with anti-HLA class II preformed DSAs had a significantly worse prognosis.

Prognostic Role of Programmed Cell Death 1 Ligand 1 in Resectable Pleural Mesothelioma

BACKGROUND

The prognostic role of programmed cell death 1 ligand 1 (PD-L1) in malignant pleural mesothelioma (MPM) is incompletely understood. Our objectives were to evaluate the evidence for tumor PD-L1 as a prognostic biomarker in MPM through meta-analysis and to determine whether tumor PD-L1 expression is associated with survival in MPM patients undergoing macroscopic complete resection.

METHODS

Meta-analysis was performed to determine the association of PD-L1 with overall survival in MPM (n = 1655) from 14 studies containing overall survival and tumor PD-L1 expression. Univariable and multivariable analyses tested the relationship of tumor PD-L1 with overall survival and recurrence-free survival in an institutional cohort of MPM patients treated by macroscopic complete resection (n = 75). To validate the association of PD-L1 with overall survival, we utilized two independent MPM cohorts (n = 284).

RESULTS

Meta-analysis demonstrated that high tumor PD-L1 expression was associated with poor overall survival. Among 75 patients undergoing macroscopic complete resection, 49 tumors (65%) expressed PD-L1 (1% or more), and high PD-L1 (50% or greater) was more commonly expressed on nonepithelial (29%) compared with epithelial tumors (14%). High tumor PD-L1 expression was independently associated with poor overall survival (P < .001, hazard ratio 5.67) and recurrence-free survival (P = .003, hazard ratio 3.28). The association of PD-L1 overexpression with unfavorable survival was more significant in epithelial MPMs than nonepithelial MPMs. These findings were validated in RNA sequencing analyses in two independent cohorts. Exploratory transcriptome analysis revealed that MPM tumors with PD-L1 overexpression displayed coexpression of other immune regulatory molecules, programmed cell death 1 ligand 2 and T-cell immunoglobulin mucin receptor 3.

CONCLUSIONS

Tumor PD-L1 expression is a prognostic biomarker in patients undergoing surgical resection for MPM and may be useful in perioperative decision making.

Detection of circulatory disturbance after pulmonary vein division during a living donor lobectomy

Indocyanine green (ICG) is widely used during thoracic surgery to enhance visualization, allowing assessment of the intersegmental plane based on intrapulmonary blood flow (Travis et al. in Ann Thorac Surg 108(2):363-369, 2019; Seshiru et al. in Gen Thorac Cardiovasc Surg 66(2):81-90, 2018). Using ICG to detect blood flow disruption after lung resection, however, has not been addressed. We therefore report a case in which the left lingular pulmonary vein was incidentally divided during left lower lobectomy in a living-lung donor. Intraoperative ICG-enhanced near-infrared fluoroscopic imaging to assess intrapulmonary blood flow detected the problem. We thus avoided potential postoperative residual lung complications in this patient.

Prolonged air leak after reoperative pulmonary resection (with prior ipsilateral chest surgery)

Reoperative pulmonary resection (with prior ipsilateral chest surgery) has been reported to be associated with a high rate of postoperative complications. The objective of this study was to evaluate prolonged air leak (PAL) after reoperative pulmonary resections. We conducted a single-centre retrospective analysis on 100 consecutive patients undergoing ipsilateral reoperative pulmonary resection at our institution between March 2012 and February 2020. We investigated the incidence of PAL after reoperative pulmonary resections in comparison to that after first operations and analysed potentially relevant factors of PAL after reoperations. After reoperations, the incidence of PAL was 24%. The incidence of PAL after reoperations was significantly higher than that after first operations (P < 0.01). On multivariable analysis, anatomical resection (P = 0.03) and thoracotomy approach (P = 0.02) were found to be significant factors associated with the occurrence of PAL, and age was a significant factor associated with chest tube duration (P < 0.01) and length of hospital stay (P < 0.01) after reoperative pulmonary resection. Our study identified significant risk factors of PAL after reoperative pulmonary resections, which would be an important step towards improved management of patients undergoing reoperative pulmonary resections.

Association Between Pretransplant Serum Carcinoembryonic Antigen Levels and Immunohistochemical Staining of Explanted Native Lungs in Patients Who Underwent Lung Transplantation

Some patients show high serum carcinoembryonic antigen (CEA) levels in the evaluation of candidate patients for lung transplantation, which might be a challenge because high serum CEA potentially implies an existence of malignancy. For further understanding of the true meaning of high serum CEA levels in lung transplantation, we retrospectively investigated the relationship between serum CEA and clinical data. We also performed immunohistochemical analysis of explanted native lungs and evaluated its relationship with serum CEA levels. Retrospective chart review was performed in consecutive patients who underwent lung transplantation with measurement of serum CEA before and after transplantation at our institution between August 2008 and June 2017. Histopathological analysis was also performed in the same cohort of patients. Survival outcomes and pathohistological findings were compared between the high serum CEA and the normal CEA group, adjusting for potential confounding factors. One hundred and fifteen patients were eligible for analysis. High serum CEA levels before lung transplantation in most cases were decreased after the transplantation (35/39, 90%, P < 0.001). Preoperative serum CEA levels were not associated with postoperative survival. The percentage of CEA-positive alveolar cells was significantly higher in the high serum CEA group (P < 0.0001). After adjusting for potential confounding factors, there was a significant difference between the high serum CEA group and normal serum CEA group (CEA-positive alveolar cells; P = 0.002). High serum CEA levels before lung transplantation might derive from native lungs in the recipients and that they were not associated with overall survival after lung transplantation.

Salvage pulmonary metastasectomy with auto-transplantation after nivolumab

A 64-year-old woman presented for potential salvage surgery with a residual and growing pulmonary metastasis from clear-cell renal cell carcinoma, originating in the left upper lobe, after immunotherapy with nivolumab. Preoperative computed tomography with contrast demonstrated that the lesion extended into the pulmonary artery branch of the anterior segment of the left lower lobe. Ex vivo dissection was performed, followed by auto-transplantation of the left lower lobe. Herein, we discuss the radiological, intraoperative and pathological findings.

The treatment and survival of patients with postoperative recurrent thymic carcinoma and neuroendocrine carcinoma: a multicenter retrospective study

PURPOSE

There are few data available on the outcomes of postoperative recurrent thymic carcinoma (TC) and thymic neuroendocrine carcinoma (TNEC). The aim of this study is to evaluate the treatment and survival in patients with recurrent TC and TNEC after undergoing surgical resection.

METHODS

A retrospective chart review was performed using our multicenter database to identify patients with a postoperative recurrence of TC and TNEC from 1995 to 2018. The clinicopathological factors were reviewed and the survival outcomes were analyzed.

RESULTS

Sixty patients were identified among 152 patients who underwent resection of TC and TNEC. The median follow-up period from the first recurrence was 14.8 months (range 0-144). The 5-year post-recurrence survival was 23% for the whole cohort. According to a univariable analysis, advanced stage [hazard ratio (HR) 2.81, 95% confidence interval (CI) 1.09-9.54], interval between primary surgery and recurrence (HR 0.97, 95% CI 0.95-0.99), any treatment for recurrence (HR: 0.27, 95% CI 0.13-0.58) and chemotherapy for recurrence (HR: 0.46, 95% CI 0.22-0.95) were significant factors related to post-recurrence survival.

CONCLUSIONS

Chemotherapy rather than surgery appears to be the mainstay treatment for managing patients with postoperative recurrent TC and TNEC and it may also be considered in multidisciplinary management. Further studies with a larger sample size are required to confirm our findings.

Tranilast Inhibits TGF-β1-induced Epithelial-mesenchymal Transition and Invasion/Metastasis via the Suppression of Smad4 in Human Lung Cancer Cell Lines

BACKGROUND/AIM

Transforming growth factor β1 (TGF-β1) is an important epithelial-mesenchymal transition (EMT) activator that regulates the expression of E-cadherin and vimentin through Smad signalling. Tranilast is an anti-allergic drug that inhibits TGF-β1, and is used in the treatment of keloids and hypertrophic scars. We investigated whether tranilast inhibits TGF-β1-induced EMT and invasiveness in human non-small cell lung cancer cell lines.

MATERIALS AND METHODS

We examined the effects of tranilast treatment on EMT markers, TGF-β1/Smad signalling, and cell invasiveness in A549 and PC14 cells. Tumours from a mouse orthotopic lung cancer model with or without tranilast treatment were also immunohistochemically evaluated.

RESULTS

Tranilast increased E-cadherin expression via Smad4 suppression and inhibited cell invasion in TGF-β1-stimulated cells. Tranilast treatment of the in vivo mouse model reduced the pleural dissemination of cancer cells and suppressed vimentin and Smad4 expression.

CONCLUSION

Tranilast inhibited TGF-β1-induced EMT and cellular invasion/metastasis by suppressing Smad4 expression in cancer cells.

Are volume-dependent parameters in positron emission tomography predictive of postoperative recurrence after resection in patients with thymic carcinoma?

This study aimed to investigate the association between the volume-dependent parameters in ¹⁸F-fluorodeoxyglucose-positron emission tomography (¹⁸F-FDG PET/CT) and a recurrence of thymic carcinoma. A retrospective chart review was performed based on our multi-institutional database to identify patients undergoing PET prior to resection of thymic carcinoma or neuroendocrine carcinoma between 1991 and 2018. The PET parameters (metabolic tumor volume and total lesion glycolysis) were evaluated retrospectively. The relevant factors were extracted and a survival analysis was performed using the Kaplan-Meier method. Sixteen patients were thus deemed to be eligible for analysis. The median follow-up period following resection was 2.65 years (range: 0.96-0.68 years). The recurrence-free survival was significantly longer in patients with a metabolic tumor volume <  = 22.755 cm³ and with total lesion glycolysis <  = 105.4006 g/mL (p = 0.001 and 0.001, respectively, by a log-rank test). The metabolic tumor volume and total lesion glycolysis may, therefore, be predictive of the postoperative recurrence of thymic carcinoma.

Is left-side DaVinci™ procedure challenging? Initial experiences of a single institute

OBJECTIVE

Among the standard techniques for anatomical lung cancer resection, left upper lobectomy has been regarded as challenging by thoracic surgeons. Thus, this study aimed to examine whether laterality of robot-assisted thoracoscopic procedures has any influence on the incidence of conversion to thoracotomy, operation time, amount of bleeding, and postoperative complications in the introduction phase of this procedure.

METHODS

The first consecutive 65 patients (right upper/middle/lower lobe with 31/3/15 cases, left upper/lower lobe with 10/6 cases) who underwent robot-assisted thoracoscopic lobectomy from December 2011 to April 2019 in Kyoto University were retrospectively reviewed.

RESULTS

Five cases were converted to open thoracotomy, including four for the left upper lobectomy and one for the right lower lobectomy (p = 0.011). The mean operation time was 229.9 ± 53.9 min (n = 12) and 192.8 ± 53.1 min (n = 48) for the left-sided and right-sided procedures, respectively (p = 0.043, conversion cases were not included). The mean bleeding amount was 29.1 ± 75.7 g (n = 49) and 136.8 ± 330.9 g (n = 16) for the right side and left side, respectively (p = 0.036). The mean operation time (min) for each lobe was as follows: 253.5 ± 73.9 for the left upper lobe (n = 6), 206.3 ± 41.3 for the left lower lobe (n = 6), 189.7 ± 51.3 for the right upper lobe (n = 31), 192.3 ± 57.5 for the right middle lobe (n = 3), and 199.9 ± 61.8 for the right lower lobe (n = 14).

CONCLUSION

Robot-assisted thoracoscopic surgery on the left side was associated with higher conversion rate, longer operation time, and more blood loss than that on the right side.

Sleep quality and its association with health-related quality of life of patients on lung transplantation waitlist in Japan

PURPOSE

Poor quality of sleep is a common feature in patients with various lung diseases and affects their health-related quality of life (HRQL). We evaluated sleep quality and HRQL in patients on the waitlist for lung transplantation in Japan.

METHODS

In this prospective study, patient-reported and physiological data were collected from patients newly registered on the waitlist for lung transplantation in Japan. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI) and HRQL using the St. George's Respiratory Questionnaire (SGRQ). The frequency of poor sleep quality, correlations between sleep quality and various clinical parameters, and predictive factors of sleep quality were examined.

RESULTS

Of 193 patients, the three most-frequent indications for lung transplantation were interstitial pneumonia (n = 96), pulmonary complications of hematopoietic stem cell transplantation (n = 25), and pulmonary hypertension (n = 17). Poor sleep quality (PSQI > 5) was observed in 102 patients (53%) and was significantly associated with worse Hospital Anxiety and Depression Score (HADS), worse SGRQ score, worse modified Medical Research Council Dyspnea score, and shorter 6-min walk distance. However, it was not associated with sex, pulmonary function, interstitial pneumonia, or arterial blood gas. Stepwise multiple regression analysis indicated that poor sleep quality was explained significantly by HADS anxiety (23%) and SGRQ Symptoms (10%).

CONCLUSION

Poor sleep quality was found to be common among patients on the lung transplantation waitlist in Japan. The two most significant factors responsible for impaired sleep quality were anxiety and respiratory symptoms. Additional care should be taken to ensuring a better quality of sleep for such patients.

Survival outcomes of patients with high-grade and poorly differentiated thymic neuroendocrine carcinoma

High-grade and poorly differentiated thymic neuroendocrine carcinoma is the rarest entity in thymic epithelial tumours. The aim of this study is to report survival data in a multi-institutional database in comparison to data in the literature. Retrospective chart review was performed on the basis of our multi-institutional database to identify patients undergoing the resection of poorly differentiated thymic neuroendocrine carcinoma between 1991 and 2018. Relevant factors were extracted, and survival analysis was performed using the Kaplan–Meier method. Twenty-one patients were identified. Five-year overall survival and recurrence-free survival were 64.6% and 51.8%, respectively. Twelve (57.1%) patients had recurrences. Due to the scarcity of data reported in the literature, our data may be used as a standard in high-grade and poorly differentiated thymic neuroendocrine carcinoma.

Survival outcomes of resection for pulmonary malignancies including non-small cell lung cancer and pulmonary metastasis after esophagectomy for esophageal carcinoma

OBJECTIVES

This study investigated survival outcomes of resection for pulmonary malignancies after esophagectomy for esophageal carcinoma, comparing non-small cell lung cancer and pulmonary metastases.

METHODS

We retrospectively reviewed consecutive patients who underwent resection for pulmonary malignancies after esophagectomy for esophageal carcinoma between 2009 and 2018. The overall survival and relapse-free survival rate were assessed using Kaplan-Meier analysis.

RESULTS

Eleven patients had non-small cell lung cancer and eight patients had pulmonary metastases from esophageal carcinoma. The 5-year overall survival rate was 92.9% in all patients with a median follow-up period of 50.4 (range: 9.1-130.2) months. While the 5-year overall survival rate was 100.0% in patients with non-small cell lung cancer, it was 85.7% in patients with pulmonary metastases from esophageal carcinoma. The 5-year relapse-free survival rate was 85.7% in patients with non-small cell lung cancer.

CONCLUSIONS

Our data suggest that resection for pulmonary malignancies after esophagectomy for esophageal carcinoma is associated with favorable survival outcomes and should be considered in selected patients.

Salvage thoracoscopic resection after nivolumab for stage IV

There are limited data on the surgical management of localized and residual diseases in patients with stage IV non-small-cell lung cancer that was treated with nivolumab. Herein, we present two patients who underwent salvage thoracoscopic resection for residual diseases (left lower lobectomy and paratracheal lymph node resection, respectively) after chemotherapy and immunotherapy for stage IV adenocarcinoma. The indications, intraoperative findings, and histopathological findings are discussed in this report.