Ex Vivo Expanded and Activated Natural Killer Cells Prolong the Overall Survival of Mice with Glioblastoma-like Cell-Derived Tumors.

Glioblastoma (GBM) is the leading malignant intracranial tumor and is associated with a poor prognosis. Highly purified, activated natural killer (NK) cells, designated as genuine induced NK cells (GiNKs), represent a promising immunotherapy for GBM. We evaluated the anti-tumor effect of GiNKs in association with the programmed death 1(PD-1)/PD-ligand 1 (PD-L1) immune checkpoint pathway. We determined the level of PD-1 expression, a receptor known to down-regulate the immune response against malignancy, on GiNKs. PD-L1 expression on glioma cell lines (GBM-like cell line U87MG, and GBM cell line T98G) was also determined. To evaluate the anti-tumor activity of GiNKs in vivo, we used a xenograft model of subcutaneously implanted U87MG cells in immunocompromised NOG mice. The GiNKs expressed very low levels of PD-1. Although PD-L1 was expressed on U87MG and T98G cells, the expression levels were highly variable. Our xenograft model revealed that the retro-orbital administration of GiNKs and interleukin-2 (IL-2) prolonged the survival of NOG mice bearing subcutaneous U87MG-derived tumors. PD-1 blocking antibodies did not have an additive effect with GiNKs for prolonging survival. GiNKs may represent a promising cell-based immunotherapy for patients with GBM and are minimally affected by the PD-1/PD-L1 immune evasion axis in GBM.

[Effectiveness of Osimertinib for Postoperative Recurrence of Lung Cancer with L861Q Activating EGFR Mutation:Report of a Case].

A 69-year-old woman was referred to our hospital because of an abnormal shadow on a chest roentgenogram at a medical check-up. Chest computed tomography showed a 2.5 cm-diameter tumor in the right pulmonary lower lobe. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) could not detect the other lesions. The patient underwent thoracoscopic right lower lobe lobectomy for lung adenocarcinoma. Pathological diagnosis was invasive adenocarcinoma (pT1cN0M0). EGFR status was positive for the L861Q mutation in exon 21. At 31 months after surgery, the recurrence appeared as vertebral and multiple pulmonary lesions, and the treatment with osimertinib showed satisfactory response seven months after starting the treatment.

Implications of Preoperative Transbronchial Lung Biopsy for Non-small Cell Lung Cancer Less than 3-cm.

BACKGROUND/AIM: Transbronchial lung biopsy (TBLB) has been recommended for patients with suspected lung cancer. However, its diagnostic value is limited to small lesions, and some studies have indicated that biopsy might be related to metastasis and/or dissemination. This study aimed to evaluate the outcomes after preoperative TBLB for non-small cell lung cancer (NSCLC) patients. PATIENTS AND METHODS: Data were reviewed from 371 patients with resected pN0 NSCLC less than 3-cm. Patients were divided into two groups: TBLB and Non-TBLB. Recurrence-free survival (RFS) curves were plotted using the Kaplan-Meier method. Cox regression analyses were used to evaluate the hazard ratio (HR) with the endpoint RFS. RESULTS: The 5-year RFS rates were 75.5% in the TBLB group and 91.4% in the Non-TBLB group (p<0.001). Poor RFS was independently associated with TBLB (HR=2.491, 95%CI=1.337-4.640; p=0.004). CONCLUSION: Preoperative TBLB may adversely affect RFS among NSCLC patients with small size tumours.

Surgical treatment for secondary spontaneous pneumothorax: a risk factor analysis.

PURPOSE: While surgery is an effective treatment for secondary spontaneous pneumothorax (SSP), it can be difficult, because affected patients are usually in a poor general condition. The present study investigated the risk factors of postoperative complications after surgery for SSP. METHODS: Eighty-eight patients with SSP who underwent surgery from January 2006 to March 2018 were investigated. Clinical data were reviewed, and a multivariate analysis was performed. RESULTS: Eighty-four patients (95%) were males, and the median patient age was 72 years. Underlying lung diseases were chronic obstructive pulmonary disease in 58 patients (65.9%), interstitial pneumonia in 26 (29.5%), and others in 4 (4.5%). Postoperative complications developed in 21 patients (24%). Hospital mortality/prolonged length of stay occurred in 6 patients (7%). A multivariate analysis showed that the preoperative performance status (performance status 0-2 vs. 3, hazard ratio: 6.570, 95% confidence interval: 1.980-21.800) was an independent predictor of postoperative complications. CONCLUSION: Surgery for SSP contributed to early chest tube removal and favorable outcomes. However, rare fatal events occurred, and the patient performance status was a risk factor for postoperative complications. A careful evaluation of each patient's performance status is needed to determine the need for surgical intervention for SSP.

Status of pleural lavage cytology in cases of pulmonary metastasis: a single-institution retrospective study.

OBJECTIVE: In primary lung cancer surgery, intraoperative pleural lavage cytology (PLC) has been identified as a prognostic marker. However, there have been no reports on PLC for pulmonary metastasectomies. Therefore, the impact of PLC status for patients undergoing pulmonary metastasectomy remains unknown. We aimed to know the incidence and prognostic impact of positive PLC findings in pulmonary metastasectomies. METHODS: We retrospectively reviewed patients undergoing pulmonary metastasectomies between January 2013 and December 2018. One hundred and eighty-nine PLC procedures in 159 patients undergoing pulmonary metastasectomy were analyzed. Follow-up information was available in 107 patients who underwent 132 procedure, and they were investigated for pleural recurrence-free probability (PRFP) and overall survival (OS) after pulmonary metastasectomy. RESULTS: The type of primary lesion was colorectal cancer (101/189, 53%), urothelial/kidney cancer (17/189, 9%), skeletal/soft tissue tumor (18/189, 10%), hepatobiliary/pancreatic cancer (19/189, 10%), uterine/ovarian cancer (14/189, 7%), otorhinolaryngological cancer (11/189, 6%), and other minor lesions (9/189, 5%). Nine PLC-positive metastasectomies were revealed (9/189, 4.8%). They consisted of six metastasectomies from pancreatic cancer, two from osteosarcoma, and one from tongue cancer. Significant predictors for PLC status was type of primary tumor (P < 0.001). PRFP and OS rate of PLC-positive group were significantly lower than PLC-negative (P < 0.001, respectively). CONCLUSION: PLC-positive results were rarely seen in pulmonary metastasectomies. PLC status was associated with the incidence of ipsilateral pleural recurrence and survival after metastasectomy. Cytologic examination of PLC should be considered in patients undergoing pulmonary metastasectomy.

Preoperative Detection of Pleural Adhesions Using Ultrasonography for Ipsilateral Secondary Thoracic Surgery Patients.

BACKGROUND/AIM: Video-assisted thoracic surgery (VATS) for ipsilateral reoperations is challenging because of the potential for pleural adhesions. Insertion of the initial port can lead to lung injury because of the blinded intrathoracic area. We assessed the usefulness of ultrasonography before VATS to reduce the incidence of lung injury at the time of the initial port insertion during secondary ipsilateral VATS. PATIENTS AND METHODS: Thirty-three patients who underwent repeat VATS for ipsilateral pulmonary lesions were included. All patients underwent preoperative ultrasonography to assess the possible presence of pleural adhesions using the lung sliding sign. RESULTS: Seven adhesions were found at the VATS ports. Two of these adhesions were not evaluated as pleural adhesions using ultrasonography; however, they were loose. All initial ports were inserted without lung injury. There were no major complications. CONCLUSION: Preoperative detection of pleural adhesions using ultrasonography can determine the best initial port for secondary ipsilateral VATS.

[Preoperative Detection of Pleural Adhesions Using Transthoracic Ultrasonography].

Recently, there has been an increase in the experience of lung surgery in cases with a history of thoracotomy or pneumonia. In these cases, pleural adhesion is often seen and makes the surgery to be difficult. Especially in thoracoscopic surgery, lung damage must be care at the 1st port insertion. In this report, the usefulness of the extent of pleural adhesion to the chest wall before surgery by using a transthoracic ultrasonography was assessed. Between April 2017 and September 2018, 32 patients underwent preoperative ultrasound examination, and 128 ports were evaluated whether had adhesions or not using lung sliding sign. All patients of 128, 24 adhesions were found at surgery, resulting in 14 true positive, 10 false negative, 0 false positive, and 104 true negative findings [sensitivity:58.3% (14/24), specificity: 100.0% (104/104), accuracy:92.2% (118/128)]. Especially, about the 1st port, accuracy was 93.8 % (30/32). In Conclusion, preoperative transthoracic ultrasonography could provide useful information on the pleural adhesion leading safe initial thoracoscopic access without lung injury.

Isolation and culture of pleural mesothelial cells.

Purpose: Although the isolation of rat and mouse mesothelial cells has previously been reported, most mesothelial cells used for experimental studies are obtained from peritoneal cells. Here, we describe an optimized method for the isolation and in vitro propagation of rodent pleural mesothelial cells without the requirement for specialized surgical techniques. Materials and Methods: To harvest pleural mesothelial cells, the pleural space of 8-9-week-old rats or older mice was filled with 0.25% trypsin in ethylenediaminetetraacetic acid (EDTA) buffer for 20 min at 37 °C. Cells were then harvested, and incubated at 37 °C in a humidified atmosphere with 5% CO2. Immunofluorescence analysis of plated pleural mesothelial cells was performed using Alexa 546 (calretinin). To investigate optimal proliferation conditions, medium enriched with various concentrations of fetal calf serum (FCS) was used for pleural mesothelial cell proliferation. Results: By day 10, confluent cell cultures were established, and the cells displayed an obvious cobblestone morphology. Immunofluorescence analysis of the cells demonstrated that all stained positive for Alexa 546 (calretinin) expression. Mesothelial cells grew better in medium containing 20% FCS than with 10% FCS. Conclusions: This is a simple procedure for the efficient collection of primary pleural mesothelial cells, which were obtained in defined culture conditions from the euthanized rodent thoracic cavity using trypsin-EDTA treatment. The ability to easily culture and maintain identifiable pleural mesothelial cells from rodents will be helpful for future experiments using these cells.

Ultrasonography for Detecting Adhesions: Aspirin Continuation for Lung Resection Patients.

BACKGROUND/AIM: Aspirin reduces cardiovascular disease and/or stroke risks. However, perioperative aspirin use remains controversial. We assessed the efficacy of ultrasonography to facilitate video-assisted thoracic surgery (VATS). We analyzed the perioperative management of patients using aspirin and its association with bleeding events during lung cancer surgery. PATIENTS AND METHODS: A total of 38 patients who underwent VATS after continuing or discontinuing aspirin were examined. Ultrasound was performed preoperatively to evaluate the pleural adhesions. Fisher's exact test was used to analyze correlations between the two groups. RESULTS: Dense adhesions were found at VATS ports using ultrasonography (accuracy: 100%). No differences were detected in bleeding, thrombotic events, or operative times between the aspirin and non-aspirin groups. There were differences in bleeding (p=0.009) and operative times (p=0.021) between the dense adhesion and non-dense adhesion groups. CONCLUSION: Preoperative detection of pleural adhesions using ultrasonography was useful in selecting pulmonary resection patients who continued aspirin perioperatively.

Effect of covering with cross-linked gelatin glue on tissue regeneration in a rat lung injury model.

OBJECTIVES: Thoracic reintervention is a common treatment; however, preventing adhesion of the lung to the thoracic cavity wall remains a problem. This study aimed to investigate the effect on pleural adhesion of covering the postoperative pleural injury site with cross-linked gelatin glue (gelatin plus glutaraldehyde, hereafter 'gelatin glue') and to evaluate the proliferation of healing cells on gelatin glue. METHODS: We created a rat incisional lung-wound model and compared the effects of sealing the wound with gelatin glue (group A, n = 5), fibrin glue (group B, n = 5) or fibrin glue with a polyglycolic acid sheet (group C, n = 5). Adhesions were assessed 28 days postoperatively and compared among the groups using the Karacam's scoring method. Lung-wound healing was studied histologically at day 7 postoperatively. Mesothelial cell proliferation was investigated on gelatin and fibrin glues in vitro. RESULTS: There were no or few adhesions of the chest wall in group A. The adhesion scores (mean ± standard deviation) were 1.2 ± 0.4, 2.6 ± 1.4 and 3.2 ± 1.2 in groups A, B and C, respectively (A vs C, P = 0.0496). During the healing process, the gelatin glue surface was covered by mesothelial-like cells. Proliferation of cultured mesothelial cells was promoted on the gelatin glue compared with the fibrin glue. CONCLUSIONS: Covering lung wounds with the gelatin glue reduced adhesions and promoted the growth of healing cells compared with the fibrin glue. These findings suggest that the gelatin glue may help prevent adhesions and thus be a therapeutically effective biomaterial in lung surgery.

Prognostic impact of underlying lung disease in pulmonary wedge resection for lung cancer.

BACKGROUND: Pulmonary wedge resection is an option for lung cancer patients with limited cardiopulmonary preservation. As the impact of underlying lung status on the prognosis of such patients remains unclear, we assessed this issue. METHODS: A total of 149 borderline surgical candidates with localized lung cancer who had undergone wedge resection were retrospectively investigated. Clinical variables related to perioperative morbidity, local control rate, and oncological outcomes based on underlying lung disease were analyzed. RESULTS: According to the risk analysis of postoperative complications, underlying lung disease did not influence the surgical morbidity. Postoperative recurrence occurred in 65 patients (locoregional recurrence in 36, distant metastasis in 12, and both simultaneously in 17). Multivariate analysis revealed that emphysema on computed tomography (CT) [hazard ratio (HR) 0.45; 95% confidence interval (CI) 0.21-0.99] was an independent indicator of locoregional recurrence. Forty-four patients died of lung cancer and 29 of other causes. Multivariate analysis demonstrated that interstitial lung disease on CT (HR 1.98; 95% CI 1.01-3.89) was a predictor of poor prognosis. CONCLUSION: Pulmonary wedge resection can be safely undergone by lung cancer patients regardless of pulmonary comorbidity, although underlying lung disease may influence the prognosis after wedge resection.

Endobronchial Watanabe Spigots for Treatment of Pyopneumothorax due to Nontuberculous Mycobacteriosis in a Patient with Rheumatoid Arthritis: A Case Report Based on Past Experience.

Nontuberculous mycobacterial lung disease sometimes causes pneumothorax and empyema, which are often intractable because of patients' background factors. Biological products used in the treatment of rheumatoid arthritis have caused the problem of an increase in infection rates as a side effect, one of which is nontuberculous mycobacteriosis (NTM). On the basis of past experience, we report the case of a patient who had a history of undergoing treatment with biological products against rheumatoid arthritis. The patient was treated for NTM-induced pyopneumothorax by endoscopic bronchial occlusion therapy using endobronchial Watanabe spigots.

Clinical and pathological characteristics of surgically resected intrapulmonary lymph nodes: Can they be differentiated from other malignant nodules?

BACKGROUND: Intrapulmonary lymph nodes (IPLNs) are often recognized as sub-centimeter solid pulmonary nodules (SCPNs). The present study investigated their clinical and pathological characteristics to allow clinicians to distinguish them from malignant nodules. METHODS: Among 194 SCPNs surgically resected between 2006 and 2016, 26 IPLNs were investigated histopathologically. In addition, 145 resected malignant SCPNs were compared radiographically with the 26 IPLNs. RESULTS: Radiographically, most IPLNs were in a middle or lower lobe, and all lesions were within 20 mm of the visceral pleura. Enlargement was seen in one lesion. Three lesions demonstrated linear density contiguous to pleura (LD), and 13 lesions were adjacent to the peripheral pulmonary vein (APV). Microscopically, all IPLNs showed adjacency to pulmonary veins, 23 showed interlobular septa extending from the IPLN, and 18 were surrounded by a dilatated lymphoid channel. Radiographical findings of LD and APV were also seen in malignant SCPNs (LD, 12/145; APV, 25/145). Comparative analysis revealed that enlargement and APV were significant predictors differentiating IPLNs from malignant SCPNs. The sensitivity/specificity of enlargement and APV were 92%/92% and 17%/50%, respectively. CONCLUSIONS: IPLNs show typical high-resolution computed tomography findings that reflect their histopathological characteristics. Such findings help identify IPLNs prior to surgery. Specifically, enlargement and APV may differentiate IPLNs from malignant SCPNs. However, atypical cases are also possible, and radiological findings are not specific for differentiating IPLNs from malignant lesions. Thus, clinicians should consider surgical exploration when diagnosing SCPNs.

Induction of lung-like cells from mouse embryonic stem cells by decellularized lung matrix.

Decellularization of tissues is a recently developed technique mostly used to provide a 3-dimensional matrix structure of the original organ, including decellularized lung tissues for lung transplantation. Based on the results of the present study, we propose new utilization of decellularized tissues as inducers of stem cell differentiation. Decellularized lung matrix (L-Mat) samples were prepared from mouse lungs by SDS treatment, then the effects of L-Mat on differentiation of ES cells into lung cells were investigated. ES cell derived-embryoid bodies (EBs) were transplanted into L-Mat samples and cultured for 2 weeks. At the end of the culture, expressions of lung cell-related markers, such as TTF-1 and SP-C (alveolar type II cells), AQP5 (alveolar type I cells), and CC10 (club cells), were detected in EB outgrowths in L-Mat, while those were not found in EB outgrowths attached to the dish. Our results demonstrated that L-Mat has an ability to induce differentiation of ES cells into lung-like cells.

[Prognostic Significance of Mode of Nodal Involvement in Pulmonary pN1 Squamous Cell Carcinoma].

According to the tumor, node, metastasis (TNM) classification of the Union for International Cancer Control (UICC) and the International Association for the Study of Lung Cancer (IASLC), N factor is defined by the anatomic extent of the metastatic lymph nodes, but is not related to the metastatic pattern. N1 is defined as "metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension". Lymph node involvement is one of the most important prognosistic factors in non-small cell lung cancer patients. Squamous cell carcinoma (SCC) arises in the central airway and directly invades adjacent lymph nodes more frequently compared to the other histologic types. We retrospectively evaluated the prognostic impact of lymph node involvement patterns in pulmonary pN1 squamous cell carcinoma (SCC) patients. The clinical records of 23 patients with pN1 SCC who underwent complete resection and systematic lymph node dissection at our institute were retrospectively reviewed. We classified the patient into 2 N1 groups based on the nodal involvement pattern:metastatic N1 nodes involved directly by the main tumor (direct group) and metastatic N1 nodes not directly involved by the main tumor (separate group). The direct group consisted of 10 patients, and the separate group comprised 13 patients. There were no significant difference in the gender, tumor size, surgical procedure, and number of metastatic lymph nodes. Overall survival and disease-free survival curves were plotted using the Kaplan-Meier method, and the statistical differences between both groups was determined by the log-rank test. P values <0.05 were considered statistically significant. The direct group had a much better 5-year overall survival rate of 100.0% compared with 55.9% for the separate group (p=0.037). The N factors in TNM classification are defined only by anatomical location. However, our results suggest that the mode of nodal involvement in pulmonary pN1 SCC might be a prognostic factor. Accordingly, it is likely that biological behaviors are different between direct metastasis and separate metastasis. Since there are some limitations in this study:its retrospective design and small sample size, the clinical implication of direct extension to N1 lymph nodes needs to be confirmed by a large scale prospective study in the future.

A no-touch technique for pulmonary wedge resection of lung cancer.

OBJECTIVE: Many of the surgical patients with lung cancer die by metastasis originated from circulating tumor cells (CTCs) which are seeds of metastases. A ring-shaped catching forceps, which generates the great pressure by compression, may reduce the risk of tumor cell spreading. Here, we investigated the efficacy of such forceps based on CTC occurrence. METHODS: Twenty-three patients with clinical stage IA lung cancer who underwent a pulmonary wedge resection were investigated in a clinical-pathological manner. They were divided into those treated using ring forceps catching without tumor release (R group) (n = 16) and non-complete use of ring forceps (N group) (n = 7), then were determined circulating tumor cells (CTCs). RESULTS: Radiographic findings, tumor location, pathological diagnosis, and stapling method were not significantly different between the groups. The risk of detection of CTCs after surgery was significantly lower in group R (12.5 vs. 85.7%, p = 0.02), whereas there were no significant differences found in risk of negative-stapled margin cytology, pre-OP CTC detection, V (+), Ly (+), and Pl (+). CONCLUSIONS: Patients who underwent pulmonary wedge resection of lung cancer had low chance of CTC detection after surgery when they were treated with ring forceps without tumor release, which might become a no-touch isolation technique.

Surgical Treatment for Pulmonary Metastasis of Pancreatic Ductal Adenocarcinoma: Study of 12 Cases.

BACKGROUND/AIM: Few studies have reported results with pulmonary metastasectomy for pancreatic ductal adenocarcinoma (PDAC), probably because of their extremely poor outcomes. The aim of this study was to review our institutional experience and analyze the outcomes of pulmonary metastasectomy for PDAC. PATIENTS AND METHODS: A retrospective case-control study of patients undergoing pulmonary metastasectomy for isolated lung metastasis of PDAC between 2004 and 2016. Clinicopathological features were analyzed and survival curves were plotted using the Kaplan-Meier method. RESULTS: Twelve patients were included. The median follow-up period after metastasectomy was 33 months. At the time of analysis, five patients had deceased, two were alive with disease, and five were alive without disease. The median survival time after pulmonary metastasectomy was 47 months. The estimated 3- and 5-year overall survival rates were 62.3% (95%CI=27.8-84.0) and 31.2% (95%CI=1.7-71.7). CONCLUSION: Outcomes were favorable following pulmonary metastasectomy in selected patients with PDAC.

Low-voltage coagulation, polyglycolic acid sheets, and fibrin glue to control air leaks in lung surgery.

OBJECTIVE: We evaluated the efficacy of low-voltage coagulation (LVC) with polyglycolic acid (PGA) sheets (Neoveil, GUNZE Ltd., Japan) and fibrin glue to control intraoperative alveolar air leaks after lung surgery. METHODS: We included 176 patients with non-small cell lung cancer who underwent thoracoscopic lobectomies. When alveolar air leak was confirmed after lung resection, we applied LVC system to the pleural defect followed by layers of PGA sheets and fibrin glue (n = 40). We then analyzed postoperative air leaks (rate of occurrence and duration time). RESULTS: 73% of patients (29/40 cases) experienced no postoperative air leaks. Although 11 patients experienced air leaks after surgery, there were no prolonged air leaks (>7 days) (resolution time, 3.5 ± 1.4 days; range, 2-6 days). Two patients required drainage for late-onset air leaks, but their conditions improved without further treatment. There were no further adverse events. CONCLUSIONS: The use of LVC with PGA sheets and fibrin glue following pulmonary resection efficiently prevented both intraoperative air leaks and prolonged air leaks after lung surgery.

[Resection of a Posterior Mediastinal Tumor Using Intraoperative Motor Evoked Potential Monitoring;Report of a Case].

A 20-year-old man with a posterior mediastinal tumor incidentally found on a chest X-ray was referred to our hospital. Chest computed tomography showed a 3 cm nodule located on the left side of the 10-11th thoracic vertebra, where the artery of Adamkiewicz is presumed to arise. He underwent left thoracotomy to remove the lesion. The tumor was safely resected with the assistance of intraoperative motor evoked potential(MEP) monitoring. The postoperative diagnosis was a benign schwannoma. In thoracic surgery for posterior mediastinal tumors, intraoperative MEP monitoring is useful for preventing paraplegia.

Rapid progression of solitary fibrous tumor after induction of hemodialysis.

A 42-year-old male patient presented in 2002 with a solitary fibrous tumor (SFT) arising from the visceral pleura of the right lung. Thoracic surgery was performed to remove the tumor. A second operation to remove a recurrent tumor on the parietal pleura of the right thorax was performed in 2010. A follow-up computed tomography (CT) scan revealed local recurrence in the chest wall. And then a third operation involving en bloc resection of chest wall was performed in 2012. Thereafter, a CT scan in 2015 revealed slow-growing local recurrence. In 2016, he was started on hemodialysis. Two months later he was hospitalized because of chest pain and dyspnea. Imaging showed bilateral massive pleural effusion and dissemination along with left pulmonary metastasis. We report a case of SFT recurrence, which rapidly worsened after induction of hemodialysis. Induction of hemodialysis is potentially challenging that may lead to be in a tumor-bearing condition.