Postrecurrence survival of surgically resected pulmonary adenocarcinoma patients according to EGFR and KRAS mutation status

The aim of this study was to investigate the prognosis of pulmonary adenocarcinoma patients following postoperative recurrence, according to epidermal growth factor receptor (EGFR) and Kirsten rat sarcoma 2 viral oncogene homolog (KRAS) gene mutation status and recurrence site. In total 58 adenocarcinoma patients with recurrence following surgical resection were retrospectively evaluated between 2002 and 2011. The patients were divided into groups according to the presence or absence of EGFR and KRAS mutations and the clinicopathological characteristics, recurrence sites and postrecurrence survival were compared. EGFR and KRAS mutations were detected in 26 (45%) and 11 patients (19%), respectively. Initial recurrence was distant in 25 (43%), local in 17 (29%) and both distant and local in 16 cases (28%). In EGFR-mutant (EGFR+) cases, bilateral/contralateral lung recurrence was a frequent finding. EGFR+ cases exhibited significantly better outcomes compared to KRAS+ and EGFR-KRAS- (wild-type) cases. The 2-year post-recurrence survival rates were 81, 18 and 47% in EGFR+, KRAS+ and wild-type cases, respectively. The patients with distant organ recurrence exhibited significantly worse survival compared with those without distant recurrence in wild-type, but not in the EGFR+ cases or the entire cohort. Multivariate analysis revealed that EGFR mutations and a number of recurrent lesions were the only statistically significant independent predictors of postrecurrence prognosis. Our results indicated distinct survival differences in recurrent adenocarcinoma patients according to driver mutations. Patients with EGFR-mutated tumors exhibited increased survival, regardless of recurrence at distant sites, whereas patients with KRAS-mutated adenocarcinoma exhibited poor outcome following postoperative recurrence. Therefore, the assessment of driver mutations is essential for predicting postrecurrence survival following surgical resection.

Profuse mediastinal hemorrhage due to mediastinitis after a sternal infection

A 79-year-old female patient was admitted because of profuse bleeding from a skin defect in the anterior chest due to a deep sternal wound infection. Eighteen years earlier, she had undergone irradiation to treat a sternal metastasis from breast cancer. Computed tomography (CT) showed the extravasation of iodinated contrast material from the ascending aorta. The patient underwent an immediate thoracotomy and recovered. This report presents a very rare case of massive bleeding from the thoracic aorta due to a mediastinal infection after irradiation for sternal metastasis from breast cancer.

[Lung metastasectomy for postoperative colorectal cancer in patients with a history of hepatic metastasis]

OBJECTIVES

Our objective was to evaluate the validity of pulmonary metastasectomy for postoperative colorectal cancer with hepatic metastasis and to investigate the role of clinicopathological factors as predictors of outcome.

METHODS

Consecutive patients undergoing pulmonary metastasectomy for colorectal cancer with (group PH, n=27) or without (group P, n=46) a history of hepatic metastasis were included in the study. Clinicopathological variables, including sex, age, site, serum carcinoembryonic antigen level of the primary tumor, disease-free interval, prior hepatic resection, timing of pulmonary metastases, preoperative chemotherapy, type of pulmonary resection, and number, size, and location of pulmonary metastases were retrospectively collected and investigated for prognostic significance.

RESULTS

The 5-year survivals were 59.5% (PH) and 70.0% (P) with no significant difference. Among all investigated prognostic variables, sex (female vs male) and the number of pulmonary metastases( 1 vs >1) were the most important factors affecting outcome after colorectal resection and pulmonary resection.

CONCLUSIONS

Pulmonary resection is not contraindicated in clinical practice. The presence of female gender and a single pulmonary metastasis were favorable predictors of survival after complete pulmonary resection for metastatic colorectal cancer.

A resectable pancreatic metastasis from pulmonary adenocarcinoma

A 67-year-old man, diagnosed as primary pulmonary adenocarcinoma by intraoperative fine-needle aspiration biopsy cytology, underwent right lower lobectomy with radical lymphadenectomy. The pathological stage was Stage IIA (pT1bN1M0, N-reason: 12L positive). After surgery, nodular shadows without intrathoracic lymph node or distant metastasis were demonstrated metachronously three times by follow-up CT. Wedge resection was performed for each of the tumors, and the pathological diagnosis in each case was primary pulmonary adenocarcinoma, Stage IA (T1b), IA (T1a) and IA (T1a), respectively. Five years after the initial pulmonary resection, a follow-up abdominal CT revealed a20-mm nodular shadow. We suspected that this pancreatic tumor might be a primary rather than metastatic one, therefore, pancreatoduodenectomy was performed. Pathological examination revealed adenocarcinoma that was positive for thyroid transcription factor (TTF)-1, allowing a final diagnosis of metastatic pulmonary adenocarcinoma.This case is very rare, because most cases of pancreatic metastasis from lung cancer have already widespread disease at the time of diagnosis.This case illustrates that pancreatic metastasis from pulmonary adenocarcinoma should be borne in mind, even if the pancreatic tumor is a solitary lesion without additional organ metastasis.

Roentgenological occult large-cell neuroendocrine carcinoma: Report of a long-term survivor

A 64-year-old male patient complained of a one-month history of bloody sputum. A polypoid tumor was almost obstructing the orifice of the subsegmental bronchus (B8b) of the anterior basal segment of the right lower lobe on bronchoscopy. Biopsy specimens of the tumor surface yielded a diagnosis of undifferentiated carcinoma. Clinical staging was T1aN0M0, stage IA. Surgical resection that comprised a right upper lobectomy with systematic mediastinal and hilar lymph node dissection was performed. Histopathologically, the tumor specimen was compatible with large-cell neuroendocrine carcinoma (LCNEC) of the subsegmental bronchus. Pathological staging was T1aN0M0, stage IA. To our knowledge, few cases of central-type LCNEC have been reported in the English literature, and ours is the first report of roentgenological occult LCNEC.

Diagnosis and surgical resection of solitary pulmonary nodules in patients with breast cancer

The differential diagnosis of solitary pulmonary nodules (SPNs) using radiological features in patients with breast cancer is vital yet difficult. The nature of SPNs, of these patients, as well as the role of surgery in the diagnosis and treatment were evaluated. Thirty consecutive patients, who underwent surgery for an SPN between 2002 and 2011 subsequent to curative surgery for breast cancer were retrospectively evaluated. The overall survival and disease-free survival periods were estimated using the Kaplan-Meier method. The Student's t-test and the χ² test were performed to compare percentages and the mean values, respectively. The values were considered statistically significant at P<0.05. Most (93%) SPNs were malignant. The pathological diagnoses in patients with SPNs were primary lung cancer (n=20, 67%), pulmonary metastasis from breast (n=7, 23%) or colon (n=1, 3%) cancers and benign conditions (n=2, 7%). Of the 20 patients with primary lung cancer, 15 (75%) had stage IA tumors (T1aN0M0). The average disease-free interval was significantly longer in patients with primary lung cancer compared to patients with pulmonary metastases from breast cancer (P= 0.031). The five-year survival rates after pulmonary resection for lung metastasis from breast cancer patients and primary lung cancer patients were 100 and 61.1%, respectively. SPNs found in patients with breast cancer were found to have a high probability of malignancy, especially primary lung adenocarcinoma. The early resection of SPNs in patients diagnosed with both primary and metastatic lung cancer led to a good prognosis. The early pathological diagnosis by surgical resection was suggested to be conducted for the early diagnosis and appropriate treatment of SPNs in patients with breast cancer.

Establishment of a human lung cancer cell line with high metastatic potential to multiple organs: gene expression associated with metastatic potential in human lung cancer

Convenient and reliable multiple organ metastasis model systems might contribute to understanding the mechanism(s) of metastasis of lung cancer, which may lead to overcoming metastasis and improvement in the treatment outcome of lung cancer. We isolated a highly metastatic subline, PC14HM, from the human pulmonary adenocarcinoma cell line, PC14, using an in vivo selection method. The expression of 34,580 genes was compared between PC14HM and parental PC14 by cDNA microarray analysis. Among the differentially expressed genes, expression of four genes in human lung cancer tissues and adjacent normal lung tissues were compared using real-time reverse transcription polymerase chain reaction. Although BALB/c nude mice inoculated with parental PC14 cells had few metastases, almost all mice inoculated with PC14HM cells developed metastases in multiple organs, including the lung, bone and adrenal gland, the same progression seen in human lung cancer. cDNA microarray analysis revealed that 981 genes were differentially (more than 3-fold) expressed between the two cell lines. Functional classification revealed that many of those genes were associated with cell growth, cell communication, development and transcription. Expression of three upregulated genes (HRB-2, HS3ST3A1 and RAB7) was higher in human cancer tissue compared to normal lung tissue, while expression of EDG1, which was downregulated, was lower in the cancer tissue compared to the normal lung. These results suggest that the newly established PC14HM cell line may provide a mouse model of widespread metastasis of lung cancer. This model system may provide insights into the key genetic determinants of widespread metastasis of lung cancer.

A new application of a wound retractor for chest wall surgery

Use of a wound retraction (WR) is useful for lung resection by video-assisted thoracic surgery via a mini-thoracotomy. We have employed a WR for chest wall surgery involving surgical rib fixation in a patient with rib fractures, and obtained successful results in terms of a good surgical view and lack of postoperative wound infection. On the basis of our experience, we consider that a WR is useful even for chest wall surgery.

Segmentectomy guided by three-dimensional computed tomography angiography and bronchography

We describe the benefits of a three-dimensional multidetector computed tomography angiography and the bronchography-guided segmentectomy technique. Preoperative determination of the anatomical intersegmental plane is possible by visualizing the segmental branches of the pulmonary veins and segmental bronchi. This new technique may be useful in segmentectomy of the lung.

Unanticipated troubles in video-assisted thoracic surgery: a proposal for the classification of troubleshooting

INTRODUCTION

Most thoracic surgeons encounter atypical cases or unexpected situations that usually lead them to convert minimally invasive surgery to open thoracotomy. But are there other options besides open surgery? The purpose of this study was to suggest a video-assisted thoracic surgery (VATS) classification system and present tips for the application of VATS to atypical cases or unexpected situations. We have categorized VATS procedures for atypical cases or unexpected situations into two groups: the modification of techniques/instruments and the creation of additional access incisions.

METHODS

We retrospectively reviewed VATS with optional additional techniques. We used direct visualization or monitoring as the situation demanded, switching back and forth between the monitor and direct vision.

RESULTS

Of the 33 cases we reviewed, 27 patients had malignant lung disease and 6 had benign lung disease. All patients underwent lobectomies including one or more of the following: bronchoplasty (n = 12), control of the main pulmonary artery (n = 9), total adhesiotomy (n = 7), combined resection with the diaphragm (n = 3), and separation of totally fused fissures (n = 2). The mean length of the skin incision was 8 cm, the mean total operating time was 208 min, and the mean blood loss was 173 mL No operative or hospital deaths occurred.

CONCLUSIONS

Veteran surgeons can instinctively deal with intraoperative variance, but we frequently see inexperienced surgeons panic and change the course of their procedures. A VATS classification system may have educational benefits for newer surgeons. We believe that the creation of a categorized coping plan will help inexperienced surgeons deal with unanticipated problems.

A useful technique for specimen extraction from the thorax: the vacuum-packing method

Most thoracic surgeons have encountered a number of situations in which a specimen was too large to fit through a small intercostal incision. This report highlights a useful technique for specimen extraction from the thorax using a vinyl bag and a sucker. The sucker creates negative pressure, and the liquid and air components from the specimen are removed. The specimen can be deflated and removed from the thoracic cavity through the access incision. We call this method the 'vacuum-packing method'.

Rib fixation for severe chest deformity due to multiple rib fractures

The operative indications for rib fracture repair have been a matter of debate. However, several reports have suggested that flail chest, pain on respiration, and chest deformity/defect are potential conditions for rib fracture repair. We describe our experience of rib fixation in a patient with severe chest deformity due to multiple rib fractures. A 70-year-old woman was admitted with right-sided multiple rib fractures (2nd to 7th) and marked chest wall deformity without flailing caused by an automobile accident. Collapse of the chest wall was observed along the middle anterior axillary line. At 11 days after the injury, surgery was performed to repair the chest deformity, as it was considered to pose a risk of restrictive impairment of pulmonary function or chronic intercostal pain in the future. Operative findings revealed marked displacement of the superior 4 ribs, from the 2nd to the 5th, and collapse of the osseous chest wall towards the thoracic cavity. After exposure of the fracture regions, ribs fixations were performed using rib staplers. The total operation time was 90 minutes, and the collapsed portion of the chest wall along the middle anterior axillary line was reconstructed successfully.

An immunoglobulin G4-related disease mimicking postoperative lung cancer recurrence

A postoperative lung cancer patient presented with lymphadenopathy, pleural thickening, and 18F-fluorodeoxyglucose (FDG) uptake on a positron emission tomography-computed tomography (PET-CT) scan. Lung cancer recurrence was initially suspected, but bilateral submandibular masses with 18F-FDG uptake indicated the possibility of a systemic disease, such as Mikulicz's disease. High serum immunoglobulin G4 (IgG4) and IgG4-positive plasma cell infiltration in the submandibular glands led to the diagnosis of IgG4-related disease. After systemic steroid therapy, 18F-FDG uptake decreased in both the submandibular glands and the suspected recurrent lesions.

Effect of landiolol hydrochloride, an ultra-short-acting beta 1-selective blocker, on supraventricular tachycardia, atrial fibrillation and flutter after pulmonary resection

WHAT IS KNOWN AND OBJECTIVE

Supraventricular tachycardia is a common complication after pulmonary resection. The objective of this study was to investigate the efficacy of landiolol hydrochloride, an ultra-short-acting β1-blocker, in patients with post-operative supraventricular tachycardia after pulmonary resection.

METHODS

The response to continuous intravenous infusion of landiolol was evaluated in 25 patients who developed post-operative atrial fibrillation or atrial flutter after major pulmonary resection. Four patients had preoperative rate-controlled chronic atrial fibrillation. The heart rate and blood pressure were compared before and after infusion of landiolol. Side effects and recurrence of supraventricular tachycardia after termination of landiolol infusion were also monitored.

RESULTS AND DISCUSSION

The heart rate was reduced from 135±24 bpm before landiolol infusion to a plateau rate of 85±19 bpm during infusion (P<0·0001). Heart rate reduction occurred in all but two patients. Conversion to normal sinus rhythm from supraventricular tachycardia occurred in 14 patients (56%). Recurrence of supraventricular tachycardia after stopping landiolol infusion was observed in 17 patients (68%), but all patients without preoperative AF were cured of post-operative AF. There were no detectable side effects, including no adverse influence on the circulatory and respiratory systems.

WHAT IS NEW AND CONCLUSION

Continuous intravenous infusion of landiolol was found to be effective and safe for supraventricular tachycardia after pulmonary resection.

A tip for keeping the surgical sutures in order during bronchoplasty

We describe a device that we use to keep many surgical sutures in order during bronchoplasty. This device is torus-shaped with slits at regular intervals radially, which encircles the surgical field. We tuck the suture material into the slits in the suture runner. Traditionally, they are controlled by the use of many mosquito forceps. We believe that this device is useful, and that our method is simpler than the traditional method.