Can the Japanese National Clinical Database risk calculator predict long-term survival of patients who undergo palliative segmentectomy for primary lung cancer?

OBJECTIVES: Selection criteria for palliative limited surgery in patients with non-small cell lung cancer (NSCLC) can vary by institution or surgeon. We retrospectively reviewed outcomes of poor-risk patients who underwent palliative segmentectomy (PS), using the National Clinical Database Risk Calculator (RC). METHODS: We retrospectively analyzed medical records of patients with NSCLC tumors ≥ 20 mm and consolidation/tumor ratios ≥ 0.5 on computed tomography, who underwent PS from January 2009 to March 2016. Median follow-up time was 47 months (range 2-102 months). RESULTS: We enrolled 67 patients (median age: 73.0 years), of whom 54 received thoracoscopic surgery and 28 received medial lymph-node dissection. The RC's mean predictive probability rate for perioperative mortality or severe complications was 7.1%. Of the 67 patients, 24 patients (43.0%) suffered post-surgical complications, including 2 (3%) who died in hospital; 17 eventually suffered NSCLC recurrences and/or metastases, 11 eventually died from NSCLC, and 17 died from other diseases. Five-year overall survival (OS) was 59.4%. When the patients were divided into high-risk (HR) and low-risk (LR) groups based on the RC, 5-year OS was significantly less in the HR group (43.9%) than in the LR group (82.2%; P < 0.05). CONCLUSION: The RC, which was developed primarily to determine perioperative risk, can predict long-term prognosis for compromised patients who undergo PS.

[Desmoid Tumor Treated by Wide Resection of the Anterior Chest Wall].

Desmoid tumors are rare mesenchymal proliferative tumors that are highly invasive but lack metastatic potential. We report the case of a 72-year-old man with a desmoid tumor arising from the anterior chest wall which invaded neighboring organs extensively. The patient complained of dyspnea on exertion and appetite loss and was referred to our hospital. Chest computed tomography revealed an anterior chest wall tumor 12 cm in diameter adjacent to the right lung, diaphragm, and sternum. An ultrasound-guided biopsy was conducted, and the tumor was diagnosed as a desmoid tumor. He underwent right-sided anterior chest wall resection with combined resection of the right lung, diaphragm, and sternum body. The chest wall defect was reconstructed using an expanded polytetrafluorethylene mesh (dualmesh). Although initial active surveillance has recently been recommended for asymptomatic patients with non-progressing desmoid tumors, our patient underwent resection because of his symptoms.

Pazopanib Confers a Progression-free Survival in a Patient with Ewing's Sarcoma/Primitive Neuroectodermal Tumor of the Lung.

Ewing's sarcoma (ES)/primitive neuroectodermal tumors (PNETs) are highly malignant neoplasms that usually affect the bones and soft tissues in children and young adults. ES/PNET of the lung is very rare and is associated with a poor prognosis. We herein report a case of ES/PNET of the left lung in a 45-year-old man. He was treated with neoadjuvant chemotherapy and pneumonectomy, but unfortunately his disease recurred 1.5 months after surgery. He was started on pazopanib, which resulted in a five-month progression-free survival. To our knowledge, this is the first demonstration of pazopanib efficacy in ES/PNET of the lung.

Left mediastinal node dissection after arterial ligament transection via video-assisted thoracoscopic surgery for potentially advanced stage I non-small cell lung cancer.

BACKGROUND: Left mediastinal node dissection during lung cancer surgery can be difficult because paratracheal and subcarinal lymph nodes are concealed by mediastinal structures. Arterial ligament transection (ALT) offers a wide surgical view of concealed mediastinal spaces, thus enabling extended en bloc lymph node dissection (LND). We analyzed surgical outcomes of patients who underwent extended LND after ALT via video-assisted thoracoscopic surgery (VATS) for potentially node-positive clinical stage I non-small cell lung cancer (NSCLC). METHODS: We retrospectively investigated the medical records of 75 patients who had undergone extended mediastinal node dissection after ALT via VATS for potentially node-positive NSCLC at our centers during the period from September 2008 through November 2015. Operative data and rates of overall survival (OS), in addition to mortality and morbidity, were analyzed in relation pathological stage and nodal stage. RESULTS: Operative time was 238±58 minutes, and an average of 32.7±12.9 hilar and mediastinal lymph nodes were dissected. Lymph node metastases were detected in 34 patients (6 pN1 patients, 27 pN2 patients, and 1 pN3 patient). Mediastinal lymph node metastases were detected around the carina (stations 2L, 4L, and 7) in 19 of 27 patients with pN2 cancer. Nineteen patients had a total of 24 postoperative complications. Recurrent nerve paralysis was the most frequent complication (n=11) but resolved in eight patients during follow-up. Survival rates at 3 and 5 years were 92.2%/88.4%, 100.0%/60.0%, and 87.7%/81.0% for p-stage I, II, and III, respectively, and 92.2%/88.4%, 100.0%/60.0%, and 87.4%/80.7% for pN0, pN1, and pN2, respectively. CONCLUSIONS: Extended mediastinal node dissection after ALT allowed detection of lymph node micrometastases in selected patients with potentially node-positive left NSCLC and may improve outcomes.

Giant solitary fibrous tumor of the pleura with high-grade sarcomatous overgrowth accompanied by lipid-rich, rhabdomyosarcomatous, and pleomorphic components: A case report.

RATIONALE: Solitary fibrous tumors are mesenchymal tumors presenting as fibroblastic neoplasms with prominent branching vascular patterns, which are often generated from the pleura. Most solitary fibrous tumors are benign; however, some can turn malignant. High-grade sarcomas from solitary fibrous tumors include multidirectional histopathological components. PATIENT CONCERNS: We describe our experience of a giant high-grade sarcoma with mixed components generated from a solitary fibrous tumor of the pleura in a 67-year-old female patient presenting with cough and left-sided chest pain. The patient had been diagnosed with a pleural mass in the left chest by X-ray about 30 years earlier. However, the tumor was allowed to grow, without surgical intervention, for a long time. INTERVENTIONS: Thoracic surgeons performed the removal of the giant pleural tumor; the tumor measured 18.0 × 14.5 × 10 cm in size, and was considered a giant tumor generated from the pleura of the left chest cavity. DIAGNOSES: The surgically removed tumor was solid and light brownish, and included myxoid and arabesque pattern lesions. The tumor also showed hemorrhagic and necrotic lesions. Moreover, spindle cells with less atypia, resembling fibroblasts, were noted. These spindle tumor cells were CD34- and Stat6-positive, suggesting a solitary fibrous tumor. Some of the spindle tumor cells were surrounded by thick collagenous fibers. Considering that the tumor originated from the parietal pleura, the tumor was defined as a solitary fibrous tumor in origin. The tumor also comprised high-grade sarcomatous components; these included lipid-rich, rhabdomyosarcomatous, and pleomorphic components. The high-grade sarcoma component included bizarre tumor cells with severe atypia. OUTCOMES: Tumor recurrence occurred in the left chest about 4 months after the surgery, and the patient died 8 months postoperatively. LESSONS: The present case clearly demonstrates that a solitary fibrous tumor can develop into high-grade sarcomatous overgrowth, including lipid-rich, rhabdomyosarcoma, and pleomorphic sarcoma components, if left untreated for a prolonged period. This case provides profound insights about the natural history, histogenesis, differentiation, and malignant transformation of solitary fibrous tumors.

Asymptomatic localized pleural amyloidosis mimicking malignant pleural mesothelioma: report of a case.

We herein report an asymptomatic 65-year-old male with localized pleural amyloidosis mimicking malignant pleural mesothelioma. He had a history of exposure to asbestos and was admitted for investigation of an abnormal pleural thickness detected by chest radiography. Positron emission tomography showed elevation of standardized uptake value corresponding to the pleural thickness. Partial pleurectomy including the tumor was performed for the purpose of diagnosis and local disease control. The pathological examination showed that the tumor was pleural amyloidosis. The tumor was diagnosed as localized primary amyloidosis, because serum monoclonal protein concentration did not increase. Pleural amyloidosis should be considered as a differential diagnosis from pleural mesothelioma.

Peripherally located endobronchial hamartoma mimicking aspergilloma: a case report.

We herein report the case of a 75-year-old man with a pulmonary hamartoma that mimicked aspergilloma on chest computed tomography (CT). A CT scan performed to assess an asymptomatic lesion detected on a screening chest radiograph showed a 1.3-cm diameter nodule with an air crescent sign in the left lower lobe. A diagnosis of aspergilloma was made and the patient treated with an antifungal agent for 1 year, following which he underwent radical surgery because of failure of the radiologic lesion to resolve. Pathologic examination of the resected specimen showed an endobronchial hamartoma within the B9 periphery. Peripherally located hamartomas can develop within the peripheral bronchi resulting in an air crescent appearance on radiological images.

Potentially disseminated solitary fibrous tumor of the pleura: a case report.

We report a case involving a female patient with frequent relapse, pleural dissemination, and port site recurrence (PSR) of a pleural solitary fibrous tumor (SFT). At the age of 55 years, she underwent tumor resection via video-assisted thoracoscopic surgery (VATS). The tumor arose from the mediastinal pleura; it was 7 cm in diameter and well demarcated. Histological examination showed neither hemorrhage nor necrosis, but moderate cellularity was present, and the Ki-67 labeling index was 15%. Despite complete resection, the tumor relapsed in the ipsilateral thoracic cavity 3 years postoperatively, and thoracoscopic complete tumor resection was performed; however, pleural lavage cytology (PLC) showed the presence of tumor cells. Multiple pleural dissemination and PSR developed 7 years after the initial surgery. The port site recurrent tumor was resected with the intercostal muscle via VATS. This case illustrates that a SFT may disseminate despite the fact that histological examination shows no evidence of malignancy.

Polyglycolic acid mesh occlusion for postoperative bronchopleural fistula.

BACKGROUND: Postoperative bronchopleural fistula is one of the most life-threatening complications after anatomical pulmonary resection. Bronchopleural fistula may cause empyema and aspiration pneumonia with subsequent acute respiratory distress syndrome. Surgical interventions for bronchopleural fistula can prolong hospitalization and impair postoperative quality of life. Postoperative care requires minimally invasive endoscopic occlusion. METHODS: We retrospectively reviewed the records of 7 patients who developed bronchopleural fistula among 689 patients who underwent segmentectomy or lobectomy without sleeve resection for lung cancer in Jichi Medical University from 2009 to 2013. Bronchopleural fistula occurred in the right lower bronchial stump in 3 patients, in the superior segmental bronchus of the right lower lobe in 2, in the superior segmental bronchus of the left lower lobe in one, and in the right intermediate bronchus in one. Flexible bronchoscopy was used to occlude 3-mm fistulas with polyglycolic acid mesh in 2 patients. Larger fistulas in 5 patients were occluded with polyglycolic acid mesh plus fibrin glue to secure the mesh. The median procedure was 37 min. Procedures were considered complete upon resolution of air leakage from the chest drainage system. RESULTS: Bronchoscopic interventions for bronchopleural fistula were repeated an average of 2 times. No procedure-related complications or death occurred. Bronchoscopic interventions were successful in all patients. CONCLUSIONS: Bronchoscopic occlusion with polyglycolic acid mesh with or without fibrin glue is easy and feasible as the first step in postoperative management of bronchopleural fistula.

Intrathoracic desmoid tumor arising at a distance from thoracotomy sites after thoracoscopic segmentectomy: report of a case.

We report a case involving an intrathoracic desmoid tumor in a 68-year-old woman who had undergone video-assisted thoracoscopic right basal segmentectomy for lung cancer 1 year earlier. The well demarcated tumor was 9 cm × 6 cm × 6 cm in size, was located in the right apico-posterior thorax and had invaded the chest wall. The patient complained of a dull shoulder pain as a result of rapid tumor enlargement. En bloc tumor resection, including the apico-posterior chest wall extending from the 1st to the 4th rib, was successful. The patient had no recurrent tumor at 5 years after the second surgery. Intrathoracic desmoid tumor could occur, even when the tumor arises at a distance from the port and thoracotomy sites after thoracoscopic surgery.

Surgical Outcome of Video-Assisted Thoracoscopic Surgery vs. Thoracotomy for Primary Lung Cancer >5 cm in Diameter.

OBJECTIVES: The indications for video-assisted thoracoscopic surgery (VATS) for advanced-stage lung cancer are expanding, but the criteria vary among institutions. This study compared the minimal invasiveness and oncologic validity of VATS lobectomy and thoracotomy lobectomy for the treatment of large-diameter primary lung cancer. METHODS: We retrospectively reviewed clinical features and surgical outcomes of 68 patients who underwent anatomical pulmonary resection for primary lung cancer of >5-cm diameter from July 2006 to March 2013. The patients were divided into a VATS group (Group V, n = 35) and a thoracotomy group (Group T, n = 33). RESULTS: Group V exhibited less intraoperative bleeding (p = 0.012) and had a shorter length of postoperative hospital stay (p = 0.024). The 1- and 5-year overall survival rates were 91.3% and 39.3% in Group V and 84.8% and 56.9% in Group T, respectively (p = 0.48). Multivariate analysis showed that limited lymph node dissection contributed to local recurrence. The extraction bag lavage cytology in Group V revealed that the positivity rate was 35.7%. CONCLUSIONS: VATS for primary lung cancer of >5-cm diameter is similar to thoracotomy in terms of surgical outcomes. Large tumors must be carefully maneuvered during VATS to prevent cancer cell spillage.

Aberrant aneurysm of adult-type pulmonary sequestration: report of a case.

Aberrant pulmonary artery exposed by high-blood pressure over a long period in adult-type pulmonary sequestration can be susceptible to arteriosclerotic change and aneurysmal formation. Dividing this aneurysmal artery has a risk of stump leakage and aneurysm. We herein report a 64-year-old man with an aberrant aneurysm of intralobar pulmonary sequestration. Thoracoscopic resection of the sequestrated lung was performed uneventfully by prior endovascular occlusion of the aberrant aneurysm.

Extraction of mediastinal teratoma contents for complete thoracoscopic resection.

OBJECTIVES: Video-assisted thoracic surgery is widely applied for resection of mediastinal tumors. The mediastinal mature teratoma, however, is usually operated on via an open approach because it is generally large, making it difficult to dissect under a thoracoscopic view and remove it from the thoracic cavity. We attempted to extract intracystic material during video-assisted thoracic surgery to facilitate dissection and removal of the tumor from the thoracic cavity. METHODS: From January 1998 to April 2013, 13 patients (9 women, 4 men; mean age 33 years, range 17-54 years) with mediastinal mature teratomas were operated on via video-assisted thoracic surgery. Intracystic contents of the tumor were aspirated before dissection or after the teratoma was dissected and placed in the retrieval pouch. RESULTS: None of the patients required conversion to an open procedure. Operating time was 95-184 min (mean 132 min). Blood loss during the operation amounted to 10-300 mL (mean 78 mL). The tumor size ranged from 5 to 12 cm (mean 8 cm). In all cases, the tumors were confirmed pathologically to be mature cystic teratomas with no malignant components. During and after follow-up, all patients continue to do well without recurrence. CONCLUSION: Extraction of intracystic contents enabled thoracoscopic resection of large mature mediastinal teratomas.

[Diaphragmatic hernia complicated with diaphragmatic resection by automatic stapling device].

Nowadays, a diaphragmatic lesion is sometimes resected with use of an automatic stapling device, especially through video-assisted thoracoscopic procedure. We herein report 2 patients with a diaphragmatic hernia after diaphragmatic resection by automatic stapling devices. Etiology and cause of postoperative diaphragmatic hernia are discussed. Diaphragmatic resection by mechanical stapler was performed for thymic epithelial tumor recurring at the diaphragmatic pleura in both patients: 48-year-old man and 72-year-old woman. The former patient underwent a right diaphragmatic resection (3×4 cm in size) with a cartridge of mechanical stapler. Computed tomography (CT) and magnetic resonance imaging showed asymptomatic right diaphragmatic hernia 2 months after surgery. No symptom and progression occurred 8 years later. The latter patient underwent a right diaphragmatic resection (6×7 cm in size) with 2 cartridges of mechanical stapler. Diaphragmatic hernia advanced 7 months after surgery and required surgical intervention. Diaphragmatic repair was successful with the use of 8×6 cm expanded polytetrafluoroethylene patch. Surgical stump after diaphragmatic resection with automatic stapling device is easy to rupture during diaphragmatic movement synchronized with respiratory movement. Diaphragmatic resection with use of stapling device, which is a simple procedure, should be contraindicated.

Strangulation of aberrant artery in extralobar pulmonary sequestration on video imaging.

We report a case of an 18-year old female patient with symptomatic extralobar pulmonary sequestration. The initial symptom was sudden-onset right lateral abdominal pain. Enhanced computed tomography showed a 5 cm in diameter, spindle-shaped mass located in the costophrenic sinus with no aberrant artery. Exploratory thoracoscopy showed a haemorrhagic mass caused by strangulation of an aberrant vessel originating from the intercostal artery. Pathological findings revealed pulmonary sequestration with haemorrhagic infarction. The strangulated aberrant artery was clearly demonstrated by video imaging.

Extraction bag lavage cytology during video-assisted thoracoscopic surgery for primary lung cancer.

OBJECTIVES: Sample extraction from the thoracic cavity through an intercostal space during video-assisted thoracoscopic surgery can result in cancer cell contamination by tumour crushing and tumour cell extravasation, and may have adverse effects on the surgical outcome. Lavage cytology of the sample extraction bag was investigated to clarify the risk of cancer cell spillage and identify the clinicopathological features associated with susceptibility to cancer cell spillage during extraction. METHODS: Lavage cytology of the sample extraction bag was investigated in 464 patients with negative pleural lavage cytology who underwent lung resection for primary lung cancer via video-assisted thoracoscopic surgery between January 2010 and December 2012. The surgical procedures, pathological findings and clinical course were evaluated by hospital record review. RESULTS: The incidence of positive bag lavage cytology (BLC) was 13.6%. Statistically significant factors associated with susceptibility to BLC positivity were tumour size, standardized uptake value of positron emission tomography, pathological features such as pathological N score, pleural invasion, vascular invasion and papillary-predominant adenocarcinoma. Among patients with Stage I lung cancer, the survival rate was significantly lower in the BLC-positive group than in the BLC-negative group. CONCLUSIONS: BLC positivity can be related to oncological characteristics such as tumour invasiveness and adhesiveness as opposed to tumour size and surgical margin, and may help to determine the prognosis of Stage I lung cancer. The sample extraction bag must be carefully manoeuvred through the intercostal space to prevent cancer cell dissemination to the chest wall or thoracic cavity.

Surgical outcomes after superior vena cava reconstruction with expanded polytetrafluoroethylene grafts.

OBJECTIVES: Graft occlusion is a problem after superior vena cava (SVC) reconstruction for thoracic malignancy. Expanded polytetrafluoroethylene (ePTFE) is considered to be an optimal material for venous reconstruction. METHODS: We reviewed the hospital records of 13 patients who underwent complete resection of thoracic malignancy invading the SVC, including SVC reconstruction with ePTFE grafts. Single bypass grafting was performed in two patients (one right-sided, one left-sided) and double bypasses grafting was performed in the other patients. All patients received antithrombotic therapy after surgery. Eight patients died of recurrence or other disease during the follow-up period (range 5-41 months). RESULTS: Of the 24 grafts in 13 patients, graft patency was confirmed in 20 grafts in 9 patients at a mean time follow-up time of 47.8 ± 50.0 months after surgery. In the remaining four grafts in four patients, occlusion was diagnosed at a mean time of 1.25 ± 0.50 months after surgery. All obstructed grafts were left-sided bypass grafts in patients who underwent double bypass grafting, and did not result in SVC syndrome. CONCLUSIONS: SVC reconstruction with ringed ePTFE grafts was safe and had good outcomes. In patients who underwent double bypasses grafting, the left-sided bypass grafts were susceptible to occlusion.

[Stump recurrence after pulmonary metastasectomy from colorectal cancer].

Pulmonary metastasectomy with wedge resection is an ideal procedure in terms of less invasiveness and preservation of respiratory function, while local recurrence is a major problem. The goal of this study was to verify risk factors of stump recurrence after pulmonary metastasectomy from colorectal cancer. Pulmonary metastasectomies including 112 operations for 131 lesions in 85 patients with colorectal cancer were performed in our department since March, 2005 until the end of 2010. In our cases, stump recurrence significantly occurred in patients who underwent wedge resection than segmentectomy or lobectomy. Stump recurrence developed in 14 operations among 62 wedge resections (recurrence rate: 23%). Diameter more than 10 mm and distance between pleura and deepest end of the tumor (depth value) more than 14 mm were risk factors as stump recurrence. Tumor diameter and depth value can be a decisional factor for wedge resection in pulmonary metastasectomy in the colorectal cancer patients.

Left pneumonectomy for complex aspergilloma after patent ductus arteriosus ligation.

Surgery for complex pulmonary aspergilloma is known to be technically challenging, often for indurated hilar structures and obliterated pleural space. We report a case of left pneumonectomy for pulmonary aspergilloma with a history of patent ductus arteriosus ligation via anterolateral thoracotomy and aortopexy via median sternotomy and pericardiotomy. Left pneumonectomy was successfully accomplished by devising a surgical approach and procedures for transection of the left main pulmonary artery.

Thoracoscopic findings of an asymptomatic solitary costal exostosis: is surgical intervention required?

We report a case of a 21-year old male with an asymptomatic solitary costal exostosis incidentally detected on a chest X-ray. The exostosis originated from the costochondral junction of the left fourth rib and protruded into the thoracic cavity. Exploratory thoracoscopy showed that the exostosis had scratched the adjacent pericardium and visceral pleura. A 5.5-cm long rib segment including the exostosis was excised. This report describes that the thoracoscopic findings of an asymptomatic costal exostosis originate from the costochondral junction, demonstrating that this condition may cause more extensive thoracic organ injury than expected.