A Case of Traumatic Hemothorax From an Isolated Thoracic Vertebral Fracture in an Elderly Patient on Combined Anticoagulant and Antiplatelet Therapy.

Traumatic hemothorax is typically easy to diagnose because of the distinct onset of trauma with significant complaints such as severe chest pains. However, in elderly patients, the clinical symptoms are less clear and the frequent use of antithrombotic therapy may prolong the bleeding from a minor fracture. We report a case of traumatic hemothorax from an isolated thoracic vertebral fracture in an elderly patient on anticoagulant and antiplatelet therapy. A 91-year-old male on anticoagulant and antiplatelet therapy was admitted to our hospital with a complaint of persistent hemoptysis after a fall. A computed tomography (CT) demonstrated a worsening right hemothorax and thoracic vertebral fracture without lung or diaphragm injury, rib fracture, or contrast medium extravasation. The patient was taken to the operating room for the exploratory thoracoscopy and evacuation of the hemothorax without a preoperative diagnosis of the bleeding source. The bleeding was from the transverse laceration of the 10th thoracic vertebra exposed to the pleural space. The minor bleeding from the cancellous bone was prolonged, possibly due to the use of anticoagulant and antiplatelet therapy, which was not identified as contrast medium extravasation on chest CT before surgery. In cases of hemothorax with an unclear bleeding source, a vertebral fracture could be considered a source of bleeding even without any signs of bone dislocation or contrast medium extravasation on a CT scan.

[Chest Tube is Unnecessary after Video-assisted Thoracoscopic Mediastinal Tumor Resection].

Of the 64 patients who underwent surgery for mediastinal tumors at our department from April 2019 to December 2022, 59 patients( 92.2%) underwent video-assisted thoracic surgery( VATS). Among the patients who underwent open surgery, 5 patients underwent median sternotomy and 1 patient underwent posterolateral thoracotomy. We usually perform 3-port VATS for mediastinal tumors. After surgery, patients are allowed to drink water after awakening from anesthesia, and they can have dinner on the day. If no lung resection is performed, we use a Nélaton catheter to remove air from the thoracic cavity and do not place a chest tube, and none had a chest tube insertion after surgery. As a result, postoperative pain was minimal, early ambulation was possible, and hospital stay was shortened.

Characteristics of non-small-cell lung cancer with interstitial pneumonia: variation in cancer location, histopathology, and frequency of postoperative acute exacerbations in interstitial pneumonia.

BACKGROUND: Non-small-cell lung cancer (NSCLC) has been reported to develop in patients with interstitial pneumonia (IP); however, clinical, radiological, and pathological features remain to be elucidated. METHODS: We retrieved the records of 120 consecutive NSCLC patients associated with IP who underwent surgery at Toranomon Hospital between June 2011 and May 2017. We classified the patients into three groups according to NSCLC location using high-resolution computed tomography: group A, within a fibrotic shadow and/or at the interface of a fibrotic shadow and normal lung; group B, within emphysematous tissue and/or at the interface of emphysematous tissue and normal lung; and group C, within normal lung. In 64 patients, programmed death ligand-1 (PD-L1) status was assessed with immunohistostaining. RESULTS: Most of the patients (89; 70%) were classified as group A. This group tended to have squamous cell carcinoma with the usual interstitial pneumonia (UIP). These cancers were located mainly in the lower lobes and seven of the eight postoperative acute exacerbations (pAE) of IP developed in this group. NSCLC in the group B were mainly squamous cell carcinomas located in the upper lobes. No patient with PD-L1 negative was classified into group B. None of the patients in group C showed UIP. and most of the cancers were adenocarcinoma. The frequency of epidermal growth factor receptor mutation-positive NSCLC was the highest in this group. CONCLUSIONS: The three groups each showed characteristic features in terms of tumor location, histopathology, PD-L1 expression, and frequency of pAEof IP.

Extracellular Vesicles from Fibroblasts Induce Epithelial-Cell Senescence in Pulmonary Fibrosis.

Aberrant epithelial-mesenchymal interactions have critical roles in regulating fibrosis development. The involvement of extracellular vesicles (EVs), including exosomes, remains to be elucidated in the pathogenesis of idiopathic pulmonary fibrosis (IPF). Here, we found that lung fibroblasts (LFs) from patients with IPF induce cellular senescence via EV-mediated transfer of pathogenic cargo to lung epithelial cells. Mechanistically, IPF LF-derived EVs increased mitochondrial reactive oxygen species and associated mitochondrial damage in lung epithelial cells, leading to activation of the DNA damage response and subsequent epithelial-cell senescence. We showed that IPF LF-derived EVs contain elevated levels of microRNA-23b-3p (miR-23b-3p) and miR-494-3p, which suppress SIRT3, resulting in the epithelial EV-induced phenotypic changes. Furthermore, the levels of miR-23b-3p and miR-494-3p found in IPF LF-derived EVs correlated positively with IPF disease severity. These findings reveal that the accelerated epithelial-cell mitochondrial damage and senescence observed during IPF pathogenesis are caused by a novel paracrine effect of IPF fibroblasts via microRNA-containing EVs.

Feasibility of autologous fibrin glue in general thoracic surgery.

BACKGROUND: Fibrin glue effectively controls air leakage in lung surgery; however, allogenic fibrin glue cannot eliminate the risks of infection and allergy despite current sterilization methods. Autologous fibrin glue (AFG) could be a good alternative, but is not commonly used worldwide because of its limited availability and lack of evidence. Herein, we report clinical outcomes of AFG in thoracic surgery. METHODS: We retrospectively analyzed patients who underwent lobectomies or segmentectomies between November 2016 and September 2017 in our institution. We used two types of AFGs. One was a partially-autologous fibrin glue (PAFG), the components of which are largely autologous but which contains allogenic thrombin. The other was a completely-autologous fibrin glue (CAFG) which has no allogenic components. PAFG was used in the first half of the study period, after which CAFG was used from March 2017 onward. Patients who did not undergo AFG generation were categorized as the non-AFG group. The perioperative outcomes of the three groups were evaluated. RESULTS: A total of 207 patients underwent lung surgery, including 118 lobectomies and 89 segmentectomies. Among them, 83 patients received PAFG, 94 received CAFG, and 30 received non-AFG. The mean postoperative drainage period was within a few days in each group (PAFG vs. CAFG vs. non-AFG: 3.23±3.91 vs. 3.16±4.04 vs. 3.17±4.16 days, respectively; P=0.405), and the incidence of postoperative prolonged air leakage was within an acceptable range (PAFG vs. CAFG vs. non-AFG: 13.3% vs. 12.8% vs. 16.7%, respectively; P=0.821). CONCLUSIONS: The use of AFG is clinically feasible for patients who undergo lobectomies or segmentectomies. AFGs could be a viable alternative to conventional allogenic fibrin glues.

[Indication and Results of 3-port Thoracoscopic Limited Resection for Lung Cancer].

The tumors with the size of 15 mm or less and less than 50 percent of solid component have been eligible for our radical surgical indication of 3-port thoracoscopic limited resection. The objective is to evaluate the indication. Between 2010 and 2015, we reviewed 206 segmentectomy and 87 partial resection. In those patients, non-radical limited resections included 129 segmentectomy and 29 partial resection. As for imaging findings, the maximum tumor diameter were 16.7 mm vs 10.8 mm and the consolidation/tumor (C/T) ratio were 0.54 vs 0.39. At a mean follow up of 48 months, 5-year overall survival (OS) were 91.4% vs 93.1%, and 5-year recurrent free survival (RFS) were 88.6% vs 93.1%. Overall recurrence(10 patients vs 6 patients) happened in the patients with non-radical limited resections for pure or part solid tumors, therefore it is necessary to consider an indication of limited resection for solid tumors carefully.

Simultaneous three-port thoracoscopic surgery for bilateral lung cancers with a pulmonary vein anomaly: A case report.

INTRODUCTION: Simultaneous resection of bilateral lung cancers is technically challenging but may be preferable to a staged procedure in patients with a partial anomalous pulmonary venous connection (PAPVC) in an affected lobe. We performed single-stage resection of bilateral lung cancers in a patient with a PAPVC. PRESENTATION OF CASE: A 73-year-old man was diagnosed as having bilateral lung cancers (right, cT3N1M0, stage IIIA and left, cT2aN0M0, stage IB). Left upper trisegmentectomy was performed, followed by right upper lobectomy with deep wedge bronchoplasty. A PAPVC was found incidentally in the affected right upper lobe and successfully divided. The postoperative course was uneventful and he commenced chemoradiotherapy. DISCUSSION: Resection of the PAPVC, which was located in the same lobe as the lung cancer, would have mitigated load increase in the right heart and may have alleviated the adverse effects of bilateral lung resection. Moreover, the single-stage procedure likely shortened the overall duration of treatment. CONCLUSION: Single-stage bilateral thoracoscopic resection may have advantages over staged procedures in some patients with PAPVCs.

Management of complications in thoracoscopic surgery.

BACKGROUND: Thoracoscopic surgery has been widely performed. However, sometimes open conversion becomes necessary to manage complications. We have been applying thoracoscopic technique to manage complications to minimize the rate of open conversion. METHODS: Thoracoscopic suture technique in addition to some other technique has been used to control intraoperative bleeding, nerve injury and bronchial damage. Pulmonary artery bleeding could happen in thoracoscopic surgery. First step is to give compression to the bleeding point. Usually the lung nearby is used then a gauze is taken over. A piece of Tachosil® is placed to stop bleeding. When this technique is not successful, the proximal part of the PA is encircled with a vascular sling to reduce the blood flow. In some occasion, bleeding point is suture closed. This technique is also used in controlling the bleeding from the right atrium. Phrenic nerve could be severed incidentally or on purpose to remove malignancy. Direct suture or intercostal nerve interposition may fix the problem. Trachea or bronchus could be damaged incidentally. Thoracoscopic suture closure will be helpful. Between 2013 and 2017, we performed 2,527 thoracoscopic surgical procedures including 1,196 major lung resections were performed in our department. RESULTS: There was no procedure related mortality. In our institution, open conversion to manage complications was 0.3% in consecutive 6,929 thoracoscopic surgery and 0.63% in thoracoscopic major lung resection since 2000. In 2014 to 2017 open conversion could be reduced to 0.4% of the major lung resections. Most of the complications in thoracoscopic surgery were managed with thoracoscopic methods. CONCLUSIONS: Applying thoracoscopic suture technique and other options could reduce the rate of open conversion in thoracoscopic surgery.

Semiquantitative Assessment of Tumor Spread through Air Spaces (STAS) in Early-Stage Lung Adenocarcinomas.

INTRODUCTION: Tumor spread through air spaces (STAS) has recently been reported as a form of tumor invasion having an unfavorable prognosis, but the significance of a small amount of STAS is not known. The aim of this study was to perform a semiquantitative assessment of STAS. METHODS: Small (≤2 cm) stage I lung adenocarcinomas surgically resected at our institution between 2003 and 2009 were assessed semiquantitatively in the most prominent area as no STAS, low STAS (1-4 single cells or clusters of STAS), or high STAS (≥5 single cells or clusters of STAS) by using a 20× objective and a 10× ocular lens. A statistical analysis was performed to determine the impact of clinicopathologic parameters on STAS and to clarify the relationship between STAS and patient survival. RESULTS: STAS was assessed as no STAS in 109 of 208 cases (52.4%), as low STAS in 38 cases (18.3%), and as high STAS in 61 cases (29.3%). There were statistically significant associations between higher STAS and solid predominant invasive adenocarcinoma (p < 0.001), pleural invasion (p < 0.001), lymphatic invasion (p < 0.001), vascular invasion (p < 0.001), and tumor size of 10 mm or more (p = 0.037). There was a significant association between increasing STAS and shorter recurrence-free survival (RFS) in univariate analysis (no STAS, 154.2 months; low STAS, 147.6 months; and high STAS, 115.6 months). In a multivariate Cox proportional hazards model, only STAS (p = 0.015) remained a significant predictor of RFS. CONCLUSIONS: We found that one-third of resected small adenocarcinomas had high STAS. Higher STAS was predictive of worse RFS.

Single-stage video-assisted thoracoscopic surgery: Right upper lobectomy and left lower lobectomy for synchronous bilateral lung cancers.

INTRODUCTION: Single-stage bilateral radical surgery for synchronous bilateral multiple lung cancers (SBMLCs) has strong advantages; however, it is considered highly invasive. We have therefore adopted video-assisted thoracoscopic surgery (VATS) as a minimally invasive surgical maneuver for bilateral lung resection. Although there have been a few reports concerning bilateral lung resection, the safety and appropriate operative indications remain unclear, especially for bilateral VATS-lobectomy. A case of single-stage bilateral radical lobectomy with a good result is reported. PRESENTATION OF CASE: A 58-year-old man was found to have abnormal opacities in the right upper zone and left lower zone at a health checkup. Double primary bilateral lung cancers was suspected, and surgical resection was considered. Consequently, right upper lobectomy with D2 lymph node dissection and left lower lobectomy with D2 lymph node dissection as radical resection were performed under VATS. The lesions were finally diagnosed to be double primary adenocarcinomas of the right upper lobe (pT1N0M0, stage IA) and left lower lobe (pT1N0M0, stage IA). The patient's postoperative course was uneventful, and he was discharged on postoperative day 6. The patient is doing well with no evidence of recurrence for 9 years. CONCLUSION: While careful consideration of the surgical options is needed, if properly done, bilateral VATS-lobectomy for SBMLC has advantages for selected patients.

Loss of BAP1 protein expression in the first metastatic site predicts prognosis in patients with clear cell renal cell carcinoma.

OBJECTIVES: To investigate the intratumoral heterogeneity of BAP1 and PBRM1 expression at the primary site and metastatic sites and to evaluate whether BAP1 and PBRM1 expression in metastatic sites of clear cell renal cell carcinoma (ccRCC) has prognostic value. METHODS AND MATERIALS: We collected paired samples from the primary site and the first metastatic site in 41 patients with ccRCC. Immunohistochemistry analyses were performed for the expression of BAP1 and PBRM1 proteins. We retrospectively analyzed the associations between the expression of BAP1 and PBRM1 and overall survival (OS). RESULTS: The most common first metastatic sites were lung (68.3%) and lymph node (12.2%). BAP1 protein expression was negative in 8 (19.5%) primary sites and in 11 (26.8%) metastatic sites. PBRM1 protein expression was negative in 9 (22.0%) primary sites and in 11 (26.8%) metastatic sites. The incidences of intratumoral heterogeneity for BAP1 and PBRM1 protein expression in primary/metastatic sites were 9.8%/2.4% and 24.4%/7.3%, respectively. The concordance rates between primary and metastatic sites for BAP1 and PBRM1 protein expression were 82.9% and 63.4%, respectively. Median OS from the first occurrence of metastasis in patients with BAP1-positive and BAP1-negative metastatic sites were 97 months (95% CI: 58-136) and 51 months (95% CI: 13-82), respectively (P = 0.0077). Median OS in patients with PBRM1-positive and PBRM1-negative metastatic sites were 82 (95% CI: 42-97) and 120 (95% CI: 52-120) months, respectively (P = 0.25). CONCLUSION: Intratumoral heterogeneity of BAP1 protein expression is more frequent in primary tumor than in metastatic sites. The loss of BAP1 protein expression in metastatic sites predicts poor prognosis in patients with ccRCC.

Salvage surgery for local recurrence after carbon ion radiotherapy for patients with lung cancer.

OBJECTIVES: Carbon ion radiotherapy (CIRT) has been expected to be an alternative for surgery for early-stage non-small-cell lung cancer (NSCLC) and adopted as the second-best choice even in operable patients although local recurrence after CIRT is sometimes experienced. The purpose of this study was to investigate the demographic data, perioperative courses and therapeutic outcomes of patients who underwent salvage resection for local recurrence after CIRT. METHODS: From November 1994 to February 2012, CIRT was applied for 602 c-T1/T2/T3N0M0 NSCLC lesions of 599 patients at the National Institute of Radiological Science. A total of 95 (16%) patients were diagnosed as having local recurrence, of whom 12 underwent salvage surgeries. The medical records were retrospectively reviewed. RESULTS: There were 7 men and 5 women (mean age, 63 ± 7.4 years). The clinical stages upon initial presentation with NSCLC were as follows: 4 IA, 7 IB and 1 IIB. All the patients were operable, but refused surgery and underwent CIRT. The median progression-free survival time after CIRT was 20 months (range, 7.1-77 months), and salvage surgery was performed at a median of 24 months (range, 9-78 months) after CIRT. All surgeries were successfully performed without any significant CIRT-related adhesions during the surgery, resulting in no mortality or Clavien-Dindo grade 3-4 postoperative complications. However, the distribution of pathological stages was as follows: 4 IA, 3 IB, 2 IIB, 2 IIIA and 1 IV, which included 6 upstages from the clinical stages before CIRT. The Kaplan-Meier estimate of overall survival after the salvage surgery showed that the 3-year survival rate was 82%. CONCLUSIONS: The dose intensity of CIRT spared the hilum of the lungs and parietal pleura, none of the patients developed adhesions outside of the radiation field, such that the salvage surgeries for local recurrence after CIRT were safe and feasible.

[MINIMALLY INVASIVE THORACIC SURGERY: PRESENT STATUS AND FUTURE PERSPECTIVES].

Minimally invasive general thoracic surgery entered a new era with the introduction of thoracoscopic surgery into clinical practice in the early 1990s. Thoracoscopic surgery is already widely accepted in most countries. However, single-port thoracic surgery, needlescopic thoracic surgery, and robot-assisted thoracic surgery are not yet accepted widely. More advances in the instruments and equipment appear necessary.

Three-port thoracoscopic middle lobectomy in a patient after left pneumonectomy.

Lung lobectomy after contralateral pneumonectomy is a challenging procedure associated with high morbidity and mortality. To date, only limited evidence has been available, and adequate indication or surgical approach remain unclear. We herein report a successful case of thoracoscopic lobectomy in a single-lung patient. A 63-year-old man, who had a history of left pneumonectomy for lung cancer, was found to have an abnormal opacity in the right middle zone at a health checkup 13 years after the previous operation. This nodule was later diagnosed as squamous cell cancer (cT2N0M0, stage IB) and surgical resection was considered. Thoracoscopic middle lobectomy with D1 lymph node dissection was performed for this patient under selective ventilation of the right upper and lower lobes. Postoperative course was uneventful and he was discharged on postoperative day 7, requiring no oxygen. The patient is doing well with no evidence of recurrence for 5 years. Given the lower invasiveness, thoracoscopic lobectomy under the selective ventilation of residual lobes could be an option after contralateral pneumonectomy in selected patients.

Bronchial bleeding caused by recurrent pneumonia after radical esophagectomy for esophageal cancer.

We herein report a case of bronchial bleeding after radical esophagectomy that was treated with lobectomy. A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis. After the esophagectomy, bilateral vocal cord paralysis was observed, and the patient suffered from repeated episodes of aspiration pneumonia. Bronchoscopy revealed hemosputum in the right middle lobe bronchus, and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus. Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis, the procedures were unsuccessful. Right middle lobectomy was therefore performed via video-assisted thoracic surgery. Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen. The patient recovered uneventfully and was discharged on postoperative day 14.

The Impact of Endoscopic Linear Stapling Device Stability in Thoracic Surgery: A Delphi Panel Approach.

Objectives: To develop consensus statements outlining the impact of endoscopic linear stapling device stability on potential complications of thoracic surgery and the stress/concern of thoracic surgeons. Methods: Eight thoracic surgeons representing 8 countries participated in a Delphi panel process using 2 anonymous surveys. The first included binary, multiple-response, and Likert scale-type questions, which were converted into affirmative statements for survey 2 if an adequate number of respondents answered similarly. Consensus was defined a priori when ≥70% agreed with the affirmative statement in survey 2. Results: All panelists completed both surveys. Panelists unanimously agreed that: 1) an endoscopic linear stapling device with improved stability would result in less stress/concern for critical firings, surgeries where a fellow is trained, and robot-assisted surgeries requiring an assistant; 2) reduced unintentional tissue/structure damage and reduced tension on tissue being fired upon may result from use of an endoscopic linear stapling device that provides improvement in stability; and 3) endoscopic linear stapling device stability had more clinical importance in video-assisted thoracic surgery compared to open thoracic surgery. Conclusions: Improved endoscopic linear stapling device stability is a critical component of thoracic surgery likely to result in more frequent positive surgical outcomes when compared to a device with greater instability.

Phrenic nerve reconstruction in complete video-assisted thoracic surgery.

OBJECTIVES: Primary or metastatic lung cancer or mediastinal tumours may at times involve the phrenic nerve and pericardium. To remove the pathology en bloc, the phrenic nerve must be resected. This results in phrenic nerve paralysis, which in turn reduces pulmonary function and quality of life. As a curative measure of this paralysis and thus a preventive measure against decreased pulmonary function and quality of life, we have performed immediate phrenic nerve reconstruction under complete video-assisted thoracic surgery, and with minimal additional stress to the patient. This study sought to ascertain the utility of this procedure from an evaluation of the cases experienced to date. METHODS: We performed 6 cases of complete video-assisted thoracic surgery phrenic nerve reconstruction from October 2009 to December 2013 in patients who had undergone phrenic nerve resection or separation to remove tumours en bloc. In all cases, it was difficult to separate the phrenic nerve from the tumour. Reconstruction involved direct anastomosis in 3 cases and intercostal nerve interposition anastomosis in the remaining 3 cases. RESULTS: In the 6 patients (3 men, 3 women; mean age 50.8 years), we performed two right-sided and four left-sided procedures. The mean anastomosis time was 5.3 min for direct anastomosis and 35.3 min for intercostal nerve interposition anastomosis. Postoperative phrenic nerve function was measured on chest X-ray during inspiration and expiration. Direct anastomosis was effective in 2 of the 3 patients, and intercostal nerve interposition anastomosis was effective in all 3 patients. Diaphragm function was confirmed on X-ray to be improved in these 5 patients. CONCLUSIONS: Complete video-assisted thoracic surgery phrenic nerve reconstruction was effective for direct anastomosis as well as for intercostal nerve interposition anastomosis in a small sample of selected patients. The procedure shows promise for phrenic nerve reconstruction and further data should be accumulated over time.

[Thoracoscope for thoracoscopic surgery].

Thoracoscope is very important in thoracoscopic surgery (TS). There are many types of telescope and monitor. Also the placement of access port and location of the monitor image often differ between each institutions. Thoracic surgeons need to know these features to perform good TS. In our department, 2,375 patients (98% of all operation) were underwent 3-ports TS for 5 years. Operator always stands by patient's right side and camera assistant stands by patient's left side. Using 2 monitors, left side of monitors image sets to patient's head side and camera assistant see the inverted image monitor. Regardless of the localization of the lesion, three ports are always placed in same intercostal space. One of the advantages of TS is the ability of obtaining close and magnified operative image which can be possible to be shared with assistant and other surgical staff. The other advantages is that surgeons can review the recorded surgical digital versatile disc(DVD).

Pulmonary metastasectomy secondary to esophageal carcinoma: long-term survival and prognostic factors.

BACKGROUND: Lung metastasectomy has become an effective treatment for selected patients with colorectal cancer, renal cancer, and other malignancies; however, limited experience has been reported regarding pulmonary metastasectomy for esophageal carcinoma. We reviewed 23 patients with esophageal cancer who underwent pulmonary metastasectomy and investigated their long-term prognosis and prognostic factors. METHODS: A total of 23 patients who underwent 30 curative pulmonary metastasectomies at Toranomon Hospital, Japan, between 2001 and 2011 were included. Four patients underwent repeated metastasectomy. The overall survival rate was examined by the Kaplan-Meier method and various characteristics were assessed by univariate analysis to identify prognostic factors. RESULTS: The overall 1-, 3-, and 5-year survival rate was 82.6, 46, and 34.1 %, respectively. Median follow-up was 37.4 months (range 1-114 months). Univariate analysis revealed a history of extrapulmonary metastases before pulmonary metastasectomy, poorly differentiated primary esophageal carcinoma, and short disease-free interval (DFI) as unfavorable prognostic factors. Five patients who underwent repeated metastasectomy for recurrent pulmonary metastases survived a mean 58 months (range 24-114 months). The other patients survived a mean 29.4 months (range 1-109 months). CONCLUSIONS: Pulmonary resection for lung metastases from esophageal carcinoma should be considered in selected patients, and repeated metastasectomy should be encouraged. Extrapulmonary metastases before pulmonary metastasectomy, poor differentiation of primary esophageal carcinoma, and short DFI are unfavorable prognostic factors. Due to poor prognosis, metastasectomy in patients with these factors should be more carefully considered before being indicated.