Clinical efficacy of adjuvant chemotherapy in stage IB (< 4 cm) non-small cell lung cancer patients with high-risk factors

Background/Aims@#Adjuvant chemotherapy is the standard of care for resected stage II-IIIA non-small cell lung cancer (NCSLC). The efficacy of adjuvant chemotherapy in stage IB (< 4 cm) NSCLC with high-risk factors is controversial. @*Methods@#This retrospective multicenter study included 285 stage IB NSCLC patients with high-risk factors according to the 8th edition tumor, node, metastasis (TNM) classification from four academic hospitals. High-risk factors included visceral pleural invasion, vascular invasion, lymphatic invasion, lung neuroendocrine tumors, and micropapillary histology patterns. @*Results@#Of the 285 patients, 127 (44.6%) were included in the adjuvant chemotherapy group and 158 (55.4%) were included in the non-adjuvant chemotherapy group. The median follow-up was 41.5 months. Patients in the adjuvant chemotherapy group had a significantly reduced recurrence rate and risk of mortality than those in the non-adjuvant chemotherapy group (hazards ratio, 0.408; 95% confidence interval, 0.221 to 0.754; p = 0.004 and hazards ratio, 0.176; 95% confidence interval, 0.057 to 0.546; p = 0.003, respectively). Adjuvant chemotherapy should be particularly considered for the high-risk factors such as visceral pleural involvement or vascular invasion. Based on the subgroup analysis, adjuvant chemotherapy should be considered when visceral pleural involvement is present, even if the tumor size is < 3 cm. @*Conclusions@#Adjuvant chemotherapy may be useful for patients with stage IB NSCLC with high-risk factors and is more relevant for patients with visceral pleural involvement or vascular invasion.

Korean Clinical Imaging Guidelines for the Appropriate Use of Chest MRI

MRI has the advantages of having excellent soft-tissue contrast and providing functional information without any harmful ionizing radiation. Although previous technical limitations restricted the use of chest MRI, recent technological advances and expansion of insurance coverage are increasing the demand for chest MRI. Recognizing the need for guidelines on appropriate use of chest MRI in Korean clinical settings, the Korean Society of Radiology has composed a development committee, working committee, and advisory committee to develop Korean chest MRI justification guidelines. Five key questions were selected and recommendations have been made with the evidence-based clinical imaging guideline adaptation methodology.Recommendations are as follows. Chest MRI can be considered in the following circumstances:for patients with incidentally found anterior mediastinal masses to exclude non-neoplastic conditions, for pneumoconiosis patients with lung masses to differentiate progressive massive fibrosis from lung cancer, and when invasion of the chest wall, vertebrae, diaphragm, or major vessels by malignant pleural mesothelioma or non-small cell lung cancer is suspected. Chest MRI without contrast enhancement or with minimal dose low-risk contrast media can be considered for pregnant women with suspected pulmonary embolism. Lastly, chest MRI is recommended for patients with pancoast tumors planned for radical surgery.

Korean Clinical Imaging Guidelines for the Appropriate Use of Chest MRI

MRI has the advantages of having excellent soft-tissue contrast and providing functional information without any harmful ionizing radiation. Although previous technical limitations restricted the use of chest MRI, recent technological advances and expansion of insurance coverage are increasing the demand for chest MRI. Recognizing the need for guidelines on appropriate use of chest MRI in Korean clinical settings, the Korean Society of Radiology has composed a development committee, working committee, and advisory committee to develop Korean chest MRI justification guidelines. Five key questions were selected and recommendations have been made with the evidence-based clinical imaging guideline adaptation methodology.Recommendations are as follows. Chest MRI can be considered in the following circumstances:for patients with incidentally found anterior mediastinal masses to exclude non-neoplastic conditions, for pneumoconiosis patients with lung masses to differentiate progressive massive fibrosis from lung cancer, and when invasion of the chest wall, vertebrae, diaphragm, or major vessels by malignant pleural mesothelioma or non-small cell lung cancer is suspected. Chest MRI without contrast enhancement or with minimal dose low-risk contrast media can be considered for pregnant women with suspected pulmonary embolism. Lastly, chest MRI is recommended for patients with pancoast tumors planned for radical surgery.

Fluorescence Image-Based Evaluation of Gastric Tube Perfusion during Esophagogastrostomy

During esophagectomy and esophagogastrostomy, the prediction of anastomotic leakagerelies on the operating surgeon’s tactile or visual diagnosis. Therefore, anastomoticleaks are relatively unpredictable, and new intraoperative evaluation methods or tools areessential. A fluorescence imaging system enables visualization over a wide region of interest,and provides intuitive information on perfusion intraoperatively. Surgeons can choosethe best anastomotic site of the gastric tube based on fluorescence images in real timeduring surgery. This technology provides better surgical outcomes when used with anoptimal injection dose and timing of indocyanine green.

Thoracoscopic Needle Aspiration Biopsy for a Centrally Located Solitary Pulmonary Nodule

Thoracoscopic needle aspiration is a good alternative for a centrally-located solitary pulmonary nodule (SPN) suspected of being lung cancer without severe pleural adhesion. The authors report the technique of thoracoscopic needle aspiration biopsy in a SPN just in the medial aspect of the truncus anterior pulmonary artery and the right upper lobe bronchus.

Surgical Management for Pulmonary Artieriole Rupture During Subclavian Vein Catheterization: A Case Report / 대한구급학회지

We experienced an extremely unusual case of a 37-year-old woman who suffered from hemothorax soon after subclavian vein catheterization. Many case reports of a hemothorax or hematoma after central vein catheterization through the great vessels, such as the subclavian vein and internal jugular vein, have been published. However, this rare case showed a pinpoint-sized active bleeding site from a pulmonary arteriole rupture. During an emergency operation using thoracoscopy-assisted minithoracotomy, this bleeding site was successfully managed by primary repair.

Video-assisted thoracoscopic lobectomy for lung cancer

Video-assisted thoracoscopic surgery (VATS) provides a new approach for treating early-stage lung cancer. VATS lobectomy has significant perioperative advantages such having as a lower rate of morbidity and being less immunosuppressive than open lobectomy, and it also provides a shorter recovery time, less postoperative pain, and faster resumption of a normal lifestyle. However, a clear definition of VATS lobectomy is lacking in the current literature. The generally accepted method of VATS lobectomy is from three to four incisions in number of port, 4.0 to 8.0 cm in utility length, and without rib spreading. However, there is still much debate on the role of VATS in lobectomy for the treatment of lung cancer. Concerns regarding safety, the extent of mediastinal lymph node dissection, and long-term survival have made some surgeons apprehensive of its validity for lung cancer. Nevertheless, recent data have shown that VATS lobectomy appears to have equivalent oncological results compared with open lobectomy for patients with early stage non-small cell lung cancer. With growing experience with VATS and development of thoracoscopic instrument, VATS can be beneficial to patients with early stage of lung cancer.

Successful Localization of Distant Metastasis in Parathyroid Carcinoma Using Intraoperative Parathyroid Hormone Assay

Intra-operative parathyroid hormone (IOPTH) assay is a useful tool to confirm complete excision of all hyper-functioning parathyroid gland tissue. In this report, we describe a case with successful localization of distant metastasis in a patient with parathyroid carcinoma using the IOPTH assay. A 53-year-old man presented to our clinic with a serum calcium level of 11.8 mg/dL and an intact PTH level of 233.3 pg/mL. He had been treated for parathyroid carcinoma eleven years ago. Two suspected metastatic lesions were detected on the chest computed tomography. Due to the vastly different surgical field necessary to excise each lesion, we preferentially removed only one lesion and we monitored the other remaining suspected lesion without resection via IOPTH assay. Six months later, the patient's serum calcium and intact PTH levels remained within their normal ranges. To the best of our knowledge, this is the first case to effectively utilize IOPTH assay for the management of metastatic parathyroid carcinoma.

Emergency Repair Using Cervico-median Sternotomy for Cervicothoracic Penetrating Injury

A great variety of penetrating injuries is happening due to the increasing population and violence today. An optimal surgical approach is the key factor for successful repair of a complicated penetrating injury. A 23-yearold woman fell down the stairs from the second floor and received cervico-thoracic penetration injury due to a metalic bar. The metalic bar ruptured the right jugular vein and penetrated the left upper and lower lung. Under cervico-median sternotomy, neck vessels were repaired and the left thorax was successfully entered to repair the damaged lung through the mediastinal pleura. With this approach, the patient's position did not need to be changed during operation, while reduced the operation time compared to the conventional approach (cervical incision and standard thoracotomy).

A Comparative Study of Pericostal and Submuscular Bar Fixation Technique in the Nuss Procedure

We evaluated the safety and stability of the less-invasive submuscular bar fixation method in the Nuss procedure. One hundred and thirteen patients undergoing the Nuss procedure were divided into three groups according to the bar fixation technique employed. Group 1 consisted of 25 patients who had undergone bilateral pericostal bar fixation, group 2 consisted of 39 patients with unilateral pericostal one, and group 3 included 49 patients with bilateral submuscular one. The patients' age ranged from 2 to 25 yr, with an average of 7.2+/-5.67 yr. Bar dislocation occurred in 1 patient (4%) in Group 1, 2 patients (5.1%) in Group 2, and 1 patient (2.0%) in Group 3 (p=0.46). Hemothorax was noted in 2 patients (8%) in Group 1, 2 (5.1%) in Group 2, and none (0%) in Group 3 (Group 1 vs. Group 3, p=0.028). The mean operation time was shorter in Group 3 than Group 1 (50.1+/-21.00 in Group 3 vs. 67.2+/-33.07 min in Group 1, p=0.041). The submuscular bar fixation results in a decrease in technique-related complications and operation time and is associated with favorable results with regard to the prevention of bar dislodgement.

Changes in N-terminal Pro B-type Natriuretic Peptide Concentration: Comparative Study of Percutaneous Transluminal Coronary Angioplasty and Off-Pump Coronary Artery Bypass Graft

The goal of this study was to compare the effects of different reperfusion methods on N-terminal B-type natriuretic peptide (NT-proBNP) in percutaneous transluminal coronary angioplasty (PTCA) or off-pump coronary artery bypass (OPCAB) patients. Fifty subjects were enrolled in the study, 32 patients received PTCA and 18 OPCAB. An NT-proBNP measurement was performed before intervention and at 1, 3, and 7 days after the procedures. NT-proBNP levels were not significantly different before intervention (PTCA group 297+/-147.3 vs. OPCAB group 235+/-167.8 pg/mL, p>0.05). However, 1 day after the procedures, NT-proBNP levels were higher in the OPCAB group (PTCA 375+/-256.4 vs. OPCAB 1,415+/-737.6 pg/mL, p0.05). PTCA induced a mild and transient increase in NT-proBNP concentration, but OPCAB caused sustained high NT-proBNP levels during the 7 day postoperatively. However, differences between NT-proBNP levels associated with these two modalities showed a tendency to decrease rapidly postoperatively.

Assessment of the Quality of Esophago-gastric Anastomosis by Endoscopic Examination Cervical Versus Intrathoracic Anastomosis / 대한흉부외과학회지

BACKGROUND: Mortality and morbidity of anastomotic complications after esophagectomy have gradually decreased in recent years. However, swallowing difficulties and reflux symptoms after esophagogastrostomy continue to be a burden jeopardizing the quality of life. In the present study, we evaluated the quality of esophagogastrostomy by analyzing anastomotic stenosis and reflux esophagitis. MATERIAL AND METHOD: A retrospective analysis was made in 74 patients who underwent esophagogastrostomy after esophagectomy by one surgeon between January 1995 and December 2004. 53 patients of them received endoscopic examination during follow-up (29+/-23.6 months, range 5~111 months). Reflux esophagitis and stenosis at anastomostic site were analyzed according to the techniques and locations of esophagogastrostomy. RESULT: The median age at the time of repair was 60.3+/-8.87 years (range 39~81 years). 23 patients received a hand-sewn esophagogastric anastomosis and 30 patients a circular stapled one. There was no significant statistical difference in terms of anastomotic stenosis (p=0.64) and reflux esophagitis (p=0.41) between the two groups. Cervical anastomosis was performed in 26 patients and intrathoracic anastomosis in 27 patients. No significant statistical difference in anastomotic stenosis between the two groups was found (p=0.44), but reflux esophagitis was noted in 3 patients in the cervical anastomosis group and 14 patients in the intrathoracic anastomosis group (p=0.003). CONCLUSION: Cervical anastomosis was supposed to have a better quality of esophagogastrostomy by lowering the risk of reflux esophagitis. In the future, the comprehensive study including a patient's subjective symptom and Barrett's metaplasia should be performed in larger cases.

Sinus Node Function after Extended Transseptal Approach for Mitral Valve Surgery: 164 Clinical Cases / 대한흉부외과학회지

BACKGROUND: Extended transseptal approach can provide an excellent view of the mitral valve but the safety of this approach is controversial because this incision requires transection of the sinus node artery, which in most cases and can result postoperative arrhythmia. The purpose of this study was to evaluate perioperative and longterm conduction disturbances and the cardiac rhythms of patients who underwent an extended transseptal approach for mitral valve surgery. MATERIAL AND METHOD: Postoperative cardiac rhythms were analyzed in the 164 consecutive patients who received mitral valve replacements with a extended transseptal approach between March 1992 and July 2003. RESULT: Of the 84 patients in normal sinus rhythm, 34 (39%) had developed transient junctional rhythm and atrial fibrillation after operation, lasting less than 72 hours in most of cases. No intractable arrhythmias occurred. Most of these arrhythmia were not detected at the time of discharge and only 8 patients (9%) had atrial fibrillation at discharge. Postoperative PR intervals increased for 1 week, then decreased within 2 weeks postoperatively, and returned to normal range by 6 months postoperatively. During the postoperative period, 4 of the 78 patients with preoperative atrial fibrillation developed normal sinus thythm. CONCLUSION: The postoperative arrhythmias were temporary and showed no significant complications after extended transseptal approach for the mitral valve surgery.

Surgical Treatment of Occluded Aberrant Left Subclavian Artery with Right-sided Aortic Arch: A case report / 대한흉부외과학회지

A 57-year-old man with numbness and paresthesia of left arm is presented. There was no pulse in the left arm was absent and his chest radiograph suggested right-sided aortic arch. The aortogram showed right-sided aortic arch with Kommerell's diverticulum. The proximal portion of left subclavian artery was totally occluded and blood was being supplied through vertebral arteries to distal subclavian artery. He underwent bypass grafting between both subclavian arteries by an expanded polytetrafluoroethylene graft. Because the size of Kommerell's diverticulum was small, it need to be observed closely.

Intramural Bronchogenic Cyst of the Esophagus: A case report / 대한흉부외과학회지

Bronchogenic cysts are anomalous cystic lesions of foregut and usually located in the lung or mediastinum. Generally intramuscular cysts of the esophagus are considered as enterogenous foregut malformations. We report a young adult with an intramural bronchogenic cyst causing dysphagia and heartburn. It was located in the muscular layer of the esophagus and was removed without any damage to the mucosa. Histopathologic findings revealed that it was a bronchogenic cyst.

Effect of Pulsatile Versus Nonpulsatile Blood Flow on Renal Tissue Perfusion in Extracorporeal Circulation / 대한흉부외과학회지

BACKGROUND: It has been known that pulsatile flow is physiologic and more favorable to tissue perfusion than nonpulsatile flow. The purpose of this study is to directly compare the effect of pulsatile versus nonpulsatile blood flow to renal tissue perfusion in extracorporeal circulation by using a tissue perfusion measurement system. MATERIAL AND METHOD: Total cardiopulmonary bypass circuit was constructed to twelve Yorkshire swines, weighing 20~30 kg. Animals were randomly assigned to group 1 (n=6, nonpulsatile centrifugal pump) or group 2 (n=6, pulsatile T-PLS pump). A probe of the tissue perfusion measurement system (QFlow(TM)-500) was inserted into the renal parenchymal tissue. Extracorporeal circulation was maintained for an hour at a pump flow of 2 L/min after aortic cross-clamping. Tissue perfusion flow of the kidney was measured at baseline (before bypass) and every 10 minutes after bypass. Serologic parameters were collected at baseline and 60 minutes after bypass. RESULT: Baseline parameters were not different between the groups. Renal tissue perfusion flow was substantially higher in the pulsatile group throughout the bypass (ranged 48.5~4 in group 1 vs. 65.8~8.3 mL/min/100 g in group 2, p=0.026~0.45). The difference was significant at 30 minutes bypass (47.5+/-18.3 in group 1 vs. 83.4+/-28.5 mL/min/100 g in group 2, p=0.026). Serologic parameters including plasma free hemoglobin, blood urea nitrogen, and creatinine showed no differences between the groups at 60 minutes after bypass (p=NS). CONCLUSION: Pulsatile flow is more beneficial to tissue perfusion of the kidney in short-term extracorporeal circulation. Further study is suggested to observe the effects to other vital organs or long-term significance.

Infected Infradiaphragmatic Retroperitoneal Extralobar Pulmonary Sequestration: A Case Report

Infradiaphragmatic extralobar pulmonary sequestration is an extremely rare congenital malformation. It is more frequently diagnosed in the antenatal period due to routine ultrasonic examination of the fetus or in the first 6 months of life, though on rare occasions it is discovered incidentally in adults. A 32-yr-old man presenting with epigastric discomfort and fever was referred. Computed tomographic scanning showed that a 16-cm, multiseptated, dumbbell-shaped, huge cystic tumor was located beneath the diaphragm. On the next day, 850 mL of thick yellowish pus was drained by sonography-guided fine needle aspiration for the purpose of infection control and diagnosis, but no microscopic organisms were found in repeated culture studies. Surgical removal of the cyst was performed through thoracoabdominal incision and most of these pathologic lesions were removed but we could not find the feeding arteries or any fistulous tract to surrounding structures. Histopathologic study revealed that it was extralobar pulmonary sequestration and culture study showed that many WBC and necrotic materials were found but there were no microorganisms in the cystic contents. We report the first case of an infected infradiaphragmatic retroperitoneal extralobar sequestration which was administered a staged management and achieved an excellent clinical course.

Clinical Outcomes of Corrective Surgical Treatment for Esophageal Cancer / 대한흉부외과학회지

BACKGROUND: Clinical outcomes of esophageal cancer have not been satisfactory in spite of the development of surgical skills and protocols of adjuvant therapy. We analyzed the results of corrective surgical patients for esophageal cancer from January 1992 to July 2002. MATERIAL AND METHOD: Among 129 patients with esophageal cancer, ths study was performed in 68 patients who received corrective surgery. The ratio of sex was 59 : 9 (male : female) and mean age was 61.07+/-7.36 years old. Chief complaints of this patients were dysphagia, epigastric pain and weight loss, etc. The locations of esophageal cancer were 4 in upper esophagus, 36 in middle, 20 in lower, 8 in esophagogastric junction. 60 patients had squamous cell cancer and 7 had adenocarcinoma, and 1 had malignant melanoma. Five patients had neoadjuvant chemotherapy. RESULT: The postoperative stage I, IIA, IIB, III, IV patients were 7, 25, 12, 17 and 7, respectively. The conduit for replacement of esophagus were stomach (62 patients) and colon (6 patients). The neck anastomosis was performed in 28 patients and intrathoracic anastomosis in 40 patients. The technique of anastomosis were hand sewing method (44 patients) and stapling method (24 patients). One of the early complications was anastomosis leakage (3 patients) which had only radiologic leakage that recovered spontaneously. The anastomosis technique had no correlation with postoperative leakage, which stapling method (2 patients) and hand sewing method (1 patient). There were 3 respiratory failures, 6 pneumonia, 1 fulminant hepatitis, 1 bleeding and 1 sepsis. The 2 early postoperative deaths were fulminant hepatitis and sepsis. Among 68 patients, 23 patients had postoperative adjuvant therapy and 55 paitents were followed up. The follow up period was 23.73+/-22.18 months (1~76 month). There were 5 patients in stage I, 21 in stage 2A, 9 in stage IIB, 15 in stage III and 5 in stage IV. The 1, 3, 5 year survival rates of the patients who could be followed up completely was 58.43+/-6.5%, 35.48+/-7.5% and 18.81+/-7.7%, respectively. Statistical analysis showed that long-term survival difference was associated with a stage, T stage, and N stage (p <0.05) but not associated with histology, sex, anastomosis location, tumor location, and pre and postoperative adjuvant therapy. CONCLUSION: The early diagnosis, aggressive operative resection, and adequate postoperative treatment may have contributed to the observed increase in survival for esophageal cancer patients.

Surgical Treatment of Superior Vena Cava Syndrome Caused by Hemodialysis Catheter: Report of 2 cases / 대한흉부외과학회지

The major etiology of superior vena cava (SVC) syndrome is malignancy. Radiologic endovascular intervention is the treatment of choice for patients with SVC syndrome due to malignant disease, which is unresponsive to radiation therapy and chemotherapy. However, it is not clear whether endovascular intervention can replace open surgery as the primary method of management of benign SVC syndrome. We report two cases of benign SVC syndrome resulting from dialysis catheters placed in the central veins. One patient underwent bypass surgery between innominate vein and right atrium by expanded polytetrafluoroethylene. Another patient had large thrombi in SVC and other central veins. We removed them under cardiopulmonary bypass to prevent pulmonary embolism, and SVC was repaired and augmented by autologous pericardium. Prompt symptomatic relief and angiographic improvements of collateral flow were achieved in both patients.

Significance of Vascular Endothelial Growth Factor in Pleural Effusion / 대한흉부외과학회지

Background: None of the currently available strategies for diagnosis and management of the pleural effusion are ideal. We tried to evaluate the validity of VEGF in differential diagnosis of the pleural effusion and find out if VEGF were correlated with the established markers. Material and Method: 35 patients with pleural effusion were divided into malignant effusion (n=10), benign effusion (n=5), infectious effusion (n=10), and pneumothorax (n=10), respectively. The pleural fluids from each group were examined for differential cell count, chemistry (glucose, protein, LDH, and ADA), and VEGF. Result: Glucose level was lower in infectious effusion compared with benign effusion (60.5+/-36.09 mg/dL vs. 162.0+/-19.80 mg/dL, p=0.011). ADA level in infectious effusion was higher compared with malignant effusion (87.9+/-42.62 IU/L vs. 27.7+/-31.04 IU/L, p=0.024). Malignant effusion (p=0.026) and infectious effusion (p=0.048) showed significantly higher level of VEGF than that of pneumothorax. VEGF level was substantially higher in malignant effusion compared with benign effusion (364.38+/-433.83 pg/dL vs. 53.3+/-22.20 pg/dL, p=NS). The pleural VEGF level did not correlate with the other markers. Conclusion: The measuring pleural VEGF may be helpful in diagnosing malignant and infectious pleural effusion that increase angiogenesis and vascular permeability, but it can not discriminate between the two. The pleural VEGF may not be correlated with the established markers. The measurement of pleural VEGF might discriminate between malignant and benign effusion.