Long-term outcomes and risk factors for recurrence after lung segmentectomy.

OBJECTIVES: The long-term oncological outcomes and risk factors for recurrence after lung segmentectomy are unclear. The aims of this study were to investigate the long-term prognosis and to evaluate risk factors for recurrence after segmentectomy. METHODS: Between January 2008 and December 2012, a total of 177 patients underwent segmentectomy for clinical stage I non-small cell lung cancer. The median follow-up period was 120.1 months. The overall survival (OS) and recurrence-free survival curves were analysed using the Kaplan-Meier method with a log-rank test. Univariable and multivariable analyses were used to identify significant factors that predicted recurrence. RESULTS: The study included 177 patients with a median age of 67 years. The median operative time was 155 min. No 30-day deaths were observed. Nine patients (5.1%) had recurrences: loco-regional in 3, distant in 3 and both in 3. The 5-year and 10-year recurrence-free survival rates were 89.7% and 79.8%, and the OS rates were 90.9% and 80.4%, respectively. On multivariable analysis, the risk factor associated with recurrence was a pure solid tumour [hazard ratio, 23.151; 95% confidence interval 2.575-208.178; P = 0.005]. The non-pure solid tumour group had a significantly better probability of survival (5-year OS: 95.4% vs 77.2%; 10-year OS: 86.5% vs 61.8%; P < 0.0001). A total of 113 patients received preoperative positron emission tomography/computed tomography. Patients with a higher maximum standardized uptake value had a significantly higher recurrence rate. CONCLUSIONS: Segmentectomy for clinical stage I non-small cell lung cancer produced acceptable long-term outcomes. Pure solid radiographic appearance was associated with recurrence and decreased survival.

Usefulness of final transection of the proximal pulmonary artery in robotic left upper lobectomy.

OBJECTIVES: The pulmonary artery runs around the left upper bronchus, which poses the risk of blood vessel injury when cutting in the blind spot of the bronchus. During robotic surgery, the robotic arm holds the tissue under constant tension; therefore, even if the pulmonary artery is left for final transection, it is not injured by unexpected tension. In this study, we examined the usefulness of final transection of the proximal pulmonary artery in robotic left upper lobectomy. METHODS: This retrospective single-institution study evaluated patients who had undergone robotic lung resection. Of the 453 robotic lung resections performed at our institution between 2017 and 2022, 49 patients who had undergone left upper lobectomy were evaluated. Patients who had undergone bronchial transection followed by pulmonary artery transection were assigned to the group, bronchus prior transection (BT group, n = 38), and those who had undergone pulmonary artery transection followed by bronchial transection were assigned to the group, pulmonary artery prior transection (AT group, n = 11). Patient characteristics and perioperative outcomes were compared between the groups. RESULTS: The groups did not differ significantly in age, sex, smoking history, tumour size, complication rates or 30-day mortality. The BT group inclined to shorter operative times and lesser blood loss. No active intraoperative bleeding occurred in the BT group. However, the AT group had 2 cases of intraoperative pulmonary artery bleeding, one of which required urgent conversion to thoracotomy. CONCLUSIONS: Final transection of the proximal pulmonary artery is a novel and effective surgical technique for robotic left upper lobectomy.

[Robot-assisted Thoracic Surgery for Mediastinal and Chest Wall Tumors:Atypical Surgical Approaches by the Tumor Localization].

Surgery for mediastinal and chest wall tumors requires various approaches, including open and thoracoscopic, depending on the size and localization of the tumor. While robotic surgery for anterior mediastinal tumors has become a standardized approach, the approaches for tumors of the superior, middle, and posterior mediastinum, in particular, have not been generalized. Our institution introduced robotic surgery in 2017 and has performed 785 robot-assisted surgeries until November 2022. In this report, we describe our clinical experience with robotic surgery for mediastinal tumors, which required an atypical approach, as well as a case of hybrid robot-assisted extended surgery combined with an open chest procedure for lung cancer with chest wall invasion.

Surgical Outcome after Sleeve Pneumonectomy for Thoracic Malignancy: A Comparison Between Salvage and Non-salvage.

Objectives: Tumors invading the tracheobronchial angle or carina have long presented a challenge due to the complexity of airway reconstruction and management; thus, few medical centers have developed experience with this type of surgery. In this report, we review our experience with Sleeve Pneumonectomy (SP) and analyze both operative risks and outcomes. Materials and Methods: A retrospective review identified 34 patients who underwent SP: 19 underwent salvage SP and 15 underwent non-salvage SP. Salvage surgery was performed for recurrent lung cancer after chemoradiotherapy and could be considered if there were no other therapeutic options or in the presence of urgent symptoms, such as hemoptysis, obstructive pneumonia, superior vena cava syndrome, or tracheoesophageal fistula.The perioperative morbidity and oncological outcomes of salvage and non-salvage SP were analyzed. Results: Most cases were of lung cancer, whereas salvage SP included one case of SVC syndrome due to metastasis of colon cancer and one case of hemoptysis due to metastasis of leiomyosarcoma. Complications occurred in 47% of the non-salvage SP cases and 53% of the salvage SP cases. The 30-day mortality rates were zero in the non-salvage cases and 11% in the salvage cases. The 90-day mortality rates were 20% and 16% in the non-salvage and salvage groups, respectively. Conclusions: The salvage of SP after chemoradiotherapy or in the presence of urgent symptoms is feasible. We believe that it can be an option that improves quality of life (QOL) through longer desease-free survival (DFS) and alleviation of symptoms, rather than waiting for tumor growth progression and exacerbation of symptoms.

Hybrid robotic lobectomy with thoracic wall resection for superior sulcus tumor.

A major challenge in treating superior sulcus tumors is achieving complete surgical resection because of technical difficulties associated with the anatomical structures and approaches to the thorax. Our technique combines posterior minimally invasive thoracotomy with robot-assisted right upper lobectomy, thereby reducing the invasiveness of the surgical approach and postoperative complications, including wound pain. In the presented case, the tumor was located on the apical right upper lobe, directly invading the apical thoracic wall structures. Hybrid robotic and minimally invasive thoracotomy with thoracic wall resection was performed. The postoperative course was uneventful. The patient discharged from our hospital with minimal wound pain.

Salvage Surgery Compared to Surgery After Induction Chemoradiation Therapy for Advanced Lung Cancer.

BACKGROUND: Salvage surgery is performed for selected patients with relapses of locally advanced lung cancer after definitive chemoradiation therapy (CRT), and it seems to be effective. To assess the feasibility of salvage surgery after definitive CRT, this study compared clinical outcomes of surgery after definitive CRT with those of surgery after induction CRT. METHODS: Medical records of patients who underwent surgery from January 2000 to January 2018 were reviewed. The study compared patients with salvage anatomic pulmonary resection after definitive CRT with patients with surgery after induction CRT in terms of perioperative and long-term outcomes. RESULTS: A total of 23 patients underwent salvage surgery after definitive CRT for locally advanced lung cancer (salvage group), and 36 underwent surgery after induction CRT for cN2 stage III non-small cell lung cancer (induction CRT group). The surgical procedures in the salvage group were 2 segmentectomies, 13 lobectomies, 1 bilobectomy, and 7 pneumonectomies, and those in the induction CRT group were 34 lobectomies and 2 bilobectomies. There was no 30-day or 90-day mortality in either group. The 5-year overall survival was 44.7% for the salvage group and 58.6% for the induction CRT group. The 5-year progression-free interval was 42.2% for the salvage group and 47.7% for the induction CRT group. CONCLUSIONS: Salvage anatomic pulmonary resection after definitive CRT for locally advanced lung cancer is feasible, with acceptable morbidity and prognosis in highly selected patients.

Extended double sleeve lobectomy combined with thoracic wall resection to treat a huge lung cancer.

A 58-year-old man came to our hospital with numbness of the left arm, fatigue, and fever. A huge solid mass with necrotic changes located in the left upper lobe was noted on the computed tomography scan. The tumor directly invaded the extrathoracic wall, the left main pulmonary artery, and the superior segment of the lower lobe. To avoid pneumonectomy, a combination of an extended double sleeve lobectomy and thoracic wall resection was performed. The postoperative course was uneventful. The patient has survived without any recurrence for 6 months postoperatively.

Factors Associated with Unexpected Readmission Following Lung Resection.

BACKGROUND: Identification of the predictors of readmission can facilitate appropriate perioperative management. The current study aimed to investigate the potential predictors of unexpected readmission after lung resection for primary lung cancers. METHODS: This retrospective study enrolled 1000 patients who underwent pulmonary resection for lung cancer at our institution between January 2016 and December 2017. Unexpected readmission was defined as unscheduled readmission to our hospital within 30 days after discharge. Univariate and multivariate analyses were performed for identification of perioperative factors associated with readmission. RESULTS: Forty-three patients (4.3%) required unexpected readmission, and the median interval between the day of discharge and readmission was 10 days (range 1-29 days). The reasons for readmission included empyema and pleural effusion (n = 11), acute exacerbation of idiopathic pulmonary fibrosis (n = 7), pneumothorax (n = 7), and others (n = 18). The median hospitalization length after readmission was 14 days (range 2-90 days). Four patients (9.3%) died in the hospital because of acute exacerbation of idiopathic pulmonary fibrosis after readmission. In multivariate logistic regression analysis, postoperative refractory air leakage, defined as prolonged air leakage lasting > 5 days or requiring reoperation, was identified as a significant predictor associated with an increased risk of readmission (odds ratio 2.87; 95% confidence interval 1.22-6.72; p = 0.015). CONCLUSIONS: Unexpected readmission was an inevitable event following lung resection. Patients with readmission had an increased risk of death. Refractory air leakage after lung resection for primary lung cancer was strongly associated with unexpected readmission.

Salvage surgery after chemotherapy and/or radiotherapy including SBRT and proton therapy: A consecutive analysis of 38 patients.

BACKGROUND: Local recurrence after definitive chemoradiation therapy, chemotherapy or radiotherapy with curative intent is often seen in patients with advanced non-small cell lung cancer. We evaluated the feasibility of salvage pulmonary resection after definitive non-surgical treatments and the postoperative morbidity and mortality rates. METHODS: We retrospectively analyzed the characteristics and medical courses of patients who had undergone salvage pulmonary resections after local relapse or progression between January 2000 and March 2018 at the National Cancer Centre Hospital, Tokyo, Japan. All the candidates were evaluated, and curability by surgical resection was assessed by a multidisciplinary tumor board. RESULTS: A total of 38 patient received salvage surgery: 26 of the patients were men, and the median age was 64.5 years (range, 20-78 years). Among these 38 patients, salvage lung resection was performed after chemoradiotherapy in 23 patients, after chemotherapy in 9 patients, and after radiotherapy with curative intent in 6 patients. The surgical resection methods were as follows: 26 lobectomies (2 bilobectomy, 15 right upper, 5 right lower, 1 right middle, 2 left lower and 1 left upper), 8 pneumonectomies (5 left and 3 right), and 4 segmentectomies. A complete resection (R0 resection) was achieved in 35 cases (92.1 %). Postoperative complications were observed in 3 patients (prolonged air leakage, bronchopleural fistula and surgical site infection in 1 patient each). No postoperative deaths occurred within 30 days after surgery. CONCLUSION: Along with better outcomes after definitive chemoradiotherapy, chemotherapy, and radiotherapy, the frequency of salvage surgery has been increasing in recent years. Salvage pulmonary resections after definitive non-surgical treatments with curative intent are feasible with an acceptable morbidity rate and oncological outcomes in thoroughly assessed patients.

Aberrant mediastinal trunk of pulmonary artery.

Anatomic variations of the pulmonary artery (PA) cause vascular injuries and result in critical mistakes. Here we report the first case of lung cancer with a fissureless left upper lobectomy, an aberrant mediastinal trunk of the lingular and basal segments of the PA. A 65-year-old man was referred to our hospital with a solid mass on the left upper lobe. A fissureless left upper lobectomy was performed due to severe incomplete lobulation. Intraoperative findings showed an extremely rare anatomic variation (left A5+A8+A9b) that arose as a common trunk from the left main PA. To prevent intraoperative injury, it is essential to consider the unexpected mediastinal inferior branch and perform a surgical procedure such as fissureless lobectomy upon encountering incomplete lobulation.

Trimodality therapy for superior sulcus tumour: experience of a single institution over 19 years.

OBJECTIVES: Induction chemoradiotherapy followed by surgery is the standard treatment for superior sulcus tumours (SSTs). However, the protocols, chemotherapy agents and cycles used as well as the mode and intensity of radiotherapy vary between institutions. Thus, the objective of the study was to investigate the effects of trimodality therapy on the outcomes of patients with SSTs. METHODS: Sixty patients with SSTs were enrolled between January 1999 and December 2017. Induction therapy consisted primarily of 2 cycles of mitomycin-vindesine-cisplatin or cisplatin-vinorelbine delivered concurrently to the tumour with 40-45 Gy of radiation. Surgery was performed 2-6 weeks after completion of induction therapy. RESULTS: Fifty-four (90%) patients underwent radical surgical resection. Complete pathological resection was achieved in 44 patients (81%). There was no 30-day mortality. After a median follow-up of 57.0 months, 19 (35%) patients experienced recurrence, and 8 (15%) patients showed brain metastasis. A pathological complete response (PCR) was observed in 12 (22%) patients. The 5-year survival rate for the entire population (n = 54) was 69% (95% confidence interval 55-81%). The survival rate was better for patients who underwent complete resection than for those who underwent incomplete resection (73% vs 51%, P = 0.46). A better survival rate was evident in patients with PCR than in those without PCR (92% vs 62%, P = 0.12). CONCLUSIONS: Trimodality therapy for SSTs was efficacious and associated with favourable outcomes, with acceptable morbidity and mortality. PCR in patients with resected SSTs reveals promising long-term survival prospects with the trimodality therapy.

Radiopathologic correlation of collision lung cancer with ground-glass opacity.

Pulmonary collision tumors have been described as a special entity of synchronous multiple lung cancer. There have been no reports detailing the chronological changes in primary collision lung cancers on chest computed tomography. We report a case of ground-glass lung nodules gradually colliding with each other. The collision tumors of the lung were composed of minimally invasive adenocarcinoma and adenocarcinoma in situ with epidermal growth factor mutations. Immunohistochemically, the Ki-67 labeling indices were different in the 2 components. Ki-67 staining was useful to distinguish the 2 components. The 2 dominant ground-glass tumors grew slowly with radiologic and pathologic heterogeneity.

Effective treatment of empyema with bronchopleural fistula after esophagectomy by endobronchial embolization using endobronchial Watanabe Spigots.

INTRODUCTION: Empyema and bronchopleural fistula are well known complications after thoracic surgery. We report a case of refractory air leakage of bronchopleural fistula in a patient with empyema that was successfully treated by endobronchial embolization using Endobronchial Watanabe Spigots (EWSs). PRESENTATION OF CASE: A 71-year-old man underwent esophagectomy for primary esophageal cancer. A right empyema with bronchopleural fistula (BPF) developed four months after surgery. Right thoracic drainage tube was inserted. Although the empyema was treated by drainage and anti-biotics therapy, the air leakage was apparent. The chest computed tomography (CT) scan revealed that the bronchopleural fistula existed in the segment 6 and 10. Endobronchial embolization was performed to the responsible bronchus using EWSs. After the EWSs of middle and large sizes were inserted into the B6c and B10b+c, the air leakage was stopped. The thoracic tube of drainage was removed after endobronchial embolization. Complications due to the EWSs insertion were not observed, and the patient was discharged. DISCUSSION: The management of BPF has evolved over the years. Surgical approach is frequently needed to control the BPF, though endobronchial embolization is effective in closing the BPF in some patients. In our case, EWSs of middle and large size were useful to control air leakage. We safely retried the 2nd endoboronchial embolization using the EWS. The patient had no complication after insertion the EWS again. CONCLUSION: Endobronchial embolization using EWSs was an effective treatment of an empyema with bronchopleural fistula after esophagectomy.

Genomic Amplification of CD274 (PD-L1) in Small-Cell Lung Cancer.

Purpose: Programmed death ligand-1 (PD-L1), encoded by the CD274 gene, is a target for immune checkpoint blockade; however, little is known about genomic CD274 alterations. A subset of small-cell lung cancer (SCLC) exhibits increased copy number of chromosome 9p24, on which CD274 resides; however, most SCLCs show low expression of PD-L1. We therefore examined whether CD274 is a target of recurrent genomic alterations.Experimental Design: We examined somatic copy number alterations in two patient cohorts by quantitative real-time PCR in 72 human SCLC cases (cohort 1) and SNP array analysis in 138 human SCLC cases (cohort 2). Whole-genome sequencing revealed the detailed genomic structure underlying focal amplification. PD-L1 expression in amplified cases from cohorts 1 and 2 was further examined by transcriptome sequencing and immunohistochemical (IHC) staining.Results: By examining somatic copy number alterations in two cohorts of primary human SCLC specimens, we observed 9p24 copy number gains (where CD274 resides) and focal, high-level amplification of CD274 We found evidence for genomic targeting of CD274, suggesting selection during oncogenic transformation. CD274 amplification was caused by genomic rearrangements not affecting the open reading frame, thus leading to massively increased CD274 transcripts and high level expression of PD-L1.Conclusions: A subset (4/210, 1.9%) of human SCLC patient cases exhibits massive expression of PD-L1 caused by focal amplification of CD274 Such tumors may be particularly susceptible to immune checkpoint blockade. Clin Cancer Res; 23(5); 1220-6. ©2016 AACR.

Surgical intervention strategy for postoperative chylothorax after lung resection.

PURPOSE: The optimal surgical management of postoperative chylothorax has not been established. Thus, we evaluated the treatment strategy for postoperative chylothorax and identified associated predictors of surgical intervention. METHODS: The subjects of this retrospective study were 50 patients who suffered postoperative chylothorax, representing 4 % of 1235 patients who underwent pulmonary resection between 2008 and 2012. The chylothorax patients were classified into two groups based on their postoperative management: a conservative group and a surgical group. The following parameters were investigated to establish the predictors of surgical intervention for chylothorax: mode of surgery, preoperative complications, intraoperative management, and postoperative clinical status. RESULTS: Forty-one (82 %) patients were treated conservatively and 9 (18 %) underwent reoperation, as direct or concomitant ligation of the thoracic duct at the point of leakage. The frequency of postoperative chest tube drainage just after initial surgery was significantly greater in the surgical group than the conservative group before oral intake was restarted (448 ± 189 vs. 296 ± 117 ml/12 h, respectively; p = 0.003). Furthermore, it was a significant predictor of reoperation based on a multivariate analysis (p = 0.010). CONCLUSIONS: The amount of chest tube drainage just after surgery and before oral intake was a useful predictor to help us decide on the need for early surgical intervention for postoperative chylothorax.