Bevacizumab-Containing Chemoimmunotherapy for Recurrent Non-Small-Cell Lung Cancer after Chemoradiotherapy: Case Report.

Chemoimmunotherapy has become the standard of care as the first-line treatment of advanced or recurrent non-small-cell lung cancer (NSCLC). The bevacizumab-containing chemoimmunotherapy regimen is theoretically more effective than a non-bevacizumab-containing regimen via two mechanisms: a superior outcome of bevacizumab-containing chemothrerapy than the standard platinum doublet regimen, and the synergistic effect of bevacizumab with an immune checkpoint inhibitor (ICI). Bevacizumab effectively normalizes vascularization, especially when the vascular bed is damaged by previous treatment. Bevacizumab promotes immunomodulation when used with ICI. We describe a patient with nonsquamous NSCLC who returned 2.5 years after definitive chemoradiotherapy for postoperative locoregional recurrence in the right supraclavicular lymph node. Considering the destroyed vascular bed due to prior chemoradiotherapy, attaining vascular normalization was critical for effective drug delivery. The patient was treated with a bevacizumab-containing chemoimmunotherapy regimen, which resulted in a complete metabolic response. The patient responded well for 23 months and is receiving ongoing treatment. Thus, bevacizumab-containing chemoimmunotherapy could be advantageous in some recurrent cases after chemoradiotherapy.

[Surgical Strategy for Multiple Synchronous Primary Lung Cancer Showing Ground Glass Opacities:Percutaneous Preoperative Computed Tomography-guided Lipiodol Marking Followed by Video-assisted Thoracic Surgery].

From May 2006 to March 2018, a total of 30 patients with multiple ground glass opacities( GGO) lessor equal to 2.0 cm underwent percutaneous preoperative computed tomography (CT)-guided Lipiodolmarking and subsequent video-assisted thoracic surgery( VATS). There were 22 patients with 2 GGOs,6 patients with 3 GGOs, 1 patient with 4 GGOs, and 1 patient with 5 GGOs. Of the 71 CT-guided Lipiodolmarking procedures were successfully completed. All 71 Lipiodol spots were detected with C-armshapedfluoroscopy and completely resected. Pneumothorax was the most common complication andoccurred in 22 (73.3%) of 30 cases. There were severe complications in two (6.7%) cases of pneumothoraxrequiring chest tube placement and three( 10.0%) cases of bloody sputum. Of 30 cases multipleGGOs revealed 24 synchronous lung cancer (19 patients with double lung cancer, 3 patients with triplelung cancer, 1 patient with quadruple lung cancer, and 1 patient with quintuple lung cancer). PreoperativeCT-guided lipiodol marking and VATS resection is a safe and reliable method for synchronous multiplelung cancer showing GGO.

Long-Term Prognostic Impact of Severe Postoperative Complications After Lung Cancer Surgery.

BACKGROUND: Postoperative complications are reportedly related to poor prognosis following lung cancer surgery; however, the difference in the prognostic impact according to immune-nutritional status is unknown. METHODS: In 411 patients with completely resected non-small cell lung cancer, the relationship between severe postoperative complications (SPCs; Clavien-Dindo grade III or higher) and survival was retrospectively analyzed, with special reference to preoperative immune-nutritional status based on the prognostic nutritional index (PNI), which was calculated using serum albumin level and total lymphocyte count. RESULTS: A total of 52 (12.7%) patients had SPCs. The most common SPC was air leak (n = 39), atelectasis/sputum (n = 4), pneumonia (n = 2), pyothorax (n = 2), and bleeding (n = 2). The 5-year overall survival (OS) rates in patients with and without SPCs were 63.8% and 80.1%, respectively (p = 0.007). A multivariate Cox proportional hazard model revealed SPCs had a negative prognostic impact on patients with preserved immune-nutritional status (PNI ≥ 48.3; first to third quartile), but not on those with poor immune-nutritional status (PNI < 48.3; fourth quartile), with statistically significant interaction. Further analysis focused on 309 patients with preserved immune-nutritional status. The OS and relapse-free survival (RFS) rates were significantly worse in patients with SPCs than in those without (p < 0.001). After controlling for potential confounders, SPCs remained significantly associated with worse OS (adjusted hazard ratio [HR] 2.49, 95% confidence interval [CI] 1.21-4.83; p = 0.015) and RFS (adjusted HR 2.02, 95% CI 1.10-3.53; p = 0.025). CONCLUSION: Severe complications following lung cancer surgery could negatively impact prognosis, particularly in patients with preserved immune-nutritional status.

Risk Stratification According to the Prognostic Nutritional Index for Predicting Postoperative Complications After Lung Cancer Surgery.

BACKGROUND: The prognostic nutritional index (PNI), an immune nutritional marker based on serum albumin levels and total lymphocyte count, predicts postoperative complications in various types of malignancies. However, the clinical significance of the PNI for postoperative complications following lung cancer surgery is uncertain. METHODS: Patients with resected non-small cell lung cancer (n = 515) were retrospectively analyzed and the relationship between the preoperative PNI and postoperative complications was evaluated. RESULTS: Multivariate logistic regression analysis revealed that a preoperative low PNI was a significant independent predictor of postoperative complications of Clavien-Dindo Grade ≥ II (odds ratio: 1.06 per unit decrease, 95.0% confidence interval 1.01-1.11). Patients were divided into three groups according to the preoperative PNI: normal (≥ 50; n = 324), mildly low (< 50, ≥ 45; n = 134), and severely low (< 45; n = 57). The incidence of postoperative complications of Grade ≥ II and Grade ≥ III in the normal, mildly low, and severely low PNI groups was 22.2, 39.6, and 42.1% and 7.1, 16.4, and 22.8%, respectively. The incidence of postoperative complications of Grade ≥ II and Grade ≥ III was significantly higher in the mildly low and severely low PNI groups than in the normal PNI group (p < 0.001 and p < 0.001, respectively). The incidence of air leak, pneumonia, and extrapulmonary infection, but not arrhythmia, was significantly higher in the mildly low and severely low PNI groups than in the normal PNI group. CONCLUSIONS: The PNI could be a useful marker to predict the risk of postoperative complications after lung cancer surgery.

Prolonged air leak following lobectomy can be predicted in lung cancer patients.

PURPOSE: The purpose of this study was to identify the factors associated with prolonged air leak (PAL) following pulmonary lobectomy for lung cancer. METHODS: The data of 146 patients who underwent pulmonary lobectomy for lung cancer between August 2010 and July 2015 were retrospectively reviewed. Air leaks were assessed daily by a visual evaluation and were categorized as follows: forced expiratory only (Grade 1), expiratory only (Grade 2), or continuous (Grade 3). Logistic regression analyses were performed to identify the predictors of PAL (>5 days). RESULTS: PAL occurred in 23 patients (16%). An air leak at rest (Grade ≥ 2) was detected on postoperative day (POD) 1 in 48% of the patients with PAL and 7% of the patients without PAL. A univariate analysis demonstrated that PAL was significantly associated with male sex, a smoking history of ≥ 40 pack years, a serum albumin level of ≤4.0 mg/dL, and an air leak on POD1 (Grade ≥ 2). A multivariate analysis demonstrated that a serum albumin level of ≤4.0 mg/dL (p = 0.027) and an air leak on POD1 (p = 0.006) were independent predictors of PAL. PAL occurred in 75% of the patients with these two risk factors. CONCLUSIONS: The preoperative serum albumin level and the presence of a visually evaluated air leak on POD1 may be useful indicators for the perioperative management of air leaks.

CT findings after lipiodol marking performed before video-assisted thoracoscopic surgery for small pulmonary nodules.

BACKGROUND: In preoperative lipiodol marking for small pulmonary nodules, lipiodol has a potential risk of distribution in the surrounding lung structure. There are no reports about the detailed accumulation and distribution of lipiodol. PURPOSE: To evaluate computed tomography (CT) findings after lipiodol marking before thoracoscopic surgery for pulmonary nodules. MATERIAL AND METHODS: Sixty-four consecutive CT-guided lipiodol markings for 103 nodules were performed in 55 patients. Lipiodol (0.2-0.4 mL) was injected using a 21-gauge needle near the nodule. The appearance of lipiodol spots was classified into the following three types on CT: type 1, dense; type 2, punctate; and type 3, unclear. The distribution of lipiodol was also investigated. Statistical analyses were performed on the accumulation and distribution related to nodule factors. Incidences of complications were also investigated. RESULTS: A total of 110 markings were performed because of seven additional procedures due to insufficient marking. All nodules were successfully resected on the same day. The appearances of the lipiodol spots were type 1 (82%), type 2 (11%), and type 3 (7.3%). The areas of distribution were lung parenchyma (54%), central bronchus (39%), peripheral bronchovascular bundle (24%), needle tract (20%), pleural space (19%), another segment of ipsilateral lung (5.5%), and contralateral lung (0.9%). Distribution into pleural space and central bronchus was frequently seen in the shallow nodules (P < 0.05). Complications were pneumothorax (61%) and pulmonary hemorrhage (35%). There were no serious symptoms. CONCLUSION: The appearance of the lipiodol spot was dense in most cases, despite frequent distribution in the surrounding lung structures without serious complications.

Nasogastric administration of osimertinib suspension for an epidermal growth factor receptor-mutated lung cancer causing an esophageal stricture: case report.

An esophageal stricture is an abnormal esophageal narrowing, usually caused by esophageal diseases and rarely by lung cancer. They cause malnutrition, performance status (PS) deterioration, and difficulty in the oral administration of antitumor drug tablets. A 78-year-old female patient with lung adenocarcinoma, harboring an epidermal growth factor receptor (EGFR)-sensitizing mutation, experienced dysphagia due to an esophageal stricture caused by retrotracheal lymph node metastases. Osimertinib is a third-generation EGFR-tyrosine kinase inhibitor that is efficacious against EGFR-sensitizing mutations. The esophageal stricture hampered food intake and oral administration of osimertinib, causing severe malnutrition and deterioration to PS 3. Esophagogastroduodenoscopy (EGD) revealed severe and entire circumferential stenosis (7 cm in length) of the upper esophagus without mucosal abnormality. A nasogastric tube was inserted under EGD guidance, and an osimertinib suspension was administered accordingly: a tablet containing 80 mg of osimertinib was suspended in 50 mL of sterile hot water (55 ℃) for ten minutes, and the suspension was administered through a nasogastric tube once daily. Dysphagia improved 15 days after the introduction of osimertinib. After 21 days, the patient could take foods and drugs orally, and her PS improved to 1. Administering an osimertinib suspension via a nasogastric tube was a viable option in managing esophageal strictures in patients with EGFR-sensitizing mutations.

External Corset Technique in a Patient With Anomalous Artery Supply to the Left Basal Segment.

Postoperative aneurysmal formation of the anomalous artery stump has been reported in the systemic arterial supply to the basal segment of the left lung, whereas the effective preventive strategy remains unclear. Herein we report a case successfully treated with a new external corset technique of an anomalous artery stump. A 54-year-old man with a history of repeated hemoptysis underwent a left lower lobectomy. The anomalous artery stump with a 1.1 cm diameter was wrapped using woven Dacron vascular graft. No aneurysmal change has been observed in the computed tomography obtained after 3 years of follow-up.

Predictors of survival among Japanese patients receiving first-line chemoimmunotherapy for advanced non-small cell lung cancer.

BACKGROUND: First-line chemoimmunotherapy (CIT) has improved overall survival (OS) and progression-free survival (PFS) outcomes among patients with non-small cell lung cancer (NSCLC). The immunological and nutritional statuses of patients fluctuate during treatment using immune checkpoint inhibitors, and are closely related to treatment outcomes. However, it is unclear whether these markers are significant in patients who are receiving CIT. METHODS: This retrospective single-center study evaluated 34 consecutive Japanese patients with NSCLC who were treated using first-line CIT. Previously reported markers that reflect immunological and nutritional statuses were evaluated at three time points: at the start of CIT, after three weeks, and at the end of induction therapy. RESULTS: The median PFS was 7.2 months (95% confidence interval: 6.3 months-not reached) and the median OS was not reached (95% confidence interval: 9.6 months-not reached). The PFS duration was significantly associated with the baseline neutrophil-to-lymphocyte ratio and the three-week values for the modified Glasgow prognostic score, C-reactive protein-albumin ratio, prognostic nutrition index, and advanced lung cancer inflammation index. The OS duration was significantly associated with the pre-treatment values for the neutrophil-to-lymphocyte ratio and advanced lung cancer inflammation index, as well as the prognostic nutrition index at the end of induction therapy. CONCLUSIONS: Immunological and nutritional markers could be useful for predicting the outcomes of CIT for Japanese patients with advanced non-small cell lung cancer. The timing of their evaluation may also be important. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Overall survival in patients receiving first-line chemoimmunotherapy for advanced lung cancer were associated with pretreatment values of neutrophil-to-lymphocyte ratio, advanced lung cancer inflammation index, and the prognostic nutrition index at the end of induction therapy. WHAT THIS STUDY ADDS: Repetitive evaluation of immunological and nutritional markers may be useful for guiding prognostication and treatment selection for Japanese patients with advanced lung cancer.

Omental Flap for Bronchopleural Fistula After Pneumonectomy and Aorta Replacement.

Bronchopleural fistula (BPF) is a fatal complication after lung cancer surgery. We report the case of a 56-year-old man treated with omental flap for BPF after pneumonectomy along with descending aorta replacement. He underwent left pneumonectomy with combined resection of the descending aorta, followed by replacement with prosthetic graft after the diagnosis of lung cancer, cT4 N1 M0 stage IIIA. He had BPF postoperatively and underwent an omental flap plombage after unsuccessful repair using the latissimus dorsi muscle. He did not have BPF recurrence or aortic graft infection. An omental flap is a useful option for treating BPF with an intrathoracic prosthetic graft.

Safety and reliability of computed tomography-guided lipiodol marking for undetectable pulmonary lesions.

OBJECTIVES: This study aimed to evaluate the safety and reliability of percutaneous computed tomography (CT)-guided lipiodol marking for undetectable pulmonary lesions before video-assisted thoracic surgery (VATS). METHODS: We retrospectively analysed the cases of CT-guided lipiodol marking followed by VATS in 9 institutes from May 2006 to March 2018. Lipiodol (0.2-0.5 ml) was percutaneously injected closely adjacent to undetectable pulmonary lesions with computed-tomography guidance. Lipiodol spots were identified using C-arm-shaped fluoroscopy during VATS. We grasped the lipiodol spots, including the target lesions, with ring-shaped forceps and resected them. RESULTS: Of 1182 lesions, 1181 (99.9%) were successfully marked. In 1 case, the injected lipiodol diffused, and no spot was created. Of the 1181 lesions, 1179 (99.8%) were successfully resected with intraoperative fluoroscopy. Two lipiodol spots were not detected because of the lipiodol distribution during the division of pleural adhesions. The mean lesion size was 9.1 mm (range 1-48 mm). The mean distance from the pleural surface was 10.2 mm (range 0-43 mm). Lipiodol marking-induced pneumothorax occurred in 495 (57.1%) of 867 cases. Of these, chest drainage was required in 59 patients (6.8%). The other complications were 19 (2.2%) cases of bloody sputum, 3 (0.35%) cases of intravascular air, 1 (0.12%) case of pneumonia and 1 (0.12%) case of cerebral infarction. There were no lipiodol marking-induced deaths or sequelae. CONCLUSIONS: Preoperative CT-guided lipiodol marking followed by VATS resection was shown to be a safe and reliable procedure with a high success rate and acceptably low severe complication rate.

Microthymoma and microscopic thymomas associated with a thymic cyst without solid component.

A 75-year-old asymptomatic man presented with an anterior mediastinal cyst without a solid component on computed tomography. Pathologic examination of the specimens obtained by thoracoscopic resection showed a thymic cyst with a 1.6-mm type A microthymoma in the surrounding thymic tissue. In addition, there were multiple hyperplastic nodules smaller than 1 mm histologically corresponded to microscopic thymomas. The patient underwent completion thymectomy through median sternotomy; thereafter, there was no residual thymic neoplasm detected. This was the first case report of a type A microthymoma. Microthymoma or microscopic thymoma could be present concomitantly with a thymic cyst without a solid component.

Clinical application of postoperative non-invasive positive pressure ventilation after lung cancer surgery.

OBJECTIVE: The purpose of this study was to clarify the clinical efficacy of postoperative non-invasive positive pressure ventilation (PONIV) after pulmonary lobectomy in patients with lung cancer. METHODS: From August 2010 and July 2015, 143 patients with lung cancer who underwent pulmonary lobectomy were retrospectively reviewed. PONIV was used immediately after surgery until the morning of postoperative day (POD) 1. Arterial blood gas was analyzed before and just after surgery (POD0) and on POD1. Oxygenation ability was perioperatively assessed by PaO2/FiO2 ratio, alveolar-arterial oxygen difference (A-aDO2), and respiratory index (A-aDO2/PaO2). RESULTS: 112 patients received PONIV. From POD0 to POD1, the PaO2/FiO2 ratio significantly improved in all patients who received PONIV (333 ± 83 to 359 ± 47 mmHg, p = 0.004). Moreover, A-aDO2 and respiratory index significantly decreased following PONIV. PONIV significantly improved the PaO2/FiO2 ratio in patients with PaO2/FiO2 ratio of ≤ 300 on POD0, older age (≥ 70 years), higher body mass index (≥ 25 kg/m2), and longer one-lung ventilation time (≥ 180 min). There was no respiratory failure requiring mechanical ventilation and no mortality. CONCLUSIONS: PONIV effectively improved oxygenation in patients undergoing pulmonary lobectomy in patients with poor status, especially in patients with PaO2/FiO2 ratio of ≤ 300 on POD0. PONIV could be an option of perioperative management for major thoracic surgery.

Significance of PD-L1 expression in pulmonary metastases from head and neck squamous cell carcinoma.

BACKGROUND: The mechanism by which tumors escape the immune system has been actively investigated and is partly explained by the programmed death-1 (PD-1) and its ligand (PD-L1) pathway. This study is aimed at clarifying the prognostic significance of PD-L1 expression in patients with surgically resected pulmonary metastases of head and neck squamous cell carcinoma (HNSCC). PATIENTS AND METHODS: A retrospective review was conducted of 26 HNSCC patients who underwent complete resection of pulmonary metastases. PD-L1 expression in both the primary and metastatic tumors was evaluated using immunohistochemistry (anti-PD-L1 antibody, clone SP263). High PD-L1 expression was defined as ≥50% of tumor cells with positive staining. Survival and prognostic impacts following pulmonary metastasectomy were analyzed based on the PD-L1 expression level. RESULTS: The patients included 23 men and 3 women, with a median age of 65 years. Six (23%) of the pulmonary metastatic cases showed high PD-L1 expression, while their corresponding primary lesions had low PD-L1 expression. The 5-year overall survival rate after pulmonary metastasectomy was 57.6% in all cases. The 5-year overall survival rates were 72.5% and 16.7% in the low and high PD-L1 groups, respectively (p < 0.001). Multivariate analysis demonstrated that high PD-L1 expression and older age (>65 years) correlated independently with a shorter overall survival (p < 0.001). CONCLUSIONS: High PD-L1 expression in pulmonary metastases could be an independent predictor of poor outcome in HNSCC patients undergoing pulmonary metastasectomy. This is the first report evaluating the prognostic implication of PD-L1 expression in metastatic HNSCC.

Surgical outcome of wide wedge resection in poor-risk patients with clinical-N0 non-small cell lung cancer.

OBJECTIVE: Sublobar resection is practically indicated in poor-risk patients compromised cardiopulmonary reserve or for small ground-glass opacity-dominant adenocarcinomas. The aim of this study was to clarify the surgical outcomes of wide wedge resection in poor-risk patients with clinical-N0 non-small cell lung cancers. METHODS: Sixty-two poor-risk patients, who underwent wedge resection for clinical-N0 lung cancer, were retrospectively reviewed. We defined the ratio of the maximum diameter of the consolidation to the maximum tumour diameter as the consolidation-to-tumour ratio using high-resolution computed tomography. RESULTS: The 5-year overall, recurrence-free, and lung cancer specific survivals of all patients were 56.4, 46.6, and 81.1%, respectively, while other malignancies were frequently found as causes of death. Overall and recurrence-free survivals were favourable in patients with tumour size ≤3 cm, consolidation-to-tumour ratio ≤0.50, solid tumour size ≤1.2 cm, carcinoembryonic antigen level <5.0 ng/mL and adenocarcinoma. Multivariate Cox proportional hazard model revealed that solid tumour size ≤1.2 cm and consolidation-to-tumour ratio ≤0.50 were independent prognostic factors. CT-guided lipiodol marking was applied in 20 patients to identify the tumour location had no recurrence. CONCLUSIONS: Wide wedge resection could be radical treatment option in poor-risk patients with clinical-N0 non-small cell lung cancer, though careful follow-up might be necessary for other malignancies. Patients with solid tumour ≤1.2 cm or ground-glass-dominant lesion are good candidates for wedge resection. CT-guided lipiodol marking is a useful option to identify the location and safe surgical tumour margin in wedge resection.

Clinical Significance of Prognostic Nutritional Index After Surgical Treatment in Lung Cancer.

BACKGROUND: The prognostic nutritional index (PNI), calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (cells/mm3), can reportedly predict postoperative complications and prognosis for various types of malignancy. However, the clinical significance and prognostic value of the PNI for both short- and long-term outcomes remains uncertain in patients with lung cancer. METHODS: We retrospectively reviewed 248 patients with completely resected non-small cell lung cancer (NSCLC). Clinicopathologic characteristics were evaluated according to the PNI, and the prognostic significance for postoperative outcomes was assessed using Cox proportional regression analysis. The survival rate was calculated using the Kaplan-Meier method. RESULTS: An optimal cutoff of 48 for recurrence-free survival (RFS) was determined using the minimum p value approach. Old age, low body mass index, large tumor size, and elevated C-reactive protein levels correlated significantly with low PNI. Logistic regression analysis demonstrated that low PNI status was statistically related to postoperative complications (Clavien-Dindo grade ≥II) and pulmonary air leakage. Five-year overall survival (OR) rates in the high- and low-PNI groups were 80.6% and 58.5%, respectively (p = 0.002). Five-year RFS rates were 73.6% and 48.6%, respectively (p < 0.001). Furthermore, PNI was identified as an independent prognostic factor for OS (hazard ratio [HR], 2.18; 95% confidence interval [CI], 1.08-4.21) and RFS (HR, 2.57; 95% CI, 1.46-4.38) by multivariate analysis. CONCLUSIONS: The PNI could represent a useful biomarker to predict postoperative complications and survival in patients with completely resected NSCLC.

Successful treatment with afatinib for pancreatic metastasis of lung adenocarcinoma: a case report.

Metastatic lung cancer of the pancreas is rare and optimal treatment protocols have not been determined. An asymptomatic 53-year-old man with primary lung cancer underwent a right lower lobectomy and was diagnosed with acinar adenocarcinoma, pT2bN2M0 stage IIIA. An epidermal growth factor receptor (EGFR) mutation (exon 19 deletion L747-A750insP) was detected in the primary tumor. Adjuvant platinum-based chemotherapy was administered. The patient's serum carcinoembryonic antigen (CEA) level had increased to 38.6 ng/mL 32 months after surgery, and positron emission tomography-computed tomography (PET-CT) revealed a 2.5-cm, hypermetabolic nodule in the pancreatic body. Using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), the nodule was pathologically diagnosed as a pancreatic metastasis of lung adenocarcinoma. The EGFR status of the pancreatic metastasis was confirmed to be the same as that of the primary lung tumor. The patient started afatinib therapy and his serum CEA level immediately decreased and remained at approximately the reference limit. On a follow-up PET-CT scan after 10 months of treatment with afatinib, the metastatic nodule in the pancreas had disappeared and no accumulation of fluorine-18-deoxyglucose (FDG) was detected. To the best of our knowledge, this is the first reported case of a complete response of pancreatic metastatic lung adenocarcinoma to EGFR-tyrosine kinase inhibitors (TKIs).

A touch panel surgical navigation system with automatic depth perception.

PURPOSE: A touch panel navigation system may be used to enhance endoscopic surgery, especially for cauterization. We developed and tested the in vitro performance of a new touch panel navigation (TPN) system. METHODS: This TPN system uses finger motion trajectories on a touch panel to control an argon plasma coagulation (APC) attached to a robot arm. Thermal papers with printed figures were soaked in saline for repeated recording and analysis of cauterized trajectory. A novice and an expert surgeon traced squares and circles displayed on the touch panel and cauterized them using the APC. Sixteen novices and eight experts cauterized squares and circles using both conventional endoscopic and TPN procedures. Six novices cauterized arcs using the endoscopic and TPN procedures 20 times a day for 5 consecutive days. RESULTS: For square shapes, the offset was 5.5 mm with differences between the novice and the expert at 2 of 16 points. For circles, the offset was 5.0 mm and did not differ at any point. Task completion time for the TPN procedure was significantly longer than that for the endoscopic procedure for both squares and circles. For squares, the distance from the target for the TPN procedure was significantly smaller than that for the endoscopic procedure. For circles, the distance did not differ. There was no difference in task completion time and distance between the novices and the experts. Task completion time and distance improved significantly for the endoscopic procedure but not for the TPN procedure. CONCLUSIONS: A new TPN system enabled the surgeons to accomplish continuous 3D positioning of the surgical device with automatic depth perception using finger tracing on a 2D monitor. This technology is promising for application in surgical procedures that require precise control of cauterization.

Improvements in thoracic surgery outcomes: a multi-institutional collaboration study.

BACKGROUND: Treatment protocols (including those for thoracic surgery) tend to be customized for individual hospitals. Procedural standardization is required to improve surgical tasks and patient outcomes. This study aimed to evaluate the effects of an initiative to standardize surgical tasks for efficient and safe performance. METHODS: Hospitals associated with the Division of Chest Surgery of the Kyoto Prefectural University of Medicine held joint meetings involving their thoracic surgeons and operating room nurses between February 2011 and November 2012 to standardize surgical tasks. Operation times and blood loss were compared before and after standardization. RESULTS: The implementation rate of standardized surgical tasks was 97%. The pre-operative (from entry to the operating room until commencement of surgery) and post-operative (from conclusion of surgery until departure from the operating room) times were significantly decreased after the standardization. When compared according to operative group (all thoracic surgery, lung lobectomy, and partial lung resection), operation times were shorter for all three groups; in addition, the amount of blood loss was lower in all three groups after standardization. A post-standardization survey showed improved morale among the meeting participants. CONCLUSIONS: Interdisciplinary standardization of surgical tasks across institutions improved thoracic surgery tasks and surgical outcomes.

Usefulness of new automated cutting needle for tissue-core biopsy of lung nodules under CT fluoroscopic guidance.

OBJECTIVES: The goal of our study was to evaluate the efficacy and safety of a new type of automated cutting needle for tissue-core lung biopsy under real-time CT fluoroscopic guidance. DESIGN: Observational MATERIALS AND METHODS: One hundred ten percutaneous needle tissue-core lung biopsies were performed with the Auto Surecut needle (Create Medic; Yokohama, Japan) under CT fluoroscopic guidance, and the specimens obtained underwent histopathologic evaluation. A final diagnosis was confirmed by independent surgical pathology. RESULTS: The rate of success for the diagnosis for specimens that were adequate for histopathologic analysis was 94.5% (104 of 110 specimens). The sensitivity, specificity, and accuracy in diagnosing malignancy were 95.1%, 100%, and 96.2%, respectively. A specific cell type could be characterized in 95.2% of those 104 lesions (99 lesions; malignant, 76 lesions; benign, 23 lesions). The specific cell type was precisely diagnosed, and was confirmed after surgery in 65 malignant lesions and 23 benign lesions. The biopsy-induced complications encountered were pneumothorax in 34.5% (38 of 110 patients) and hemoptysis in 6.4% (7 of 110 patients). No patient had a serious complication. CONCLUSION: CT fluoroscopy-guided lung biopsy using the Auto Surecut needle provides a high degree of diagnostic accuracy, allows for the specific characterization of lung nodules, and can be performed safely.