Detection of sentinel lymph node with a novel near-infrared fluorescence spectrum system and indocyanine green fluorescence in patients with early breast cancer: First clinical experience.

BACKGROUND: Sentinel lymph node biopsy (SLNB) for early breast cancer is common, and many studies have reported its usefulness with indocyanine green (ICG). However, in the case of sentinel lymph node (SNs) identification using ICG, it is difficult to accurately identify the fluorescence signal of SNs through the skin because of the weakening of the signal due to the intervening tissue thickness. In this study, we examined whether fluorescence spectroscopy can detect weaker fluorescence signals and accurately identify SNs that have accumulated ICG. METHODS: Six women with early breast cancer and clinically confirmed negative axillae were recruited. The periareolar region was subcutaneously injected with ICG (1 ml, 5 mg/mL). The identification rate of SNs in the skin was studied using the novel fluorescence spectroscopy (Lumifinder™, ADVANTEST, Tokyo, Japan). RESULTS: Lumifinder™ was able to identify 100% of SNs in the skin (6/6 patients). In addition, for SNs identification in deeper axillary areas, pressing the probe tip against the body surface allows clearer fluorescence observation. CONCLUSION: Novel fluorescence spectroscopy (Lumifinder™) may overcome the problem of SLNB using ICG for breast cancer.

[A Case of Hormone Receptor‒Positive HER2‒Negative Advanced/Recurrent Breast Cancer with 1.5 Years Withdrawal Period of Palbociclib Showed a Good Response Treated by Abemaciclib and Fulvestrant].

A 58‒year‒post‒menoposal woman was presented with left chest pain and shortness of breath because her breast cancer metastasized to the skin, lung, and pleural dissemination. In late‒line treatment for hormone receptor‒positive HER2‒negative advanced/recurrent breast cancer, we experienced a patient with tumor shrinkage leading to pain relief who was treated with a second combination of a CDK4/6 inhibitor and fulvestrant. Due to her poor performance status, she was treated with combined therapy to avoid severe adverse events. The CDK4/6 inhibitor was reintroduced after 1.5 years withdrawal period of endocrine therapy during anticancer drugs and radiation treatment. It has also been reported that withdrawal of CDK4/6 inhibitors might restore susceptibility related to the inhibitory signal. Rather than sequentially administering combined endocrine therapy with a CDK4/6 inhibitor, the withdrawal strategy of endocrine therapy continuing to administer anticancer drugs should be considered in case of reintroduction of CDK4/6 inhibitor.

Extrapleural pneumonectomy of recurrent thymoma with pleural dissemination.

Complete surgical resection has been considered the only curable treatment for thymoma. The efficacy of extrapleural pneumonectomy (EPP) for stage IV thymomas remains controversial. In this case report, we utilize EPP for recurrent thymoma with pleural dissemination and describe the resulting outcome. A 39-year-old female with a history of thoracoscopic thymectomy for type B2 thymoma was referred to our hospital for a recurrence of thymoma with pleural dissemination. She underwent EPP as a radical surgery. Histopathological investigation revealed complete resection. The postoperative course was uneventful. She returned to her full-time job and showed no sign of recurrence at 31 months after surgery. EPP for recurrent thymoma with pleural dissemination may be considered to achieve macroscopically complete resection when the patient is young and has a sufficient pulmonary function reservoir without preoperative complications.

[Investigation of lung cancer patients with cardiovascular disease].

BACKGROUND: According to the aging in Japan, surgery of lung cancer with cardiovascular disease is increasing. Among them, the merger of the heart and large blood vessel disease would be expected to be directly linked to the perioperative management. MATERIALS AND METHODS: We conducted a retrospective analysis of 1,005 patients who had undergone surgical resection of primary lung adenocarcinoma between January 1997 and June 2014 at Hokkaido University Hospital. Among them, 81 patients had more than one cardiovascular disease. RESULTS: The median age was 71 years old. Men are 62 cases(76%). 64 cases (79%)had smoking history. Ischemic heart disease( IHD) was 29 cases(33%), followed by atrial fibrillation(Af), arrhythmia other than Af, valve disease and macrovascular disease. Anticoagulant or antiplatelet therapy were preoperatively done in 41% of IHD cases, 39% of Af cases. Thirty four% of IHD, 50% of vascular disease received the treatment other than medication. Video-assisted thoracic surgery was performed in 67 cases(83%). Lobectomy, sublobectomy were performed for 59 cases(73%), 19 cases(23%), respectively. Postoperative complications were occurred in 32 cases(40%). Two patients(2.5%)died in hospital without discharge. Univariate analysis revealed tumor size, pStage, lymph node dissection, operation time or blood loss were correlated with postoperative complication. CONCLUSIONS: For the patients with cardiovascular disease, careful evaluation of surgical indication, perioperative management is required.

Use of maximum standardized uptake value on fluorodeoxyglucose positron-emission tomography in predicting lymph node involvement in patients with primary non-small cell lung cancer.

AIM: Surgical resection is a standard therapeutic approach for some cases of non-small cell lung cancer (NSCLC). Fluorodeoxyglucose positron-emission tomography (FDG-PET) is now widely used in clinical diagnosis and staging of various types of cancers, including NSCLC. We investigated whether the maximum standardized uptake value (SUVmax) of primary tumors is useful in predicting the extent of lymph node involvement. PATIENTS AND METHODS: We retrospectively evaluated 354 patients with NSCLC who underwent surgery following FDG-PET and computed tomographic (CT) scans in our hospital. Logistic regression analyses were used to assess associations between categories (age, sex, tumor size, SUVmax, serum Squamous cell carcinoma-related antigen (SCC), cytokeratin 19 fragment (CYFRA), carcinoembryonic antigen (CEA), Brinkman index and histologic type. Differences in SUVmax of primary tumors between positive and negative lymph node involvement were examined by Mann-Whitney U-test. RESULTS: SUVmax of primary tumors in patients without lymph node involvement was significantly lower than in those with involvement, in both adenocarcinoma and squamous cell carcinomas (median, 2.2 vs. 4.9 in adenocarcinoma and 5.0 vs. 8.1 in squamous cell carcinoma, p<0.001 for both). Among node-positive cases, the lowest primary tumor SUVmax was 1.24 in an adenocarcinoma and 2.05 in a squamous cell carcinoma. However, primary tumor SUVmax and extent of lymph node metastases showed no significant differences between pN1 and pN2, single and multiple lymph node involvement, or single and multiple station involvement. CONCLUSION: A low primary tumor SUVmax in NSCLC may help identify patients with no lymph node involvement. However, SUVmax does not discriminate between minimal and extended lymph node involvement.

Outcome analysis of (18)F-fluorodeoxyglucose positron-emission tomography in patients with lung cancer after partial volume correction.

BACKGROUND: This study aimed to evaluate the necessity for the partial volume effect (PVE) correction of the maximum standardized uptake value (SUVmax) in (18)F-fluorodeoxyglucose positron-emission tomography (FDG-PET) for predicting outcome in patients with non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: A total of 191 patients, with tumor diameters ranging from 10-37 mm, underwent pre-operative FDG-PET and curative resection. The SUVmax (Pre-SUV) of the primary tumor was corrected (Cor-SUV) using a recovery coefficient curve based on phantom experiments. RESULTS: The 5-year overall survival (OS) and disease-free survival (DFS) of the patients with high Pre-SUVs were lower than those with low Pre-SUVs (p<0.001 and p=0.002, respectively). The 5-year OS and DFS of patients with high Cor-SUVs were significantly lower than those with low Cor-SUVs (p<0.001 and p=0.005, respectively). CONCLUSION: Even without PVE correction, SUVmax was able to predict for outcome in patients with NSCLC.

Reduced port video-assisted thoracoscopic surgery using a needle scope for lung and mediastinal lesions.

OBJECTIVES: There are many recent and minimally invasive surgical innovations, yet there has been little evaluation of the limitations of such techniques, particularly those related to video-assisted thoracoscopic surgery. The aims of this study were to determine the usefulness and limitations of video-assisted thoracoscopic surgery using one-port access and needle scope and to evaluate the feasibility of this procedure based on our institutional experience. METHODS: This retrospective study involved 127 patients who underwent video-assisted thoracoscopic surgery using the one-window and puncture method at our institute from 1997 to 2011. One hundred patients underwent surgical treatment and 27 underwent diagnostic procedures. If there was one lesion present with only mild adhesion that did not require lymph node dissection, we decided to opt for the one-direction approach that provisionally indicates the one-window and puncture method. We compared the conversion and success groups for factors like age, sex, laterality of surgery, objective of surgery, target organ and surgery location. RESULTS: Of 127 cases, 115 (91%) successfully underwent the one-window and puncture procedure. Twelve cases (9%) were converted to the two-window method or thoracotomy. Compared with those targeting the lung, patients with mediastinal lesions demonstrated a higher tendency for conversion (P<0.05). However, age (P=0.89), sex (P=0.46), laterality of surgery (P=0.34) and purpose of surgery (P=0.68) did not show any significant differences between the groups. CONCLUSIONS: For lung and mediastinal diseases, video-assisted thoracoscopic surgery with the one-window and puncture method can be performed at any location (upper, middle and lower lobe of lung and anterior, middle and posterior of the mediastinum) under limited indications that include the possibility of one-way resection, mild adhesion and no requirement of lymph node dissection. Under provisional criteria, the procedure may be feasible.

Thrombosis in the pulmonary vein stump after left upper lobectomy as a possible cause of cerebral infarction.

BACKGROUND: Thrombus in the stump of the pulmonary vein (PV) is not a well-known complication after lung resection, and it has the potential to cause embolism to vital organs. To clarify the frequency, risk factors, and cause of this complication, a retrospective clinical study of patients who underwent lobectomy was performed. METHODS: The study evaluated 193 patients with primary lung cancer who underwent lobectomy from 2005 to 2011 and contrast-enhanced chest computed tomography (CT) within 2 years after lobectomy. Contrast-enhanced CT was retrospectively interpreted to check for thrombus in the PV stump. RESULTS: The operative procedures were 65 right upper lobectomies, 14 right middle lobectomies, 40 right lower lobectomies, 52 left upper lobectomies (LUL), and 22 left lower lobectomies. Thrombus developed in the PV stump in 7 of the 193 patients (3.6%) after lobectomy. All patients with thrombus had undergone LUL, and 13.5% of those who had undergone LUL developed thrombus. Univariate analyses revealed that LUL and operation time were significant risk factors and that adjuvant chemotherapy was marginally significant. It appears that thrombus may be attributable to the length of the PV stump. Measurement of the length of the PV stump using 3-dimensional CT images of the PV revealed that the stump of the left superior PV was longer than the others. CONCLUSIONS: Thrombus in the PV stump occurred in 13.5% of patients after LUL. These findings suggest that contrast-enhanced CT should be recommended for patients after LUL to help identify those with a high risk for thromboembolism.

Limited resection and two-staged lobectomy for non-small cell lung cancer with ground-glass opacity.

BACKGROUND: Lung tumors showing ground-glass opacities on high-resolution computed tomography indicate the presence of inflammation, atypical adenomatous hyperplasia, or localized bronchioloalveolar carcinoma. We adopted a two-staged video-assisted thoracoscopic lobectomy strategy involving completion lobectomy for localized bronchioloalveolar carcinoma with an invasive component according to postoperative pathological examination by permanent section after partial resection. METHODS: Forty-one patients with undiagnosed small peripheral ground-glass opacity lesions underwent partial resection from 2001 to 2007 in Hokkaido University Hospital. Localized bronchioloalveolar carcinoma was classified according to the Noguchi classification for adenocarcinoma. Malignant lesions other than Noguchi types A and B were considered for completion lobectomy and systemic mediastinal lymphadenectomy. Perioperative data of completion video-assisted thoracoscopic lobectomies were compared with data of 67 upfront video-assisted thoracoscopic lobectomies for clinical stage IA adenocarcinoma performed during the same period. RESULTS: Postoperative pathological examination revealed 35 malignant and 6 non-malignant diseases. Histologically, all of the malignant diseases were adenocarcinomas of Noguchi type A (n = 7), B (n = 9), C (n = 18), and F (n = 1). Eleven of 19 patients (58%) with Noguchi type C or F underwent two-staged video-assisted thoracoscopic lobectomy. Three patients refused a second surgery. There was no cancer recurrence. The two-staged lobectomy group had a significantly longer operative time and more blood loss than the upfront lobectomy group. There was no surgical mortality or cancer recurrence. CONCLUSIONS: Two-staged lobectomy for undiagnosed small peripheral ground-glass opacity lesions showed satisfactory oncological results. However, low compliance for and invasiveness of the second surgery are concerns associated with this strategy.

[Indication of video-assisted thoracic surgery for mediastinal mass lesions].

BACKGROUND: Most of mediastinal tumors are benign cysts and neoplasms. Resection is indicated for cystic lesions because of possibility of malignancy, compression symptom and possible rupture in future. However careful observation might be appropriate for asymptomatic tumors without risk of malignancy. Although video-assisted thoracoscopic surgery (VATS) is increasingly performed, its indication is still controversial. PATIENTS AND RESULTS: Among 37 mediastinal cystic lesions with confirmed pathological diagnosis, 17 were neoplasms. All of 20 non-neoplastic lesions have cyst wall thinner than 5 mm. Five cases( 29%) of neoplastic lesions have cyst wall thinner than 5 mm. Three of them underwent preoperative fluorodeoxyglucose-positron emission tomography( FDG-PET) or PET-computed tomography( CT). All 3 neoplastic lesions with thin wall showed accumulation of FDG. None of non-neoplastic cyst had FDG accumulation. Ninety-seven patients underwent surgical resection for mediastinal tumors. Out of 51 VATS, 2 were converted to open thoracotomy. One patient with thymoma had ipsilateral pleural recurrence after VATS. Tumor sizes of those 3 patients were larger than 7 cm. CONCLUSIONS: Cystic mediastinal tumor with wall thickness less than 5 mm and no FDG accumulation might be observed without resection because it is very unlikely to be a neoplasm. Mediastinal tumor larger than 7 cm might not be suitable for VATS.

Closed irreducible dislocation of the interphalangeal joint of the thumb: report of two cases.

Two cases of closed dislocation of the interphalangeal joint of the thumb are presented. It was impossible to achieve manual reduction in either patient. This rare injury required open reduction with anatomical repositioning of the volar plate in both patients. We fixed the IP joint with a steel wire after reduction in both cases because of slight joint instability. At the latest follow-up, both patients do not have any problems with in daily life.

Combined preoperative autologous blood donation and intra-operative cell salvage for hip surgery.

PURPOSE: To review records of 161 consecutive hip surgery patients for whom preoperative autologous blood donation (PABD) was used in combination with intra-operative cell salvage (ICS). METHODS: 114 women and 14 men aged 41 to 86 (mean, 64) years underwent 135 primary total hip arthroplasties (THAs), whereas 19 women and 7 men aged 16 to 52 (mean, 35) years underwent 26 rotational acetabular osteotomies (RAOs). Two or 3 weeks before the operation, patients deposited one unit (400 ml) of blood weekly, so long as their haemoglobin levels exceeded 110 g/l (if they had osteoarthritis) or 100 g/l (if they had rheumatoid arthritis). Patients were given oral ferrous sulphate, lactated Ringer's solution, and recombinant human erythropoietin. 800 and 1200 ml of blood were deposited for patients undergoing THA and RAO, respectively. Intra-operatively, ICS was carried out using a continuous autotransfusion system. The blood from ICS was transfused first, and then the blood from PABD was transfused during the latter half of the operation. RESULTS: By combining PABD and ICS, homologous blood transfusion was avoided in all patients, even in those with unexpected massive bleeding during surgery. In 3 patients, one unit of deposited autologous blood was discarded, because they showed no sign of anaemia. The mean total blood loss was almost 1.5 times higher in RAO than in THA patients (1095 vs 1550 ml). In the THA and RAO patients respectively, the mean amount of ICS was 181 and 210 ml, whereas the mean total blood transfusion volume was 975 and 1394 ml. No complications (including infection) related to autologous blood transfusion were observed during PABD, the surgery or the postoperative period. CONCLUSION: Homologous blood transfusion was avoided with the use of PABD and ICS. Preoperative donation of 800 and 1200 ml of blood (combined with ICS) seemed optimal, as only 3 units of blood were discarded.

Subcapital femoral neck fracture after fixation of an intertrochanteric fracture with a proximal femoral nail: a report of two cases.

Subcapital femoral neck fractures are a rare complication after fixation of an intertrochanteric fracture with a proximal femoral nail. We report 2 such cases where the patients had severe osteoporosis, based on Singh's index and pathological findings. In one case there was a technical error leading to a tip-apex distance of more than 20 mm, but osteoporosis appeared to be a more significant cause than any technical problems.

Bizarre accessory metatarsal located between the left fourth and fifth metatarsals: a case report.

We report a case of bizarre accessory metatarsal located between the left fourth and fifth metatarsals without a supernumerary digit in a 6-year-old girl. The accessory metatarsal was resected to alleviate foot pain on walking. This metatarsal dysplasia might have arisen from sequential failures of digital formation at an early stage of development.

Rapid resolution of femoral head osteonecrosis after rotational acetabular osteotomy.

The natural history of osteonecrosis of the femoral head is generally thought to be one of progressive deterioration if no intervention is undertaken. However, it is unknown whether surgical intervention is beneficial for patients with a small region of osteonecrosis. We observed rapid improvement of MRI findings after rotational acetabular osteotomy (RAO) was performed in a young patient with osteonecrosis of the femoral head. The band-like low signal area on T2-weighted images almost resolved by six months after surgery. He returned to work as an electrician by six months after surgery. Early surgical intervention such as RAO that alters the mechanical force acting on the necrotic region of the femoral head may accelerate the recovery of osteonecrosis and the improvement of symptoms.