Thoracoscopic surgery versus open surgery for lung metastases of colorectal cancer: a multi-institutional retrospective analysis using propensity score adjustment†.

OBJECTIVES: Thoracoscopic surgery for lung metastasectomy remains controversial. The study aimed at determining the efficacy of thoracoscopic surgery for lung metastasectomy. METHODS: This was a multi-institutional, retrospective study that included 1047 patients who underwent lung metastasectomy for colorectal cancer between 1999 and 2014. Prognostic factors of overall survival were compared between the thoracoscopic and open thoracotomy groups using the multivariate Cox proportional hazard model. The propensity score, calculated using the preoperative covariates, included the era of lung surgery as a covariate. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. The difference between the radiological tumour number and the resected tumour number (delta_num) was also evaluated. RESULTS: The c -statistics and the P -value of the Hosmer-Lemeshow Chi-square of the propensity score model were 0.7149 and 0.1579, respectively. After adjusting for the propensity score, the thoracoscopy group had a better survival rate than the open group (stratified log-rank test: P = 0.0353). After adjusting for the propensity score, the most powerful predictive model for overall survival was that which combined thoracoscopy [hazard ratio (HR): 0.468, 95% CI: 0.262-0.838, P = 0.011] and anatomical resection (HR: 1.49, 95% CI: 1.134-1.953, P = 0.004). Before adjusting for the propensity score, the delta_num was significantly greater in the open group than in the thoracoscopy group (thoracoscopy: 0.06, open: 0.33, P = 0.001); however, after adjustment, there was no difference in the delta_num (thoracoscopy: 0.04, open: 0.19, P = 0.114). CONCLUSIONS: Thoracoscopic metastasectomy showed better overall survival than the open approach in this analysis. The thoracoscopic approach may be an acceptable option for resection of pulmonary metastases in terms of tumour identification and survival outcome in the current era.

[A case of metachronous double primary adenocarcinoma in both lungs].

A 78-year-old man underwent a right lower lobectomy for adenocarcinoma in January 2004. The follow-up CT scanning showed a nodule in the left upper lobe in March 2006, and we suspected pneumonia. After clarithromycin (CAM) was administered for three months, CT scanning demonstrated in July 2008 that the nodule was enlarged more than the CT scanning of 2006. We had performed bronchoscopy on April 2009, and obtained a specimen for the nodule. We diagnosed adenocarcinoma from the specimen. We planned adjuvant surgery of left S4S5 partial resection after chemotherapy of carboplatin 450 mg/body (day 1)+paclitaxel 80 mg/body (day 1, 8, 15). We demonstrated the standard thoracotomy and S4S5 partial resection in June of 2009. We experienced two adenocarcinomas as metachronous double primary lung cancer. For both lung cancers one must consider the range of the surgical resection and the respiratory function of the residual lungs. If we find an abnormal shadow in the lung of postoperative lung cancer, it is necessary to consider the possibility of metachronous lung cancer.

Complete port-accessed lobectomy by the muscle-sparing method.

We report the case of a 53-year-old woman who underwent complete port-accessed middle lobectomy by a new technique that preserves all muscles, including the extracostal and intercostal muscles. The operation was performed by using only thoracovideoscopy, and the resected lobe was withdrawn in a pouch through a subxiphoid incision through the substernal route. This complete port-accessed lobectomy is a new technique and is thought to be less invasive than video-assisted lobectomy with minithoracotomy.

CT findings of cystic duct carcinoma two years before obstructive jaundice.

We describe a case of cystic duct carcinoma, the computed tomography findings of which had been incidentally obtained several times over the preceding three years before obstructive jaundice appeared. Under the diagnosis of extrahepatic bile duct carcinoma, a 75-year-old man underwent surgery. Two years before obstructive jaundice appeared, the arterio-portal phase of enhanced computed tomography demonstrated an ovoid mass with peripheral rim enhancement, measuring 1.5 cm in diameter, beside the extrahepatic bile duct. One year later, a repeat enhanced computed tomography consistently showed the ovoid mass with peripheral rim enhancement, and the lower slice of the contiguous computed tomography scan revealed a uniformly enhanced mass compressing the neck of the gallbladder. Four months before obstructive jaundice, the uniformly enhanced mass beside the extrahepatic bile duct markedly infiltrated the surrounding tissues with spicula-formation. At laparotomy, a solid and hard tumor was localized on the right side of the extrahepatic bile duct, in the cholecystic duct and the neck of the gallbladder. Of 29 reported cases fulfilling Farrar's criteria in the English literature other than autopsy cases, computed tomography imaging was only performed in two cases, and the computed tomography findings of cystic duct carcinoma in its early stages, have never been fully described.