Resection of a giant mediastinal atypical lipomatous tumor involving the esophagus.

Liposarcoma is one of the common soft tissue tumors but barely arises from the mediastinum. Complete surgical resection with a negative surgical margin is required for the treatment; however, mediastinal liposarcomas tend to be large due to its slow-growing nature. A 57-year-old man was referred to us for having an abnormal mediastinal shadow in a chest X-ray. Computed tomography scanning revealed a giant posterior mediastinal tumor, completely involving the esophagus. Because of the unusual size and location of the tumor, we took a bilateral video-assisted thoracoscopic approach. First, the soft lipomatous compartment of the tumor was dissected from the esophagus and the descending aorta via the left thoracic cavity complete thoracoscopic procedure. Then, the patient was placed in the left lateral position, and the solid part of the tumor was completely resected using 13 cm of right-side thoracotomy. There was no complication or local recurrence in the first 26 months of follow-up.

Clinical significance of bifocal treatment for synchronous brain metastasis in T1-2 non-small-cell lung cancers: JNETS0301.

OBJECTIVES: The treatment of patients with brain metastases associated with non-small-cell lung cancer (NSCLC) is frequently challenging. Starting in 2003, we conducted a phase II study of surgery for patients with clinical T1-2N0-1 NSCLC with oligometastasis. The aim of this subset study was to assess the clinical significance of bifocal treatment for synchronous brain metastases in T1-2N0-1 NSCLC using prospectively collected data. METHODS: In this phase II study of clinical T1-2N0-1 NSCLC patients with oligometastasis, 47 patients were enrolled from December 2003 to December 2016. Among them, 18 NSCLC patients with synchronous brain metastases were investigated in this subset analysis. RESULTS: Fourteen patients underwent complete resection, and 4 underwent incomplete resection of the primary lung cancer. The number of synchronous brain metastases was one in 14 and multiple in 4 patients. After surgery for the primary lung cancer, 12 of 18 patients underwent treatment for their brain lesions, including stereotactic radiosurgery (SRS) in 10, surgical resection in 1, and SRS followed by surgical resection in 1. In 5 of the 18 patients (28%), the brain lesion was diagnosed as benign on follow-up radiological imaging. The 5-year overall survival rate after enrollment was 31.8% for all 18 patients and 35.2% for the 13 patients with brain metastases. Univariate analysis showed that having multiple brain lesions was a significant factor related to a worse prognosis. CONCLUSION: For patients with suspected brain metastases associated with NSCLC, bifocal local treatment could be an acceptable therapeutic strategy, especially for solitary brain metastasis.

A phase 2 study of adjuvant carboplatin plus S-1 followed by maintenance S-1 therapy for patients with completely resected stage II/IIIA non-small cell lung cancer-Japanese Northern East Area Thoracic Surgery Study Group JNETS1302 study.

BACKGROUND: The standard adjuvant chemotherapy regimen for completely resected pathological stage II/IIIA non-small cell lung cancer (NSCLC) is four courses of cisplatin plus vinorelbine. However, the continuity and toxicity of cisplatin-based regimens remain problematic. Conversely, carboplatin-based chemotherapy is a less toxic and more tolerable regimen for various stages of NSCLC. In particular, the efficacy and tolerability of carboplatin plus S-1 in advanced NSCLC were confirmed by previous pivotal studies such as the LETS trail. Therefore, this phase II study assessed the feasibility, safety, and usefulness of carboplatin plus S-1 followed by maintenance S-1 as an adjuvant treatment. METHODS: In this single-arm, multicenter phase II study, 40 patients who previously underwent complete resection of NSCLC were enrolled from November 2013 to January 2015. The chemotherapy protocol was four cycles of carboplatin (AUC 5 on day 1) and oral S-1 (80 mg/m2 every other day from days 1 to 21) followed by oral S-1 (80 mg/m2 every other day for 48 weeks). The primary endpoint was the treatment completion rate, and the secondary endpoints were adverse events and 2-year recurrence-free survival. RESULTS: The treatment completion rate of the planned schedule was as low as 30.0% (90% confidence interval: 40.3-63.0%). The reasons for adjuvant chemotherapy discontinuation were adverse events, refusal, tumor recurrence, and other reasons in 13, 6, 10, and 2 patients, respectively. The 2-year progression-free survival rate was 66.7% among patients who completed maintenance chemotherapy. There were no treatment-related deaths, and most adverse events were less than grade 3. CONCLUSIONS: Carboplatin plus S-1 followed by S-1 maintenance for 1 year in the adjuvant treatment of NSCLC was not tolerable, although most adverse events were not severe. However, patients who can fully complete the regimen might experience clinical benefit.

Clinicopathological features of intraoperative pleural lavage cytology for non-small cell lung cancer.

OBJECTIVE: The significance of clinicopathological features of pre- and post-resection pleural lavage cytology (PLC) for non-small cell lung carcinoma (NSCLC) currently remains unknown. METHODS: Between January 2010 and December 2012, pre- and post-resection PLC were performed for NSCLC in 565 patients at Tohoku University, Miyagi Cancer Center, or Sendai Medical Center. The relationship between the clinicopathological features and patient outcomes was analyzed. RESULTS: Twenty-two patients (3.9%) had positive findings from pre- or post-resection PLC. Both PLC were correlated with pT and pl factors, while only post-resection PLC was correlated with pN factor (p < 0.005). The 5-year disease-free survival (DFS) rate of the positive pre-resection PLC was significantly poorer than that of negative (26.7% vs. 76.9%, p < 0.0001). In addition, the 5-year DFS of the positive post-resection PLC was also poorer than that of negative (14.3% vs. 76.0%, p < 0.0001). Multivariate analyses revealed that both PLC were not independent prognostic factors in our study. CONCLUSIONS: A significant association of post-resection PLC with N factor is considered to be characteristics of post-resection PLC different from pre-resection PLC. A prognostic impact of post-resection PLC and its detailed difference from pre-resection PLC should be clarified by further investigations.

What factors determine the survival of patients with an acute exacerbation of interstitial lung disease after lung cancer resection?

PURPOSES: Acute exacerbation of interstitial pneumonia (AEIP) is a leading cause of death after lung cancer resection in patients with interstitial lung disease. METHODS: We retrospectively analyzed 1763 patients with non-small cell lung cancer with a clinical diagnosis of interstitial lung disease (ILD) who underwent lung cancer resection between 2000 and 2009 at 61 hospitals in Japan. AEIP occurred in 164 of 1763 (9.3%) patients with a mortality rate of 43.9% (72/164). Univariate and multivariate analyses were carried out to identify possible risk factors of fatal AEIP. We then analyzed the 164 patients who developed postoperative AEIP and identified the preoperative and postoperative risk factors. RESULTS: A multivariate regression analysis identified that the sex, percent vital capacity, neoadjuvant radiation, preoperative history of AEIP, preoperative use of steroids, usual interstitial pneumonia pattern on CT, and surgical procedures were independent preoperative risk factors for death due to AEIP. ILD patients with emphysema somehow showed a lower risk of fatal AEIP than those without emphysema in this study. CONCLUSIONS: This study revealed eight risk factors for fatal AEIP.

A prospective 5-year follow-up study after limited resection for lung cancer with ground-glass opacity.

OBJECTIVES: The incidence of small-sized pulmonary adenocarcinomas with ground-glass opacity (GGO) has recently increased, with excellent postoperative prognosis. The limited resection of such cancers has been deemed to be acceptable based on retrospective studies. We conducted a prospective multi-institutional study evaluating the validity of limited resection for small-sized pulmonary adenocarcinoma with GGO. METHODS: The inclusion criteria were 25-80 years of age, no prior treatment, a maximum tumour diameter of 8-20 mm, a GGO ratio of ≥ 80%, clinical T1N0M0, lower 18F-fluorodeoxyglucose accumulation than the mediastinum, resectable by sublobar resection, pulmonary lobectomy tolerable and an intraoperative pathological diagnosis of bronchiloalveolar carcinoma. Wedge resection was preferred, but segmentectomy was permitted. Disease-specific survival and overall survival were analysed. RESULTS: From November 2006 to April 2012, 73 patients were enrolled from 13 institutions. One patient was ineligible, and the remaining 72 patients were preregistered. The tumours of 3 and 14 patients were intraoperatively diagnosed as benign lesions and adenocarcinomas with mixed subtype, respectively. Intraoperative cytological/histological examination of surgical margin was not performed in 2 patients, and the remaining 53 patients were ultimately eligible for this study. The mean tumour size was 14.0 mm and the mean GGO ratio was 95.9%. Thirty-nine and 14 patients underwent wedge resection and segmentectomy, respectively. Although all tumours were intraoperatively diagnosed as bronchioloalveolar carcinomas, 6 were ultimately diagnosed as adenocarcinoma with a mixed subtype. No completion lobectomy was performed. As of 1 May 2017, no recurrence of the original lung cancer was observed during 60.0-126.3 months after surgery. Two patients died from other diseases. The 5-year disease-specific and overall survival rates were 100% and 98.1%, respectively. The reduction in the pulmonary function after limited resection was minimal. CONCLUSIONS: With these criteria, limited resection was performed safely without any recurrence, and the postoperative pulmonary function was well preserved. The outcomes of limited resection for small-sized lung cancer with GGOs that met the criteria of this study were satisfactory.

[Vacuum-assisted Closure Therapy for Residual Space after Open Window Thoracotomy for Pleural Empyema due to Bronchopleural Fistula].

A 73-year-old man underwent right middle-lower bilobectomy for lung adenocarcinoma. He suffered from pneumonia followed by empyema due to bronchopleural fistula. On day 19 after the operation, an open window thoracostomy was created. Then the pleural space was treated conservatively with saline irrigation and petrolatum gauze packing. Progressive formation of healthy granulation tissue was observed around the bronchopleural fistula and the adjacent pulmonary artery, resulting in a complete closure of the bronchopleural fistula. And then we applied vacuum-assisted closure (VAC) therapy to the residual pleural cavity. At 4 weeks after the initiation of VAC therapy, the pleural cavity was completely filled with granulation tissue and re-expanded residual lung. In conclusion, VAC therapy is a safe and effective treatment for residual space after open window thoracostomy for empyema due to bronchopleural fistula, if it is applied after closure of bronchopleural fistula and adequate granulation tissue formation on the great vessels.

A prospective study of surgical procedures for patients with oligometastatic non-small cell lung cancer.

BACKGROUND: Purely localized, oligometastatic, and widely metastatic tumors are likely to require different therapeutic strategies. Although surgical procedures for isolated pulmonary, brain, or adrenal metastases from lung cancer have been extensively evaluated, most data are from retrospective studies; accordingly, we conducted a prospective multicenter trial. METHODS: Patients were eligible if they had previously untreated clinical T1-2N0-1 lung cancer with single-organ metastasis, or single-organ metachronous metastasis after complete resection of pathologic T1-2N0-1 lung cancer. Metastatic lesions were classified into three groups: group A included metastasis in single organs other than brain or lung; group B included synchronous brain metastasis; and group C included pulmonary metastasis. The treatment intervention was surgical resection of metachronous metastasis or of both synchronous metastasis and primary lung cancer. RESULTS: From December 2002 through June 2011, 36 patients were enrolled. Two patients were ineligible, and the remaining 34 were analyzed; 6 (18%) had a benign lesion and no metastasis, 5 patients (15%) underwent incomplete resection of primary lung cancer, and 20 patients (59%) underwent complete resection of both primary lung cancer and metastasis. The 5-year survival rate for these 20 cases was 44.7%. CONCLUSIONS: Clinical T1-2N0-1 lung cancer with a single-organ metastatic lesion was a good candidate for surgical resection. A 5-year survival rate of about 40% can be expected, which could be comparable with that for stage II non-small cell lung cancer.