[Carinal Resection and Reconstruction for Second Primary Lung Cancer Five Years After the Left Upper Lobectomy].

A tumor was detected at the tracheal carina to the orifice of the left main bronchus in a 66-year-old man who had undergone a left upper lobectomy for lung cancer five years before and was diagnosed as a squamous cell carcinoma. Carinal resection and reconstruction was performed because of the tumor relapse after the treatment by argon plasma coagulator. Carinal resection was performed under the median sternotomy with reconstruction by the montage method. The patient was discharged on the 8th postoperative day without any postoperative complications.

[Growing Mixed Squamous Cell and Glandular Papilloma Difficult to Differentiate from Primary Lung Cancer:Report of a Case].

A 76-year-old woman was referred to our hospital due to abnormal chest radiography findings. Chest computed tomography (CT) revealed a nodule in the right lower lobe. Fluorodeoxyglucose-positronemission tomography (FDG-PET) showed abnormal accumulation in the nodule. Bronchoscopy did not provide a definitive diagnosis. Since the nodule tended to increase in size, primary lung cancer was suspected and surgery was performed. During the surgery, pathological diagnosis of squamous cell carcinoma was made, and a right lower lobectomy was performed. Subsequently, a pathological diagnosis of mixed squamous cell and glandular papilloma (mixed papilloma) was made. She has had no sign of recurrence for approximately four years since the surgery.

[Diffuse Pulmonary Meningotheliomatosis Needed to be Differentiate from Metastatic Lung Tumor:Report of a Case].

A 77-year-old woman was found to have multiple granular shadows in the bilateral lungs and a right mammary mass on chest computed tomography (CT) scan for preoperative check of colorectal cancer. The right mammary mass was diagnosed as breast cancer as a result of vacuum-assisted breast biopsy. Fluorodeoxyglucose-positron emission tomography( FDG-PET) showed no abnormal uptake in the lung fields. Since a transbronchial lung biopsy did not establish a diagnosis, an incisional biopsy was performed via a thoracoscopic approach. The histology of the pulmonary nodules revealed minute pulmonary meningothelial-like nodules (MPMNs) and the patient was diagnosed with diffuse pulmonary meningotheliomatosis (DPM). When multiple pulmonary nodules are found in patients with coexisting malignancy, DPM should be considered in addition to metastatic lung tumors.

Prognostic significance of propofol-based intravenous anesthesia in early-stage lung cancer surgery.

PURPOSE: The purpose of this study was to assess whether the anesthetic type is associated with the prognosis of pathological stage I non-small cell lung cancer (NSCLC). METHODS: Clinicopathological data from 431 consecutive patients who underwent lobectomy for NSCLC between 2010 and 2016 were collected. Patients were classified into groups according to the type of anesthesia: propofol-based total intravenous anesthesia (TIVA) or inhalation anesthesia (INHA). We investigated the prognostic differences between these two groups. RESULTS: A total of 72 patients in the TIVA group and 158 patients in the INHA group were eligible for the analysis. Recurrence was observed in 4 (5.6%) patients in the TIVA group and 19 (12.0%) patients in the INHA group (P = 0.159), and all-cause death occurred in 4 (5.6%) patients in the TIVA group and 24 (15.2%) patients in the INHA group (P = 0.049). The 5-year recurrence-free survival (RFS) and overall survival rates of the TIVA/INHA groups were 91.7%/77.4% and 94.4%/83.5%, respectively. TIVA was associated with a significantly better prognosis. A multivariable analysis of factors associated with RFS revealed that the type of anesthesia as a significant prognostic factor (P = 0.047). CONCLUSION: Propofol-based TIVA was associated with a better prognosis in comparison to INHA in patients with surgically resected pathological stage I NSCLC.

[Lung Abscess by Drug-resistant Pseudomonas Aeruginosa Necessary to Differentiate from Lung Cancer:Report of a Case].

A 64-year-old man visited our hospital because of an abnormal shadow on an annual health check-up. Chest computed tomography demonstrated a nodule 22 mm in size in the right lung. 18-F fluorodeoxyglucose positron emission tomography showed abnormal accumulation in the nodule. Since lung cancer was suspected, a right wedge resection was performed. Pathological examination showed no malignant findings in the nodule. The diagnosis of lung abscess by drug resistance Pseudomonas aeruginosa was made by the pus culture and the postoperative course was uneventful.

[Mediastinal Dedifferentiated Liposarcoma Resected with Partial Resection of Pericardium].

An anterior mediastinal tumor was detected by computed tomography (CT) in a 66-year-old man who complained of left flank pain, and the surgical treatment was performed. At surgery, partial resection of the pericardium was also conducted because the pericardial inversion was suspected. The histopathological diagnosis was dedifferentiated liposarcoma. The patient is well without adjuvant chemotherapy 23 months after the surgery.

[Aspergillus Empyema with Bronchopleural Fistula due to Destroyed Lung after Postoperative Radiotherapy for Thymoma].

A 35-year-old man underwent adjuvant chemoradiation therapy to the surgical margin of the thymoma. Five years after the therapy, an area of the right upper lung lobe, which was included in the irradiation field, developed destroyed lung, resulting in Aspergillus empyema with bronchopleural fistula. To control the infection, an open window thoracostomy was performed. As the bronchopleural fistula resulted in pneumonia, bronchial embolization was performed with an Endobronchial Watanabe Spigot. After the empyema cavity was cleaned, the empyema space was closed with omental and muscular flap, thoracoplasty. Negative pressure wound therapy was carried out because of poor wound healing. The patient is doing well without relapse 15 months after the thoracoplasty.

[Long-term Results of Sublobar Resection for Lung Cancer;a 10-year Follow-up Study].

As a treatment for lung cancer, sublobar resection has been performed not only for high-risk patients but also for patients with radiographic early stage lung cancer. Although many studies revealed the short-term results of sublobar resection, long-term outcomes are still unclear. Here, we examined the 10-year follow-up results of sublobar resection for lung cancer, especially in overall survival(OS), cause-specific survival(CSS)and recurrence or death dynamics. Data from 48 consecutive patients who underwent sublobar resection for lung cancer between 2004 to 2008 were collected(21 patients:segmentectomy, 27:wedge resection). The median length of follow-up was 10 years. During follow-up, recurrences developed in 12 patients(25%)and 19 patients(40%)died, including 9(19%)patient deaths due to lung cancer. The 3-/5-/10-year OS and CSS rates for all patients were 81/77/61% and 87/85/80%, respectively. In terms of recurrence or death, 11 out of 12 patients with recurrences were diagnosed within the 3rd year. The peak of death due to lung cancer was shown to be years after surgery to which wedge resection contributed. On contrast, small peaks of non-cancer death were shown to be 8-10 years after surgery without relation to surgical procedure.

[Surgical Resection for Locally Advanced Lung Cancer].

Lung cancer invading neighboring anatomical structures is categorized as T3 or T4 and is regarded as locally advanced lung cancer. The 8th Edition Lung Cancer Stage Classification reclassified tumors 5~7 cm in size as T3 and tumors >7 cm or invading the diaphragm as T4. The purpose of this study was to evaluate the treatment results for resectable cT3-4N0-1M0 non-small cell lung cancer. From 1985 to 2016, 138 patients were surgically treated in our hospital, and their median follow-up was 78 months. Overall, the 5-year survival was 50%. According to the cT factor, the 5-year survival was 60% in patients with 5~7 cm tumors, 35% in patients with >7 cm tumors, and 58% in the group with chest wall invasion;however, no patients with tumors invading the diaphragm, pericardium or great vessels survived 5 years postoperatively. Preoperative chemotherapy was given to 16 patients( 12%), and 6 of those patients received chemoradiotherapy;40 patients (29%) received postoperative chemotherapy. All patients who received preoperative chemoradiotherapy followed by surgery had a complete resection and good pathological effects. While surgery alone is associated with an insufficient prognosis in patients with T3-T4 lung cancer, the addition of preoperative treatment is promising for improving survival.

[Penetrating Injury of the Lung with a Glass Splinter].

A 62-year-old man got drunk and dived into the windowpane. He received lacerations on his face and incised wound at his right chest, and was carried to our hospital. Computed tomography showed a glass splinter, about 14 cm of length, in the chest cavity. The patient underwent an emergency thoracotomy and it was found that the glass splinter penetrated through the upper lobe to the hilum. After removing the glass, simple closure by suturing the entrance and exit of the upper lobe was performed. The post operational course was uneventful. Selected patients can be rescued by simple pneumonorrhaphy without resection of lung.

[Curative Left Pulmonary Resection Combined with Total En Bloc Spondylectomy for Lung Cancer Invading the Second and Third Thoracic Vertebral Bodies].

Introduction of spinal surgery into the operation of lung cancer has made extensive surgical treatment feasible with acceptable long-term survival. We report our experience on total en bloc total spondylectomy for lung cancer invading the spine. A 60-year-old man was diagnosed with lung adenocarcinoma of the apicodorsal segment of the left lobe with invasion of the 2nd and 3rd thoracic vertebral bodies. After induction chemoradiotherapy, we performed en bloc resection through a posterolateral thoracotomy in the right decubitus position and a posterior median approach in the prone position. The thoracic manipulation was done earlier, making it useful for the dissection of the prevertebral plane from the posterior mediastinum at the upper thoracic level in addition to confirmation of non-N2 disease. Vertebral stabilization was achieved with rod fixation and placement of a titanium mesh cage between the remaining vertebral bodies.

[Complete Resection of Non-seminomatous Germ Cell Tumor with Plastron Approach].

A 17-year-old man was admitted to our hospital for the abnormal chest shadow. Chest computed tomography(CT) demonstrated mediastinal tumor, measuring 13 cm in diameter with high serum level of alpha fetoprotein (AFP) and human chorionic gonadotropin (hCG). The lesions were diagnosed as mixed germ cell tumors including a non-seminomatous malignant component by CT guided needle biopsy. After 5 courses of chemotherapy, the serum AFP and hCG were decreased almost normal level but the tumor size was not changed. Because it seemed to be difficult to get sufficient operating field with standard median sternotomy and patient wanted to treat funnel chest, we selected tumor resection with plastron approach. The tumor was completely resected with a good operation field by this procedure.

[Chest Wall Reconstruction Using Titanium Plates Sandwiched Between Sheets after Resection of Chest Wall Chondrosarcoma].

Extensive chest wall resection carries the risk of difficult reconstruction and surgical complications. We report our experience on chest wall reconstruction using titanium plates for a wide thoracic defect after tumor resection. A 74-year-old man was diagnosed with chondrosarcoma of the 6th rib on the right. He needed extensive chest wall resection because of skip lesions on 4th rib noted on operative inspection, leaving a defect measuring 33 × 20 cm. Reconstruction using 5 transverse titanium plates sandwiched between an expanded polytetrafluoroethylene patch and a polypropylene mesh sheet stabilized the chest wall. This reconstruction allowed successful separation from ventilatory support after operation. The postoperative course was uneventful, and he was discharged on postoperative day 20. The advantages of this form of reconstruction over conventional prostheses are rigidity, and stability and usability.

Risks of segmentectomy for interstitial pneumonia with diffuse pulmonary ossification.

An 84-year-old man with a history of progressive interstitial pneumonia presented to our department with lung cancer (cT2aN0M0-IB) in right S6. Moreover, computed tomography revealed progressive diffuse pulmonary ossification in the bilateral lower pulmonary lobes. S6 segmentectomy was performed via video-assisted thoracoscopic surgery. It was difficult to divide the intersegmental plane using a stapler because of severe fibrosis and pulmonary ossification with bone marrow formation. Pulmonary ossification may be an important finding for surgical planning because of severe fibrosis or inflammation associated with severe lung condition. We suggest that the surgical indications and approaches for such cases should be reconsidered because pulmonary ossification can be associated with severe lung conditions.

Risk-adjusted hazard analysis of survival after pulmonary metastasectomy for uterine malignancies in 319 cases.

Objective: There is little evidence of the outcome of pulmonary metastasectomy for uterine tumors when comparing different histologies. This study aimed to delineate the primary histology that leads to more favorable outcomes after pulmonary metastasectomy. Methods: The database of the Metastatic Lung Tumor Study Group of Japan for 1984 to 2016 was used to analyze the outcomes of patients with gynecologic malignancies who underwent pulmonary metastasectomy. Prognostic factors and long-term outcomes were compared according to the histology of the primary uterine tumors, specifically adenocarcinoma, squamous cell carcinoma, and sarcoma. The adjusted hazard risks according to disease-free intervals (DFIs) and the number and maximum size of resected tumors were also analyzed to delineate the pattern of risk trends. Results: A total of 319 patients were included in the analysis (122 with adenocarcinomas, 113 with squamous cell carcinomas, 46 with sarcomas, and 38 with other types). The 5-year survival rate was 66.5% for the entire cohort, 71.6% for the patients with adenocarcinoma, 61.3% for those with squamous cell carcinoma, and 55.4% for those with sarcoma. Multivariate analyses identified the positive prognostic factors as DFI ≥12 months in adenocarcinoma and sarcoma and the primary site (corpus) of uterine tumors in adenocarcinoma. The nonlinear adjusted hazard risks indicated that a shorter DFI was associated with an elevated risk of death in patients with adenocarcinoma and sarcoma. Conclusions: The survival outcome after pulmonary metastasectomy varies according to primary tumor histology, and the prognostic factors differ among histologic subtypes. Surgical indications should be determined based on the prognostic factors for each histology.

Prospective exosome-focused translational research for afatinib (EXTRA) study of patients with nonsmall cell lung cancer harboring EGFR mutation: an observational clinical study.

Background: The exosome-focused translational research for afatinib (EXTRA) study is the first trial to identify novel predictive biomarkers for longer treatment efficacy of afatinib in patients with epidermal growth factor receptor (EGFR) mutation-positive nonsmall cell lung cancer (NSCLC) via a comprehensive association study using genomic, proteomic, epigenomic, and metabolomic analyses. Objectives: We report details of the clinical portion prior to omics analyses. Design: A prospective, single-arm, observational study was conducted using afatinib 40 mg/day as an initial dose in untreated patients with EGFR mutation-positive NSCLC. Dose reduction to 20 mg every other day was allowed. Methods: Progression-free survival (PFS), overall survival (OS), and adverse events (AEs) were evaluated. Results: A total of 103 patients (median age 70 years, range 42-88 years) were enrolled from 21 institutions in Japan between February 2017 and March 2018. After a median follow-up of 35.0 months, 21% remained on afatinib treatment, whereas 9% had discontinued treatment because of AEs. The median PFS was 18.4 months, with a 3-year PFS rate of 23.3%. The median afatinib treatment duration in patients with final doses of 40 (n = 27), 30 (n = 23), and 20 mg/day (n = 35), and 20 mg every other day (n = 18) were 13.4, 15.4, 18.8, and 18.3 months, respectively. The median OS was not reached, with a 3-year OS rate of 58.5%. The median OS in patients who did (n = 25) and did not (n = 78) receive osimertinib during the entire course of treatment were 42.4 months and not reached, respectively (p = 0.654). Conclusions: As the largest prospective study in Japan, this study confirmed favorable OS following first-line afatinib in patients with EGFR mutation-positive NSCLC in a real-world setting. Further analysis of the EXTRA study is expected to identify novel predictive biomarkers for afatinib. Trial registration: UMIN-CTR identifier (UMIN000024935, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_his_list.cgi?recptno=R000028688.

[Giant cell tumor of the ribs that required emergency surgery due to massive hemothorax; report of a case].

A 63-year-old man with a left rib tumor, which had been diagnosed as a giant cell tumor 2 years previously, had been followed up at another hospital after embolization of a feeding artery of the tumor. He was admitted to the emergency room of our hospital with complaints of breathing difficulties. A chest computed tomography (CT) revealed a left chest wall tumor, about 11 cm in size, originating from the 8th rib and a massive left hemothorax. Emergency operation was performed to releave hemorrhagic shock. Bleeding from the tumor was confirmed at thoracotomy. Tumor was removed with combined resection of the adjacent chest wall and diaphragm. His postoperative course was uneventful and he was discharged on the 8th postoperative day.

Presence of a Ground-Glass Opacity Component Is the True Prognostic Determinant in Clinical Stage I NSCLC.

Introduction: Recent studies have suggested that including presence or absence of ground-glass opacity (GGO) may improve the tumor descriptor (T descriptor) classification in clinical stage I NSCLC. In this study, we analyzed prognostic implications of presence or absence of GGO, size of the solid component, and predominant histology to identify the true prognostic determinant for early-stage NSCLC. Methods: We retrospectively examined 384 patients with clinical stage I NSCLC (solid: 242, part solid: 142) who underwent complete resection between 2009 and 2013. Results: Survival curves of the whole cohort revealed good separation using the current TNM classification. Nevertheless, the part-solid group had a favorable prognosis irrespective of solid component size. Conversely, patients in the solid tumor group with tumors between 3 and 4 cm had a worse prognosis than patients whose tumors were less than or equal to 3 cm. Thus, we propose the following novel T descriptor classification: IA, part-solid tumors; IB, solid tumors less than or equal to 3 cm; and IC, solid tumors between 3 and 4 cm. This novel classification system stratified patient prognosis better than the current classification. On pathologic evaluation, the part-solid group always had better prognoses than the solid group in each subgroup divided by pathologic grade. Conclusions: These results suggest that presence of GGO is the true prognostic determinant of stage I NSCLC, irrespective of the size of the solid component. Our novel T descriptor classification system could more accurately predict prognoses of clinical stage I NSCLC cases.

The Frequency of DNA Mismatch Repair Deficiency Is Very Low in Surgically Resected Lung Carcinoma.

INTRODUCTION: DNA mismatch repair (MMR) deficiency leads to changes in the length of nucleotide repeat sequences of tumor DNA. In that situation, DNA replicational errors occur and accumulate during DNA replication. As a result, this mechanism frequently affects the coding regions of oncogenes and tumor suppressor genes and causes carcinogenesis. Recently, DNA MMR deficiency has been recognized as a predictive biomarker for immunotherapy. The aim of this study is to examine the frequency of DNA MMR deficiency and clinicopathological characteristics in surgically resected lung carcinoma (LC) and their correlation. METHODS: A total of 1153 LCs were examined. Tissue microarrays were constructed. The status of MMR deficiency was evaluated by immunohistochemical analysis of MMR protein expression (hMLH1, hMSH2, hMSH6, and hPMS2). Microsatellite instability analysis, BRAF mutation, and MLH1 methylation analysis were performed for cases that showed MMR deficiency. RESULTS: Only 2 of the 1153 cases (0.17%) showed a loss of hMLH1/hPMS2 protein expression. They also had high levels of microsatellite instability (MSI-H), had neither MLH1 promoter methylation nor BRAF mutation, and were male smokers. Histopathologically, one was a squamous cell carcinoma, and the other was combined small cell carcinoma with squamous cell carcinoma. Regarding PD-L1 protein expression, one had high expression, and the other had none. CONCLUSION: The frequency of MMR deficiency was very low in LC. However, our two cases were non-adenocarcinoma and differed from previous studies. Because of its very low frequency, MMR deficiency is not a practical biomarker to predict the effect of immune checkpoint inhibitors in LC.

A surgical case of mediastinal hematoma caused by a minor traffic injury.

BACKGROUND: Mediastinal hematoma rarely occurs after a minor traffic injury. CASE PRESENTATION: A woman in her forties was transferred to the emergency room by ambulance due to a traffic accident. Computed tomography (CT) revealed no abnormal findings, and she went home. Two days after the accident, the contrast-enhanced CT was repeated, which revealed cervical and mediastinal hematomas. Because it was possible that there was active bleeding from the right inferior thyroid artery, embolization of the right inferior thyroid artery was performed; however, her condition further deteriorated, so we performed emergency surgery to achieve hemostasis and remove the hematoma. Because of oozing from the right thyroid lobe, we performed right hemithyroidectomy and drainage of mediastinal space and right thoracic cavity. Since there was no bleeding site in the mediastinum, we thought that the mediastinal hematoma was due to bleeding from the thyroid gland. Her postoperative course was uneventful, and she is doing well at 9 months of follow-up after surgery. CONCLUSIONS: It is possible that mediastinal hematoma might be caused by a minor traffic injury.