Prognostic factors affecting survival in patients with non-small cell lung cancer treated with salvage surgery after drug therapy: a multi-institutional retrospective study.

BACKGROUND: The prevalence of salvage surgeries after drug therapy for non-small cell lung cancer (NSCLC) has risen, mainly due to recent progress in molecular-targeted drugs and immune checkpoint inhibitors for NSCLC. While the safety and effectiveness of salvage surgery after drug therapy for NSCLC have been studied, its indications remain unclear. We aimed to identify the prognostic factors affecting survival in patients with advanced-stage (stages III-IV) NSCLC treated with salvage surgery after drug therapy. METHODS: A retrospective investigation was conducted on patients who received salvage surgery after drug therapy at four hospitals between 2007 and 2020. Salvage surgery was defined as surgery after drug therapy for local progression, tumor conversion to resectable status, and discontinuation of prior drug therapy owing to serious complications. RESULTS: Thirty-two patients received cytotoxic agents alone (n = 12 [38%]), tyrosine kinase inhibitors (TKIs; n = 16 [50%]), or immune checkpoint inhibitors (n = 4 [13%]) as prior drug therapy. In 11 (34%) and 21 (66%) patients, the clinical stage before treatment was III or IV, respectively. The median initial and preoperative serum carcinoembryonic antigen (CEA) levels were 10.2 (range, 0.5-1024) ng/mL and 4.2 (range, 0.6-92.5) ng/mL, respectively. Among the patients, 28 (88%) underwent lobectomy, 2 (6%) underwent segmentectomy, and 2 (6%) underwent wedge resection. Complete resection of the primary lesion was accomplished in 28 (88%) patients. Postoperative complications were documented in six (19%) patients. Mortality rates were 0% at 30 days and 3% at 90 days post-operation. The 5-year overall survival rate stood at 66%, while the 5-year progression-free survival rate was 21%. Multivariate analyses showed that prior TKI therapy and preoperative serum CEA level < 5 ng/mL were prognostic factors influencing overall survival (hazard ratio [95% confidence interval]: 0.06 [0.006-0.68] and 0.03 [0.002-0.41], respectively). The 5-year overall survival in the 11 patients with both favorable prognosticators was 100%. CONCLUSIONS: In this study, prior TKI therapy and preoperative serum CEA level < 5 ng/mL were favorable prognostic factors for overall survival in patients with NSCLC treated with salvage surgery. Patients with these prognostic factors are considered good candidates for salvage surgery after drug therapy.

[Surgical Resection of Pulmonary Metastases from Gastric Cancer;Report of a Case].

Lung metastasis of gastric cancer often presents as multiple pulmonary metastases or cancerous lymphadenopathy, which is rarely indicated for surgery and has a poor prognosis. We report a case of solitary metastases that were surgically resected. The patient underwent distal gastrectomy for stomach cancer and then received chemotherapy for abdominal lymph node metastasis. However, he developed pulmonary metastases in the right S6 and S8, and thus underwent right S6 resection and partial resection 29 and 41 months after the gastrectomy, respectively. The pathological diagnosis was gastric cancer metastases. After undergoing surgery for resection of the metastases, he developed new metastases in abdominal lymph nodes and died 5 years after the 1st surgery.

[Pneumocystis Pneumonia-induced Pneumothorax Treated with Surgery and Insertion of an Endobronchial Watanabe Spigot;Report of a case].

Pneumothorax induced by Pneumocystis jirovecii( P. jirovecii) pneumonia is often refractory to treatment. A man in his 30's who had malignant lymphoma and received chemotherapy developed P. jirovecii pneumonia. A month after treatment for pneumonia, he developed a secondary pneumothorax. Since drainage was not effective, he underwent right lower lobectomy and bulla resection. Air leakage stopped after surgery but recurred on postoperative day 5. Chest computed tomography showed a new bulla on his right lung. On postoperative day 15, we inserted an endobronchial Watanabe spigot( EWS),and air leakage completely stopped.

[Resection of a Chest Wall Desmoid Tumor with Chest Wall Reconstruction;Report of a Case].

A primary desmoid tumor arising from the chest wall is extremely rare. We report the case of a 57-year-old man presenting with a desmoid tumor arising from his chest wall. Chest radiograph at a regular medical checkup indicated an abnormal shadow. By computed tomography-guided biopsy, he was diagnosed as having a desmoid tumor. He underwent right-sided chest wall resection and reconstruction. Desmoid tumor is histopathologically benign tumor, however, they tend to show high rates of local recurrence after surgery. In case of recurrence on unresectable case, radiotherapy or some medical treatment should be chosen as a treatment option.

[Resection and reconstruction of sternum].

We have experienced 6 cases with resection and reconstruction of sternum. They were 1 with osteosarcoma, 1 with synovial sarcoma, 1 with sternal metastasis of fallopian tube cancer, 1 with sternal metastasis of thyroid cancer, 1 with desmoid tumor, and 1 with dermatofibrosarcoma protuberance. Resection of both manubrium and sternum was performed in 3 cases and sternum resection in 3. There was no total resection. We used a titanium reconstruction plate and titanium mesh in 3 cases, a titanium reconstruction plate and polypropylene mesh in 2, titanium mesh in 1 for reconstruction of bony defect, and rectus abdominis myocutaneous flap in 3, pectralis major muscle flap in 2, latissimus doris myocutaneous flap in 1 for reconstruction of soft tissue defect. Postoperative courses were uneventful, and flail chest was not observed. Reconstruction of the bony defect of the anterior chest wall with the titanium reconstruction plate and titanium mesh or polypropylene mesh was effective by providing sufficient rigidity as well as protection of the thoracic organs.

Bronchioloalveolar carcinoma as a second malignancy in a pediatric osteosarcoma survivor: case report.

BACKGROUND: Primary lung cancer is extremely rare in children, while secondary malignancies reportedly develop in 2% to 3% of pediatric osteosarcoma survivors. CASE PRESENTATION: A 14-year-old girl was found to have two pulmonary lesions on computed tomography. These tumors had developed 1 year after osteosarcoma surgery. Segmentectomy of right segment 1 and wedge resection of right segment 9 were performed. Both lesions were completely resected and postoperative histopathological examination revealed metastasis of osteosarcoma and bronchioloalveolar carcinoma, respectively. CONCLUSION: Bronchioloalveolar carcinoma may present as a solitary pulmonary lesion indistinguishable from a metastatic lesion and should be included in the differential diagnosis of pulmonary lesions in survivors of pediatric cancer. Thus, pulmonary lesions identified in these patients should be biopsied or resected to establish a histological diagnosis.

Innovative segmentectomy to remove the posterior segment of the lower lobe (S¹°) of the lung.

We describe our innovative technique for performing segmentectomy of the posterior segment of the lower lobe of the lung, being segment number 10 (S¹°). In segmentectomy of S¹°, it is difficult to identify A¹° from the interlobar fissure because the pulmonary artery to S¹° (A¹°) branches from A(9+10) and runs dorsally and deeply into the lung tissue. Moreover, to reach S¹° from the interlobar fissure, the lung tissue should be cut between S6 and S8, because S¹° is not located beside the interlobar fissure. However, it is difficult to identify the boundary between the S6 and S8 without a route marker. To solve these difficulties, we divided S6 and S¹° from each other at the beginning of the procedure, which enabled A¹° to be identified easily from the dorsal side. Because S6 and S(8-10) should be divided in S¹° segmentectomy at the end, the division between S6 and S(8-10) at the beginning of procedure is not only reasonable, but makes the procedure simple.

Safety and efficacy of salvage surgery for non-small cell lung cancer: a retrospective study of 46 patients from four Keio-affiliated hospitals.

OBJECTIVES: Advances in drug therapy and radiotherapy for non-small cell lung cancer resulted in an increased number of salvage surgeries for initially unresectable tumors. This study aimed to evaluate the safety and efficacy of salvage surgery for non-small cell lung cancer. METHODS: We defined salvage surgery as (1) surgery for local recurrence/residual tumor after definitive chemoradiotherapy/radiotherapy (salvage surgery in a narrow sense) or (2) conversion surgery after non-surgical treatment. We retrospectively analyzed patients who underwent salvage surgery at four Keio University-affiliated hospitals. RESULTS: Forty-six patients were included. The initial clinical stage was I in 4 patients (9%), III in 19 (41%), and IV in 23 (48%). Initial treatment before salvage surgery was chemoradiotherapy in 10 patients (24%), radiotherapy in 4 (9%), and drug therapy in 32 (67%). Pneumonectomy, lobectomy, segmentectomy, and wedge resection were performed in 2 (4%), 37 (80%), 3 (7%), and 4 (9%) patients, respectively. Complete resection was achieved in 41 patients (89%). Postoperative complications occurred in 11 patients (24%). Initial chemoradiotherapy/radiotherapy was an independent predictor of postoperative complications (odds ratio 10, p = 0.03). The 30- and 90-day mortality rates were 0 and 2%, respectively. The 5-year overall and progression-free survival rates were 66 and 30%, respectively. CONCLUSION: The safety and efficacy of salvage surgery for non-small cell lung cancer were acceptable. Salvage surgery was a viable treatment option for selected patients with recurrent/residual tumors after non-surgical treatments.

The prognostic nutritional index in resected high-grade pulmonary neuroendocrine carcinoma.

OBJECTIVE: The prognostic nutritional index is a potential predictive indicator in other cancers and can be easily determined at low cost. To identify useful prognostic markers for high-grade neuroendocrine carcinomas, we examined the prognostic significance of the prognostic nutritional index in patients with resected high-grade pulmonary neuroendocrine carcinoma. METHODS: We retrospectively reviewed perioperative clinical and laboratory data of patients who underwent pulmonary resection for high-grade neuroendocrine carcinoma between January 2000 and December 2014. Associations between the preoperative prognostic nutritional index and the patients' clinicopathological characteristics were analyzed to determine its prognostic significance. RESULTS: The study comprised 61 patients, the majority of whom were men (85%). The median age was 70.0 years, and the median follow-up period was 42 months. No significant differences in the clinicopathological characteristics were observed between the high and low prognostic nutritional index groups. The 5-year overall survival and recurrence-free survival times were significantly shorter in the low prognostic nutritional index group than in the high prognostic nutritional index group (78.8% vs. 51.4% and 71.7% vs. 34.5%, respectively; p < 0.05). The prognostic nutritional index was confirmed as an independent prognostic factor (hazard ratio: 2.419, 95.0% confidence interval: 1.044-5.606; p < 0.05). A significantly greater proportion of patients developed distant metastases in the low prognostic nutritional index group than in the high prognostic nutritional index group (p < 0.05). CONCLUSION: A low prognostic nutritional index is associated with poor survival in patients with resected high-grade pulmonary neuroendocrine carcinoma.

Clinical features of HIV-infected patients with non-small-cell lung cancer after lung resection.

OBJECTIVE: The purpose of this study was to clarify the surgical outcome for HIV-infected patients with non-small-cell lung cancer (NSCLC). METHODS: Six HIV-positive patients underwent lung resection as treatment for NSCLC at our hospital from July 2010 to December 2017. Their clinical information was collected based upon review of their medical records. RESULTS: All the patients included in this study had received highly active antiretroviral therapy (HAART) before lung resection with a mean duration of 99 months. Five patients underwent lobectomy and one patient underwent segmentectomy. Median preoperative CD4-positive T-cell count was 234/µL (range 138-428/µL). One patient contracted pneumonitis within 30 days post-surgery, whereas others had no postoperative complications. There was no postoperative mortality. For four patients, the pathological stage was upstaged compared to their clinical stage; IA1-IA3 (1 patient), IA3-IIB (1 patient), IB-IIIA (1 patient), and IB-IIIB (1 patient). Two patients died of lung cancer 2 years after surgery. CONCLUSION: Surgical treatment for HIV-infected patients with NSCLC receiving HAART therapy and keeping adequate CD4-positive T-cell counts is safe and feasible. Preoperative precise staging using diagnostic imaging is difficult for these patients.

Clinico-bacteriological analysis for video-assisted thoracoscopic biopsy of non-tuberculous mycobacteria.

BACKGROUND: The prevalence of non-tuberculous mycobacteria (NTM) has been increasing in recent years, and thus the number of related surgeries. In recent studies, a few recent studies reported that NTM patients require preoperative treatment. In addition, some cases are found to be granuloma suspected to be NTM (gsNTM) after surgery. We conducted a clinico-bacteriological examination of resected NTM and gsNTM cases we managed. METHODS: Between 2003 and 2017, 82 patients with NTM and gsNTM underwent video-assisted thoracoscopic (VATS) biopsy at our institution. The objectives of surgery, perioperative treatment, progression of NTM and gsNTM, and bacteriological data were analyzed. RESULTS: We enrolled 42 men and 40 women with a median age of 65 years. The bacteriological findings were Mycobacterium avium in 38 cases, M. intracellulare in 6 cases, M. kansasii in 3 cases, and gsNTM in 35 cases. The objectives of surgery were the diagnosis in 77 cases, and resistance to treatment in 6 cases. We performed postoperative treatment in 8 cases. There was no surgery-related (30-day mortality) death or complication. CONCLUSIONS: We analyzed surgical outcome for pulmonary NTM infections. We need to reconsider the surgical procedure for single pulmonary NTM lesion and whether adjuvant chemotherapy is necessary for NTM treatment.

The impact of pulmonary metastasectomy from gastric cancer.

Gastric cancer remains the most commonly-occurring cancer and the third most frequent cause of cancer-associated mortality in Japan. Solitary pulmonary metastasis of gastric cancer is rare and the outcome of pulmonary metastasectomy is still unclear. Herein we report the impact of pulmonary resection in patients with metastasis from gastric cancer. The present study retrospectively reviewed the preoperative data and clinical courses of 10 patients who underwent pulmonary resection for metastasis from gastric cancer at our institution between July 1986 and December 2017. The data on the outcomes, including morbidity, mortality and survival, were obtained from the patient records. All patients were followed-up from the time of pulmonary resection until mortality or referral to another hospital. The statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for the R software program (The R Foundation for Statistical Computing, Vienna, Austria). The study population included 7 male patients and 3 female patients. A total of 5 patients underwent total gastrectomy, and 5 underwent distal gastrectomy. The median disease-free interval after initial gastric resection was 34.5 months. Five patients received adjuvant chemotherapy, of the 10 thoracotomies, 5 were lobectomy, 3 were wedge resection and 2 were segmentectomy. The median overall survival following pulmonary metastasectomy was 59 months and the 5-year survival rate was 40.5%. Taken together, the results of the present study suggest that pulmonary resection may be an effective therapeutic option for metastatic gastric cancer when a patient has a solitary metastatic lesion.

Surgery for Pulmonary Fungal Infections Complicating Hematological Malignancies.

BACKGROUND: The complication rate of fungal disease is higher among patients with hematological malignancies. We investigated the clinicobacteriological outcomes of resected pulmonary fungal infections complicating hematological malignancies. METHODS: Between 2001 and 2017, 21 patients with pulmonary fungal infections complicating hematological malignancies underwent resection, and their clinical records and survival were retrospectively reviewed. RESULTS: The median age of the patients was 47 years, and 13 were male. The histological diagnoses were pulmonary aspergillosis (19 cases), mucormycosis (1 case), and cryptococcosis (1 case). The indications for surgery were resistance to antifungal therapy and the necessity of surgery before hematopoietic stem cell transplantation in 13 and 8 cases, respectively. The diagnoses of the hematological malignancies were acute myelogenous leukemia (10 cases), acute lymphocytic leukemia (5 cases), myelodysplastic syndrome (3 cases), and chronic myelogenous leukemia, malignant lymphoma, and extramedullary plasmacytoma (1 case each). The surgical procedures were partial resection (11 cases), segmentectomy (5 cases), lobectomy (4 cases), and cavernostomy (1 case). The size of the lesions was 0.9-8.5 cm. Fourteen cases had cavitation. There were no surgical-related deaths or fungal progression. CONCLUSION: Pulmonary fungal infections are resistant to treatments for hematological malignancies. Since the treatment of the underlying disease is extended and these infections often recur and are exacerbated, surgery should be considered when possible.

Dyspnea caused by osteochondroma of the clavicle head: a case report.

Osteochondroma is a benign cartilaginous neoplasm and is the most common benign bone tumor. Osteochondromas arising from the clavicular head are extremely rare and symptomatic cases are even less common. We report a 23-year-old man who presented with dyspnea due to tracheal displacement resulting from a clavicular osteochondroma. The patient underwent successful resection involving a trap-door thoracotomy.

Clinicopathologic features of minute pulmonary meningothelial-like nodules.

Purpose Minute pulmonary meningothelial-like nodules are incidentally discovered in lung specimens. We analyzed the clinicopathologic features of 14 cases identified in surgically resected lungs. Methods Among patients who underwent lung resection in our hospital from October 2007 to March 2016, 14 were found to have minute pulmonary meningothelial-like nodules. The clinical parameters, radiologic findings, and pathologic features of these patients were retrospectively reviewed using the medical records. Results The patients included 4 men and 10 women, with a mean age of 69 years (range 53-82 years). The coexisting main disease was adenocarcinoma in 8 patients, squamous cell carcinoma in 1, atypical adenomatous hyperplasia in 1, and metastatic pulmonary tumor in 3. In one patient, the minute pulmonary meningothelial-like nodules presented as multiple lung nodules on chest computed tomography. The median size of the nodules was 1.4 mm (range 0.3-6.0 mm). Similar to meningioma, one case had immunoreactivity to progesterone receptor and epithelial membrane antigen, although the minute pulmonary meningothelial-like nodules were not associated with a meningioma. Conclusions The relationship between minute pulmonary meningothelial-like nodules and meningioma should be investigated. If minute pulmonary meningothelial-like nodules are found on preoperative computed tomography, thoracoscopic lung biopsy is helpful for differential diagnosis.

Prognostic significance of neutrophil-lymphocyte ratios in large cell neuroendocrine carcinoma.

OBJECTIVES: Large cell neuroendocrine carcinomas (LCNECs) are rare neuroendocrine pulmonary malignancies with poor survival. Towards the goal of identifying a useful prognostic marker for LCNEC, we examined the prognostic significance of the neutrophil-lymphocyte ratio (NLR) in LCNEC patients after complete resection. The NLR is a potential predictive indicator in other cancers and can be easily determined at low cost. METHODS: We retrospectively reviewed the perioperative clinical and laboratory data of patients who underwent complete resection for LCNEC between 1995 and 2014. Correlations between the preoperative NLR and clinicopathological parameters were determined to assess its prognostic significance. RESULTS: Our study consisted of 26 patients, most of whom were men (88.5%) with a median age of 68.8 years. The median follow-up time was 54.4 months. Univariate analysis identified 3 clinically significant overall survival predictors: serum albumin level [≥4.0 g/dL (5-year overall survival rate; 80.0%) vs. <4.0 g/dL (30.0%), p = 0.048], pathological T stage [T1 and T2 (79.6%) vs. T3 and T4 (0%), p = 0.001], and preoperative NLR [<1.7 (90.9%) vs. ≥1.7 (51.7%), p = 0.012]. In a multivariate analysis, the NLR was an independent prognostic factor for overall survival (hazard ratio 8.559, 95% confidence interval 1.783-80.230, p = 0.011). CONCLUSIONS: The preoperative NLR inversely correlates with post-resection survival rates in patients with LCNEC and thus is a viable prognostic marker in LCNEC.

Resection for Pancreatic Cancer Lung Metastases.

BACKGROUND: Pancreatic cancer is a highly aggressive solid tumor. Patients with metastases from pancreatic cancer have poor survival rates. Here, we report the outcomes of 6 patients for whom resection of lung metastases was performed after a pancreatectomy to treat pancreatic cancer. METHODS: We retrospectively reviewed the perioperative clinical data of patients with lung metastases resulting from primary pancreatic cancer who were treated with lung resection between 2008 and 2015. We report 6 cases where lung resection was performed to treat lung metastases after a pancreatectomy. RESULTS: The number of lung metastases was 1 in 5 cases and 2 in 1 case. The surgical procedures performed to treat the lung metastases included 4 wedge resections and 2 lobectomies. The cell type of the primary tumor and metastases was tubular adenocarcinoma in 5 cases and intraductal papillary-mucinous carcinoma in 1 case. All 6 patients survived with a mean follow-up period of 65.6 months, although the disease recurred in 2 patients. CONCLUSION: Resection of lung metastases resulting from primary pancreatic cancer may lengthen survival, provided the patient can tolerate surgery.

Pure Red Cell Aplasia Associated with Good Syndrome.

Pure red cell aplasia (PRCA) and hypogammaglobulinemia are paraneoplastic syndromes that are rarer than myasthenia gravis in patients with thymoma. Good syndrome coexisting with PRCA is an extremely rare pathology. We report the case of a 50-year-old man with thymoma and PRCA associated with Good syndrome who achieved complete PRCA remission after thymectomy and postoperative immunosuppressive therapy, and provide a review of the pertinent literature.

Intractable Pneumothorax Treated With Endobronchial Watanabe Spigots.

Pneumothorax secondary to nontuberculous mycobacterial lung disease is often intractable and associated with high mortality. An endobronchial Watanabe spigot (EWS) is a silicon plug developed for bronchoscopic bronchial occlusion. Here we report a case of intractable pneumothorax secondary to nontuberculous mycobacterial lung disease successfully treated using EWSs. Occlusion of the multiple ectatic bronchi connected to the bronchopleural fistula was essential for optimal effect of the EWSs.

Alveolar macrophage phenotype expression in airway-instilled bone marrow cells in mice.

No uniform consensus has been established regarding post-pneumonectomy lung regeneration. This study was undertaken to determine whether airway-instilled lung- or bone marrow-derived cells are able to differentiate and reconstitute as lung component cells in the course of post-pneumonectomy lung growth. Bone marrow cells or lung cells obtained from C57 black (BL)/6-GFP mice were intratracheally instilled into C57BL/6 mice treated with left pneumonectomy and cell differentiation was examined. It is unclear whether intratracheally instilled lung or bone marrow cells differentiate into non-hematopoietic cells after pneumonectomy. However, regardless of whether pneumonectomy is performed, intratracheally instilled bone marrow cells display a surface antigen profile that is similar to alveolar macrophages. Furthermore, these newly differentiated macrophages function similarly to resident macrophages in terms of TNF-α production, suggesting that bone marrow stem cells acquire the same macrophage phenotype. In conclusion, intratracheally instilled bone marrow cells adapt to the surrounding microenvironment, directly differentiating into alveolar macrophages, and remain in the alveolar space for at least 3 months.