Left Main Bronchus Obstruction in a Patient with Small-cell Lung Cancer Successfully Treated with Venovenous Extracorporeal Membrane Oxygenation.

Lung cancer can cause fatal central airway obstruction. Rapid airway clearance is necessary in some cases, but ventilator management may be insufficient to maintain oxygenation levels. Venovenous extracorporeal membrane oxygenation (VV-ECMO) may be an effective rescue therapy for respiratory failure, but its efficacy in treating tumor-related airway obstruction is unknown. We herein report a case of central airway obstruction and severe acute respiratory failure due to small-cell lung cancer successfully treated with VV-ECMO, bronchoscopic airway intervention, and chemotherapy. VV-ECMO can be an effective option for the treatment of central airway obstruction with acute respiratory failure due to lung cancer.

Association between intrapleural urokinase monotherapy and treatment failure in patients with pleural infection: a retrospective cohort study.

BACKGROUND: Pleural infection, an infection of the pleural space, is frequently treated with antibiotics and thoracic tube drainage. In case of insufficient drainage, an intrapleural fibrinolytic agent is considered before surgical intervention. However, the effectiveness of fibrinolytic monotherapy is still controversial. Therefore, we aimed to examine the association between urokinase monotherapy and treatment failure in patients with pleural infection. METHODS: In this retrospective observational study, patients with pleural infection underwent chest tube insertion were divided into two groups including patients treated with or without intrapleural instillation of urokinase. The propensity score overlap weighting was used to balance the baseline characteristics between the groups. Treatment failure was defined by the composite primary outcome of in-hospital death and referral for surgery. RESULTS: Among the 94 patients, 67 and 27 patients were in the urokinase and non-urokinase groups, respectively. Urokinase monotherapy improved the composite outcome between the groups (19.4% vs. 48.1%, p = 0.01). After adjusting using propensity score overlap weighting, urokinase monotherapy improved the composite outcome compared to the non-urokinase group (19.0% vs. 59.5%, p = 0.003). CONCLUSIONS: Urokinase monotherapy can be an important nonsurgical treatment option for patients with pleural infection. TRIAL REGISTRATION: The participants were retrospectively registered.

The relationship between chest tube position in the thoracic cavity and treatment failure in patients with pleural infection: a retrospective cohort study.

BACKGROUND: Pleural infection is an infection of the pleural space that is usually treated with antibiotics and source control. Chest tube insertion is the most popular and widely used drainage technique. We typically attempt to place the tube at the bottom of the thoracic cavity to consider the effects of gravity; however, the effectiveness of this practice is not well-defined. Therefore, we aimed to examine whether the position of the tip of the thoracic tube affects treatment failure in patients with pleural infection. METHODS: In this retrospective observational study, patients with pleural infection who underwent thoracic tube insertion were divided into two groups: those with the tip of the tube positioned below the 10th thoracic vertebra at the level of the diaphragm (lower position group) and those with the tip placed above the 9th thoracic vertebra (upper position group). We compared whether the position of the tube tip affected treatment failure. Stabilized inverse probability treatment weights (SIPTW) were used to balance the baseline characteristics between the groups. Treatment failure showed a composite outcome of hospital death, referral to surgeons for surgery, and additional chest tube insertion. RESULTS: Among the 87 patients, 41 and 46 patients were in the lower and upper groups, respectively. No significant difference was observed in the composite outcomes between the groups (46.3% vs. 54.3%, P = 0.596). There was also no significant difference in the composite outcome between both groups after adjusting for SIPTW (52.3% vs. 68.8%, P = 0.286). CONCLUSIONS: There were no significant differences in the treatment failure in this study addressing pleural infection treatment, in which the drain tip position was stratified by the 9th and 10th thoracic vertebrae. The position of the tip of the thoracic tube may not be important for pleural infection treatment providing that it is in the thoracic cavity. Trial registration The participants were registered retrospectively.

Lobectomy versus segmentectomy: a propensity score-matched comparison of postoperative complications, pulmonary function and prognosis.

OBJECTIVES: To demonstrate the differences in clinical outcomes between lobectomy and segmentectomy for non-small cell lung cancer using propensity score matching. METHODS: A single-centre, retrospective, matched cohort study was conducted in clinical T1N0M0 non-small cell lung cancer patients treated by surgery between 2012 and 2019. Differences in freedom from recurrence, overall survival, postoperative complications, chest drainage and preservation of pulmonary function between lobectomy and segmentectomy were evaluated using the propensity score model. Matched variables of patients were age, sex, comorbidity index and pulmonary function. Matched variables of tumours were tumour size, T-stage, fluorodeoxyglucose uptake on positron emission tomography, histopathology, lobe site and tumour distance ratio from the hilum. RESULTS: Of the 112 patients treated by lobectomy and 233 patients treated by segmentectomy, 93 patients each from both groups were selected after the matching. The median tumour distance ratio from hilum was 0.7 in lobectomy and 0.8 in segmentectomy group (P = 0.59), i.e. almost outer third tumour location. There were no significant differences in freedom from recurrence (P = 0.38), overall survival (P = 0.51), postoperative complications (P = 0.94), drainage period (P = 0.53) and prolonged air leakage (P = 0.82) between the two. Median preservation of pulmonary function was 93.2% after segmentectomy, which was significantly higher than 85.9% after lobectomy (P < 0.001). CONCLUSIONS: Freedom from recurrence, overall survival, postoperative complications and chest drainage were similar between segmentectomy and lobectomy. Segmentectomy could be one of the options for clinical T1N0M0 non-small cell lung cancer located outer third as well as being able to preserve pulmonary function better than lobectomy.

[Successful treatment of refractory chylothorax associated with diffuse large B-cell lymphoma by multidisciplinary care].

Chylothorax is an intrathoracic leakage of chyle due to thoracic duct damage. Malignant lymphoma is the most common nontraumatic cause of chylothorax. In March 2019, a 74-year-old woman presented to our department with bilateral pleural effusion and mesenteric/retroperitoneal masses. She was diagnosed with diffuse large B-cell lymphoma upon performing a biopsy. In May 2019, she was hospitalized for dyspnea due to pleural effusion, and thoracentesis revealed abundant chyle. Although the tumor shrunk after chemotherapy, chylothorax improvement was poor; thus, she could not be discharged. For the management of refractory chylothorax, lymphangiography, thoracic duct embolization, and pleurodesis were performed, and the chylothorax improved immediately. However, in May 2020, right chylothorax recurred without a relapse of malignant lymphoma, which did not improve with conservative treatment. Lymphangiography was performed again; however, treatment via the lymphatic vessels was difficult. Thus, pleurodesis was performed four times, after which the chylothorax regressed. Chylothorax is often refractory. When chemotherapy for malignant lymphoma does not improve chylothorax, multidisciplinary treatment is effective.

Predictors of Spondylolysis on Magnetic Resonance Imaging in Adolescent Athletes With Low Back Pain.

BACKGROUND: Spondylolysis and undiagnosed mechanical low back pain (UMLBP) are the main causes of low back pain (LBP) in adolescent athletes. No studies have evaluated the difference in clinical and radiographic factors between these 2 conditions. Furthermore, it remains unclear which adolescent athletes with LBP should undergo advanced imaging examination for spondylolysis. PURPOSE: To compare the clinical and radiographic factors of adolescent athletes with spondylolysis and UMLBP who did not have neurological symptoms or findings before magnetic resonance imaging (MRI) evaluation and to determine the predictors of spondylolysis findings on MRI. STUDY DESIGN: Cohort study, Level of evidence, 3. METHODS: The study population included 122 adolescent athletes aged 11 to 18 years who had LBP without neurological symptoms or findings and who underwent MRI. Of these participants, 75 were ultimately diagnosed with spondylolysis, and 47 were diagnosed with UMLBP. Clinical factors and the following radiographic parameters were compared between the 2 groups: spina bifida occulta, lumbar lordosis (LL) angle, and the ratio of the interfacet distance of L1 to that of L5 (L1:L5 ratio, %). A logistic regression analysis was performed to evaluate independent predictors of spondylolysis on MRI scans. RESULTS: Significantly more athletes with spondylolysis were male (82.7% vs 48.9%; P < .001), had a greater LL angle (22.8° ± 8.1° vs 19.3° ± 8.5°; P = .02), and had a higher L1:L5 ratio (67.4% ± 6.3% vs 63.4% ± 6.6%; P = .001) versus athletes with UMLBP. A multivariate analysis revealed that male sex (odds ratio [OR], 4.66; P < .001) and an L1:L5 ratio of >65% (OR, 3.48; P = .003) were independent predictors of positive findings of spondylolysis on MRI scans. CONCLUSION: The study findings indicated that sex and the L1:L5 ratio are important indicators for whether to perform MRI as an advanced imaging examination for adolescent athletes with LBP who have no neurological symptoms and findings.

Positron Emission Tomography in Segmentectomy for cT1N0M0 Nonsmall Cell Lung Cancer.

BACKGROUND: This study was aimed to examine the significance of fluorodeoxyglucose positron emission tomography in predicting prognosis after segmentectomy in lung cancer. METHODS: This was a retrospective cohort study, including 227 patients with cT1N0M0 nonsmall cell lung cancer who underwent positron emission tomography followed by segmentectomy between 2012 and 2019. Significance of tumor histology, T-stage, tumor size, and standardized uptake value on positron emission tomography in relation to recurrence-free survival were examined using Cox's proportional hazard analysis. Median follow-up period was 56 months (range: 1-95 months). RESULTS: Tumor stages were Tis in 25 patients, T1mi/T1a in 51, T1b in 98, and T1c in 53. Twenty-six patients (11%) experienced recurrences, including local (n = 8) and distant (n = 18). Multivariate analysis showed that the significant variables for recurrence-free survival were T-stage and standardized uptake value (p = 0.002 and 0.015, respectively), whereas tumor histology and tumor size were not significant (p = 0.28 and 0.44, respectively). When tumor size was divided into ≤2 cm and >2 cm for analysis, it was not significant again (p = 0.49), whereas standardized uptake value remained significant (p = 0.008). While standardized uptake value of tumors with recurrences was significantly higher than those without (4.9-2.8 and 2.6-2.5, respectively, p < 0.001), there was no significant difference between local and distant recurrences (p = 0.32). Cut-off value of standardized uptake value for recurrences was 3.2. Five-year recurrence-free survival rates in tumors with standardized uptake value <3.2 and ≥3.2 were 86 and 65%, respectively (p < 0.001). CONCLUSION: Positron emission tomography could predict the prognosis after segmentectomy better than tumor size.

Extent of Segmentectomy That Achieves Greater Lung Preservation Than Lobectomy.

BACKGROUND: This study sought to clarify the extent of segmentectomy that achieves greater lung preservation than lobectomy. METHODS: This was a single-center retrospective cohort study involving 374 patients with lung cancer who were treated with either lobectomy or segmentectomy between 2013 and 2018. The percentage of preserved pulmonary function (%PPF) after surgery was compared among patients who underwent lobectomy (n = 164), segmentectomy of 2 or more segments (Seg ≥2S; n = 42), and segmentectomy of less than 2 segments (Seg <2S; n = 168). Using perfusion scintigraphy, forced expiratory volume in 1 second of the preserved target lobe was measured to examine its effect on the %PPF. The number of resected subsegments (SSs) in segmentectomy that made the %PPF higher than that observed with lobectomy was also examined. RESULTS: Mean %PPF was lowest in those patients who underwent lobectomy (86%), followed by Seg ≥2S (89%) and Seg <2S (95%) (P < .001), but the difference between the lobectomy and Seg ≥2S was not significant (P = .21). The forced expiratory volume in 1 second of the preserved target lobe was significantly lower in the Seg ≥2S group than in the Seg <2S group (P < .001). The number of resected SSs was 6 to 12 in lobectomy, 4 to 7 in Seg ≥2S, and 1 to 4 in Seg <2S. Although the %PPF after segmentectomy of less than 5 SSs (Seg <5SS) was significantly higher than that after lobectomy (P < .001), the %PPF after segmentectomy of 5 or more SSs (Seg ≥5SS) was not significantly different from that after lobectomy (P = .68). CONCLUSIONS: Both the Seg ≥2S and Seg ≥5SS groups did not differ from lobectomy in %PPF because of the low function of preserved target lobe.

Differences between lung adenocarcinoma and squamous cell carcinoma in histological distribution of residual tumor after induction chemoradiotherapy.

AIMS: To facilitate dose planning for convergent beam radiotherapy in non-small cell lung cancer (NSCLC), tumor response and histological distribution of residual tumors after induction chemoradiotherapy (ICRT) were compared between adenocarcinoma (AD) and squamous cell carcinoma (SQ). METHODS: Ninety-five patients with N1-2 or T3-4 NSCLC were treated with ICRT followed by surgery; 55 had AD and 40 had SQ. For the evaluation of distribution of residual tumors, the location of the external margin of residual tumors was assessed on surgical materials as follows: radius of whole tumor ("a"); distance between the center of tumor and the external margin of residual tumor ("b"); and its location ("b/a"). RESULTS: Of the 55 AD cases, 8 (15%) showed pathological complete remission, which was significantly less frequent than 22 of 40 SQ cases (55%) (p < 0.001). AD showed the residual tumors at the most periphery of tumor (b/a = 1.0) more frequently than SQ, i.e., 39/55 (71%) versus 6/40 (15%), respectively (p < 0.001). Even in 65 cases other than the pathological complete remission, external margins in 47 AD cases located more periphery than those in 18 SQ cases, of which mean b/a values were 0.97 ± 0.17 and 0.70 ± 0.29, respectively (p < 0.001). CONCLUSION: AD showed worse tumor response to ICRT than SQ. After ICRT, AD remained at the periphery of primary tumor more frequently than SQ. It seems that, also in the convergent beam radiotherapy, the periphery part of AD would be more resistant than that of SQ.

Comparison of symptomatic spondylolysis in young soccer and baseball players.

BACKGROUND: Spondylolysis is the main cause of low back pain (LBP) in young athletes. There are few studies analyzing the difference of spondylolysis among young athletes with different sports activities. The purpose of this study was to compare the clinical factors and distribution of the lesions of spondylolysis on magnetic resonance imaging (MRI) scans in young soccer and baseball players with symptomatic spondylolysis. METHODS: The medical records of 267 young athletes aged 7 to 18 years old who underwent MRI to evaluate the cause of LBP between 2017 and 2020 were retrospectively reviewed to identify patients with spondylolysis. Of the young athletes with symptomatic spondylolysis, clinical factors and MRI findings in soccer and baseball players were retrospectively evaluated. The clinical factors were age, sex, interval from onset of LBP to MRI, and side of the dominant leg in the sports field. MRI findings included number, lumbar level, and side of the lesions. RESULTS: A total of 33 soccer players (mean age, 15.4 ± 1.4 years) and 49 baseball players (mean age, 15.4 ± 1.6 years) with symptomatic spondylolysis were enrolled. All patients were male. No significant differences were noted in age and the interval from onset of LBP to MRI between the groups. Soccer players had greater numbers of multiple (p < 0.001) and bilateral (p < 0.001) lesions than baseball players. The dominant side of the hand for pitching or batting was correlated with the contralateral-side lesions in baseball players (p = 0.001). CONCLUSIONS: The distribution of the lesions of spondylolysis differed in young soccer and baseball players. Pitching or batting with the dominant-side hand would be associated with contralateral-side lesions in baseball players. Sports-specific movements and the side of the dominant leg should be considered when treating young athletes with symptomatic spondylolysis.

Ribcage procedure after neoadjuvant chemoradiotherapy for non-small cell lung cancer involving the chest wall.

PURPOSE: Non-small cell lung cancer (NSCLC) involving the chest wall is usually treated with en bloc rib resection or parietal pleurectomy; however, the former causes chest wall deformity and the latter is associated with local recurrence. To prevent both these sequalae, we performed the "ribcage" procedure for tumors involving the chest wall after induction chemoradiotherapy. METHODS: This was a single center retrospective study conducted from 2012 to 2018. The "ribcage" procedure is designed to preserve the ribs of patients with lung tumors involving chest wall and involves peeling the intercostal muscles and periosteum from the ribs, resulting in a birdcage-like appearance. Seventeen patients with NSCLC clearly involving the chest wall, but not destroying the ribs, were treated with induction chemoradiotherapy, followed by the ribcage procedure. A negative margin at the ribs was confirmed by intraoperative frozen sections in 16 of these patients, who then underwent the ribcage procedure. RESULTS: Complete resection was achieved in all 16 patients, none of whom experienced major postoperative complications. After a median follow-up period of 37 months, there was no evidence of local recurrence in any of the patients. CONCLUSION: Our findings suggest that the ribcage procedure is the preferable surgical option as it can prevent chest wall deformities as well as local recurrence.

Positron Emission Tomography in T3/T4 Non-Small Cell Lung Cancer After Induction Chemoradiotherapy.

BACKGROUND: To predict pathological response and survival in T3/T4 non-small cell lung cancer after induction chemoradiotherapy by assessing fluorodeoxyglucose uptake with positron emission tomography. METHODS: In this retrospective observational study, standard uptake values of whole tumors and extrapulmonary involvement sites were measured after induction chemoradiotherapy. The values were then compared with pathological responses and recurrence-free survival. RESULTS: Fifty-seven patients with clinical T3/T4 tumors were treated by chemoradiotherapy followed by surgery. Pathological complete response was observed in 33% of patients (19 of 57). With the cutoff value of 3.3 for whole tumor fluorodeoxyglucose uptake for estimating complete response, 38% patients (9 of 24) with values lower than the cutoff value were false-negative. Tumor remission at extrapulmonary involvement sites was observed in 82% patients (47 of 57), and the cutoff value of the extrapulmonary uptake was 3.0 without any false negatives. Recurrence-free survival was significantly better in patients with values lower than both the whole- and extrapulmonary-uptake cutoff values than in patients with higher values (P = .016 and P = .001, log-rank test, respectively). Among 7 patients who avoided en bloc resections of involved structures because of lowered extrapulmonary uptakes and negative findings in intraoperative frozen sections, none experienced margin recurrence. CONCLUSIONS: Even when whole tumor uptakes in patients with T3/T4 tumors markedly decrease after induction chemoradiotherapy, surgical treatment is still indicated because of possible residual tumors. Tumor remission at extrapulmonary involvement sites could be predicted by extrapulmonary uptake values. Both whole- and extrapulmonary-uptake values after induction chemoradiotherapy could be used to predict prognosis.

Impact of induction chemoradiotherapy on pulmonary function after lobectomy for lung cancer.

OBJECTIVE: Our study aim was to determine whether there are differential changes in whole-lung and regional lung functions after lobectomy for lung cancer between propensity score-matched patients treated with and without induction chemoradiotherapy, by using single-photon emission computed tomography lung perfusion. METHODS: This study was a retrospective matched cohort study of consecutively acquired data. Pulmonary function test and perfusion scintigraphy were conducted before lobectomy and 6 months after lobectomy in patients treated with induction therapy (n = 72) and in those not treated (n = 170), for measuring functional changes of whole lung, contralateral lung, and lobes. After exact matching on resected lobe site, propensity scores for age, smoking status, preoperative pulmonary functions, and predicted postoperative pulmonary function were used to match the groups. RESULTS: After the matching, 46 patients were selected from the groups. Standardized mean differences of the 5 matched variables were <0.1. Whole lung function significantly decreased after lobectomy in the induction therapy group than in the noninduction therapy group (P < .001). Although ipsilateral preserved lobe function before surgery was not different between the groups (P = .33), postoperative value was significantly lower in the induction therapy group than in the noninduction therapy group (P < .001). Although both groups showed a significant increase of contralateral lung function after lobectomy (P < .01), the increases were not significantly different between the groups (P = .81). CONCLUSIONS: Induction chemoradiotherapy was associated with reduced pulmonary function after lobectomy because of a decrease in ipsilateral preserved lobe function, which could be caused by the chronic effects of the induction chemoradiotherapy.

Differences in postoperative changes in pulmonary functions following segmentectomy compared with lobectomy.

OBJECTIVES: To clarify differences in postoperative changes in systemic and regional pulmonary functions between segmentectomy and lobectomy in patients with lung cancer, we compared the 2 procedures using lung perfusion scintigraphy with a fusion image of single-photon emission computed tomography and computed tomography. METHODS: This study is a retrospective matched cohort study of consecutively acquired data. Pulmonary function tests and perfusion single-photon emission computed tomography/computed tomography were conducted before surgery and 6 months after surgery to measure changes in forced expiratory volume in 1 s of a whole lung, contralateral lung and a lobe. After exactly matching the site of the resected lobe between the 2 procedures, propensity scores for age, sex, smoking status and pulmonary function were used to match them. RESULTS: Of the 184 patients treated with segmentectomy and the 208 patients treated with lobectomy between 2013 and 2016, 103 patients were selected from each group after the matching. Whole lung function was significantly more preserved after segmentectomy than after lobectomy (P < 0.001). Segmentectomy preserved the function of the operated lobe with 48 ± 21% of the preoperative function. The function of the ipsilateral non-operated lobe increased after segmentectomy (P = 0.003) but not after lobectomy (P = 0.97). Contralateral lung function increased after both procedures (P < 0.001). CONCLUSIONS: Our data suggest that segmentectomy preserved whole lung function better than lobectomy, because it not only preserved the lobe but also increased the function of the ipsilateral non-operated lobe. Lobectomy did not result in an increase of ipsilateral non-operated lobe function. Contralateral lung function increased after both procedures. The postoperative increase in regional functions could be the result of compensatory lung growth.

A case of tracheo-innominate artery fistula successfully treated with endovascular stent of the innominate artery.

Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication of tracheostomy. We describe a 44-year-old man who was admitted for a pressure ulcer infection with a third tracheostomy in place. He showed massive hemoptysis from the TIF, followed by cardiopulmonary arrest. The cuff of the tube was hyperinflated; however, even a slight movement of the tube resulted in recurrent massive hemorrhage. Thus, an endovascular stent graft was placed. Our case shows that sentinel bleeding may be found prior to TIF, and an endovascular repair can be a lifesaving temporizing option, when the hemorrhage was not controlled by hyperinflating the cuff of the tube.

Preceding bronchial cutting for exposure of the pulmonary artery buried in scar tissue after chemoradiotherapy.

It is often difficult to expose the pulmonary artery buried in a scar tissue, especially in lung cancer patients that responded well to neoadjuvant chemoradiotherapy. Difficulty to access pulmonary artery branches may lead to potentially unnecessary pneumonectomy. To complete lobectomy in such cases, a technique with preceding bronchial cutting for exposure of the pulmonary artery is presented. After dissecting the pulmonary vein, the lobar bronchus is cut from the opposite side of the pulmonary artery with scissors. The back wall of the lobar bronchus is cut using a surgical knife from the luminal face, which can expose the pulmonary artery behind the bronchial stump and then complete lobectomy. Fourteen patients have been treated using the present technique, enabling complete resection by lobectomy (including sleeve lobectomy in 3 patients) without major bleeding. The present procedure can expose pulmonary artery buried in scar tissue, resulting in making the lobectomy safer.

Systemic and regional pulmonary function after segmentectomy.

OBJECTIVE: Segmentectomy includes numerous kinds of procedures that may result in decreased postoperative pulmonary function. This causes controversy regarding the functional advantage of segmentectomy over lobectomy. To clarify the difference between the procedures, systemic and regional pulmonary functions of the resected segments must be examined. METHODS: Pulmonary function tests and lung perfusion single-photon emission computed tomography (SPECT) were prospectively conducted before and after segmentectomy in 117 patients who were divided into groups based on resection of <2 segments (n = 83), ≥2 segments (n = 20), and left upper division (LUD) (n = 14). Left upper lobectomy (n = 13) was used as a control for the LUD group. Forced expiratory volume in 1 second (FEV1) of segment and lobe were measured from a fusion image of SPECT and computed tomography. RESULTS: Percentage of postoperative/preoperative pulmonary function was the highest in the <2 segments group (97% ± 10%), which was followed by the ≥2 segments group (90% ± 9%), LUD group (84% ± 7%), and left upper lobectomy group (83% ± 7%), and the differences between the segmentectomy groups were significant (P < .001-.03), although there was no difference between the LUD and lobectomy groups. Whereas actual FEV1 of preserved lobes were significantly lower than the predicted value in all segmentectomy groups (P < .001), the percentage of actual/predicted value in the LUD group (43% ± 19%) was significantly lower than those in the <2 (72% ± 23%) and ≥2 segments (68% ± 30%) groups (P < .001 and P = .02, respectively). CONCLUSIONS: Segmentectomy decreased the pulmonary function with increasing number of resected segments. LUD segmentectomy decreased both systemic and lobar function significantly due to not only large resection, but also marked depression of the preserved lobe, resulting in similar decrease as lobectomy.

Limited thoracotomy for segmentectomy: a comparison of postoperative pain with thoracoscopic lobectomy.

PURPOSES: To assess whether a video-assisted thoracoscopic surgery (VATS) procedure is superior to limited thoracotomy (LT) for segmentectomy; postoperative pain was compared between VATS-lobectomy (VATS-L) and LT-segmentectomy (LT-S). Widely opened anterolateral thoracotomy segmentectomy (WT-S) was used as a control. METHODS: This study was a retrospective analysis of prospectively collected data for 220 consecutive patients with stage I NSCLC treated between 2012 and 2015 at a single institute using VATS-L (n = 58), LT-S (n = 93), or WT-S (n = 69). Pain scores from postoperative days (POD) 1-4 were measured using a visual analog scale three times a day. Chronic pain was assessed by the need for analgesics at 1, 2, and 3 months postoperatively. RESULTS: No significant differences in pain from POD 1 to 4 were observed between VATS-L and LT-S, whereas WT-S showed significantly higher pain scores than these two procedures (p = 0.0001-0.02). Chronic pain did not differ significantly among the procedures. CONCLUSION: Postoperative pain does not differ significantly between VATS-L and LT-S. LT may be preferable to VATS for segmentectomy to identify the anatomy, dissect the hilar nodes, and establish surgical margins.

Utility and pitfalls of sentinel node identification using indocyanine green during segmentectomy for cT1N0M0 non-small cell lung cancer.

PURPOSES: Sentinel node identification using indocyanine green (ICG) is not only simpler, but also more cost-effective, than using radioisotope tracers. We herein examined the utility and pitfalls of sentinel node (SN) identification using ICG during segmentectomy in patients with cT1N0M0 non-small cell lung cancer (NSCLC). METHODS: ICG was injected around the tumor after thoracotomy, followed by segmentectomy and lymph node dissection, in 135 patients with cT1N0M0 NSCLC. The dissected nodes were examined using an ICG fluorescence imaging system. RESULTS: SNs could be identified in 113 patients (84 %). The mean number of SNs was 2.3 ± 1.3. The percentages of being an SN were 57 % for both stations #12 and #13, which was significantly higher than the 18 % for #10 and 22 % for #11 (p < 0.001). Fourteen patients had N1 or N2 disease. Of these, the SNs were true positive (i.e., SNs contained metastasis) in 11 patients (79 %) and false negative (i.e., SNs did not contain metastasis, while non-SNs contained metastasis) in three patients (21 %). Of the three patients with false-negative results, all non-SNs containing metastases were at station #12 or #13. CONCLUSION: While ICG makes it simple to identify SNs during segmentectomy for cT1N0M0 NSCLC, stations #12 and #13 should be submitted for frozen sections along with the identified SNs to avoid missing true SNs.