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.

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.

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.

[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.

[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.

[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.

[Primary Pulmonary Synovial Sarcoma Confirmed by Demonstration of SYT-SSX Fusion Gene Translocation by Fluorescence In Situ Hybridization].

A 58-year-old man was referred to our hospital due to a mass shadow noted on a chest X-ray. Chest computed tomography showed a 3 cm nodule in the left lung. Thoracoscopic left upper lobectomy was performed to remove the lesion, and the postoperative diagnosis was primary pulmonary synovial sarcoma according to the histology and SYT-SSX gene analysis.

A new minimally invasive technique of combined chest wall resection for lung cancer.

We describe our technique of minimally invasive chest wall resection for primary lung cancer. We used this technique to perform two lobectomies combined with chest wall resection using thoracoscopic assistance. The intercostal muscles and vessels were divided using a vessel-sealing device, which was easy to maneuver through the access incision, achieving reliable hemostasis. In one patient, adding the utility port just over the dorsal edge of the chest wall proved useful for dissecting the distal area of the chest wall. This approach required only minimal incision without cutting the uninvolved extrathoracic musculature of the chest.

[Non Small Cell Lung Cancer with Mycosis Fungoides].

77-year-old man having a history of mycosis fungoides was admitted to our hospital with abnormal shadow in his chest computed tomography(CT). Chest CT showed a 1 cm nodule in the left lung. Left lung wedge resection was performed to remove the lesion, and the postoperative histological diagnosis was adenocarcinoma, primary lung cancer. After surgery, the patch and plaque on his skin disapperered within a month.

[Application of Curved Stapler for Pulmonary Wedge Resection].

End stapler is one of the indispensable devices for pulmonary resections. Various surgical staplers are now available and appropriate types are selected to dissect pulmonary parenchyma, vessel, or bronchus. In this study, we retrospectively reviewed the patients who received pulmonary wedge resections using newly released curved stapler (Endo GIA Radial Reload with Tri-Staple technology). Between April 2013 and October 2014, 10 lesions from the 9 patients were resected using the curved staplers. The reasons for the application of the staplers were pleuro-pulmonary adhesion in 3 lesions and centrally location in 7 lesions. There was no intraoperative complication. After the operations, temporary residual lobe congestion caused by the pulmonary vein stenosis was developed in 1 patient.

[Intercostal Lung Hernia after Video-assisted Thoracoscopic Lobectomy].

A 52-year-old woman had undergone video-assisted thoracoscopic right upper lobectomy for primary lung cancer. Although her postoperative course was uneventful progressive subcutaneous emphysema of the thorax and neck was developed 6 weeks after the lobectomy. Her chest computed tomography revealed intercostal lung herniation and subcutaneous emphysema. Surgical repair was performed via thoracoscopic assistance. The damaged portion of the lung was resected and the ribs were fixed using a wire for sternal suturing.

[Temporary Middle Lobe Congestion after Wedge Resection].

A 55-year-old woman, who had undergone laparoscopic resection for colorectal cancer, detected a solitary pulmonary nodule on her surveillance chest computed tomography. The lesion located in the right middle lobe, and she received thoracoscopic resection for metastasis from the colorectal cancer. The lesion was removed by wedge resection. During the operation we noticed the middle pulmonary vein was partially stapled because the nodule located close to the vein. There was no macroscopic and hemodynamic problem after the wedge resection, therefore, we decided to complete the operation without resection of the residual middle lobe. After the operation, pulmonary congestion localized to the residual middle lobe progressed within a few days. Because she had no severe symptom nor hemodynamic instability, we continued observation without additional intervention. The congestion gradually improved, and then she discharged from our hospital on 20 days after operation.

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.

Wedge Resection of Tumor Before Lobectomy for Lung Cancer Could Be a No-touch Isolation Technique.

BACKGROUND/AIM: Circulating tumor cells (CTCs) can be a surrogate biomarker of prospective prognosis. Surgical manipulation can promote the dissemination of CTCs. Prognosis improvement is expected with the no-touch isolation technique (NTIT), preventing surgical manipulation. The Wedge resection of the tumor site before lobectomy could prevent surgical manipulation during lobectomy for non-small cell lung cancer (NSCLC) and reduce the shedding of tumor cells, similar to a NTIT. This study aimed to evaluate the effect of wedge resection technique. PATIENTS AND METHODS: A total of 624 resected NSCLC patients were retrospectively analyzed. Patients were divided in two groups: Wedge and Non-Wedge. Overall survival (OS) curves were plotted using the Kaplan-Meier method. RESULTS: The 5-year OS rates were 89.9% and 84.0% in the Wedge and Non-Wedge groups, respectively (p=0.033). CONCLUSION: The OS in the Wedge group was significantly better than that in the Non-Wedge group. Wedge resection technique for NSCLC may be a NTIT.

A case of a rare non-invasive lung adenocarcinoma.

BACKGROUND: According to the WHO classification, adenocarcinoma in situ (AIS) is a localised small (≤3 cm) adenocarcinoma whose growth is restricted to neoplastic cells along pre-existing alveolar structures, lacking stromal, lymphovascular, or pleural invasion. There is no evidence to define AIS as having a tumour size of ≤3 cm. It is extremely rare for adenocarcinomas with pure lepidic growth lacking invasion to be >3.0 cm. The biological characteristics of these large AISs should be revealed. PRESENTATION OF CASE: The patient was an 82-year-old asymptomatic woman. Chest computed tomography showed a 6-cm-diameter pure ground-glass opacity in the left lower lung. The patient underwent lobectomy. On histologic examination, the tumour was restricted to neoplastic cells along pre-existing alveolar structures, lacking stromal, vascular, alveolar space, and pleural invasion. Papillary patterns were absent. Initially, the histopathological diagnosis was AIS, but the total tumour diameter exceeded 3 cm. The final pathological diagnosis was lepidic adenocarcinoma lacking an invasive component and harbouring an EGFR exon 20 insertion V774_C775insHV mutation using next-generation sequencing (NGS). CONCLUSION: We report a rare case of lepidic adenocarcinoma with a total tumour diameter of 6 cm and without an invasive component. Although EGFR mutations are oncogenic driver mutations, AISs have fewer EGFR mutations than invasive adenocarcinomas do. An adenocarcinoma that progresses to AIS, not stepwise progression, might have uncommon mutations and might be another type of adenocarcinoma. NGS could be useful for detecting uncommon genes that reveal the biological characteristics of AIS, and may contribute to the validation of next TNM classification.

Cluster circulating tumor cells in surgical cases of lung cancer.

OBJECTIVES: A cancer lesion sheds tumor cells into the circulating blood as circulating tumor cells (CTCs). Since cluster CTCs have been considered as precursor lesions of metastasis, their clinical implication was investigated in this study according to the preoperative status of cluster CTC detection in surgical cases of clinically early-stage lung cancer. METHODS: Among 104 surgical patients of early-stage lung cancer, CTCs were extracted from the peripheral blood before surgery using a micro-pore size selection method (ScreenCell®) and diagnosed microscopically. Implications of detecting cluster CTC were assessed according to the prognosis and clinicopathological characteristics. RESULTS: The status of CTC detection was not detected in 77 cases (74.0%), single CTC only detection in 7 cases (6.7%), and cluster CTC detected in 20 cases (19.2%). Patients with cluster CTCs exhibited significantly lower recurrence-free survival and overall survival than did patients of other groups. In addition, in hazard ratio analysis, the hazard ratios were independent of other predictors of poor prognosis, and detection of cluster CTCs was associated with predictors of poor prognosis. CONCLUSION: Cluster CTCs were detected in cases where the original lung cancer lesion had clinical predictors of poor prognosis and were independent negative predictors of survival.

A case of atypical thymic carcinoid mimicking a paraganglioma.

BACKGROUND: Thymic atypical carcinoid has high recurrence and metastasis rates due to frequent lymph node metastases. The aim of the study is to report a case of atypical thymic carcinoid mimicking a paraganglioma and to further explain the benefits of using median sternotomy (MS) approach even in thymic epithelial tumours (TETs) sized less than 5 cm. CASE PRESENTATION: The patient was a 59-year-old asymptomatic man. During a medical check-up, positron emission tomography/computed tomography (PET/CT) showed a 4.5 cm-diameter thymus with remarkable uptake. Thoracic surgery was performed to completely remove the tumour with lymph node dissection using MS because of possible malignancy. Although MS is accepted as the standard approach for TETs, minimally invasive thoracotomy (MIT) has emerged over recent decades. Maintaining surgical safety is priority; MIT is generally selected in <5-cm-diameter tumours. Here, we considered that the tumour could be resected using MIT. However, because PET/CT showed marked uptake, we selected the MS approach. Thus, MS can be applied even for small-sized TETs. CONCLUSION: Thymic atypical carcinoid should be considered when PET/CT shows high-uptake tumours in the anterior mediastinum. Clinicians should consider using the MS approach, even if the tumour is <5 cm.

[An autopsied case of giant small cell carcinoma of the pancreas].

A 58-year-old man who complained of an abdominal tumor was admitted to our hospital. Abdominal CT scan showed that a 15-cm tumor occupied the entire right upper abdomen and that there were ascites and liver metastases. A liver biopsy was performed. The liver biopsy showed a small cell carcinoma pattern, but no definitive origin of the tumor was determined. Considering the extensive peritoneal invasion and multiple liver metastases, he received 2 / courses of cisplatin/etoposide chemotherapy, but his tumor became larger with concomitant abdominal pain and nausea. The patient suddenly died due to multiple organ failure caused by tumor necrosis. The autopsy revealed a pathological diagnosis of primary small cell carcinoma of the pancreas.

Effectiveness of Intraoperative Pulmonary Wedge Resection of Tumor Site Before Lobectomy for Early Lung Adenocarcinoma.

BACKGROUND/AIM: Circulating tumor cells (CTCs) are tumor cells shed from tumor sites and circulate in the peripheral blood. CTCs can be a surrogate biomarker of recurrence and prognosis. Because surgical manipulation could promote CTCs, it is important to reduce CTCs during surgery. This study aimed to evaluate the effectiveness of intraoperative wedge resection of the tumor site before lobectomy. PATIENTS AND METHODS: A total of 297 resected stage I lung adenocarcinoma patients were retrospectively reviewed. Patients were divided into two groups: Wedge and Non-Wedge. 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 92.9% and 85.5%, in Wedge and Non-Wedge groups, respectively (p=0.006). Wedge resection was an independent factor associated with RFS (HR=0.342, 95%CI=0.141-0.830, p=0.018). CONCLUSION: Wedge resection before lobectomy for lung adenocarcinoma patients can improve RFS rates.