Surgical resection of an intraluminal tumor in the azygos vein with an unknown primary site causing superior vena cava syndrome.

Intraluminal tumor in the azygos vein is a rare disease that can cause superior vena cava (SVC) syndrome. Radiotherapy and endovascular stenting with or without chemotherapy are reported to have a high clinical success rate for the management of SVC syndrome with malignancy, but a poor survival rate. Here, we report a 69-year-old man who presented with swelling of the face and upper extremities, who was diagnosed with SVC syndrome caused by an intraluminal tumor in the azygos vein. Enhanced chest computed tomography revealed an intraluminal mass with a filling defect from the azygos vein to the SVC, with no extravascular extension or dissemination of the primary tumor. Surgical resection of the mass en bloc with the azygos vein and SVC reconstruction was performed. A poorly differentiated carcinoma was diagnosed on postoperative pathological evaluation. Twelve months after resection, the patient was well with no signs of recurrent disease. This case highlights that surgical resection should be considered as a treatment of choice for the management of SVC syndrome caused by an intraluminal malignancy in the azygos vein.

[Solitary Fibrous Tumor of Pleura Communicating with Pulmonary Artery and Vein].

A 68-year-old man was noted to have an abnormal shadow on chest X-ray. Chest computed tomography (CT) showed a 100 mm mass in the lower right thoracic cavity. The mass was lobulated and compressed the surrounding lung tissue and diaphragm. Contrast-enhanced CT showed that the mass was heterogeneously enhanced and contained expanded blood vessels within it. The expanded vessels communicated with the pulmonary artery and vein via the diaphragmatic surface of the right lung. The mass was diagnosed as a solitary fibrous tumor of the pleura (SFTP) by CT-guided lung biopsy. We performed partial resection of the lung including the tumor via right eighth intercostal lateral thoracotomy. Intraoperative examination showed that the tumor was pediculated from the diaphragmatic surface of the right lung. The stem was about 3 cm long and easily cut with a stapler. The tumor was definitively diagnosed as a malignant SFTP. No recurrence was found for 12 months postoperatively.

Surgical outcome of ipsilateral anatomical resection for lung cancer after pulmonary lobectomy.

OBJECTIVES: Ipsilateral reoperation after pulmonary lobectomy is often challenging because of adhesions from the previous operation. We retrospectively examined the surgical outcome and prognosis of ipsilateral anatomical resection for lung cancer after pulmonary lobectomy using a multicentre database. METHODS: We evaluated the perioperative outcomes and overall survival of 51 patients who underwent pulmonary lobectomy followed by ipsilateral anatomical resection for lung cancer between January 2012 and December 2018. In addition, patients with stage I non-small-cell lung cancer (NSCLC) were compared with 3411 patients with stage I lung cancer who underwent pulmonary resection without a prior ipsilateral lobectomy. RESULTS: Ipsilateral anatomical resections included 10 completion pneumonectomies, 19 pulmonary lobectomies and 22 pulmonary segmentectomies. Operative time was 312.2 ± 134.5 min, and intraoperative bleeding was 522.2 ± 797.5 ml. Intraoperative and postoperative complications occurred in 9 and 15 patients, respectively. However, the 5-year overall survival rate after anatomical resection followed by ipsilateral lobectomy was 83.5%. Furthermore, in patients with c-stage I NSCLC, anatomical resection followed by ipsilateral lobectomy was not associated with worse survival than anatomical resection without prior ipsilateral lobectomy. CONCLUSIONS: Anatomical resection following ipsilateral lobectomy is associated with a high frequency of intraoperative and postoperative complications. However, the 5-year overall survival in patients with c-stage I NSCLC who underwent ipsilateral anatomical resection after pulmonary lobectomy is comparable to that in patients who underwent anatomical resection without prior pulmonary lobectomy.

Clinical Features of Patients With Second Primary Lung Cancer After Head and Neck Cancer.

BACKGROUND: In survivors of head and neck cancer (HNC), second primary lung cancer (SPLC) often develop as a result of a common risk factor, that is, smoking. A multicenter experience was reviewed to evaluate how the history of a diagnosis of HNC affects the outcomes of patients undergoing pulmonary resection for SPLC. METHODS: A multicenter retrospective analysis of patients hospitalized between January 2012 and December 2018 was performed. From a cohort of 4521 patients undergoing therapeutic pulmonary resection for primary non-small cell lung cancer, 100 patients with a previous history of HNC (HNC group) were identified. These patients were compared with a control group consisting of 200 patients without an HNC history from the same cohort pair-matched with operating facility, age, sex, and pathologic stage of lung cancer. RESULTS: At the time of surgery for SPLC, the HNC group showed malnutrition with a lower prognostic nutritional index compared with the control group (P < .001). The HNC group was determined to have postoperative complications more frequently (P = .02). The 5-year overall survival rates in the HNC and control groups were 59.0% and 83.2%, respectively (P < .001). Statistically, HNC history, lower prognostic nutritional index, squamous cell lung cancer, and TNM stage were identified to be independently associated with poor survival. CONCLUSIONS: Patients with SPLC after primary HNC often present with malnutrition and are predisposed to postoperative complications and poor survival after pulmonary resection.

Surgery for Right Upper Lobe Lung Cancer in a Patient With Bridging Bronchus.

A 70-year-old man with back pain presented with a tumor invading the chest wall of his right upper lobe. Three-dimensional computed tomography revealed an aberrant right lower bronchus originating from the left main bronchus. Open thoracotomy right upper lobectomy with combined resection of the chest wall was performed under ventilation for the left and right lower lobes. The aberrant bronchus was defined as a bridging bronchus, a rare congenital anomaly. For such cases, careful planning is necessary to manage ventilation during operation. The area and extent of lymph node dissection are debatable.

Continuing surgical education of non-technical skills.

BACKGROUND: The non-technical skills for surgeons (NOTSS) system was developed as a tool to assess surgical skills for patient safety during surgery. This study aimed to develop a NOTSS-based training system for surgical trainees to acquire non-technical skills using a chest surgery scenario in a wet lab. MATERIALS AND METHODS: Trainees were categorized into three subgroups according to the years of experience as follows: Level A: 6 years or more; Level B: 3-5 years; and Level C: 1-2 years. Three stages of surgical procedure were designed: 1. chest wall resection and right upper lobe lobectomy, 2. right middle lobe sleeve lobectomy, and 3. right lower lobe lobectomy. One instructor was assigned to each operation table, who evaluated each participant's NOTSS scores consisting of 16 elements. RESULTS: When comparing average NOTSS score of all the three procedures, significant differences were observed between Level A, B, and C trainees. As an example of varying elements by procedure, Level A trainees demonstrated differences in Situation Awareness, and a significant difference was observed in Level C trainees regarding the elements of Decision Making. On the contrary, no significant difference was observed among Level B trainees. In the comparison between first-time and experienced participants, a significant improvement was observed in some elements in Level B and C trainees. CONCLUSION: This study highlights the usefulness and feasibility of the NOTSS scoring system for surgeons with different experiences and the effectiveness of providing feedback to trainees during intraoperative handoffs in a wet lab.

A case report of intrapulmonary schwannoma.

A 38-year-old man without any symptoms was admitted to our institution because of an abnormal shadow found incidentally on a chest X-ray. Chest computed tomography showed a round mass in the lingular segment of the left upper lobe. Lingular segmentectomy was performed, and the histopathological diagnosis was intrapulmonary schwannoma. Immunohistochemical staining revealed a positive result for S-100 protein and negative results for CD34 and desmin. We report this case of intrapulmonary schwannoma, which is extremely rare.

Role of 2-[18F]fluoro-2-deoxyglucose positron emission tomography in preoperative management of solid-type small-sized lung cancer.

OBJECTIVE: 2-[18F]Fluoro-2-deoxyglucose positron emission tomography (FDG-PET) is routinely used for the diagnosis of primary lung cancer. However, the role of FDG-PET in the diagnosis and staging of small-sized lung cancer has not been sufficiently evaluated. The purpose of this study was to determine the utility of FDG-PET for preoperative staging of solid-type small-sized lung cancer manifesting as solid-component predominant nodules. METHODS: One-hundred and eighteen patients with solid-type small-sized (≤2 cm) lung cancer diagnosed as clinical stage IA based on thin-slice computed tomography (TS-CT) were included in this study. Before surgery, FDG-PET was performed in 78 patients (CT/PET group), and TS-CT alone was performed in 40 patients (CT group). Clinical and pathological stage and prognosis were retrospectively reviewed according to whether FDG-PET had been performed. RESULTS: No significant differences in clinical factors were observed when comparing the CT/PET group and the CT group. Of the 78 patients in the CT/PET group, 12 (15.4 %) were diagnosed with clinical stage IIA or IIIA disease based on FDG-PET findings, but no advanced cases with contraindications for curative surgery were seen. In the CT/PET group, the pathological stage was IA in 66 patients, IB in eight patients, IIA in one patient, and IIIA in three patients; 16 patients had incorrectly staged disease. The accurate staging rate was 79.5 % for the CT-PET group and 70.0 % for the CT group (P = 0.262). Among patients diagnosed with clinical stage IA disease, the 3-year overall survival rate was 85.5 % for the 66 patients in the CT/PET group and 76.8 % for the 40 patients in the CT group (P = 0.554). No significant difference was observed in accuracy of preoperative staging and prognosis between the two groups. CONCLUSIONS: FDG-PET produced no clear benefit for the preoperative management of patients with solid-type clinical T1aN0M0 lung cancer, in terms of postoperative survival and the concordance rate of clinical and pathological stage.

Lung cancer with sarcoid reaction in the lymph nodes following chemoradiotherapy.

This report describes a case of lung cancer with sarcoid reaction following chemoradiotherapy, showing false-positive accumulation of (18)F-fluorodeoxyglucose on positron-emission tomography in a 55-year-old man. Treatment-related sarcoid reaction should be considered when the accumulation of (18)F-fluorodeoxyglucose shows rapid extension in the course of treatment.

Case of pleural metastasis of prostate cancer.

The most frequent sites of prostate cancer metastases are the bone and lung. Pleural metastasis of prostate cancer is clinically rare. We report a case with solitary pleural thickening arising from the metastasis of prostate cancer. A 71-year-old man was referred to our hospital for further examination of pleural thickening detected during a chest computed tomography (CT) examination. A video-assisted pleural biopsy was performed. The pathological findings showed that the tumor cells had spread from the parietal pleura to adipose tissue around the costal muscles. The tumor cells were positive for prostate-specific antigen (PSA) and negative for calretinin, cytokeratin (Ck5/6) and D2-40. These findings suggested that the pleural lesion was a metastasis of the prostate cancer.

Influence of vascular endothelial growth factor single nucleotide polymorphisms on non-small cell lung cancer tumor angiogenesis.

Vascular endothelial growth factor (VEGF) plays an important role in tumor angiogenesis. Several studies have reported that genomic VEGF polymorphisms may influence VEGF synthesis. To evaluate the role of VEGF single nucleotide polymorphisms (SNPs), we examined the expression of several angiogenesis-related proteins [VEGF, hypoxia-inducible factor-1α (HIF-1α) and delta-like ligand 4 (Dll4)] and the spread of microvessels in resected non-small cell lung cancer (NSCLC). Blood and tumor tissue from 83 patients with NSCLC were examined for VEGF -460T/C (rs833061) and VEGF +405G/C (rs2010963) SNPs using the SNaPshot method. Immunohistochemical staining was performed to measure protein expression and microvessel density (MVD). VEGF -460T/C and +405G/C SNPs showed no association with VEGF or HIF-1α expression and MVD. Patients with VEGF -460TT and the TC genotype had significantly higher MVD compared to those with the CC genotypes. Furthermore, patients with the VEGF -460TT genotype had significantly higher Dll4 expression compared to those with the TC or CC genotypes, while the VEGF +405G/C SNP displayed no association with Dll4 expression and MVD. These findings indicate that the VEGF -460T/C SNP may have a functional influence on tumor angiogenesis in NSCLC. We hypothesize that VEGF SNPs may influence angiogenesis through Dll4.

Unknown primary large cell neuroendocrine carcinoma (LCNEC) in the mediastinum.

Unknown primary large cell neuroendocrine carcinoma (LCNEC) in the mediastinum is extremely rare. In this report, we present a case of a 53-year-old man with superior vena cava (SVC) syndrome who developed LCNEC in the middle mediastinum. His chief complaint was facial edema. Chest X-ray revealed an abnormal shadow in the right upper mediastinum. Computed tomography (CT) scan of the chest revealed a 67-mm mass in the middle mediastinum. Tumor invasion caused constriction of the SVC. The patient underwent induction chemoradiotherapy with vinorelbin and cisplatin and concurrent radiation therapy. After induction therapy, the tumor size decreased remarkably and was resected completely. The pathological diagnosis was LCNEC.

Post-recurrence survival of patients with non-small-cell lung cancer after curative resection with or without induction/adjuvant chemotherapy.

OBJECTIVES: Recently, the prognosis of patients with non-small-cell lung cancer (NSCLC) has improved, thanks to the standardization of adjuvant chemotherapy and the introduction of molecular-targeted drugs, notably epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors and other new anti-cancer agents. However, the survival characteristics and prognosis of patients with recurrent NSCLC after curative resection are not well understood. METHODS: Of the 430 consecutive patients with NSCLC who underwent complete surgical resection at our institution between January 2004 and July 2011, we included 76 patients with recurrence whose post-recurrence treatment and outcome could be confirmed. We then retrospectively evaluated the effect of prognostic factors on post-recurrence survival. RESULTS: There were 50 men and 26 women, and the median age at recurrence was 74.5 years. The median time from surgical resection to recurrence was 12.7 months. Thirty-eight of the 76 (50%) patients underwent multimodality treatment with surgery and preoperative and/or postoperative chemotherapy as their initial treatment. For recurrence, systemic chemotherapy was administered to 64 (84%) patients, and the disease control rate for first-line chemotherapy was 55%. The 1- and 2-year post-recurrence survival rates were 68.3 and 45.8%, respectively, and the median post-recurrence survival time was 17.7 months. Six independent prognostic factors were identified: wild-type EGFR, no adjuvant chemotherapy for the primary lung cancer, age ≥ 80 years at recurrence, a poor Eastern Cooperative Oncology Group performance status at recurrence, symptomatic at recurrence and no systemic chemotherapy for recurrence, which significantly decreased the post-recurrence survival. CONCLUSIONS: The prognosis of patients with NSCLC recurrence after surgery is currently improving. Our results suggested two new prognostic factors, adjuvant chemotherapy and EGFR mutations, neither of which have been previously reported. Treatment strategies for postoperative recurrence should be established based on a more detailed subdivision of factors, such as histology and molecular markers, in the future.

Heterogeneity of the EGFR mutation status between the primary tumor and metastatic lymph node and the sensitivity to EGFR tyrosine kinase inhibitor in non-small cell lung cancer.

The purpose of this study was to clarify the distribution of epidermal growth factor receptor (EGFR) mutations between primary tumors (PT) and metastatic lymph node (MLN) in patients with resected non-small cell lung cancer (NSCLC) and to identify a better predictive marker of the response to EGFR tyrosine kinase inhibitor (EGFR-TKI). We conducted a retrospective review of the data of 70 lung cancer patients with lymph node metastasis who underwent surgical resection. Analysis to detect EGFR mutations was performed by a peptide nucleic acid-locked nucleic acid polymerase chain reaction clamp method. EGFR mutations were detected in 15.7 % of both the PT and MLN and in 14.3 % of the PT only. The response rate to EGFR-TKI tended to be higher in patients with EGFR mutations in the MLN, as all patients with EGFR mutations in the MLN showed disease control to treatment with EGFR-TKI. Our results demonstrated that the EGFR mutation status of MLN is a predictive marker of the response to EGFR-TKI therapy in patients with recurrent NSCLC after surgical resection.

Membrane-bound estrogen receptor-α expression and epidermal growth factor receptor mutation are associated with a poor prognosis in lung adenocarcinoma patients.

BACKGROUND: The purpose of this study is to clarify the correlations between the expression of membrane-bound estrogen receptor-α (mERα) and epidermal growth factor receptor (EGFR) mutation and clinicopathological factors, especially in relation to the prognosis, in patients with lung adenocarcinoma. METHODS: We conducted a retrospective review of the data of 51 lung adenocarcinoma patients with tumors measuring less than 3 cm in diameter. Immunohistochemical staining for mERα expression and detection of the EGFR mutation status were performed. RESULTS: Among the 51 patients, the tumors in 15 showed both mERα expression and EGFR mutation. ("double positive") Significant associations between "double positive" and vascular invasion, vascular endothelial growth factor expression, and Ki-67 expression were observed. A multivariate analysis revealed that only "double positive" was an independent risk factor influencing the recurrence-free survival. CONCLUSIONS: Presence of mERα expression together with EGFR mutation was found to be an independent prognostic factor for survival in patients with lung adenocarcinoma, suggesting cross-talk between mERα and EGFR mutation.

Maximal standardized uptake value on FDG-PET is correlated with cyclooxygenase-2 expression in patients with lung adenocarcinoma.

BACKGROUND: Cyclooxygenase-2 (COX-2) is constitutively overexpressed in a variety of epithelial malignancies and is usually associated with a poor prognosis. Fluorodeoxyglucose positron emission tomography (FDG-PET) has become an important tool for the diagnosis and staging of non-small-cell lung cancer. The maximal standardized uptake values (SUVmax) of primary tumors on FDG-PET have been shown to be correlated with some clinicopathologic factors. In this study, we investigated the prediction of intratumoral COX-2 expression by FDG-PET in cases of lung adenocarcinoma. METHODS: We conducted a retrospective review of the data of 60 patients with lung adenocarcinoma measuring less than 3 cm in diameter. Immunohistochemical staining for COX-2 and other biological factors that might influence cancer progression was performed, and the correlations of the selective tumor marker expression with the SUVmax were evaluated. RESULTS: A significant correlation was observed between the SUVmax and the expressions of COX-2, Ki-67, and vascular endothelial growth factor (VEGF). Multiple stepwise regression analysis revealed significant relationships between the SUVmax and the expression of COX-2 (p<0.001) and Ki-67 (p=0.016). Of the 2, COX-2 expression was the stronger determinant of the SUVmax, which increased in proportion to the score for COX-2 expression. The recurrence-free survival of patients with elevated COX-2 expression was significantly worse than that of patients not showing COX-2 expression. CONCLUSIONS: The expression of COX-2 in primary tumors is as strongly correlated with a worse clinical outcome as is increased FDG uptake in cases of lung adenocarcinoma. These findings indicate that the SUVmax of primary tumors might reflect the biological malignant potential in lung adenocarcinomas.

Induction chemoradiation therapy with cisplatin plus irinotecan followed by surgical resection for superior sulcus tumor.

PURPOSE: In this study, we retrospectively evaluate the safety and efficacy of induction chemoradiation using cisplatin plus irinotecan followed by surgical resection for superior sulcus tumor (SST). METHODS: We reviewed the records of four patients with solitary, previously untreated T3-4, N0-1 superior sulcus nonsmall cell lung cancers. Patients received two cycles of chemotherapy, cisplatin and irinotecan, every 4 weeks. Radiotherapy directed at the tumor was administered with a split schedule at the total dose of 40 Gy in 20 fractions. Thoracotomy was performed 4 weeks after completion of the chemoradiation. RESULTS: The toxicities of chemoradiation were mainly hematologic and were well-tolerated. Complete resection could be performed in all cases, and there was no postoperative mortality. At present, all the patients remain alive, and one has a local recurrence. CONCLUSION: This trimodality approach is a safe and effective approach for the local control of SST. Further studies are necessary to confirm the results.

Pulmonary apical mass, the so-called pulmonary apical cap, in a 43-year-old woman.

A 43-year-old woman had a pulmonary tumor detected by a computed tomographic (CT) scan during follow-up for breast cancer 15 years previously. The tumor showed a solid mass measuring 42 × 32 × 12 mm in extensive contact with the pleura of the apex of the left upper lobe. The edge of the tumor was relatively well-defined with an irregular shape, and a bubblelike area was seen within it. The longitudinal slice high-resolution CT findings showed a flat and thick mass, and its inferior border was distinct and horizontal. The pathological findings by a thoracoscopic lung biopsy showed a localized pulmonary fibrosis of the apex, a so-called pulmonary apical cap (PAC). With the recent advances in CT scan technology, the detection of PACs is very likely to increase, and they must be differentiated from superior sulcus tumors.

Tumor-infiltrating Foxp3+ regulatory T cells are correlated with cyclooxygenase-2 expression and are associated with recurrence in resected non-small cell lung cancer.

BACKGROUND: Cyclooxygenase-2 (COX-2) is constitutively overexpressed in a variety of epithelial malignancies and is usually associated with a poor prognosis. COX-2-derived prostaglandin E2 transforms CD4+CD25+ T regulatory (Treg) cells (Tregs), and Tregs are thought to moderate the antitumor immune response. Herein, we investigated the prognostic value of tumor-infiltrating Treg cells and their correlation with COX-2 expression in resected non-small cell lung cancer (NSCLC). MATERIAL AND METHODS: Intratumoral COX-2 and Treg expression were retrospectively assessed using immunohistochemistry in paraffin-embedded samples from 100 patients who had undergone complete resections for NSCLC. The expressions of COX-2 and Foxp3, which was most specific Treg cell marker, were compared with the clinicopathological variables, and the correlation between Foxp3+ Tregs and COX-2 expression was analyzed. RESULTS: The recurrence-free survival (RFS) of patients with elevated COX-2 expression was significantly worse than that of patients without COX-2 expression. Tumor-infiltrating Foxp3-positive lymphocytes were positively correlated with COX-2 expression. The median count for Foxp3-positive lymphocytes was 3 (minimum-maximum, 0-24) in 10 high-power fields. The RFS of patients with tumors containing >or=3 Foxp3-positive cells (Foxp3 expression group) was significantly worse than that of patients with tumors containing <3 Foxp3-positive cells. In a multivariate analysis, only nodal status was an independent predictor of a significantly shorter RFS. However, in node-negative NSCLC, Foxp3 expression was an independent predictor of a significantly shorter RFS. CONCLUSIONS: Tumor-infiltrating Foxp3+ Tregs were positively correlated with intratumoral COX-2 expression and were associated with a worse RFS, especially among patients with node-negative NSCLC.

Recent results regarding the clinical impact of smoking history on postoperative complications in lung cancer patients.

Cigarette smoking is a well-known risk factor for perioperative surgery-related complications; however, steady progress in perioperative management has been made year by year. This study investigated the influence of cigarette smoking on postoperative complications in patients with lung cancer over the last three years in our institution. Clinical records of 194 patients who had undergone a pulmonary resection for lung cancer were retrospectively reviewed. The clinico-pathological findings and postoperative complications were compared among patients with smoking history. Smokers, including a higher number of men, had more preoperative respiratory complications, a lower FEV(1)/FVC, larger tumors, and included more squamous cell carcinoma in comparison to non-smokers. A univariate analysis revealed that sex, age and smoking history were independent risk factors in the postoperative complications; however, a multivariate analysis revealed that those factors including smoking history were not independent. In a subgroup of smokers subclassified by their smoking status or smoking index, there were no significant differences in postoperative complications. Over the recent three years of this study, smoking history was not a significant risk factor in postoperative complications. Especially in smokers, smoking status or smoking index was not a significant risk factor in postoperative complications, too.