[Introduction of Support for Thoracoscopic Surgery by Clinical Engineers:Task Shift as Scopist by Clinical Engineers].

On October 1, 2021, the Clinical Engineer Law was revised and expanded the task of clinical engineers (CEs). After that, they can hold and operate a endoscope in endoscopic surgery. On June 9, 2022, our hospital asked CEs to directly participate in thoracoscopic pleural biopsy as scopist( scope operator) for the first time, and since then, a total of 54 thoracoscopic surgery cases were performed by CEs as scopist over the course of one year. In the CE-supported lung surgery of lobectomy and segmentectomy cases, there was a trend toward an increase in operating time of about 15 minutes, although there was no significant difference in operating time compared with conventional surgery. Other than that, however, there were no particular problems, and we expect that further CE education will provide a favorable surgical environment.

[Complete Transection of the Cervical Trachea Caused by Chest Blunt Trauma].

A 52-year-old man was injured when driving through the gate by a motorcycle without noticing the rope between the gateposts. He developed hoarseness, subcutaneous emphysema and dyspnea, and was transferred to our hospital by an ambulance. Chest X-ray and computed tomography showed subcutaneous and mediastinal emphysema, and complete transection of the cervical trachea. Since respiratory distress progressed rapidly, we performed tracheostomy in the intensive care unit, and the patient was carried to the operating room. Tracheoplasty was performed with 3-0 prolene. The postoperative course was satisfactory except for bilateral recurrent nerve palsy.

[Penetrating Injury of the Lung with a Glass Splinter].

A 62-year-old man got drunk and dived into the windowpane. He received lacerations on his face and incised wound at his right chest, and was carried to our hospital. Computed tomography showed a glass splinter, about 14 cm of length, in the chest cavity. The patient underwent an emergency thoracotomy and it was found that the glass splinter penetrated through the upper lobe to the hilum. After removing the glass, simple closure by suturing the entrance and exit of the upper lobe was performed. The post operational course was uneventful. Selected patients can be rescued by simple pneumonorrhaphy without resection of lung.

The Clinical Impact of Solid and Micropapillary Patterns in Resected Lung Adenocarcinoma.

INTRODUCTION: Since the new adenocarcinoma (ADC) classification was presented in 2011, several authors have reported that patients with solid (S) and/or micropapillary (MP) predominant patterns showed a worse prognosis. On the other hand, there are several patients who have S and/or MP patterns even if their patterns are not predominant. However, the evaluation of these patients is uncertain. METHODS: A total of 531 ADCs were examined. We classified the patients into five subgroups according to the proportion of S and/or MP patterns: (1) both patterns absent (S-/MP-), (2) S predominant (S pre), (3) MP predominant (MP pre), (4) S pattern present although not predominant and MP pattern absent (S+ not pre/MP-), and (5) MP pattern present although not predominant (MP+ not pre). RESULTS: Of the 531 ADCs, 384 (72.3%) were classified as S-/MP-, 55 (10.4%) as S pre, 11 (2.1%) as MP pre, 42 (7.9%) as S+ not pre/MP-, and 39 (7.3%) as MP+ not pre. In a univariate analysis, the recurrence-free survival (RFS) and overall survival differed significantly among the five subgroups (p < 0.01 and p < 0.01, respectively). In a multivariate analysis, patients with S-/MP- had significantly higher RFS rates than did those with other subgroups. On the other hand, patients with MP pre had lower RFS rates than did those with other subgroups. CONCLUSION: Patients with S and/or MP patterns have a poorer prognosis even if their patterns are not predominant. The S and/or MP patterns must be treated at the time of diagnosis.

[Primary Synovial Sarcoma in the Anterior Mediastinum;Report of a Case].

We report a rare case of synovial sarcoma in the anterior mediastinum. A 43-year-old man consulted our hospital with a complaint of dyspnea and chest discomfort. Chest computed tomography revealed an anterior mediastinal mass. Small open biopsy was performed, and the pathological examination revealed spindle-shaped cells with severe atypia. Tumor resection was performed. On pathology, fascicular and storiform patterns of spindle-shaped cells with severe atypia were noted. The tumor cells were positive for cytokeratin 7, vimentin, Bcl -2 and CD99, and the amplification of SYT-SSX fusion gene was also found. Therefore it was diagnosed as a synovial sarcoma.

[Port site recurrence after thoracoscopic resection of the pulmonary metastasis of sigmoid colon cancer].

A 71-year-old female underwent thoracoscopic resection for pulmonary metastasis from sigmoid colon cancer in March 2012. After 7 months, postoperative computed tomography (CT) showed a chest tumor around the left 6th rib. At the same time, she complained of left chest pain. These findings were initially considered as posttreatment changes. But the lesion of the chest wall enlarged and the pain worsened. We made a diagnosis of chest wall recurrence and performed a surgery in June 2013. The pathological diagnosis was chest wall metastasis from colon cancer. A port site recurrence on the chest wall was strongly suggested because it was extremely close to the port site of thoracoscopic resection. This patient is free from recurrence 16 months after surgery.

Noninvasive Differential Diagnosis of Pulmonary Nodules Using the Standardized Uptake Value Index.

OBJECTIVES: We previously showed that the standardized uptake value (SUV) index, which was defined as the ratio of the maximum SUV of the tumor to mean SUV of the liver, was a surrogate marker of lung cancer aggressiveness. In this study of patients with pulmonary nodules (PNs), we explored whether the SUV index could be used to differentiate small malignant from small benign PNs. METHODS: A total of 284 patients with solitary PNs ≤2 cm in size underwent positron emission tomography/computed tomography and surgery. The associations between pathological findings and clinical factors were evaluated. RESULTS: The median SUV indices of lung cancer, metastatic PNs and benign nodules were 1.2, 1.5, and 0.6, respectively (P <0.01). A SUV index cut-off value of 1.2 was used to differentiate benign from malignant nodules. When patients were grouped according to SUV index cut-off values of <1.2 or ≥1.2, the following cases were false-negative: lung adenocarcinoma (P <0.01), kidney as primary site (P <0.01), and metastatic PNs with long disease-free survival (P = 0.02). CONCLUSIONS: As a noninvasive diagnostic marker, the SUV index was found to be useful for differentiating benign from malignant small PNs.

Smoking is a perioperative risk factor and prognostic factor for lung cancer surgery.

OBJECTIVE: The aim of this study was to investigate the smoking status of lung cancer patients and to confirm the risk of smoking for patients undergoing lung cancer surgery. METHODS: We conducted a retrospective study of patients undergoing lung cancer surgery. Between May 2004 and March 2013, 716 patients underwent lung cancer surgery at our institution. Based on smoking status, the patients were classified into 3 groups: nonsmoker, past smoker, and current smoker. Based on exclusion criteria, a final total of 670 patients were investigated for the association between smoking status and postoperative complications. In addition, we explored the effect of smoking on survival after surgery. RESULTS: There were 254 non-smokers, 246 past smokers, and 170 current smokers. The percent of female patients, adenocarcinoma, and stage IA cancer was highest in the nonsmokers. Respiratory function was significantly impaired in past and current smokers. Respiratory and cardiac complications were found less frequently in non-smokers (11.4%) followed by 17.1% of past smokers and 21.2% of current smokers (p = 0.0226). Univariate analysis showed that smoking was a significantly poor prognostic factor for overall survival. The 5-year survival rates for non-smokers, past, and current smokers were 81.4, 65.4, and 68.8%, respectively (p = 0.0003). CONCLUSIONS: Smokers with lung cancer tended to have advanced lung cancer, impaired pulmonary function, and high morbidity after lung cancer surgery. Although multivariate analysis did not show that smoking was associated with poor outcome, non-smokers had significantly better overall survival, even for patients with stage IA lung cancers.

[Vagal Nerve Schwannoma Complicated with Bloody Pleural Effusion；Report of a Case].

A 51-year-old male who had received hemodialysis twice a week was referred to our hospital for a further examination of bloody pleural effusion in the right chest. He has been suffering from a fever and cough for 2 months. Chest computed tomography and magnetic resonance imaging revealed a pleural effusion in the right pleural cavity and posterior mediastinal tumor in paravertebral lesion. Chest drainage was performed, and cytological diagnosis did not show malignant findings. To make a definite diagnosis and treatment, surgical resection was carried out. During surgery, posterior mediastinal tumor originated from vagal nerve, and a schwannoma was diagnosed by frozen section. After resection, postoperative course was uneventful, and bloody pleural effusion disappeared.

[Hemorrhagic Cerebral Infarction after Right Segmental Lung Resection；Report of a Case].

Postoperative hemorrhagic cerebral infarction is rare but fatal complication. We report a case of hemorrhagic cerebral infarction after lung cancer surgery without a history of atrial fibrillation and cerebrovascular disease. A 58-year-old man who have a history of diabetes mellitus, hypertension and dyslipidemia underwent right segmental lung resection. During surgery, he had no atrial fibrillation episode. On postoperative day 1, he presented a slight consciousness disturbance. On the day 2, he suffered from a headache and nausea. Brain computed tomography demonstrated a hemorrhagic infarction at the right posterior cerebral artery territory. Transesophageal echocardiography and magnetic resonance angiography did not show the thrombus. The symptoms were gradually improved with intensive medical therapy, and he was discharged with a left homonymous hemianopsia. Although a diagnosis of the consciousness disturbance in the early-phase postoperative period is difficult, perioperative cerebral infarction should be recognized as a postoperative complication.

[Intravascular papillary endothelial hyperplasia of the lung].

We report a rare case of pulmonary intravascular papillary endothelial hyperplasia. The patient was a 63-year-old male. Multiple lung nodules were noted on chest computed tomography( CT) at preoperative check for gastric cancer. Metastatic lung tumor was suspected, and partial resection of the right lung was performed. Histopathologic examination revealed papillary proliferation lined by endothelial cells and a hematoma. Immunohistochemically, the endothelial cells were positive for CD31/CD34 and factor VIII related antigen.

[A case of recurrent lung cancer with bone metastases treated with tegafur-uracil and zoledronic acid for long-term survival].

We present the case of an 84-year-old man with lumbago due to bone metastases from lung cancer that recurred three years after surgery. The patient received carboplatin-paclitaxel combination as first-line chemotherapy for the treatment of lung cancer, and palliative radiotherapy for the treatment of bone metastases. Gemcitabine was administered as second-line chemotherapy. However, disease progression was observed after three years, and he developed pulmonary metastases. The general condition of the patient worsened, and tegafur-uracil chemotherapy was initiated. Zoledronic acid was also administered. The tegafur-uracil treatment resulted in the disappearance of pulmonary metastases, and a stabilization of the bone metastases. Disease progression was observed after 6 years with a recurrence of pulmonary metastases; however, this did not have a negative impact on the patient's quality of life. Although slow progression may be inherent to lung cancers, it is also possible that the tegafur-uracil and zoledronic acid combination might have contributed to the patient's improved performance.

Detection of non-aggressive stage IA lung cancer using chest computed tomography and positron emission tomography/computed tomography.

OBJECTIVES: In contrast to lung cancer with ground-glass opacity, the radiological investigation of solid lung cancer has not been well examined. The aim of this study was to explore chest computed tomography (CT) and positron emission tomography (PET)/CT findings with regard to outcomes after lung cancer surgery in order to radiologically classify clinical stage IA lung cancers by tumour aggressiveness. METHODS: Three hundred and fifteen clinical stage IA patients were analysed. Four groups were defined by tumour solidity on CT and by the standardized uptake value (SUV) index on PET-CT (tumour maximum SUV/mean right liver lobe SUV). We analysed the association between radiological findings and both pathological invasiveness and postoperative outcome. RESULTS: Group A (n = 84) had an SUV index <1.0 and non-solid tumours, Group B (n = 24) had an SUV index <1.0 and solid tumours, Group C (n = 54) had an SUV index ≥1.0 and non-solid tumours, while Group D (n = 153) had an SUV index ≥1.0 and solid tumours. Invasive lung cancer was found in 2/84 (2.4%) patients in Group A, 1/24 (4.2%) in Group B, 13/54 (24.1%) in Group C and 58/153 (37.9%) in Group D (P < 0.01). The 5-year recurrence-free rate was 100% in Groups A and B, 90.3% in C and 65.7% in D (P < 0.01). The cancer-specific survival rate was 100% in A and B, 94.6% in C and 81.7% in D (P < 0.01). CONCLUSIONS: The present results suggest that preoperative PET/CT and thin-section CT findings provide important information for a selection of surgical procedures for clinical stage IA lung cancers. In clinical stage IA lung cancers displaying solid or non-solid density in thin-section findings, an SUV index <1.0 may be a better criterion for detecting non-aggressive lung cancer even in solid lung cancers.

The correlation of the International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification with prognosis and EGFR mutation in lung adenocarcinoma.

BACKGROUND: The purpose of this study was to validate the prognostic effect and the frequency of mutations in the gene expressing epidermal growth factor receptor (EGFR) in lung adenocarcinoma of Japanese patients, on the basis of the new adenocarcinoma classification proposed by the International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society. METHODS: The new classification was used to reclassify 486 adenocarcinomas. The percentage of each histopathologic subtype and the predominant pattern were determined. EGFR mutation was also investigated. The relationship between these results and clinicopathologic backgrounds was investigated statistically. RESULTS: No patients with adenocarcinoma in situ or minimally invasive adenocarcinoma died within the follow-up periods, followed by patients with lepidic predominant. Patients with papillary or acinar predominant, or invasive mucinous adenocarcinoma, showed almost similar overall survival (OS). The patients with solid predominant and micropapillary predominant showed the worst OS. Multivariate analysis showed that the new classification was an independent predictor of OS. The frequency of EGFR mutation was adenocarcinoma in situ (62%), minimally invasive adenocarcinoma (60%), lepidic (77%), acinar (49%), papillary (50%), solid (28%), micropapillary (43%), and invasive mucinous adenocarcinoma (0%). CONCLUSIONS: This new adenocarcinoma classification is a very useful predictive marker to plan and determine a therapeutic strategy for lung adenocarcinoma.

Positive intraoperative pleural lavage cytology is a predictive marker of disease recurrence in stage I lung adenocarcinoma.

OBJECTIVES: This study aimed at analysing the relationship between the pleural lavage cytology (PLC) status and clinicopathological characteristics, including the outcome of examined patients and tumour recurrence sites in surgically resected stage I non-small-cell lung carcinoma. METHODS: From April 2002 to August 2012, PLC was performed immediately after thoracotomy in 428 consecutive patients undergoing pulmonary resection for lung cancer. The relationship between clinicopathological characteristics and the PLC status was retrospectively analysed. RESULTS: The frequency of PLC-positive results was 4.4%, and larger tumour size, stage IB and pleural invasion were found more frequently in PLC-positive patients. Patients with a PLC-positive status had significantly worse disease-free survival (DFS) than those with a PLC-negative status (PLC positive versus PLC negative: hazard ratio [HR] = 2.79, 95% confidence interval [CI]: 1.4-5.57, P < 0.004; 5-year DFS: 46.6 vs 76.5%). With regard to the PLC status and histological type, adenocarcinoma was associated with a worse DFS in PLC-positive patients when compared with PLC-negative patients (5-year DFS: 38.1 vs 81.1%, P < 0.001). In multivariate analysis, PLC status remained significantly associated with DFS in patients with a PLC-positive status having an increased risk of recurrence, compared with PLC-negative patients (HR = 2.494, 95% CI: 1.241-5.011, P = 0.01) only in the case of adenocarcinoma. CONCLUSIONS: Our current study showed the clinicopathological characteristics associated with PLC status and demonstrated that PLC status was an independent predictor of increased recurrence in stage I lung adenocarcinoma.

Stage II-IV lung cancer cases with lymphovascular invasion relapse within 2 years after surgery.

OBJECTIVE: For recurrent lung cancer, postoperative follow-up methods have not been adequately assessed, and no evidence-based postoperative surveillance methods currently exist. Herein, we evaluated postoperative lung cancer recurrence and the personalized postoperative surveillance periods and methods used. METHODS: Follow-up after surgery consisted of a regular outpatient clinic check-up, including physical examination, history, blood tests, and chest X-ray, which were conducted three or four times per year for 5 years. During the follow-up period, annual chest and brain computed tomography scanning was performed. Between May 2004 and December 2011, 547 lung cancer patients underwent complete resection in our institution. We retrospectively reviewed their prospectively collected data. RESULTS: We selected 106 patients (19.4 %) who had a postoperative recurrence. Multivariate analysis showed that advanced stage (stage II-IV; p < 0.01) and lymphovascular invasion positivity (LVI; p = 0.01) were independent risk factors for earlier recurrence. Overall, 90.8 % of patients with advanced-stage disease and LVI positivity experienced a relapse within 2 years after surgery, compared to 55.1 % of patients who did not have these factors (p < 0.01). Multivariate analysis showed that recurrence with symptoms (p < 0.01) and shorter time to recurrence (<24 months; p < 0.01) were independent prognostic factors after recurrence. CONCLUSIONS: Although this study was retrospective and included some biases, patients with advanced-stage lung cancer and LVI positivity should be intensively followed up. Personalized follow-up programs should be considered for lung cancer patients who have undergone resection.

Prognostic impact and initial recurrence site of lymphovascular and visceral pleural invasion in surgically resected stage I non-small-cell lung carcinoma.

OBJECTIVES: This study aimed to analyse and validate the prognostic impact and effect of the initial recurrence site of lymphovascular and visceral pleural invasion (VPI) on survival outcomes for Stage I non-small-cell lung carcinoma (NSCLC). METHODS: We retrospectively reviewed 433 patients undergoing resection of Stage I NSCLC. The relationship between the clinicopathological background and the pathological variables, lymphovascular invasion (LVI) and VPI, was evaluated by univariate and multivariate analyses. RESULTS: Lymphovascular and VPI was observed in 41 and 45 patients, respectively. On univariate analysis, the presence of LVI was associated with a significant decrease in relapse-free survival (RFS) (P < 0.001) and overall survival (OS) (P < 0.001). The RFS of the patients of Stage IB with LVI was worse than the RFS of those of Stage IIA (T2aN1 and T2bN0)/IIB (T3N0), and similar to the RFS of those of Stage IIB (T2bN1). The presence of VPI was also associated with a significant decrease in RFS (P < 0.001) and OS (P = 0.01). On multivariate analysis, LVI was found to be an independent predictor of both decreased RFS and decreased OS. However, VPI was not an independent predictor of both. Recurrence was seen in 68 patients. As an initial recurrence site, distant recurrence was seen in 32 patients and local recurrence, in 36. The proportion of local recurrence was significantly higher in the patients with VPI than in those without VPI compared with between the patients with LVI and those without LVI. CONCLUSIONS: We propose that LVI and/or VPI may be a candidate marker to determine adjuvant therapy or a more careful follow-up for these patients.

New IASLC/ATS/ERS classification and invasive tumor size are predictive of disease recurrence in stage I lung adenocarcinoma.

INTRODUCTION: The purpose of this study is to analyze and validate the prognostic impact of the new lung adenocarcinoma (ADC) classification proposed by the International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society and invasive tumor size in stage I lung ADC of Japanese patients. METHODS: We reclassified 191 stage I ADCs according to the new classification. The percentage of each histological subtype and the predominant type were determined. In addition, both total tumor size and invasive tumor size were examined. The relationship between these results and clinicopathological backgrounds was investigated statistically. RESULTS: The 5-year disease-free survival (DFS) of adenocarcinoma in situ and minimally invasive adenocarcinoma was 100%; lipidic-predominant ADCs, 94.9%; papillary-predominant ADCs, 85.4%; acinar-predominant ADCs, 89.7%; and solid-predominant ADCs, 54%. The predominant growth pattern was significantly correlated with DFS (p < 0.001, overall). With regard to tumor size, total tumor size was not correlated with DFS (p = 0.475, overall), however, invasive tumor size was significantly correlated with DFS (≤ 0.5 cm/ > 0.5 cm, ≤ 1 cm/ >1 cm, ≤ 2 cm/>2 cm, ≤ 3 cm/ >3 cm, 100%/91.5%/85.9%/80.8%/66.7%% in 5-year DFS) (p = 0.006, overall). A multivariate analysis showed solid-predominant and invasive tumor size were independent predictors of increased risk of recurrence (solid versus nonsolid: hazard ratio = 4.08, 95% confidence interval:1.59-10.5, p = 0.003; invasive tumor size: hazard ratio = 2.04, 95% confidence interval:1.14-3.63, p = 0.016). CONCLUSION: : The new International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society ADC classification and invasive tumor size are very useful predictors of recurrence of stage I ADCs in Japanese patients.

Postoperative complications in elderly patients after lung cancer surgery.

OBJECTIVES: The purpose of this study was to identify the risk factors for postoperative complications in elderly patients undergoing lung cancer surgery. These complications remain higher in elderly patients than in young patients, and decreasing their incidence is an important goal. We investigated surgical factors in particular, including surgical time, blood loss and thoracotomy length. METHODS: Between January 2000 and September 2009, 567 patients underwent lung cancer surgery at our institution. We retrospectively reviewed the records of 119 patients who underwent lobectomy, aged 75 years or older, for possible postoperative complication risk factors. RESULTS: The patients' median age was 77 years (range, 75-88 years); there were 79 men and 40 women. There were no perioperative or postoperative deaths. Postoperative complications developed in 41 (34.5%) patients, including 17 (14.3%) with arrhythmia, 10 (8.4%) with prolonged air leak, 10 (8.4%) with delirium, 8 (6.7%) with pneumonia, 4 (3.4%) with hypoxia, 2 (1.7%) with cerebrovascular disease and 1 (0.8%) with postoperative haemorrhage. Univariate analysis showed that the risk factors for postoperative complications consisted of longer surgery time (P = 0.002), blood loss (P = 0.021) and undergoing surgery prior to May 2004 (P = 0.002). Multivariate analysis revealed that surgery time (P = 0.041) and surgery prior to May 2004 (P = 0.008) were independent risk factors for postoperative complications. CONCLUSIONS: This study demonstrates that the quality of surgery is an important factor in determining the risk of postoperative complications. Severe adhesions and lung inflammation are conditions that make lung cancer surgery difficult; a skillful and meticulous surgical technique is required in elderly patients.