Results of surgical treatment of lung cancer involving the diaphragm

Management of Diaphragm Tumors

Diaphragm tumors are very rare, with secondary tumors being more common than primary tumors. The most common benign primary tumors include lipomas and cysts, and malignant primary tumors include rhabdomyosarcoma and leiomyosarcoma. Endometriosis is the most common benign secondary tumor, followed by malignant tumors with localized spread of disease. In addition, widely metastatic disease has been described. Benign lipomas and cysts can be managed conservatively, but more complex or concerning disease typically requires resection. The diaphragm can often be repaired primarily, though any large defect or tension would indicate the need for mesh or an autologous reconstruction.

Complete videothoracoscopic en-bloc resection of lung cancer invading the diaphragm

Locally advanced non-small cell lung cancer invading the diaphragm is an infrequent clinical presentation. A 74-year-old male patient was operated using video-assisted thoracoscopic surgery in our clinic for a tumor originating from the right lower lobe. A right lower lobectomy with diaphragmatic resection was performed to the tumor with a diameter of 3 cm that invaded the diaphragm, and the resulting defect was repaired primarily with video-assisted thoracoscopic surgery. The patient did not develop complications in the postoperative period and was discharged on Day 6. In conclusion, patients with non-small cell lung cancer invasive to the diaphragm can be even safely operated with the video-assisted thoracoscopic surgery.

Oncologic Outcomes of Patients With Resected T3N0M0 Non-small Cell Lung Cancer

In the eighth edition TNM staging, the T3N0M0 category represents a heterogeneous group of non-small cell lung cancers (NSCLC). This study aims to compare the oncologic outcomes associated with individual T3 features. We performed a single-institution, retrospective analysis of 280 consecutive patients with pT3N0M0 NSCLC. Multivariate regression models were used to estimate associations of clinical factors with oncologic outcomes. The patients were grouped according to their T3 features into 4 prognostic groups: chest wall infiltration (CWI-PG), largest diameter >5 cm and ≤7 cm (Size-PG), presence of a satellite nodule (SN-PG), and all other T3 features. Overall survival (OS) and progression-free survival (PFS) were estimated using Kaplan-Meier and Cox proportional hazard analyses. Tumors were most often classified as T3N0M0 by size (156 patients, 55.7%), and the highest rate of incomplete resection occurred in patients with CWI (n = 7, 25.9%). In multivariate analysis, CWI (hazard ratio [HR] 2.45, 95% confidence interval [CI] 1.36, 4.44), incomplete resection (HR 3.01, 95% CI 1.29, 7.05), and age >65 (HR 1.6; 95% CI 1.08, 2.38) were independently associated with worse OS, and female sex was associated with better OS (HR 0.6, 95% CI 0.42, 0.87). The CWI-PG had poorer OS when compared with each of the other prognostic groups (P < 0.05), and the Size-PG had inferior OS when compared with the SN-PG (P = 0.039). This single-center study demonstrated significant differences in OS and PFS between patients with different T3 classifying features and suggest that further subdivision of the T3 category should be considered.

Long-term outcome after en bloc resection and reconstruction of the spinal column and posterior chest wall in the treatment of malignant tumors

BACKGROUND

Malignant tumors occurring around both the spinal column and posterior chest wall are uncommon. Surgical resection of chest wall tumors adjacent to the spinal column is still challenging due to the surrounding anatomical structures. The purpose of the present study was to evaluate the long-term outcomes of surgical management in malignant tumors involving the spinal column and posterior chest wall.

METHODS

Between 1999 and 2007, 10 consecutive patients underwent en bloc resection combined with the posterior chest wall in the treatment of malignant tumors around the spinal column. There were 6 males and 4 females with a mean age at the surgery of 40.9 years old (range, 14-62 years old). The mean postoperative follow-up period was 159.7 months (range, 84-245 months). The clinical history, physical examination, laboratory data, radiological findings, and operative findings for each patient were retrospectively reviewed.

RESULTS

All surgeries were performed via a combined anterior and posterior approach. The mean numbers of partially resected vertebrae and ribs were 3.1 and 4.1, respectively. Lower or upper lobectomy was performed in four patients, and the diaphragm was partially resected in two patients. The surgical margin was wide in seven patients and marginal in two patients. Although five patients had postoperative respiratory problem, all patients improved immediately without life-threatening complications. There were no patients with respiratory insufficiency after surgery. One patient with osteosarcoma died of lung metastases 99 months after surgery. At the final follow-up, only one patient had local recurrence, five had been continuously disease-free, and three were alive with no evidence of disease.

CONCLUSIONS

En bloc resection and reconstruction in selected patients with malignant tumors involving both the spinal column and posterior chest wall demonstrated good long-term results for local control and the respiratory function.

Diaphragm reconstruction combined with thoraco-abdominal wall reconstruction after tumor resection

BACKGROUND

Thoraco-abdominal wall resection including diaphragm resection results in a challenging surgical defect. Various methods have been used for diaphragm reconstruction. The aim of this study was to describe our methods of diaphragm and thoraco-abdominal wall reconstruction after combined resection of these anatomical structures.

METHODS

Twenty-one patients underwent diaphragm resection at our institution between 1997 and 2015. We used a mesh or direct closure for diaphragm defect and a mesh for chest wall stabilization. A pedicled or free flap for soft tissue coverage was used when direct closure was not possible.

RESULTS

Indications for resection were primary sarcoma (n = 14), cancer metastasis (n = 4), desmoid tumor (n = 2), and solitary fibrous tumor (n = 1). The median patient age was 58.9 years. The diaphragm was pulled to its original position and sutured directly (n = 15) or reconstructed with mesh (n = 6). Chest wall reconstructions were performed with a mesh (n = 14), mesh and a pedicled flap (n = 4), mesh and a free flap (n = 3). No perioperative mortality occurred. One-year and 5-year survival rates were 85.7 and 65.9%, respectively, while overall recurrence-free rates were 80.4 and 60.8%, respectively.

CONCLUSIONS

We have described our surgical methods for the resection of tumors of the chest or abdominal wall, including our method of distal diaphragm resection with wide or clear surgical margins. The method is safe and the reconstructions provided adequate stability, as well as water-tight and air-tight closure of the chest cavity. There were no cases of paradoxical movement of the chest or of diaphragm or thoraco-abdominal hernia.

Prognostic Differences in Subgroups of Patients With Surgically Resected T3 Non-Small Cell Lung Cancer

BACKGROUND

This study determined the characteristics and prognosis of each descriptor of T3 non-small cell lung cancer (NSCLC).

METHODS

A total of 3,241 patients underwent an operation for NSCLC between 2001 and 2013, and this study included 461 patients who received complete anatomic resection of T3 NSCLC. The T3 descriptors were coded as follows: tumor invading main bronchus within 2 cm of the carina (T3-cent), tumor invading beyond visceral pleura (T3-inv), tumor larger than 7 cm (T3-size), separate tumor nodules (T3-sep), or tumor with combined T3 descriptors (T3-comb).

RESULTS

The T3 distribution was as follows: T3-cent, 75 patients (16.3%); T3-inv, 157 patients (34.1%); T3-size, 132 patients (28.6%); T3-sep, 34 patients (7.4%); and T3-comb, 63 patients (13.7%). Subgroup analyses revealed a significant survival benefit in the T3-cent group compared with the other groups (all p < 0.05). The 5-year disease-free survival (DFS) values were 55.4%, 36.7%, 40.9%, 30.3%, and 32.0% in the T3-cent, T3-inv, T3-size, T3-sep, and T3-comb subgroups, respectively. Multivariable analyses revealed that age (p = 0.019), N status (p = 0.001), adjuvant chemotherapy (p < 0.001), and T3 descriptors (T3-cent versus others, p < 0.001) were the most important independent prognostic factors for DFS. Additional analyses were performed to evaluate prognostic factors for DFS in the T3-cent group. Multivariable analysis revealed that bronchoplastic procedures (p = 0.004) was an independent prognostic factor for DFS.

CONCLUSIONS

Survival for centrally located T3 NSCLC is better than other types of T3 NSCLC. Lung-preserving operations such as bronchoplastic procedures might result in improved survival of these patients.

Evaluation of a tuberculous abscess on the right side of the diaphragm with contrast-enhanced computed tomography: A case report

We herein investigate the case of a patient with a tuberculous diaphragmatic abscess confirmed by pathology. The patient underwent plain computed tomography (CT) examination of the chest and contrast-enhanced abdominal CT examination. The abscess appeared as hypodense mass with thick and irregular wall, which was enhanced on the contrast-enhanced CT images. The shape of the mass resembled an irregular double convex lens. No enlarged lymph nodes were detected on the CT images. The presence of a tuberculous diaphragmatic abscess should be suspected in patients with a diaphragmatic hypodense mass with enhanced thick walls, even when there is absence of enlarged lymph nodes on the CT images.

The IASLC Lung Cancer Staging Project: Proposals for the Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer

INTRODUCTION

An international database was collected to inform the 8 edition of the anatomic classification of lung cancer. The present analyses concern its primary tumor (T) component.

METHODS

From 1999 to 2010, 77,156 evaluable patients, 70,967 with non-small-cell lung cancer, were collected; and 33,115 had either a clinical or a pathological classification, known tumor size, sufficient T information, and no metastases. Survival was measured from date of diagnosis or surgery for clinically and pathologically staged tumors. Tumor-size cutpoints were evaluated by the running log-rank statistics. T descriptors were evaluated in a multivariate Cox regression analysis adjusted for age, gender, histological type, and geographic region.

RESULTS

The 3-cm cutpoint significantly separates T1 from T2. From 1 to 5 cm, each centimeter separates tumors of significantly different prognosis. Prognosis of tumors greater than 5 cm but less than or equal to 7 cm is equivalent to T3, and that of those greater than 7 cm to T4. Bronchial involvement less than 2 cm from carina, but without involving it, and total atelectasis/pneumonitis have a T2 prognosis. Involvement of the diaphragm has a T4 prognosis. Invasion of the mediastinal pleura is a descriptor seldom used.

CONCLUSIONS

Recommended changes are as follows: to subclassify T1 into T1a (≤1 cm), T1b (>1 to ≤2 cm), and T1c (>2 to ≤3 cm); to subclassify T2 into T2a (>3 to ≤4 cm) and T2b (>4 to ≤5 cm); to reclassify tumors greater than 5 to less than or equal to 7 cm as T3; to reclassify tumors greater than 7 cm as T4; to group involvement of main bronchus as T2 regardless of distance from carina; to group partial and total atelectasis/pneumonitis as T2; to reclassify diaphragm invasion as T4; and to delete mediastinal pleura invasion as a T descriptor.

Recent evidence, advances, and current practices in surgical treatment of lung cancer

In the last 10-15 years, strategies and modalities of lung cancer treatment have changed dramatically. Meanwhile, the treatment objectives, the lung cancers themselves, have also changed, probably owing to early detection by computed tomography and aging of the population. In particular, the proportions of smaller lung cancers, lung adenocarcinomas with ground-glass opacity, and lung cancers in older patients are increasing. Along with these changes, surgeons have innovated and evaluated novel procedures for pulmonary resection. These include the application of minimally invasive surgical techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic surgery, and sub-lobar resection, such as wedge resection and segmentectomy, for small peripheral lung cancers. Currently, VATS has gained wide acceptance and several institutions in Japan have started using robotic surgery for lung cancers. Two important clinical trials of sub-lobar resection for small peripheral lung cancers are now underway in Japan. In addition, surgery itself is of growing importance in lung cancer treatment. In particular, recent evidence supports the use of surgery in strictly selected patients with locally advanced disease, lung cancers with N2 lymph node metastases, small cell lung cancers, recurrent oligo-metastasis after pulmonary resection, or relapsed tumors after drug treatment. Surgical treatment also provides abundant tumor samples for molecular analysis, which can be used for drug selection in the adjuvant setting or after disease relapse. In the era of personalized treatment, surgery is still one of the most important treatment modalities to combat lung cancer.

Lung cancer surgery: an up to date

According to the International Agency for Research on Cancer (IARC) GLOBOCAN World Cancer Report, lung cancer affects more than 1 million people a year worldwide. In Greece according to the 2008 GLOBOCAN report, there were 6,667 cases recorded, 18% of the total incidence of all cancers in the population. Furthermore, there were 6,402 deaths due to lung cancer, 23.5% of all deaths due to cancer. Therefore, in our country, lung cancer is the most common and deadly form of cancer for the male population. The most important prognostic indicator in lung cancer is the extent of disease. The Union Internationale Contre le Cancer (UICC) and the American Joint Committee for Cancer Staging (AJCC) developed the tumour, node, and metastases (TNM) staging system which attempts to define those patients who might be suitable for radical surgery or radical radiotherapy, from the majority, who will only be suitable for palliative measures. Surgery has an important part for the therapy of patients with lung cancer. "Lobectomy is the gold standard treatment". This statement may be challenged in cases of stage Ia cancer or in patients with limited pulmonary function. In these cases an anatomical segmentectomy with lymph node dissection is an acceptable alternative. Chest wall invasion is not a contraindication to resection. En-bloc rib resection and reconstruction is the treatment of choice. N2 disease represents both a spectrum of disease and the interface between surgical and non-surgical treatment of lung cancer Evidence from trials suggests that multizone or unresectable N2 disease should be treated primarily by chemoradiotherapy. There may be a role for surgery if N2 is downstaged to N0 and lobectomy is possible, but pneumonectomy is avoidable. Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. The efficacy of surgical intervention for SCLC is not clear. Lung cancer resection can be performed using several surgical techniques. Video-assisted thoracoscopic surgery (VATS) lobectomy is a safe, efficient, well accepted and widespread technique among thoracic surgeons. The 5-year survival rate following complete resection of lung cancer is stage dependent. Incomplete resection rarely is useful and cures the patient.

Anatomy and physiology of the thoracic lymphatic system

The thoracic lymphatic system is one of the most complex and poorly understood systems of the human body, and much is still to be learned, especially in lymphatic physiology. Knowledge of the normal anatomy of this system as well as of its variations is nevertheless important for thoracic surgeons investigating and treating patients with lung or esophageal neoplasms.

Tumors of the diaphragm

Primary tumors of the diaphragm are rare. The most common benign cystic lesions of the diaphragm are bronchogenic or mesothelial cysts, while the most common benign solid lesion is a lipoma. Benign tumors of the diaphragm are resected if they are symptomatic or if there is a doubt about the diagnosis. The most common primary malignant lesion is rhabdomyosarcoma. Malignant tumors are treated based on histology and often with chemotherapy and/or radiation along with surgical resection if feasible. Endometriosis, a benign process that metastasizes to the diaphragm, is typically treated medically; surgical ablation or resection is considered only after failed conservative treatment. Surgical resection of metastatic malignant tumors, such as ovarian cancer and thymoma, as well as malignancies affecting the diaphragm by direct extension, such as mesothelioma, lung, and esophageal cancer, may provide some survival advantage.

Radical nephrectomy with en bloc resection of liver, diaphragm, and lung for locally invasive sarcomatoid renal cell carcinoma

Despite the widespread use of abdominal imaging, some patients with renal cell carcinoma still present with advanced disease. We report 1 case of locally invasive sarcomatoid renal cell carcinoma requiring resection of the kidney, adrenal glands, liver, diaphragm, and lung, with diaphragmatic reconstruction with a polytetrafluoroethylene patch. The patient was alive and well 5 years postoperatively. However, we acknowledge that the success experienced with this case does not represent the typical outcome for a patient with such advanced disease.