Verification of the eighth edition of the UICC-TNM classification on surgically resected lung adenocarcinoma: Comparison with previous classification in a local center.

BACKGROUND: The UICC 8th TNM classification of lung cancer has been changed dramatically, especially in measuring methods of T-desriptors. Different from squamous- or small-cell carcinomas, in which the solid- and the invasive-diameter mostly agree with each other, the diameter of the radiological solid part and that of pathological invasive part in adenocarcinomas often does not match. AIM: We aimed to determine radiological and pathological tumor diameters of pulmonary adenocarcinomas with clinicopathological factors and evaluate the validity of the 8th edition in comparison with the 7th edition. METHODS AND RESULTS: We retrospectively analyzed clinicopathological factors of 429 patients with surgically resected pulmonary adenocarcinomas. The maximum tumor and their solid-part diameters were measured using thin-sectioned computed tomography and compared with pathological tumor and invasive diameters. Overall survival (OS) rate was determined using the Kaplan-Meier method for different subgroups of clinicopathological factors. Akaike's information criteria (AIC) was used as a discriminative measure for the univariate Cox model for the 7th and 8th editions. Multivariate Cox regression analysis was performed to explore independent prognostic factors. Correlation coefficients between radiological and pathological diameters in the 7th and 8th editions were 0.911 and 0.888, respectively, without a significant difference. The major reasons for the difference in the 8th edition were the presence of intratumoral fibrosis and papillary growth pattern. The weighted kappa coefficients in the 8th edition were superior those in the 7th edition for both the T and Stage classifications. In the univariate Cox model, AIC levels were the lowest in the 8th edition. Multivariate analysis revealed that age, lymphovascular invasion, pT(8th), and stage were the most important determinants for OS. CONCLUSION: The UICC 8th edition is a more discriminative classification than the 7th edition. For subsolid nodules, continuous efforts are necessary to increase the universality of the measurement of solid and invasive diameters.

[Thoracoscopic Surgery by Thin Thoracoscope with Fine Needlescopic Forceps for Cavernous Hemangioma in the Chest Wall].

A 27-year-old women was referred to our hospital because of abnormal subpleural nodule in her right thoracic cavity. Chest computed tomography demonstrated an 11 mm nodule with smooth and clear boundary adjacent to the right first rib. Chest magnetic resonance imaging revealed an iso-intensity area on T1-weighted images, a high-intensity on T2-weighted images, and enhanced homogeneously on contrast-enhanced images. Tumor extirpation was performed using a 2.7 mm grasp fine needlescopic forceps, a 3 mm thoracoscope and a 5 mm vascular sealing device. The histological diagnosis was cavernous hemangioma. Thoracoscopic surgery using fine needlescopic forceps and thin thoracoscope is useful in considering esthetic purposes.

[Surgical Treatment to Bilateral Multiple Primary Lung Cancer Patients].

OBJECTIVES: Multiple primary lung cancer( MPLC) has increased due to the extensive detection survey and patient's life-prolonging, but the treatment strategy remains disputable. There is no consensus on the surgical treatment strategy, especially for bilateral multiple primary lung cancer (BMPLC) among MPLC. This paper aimed to discuss the surgical strategy in patients with bilateral multiple lung cancer by our experiences of surgical outcomes. METHODS: Patients who underwent curative operations for BMPLC based on the Martini-Melamed criterion and oncogene mutation analysis between January 2007 and May 2019 in Ishikawa Prefectural Central Hospital were reviewed retrospectively. RESULTS: We studied 53 patients( 26 males and 27 females, from 64~84 years of age) with MPLC, 43 patients with metachronous lesions, and 10 patients with synchronous lesions. The type of resection for the first tumor was lobectomy 35( 66.0%) and segmentectomy or wedge, 18( 34.0%), and for the second tumor was lobectomy 5( 9.4%) and segmentectomy or wedge, 17( 32.1%) respectively. Bilateral lobectomies underwent in four cases. Histologic classification was similar in 62.3% of patients. Overall survival at five years after the second operation was 75.1%, respectively. There was no difference in subgroups of lobectomy and limited resection (wedge or segmentectomy). Respiratory function in four patients performed with bilobectomy is enough before the second surgery( % vital capacity:84~136%, forced expiratory volume in one second:1,490~3,400 ml, DLco:82~151%). There was no postoperative complication, but one patient suffered from low respiratory function and indications for oxygen therapy at 99 days after the second operation. CONCLUSIONS: We selected the surgical procedures that preserve much lung tissues for BMPLC. Bilateral lobectomy did not usually perform in most cases. However, bilobectomy was no contraindication for BMPLC if a preoperative respiratory function was enough for the second tumor.

[Improved Method of Closure of Chest Drain Wound by Barbed Suture].

In this report, chest drain wound closure using barbed suture material in patients with thoracic disease is presented. From October to December 2019, 77 patients underwent thoracic surgery and closed chest drain wound using barbed suture material. Of them,( median age 67 years, range 16 to 89 years) 51 were men (66%) and 26 were women. Most was 50 cases of primary lung cancer (65%). Chest tube was inserted after continuous subcutaneous suture by barbed suture material. The mean chest tube duration was 2.3±0.6. No harmful events due to this procedure nor wound complication during the median follow-up period of 1 months after operation were noted.

The Impact of Endoscopic Stapler Selection on Bleeding at the Vascular Stump in Pulmonary Artery Transection.

OBJECTIVE: To assess bleeding following transection of the pulmonary artery with powered and manual endoscopic staplers. METHODS: Cases of video-assisted and open-chest thoracic surgical procedures for non-small cell lung cancer at Ishikawa Prefectural Central Hospital were reviewed between 2012 and 2018. Three stapler groups were assessed: Group 1 - Ethicon ECHELON FLEXTM Powered Vascular Stapler (PVS), Group 2 - Medtronic Endo-GIATM iDriveTM powered stapler, Group 3 - Ethicon and Medtronic manual staplers. RESULTS: Of 239 patients, 82 cases (34.3%) were Group 1, 94 cases (39.3%) were Group 2 and 63 cases (26.4%) were Group 3. Mean age was 68.3 years (range 36-88 years), and most patients received video-assisted right upper lobectomy (82.8%). Bleeding occurred in 24 cases: 17 (70.8%) in Group 2 and 7 (29.2%) cases in Group 3. No bleeding occurred in Group 1. The loaded ECHELON FLEXTM PVS and Endo-GIATM iDriveTM with gray cartridge combinations had the greatest and smallest closed anvil jaw gaps (>0.63 µm and <0.15 µm, respectively); Endo-GIATM iDriveTM gray cartridge combinations resulted in ruptures of inner and middle membranes of the pulmonary artery. No ruptures were observed using the ECHELON FLEXTM PVS. CONCLUSION: An excessively narrow gap between cartridge and anvil may damage the blood vessel wall and lead to bleeding following transection. This study provides preliminary evidence that the use of the ECHELON FLEXTM PVS and tan cartridges for pulmonary artery stapling may help to prevent tissue damage and intraoperative bleeding.

What factors determine the survival of patients with an acute exacerbation of interstitial lung disease after lung cancer resection?

PURPOSES: Acute exacerbation of interstitial pneumonia (AEIP) is a leading cause of death after lung cancer resection in patients with interstitial lung disease. METHODS: We retrospectively analyzed 1763 patients with non-small cell lung cancer with a clinical diagnosis of interstitial lung disease (ILD) who underwent lung cancer resection between 2000 and 2009 at 61 hospitals in Japan. AEIP occurred in 164 of 1763 (9.3%) patients with a mortality rate of 43.9% (72/164). Univariate and multivariate analyses were carried out to identify possible risk factors of fatal AEIP. We then analyzed the 164 patients who developed postoperative AEIP and identified the preoperative and postoperative risk factors. RESULTS: A multivariate regression analysis identified that the sex, percent vital capacity, neoadjuvant radiation, preoperative history of AEIP, preoperative use of steroids, usual interstitial pneumonia pattern on CT, and surgical procedures were independent preoperative risk factors for death due to AEIP. ILD patients with emphysema somehow showed a lower risk of fatal AEIP than those without emphysema in this study. CONCLUSIONS: This study revealed eight risk factors for fatal AEIP.

[Results of Partial Atrial Resection in Advanced Lung Cancer].

The present study analyzed double centers experiences with extended combined resection of the left atrium in patients with lung cancer. From January 1972 to May 2017, 32 patients underwent lung resection with partial resection of the left atrium for lung cancer. Of them,( median age 62 years, range 40 to 79 years), 25 were men (78%) and 7 were women. Twenty-three pneumonectomies (72%)were performed, of which 19 (59%) were right sided. Dissection of the interatrial groove was completed in 4 patients( 36.3%). Extracorporeal circulation system was used in 4 patients( 12%). Pathological analysis of resected lymph nodes identified 6 patients (19%) with N0, 13 patients with N1 (40%) and 13 patients with N2( 40%). There were 17 squamous cell carcinomas( 53%), 8 adenocarcinomas( 25%), 3 pleomorphic carcinomas, 1 large cell carcinoma, 1 mucoepidermoid carcinoma, adenosquamous cell carcinoma and 1 combined small cell carcinoma and adenocarcinoma. Two patients underwent induction chemotherapy and 26 patients( 81.2%) underwent adjuvant treatment. With a median follow-up of 21.8 months (0~120), the 3 and 5-year survival rate after the surgical resection was 13.7% and 23.8 %. Since January 2000, 11 patients were operated, 3 and 5-year survival rate was 50.0 and 36.3%. Histological N0-1 was associated with better median overall survival(OS) compared with N2, with a corresponding 5-year OS rate of 18.9 and 7.7%, respectively.

The case of double primary lung adenocarcinomas with an EGFR mutation and ALK translocation successfully treated with alectinib at the post-surgical recurrence.

A 36-year-old male was found two nodules in the right lower lobe of the lung. After the surgical resection, both lesions were diagnosed as invasive adenocarcinomas. One lesion was primarily lepidic growth component with EGFR-L858R mutation, and the other was micropapillary component with ALK translocation accompanying mediastinal lymphnode metastases. While he experienced disease recurrence, the disease was controlled by an ALK inhibitor, given based on the findings of surgical specimens. This is the first case who had two simultaneous lung cancers with EGFR mutation and ALK translocation in each respective lesion, and was successfully treated with ALK inhibitor at the post-surgical recurrence. J. Med. Invest. 64: 305-307, August, 2017.

[Thoracoscopic Temporary Segmental Bronchus Incision Technique for Fissureless Lobectomy].

Several thoracoscopic fissureless lobectomy techniques have been reported;however, the indications for the same remain controversial. One of the reasons for conversion to open lobectomy is the swelling or inflammation of lymph nodes between the lobar bronchus and the adjacent pulmonary artery. In this report, we advocate temporary segmental bronchus incision technique(T-BIT)and describe its application for lung cancer patients with fused fissures. T-BIT involves initial segmental bronchus incision before lobar bronchus stapling to safely dissect the lymph nodes between the lobar bronchus and the pulmonary artery. Eight patients who underwent thoracoscopic fissureless lobectomy with T-BIT between August 2014 and August 2016 were included in the study. Five patients underwent left upper lobectomy, one underwent left lower lobectomy, and 2 underwent right middle lobectomy. With T-BIT, complete peribronchial lymph node dissection was easily performed in all patients. There were no intraoperative complications, such as pulmonary artery bleeding or pulmonary injury. The postoperative chest tube drainage time was 2.5±0.5 days. Taken together, T-BIT appears useful for lymph node dissection in thoracoscopic fissureless lobectomy.

[Extended Right Pneumonectomy with Partial Resection of the Left Atrium without Cardiopulmonary Bypass].

A 62-year-woman suffered a palpitation for 1 years and was admitted to our hospital with complaints of hemosputum. Chest computed tomography(CT) revealed right hilum tumor diffusely invaded to left atrium. The patient was resected without cardiopulmonary bypass, the interatrial groove (Waterston's or Sondergaard's groove) was carefully dissected and right pneumonectomy with systematic lymph nodes dissection and partial left atrium resection were performed. The posteoperative left atrial volume decreased to half of preoperative volume (from 73 ml to 36 ml) judging from 3D-CT scan. Her postoperative course was uneventful and palpitation, disappeared postoperatively. The histlogical examinarion revealed pleomorphic carcinoma with mediastinal single lymph nodes matastasis (#7), the pathological stage was pT4N2M0. She did not receive adjuvant chemotherapy, but has had no sign of recurrence for 3 years after surgery.

Intraoperative rupture of an interlobar bronchial artery aneurysm: a case report.

Here we report the rare case of an intraoperative bronchial artery aneurysm (BAA) rupture. An asymptomatic 52-year-old woman was found to have bilateral, multiple dilated bronchial arteries feeding the BAA that was further connected to the pulmonary artery on computed tomography and angiography. Transcatheter arterial embolization was thought not to be succeed. During a thoracoscopic procedure, the BAA ruptured suddenly and was treated with a thoracotomy under percutaneous cardiopulmonary support (PCPS). For anatomical complex BAA like the present case, the use of an open procedure and the preparation of PCPS are strongly recommended.

New indication for preoperative marking of small peripheral pulmonary nodules in thoracoscopic surgery.

The aim of this work was to analyze parameters to determine the possibility for detection of tumor location, and clarify the indication for preoperative marking of small peripheral pulmonary nodules in thoracoscopic resection. In a series of 97 patients who underwent video-assisted thoracoscopic surgery, information on standard uptake values (SUVs) and the detectability of tumor location was assessed. In patients whose lesions were <15 mm in diameter and where the distance to the pleura was >10 mm, lesions were not detected. Multivariate analysis to determine the factors related to the possibility of detecting tumor localization revealed that the distance to the pleural surface (P=0.0001), and the ratio of solid portion (P=0.0104) were statistically significant. In the non-solid tumor group, we should perform preoperative marking for tumors located more than 3 mm in depth from the visceral pleura. In the solid tumor group, the linear function (depth=0.4×size-0.9) may be used to separate detectable and undetectable groups. However, the sensitivity was 90.3% even if this formula was applied. Here we advocate the algorithm for detection of indication for preoperative marking using the ratio of solid portion, tumor size and SUV of fluorodeoxyglucose positron emission tomography.

[Lung adenocarcinoma originated from bulla wall accompanying spontaneous hemopneumothorax; report of a case].

A 68-year-old male was referred to our hospital for treatment of left hemopneumothorax. Chest X-ray film and chest computed tomography scans showed emphysematous bulla at the apical portion of the left lung, pleural effusion and atelectasis of the lingular segment and lower lobe of the left lung. He underwent bullectomy and decortication. On the 9 post operative days, the patient was discharged without complication. Pathological diagnosis was lung adenocarcinoma originated from bulla wall. We must recognize that cystic lung disease is a high risk factor of the lung cancer.

Double-barrel reconstruction for complex bronchial disruption due to blunt thoracic trauma.

We herein present a case of a 20-year-old man who presented with complex rupture of bronchus after blunt chest trauma. The involvement of both the main bronchus and right upper bronchus separately is unusual. Emergency double-barrel bronchial reconstruction was performed with complete preservation of the right lung. Such a serious bronchial injury with a positive outcome has not been reported so far. The features of this uncommon entity are discussed.

Management of tracheobronchial ulceration induced by high-dose brachytherapy.

The most severe complication of high-dose endobronchial brachytherapy is fatal hemoptysis. Intractable tracheobronchial ulceration due to high-dose endobronchial brachytherapy often develops into tracheobronchial necrosis and fatal hemoptysis. Our experience demonstrated that when bleeding from tracheobronchial ulcer, after high-dose endobronchial brachytherapy occurs, blocking the blood supply to the tracheobronchial ulcer alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis. This is the first report that describes an effective management for preventing fatal hemoptysis.

[Case with diffuse duodenitis and enteritis following total colectomy for ulcerative colitis].

A 25-year-old-woman with four years history of pancolonic ulcerative colitis (UC) underwent laparoscopy-assisted restorative proctocolectomy. She developed postoperatively abdominal pain, high fever, bloody diarrhea. Computed tomography showed thickening of duodenal and small intestinal wall, and endoscopic examination revealed diffuse mucosal edema, redness, erosion and ulceration involving duodenum, small intestine and ileal pouch that was similar in appearance to UC. She experienced massive melena five times and was successfully treated by transcatheter arterial embolization. Some antibiotics and prednisolone failed to decrease activity of the lesion but the symptoms and endoscopic findings improved since intravenous dexamethasone injection.