Pulmonary Metastasectomy in Colorectal Cancer: A Population-Based Retrospective Cohort Study Using the Korean National Health Insurance Database / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#The study aimed to investigate the current status and prognostic factors for overall survival in patients who had undergone pulmonary metastasectomy for colorectal cancer. @*Materials and Methods@#The data of 2,573 patients who had undergone pulmonary metastasectomy after surgery for colorectal cancer between January 2009 and December 2014 were extracted from the Korean National Health Insurance Service claims database. Patient-, colorectal cancer–, pulmonary metastasis–, and hospital-related factors were analyzed using the Kaplan-Meier method, log-rank test, and Cox proportional hazards analysis to identify prognostic factors for overall survival after pulmonary metastasectomy. @*Results@#The mean age of the patients was 60.9±10.5 years; 66.2% and 79.1% of the participants were male and had distally located colorectal cancer, respectively. Wedge resection (71.7%) was the most frequent extent of pulmonary resection; 21.8% of the patients underwent repeated pulmonary metastasectomies; 73% of pulmonary metastasectomy cases were performed in tertiary hospitals; 53.9% of patients were treated in Seoul area; 82% of patients received chemotherapy in conjunction with pulmonary metastasectomy. The median survival duration was 51.8 months. The 3- and 5-year overall survival rates were 67.7% and 39.4%, respectively. In multivariate analysis, female sex, distally located colorectal cancer, pulmonary metastasectomy-only treatment, and high hospital volume (> 10 pulmonary metastasectomy cases/yr) were positive prognostic factors for survival. @*Conclusion@#Pulmonary metastasectomy seemed to provide long-term survival of patients with colorectal cancer. The female sex, presence of distally located colorectal cancer, and performance of pulmonary metastasectomy in high-volume centers were positive prognostic factors for survival.

Single-Port Video-Assisted Thoracic Surgery for Secondary Spontaneous Pneumothorax: Preliminary Results

BACKGROUND: The aim of this study was to evaluate the feasibility of single-port video-assisted thoracic surgery (VATS) in the treatment of secondary spontaneous pneumothorax (SSP). METHODS: Twenty-four patients who were scheduled to undergo single-port VATS for SSP were studied. The medical records of the patients were retrospectively reviewed. The mean follow-up duration was 26.1+/-19.8 months. In order to evaluate the feasibility of single-port VATS for SSP, the postoperative results of single-port VATS (n=15) in patients with emphysema were compared with those of emphysematous patients who underwent three-port VATS (n=15) during the study period. RESULTS: Single-port VATS was feasible in 19 of 24 patients (79.2%), while an additional port was needed in five patients. In the single-port VATS patients, the median operation time, duration of chest tube drainage, and hospital stay were 84.0 minutes, one day, and two days, respectively. Postoperative complications included prolonged chest tube drainage for more than five days (n=1), wound infection (n=1), and vocal fold palsy (n=1). No recurrence of pneumothorax was observed during the follow-up period. The median operation time, duration of chest tube drainage, and hospital stay of the emphysematous patients who underwent single-port VATS were shorter than those who underwent three-port VATS group (p<0.05 for all parameters). CONCLUSION: Single-port VATS proved to be a feasible procedure in the treatment of patients with secondary spontaneous pneumothorax.

Effects of Alveolar Recruitment and Positive End-Expiratory Pressure on Oxygenation during One-Lung Ventilation in the Supine Position

PURPOSE: Hypoxemia during one-lung ventilation (OLV) remains a serious problem, particularly in the supine position. We investigated the effects of alveolar recruitment (AR) and positive end-expiratory pressure (PEEP) on oxygenation during OLV in the supine position. MATERIALS AND METHODS: Ninety-nine patients were randomly allocated to one of the following three groups: a control group (ventilation with a tidal volume of 8 mL/kg), a PEEP group (the same ventilatory pattern with a PEEP of 8 cm H2O), or an AR group (an AR maneuver immediately before OLV followed by a PEEP of 8 cm H2O). The tidal volume was reduced to 6 mL/kg during OLV in all groups. Blood gas analyses, respiratory variables, and hemodynamic variables were recorded 15 min into TLV (TLVbaseline), 15 and 30 min after OLV (OLV15 and OLV30), and 10 min after re-establishing TLV (TLVend). RESULTS: Ultimately, 92 patients were analyzed. In the AR group, the arterial oxygen tension was higher at TLVend, and the physiologic dead space was lower at OLV15 and TLVend than in the control group. The mean airway pressure and dynamic lung compliance were higher in the PEEP and AR groups than in the control group at OLV15, OLV30, and TLVend. No significant differences in hemodynamic variables were found among the three groups throughout the study period. CONCLUSION: Recruitment of both lungs with subsequent PEEP before OLV improved arterial oxygenation and ventilatory efficiency during video-assisted thoracic surgery requiring OLV in the supine position.

Autophagy Activity in Pulmonary Metastatic Tumor Tissues from Colorectal Cancer: A Pilot Study

PURPOSE: Autophagy has been reported to be involved in treatment failure in tumor. We aimed to evaluate autophagy activity in tumor tissue and compare them between the recurrence and non-recurrence groups. MATERIALS AND METHODS: We analyzed expressions of autophagy-related proteins in tumor tissues which were obtained from pulmonary metastases of colorectal cancer patients by Western blot. We also analyzed autophagosomes by transmission electron microscopy. RESULTS: Tumor tissues from recurrence group showed increased levels of LC3B-II, decreased levels of p62/SQSTM1, and also a marked accumulation of autophagosomes compared with tissues from non-recurrence group. CONCLUSION: The present study suggests that autophagy may be associated with treatment failure of metastatic colorectal cancer.

Predictors of Recurrence after Thymoma Resection

PURPOSE: Recurrence rate is considered a better measure of clinical outcomes after thymoma resection than overall survival due to the indolent behavior of thymomas. This study was designed to determine predictors of recurrence after thymoma resection. MATERIALS AND METHODS: A single-institution, retrospective study was performed, including 305 patients who had undergone thymoma resection between 1986 and 2009. RESULTS: Among 305 patients, recurrence was observed in 41 patients (13.4%). The recurrence rates were 0% (0/19), 6.3% (4/63), 4.2% (2/48), 18.6% (11/59) and 20.7% (24/116) for type A, AB, B1, B2 and B3 tumors, respectively. The recurrence rate according to Masaoka stage was 6.1% (8/132), 11.4% (13/114), 26.8% (11/41) and 50.0% (9/18) for stages I, II, III and IV, respectively. After univariate analysis, completeness of resection (R0 versus R1), World Health Organization (WHO) histologic type (A, AB, B1 versus B2, B3), Masaoka stage, and size of tumor ( or =8 cm) demonstrated significant differences with freedom from recurrence. Upon multivariate analysis, Masaoka stage was the only independent predictor of recurrence. CONCLUSION: WHO histologic type, Masaoka stage, and size of tumor were associated with recurrence. Particularly, Masaoka stage was the only independent predictor of recurrence after thymoma resection.

Myxoinflammatory Fibroblastic Sarcoma in the Chest Wall

Myxoinflammatory fibroblastic sarcoma (MIFS) is a recently defined rare tumor. It is mainly found in the upper and lower extremities of adults. Due to its high local recurrence rate and low metastatic rate, it is classified as a low grade-malignancy. Accurate diagnosis and early, wide excision are important for prognosis. Herein, we report a case of MIFS in a 35-year-old male patient that presented in an unusual location, the left chest wall. To our knowledge, this is the first reported case of MIFS in Korea and the second case to be reported within the global scientific literature involving the chest wall.

Changes in the Demographics and Prognoses of Patients with Resected Non-Small Cell Lung Cancer: A 20-Year Experience at a Single Institution in Korea

The demographics and prognosis of non-small cell lung cancer patients have changed during the last few decades. We conducted this study to assess the change in demographics and prognosis in resected non-small cell lung cancer patients during a 20-yr single-institution study in Korea. We retrospectively reviewed the medical records of 2,076 non-small cell lung cancer patients who underwent pulmonary resection between 1990 and 2009. Their clinical characteristics and survival were analyzed over a five-year period. With time, the proportions of female, adenocarcinoma, stage IA, and lobectomy patients increased, whereas the proportions of male, squamous cell carcinoma, stage IIIA, and pneumonectomy patients decreased. These demographic changes caused improved prognosis. The five-year survival rate of all patients was 53.9%. The five-year survival rate increased from 31.9% in 1990-1994, to 43.6% in 1995-1999, 51.3% in 2000-2004, and 69.7% in 2005-2009 (P < 0.001). In conclusion, among patients with resected non-small cell lung cancer, the proportions of female, adenocarcinoma, stage IA, and lobectomy patients have increased, and the five-year survival rate has gradually improved during the last 20 yr in Korea.

Immediate Postoperative Care in the General Thoracic Ward Is Safe for Low-risk Patients after Lobectomy for Lung Cancer

BACKGROUND: Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer. MATERIALS AND METHODS: 316 patients who had undergone lobectomy for lung cancer were reviewed. These patients were divided into two groups: 275 patients were cared for in the ICU while 41 patients were care for in the GTW immediately post-operation. After propensity score matching, postoperative complications and hospital costs were analyzed. Risk factors for early complications were analyzed with the whole cohort. RESULTS: Early complications (until the end of the first postoperative day) occurred in 11 (3.5%) patients. Late complications occurred in 42 patients (13.3%). After propensity score matching, the incidence of early complications, late complications, and mortality were not different between the two groups. The mean expense was higher in the ICU group. Risk factors for early complications were cardiac comorbidities and low expected forced expiratory volume in one second. The location of postoperative care had no influence on outcome. CONCLUSION: Immediate postoperative care after lobectomy for lung cancer in a GTW was safe and cost-effective without compromising outcomes in low-risk patients.

Mediastinoscopic Bilateral Bronchial Release for Long Segmental Resection and Anastomosis of the Trachea

The extent of resection and release of the trachea is important for successful anastomosis. Bilateral bronchial dissection is one of the release techniques for resection of the lower trachea. We present the experience of cervical video-assisted mediastinoscopic bilateral bronchial release for long segmental resection and anastomosis of the lower trachea.

N-Terminal Pro-B-type Natriuretic Peptide Is Useful to Predict Cardiac Complications Following Lung Resection Surgery

BACKGROUND: Cardiovascular complications are major causes of morbidity and mortality following non-cardiac thoracic operations. Recent studies have demonstrated that elevation of N-Terminal Pro-B-type natriuretic peptide (NT-proBNP) levels can predict cardiac complications following non-cardiac major surgery as well as cardiac surgery. However, there is little information on the correlation between lung resection surgery and NT-proBNP levels. We evaluated the role of NT-proBNP as a potential marker for the risk stratification of cardiac complications following lung resection surgery. MATERIAL AND METHODS: Prospectively collected data of 98 patients, who underwent elective lung resection from August 2007 to February 2008, were analyzed. Postoperative adverse cardiac events were categorized as myocardial injury, ECG evidence of ischemia or arrhythmia, heart failure, or cardiac death. RESULTS: Postoperative cardiac complications were documented in 9 patients (9/98, 9.2%): Atrial fibrillation in 3, ECG-evidenced ischemia in 2 and heart failure in 4. Preoperative median NT-proBNP levels was significantly higher in patients who developed postoperative cardiac complications than in the rest (200.2 ng/L versus 45.0 ng/L, p=0.009). NT-proBNP levels predicted adverse cardiac events with an area under the receiver operating characteristic curve of 0.76 [95% confidence interval (CI) 0.545~0.988, p=0.01]. A preoperative NT-proBNP value of 160 ng/L was found to be the best cut-off value for detecting postoperative cardiac complication with a positive predictive value of 0.857 and a negative predictive value of 0.978. Other factors related to cardiac complications by univariate analysis were a higher American Society of Anesthesiologists grade, a higher NYHA functional class and a history of hypertension. In multivariate analysis, however, high preoperative NT-proBNP level (>160 ng/L) only remained significant. CONCLUSION: An elevated preoperative NT-proBNP level is identified as an independent predictor of cardiac complications following lung resection surgery.

Respiratory Support by Performing Percutaneous CardiopulmonarySupport (PCPS) for Tracheal Resection and Reconstruction in Patients withSevere Distal Tracheal Stenosis / 대한흉부외과학회지

Surgery on the distal trachea or the carina presents special problems for maintaining the airway and systemic oxygenation. Cardiopulmonary bypass is an alternative method for respiratory support for the patients with these conditions. Percutaneous cardiopulmonary support (PCPS) applied under local anesthesia has recently been used for respiratory support in tracheal surgery and the outcome is satisfactory. We encountered a patient who had severe distal tracheal stenosis after prolonged intubation. We had a gratifying result with performing tracheal resection and repair under the support of PCPS.

Cause-specific Analysis of Risk Factors in Completely Resected Pathologic Stage Ia Non-small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Lobectomy and more extended anatomic resection are regarded as standard treatment for stage Ia non-small cell lung cancer, but approximately 15~40% of patients suffer from treatment failures such as cancer recurrence or death. The authors analyzed types and causes of treatment failures in surgically treated cases of stage Ia non small cell lung cancer. MATERIAL AND METHOD: We retrospectively reviewed the medical records of 156 patients who had undergone complete resection for stage Ia NSCLC between Jan 1992 and Aug 2005. Patients were divided into two different treatment failure groups: cancer-related deaths and non-cancer-related deaths. Risk factors were analyzed in each group by the Kaplan-Meyer survival method and the Cox proportional hazard model. RESULT: Among the 156 patients, 93 were males; the mean age was 61. The median follow-up period was 33.8 months. The 5 year survival rate was 87.6%. Microscopic lympho-vascular permeation was reported in 10 patients. Recurrence was reported in 19 patients and 12 patients died due to recurrent lung cancer. Non- cancer related deaths occurred in 16 patients. Risk factors for cancer recurrence and cancer related death were microscopic lympho-vascular permeation (HR=6.81, p=0.007, HR=7.81, p<0.001); for non-cancer related death, risk factors were pneumonectomy (HR=25.92, p=0.001) and postoperative cardiopulmonary complications (HR=29.67, p=0.002). CONCLUSION: After complete resection of stage Ia non small cell lung cancer patients, mortality includes not only cancer related deaths but also cancer unrelated deaths. Adjuvant chemotherapy is advised for patients who show microscopic lympho-vascular permeation, which is a risk factor for recurrence and for cancer related death. Patients who had pneumonectomy or who suffered from cardiac or respiratory complications need meticulous care in order to reduce comorbidity-induced death.

Restoration of Blood Pressure after Administering Methylene Blue for Vasoplegic Syndrome, which Developed after Open Heart Surgery for Septic Infective Endocarditis: A case report / 대한흉부외과학회지

Vasoplegic syndrome occurs in 8~10% of patients following cardiac surgery, and this happens in part because of inducing the inflammatory response. Nitric oxide and guanylate cyclase play an important role in this response, and this is associated with increased morbidity and mortality. For our case, we administered methylene blue (MB), an inhibitor of guanylate cyclase, early after performing cardiopulmonary bypass in a patient with vasoplegic syndrome. The patient recovered immediately after MB administration and maintained an optimal blood pressure without the aid help of any vasopressors.

Ten Years Experiences of ATS Mechanical Valve / 대한흉부외과학회지

BACKGROUND: This study is to evaluate the safety of ATS valve by examining the clinical results of ten-years experience. MATERIAL AND METHOD: From July 1995 to March 2005, we reviewed 305 patients with ATS valve implantation. Mean age was 49.8+/-11.7 years and 140 (45.6%) males were included. Etiologies were rheumatic diseases in 207 cases (67.4%), degenerative changes in 57 cases (18.6%), valve dysfunction in 23 cases (7.5%) and infective endocarditis in 14 cases (4.6%). AVR was performed in 72 patients (23.5%), MVR in 156 patients (50.8%), DVR (AVR+MVR) in 63 patients (20.5%) and TVR in 16 patients (5.2%). RESULT: There were 9 operative mortalities (2.9%). Follow up period was 56.5+/-34.0 (0~115) months and 96.4% patients were followed up with 9 late deaths. Five and ten years survival rates were 94.9 +/-1.3%, 91.2+/-2.3% using Kaplan-Meier's methods. Valve related event free survival rates in 5 and 10 years were 90.8+/-2.0% and 86.9+/-3.2%. There were 16 anticoagulation-related hemorrhages, 6 thromboembolisms, 3 prosthetic valve endocarditis and 1 paravalvular leakage. NYHA class improved after operation (p <0.05). Postoperative echocardiography showed significant decrease in LA size, LVEDD and LVESD (p <0.01). Patients with 19 and 21 mm valve showed significantly higher transvalvular pressure gradient in aortic position (p <0.001, p <0.001). CONCLUSION: ATS valve showed good hemodynamic results with few valve related complications and thus can be used with acceptable risk.

The Comparison Study of Early and Midterm Clinical Outcome of Off-Pump versus On-Pump Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction (LVEF< or =35%) / 대한흉부외과학회지

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) has been proven to result in less morbidity. The patients who have left ventricular dysfunction may have benefits by avoiding the adverse effects of the cardiopulmonary bypass. The present study compared early and midterm outcomes of off-pump versus on-pump coronary artery bypass grafting (On pump CABG) in patients with severe left ventricular dysfunction. MATERIAL AND METHOD: Ninety hundred forth six patients underwent isolated coronary artery bypass grafting by one surgeon between January 2001 and Febrary 2005. Data were collected in 100 patients who had left ventricular ejection fraction (LVEF) less than 35% (68 OPCAB; 32 On pump CABG). Mean age of patients were 62.9+/-9.0 years in OPCAB group and 63.8+/-8.0 years in On pump CABG group. We compared the preoperative risk factors and evaluated early and midterm outcomes. RESULT: In OPCAB and On pump CABG group, mean number of used grafts per patient were 2.75+/-0.72, 2.78+/-0.55 and mean number of distal anastomoses were 3.00+/-0.79, 3.16+/-0.72 respectively. There was one perioperative death in OPCAB group (1.5%). The operation time, ventilation time, ICU stay time, CK-MB on the first postoperative day, and occurrence rate of complications were significantly low in OPCAB group. Mean follow-up time was 26.6+/-12.8 months (4~54 months). Mean LVEF of OPCAB and On pump CABG group improved significantly from 27.1+/-4.5% to 40.7+/-13.0% and 26.9+/-5.4% to 33.3+/-13.7%. The 4-year actuarial survival rate of OPCAB and On pump CABG group were 92.2%, 88.3% and the 4-year freedom rates from cardiac death were 97.7%, 96.4% respectively. There were no significant differences between two groups in 4 year freedom rate from cardiac event and angina. CONCLUSION: OPCAB improves myocardial function and favors early and mid-term outcomes in patients with severe left ventricular dysfunction compared to On pump CABG group. Therefore, OPCAB is a preferable operative strategy even in patients with severe left ventricular dysfunction.

Prognostic Factors of Thymic Carcinoma / 대한흉부외과학회지

BACKGROUND: Thymic carcinoma is a rare malignant disease with sparse data for treatment and prognosis. We intended to investigate the prognostic factors of thymic carcinoma. MATERIAL AND METHOD: Data of 42 patients, who were diagnosed and treated for thymic carcinoma from January of 1986 to August of 2003 were reviewed retrospectively. Influences of characteristics of patients, Masaoka stage, histologic grade, completeness of resection and adjuvant treatment on survival were evaluated. RESULT: There were 30 male and 12 female patients and their mean age was 52.0+/-15.7 years old. There were 28 patients with low-grade histology and 13 patients with high- grade histology. Clinical stage according to Masaoka stage were I in 2, II in 2, III in 15 (35.7%), IVa in 10 (23.8%), and IVb in 13 (31%) patients. Surgical resection was done in 22 patients. Complete resection was possible in 13 patients and incomplete resection was done in 9 patients. Among 20 patients without resection, 8 patients received chemotherapy, 7 patients received radiotherapy and 5 patients received combined therapy. Median survival time was 31.7+/-6.1 months and 5 year survival rate was 28.6%. High grade histology (hazard ratio=3.009, 95% confidence interval=1.178~7.685, p=0.021) and incompleteness of resection (hazard ratio=3.605, 95% confidence interval=1.154~11.580, p=0.023) were the prognostic factors of thymic carcinoma. CONCLUSION: In thymic carcinoma, low grade histology is a good prognostic factor and complete resection can prolong the survival of patients.

Sugical Treatment of Ruptured Hemangiopericytoma of the Lung: One case report / 대한흉부외과학회지

Hemangiopericytoma of the lung is a very rare malignant tumor despite it's high vasculities of the lung, because this tumor arises from the pericytes enveloping capillaries. A pulmonary hemangiopericytoma was diagnosed in a 63-year-old female who had complained of cough, sputum, and intermittent chest pain for about 8 years. She was admitted to our hospital, because of progressive severe dyspnea on exertion and orthopnea for about 3 months. She was taken explothoracotomy and left pneumonectomy including evacuation of lots of blood clots due to ruptured large tumor and ineffective drainage with closed thoracic tube. She was discharged at post-operative 7 days under very good condition. She has been treated with radiotherapy&chemotherapy since then.