Postoperative management using a digital drainage system for massive air leakage after pulmonary resection.

PURPOSE: To elucidate clinical outcomes using a digital drainage system (DDS) for massive air leakage (MAL) after pulmonary resection. METHODS: A total of 135 consecutive patients with pulmonary resection air leakage of > 100 ml/min on the DDS were evaluated retrospectively. In this study, MAL was defined as ≥ 1000 ml/min on the DDS. We analyzed the clinical characteristics and surgical outcomes of patients with MAL compared with non-MAL (101-999 ml/min). Using the DDS data, the duration of the air leak was plotted with the Kaplan‒Meier method and compared using the log-rank test. RESULTS: MAL was detected in 19 (14%) patients. The proportions of heavy smokers (P = 0.04) and patients with emphysematous lung (P = 0.03) and interstitial lung disease (P < 0.01) were higher in the MAL group than in the non-MAL group. The MAL group had a higher persistence rate of air leakage at 120 h after surgery than the non-MAL group (P < 0.01) and required significantly more frequent pleurodesis (P < 0.01). Drainage failure occurred in 2 (11%) and 5 (4%) patients from the MAL and non-MAL groups, respectively. Neither reoperation nor 30-day surgical mortality was observed in patients with MAL. CONCLUSIONS: MAL was able to be treated conservatively without surgery using the DDS.

Salvage extended surgery after immune-checkpoint inhibitor treatment for advanced non-small cell lung cancer.

PURPOSE: We evaluated the surgical outcomes of salvage extended surgery after definitive medical treatment with an immune-checkpoint inhibitor (ICI) for locally advanced or unresectable non-small-cell lung cancer (NSCLC). METHODS: The subjects of this single-center retrospective analysis were 14 patients who underwent salvage surgery after ICI treatment between May, 2017 and April, 2023 at our institute. We reviewed the comprehensive surgical outcomes, including operative procedures, intraoperative findings, and postoperative morbidities. Overall survival (OS) was calculated using a Kaplan-Meier estimation. RESULTS: The initial clinical stage before medical treatment (c-stage) was stage III in eight patients, stage IV in five patients, and one patient had postoperative lung cancer recurrence. The indications for surgery were as follows: local control for relapse or residual tumor in ten patients and discontinuation of systemic therapy because of treatment-related complications in four patients. The surgical modes were segmentectomy (n = 1), lobectomy (n = 4), bilobectomy (n = 3), pneumonectomy (n = 6), and bronchoplasty (n = 7). Grade 3 or higher postoperative morbidities were observed in six patients, including only one case of 90-day mortality. CONCLUSIONS: Our series demonstrated that the surgical outcome of salvage extended surgery after ICI therapy may be positive with careful selection of the procedure and indication.

Efficacy of Adjuvant Chemotherapy for Stage II/III Nonsmall Cell Lung Cancer with Epidermal Growth Factor Receptor Mutations.

BACKGROUND: Adjuvant cisplatin-based chemotherapy improves the survival of patients with resected pathological stage II/III nonsmall cell lung cancer (NSCLC). However, the efficacy in patients with epidermal growth factor receptor (EGFR) mutations remains controversial. METHODS: This retrospective study included 353 patients with resected pathological N1/N2 stage II/III NSCLC between 2010 and 2016. Mutant EGFR (mEGFR) was detected in 76 patients. Adjuvant chemotherapy (AC) was administered to 151 patients. We compared cancer-specific survival (CSS) and recurrence-free survival (RFS) between AC and surgery-alone (SA) groups, including patients with wild-type EGFR (wEGFR) and mEGFR. Using multivariate analysis, we evaluated the prognostic factors in patients with wEGFR and mEGFR. RESULTS: The median follow-up time was 4.7 years. In patients with wEGFR, the differences in CSS and RFS between the AC (n = 114) and SA (n = 163) groups were significant (CSS: 66.8% [5 years] vs. 49.4% [5 years], p = 0.001; RFS: 54.2% [5 years] vs. 39.2% [5 years], p = 0.013). The significant prognostic factors were AC (vs. SA; p < 0.0001), diffusing capacity of the lung for carbon monoxide > 60% (p = 0.028), tumor size (p < 0.001), lymphatic permeation (p = 0.041), and pN1 (vs. pN2; p < 0.001). However, the differences in CSS and RFS between the AC (n = 37) and SA (n = 39) groups were not significant (CSS: 64.0% [5 years] vs. 58.1% [5 years], p = 0.065; RFS: 45.0% [5 years] vs. 33.8% [5 years], p = 0.302). Multivariate analysis identified no significant prognostic factors in patients with mEGFR. CONCLUSION: We demonstrated the efficacy of AC in patients with mEGFR and wEGFR. The efficacy of AC may be lower in patients with mEGFR than in those with wEGFR.

The balance between lung regulatory T cells and Th17 cells is a risk indicator for the acute exacerbation of interstitial lung disease after surgery: a case-control study.

BACKGROUND: Acute exacerbation (AE) of interstitial lung disease (ILD) (AE-ILD) is a life-threatening condition and the leading cause of 30-day mortality among patients who underwent pulmonary resection for lung cancer in Japan. This study was conducted to clarify the characteristics of the immune environment of lung tissues before the onset of AE-ILD. METHODS: This retrospective matched case-control study compared the immune phenotypes of helper T cells in lung tissues from patients with and without AE-ILD after surgery. In total, 135 patients who underwent surgical resection for lung cancer and were pathologically diagnosed with idiopathic interstitial pneumonia (IIP) at our institute between 2009 and 2018 were enrolled. Thirteen patients with AE-IIP and 122 patients without AE (non-AE) were matched using a propensity score analysis, and 12 cases in each group were compared. We evaluated the percentages of T helper (Th)1, Th2, Th17, regulatory T (Treg), and CD8 cells in CD3+ T cells and the Th1:Th2, Th17:Treg, and CD8:Treg ratios in patients with AE by immunostaining of lung tissues in the non-tumor area. RESULTS: We found a significant difference in the lung Th17:Treg ratio between the AE and non-AE groups (1.47 and 0.79, p = 0.041). However, we detected no significant differences in the percentages of lung Th1 (21.3% and 29.0%), Th2 (34.2% and 42.7%), Th17 (22.3% and 21.6%), Treg (19.6% and 29.1%), and CD8+ T cells (47.2% and 42.2%) of CD3+ T cells between the AE and non-AE groups. CONCLUSION: The ratio of Th17:Treg cells in lung tissues was higher in participants in the AE group than in those in the non-AE group. CLINICAL TRIAL REGISTRATION: This study was approved by the ethics committee of our institute (2,016,095).

Risk factors for bronchopleural fistula based on surgical procedure and sex in 4794 consecutive patients undergoing anatomical pulmonary resection.

PURPOSE: Bronchopleural fistula (BPF) is a lethal complication, even in the modern era. Therefore, we investigated the details of patients with BPF to select an appropriate surgical strategy. METHODS: This retrospective study included 4794 consecutive patients who underwent anatomical pulmonary resection between 2008 and 2022. We evaluated the predictors of BPF using a multivariable analysis and investigated the mortality and clinical course after BPF in detail. RESULTS: BPF was observed in 32 patients (0.67%). In the multivariable analysis, the predictors for BPF were male sex (odds ratio [OR], 6.91), the body mass index (OR, 2.40), the vital capacity (%VC) (OR, 2.93), surgery performed (right lower lobectomy [OR, 10.92], right middle and lower lobectomy [OR, 6.97], and right pneumonectomy [OR, 16.68]), and additional resection of surrounding organs (OR, 3.47). Among the risk factors, surgery performed and male sex were very strong risk factors, with the frequency itself very low in females (0.1%). The 90-day mortality was 15.6%, and the 5-year overall survival in patients with BPF was 28.1%. CONCLUSION: Our study revealed that independent risk factors and consideration of the surgical methods and sex might help determine whether or not special attention should be given to the bronchial stump, which will be of great help in surgical strategies.

Predictive factors inhibiting recovery of the respiratory function after anatomical pulmonary resection.

PURPOSE: Some patients have worse actual observed postoperative (apo) respiratory function values than predicted postoperative (ppo) values. The present study therefore clarified the predictive factors that hinder the recovery of the postoperative respiratory function. METHODS: This study enrolled 255 patients who underwent anatomical pulmonary resection for lung cancer. A pulmonary function test (PFT) was carried out before surgery and at one, three, and six months after surgery. In each surgical procedures, the forced expiratory volume in 1 s (FEV1) ratio was calculated as the apo value divided by the ppo value. In addition, we investigated the predictive factors that inhibited postoperative respiratory function improvement in patients with an FEV1 ratio < 1.0 at 6 months after surgery. RESULTS: The FEV1 ratio gradually improved over time in all surgical procedures. However, 49 of 196 patients who underwent a PFT at 6 months after surgery had an FEV1 ratio < 1.0. In a multivariate analysis, right side, upper lobe, segmentectomy and pleurodesis for prolonged air leakage were independent significant predictors of a decreased FEV1 ratio (p = 0.003, 0.006, 0.001, and 0.009, respectively). CONCLUSION: Pleurodesis was the only controllable factor that might help preserve the postoperative respiratory function. Thus, the intraoperative management of air leakage is important.

Outcomes of lung cancer surgery for patients with interstitial pneumonia and coronary disease.

PURPOSE: To evaluate the surgical outcomes of lung cancer patients with idiopathic interstitial pneumonia (IIP) and/or coronary artery disease (CAD). METHODS: The subjects of this retrospective study were 2830 patients who underwent surgical resection for lung cancer between 2009 and 2018. Seventy-one patients (2.6%) had both IIP and CAD (FC group). The remaining patients were divided into those with IIP only (group F), those with CAD only (group C), and those without IIP or CAD (group N). We compared mortality and overall survival (OS) among the groups. RESULTS: The 90-day mortality and OS were poorer in group FC than in groups C and N, but equivalent to those in group F. Multivariate analyses revealed that IIP (odds ratio [OR] 3.163; p = 0.001) and emphysema (2.588; p = 0.009) were predictors of 90-day mortality. IIP (OR 2.991, p < 0.001), diabetes (OR 1.241, p = 0.043), and a history of other cancers (OR 1.347, p = 0.011) were all predictors of OS. CONCLUSIONS: Short-term and long-term mortality after lung cancer surgery were not dependent on coexistent CAD but were related to IIP. Thus, computed tomography (CT) should be done preoperatively to check for IIP, which is a risk factor for surgical mortality.

Evaluation of solid portions in non-small cell lung cancer-the solid part is not always measurable for clinical T factor.

BACKGROUND: Solid component size on thin-section computed tomography is used for T-staging according to the eighth edition of the Tumor Node Metastasis classification of lung cancer. However, the feasibility of using the solid component to measure clinical T-factor remains controversial. METHODS: We evaluated the feasibility of measuring the solid component in 859 tumours, which were suspected cases of primary lung cancers, requiring surgical resection regardless of the procedure or clinical stage. After excluding 126 pure ground-glass opacity tumours and 450 solid tumours, 283 part-solid tumours were analysed to determine the frequency of cases where the measurement of the solid portion was difficult along with the associated cause. Pathological invasiveness was also evaluated. RESULTS: The solid portion of 10 lesions in 283 part-solid nodules was difficult to measure due to an underlying lung disease (emphysema and pneumonitis). The solid portion of 62 lesions (21.9%) without emphysema and pneumonitis was difficult to measure due to imaging features of the tumours. Among the 62 patients, five had no malignancy and one with a tumour size of 33 mm had nodal metastasis. There were 56 lesions with a tumour size of ≤30 mm, wherein nodal metastases, vascular and/or lymphatic invasions were not observed. CONCLUSION: For one-fifth of the part-solid tumours, measurement of the solid component was difficult. Moreover, these lesions had low invasiveness, especially in T1. The measurement of the solid portion and the classification of T1 in 1-cm increments may be complex.

Hermansky-Pudlak syndrome-associated pneumothorax with rapid progression of respiratory failure: a case report.

BACKGROUND: Hermansky-Pudlak syndrome (HPS) is an extremely rare disease with pulmonary fibrosis (PF), oculocutaneous albinism, induced platelet dysfunction, and granulomatous colitis. Although patients with HPS-associated PF (HPS-PF) often receive treatment with anti-fibrotic agents, including pirfenidone, many HPS-PF cases are progressive. The development of pneumothorax is known to be rare in HPS-PF. Pneumothorax development is generally important for prognosis in patients with interstitial pneumonia. However, there are few reports regarding the development of pneumothorax in patients with HPS-PF. CASE PRESENTATION: A 50-year-old Japanese man with chestnut hair, white skin, and light brown squint eyes visited our hospital for interstitial pneumonia examination. Chest high-resolution computed tomography (HRCT) demonstrated diffuse bilateral reticular opacities along the bronchovascular bundles and traction bronchiectasis predominantly in the upper lung fields. He was definitively diagnosed with HPS because genetic analysis showed that he had a homozygous mutation, c.398 + 5G > A, in the HPS-1 gene. After diagnosis with HPS-PF, he initiated home oxygen therapy due to gradually progressive hypoxemia. Three months after the HPS-PF diagnosis, the patient suddenly developed severe chest pain and dyspnea and was admitted to our hospital on emergency. He was diagnosed with pneumothorax by chest radiological findings. He immediately received chest drainage; however, his pneumothorax did not improve. Therefore, he underwent video-assisted surgery by thoracic surgeons. The leak point was not detected, but multiple bullae were found, mainly in the upper lung lobes. Thus, the surgeons did not perform bullectomy and only covered the apical areas. Fifteen days after the surgery, the patient developed high fever and dyspnea with a new diffuse reticular shadow found through HRCT. We first initiated the patient on broad-spectrum antibiotics; however, the symptoms and radiological findings worsened. Therefore, we started treatment with pirfenidone for inhibition of PF progression. The patient re-developed pneumothorax with severe respiratory failure. Although he re-underwent chest drainage, he died of progressive respiratory failure. CONCLUSIONS: We herein report the case of a rare HPS patient who developed pneumothorax with progressive PF. Pneumothorax may cause rapid progressive respiratory failure and may be associated with PF progression in HPS-PF.

The maximum dimension of the inferior vena cava is a significant predictor of postoperative mortality in lung cancer patients with idiopathic interstitial pneumonia.

PURPOSE: Several vascular measurements in computed tomography (CT) were reported to be indicators of pulmonary hypertension in chronic obstructive pulmonary disease (COPD) patients. We evaluated the usefulness of these parameters as predictors of postoperative mortality in lung cancer patients with IIP. METHODS: This retrospective study was performed on 1888 patients. The following CT findings were evaluated: diameter of the main pulmonary artery, ascending aorta, and the short axis of the inferior vena cava (IVC). Univariate and multivariate analyses were conducted to determine predictors of surgical mortality. RESULTS: In the IIP patients, the 90-day mortality was 0.8%, and the 2-year mortality was 5.8%. Regarding the 90-day mortality in patients with IIP, a multivariate analysis revealed a short axis of IVC > 21 mm [odds ratio (OR) 6.4, p < 0.01) and the risk score reported by Japanese Association for Chest Surgery (JACS) (OR 1.4, p = 0.01) as independent predictors. Regarding the 2-year mortality in patients with IIP, a multivariate analysis revealed IVC > 21 mm (OR 2.3, p < 0.04), %VC < 80% (OR 2.4, p = 0.02), and pathological cancer stages II and III vs. I (OR 7.2, p < 0.001) as independent predictors. CONCLUSIONS: Enlargement of the IVC as measured by CT was a significant predictor of mortality after surgery for lung cancer with IIP patients.

New simple radiological criteria proposed for multiple primary lung cancers.

BACKGROUND: Controversies remain as to the differential diagnosis between multiple primary lung cancer (MPLC) and intrapulmonary metastasis (IM) in lung cancers. We have investigated the clinical criteria for MPLC and here propose a set of new and simple criteria from the stand point of prognosis. METHODS: A retrospective study was conducted on 588 consecutive patients with resected lung cancer of clinical Stage IA between 2009 and 2012. Multiple lung cancers (MLCs) were observed in 103 (17.5%) of the 588 patients. All main and other tumors were divided into solid tumor (ST) and non-solid tumor (non-ST). We defined Group A as MLCs having at least one non-ST and Group B as all tumors being ST. Cox's proportional hazard model was used for the multivariate analyses to investigate the preoperative prognostic factors. We divided the MLCs into MPLC and IM based on the preoperative prognostic factors, and survival was estimated by the Kaplan-Meier method. RESULTS: A multivariate analysis with Cox's proportional hazards model revealed that Group A independently predicted good overall survival (HR = 0.165, 95% CI: 0.041-0.672).Differences in the 3- and 5-year overall survivals between Groups A and B were statistically significant (96.3%/92.2% vs. 70.0%/60.0%, Pvalue = 0.0002). CONCLUSIONS: We suggest that Group A, defined as the presence of at least one tumor with a ground glass opacity component and clinical N0, should be excluded from the conventional concept of multiple lung cancers based on the criteria of Martini and Melamed as it has a very good prognosis. This group would be considered to be radiological MPLC.

Surgical intervention for ground glass dominant lesions: observation or outright resection?

BACKGROUND: The management of ground glass opacity (GGO) on computed tomography (CT) remains controversial. Information of the relationship between clinical behavior and pathological invasiveness of GGO is valuable for management. We conducted this retrospective study to establish differences in the pathological invasiveness between GGO with and without changes. METHODS: Among 1762 patients, the following criteria was used: (1) maximum tumor diameter of 3 cm or less, (2) tumor having 50% or more GGO and (3) resection after at least three months of follow up. A change of CT findings was defined as an increase in the diameter or consolidation compared with the initial CT. The relationship between preoperative changes and ratio of invasive adenocarcinoma was investigated. Predictors of GGO growth were also examined. RESULTS: There were 250 patients: pure GGO without changes (G-N group; n = 118), pure GGO with changes (G-C group; n = 35), part-solid GGO without changes (S-N group; n = 78), and part-solid GGO with changes (S-C group; n = 20). The ratio of invasive adenocarcinoma in each group was 0.54, 0.89, 0.8, and 0.90. There was a significant difference between the G-N and G-C group (P < 0.001). However, there was no significant difference between the G-C, S-N and S-C group. Multivariate analysis indicated age was a predictor of preoperative changes (OR = 1.953, P = 0.049). CONCLUSIONS: The pathological results of part-solid GGO with changes were not different from those without changes. Therefore surgery can be deferred until those lesions demonstrate changes. The pathological results of pure GGO with changes were equivalent to those of part-solid GGO. Therefore, even for pure GGO, follow up is necessary especially in elderly patients.

Surgical resection for clinical-Stage I radiological pure-solid lung cancer that met the current high risk criteria.

OBJECTIVE: We assessed whether surgical resection is acceptable for radiological invasive non-small cell lung cancer (NSCLC) that met the current high-risk criteria. METHODS: We reviewed 500 clinical-Stage I NSCLCs with a radiological pure-solid appearance. High-risk criterion was defined as follows: (1) preoperative FEV1% ≤ 50% or DLco% ≤ 50%, (2) age > 75y with 50% < FEV1% < 60% or 50% < DLco% < 60%, and (3) three or more severe general comorbidities. RESULTS: The high-risk group comprised 184 (37%) patients. The percentages for elderly, male, smoker, non-adenocarcinoma histology were significantly higher than those of the normal-risk group (P < 0.001). Lobectomy was performed in 148 (80%) patients. Overall survival (OS) was significantly worse in the high-risk group (59.4% vs 73.1%, P = 0.004), however, a multivariate analysis revealed that high-risk was not associated with poor survival (P = 0.519). Furthermore, there were no significant differences between the high-risk and normal-risk groups regarding cancer-specific survival (74.5% vs 79.2%, P = 0.569). Postoperative morbidity rates were significantly different between the two study arms (45% vs 25%, P < 0.001), however, the 30-day and 90-day mortality rates for the high-risk group were 1.6% and 3.8%, respectively. In the high-risk patients, the difference in survival between lobectomy and sublobar resection was not significant (69.4% vs 78.6%, P = 0.716), and was also proven in the propensity-score matched patients (82.1% vs 76.0%, P = 0.623). CONCLUSIONS: Conventional high-risk criteria are not always appropriate prognostic variables, and lung cancer specific survival or short-term mortalities for high-risk patients were fully acceptable. Surgical therapy including lobectomy should not be readily excluded from radical local management even when a patient meets the high-risk criteria.

Surgical Management of Multifocal Ground-Glass Opacities of the Lung: Correlation of Clinicopathologic and Radiologic Findings.

Background We evaluated the clinicopathologic characteristics and oncologic outcome in patients who underwent surgical resection for multifocal ground-glass opacities (GGOs) of the lung. Methods We examined 131 patients who underwent surgical resections for multiple clinical-N0 lung cancers. Multifocal GGOs were defined as tumors showing GGO dominance with a consolidation/tumor ratio (CTR) < 0.5 for all, whereas solid lesions were defined as having at least one tumor that showed CTR ≥0.5. Results Multifocal GGOs were found in 53 (40.5%) patients. A significantly large number of GGOs with a median of 3 per patient (range 2-41) was observed in multifocal GGOs (p < 0.0001). A multivariate analysis demonstrated tumor size ≤ 20 mm (p = 0.0407) and multifocal GGOs (p = 0.0345) were significantly associated with the survival. Regarding surgical managements for multifocal GGOs, the 5-year overall survival (OS) of multiple synchronous or staged limited resection only (n = 26) versus anatomical resection with or without additional limited resection (n = 27) was not significantly different (100% and 91.9%, p = 0.2287). The total number of resected multifocal GGOs was 278, most of which revealed adenocarcinoma or precancerous lesions. Unresected or new GGOs developed in 19 (35.8%) patients, all of which remained pure-GGO of < 10 mm in size without any interventions. The 5-year OS of multifocal GGOs and solid lesions were 94.4% and 80.6% (p = 0.0096), with a median follow-up time of 60 months. Conclusion Surgical interventions combined with limited surgery or adequate follow-up management based on the findings on thin-section CT could provide acceptable oncologic outcomes for multifocal GGOs.

The impact on the prognosis of unsuspected N2 disease in non-small-cell lung cancer: indications for thorough mediastinal staging in the modern era.

PURPOSE: Predicting the prognosis of advanced non-small-cell lung cancer (NSCLC) patients who present with clinically unsuspected N2 is very different due to the heterogeneity of this cohort. Thus, this study was undertaken to identify the clinicopathological features and survival of patients with clinical N0 or N1 and pathological N2, namely, unsuspected N2. METHODS: Among 239 patients with pathological N2 NSCLC, we reviewed the cases of 92 (38.5 %) patients who showed unsuspected N2. The prognosis was investigated using the Kaplan-Meier method and a Cox regression model. RESULTS: The 5-year overall survival (5yOS) of the patients with unsuspected N2 was 51.2 %. Based on a multivariate analysis, age and 18F-fluorodeoxyglucose (FDG) uptake in the lymph nodes were significant prognostic factors of unsuspected N2 (p = 0.0081, 0.0228, respectively). The 5yOS of PET-negative unsuspected N2 (n = 68) was 58.9 %, whereas that of PET-positive unsuspected N2 (n = 24) was 29.7 % (p = 0.0026). Furthermore, the 5yOS of PET-negative unsuspected N2 was significantly better than that of both clinical and pathological N2 s (i.e., suspected N2; n = 60; 5yOS, 42.1 %; p = 0.0051), while no significant difference was observed between PET-positive unsuspected N2 and suspected N2 (p = 0.6325). CONCLUSIONS: A preoperative evaluation of the lymph nodes by PET/CT has a potential benefit in predicting the prognosis. A thorough evaluation of the lymph nodes is, therefore, needed if the lymph nodes show an FDG uptake, even in cases that show a clinical N0 status on thin section CT scans.

Clinicopathological characteristics of lung cancer mimicking organizing pneumonia on computed tomography-a novel radiological entity of pulmonary malignancy.

OBJECTIVE: Lung cancer could be misdiagnosed as benign due to its atypical radiological findings or difficulty in the histological diagnosis. We intended to elucidate the clinicopathological features of such lung cancers. METHODS: Between 2008 and 2011, we performed surgical resection for 564 consecutive patients with lung adenocarcinoma. Findings on thin-section computed tomography were reviewed for all patients, 13 of whom were found to have lung cancer mimicking organizing pneumonia. The radiological and clinicopathological features of lung cancer mimicking organizing pneumonia and other adenocarcinomas were evaluated. RESULTS: Among 13 patients with lung cancer mimicking organizing pneumonia, 4 were men. The median age was 70 years (range 62-81 years). Six patients were followed up for more than 1 year (range 1-108 months) as their lesions were misdiagnosed as organizing pneumonia. Preoperative carcinoembryonic antigen was significantly high (P = 0.025), and maximum tumor dimension was significantly large for lung cancer mimicking organizing pneumonia (30 vs. 23.6 mm, P = 0.001). Pathologically, there was no vascular invasion (P = 0.012) and only one lymphatic invasion (P = 0.064). One case of lymph node metastasis to the N2 node was found due to misdiagnosis as organizing pneumonia for 9 years. CONCLUSIONS: Basically, lung cancer mimicking organizing pneumonia was less invasive and showed slow growth. However, nodal metastasis could be found. Thus, radiological diagnosis based on the findings of thin-section computed tomography is valuable to avoid delay in diagnosis.

The oncological outcomes of segmentectomy in clinical-T1b lung adenocarcinoma with a solid-dominant appearance on thin-section computed tomography.

PURPOSE: We investigated the surgical outcomes of clinical-T1b lung adenocarcinomas patients whose tumors had a solid-dominant radiological appearance and who were treated with segmentectomy or lobectomy. METHODS: We examined 154 surgically resected clinical-T1b lung adenocarcinomas with a "solid-dominant" appearance on thin-section computed tomography (CT). The preoperative thin-section CT images of all cases were reviewed. "Solid-dominant" was defined as 0.5≤ consolidation/tumor ratio (CTR) <1.0. RESULTS: Pathological nodal metastasis, lymphatic invasion, vascular invasion, and pleural invasion were found in 7 (4.5 %), 27 (18 %), 21 (14 %), and 15 (10 %) patients with clinical-T1b solid-dominant lung adenocarcinoma, respectively. Lobectomy and segmentectomy were performed in 123 (80 %) and 31 (20 %) cases, respectively. The 3-year overall survival (OS) and relapse-free survival (RFS) of patients with clinical-T1b solid-dominant lung adenocarcinoma were 95.5 and 92.4 %, respectively. The 3-year RFS and OS did not differ significantly between the patients who underwent lobectomy or segmentectomy (3-year RFS, 92.3 vs. 93.4 %, p = 0.8713; 3-year OS, 95.3 vs. 96.6 %, p = 0.7603). Segmentectomy was not found to be a prognostic factor for RFS (p = 0.8714), or OS (p = 0.7613). CONCLUSIONS: Segmentectomy can achieve acceptable oncological outcomes (both in terms of OS and RFS), which are similar to those achieved with standard lobectomy, in patients with clinical-T1b solid-dominant lung adenocarcinoma.

Outcomes of lung cancer resection for patients with combined pulmonary fibrosis and emphysema.

PURPOSE: Combined pulmonary fibrosis and emphysema (CPFE) has recently been reported as a prognostic factor that may increase the risk of lung cancer for patients with respiratory disorders; however, there have been no reports published on mortality and morbidity following major lung resection for patients with CPFE. METHODS: The subjects of this retrospective study were 1507 patients who underwent surgical resection of lung cancer at our institute between 2008 and 2013. We reviewed the computed tomography findings and divided the patients into four groups: CPFE group, fibrosis group, emphysema group, and normal group. The surgical outcomes of the patients with CPFE were compared with those of the patients in the other groups. RESULTS: The CPFE group comprised 137 (10.0 %) patients. This group had worse surgical morbidity and mortality rates than either the fibrosis group or the emphysema group. The 90-day mortality rates for the CPFE, fibrosis, and emphysema groups were 7.3, 0, and 3.0 %, respectively. A multivariate analysis of the CPFE group revealed that the distribution of IIP (HR 13.29, p = 0.038) and blood loss (ml) (HR 1.001, p = 0.013) predicted the hazard ratio for 90-day mortality. CONCLUSIONS: The postoperative outcome of patients with CPFE in this study was poor with respect to morbidity and mortality. The high rate of complications and poor survival warrants further investigation of the indications for surgery in patients with CPFE.

Patency of grafts after total resection and reconstruction of the superior vena cava for thoracic malignancy.

PURPOSES: Resection and reconstruction of the superior vena cava (SVC) is used for the complete resection of advanced lung cancer and mediastinal tumors. However, the optimal postoperative management for this procedure remains to be elucidated. METHODS: 1897 patients with lung cancer and/or mediastinal tumors underwent surgical resection at our institute. Among them, 12 patients underwent combined resection and replacement with a vascular graft of the SVC. Preoperative SVC syndrome was noted in 4, and preoperative chemo and/or radiotherapy were used in 2. The SVC pathway was reconstructed bilaterally in 9 patients (75 %), while 2 patients underwent a right-side single bypass, and 1 had a Y-shaped bypass. Antithrombotic agents were not used postoperatively. The factors related to occlusion of the graft were investigated. The median follow-up time for the surviving patients was 474 days. RESULTS: There were no instances of surgical mortality. Among the 22 grafts, three (14 %) were occluded. One (8 %) case of occlusion was noted on the right side and 2 (20 %) in the left graft. Bilateral reconstruction was performed in all except 2. Two single side reconstructions did not result in occlusion, while 3 occlusions were noted in the patients who had undergone bilateral reconstruction. CONCLUSION: Resection and reconstruction of the SVC system was feasible. Postoperative anti-thrombotic agents are not always needed to prevent acute graft occlusion.

Predictors of pathological non-invasive lung cancer with pure-solid appearance on computed tomography to identify possible candidates for sublobar resection.

PURPOSE: This study aimed to establish favorable predictors for patients with clinical stage IA radiological pure-solid lung cancer to identify possible candidates for sublobar resection. METHODS: We examined 275 patients with surgically resected clinical stage IA radiological pure-solid lung cancer. Pathological grade PL0, Ly0, V0, or N0 disease was defined as non-invasive pure-solid lung cancer (NIPS). RESULTS: Nodal involvement was observed in 63 (23 %) patients with clinical stage IA pure-solid lung cancer, while NIPS was identified in 77 (28 %). Multivariate analysis revealed that air bronchogram (p = 0.0328), clinical T1a (p = 0.0041), and SUVmax (p = 0.0002) were significant clinical predictors of NIPS. When these clinical predictors were combined and the relevant patients' disease was classified as favorable, the frequency of nodal involvement was only 4 %. Furthermore, the 3-year overall survival (OS) of the patients with "favorable" clinical stage IA pure-solid lung cancer was 100 % despite their operative modes. In contrast, the 3-year OS even for patients with clinical stage IA disease, if they had neither of these clinical predictors, was 74.1 %. CONCLUSIONS: Tumor size, the presence of air bronchogram, and the SUVmax level were significant favorable predictors of pathological non-invasive status, and patients with these clinical predictors could be candidates for sublobar resection for clinical stage IA pure-solid lung cancers.