[Multidisciplinary Approach to Recurrence after Resection of Primary Lung Cancer].

BACKGROUND: The standard approach for treating recurrence after complete resection of primary non-small cell lung cancer has been controversial. We present here a multidisciplinary strategy for postoperative recurrence in patients with primary lung cancer. PATIENTS AND METHODS: Over the last 7 years, we examined the disease-free survival and overall survival of 70 patients who underwent multidisciplinary treatment for recurrence after surgical resection of primary lung cancer. RESULTS: The median overall survival was 32.3 months after surgery and 17.4 months after recurrence developed, indicating significantly better prognoses in females and in patients with adenocarcinoma, stage I disease, driver mutation positivity, a longer postoperative disease-free period, and never smokers. Eight patients survived more than 5 years after recurrence;of these patients, all had adenocarcinomas, 7 had oligometastases and/or tumor dormancy, and 5 received multiple-drug regimens. CONCLUSION: Multidisciplinary treatment for recurrence after resection of primary lung cancer was effective for patients receiving various drug regimens. In patients with oligometastases, disease control was achieved by a combination of local treatments targeting each involved organ. In patients with tumor dormancy, follow-up or a drug holiday was important to maintain the patient's quality of life.

A minimally invasive technique for stabilizing the diaphragm on the thoracic wall after blunt chest trauma: the "lifting-up method".

Most traumatic diaphragmatic tears are located centrally or radially and may be amenable to repair by direct suturing or suturing with a surgical patch. However, diaphragmatic tears, such as those immediately adjacent to the costal margin, are uncommon. We describe how we repaired this type of tear using a needle loop retractor to pass a 2-0 braided suture through the chest wall on both sides of the rib to suture the torn diaphragm to the chest wall. Our technique is more physiologically and anatomically consistent than previously reported techniques. We have termed this technique the "lifting-up method", which we believe to be an easy and useful technique for repairing traumatic diaphragmatic injuries with no seam allowance.

[Perioperative Oral Management of Lung Cancer Patients; Medical, Dental, and Regional Dental Clinic Collaboration].

PURPOSE: To prevent oral problems in lung cancer patients, dental intervention should be performed in conjunction with cancer treatment in cancer base hospitals. This paper reports on the perioperative oral care management of lung cancer patients. PATIENTS AND METHODS: From January 2013 to August 2015, perioperative oral management was performed in 123 patients undergoing pulmonary lobectomy. We ensure cooperation between the departments of medicine and dentistry. First, the dentist plans oral management based on the patient's individual oral status. Then, the actual oral management is performed by an in-hospital dentist and at the regional dental clinic. RESULTS: The patients comprised 70 males and 53 females with an average age of 69.4 years;118 had primary lung cancer and 5 had metastatic lung cancer. Abnormal findings were detected in approximately 50% of the patients, of whom 6 received oral treatment before starting their cancer treatment. Two patients(1.3%)had postoperative complications. In all cases, the oral care support team provided both tooth and oral mucosal care. CONCLUSION: About half of the referred patients required oral treatment. There were no serious adverse events due to the oral care intervention. Further investigation is necessary to establish appropriate treatment policy guidelines for dental disease requiring oral maintenance.

[Initial report of uniportal video-assisted thoracoscopic lobectomy in Japan].

To date, more than 100 reports of several major pulmonary resections through a uniportal approach have been published. However, there have been no reports of uniportal thoracoscopic lobectomy in Japan. We present herein a successful case of uniportal thoracoscopic right lower lobectomy through a 3.5-cm incision for 84- year-old female patient with primary lung cancer (clinical stage I A). Postoperative course was uneventful and she discharged from the hospital on day 5 postoperatively. Pathological diagnosis was primary adenocarcinoma of T1aN0M0, stage I A.

[Current surgical treatment of primary chest wall tumor].

Primary chest wall tumor is relatively rare. According to the annual report by The Japanese Association for Thoracic Surgery in 2012, 447 primary chest wall tumors were resected in 2010. It was only 0.66% of the total number of operations in general thoracic surgery in Japan. From January 1992 to December 2012, 3,022 cases in general thoracic surgery were operated in our department. Of these, 30 patients (1%) with primary chest wall tumor were surgically treated. We retrospectively reviewed the medical records of them and investigated the details of this tumor. The patients group included 11 males and 19 females, with a mean age 57.6 years (range, 16 to 79 years). The majority of these patients were referred to us because of radiographical abnormalities on chest X-ray( 56.7%) or clinical symptoms( 33.3%). The operative procedure was tumor extirpation in 25 cases and chest wall resection in 5 cases. Histologically, 23 cases (76.7%) were benign tumors, 7 cases (23.3%) were malignant tumors. Malignant tumors included aggressive and poor prognostic cases such as malignant fibrous histiocytoma or malignant peripheral nerve sheath tumor, on the other hand, extremely rare tumor with low grade malignancy such as parachordoma arising from the chest wall soft tissue was included. In conclusion, although, the standard therapy for malignant primary chest wall tumors has not been established, aggressive surgical resection remains the treatment of choice and to provide an accurate diagnosis.

[Lung metastasectomy for postoperative colorectal cancer in patients with a history of hepatic metastasis].

OBJECTIVES: Our objective was to evaluate the validity of pulmonary metastasectomy for postoperative colorectal cancer with hepatic metastasis and to investigate the role of clinicopathological factors as predictors of outcome. METHODS: Consecutive patients undergoing pulmonary metastasectomy for colorectal cancer with (group PH, n=27) or without (group P, n=46) a history of hepatic metastasis were included in the study. Clinicopathological variables, including sex, age, site, serum carcinoembryonic antigen level of the primary tumor, disease-free interval, prior hepatic resection, timing of pulmonary metastases, preoperative chemotherapy, type of pulmonary resection, and number, size, and location of pulmonary metastases were retrospectively collected and investigated for prognostic significance. RESULTS: The 5-year survivals were 59.5% (PH) and 70.0% (P) with no significant difference. Among all investigated prognostic variables, sex (female vs male) and the number of pulmonary metastases( 1 vs >1) were the most important factors affecting outcome after colorectal resection and pulmonary resection. CONCLUSIONS: Pulmonary resection is not contraindicated in clinical practice. The presence of female gender and a single pulmonary metastasis were favorable predictors of survival after complete pulmonary resection for metastatic colorectal cancer.

Taste disorder in a patient with invasive thymoma without myasthenia gravis: a rare case report.

Taste disorder has been reported as a non-motor symptom caused by myasthenia gravis (MG)-related autoimmune mechanism. Taste disorder in some cases recovered along with MG treatment, such as thymothymectomy or immunosuppressive treatment. However, symptom of taste disorder in thymoma patients without MG is very rare. Here, we reported a case of invasive thymoma without MG which had concurrent taste disorder. The taste disorder was successfully treated with cyclosporine. A female in her seventies had an anterior mediastinal tumor of 78-mm in diameter and pleural dissemination. She also had taste disorder, limited to sweet taste, and pure red cell aplasia (PRCA). Symptoms and physical findings showed no feature of MG. Pre-operative blood examination revealed no elevation of anti-acetylcholine receptor antibody . Extended total thymothymectomy and resection of all detectable pleural disseminations was performed. Pathological examination showed type B3 thymoma. Clinical stage was Masaoka stage IVa. After operation, there was no improvement in taste disorder and PRCA. Six months after operation, cyclosporine was administered for PRCA. In parallel with gradual improvement of anemia, taste disorder also gradually improved. Three months after the first administration of cyclosporine, taste disorder had completely recovered. This is the first case of taste disorder without any myasthenic status, which recovered with immunosuppressive drug. Our case suggested the potency of immunosuppressive treatment for taste disorder associate with thymoma without MG.

[High-grade fetal adenocarcinoma of the lung; report of a case].

82-year-old man was admitted with an abnormal shadow on the chest roentgenogram. Computed tomography showed a 2.8 x 2.4 cm solid tumor in S3 of the left lung. Transbronchial lung biopsy revealed adenocarcinoma and a left upper lobectomy (ND2a-1) was performed. The tumor consisted mainly of tall columnar clear cells, and no morules were found. Immunohistochemically, the tumor was positive for alpha-fetoprotein (AFP) and p53. Accordingly, we made the histological diagnosis of high-grade fetal adenocarcinoma of the lung, pT2N0M0, stage IB. The patient was not received adjuvant therapy and has been doing well without any tumor recurrence for 3 months postoperatively.

Comprehensive expressional analysis of chemosensitivity-related markers in large cell neuroendocrine carcinoma of the lung.

OBJECTIVES: Various drug-sensitivity markers have been reported to be associated with tumor progression and chemotherapy resistance. Detailed expression profiles of sensitivity markers for cytotoxic chemotherapy in pulmonary large cell neuroendocrine carcinoma (LCNEC) remain unclear. Herein, we aimed to clarify the correlation between the expression of drug-sensitivity markers and clinicopathological features, prognostic impact, and status of tumor immunity in patients with LCNEC. METHODS: We retrospectively analyzed the correlation between clinicopathological features and the expression of drug-sensitivity-related markers, including vascular endothelial growth factor 2 (VEGFR2), thymidylate synthase (TS), tubulin beta 3 class III (TUBB3), topoisomerase I (Topo-I), and Topo-II in 92 surgically resected LCNEC samples. Furthermore, we examined the prognostic significance of expression of these and their correlation with the immune cell status. RESULTS: Overall, high expression of TS, TUBB3, VEGFR2, Topo-I, and Topo-II was detected in 50 (54%), 31 (34%), 23 (25%), 65 (71%), and 36 (39%) samples, respectively. Univariate and multivariate analyses revealed that advanced pathological T and N factors, positive lymphatic permeation, and Topo-II expression were independent unfavorable prognosticators for recurrence-free survival, and advanced pathological T and N factors, Topo-II positive expression, and TS positive expression were independent unfavorable prognosticators for overall survival. In terms of correlation with immune cell status, higher expression of VEGFR2 was closely linked to negative PD-L1 expression. CONCLUSIONS: These findings suggest that elevated Topo-II and TS expression may contribute to poor outcomes through protumoral biology in patients with LCNEC, and elevated VEGFR2 expression might negatively impact tumor immune reactions in LCNEC.

High-grade neuroendocrine carcinoma of the lung shows increased thymidylate synthase expression compared to other histotypes.

BACKGROUND: Thymidylate synthase (TS) expression has been reported in various tumors, including non-small-cell lung carcinoma (NSCLC), but not in high-grade neuroendocrine (HGNE) carcinoma of the lung. METHODS: We measured TS expression in surgically resected pulmonary tumors, comparing HGNE carcinomas of the lung (13 large-cell neuroendocrine carcinomas, 8 small-cell lung carcinomas) with squamous cell carcinoma and adenocarcinoma of the lung using laser-capture microdissection for tissue isolation, real-time polymerase chain reaction (PCR), and immunohistochemistry. We also measured TS mRNA expression in small-cell lung carcinoma (SCLC) and NSCLC cell lines using real-time PCR. RESULTS: At both mRNA and protein levels, TS expression was significantly higher in squamous cell carcinoma compared to adenocarcinoma. Moreover, TS expression was significantly higher in HGNE carcinomas of the lung compared to squamous cell carcinoma. A significant correlation was found between mRNA and protein expression. TS mRNA expression in SCLC cell lines was significantly higher than in NSCLC cell lines. CONCLUSIONS: TS expression was higher in HGNE carcinomas of the lung than in squamous cell carcinoma, which was higher than in adenocarcinoma. This information may be useful in predicting the effects of TS-inhibiting agents in patients with NSCLC and HGNE carcinomas of the lung.

Digit-assisted thoracoscopic surgery for mediastinal tumors: a novel technique.

Digit-assisted thoracoscopic surgery (DATS) is a novel, minimally invasive approach for achieving a superior mediastinal mass, by allowing the surgeon's finger to pass into the superior mediastinum through a suprasternal route. In this study a DATS procedure for a bronchogenic cyst in the superior mediastinum was performed. The procedure worked well for dissecting the tissue around the mass, and thus reduced the effort required to perform the operation. In the current study DATS was found to be superior to the standard technique.

[Surgical treatment and outcome for postoperative recurrent or second primary lung cancer].

From 2000 to 2009, we retrospectively reviewed 62 patients who underwent surgical treatment for postoperative recurrent or 2nd primary lung cancer. Of the 62 patients, 43 were men and 19 were women with an average age of 67.6 years old. The histology of the initial primary lung cancer was adenocarcinoma in 42 patients, squamous cell carcinoma in 18, large cell carcinoma in 1 and small cell carcinoma in 1. The surgical procedures for 1st operation were lobectomy with mediastinal lymph node dissection in 52, bilobectomy with mediastinal lymph node dissection in 4, sleeve lobectomy with mediastinal lymph node dissection in 3, and lobectomy + segmentectomy or wedge resection with mediastinal lymph node dissection in 3. p-stage of the 1st primary lung cancer was IA in 22, IB in 16, II A in 7, IIB in 6, IIIA in 6, IIIB in 4, and IV in 1. On the 2nd operation, 56 patients underwent limited surgery. Five patients underwent a lobectomy twice metachronous bilateral lesions and 1 patient underwent completion pneumonectomy (CP) at the 2nd operation. The average age at 2nd operation was 71.8 years old. Of these, 42 patients were diagnosed 2nd primary lung cancer, 20 patients were recurrent disease histologically. The 5-year survival rate of the patients with metachronous and recurrent disease from the 2nd operation was 54.1%, and 43.1%, respectively. Although lobectomy or CP should be considered the surgical procedure of choice for patients with metachronous lung cancer, with this result, we consider that postoperative good survival can be expected by even the limited operation for cases of postoperative recurrent or 2nd primary lung cancer because of possible early detection. We conclude that limited surgery may be a treatment of choice for recurrent or 2nd primary lung cancer after initial operation.

Author Correction: Butterfly-shaped magnetoresistance in triangular-lattice antiferromagnet Ag2CrO2.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Butterfly-shaped magnetoresistance in triangular-lattice antiferromagnet Ag2CrO2.

Spintronic devices using antiferromagnets (AFMs) are promising candidates for future applications. Recently, many interesting physical properties have been reported with AFM-based devices. Here we report a butterfly-shaped magnetoresistance (MR) in a micrometer-sized triangular-lattice antiferromagnet Ag2CrO2. The material consists of two-dimensional triangular-lattice CrO2 layers with antiferromagnetically coupled S = 3/2 spins and Ag2 layers with high electrical conductivity. The butterfly-shaped MR appears only when the magnetic field is applied perpendicularly to the CrO2 plane with the maximum MR ratio (≈15%) at the magnetic ordering temperature. These features are distinct from those observed in conventional magnetic materials. We propose a theoretical model where fluctuations of partially disordered spins with the Ising anisotropy play an essential role in the butterfly-shaped MR in Ag2CrO2.

Pulmonary Artery Compression Facilitates Intersegmental Border Visualization.

Intravenous indocyanine green injection is useful for the identification of the intersegmental border by infrared thoracoscopy during anatomic segmentectomy. However, surgeons encounter cases in which visualization of the intersegmental border is difficult. In particular, intravenous indocyanine green fluorescence in the upper lobe is occasionally obscured by to the relatively lesser blood flow in the upper lobe pulmonary arteries. This report describes an interlobar pulmonary artery compression method that is a simple and effective technique for clearly visualizing the intersegmental border through infrared thoracoscopy with intravenous indocyanine green during upper lobe segmentectomy.

Prognostic significance of PD-L1 expression and tumor infiltrating lymphocytes in large cell neuroendocrine carcinoma of lung.

OBJECTIVES: Since large cell neuroendocrine carcinoma (LCNEC) is a relatively rare histologic type of primary lung cancer, little is known about the immunological status of patients with LCNEC. We aimed to clarify the expression and prognostic impact of programmed cell death ligand 1 (PD-L1), CD8, CD4, and Forkhead box protein P3 (Foxp3) in LCNEC. METHODS: We retrospectively analyzed PD-L1, CD8, CD4, and Foxp3 expressions in 95 surgically resected LCNEC. PD-L1 positive staining was determined in tumors with more than 1% of tumor cells stained to any intensity, and CD8, CD4, and Foxp3 positivity was determined in tumors with more than 5% of lymphocytes stained. RESULTS: Positive expression of PD-L1, CD8, CD4, and Foxp3 was observed in 70 (74%), 52 (55%), 76 (80%), and 43 (45%) tumors, respectively. The expression of PD-L1 was significantly correlated with positive lymphatic permeation. Positive correlations were mutually observed among tumor infiltrating immune cells. Univariate and multivariate analyses showed that positive pleural invasion and Foxp3 negative expression were independent unfavorable prognostic factors for overall survival (OS). Advanced pathological stage, positive pleural invasion, CD4 negative expression in cancer stroma, and Foxp3 negative expression were identified as independent unfavorable prognostic factors for recurrence free survival (RFS). CONCLUSIONS: Foxp3 positive tumor infiltrating lymphocytes (TILs) were an independent favorable prognostic factor for both OS and RFS, whereas CD4 positive TILs were an independent significant unfavorable prognostic factor for RFS. The high frequency of PD-L1 expression could support the use of anti-programmed cell death 1 antibody in the treatment of LCNEC.

Thoracoscopic lateral and posterior basal (S9 + 10) segmentectomy using intersegmental tunnelling.

The appropriate lateral and posterior basal (S9 + 10) segmentectomy requires exposure and recognition of common basal pulmonary vein branches located deeply in the lung parenchyma. Therefore, we applied the intersegmental tunnelling method in S9 + 10 segmentectomy to recognize the dominant veins to the S9 + 10 segment accurately. Between April 2014 and December 2015, five patients underwent thoracoscopic S9 + 10 segmentectomy using intersegmental tunnelling. By using this technique, we can recognize the branches of the pulmonary vein to the affected S9 + 10 segment accurately. This technique can let us perform appropriate S9 + 10 segmentectomy.

Troubleshooting for bleeding in thoracoscopic anatomic pulmonary resection.

Introduction The objective of this study was to evaluate intraoperative vessel injury and assess troubleshooting during thoracoscopic anatomic pulmonary resection. Methods Between April 2012 and March 2016, 240 patients underwent thoracoscopic anatomic lung resection, 26 of whom were identified as having massive bleeding intraoperatively. We analyzed the injured vessel and the hemostatic procedure employed, then compared the perioperative outcomes in patients with ( n = 26) and without ( n = 214) vessel injury. In addition, we compared perioperative results based on the period when surgery was performed: early period: April 2012 to March 2014 ( n = 93) or late period: April 2014 to March 2016 ( n = 146). Results The surgical procedures included 20 lobectomies and 6 segmentectomies. One of the 26 patients had vessel injury at 2 points, giving a total of 27 points of injury. Hemostasis was mostly achieved by application of thrombostatic sealant (63.0%). There were no significant differences in the length postoperative hospitalization ( p = 0.67) or morbidity rate ( p = 0.43) between the vessel injury and the no-vessel injury groups. There were no significant differences in the incidence of significant intraoperative bleeding ( p = 0.13) and total blood loss ( p = 0.13) between the early and late periods. Conclusions Application of thrombostatic sealant is one of the useful methods to achieve hemostasis during thoracoscopic anatomic pulmonary resection. Vascular hazards are inherent to a thoracoscopic approach. Therefore, thoracic surgeons should always be concerned about significant intraoperative bleeding and treat it appropriately.

Paraspinous muscle flap for the treatment of an empyema cavity: three case reports.

A surgical option is commonly chosen when conservative medical therapy for empyema is impossible. The muscles used include the latissimus dorsi, trapezius, and pectoris major, based on the size and location of the empyema cavity. However, these volumes are decreased in patients suffering from malnutrition, and flap dissection and elevation are sometimes invasive. Therefore, we developed an alternative method, and present three successful cases in which we used a pedicled paraspinous muscle flap to fill the dead space caused by empyema fenestration in the medial region of the back. The paraspinous muscle flap remains an important tool in reconstruction. However, such flaps should be created only in selected cases, such as those with empyema in the posterior region. Also, if the pleural space is large, additional muscle flaps will be required.