Mortality from extrathymic malignancy after thymic tumour resections: incidences and risk factors

OBJECTIVES

To identify risk factors associated with extrathymic malignancy-related mortality after thymic epithelial tumour resection.

METHODS

The Japanese Association for Research on the Thymus database registered the records of 2835 patients collected from 32 Japanese institutions from 1991 to 2010. The cumulative incidence function of death due to extrathymic malignancies or recurrence was calculated, with other causes of death as competing risks. Relevant risk factors associated with extrathymic malignancy-related deaths in patients with thymoma were evaluated using the Fine and Gray model.

RESULTS

In total, 2701 patients were eligible for the analysis (thymoma, 2374; thymic carcinoma, 273; thymic neuroendocrine tumour, 54). The median follow-up period was 4.6 years. The cumulative incidence function of death due to extrathymic malignancies at 10 years was 2.2% (3.2% due to recurrence) in patients with thymoma, 1.6% (38.6% due to recurrence) in patients with thymic carcinoma and 0% (36.6% due to recurrence) in patients with thymic neuroendocrine tumour. In the multivariable analysis, age (every 10 years) at thymectomy [hazard ratio (HR) 2.19, 95% confidence interval (CI) 1.53-3.14; P < 0.001], male gender (HR 2.62, 95% CI 1.19-5.77; P = 0.017) and previous malignancies (HR 3.09, 95% CI 1.18-8.11; P = 0.022) were significant factors for death due to extrathymic malignancies after thymectomy.

CONCLUSIONS

Continued management and early detection of extrathymic malignancies may improve survival of patients with thymoma who are male, of advanced age, or have previous malignancies. Prospective studies are required to further investigate the management of extrathymic malignancies.

Sub-centimeter adenocarcinoma arising from mature mediastinal teratoma during 11 years of follow-up

A 54-year-old male presented with exertional dyspnea, right massive pleural effusion, and an anterior mediastinal tumor (6.5 × 6.2 × 7.6 cm) which continued to grow during the 11-year follow-up period. Fluorodeoxyglucose positron emission tomography demonstrated a focal but remarkable uptake within the tumor mass. After chest tube drainage, the patient underwent surgical resection via a right thoracotomy. The final pathology was determined to be a mature cystic teratoma with malignant transformation to adenocarcinoma. Teratomas with somatic-type malignancy are challenging to diagnose using only preoperative evaluations. Intra-operative findings, histopathological findings, and postoperative management techniques are discussed in this report and emphasize the importance of early resection for treatment of mature teratomas, as well as the recommendation of careful inspection of pathological specimens of long-standing teratomas.

Characteristics of incomplete endobronchial ultrasound-guided transbronchial needle aspiration cases

Backgrounds

The number of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) cases is increasing due to its less-invasiveness and usefulness. However, there are several unresolved issues, including the existence of incomplete cases and complications. This study aimed to investigate the frequency and diagnostic management of incomplete EBUS-TBNA cases.

Methods

Between July 2009 and December 2017, 424 patients underwent EBUS-TBNA for the diagnosis of suspected malignancy. Among them, we retrospectively reviewed the frequency, characteristics and diagnostic managements of incomplete cases of EBUS-TBNA.

Results

EBUS-TBNA was not completed in 16 patients (3.8%), all of whom underwent EBUS-TBNA cases under conscious sedation. The factors for incompleteness of EBUS-TBNA under conscious sedation were divided into two groups: impossibility to perform EBUS-TBNA under conscious sedation (n=8) and impossibility to perform safe needle biopsy (n=8). The former factor consisted of strong coughing reflex and insufficient sedation (n=5), frequent desaturation during EBUS-TBNA (n=2), and allergy to lidocaine (n=1), while the latter factor consisted of anatomical reasons (n=4), abundant blood flow in the target lesion (n=3), and invisibility of the target lesion due to airway deformation (n=1). Eventually, 10 out of 16 cases were histologically diagnosed as having malignancy by a surgical approach (n=5) and EBUS-TBNA under general anesthesia (n=5).

Conclusions

Although the number was small, we did note some incomplete cases of EBUS-TBNA under conscious sedation. In incomplete cases under conscious sedation, EBUS-TBNA under general anesthesia and other surgical approaches can be considered as additional options.

Expanded indications for auto-lung transplant technique

OBJECTIVE

Lung autotransplantation was originally developed to avoid pneumonectomy for centrally located lung cancer. We herein report our experience with lung autotransplantation for the treatment of various types of lung diseases.

METHODS

This is a single-center case series of lung autotransplantation with ex vivo bench surgery. Five patients underwent lung autotransplantation between September 2014 and October 2018. A common surgical technique was as follows: pneumonectomy was first completed. The intact lobes were then separated ex vivo, flushed using cold ET-Kyoto solution on a back table, and reimplanted.

RESULTS

The indications for lung autotransplantation were postpneumonectomy-like syndrome, locally advanced lung cancer, pulmonary artery sarcoma, central lung cancer, and bronchopleural fistula after right upper bronchial sleeve lobectomy. No major post-transplant complications were observed except for mild stenosis of bronchial anastomosis in one case that required bronchial intervention. One patient died of recurrence of pulmonary artery sarcoma 14 months after surgery. The other patients are alive without any recurrence of the native respiratory diseases or symptoms.

CONCLUSIONS

Lung autotransplantation following ex vivo bench surgery was found to be technically feasible for various lung diseases, showing a favorable early post-transplant outcome.

Paratracheal Middle Mediastinal Thymic Carcinomas

We describe case studies of two patients who underwent resection of paratracheal middle mediastinal thymic carcinomas. In both patients, complete resection of these masses via right thoracotomy was performed using three-dimensional computed tomography. Final pathologic diagnoses were thymic squamous cell carcinoma and thymic atypical carcinoid tumor. Challenges and debates in preoperative, intraoperative, and postoperative management are discussed in this article.

Surgery and stereotactic body radiotherapy for early-stage non-small cell lung cancer: prospective clinical trials of the past, the present, and the future

Stereotactic body radiotherapy (SBRT) may be a potential alternative to surgical resection in high-risk operable patients with early-stage non-small cell lung cancer (NSCLC). A number of clinical studies have been undertaken to answer this question, although the conclusion has remained undetermined. Although three randomized clinical trials have failed, currently several prospective clinical trials are ongoing on SBRT versus surgery for early-stage NSCLC. This review article was designed to overview the previous and ongoing clinical trials and to discuss the future perspectives in the comparisons.

Diameter of the dilated main pulmonary artery in patients with pulmonary hypertension decreases after lung transplantation

PURPOSE

The pulmonary artery (PA) in patients with pulmonary hypertension (PH) becomes dilated. We analyzed the postoperative changes of the main PA after lung transplantation (LuTx).

METHODS

The subjects of this retrospective study were 68 LuTx recipients, divided into a PH group (n = 36) and a non-PH group (n = 32), based on preoperative right heart catheterization findings. The PA diameter was measured on chest computed tomography. We evaluated the correlation between the mean pulmonary arterial pressure (mPAP) and the main PA diameter and compared the main PA diameters before and 3 months after LuTx.

RESULTS

The main PA diameter was significantly correlated with the mPAP (r = 0.423, P < 0.001). Preoperatively, the mean main PA diameter in the PH group was significantly greater than that in the non-PH group. However, by 3 months after LuTx, the main PA diameter in the PH group had decreased significantly from 32.4 ± 6.7 to 26.9 ± 4.8 mm (P < 0.001), while that in the non-PH group had decreased minimally from 28.3 ± 4.9 to 26.4 ± 4.6 mm (P < 0.001), resulting in no significant difference in postoperative main PA diameters between the two groups.

CONCLUSIONS

The main PA diameter in recipients with PH was enlarged and correlated with the mPAP. The dilated main PA diameter in PH patients decreased shortly after LuTx.

Surgery and stereotactic body radiotherapy for early stage non-small cell lung cancer: review of meta-analyses

Observational or randomized studies on survival outcome following surgery versus stereotactic body radiotherapy (SBRT) for early-stage non-small cell lung cancer (NSCLC) demonstrated various results, and several meta-analyses on this topic have been published. The PubMed database was queried for meta-analyses comparing surgery and SBRT for early stage NSCLC. Six meta-analyses on this comparison were identified and 4 (66.7%) suggested that surgery be associated with significantly more favorable overall survival than SBRT, using odds ratio or hazard ratio (HR) as measures of effect. Most of the included studies in the meta-analyses were observational studies and those meta-analyses should be interpreted with caution.

Use of a Three-Dimensional Model in Lung Transplantation for a Patient With Giant Pulmonary Aneurysm

Management of a giant pulmonary trunk aneurysm in lung transplantation is a challenge. Herein, we present a patient undergoing replacement of the giant pulmonary artery aneurysm with a donor's aorta in bilateral lung transplantation for idiopathic pulmonary arterial hypertension. A plastic three-dimensional model of the pulmonary artery aneurysm created accurately based on computed tomography data allowed us to simulate the procedure on the back table. Our intraoperative findings and management are discussed in this article.

Low incidence of and mortality from a second malignancy after resection of thymic carcinoma†

OBJECTIVES

Previous studies have suggested that a second malignancy often develops after resection of thymoma; however, it remains unknown whether this is applicable to thymic carcinoma.

METHODS

A retrospective chart review was performed based on our multi-institutional database of resected thymic epithelial tumours between 1991 and 2016. A second malignancy was defined as newly diagnosed after thymic tumour resection. The cumulative incidence of and related death from a second malignancy after thymic and neuroendocrine carcinoma resections were estimated using a competing risk model and were compared to those of patients undergoing a thymoma resection.

RESULTS

Two hundred and thirty-eight patients were identified (thymic carcinoma 59; thymoma 179). A second malignancy developed in 1 patient (1.7%) with thymic carcinoma and in 17 patients (9.5%) with thymoma. Deaths from second malignancies were noted in 7 patients with thymoma. There was a tendency towards a lower cumulative incidence of and a lower cumulative death from a second malignancy after thymic carcinoma resection (P = 0.139 and P = 0.20, respectively) than after thymoma resection. The cumulative incidence of a second malignancy in patients with thymic carcinoma was 2.8% at 5 years and at 10 years (8.0% at 5 years and 11.8% at 10 years in patients with thymoma).

CONCLUSIONS

After resection of thymic and thymic neuroendocrine carcinoma, the probability of developing a second malignancy, as well as mortality from a second malignancy, is very low. A prospective study with a larger sample size is required to validate our results.