Lack of Association of Plasma Levels of Soluble Programmed Cell Death Protein 1, Programmed Death-Ligand 1, and CTLA-4 With Survival for Stage II to IIIA NSCLC After Complete Resection and Adjuvant Chemotherapy.

Introduction: Perioperative treatment in NSCLC has gained marked attention with the introduction of immune checkpoint inhibitors. Such a paradigm shift has given us additional opportunities to evaluate potential biomarkers in patients with these curable disease stages. Methods: This study (WJOG12319LTR) was designed as a biomarker study to evaluate whether soluble immune markers were prognostic or predictive on relapse-free survival in patients with stage II to IIIA NSCLC who underwent complete resection and adjuvant chemotherapy with cisplatin plus S-1, which is an oral fluoropyrimidine formulation that consists of tegafur, gimeracil, and oteracil, or S-1 alone in the previous WJOG4107 study. Archived plasma samples were assayed for soluble (s) forms of programmed cell death protein 1 (sPD-1), programmed death-ligand 1(sPD-L1), and CTLA-4 (sCTLA-4) with the highly sensitive HISCL system. Using time-dependent receiver operating characteristic curve analysis, the area under the curves were derived and optimal cutoff values were determined. Using the cutoff values, whether the marker was prognostic or predictive was assessed by survival analysis. Results: A total of 150 patients were included in the study. The time-dependent receiver operating characteristics analysis revealed that the area under the curves for sPD-1, sPD-L1, and sCTLA-4 were 0.54, 0.51, and 0.58, respectively. The survival analysis did not reject that hazard ratios were 1 in terms of the soluble immune marker and the treatment-marker interaction for all three markers. Conclusions: There was no proof that circulating concentrations of sPD-1, sPD-L1, and sCTLA-4 were prognostic or predictive factors of the outcome for adjuvant chemotherapy after complete resection in patients with NSCLC.

Detection of lymph node metastasis in non-small cell lung cancer using the new system of one-step nucleic acid amplification assay.

INTRODUCTION: The prognosis of non-small cell lung cancer greatly depends on the presence of lymph node metastasis, which limits the need for surgery and adjuvant therapy for advanced cancer. One-step nucleic acid amplification of cytokeratin19 (CK19) mRNA was used to detect lymph node metastasis. Automated Gene Amplification Detector RD-200 and the LYNOAMP CK19 gene amplification reagent as components of the new one-step nucleic acid amplification system, which has increased gene amplification efficiency by improving the reagent composition, have shorter preprocessing and measurement times than conventional systems. We aimed to compare the clinical performance of the new system with that of histopathology and the conventional system. MATERIALS AND METHODS: 199 lymph nodes from 58 non-small cell lung cancer patients who underwent lymph node dissection were examined intraoperatively using the new system, conventional system, and histopathology. RESULTS: Lymph node metastasis was diagnosed in 32, 42, and 44 patients using histopathological analysis, the new system, and the conventional system, respectively. Compared with histopathological analysis, the concordance rate, sensitivity, specificity, positive predictive value, and negative predictive value of the new system were 92.0%, 90.6%, 92.2%, 69.0%, and 98.1%, respectively, and compared with the conventional system, the values were 95.0%, 86.4%, 97.4%, 90.5%, and 96.2%, respectively. CONCLUSION: The clinical performance of the new one-step nucleic acid amplification system in detecting lymph node metastasis of lung cancer is comparable to that of histopathology and the conventional system; its performance was sufficient for determining the appropriate clinical treatment. The new rapid system can be effectively utilized during lung cancer treatment intraoperatively and postoperatively.

Efficacy of pleural coverage with polyglycolic acid sheet after bullectomy for postoperative recurrence of spontaneous pneumothorax in young patients: a multi-institutional cohort study.

OBJECTIVE: Various surgical procedures have been performed to decrease the recurrence of primary spontaneous pneumothorax after video-assisted thoracic surgery. This study aimed to examine the efficiency of pleural coverage for the prevention of postoperative recurrence in relatively young patients. METHODS: Between January 2008 and December 2012, a total of 357 cases of 345 patients (age 15-29 years) with primary spontaneous pneumothorax who underwent bullectomy at 13 institutions were enrolled in this multi-institutional retrospective cohort study. A concurrent bilateral operation was counted as two cases. Polyglycolic acid sheets were used in 238 cases, and oxidized regenerated cellulose sheets were used in 37 cases to cover the visceral pleura, with no pleural coverage in 82 cases. The average observation period was 4.2 ± 2.0 years. RESULTS: Postoperative recurrence was observed in 50 cases (14.0%) after video-assisted thoracic surgery. Twenty-six cases (10.9%) in the polyglycolic acid group, eight (21.6%) in the oxidized regenerated cellulose group, and sixteen (19.5%) in the non-coverage group experienced postoperative recurrence. Kaplan-Meier analysis revealed that the rate of freedom from postoperative recurrence in the polyglycolic acid group was significantly higher than that in the non-coverage group. Multivariate analysis showed that age ≥ 20 years and coverage with polyglycolic acid sheets were associated with reduced risk factors for postoperative recurrence. CONCLUSION: Pleural coverage with a polyglycolic acid sheet is suggested to be effective in preventing postoperative recurrence of pneumothorax compared with non-coverage in relatively young patients.

Outcomes of surgical resection for pulmonary metastasis from ovarian cancer.

BACKGROUND: Due to its rarity, information on pulmonary metastasectomy for pulmonary metastasis from ovarian cancer is limited. METHODS: Cases of pulmonary metastasectomy for ovarian cancer were collected in a multi-institutional setting and the outcomes were analyzed. RESULTS: Among 1508 cases in which pulmonary resection was performed to treat pulmonary metastasis from tumors of various organs, 6 cases (0.4%) involved pulmonary metastasis from ovarian cancer. The mean age was 61 years (range, 39-75 years). The histological types were undifferentiated carcinoma in 2 patients, and clear cell adenocarcinoma, serous papillary cystadenocarcinoma, serous adenocarcinoma, and endometroid adenocarcinoma in 1 patient each. One patient (17%) had a history of liver metastasis at the time of pulmonary resection. The median disease-free interval was 22 months (range, 0 [synchronous]-188 months). The tumor was solitary in 5 patients (83%). The mean tumor size was 15 mm (range, 5-23 mm). All 6 patients underwent complete resection. The type of resection was wide wedge resection in 3 patients, segmentectomy in 2 patients, and lobectomy in 1 patient. Four patients (67%) received postoperative chemotherapy. Thus far, 4 patients (67%) have experienced recurrence after pulmonary resection. In terms of outcomes, 1 patient who had synchronous pulmonary metastasis with the primary tumor died in the early period after pulmonary resection, 1 patient is alive without recurrence after a short follow-up period (5 months), 3 patients have achieved mid- to long-term survival and are alive with disease (38-61 months), and 1 patient achieved long-term (61 months) disease-free survival. CONCLUSIONS: Patients with pulmonary metastasis from ovarian cancer who fulfill the eligibility criteria for pulmonary metastasectomy are rare. Pulmonary metastasectomy for ovarian cancer can provide favorable outcomes in highly selected patients. Patients with synchronous pulmonary metastasis from ovarian cancer are not good candidates for pulmonary metastasectomy.

Long-Term Outcomes of Pulmonary Metastasectomy for Uterine Malignancies: A Multi-institutional Study in the Current Era.

BACKGROUND: Information on pulmonary metastasectomy (PM) for uterine malignancies in the current era is limited. In the present study, we analyzed the clinical course and results of PM for uterine malignancies in the era of modern imaging diagnostics to clarify the role of PM in the current era in a multi-institutional setting. METHODS: Fifty-seven patients who underwent PM for uterine malignancies between 2006 and 2015 were retrospectively reviewed. The short- and long-term outcomes, along with factors associated with the prognosis, were analyzed. Details of the clinical course after PM were described. RESULTS: The mean age of patients was 59.4 years. The primary tumor was located in the uterus corpus in 34 cases (60%) and in the uterus cervix in 23 cases (40%). The median disease-free interval (DFI) was 32 months. Forty patients (70%) received fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography before PM, and complete resection was achieved in 52 patients (91%). Postoperative complications occurred in 4 patients (7%). Of the 52 patients who underwent complete resection of pulmonary metastases, 28 experienced recurrence, and among these, 17 (60%) underwent local therapy, including six repeat PMs. Among the 52 patients who underwent complete resection, the 5-year relapse-free survival rate was 40.7% and the 5-year overall survival (OS) rate was 68.8%. The univariate analysis revealed that a DFI of ≤ 24 months was associated with significantly poorer OS. CONCLUSIONS: PM for uterine malignancies is safe and provides favorable long-term outcomes in selected patients. Patients with a DFI of > 24 months have better OS and are good candidates for PM.

Efficacy and safety of concurrent anti-Cancer and anti-tuberculosis chemotherapy in Cancer patients with active Mycobacterium tuberculosis: a retrospective study.

BACKGROUND: In our previous study, colorectal cancer (CRC) patients with active Mycobacterium tuberculosis (MTB) tolerated concurrent anti-cancer chemotherapy (anti-CCT) and anti-MTB chemotherapy. In this study, we retrospectively confirmed the efficacy and safety of concurrent chemotherapy in a greater number of patients with different types of malignancies. METHODS: We enrolled 30 patients who were treated concurrently with anti-CCT and anti-MTB regimens between January 2006 and February 2016. Cancer and MTB treatments were administered according to the approved guidelines. RESULTS: Patient demographics included: men/woman: 24/6; median age: 66.5 years; Eastern Cooperative Oncology Group performance status 0-1/2/3-4: 24/4/2; Stage IIB-IIIC/IV/recurrence: 6/22/2; lung cancer (LC)/CRC/other: 15/10/5; and MTB diagnosis (before or during anti-CCT): 20/10 (LC: 8/7; CRC: 8/2; other: 4/1). For anti-CCT, 23 patients received two cytotoxic agents with or without targeted agents and 7 patients received a single cytotoxic or targeted agent. The overall response rate was 36.7%. Regarding anti-MTB chemotherapy, 22 patients received a daily drug combination containing isoniazid, rifampicin, and ethambutol, plus pyrazinamide in 15 of the 22 patients, followed by daily isoniazid and rifampicin; the remaining 8 patients received other combinations. Hematological adverse events of Grade ≥ 3 were observed in 19 (67.9%) of 28 patients; laboratory data were lost for the remaining 2. Grade 3 lymphopenia and higher were significantly more frequent in LC compared to other malignancies (P < 0.005). Non-hematological adverse events of Grade ≥ 3 were observed in 5 (16.7%) of 30 patients. One CRC patient experienced Grade 3 hemoptysis and another 2 experienced Grade 3 anaphylaxis. One patient with cholangiocellular carcinoma and gastric cancer experienced Grade 3 pseudomembranous colitis as a result of a Clostridium difficile infection. One patient (3.3%) died of pemetrexed-induced pneumonitis. The success of the anti-MTB chemotherapy was 70.0%. There were no MTB-related treatment failures. The median overall survival (months, 95.0% confidence interval) was 10.5 (8.7-36.7), 8.7 (4.7-10.0), 36.7 (minimum 2.2), and 14.4 (minimum 9.6) for all patients combined, LC, CRC, and Other malignancies, respectively. LC patients experienced delayed MTB diagnosis and shorter overall survival. CONCLUSIONS: Concurrent chemotherapy is effective and safe for treating cancer patients with active MTB.

Upfront surgery in patients with clinical skip N2 lung cancer based on results of modern radiological examinations.

BACKGROUND: Direct lymphatic drainage from a primary tumor to the right paratracheal or aortic window lymph nodes is often noted in pN2 disease. This multi-institutional retrospective study investigated the outcomes of upfront surgery in patients with clinical skip N2 disease (N2 disease without N1 disease) and a tumor in the right upper lobe or left upper segment based on results of modern radiological examinations, including positron emission tomography (PET). METHODS: We identified 143 patients with cN2 disease who underwent upfront surgery in 12 institutions under the Thoracic Surgery Study Group of Osaka University between January 2006 and December 2013. Among 143 patients, 94 who underwent PET were analyzed. We classified these patients into Group A (n=39; clinical skip N2 disease and a tumor in the right upper lobe or left upper segment) and Group B (n=55; other). RESULTS: The median follow-up was 56.5 months. Among the 94 patients, 50 (53.2%) had skip N2 disease and 65 (69.1%) had a tumor in the right upper lobe or left upper segment. The 5-year overall survival (OS) rates of the 94 patients with cN2 disease was 47.9%. The 5-year OS rates for the cN2pN0/1 (n=22) and cN2pN2 (n=70) groups were 74.9% and 41.2%, respectively (P=0.034). The univariate analysis of OS revealed no significant differences in age, sex, histology, carcinoembryonic antigen (CEA) level, tumor size, PET findings, and number of metastatic lymph nodes when these parameters were dichotomized. A significantly better 5-year OS rate was observed in Group A than in Group B (64.0% vs. 37.0%; P=0.039). The multivariate analysis of OS revealed that Group A was a significantly prognostic factor (P=0.030). CONCLUSIONS: Patients with cN2 disease in Group A had a more favorable prognosis. Upfront surgery may be a treatment option for such selected patients with non-small lung cancer in the specific group.

Minimally invasive surgical procedures for thymic disease in Asia.

Video-assisted thoracic surgery (VATS) procedures for thymic tumors and myasthenia gravis were introduced in Asia in the middle 1990s in at least two regions, Hong Kong and Japan. To overcome difficulties in obtaining a wide view of the anterior mediastinum, several methods for lifting the sternum or anterior chest wall have been presented, mainly by Japanese surgeons. More recently, single port VATS through a subxiphoid incision was also introduced in Japan. The long-term outcome of a VATS extended thymectomy for myasthenia gravis has been shown to be comparable to that of a trans-sternal extended thymectomy, while the long-term outcome of a VATS thymectomy for thymic epithelial tumors remains to be elucidated. Nevertheless, its indication for tumors in an early stage is now widely accepted, and the number of VATS procedures is steadily increasing in Japan and China. Single-port VATS through a subxiphoid incision was developed in Japan and might become accepted as a useful approach in the near future when combined with robot-assisted thoracoscopic surgery. In addition, robot-assisted thoracoscopic surgery for the thymus has also been introduced in some areas in Asia. Although few of those surgical procedures for the thymus have been performed, results obtained thus far indicate that it might be preferable to lung resection. Several novel minimally invasive thymectomy techniques have been invented and developed in Asia, and further advancements in this field by Asian surgeons are anticipated.

JLCS medical practice guidelines for thymic tumors: summary of recommendations.

The Guideline Committee of the Japan Lung Cancer Society (JLCS) for Thymic Tumors published the Medical Practice Guideline for Thymic Tumors in Japanese as Chapter 3 of the Medical Practice Guidelines for Lung Cancers according to evidence-based medicine in December 2016. This medical practice guideline is the first for thymic epithelial tumors in Japan, and comprises a set of recommendations covering clinical diagnosis, treatment and pathological diagnosis. Thymic epithelial tumors include thymoma, thymic carcinoma and thymic neuroendocrine tumor. The recommendations for clinical diagnosis concern detection of the symptoms, blood and serum tests according to clinical presentation, essential imaging for differential diagnosis and staging, and the necessity and methods of definitive diagnosis. The recommendations for treatment are dependent on tumor stage and recurrence status, and the treatment modalities included surgery, radiation therapy, chemotherapy and multimodality therapy. Those for pathological diagnosis deal with the handing methods of resected specimen and essential reporting contents for pathological diagnosis. Since data from large-scale analyses or clinical studies of thymic epithelial tumor are limited due to its low prevalence, the relevant recommendations and grading were based on available reported evidence and expert opinions as well as diagnostic methods and treatments commonly used in Japan. This report summarizes the recommendations concerning each topic addressed by this JLCS guideline for thymic tumors.

Surgical resection for advanced lung cancer using the hemi-clamshell approach.

OBJECTIVES: The hemi-clamshell (HCS) approach consists of partial sternotomy with antero-lateral thoracotomy. This study evaluated the utilities and outcomes of the HCS approach in advanced lung cancer patients. METHODS: We retrospectively investigated 45 patients who underwent surgery for advanced lung cancer via the HCS procedure between 2000 and 2014, the indications for surgery being tumour invasion extending to the aorta arch in 5, descending aorta in 9, main pulmonary artery in 5, superior vena cava in 6, right or left atrium in 4, apical thoracic dome in 7 patients and mediastinal lymphadenopathy for left-sided lung cancer in 12. Preoperative chemo-radiation induction therapy was given to 33 of these patients. RESULTS: We performed 34 lobectomies, including 8 sleeve lobectomies, 10 pneumonectomies and 1 wedge resection of the lung. Cardiovascular reconstruction of the aortic arch was performed in 3, descending aorta in 4, subclavian arteries in 4, superior vena cava in 5, atrial wall in 4 and pulmonary artery in 12 patients with some overlap. En bloc chest wall resection was performed in 7 patients. Lymphadenectomy in the pre-tracheal and subcarinal areas was routinely performed. Forty-two operations (93%) were complete resections. No postoperative mortalities occurred and the 5-year survival rate for all patients was 53%. CONCLUSIONS: The HCS approach is suitable for advanced lung cancer, including invasion of mediastinal structures, the apical dome and mediastinal lymph nodes. It provides a wide view of the mediastinum and apex of the chest, and safe access to the thoracic great vessels, resulting in better long-term survival rates.

Total pleural covering technique for intractable pneumothorax in patient with Ehlers-Danlos syndrome.

We report a patient with vascular-type Ehlers-Danlos syndrome (vEDS) who developed pneumothorax and was treated with a total pleural covering technique (TPC). A 24-year-old man developed repeat pneumothorax with intermittent hemo-sputum. Based on unusual radiological manifestations of lung lesions and physical findings, EDS was suspected as an underlying cause of the pneumothorax. Surgical treatment was performed using a mediastinal fat pad and TPC, and no relapse was seen up to 2 years after surgery. TPC is a less invasive surgical approach for selected patients with vEDS. Accurate underlying diagnosis of vEDS and systemic evaluation of vascular complications are necessary before planning surgery.

A Rare Case of Pleomorphic Carcinoma of the Lung Harboring an Anaplastic Lymphoma Kinase (ALK) Rearrangement.

Molecular testing for anomalies, such as epidermal growth factor receptor mutations and anaplastic lymphoma kinase (ALK) rearrangement, is part of the current standard of care for non-small cell lung cancer, particularly adenocarcinoma. ALK rearrangement occurs most frequently in adenocarcinoma cells and rarely in non-adenocarcinoma cells. We herein report a rare case of pleomorphic lung carcinoma with ALK rearrangement in both its adenocarcinoma and spindle cell components. This case suggests the possibility of ALK rearrangement in pleomorphic carcinoma.

Clinicopathological characteristics and lymph node metastasis pathway of non-small-cell lung cancer located in the left lingular division.

OBJECTIVES: The purpose of this study is to assess the clinicopathological characteristics of non-small-cell lung cancer (NSCLC) occurring in the left lingular division (LLD) in association with a proposal of the LLD-specific regional lymph node stations. METHODS: Medical records of patients, who underwent complete tumour resection with mediastinal lymph node dissection (MLND) for LLD-NSCLC from 2000 to 2009 in multiple institutions, were retrospectively examined. We analysed patient clinicopathological characteristics and obtained the LLD-specific regional lymph node stations, and then the validity of intraoperative navigation in lymphadenectomy for LLD-NSCLC was investigated. RESULTS: One hundred and eighty-four LLD-NSCLC patients (97 males and 87 females, and 128 adenocarcinomas and 56 non-adenocarcinomas) were studied. The 5-year overall survival (OS) and disease-free survival (DFS) rates for all LLD-NSCLC patients were 72.9 and 58.3%, respectively. We examined the lymph node metastasis patterns in 42 node-positive tumours. The frequent metastatic lymph node stations were #12u lobar node (n = 22), #5 subaortic node (n = 15) and #11 interlobar node (n = 13) in order. These three node stations were also single metastatic sites in some patients. Metastases to sub-carinal (#7) or inferior mediastinal nodes (#8) were rare. Thus, we assigned the three stations (#5, #11, #12u) as the regional lymph node stations for LLD-NSCLC. If these regional lymph node stations had been examined pathologically during surgery for a total of 160 LLD-NSCLC patients with c-T2N1M0 or lower stage disease, 125 p-N0 and 5 p-N1 patients diagnosed with no metastasis would have been subjected to selective MLND, while 14 p-N1 and all 16 p-N2 patients diagnosed with metastasis would have had complete MLND carried out. As a result, these regional lymph node stations could accurately predict the existence of p-N2 metastasis, and appropriately lead to a selective or complete MLND. CONCLUSIONS: An intraoperative pathological examination using our proposed LLD-specific regional lymph node stations may accurately diagnose the status of node metastasis, and appropriately lead to selective or complete MLND in LLD-NSCLC patients with c-T2N1M0 or lower stage disease.

Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014.

Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.

Risk assessment of lung resection for lung cancer according to pulmonary function: republication of systematic review and proposals by guideline committee of the Japanese association for chest surgery 2014.

BACKGROUND: This manuscript provides preoperative physiologic assessments for patients considered for surgical resection of lung cancer. METHODS: Medical studies of risk assessment of surgical resection for lung cancer according to pulmonary function were collected and a review article was written to present guidelines. RESULTS: Preoperative physiologic assessment should begin with a cardiovascular evaluation, and spirometry to measure FEV 1 and the diffusing capacity of carbon monoxide (DLCo). Predicted postoperative (ppo) lung functions should also be calculated. If both %ppo-FEV 1 and %ppo-DLCo values are ≥ 60%, the patient is considered to be at low risk for anatomic lung resection. If either of those are <60% of the predicted value, an exercise test should be performed for screening. If performance on the exercise test is acceptable, the patient is regarded to be at low risk for anatomic resection. These findings can be summarized as an algorithm. CONCLUSIONS: Careful preoperative physiologic assessment is useful for identifying patients at increased risk for standard lung cancer resection and enabling informed decisions by the patient about an appropriate therapeutic approach for their lung cancer.

Video-assisted thoracic surgery for pneumothorax: republication of a systematic review and a proposal by the guideline committee of the Japanese association for chest surgery 2014.

OBJECTIVE: The purpose of this consensus conference was to determine whether video-assisted thoracic surgery (VATS) improves clinical outcomes compared with conventional thoracotomy in patients undergoing surgery for pneumothorax, and to outline evidence-based recommendations for the use of VATS. METHODS: Before the consensus conference, the best available evidence was reviewed, with systematic reviews, randomized trials, and nonrandomized trials all taken into consideration in descending order of validity and importance. At the consensus conference, evidence-based interpretative statements were created, and consensus processes were used to determine the ensuing recommendations. The Medical Information Network Distribution Service in Japan (Minds) system was used to label the levels of evidence for the references and the classes of recommendations. RESULTS AND RECOMMENDATIONS: The consensus panel agreed upon the following statements and recommendations for patients with pneumothorax undergoing surgery: 1. VATS is broadly indicated as surgery for pneumothorax. 2. VATS is judged to be less invasive, as it results in minimal postoperative pain, the periods of chest tube placement and hospitalization are short, and it shows a trend toward early realization of social integration. 3. There is no difference in terms of safety and complications between VATS and open thoracotomy. 4. As it is anticipated that VATS will result in a higher recurrence rate than open thoracotomy, it may be desirable to add a supplemental procedure during surgery. In summary, VATS can be recommended as pneumothorax surgery (Recommendation grade: Level B).

Improved procedures and comparative results for video-assisted thoracoscopic extended thymectomy for myasthenia gravis.

INTRODUCTION: We previously introduced video-assisted thoracoscopic ET (VATS-ET) as a therapeutic option for MG with acceptable results. We have conducted further investigations to improve the procedure without deterioration of operative results, including myasthenia gravis (MG) remission rate and palliation rate. Here, we report the details of our current procedure, as well as surgical results and patient outcomes as compared with the original VATS-ET procedure. MATERIAL AND METHODS: From January 2002 to September 2013, we performed a VATS-ET procedure with an anterior chest wall lifting method for 77 patients who had MG with or without a thymoma. During that period, we investigated the appropriate indications and improved the procedure. RESULTS: Our current indication for this procedure is MG with the anti-acetylcholine receptor antibody or sero-negative type, or MG with a thymoma <5 cm in diameter without invasion to adjacent organs. With our procedure, the thymus and surrounding tissue are sufficiently resected using a bilateral thoracoscopic surgical method without neck incision. Remission and palliation rates were found to be equivalent to those obtained with the original VATS-ET procedure. CONCLUSION: VATS-ET is suitable for select patients with MG with or without a thymoma. In addition, our current method has shown to be effective while also offering cosmetic advantages as compared with the original, neck incision needed, VATS-ET method.

Video-assisted thoracic surgery for lung cancer: republication of a systematic review and a proposal by the guidelines committee of the Japanese Association for Chest Surgery 2014.

BACKGROUND: Patients with early-stage non-small cell lung cancer (NSCLC) are candidates for surgical intervention with curative intent. For these early-stage lung cancer surgeries, video-assisted thoracic surgery (VATS) is considered. The purpose of this article is to propose a recommendation for this according to the evidence and provide information for patients with operable early-stage lung cancer from the Japanese Association for Chest Surgery. The clinical question here is whether VATS lobectomy is recommended for patients with clinical stage I NSCLC. METHODS: The Japanese Association for Chest Surgery guidelines committee reviewed and summarized the available literature and assessed the quality of the evidence. The available literature on VATS was examined using references from MEDLINE. The recommendations were provided according to the Medical Information Network Distribution Service in Japan (Minds). RESULTS: VATS lobectomy may be considered and applied to patients with clinical stage I NSCLC; however, well-established evidence is lacking. VATS showed better or at least equivalent outcomes regarding intra- or postoperative complications compared with thoracotomy, with less invasiveness. Additionally, long-term survival by VATS lobectomy was suggested to be at least equivalent, although there is a lack of evidence. CONCLUSIONS: VATS lobectomy by an experienced surgeon is associated with minimal invasiveness and an outcome equivalent to that of open lobectomy in stage I NSCLC. (Recommendation grade: Level C1).

Simple technique for reconstruction of superior vena cava and brachiocephalic vein after removal for thoracic malignancies.

A ringed polytetrafluoroethylene graft was applied to reduce clamping time for a patent major vein. In case 1, after suturing the ringed graft to the right appendage, the other end was inserted in the distal direction of the left brachiocephalic vein and secured by ligation. In case 2, to repair an extensive superior vena cava defect, the graft was wrapped with the remnant venous wall and fixed with a continuous suture. Only 5 minutes were required to reconstruct the left brachiocephalic vein and 20 minutes for the superior vena cava. Long-term graft patency was obtained without thrombosis.

Does gefitinib have effects on EGFR mutation-positive thymoma? -Case report of thymoma recurrence.

A 56-year-old woman heavily pretreated for a thymoma was referred to our hospital with recurrence. Following additional surgery, the tumor recurred again in the left thoracic cavity. Because of previous multiple operations and repeated chemotherapies, the patient was considered unable to tolerate additional surgery or chemotherapy. After we obtained positive evidence of epidermal growth factor receptor (EGFR) mutation, she was administrated gefitinib for 3 months. Although immunohistochemistry findings showed that the tumor was EGFR positive, gefitinib therapy led no reduction of the tumor size. After undergoing immunotherapy, the patient suffered from repeated occurrences of pneumonia, and died from respiratory failure.