Preference of grade and lymphovascular invasion over invasive size measurement in stage I lung adenocarcinoma.

AIMS: Although it is necessary to measure the invasive size of lung adenocarcinoma with a lepidic component, it is not uncommon to have trouble in measuring the invasive size of lung adenocarcinoma. This study examined whether there were other stronger prognostic factors than invasive size. METHODS: We characterised the clinicopathological features associated with recurrence-free survival (RFS) of 686 patients with the pathological stage (p-Stage) I lung adenocarcinoma. Moreover, we compared the area under the curve (AUC) values for recurrence between various combinations of pathological-baseline (age & sex & p-Stage based on invasive size) (B(i)) and several prognostic factors, and various combinations of p-baseline based on total tumour size (B(t)) and several prognostic factors. RESULTS: AUC showed no significant differences between B(i) & new International Association for the Study of Lung Cancer grade (G) or vascular invasion (V), and B(t) & G or V. AUC was the highest in B & G & lymphatic invasion (L) & V. RFS was significantly shorter in patients with G3 OR L(+) OR V(+) than in those with G≤2 AND L(-) AND V(-) in each p-Stage based on invasive size (p-Stage(i)) and p-Stage based on total tumour size (p-Stage(t)) (p<0.05), and there were no significant differences in RFS between each p-Stage(i) and p-Stage(t). CONCLUSIONS: In any invasive size or total tumour size of p-Stage I lung adenocarcinoma, G, L and V are more powerful prognostic factors than the size criteria of p-Stage. Therefore, pathologists should focus on these pathological findings.

Vein-first Lobectomy for Lung Cancer Assessed According to the Status of Clustered Circulating Tumour Cells.

Background/Aim: Vein-first lobectomy (VFL) in lung cancer might reduce shedding of circulating tumour cells (CTCs). This study assessed the clinical significance of VFL. Patients and Methods: Lung cancer patients undergoing lobectomy and CTC testing were evaluated. The primary evaluation item was postoperative clustered CTC detection, and the secondary outcome measures were the 2-year overall survival and recurrence-free survival rates according to the status of VFL and postoperative clustered CTC. Results: Eighty-six patients with similar backgrounds, except for lobe resection and pulmonary vein dissection time, showed postoperative clustered CTC identification rates of 43.8% and 37.9% in the VFL group (n=57) and no-VFL group (n=29), respectively. However, prognosis was not significantly different, although the presence of clustered CTC after surgery was a predictor of recurrence. Conclusion: The status of postoperative clustered CTC was similar regardless of VFL or not, although the detection of clustered CTC was a predictor of recurrence.

Clustered Circulating Tumor Cells in Lung Adenocarcinoma: Implications of Test Results of Continuous Variables.

BACKGROUND/AIM: We investigated the relationship between solid component size (SS), carcinoembryonic antigen (CEA), and standardized uptake value (SUVmax) as continuous variables and postoperative clustered circulating tumor cell (C-CTC) detection in patients with pulmonary adenocarcinoma who underwent surgery. PATIENTS AND METHODS: C-CTC detection was the main evaluation item, which was analyzed using the receiver operating characteristic curve to calculate areas under the curves (AUCs) for the variables. Additionally, the two-year recurrence-free survival rates (2Y-RFSRs) were analyzed. RESULTS: Among the 84 patients examined, SS, CEA, and SUVmax had AUCs>0.7, and were independent. Their thresholds were 2.1 cm, 7.5 ng/ml, and 2.9, respectively. The 2Y-RFSR were significantly better in the non-C-CTC group (n=58) and in the group of patients without high levels of these predictors (n=32). CONCLUSION: SS, CEA level, and SUVmax predicted postoperative CTC detection in pulmonary adenocarcinoma patients.

Sealing Effect of Cross-Linked Gelatin Glue in the Rat Lung Air Leak Model.

BACKGROUND: Air leak is a common problem in pulmonary surgical procedures. In this study, we evaluated the efficacy and safety of gelatin glue (cross-linked with glutaraldehyde) in a rat model of lung air leak. METHODS: A model of pulmonary fistula was created in the rat lung with the use of a needle. The fistula was then sealed with either gelatin glue (group A), fibrin glue (group B), or fibrin glue with a polyglycolic acid sheet (group C). The seal breaking pressures were measured for each group, and the results were compared. To assess the biocompatibility of the gelatin glue, a model of lung damage was created with incision, and the gelatin glue was applied to seal the wound. Histologic analysis was then performed on the lung tissue. RESULTS: The seal breaking pressure in group A (47.88 ± 6.69 mm Hg) was significantly higher than that in group B (24.67 ± 3.24 mm Hg, p = 0.0302) or group C (28.67 ± 3.55 mm Hg, p = 0.0406). Histologically, the gelatin glue adhered firmly to the lung surface, and only localized tissue inflammation was observed. CONCLUSIONS: The sealing effect of gelatin glue was superior to that of fibrin glue, with or without a polyglycolic acid sheet. In addition, the gelatin glue only caused mild inflammation of the lung and was absorbed without any adverse foreign body response. These findings suggest that gelatin glue may be a therapeutically effective biomaterial for sealing lung wounds and restoring respiratory function.

Can preoperative imaging studies accurately predict the occurrence of bullae or blebs? Correlation between preoperative radiological and intraoperative findings.

BACKGROUND: Radiological findings of patients with primary spontaneous pneumothorax (PSP) undergoing surgery have not been well analyzed. The aim of this study was to evaluate the accuracy of imaging studies for predicting the presence of emphysema-like changes (ELCs) detectable during surgery. METHODS: Ninety-three PSP patients who underwent surgery from September 2005 to October 2009 were included in the study. We analyzed preoperative chest radiographic and computed tomographic (CT) findings, and compared the findings with intraoperative detection of ELCs. Chest radiographic findings were analyzed by classifying the PSP size into three categories: small, moderate, and complete. RESULTS: Seventy-six of the 93 patients (82%) had ELCs detected during surgery. The size of the PSP on a radiograph was significantly correlated with the presence of ELCs (p=0.0121). Preoperative CT revealed 64 of the 76 ELCs (sensitivity, 84%; specificity, 100%; accuracy, 87%). Twenty-nine patients without ELCs detected by preoperative CT were analyzed separately. In this group, a larger PSP size also increased the likelihood of ELCs being present (p=0.0049). Seven patients (8%) experienced a recurrence after surgery. No factor could significantly predict recurrence. CONCLUSIONS: Chest CT analysis alone was associated with a false-negative rate of about 15% for ELCs. Combining the analysis of chest radiographic and CT findings could improve sensitivity.

Clinical significance of prostate stem cell antigen expression in non-small cell lung cancer.

OBJECTIVE: Prostate stem cell antigen was originally identified as an overexpressed gene in prostate cancer and its overexpression correlated with disease progression and prognosis. In this study, we investigated the clinical significance and therapeutic potential of prostate stem cell antigen expression in non-small cell lung cancer. METHODS: Prostate stem cell antigen expression was examined by immunohistochemistry in 97 primary tumors and 21 metastatic lymph nodes from non-small cell lung cancer patients who underwent curative resection from January 2001 through March 2003. Therapeutic potential of targeting prostate stem cell antigen was further examined by small interfering RNA method using human lung cancer cell line (A549). RESULTS: Prostate stem cell antigen protein expression was detected in 94 of 97 primary lesions (97%) and all metastatic lymph nodes. Prostate stem cell antigen expression intensity was positively correlated with advanced pathological T-factor and stage (T1 vs. T2-4, P = 0.014; Stage I vs. Stages II-IV, P = 0.029, respectively). The prognosis of patients with low prostate stem cell antigen expression was significantly better than those with high prostate stem cell antigen expression (5-year disease-free survival rate; 90% vs. 53%, P = 0.001). Finally, small interfering RNA-mediated knockdown of prostate stem cell antigen resulted in the inhibition of lung cancer cell growth. CONCLUSIONS: Prostate stem cell antigen is highly expressed in non-small cell lung cancer and may be functionally important for this fatal disease.

Influence of the site of lobectomy and chronic obstructive pulmonary disease on pulmonary function: a follow-up analysis.

The aim of this retrospective study was to evaluate the influence of the site of lobectomy and the presence of chronic obstructive pulmonary disease (COPD) on pulmonary function at different postoperative periods. The patients were divided into groups of COPD and non-COPD patients, and the differences between observed and predicted postoperative values of pulmonary function at different evaluation times according to the resected lobe were assessed. The observed postoperative percentage change in FEV(1) (opo%DeltaFEV(1)) - predicted postoperative percentage change in FEV(1) (ppo%DeltaFEV(1)) one month and six months after right upper lobectomy or left upper lobectomy in COPD patients was of significantly higher positive value than in non-COPD patients. In non-COPD patients, opo%DeltaFEV(1) - ppo%DeltaFEV(1) one month and six months after surgery was of significantly higher negative value in those who had right upper lobectomy than in those who had right lower lobectomy or left lower lobectomy (P<0.05). COPD may strongly influence pulmonary function at early- and late-terms after upper lobectomy. In non-COPD patients, the site of lobectomy may strongly influence pulmonary function at early- and late-terms after surgery.

Short-and long-term outcomes after pneumonectomy for primary lung cancer.

PURPOSE: The purpose of this study was to investigate the recent results of pneumonectomy (Pn) for primary lung cancer. PATIENTS AND METHODS: Thirty-four patients undergoing Pn and 26 patients undergoing broncho-or angioplastic lobectomy (namely, parenchyma-sparing lung resection) from January 1993 to December 2004 were reviewed. The oncological outcome of Pn was analyzed by disease-free survival (DFS). To assess morbidity and mortality, we compared the outcomes of patients undergoing Pn and parenchyma-sparing lung resection. RESULTS: Five-year DFS of the Pn group was 43%. DFS of pathological stage I/II patients was significantly better than that of stage III/IV (73.3% vs. 8.5%, P = 0.0001). The occurrence of minor and major postoperative complications was not different between Pn and parenchyma-sparing lung resection (52.9% vs. 61.5%, P = 0.5054; 17.6% vs. 7.7%, P = 0.1675). In the late period, respiratory function after Pn was significantly impaired in comparison with parenchyma-sparing lung resection. Moreover, 4 noncancer-related deaths occurred in the Pn group. CONCLUSION: The oncological outcome after Pn for patients with lung cancer of less than stage III was satisfactory. Although operative morbidity was not different between the two groups, the loss of pulmonary reserve after Pn was more severe after than the parenchyma-sparing lung resection.

Changes in ventilatory capacity, exercise capacity, and pulmonary blood flow after lobectomy in patients with lung cancer--which lobectomy has the most loss in exercise capacity?

The aim of this study was to compare the changes in ventilatory capacity, exercise capacity, and pulmonary blood flow (PBF) in the operated lung after lobectomy according to the lobe resected. Thirty-one patients underwent right upper lobectomy (RUL), 26 left upper lobectomy (LUL), 24 right lower lobectomy (RLL), and 25 left lower lobectomy (LLL). Pulmonary function tests, exercise capacity tests, and perfusion lung scans were performed preoperatively and six months to one year after lobectomy. RUL was associated with significantly less loss in forced vital capacity (FVC) than RLL or LLL (P<0.05). LUL was associated with the greatest loss in maximum oxygen consumption (VO2) (P<0.05). LUL was associated with significantly greater loss in PBF in the operated lung than RUL (P<0.05). LUL had a significantly higher negative value in percentage change in (VO2) --percentage change in FVC, and percentage change in PBF--percentage change in FVC than RLL or LLL (P<0.05). LUL was not associated with the greatest loss in ventilatory capacity or PBF, although it was associated with the greatest loss in . Each lobectomy has its own peculiarity in magnitude of loss in (VO2), PBF or FVC.

Exercise capacity after lobectomy in patients with chronic obstructive pulmonary disease.

The aim of this study is to clarify whether patients with chronic obstructive pulmonary disease (COPD) lose less exercise capacity after lobectomy than do those without COPD, to the same extent as ventilatory capacity and lobectomy for selected patients with severe emphysema improve exercise capacity like ventilatory capacity. Seventy non-COPD patients (N group), 16 mild COPD patients (M group), and 14 moderate-to-severe COPD patients (S group) participated. Pulmonary function and exercise capacity tests were performed on the same day preoperatively and six months to one year after lobectomy. The S group lost significantly less FEV(1) (forced expiratory volume in 1 s) after lobectomy than did the N or M group (P<0.0001 and P<0.005). However, their loss of exercise capacity was equivalent to that for the N and M groups. For the S group, there was a significant, negative correlation between preoperative FEV(1) % of predicted and percentage change in FEV(1) and maximum oxygen consumption (VO2 max) after lobectomy (r=-0.93, P<0.0001 and r=-0.64, P=0.01). In moderate-to-severe COPD patients, patients with a lower preoperative FEV(1) % of predicted experienced a smaller decrease in FEV(1) and VO2 max after lobectomy.

Outcome of surgical intervention for isolated intrathoracic lymph node metastasis from infradiaphragmatic malignancy: report of two cases.

We report 2 cases with isolated intrathoracic lymph node involvement. This is an unusual manifestation of metastatic spread from an extrathoracic malignancy. Case 1 was a 47-year-old female with a history of radical hysterectomy for cervical cancer of the uterus. Left intrathoracic lymphadenopathy was detected during follow-up. These lesions were surgically removed and diagnosed as multiple lymph node metastases. Two years later, right intrathoracic lymphadenopathy was evident and excised again. Eight months after the re-thoracotomy, retroperitoneal recurrence appeared and she died of the disease. Case 2 was a 41-year-old female with a history of resection of sigmoid colon cancer with liver metastases. A solitary nodule in the left upper lobe was shown by a chest computed tomography (CT). Left upper lobectomy was performed and the lesion was diagnosed as a solitary lymph node metastasis. She has had no recurrence for 3 years since thoracotomy.

Intralobar sequestration presenting as a large intrapulmonary hematoma and massive hemothorax.

Intralobar sequestration is a relatively rare anomaly that is usually diagnosed with symptoms of cough, expectoration, or recurrent pneumonia. We experienced a case of a 27-year-old man with a symptom of massive hemoptysis. His chest computed tomography (CT) scan revealed a large intrapulmonary hematoma and massive hemothorax, mimicking a benign lung tumor ruptured into the pleural cavity. We should keep the possibility of this anomaly in mind if a patient with hemoptysis has a cystic lung tumor and hemothorax on CT scan.

Operative indications for lung cancer with satellite lesions.

In deciding the surgical treatment for lung cancer, it is important to differentiate between a small satellite lesion that is probably benign, a pulmonary metastatic lesion, or a double cancer. The operative indications for lung cancer with small satellite lesions detected on preoperative helical computed tomography were retrospectively examined. We collected 43 small nodules < or = 1 cm in diameter from 32 patients. A definitive diagnosis was made by follow-up computed tomography in 3 of 19 ipsilateral lesions and in 9 of 24 contralateral lesions. The final diagnosis of the satellite lesions was malignant in 13 and benign in 30. The 13 malignant lesions consisted of 2 pulmonary metastases and 11 double cancers. Two patients with stage IIb and IIIb disease on clinical staging of the main tumor had pulmonary metastases. Patients with clinical stage I disease had a higher probability that the small lesions were benign or double cancers than those with advanced disease beyond clinical stage I.

Assessment of pulmonary function after lobectomy for lung cancer--upper lobectomy might have the same effect as lung volume reduction surgery.

OBJECTIVE: Lung volume reduction surgery (LVRS) in well-selected patients with severe emphysema results in postoperative improvement in symptoms and pulmonary function. Experience with LVRS suggests that predicted postoperative FEV(1.0) may be underestimated after lobectomy in patients with lung cancer and emphysema. As most of the patients with lung cancer have more or less emphysematous changes in the lungs, we assumed that lobectomy would achieve the same effect as LVRS even in patients without chronic obstructive pulmonary disease on the pulmonary function test. We assessed changes in pulmonary function in terms of 'volume reduction effect' after lobectomy for lung cancer. METHODS: Forty-three patients underwent right upper lobectomy (RUL), 38 patients left upper lobectomy (LUL), 39 patients right lower lobectomy (RLL), and 38 patients left lower lobectomy (LLL). Pulmonary function tests were performed preoperatively and 6 months to 1 year after surgery. RESULTS: Percent change in FEV(1.0) after lobectomy was -6.9+/-16.1% in RUL group, -11.2+/-16.9% in LUL group, -14.7+/-9.8% in RLL group, and -12.8+/-9.5% in LLL group. We evaluated the correlation between a preoperative FEV(1.0)% of predicted and percentage change in FEV(1.0) after lobectomy. There were no significant relationships between these variables in RLL or LLL group. In contrast, there were significant negative relationships between these variables in RUL and LUL groups. Correlation coefficients were r = -0.667, p < 0.0001 for RUL and r = -0.712, p < 0.0001 for LUL. In RUL and LUL groups, patients with a higher preoperative FEV(1.0)% of predicted had a more adverse percentage change in FEV(1.0) after surgery. In addition, all 13 patients with a preoperative FEV(1.0)% of predicted <60% in RUL and LUL groups had an increase in FEV(1.0) postoperatively. Patients with a lower preoperative FEV(1.0)% of predicted had a greater 'volume reduction effect' with an increase in FEV(1.0) after upper lobectomy. CONCLUSION: Upper lobectomy might have a volume reduction effect.

Ectopic pancreas in the anterior mediastinum.

We report an uncommon clinical case of anterior mediastinal localization of ectopic pancreatic tissue. A 39-year-old male was referred to our institution for investigation of an abnormal mediastinal shadow on a chest X-ray, and a large cystic lesion measuring 10 x 8 cm located in the anterior mediastinum was observed on a computed tomographic scan. He underwent complete surgical resection of the lesion. The postoperative pathological examination confirmed the diagnosis of ectopic mediastinal pancreas. No recurrence or metastasis was detected during a follow-up period of 8 years. We speculate that this lesion represents abnormal differentiation of the pluripotent epithelial cells of the ventral primary foregut. Details of the clinical and histopathological features are presented.

Bluntly traumatic tracheal transection: usefulness of percutaneous cardiopulmonary support for maintenance of gas exchange.

Respiratory management of tracheal injuries is a crucial key to successful treatment. We present herein a patient with a traumatic tracheal transection in whom we confronted difficulty in airway management after false intratracheal intubation. No associated injuries were seen in the patient, then, primary repair of the trachea was carried out under ventilatory support via percutaneous cardiopulmonary support system (PCPS). For a short period in the application of PCPS, the use of a heparin-coated circuit made systemic heparinization unnecessary during and after operation, and the outcome was satisfactory. In a carefully selected patient, ventilatory support via PCPS is useful.

A case of idiopathic sclerosing mediastinitis in a 7-year-old Japanese boy.

UNLABELLED: Sclerosing mediastinitis is a very rare benign disorder characterised by the development of dense fibrous tissue within the mediastinum. Affected patients are typically young adults with infant cases being uncommon especially in areas without endemic histoplasmosis. We report a Japanese boy with markedly elevated serum inflammatory markers for more than 1 year in the absence of any clinical manifestations. 67Ga-scintigraphy demonstrated an accumulation in the mediastinal region and an open biopsy revealed a hard fibrous mass in the anteriosuperior mediastinum. Thus, a diagnosis of idiopathic sclerosing mediastinitis was made. CONCLUSION: To the best of our knowledge, this case is the youngest patient reported with this disorder. In patients with mediastinal mass lesions the diagnosis of sclerosing mediastinitis should be considered as well as infectious, autoimmune or neoplastic disease even in children.

[Lung resections for lung cancer with idiopathic pulmonary fibrosis].

PURPOSE: The aim of this study was to investigate the postoperative complications after lung resections for lung cancer with idiopathic pulmonary fibrosis (IPF). MATERIAL AND METHODS: There were 23 patients who underwent lung resections for lung cancer with IPF. There were 8 major complications. Acute exacerbation of IPF occurred in 4 cases, pulmonary edema in 1 case, bronchofistula in 1 case, bacterial pneumonia in 1 case, prolonged hypoxia in 1 case. Three cases died due to acute exacerbation of IPF (2 cases) and bronchofistula (1 case). RESULTS: There were 4 complications among 7 patients who underwent wedge resections and 4 complications among 16 patients who underwent lobectomy. All the 4 complicated cases who underwent wedge resections had low preoperative percent forced vital capacity (%VC) for 79+/-6%. For the patients who had lobectomy, the preoperative %VC and predicted postoperative %VC was significantly different between the 2 groups of complicated patients and uncomplicated ones (p < 0.05). For the prevention of acute exacerbation of IPF, we used clarithromycin in 11 cases, steroid in 2 cases, ulinastatin in 2 cases. However, the acute exacerbation was occurred in 4 cases. CONCLUSIONS: For the patients of lung cancer with IPF who had low preoperative %VC, even wedge resections should be carefully indicated.

Resection of primary pleural pedunculate hemangiopericytoma.

We are reporting an uncommon clinical case of primary pleural hemangiopericytoma, of which only a few reports have been published in the literature to date. A 40-year-old woman was treated by complete surgical resection of the tumor. No recurrence or metastasis was detected during follow-up at 12 months after the resection. The postoperative pathologic examination confirmed the diagnosis of primary pleural hemangiopericytoma. Details of the clinical and radiographic feature are presented.

Video-assisted thoracoscopic surgery is a promising treatment for solitary fibrous tumor of the pleura.

STUDY OBJECTIVES: Solitary fibrous tumors of the pleura (SFTPs) are slow-growing neoplasms. Approximately 800 cases have been reported in the literature to date. The aim of this study was to address our experience with the management of SFTPs and to evaluate the advantage of video-assisted thoracoscopic surgery (VATS) in SFTP treatment. DESIGN: Retrospective analysis of our experience. SETTING: Department of Thoracic and Cardiovascular Surgery, Nara Medical University. PATIENTS: From January 1992 to August 2002, 13 patients with a SFTP were referred to us for surgical resection after VATS was adopted in our hospital. The study group consisted of seven men and six women with a mean age of 49.8 years (age range, 37 to 72 years). RESULTS: Surgical excision was performed with VATS only in nine patients, with VATS plus a small thoracotomy in three patients, and by a posterolateral thoracotomy without VATS in one patient. The mean chest-drain duration was 1.3 days (range, 1 to 3 days), and the mean duration of hospital stay was 8.6 days (range, 3 to 30 days). Eleven tumors, originating from the visceral pleura, were pedunculate, and 2 tumors from the parietal pleura were not pedunculate. Two cases were focally characterized by a mitotic count in excess of four mitoses per 10 high-power fields and by cellular pleomorphism. Follow-up periods ranged from 6 to 120 months, with a mean of 49.7 months and a median of 42 months. All patients have remained well with no recurrence or metastasis. CONCLUSIONS: Complete surgical resection is the treatment of choice for SFTPs. For the pedunculate tumors, therefore, VATS is a powerful and useful approach. Even when it is necessary to perform a small thoracotomy in addition to VATS for the removal of a large tumor, VATS may play an important role in reducing the size of the thoracotomy incision, which results in less invasive surgery. To minimize postoperative morbidity, VATS may be the most promising surgical approach for the resection of SFTPs.