Significance of Body Mass Index for Postoperative Outcomes after Lung Cancer Surgery in Elderly Patients.

BACKGROUND: Although the frequency of elderly patients undergoing surgery for lung cancer has been increasing, indications for surgery in elderly patients are still controversial. Low body mass index is a significant predictor of poor prognosis in elderly patients with various medical conditions. Then, we examined the long-term outcome of elderly patients who had undergone thoracic surgery for lung cancer, focusing especially on body mass index. PATIENTS AND METHODS: Between January 2004 and March 2011, 1673 patients with lung cancer underwent surgical resection at our institution. Among these patients, we retrospectively examined 158 patients aged 80 years or older. RESULTS: Perioperative morbidity and mortality rates were 41.8 and 1.3%, respectively. Among 149 patients who were completely followed up, 80 patients (53.7%) died. The overall postoperative survival rates at 3 and 5 years were 66.9 and 49.9%, respectively. Univariate analysis demonstrated that sex (female), smoking index (pack-years <20), histology (non-squamous cell carcinoma), pathological stage (stage I) and BMI (within normal BMI) were statistically significant factors associated with better outcome. Multivariate analysis revealed that patients with a low (<18.5 kg/m2) or high (≥25 kg/m2) body mass index had a significantly and poorer prognosis than patients with a normal body mass index. CONCLUSION: Body mass index is a more useful prognostic factor than other clinical factors including pathological stage in elderly patients. Because elderly patients with low and high body mass index have a significant poor prognosis, surgeons and pulmonologist should take this into account when consider surgical indication for such elderly patients.

[Organizing Pneumonia with High Radiotracer Concentration on Fluorodeoxyglucose-positron Emission Tomography, Mimicking Pleural Dissemination of Lung Cancer;Report of a Case].

A 68-year-old man was referred to our hospital because of an abnormal shadow in the chest roentgenogram. Chest computed tomography (CT) showed the nodule in the right upper lobe (S3), 17 mm in size. One month later, fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT scanning revealed positive reaction in the right upper lobe lesion and new lesion close to another lobe. In addition, interloblar small nodules were detected, 5 mm and 7 mm in size. A transbronchial brush cytology by bronchoscopy was performed, and the microscopic findings demonstrated the presence of atypical cells, suspected adenocarcinoma. The video-assisted thoracoscopic surgery was performed to establish a diagnosis and a treatment. Histopathological examination showed no malignancy and organizing pneumonia with inflammation. In case of the PET-positive solitary nodule increasing in size, organizing pneumonia should be included in the differential diagnosis.

Intraoperative fine-needle aspiration biopsy (FNA) for lung cancer: diagnostic value and risk of pleural dissemination.

PURPOSE: Intraoperative fine-needle aspiration biopsy (FNA) is one of the most important diagnostic tools for undiagnosed lung nodules suspected of being lung cancer; however, the sensitivity and safety of FNA, including the risk of intrapleural dissemination of cancer cells, have not been established. METHODS: Between 2006 and 2008, 324 patients underwent lung resection for cancers located in the lung periphery. Intraoperative FNA for definite diagnosis was performed immediately after thoracotomy in 147 (45.4%) of these patients, but not in the other 177. RESULTS: A diagnosis of lung cancer was obtained by the intraoperative FNA in 124 (84.4%) of the 147 patients. During a median follow-up of 55 months, pleural dissemination or malignant effusion ipsilateral to the operated side as the first recurrent site occurred in 11 (7.4%) of the 147 patients who underwent the needle biopsy and 10 (5.6%) of the 177 patients who did not. This difference was not significant (P = 0.5046). CONCLUSION: Intraoperative FNA was safe and useful for the diagnosis of peripheral lung cancer and did not increase the risk of pleural dissemination in this series.

[Interlobar neurinoma with a cystic formation derived from the vagal pulmonary branches].

A 60-year-old woman was referred to our hospital because of an abnormal shadow in the chest roentgenogram. Chest computed tomography (CT) showed the mass with heterogeneous low attenuation in the right lower lobe (S6), 40 mm in size. Fluorodeoxyglucose-positron emission tomography (FDGPET)/CT scanning revealed slight positive reaction in the right lower lobe lesion. The video-assisted thoracoscopic surgery (VATS) was performed to establish diagnosis and treat. Intraoperative finding showed the tumor was located between the left upper lobe and the left lower lobe, and the inflow of the vagal pulmonary branches. Histopathological examination showed no malignancy and neurinoma with a cystic formation derived from the vagus nerve.

[Chronic eosinophilic pneumonia presenting as a solitary nodule, suspicious of lung cancer;report of a case].

A 70-year-old man was followed up at the surgery department of our hospital after colon polypectomy. It was pointed out that the level of carcinoembryonic antigen(CEA) was high at blood test. Chest computed tomography (CT) showed small nodule close to the pulmonary vein in the right lower lobe (S6-S10), 15 mm in size, in September 2011. Fluorodeoxyglucose-positron emission tomography( FDG-PET)/CT scanning revealed a positive reaction in the right lower lobe lesion. He was introduced to our department. The video-assisted thoracoscopic surgery (VATS) was performed to establish diagnosis and treat. Histopathological examination showed no malignancy and chronic eosinophilic pneumonia(CEP).In a case of the solitary lung nodule patient with the past history of asthma or the atopic disease, CEP should be included in the differential diagnosis.

[Minute pulmonary meningothelial-like nodules （MPMNs） incidentally detected at surgical biopsy for ground-glass opacity（ GGO）].

A 75-year-old woman was followed up at the urology department of our hospital after left nephrectomy for renal cell carcinoma. Chest computed tomography (CT) showed ground-glass opacity in the right lower lobe( S6), 6 mm in size, in December 2010. 3 months later, the tumor was enlarged and she was introduced to our department. Wedge resection was performed to establish giagnosis. Pathological diagnosis was atypical adenomatous hyperplasia( AAH) and many small spindle-shaped cell nests were found at the same tissue. Immunohistochemically, this nest was shown to be minute pulmonary meningothelial-like nodules(MPMNs). MPMNs are asymptomatic small pulmonary nodules incidentally found during pathologic evaluation of pulmonary specimens. Combinations of MPMNs with adenocarcinoma or AAH have been reported, and the genetic relation of MPMNs and AAH is suggested.

[Hourglass transmural lipoma; report of a case].

A 52-year-old man admitted to our hospital with a pulmonary nodule detected by chest X-ray. Painless mass was located on the right anterior chest below the right clavicle, but enlarged recently. Chest computed tomography (CT) and magnetic resonance imaging (MRI) showed the hourglass shaped mass penetrating his right 2nd intercostal muscle, and growing to intra- and extra-thoracic areas. 60 x 40 x 50 mm in size. His laboratory findings were almost within normal ranges. We performed resection of the tumor and partial resection of the 2nd and 3rd ribs with a help of thoracoscopy. Pathological diagnosis was "intramuscular lipoma-infiltrating type, no malignancy". Assistance of thoracoscopic approach was found to be useful for complete resection of the tumor existing intra- and extra-thoracic areas.

Solitary Splenic Metastasis of Lung Cancer Presenting as Benign Cystic Disease.

Solitary splenic metastasis from primary lung cancer is extremely rare. Here, we demonstrated a solitary splenic metastasis of primary lung cancer that was difficult to distinguish from benign cystic disease. A 69-year-old-female was diagnosed as middle lobe lung cancer. Although preoperative abdominal computed tomography (CT) demonstrated a low-density splenic nodule, fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed no fluorodeoxyglucose uptake in the splenic nodule. Therefore, the nodule was diagnosed as benign cystic disease and middle lobe lobectomy was performed. Postoperative pathologic examination demonstrated papillary-predominant adenocarcinoma with mucin, and the tumor was diagnosed as primary lung cancer. However, the splenic nodule continued to increase postoperatively. Splenectomy was undergone 30 months after the pulmonary resection and the splenic tumor was diagnosed as the splenic metastasis of lung cancer. In the 24 months since the splenectomy, no recurrence has been observed in the absence of treatment. Splenectomy was an effective treatment for solitary splenic metastasis of lung cancer in this case. FDG uptake in the splenic tumor was not evident due to marked mucus production.

[Inflammatory myofibroblastic tumor suspected of lung cancer; report of a case].

A 57-year-old man admitted to our hospital with a pulmonary nodule detected by chest X-ray. Chest X-ray and chest computed tomography (CT) showed a solitary nodule with a spiculation in the right lower lobe (S8), 17 x 15 mm in size. His laboratory findings were almost within normal ranges. Positron emission tomography (PET) showed positive detection correspond to the nodule (SUV max: 5.76). Pathological diagnosis by CT-guided lung biopsy was suspected of gastrointestinal stromal tumor (GIST). Further examination of digestive organs revealed no abnormalities. The enlargement of the nodule was noted 2 weeks later, 23 x 18 mm in size. We couldn't rule out a malignant tumor and performed partial resection of the right lower lobe. Pathological diagnosis by intraoperative frozen section was "inflammatory myofibroblastic tumor (IMT), no malignancy". The patient is alive without any signs of recurrence for 4 months postoperatively.

[Synchronous multiple lung cancer including a lesion with a thin-walled cavity; report of a case].

A 79-year-old woman underwent video-assisted thoracic surgery (VATS)-left S6 segmentectomy for left lung cancer (papillary adenocarcinoma, pT1N0M0, stage IA), and were followed-up at our hospital. Chest X-ray and chest computed tomography (CT) showed ground-glass opacity (GGO) with thin-walled cavity in the right S1, 3 cm in size and small nodule in the right S2, S3 at 1st operation. The shadow in S1 was not changed but nodular lesion in S2, S3 enlarged 7 months later. CT-guided biopsy revealed well differentiated adenocarcinoma VATS-right upper lobectomy was performed and both lesions were diagnosed as "adenocarcinoma with mixed subtypes (BAC : acinar type), synchronous multiple lung cancer one of which formed thin-walled cavity" histopathologically. The patient was discharged on 20th-postoperative day and alive without any signs of recurrence for 16 months post-operatively.

Case report of thoracoscopic resection for broncholithiasis with severe obstructive pneumonia.

Broncholithiasis is a rare disease characterized by bronchial erosion or distortion due to hilar or parenchymatous calcification. When a broncholith has no mobility and there is a risk of major bleeding if removal is attempted, surgical intervention is required. Most operations for broncholithiasis are performed via a thoracotomy, and bronchial lithotripsy under complete video-assisted thoracoscopic surgery has been reported only rarely. We have experienced a case of broncholithiasis with severe obstructive pneumonia that was treated successfully by video-assisted thoracoscopic surgery. Thoracoscopic surgery is an effective treatment for broncholithiasis because it is minimally invasive and aids smooth recovery after surgery. When the adhesion between the pulmonary artery and the bronchus is highly advanced, it is advocated to cut them together using an endostapler.

Nodule around the staple line after pulmonary resection: benign granuloma or cancer recurrence?

PURPOSE: When a mass develops around the staple line after lung cancer surgery, differential diagnosis between lung cancer recurrence and benign granuloma can be clinically problematic. Therefore, we investigated the clinical characteristics of benign granuloma and cancer recurrence around the staple line to determine clinical factors that can distinguish staple line granuloma and cancer recurrence. METHODS: We retrospectively investigated the clinical records of 25 patients who developed a nodule around the staple line after pulmonary resection for lung cancer and conducted a comparative study of staple line granuloma and cancer recurrence. RESULTS: Among 25 patients, the nodule was diagnosed as benign granuloma in 9, recurrence of primary lung cancer in 8, and recurrence of metastatic lung cancer in 8. Among these three groups, there were no significant differences in age, maximum standardized uptake value of fluoro-deoxyglucose, laboratory data, or radiological findings. However, in comparison with the cancer recurrence cases, the proportion of patients who had undergone segmentectomy as initial surgery was significantly higher in the granuloma group. Moreover, in five patients in the granuloma group, mycobacterium was detected. CONCLUSION: It seemed difficult to differentiate between cancer recurrence and granuloma on the basis of radiological examination and laboratory findings. However, if a mass shadow around the staple line appeared after segmentectomy, the mass is likely to be a granuloma. Mycobacterial infection may be an important factor for development of granuloma on the staple line.

Preoperative Smoking Cessation Period Is Not Related to Postoperative Respiratory Complications in Patients Undergoing Lung Cancer Surgery.

PURPOSE: Smoking is reported to be a risk factor for postoperative complications. However, there is no consensus regarding the length of time for which patients need to give up smoking. Therefore, we examined the relationship between preoperative smoking status and postoperative complications in patients who underwent lobectomy for treatment of lung cancer. METHODS: Between January 2009 and December 2014, 1380 patients underwent lobectomy for lung cancer at our institution. After excluding patients who had undergone induction therapy, 1248 patients were enrolled in this study. We examined the relationship between postoperative complications and preoperative smoking habitation. RESULTS: Among the enrolled patients, 1210 (97%) underwent video-assisted thoracoscopic lobectomy and 38 (3%) underwent lobectomy via open thoracotomy. The incidence of postoperative complications was higher in smokers than in nonsmokers, and the frequency of respiratory-related complications increased along with the number of pack-years. However, there was no relationship between the length of the preoperative smoking cessation period and the frequency of postoperative complications. CONCLUSION: The risk of postoperative complications does not increase even if smoking is continued within 2 weeks before surgery. It seems unnecessary to delay the timing of surgery to allow patients to cease smoking, especially those scheduled for thoracoscopic surgery.

[Paravertebral muscle metastasis from lung cancer; report of a case].

A 69-year-old man had undergone right S6 segmentectomy for lung cancer (poorly differentiated adenocarcinoma, pT2N0M0, stage IB). One years later, computed tomography (CT) showed abnormal shadow in the right paravertebral muscle of 7 x 5 cm in size. The patient underwent resection of the tumor. The tumor was white, solid and elastic hard mass. Histopathologically, the tumor was paravertebral muscle metastasis from lung cancer. The patient was discharged on 23rd postoperative day, but died of other disease after 1 and a half month postoperatively.

[Intrapulmonary and mediastinal, double bronchogenic cysts; report of a case].

A 59-year-old woman was pointed out abnormal shadows on chest film and has been followed up since 2001. In October 2006, she consulted our hospital for further examination. Computed tomography (CT) showed double cystic lesions located in the right lower lobe, and in the paraesophageal region. The patient underwent video-assisted thoracic surgery (VATS) right lower lobectomy and resection of the tumor in the mediastinum. The content of the tumor were greenish and whitish discharge. Histopathologically, both were bronchogenic cysts. The patient was discharged on 17th postoperative day and doing well for 6 months postoperatively.

Video-assisted thoracoscopic surgery for lung cancer after induction therapy.

Background Although thoracoscopic surgery is widely performed for early-stage lung cancer, only a few small studies have evaluated the role of video-assisted thoracoscopic surgery in patients with locally advanced lung cancer who had received preoperative chemotherapy. Methods Among 1655 patients who underwent anatomical lung resection for lung cancer between January 2009 and December 2014 in our institution, we retrospectively examined the short- and long-term outcomes of 110 (6.6%) who had undergone induction therapy. Thoracoscopic surgery was performed in 79 of these patients and thoracotomy in 31. Results In the thoracoscopic group, conversion to a thoracotomy was required in 4 patients. More combined resections were included in the thoracotomy group, and combined resection of large vessels or the carina was carried out only via a thoracotomy. Postoperative complications of grade 3 or above were found in 15 (13.6%) patients, and there was no significant difference in the incidence of postoperative complications between the 2 groups. The 3- and 5-year survival rates for the patients overall were 58.6% and 50.3%, respectively. Although there was no significant difference in overall outcome between the 2 groups, the patients with postoperative ypN2 status in the thoracoscopic group had a significantly better outcome than those in the thoracotomy group. Conclusion Although video-assisted thoracoscopic surgery was not suitable for central advanced lung cancer requiring angioplasty or carinal resection, it seems to be useful for patients with locally advanced lung cancer who had undergone induction therapy, especially patients with peripheral lung cancer and mediastinal lymph node metastasis.

The outcomes of anatomical lung resection for nontuberculous mycobacterial lung disease.

BACKGROUND: The number of cases of nontuberculous mycobacterial (NTM) lung disease has been increasing in recent years, and the efficacy of surgical treatment has been recognized. We investigated the clinical characteristics and behavior of NTM lung disease and analyzed the outcomes of surgery. METHODS: The data of 25 patients who underwent anatomical resection for NTM lung disease in our institution between January 2004 and December 2014 were retrospectively examined. RESULTS: The patients included 10 men and 15 women (mean age, 63.1 years). Twenty patients had Mycobacterium avium, and 5 had Mycobacterium intracellular. The indications for lung resection in 20 definitively diagnosed patients included a remaining or worsening lesion despite medical treatment (n=16), massive hemoptysis or bloody sputum (n=5), and prolonged smear positivity (n=1); multiple reasons were allowed. In five cases without a definitive diagnosis, surgery was performed due to the suspicion of lung cancer. The surgical procedures included pneumonectomy, n=4; lobectomy, n=13; and segmentectomy, n=8. Complete resection was achieved in 10 cases (40.0%). Video-assisted thoracoscopic surgery (VATS) was performed in 17 cases (68.0%), especially in 6 of 8 cases (75.0%) that underwent segmentectomy and in 10 of 11 cases (90.9%) that received simple lobectomy. There was one case of hospital mortality. Among the 22 patients who were followed at our institution, relapse occurred in 4 patients, and new infection occurred in 1 patient. NTM lung disease was controlled in 17 patients (77.3%). In the four cases that relapsed, the median relapse-free interval was 29.5 months. CONCLUSIONS: Surgical resection was a feasible treatment for NTM lung disease and was associated with favorable outcomes, although there was 1 case of hospital mortality. VATS procedures were considered adequate for the treatment of NTM lung disease; however, the surgical indications must be carefully considered.

Phrenic Nerve Reconstruction and Bilateral Diaphragm Plication After Lobectomy.

A 49-year-old man with left phrenic nerve paralysis caused by mediastinal tumor resection 28 years earlier was found to have a nodule in the right upper lobe. The right phrenic nerve was severed during right upper lobectomy but was reconstructed along with bilateral plication of the diaphragm. The patient was weaned from the ventilator during the daytime on postoperative day 13 and was discharged home on postoperative day 48. Three months postoperatively, chest fluoroscopic imaging showed recovery of movement of the right diaphragm. Nerve conduction studies showed improvement of function of the reconstructed right phrenic nerve.

[Clear cell adenocarcinoma with acomponent of well-differentiated fetal adenocareinoma; report of a case].

A 69-year-old woman complaining of a cough was admitted to our hospital. Chest X-ray showed a mass in the right lower lung field. Chest computed tomography (CT) showed a tumor with notch, 3 cm in diameter, in the right lower lobe (S9-S10). The tumor was diagnosed as adenocarcinoma by the biopsy under chest CT. The patient underwent right lower lobectomy (ND2a). The tumor was whitish solid mass, 35 x 34 x 29 mm in size. Histopathologically, the tumor was diagnosed as clear cell adenocarcinoma with a component of well-differentiated fetal adenocarcinoma (WDFA), pT2N0M0, stage IB. The patient was discharged and received postoperative chemotherapy (UFT). The patient has been doing well without any tumor recurrence for 1 year postoperatively.