Impact of additional pleurodesis in video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax.

BACKGROUND: Bullectomy for primary spontaneous pneumothorax has been associated with high postoperative recurrence rates when video-assisted thoracoscopic surgery (VATS) has been used rather than thoracotomy. The aim of this study was to evaluate the efficacy and identify the disadvantages, if any, of adding pleurodesis to VATS bullectomy to prevent recurrent pneumothorax. METHODS: Fifty-three patients who underwent VATS bullectomy with additional pleurodesis for pneumothorax after November 1996 and 50 who underwent VATS bullectomy alone before October 1996 were compared retrospectively in terms of intraoperative factors and postoperative chest pain, pulmonary function, and pneumothorax recurrent rates. Pleurodesis was achieved by electrocauterizing the upper surface of the parietal pleura in a patchy fashion. RESULTS: There were no significant differences between the additional pleurodesis group and the bullectomy alone group in terms of age, sex, operating time, intraoperative bleeding, number of resected bullae, duration of chest drainage, or volume of fluid drained. Postoperative chest pain and pulmonary function were also similar in both groups. A recurrent pneumothorax occurred in one patient (1.9%) in the additional pleurodesis group; this recurrence rate was significantly lower than that for the bullectomy alone group (eight patients, 16%; p = 0.029). Although the mean postoperative follow-up period was considerably shorter in the additional pleurodesis group (38 months [range, 26-49]) than in the bullectomy alone group (63 months [range, 50-72] ), eight (89%) of all nine recurrences occurred within 26 months of surgery-i.e., within the minimum follow-up period for the additional pleurodesis group. CONCLUSIONS: Pleurodesis is a minimally invasive technique that is effective in preventing postoperative recurrences of pneumothorax when added to VATS bullectomy. Additional pleurodesis has no disadvantages vs bullectomy alone in terms of worsening postoperative chest pain or pulmonary function.

A case of multiple atypical adenomatous hyperplasia of the lung detected by computed tomography.

Multiple atypical adenomatous hyperplasia (AAH) of both lungs in a 72-year-old male, detected by computed tomography, is reported. The lesions of the right lung were resected for diagnosis via video-assisted thoracoscopic surgery (VATS). The resected specimen had 22 AAH lesions up to 10 mm in size. For nine of these lesions, the expressions of carcinoembryonic antigen (CEA), c-erbB-2 oncoprotein and p53 gene product were examined by immunohistochemistry and the loss of heterozygosity (LOH) on chromosomes was investigated by polymerase chain reaction analysis. These lesions showed a variety of expressions for CEA, c-erbB-2 and p53 oncoprotein. Three of the nine lesions showed LOH on chromosome 13q, although this was not exhibited in the largest one. These results indicate that each AAH in this case has independent genetic abnormalities and is multicentric.

What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery?

BACKGROUND: To clarify any advantages of video-assisted thoracoscopic surgery (VATS) over anterior limited thoracotomy (ALT) for lobectomy in lung cancer, we compared the two procedures in a retrospective analysis. METHODS: Sex- and age-matched (+/- 5 years) lung cancer patients in clinical stage I who underwent lobectomy by means of VATS (n = 33) or ALT (n = 33) were compared in terms of the number of resected lymph nodes, operating time, intraoperative blood loss, duration of postoperative chest tube drainage, and chest pain. Pain was evaluated using a visual analog scale and analgesic requirements. Vital capacity (VC), respiratory muscle strength, and results of a 6-minute walking (6 MW) test were also compared preoperatively and 1 and 2 weeks postoperatively. RESULTS: Compared with the ALT group, the VATS group experienced less pain between postoperative day (POD) 1 and POD 7 (p < 0.05 to 0.001) and had lower analgesic requirements up to POD 7 (p < 0.001). However, there were no significant differences in pain on POD 14. There were also no significant differences in intraoperative factors or in the postoperative impairment of VC, respiratory muscle strength, and 6 MW test results. CONCLUSIONS: Although VATS lobectomy reduces chest pain during the first week after surgery compared with ALT, this advantage is lost within 2 weeks. Both techniques result in similar impairments of pulmonary function, respiratory muscle strength and walking capacity. Therefore, if curative resection of lung cancer by VATS would be technically difficult for any reason, including the surgeon's skill and experience, a limited open thoracotomy would be preferable from the standpoints of safety and the patient's prognosis.

Prognosis and survival after resection for bronchogenic carcinoma based on the 1997 TNM-staging classification: the Japanese experience.

BACKGROUND: A new TNM staging system was proposed, and the previous system was revised in 1997. METHODS: To evaluate the new TNM staging system for lung cancer, records of 3,043 lung cancer patients who underwent pulmonary resection at the National Cancer Center Hospital, Tokyo, were analyzed. RESULTS: With regard to clinical stages, 3 patients had occult carcinoma; 786 patients had stage IA disease; 759 patients, stage IB; 54 patients, stage IIA; 469 patients, stage IIB; 582 patients, stage IIIA; 211 patients, stage IIIB; and 179 patients, stage IV. The 5-year survival rates for the respective stages were 70.8% for stage IA, 44.0% for stage IB, 41.1% for stage IIA, 36.9% for stage IIB, 22.7% for stage IIIA, 20.1% for stage IIIB, and 21.6% for stage IV. In terms of postoperative stages, 7 patients were classified in stage 0, 610 in stage IA, 506 in stage IB, 114 in stage IIA, 432 in stage IIB, 702 in stage IIIA, 448 in stage IIIB, and 224 in stage IV. The 5-year survival rates were as follows: stage IA, 79.0%; stage IB, 59.7%; stage IIA, 56.9%; stage IIB, 45.0%; stage IIIA, 23.6%; stage IIIB, 16.5%; and stage IV, 5.1%. CONCLUSIONS: In the clinical stage, there were significant prognostic differences between stage IA and stage IB, stage IIB and IIIA, and stage IIIA and stage IIIB, but there was no significant difference in 5-year survival rates between stage IB and stage IIA, stage IIA, and IIB, and stage IIIB and stage IV. In the postoperative stage, there were significant differences in 5-year survival rates between each stage except for stage IB and stage IIA.

[A case of lung cancer with extensive pleural adhesion, which could be resected by a thoracoscopic middle lobectomy].

A thoracoscopic middle lobectomy was performed for a 78-year-old male with lung cancer associated with extensive pleural adhesion. After peeling off the area of pleural adhesion surrounding the surgical ports by finger, the thoracoscope was inserted into the thorax and then the area of adhesion in the other area was also peeled off under thoracoscope. A pulmonary vein was resected using a stapler. Due to adhesion at the fissures between the lobes, a pulmonary artery and bronchus of the middle lobe were cut from the front of the lung hilum. After that, the fissures between the lobes were also cut using a stapler thus resulting in a complete middle lobectomy. The operation time was 5 hours and 28 minutes, and the intraoperative bleeding was 200 ml. There was no postoperative air leakage, and the chest drain could be removed the day after surgery. In conclusion, even for lung cancer with extensive pleural adhesion, a thoracoscopic lobectomy can still be successfully performed. When a fissure between the lobes is found to adhere, the approach to pulmonary artery and bronchus from the front of the lung hilum is useful for performing a thoracoscopic middle lobectomy.

[A case of lung cancer underwent carinal resection with right upper lobectomy and carinal reconstruction with double-barreled anastomosis].

A 70-year-old male complaining cough was admitted to our hospital. Bronchoscopic examination revealed a tumor mass which occluded the orifice of the right upper lobe. Chest computed tomographic (CT) scans gave the image of tumor invasion at the carina. The pathological diagnosis of the tumor was squamous cell carcinoma. Operation was accomplished by right posterolateral thoracotomy approach through the fifth rib bed. The carinal resection with right upper lobectomy was followed by a double-barreled anastomosis of the right intermediate trunk and left main-stem bronchus into the carina. The operation was successfully performed and was considered curative. The length of resected airway measured 4.0 cm from tracheal line of resection to the divided the right intermediate trunk. Reinforcement of the anastomosis was not performed in this case. No postoperative complication occurred but mild ischemia of the anastomosis. The patient died of recurrent tumor in a year and 2 months after operation.

[Video-assisted thoracoscopic surgery, with special reference to primary treatment for lung cancer].

From the viewpoint of patients, physicians, and health insurers, the ideal surgical treatment would be based on a precise diagnosis, followed by minimally invasive, high-technology-assisted, potentially curative surgery and the shortest possible period of hospitalization, while incurring the lowest possible medical fees. Such treatment would also be tailored to the medical, social, and employment needs of individual patients. Remarkable advances in video-assisted thoracoscopic surgery (VATS) techniques occurred in the late 20th century, making it minimally invasive compared with conventional thoracotomy. VATS results in less postoperative pain, shortens hospital stay, and improves the postoperative quality of life of patients. Among 570 institutions in Japan, the nationwide statistical record revealed that a total of 34,987 thoracic field surgeries were performed ??BETWEEN 19?? AND 19?? PLEASE GIVE YEARS??, of which 29.4% involved VATS. Of total thoracic surgical procedures recorded, VATS was performed in 76.7% of pneumothorax cases, 58.5% of benign tumor cases, and 38.8% of inflammatory disease cases. In cases of bullous disease excluding pneumothorax, VATS was performed in 44.5% of cases, in 38.0% of pleural tumor cases, and in 30.2% of mediastinal lung disease cases. The technique is also used in lung cancer. Of a total of 11,323 lung cancer lobectomies, VATS was performed in 539 (4.7%). Mediastinal dissection with VATS is becoming increasingly common. Satisfactory results have been achieved in terms of survival in patients with stage T1N0M0 lung cancer, which is recognized as an indication for VATS. This paper describes the current status of VATS in the field of general thoracic surgery as well in lung cancer.

Computed tomography screening for lung carcinoma in Japan.

BACKGROUND: In Japan, lung carcinoma is the leading cause of cancer-related deaths. Adenocarcinoma accounts for roughly half of all lung carcinomas. Earlier detection of lung carcinoma is expected to reduce mortality rates. Computed tomography (CT) provides higher contrast resolution and greater visualization of chest compartments that are difficult to view with chest radiography, such as the mediastinum. CT further permits the detection of minute peripheral nodules. At present, several institutions and research groups are evaluating the utility of low dose spiral CT for lung carcinoma screening. METHODS: From September 1993 to December 1998, 1669 individuals underwent a biannual screening program for lung carcinoma. The program included posteroanterior radiograph, sputum cytology, and low dose spiral CT at a for-profit organization: The Anti-Lung Cancer Association (ALCA). A total of 9993 examinations were carried out. The low dose spiral CT parameters used were 120 kvP, 50 mA, 10-mm collimation, and 2:1 pitch. RESULTS: Peripheral lung carcinoma was detected in 31 of 9993 examinations (0.3%). Of the 31 cases, 24 tumors (77%) were detected by low dose spiral CT but were not visible on standard chest radiography. Twenty-two of the 24 tumors were Stage IA (T1N0M0, according to staging system revised in 1997). CONCLUSIONS: Low dose spiral CT shows promise for lung carcinoma screening. The effectiveness of the technique for the detection of minute lung lesions remains to be established. Routine use of the technique will require resolution of several issues. These issues include the establishment of CT diagnostic criteria, the development of a diagnostic support system, the establishment of methods for definite diagnosis, and assessments of efficacy.

Clinical features and management of bronchogenic cysts: report of 17 cases.

Between 1966 and 1996, 17 patients, comprising 1 child and 16 adults, underwent surgical treatment for bronchogenic cysts at the National Cancer Center Hospital. The bronchogenic cysts were located in the mediastinum in 11 patients and in the pulmonary parenchyma in 6. Of the 17 patients, 5 (29.4%) manifested symptoms, being more frequently seen in those with intrapulmonary cysts than in those with mediastinal cysts. Chest radiographs were ineffective for accurate preoperative diagnosis, but accurate diagnosis was possible with 69.2% of computed tomography (CT) scans and 100% of magnetic resonance imaging (MRI) scans. MRI also proved very useful for qualitatively diagnosing the mediastinal tumors as cystic or solid. Surgery was performed through a thoracotomy in 14 patients and by video-assisted thoracic surgery (VATS) in 3 patients, achieving complete resection in 16 patients. In one patient, a mediastinal bronchogenic cyst was excised by VATS and incompletely resected because of tight adhesion to the membranous part of the trachea; however, no late complication or recurrence developed after the residual cystic wall had been ablated by electrocautery. VATS, which is an easy procedure to perform with only minimal surgical invasion, may be indicated for bronchogenic cysts if patients who undergo incomplete resection can be followed up carefully. Recent advances in imaging techniques have made it unnecessary to perform surgical excision for diagnostic confirmation, but we recommend surgery for most patients to relieve symptoms and prevent complications.

Histologic types of lung carcinoma and related family history of anatomic sites and histologic types of cancers.

BACKGROUND: Familial factors are suggested to play roles in lung carcinogenesis, but may well be different for each histologic cell type. METHODS: Information regarding smoking, past medical history, and family history of malignant diseases among first-degree relatives was collected from a total of 1188 patients with primary lung carcinoma (participants) who were treated in the thoracic oncology ward at the National Cancer Center Hospital, Tokyo, Japan. These data were analyzed for associations with the histologic type of the lung carcinoma. The main outcome measures were the relative risk of developing a malignancy, at any site or at certain specific sites, in first-degree relatives of participants who had a specific histologic type of lung carcinoma compared with the relative risk in those first-degree relatives of participants with other cell types. RESULTS: Participants with multiple malignant lesions reported significantly more first-degree relatives with a malignancy than those without multiple tumors (P = 0.008 by the Wilcoxon rank sum test). There was no statistically significant correlation between age, gender, smoking history, or histologic tumor type in the participant and the overall family history of malignancy. Site specific analyses revealed that participants with adenocarcinoma reported a family history of colorectal carcinoma, and those with squamous cell carcinoma reported a family history of head and neck carcinoma, more frequently than other participants (P = 0.041 and 0. 001, respectively, by chi-square analysis). CONCLUSIONS: The data from the current study suggest an association between familial factors and histologic type of lung carcinoma. Genetic factors to determine individual susceptibility to lung carcinogenesis should be investigated according to each histologic type.

Lymph node sampling in lung cancer: how should it be done?

OBJECTIVES: Systematic lymph node dissection in radical operation for lung cancer is recognized as an operative procedure which is expected to improve local control. We investigate the most effective method of lymph node dissection or sampling. METHODS: A retrospectrive study was carried out on 1815 patients who underwent systematic lymph node dissection and complete resection. The lymphatic route of metastatis from each lobe was investigated by examining which nodes had the most likelihood of metastasis, or to find out which is the sentinel lymph node in the case of small sized tumor, suitable for the video assisted thoracic surgery (VATS) approach. RESULTS: At N2 level, distribution of major metastases from each lobe are as follows: right upper lobe tumor, #3 - 12.3% (80/648) and/or #4 - 8% (52/648); right middle lobe tumor, #3 and/or #7 - 16.4% (13/79); right lower lobe tumor, #7 - 13.7% (52/380); left upper lobe tumor, #5 - 12.3% (60/489) and/or #6 - 6.7% (33/489); and left lower lobe tumor, #7 - 11.9% (26/219). Small sized tumor requires lymph node sampling upon staging, and the lymph node most likely to become the first metastasis, i.e. sentinel node, are as follows: regardless of the location of tumor, #12, #11, and/or #10 in N1 level, which means dissection or sampling within these locations of lymph nodes are prerequisite. In N2 level, #3 and/or #4 in right upper lobe tumor, #3 and/or #7 in right middle lobe tumor, #7 in right lower lobe tumor, #5 and/or #6 in left upper lobe tumor, and, #7 in left lower lobe tumor. CONCLUSIONS: In clinical T1NO lung cancer, sentinel lymph node sampling should be done first, if the nodes are negative, complete mediastinal lymph node dissection might be omitted. On the other hand, if the sentinel nodes are positive for pathology, complete medistinal lymph node dissection is required for curative resection.

Detection failures in spiral CT screening for lung cancer: analysis of CT findings.

PURPOSE: To clarify the computed tomographic (CT) findings and the progression of minute lung cancers that were missed at initial spiral CT screening but were later detected. MATERIALS AND METHODS: The findings from seven patients with lung cancer that was missed at the initial spiral CT screening were reviewed. Retrospective CT findings, time to detection, cell type, and pathologic stage were evaluated. RESULTS: Minute lung cancers missed at early spiral CT included a nodule among the shadows of old tuberculosis (n = 2), a faint nodule with high attenuation in the center of the nodule (n = 1), an increase in attenuation just adjacent to an axial peripheral pulmonary vessel (n = 1) and adjacent to a craniocaudal peripheral pulmonary vessel (n = 1), and a minute faint nodule (n = 2). The time to detection ranged from 6 to 18 months. At pathologic examination, six cancers were stage I, and one was stage II. CONCLUSION: Minute nodules of lung cancer that are near the threshold of detectability may be missed at spiral CT screening. It is important to examine noncalcified nodules with thin-section CT even when lesions from prior disease, such as those from old tuberculosis, exist and to evaluate the shadows of pulmonary vessels carefully. A follow-up examination is highly recommended.

Lobe-specific extent of systematic lymph node dissection for non-small cell lung carcinomas according to a retrospective study of metastasis and prognosis.

BACKGROUND: Complete lymphadenectomy of the mediastinum is advised for patients with lung cancer to provide prognostic information and possible survival benefit. The proper extent of dissection should be further defined. METHOD: The lymphatic metastatic patterns according to the primary site and prognoses were retrospectively analyzed in 166 patients with non-small cell carcinoma who underwent at least lobectomy with hilar and mediastinal lymphadenectomy. All patients had histologically proven mediastinal metastasis (pN2). RESULTS: Among 54 right upper lobe tumors the most common site of metastasis was the lower pretracheal station (74%), whereas metastases to the subcarinal station were seen only in 13%. Among 8 patients with right middle lobe tumors and 41 patients with right lower lobe tumors, both superior mediastinal and subcarinal stations were involved. The 34 left upper segment tumors metastasized to the aorticopulmonary window most commonly (71%) and to the subcarina only in 12% of cases. Inversely, the 10 left lingular tumors metastasized to the subcarina most commonly (50%) and to the aorticopulmonary window only in 20% of cases. Among 44 left lower lobe tumors the subcarinal station was most common for metastasis (58%), with infrequent metastases to the aorticopulmonary window. The 5-year survival for all 166 patients was 35%. Patients with single-station and single-node metastases had a significantly better prognosis than those with more extensive metastases. Right lower lobe tumors with superior mediastinal metastasis carried a particularly poor 5-year survival of only 4.1%. COMMENT: Subcarinal lymphadenectomy is not always necessary for tumors of the right upper lobe and left upper segment. For tumors of other lobes both superior mediastinal dissection and subcarinal dissection are advised. However, superior mediastinal metastasis should be recognized as an indicator of poor prognosis in tumors of both lower lobes.

Aldehyde oxidase-dependent marked species difference in hepatic metabolism of the sedative-hypnotic, zaleplon, between monkeys and rats.

A marked difference in hepatic activity of aldehyde oxidase between rats and monkeys was found to be responsible for the previously reported marked species difference in the metabolism of Zaleplon in vivo. In the postmitochondrial fractions, S-9s, from liver homogenates of these animals, Zaleplon was transformed in the presence of NADPH into the side chain oxidation product, N-desethyl-Zaleplon, and the aromatic ring oxidation product, 5-oxo-Zaleplon. In the rat S-9, N-desethyl-Zaleplon and 5-oxo-Zaleplon were a major and a very minor metabolites, respectively. However, in the monkey S-9, Zaleplon was transformed into 5-oxo-Zaleplon at a much higher rate than that for N-desethyl-Zaleplon formation. N-Desethyl-Zaleplon was formed in the monkey S-9 at a rate almost equal to that in the rat S-9. N-Desethyl-5-oxo-Zaleplon was formed at a minor rate only in the monkey S-9 through N-desethyl-Zaleplon as an obligatory intermediate. The hepatic activity for the formation of 5-oxo-Zaleplon in the monkey and rat was localized in cytosol and did not require NADPH. Sensitivity to various inhibitors and requirement of water as oxygen source, using H218O, strongly suggested that the hepatic cytosolic formation of 5-oxo-Zaleplon was mediated by aldehyde oxidase. N-Desethyl-Zaleplon was formed in the presence of NADPH by microsomes from the liver of rats and monkeys, and its formation was strongly suggested using various cytochrome P-450 inhibitors to be mediated by a number of cytochrome P-450 isoforms, such as 3A, 2C, and 2D subfamilies.

Spinal epidural abscess associated with epidural catheterization: report of a case and a review of the literature.

We describe a 53-year-old man who developed a catheter-related epidural abscess 8 days after left upper lobectomy for lung cancer. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in a culture of the epidural pus. Magnetic resonance imaging was essential for the diagnosis of epidural abscess and for determining the extent of spread. The patient was treated by laminectomy and administration of appropriate antibiotics, with almost complete recovery, except for urinary retention. A literature search yielded 29 additional cases of catheter-related epidural abscess. The median duration of catheterization was 4 days and the median time to onset of the clinical symptoms after catheter placement was 8 days. Eleven of the 30 patients had some underlying disorders, including malignancy or herpes zoster, or were receiving steroids. Nine of the 10 patients with thoracic epidural abscess had persistent neurological deficits, whereas 12 of the 15 patients with lumbar epidural abscess showed a full recovery after treatment. Surgical decompression was not required in six patients without significant neurological deficits, who recovered following antibiotic treatment (four patients) or percutaneous drainage (two patients). Thoracic catheters are associated with a disproportionately high incidence of epidural abscess and persistent neurological sequelae following treatment.

Surgical resection of pulmonary metastases from gastric cancer.

BACKGROUND AND OBJECTIVES: There are no reports concerning surgical treatment on pulmonary metastases from gastric cancer. The aims of this study were to characterize patients with pulmonary metastasis from gastric cancer and to determine the efficacy of surgical therapy. METHODS: Between 1977 and 1993, 3,076 patients underwent curative resection for gastric cancer. Among them, four patients (0.1%) with pulmonary metastases from gastric cancer underwent pulmonary resection. RESULTS: All four patients had advanced gastric cancers involving regional lymph nodes far from the primary gastric lesion. The median tumor-free interval after the initial gastrectomy was 32.0 months (range: 19-48 months). All patients underwent a lobectomy for a solitary pulmonary lesion. Although transthoracic fine-needle aspiration cytology revealed adenocarcinoma in all cases, none of them were definitely diagnosed as metastasis from gastric cancer preoperatively. The diagnosis was obtained after pulmonary resection. All patients received postoperative chemotherapy or radiotherapy, or both. However, they all subsequently developed systematic metastases. The time interval to recurrence after pulmonary resection ranged from 6 to 36 months and they were all dead at a median follow-up of 24.3 months after the pulmonary resection. CONCLUSIONS: An aggressive surgical approach was not warranted in patients with isolated resectable pulmonary metastases from gastric cancer. However, the possibility of surgical treatment could not be eliminated because surgery is the only diagnostic method for a solitary pulmonary nodule when there is some doubt about the diagnosis of primary or secondary lung cancer in patients with gastric cancer.

[Surgical treatment for metastatic lung tumors].

Surgical treatment for metastatic lung tumors has been reported to be efficacious in selected patients by many authors. Most of these reports are retrospective studies. In our hospital, metastatic lung tumors were resected in 624 patients, and the 5- and 10-year survival rates after pulmonary metastatectomy were 38.3% and 26.6%, respectively. There are many long-time survivors without recurrence after thoracotomy. However, pulmonary metastatectomy seems to offer no survival benefit in some cancers, e.g., gastric cancer, even if the patients satisfy the criteria for surgery. Prospective studies for each type of primary cancer are needed to determine the true efficacy of pulmonary metastatectomy.