Oncological issues in staging mediastinal lymph node metastasis for left lung cancer.

OBJECTIVE: We aimed to discuss the underlying oncological issues in staging of mediastinal lymph node metastasis in patients with left lung cancer who underwent extended radical lymphadenectomy (ERL). METHODS: This multi-institutional retrospective study analyzed 116 patients with left non-small-cell lung cancer who underwent bilateral paratracheal lymph node dissection (ERL) via median sternotomy. The clinicopathological records of patients with mediastinal lymph node metastasis were examined for prognostic factors, including age, sex, histology, tumor size, cN number, preoperative data, metastatic stations (number and distribution), pT, and adjuvant chemotherapy. RESULTS: Mediastinal lymph node metastases were found in 43 patients, and right paratracheal lymph node metastases (pN3) were found in 13 patients. The 5-year overall survival rate was 25.2% in patients with pN3 tumors (n = 13) and 23.1% in patients with pN2 tumors (n = 30). The prognosis did not differ between patients with pN3 and pN2. Univariate analyses showed that histology, cN, and adjuvant chemotherapy were significant prognostic factors in patients with mediastinal lymph node metastasis. In these 43 patients, cN and adjuvant chemotherapy were significant independent prognostic factors in multivariate analysis. CONCLUSIONS: The prognostic factors for left lung cancer with mediastinal lymph node metastasis were cN status and adjuvant chemotherapy, and not pN status (pN2 or pN3). We hope that the study results, which suggest that there may be no difference in prognosis between pN2 and pN3, would broaden the discussion of oncological issues in the staging of mediastinal lymph node metastasis of left lung cancer.

Partial pleural covering for intractable pneumothorax in patients with Birt-Hogg-Dubé Syndrome.

BACKGROUND AND AIMS: Birt-Hogg-Dubé syndrome (BHD) is an inherited disorder associated with a germline mutation of the folliculin (FLCN) gene. Most patients with BHD have multiple pulmonary cysts, and are at high risk of repeated pneumothorax. Although an increasing number of patients are diagnosed with BHD by genetic testing, therapeutic approaches for intractable pneumothorax have not yet been described. METHODS: We treated three patients who had repeated episodes of pneumothorax. All had multiple pulmonary cysts in the lower lobes, and two had a family history of pneumothorax. Video-assisted thoracic surgery was used to perform wedge resections and partial pleural covering of the cystic lesions. The partial pleural covering technique used sheets of polyglycolic acid felt or regenerative oxidized cellulose mesh. The resected tissues underwent histopathological evaluation, and peripheral blood leukocytes were tested for FLCN mutations. RESULTS: The operative times were less than 2 h, and there were no complications. The resected cysts had histopathological features characteristic of BHD lung. All patients were found to have FLCN germline mutations; thus their repeated pneumothoraces were a manifestation of BHD. None of the patients developed respiratory problems after undergoing the partial pleural covering procedure, and they have all been well without pneumothorax for 30 months or more. CONCLUSIONS: Partial pleural covering combined with resection of protruding cysts should be a safe and effective therapeutic approach for BHD patients with intractable pneumothorax. Further investigation is needed to establish a detailed protocol for treatment of pneumothorax that results in minimal functional impairment.

Congenital bronchial atresia with partial anomalous pulmonary venous return.

A 35-year-old woman with a high fever had a cystic lesion of the right lung including fluid and air. She was diagnosed with an infected bronchial cyst caused by congenital bronchial atresia with partial anomalous pulmonary venous return. She underwent a right upper lobectomy successfully. Patients with congenital bronchial atresia often have recurrent pulmonary infections with various imaging findings. The aberrant vein may relate to interruption of the bronchus in a patient with partial anomalous pulmonary venous return. Although segmental resection is recommended for this benign disease, lobar resection may be unavoidable because of adhesions or destruction of adjacent segments.

Safety and prognosis of limited surgery for octogenarians with non-small-cell lung cancer.

PURPOSE: Curative lobectomy and systematic lymph node dissection for lung cancer in elderly patients are often associated with increased risk of postoperative morbidity and decreased quality of life. Conversely, avoiding surgery may mean not curing the cancer. We retrospectively examined data on surgery for octogenarians with clinical stage I non-small-cell lung cancer (NSCLC) to assess the safety and prognosis for patients who underwent radical or limited surgery. METHODS: Subjects comprised 44 octogenarians who underwent surgery for clinical stage I NSCLC from 1996 to 2008. Preoperative co-morbidities, surgical procedures, postoperative morbidity, and prognoses were compared between radical and limited surgery. RESULTS: A total of 14 patients (32%) underwent complete lobectomy and systematic lymph node dissection (radical surgery), and 30 patients (68%) underwent segmentectomy or wedge resection or limited lymph node dissection (limited surgery). No significant differences in preoperative clinicopathological features were seen between groups except that significantly more clinical stage IA patients were in the limited surgery group than in the radical group. Surgical time was significantly shorter with limited surgery. Frequencies of postoperative morbidity and recurrence were similar for each type of surgery. Overall and disease-specific 5-year survival rates did not differ significantly between groups. CONCLUSION: Limited surgery is less invasive and is associated with the same prognosis as radical surgery for octogenarians with NSCLC. Limited surgery for this cohort thus appears reasonable to prevent postoperative morbidity, particularly for patients with poor pulmonary reserve.

[Surgical results for second primary lung cancer].

Of 897 patients who underwent operation for lung cancer between April 1996 and March 2010, 57 patients underwent pulmonary resection for 2nd primary lung cancer. There were 44 men and 13 women. The average age at the 2nd operation was 71. The initial pulmonary resection was lobectomy in 49 patients, segmentectomy in 4 and wedge resection in 4. The 2nd pulmonary resection was lobectomy in 10 patients, segmentectomy in 12 and wedge resection in 35. Preoperative stage of the 2nd primary lung cancer was IA in 43, IB in 13 and IIB in 1. Postoperative stage was IA in 38, IB in 10, IIA in 1, IIB in 3, IIIA in 2 and IIIB in 3. Surgical complications occurred in 4, but there were no perioperative deaths. The 5-year survival rate for 2nd primary lung cancers was 59.9%. The 5-year survival rate for patients treated with wedge resection was 71.1%. The 5-year survival rate of the patients with p-stage IA was 72.7%, and that for patients with p-stage IB or more advanced diseases was 32.9%. We conclude that an aggressive surgical approach for a 2nd primary lung cancer is effective and is linked with good outcome if the tumor is detected at stage IA, when the possible cure by performing wedge resection is promissing.

Intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration.

OBJECTIVE: The aim of this study was to assess the adequacy of our intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration. METHODS: Patients who had stage IA non-small cell lung cancer (NSCLC) with a maximum tumor diameter of 2 cm or less were candidates for limited resection. If bronchioloalveolar carcinoma (BAC) was suspected on computed tomography and intraoperative pathologic exploration revealed the lesion as BAC without foci of active fibroblastic proliferation (Noguchi type A and B), wedge resection was performed. If the tumor was not suspected of being Noguchi type A or B, extended segmentectomy with intraoperative lymph node exploration was performed. RESULTS: Limited resection was performed in 34 patients, wedge resection in 14, and extended segmentectomy in 20. The median follow-up period after wedge resection was 36 months, and all patients are alive with no signs of recurrence. The median follow-up period after extended segmentectomy was 54 months. No local recurrences were found, but distant metastasis was diagnosed in one patient. The 5-year survival rate after extended segmentectomy was 93%. In the same period, lobectomy was performed in 57 patients with stage IA NSCLC with a maximum tumor diameter of 2 cm or less, and the 5-year survival rate was 84%. There were no significant differences in 5-year survival between extended segmentectomy and lobectomy. CONCLUSIONS: Careful selection of patients based on high-resolution computed tomography findings and intraoperative pathologic exploration makes intentional limited resection an acceptable option for the treatment of small peripheral NSCLC.

Registration of resected lung cancer in Niigata Prefecture.

OBJECTIVES: Our registration of surgically treated lung cancer patients in Niigata Prefecture began in 2001. The purpose of this study was to identify the characteristics of patients and surgical treatment of lung cancer. METHODS: All patients who underwent resection for lung cancer in Niigata Prefecture from January 2001 to December 2002 were eligible for registration. A total of 31 medical data for each patient were registered. RESULTS: During the 2-year period, 1,211 patients were registered. A total of 605 cases (50%) were detected by mass screening, and 874 cases (72%) were diagnosed preoperatively. There were 718 (59%) c-stage IA cases and 317 (26%) c-stage IB cases. The most common operative procedure was lobectomy; 850 patients underwent single lobectomy. Limited resection was performed in 301 patients (25%), and video-assisted thoracoscopic surgery in 193 (16%). The most common histological type was adenocarcinoma in 860 cases (71%), followed by squamous cell carcinoma in 273 (23%). Pathologic staging yielded stage IA in 635 cases (52%) and stage IB in 262 (22%). CONCLUSIONS: The results of our registration demonstrate a very high ratio of surgically treated stage IA cases in Niigata Prefecture and that limited resection was performed in many patients. Accumulation of these data will reveal the characteristics of lung cancer surgically treated in Niigata Prefecture and will provide a basis for determining the future course of surgical treatment for lung cancer. Registration is continuing, and it will provide new and useful information about lung cancer, eventually including 5-year survival data.

The impact of residual multi-level N2 disease after induction therapy for non-small cell lung cancer.

BACKGROUND: The presence of residual N2 disease following induction therapy for locally advanced non-small cell lung cancer (NSCLC) has been proposed as a contraindication to surgery. However, single level N2 metastases found in the operative specimens of patients with clinical N0 NSCLC who did not receive induction therapy is associated with prolonged survival. In order to investigate whether residual single level N2 disease following induction therapy was similarly associated with prolonged survival, we conducted a retrospective review of patients with stages IIIa and IIIb NSCLC who had undergone induction therapy followed by surgery. METHODS: A retrospective review was performed of the hospital records of patients with stages IIIa and IIIb NSCLC who had undergone induction therapy consisting of chemotherapy and/or radiotherapy followed by tumor resection and mediastinal lymph node dissection at 11 Japanese national referral hospitals. Survival was analyzed by the Kaplan-Meier method and prognostic factors were determined by the log-rank and Cox regression methods. RESULTS: One hundred thirty-one patients underwent induction therapy of NSCLC stages IIIa (n=95) and IIIb (n=36) followed by complete tumor resection during a 12-year interval. Clinical N2 disease was present in 114 (87%) patients and N3 disease in 17 (13%) patients. Median follow up was 48 months. Eighteen patients had residual single level N2 disease and 25 patients had multiple residual N2 level metastases. The 5-year survival was 54% for patients with pathologic single level N2 disease and 11% for patients with multiple N2 level disease (P<0.01). In a multivariate analysis, only the pathologic N status significantly influenced survival. CONCLUSION: Patents who have multiple levels of N2 disease have a much worse prognosis than patients who have single level of N2.

Surgical strategy for clinical stage I non-small cell lung cancer in octogenarians.

OBJECTIVE: The purpose of this study was to determine whether lobectomy without radical systematic mediastinal lymphadenectomy (LA) is a satisfactory alternative surgical treatment for octogenarians with clinical stage I non-small cell lung cancer (NSCLC). METHODS: From April 1985 through December 2001, 49 patients aged 80 years and older who underwent surgical treatment for clinical stage I NSCLC were reviewed. Lobectomy without radical systematic mediastinal LA was performed for 27 patients (LA0 group) and lobectomy with radical systematic mediastinal LA was performed for 22 patients (LA group). RESULTS: The mortality rate was 0% in the LA0 group and 4.5% in the LA group. Five-year survival rate according to the type of surgery was 44.8% in the LA0 group and 55.5% in the LA group, a difference that was not significant (P=0.88). Although there was no significant statistical difference, postoperative pulmonary complication was more frequent in the LA group than in the LA0 group (32% in the LA group versus 11% in the LA0 group P=0.07). Five-year survival rates according to serum carcinoembryonic antigen (CEA) levels were 0% for patients with elevated CEA levels (n=9) and 56.5% for patients with normal CEA levels (n=40) (P<0.01). CONCLUSION: Lobectomy without radical systematic mediastinal LA appears to be a satisfactory surgical procedure for octogenarians with clinical stage I NSCLC. However, mediastinoscopy is necessary in such octogenarians if their serum CEA level is elevated so that the precise clinical stage can be determined and an accurate prognosis can be given.