[Outcomes of Surgical Treatment for Chest Trauma]

BACKGROUND

Intra-thoracic organ bleeding and chest wall injury following chest trauma can easily lead to life-threatening emergencies and a delay in treatment may lead to fatal outcomes. Interestingly, the optimal timing, indications, and surgical techniques have not been standardized.

METHOD

We retrospectively analyzed 35 patients who underwent surgical treatment for chest trauma.

RESULTS

All patients with penetrating trauma (n=4) underwent emergency surgery for a hemothorax. There were no postoperative complications or hospital deaths. All patients with blunt trauma( n= 31) had multiple rib fractures;rib fixation was performed in 29 patients( 94%). Eight patients( 26%) had flail chest. The duration from injury to surgery averaged 7.5 days. The prognosis was generally favorable with no postoperative complications, but two patients died in the hospital due to multiple organ failure caused by high-energy trauma. Patients with flail chest or multiple organ injury had prolonged postoperative hospital stays.

CONCLUSIONS

Patients who sustain chest trauma follow various clinical courses. Appropriate timing of surgical intervention at an early stage after injury can be life saving and hasten a functional recovery.

Impact of partial pressure of arterial oxygen and radiologic findings on postoperative acute exacerbation of idiopathic interstitial pneumonia in patients with lung cancer

PURPOSE

To establish accurate diagnostic criteria and predictors of treatment response for postoperative acute exacerbation (AE) in patients with lung cancer and idiopathic interstitial pneumonia (IIP).

METHODS

Among 93 patients with IIP who underwent surgery for lung cancer, suspected postoperative AE developed in 20 (21.5%). Patients were divided into a progressive AE group, comprising patients with bilateral alveolar opacities and decreasing PaO2 ≥ 10 mmHg (n = 5); an incipient AE group, comprising patients with unilateral alveolar opacities and decreasing PaO2 ≥ 10 mmHg (n = 10); and an indeterminate AE group, comprising patients with alveolar opacities but decreasing PaO2 < 10 mmHg (n = 5).

RESULTS

The progressive AE group had significantly higher 90-day mortality (80%) than the incipient AE group (10%, P = 0.017) or the indeterminate AE group (0%, P = 0.048). Bilateral opacities may indicate advanced AE and poor prognosis, whereas unilateral opacities may indicate an early stage of AE and a good prognosis. PaO2 < 10 mmHg may indicate conditions other than AE.

CONCLUSIONS

In patients with lung cancer and IIP, decreasing PaO2 and HRCT findings may allow for the initiation of rapid and accurate treatment strategies for postoperative AE.

[Validity of Video-assisted Thoracic Surgery for Thymoma]

OBJECTIVES

This study aimed to identify the validity of video-assisted thoracic surgery (VATS) for thymoma, including myasthenia gravis( MG).

METHODS

A total of 20 patients who underwent VATS for thymoma at our institution between 2011 and 2019 were included in the study. Preoperative complications and prognosis were analyzed to detect the safety and efficiency of VATS thymectomy. MG improvement after VATS extended thymectomy was evaluated using a quantitative myasthenia gravis score( QMGS) and Myasthenia Gravis Foundation of America post-intervention status( MGFA-PIS).

RESULTS

The median tumor size was 2.6 cm (range, 1.0-8.0 cm). All thymomas were classified as TNM stageⅠ. Two patients had type A thymoma, five had type AB, six had type B1, six had type B2, and one had type B3. Postoperative complications were only observed in one patient with pneumonia. The median follow-up period was 5.1 years;no recurrence and disease-related deaths were observed. However, three patients died of other diseases. In patients with MG, postoperative crisis was not observed, and the symptoms improved in all the patients as evaluated by QMGS and MGFA-PIS.

CONCLUSIONS

VATS thymectomy and VATS extended thymectomy for patients with thymoma may be effective methods to improve not only prognosis but also MG, provided the range of resections are comparable to that of conventional open surgery.

Guidelines for Handling of Cytological Specimens in Cancer Genomic Medicine

Rapid advances are being made in cancer drug therapy. Since molecularly targeted therapy has been introduced, personalized medicine is being practiced, pathological tissue from malignant tumors obtained during routine practice is frequently used for genomic testing. Whereas cytological specimens fixed mainly in alcohol are considered to be more advantageous in terms of preservation of the nucleic acid quality and quantity. This article is aimed to share the information for the proper handling of cytological specimens in practice for genomic medicine based on the findings established in "Guidelines for Handling of Cytological Specimens in Cancer Genomic Medicine (in Japanese)" published by the Japanese Society of Clinical Cytology in 2021. The three-part practical guidelines are based on empirical data analyses; Part 1 describes general remarks on the use of cytological specimens in cancer genomic medicine, then Part 2 describes proper handling of cytological specimens, and Part 3 describes the empirical data related to handling of cytological specimens. The guidelines indicated proper handling of specimens in each fixation, preparation, and evaluation.

[Surgical Technique and Prognosis of Limited Resection in High-risk Patients with Primary Lung Cancer]

OBJECTIVES

To identify adaptations of limited resection for poor-risk patients with primary lung cancer and the efficacy of ensuring an adequate surgical margin.

METHODS

A total of 139 poor-risk patients who underwent limited resection for their primary lung cancer in our institution between 2005 and 2020 were included. The efficacy of ensuring a surgical margin was determined by analyzing the rate of recurrence, and the prognosis was analyzed via the Kaplan-Meier method.

RESULTS

Wedge resection was performed for 105 patients, and segmentectomy was performed for 34 patients. Recurrence was observed in 29 (20.8%) patients, while stump recurrence was observed in only 4( 3.8%) patients with wedge resection. The median surgical margin was 15 mm, which was equal to the median tumor size, and all histopathological margins were negative. An analysis of the 68 patients excluding those with multiple lung cancer showed that the pathological stage was not related to the prognosis. Surgical death and severe complications were not observed, and only 3 patients died of lung cancer during the observational period of 3.4 years.

CONCLUSIONS

Limited resection improves the patient's prognosis and ensures an adequate surgical margin to control recurrence.

Impact of accurate diagnosis of interstitial lung diseases on postoperative outcomes in lung cancer

OBJECTIVE

The prognostic impact of interstitial lung disease (ILD) subclassification based on both high-resolution computed tomography (HRCT) scan findings and histopathological findings is unknown.

METHODS

We retrospectively analyzed 104 patients who were diagnosed with clinical ILD according to HRCT scan findings and who underwent lung cancer surgery. Via an expert multidisciplinary discussion, we re-classified HRCT scan findings and validated the histopathological patterns of ILDs in lung specimens.

RESULTS

There were several mismatches between HRCT scan findings and histological patterns. Moreover, 87 (83.7%) and 6 (5.8%) patients were diagnosed with definitive ILD and pathological non-ILD, respectively. Finally, 82 patients with idiopathic interstitial pneumonias (IIPs) were divided into the idiopathic pulmonary fibrosis (IPF) (n = 61) group and the other group (n = 21). The 5-year overall survival rate of the IPF group was significantly lower than that of the other group (22.8% vs 67.9%; p = 0.011). Sub-classification of IIPs was found to be an independent prognostic factor for overall survival in patients with lung cancer.

CONCLUSION

An accurate diagnosis of IIPs/IPF according to both HRCT scan findings and histological patterns is important for providing an appropriate treatment among patients with lung cancer who presented with clinical ILD.

[Chest Wall Injury]

A traumatic chest wall injury is a condition that is often encountered in medical practice, but the underlying pathophysiology varies widely depending on the circumstances of the injury and the patient's background. The chest wall, which protects vital organs and provides respiratory movement, can be a life-threatening emergency when injured, thus it is important to respond promptly and appropriately. Because a penetrating chest wall trauma is often associated with intra-thoracic organ damage, it is important to consider an emergency thoracotomy in cases involving massive hemorrhage or air leakage. The ribs and sternum are primarily injured in patients with blunt wall trauma. Flail chest, which is defined as multiple bifocal fractures of the ribs or multiple rib fractures with a sternal fracture, causes respiratory failure secondary to paradoxical respiration. The main treatment for flail chest is ventilatory care and surgical treatment, although early rib fixation has been reported to improve prognosis in recent years. There are several types of devices to fix the ribs and sternum, but selection criteria have yet to be established.

Necessity of Multi-Step Surgical Treatment for Patients with Interstitial Lung Disease and a Pneumothorax

Purpose: A pneumothorax occurs in 3%–8% of patients with idiopathic pulmonary fibrosis. A pneumothorax may predict a poor outcome in patients with interstitial lung disease (ILD), and it is difficult to treat patients with ILD and a pneumothorax.

Patients and Methods: We retrospectively studied data from all 12 patients with ILD and a pneumothorax who underwent surgical treatment at Toho University Omori Medical Center Hospital between 2009 and 2021.

Results: Of the 12 patients, 2 had home oxygen therapy preoperatively and were classified with grade IV interstitial pneumonia (IP). Six patients had preoperative pleurodesis and two had postoperative one using auto-blood. Three patients (25%) had multi-step surgery ≥2, and 5 patients had surgical resection of bullae. No patients had postoperative acute exacerbations and all were discharged from the hospital in a stable condition. The 5-year overall survival rate for all patients was 70.0%. The median survival time was not reached. One patient with unclassified IP was doing well 116 months after surgery.

Conclusion: Patients with ILD and a pneumothorax were shown to require multi-step surgical treatment and can anticipate long-term survival.

Machine learning-based gene alteration prediction model for primary lung cancer using cytologic images

BACKGROUND

Understanding the gene alteration status of primary lung cancers is important for determining treatment strategies, but gene testing is both time-consuming and costly, limiting its application in clinical practice. Here, potential therapeutic targets were selected by predicting gene alterations in cytologic specimens before conventional gene testing.

METHODS

This was a retrospective study to develop a cytologic image-based gene alteration prediction model for primary lung cancer. Photomicroscopic images of cytology samples were collected and image patches were generated for analyses. Cancer-positive (n = 106) and cancer-negative (n = 32) samples were used to develop a neural network model for selecting cancer-positive images. Cancer-positive cases were randomly assigned to training (n = 77) and validation (n = 26) data sets. Another neural network model was developed to classify cancer images of the training data set into 4 groups: anaplastic lymphoma kinase (ALK)-fusion, epidermal growth factor receptor (EGFR), or Kirsten rat sarcoma viral oncogene homologue (KRAS) mutated groups, and other (None group), and images of the validation data set were classified. A decision algorithm to predict gene alteration for cases with 3 probability ranks was developed.

RESULTS

The accuracy and precision for selecting cancer-positive patches were 0.945 and 0.991, respectively. Predictive accuracy for the EGFR and KRAS groups in the validation data set was ~0.95, whereas that for the ALK and None groups was ~0.75 and ~ 0.80, respectively. Gene status was correctly predicted in the probability rank A cases. The model extracted characteristic conventional cytologic findings in images and a novel specific feature was discovered for the EGFR group.

CONCLUSIONS

A gene alteration prediction model for lung cancers by machine learning based on cytologic images was successfully developed.

Multifocal locules including the anterior mediastinum side as a surgical indicator in pleural infection

Background

The indication for and the timing of surgery in patients with pleural infection remains unclear. Determining the need for surgery in patients with pleural infection may help in the early consultation of surgeons.

Methods

Data of 167 consecutive patients with pleural infection were retrospectively reviewed. To detect a surgical indicator, the variables of patients who required surgery were compared with those of patients who were cured by non-surgical therapy (n=94) and patients resistant to the non-surgical therapy (n=73; 62 underwent surgery, and 11 showed recurrence or disease-related death after non-surgical treatment). Prognosis and timing of surgery were analyzed by comparing three groups: patients who underwent surgery within 7 days of admission (n=33), patients who underwent surgery after 7 days of admission (n=29), and patients who underwent non-surgical therapy (n=105).

Results

The presence of multifocal locules, including a locule on the anterior mediastinum side (LAMS) was a significant indicator of resistance to initial non-surgical therapy, as compared to the absence of locules (P<0.0001), a single locule (P<0.0001), or multifocal locules without a LAMS (P=0.0041). Recurrence and mortality were not observed in the patients who underwent surgery within 7 days of admission, and the hospitalization period (P=0.0071) and duration of C-reactive protein (CRP) improvement (P<0.0001) were significantly shorter in these patients compared with those who that underwent surgery after 7 days.

Conclusions

In patients with pleural infection, the presence of multifocal locules, including a LAMS, was associated with resistance to non-surgical therapy. Early surgery should be considered for these patients to shorten the hospitalization period and improve the prognosis.

Surgical lung biopsy for interstitial lung diseases-a single center study of 129 patients

Background

According to guidelines for the diagnosis and treatment of interstitial lung diseases (ILDs), a diagnostic surgical lung biopsy should be used to obtain the differential diagnosis of an ILD in patients with ILDs, which are difficult to distinguish clinically. However, the risk of developing postoperative complications such as postoperative pulmonary fistula or acute exacerbation is a concern. The purpose of this study was to evaluate the safety of surgical lung biopsy for the differential diagnosis of ILDs.

Methods

From October 2007 to July 2019, 129 patients thought to have ILD underwent a surgical lung biopsy at Toho University Omori Medical Center. We conducted a retrospective study on the diagnosis and safety of surgical lung biopsy for patients with ILD.

Results

The 30- and 60-day mortality was 0%. Postoperative complications occurred in 13 of 129 (10.1%) patients. The complications included pneumothorax in 8 (6.2%) patients after removal of the chest tube, postoperative pneumonia in 2 (1.0%), and acute exacerbation in 1 (0.8%). Postoperative pneumothorax was observed in 4 of 13 patients (30.7%) who underwent a biopsy of the apex of the lung (right S1, left S1+2), which was a significantly higher rate of postoperative pneumothorax than seen for patients undergoing biopsy at other sites (P=0.0086).

Conclusions

Surgical lung biopsy for the differential diagnosis of an ILD was performed safely. However, biopsy sites for ILDs need to be carefully selected to avoid postoperative complications.

Adenocarcinoma in situ detected on a thin-walled lung cavity: a case report

BACKGROUND

Cavitary lesions pathologically diagnosed as adenocarcinoma in situ (AIS) have been rarely reported. The examination of these type of lesions is necessary for a better understanding of the mechanisms underlying their formation and development of more efficient diagnostic and treatment strategies. Here, we present the case of a patient with cavitary lung carcinoma, diagnosed as AIS, who underwent partial resection.

CASE PRESENTATION

A 72-year-old man presented with an abnormal shadow on chest radiography. Computed tomography findings showed a nodule in the right upper lobe, which was later diagnosed as an adenocarcinoma via transbronchial biopsy. A thin-walled cavity with partial thickening in the right lower lobe was also noted. We suspected that the thin-walled cavitary lesion was malignant, and performed wedge resection during a right upper lobectomy. AIS was diagnosed based on the histopathological findings of the thickened part of the thin-walled cavity.

CONCLUSIONS

This study highlights that, although rare, AIS may be observed in cavitary lung carcinoma cases, particularly in thin-walled lesions.

Combination of mean CT value and maximum CT value as a novel predictor of lepidic predominant lesions in small lung adenocarcinoma presenting as solid nodules

Lung adenocarcinomas presenting as solid nodules are occasionally diagnosed as lepidic predominant lesions. The aim of this study was to clarify the histological structure and to identify factors predictive of lepidic predominant lesions. We retrospectively reviewed 38 patients that underwent lobectomy for small (≤ 2 cm) adenocarcinoma presenting as solid nodules. Resected tumor slides were reviewed and histological components were evaluated. Clinical and radiological data were analyzed to identify factors predictive of lepidic predominant lesions. Of 38 solid nodules, 9 (23.7%) nodules were lepidic predominant lesions. Five-year disease-free survival (DFS) rates were 100% for lepidic predominant lesions (n = 9) and 74.6% for non-lepidic predominant lesions (n = 29). Mean CT values (p = 0.039) and maximum CT values (p = 0.015) were significantly lower in lepidic predominant lesions compared with non-lepidic predominant lesions. For the prediction of lepidic predominant lesions, the sensitivity and specificity of mean CT value (cutoff, - 150 HU) were 77.8% and 82.8%, respectively, and those of maximum CT value (cutoff, 320 HU) were 77.8% and 72.4%, respectively. A combination of mean and maximum CT values (cutoffs of - 150 HU and 380 HU for mean CT value and maximum CT value, respectively) more accurately predicted lepidic predominant lesions, with a sensitivity and specificity of 77.8% and 86.2%, respectively. The prognosis of lepidic predominant lesions was excellent, even for solid nodules. The combined use of mean and maximum CT values was useful for predicting lepidic predominant lesions, and may help predict prognosis.

Thoracoscopic resection of bilateral multiple superior mediastinal neurofibromas

Background

The indications for surgical resection concerning multiple bilateral neurofibromas in the superior mediastinum remain controversial, because vascular injury or development of postoperative Horne syndrome are concerned.

Case presentation

A 60-year-old woman presented with multiple nodules in her right neck and bilateral chest cavity tops which indicated neurofibromatosis. The thoracic masses grew slowly over 9 years, and she then underwent a 2-stage resection starting with the left to right side. Bilateral tumors were completely removed via video-assisted thoracic surgery. The patient’s postoperative course was uneventful, without postoperative Horner syndrome.

Conclusions

To the best of our knowledge, this is the first case of multiple bilateral superior mediastinal neurofibromas resected from the pulmonary apices via thoracoscopy. We selected a minimally invasive pure video-assisted thoracoscopic surgery approach and enucleated some tumors to avoid nerve injury. This approach may be safe and useful for multiple neurofibromas in patients with neurofibromatosis.

Intraoperative argon-plasma coagulation treatment for patients with malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is often associated with asbestos exposure and carries an extremely poor prognosis. The present study assessed the effectiveness of argon plasma coagulation (APC) treatment in patients with MPM who underwent radical pleural decortication (PD). The clinical data from 11 patients who underwent radical PD treated with APC at Toho University Omori Medical Center from July 2015 to March 2020 were retrospectively analyzed. Clinical features, local recurrence, and clinical prognoses were evaluated. The median overall survival was 18.5 months, and the 1- and 2-year overall survival rates were 71.6 and 43.0%, respectively. One patient survived 5 years but had recurrent tumors. The median disease-free survival was 11.1 months. The 1- and 2-year disease-free survival rates were 49.9 and 12.5%, respectively. Three patients had no recurrences, two of whom were followed continuously (39.6 and 10.2 months). The present study revealed that APC treatment for MPM might be associated with good survival and prognosis. APC as an additional intraoperative treatment for patients with MPM may be further investigated with larger multi-center clinical trials to support its efficacy.

Contributions of Airway Stent for Long-term Outcome in Patients With Malignant Central Airway Stenosis or Obstruction

BACKGROUND

Although an airway stent is used for malignant central airway stenosis or obstruction, long-term outcomes are unknown. In this study, we retrospectively analyzed the clinical features of patients who required stenting for malignant central airway stenosis or obstruction.

PATIENTS AND METHODS

We retrospectively analyzed clinical data from 116 patients with stenting for central airway stenosis or obstruction who underwent treatment at Toho University Hospital from 1998 to 2018. We evaluated the clinical features, prognoses, and complications for stenting in these patients.

RESULTS

The distribution of the 116 patients was as follows: lung cancer, 53; esophageal cancer, 40; thyroid cancer, 8; and others, 15. Patients with thyroid cancer had a significantly higher rate of complications after stenting than patients with lung cancer (P=0.0062), esophageal cancer (P=0.0029), and others (P=0.0062). Patients with esophageal cancer had a significantly worse prognosis than patients with lung and thyroid cancer. In patients with lung cancer the prognosis was significantly different between patients who underwent additional treatment for lung cancer after stenting and patients with no treatment (P=0.0398), and patients who received chemoradiotherapy for lung cancer after stenting had a significantly better prognosis than patients with no treatment (P=0.0306).

CONCLUSION

Stenting for airway stenosis/obstruction may improve prognosis in patients with lung or thyroid cancer, especially if patients with lung cancer undergo additional treatments after stenting, although airway stenting for patients with esophageal cancer was palliative. New treatment strategies may be necessary for patients with esophageal cancer after stenting to improve prognosis.

Necessity of Thin Section CT in the Detection of Pulmonary Metastases: Comparison between 5 mm and 1 mm Sections of CT

Background: The aim of this study was to evaluate the difference in the ability of 1-mm and 5-mm section Computed Tomography(CT) to detect pulmonary metastases in patients with pulmonary metastases.

Methods: We retrospectively analyzed the CT findings of 106 patients with pulmonary metastases due to malignancies treated at Toho University Omori Medical Center between 2013 and 2020.

Results: Cases with only one nodule evaluated by 5-mm section CT had significantly lower discordance with 1-mm section CT than cases with two or more nodules detected by a 5 mm section (p = 0.0161). After reference to a 1 mm section, cases with only one nodule reevaluated by 5-mm section CT had significantly lower discordance than cases with two or more nodules reevaluated using 5-mm section CT. In cases with only one nodule, reevaluation using a 5 mm section was consistent with evaluation using a 1 mm section. However, this was not observed in cases with two or more nodules, with a significant difference between one nodule and two or more nodules.

Conclusions: If there are two or more nodules observed in 5-mm section CT it may be necessary to reevaluate using 1-mm section CT to determine the exact number of pulmonary metastases.

Prognostic and functional impact of perioperative LAMA/LABA inhaled therapy in patients with lung cancer and chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an important risk factor for postoperative complications and mortality. To determine the effects of perioperative combination therapy, using a long-acting muscarinic antagonist (LAMA) and a long-acting β₂ agonist (LABA), on preoperative lung function, postoperative morbidity and mortality, and long-term outcome in COPD patients.

METHODS

Between January 2005 and October 2019, 130 consecutive patients with newly diagnosed COPD underwent surgery for lung cancer. We conducted a retrospective review of their medical record to evaluate that LAMA/LABA might be an optimal regimen for patients with COPD undergoing surgery for lung cancer. All patients were received perioperative rehabilitation and divided into 3 groups according to the type of perioperative inhaled therapy and management: LAMA/LABA (n = 64), LAMA (n = 23) and rehabilitation only (no bronchodilator) (n = 43). We conducted a retrospective review of their medical records.

RESULTS

Patients who received preoperative LAMA/LABA therapy showed significant improvement in lung function before surgery (p < 0.001 for both forced expiratory volume in 1 s (FEV₁) and percentage of predicted forced expiratory volume in 1 s (FEV₁%pred). Compared with patients who received preoperative LAMA therapy, patients with LAMA/LABA therapy had significantly improved lung function (ΔFEV₁, LAMA/LABA 223.1 mL vs. LAMA 130.0 mL, ΔFEV₁%pred, LAMA/LABA 10.8% vs. LAMA 6.8%; both p < 0.05). Postoperative complications were lower frequent in the LAMA/LABA group than in the LAMA group (p = 0.007). In patients with moderate to severe air flow limitation (n = 61), those who received LAMA/LABA therapy had significantly longer overall survival and disease-free survival compared with the LAMA (p = 0.049, p = 0.026) and rehabilitation-only groups (p = 0.001, p < 0.001). Perioperative LAMA/LABA therapy was also associated with lower recurrence rates (vs. LAMA p = 0.006, vs. rehabilitation-only p = 0.008).

CONCLUSIONS

We believe this treatment combination is optimal for patients with lung cancer and COPD.

Persistence of the Postoperative Change in the Six-minute Walking Distance of Lung Cancer Patients with Chronic Obstructive Pulmonary Disease

Objectives:

The aim of this prospective follow-up study was to investigate the difference before and after surgery in the six-minute walking distance (6MD) of lung cancer patients with chronic obstructive pulmonary disease (COPD) and to examine the long-term effect of the change in 6MD in the early postoperative period.

Methods:

This was a retrospective analysis of 25 COPD patients who underwent lung cancer surgery and perioperative rehabilitation in our department. Assessments of 6WD were carried out preoperatively and at 1, 3, and 6 months postoperatively. The changes in 6MD at 1, 3, and 6 months postoperatively compared with the preoperative value were designated the 1-month Δ6MD, the 3-month Δ6MD, and the 6-month Δ6MD, and the associations between them were investigated.

Results:

The mean 6MD distance was 412.0±27.3 m (95% confidence interval) preoperatively, 369.0±33.8 m at 1 month, 395.6±32.2 m at 3 months, and 400.0±38.2 m at 6 months, with a significant difference between the preoperative and 1-month values (P<0.01). There were strong correlations between 1-month and 3-month Δ6MDs (r =0.74, P<0.0001) and between 1-month and 6-month Δ6MDs (r =0.88, P<0.0001).

Conclusions:

In lung cancer patients with COPD, the 1-month Δ6MD was strongly associated with both the 3-month Δ6MD and the 6-month Δ6MD. These findings suggest that the decrease in exercise tolerance of patients whose 6MD is low at 1 month postoperatively may be prolonged, and such patients may therefore be in greater need of postoperative outpatient rehabilitation.

Quantification of BIM mRNA in circulating tumor cells of osimertinib-treated patients with EGFR mutation-positive lung cancer

BACKGROUND

The response rate for osimertinib is high among patients with untreated epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC). However, there exist no biomarkers to predict the efficacy of the same. This study investigated whether BIM-γ mRNA expression in circulating tumor cells (CTCs) predicts poor outcomes for osimertinib treatment in patients with EGFR mutation-positive NSCLC.

METHODS

Patients with advanced EGFR-tyrosine kinase inhibitor-untreated NSCLC or post-operative recurrence with EGFR-sensitive mutations (exon 19 deletion or L858R mutation) were included. Informed consent was obtained from all participants. The candidate biomarker BIM-γ was measured in CTCs after blood collection (10 mL of whole blood) at baseline. CTCs were collected with the ClearCell FX system, and quantitative real-time PCR was performed. Relative expression of BIM-γ mRNA from CTCs, as normalized to the reference gene (GAPDH mRNA), was calculated using the KCL22 cell line for calibration.

RESULTS

We enrolled 30 EGFR mutation-positive NSCLC patients treated with osimertinib during the period from April 2018 through December 2019. All the patients had an EGFR mutation at the primary site: exon 19 deletion in 15 cases and L858R in 15 cases. Median CTC count at baseline was 12 (range 3-127)/7.5 mL, and median BIM-γ mRNA expression was 0.073 (range 0-1.37). Furthermore, the response rate to osimertinib was worse in patients with high than in those with low BIM-γ mRNA expression (n = 15 each) (26.6% vs. 73.3%, respectively; p = 0.011). Progression-free survival did not significantly differ between groups (p = 0.13).

CONCLUSIONS

BIM-γ mRNA overexpression in CTCs from EGFR mutation-positive NSCLC patients is a potential a biomarker for poor response to osimertinib.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN:00032055.

Long-term survival of airway silicone stents in patients with central airway stenosis or obstruction due to thoracic malignancy

OBJECTIVES

Silicone airway stents are used to manage central airway stenosis or obstruction, although their impact on long-term survival remains unknown in patients with central airway stenosis or obstruction due to thoracic malignancy. In this study, we retrospectively analyzed the impact of silicone stents on survival.

METHODS

We retrospectively analyzed clinical data of 106 patients with central airway stenosis or obstruction due to thoracic malignancy treated by stenting at Toho University Omori Medical Center between 1998 and 2018.

RESULTS

Patients treated with silicone stents had significantly higher survival rates than patients treated with metallic stents (p = 0.0173). Silicone stents patients also had significantly more additional treatments for thoracic malignancy after stenting than metallic stents patients (p = 0.0007). Notably, significantly more silicone stents patients underwent chemoradiotherapy or radiotherapy (p = 0.0268, p = 0.0300). During multivariate analyses, the additional treatment, including chemoradiotherapy or radiotherapy, was an independent optimal prognostic factor.

CONCLUSIONS

Silicone stents patients had significantly higher survival rates than metallic stents patients. Although stenting for airway stenosis or obstruction due to thoracic malignancy may be mainly palliative, additional treatments after stenting should be considered to improve the prognoses of patients with airway stenosis or obstruction due to thoracic malignancy.

Acceptability and feasibility of S-1 plus cisplatin adjuvant chemotherapy for completely resected non-small cell lung cancer: an open-label, single arm, multicenter, phase 2 trial

Background

Although platinum-based chemotherapy is accepted as adjuvant chemotherapy for resectable advanced non-small cell lung cancer (NSCLC), its completion rate is low due to severe adverse events. S-1 plus cisplatin is associated with relatively low toxicity and an unimpaired quality of life, and has been used for unresectable advanced lung cancer. We investigated the acceptability and feasibility of combination therapy with S-1 plus cisplatin as postoperative adjuvant chemotherapy following complete resection of pathological stage II-IIIA NSCLC.

Methods

Enrolled patients received oral S-1 at a dose depending on their body weight twice daily for 21 days with intravenous cisplatin 60 mg/m² on day 8, with 1 cycle comprising 5 weeks and 4 cycles. Patients received standard precautions against adverse events and received standard treatment when adverse events occurred. The primary endpoint was completion rate; secondary endpoints included safety, status of drug administration, disease-free survival (DFS), and overall survival (OS).

Results

A total of 19 patients [14 men, 5 women; mean age, 59.1 years; mean body surface area, 1.688 m²; 17 with an Eastern Cooperative Oncology Group performance status (PS) of 0 and 2 with a PS of 1; 7 (36.8%) with stage II disease and 12 (63.2%) with stage IIIA disease] were enrolled. The rate of completion of 4 cycles was 68.4%. Grade 3 adverse events that occurred in ≥10% of patients included neutropenia (21.1%), nausea (21.1%), and anorexia (15.8%). No grade 4 adverse events, febrile neutropenia, or treatment-related deaths occurred. The mean relative dose intensity (RDI) was 79% for S-1 and 80% for cisplatin. The 2-year DFS rate was 42.1%, and 2-year OS rate was 83.3%.

Conclusions

This study demonstrated the acceptability and feasibility of using S-1 plus cisplatin as adjuvant chemotherapy.

Trial registration

This study was registered on the UMIN clinical study registration site (protocol ID: UMIN000016191) on December 1, 2015.

Diaphragm reconstruction by GORE DUALMESH in patients undergoing resection for thoracic malignancies

Background

We used GORE DUALMESH for the reconstruction of diaphragms in patients with thoracic malignancies. Here, we report the results.

Methods

Between July 2015 and August 2017, diaphragm reconstruction using 2-mm GORE DUALMESH was performed in 7 patients undergoing surgical resection for thoracic malignancies. After resection of the diaphragm, the mesh was trimmed to the size of defect and placed with the smooth surface facing the chest cavity and the rough surface facing the abdomen. It was fixed with interrupted sutures consisting of synthetic monofilament nonabsorbable 1–0 to 2 threads.

Results

Indications for resection were malignant pleural mesothelioma and primary lung cancer in 5 and 2 patients, respectively. Patients with malignant pleural mesothelioma underwent pleurectomy with decortication; patients with primary lung cancer underwent lung lobectomy. Right and left diaphragm reconstruction was performed for 4 and 3 patients, respectively. Neither complications related to diaphragm reconstruction nor displacement of mesh occurred during a follow-up period ranging from 11 days to 37 months.

Conclusions

GORE DUALMESH is a good synthetic material for diaphragm reconstruction, because its smooth surface prevents adhesions to the lung and its rough surface allows adherence to abdominal tissue.

Streptococcus anginosus group infection as a predictor for the progression of descending necrotizing mediastinitis

BACKGROUND

The prognosis of descending necrotizing mediastinitis (DNM), especially that extending inferiorly to the carina, remains poor. The identification of additional prognostic factors may improve the prognosis.

METHODS

We retrospectively analyzed six patients who underwent thoracic surgery for DNM extending to the anterior and posterior mediastinum inferior to the carina (Endo classification type IIB) from 2014 to 2020. We reviewed their characteristics, clinical course, causative bacteria, and treatment to investigate their prognostic factors.

RESULTS

The median patient age was 62 years. Five patients were men and one patient was a woman. The causative disease in three of the patients was pharyngolaryngeal, and for the others, it was an odontogenic infection. Five patients had sepsis and four had disseminated intravascular coagulation (DIC) at surgery. Four patients had polymicrobial infections of aerobic and anaerobic bacteria, all of whom showed gas bubbles on a chest computed tomography scan and detection of Streptococcus anginosus group (SAG). All patients underwent cervicotomy, tracheostomy, and mediastinal drainage and debridement via a transthoracic approach. Three patients underwent additional surgery or drainage because an additional abscess appeared postoperatively. The median duration of hospitalization was 58 days and the mixed infections, including SAG, were all detected in the three cases of long-term hospitalization. No disease-associated death was observed during the follow-up period of 18 months.

CONCLUSIONS

Mixed infection, including SAG, may be a predictor for DNM aggravation and spread. Gas bubbles on a chest computed tomography scan suggest polymicrobial aerobic and anaerobic infections including SAG, which require broad-spectrum antibiotic therapy and aggressive drainage and surgery.

Preoperative undernutrition predicts postoperative complications of acute empyema

INTRODUCTION

Surgery for acute empyema is associated with postoperative complications and relapse. Establishing a predictor for postoperative complications may improve prognosis.

OBJECTIVES

To demonstrate undernutrition as a predictor of complications after surgery for acute empyema.

METHODS

We retrospectively analyzed 52 consecutive patients who underwent surgery for acute empyema from 2004 to 2019 and validated the correlation of undernutrition with serum albumin level, patient characteristics, hospital stay, and postoperative complications.

RESULTS

The median preoperative serum albumin level was 2.4 g/dL (range: 1.1-3.4). The levels in all patients were lower than the standard value (3.5 g/dL). Patients were divided into two groups based on the median serum albumin levels: the low serum albumin level group (group L, n = 28) and the high serum albumin level group (group H, n = 24). Group L patients were significantly older (64.5 vs 52.9 years, P = .002), had lower median body mass index (21.0 vs 24.2, P = .008), and significantly had Streptococcus anginosus group as the causative bacteria (50% vs 21%, P = .044). Their hospitalization duration was significantly longer (28.1 vs 14.8 days, P < .001), and postoperative complications were significant or tended to be more frequent (all incidence; 11 (39%) vs 2 (8%), P = .012, respiratory-related; 7 (25%) vs 1 (4%), P = .056) in group L. Further analyses revealed that other undernutrition indicators also correlated with postoperative complications.

CONCLUSIONS

Preoperative serum albumin level is a valid predictor of complications after surgery for acute empyema. Preoperative nutrition management for empyema patients may reduce the occurrence of postoperative complications.

Perioperative Bypassing Agent Therapy for Pulmonary Pleomorphic Carcinoma with Acquired Hemophilia

A 74-year-old man was admitted with lung cancer, and preoperative blood test showed abnormal activated partial thromboplastin time (APTT). Coagulation factor screening and APTT mixing test achieved a diagnosis of acquired hemophilia A (AHA). Bypassing agent therapy was indicated and lobectomy was successfully performed without bleeding complications. APTT returned to normal after the operation without any additional treatment for AHA. The pathogenesis of AHA is still unknown and there is no evidence for hemostatic strategy for AHA patients requiring surgery. This study supports the importance of hemostatic therapy and suggests that malignancy might cause AHA.

A novel finding related to bulla and bleb formation in patients with primary spontaneous pneumothorax

BACKGROUND

Spontaneous pneumothorax is a common problem globally. Bullas and blebs have been implicated in this problem, but the etiology of their formation is unknown. We aim to show the relation between a novel clinical finding, the pulmonary delayed inflation (PDI) sign, and the etiology of bulla and bleb formation in young patients.

METHODS

We retrospectively analyzed data from 111 patients with pneumothorax and a control group of 27 patients. We evaluated the relation between the PDI sign and other clinical factors.

RESULTS

The PDI sign was observed in 78 patients. Of these, 75 exhibited the PDI sign in only the upper lobe. Regardless of smoking status, patients 34 years of age or younger had a significantly higher incidence of the PDI sign than, patients 55 years of age or older and control patients. The inflation time in patients 34 years of age or younger, regardless of smoking status, was significantly longer than in patients 55 years of age or older and patients in the control group. There was no significant association between inflation time and the presence of asthma.

CONCLUSIONS

The novel PDI sign is seen in patients 34 years of age or younger. Because this sign may indicate a peripheral bronchial abnormality and may be related to the formation of blebs and bullae in young patients with spontaneous pneumothorax, it is possible that it can be used to develop effective treatments for pneumothorax in young patients.

Mediastinal tumor resection in a patient with spinocerebellar degeneration

Background

In spinocerebellar degeneration (SCD) patients, general and regional anesthesia may cause postoperative dysfunction of respiratory, nerve and muscle systems. We present the surgical case of thymoma developed in patient with SCD.

Case presentation

A 47-year-old woman with spinocerebellar degeneration was admitted because of a well-defined mass measuring 48 × 31 mm in anterior mediastinum. She showed limb, truncal, ocular, and speech ataxia; hypotonia; areflexia; sensory disturbances; and muscle weakness. Her eastern cooperative oncology group performance status was 4. Surgical resection was performed via video-assisted thoracic surgery and under general anesthesia only without epidural analgesia. The mass was diagnosed as type B1 thymoma without capsular invasion (Masaoka stage I). The patients got a good postoperative course by cooperation with anesthesiologists and neurologists in perioperative managements. She has been well over 3 years of follow-up.

Conclusions

In conclusion, careful surgical and anesthesia management is essential for providing an uneventful postoperative course in patients with SCD. Especially, selection of minimal invasive approach and avoid diaphragmatic nerve damage are the most important points in surgical procedures.

Good syndrome with cytomegalovirus hepatitis: successful resection of Thymoma: a case report

BACKGROUND

Good syndrome is a rare condition, manifesting as immunodeficiency due to hypogammaglobulinemia associated with thymoma. Herein, we present a patient with Good syndrome whose thymoma was resected after treatment of cytomegalovirus hepatitis.

CASE PRESENTATION

The patient was a 45-year-old woman presenting with fever, cough, and nasal discharge, and was diagnosed with thymoma and hypogammaglobulinemia. She subsequently developed cytomegalovirus hepatitis that was treated by immunoglobulin. After resolution of the hepatitis, she underwent thymectomy through a left anterior thoracotomy. Her postoperative course was uneventful, and while receiving ongoing immunoglobulin therapy, she has been doing well without signs of infection.

CONCLUSIONS

Management of infections is important for patients with Good syndrome. To minimize the risk of perioperative infection, we should take care while planning the surgical approach and procedure.

Neuroendocrine tumors of the lung: clinicopathological and molecular features

In 1970, neuroendocrine tumors of the lung were classified into three categories: typical carcinoid (TC), atypical carcinoid (AC), and small cell lung carcinoma (SCLC). The third edition of the World Health Organization (WHO) classification in 1999 defined large cell neuroendocrine carcinoma (LCNEC) as a variant of large cell carcinomas, whereas the fourth edition of the WHO classification redefined LCNEC as a neuroendocrine tumor. Currently, neuroendocrine tumors of the lung are classified into four main categories: TC, AC, LCNEC, and SCLC. Although the treatments for TC, AC, and SCLC have not changed remarkably, the treatment strategy for LCNEC is not yet established because of its reclassification from a variant of "large cell carcinoma" to a new category of "neuroendocrine tumor". In this review article, we discuss the pathological findings, biological behavior, and treatment of neuroendocrine tumors of the lung.

Catamenial Pneumothorax With Pulmonary Fistula Identified During Surgery

A 41-year-old woman was admitted with a recurrent pneumothorax coincident with menstruation 2 months after a first occurrence. Video-assisted thoracic surgery was performed for definitive diagnosis and pneumothorax treatment. Bluish diaphragmatic spots and three lung bullae were noted. A lung fistula was observed in one of the bullae, and the diaphragmatic lesion and bullae were resected. The bulla with air leakage and the diaphragmatic lesion were diagnosed as endometrial tissue by pathology. This case is rare as a fistula from a bulla with endometriosis was identified intraoperatively, suggesting the check-valve mechanism might be one of the etiologies of catamenial pneumothorax.

Clinical importance of long non‑coding RNA LINC00460 expression in EGFR‑mutant lung adenocarcinoma

Long non-coding RNAs (lncRNAs) have been reported to be involved in the physiological and pathological processes of tumor pathogenesis, including epithelial-mesenchymal transition (EMT). However, epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) resistance is a major challenge in the treatment of advanced and recurrent EGFR-mutant lung adenocarcinoma. An increased understanding of the underlying mechanisms would aid in the development of effective therapeutic strategies against EGFR-TKI resistance, strategies which are urgently required for clinical therapy. In this study, long non-coding RNA LINC00460 was identified as a novel marker of a poor response to EGFR-TKI and prognosis. In lung cancer cells, LINC00460 promoted EGFR-TKI resistance as a competitive decoy for miR-149-5p, thereby facilitating interleukin (IL)-6 expression and inducing EMT-like phenotypes. The knockdown or knockout of LINC00460 in gefitinib-resistant non-small cell lung cancer cells restored the response to EGFR-TKI. In addition, as compared with patients with a low LINC00460 expression in tumors, those with a high LINC00460 expression had a significantly shorter progression-free survival following gefitinib therapy, and a shorter overall survival. Therefore, LINC00460 may be a predictor of and potential therapeutic target for EGFR-TKI resistance.

Clinical importance of long noncoding RNA LINC00460 expression in plasma cell-free tumor RNA in EGFR-mutant adenocarcinoma

e20529

Background: Long noncoding RNA (lncRNA) is longer than 200 nucleotides and does not encode proteins. The IncRNA LINC00460 was reported to be involved in physiological and pathological processes such as proliferation, invasion, metastasis, and epithelial–mesenchymal transition (EMT). However, its role in epidermal growth factor receptor ( EGFR)-mutant lung adenocarcinoma is unclear. Methods: Non–small cell lung cancer (NSCLC) cells with knockout of LINC00460 were generated with a CRISPR-Cas9 system and used to investigate the effect of LINC00460 on gefitinib-induced cell death in an MTT assay. Western blot was used to observe change in EMT-related proteins, and changes in expression of EMT-related proteins were detected with an immunofluorescence assay. In addition, among 38 EGFR mutant lung adenocarcinomas treated by EGFR-TKI, cell-free tumor RNA extracted from blood plasma samples was analyzed for LINC00460 by using a real-time PCR assay. In addition, we assessed the association between LINC00460 expression and progression-free survival (PFS) after EGFR-TKI therapy. Results: LINC00460 was up-regulated by EGFR activation. LINC00460 expressions were significantly greater in NSCLC tumors than in adjacent normal tissues (p < 0.01). H1299 cells with LINC00460 knockout were more sensitive to gefitinib. LINC00460 was induced by transcription factors such as FOS and NF-κB in EGFR-mutant lung adenocarcinoma and gefitinib-resistant cells. LINC00460 overexpression was involved in gefitinib resistance. The MTT assay showed that LINC00460 expression was greater in cells with acquired resistance to EGFR-TKIs (gefitinib, erlotinib, and osimertinib). Western blot and immunofluorescence revealed that LINC00460 expression was associated with changes in the expression of EMT-related proteins. Patients with high LINC00460 expression in plasma cell-free tumor RNA had significantly shorter PFS after EGFR-TKI therapy than did those with low expression (median PFS: 688 vs 1089 days, respectively; p = 0.024). Conclusions: LINC00460 appears to be a novel factor involved in malignant transformation of EGFR mutant–positive lung adenocarcinoma and increased EGFR-TKI resistance. LINC00460 expression in plasma cell-free tumor RNA in EGFR-mutant adenocarcinoma was associated with shorter PFS after EGFR-TKI therapy.

Resection of a Superior Mediastinal Mature Teratoma Using Intraoperative Neural Monitoring

A 33-year-old woman presented with a right cervical mass. Contrast computed tomography showed a multilocular tumor with a clear border and heterogeneous contents including fat and calcification. The tumor was located adjacent to the vagus and recurrent nerves. To avoid injury of these nerves, we resected the tumor through a median sternotomy and right cervical lateral incision. Intraoperative neural monitoring was performed using an NIM TriVantage EMG tube (Medtronic, Minneapolis, MN). After the surgery, no neuropathy such as hoarseness was recognized. Pathological diagnosis showed a benign mature teratoma. Intraoperative neural monitoring is useful for superior mediastinal surgery around the vagus and recurrent nerves.

[Sublobar Resection for Patients with a Metachronous Second Primary Lung Cancer Following Curative Resection of a Primary Lung Cancer]

BACKGROUND

Surgical methods for patients with a metachronous 2nd primary lung cancer following curative resection of a primary lung cancer remain controversial. The purpose of this study was to evaluate the outcomes of patients who underwent sublobar resection for a metachronous 2nd primary lung cancer.

METHODS

We retrospectively analyzed 10 patients who underwent sublobar resection for a metachronous 2nd primary lung cancer occurring 5 years or more after the initial surgery for primary lung cancer.

RESULTS

The 5-year overall survival rate after the 2nd surgery was 68.6%. There was no operative mortality. A postoperative recurrence developed in 4 patients, 3 of whom had pathological stage ⅠA3 cancer. Moreover, patients with a stage ⅠA3 metachronous 2nd primary lung cancer had significantly lower 5-year disease-free and overall survival rates than patients with a stage ⅠA1 or ⅠA2 cancer( disease-free survival rate, p=0.022;overall survival rate, p=0.023).

CONCLUSIONS

For patients with a stage ⅠA1 or ⅠA2 metachronous 2nd primary lung cancer, sublobar resection may be acceptable because those patients had a good prognosis in this study. Early detection of a metachronous 2nd primary lung cancer following the initial surgery may be very important for improving the patient's prognosis.

The role of video-assisted thoracoscopic surgery in the diagnosis of interstitial lung disease

Background

When a clinical context is indeterminate for idiopathic pulmonary fibrosis (IPF), or a chest high-resolution computed tomography (HRCT) pattern is not indicative of typical or probable usual interstitial pneumonia (UIP) in patients with interstitial lung disease (ILD), surgical lung biopsy should be considered to make a confident diagnosis on the basis of multidisciplinary diagnosis (MDD).

Aim

The aim of this study was to evaluate the role and safety of video-assisted thoracoscopic surgery (VATS) in patients with ILD.

Methods

A total of 143 patients with ILD underwent VATS at Toho University Medical Center Omori Hospital between March 2004 and April 2017. We conducted a retrospective study on the usefulness and safety of VATS in the diagnosis of ILD under MDD.

Results

The 30-day mortality was 0%. The postoperative complication rate was 12.6%, which included 5 cases of pneumothorax after discharge (3.5%), 4 cases of prolonged air leakage (2.8%), and 2 cases of acute exacerbation (1.4%). Three of 9 cases (33.3%) complicated by pneumothorax after discharge or prolonged air leakage were resected specimens of pleuroparenchymal fibroelastosis (PPFE). Two patients had acute exacerbation, who were ultimately diagnosed as having idiopathic unclassifiable IP and had histologically significant irregular dense fibrosis and numerous fibroblastic foci. The comparison between chest HRCT and histopathological findings revealed 55 cases of possible UIP [UIP (45%), NSIP (25%), and unclassifiable IP (29%)] and 21 cases of inconsistent with UIP [UIP (10%), NSIP (33%), organizing pneumonia (10%), unclassifiable IP (24%), and PPFE (24%)].

Conclusion

VATS can be safely performed to obtain a confident diagnosis for appropriate treatment strategies in patients with ILD.

Link between tumor-promoting fibrous microenvironment and an immunosuppressive microenvironment in stage I lung adenocarcinoma

OBJECTIVES

Podoplanin-positive cancer-associated fibroblasts [PDPN (+) CAFs] play an important role in cancer progression in non-small-cell lung cancer. The aim of this study was to clarify the correlation between a fibrous microenvironment containing PDPN (+) CAFs and an immune microenvironment.

MATERIALS AND METHODS

A total of 174 patients with pathological stage I lung adenocarcinoma were analyzed. We evaluated PDPN (+) CAFs and immune-related cells, CD 204-positive tumor-associated macrophages [CD204 (+) TAMs], CD8-positive T cells, and FOXP3-positive T cells, in cancer stroma by using immunohistochemical staining. We compared the expression levels of immune-regulatory cytokines between the PDPN high and low expression groups by analyzing the gene expression profiles of lung adenocarcinoma (n = 442).

RESULTS

Presence of PDPN (+) CAFs was a risk factor for recurrence (P =  0.042). The number of CD204 (+) TAMs was significantly higher (P <  0.001) and the CD8/FOXP3 T cell ratio was significantly lower in PDPN (+) CAFs cases than in PDPN (-) CAFs cases (P =  0.027). Within the same tumor, the number of CD 204 (+) TAMs was significantly higher (P <  0.001) and CD8/FOXP3 T cell ratio tended to be lower (P =  0.062) in PDPN (+) CAF areas. Microarray analysis revealed that the PDPN expression-high group had significantly higher gene expression levels of cytokines that inducing M2 macrophage polarization and suppressing immune-related lymphocytes.

CONCLUSION

The current results show that lung adenocarcinoma with PDPN (+) CAFs is typified by the immunosuppressive microenvironment, suggesting a close link between the tumor-promoting fibrous microenvironment and the immunosuppressive microenvironment.

[Energy Device and Soft Coagulation System in Thoracic Surgery]

While the recent emergence of energy-based surgical techniques and soft coagulation has made surgical procedures less invasive, the safety and proper use of such advances have yet to be investigated. Herein we review the experimental and clinical use of ultrasonically-activated coagulating shears, a vessel sealing system, incorporating ultrasonic and vessel sealing technology, and a soft coagulation system in thoracic surgery. All energy devices have been reported to be safe for use on pulmonary vessels, and use in combination with a ligature appears to be adequate. The thoracic duct has been reported to be sealed with sufficient pressure using energy devices, which are expected to prevent chylothorax formation. Bipolar scissors can be safely and efficiently applied for dissection of pulmonary vessels without damage to the vessel wall. Monopolar soft coagulation can be applied to shrink bullous changes and stop air leakage or bleeding within the lung.

PD-L1 mRNA expression in EGFR-mutant lung adenocarcinoma

Molecular mechanisms of programmed death-ligand 1 (PD-L1) mRNA expression and roles of apoptosis and biomarkers are poorly understood in epidermal growth factor receptor (EGFR)-mutant lung adenocarcinoma patients. Thirty-three patients with recurrent postoperative EGFR-mutant lung adenocarcinoma (exon 19 deletion in 16, L858R in 15, G719C in 2 patients) treated with gefitinib were studied. PD-L1 mRNA expression of formalin-fixed paraffin-embedded paratumoral and intratumoral tissues was quantified by PCR. Correlations of PD-L1 mRNA expression with BIM, p53 upregulated modular of apoptosis (PUMA), human epidermal growth factor receptor 2 (HER2), mesenchymal-epithelial transition (MET), EGFR, and vascular endothelial growth factor A (VEGFA) were determined. Eleven of the 33 patients (33.3%) and 14/33 patients (42.4%) expressed intratumoral and paratumoral PD-L1 mRNA, respectively. Patients with intratumoral PD-L1 mRNA expression had significantly higher BIM and lower VEGFA expression compared with paratumoral PD-L1 mRNA patients (P=0.049, P=0.009). PD-L1 mRNA expression was not associated with the expression of PUMA, HER2, EGFR and MET but was positively correlated with BIM expression (r=0.41, P=0.017) and inversely correlated with VEGFA expression (r=-0.33, P=0.043). Patients with intratumoral PD-L1 mRNA expression had significantly shorter median progression-free survival (PFS) after gefitinib therapy compared with no PD-L1 expression (255 vs. 732 days, respectively; P=0.032). Thus, PD-L1 mRNA expression in EGFR-mutant lung adenocarcinoma was associated with BIM and VEGFA mRNA expression and with shorter PFS after gefitinib therapy.

Giant thymoma successfully resected via median sternotomy and anterolateral thoracotomy: a case report

Background

Some patients with thymoma present with a very large mass in the thoracic cavity. Although the most effective treatment for thymoma is surgical resection, it is difficult to perform because of the size of the tumor and the infiltration of tumor into the surrounding organs and vessels. We report a patient with a giant thymoma that was completely resected via a median sternotomy and left anterolateral thoracotomy.

Case presentation

A 63-year-old woman presented with a mass in the left thoracic cavity that was incidentally found on a chest X-ray. Chest computed tomography revealed a giant mass (16 × 10 cm) touching the chest wall and diaphragm and pressed against the heart and left upper pulmonary lobe. Complete resection was performed via a median sternotomy and left anterolateral thoracotomy. The tumor was histologically diagnosed as a WHO type B2 thymoma, Masaoka stage II.

Conclusions

Giant thymomas tend to grow expansively without invasion into surrounding organs and vessels. Surgical resection that employs an adequate approach must be considered, regardless of the size of the tumor.

Long-acting muscarinic antagonist and long-acting β2-agonist therapy to optimize chronic obstructive pulmonary disease prior to lung cancer surgery

Bronchodilators are essential for the perioperative management of patients with chronic obstructive pulmonary disease (COPD) undergoing surgery for lung cancer. The objective of the present study was to examine whether the usage of a long-acting β2-agonist (LABA) with a long-acting muscarinic antagonist (LAMA) could optimize preoperative lung function and reduce the risk for postoperative pulmonary complications. Thirty-two consecutive patients with moderate-to-severe COPD who underwent a lobectomy for lung cancer and received preoperative LAMA (n=19) or LAMA/LABA (n=13) therapy between January 2005 and December 2015 were enrolled in this retrospective study. The improvement of preoperative pulmonary function and the postoperative morbidity were compared between the patients with preoperative LAMA, and LAMA/LABA therapy. Increases in the forced expiratory volume in one second (FEV₁) were significantly larger in the LAMA/LABA group than in the LAMA group (0.26±0.05 l vs. 0.07±0.05 l; P=0.0145). More patients in the LAMA/LABA group than in the LAMA group showed a marked improvement of >10% in %FEV₁ after bronchodilators (85 vs. 32%; P=0.0046). The incidence of postoperative pneumonia was significantly lower in the LAMA/LABA group than in the LAMA group (0 vs. 26%; P=0.044). In conclusion, the present study showed that preoperative LAMA/LABA therapy was associated with larger improvements in preoperative pulmonary function and less postoperative pneumonia than LAMA therapy. These results may lead to greater improvements in FEV₁ and less postoperative pneumonia by encouraging preoperative LAMA/LABA therapy in this patient population.

Adherence and feasibility of 2 treatment schedules of S-1 as adjuvant chemotherapy for patients with completely resected advanced lung cancer: a multicenter randomized controlled trial

BACKGROUND

We conducted a multicenter randomized study of adjuvant S-1 administration schedules for surgically treated pathological stage IB-IIIA non-small cell lung cancer patients.

METHODS

Patients receiving curative surgical resection were centrally randomized to arm A (4 weeks of oral S-1 and a 2-week rest over 12 months) or arm B (2 weeks of S-1 and a 1-week rest over 12 months). The primary endpoints were completion of the scheduled adjuvant chemotherapy over 12 months, and the secondary endpoints were relative total administration dose, toxicity, and 3-year disease-free survival.

RESULTS

From April 2005 to January 2012, 80 patients were enrolled, of whom 78 patients were eligible and assessable. The planned S-1 administration over 12 months was accomplished to 28 patients in 38 arm A patients (73.7%) and to 18 patients in 40 arm B patients (45.0%, p = 0.01). The average relative dose intensity was 77.2% for arm A and 58.4% for arm B (p = 0.01). Drug-related grade 3 adverse events were recorded for 11% of arm A and 5% of arm B (p = 0.43). Grade 1-3 elevation of bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine transaminase were more frequently recorded in arm A than in arm B. The 3-year disease-free survival rate was 79.0% for arm A and 79.3% for arm B (p = 0.94).

CONCLUSIONS

The superiority of feasibility of the shorter schedule was not recognized in the present study. The conventional schedule showed higher completion rates over 12 months (p = 0.01) and relative dose intensity of S-1 (p = 0.01). Toxicity showed no significant difference among the shorter schedule and the conventional schedule, except for grade 1-3 elevation of bilirubin.

TRIAL REGISTRATION

This randomized multicenter study was retrospectively registered with the UMIN-CTR (UMIN000016086, registration date December 30, 2014).

Diffuse fluorodeoxyglucose-positron uptake in the bone marrow of a patient with granulocyte colony-stimulating factor-producing pleomorphic carcinoma of the lung: A case report

The current study presents the case of a 66-year-old male presenting with fever and chest pain. Chest enhanced computed tomography scanning revealed a mass shadow in the right upper lobe with chest wall invasion. 18-Fluorodeoxyglucose-positron emission tomography (FDG-PET) identified the localized uptake of the mass lesion in the right upper lobe, in addition to diffuse uptake by the bone marrow. The laboratory data on admission revealed marked leukocytosis and an elevated C-reactive protein level (CRP). Serum concentrations of granulocyte colony-stimulating factor (G-CSF) and interleukin 6 were increased. Based on a clinical diagnosis of non-small cell lung cancer (c-T3N0M0 stage IIB), the patient underwent right upper lobectomy with chest wall resection. The histological examination showed a pulmonary pleomorphic carcinoma. Immunohistochemical analysis of the resected tumor tissues revealed positive staining for G-CSF. The patient's high-grade fever, leukocytosis, and elevated CRP level rapidly subsided following the resection. This confirmed that the tumor was a G-CSF-producing pulmonary pleomorphic carcinoma. Five months after the resection, the diffuse FDG uptake in the bone marrow was absent, even with the presence of a small pulmonary metastasis and marginal serum G-CSF elevation. Diffuse FDG uptake in bone marrow induced by G-CSF producing pleomorphic carcinoma must be taken into consideration, in order for it not to be misinterpreted as diffuse bone marrow metastases or hematologic malignancy.