Complex video-assisted thoracoscopic surgery lobectomy for locally advanced lung cancer: a prospective feasibility study.

PURPOSE: The limitations regarding indications for video-assisted thoracoscopic surgery lobectomy requiring complex surgery remain unclear. A prospective cohort study was conducted to elucidate the safety and feasibility of complex thoracoscopic lobectomy for patients with locally advanced non-small-cell lung cancer. METHODS: We planned to enroll patients who were suspected of needing thoracoscopic lobectomy or more with complex surgery, including tracheo-bronchoplasty, pulmonary arterioplasty, and combined resection of adjacent organs. Between February 2016 and January 2019, 28 consecutive patients were prospectively enrolled. RESULTS: After excluding 1 patient due to disease progression, 27 patients were included in this study. Three patients underwent thoracoscopic lobectomy without complex surgery. Of the remaining 24 patients, complex thoracoscopic lobectomy was successfully completed in 21 (88%), and the 3 conversions were due to surgery for the great vessels. All 27 patients achieved complete resection. Six patients (22%) suffered grade 2 complications, and the in-hospital, 30-day, and 90-day mortality rates were all 0%. At a median follow-up time of 900 days, the 3-year overall and disease-free survival rates were 75% and 54%, respectively. CONCLUSIONS: Complex thoracoscopic lobectomy was shown to be safe and feasible in select patients with locally advanced non-small-cell lung cancer excluding invasion to the great vessels. CLINICAL REGISTRATION NUMBER: University Hospital Medical Information Network Clinical Trials Registry, 000,019,441 (JAPAN). Institutional Review Board number: 46-15-0003 (accepted at September 7, 2015).

The Subxiphoid Approach Leads to Less Invasive Thoracoscopic Thymectomy Than the Lateral Approach.

OBJECTIVE: Video-assisted thoracic surgery (VATS) is widely used in thoracic surgery. This study investigated the usefulness of the subxiphoid approach in thymectomy using VATS techniques. METHODS: Sixty operations were performed using the lateral approach (n = 46) and subxiphoid approach (n = 14). Using the lateral approach, 39 partial thymectomies (PT), 5 total or subtotal thymectomies (TT), and 2 total or subtotal thymectomies with combined resection of the surrounding organs (or tissues) (CR) were performed. Using the subxiphoid approach, 11 TT and 3 CR were performed. RESULTS: There were 33 females and 27 males, with a mean age of 55 years. The mean maximum tumor diameter was 4.0 cm. The operation time was prolonged according to the volume of thymectomy (PT: 119, TT: 234, CR: 347 min). Additionally, the intraoperative blood loss increased according to the volume of thymectomy (PT: 29, TT: 47, CR: 345 g). To compare the invasiveness of both approaches, we compared 16 TT operations. In the group using the subxiphoid approach, the operation time became shorter (158 vs. 392 min), and the blood loss decreased (5 vs. 135 g) compared with the lateral approach. Regarding laboratory data, white blood cell counts on postoperative day 1 (1POD) (8200 vs. 10,300/µl) and CRP on 1POD and 3POD (2.8 and 2.8 vs. 7.9 and 10.2 mg/dl, respectively) decreased in the subxiphoid approach compared with the lateral approach. CONCLUSIONS: The subxiphoid approach leads to a less invasive operation for anterior mediastinal tumors and extends the indications for VATS for invasive anterior mediastinal tumors.

The Outcomes of a Limited Resection for Non-Small Cell Lung Cancer Based on Differences in Pathology.

OBJECTIVE: A precise preoperative diagnosis of in situ or minimally invasive carcinoma may identify patients who can be treated by limited resection. Although some clinical trials of limited resection for lung cancer have started, it will take a long time before the results will be published. We have already reported a large-scale study of limited resection. We herein report the data for a subclass analysis according to differences in pathology. METHODS: Data from multiple institutions were collected on 1710 patients who had undergone limited resection (segmentectomy or wedge resection) for cT1N0M0 non-small cell carcinoma. The disease-free survival (DFS) and recurrence-free proportion (RFP) were analyzed. Small cell carcinomas and carcinoid tumors were excluded from this analysis. Adenocarcinomas were sub-classified into four groups using two factors, the ratio of consolidation to the tumor diameter (C/T) and the tumor diameter alone. RESULTS: The median patient age was 64 (20-75) years old. The mean maximal diameter of the tumors was 1.5 ± 0.5 cm. The DFS and RFP at 5 years based on the pathology were 92.2 and 94.7 % in adenocarcinoma (n = 1575), 76.3 and 82.4 % in squamous cell carcinoma (SqCC) (n = 100), and 73.6 and 75.9 % in patients with other tumors (n = 35). The prognosis of adenocarcinoma in both groups A (C/T ≤0.25 and tumor diameter ≤2.0 cm) and B (C/T ≤0.25 and tumor diameter >2.0 cm) was good. In SqCC, only segmentectomy was a favorable prognostic factor. In the groups with other pathologies, large cell carcinomas were worse in prognosis (the both DFS and RFP: 46.3 %). CONCLUSION: Knowing the pathological diagnosis is important to determine the indications for limited resection. Measurement of the tumor diameter and C/T was useful to determine the indications for limited resection for adenocarcinoma. Limited resection for adenocarcinomas is similar with a larger resection, while the technique should be performed with caution in squamous cell carcinoma and other pathologies.

The advantages of selecting cartridges with a 1.8 mm height for pulmonary stapling.

PURPOSES: The purpose of this study was to retrospectively analyze the complications arising from stapling of the pulmonary parenchyma and to determine the most appropriate cartridges to use for pulmonary stapling. METHODS: A retrospective multi-institutional review was conducted by the Central Japan Lung Cancer Surgery Study Group. We analyzed both Echelon™ (EC) and EndoGIA™ (EGIA) staplers in this study. The stapling cartridges were classified into 3 colors according to the height of the ß loops: green (2.0 mm), gold (1.8 mm), and blue (1.5 mm). RESULTS: Stapling of the pulmonary parenchyma was performed 9016 times. The total number of complications related to stapling was 61 (0.68 %). These complications were mainly caused by stapler-tissue thickness mismatch (n = 30, 49.2 %) and tissue fragility (n = 27, 44.3 %). The number and rate of complications of the different cartridges were 19 and 0.63 % for EGIA blue, 25 and 0.94 % for EGIA green, 1 and 0.067 % for EC gold, 12 and 0.98 % for EC blue, and 4 and 0.64 % for EC green, respectively. Complications associated with stapling using EC gold cartridges occurred less frequently than with the other cartridges (p = 0.0022). CONCLUSION: The gold cartridge appears to cause the least complications and may therefore be the most appropriate cartridge for stapling the pulmonary parenchyma among the tested staplers.

A safe method for marking small pulmonary nodules with crystal violet.

INTRODUCTION: The number of cases of wedge resection of small-sized pulmonary nodules performed under video-assisted thoracoscopic surgery (VATS) is increasing. Computed tomography (CT)-guided marking with hook wires has been used to locate the nodules that are not identifiable under VATS. However, this method is invasive and is associated with a risk of complications. METHODS: We evaluated the usefulness of marking the pleural surface above the nodule using crystal violet for 22 small-sized pulmonary nodules. Following the collapse of the lung, a long stick with a cotton tip dipped in crystal violet was inserted from the thoracic port or a small thoracotomy, and was placed against the inside of the chest wall right above the nodule with reference to the preoperative CT image. The lung was then expanded, and the crystal violet-infiltrated tip stained the visceral pleura. Regardless of the marking point, wedge resection of the lung was performed. To evaluate the accuracy of the marking, we measured the distance from the center of the marking to the point on the visceral pleural nearest to the nodule (DMN) in the resected lung specimen. RESULTS: This marking method caused no morbidity during or after the operation. The DMN ranged between 0 and 50 mm (mean ± SD 18.2 ± 12.6 mm). In 18 of 22 cases (81.8%), the DMN was 20 mm or less. CONCLUSIONS: The intraoperative marking method using crystal violet was performed with reasonable accuracy. It also caused no morbidity. It was easy and non-invasive. This method can be used in the cases in which CT-guided percutaneous marking is not feasible due to the nodule's location.

Estimation of the success rate of anesthetic management for thymectomy in patients with myasthenia gravis treated without muscle relaxants: a retrospective observational cohort study.

Although maintaining anesthesia for myasthenia gravis (MG) with minimal muscle relaxants (MR) is common, the success rate of anesthetic management for MG without MR is not clear. We therefore retrospectively examined the success rate of anesthetic management for MG without MR among 66 consecutive cases of thymectomy for MG performed at our hospital between January 2004 and April 2010, before approval of using sugammadex. A total of 60 patients (90.9 %) were treated without MR (N group). Among the 60 cases, 17 (28.3 %) patients were not extubated in the operating room due to postoperative respiratory depression or other reasons. Therefore, the success rate of anesthetic management for thymectomy in patients with MG without treating MR was 71.7 % (43/60) [95 % confident interval (CI): 65.9-77.5 %]. The reasons for using MR included coughing at intubation in one case, bucking during surgery in two cases, and MR was considered to be safer by the attending anesthesiologist in three cases. The number of cases of impossible extubation requiring ventilation on that day was three in the N group and none in the R group. Finally, the success rate of anesthetic management for MG without MR was estimated to be 71.1 % (95 % CI: 65.9-77.5 %).

Clinicopathological analysis of small-sized anterior mediastinal tumors.

PURPOSE: The purpose of this study was to determine the clinicopathological findings and prognosis of small-sized anterior mediastinal tumors (SSAMTs). METHODS: A retrospective study was conducted on 43 patients who underwent surgery between January 1989 and December 2011 for SSAMTs. RESULTS: From the preoperative radiological findings, the tumors were classified into solid (n = 28) and cystic lesions (n = 15). The pathological diagnoses of the solid lesions included thymoma (n = 24), thymic carcinoma (n = 1), mucosa-associated lymphoid tissue lymphoma (n = 1), teratoma (n = 1) and neurofibroma (n = 1), and those of the cystic lesions included thymic cysts (n = 8), thymoma (n = 3), bronchogenic cysts (n = 2), teratoma, (n = 1) and a pericardial cyst (n = 1). The 27 thymomas were composed of stages I (n = 22), II (n = 3), III (n = 1) and IVb (n = 1). The overall survival in the 43 patients was 97.1 % at 5 years. In the 28 patients with solid lesions, the overall survival was 95.8 % at 5 years. All patients with cystic lesions were still alive at the last follow-up. CONCLUSION: Cystic lesions of SSAMTs were benign lesions or stage I thymoma, and most of the solid lesions of SSAMTs were stage I or II thymomas. SSAMTs are good candidates for video-assisted thoracic surgery procedures, as conversion to sternotomy can be selected based on the intraoperative findings of pericardial invasion and a rapid pathological diagnosis of thymic carcinoma.

A prospective multi-institutional study to verify the non-inferiority of postoperative pain in robot-assisted thoracic surgery in comparison with video-assisted thoracoscopic surgery for lung cancer: The Japanese RATS interest group 01 (J-RATSIG 01).

OBJECTIVES: We sought to compare the latest data on postoperative pain between robot-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS), and to clarify the relationship between the number or placement of ports and postoperative pain in patients with lung cancer. METHODS: Patients who underwent anatomical lung resection by RATS or VATS and whose chest tube was removed within 7 days were enrolled. The primary endpoint was the percentage of patients with a numeric rating scale (NRS) score ≤ 3 on postoperative day 30 (POD30). The target sample size was 400 patients. RESULTS: Four hundred five patients (RATS, n = 196; VATS, n = 209) managed at 12 institutions were included. Ninety-nine patients in the VATS group underwent a uniport procedure. Significant differences were observed between the RATS and VATS groups in the mean number of inserted ports (5.0 vs. 2.2), number of injured intercostal sites (2.9 vs. 1.9), largest wound size (3.4 vs. 3.7 cm), operation time (202 vs. 165 min), and use of epidural anesthesia or continuous nerve block (45 vs. 31 %). In the RATS and VATS groups, the rates of NRS≤3 on POD30 were 82.0 % and 94.7 % (95 %CI: -19.0 to -6.6 %), respectively, which could not prove noninferiority. However, in a multivariable analysis, the RATS approach was not proven to be a significant risk factor. CONCLUSION: In the current status of minimally invasive thoracic surgery in Japan, RATS involves a greater number of ports, longer operation time, and higher frequency of local anesthesia than VATS and may be inferior in terms of postoperative pain.

Pedunculated solitary fibrous tumor of the pleura manifesting as a migrating chest mass: report of a case.

We report the case of solitary fibrous tumor of the pleura, which appeared to change its location. A computed tomography (CT) scan done at a previous hospital showed a tumor in the posterior mediastinum, suggesting that it was neurogenic. However, on the initial preoperative CT scan, the tumor seemed to have moved anteriorly, but when contrast material was injected; the tumor appeared in its original position. Video-assisted thoracoscopic surgery (VATS) revealed a pedunculated and free-moving tumor, originating from the visceral pleura. We diagnosed this unusual migrating tumor as a pedunculated solitary fibrous tumor of the pleura.

Middle lobe preservation and fixation: right upper and lower sleeve bilobectomy. How to do it.

We herein report the case of a 65-year-old female with primary lung cancer who underwent a right upper and lower sleeve bilobectomy. The radiological findings revealed that the tumor was located in the superior segment of the right lower lobe and had invaded the posterior segment of the upper lobe and the truncus intermedius. We performed a right upper and lower sleeve bilobectomy. A latissimus dorsi flap was utilized to separate the thoracic cavity into upper and lower portions, and the preserved middle lobe was fixed in the upper portion to prevent torsion. Postoperative radiography showed good expansion of the middle lobe.

LKB1 gene alterations in surgically resectable adenocarcinoma of the lung.

PURPOSE: Germline mutations of LKB1 (also known as SKT11; locus 19p13.3) cause the occurrence of autosomal dominant Peutz-Jeghers syndrome (PJS). Nearly half of the non-small cell lung cancer (NSCLC) cell lines and one-third of lung adenocarcinoma in Caucasian patients have an LKB1 mutation. METHODS: This study examined the mutational hot spots of the LKB1 gene in surgical resectable lung adenocarcinoma. Exons 1, 6, and 7 of the LKB1 gene were sequenced in 174 Japanese patients with lung adenocarcinoma (including 157 men and 17 women). RESULTS: Only five patients had LKB1 gene alterations (2.9%). All of them were male smokers, and no LKB1 mutation was observed in any of the females. The details of LKB1 alterations were: one 5 bp deletion in intron 5, one Gly to Phe substitution at codon 279 of exon 6, and three Pro to Leu substitutions at codon 281 of exon 6. The P281L alteration and 5 bp deletion in the intron 5 were found to be germline polymorphisms. The G279F was confirmed to be a novel somatic mutation. None of the five patients with an LKB1 alteration showed either an EGFR or K-ras mutation. CONCLUSION: The LKB1 gene alteration is rare in Japanese patients with lung adenocarcinoma, and is generally limited to male smokers.

Talc pleurodesis for secondary pneumothorax in elderly patients with persistent air leak.

BACKGROUND: We herein report the usefulness of two types of talc pleurodesis for secondary pneumothorax of elderly patients with persistent air leak who have severe pulmonary emphysema. METHODS: We assessed 17 elderly patients with persistent air leak who received talc pleurodesis for secondary pneumothorax from April 2013 to March 2017. Thoracoscopic talc poudrage (TTP) (n=11) was performed in patients whose general condition was thought to sufficiently stable to tolerate for general anesthesia. Talc slurry pleurodesis (TSP) (n=6) via a chest tube was performed in patients whose general condition was thought to be insufficiently stable to tolerate general anesthesia. RESULTS: The median drainage period after pleurodesis was 6 days in patients who received TTP and 12 days in patients who received TSP. Complications associated with talc pleurodesis included atrial fibrillation (n=1) in the thoracoscopic poudrage group, while the slurry pleurodesis group showed chest pain (n=2), asthmatic attack (n=1), and pneumonia (n=1). All patients who received thoracoscopic poudrage were able to leave the hospital after removal of the chest tube. Five of the six patients who received slurry pleurodesis were able to leave the hospital, but one of them died of acute exacerbation of interstitial pneumonia (IP) on the 45th day after pleurodesis. The success rate was 94% (16/17). There were no cases of recurrence during the observation period. CONCLUSIONS: TTP was deemed likely to be safe and effective for patients able to tolerate general anesthesia. In patients with IP, especially those treated with steroids, the indication of talc pleurodesis should be cautiously considered.

Pure red cell aplasia associated with thymoma: a report of a single-center experience.

BACKGROUND: Pure red cell aplasia (PRCA) associated with thymoma is relatively rare, and relevant reports are limited. We investigated the clinical features and outcomes of PRCA associated with thymoma in this study. METHODS: A retrospective review of all PRCA patients who underwent surgical resection of thymoma from April 1, 2004, to December 31, 2015, was performed. RESULTS: We experienced eight patients with PRCA among 146 patients who underwent surgical resection of thymoma. Extended thymectomy (n=4) and thymectomy (n=4) were performed for thymoma. Regarding the WHO classification of thymoma, the subtypes were type B2 or B3 in seven patients, and the stage of thymoma was advanced in seven patients. Complete resection was achieved macroscopically in only five patients. Recurrence of thymoma occurred in four patients who underwent complete resection. PRCA was diagnosed after surgical resection of thymoma in six patients (range 1-101 months, median 56.5 months). Cyclosporine was used for PRCA in six patients. Pneumonia of treatment-related complications due to cyclosporine occurred in all patients. The follow-up period ranged from 13-147 months (median 54.5 months) after the PRCA diagnosis. Three patients obtained complete remission of anemia by cyclosporine. Although one patient was able to stop taking cyclosporine because of complete remission of anemia, transfusion was needed due to relapse of PRCA. Five patients died, with the main causes of death diagnosed as pneumonia (n=4) and cardiac failure (n=1). CONCLUSIONS: PRCA associated with thymoma was diagnosed postoperatively in three-quarter of patients. We should be alert for the occurrence of PRCA even after resection of thymoma, especially in patients with incomplete resection or advanced disease. Cyclosporine was effective for PRCA, but treatment-related complications occurred, particularly pneumonia. As treatment for PRCA associated with thymoma and its complications were combined in a complex manner, treating PRCA associated with thymoma can be quite difficult.

Unilateral pulmonary artery pre-operative occlusion test: technical feasibility and safety prior to pneumonectomy or pleuropneumonectomy for malignancy.

OBJECTIVE: The aim of the present study was to assess the technical feasibility and safety of the unilateral pulmonary artery occlusion (UPAO) test in pre-operative evaluation of pneumonectomy or pleuropneumonectomy for lung or pleural tumours. METHODS: The UPAO test was performed on 91 patients who were scheduled to undergo or were being considered for pneumonectomy or pleuropneumonectomy between June 2003 and July 2016. There were 74 males and 17 females, with a median age of 65 years (range, 23-80). The technical success rate, procedure time and complication rate were evaluated. Technical success was defined as completion of the UPAO test. RESULTS: The diagnoses of the 91 patients were as follows: lung cancer in 63, malignant pleural mesothelioma in 21, thymoma in 5, lung metastasis in 1 and lung carcinoid in 1. The UPAO test was performed successfully on 88 out of 91 patients (technical success rate: 97%). The median procedure time was 57 min (range, 34-120). Cardiac arrest due to migration of the balloon catheter to the pulmonary trunk occurred in 1 patient (complication rate: 1.1%). CONCLUSION: The UPAO test in pre-operative evaluation of pneumonectomy or pleuropneumonectomy for lung or pleural tumours appears to be technically feasible. However, it needs to be performed with care in order to avoid severe complications. Advances in knowledge: The UPAO test can be safely performed and is helpful in evaluating patients for pneumonectomy or pleuropneumonectomy.

Four immunohistochemical assays to measure the PD-L1 expression in malignant pleural mesothelioma.

Immune checkpoint inhibitors (ICIs) targeting the PD-1/PD-L1 pathway are expected to be a novel therapy for combating future increases in numbers of malignant pleural mesothelioma (MPM) patients. However, the PD-L1 expression, which is a predictor of the response to ICIs, is unclear in MPM. We studied the PD-L1 expression using four immunohistochemical assays (SP142, SP263, 28-8 and 22C3) in 32 MPM patients. The PD-L1 expression in tumor cells and immune cells was evaluated to clarify the rate of PD-L1 expression and the concordance among the four assays in MPM. The positivity rate of PD-L1 expression was 53.1% for SP142, 28.1% for SP263, 53.1% for 28-8, and 56.3% for 22C3. Nine cases were positive and 10 were negative for all assays. Discordance among the four assays was found in 13 cases. The concordance rates between SP142 and 22C3 and between 28-8 and 22C3 were the highest (84.4%). The concordance rates between SP263 and the other three assays were low (71.9% to 75.0%). The PD-L1 expression in MPM was almost equivalent for three of the assays. Given the cut-off values set in our study, these findings suggested that these assays, except for SP263, can be used for accurate PD-L1 immunostaining in MPM.

S-1 vs. paclitaxel plus carboplatin as adjuvant chemotherapy for completely resected stage II/IIIA non-small-cell lung cancer.

The majority of patients with completely resected stage II or IIIA non-small-cell lung cancer (NSCLC) require adjuvant chemotherapy to improve survival following surgery. In the present trial, the 2-year disease-free survival (DFS), and the feasibility and safety of S-1 as an adjuvant chemotherapy for advanced lung cancer were evaluated. A total of 40 patients with completely resected stage II or IIIA NSCLC were enrolled and randomized to receive postoperative chemotherapy with either up to 4 cycles of paclitaxel plus carboplatin (arm A) or with up to 1 year of S-1 (arm B). The primary endpoint was 2-year DFS. The secondary endpoints were feasibility and toxicity. A total of 40 patients were enrolled, but 3 were excluded in accordance with the exclusion criteria. The remaining 37 patients were analyzed. The 2-year DFS rate was 54.2% in arm A and 84.2% in arm B. Overall, 15/18 (83.3%) patients completed 4 cycles of paclitaxel plus carboplatin and 13/19 (68.4%) completed 1-year of S-1adjuvant chemotherapy. Of the 18 (16.7%) patients in arm A, 3 experienced grade 3 or 4 adverse events, while none in arm B experienced such events. Therefore, S-1 chemotherapy for patients with completely resected stage II or IIIA NSCLC was a feasible and safe regimen, and it may therefore be considered as a potential adjuvant chemotherapy option for advanced NSCLC.

The relationship between the expression of thymidylate synthase, dihydropyrimidine dehydrogenase, orotate phosphoribosyltransferase, excision repair cross-complementation group 1 and class III ß-tubulin, and the therapeutic effect of S-1 or carboplatin plus paclitaxel in non-small-cell lung cancer.

Previous studies have reported that the expressions of specific proteins may predict the efficacy of chemotherapy agents for non-small cell lung cancer (NSCLC) patients. The present study evaluated the expression of proteins hypothesized to be associated with the effect of chemotherapeutic agents in 38 NSCLC patients with pathological stage II and IIIA. The subjects received carboplatin plus paclitaxel (CP) or S-1 as adjuvant chemotherapy following complete resection. The protein expressions evaluated were those of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD) and orotate phsphoribosyltransferase (OPRT), which were suspected to be associated with the effect of S-1 agents, excision repair cross-complementation group 1 (ERCC1), which was suspected to be associated with the effect of platinum-based agents, and class III ß-tubulin (TUBB3), which was suspected to be associated with the effect of taxane-based agents. The positive rate of TS was 55.3% (n=21/38), DPD was 57.9% (n=22/38), OPRT was 42.1% (n=16/38), ERCC1 was 47.4% (n=18/38) and TUBB3 was 44.7% (n=17/38). Among the patients who received S-1 adjuvant chemotherapy, TS-negative cases demonstrated a significantly better disease-free survival than positive cases. Thus, TS protein expression may have been a factor that predicted the effect of S-1 agent as adjuvant chemotherapy.

A comparative study of PD-L1 immunohistochemical assays with four reliable antibodies in thymic carcinoma.

Currently, four immunohistochemical assays are registered with the US Food and Drug Administration to detect the expression of PD-L1. We investigated the PD-L1 expression in thymic carcinomas using these four diagnostic assays. The cases of 53 patients were reviewed and their specimens were subjected to four PD-L1 assays with different antibodies (SP142, SP263, 22C3, and 28-8). The PD-L1 expression in tumor cells (TCs) and immune cells (ICs) was evaluated. In TCs, the four assays showed similar scores in each case. Histopathologically, high TC scores were observed in squamous cell carcinomas (SqCCs). Meanwhile, there were no significant relationships among the IC scores in the four assays. In SqCCs, the high expression of PD-L1 (defined as ≥50% TC score) in TCs tended to be associated with early stage cancer. The patients with high expression levels of PD-L1 tended to show longer overall survival in the 22C3 assays (p=0.0200). In thymic carcinomas, the staining pattern showed high concordance among the four assays when TCs - rather than ICs - were stained. High PD-L1 positivity in TCs, especially in SqCCs, indicated that PD-1/PD-L1 targeted therapy may be a promising therapeutic approach.

Pulmonary inflammatory myofibroblastic tumor with TPM4-ALK translocation.

A 35-year-old woman with shortness of breath and cough was referred to our hospital and agreed to receive therapy for lung tumor in our hospital. Based on the findings from a bronchoscopic biopsy, she was suspected of having pulmonary inflammatory myofibroblastic tumor (IMT), but a correct diagnosis was not indicated. Right upper wedge lobectomy was performed. The findings of a pathological examination of the permanent surgical resected tissue, the ultimate diagnosis was pulmonary IMT. The immunohistochemistry of ALK using the intercalated antibody-enhanced polymer (iAEP) method was positive. We extracted the RNA from frozen surgical resected tumor tissue and proved the tropomyosin alpha-4 chain (TPM4)-ALK by 5' rapid amplification of cDNA end (5' RACE) and reverse transcription polymerase chain reaction. The preoperative bronchial biopsy specimen was also found to be positive for anti-ALK immunohistochemistry with the iAEP method. A molecular therapeutic drug may be useful as personalized therapy for tumors with ALK translocation as oncogenic drivers. We should examine the ALK protein expression and translocation in cases of lung cancer and IMT using an adequate ALK immunohistochemistry system. We experienced a case of pulmonary IMT with TPM4-ALK translocation.

Expression of excision repair cross-complementation group 1 and class III ß-tubulin in thymic carcinoma.

Thymic carcinoma is a rare mediastinum malignant tumor derived from thymic epithelial cells. With the exception of complete resection, an effective therapy has not been established to date for advanced or relapsed thymic carcinoma. The present study examined the protein expression of excision repair cross-complementation group 1 (ERCC1) and class III ß-tubulin (TUBB3), which are consider to be indicators of the anticancer activity of platinum-based and taxane-based chemotherapy, respectively. The expression of ERCC1 and TUBB3 proteins was examined in 40 thymic carcinoma patients who underwent either surgical resection or core-needle biopsy. The present study investigated whether the expression of ERCC1 and TUBB3 proteins was associated with the overall survival and clinicopathological factors of thymic carcinoma patients. The expression of ERCC1 and TUBB3 proteins was also evaluated in 50 patients who underwent curative resection for non-small cell lung cancer (NSCLC). The expression of ERCC1 and TUBB3 proteins was positive in 8 cases (20%) among the thymic carcinoma patients. ERCC1 was expressed in 21 cases (42%), while TUBB3 was expressed in 27 cases (54%), among the 50 NSCLC patients evaluated in the present study. Only complete resection was observed to be associated with a better prognosis than incomplete resection (P=0.0341). Other clinicopathological factors, including expression of ERCC1 and TUBB3 proteins, exhibited no effect on overall survival. The expression of ERCC1 and TUBB3 proteins in the thymic carcinoma cases was lower than that in the NSCLC cases. The present results suggest a possibility for better antitumor effects of platinum-based and taxane-based chemotherapy on thymic carcinoma patients.