Long-term survival of thoracoscopic surgery compared with open surgery for clinical N0 adenocarcinoma.

BACKGROUND: Early stage non-small cell lung cancer (NSCLC) is good candidate for video-assisted thoracoscopic surgery (VATS). Long-term outcome compared between VATS and open surgery remains unclear. The aim of this study was to assess the long-term outcome of VATS in early stage adenocarcinoma. METHODS: A retrospective study was performed in 546 patients which were operated between January 2006 and December 2010 in our institute and of those, 240 (220 lobectomies, and 20 segmentectomies) were clinical N0 adenocarcinoma. One hundred and thirty-five patients underwent VATS and 105 patients for open surgery. Long-term oncological outcomes were compared in both groups. RESULTS: There were significant differences in age, gender, Blinkman index, clinical T factor and tumor size between two groups. VATS group showed statistically longer operation time (P=0.01), less blood loss (P=0.005), shorter length of stay (P=0.001), and less dissected number of lymph nodes (P<0.001) compared with open surgery. Disease-free survival in VATS was significantly better than open surgery (5- and 10-year survival; VATS, 91.4%, 79.0%; open, 85.1%, 73.6%; respectively, P=0.04). Overall survival in VATS was not different from open (P=0.58). Propensity matched disease-free and overall survival was not significantly different between two groups. Multivariate Cox regression analysis showed that age [P=0.04, 95% confidence interval (CI): (1.02-6.81)] in overall and T factor [P=0.01, 95% CI: (1.41-17.3)] in disease-free survival was prognostic significant after propensity matching. CONCLUSIONS: Our study demonstrated that long-term outcome in VATS for early stage adenocarcinoma was equivalent to open surgery. VATS may be a treatment of choice for promising long-term prognosis.

How to manage tumor located between upper division and lingular segment "S3+S4 segmentectomy and S3b+S4 segmentectomy".

Segmentectomy is one of the treatment of choice for small-sized non-small cell lung cancer (NSCLC). Although simple segmentectomy is feasible even if under thoracoscopy, complicated segmentectomy which contains more than two segmental plane divisions is difficult especially thoracoscopic surgery. We here present the case of totally thoracoscopic segmentectomy between upper division and lingular segment. In the first case, the 64-year-old female patient admitted for further examination and treatment of left lung ground glass nodule. Tumor located between upper division (S3) and lingular (S4) segment was operated by bi-segmentectomy and intraoperative frozen section pathology showed minimally invasive adenocarcinoma. Systematic nodal dissection was followed after retrieval of specimens. A3b A3a+c, and A4 was individually divided and followed by division of B3 and B4. Finally, intersegmental veins V1+2a and V1+2d was identified between segments and V3a+b was divided. In the second case, the 76-year-old female patient with left lung nodule between upper division (S3b) and lingular (S4) segment was operated by bi-segmentectomy. Since sealing test revealed air leakage from resected segmental planes, fibrin glue was applied to stop air leakage and direct suturing by 4-0 prolene between S3a+S3c and S5 was performed. Target lesion between upper division and lingular segments may be resected safely if appropriate demarcation lines are identified regardless of without highly sophisticated imaging systems.

Successful use of mediastinal repositioning employing PTFE sheet for right-sided post-pneumonectomy syndrome.

Post-pneumonectomy syndrome (PPS) is a rare late complication of pneumonectomy, and diverse treatments have been employed. We herein present a useful technique for right-sided PPS. The patient was a 53-year-old female who underwent a right pneumonectomy for locally advanced squamous cell lung cancer (pT2N2M0). Mild dyspnea and stridor developed and progressed 1 year after surgery. A chest roentgenogram and computed tomography (CT) scan showed a right-sided mediastinal shift. Under local anesthesia, a chest tube with a balloon was inserted into the right thoracic cavity, and the balloon was inflated with air. Dyspnea and stridor improved and disappeared as the balloon expanded. Then, mediastinal fixation was performed under general anesthesia. Mediastinal fixation involved a PTFE (polytetrafluoroethylene) sheet which was sewn on the sternum and costal cartilage anteriorly, on the vertebra posteriorly, and covered the azygos vein level superiorly and two thirds of the pericardium inferiorly using nonabsorbable sutures. A post-operative chest roentgenogram and CT scan showed improvement of the right-sided mediastinal shift. The post-operative course was uneventful, and dyspnea and stridor were improved and became stable. In conclusion, the presented method is a useful procedure for right-sided PPS.

Basal cell carcinoma of the nipple in male patients with gastric cancer recurrence: report of a case.

Although basal cell carcinoma (BCC) is the most common dermatological malignancy arising from sun exposed skin, BCC of the nipple is extremely rare. To our knowledge only 34 cases have been reported. We report a 78-year-old man who was undergoing chemotherapy for liver metastasis of gastric cancer 1 year after surgery. The chief complaint was exudation and oozing from the nipple. A mass lesion was palpable and detected on mammography and enhanced computed tomography, and atypical cells were detected on cytological examination. Simple resection was performed because histopathological diagnosis of an intraoperative frozen section revealed BCC. Final pathological diagnosis was also BCC. The authors report this case and review the previous reports, and discuss the clinicopathologic characteristics and adequate treatment for this disease.

Successful chemoradiotherapy for small-cell carcinoma of the esophagus in an octogenarian Japanese woman: report of the oldest case and review of long-term survival cases.

Small-cell carcinoma of the esophagus (SCCE) is a rare and rapidly progressive malignant tumor with an extremely unfavorable prognosis. We report a case of long-term survival and review similar cases in the literature. An 84-year-old Japanese woman visited a clinic complaining of tarry stools. Type-1 tumor was detected in the left posterior wall of the middle thoracic esophagus on endoscopic examination, and the pathological diagnosis following immunohistochemical examination was SCCE. Chemoradiotherapy was adopted after taking the characteristics of poor prognosis, rapid progression, and patient age into consideration. Chemoradiotherapy comprised 56 Gy of irradiation over 43 days and two courses chemotherapy with cisplatin and vincristine. Therapeutic effect was evaluated as complete response after endoscopic examination and computed tomography at one month after treatment. No recurrence or metastasis has been identified as of more than five years after achieving complete response, with endoscopic examination every six months and computed tomography every three months. To date, long-term survival has only been reported in octogenarian patients with SCCE, and the present case describes the oldest patient for whom successful radical therapy has been reported.

Long-term survival after excision of a giant esophageal gastrointestinal stromal tumor with imatinib mesylate resistance: report of a case.

A 69-year-old woman underwent 4 months of imatinib mesylate chemotherapy for a diagnosed gastrointestinal stromal tumor of the esophagus. This treatment was suspended because of its side effects and because radiological examinations showed that the tumor had not changed or had even increased slightly in size. Thus, we performed esophagectomy via left thoracotomy and removed a tumor that measured 18 × 17 × 10 cm. Immunohistochemical examination revealed positive reactions for c-kit and CD34, suggestive of a high-risk malignancy. The patient was discharged from hospital on postoperative day 30, and has remained well with no sign of tumor recurrence for more than 5 years, without adjuvant chemotherapy.

Retrospective study using the propensity score to clarify the oncologic feasibility of thoracoscopic esophagectomy in patients with esophageal cancer.

BACKGROUND: The present study aimed to clarify the long-term prognostic impact and oncologic feasibility of thoracoscopic esophagectomy (TSE) in patients with esophageal cancer in comparison with open thoracic esophagectomy (OTE). METHODS: Patients with esophageal cancer underwent surgically curative esophagectomy without neoadjuvant therapy from January 1991 to December 2008 and were analyzed retrospectively. Of 257 patients, 91 underwent TSE and 166 had OTE. Relations between the long-term prognosis after surgery, the surgical procedure, and clinicopathologic parameters were analyzed statistically. The propensity scores were calculated for all patients through a multiple logistic regression model that was optimized with Akaike's Information Criterion. Using Cox's proportional hazard model with prognostic variables and the propensity scores, we implemented a multivariate analysis for comparing the performance of two surgical methods. RESULTS: Patient characteristics and the incidence of perioperative morbidity or hospital death were similar for the TSE and OTE groups. Significantly more lymph nodes were dissected in the TSE group than in the OTE group (total p = 0.013; thoracic p = 0.0094; recurrent laryngeal p < 0.0001). The TSE group exhibited a more favorable prognosis after surgery than the OTE group in terms of overall survival (p = 0.011) and disease-specific survival (DSS) (p = 0.0040). Particularly in subgroup analysis of DSS, the TSE group had a favorable prognosis in upper thoracic esophageal cancer (p = 0.0053), invasive cancer (p = 0.046), node-positive cancer (p = 0.020), progressive cancer (p = 0.0052), cancer with lymphatic vessel invasion (p = 0.0019), and cancer without blood vessel invasion (p = 0.0081). In terms of DSS, the TSE group exhibited a more favorable prognosis than the OTE group regardless of the presence or absence of metastasis to lymph nodes around the thoracic (p < 0.0001) or recurrent laryngeal (p < 0.0001) nerves. TSE (p = 0.0430), lymph node metastasis (p = 0.0382), lymphatic invasion (p = 0.0418), and p stage (p = 0.0047) were independent prognostic parameters in the Cox's proportional hazard model with the propensity scores. CONCLUSIONS: TSE can contribute to prolonged survival after surgery in patients with esophageal cancer by enabling precise thoracic lymph node dissection based on a magnified surgical field. TSE might have maximum oncologic benefit and minimum invasiveness for patients with esophageal cancer.

Totally thoracoscopic surgery and troubleshooting for bleeding in non-small cell lung cancer.

BACKGROUND: Although accumulating data support the feasibility and efficacy of video-assisted thoracic surgery anatomic resection, few studies have reported on intraoperative complications, such as vessel injury. The purpose of this study was to evaluate intraoperative vessel injury and to analyze troubleshooting. METHODS: Twenty-six of 557 patients with non-small cell lung cancer who underwent thoracoscopic anatomic lung resection were identified as having intraoperative vessel injury between January 2004 and December 2011. The injured portion, devices used, recovery approach, and hemostatic procedure were analyzed. The perioperative outcomes in patients with and without vessel injury were compared. RESULTS: The most commonly used devices were ultrasonic coagulation shears in 9 cases, followed by scissors in 5 and an endostapler in 4. Seventeen of the 26 cases were injured at the branches of the pulmonary artery, and the others were at major vessels. Half of the patients were converted to thoracotomy, and 6 were treated by minithoracotomy. Hemostatic procedures were primary closure in 17 and sealant in 7. The perioperative outcomes, including operative time and blood loss, were significantly different between the two groups, but duration of chest tube drainage, length of hospital stay, and morbidity rate were not. No mortality was identified in the patients with vessel injury. CONCLUSIONS: Video-assisted thoracic surgery anatomic resection was feasible and safe, regardless of the intraoperative vessel injury. Although surgeons should pay attention to avoid unexpected bleeding, the magnitude of injury and effectual step-by-step management should lead to a safe operation.

Refractory ulcer of reconstructed gastric tube after esophagectomy: a case report.

We report a case in which rabeprazole cured gastric tube ulcer after esophagectomy for esophageal squamous cell carcinoma (ESCC). A 47-year-old Japanese man was referred to our hospital with refractory ulcer of the reconstructed gastric tube one year after esophagectomy for ESCC. The ulcer proved refractory to healing by the administration of omeprazole or lansoprazole, or eradication of Helicobacter pylori after examinations concerning ischemia, acid over-secretion and H. pylori infection. Finally, metabolizer type was examined for proton pump inhibitors (PPIs), revealing the patient as a hetero-extensive metabolizer for the CYP2C19 genotype. This suggested sensitivity to rabeprazole, but resistance to omeprazole and lansoprazole. The refractory ulcer was subsequently cured after changing the PPI to rabeprazole. Examination of PPI metabolizer type might thus be important, along with an investigation of ischemia, acid secretion and H. pylori infection in the treatment of refractory gastric tube ulcer after esophagectomy.

Contralateral mediastinal lymph node micrometastases assessed by video-assisted thoracoscopic surgery in stage I non-small cell left lung cancer.

OBJECTIVES: Survival of patients with left-sided stage I non-small cell lung cancer (NSCLC) is unsatisfactory, probably because of the high incidence of contralateral mediastinal node involvement. In this study, occult micrometastases to the right upper mediastinal nodes were retrospectively investigated in patients with left-sided stage I NSCLC. METHODS: Nineteen patients with clinical stage I NSCLC underwent video-assisted thoracoscopic lobectomy and bilateral mediastinal node dissection (BMD). Clinical data and survival of patients with BMD were compared with those of 25 left-unilateral mediastinal node dissection (UMD) patients. Occult micrometastases were detected using the cytokeratin 19 mRNA reverse transcription-polymerase chain reaction method. RESULTS: Pathological N2 disease was found in 1 patient, and 18 had pN0 disease. The operative time, blood loss, duration of chest tube drainage and duration of postoperative hospital stay were not different between BMD and UMD patients. Nodal micrometastases were detected in 11/19 (57.8%) patients. Skip micrometastases to the level N3 nodes without N1 and N2 node involvement were observed in 8/11 (72.7%) patients. Patients with BMD are all alive and have had no recurrence during the median follow-up period of 21.4 months. Overall 3-year survival and disease-free 3-year survival were not significantly different between the two groups. CONCLUSION: In this preliminary study, occult micrometastases to the level N3 nodes occurred frequently in patients with left-sided clinical N0 stage I NSCLC. Postoperative survival of patients with occult micrometastases to the level N3 node does not appear to be poor. Further follow-up and work are needed.

Surgical resection for cancer located mainly in the lower esophagus.

BACKGROUND/AIMS: The aim of the present study was to clarify the results and feasibility of surgical approaches for cancer, which is mainly occupied by squamous cell carcinoma (SCC), of the lower esophagus. METHODOLOGY: Forty-four patients (34 men, 10 women) with cancer located at the lower esophagus were enrolled in this study. SCC was diagnosed in 36 cases and adenocarcinoma (ADC) in 8 cases. Thirteen patients underwent transhiatal esophagectomy, 18 underwent lower thoracic esophagectomy by left thoracotomy, and 13 underwent esophagectomy with a right thoracic approach by open thoracotomy or thoracoscopy. RESULTS: Ten cases (ADC, n = 2; SCC, n = 8) showed involvement of mediastinal lymph nodes, although lymph node dissection varied with each surgical approach. Five-year survival rates were 75% for ADC and 31.9% for SCC, and ADC tended to be associated with a more favorable prognosis than SCC (p = 0.058). Transhiatal esophagectomy was performed more often in older patients (p < 0.05), but no other clinicopathological parameters appeared to affect the selection of surgical approach. No significant prognostic differences existed between surgical approaches (p = 0.35), even though the examination was limited to SCC (p = 0.98). CONCLUSIONS: No significant prognostic differences were identified between transhiatal and left and right transthoracic approaches for lower esophageal cancer.

Reconstruction using a free jejunal graft after resection of the cervical esophagus for malignancy.

BACKGROUND/AIMS: Reconstruction using a free jejunal graft (FJG) after resection of the cervical esophagus has become common, but postoperative morbidity remains. We report herein our procedure and the results of reconstruction for neck cancer using FJGs. METHODOLOGY: Twenty-four patients underwent FJG reconstruction after laryngo-pharyngo-esophagectomy. We perform a mini-laparotomy with a 5-cm para- or trans-rectus muscle incision. The FJG is then harvested from the jejunum supplied by the second or third mesenteric artery, and a jejunostomy is created. Pharyngo-jejunal anastomosis is performed using an Albert-Lembert suture and jejunal-esophageal anastomosis by a circular stapling technique. The facial artery or suprathyroid artery is used as the feeding artery, and the common facial vein or external jugular vein as the drainage vein. Vascular anastomosis is performed microsurgically. RESULTS: In terms of postoperative morbidity, minor anastomosis leakage of the pharyngo-jejunal anastomosis was observed in one patient, stricture of the jejunal-esophageal anastomosis in four, and wound infection in one. No cases of passage disorder due to graft bending were seen, and no patients died. CONCLUSIONS: The procedure using FJG harvested via mini-laparotomy is minimally invasive and is a feasible procedure for reconstruction after laryngo-pharyngo-esophagectomy, resulting in low morbidity.

Number of metastasis-positive lymph node stations is a simple and reliable prognostic factor following surgery in patients with esophageal cancer.

The aim of this study was to evaluate the utility of lymph node metastasis classification based on the number of positive stations in patients undergoing surgical management of esophageal cancer. Of 257 patients who underwent curative esophagectomy, 126 patients with lymph node involvement underwent assessment of nodal metastasis mode according to the 7th edition of the TNM classification (UICC), and the Japanese Guidelines for the Clinical and Pathological Studies on Carcinoma of the Esophagus. Lymph node metastasis mode was divided into single station (S) and multi-station (M) groups. The S group was subclassified into single-node-single-station (SS) or multi-node-single-station (MS), and the M group was subclassified into multi-station in pN1 (2 metastasis positive nodes; MM-pN1) or multi-station in pN2 or 3 (MM-pN2,3) by TNM classification, multi-station-single-area (MMS) or multi-station-multi-areas (MMM). The correlation between prognosis and lymph node metastasis mode was assessed. A total of 47 patients were classified as S (MS, n=11; SS, n=36), and 79 patients were classified as M (MM-pN1, n=12; MM-pN2,3, n=67; MMM, n=55; MMS, n=24). Prognosis was poorer among the M- than in the S-classified patients (p=0.0035), whereas prognosis was not significantly different between the subgroups. In conclusion, lymph node metastasis classification based on the number of metastasis-positive stations is a useful predictor of prognosis in patients undergoing surgical management of esophageal cancer. This system relies on a simple classification method that combines the Japanese classification based on lymphatic spread and the TNM classification based on the number of positive lymph nodes.

Successful application of subcutaneous adipose tissue with fibrin glue in conservative treatment of tracheobronchial rupture.

An 84-year-old woman underwent aortic and mitral valve replacement. After weaning from cardiopulmonary bypass, hemorrhage was observed in the endobronchial tube. The bleeding bronchus was isolated to protect the airway using the blocker cuff of a Univent tube (Fuji Systems Corp, Tokyo, Japan). Computed tomography showed a pulmonary pseudoaneurysm in the left upper lobe. She underwent selective pulmonary angiography and embolization of the pseudoaneurysm. Bronchoscopy revealed a 5-mm bronchial rupture at the left upper lobe bronchus. The laceration was filled with adipose tissue and fibrin glue. Bronchoscopy showed a completely reepithelialized membrane, and she was discharged 38 days postoperatively.

Serum level of HE4 is closely associated with pulmonary adenocarcinoma progression.

The human epididymis 4 (HE4) protein is expressed in the epididymis and respiratory tract. We previously reported that HE4 is also expressed in pulmonary adenocarcinoma. The purpose of this study was to investigate serum levels of HE4 as a biological marker in pulmonary adenocarcinoma. As the trained set, 102 patients with pulmonary adenocarcinoma who underwent surgery in our institute from 2008 to 2011 were evaluated. They were compared with 58 healthy controls and 16 cases of benign lung disease. In the validation, we used 104 patients with pulmonary adenocarcinoma operated on between 2000 and 2007. Postoperative changes of serum HE4 levels were investigated in 35 patients. The level of HE4 was determined by enzyme immunometric assay and compared with clinicopathological factors. In the trained set, HE4 levels in sera in pulmonary adenocarcinoma were significantly higher than in healthy controls and benign lung disease. Receiver operating characteristic curve showed that HE4 was a good discriminator of pulmonary adenocarcinoma (cut-off point, 50.3 pM; area under curve, 0.825; 95 % confidence interval, 0.76-0.89, p < 0.001). In the validation set, serum HE4 levels were significantly correlated with age, nodal status, and carcinoembryonic antigen. Furthermore, postoperative increase of HE4 serum levels showed a significant correlation with recurrence (p = 0.032). The 5-year overall survival rate was 52.6 % in the HE4-positive group compared with 97.1 % in the HE4-negative group (p = 0.001). These data showed that HE4 expression in sera is associated with progression of pulmonary adenocarcinoma and a possible biomarker.

Bronchial stump aspergillosis after stapled lobectomy for lung cancer.

Aspergillus causes several pulmonary complications, but bronchial stump aspergillosis (BSA) is very rare. To date, 31 cases of bronchial stump aspergillosis have been reported in the English, German, and Japanese literature. The bronchial stump was closed by hand-sewn suturing in most cases, but we report herein two cases of BSA that developed after stapled closure of the bronchial stump.

Incidentally discovered primary malignant melanoma of the trachea.

Primary malignant melanoma of the trachea is extremely rare. We report here the first case of primary tracheal malignant melanoma in the asymptomatic stage. Incidentally, this 73-year-old man was found to have a flat tumor at the upper trachea on chest computed tomography scans. The tumor was surgically resected with end-to-end anastomosis and was diagnosed to be primary malignant melanoma of the trachea. Four months after the surgical resection, cervical lymph node metastasis was found. Despite the resection of metastatic lymph nodes and six courses of chemotherapy, he died of cachexia approximately two years after the discovery of the tracheal tumor.

Morphology of the epithelium of the lower rectum and the anal canal in the adult human.

The anal canal is an important body part clinically. However, there is no agreement about the epithelium of the anal canal, the anal transitional zone (ATZ) epithelium in particular. The aim of this study is to clarify the structure of the epithelium of the human lower rectum and anal canal. Intact rectum and anus obtained from patients who underwent surgery for rectal carcinoma were examined by light and scanning electron microscopy (LM and SEM). By LM, three types of epithelium were observed in the anal canal: simple columnar epithelium, stratified squamous epithelium, and stratified columnar epithelium. The lower rectum was composed of simple columnar epithelium. SEM findings showed stratified squamous epithelium that consisted of squamous cells with microridges, changing to simple columnar epithelium consisting of columnar cells with short microvilli at the anorectal line. LM and SEM observations in a one-to-one ratio revealed that the area of stratified columnar epithelium based on LM corresponded to the anal crypt and sinus. In conclusion, the epithelium of the human anal canal was fundamentally composed of simple columnar epithelium and stratified squamous epithelium. We found no evidence of the ATZ.