Application of microwave surgical instrument to lung segmentectomy for small-sized lung cancer.

Objectives: For lung segmentectomy of small lung cancers, we used a microwave surgical instrument for lung parenchymal dissection mainly at the pulmonary hilum, which is difficult to handle with surgical staplers. This technique facilitated the insertion of staples. Methods: In total, 116 patients with cStage 0-1A3 non-small cell lung cancer who underwent lung segmentectomy were included in this study. We compared the perioperative factors of the group in which a microwave surgical instrument was used for dissection procedures, including lung parenchymal dissection at the pulmonary hilum, and peripheral intersegmental dissection was performed with surgical staplers (group M+S: N = 69), with those of the group in which parenchymal dissection was performed mainly with surgical staplers without using the microwave surgical instrument (group S: N = 47). Results: Although more complex segmentectomies were performed in the M+S group (P = .001), the number of staple cartridges (7 staple cartridges vs 8 staple cartridges, P = .005), the surgical times (179 vs 221 minutes, P < .0001), and the blood loss (5 mL vs 30 mL, P = .012) were significantly lower in the M+S group. The duration of chest tube placement was significantly shorter in the M+S group (P = .019), and postoperative complications of grade 2 or greater were significantly lower in the M+S group (P = .049). Conclusions: The effective use of the microwave surgical instrument combined with surgical staplers can simplify pulmonary hilar and intersegmental plane dissections not only for simple segmentectomy but also for complex segmentectomy, leading to favorable intraoperative and postoperative outcomes.

The Role of Emphysema on Postoperative Prognosis in Early-Stage Nonsmall Cell Lung Cancer.

BACKGROUND: Emphysema is generally considered a poor prognostic factor for patients with nonsmall cell lung cancer; however, whether the poor prognosis is due to highly malignant tumors or emphysema itself remains unclear. This study was designed to determine the prognostic value of emphysema in patients with early-stage nonsmall cell lung cancer. METHODS: A total of 721 patients with clinical stage IA nonsmall cell lung cancer who underwent complete resection between April 2007 and December 2018 were retrospectively analyzed regarding clinicopathological findings and prognosis related to emphysema. RESULTS: The emphysematous and normal lung groups comprised 197 and 524 patients, respectively. Compared with the normal lung group, lymphatic invasion (23.9% vs. 14.1%, P = 0.003), vascular invasion (37.6% vs. 17.2%, P < 0.001), and pleural invasion (18.8% vs. 10.9%, P = 0.006) were observed more frequently in the emphysema group. Additionally, the 5-year overall survival rate was lower (77.1% vs. 91.4%, P < 0.001), and the cumulative incidence of other causes of death was higher in the emphysema group (14.0% vs. 3.50%, P < 0.001). Multivariable Cox regression analysis of overall survival revealed that emphysema (vs. normal lung, hazard ratio 2.02, P = 0.0052), age > 70 years (vs. < 70 years, hazard ratio 4.03, P < 0.001), and SUVmax > 1.8 (vs. ≤ 1.8, hazard ratio 2.20, P = 0.0043) were independent prognostic factors. CONCLUSIONS: Early-stage nonsmall cell lung cancer with emphysema has a tendency for the development of highly malignant tumors. Additionally, emphysema itself may have an impact on poor prognosis.

Completion lobectomy under 4K three-dimensional endoscopy for surgical margin recurrence after segmentectomy.

As the adoption of segmentectomy for small-sized lung cancers expands, the need for more challenging completion lobectomy (CL) may arise to address surgical margin recurrence. Herein, we present a case of successful CL using a 4K three-dimensional (3D) (4K3D) endoscopy after segmentectomy. A 77-year-old male patient with lung cancer in the anterior segment (S3) of the left upper lobe underwent S3 segmentectomy. One year later, the patient experienced a recurrence at the surgical margin. CL was successfully performed under 4K3D endoscopy, same as the initial surgery. CL after segmentectomy requires meticulous preoperative planning and precise surgical maneuvering, and 4K3D endoscopy provides safe and reliable outcomes.

Lessons from short chest drain management for primary spontaneous pneumothorax.

OBJECTIVES: Video-assisted thoracic surgery (VATS) bullectomy is the mainstay treatment for primary spontaneous pneumothorax (PSP) but we encounter patients with pain due to chest tube. This study investigated the postoperative outcomes of shortened silicone drain as a chest tube after VATS bullectomy to reduce pain. METHODS: The current study included patients aged < 30 years who underwent VATS bullectomy for PSP. Patients with normal intrathoracic lengths of the silicone drain placed in a loop at the apex toward the diaphragm were categorized as Group L, whereas those with the silicone drain shortened to approximately 10 cm and placed toward the apex were classified as Group S. Postoperative pain evaluated using a numerical rating scale (NRS) and other perioperative outcomes were compared between the groups. RESULTS: Altogether, 43 patients were included, with 22 in Group L and 21 in Group S, respectively. The NRS before chest tube removal was significantly lower in Group S (mean, 2.1) than in Group L (4.4; p = 0.001). In Group L, 4 patients (p = 0.017) required early chest tube removal than expected due to severe pain whereas none in Group S required this intervention; additionally, more patients needed additional analgesics than in Group S (p = 0.003). CONCLUSION: In VATS bullectomy for PSP, the pain intensity could be reduced by shortening the intrathoracic length of the silicone drain, compared to a longer intrathoracic length of the silicon drain. Our findings contribute to the establishment of optimal postoperative management of general thoracic surgery.

Utility of 4 K three-dimensional endoscopic system in performing video-assisted thoracoscopic surgery lobectomy: initial results of the first year after installation.

OBJECTIVES: With the evolution of technology in the field of thoracoscopy, three-dimensional (3D) endoscopic systems with 4 K resolution have recently come into use. This study aimed to determine perioperative outcomes of video-assisted thoracoscopic surgery (VATS) lobectomy performed a year after the 4 K three-dimensional (3D) endoscopic system installation and compare them with those of the high-definition (HD) 3D endoscopic system. METHODS: We included patients who underwent complete VATS (cVATS) lobectomy for primary lung cancer using an HD3D endoscopic system (HD3D group, June 2015-September 2021, n = 251) or 4K3D endoscopic system (4K3D group, October 2021-September 2022, n = 47). The perioperative outcomes were compared between the two groups. RESULTS: The operation time was significantly shorter in the 4K3D group (mean, 189.5 min) than in the HD3D group (208.5 min; p = 0.021), and the 4K3D group did not require conversion to thoracotomy or transfusion. The 4K3D group had less blood loss volume (4K3D group: mean, 24.0 mL vs. HD3D group: 43.3 mL; p = 0.105) and shorter chest drainage duration (4K3D group: mean, 2.3 days vs. HD3D group: 3.1 days; p = 0.115) and hospitalization period (4K3D group: mean, 7.9 days vs. HD3D group:10.0 days; p = 0.226) than the HD3D group, with no significant difference. No difference was observed in the incidence of ≥ Grade IIIa complications (p = 0.634). CONCLUSION: The 4K3D endoscopic system significantly shortened the duration of cVATS lobectomy. It is useful for lung resection and may replace other endoscopy systems.

Significance of the Goddard Score in Predicting Complications Related to Air Leak After Lobectomy.

BACKGROUND: Postoperative air leakage is a frequent complication after lung resection, and emphysema is a risk factor. However, no study has investigated the relationship between emphysema severity and postoperative complications related to air leak by the Goddard score (GS), a visual evaluation method of radiologic emphysema using computed tomography. METHODS: This study included patients who underwent lobectomy for non-small cell lung cancer between April 2009 and March 2022. The utility of GS in predicting complications related to air leak (air leak prolonged for ≥5 days, pleurodesis, and reoperation for air leak) was investigated by receiver operating characteristic curve analysis and multivariable analysis with a logistic regression model. RESULTS: This study included 477 patients. The GS was a significant predictor of complications related to air leak (area under the curve, 0.696; P < .001). Based on the receiver operating characteristic curve analysis, GS of 6 points was used as the cutoff point for multivariable analysis. In the multivariable analysis, GS of ≥6 points was a significant predictor of complications related to air leak (odds ratio, 2.719; P = .007). In the subgroup analysis of patients with emphysema, GS of ≥6 points was a significant predictor of complications related to air leak (P = .014). CONCLUSIONS: The GS was useful in predicting complications related to air leak. Patients with radiologic findings of emphysema with GS of ≥6 points should be recognized as a high-risk group for complications related to air leak.

Pulmonary hypertension secondary to interstitial fibrosis with pulmonary venous lesions masquerading pulmonary veno-occlusive disease.

We present a 41-year-old man with idiopathic interstitial pneumonia and pulmonary hypertension (PH) in the setting of a non-autoimmune background whose clinical presentation masqueraded pulmonary veno-occlusive disease (PVOD). Because of no histological evidence of venous occlusion in his previous lung biopsy, phosphodiesterase type-5 inhibitor was given, resulting in sudden onset of pulmonary edema. At autopsy, there were histological features of interstitial fibrosis with occlusion of the lobular septal veins and venules. Clinical presentations of PH due to interstitial fibrosis with pulmonary venous lesions may simulate those of PVOD and careful diagnostic and therapeutic approaches are required.

Pleural plaque identification in computed tomography and intraoperative thoracic findings: Correspondence and prognosis comparison in patients with resection of non-small cell lung cancer.

BACKGROUND: We previously reported that intraoperative findings of pleural plaques were worse prognostic factors of resected non-small cell lung cancer (NSCLC). However, differences in the presence of pleural plaques detected either intraoperatively or by CT findings have not been addressed. METHOD: We included 121 patients who underwent resection for NSCLC with intraoperatively detected pleural plaques. We investigated preoperative CT findings and compared the prognosis between patients with or without evidence of pleural plaque on CT. RESULTS: Only 43% of patients with pleural plaques on intrathoracic findings had pleural plaques detected on preoperative CT. There were no differences in prognosis between patients with or without pleural plaque evidences on preoperative CT. CONCLUSION: The rate of detection of pleural plaques on preoperative CT is low even if they are present intraoperatively, and patients with intraoperative findings of pleural plaques have equally poor prognosis regardless of their evidences on preoperative CT.

Immunogenicity and safety of COVID-19 vaccine in lung cancer patients receiving anticancer treatment: A prospective multicenter cohort study.

This study assessed the immunogenicity and safety of the BNT162b2 mRNA vaccine in lung cancer patients receiving anticancer treatment. We enrolled lung cancer patients receiving anticancer treatment and non-cancer patients; all participants were fully vaccinated with the BNT162b2 vaccine. Blood samples were collected before the first and second vaccinations and 4 ± 1 weeks after the second vaccination. Anti-severe respiratory syndrome coronavirus-2 (SARS-CoV-2) spike protein S1 subunit receptor-binding domain antibody titers were measured using the Architect SARS-CoV-2 IgG II Quant and Elecsys Anti-SARS-CoV-2 S assays. Fifty-five lung cancer patients and 38 non-cancer patients were included in the immunogenicity analysis. Lung cancer patients showed significant increase in the geometric mean antibody concentration, which was significantly lower than that in the non-cancer patients after the first (30 vs. 121 AU/mL, p < .001 on Architect; 4.0 vs 1.2 U/mL, p < .001 on Elecsys) and second vaccinations (1632 vs. 3472 AU/mL, p = .005 on Architect; 213 vs 573 A/mL, p = .002 on Elecsys). The adjusted odds ratio (aOR) for seroprotection was significantly lower (p < .05) in lung cancer patients than that in non-cancer patients. Analysis of the anticancer treatment types showed that the aOR for seroprotection was significantly lower (p < .05) in lung cancer patients receiving cytotoxic agents. They showed no increase in adverse reactions. BNT162b2 vaccination in lung cancer patients undergoing anticancer treatment significantly increased (p < .05) antibody titers and showed acceptable safety. Immunogenicity in these patients could be inadequate compared with that in non-cancer patients.

Implementation of a standardised pharmacist check of medical orders prior to preparation of anticancer drugs to reduce drug wastage.

BACKGROUND: The increasing cost of anticancer drugs is now being recognised as a global problem, and measures against drug wastage are among the most important cost containment strategies for anticancer drugs. OBJECTIVE: When blood examination results or changes to a patient's condition necessitate dose reduction or discontinuation of anticancer drugs after their preparation, the compounded anticancer drugs are discarded. To reduce anticancer drug wastage after preparation, we developed a protocol that set the eligibility, start of treatment, dose reduction and discontinuation criteria for injectable anticancer drugs and assessed the effect of pharmacists' checks of these criteria based on the present protocol prior to preparation of injectable anticancer drugs. METHOD: Observations before and after introduction of the protocol were conducted at Gifu University Hospital. We recorded the number, type and cost of anticancer drugs discarded after preparation and the reason for discarding these drugs in our dedicated database. RESULTS: Checking the criteria for anticancer drug administration before preparation significantly reduced the rate at which anticancer drugs within a chemotherapy cycle were discarded after preparation compared with that prior to the protocol's introduction (0.367% [18/4909] vs 0.032% [2/6248], P < .001). Additionally, the total cost of anticancer drugs discarded after preparation was reduced from JPY 2 041 786 (USD 18 562) to JPY 398 414 (USD 3622). CONCLUSION: Pharmacists' checks of the eligibility, start of treatment, dose reduction and discontinuation criteria for anticancer drugs based on the present protocol prior to preparation of injectable anticancer drugs was useful for reducing drug wastage after preparation.

[Shewanella algae bacteremia in patients with biliary tract malignancy: report of three cases].

We encountered three cases of Shewanella algae bacteremia in patients with biliary tract malignancy. Shewanella species are mainly found in seawater and other watery environments. Human infections caused by Shewanella species have been rare. However, reports of Shewanella infections are increasing, although only a few have been from Japan. The three patients we encountered had common features, including hepatobiliary malignancy, male sex, and age over 60 years. These features are similar to those in reports from elsewhere. Shewanella infection bears consideration in patients with those characteristics who have a history of exposure to sea or fresh water or ingestion of seafood. Prompt treatment is needed as the mortality rate of this infection is high.

Lymphoepithelial carcinoma of the maxillary sinus: A case report and review of the literature.

RATIONALE: Most cases of lymphoepithelial carcinoma (LEC) occur in the nasopharynx, and LEC in the sinonasal tract is extremely rare; thus, the clinical characteristics of sinonasal LEC are not well known. PATIENT CONCERNS: A 63-year-old Japanese man presented with a three-week history of left cheek pain, nasal obstruction and cheek swelling. DIAGNOSES: Enhanced CT and MRI revealed a tumor of the left maxillary sinus that invaded the left orbit and hard palate, with multiple swollen left cervical lymph nodes. Open biopsy was performed, and the specimen was diagnosed as LEC. INTERVENTIONS: Alternating chemoradiotherapy (ALCRT) followed by salvage surgery was performed. OUTCOMES: Our patient has been disease free for 5 years. LESSONS: A literature review of the epidemiology, etiology, clinical course and management of sinonasal LEC is highlighted. We believe ALCRT followed by salvage surgery to be a highly optimal treatment for sinonasal LEC from the viewpoint of a balance between quality of life and a high curative effect.

Nosocomial Outbreak of Upper Respiratory Tract Infection With ß-Lactamase-Negative Ampicillin-Resistant Nontypeable Haemophilus influenzae.

OBJECTIVETo describe the epidemiologic features of an outbreak of an acute respiratory tract infection (ARI) caused by ß-lactamase-negative ampicillin-resistant (BLNAR) nontypeable Haemophilus influenzae (NTHi) in an acute-care ward.DESIGNCross-sectional case-control study.SETTINGAn acute-care ward (ward A) in a general hospital of Kochi in western Japan.METHODSPatients who shared a room with an index patient and all staff in ward A were screened and followed from July 1 to August 31, 2015. Sputum or throat swab samples were collected from participants and tested by culture and polymerase chain reaction (PCR). The association between detected pathogens and ARI development among all participants was examined. A case-control study was conducted to identify risk factors for disease.RESULTSIn total, 78 participants, including the index patient, were enrolled. Of all participants, 27 (34.6%) developed mild respiratory symptoms during a 3-week period: 24 were diagnosed as upper respiratory tract infections, and 3 were diagnosed as lower respiratory tract infections. The presence of BLNAR NTHi was confirmed in 13 participants, and multilocus sequence typing demonstrated that these isolates belonged to sequence type 159. All isolates showed identical pulsed-field gel electrophoresis patterns. The presence of BLNAR NTHi was strongly associated with ARI development, whereas viruses were not associated with the disease. Multivariate analyses demonstrated that a history of contact with the index patient was independently associated with ARI caused by BLNAR NTHi.CONCLUSIONSBLNAR NTHi has the potential to cause upper respiratory tract infections among adults and to spread rapidly in hospital settings.Infect Control Hosp Epidemiol 2018;39:652-659.

Preparation and clinical evaluation of a novel lozenge containing polaprezinc, a zinc-L-carnosine, for prevention of oral mucositis in patients with hematological cancer who received high-dose chemotherapy.

We previously reported that oral ingestion of polaprezinc, a zinc-L-carnosine, suspended in sodium alginate solution prevents oral mucositis in patients receiving radiotherapy or high-dose chemotherapy. In the present study, we developed a novel preparation of polaprezinc and evaluated clinical effect of the lozenge preparation in patients receiving high-dose chemotherapy for hematopoietic stem cell transplantation. The preparation contained 18.75 mg polaprezinc in a tablet and showed an excellent uniformity and stability up to 24 weeks after storage under room temperature. The incidence rate of grade ≥ 2 oral mucositis was 74 % in patients without premedication, whereas the rate was remarkably reduced in patients receiving the suspension (23 %) or lozenge (13 %) of polaprezinc (P < 0.01). The use of non-opioid analgesic drugs such as anti-inflammatory agents and local anesthetics for oral pain was also greatly reduced by polaprezinc suspension or its lozenge (16 % for suspension and 13 % for lozenge compared with 89 % with no premedication, P < 0.01). These findings suggest that polaprezinc lozenge is simple to apply and highly effective for prevention of oral mucositis associated with high-dose chemotherapy for hematopoietic stem cell transplantation.

The efficacy and safety of cefepime or meropenem in the treatment of febrile neutropenia in patients with lung cancer. A randomized phase II study.

Febrile neutropenia frequently develops after chemotherapy. There is little evidence to indicate the type of antimicrobial agents that should be used in the treatment of febrile neutropenia in patients with solid tumors. The objective is to determine the efficacy and safety of cefepime (CFPM) and meropenem (MEPM) in the treatment of febrile neutropenia in lung cancer patients in a prospective randomized study. FN patients with lung cancer were randomly divided into CFPM or MEPM groups. The primary end-point was the response rate. The secondary end-points were the defervescence rates at 72 h, 7 days, 14 days and the incidence of adverse events. Twenty-one patients were treated with CFPM and 24 patients were treated with MEPM. One patient died of FN. The CFPM treatment completion rate was 17.65% (95% CI; 0.00-35.77%), while the MEPM treatment completion rate was 38.10% (95% CI; 17.33-58.87%). The defervescence rates at 72 h, 7 days, and 14 days were 70.59%, 86.67%, and 100.00%, respectively in the CFPM group; and 65.00%, 84.21%, and 92.31% in the MEPM group. Adverse events were observed in 33.33% of the CFPM group and 45.83% of the MEPM group. The response rate of the CFPM group was 94.12% (95% CI; 73.02-98.95%), while that of the MEPM group was 85.71% (95% CI; 65.36-95.02%). No differences were found in the efficacy or safety of CFPM and MEPM in the treatment of febrile neutropenia in patients with lung cancer.

Endonasal flap suture-dacryocystorhinostomy (eFS-DCR): a new surgical technique for nasolacrimal duct obstruction (NLDO).

CONCLUSION: Endonasal flap suture-dacryocystorhinostomy (eFS- DCR) is a new and valuable technique for the treatment of nasolacrimal duct obstruction (NLDO). This technique could improve the success rate of endonasal DCR in comparison to external DCR. OBJECTIVE: The standard procedure for NLDO is DCR. DCR can be performed via either an external or endonasal approach. External DCR is now regarded as the gold standard in the treatment of NLDO because of its higher success rate. However, we report a new endonasal surgical technique, eFS-DCR, and assess its efficacy by comparison with the standard endonasal DCR. METHODS: We prospectively investigated a series of 62 consecutive patients with NLDO undergoing endonasal DCR. There were two surgical intervention groups: group 1 (24 patients, 28 sites) undergoing endonasal DCR without eFS; and group 2 (38 patients, 47 sites) undergoing eFS-DCR. Study end points were success rate, the ostium diameter (OD) of the lacrimal sac after DCR, and the duration of stent placement. We compared the two groups on these three points. RESULTS: The success rate was 78.6% (22 of 28 sites) for group 1 (DCR without eFS) and 97.9% (46 of 47 sites) for group 2 (eFS-DCR). The ostium size in patients in group 2 was larger than that in group 1. The median time for the duration of stent placement was 42.5 days for group 1 and 31.5 days for group 2. There was a statistical difference (p < 0.01) in all these parameters between the two groups.

Transbronchial biopsy using endobronchial ultrasonography with a guide sheath increased the diagnostic yield of peripheral pulmonary lesions.

OBJECTIVE: The advantage of transbronchial biopsy (TBB) using endobronchial ultrasonography (EBUS) with a guide sheath (GS) over TBB without EBUS guidance was investigated in this study. MATERIALS AND METHODS: A retrospective chart review was conducted at Nagasaki University Hospital, Japan. Data were collected from all cases of peripheral pulmonary lesions (PPLs) undergoing either EBUS-GS-guided TBB or TBB without EBUS guidance in our department from December 2003 through November 2009. The diagnostic yield in each group was compared, after adjustment for other factors. RESULTS: In total 110 PPLs were investigated in 102 patients: 65 (59.1%) were examined with EBUS-GS-guided TBB (EBUS-GS group) and 45 (40.9%) were TBB without EBUS guidance (non-EBUS group). Both procedures were performed under x-ray fluoroscopy. Basic characteristics were similar between the two groups. Of all EBUS examined lesions, 53 (81.5%) were visualized by EBUS. The diagnostic yields in EBUS-GS group and non-EBUS group were 64.6% and 46.7%, respectively (p=0.08). Adjusting for size and location of lesions, the yield of EBUS-GS guidance was 1.46 (95% confidence interval 1.03 to 2.05) times higher than without EBUS guidance. When the lesion was visualized by EBUS, the diagnostic yield ratio was further increased to 1.63 (95% CI 1.16 to 2.27). CONCLUSION: EBUS-GS-guided TBB demonstrates a higher diagnostic yield than TBB without EBUS guidance.

A low-grade chondrosarcoma presenting as an unusual cervical mass in the hyoid bone: a case report.

INTRODUCTION: A chondrosarcoma originating from the hyoid bone is very rare. Here, we describe a case of low-grade chondrosarcoma of hyoid origin and discuss its preoperative imaging features, including those on positron emission tomography-computed tomography, and its recurrence rate. CASE PRESENTATION: A 42-year-old Japanese man noticed a mass in the right submandibular region of his neck. A hard 3.0 × 2.8 cm tumor was noted on the right side of his hyoid bone. The mass was immobile and moved with deglutition. CONCLUSION: Even though radiographic studies, including positron emission tomography-computed tomography, were inconclusive, the cartilaginous tumor was surgically removed en bloc, and the tumor was diagnosed based on the results of pathological investigations. Close follow-up is recommended in such cases due to the potential for recurrences, because local recurrence occurred in 50% of the reported cases of grade one chondrosarcomas.