Repeat pulmonary resection for lung malignancies does not affect the postoperative complications: a retrospective study.

BACKGROUND: Although repeat pulmonary resection (RPR) for multiple lung cancer has been performed for non-small cell lung cancer and metastatic lung tumor, with the prognostic benefit detailed in several reports, the risk of RPR has not been well analyzed. METHODS: Patients with lung malignancies who underwent complete resection at Kanazawa Medical University between January 2010 and October 2019 were analyzed. The relationship between postoperative complications and preoperative and perioperative factors was analyzed. Postoperative complications were categorized into five grades according to the Clavien-Dindo classification system. RESULTS: A total of 41 patients who were received RPR were enrolled in this study. Primary lung tumor was found in 31 patients, and metastatic lung tumor was found in 10 patients. The postoperative complication rate of the first operation was 29%, and that of the second operation was 29%. While there were no significant factors for an increased incidence of postoperative complication in a multivariate analysis, an operation time over 2 h at the second operation tended to affect the incidence of postoperative complication (p = 0.06). Furthermore, the operation time was significantly longer (p = 0.02) and wound length tended to be longer (p = 0.07) in the ipsilateral group than in the contralateral group. The rate of postoperative complications and the length of the postoperative hospital stay were not significantly different between the two groups. CONCLUSION: RPR is safely feasible and is not associated with an increased rate of postoperative complications, even on the ipsilateral side.

Individualization of risk factors for postoperative complication after lung cancer surgery: a retrospective study.

BACKGROUND: The risk factors for postoperative complications after pulmonary resection in patients with non-small cell lung cancer (NSCLC) have not been elucidated. METHODS: Clinical data of 956 patients with NSCLC were analyzed. Patient factors such as sex, age, comorbidities, smoking history, respiratory function, and the lobe involved in lung cancer and operative factors such as operative approach and operative procedures were collected and analyzed. RESULTS: Male sex (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 1.09-2.75, p = 0.01), coexistence of asthma (OR 2.68, 95% CI 1.19-6.02, p = 0.01), low percentage of forced expiratory volume in 1 s (FEV1) (OR 1.41, 95% CI 1.02-1.95, p = 0.03), and lobectomy or greater resection (OR 2.47, 95% CI 1.66-3.68, p < 0.01) were identified as significant risk factors for postoperative complications. Male sex (OR 1.98; 95% CI 1.03-3.81, p = 0.03) and complete video-assisted thoracic surgery and robot-assisted thoracic surgery (OR 1.64; 95% CI 1.09-2.45; p = 0.01) were identified as significant risk factors for postoperative air leakage. Coexistence of asthma (OR 9.97; 95% CI 3.66-27.38; p < 0.01) was identified as a significant risk factor for postoperative atelectasis or pneumonia. Lobectomy or greater resection (OR 19.71; 95% CI 2.70-143.57; p < 0.01) was identified as a significant risk factor for postoperative arrhythmia. CONCLUSION: Male sex, coexistence of asthma, low percentage of FEV1, and operative procedure were significant risk factors for postoperative complications. Furthermore, risk factors varied according to postoperative complications.

Operative invasiveness does not affect the prognosis of patients with non-small cell lung cancer.

BACKGROUND: The relationship between operative invasiveness and the prognosis in non-small cell lung cancer (NSCLC) patients who have undergone surgery has been controversial. METHODS: Clinical data were analyzed for 463 NSCLC patients. Operative invasiveness was defined by wound length, operation time, and the postoperative C-reactive protein (postCRP) level. The operative approach was divided into video-assisted thoracic surgery (VATS) and thoracotomy. RESULTS: The wound length and operation time were significantly correlated with the postCRP level (correlation coefficient (CC) = 0.39, p <  0.01; CC = 0.54, p <  0.01, respectively). The postCRP level in the VATS group was significantly lower than that in the thoracotomy group (12.2 mg/dl vs 20.58 mg/dl, p <  0.01). The relapse-free survival differed significantly based on wound length (p <  0.01), operation time (p = 0.01), CRP level (p <  0.01), and operative approach (p <  0.01). The carcinoembryonic antigen level (hazard ratio [HR], 1.58; p = 0.02), pathological stage (pStage) (HR, 2.57; p <  0.01), vascular invasion (HR, 1.95; p = 0.01), and preoperative CRP level (preCRP) (HR, 1.91; p <  0.01) were identified as significant prognostic factors for relapse-free survival in a multivariate analysis. Furthermore, the multivariate analysis showed that smoking history (HR, 2.36; p = 0.03), pStage (HR, 3.26; p <  0.01), and preCRP level were significant prognostic factors for overall survival. CONCLUSION: Preoperative CRP level was associated with poor prognosis. Although the VATS approach might be less invasive procedure for NSCLC patients, operative invasiveness does not affect the prognosis.

[Lung Adenosquamous Cell Carcinoma in which the Administration of Nivolumab Became Untenable due to Bleeding from Small Intestine Metastasis].

A 59-year-old man who had postoperative recurrence of lung adenosquamous cell carcinoma was administered nivolumab as 3rd-line chemotherapy. Although nivolumab was considered effective, bleeding from a metastatic lesion at the jejunum was recognized by double-balloon enteroscopy, and partial resection was performed. Although the re-administration of nivolumab was planned, the patient died of acute respiratory failure 6 days postoperatively.

[A Case of Sigmoid Cancer with Six Asynchronistic Metastases to Multiple Organs That Were Resected through Four Surgeries].

A 49-year-old man underwent sigmoidectomy for the diagnosis of type 2 sigmoid cancer. Pathological findings showed a tumor 3.5×4.0cm in size, type 2, pSS, ly2, v1, pN0, cH0, cP0, cM0, pStageⅡ, R0. Asynchronistic metastases to the liver and lungs were subsequently found. Left hepatectomy was performed for 1 liver metastasis, and 4lung metastases were resected through 3 surgeries. A subcutaneous tumor in an abdominal wall scar was also resected in the 4th surgery for metastasis resection. All pathological diagnoses were metastases from sigmoid cancer, and complete curative resection was possible. The final surgery was performed 1 year and 1 month prior, and the patient has now survived without recurrence for 10 years and 2 months after sigmoidectomy. Chemotherapy was not administered during the whole course. This case shows that longterm survival is possible with repeated resection of recurrent metastasis of sigmoid cancer.

A survey about further work-up for cases with positive sputum cytology during lung cancer mass screening in Ishikawa Prefecture, Japan: a retrospective analysis about quality assurance of lung cancer screening.

OBJECTIVE: In cancer screening programs, performing appropriate further work-up is essential. In order to elucidate whether the further work-up for the subjects with positive screening results by sputum cytology was performed appropriately, the present study was conducted as the first large-scale thorough survey in Japan. METHODS: All of the lung cancer screening records from 2007 to 2012 in Ishikawa Prefecture were reviewed. Additional investigations about the further work-up were performed. RESULTS: In total, 2 234 984 people were invited to undergo lung cancer screening, and 494 424 people participated in the screening. Of these, 25 264 people underwent sputum cytology, and 68 positive cases were identified. Three of these 68 cases did not undergo further work-up, and another three cases had already been diagnosed to have lung cancer. Forty-five of the remaining 62 cases did not have suspicious chest shadows, and bronchoscopic examinations were performed in 36 cases. Seventeen of these 36 cases were diagnosed as having cancer, whereas none of the nine cases who did not receive the examination was diagnosed (P = 0.038). A bronchoscopic examination was not performed due to other medical conditions in three cases, due to the patient's refusal in another three cases and in the remaining three cases, the reasons were unknown. CONCLUSION: The participation rate for further work-up was very high. However, there are some issues to be resolved regarding the transmission of information. With our new registered hospital system, the quality assurance of our screening program will be improved.

Postoperative drainage with one chest tube is appropriate for pulmonary lobectomy: a randomized trial.

To expand postoperative residual lungs after pulmonary lobectomy, thoracic drainage with two chest tubes has been recommended. Several studies recently demonstrated that postoperative drainage with one chest tube (PD1) was as safe as that with two chest tubes (PD2). However, most of the patients in those studies underwent lobectomy by standard thoracotomy. Although the number of pulmonary lobectomies by video-assisted thoracic surgery (VATS) has been increasing in recent years, there have been no reports that compared PD1 with PD2 after pulmonary lobectomy, including that by VATS. To elucidate whether postoperative management with PD1 is as safe as that with PD2, we conducted a randomized controlled trial. Lung cancer patients who underwent lobectomies with mediastinal nodal dissection in our hospital were assigned to one of two groups: one chest tube placed in PD1 group and two chest tubes placed in PD2 group. A total of 108 patients were registered in the study. There were no significant differences in the age, gender, pathological stage or histological type between two groups. Since the residual lung expansion was good in both groups, there were no patients who needed thoracentesis. There were no significant differences in the number of cases with pleurodesis, the amount/duration of drainage or the pain of the patients between two groups. In conclusion, since PD1 has advantages in saving cost and time and in low risk of transcutaneous infection, PD1 is appropriate after pulmonary lobectomy by VATS and by open thoracotomy.

Advantages of diffusion-weighted imaging over positron emission tomography-computed tomography in assessment of hilar and mediastinal lymph node in lung cancer.

BACKGROUND: The significance of diffusion-weighted imaging (DWI) is uncertain for the diagnosis of nodal involvement. The purpose of this study was to examine diagnostic capability of DWI compared with PET-CT for nodal involvement of lung cancer. METHODS: A total of 160 lung cancers (114 adenocarcinomas, 36 squamous cell carcinomas, and 10 other cell types) were analyzed in this study. DWI and PET-CT were performed preoperatively. RESULTS: The optimal cutoff values to diagnose metastatic lymph nodes were 1.70 × 10(-3) mm(2)/s for ADC value and 4.45 for SUVmax. DWI correctly diagnosed N staging in 144 carcinomas (90 %) but incorrectly diagnosed N staging in 16 (10 %) [3 (1.9 %) had overstaging, 13 (8.1 %) had understaging]. PET-CT correctly diagnosed N staging in 133 carcinomas (83.1 %) but incorrectly diagnosed N staging in 27 (16.8 %) [4 (2.5 %) had overstaging, 23 (14.4 %) had understaging]. Sensitivity, accuracy, and negative predictive value for N staging by DWI were significantly higher than those by PET-CT. Of the 705 lymph node stations examined, 61 had metastases, and 644 did not. The maximum diameter of metastatic lesions in lymph nodes were 3.0 ± 0.9 mm in 21 lymph node stations not detected by either DWI or PET-CT: 7.2 ± 4.1 mm in 39 detected by DWI, and 11.9 ± 4.1 mm in 24 detected by PET-CT. There were significant differences among them. The sensitivity (63.9 %) for metastatic lymph node stations by DWI was significantly higher than that (39.3 %) by PET-CT. The accuracy (96.2 %) for all lymph node stations by DWI was significantly higher than that (94.3 %) by PET-CT. CONCLUSIONS: DWI has advantages over PET-CT in diagnosing malignant from benign lymph nodes of lung cancers.

[Screening for lung cancer: present and future].

A certified method for lung cancer screening in Japan is the combination of chest X-ray and sputum cytology. The chest Xray examination is intended primarily for the detection of peripheral-type lung cancer. Interpretation of the films should be performed by two different physicians, and the films of screenees suspected to have abnormal shadow should be compared to the same screenee's films from previous screening visits. Sputum cytology is conducted for heavy smokers, and is useful for early detection of central lung cancer. The efficacy of this lung cancer screening method has been shown in several case control studies. There are some problems to solve i. e., a low rate of attendance and inadequate quality control. Low-dose thoracic CT screening is performed with an exposure within a single breath hold, and its interpretation can be conducted with films, CRT, or a LCD monitor. Even when taken at low doses, the radiation exposure dose is large compared to a chest X-ray, being about 3-10 times greater than the absorbed dose and 20-40 times greater than the effective dose. Since the radiation dose in a usual clinical condition is much higher, the clinical condition is not recommended for screening. Concerning the efficacy of low-dose CT screening for heavy-smokers, a positive result was reported in June 2011, and further detailed analyses are required. There are still some problems to solve i. e., the management of undiagnosed shadows, harm caused by the screening, quality control, and efficacy in non-smokers.

Genomics of Tumor Origin and Characteristics for Adenocarcinoma and Malignant Pleural Mesothelioma: A Case Report.

A female underwent a right middle lobectomy for a pulmonary adenocarcinoma (AD). She eventually died of a right malignant pleural mesothelioma (MPM; sarcomatoid type) 4 years and 7 months after the removal of the AD even though she did not have any history of asbestos exposure, smoking, or radiation exposure. Her chest CT revealed multiple pulmonary nodules and bilateral pleural effusion with a right pleural tumor directly invading into the abdominal cavity. The genomics of tumor origin and characteristics were examined for the AD and the MPM. As a result, 50 somatic variants were detected in the AD, and 29 somatic variants were detected in the MPM. The variants which were common in both the AD and the MPM were not present, which suggested that the AD and the MPM had occurred independently in different origins. The MPM had two driver oncogenes of TP53 and EP300, but the AD did not. Two driver oncogenes of TP53 and EP300 were hypothesized to make the MPM aggressive. The speed at which the MPM progressed without the patient having a history of asbestos exposure, smoking, or radiation exposure was alarming.

Role of indocyanine green in anomalous arterial supply to the normal dorsobasal segment of the lung.

BACKGROUND: Anomalous systemic arterial supply to normal basal lung segments is a rare congenital malformation, in which aberrant arteries arising from the systemic circulation flow into the basal segment of the lung and return to normal pulmonary veins without abnormal bronchial branching. It presents a left-to-right shunt, resulting in volume overload of the pulmonary circulation, and consequently, pulmonary hypertension. Therefore, nearly all cases require surgery. Herein, we present a case, in which indocyanine green was used to demarcate the lung segment perfused by an anomalous systemic artery. CASE PRESENTATION: A 15-year-old boy was diagnosed with an anomalous artery originating from the celiac artery and supplying the right dorsobasal lung segment (S10). Via three-port video-assisted thoracoscopic surgery, the anomalous artery was ligated and processed with an auto-stapler. Indocyanine green was injected intravenously to identify the tissue perfused by the anomalous artery, and the lung was resected. CONCLUSIONS: With anomalous systemic arterial supply to normal basal lung segments, indocyanine green can be particularly helpful in identifying the boundaries of the perfused area. Then, the affected tissue can be resected by thoracoscopic surgery.

Cytological characteristics of pulmonary pleomorphic and giant cell carcinomas.

OBJECTIVE: To establish cytological features of pulmonary pleomorphic carcinoma (PC) or giant cell carcinoma (GC), we evaluated the cytological characteristics of these tumors using a multidisciplinary approach. STUDY DESIGN: Samples from 13 surgically resected and histologically confirmed PC or GC patients were collected from our institutes. Eight cases without prior chemotherapy before surgery were selected, and cytological features were analyzed. RESULTS: The background contained numerous lymphocytes and neutrophils. The tumor cells were arranged in flat loose clusters, but some were in fascicles. The shape of the tumor cell was spindle or pleomorphic, and the sizes of the tumor cells varied by more than 5-fold. The tumor cells had an abundant, thick and well-demarcated cytoplasm. The location of the nucleus was centrifugal, and the nucleus was oval or irregularly shaped. Multinucleated giant cells were frequently observed. The size of the nucleus was more than 5 times that of normal lymphocytes, and its size also varied by more than 5-fold. The nuclear membrane was thin, and nuclear chromatin was coarsely granular, while the nucleolus was single and round. CONCLUSION: PC or GC has characteristic cytological features, however, spindle cells tended to be hardly observed in cytological specimens in some cases.

Prognostic Impact of Sphingosine Kinase 1 in Nonsmall Cell Lung Cancer.

Bioactive sphingolipid is clearly relevant to lung physiology. The relationship of the bioactive sphingolipid pathway to pulmonary disease has been studied in cellular, tissue, and animal model, including lung cancer models. The samples of 53 patients diagnosed with nonsmall cell lung carcinoma (NSCLC) between June 2009 and May 2014 at our hospital were analyzed. Immunohistochemical (IHC) analysis was performed. The degree of immunostaining was reviewed and scored. Using this method of assessment, we evaluated the IHC score of sphingosine kinase 1 (SPHK1), vimentin, E-cadherin, and Ki-67. Both invasive adenocarcinoma cell and squamous cell carcinoma cell were well stained by SPHK1, and fibroblasts were also well stained by SPHK1. Although the IHC score of SPHK1 was not significantly differed between invasive adenocarcinoma and squamous cell carcinoma, the IHC scores of fibroblast, vimentin, and Ki-67 were higher in squamous cell carcinoma than invasive adenocarcinoma. Correlation among IHC scores in each of invasive adenocarcinoma and squamous cell carcinoma was performed. SPHK1 had positive correlation with both fibroblast and Ki-67, and fibroblast and Ki-67 had also positive correlation in invasive adenocarcinoma. On the contrary, SPHK1 had no significant correlation with fibroblast, and had negative correlation with Ki-67 in squamous cell carcinoma. Although there was not significant prognostic difference in SPHK1 score (P = .09), IHC score high group tended to be worse on relapse-free survival. SPHK1 might be prognostic factor in lung-invasive adenocarcinoma and novel target for drug against lung-invasive adenocarcinoma.

Risk factors of chest wall invasion in non-small cell lung cancer.

BACKGROUND: The risk factors for the development of chest wall invasion (CWI) in non-small cell lung cancer (NSCLC) patients are unclear. If the risk factors for the development of CWI can be clarified, surgical treatment might be able to be performed before CWI development, thus improving the prognosis. METHODS: In the present study, we enrolled patients who received surgery for NSCLC between January 2008 and December 2019 with available data on the maximum standardized uptake value (SUVmax) on positron emission tomography (PET) with lesions adjacent to the visceral pleura. Furthermore, the preoperative white blood cell (WBC) count, the preoperative neutrophil-to-lymphocyte ratio (NLR), platelet (Plt) count, levels of lactate dehydrogenase (LDH) and C-reactive protein (CRP) were analyzed as predictive factors of CWI. RESULTS: The relationships between CWI and clinicopathological variables were analyzed, and there were significant differences between patients with and without CWI in the age (P=0.02), maximum tumor diameter on computed tomography (CT) (P<0.01), diameter of tumors adjacent to the visceral pleura (Pmax) (P<0.01), SUVmax (P<0.01), maximum tumor diameter on a pathological examination (P<0.01), WBC count (P=0.03), Plt count (P=0.04), and levels of LDH (P<0.01) and CRP (P=0.01). Logistic regression analyses of the risk factors related to CWI showed that the age (P=0.02), Pmax (P=0.02), SUVmax (P=0.01), and LDH (P<0.01) were significant risk factors. CONCLUSIONS: The age, Pmax, SUVmax, and LDH levels might be associated with CWI.

Benign emptying of the post-pneumonectomy space: A case report.

INTRODUCTION AND IMPORTANCE: Benign emptying of the post-pneumonectomy space (BEPS) is characterized by a decreased air-fluid level after pneumonectomy, albeit without the presence of bronchopleural fistula (BPF). CASE PRESENTATION: A 66-year-old man with lung cancer diagnosed clinical stage IIIA received right pneumonectomy. The air-fluid level of the right pleural cavity suddenly dropped on the 19th postoperative day. Although we were unable to detect the fistula of the bronchial stump using bronchoscopy, we performed re-operationt. Although a pressure of 30 cmH2O was applied into the airway and air leakage from the bronchial stump was not detected, we covered the bronchial stump with the omentum. Because the air-fluid level of the right pleural cavity decreased 9 days after the 2nd operation without any symptom, we diagnosed the condition as BEPS. CLINICAL DISCUSSION: If a fistula of the bronchial stump cannot be identified using bronchoscopy or thoracoscopy, then determining whether it is BEPS or microscopic BPF can be difficult. CONCLUSION: It is currently unclear what the optimal strategy is in this case.

Unusual local and distant metastases after complete resection of roentgenographically occult squamous cell carcinoma.

Roentgenographically occult squamous cell carcinoma (ROSCC) was reported to have been cured after complete resection. We experienced unusual local and distant metastases after complete resection of a ROSCC of left B6 bronchus. During the operation due to the proximal bronchial stump being positive for squamous cell carcinoma (SCC), a left lower sleeve lobectomy was performed. Six years after the operation, a chest CT showed no abnormal shadows. 6 months later a PET-CT showed metastases on bilateral supraclavicular lymph nodes, mediastinal lymph nodes, and the right adrenal glands. A biopsy of the right supraclavicular lymph node revealed that it was a metastatic SCC. The possibility of recurrence from a second pulmonary SCC might still remain. A prolonged follow-up over many years is desirable for a heavy smoker with a ROSCC.

Differentiation between suture recurrence and suture granuloma after pulmonary resection for lung cancer by diffusion-weighted magnetic resonance imaging or FDG-PET / CT.

There has been no publication which supports the usefulness of DWI differentiating for suture recurrence and suture granuloma after resection for lung cancer. We presented efficacy of DWI or FDG-PET/CT for an assessment of suture lesions after resection for lung cancer. Thirteen suture recurrences and 15 suture granulomas were examined. There were 24 adenocarcinomas and 4 squamous cell carcinomas, and 26 partial resections and 2 segmentectomies. The period of time (907±907 days) between surgery and suture recurrence was not significantly longer than that (546±547 days) between surgery and suture granuloma. Diffusion detectability scores (a 5-point scale) of suture recurrences was significantly higher than that of suture granulomas. The ADC value (1.35±0.24 × 10-3mm2/sec) of suture recurrences was significantly lower than that (1.85±0.60 × 10-3mm2/sec) of suture granulomas. The SUVmax (6.1 ±â€¯5.0) of suture recurrences was not significantly higher than that (4.2 ±â€¯2.5) of suture granulmas. The sensitivity of 85% (11/13) with DWI was not significantly higher than 69% (9/13) with FDG-PET/CT for suture recurrences. The specificity of 73% (11/15) with DWI was not significantly higher than the 60% (9/15) with FDG-PET/CT for suture granulomas. The accuracy of 79% (22/28) with DWI was not significantly higher than that of 64% (18/28) with FDG-PET/CT for suture recurrences and granulomas. DWI can differentiate suture granuloma from suture recurrence after resection of lung cancer. DWI is more useful than FDG-PET/CT for the differentiation between suture recurrence and suture granuloma after resection for lung cancer.

Diffusion-weighted whole-body imaging with background suppression (DWIBS) is effective and economical for detection of metastasis or recurrence of lung cancer.

BACKGROUND: Diffusion-weighted whole-body imaging with background suppression (DWIBS) is used for the diagnosis and staging of cancers. The medical cost of an MR examination including DWIBS is $123, which is 80% less expensive than the cost ($798) of F18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) examination. METHODS: This study examined the efficacy of DWIBS for relapses after lung cancer resection. A total of 55 patients who had pulmonary resection of lung cancer, postoperative computed tomography (CT) every six months, and DWIBS and FDG-PET/CT (every year) were enrolled in this study. If a metastatic lesion was detected on CT scan, DWIBS and FDG-PET/CT were also used. RESULTS: A total of 55 patients who underwent pulmonary resections for lung cancer, and had CT, DWIBS and FDG-PET/CT examination during follow-up after pulmonary resection were enrolled in this study. Lung cancer in 32 patients relapsed. Postoperative radiographic examinations revealed pulmonary metastases in 17 patients, bone metastases in seven, liver metastases in five, lymph node metastases in five, pleural metastases in four, metastases to the chest wall in two, brain metastases in two, adrenal gland metastasis in one, and renal metastasis in one. The mean apparent diffusion coefficient (ADC) value of the relapse was 0.9 to 1.70 × 10-3 mm2 /s. The accuracy 0.98 (54/55) of DWIBS for detecting multiple metastatic lesions was likely to be higher than 0.94 (52/55) of CT or 0.94 (52/55) of FDG-PET/CT, but there were no significant differences. CONCLUSIONS: DWIBS can detect multiple metastatic lesions throughout the entire body and differentiate malignancy from benignity in only one examination. DWIBS has benefits of diagnostic accuracy and is less expensive in medical costs for the detection of a relapse. DWIBS could potentially replace FDG-PET/CT after lung cancer resection.