Pulmonary Vein Stump Thrombosis and Cerebral Infarction after Left Upper Lobectomy.

BACKGROUND: Pulmonary vein stump thrombosis may occur after left upper lobectomy (LUL) and is a potential risk factor for cerebral infarction. However, there are few reports on the role of pulmonary vein stump thrombosis in the development of cerebral infarction. We aimed to clarify the correlation between pulmonary vein stump thrombosis and cerebral infarction following LUL. METHODS: We evaluated 296 patients who underwent contrast-enhanced computed tomography (CT) after LUL for lung cancer at the Shizuoka Cancer Center Hospital in Shizuoka, Japan, between September 2002 and December 2015. The cerebral infarction in patients with pulmonary vein stump thrombosis was examined, and the risk factors for cerebral infarction were identified via a univariate analysis of the clinicopathological and surgical variables. RESULTS: Overall, 179 men and 117 women (median age: 68 years; range: 36-88 years) were included. The median observation period was 68 months. Pulmonary vein stump thrombosis occurred in 21 (7%) patients and cerebral infarction occurred in 15 (5%) patients. None of the 21 patients with pulmonary vein stump thrombosis developed cerebral infarction. Most cerebral infarctions (12/15) were diagnosed in the late phase (> 3 months). The pathological stage of cancer was found to be the only significant risk factor for cerebral infarction by the univariate analysis. CONCLUSION: Pulmonary vein stump thrombosis following LUL was not necessarily associated with cerebral infarction, including the late phase. A prospective observational study with contrast-enhanced chest CT would be required to investigate the risk factors for cerebral infarction in each phase of the postoperative period.

[Trial of the New Pain Assessment after Thoracic Surgery].

We evaluated postoperative pain intensity using the PainVision system for quantitative pain analysis and assessed the correlation with numerical rating scale( NRS) for subjective pain evaluation. Twelve patients were evaluated for both pain intensity by PainVision and values by NRS at 6, 24 and 48 hours following after thoracic surgery. The correlation coefficient between pain intensity and NRS values was 0.20, which suggested that degrees of pain measured by subjective and quantitative pain scales were not necessarily consistent. Assessing pains with both conventional subjective pain evaluation and quantitative pain intensity evaluation by PainVision is possibly useful in providing optimal postoperative pain management.

[Thoracic Paravertebral Block in Patients Ineligible for Epidural Block].

We retrospectively assessed the effectiveness and the safety of thoracic paravertebral block(PVB) in patients ineligible for epidural block (EP). Eleven PVB patients and 33 EP patients were enrolled. Postoperative pain was evaluated using a numerical rating scale (NRS). The mean NRS ± standard deviation at rest 24 and 48 hours after surgery were 1.36 ± 1.63 and 0.55 ± 1.03 in the PVB group and 1.07 ± 1.47 and 1.38 ± 1.31 in the EP group, respectively. There were no statistically significant differences in the NRS scores. Approximately 10% of the EP patients had complications such as hypotension, nausea and vomiting, or urinary retention. On the other hand, there were no adverse events in the PVB group. PVB can provide pain relief comparable to EP with a better side-effect profile. There were no technical complications associated with PVB. Thoracic PVB is an effective and safe method of postoperative analgesia for patients undergoing thoracic surgery with ineligibilities for EP.

Chylothorax after pulmonary resection and lymph node dissection for primary lung cancer; retrospective observational study.

BACKGROUND: Pulmonary resection with mediastinal lymph node dissection for treating primary lung cancer could sometimes causes chylothorax as a postoperative complication. This study examined the validity of treatments for chylothorax in our hospital. METHODS: We evaluated 2019 patients who underwent lobectomy, bilobectomy, or pneumonectomy with mediastinal lymph node dissection for primary lung cancer at Shizuoka Cancer Center Hospital, Shizuoka, Japan, between September 2002 and March 2018. The diagnostic criteria for postoperative chylothorax were that the drainage from the pleural drain was evidently white and turbid, or the pleural effusion contained a triglyceride level of > 110 mg/dL. The clinical courses and treatments were retrospectively reviewed. RESULTS: Postoperative chylothorax occurred in 37 patients (1.8%), 20 men and 17 women, with a median age of 70 years (33-80). A low-fat diet was instituted to all patients; 35 cases improved with conservative treatment, and 2 cases required reoperation. Nine cases had a drainage volume ≥ 500 mL one day following the low-fat diet commencement, which was resolved with conservative treatment and decreased drainage was observed on the third day of treatment in seven of those cases. Two cases with excessive drainage of ≥ 1000 mL in one day and systemic symptoms associated with chyle loss needed surgery. CONCLUSIONS: Even when the daily drainage volume exceeds 500 mL following a low-fat diet, there were many cases that could be cured conservatively. The indication for surgery needs to be carefully considered.

Quantitative severity of emphysema is related to the prognostic outcome of early-stage lung cancer.

OBJECTIVES: Although pulmonary emphysema is a component of chronic obstructive pulmonary disease, the prognostic significance of the quantitative severity of emphysema in patients with primary lung cancer is unclear. This study aimed to identify the association between the quantitative severity of emphysema detected by the low-attenuation area on computed tomography and the prognostic outcome of early non-small-cell lung cancer. METHODS: A consecutive series of 1062 patients who underwent lobectomy for clinical stage I and II non-small-cell lung cancer were enrolled in this study. The clinicopathological features and long-term outcomes of patients with primary lung cancer in emphysema were investigated. The extent of emphysema in the lobe where the tumour was present was measured by preoperative computed tomography as a percentage of the low-attenuation area (LAA%). RESULTS: LAA% ≥ 1.0% was detected in 145 (13.7%) patients. LAA% was associated with pleural invasion (P < 0.0001), vascular invasion (P < 0.0001) and a larger tumour size (P = 0.001). The overall survival and recurrence-free survival in patients with LAA% ≥ 1.0% and with LAA% < 1.0% at 5 years were 78.6% and 92.1% (P < 0.0001) and 68.7% and 85.2% (P < 0.0001), respectively. According to the Cox proportional hazards model, LAA% was an independent prognostic factor for overall survival and recurrence-free survival (P = 0.0004 and P = 0.003, respectively). CONCLUSIONS: The quantitative severity of pulmonary emphysema was found to be associated with poor prognosis and clinicopathological aggression in early non-small-cell lung cancer.

Impact of Positive Pleural Lavage Cytology for Each Stage of Non-Small Cell Lung Cancer Patients.

BACKGROUND: Positive preresection pleural lavage cytology (PLC+) is a poor prognostic factor in non-small cell lung cancer (NSCLC). This study evaluated the prognostic value of PLC+ for the different pathologic stages (p-stages) of NSCLC. METHODS: A retrospective analysis was conducted of all 1293 staged patients who underwent curative resection in the Shizuoka Cancer Center Hospital, Shizuoka, Japan, for NSCLC to evaluate the impact of PLC+ on survival, specifically in patients with p-stage I NSCLC. The survival rate between patients with and without PLC+ was compared using the Kaplan-Meier method with the log-rank test for comparison. RESULTS: PLC+ was identified in 50 of the 1293 patients (3.9%) and was correlated with lymph node metastasis (P < .001), a pathologic tumor size larger than 3 cm (P = .033), the presence of pleural invasion (P < .001), and adenocarcinoma (P = .038). In patients with PLC+, the 5-year disease-free survival (DFS) was 31.1%, compared with 75.7% for patients with a negative PLC (PLC-) (P < .001). On multivariate analysis, the PLC+ status was an independent prognostic factor of DFS (hazard ratio 1.70; P = .013). Among the 818 patients with p-stage I NSCLC, PLC+ was identified in 22, with a 5-year DFS of 40.4%. The prognosis in patients with p-stage I NSCLC with PLC+ was equal to that in patients with p-stage IIIA NSCLC with PLC- (5-year DFS, 40.4% and 39.0%). CONCLUSIONS: PLC is an independent prognostic factor in early-stage NSCLC. Therefore, it may be appropriate to up-stage an NSCLC diagnosis in the presence of PLC+, especially for patients with p stage I.

Prognostic impact of the number of involved lymph node stations in patients with completely resected non-small cell lung cancer: a proposal for future revisions of the N classification.

OBJECTIVE: The current nodal staging for lung cancer is defined only by the anatomical site of metastasis. However, the International Association for the Study of Lung Cancer (IASLC) proposed further subdivisions of the N descriptor that considers the locations and numbers of involved lymph node stations. This study aimed to test the new IASLC categories and compare their prognostic abilities to those of our proposed model that considers only the number of involved lymph node stations instead of the sites of metastasis. METHODS: Between September 2002 and December 2016, 1581 patients who underwent complete resection for pathologically diagnosed Tis-4N0-2M0 non-small cell lung cancer were retrospectively analyzed. We evaluated the survival rates according to the patients' N classification as recently proposed by the IASLC and by the number of involved lymph node stations, and determined the optimal N classification. RESULTS: The 5-year survival rates for patients with IASLC stages N1a, N1b, N2a1, N2a2, and N2b were 71.5%, 49.9%, 73.7%, 62.1%, and 46.9%, respectively. These results showed relatively good categorizations; however, some prognostic overlaps existed and not all differences were significant. After redefining the number of involved stations as Nα for 1, Nß for 2-3, and Nγ for ≥ 4 without considering the metastasis sites, the 5-year survival rates for patients in these categories were 72.1%, 58.3%, and 29.6%, respectively; the differences between them were significant. CONCLUSION: The number of involved lymph node stations is a more accurate prognostic indicator in patients with completely resected non-small cell lung cancer.

Outcomes and predictive factors for pathological node-positive in radiographically pure-solid, small-sized lung adenocarcinoma.

OBJECTIVES: The indication of limited resection for radiographically pure-solid, small-sized lung adenocarcinoma is controversial. This study aimed to reveal the long-term outcome of standard surgical treatment and determine the predictive factors for pathological lymph node metastasis in optimal candidates undergoing limited surgical resection for pure-solid, small-sized lung adenocarcinoma. METHODS: The medical records of 107 consecutive patients were retrospectively reviewed at our hospital between December 2002 and December 2013. Inclusion criteria were histopathological diagnosis of lung adenocarcinoma, radiographically pure-solid tumor, ≤ 2 cm tumor size measured using thin-section computed tomography, clinical N0M0, patients who underwent lobectomy with systematic or lobe-specific lymph node dissection, and R0 resection. Overall and disease-free survival curves were calculated using the Kaplan-Meier method. Clinicopathological factors predicting pathological node-positive metastasis were identified by univariate and multivariate analysis. RESULTS: The 5-year overall and disease-free survival rates were 91.4% and 87.3%, respectively. Multivariate analysis demonstrated maximum standardized uptake value > 5 as the independent predictor of pathological node-positive metastasis (odds ratio 3.81; 95% confidence interval 1.25-12.3; p = 0.02). In all patients, the pathological node-positive rate was 16.7%; in patients who had a maximum standardized uptake value of ≤ 5, the rate was 7.9%. CONCLUSION: The long-term outcome of standard surgical treatment was favorable. Maximum standardized uptake value was a significant predictor of pathological node-positive metastasis; however, diagnostic accuracy was not favorable. Therefore, the selection of optimal candidates is difficult, and limited surgical resection may not be applicable in pure-solid, small-sized lung adenocarcinoma.

Quantitative computed tomography for predicting cardiopulmonary complications after lobectomy for lung cancer in patients with chronic obstructive pulmonary disease.

OBJECTIVES: In lung cancer resection, chronic obstructive pulmonary disease is a risk factor for post-operative complications. Few studies on post-operative complications of lung cancer resection have considered radiographic emphysematous change as an index. Here, we have examined the relationship between the regional ratio of the emphysematous area in pre-operative computed tomography images and cardiopulmonary complications in patients with chronic obstructive pulmonary disease who underwent lung cancer resection. METHODS: We retrospectively evaluated 159 patients with chronic obstructive pulmonary disease who underwent lobectomy for lung cancer at Shizuoka Cancer Center Hospital, Shizuoka, Japan, between 2002 and 2011. Pre-operative factors, including the proportion of the emphysematous area measured by computed tomography as a percentage of the low attenuation area (LAA%), as well as intraoperative factors were analyzed. Cardiopulmonary complications, including pyothorax, pneumonia and atelectasis, acute pulmonary injury, indwelling chest tube, long duration of oxygen supply, and arrhythmia, were evaluated. RESULTS: Cardiopulmonary complications were observed among 61 patients (38%). Univariate analysis revealed that patient age, percentage of forced expiratory volume in 1 s, LAA%, and volume of blood loss were significantly associated with cardiopulmonary complications. Multivariate analysis indicated patient age and LAA% as being significant independent predictors of cardiopulmonary complications. CONCLUSIONS: The regional ratio of the emphysematous area is useful for predicting cardiopulmonary complications in patients with chronic obstructive pulmonary disease who undergo lobectomy for lung cancer. In such patients who are also ≥ 70 years of age and exhibit LAA% ≥ 1.0%, careful intra- and post-operative management is warranted.

Solitary peribronchiolar metaplasia showing a sub-solid nodule on computed tomography.

Recent advances in radiographic imaging and thoracic surgery have facilitated surgery for small lung tumors by eliminating the need for pathological diagnosis. To date, we have experienced two cases of small lung tumors that were surgically resected without pathological diagnosis as malignant. Computed tomography (CT) revealed sub-solid nodules in the peripheral lung. After tumor resection, both tumors were pathologically diagnosed as peribronchiolar metaplasia. To the best of our knowledge, solitary peribronchiolar metaplasia showing a sub-solid nodule on CT imaging has not previously been reported.