[Chest Tube is Unnecessary after Video-assisted Thoracoscopic Mediastinal Tumor Resection].

Of the 64 patients who underwent surgery for mediastinal tumors at our department from April 2019 to December 2022, 59 patients( 92.2%) underwent video-assisted thoracic surgery( VATS). Among the patients who underwent open surgery, 5 patients underwent median sternotomy and 1 patient underwent posterolateral thoracotomy. We usually perform 3-port VATS for mediastinal tumors. After surgery, patients are allowed to drink water after awakening from anesthesia, and they can have dinner on the day. If no lung resection is performed, we use a Nélaton catheter to remove air from the thoracic cavity and do not place a chest tube, and none had a chest tube insertion after surgery. As a result, postoperative pain was minimal, early ambulation was possible, and hospital stay was shortened.

Extracellular Vesicles from Fibroblasts Induce Epithelial-Cell Senescence in Pulmonary Fibrosis.

Aberrant epithelial-mesenchymal interactions have critical roles in regulating fibrosis development. The involvement of extracellular vesicles (EVs), including exosomes, remains to be elucidated in the pathogenesis of idiopathic pulmonary fibrosis (IPF). Here, we found that lung fibroblasts (LFs) from patients with IPF induce cellular senescence via EV-mediated transfer of pathogenic cargo to lung epithelial cells. Mechanistically, IPF LF-derived EVs increased mitochondrial reactive oxygen species and associated mitochondrial damage in lung epithelial cells, leading to activation of the DNA damage response and subsequent epithelial-cell senescence. We showed that IPF LF-derived EVs contain elevated levels of microRNA-23b-3p (miR-23b-3p) and miR-494-3p, which suppress SIRT3, resulting in the epithelial EV-induced phenotypic changes. Furthermore, the levels of miR-23b-3p and miR-494-3p found in IPF LF-derived EVs correlated positively with IPF disease severity. These findings reveal that the accelerated epithelial-cell mitochondrial damage and senescence observed during IPF pathogenesis are caused by a novel paracrine effect of IPF fibroblasts via microRNA-containing EVs.

Characteristics of non-small-cell lung cancer with interstitial pneumonia: variation in cancer location, histopathology, and frequency of postoperative acute exacerbations in interstitial pneumonia.

BACKGROUND: Non-small-cell lung cancer (NSCLC) has been reported to develop in patients with interstitial pneumonia (IP); however, clinical, radiological, and pathological features remain to be elucidated. METHODS: We retrieved the records of 120 consecutive NSCLC patients associated with IP who underwent surgery at Toranomon Hospital between June 2011 and May 2017. We classified the patients into three groups according to NSCLC location using high-resolution computed tomography: group A, within a fibrotic shadow and/or at the interface of a fibrotic shadow and normal lung; group B, within emphysematous tissue and/or at the interface of emphysematous tissue and normal lung; and group C, within normal lung. In 64 patients, programmed death ligand-1 (PD-L1) status was assessed with immunohistostaining. RESULTS: Most of the patients (89; 70%) were classified as group A. This group tended to have squamous cell carcinoma with the usual interstitial pneumonia (UIP). These cancers were located mainly in the lower lobes and seven of the eight postoperative acute exacerbations (pAE) of IP developed in this group. NSCLC in the group B were mainly squamous cell carcinomas located in the upper lobes. No patient with PD-L1 negative was classified into group B. None of the patients in group C showed UIP. and most of the cancers were adenocarcinoma. The frequency of epidermal growth factor receptor mutation-positive NSCLC was the highest in this group. CONCLUSIONS: The three groups each showed characteristic features in terms of tumor location, histopathology, PD-L1 expression, and frequency of pAEof IP.

[Indication and Results of 3-port Thoracoscopic Limited Resection for Lung Cancer].

The tumors with the size of 15 mm or less and less than 50 percent of solid component have been eligible for our radical surgical indication of 3-port thoracoscopic limited resection. The objective is to evaluate the indication. Between 2010 and 2015, we reviewed 206 segmentectomy and 87 partial resection. In those patients, non-radical limited resections included 129 segmentectomy and 29 partial resection. As for imaging findings, the maximum tumor diameter were 16.7 mm vs 10.8 mm and the consolidation/tumor (C/T) ratio were 0.54 vs 0.39. At a mean follow up of 48 months, 5-year overall survival (OS) were 91.4% vs 93.1%, and 5-year recurrent free survival (RFS) were 88.6% vs 93.1%. Overall recurrence(10 patients vs 6 patients) happened in the patients with non-radical limited resections for pure or part solid tumors, therefore it is necessary to consider an indication of limited resection for solid tumors carefully.

[MINIMALLY INVASIVE THORACIC SURGERY: PRESENT STATUS AND FUTURE PERSPECTIVES].

Minimally invasive general thoracic surgery entered a new era with the introduction of thoracoscopic surgery into clinical practice in the early 1990s. Thoracoscopic surgery is already widely accepted in most countries. However, single-port thoracic surgery, needlescopic thoracic surgery, and robot-assisted thoracic surgery are not yet accepted widely. More advances in the instruments and equipment appear necessary.

Pulmonary metastasectomy secondary to esophageal carcinoma: long-term survival and prognostic factors.

BACKGROUND: Lung metastasectomy has become an effective treatment for selected patients with colorectal cancer, renal cancer, and other malignancies; however, limited experience has been reported regarding pulmonary metastasectomy for esophageal carcinoma. We reviewed 23 patients with esophageal cancer who underwent pulmonary metastasectomy and investigated their long-term prognosis and prognostic factors. METHODS: A total of 23 patients who underwent 30 curative pulmonary metastasectomies at Toranomon Hospital, Japan, between 2001 and 2011 were included. Four patients underwent repeated metastasectomy. The overall survival rate was examined by the Kaplan-Meier method and various characteristics were assessed by univariate analysis to identify prognostic factors. RESULTS: The overall 1-, 3-, and 5-year survival rate was 82.6, 46, and 34.1 %, respectively. Median follow-up was 37.4 months (range 1-114 months). Univariate analysis revealed a history of extrapulmonary metastases before pulmonary metastasectomy, poorly differentiated primary esophageal carcinoma, and short disease-free interval (DFI) as unfavorable prognostic factors. Five patients who underwent repeated metastasectomy for recurrent pulmonary metastases survived a mean 58 months (range 24-114 months). The other patients survived a mean 29.4 months (range 1-109 months). CONCLUSIONS: Pulmonary resection for lung metastases from esophageal carcinoma should be considered in selected patients, and repeated metastasectomy should be encouraged. Extrapulmonary metastases before pulmonary metastasectomy, poor differentiation of primary esophageal carcinoma, and short DFI are unfavorable prognostic factors. Due to poor prognosis, metastasectomy in patients with these factors should be more carefully considered before being indicated.

[Thoracoscope for thoracoscopic surgery].

Thoracoscope is very important in thoracoscopic surgery (TS). There are many types of telescope and monitor. Also the placement of access port and location of the monitor image often differ between each institutions. Thoracic surgeons need to know these features to perform good TS. In our department, 2,375 patients (98% of all operation) were underwent 3-ports TS for 5 years. Operator always stands by patient's right side and camera assistant stands by patient's left side. Using 2 monitors, left side of monitors image sets to patient's head side and camera assistant see the inverted image monitor. Regardless of the localization of the lesion, three ports are always placed in same intercostal space. One of the advantages of TS is the ability of obtaining close and magnified operative image which can be possible to be shared with assistant and other surgical staff. The other advantages is that surgeons can review the recorded surgical digital versatile disc(DVD).

A Case of Traumatic Hemothorax From an Isolated Thoracic Vertebral Fracture in an Elderly Patient on Combined Anticoagulant and Antiplatelet Therapy.

Traumatic hemothorax is typically easy to diagnose because of the distinct onset of trauma with significant complaints such as severe chest pains. However, in elderly patients, the clinical symptoms are less clear and the frequent use of antithrombotic therapy may prolong the bleeding from a minor fracture. We report a case of traumatic hemothorax from an isolated thoracic vertebral fracture in an elderly patient on anticoagulant and antiplatelet therapy. A 91-year-old male on anticoagulant and antiplatelet therapy was admitted to our hospital with a complaint of persistent hemoptysis after a fall. A computed tomography (CT) demonstrated a worsening right hemothorax and thoracic vertebral fracture without lung or diaphragm injury, rib fracture, or contrast medium extravasation. The patient was taken to the operating room for the exploratory thoracoscopy and evacuation of the hemothorax without a preoperative diagnosis of the bleeding source. The bleeding was from the transverse laceration of the 10th thoracic vertebra exposed to the pleural space. The minor bleeding from the cancellous bone was prolonged, possibly due to the use of anticoagulant and antiplatelet therapy, which was not identified as contrast medium extravasation on chest CT before surgery. In cases of hemothorax with an unclear bleeding source, a vertebral fracture could be considered a source of bleeding even without any signs of bone dislocation or contrast medium extravasation on a CT scan.

[Change of the bronchial morphology, supine to lateral position on the 3DCT].

BACKGROUND: It is more difficult to intubate the double-lumen bronchial tube into the left bronchus than the right bronchus, and it is more difficult in a left decubitus position than normal position. And it is most difficult in the flexional decubitus position. METHODS: We examined the cause of the difficulty in intubation of the left main bronchus which is solved by 3DCT. RESULTS: The cause of the difficulty was the increase in size of the divergence angle of the left bronchus. Once the double-lumen left bronchial tube in the left bronchus has been pulled out, it is difficult to return the tube back to the left bronchus in the flexional position. For returning the tube to the bronchus, we place the head higher and change the flexional position to the extended position. CONCLUSIONS: We examined the cause of difficulty in intubation of the left bronchus in the decubitus position with 3DCT. We concluded that the cause is the increase in the size of the angle, and for the tube to be intubated in the left bronchus, the patient position must be changed from the flexional position.

[Video-assisted thoracic surgery for metachronous lung cancer].

Of 1,391 patients who underwent operation for primary lung cancer between 2000 and 2009, 50 patients (3.6%) had a past history of pulmonary resection for lung cancer. Three patients underwent completion pneumonectomy by thoracotomy and in the other 47 patients video-assisted thoracic surgery (VATS) was performed. We considered 42 cases (3 of completion pneumonectomy and 39 of VATS) to be metachronous lung cancer and 8 cases of VATS to be recurrence by detailed histologic assessment. We examined 39 cases of metachronous lung cancer resected by VATS. The patients were aged 68 +/- 8 years and 4 patients were aged 80-years or more. The surgical procedures performed were lobectomy in 4 patients, segmentectomy in 3, and wedge resection in 40. The operation time was 121 +/- 66 minutes and the blood loss was 67 +/- 140 ml. There were no major complications. We registered 6 deaths during follow-up; 3 were due to disease progression and 3 were due to other causes. The survival rate of the 42 patients including 3 patients who underwent completion pneumonectomy was 74.9% at 5 years. Early detection of metachronous lung cancer and surgical resection offers a favorable prognosis.

Feasibility of autologous fibrin glue in general thoracic surgery.

BACKGROUND: Fibrin glue effectively controls air leakage in lung surgery; however, allogenic fibrin glue cannot eliminate the risks of infection and allergy despite current sterilization methods. Autologous fibrin glue (AFG) could be a good alternative, but is not commonly used worldwide because of its limited availability and lack of evidence. Herein, we report clinical outcomes of AFG in thoracic surgery. METHODS: We retrospectively analyzed patients who underwent lobectomies or segmentectomies between November 2016 and September 2017 in our institution. We used two types of AFGs. One was a partially-autologous fibrin glue (PAFG), the components of which are largely autologous but which contains allogenic thrombin. The other was a completely-autologous fibrin glue (CAFG) which has no allogenic components. PAFG was used in the first half of the study period, after which CAFG was used from March 2017 onward. Patients who did not undergo AFG generation were categorized as the non-AFG group. The perioperative outcomes of the three groups were evaluated. RESULTS: A total of 207 patients underwent lung surgery, including 118 lobectomies and 89 segmentectomies. Among them, 83 patients received PAFG, 94 received CAFG, and 30 received non-AFG. The mean postoperative drainage period was within a few days in each group (PAFG vs. CAFG vs. non-AFG: 3.23±3.91 vs. 3.16±4.04 vs. 3.17±4.16 days, respectively; P=0.405), and the incidence of postoperative prolonged air leakage was within an acceptable range (PAFG vs. CAFG vs. non-AFG: 13.3% vs. 12.8% vs. 16.7%, respectively; P=0.821). CONCLUSIONS: The use of AFG is clinically feasible for patients who undergo lobectomies or segmentectomies. AFGs could be a viable alternative to conventional allogenic fibrin glues.

Inflammatory pseudotumour affecting the lung and orbit.

This report describes a rare case of inflammatory pseudotumour arising metachronously from the orbit and lung. A 78-year-old man with a 7-year history of orbital inflammatory pseudotumour developed a solitary mass in the right lung. Serological studies showed elevated levels of IgG and antinuclear antigen. Wedge resection of the lesion was performed under VATS. Histology showed that lymphoplasmacytic infiltration with dense fibrosis and flow cytometry proved these cells to be polyclonal. Immunostaining revealed numerous IgG4-positive plasma cells diffusely infiltrating the lesion.

Simultaneous three-port thoracoscopic surgery for bilateral lung cancers with a pulmonary vein anomaly: A case report.

INTRODUCTION: Simultaneous resection of bilateral lung cancers is technically challenging but may be preferable to a staged procedure in patients with a partial anomalous pulmonary venous connection (PAPVC) in an affected lobe. We performed single-stage resection of bilateral lung cancers in a patient with a PAPVC. PRESENTATION OF CASE: A 73-year-old man was diagnosed as having bilateral lung cancers (right, cT3N1M0, stage IIIA and left, cT2aN0M0, stage IB). Left upper trisegmentectomy was performed, followed by right upper lobectomy with deep wedge bronchoplasty. A PAPVC was found incidentally in the affected right upper lobe and successfully divided. The postoperative course was uneventful and he commenced chemoradiotherapy. DISCUSSION: Resection of the PAPVC, which was located in the same lobe as the lung cancer, would have mitigated load increase in the right heart and may have alleviated the adverse effects of bilateral lung resection. Moreover, the single-stage procedure likely shortened the overall duration of treatment. CONCLUSION: Single-stage bilateral thoracoscopic resection may have advantages over staged procedures in some patients with PAPVCs.

Pulmonary coccidioidomycosis found in healthy Japanese individuals.

BACKGROUND AND OBJECTIVE: Coccidioidomycosis is endemic in the south-western USA. This study described the clinicopathological features of pulmonary coccidioidomycosis found in otherwise healthy Japanese individuals. METHODS: Four male patients with pulmonary coccidioidomycosis were assessed by clinical examination, serology, PCR assay, high-resolution computed tomography and histopathological findings. RESULTS: All patients had returned to Japan from the USA and all presented with an abnormal CXR during routine assessment; two of the patients were symptomatic. High-resolution computed tomography showed a well-defined homogenous nodule or mass adjacent to the pleura. All patients underwent surgical wedge resection. Histopathological examination revealed encapsulated caseating epithelioid cell granulomas containing spherules and endospores. Serum IgG antibody was negative in all patients, but PCR assay using DNA from resected specimens demonstrated the presence of coccidioides-specific DNA. CONCLUSIONS: Pulmonary coccidioidomycosis is very rare in Japan, but it can be found incidentally during routine evaluation. The main high-resolution computed tomography findings are a well-defined homogenous nodule adjacent to the pleura, reflecting the histological feature of encapsulated granulomas. PCR assay is useful for confirming the presence of coccidioides.

Management of complications in thoracoscopic surgery.

BACKGROUND: Thoracoscopic surgery has been widely performed. However, sometimes open conversion becomes necessary to manage complications. We have been applying thoracoscopic technique to manage complications to minimize the rate of open conversion. METHODS: Thoracoscopic suture technique in addition to some other technique has been used to control intraoperative bleeding, nerve injury and bronchial damage. Pulmonary artery bleeding could happen in thoracoscopic surgery. First step is to give compression to the bleeding point. Usually the lung nearby is used then a gauze is taken over. A piece of Tachosil® is placed to stop bleeding. When this technique is not successful, the proximal part of the PA is encircled with a vascular sling to reduce the blood flow. In some occasion, bleeding point is suture closed. This technique is also used in controlling the bleeding from the right atrium. Phrenic nerve could be severed incidentally or on purpose to remove malignancy. Direct suture or intercostal nerve interposition may fix the problem. Trachea or bronchus could be damaged incidentally. Thoracoscopic suture closure will be helpful. Between 2013 and 2017, we performed 2,527 thoracoscopic surgical procedures including 1,196 major lung resections were performed in our department. RESULTS: There was no procedure related mortality. In our institution, open conversion to manage complications was 0.3% in consecutive 6,929 thoracoscopic surgery and 0.63% in thoracoscopic major lung resection since 2000. In 2014 to 2017 open conversion could be reduced to 0.4% of the major lung resections. Most of the complications in thoracoscopic surgery were managed with thoracoscopic methods. CONCLUSIONS: Applying thoracoscopic suture technique and other options could reduce the rate of open conversion in thoracoscopic surgery.

[Large cell neuroendocrine carcinoma of the lung incidentally found at surgery for pulmonary aspergillosis].

We report a 56-year-old man with pulmonary large cell neuroendocrine carcinoma (LCNEC) incidentally found at the surgery for pulmonary aspergillosis. In 1991, an abnormal chest radiographic shadow was found on a mass screening. A diagnosis of pulmonary aspergillosis was made by bronchoscopic examination. The patient was then followed up without treatment. He had hemoptysis in 2005, and was referred to our hospital. Chest CT scan revealed a cavitary lesion with an air crescent sign and an irregularly shaped nodule in the right apex. Wedge resection of these lesions was performed under video-assisted thoracoscopic surgery. Pathological examination revealed not only aspergilloma, but also an LCNEC 11 x 7 mm in size, which was located close to the aspergilloma. Microscopically, nests of tumor cells were distributed peribronchially. Right upper lobectomy and mediastinal lymph node dissection was performed, and the pathological stage was IIIA (T1N2M0). The patient received four cycles of adjuvant chemotherapy with carboplatin and paclitaxel. No recurrence has been observed since surgery. This is the first report describing co-existence of pulmonary aspergilloma and LCNEC.

[Value of postoperative surveillance of tumor recurrence after curative esophageactomy].

A study of 256 patients whose dates and patterns of first mode of recurrence after curative esophagectomy from 1984 to 2004 revealed the recent improvement in survival after the detection of tumor recurrence. This tendency was evident in lymphatic recurrence, particularly in the cervical area. Lung metastasis was another mode of recurrence that has shown recent improvement. In this series, 20 patients with lymph node metastases underwent reoperation for local or regional tumor control. The addition of systemic chemotherapy or chemoradiotherapy was our general rule. The 5-year survival rate after the detection of tumor recurrence in these 20 patients was 47.4%. Six with lung metastases in the group of patients whose esophagectomies were performed in the last 7 years underwent video-assisted pulmonary tumor resection. Five patients in this group are alive without signs of further recurrence for 92 to 1,437 days. The early detection of recurrent tumor, vigorous attempts to achieve locoregional control, and the addition of systemic chemotherapy are all important in achieving better results. We routinely perform conventional cervical and abdominal ultrasonography and computed tomography every 6 months until 6 years after surgery is performed.

Single-stage video-assisted thoracoscopic surgery: Right upper lobectomy and left lower lobectomy for synchronous bilateral lung cancers.

INTRODUCTION: Single-stage bilateral radical surgery for synchronous bilateral multiple lung cancers (SBMLCs) has strong advantages; however, it is considered highly invasive. We have therefore adopted video-assisted thoracoscopic surgery (VATS) as a minimally invasive surgical maneuver for bilateral lung resection. Although there have been a few reports concerning bilateral lung resection, the safety and appropriate operative indications remain unclear, especially for bilateral VATS-lobectomy. A case of single-stage bilateral radical lobectomy with a good result is reported. PRESENTATION OF CASE: A 58-year-old man was found to have abnormal opacities in the right upper zone and left lower zone at a health checkup. Double primary bilateral lung cancers was suspected, and surgical resection was considered. Consequently, right upper lobectomy with D2 lymph node dissection and left lower lobectomy with D2 lymph node dissection as radical resection were performed under VATS. The lesions were finally diagnosed to be double primary adenocarcinomas of the right upper lobe (pT1N0M0, stage IA) and left lower lobe (pT1N0M0, stage IA). The patient's postoperative course was uneventful, and he was discharged on postoperative day 6. The patient is doing well with no evidence of recurrence for 9 years. CONCLUSION: While careful consideration of the surgical options is needed, if properly done, bilateral VATS-lobectomy for SBMLC has advantages for selected patients.

Semiquantitative Assessment of Tumor Spread through Air Spaces (STAS) in Early-Stage Lung Adenocarcinomas.

INTRODUCTION: Tumor spread through air spaces (STAS) has recently been reported as a form of tumor invasion having an unfavorable prognosis, but the significance of a small amount of STAS is not known. The aim of this study was to perform a semiquantitative assessment of STAS. METHODS: Small (≤2 cm) stage I lung adenocarcinomas surgically resected at our institution between 2003 and 2009 were assessed semiquantitatively in the most prominent area as no STAS, low STAS (1-4 single cells or clusters of STAS), or high STAS (≥5 single cells or clusters of STAS) by using a 20× objective and a 10× ocular lens. A statistical analysis was performed to determine the impact of clinicopathologic parameters on STAS and to clarify the relationship between STAS and patient survival. RESULTS: STAS was assessed as no STAS in 109 of 208 cases (52.4%), as low STAS in 38 cases (18.3%), and as high STAS in 61 cases (29.3%). There were statistically significant associations between higher STAS and solid predominant invasive adenocarcinoma (p < 0.001), pleural invasion (p < 0.001), lymphatic invasion (p < 0.001), vascular invasion (p < 0.001), and tumor size of 10 mm or more (p = 0.037). There was a significant association between increasing STAS and shorter recurrence-free survival (RFS) in univariate analysis (no STAS, 154.2 months; low STAS, 147.6 months; and high STAS, 115.6 months). In a multivariate Cox proportional hazards model, only STAS (p = 0.015) remained a significant predictor of RFS. CONCLUSIONS: We found that one-third of resected small adenocarcinomas had high STAS. Higher STAS was predictive of worse RFS.