[Wedge Resection as an Alternative Procedure for Primary Pulmonary Carcinoma in Poor-risk Patients]

BACKGROUND

We present wedge resection as an alternative procedure for primary pulmonary carcinoma in poor-risk patients.

PATIENTS AND METHODS

We examined the overall survival of 94 patients who underwent wedge resection for pN0M0 primary pulmonary carcinoma over the last 20 years because of their intolerance of lobectomy.

RESULTS

In the wedge resection group, the postoperative 5-year survival in all causes of death was 59.6%, indicating significantly better prognoses in patients with adenocarcinoma aged less than 75 years old. The 5-year survival in the lobectomy group was 77.5%, while the 5-year survival in terms of primary causes of death in the wedge resection and lobectomy groups was 89.3% and 88.0%, respectively. There was a significant difference between wedge resection and lobectomy in all causes of death, but not between groups in primary causes of death.

CONCLUSION

Because there were many non-primary deaths in the wedge resection group, care should be taken to follow comorbidities that cause limited lung resection. Survival in the wedge resection group was not inferior to that in the lobectomy group in analyses of the primary causes of death. We suggest that wedge resection should be a favorable procedure for primary pulmonary carcinoma in poor-risk patients to obtain a large enough sample volume of tumor cells.

Delayed massive hemothorax due to a diaphragmatic laceration caused by lower rib fractures

A delayed hemothorax requiring surgical treatment is considered a rare minor thoracic injury. We experienced four cases of delayed massive hemothorax due to a diaphragmatic laceration caused by lower rib fractures. A computed tomography scan on admission revealed multiple rib fractures in all patients, and at least one fractured lower rib was severely displaced, which injured the diaphragm. The duration between the injury and the diagnosis were 14 h-30 days. Emergency surgical treatment was performed, and intraoperative findings revealed a diaphragmatic laceration with oozing due to injury caused by the edge of a fractured rib. After the operation, all patients were successfully discharged.

Prognostic significance of PD-L1 expression and tumor infiltrating lymphocytes in large cell neuroendocrine carcinoma of lung

OBJECTIVES

Since large cell neuroendocrine carcinoma (LCNEC) is a relatively rare histologic type of primary lung cancer, little is known about the immunological status of patients with LCNEC. We aimed to clarify the expression and prognostic impact of programmed cell death ligand 1 (PD-L1), CD8, CD4, and Forkhead box protein P3 (Foxp3) in LCNEC.

METHODS

We retrospectively analyzed PD-L1, CD8, CD4, and Foxp3 expressions in 95 surgically resected LCNEC. PD-L1 positive staining was determined in tumors with more than 1% of tumor cells stained to any intensity, and CD8, CD4, and Foxp3 positivity was determined in tumors with more than 5% of lymphocytes stained.

RESULTS

Positive expression of PD-L1, CD8, CD4, and Foxp3 was observed in 70 (74%), 52 (55%), 76 (80%), and 43 (45%) tumors, respectively. The expression of PD-L1 was significantly correlated with positive lymphatic permeation. Positive correlations were mutually observed among tumor infiltrating immune cells. Univariate and multivariate analyses showed that positive pleural invasion and Foxp3 negative expression were independent unfavorable prognostic factors for overall survival (OS). Advanced pathological stage, positive pleural invasion, CD4 negative expression in cancer stroma, and Foxp3 negative expression were identified as independent unfavorable prognostic factors for recurrence free survival (RFS).

CONCLUSIONS

Foxp3 positive tumor infiltrating lymphocytes (TILs) were an independent favorable prognostic factor for both OS and RFS, whereas CD4 positive TILs were an independent significant unfavorable prognostic factor for RFS. The high frequency of PD-L1 expression could support the use of anti-programmed cell death 1 antibody in the treatment of LCNEC.

The Risk of Misdiagnosing Pulmonary Adenocarcinoma as Traumatic Pseudocyst in a Young Adult

A 35-year-old man was transferred to our institution because of bruising on the chest. A computed tomography scan revealed a pulmonary pseudocyst. Although the pulmonary pseudocyst remained unchanged it accumulated fluid. Based on our concern regarding hemoptysis, the patient underwent S6 segmentectomy of the right lower lobe. The postoperative pathological examination revealed a cystic lesion, including a white mass on the cystic wall. Unexpectedly, the mass was composed of papillary adenocarcinoma. Acute care surgeons should be alert to the possible presence of tumor in trauma patients. A cystic lesion must be carefully distinguished from a traumatic pulmonary pseudocyst and lung cancer.

Expression of amino acid transporter (LAT1 and 4F2hc) in pulmonary pleomorphic carcinoma

Amino acid transporters are necessary for tumor growth, metastasis, and survival of various neoplasms; however, the clinicopathological significance of L-type amino acid transporter 1 (LAT1) and 4F2 cell surface antigen (4F2hc) in patients with pulmonary pleomorphic carcinoma (PPC) remainsunknown. The aim of this study is to clarify the prognostic impact of these amino acid transporters in PPC. One hundred five patients with surgically resected PPC were assessed by immunohistochemistry. The expression of LAT1 and 4F2hc, and Ki-67 labeling index were investigated using specimens of the resected tumors. LAT1 and 4F2hc were highly expressed in 35% and 53% of all patients (n = 105, P < .01), 25% and 48% of patients with an adenocarcinoma component (n = 48, P = .02), and 44% and 58% of patients with a nonadenocarcinoma component (n = 57, P = .18), respectively. A high LAT1 expression was significantly related to advanced disease, lymphatic permeation, tumor cell proliferation, and 4F2hc expression. By multivariate analysis, LAT1 and 4F2hc were identified as significant independent markers for predicting a worse prognosis. LAT1 is highly expressed in PPC, and high LAT1 expression can serve as a significant predictor linked to a worse prognosis in patients with PPC.

Schwannoma arising in a lymph node mimicking metastatic pulmonary carcinoma

Schwannomas commonly arise in the torso, extremities, and mediastinum. However, no interlobar lymph node (#11i) lesions have ever been reported. This is a thought-provoking case, because it involved a schwannoma arising in a lymph node mimicking metastatic pulmonary carcinoma. A 72-year-old man was diagnosed with primary pulmonary carcinoma, and 18F-fluorodeoxyglucose (FDG) positron emission tomography demonstrated high FDG uptake in the primary lesion and in #11i, which suggested metastasis (clinical stage IIA). A right lower lobectomy with lymph node dissection was performed. Fortunately, the enlarged #11i was a schwannoma and not metastasis. The take-home message is “a patient with multiple neuromatosis tends to have schwannomas throughout the body”.

[Multidisciplinary Approach to Recurrence after Resection of Primary Lung Cancer]

BACKGROUND

The standard approach for treating recurrence after complete resection of primary non-small cell lung cancer has been controversial. We present here a multidisciplinary strategy for postoperative recurrence in patients with primary lung cancer.

PATIENTS AND METHODS

Over the last 7 years, we examined the disease-free survival and overall survival of 70 patients who underwent multidisciplinary treatment for recurrence after surgical resection of primary lung cancer.

RESULTS

The median overall survival was 32.3 months after surgery and 17.4 months after recurrence developed, indicating significantly better prognoses in females and in patients with adenocarcinoma, stage I disease, driver mutation positivity, a longer postoperative disease-free period, and never smokers. Eight patients survived more than 5 years after recurrence;of these patients, all had adenocarcinomas, 7 had oligometastases and/or tumor dormancy, and 5 received multiple-drug regimens.

CONCLUSION

Multidisciplinary treatment for recurrence after resection of primary lung cancer was effective for patients receiving various drug regimens. In patients with oligometastases, disease control was achieved by a combination of local treatments targeting each involved organ. In patients with tumor dormancy, follow-up or a drug holiday was important to maintain the patient's quality of life.

[Video-assisted Transaortic Left Ventricular Thrombectomy]

A 50-year-old woman visited a previous hospital because of aphasia. She was diagnosed as having cardiogenic embolism and left ventricular thrombus. Anticoagulant therapy was performed but was unsuccessful because of hypermenorrhea due to the myoma of the uterus. She was transferred to our hospital to receive surgical treatment. After uterine myomectomy, we performed video-assisted transaortic left ventricular thrombectomy. Her postoperative course was uneventful. Left ventriculotomy has been the standard approach for left ventricular thrombectomy. However, this approach carries a risk of ventricular dysfunction. We report our experience of a successful outcome with video-assisted transaortic left ventricular thrombectomy, thereby avoiding a left ventriculotomy.

Thoracoscopic right upper lobectomy after an initial anatomic pulmonary resection of the lower lobe

It is challenging to redo an anatomical pulmonary resection on the ipsilateral side because of the adhesions or dense fissures caused by the initial anatomic pulmonary resection. Few reports describe surgical techniques for addressing these challenges, especially using a minimally invasive thoracoscopic approach instead of standard thoracotomy. Here, we demonstrate a thoracoscopic right upper lobectomy after an initial anatomic pulmonary resection of the right lower lobe and explain the nuances of performing it.

Thoracoscopic lateral and posterior basal (S9 + 10) segmentectomy using intersegmental tunnelling

The appropriate lateral and posterior basal (S9 + 10) segmentectomy requires exposure and recognition of common basal pulmonary vein branches located deeply in the lung parenchyma. Therefore, we applied the intersegmental tunnelling method in S9 + 10 segmentectomy to recognize the dominant veins to the S9 + 10 segment accurately. Between April 2014 and December 2015, five patients underwent thoracoscopic S9 + 10 segmentectomy using intersegmental tunnelling. By using this technique, we can recognize the branches of the pulmonary vein to the affected S9 + 10 segment accurately. This technique can let us perform appropriate S9 + 10 segmentectomy.

Troubleshooting for bleeding in thoracoscopic anatomic pulmonary resection

Introduction The objective of this study was to evaluate intraoperative vessel injury and assess troubleshooting during thoracoscopic anatomic pulmonary resection. Methods Between April 2012 and March 2016, 240 patients underwent thoracoscopic anatomic lung resection, 26 of whom were identified as having massive bleeding intraoperatively. We analyzed the injured vessel and the hemostatic procedure employed, then compared the perioperative outcomes in patients with ( n = 26) and without ( n = 214) vessel injury. In addition, we compared perioperative results based on the period when surgery was performed: early period: April 2012 to March 2014 ( n = 93) or late period: April 2014 to March 2016 ( n = 146). Results The surgical procedures included 20 lobectomies and 6 segmentectomies. One of the 26 patients had vessel injury at 2 points, giving a total of 27 points of injury. Hemostasis was mostly achieved by application of thrombostatic sealant (63.0%). There were no significant differences in the length postoperative hospitalization ( p = 0.67) or morbidity rate ( p = 0.43) between the vessel injury and the no-vessel injury groups. There were no significant differences in the incidence of significant intraoperative bleeding ( p = 0.13) and total blood loss ( p = 0.13) between the early and late periods. Conclusions Application of thrombostatic sealant is one of the useful methods to achieve hemostasis during thoracoscopic anatomic pulmonary resection. Vascular hazards are inherent to a thoracoscopic approach. Therefore, thoracic surgeons should always be concerned about significant intraoperative bleeding and treat it appropriately.

The efficacy of thoracoscopic fissureless lobectomy in patients with dense fissures

BACKGROUND

Prolonged air leakage after a lobectomy remains a frequent complication in patients with dense fissures. To avoid postoperative air leakage, we used the "thoracoscopic fissureless technique" for patients with dense fissures. A thoracoscopic approach is useful for the fissureless technique because it gives a good operative view from various angles without dividing the fissure. In this study, we compared the peri- or intraoperative results of thoracoscopic fissureless lobectomies to traditional lobectomies with fissure dissection for pulmonary artery (PA) exposure in order to identify the efficacy of thoracoscopic fissureless lobectomy.

METHODS

Between April 2012 and November 2015, 175 patients underwent a thoracoscopic lobectomy with three or four ports, of whom 14 underwent a fissureless lobectomy because of dense fissures. We compared the characteristics and perioperative outcomes of the patients who underwent the fissureless technique (fissureless technique group, n=14) and the traditional fissure dissection technique for PA exposure (traditional technique group, n=161). In our department, fissureless lobectomy is indicated for patients with a fused fissure (fissural grade III or IV as proposed by Craig in 1997) or inflammation makes it difficult to expose the PA, while the traditional technique is used for other patients.

RESULTS

Although the fissureless technique group had longer operation time than the traditional technique group (P=0.0045), there was no significant inter-group difference about blood loss (P=0.85), occurrence rate of intraoperative massive bleeding (P=0.6) or conversion rate to thoracotomy (P=0.31). According to postoperative results, there was no significant inter-group difference in duration of chest tube drainage (P=0.56), length of postoperative hospital stay (P=0.14), or morbidity rate (P=0.16). No mortality occurred in either group.

CONCLUSIONS

A thoracoscopic fissureless lobectomy is feasible and safe, and useful to avoid postoperative air-leakage in patients with dense fissures.

Successful treatment of a bronchopleural fistula after en masse lobectomy

A 72-year-old man underwent en masse lobectomy of the lower left lobe because of continued hemoptysis. We chose en masse lobectomy as a last resort because the patient had cardiopulmonary problems including chronic obstructive pulmonary disease (COPD), pulmonary hypertension, and continued hemoptysis. The patient developed a bronchopleural fistula 2 weeks later, so the Clagett window procedure was performed. After gauze exchange and cleaning of the pleural space, the Clagett window was closed using a latissimus dorsi muscle flap. He was discharged about 3 months after the initial operation. One of the most critical complications after en masse lobectomy is a bronchopleural fistula because the bronchial stump and vessel are too close to each other. The space between the bronchus and vessel can fill with tissue, such as pulmonary parenchyma or lymph nodes, which cover the fistula.

A convenient method for identifying a small pulmonary nodule using a dyed swab and geometric mapping

BACKGROUND

Computed tomography (CT)-guided lung needle marking is useful to identify pulmonary nodules. However, certain complications sometimes trigger severe after-effects or death. So, we present a convenient and safe method by which small pulmonary nodules can be identified using a particular dye [2% (w/v) gentian violet].

METHODS

A patient is initially placed in the lateral operative position. Under CT guidance, a "magic marker" is used to identify the skin above the pulmonary nodule. During the operation, the chest wall is punctured on that mark using a needle loop retractor (Mini Loop Retractor II). A swab saturated in the dye solution is attached to a silk thread and passed through the loop. The loop and string are subsequently retracted. The dye-stamp is apparent on the lung surface above the nodule after the lung is inflated. If the scapula, any vertebra, or the clavicle compromised access to a nodule, we used our geometric technique to locate that nodule.

RESULTS

We used this technique to treat 51 lesions of 50 patients presenting from 2013 to 2015. Mean tumor diameter was 7 mm. All lesions were identified via thoracoscopy, all nodules were constrained by ring forceps, and wedge resections were performed using a stapler. All lesions lay very close to the staple markings, as judged by finger or instrument palpation. No complications were encountered.

CONCLUSIONS

The advantages of our technique are that it is simple and easy, air emboli are not an issue, the skin marking is rapid, safety is assured, and the skin marking does not require hospitalization. Our method is also useful such as following situations; it defines the margins of the cut line upon anatomical segmentectomy, indicates where a skin incision is required, and identifies impalpable nodules, which aids the lung resection but provides frozen sections to the pathologist.