Reconstruction of a dominant vertebral artery during resection of a superior sulcus tumour with an incomplete circle of Willis

A 74-year-old man presented with a left superior sulcus tumour invading the subclavian artery. After induction chemoradiotherapy, he underwent a vertebral artery reconstruction in addition to the subclavian artery reconstruction via a transmanubrial approach and video-assisted thoracoscopic left upper lobectomy. The final pathology was ypT4N0M0 adenocarcinoma. The technical aspects and indication for a vertebral artery reconstruction are discussed in this article.

Near-Infrared Imaging Using Intravenous Indocyanine Green at a Conventional Dose to Locate Pulmonary Metastases: A Pilot Study

Intravenous indocyanine green (ICG) has been reported to localize intra-abdominal metastatic lesions in several clinical trials. Our pilot study aimed to investigate the feasibility and safety of ICG fluorescence localization in pulmonary metastasectomy using a near-infrared fluorescence thoracoscope. Each patient received intravenous 0.25 or 0.5 mg/kg of ICG. The maximum diameter of the tumor on computed tomography ranged from 0.5 to 3.5 (median: 1.15) cm. Intravenous ICG injection localized pulmonary metastases in a portion (3 patients) of the enrolled patients. Our preliminary results provided us with important information to modify the study protocol.

Ex Vivo Sleeve Lobectomy and Autotransplantation After Chemoradiation

A 51-year-old man presented to us for potential salvage surgery for local recurrence of a squamous cell carcinoma originating in the left lower lobe after definitive chemoradiotherapy. Salvage sleeve lower lobectomy was initially planned; however, intraoperatively the interlobar pulmonary artery was difficult to separate from the bronchus. To safely spare the upper lobe, we performed ex vivo sleeve lower lobectomy, followed by autotransplantation of the upper lobe. No major postoperative complication was noted and the patient has returned to normal life without recurrence for 9 months.

Thoracoscopic rebiopsy to detect the T790M mutation after postoperative recurrence

After pulmonary resection for non-small-cell lung cancer, some patients with postoperative recurrence and mutated epidermal growth factor receptor (EGFR) subsequently receive EGFR-tyrosine kinase inhibitors (EGFR-TKIs). Osimertinib may be efficacious if those patients become resistant to the 1st-line EGFR-TKI because of the T790M mutation. We recently performed thoracoscopic rebiopsy to detect the T790M mutation in 4 patients who became resistant to the 1st-line EGFR-TKI treatment for postoperative recurrence. Our limited experience suggests that thoracoscopic biopsy is associated with limited morbidity, can help detect the T790M mutation and may improve the management of select patients with acquired resistance to the 1st-line EGFR-TKIs.

Prognostic impact of preoperative comorbidities in geriatric patients with early-stage lung cancer: Significance of sublobar resection as a compromise procedure

OBJECTIVES

In high-risk operable geriatric patients undergoing palliative sublobar resection (SR), noncancerous comorbidities may contribute to unfavorable outcomes. The purpose of this retrospective study was to evaluate the perioperative safety and long-term survival of palliative SR in this patient population.

MATERIALS AND METHODS

We reviewed 232 patients (141 male, 91 female) aged ≥75 years who underwent surgical resection of clinical stage I lung cancer from 2006 to 2014. The patients were divided into two groups, lobectomy and SR, and preoperative comprehensive comorbidities were assessed using the Adult Comorbidity Evaluation 27 (ACE-27) and compared between the two groups. The operative safety was compared using the Clavien-Dindo classification. Survival rates were calculated with a Kaplan-Meier model under propensity score matching, and prognostic factors were analyzed using a Cox proportional hazard model.

RESULTS

Lobectomy was performed in 156 patients and SR in 76 (segmentectomy, n = 50; wedge resection, n = 26). Age (p = 0.0137), tumor size on computed tomography (p < 0.0001), central tumor location (p = 0.0008), and high ACE-27 scores (p = 0.0202) were significantly associated with selection of SR. No mortality occurred, and the incidence of Grade 3b or greater postoperative complications in lobectomy and SR was 5.1% and 5.3%, respectively. According to the analysis of propensity score-matched patients (n = 57, tumor size = 23 mm, and consolidation/tumor ratio = 83%), the 5-year survival rate in lobectomy and SR was 81.1% and 73.5%, respectively (p = 0.4374). The ACE-27 score was a more significant prognostic factor than the type of surgical procedure, as well as consolidation/tumor ratio and nodal metastatic status.

CONCLUSIONS

The severity of preoperative comorbidities is a significant prognostic factor, and SR as a compromise surgical procedure may provide promising short- and long-term outcomes in selected geriatric patients with clinical stage I lung cancer.

Native upper lobe-sparing living-donor lobar lung transplantation maximizes respiratory function of the donor graft

BACKGROUND

We have developed a novel method for native upper lobe-sparing living-donor lobar lung transplantation (LDLLT) to overcome a small-for-size graft in standard LDLLT with acceptable results. We hypothesized that grafts implanted with this procedure might work more efficiently than those in standard lobe transplantation.

METHODS

Bilateral LDLLT was performed in 31 patients with a functional graft matching of less than 60% at our institution between August 2008 and December 2015. Of these, 22 patients were available for evaluation of pulmonary function more than 1 year later: 15 undergoing standard LDLLT with less than 60% functional matching and 7 undergoing native upper lobe-sparing LDLLT.

RESULTS

Overall survival at 2 years was 87.5% in the lobe-sparing LDLLT patients and 79.0% in the standard LDLLT patients (p = 0.401). The median forced vital capacity size-matching levels were 50.7% ± 1.6% in the standard LDLLT and 45.2% ± 2.3% in the sparing LDLLT group (p = 0.074). The 1-year and 2-year post-operative volume ratios of inspiration to expiration were significantly different between the 2 groups, at 1.76 and 1.45 after standard LDLLT (p = 0.019) vs 2.41 and 2.23 after lobe-sparing LDLLT (p = 0.015).

CONCLUSIONS

The grafts in lobe-sparing LDLLT functioned more effectively than those in standard LDLLT. This advantage was associated with the improvement of pulmonary functions.

Living-donor lung transplantation after surgical repair of transposition of the great arteries

Pediatric pulmonary hypertension after surgery for congenital heart disease is a significant complication. We present a case of living-donor lung transplantation for a 12-year-old girl with pulmonary hypertension after surgical repair of transposition of great arteries. Despite repairing the transposition of great arteries, her growth was severely restricted because of progressive pulmonary hypertension; thus, lung transplantation was discussed. Standard bilateral lobar transplantation seemed unfeasible due to oversized grafts, so we performed a single lobar transplantation. Unexpectedly, she developed complications and died 3 months postoperatively despite another emergent lobar transplantation. We discussed the challenges and potential solutions regarding lobar size mismatching.

Thoracoscopic Resection of Fluorodeoxyglucose-Avid Mediastinal Lymph Nodes Associated with Advanced Ovarian Carcinoma

The indication for surgery is controversial in patients with advanced ovarian cancer and fluorodeoxyglucose (FDG)-avid mediastinal lymph nodes. Herein we report our experience in thoracoscopic resection of FDG-avid mediastinal lymph nodes associated with advanced ovarian cancer in six patients. No perioperative or long-term mortality was noted. FDG-avid mediastinal lymph nodes in advanced ovarian carcinoma may merit thoracoscopic resection with histological confirmation for more precise staging.

Thoracoscopic rebiopsy for T790M detection after postoperative recurrence

After pulmonary resection for non-small-cell lung cancer, some patients with postoperative recurrence and mutated epidermal growth factor receptor (EGFR) subsequently receive EGFR-tyrosine kinase inhibitors (EGFR-TKIs). Osimertinib may be efficacious if these patients become resistant to the 1st-line EGFR-TKI because of the T790M mutation.  We recently performed thoracoscopic rebiopsy to detect the T790M mutation in 4 patients who became resistant to the 1st-line EGFR-TKI treatment for postoperative recurrence. Our limited experience suggests that thoracoscopic biopsy is associated with limited morbidity, can help detect the T790M mutation, and may improve the management of selected patients with acquired resistance to the 1st-line EGFR-TKIs.

Abstract 2041: Suppression of mutant p53-induced EMT by statins have double-edged effects on the patients with lung adenocarcinoma according to p53 mutation status

Background: Epithelial-mesenchymal transition (EMT) is known to be pivotal for driving metastasis and recurrence in lung cancer. Some reports have shown statins suppressed EMT by inactivating mutant p53 functions in vitro. Although several clinical trials regarding conventional treatments with statins have been performed, the effect of statins on the prognosis is still controversial. The purpose of the present study is to clarify the impact of statins on EMT and the prognosis of patients with lung adenocarcinoma.

Methods: First, we transfected wild-type p53 or mutant p53 (R175H, R273H) to H1650 lung adenocarcinoma cells and administrated simvastatin. We evaluated morphologic changes by microscopic examination and analyzed EMT markers (E-cadherin, vimentin) through Western blotting of whole cell lysate. We also analyzed their invasive ability by Matrigel invasion assay. Second, a total of 282 lung adenocarcinoma specimens were collected from patients who underwent surgery in our institute from January 2001 to December 2007. We analyzed EMT markers through immunostaining of tumor specimens and we determined p53 mutation by direct sequencing. The association between EMT, p53 mutation status, and statin use as well as the patients' clinical information was statistically analyzed after propensity score matching. Correlations were analyzed using Pearson's chi-square test and overall survival was compared using the log-rank test.

Results: Mutant p53 (R175H, R273H) induction to H1650 cells showed EMT-like morphologic changes. E-cadherin expression was decreased and vimentin expression was increased in H1650 harboring mutant p53 (H1650mut.p53). Additionally, H1650mut.p53 obtained more aggressive invasiveness compared to H1650 expressing wild-type p53 (H1650wt.p53). Simvastatin-treated H1650mut.p53 lost EMT character and aggressive invasiveness; on the other hand, simvastatin exacerbated invasive abilities of H1650wt.p53. Approximately 20% of the patients were prescribed statins as a treatment of hyperlipidemia or coronary artery disease. Statin administration was correlated to less EMT only in the patients with mutant p53, which was consistent with the results of our in vitro experiments. Moreover, the statin-administrated group showed significantly better survival compared to the non-statin group, which was observed only in the patients with mutant p53. On the other hand, statins significantly impaired the prognosis of patients with wild-type p53, especially in EGFR mutants.

Conclusion: Statins suppressed EMT and improved the prognosis of patients with lung adenocarcinoma in a p53 mutation-dependent manner, whereas they impaired the prognosis of patients with wild-type p53 harboring EGFR mutations.

Citation Format: Shigeto Nishikawa, Toshi Menju, Terumasa Sowa, Koji Takahashi, Ryo Miyata, Hiroyuki Ishikawa, Daisuke Nakajima, Masatsugu Hamaji, Hideki Motoyama, Akihiro Aoyama, Toshihiko Sato, Fengshi Chen-Yoshikawa, Makoto Sonobe, Hiroshi Date. Suppression of mutant p53-induced EMT by statins have double-edged effects on the patients with lung adenocarcinoma according to p53 mutation status [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2041.

Diagnostic yield of electromagnetic navigational bronchoscopy: results of initial 35 cases in a Japanese institute

Background

Electromagnetic navigational bronchoscopy (ENB) is a new bronchoscopic technique for navigational transbronchial lung biopsy (TBLB) that guides the sheath to the target lesion in real time. Herein, we report our experience with this navigational system, its diagnostic yields, and associated complications.

Methods

A single-center, single-operator retrospective chart review was performed. We included 35 consecutive patients who underwent ENB with superDimension^TM (Medtronic, MN, USA) for the diagnosis of pulmonary lesions from February 2016 to May 2017 in Kyoto University Hospital. The size of the target lesion varied from 8 to 25 mm (median, 15.28±5.48 mm). All ENB procedures were performed under conscious sedation using 2 to 10 mg midazolam and 1 to 10 mg morphine hydrochloride. No fluoroscopic guide was employed except in three cases.

Results

A total of 25 patients were diagnosed via ENB, yielding a diagnostic rate of 71.4% (25/35). The average lesion size of the diagnosed group was 16.44±5.44 mm (range, 8-25 mm). Eighteen cases were diagnosed as primary lung cancer, 3 were metastatic lung cancer, and 4 were inflammatory diseases. The average lesion size of the 10 undiagnosed cases was 12.40±5.21 mm (range, 8-24 mm). The lesion size of the undiagnosed group was significantly smaller than that of the diagnosed group (P=0.02). The average time required for the procedure was 16.78±9.57 minutes (range, 3-46 minutes), independent of the diagnosis, the lesion size, and the tumor location. We encountered one pneumothorax which required chest drainage and one hemopneumothorax which required non-elective thoracotomy and wedge resection. One patient developed high fever over 38 °C for one day following the procedure.

Conclusions

In our initial series of 35 cases, ENB-guided TBLB showed an acceptable diagnostic yield.

Effect of early tracheostomy on clinical outcomes in critically ill lung transplant recipients

OBJECTIVES

The purpose of this study was to evaluate the effect of early tracheostomy in patients following lung transplantation and to determine its optimal timing and influence on clinical outcomes.

METHODS

We retrospectively reviewed records of 96 adult patients who underwent lung transplantation at our institution between August 2008 and January 2016. Time-to-tracheostomy was defined based on timing of the procedure: "early" if less than 3 days or "late" if 3 or more days after lung transplantation.

RESULTS

Forty-nine patients (51%) underwent tracheostomy 3.2 ± 1.8 days after lung transplantation. Among these patients, 21 patients (42.9%) underwent early tracheostomy and 28 patients (57.1%) underwent late tracheostomy. Multivariable logistic regression analysis indicated that preoperative performance status was a significant predictor for tracheostomy (p = 0.006, odds ratio 2.72). Patients in the early tracheostomy group began walking (p = 0.003) and oral feeding (p = 0.0006) earlier and had a shorter duration of mechanical ventilation (p = 0.04) and shorter length of intensive care unit (p = 0.01) and hospital stay (p = 0.04) than patients in the late tracheostomy group. No significant differences in postoperative walking (p = 0.06), oral feeding (p = 0.17), or length of hospital stay (p = 0.37) were observed between patients who underwent early tracheostomy and those who did not undergo tracheostomy.

CONCLUSIONS

Early tracheostomy following lung transplantation decreased both intensive care and hospital stay, due to improved postoperative recovery, even in patients with poor preoperative conditions. Furthermore, length of hospital stay in patients with early tracheostomy was similar to that of patients without tracheostomy after lung transplantation.

Gastrointestinal complications after lung transplantation in Japanese patients

PURPOSE

Gastrointestinal complications after lung transplantation (LTx) are an important postoperative morbidity associated with malnutrition and the malabsorption of drugs. We reviewed our experience of managing gastrointestinal complications after LTx.

METHODS

Between June, 2008 and April, 2017, 160 lung transplants were performed at our institution, as living-donor lobar lung transplants in 77 patients, and as deceased-donor lung transplants in 83. We reviewed, retrospectively, the incidence, type and management of gastrointestinal complications.

RESULTS

Among the 160 LTx recipients, 58 (36.3%) suffered a collective 70 gastrointestinal complications, the most frequent being gastroparesis, followed by gastroesophageal reflux disease. Two complications were managed surgically, by Nissen fundoplication for gastroesophageal reflux disease in one recipient and Hartmann's operation for sigmoid colon perforation in one. The other 68 complications were managed medically. Two patients died of complications: one, of aspiration pneumonia caused by gastroparesis; and one, of panperitonitis caused by a gastric ulcer. There were no significant differences in overall survival or chronic lung allograft dysfunction-free survival between the patients with and those without gastrointestinal complications.

CONCLUSIONS

Gastrointestinal complications are not uncommon in LTx recipients and may be serious; therefore, early detection and appropriate treatment are imperative. Surgical management is required for some complications, but most can be managed medically.