Single-center evaluation of prognostic factors for thymoma treated by surgery: a retrospective study.

BACKGROUND: This study aimed to retrospectively evaluate the clinical, pathological, and treatment-related factors associated with survival in patients with surgically treated thymomas. METHODS: Sixty patients with thymomas who underwent treatment at our institution between 2004 and 2015 were included. Survival analysis was performed based on curves that were obtained using the Kaplan-Meier method. The Wilcoxon test was used for all comparisons, and p < 0.05 was considered statistically significant. RESULTS: Forty-seven, four, three, four, and two patients presented tumor stages I, II, III, IVa, and IVb (according to the Masaoka classification), respectively, while six, 14, 11, 22, and seven patients had type A, AB, B1, B2, and B3 thymomas, respectively. Furthermore, 53 and eight patients underwent complete resection and required additional resection of adjacent organs, respectively, and no patients died from surgery-related complications. The five-year survival and recurrence-free survival (RFS) rates were 96 and 86%, respectively. The five-year survival rate for all stages was 100% except for those with stage IVb tumors (Masaoka classification); the survival rate for those patients was 0%. Separately, the five-year RFS rates for tumor stages I, II, III, IVa, and IVb were 100, 91, 91, 81, and 71%, respectively. Finally, the five-year survival rates in cases with complete and incomplete resections were 100 and 71%, respectively, indicating that the latter group had a significantly poorer prognosis (p < 0.001). CONCLUSIONS: These findings suggest that complete resection and the Masaoka pathological stage are significant predictors of prognosis in patients with thymomas. Surgery should aim to achieve complete resection; however, advanced cases may require multimodality therapy.

A phase 2 study of adjuvant carboplatin plus S-1 followed by maintenance S-1 therapy for patients with completely resected stage II/IIIA non-small cell lung cancer-Japanese Northern East Area Thoracic Surgery Study Group JNETS1302 study.

BACKGROUND: The standard adjuvant chemotherapy regimen for completely resected pathological stage II/IIIA non-small cell lung cancer (NSCLC) is four courses of cisplatin plus vinorelbine. However, the continuity and toxicity of cisplatin-based regimens remain problematic. Conversely, carboplatin-based chemotherapy is a less toxic and more tolerable regimen for various stages of NSCLC. In particular, the efficacy and tolerability of carboplatin plus S-1 in advanced NSCLC were confirmed by previous pivotal studies such as the LETS trail. Therefore, this phase II study assessed the feasibility, safety, and usefulness of carboplatin plus S-1 followed by maintenance S-1 as an adjuvant treatment. METHODS: In this single-arm, multicenter phase II study, 40 patients who previously underwent complete resection of NSCLC were enrolled from November 2013 to January 2015. The chemotherapy protocol was four cycles of carboplatin (AUC 5 on day 1) and oral S-1 (80 mg/m2 every other day from days 1 to 21) followed by oral S-1 (80 mg/m2 every other day for 48 weeks). The primary endpoint was the treatment completion rate, and the secondary endpoints were adverse events and 2-year recurrence-free survival. RESULTS: The treatment completion rate of the planned schedule was as low as 30.0% (90% confidence interval: 40.3-63.0%). The reasons for adjuvant chemotherapy discontinuation were adverse events, refusal, tumor recurrence, and other reasons in 13, 6, 10, and 2 patients, respectively. The 2-year progression-free survival rate was 66.7% among patients who completed maintenance chemotherapy. There were no treatment-related deaths, and most adverse events were less than grade 3. CONCLUSIONS: Carboplatin plus S-1 followed by S-1 maintenance for 1 year in the adjuvant treatment of NSCLC was not tolerable, although most adverse events were not severe. However, patients who can fully complete the regimen might experience clinical benefit.

Validation of the Proposed cN2 Subclassification in the Eighth Edition of the IASLC Staging System: A Prospective Phase II Multicenter Study.

INTRODUCTION: Surgery for N2 stage IIIA NSCLC is not recommended in major guidelines. Nevertheless, it has been noted that single-station N2 may have a better prognosis than multistation N2 and that surgery can be performed as the main therapeutic option. METHODS: We conducted a prospective phase II study for single-station clinical N2 (cN2) NSCLC to evaluate the efficacy and safety of surgical resection without induction therapy. Complete resection with lobectomy, bilobectomy, or pneumonectomy followed by ipsilateral mediastinal lymphadenectomy was performed in 32 of 34 enrolled patients, whereas the remaining two patients underwent incomplete resection. Three-quarters of the patients underwent subsequent adjuvant chemotherapy. RESULTS: The 5-year overall survival rate was 58.5% (95% confidence interval: 41.9-75.4) for all 34 patients, and eight patients (23.5%) with pN0 or pN1 seemed to have been enrolled. The 5-year overall survival rates for single-station cN2 without and with hilar node enlargement were 81.3% and 37.5%, respectively (p = 0.025). Surgical mortality was 0% for all, and no considerable perioperative complications were noted; however, two patients died of interstitial pneumonia and unknown cause within 3 months after surgical resection. CONCLUSIONS: This is the very first prospective study on the surgical approach for cN2 NSCLC, and our result partially validated the proposed classification of the N descriptor in the new staging system. The treatment for single-station cN2 without hilar node enlargement would better if it were similar to that for cN1 disease. Induction chemotherapy or chemoradiotherapy may not be needed for such an entity.

Bronchial angiolipoma successfully treated by sleeve resection of the right bronchus intermedius: a case report.

BACKGROUND: Angiolipoma is a rare, benign tumor that primarily develops in the limbs and trunk. The occurrence of angiolipoma in the lungs is extremely rare; to date, only two cases of primary bronchial angiolipoma have been reported. Here, we report a case of angiolipoma of the right bronchus intermedius that was successfully treated with sleeve resection and reconstructive surgery. CASE PRESENTATION: This report presents a case of angiolipoma that developed in the right bronchus intermedius of a 68-year-old man. A chest CT revealed a 10-mm endobronchial mass that was clearly visible as a high-attenuation area of contrast enhancement. Bronchoscopy revealed a submucosal tumor on the anterior wall of the entrance to the right bronchus intermedius that was constricting the airway lumen. The tumor surface was covered with numerous engorged blood vessels, and the middle and inferior pulmonary lobes were intact. Bronchial sleeve resection of the right bronchus intermedius was performed. Histologically, a mixture of proliferating blood vessels and adipocytes were observed within the bronchus wall. Therefore, the pathological diagnosis was angiolipoma. Lung function was preserved, and complete resection of the tumor was achieved. At present (2 years and 7 months after surgery), the patient is recurrence-free. CONCLUSION: Accordingly, using bronchial sleeve resection and end-to-end anastomosis techniques, we accomplished complete tumor excision and avoided the need to resect additional lung parenchyma. Our procedure preserved pulmonary function and yielded a curative result. Bronchoscopic intervention or minimal parenchymal resection should be considered as treatments for bronchial angiolipoma. Given the small number of reports of bronchial angiolipoma, the collection of additional data is important to elucidate the clinical characteristics of this rare tumor.

Intrathoracic fibrolipoma resected using complete thoracoscopic surgery: a case report.

BACKGROUND: Other than adipocytes, lipomas may contain mesodermal components such as varying proportions of fibrous tissues and blood vessels. Fibrolipoma is an uncommon variant of lipoma and comprises a high proportion of fibrous components. An intrathoracic fibrolipoma is extremely rare; to the best of our knowledge, only three such cases have been reported till date. CASE PRESENTATION: A 51-year-old female presented with a left intrathoracic mass, which was confirmed to be a lipomatous tumor using computed tomography. A pedunculated tumor originating from the parietal pleura was resected using complete thoracoscopic surgery. Pathological examination indicated a diagnosis of fibrolipoma. Intrathoracic fibrolipomas are extremely rare; this is one of the first reported cases of successfully resecting an intrathoracic fibrolipoma using complete thoracoscopic surgery. CONCLUSIONS: The tumor was asymptomatic and relatively small when detected during a medical checkup. This enabled the successful resection of the tumor via complete thoracoscopic surgery. Although fibrolipomas are histologically benign, careful observation and follow-up are essential owing to the possibility of recurrence.

[The Use of Octreotide Acetate in the Management of Refractory Chylothorax Following Surgical Treatment for Lung Cancer].

A 78-year-old man underwent right upper lobectomy with systemic lymph node dissection for lung cancer. On the 1st operative day, chylothorax was suspected by a large amount of yellowish-white fluid through the chest tubes. In spite of stopping the oral intake as a conservative therapy, a lot of chylous drainage was continued, and we chose surgical treatment at day 7 after operation, however, chylous discharge did not decrease significantly. Finally we decided to try octreotide administration subcutaneously. After continuous subcutaneous infusion of octreotide, the amount of chylous discharge was reduced dramatically. Then we have done 2 times of pleurodesis with OK-432. The chest tubes were removed at day 17 after the 2nd operation, and the chylothorax was improved. It was suggested that octreotide administration was a highly effective therapy against postoperative refractory chylothorax.

[Thymoma Associated with Pure Red Cell Aplasia Treated with Ciclosporin as Remission-induction Therapy before Thymectomy].

A thymoma with pure red cell aplasia( PRCA) is relatively rare, and the treatment of the disease has not established yet. We describe a case of a thymoma associated with PRCA treated with a surgery and remission-induction therapy by ciclosporin. An 80-year-old man complained of dizziness and his blood cell count showed a severe anemia. He was diagnosed as PRCA by bone-marrow aspiration biopsy, which showed abatement of erythroblasts. In addition, the chest computed tomography revealed a solid tumor in the anterior mediastinum, strongly suggesting a thymoma. Oral administration of ciclosporin as remission-induction therapy for PRCA was started at 1st. The treatment contributed to partial remission for PRCA without blood transfusion. Consecutively thymectomy through median sternotomy was performed at 6 weeks after initiation of the treatment without any transfusions or complications. Histology of the solid tumor showed the thymoma of type B2 in World Health Organization (WHO) category. We continued to treat PRCA with ciclosporin after the surgery. The patient has been surviving for 2 years after surgery without any recurrence of thymoma or relapse of anemia. Combined therapy of surgery and remission-induction therapy with ciclosporin assumed to be a good strategy of the treatment for the patient with a thymoma associated with PRCA.

[Long-term survival case of primitive neuroectodermal tumor in the chest wall of a young adult].

A very rare case of Askin's tumor is described. A 22-year-old male was admitted to our hospital because of an abnormal shadow on chest roentgenogram. His chest X-ray film showed a tumor shadow (4.0×5.0 cm) of chest wall protruding into the upper right lung field. The tumor shadow had markedly enlarged in size compared to previous examinations of chest X-ray film 1 month before. Chest computed tomography(CT) and magnetic resonance imaging( MRI) revealed an heterogenous tumor fixed on the right 4th rib, which did not infiltrate the surrounding tissues. In the examination of bone scintigram, no abnormal accumulation was seen at the site of the chest wall tumor. Because of the possibility of malignancy, an en bloc excision of the tumor was performed including the surrounding pleura. The histologic examination revealed primitive neuroectodermal tumors of the chest wall (Askin's tumor).The patient underwent both additional adjuvant chemotherapy and radiation therapy postoperatively, being alive and well without any sign of recurrence 10 years after the operation. Askin's tumor is a very rare disease with an extremely poor prognosis, however, the effective treatment has not been established yet. Complete excision at initial operation seemed to be correlated with long-term survival in this case.

[Patient with massive hemothorax due to blunt trauma saved by transcatheter arterial embolization (TAE)].

A 78-year-old man who fell from a step ladder was transported to our hospital by ambulance under the diagnosis of multiple rib fractures and right hemothorax. Since he was in shock on arrival, endotracheal intubation and tube thoracotomy were immediately performed. Though 2 liters of blood was evacuated, persistent hemorrhage was observed, requiring continuous rapid infusion and blood transfusion. Emergency thoracic arteriography revealed active bleeding from a branch of the right internal thoracic artery. Transcatheter arterial embolization (TAE) was performed using vascular embolization coils and porous gelatin particles. These procedures successfully controlled active hemorrhage from the chest. Intrathoracic hematoma was evacuated through the 2nd large chest tube. Chest tubes were removed on the 7th day. He was discharged on the 17th day without any complications.

[Right lower lobectomy with flap bronchoplasty for primary lung cancer].

A 59-year-old man was referred to our hospital for further investigation of an abnormal chest shadow. A chest computed tomography( CT) revealed a tumor shadow originating in the superior segment( S6)of the right lower lobe. Bronchoscopy showed no visible tumor, but adenocarcinoma cells were detected in brush cytology samples. We diagnosed primary lung cancer, classified as cT2aN0M0, and planned a radical operation. Intraoperatively, since the tumor had invaded the outer wall of intermediate bronchus, we considered a flap bronchoplasty to preserve the middle lobe. The right lower lobectomy and partial resection of intermediate bronchus were made with preserving unaffected ventral wall of lower bronchus. The lower bronchus remnant was used as a flap to cover the defect in the intermediate bronchus. The postoperative course was uneventful, and bronchoscopic findings revealed good healing of the suture line and sufficient airway patency.

[Thymic carcinoid associated with multiple endocrine neoplasia type 1].

We report a case of a thymic carcinoid associated with multiple endocrine neoplasia type 1( MEN-1). A 37-year-old man was referred to our hospital for further examination of an abnormal chest shadow. A chest computed tomography (CT) showed an anterior mediastinal mass measuring 6.5 cm in diameter. A pathological diagnosis of thymic carcinoid was made from a CT-guided needle biopsy specimen. Preoperative workup including endocrinological examination revealed a pituitary adenoma and hyperparathyroidism, and MEN-1 was clinically diagnosed. We performed total parathyroidectomy with autotransplantation and thymectomy with lymph node dissection through cervical collar incision and median sternotomy. The diagnosis of MEN-1 was confirmed by the genomic analysis postoperatively. Since 25% of thymic carcinoids are MEN-1 related and 95% of MEN-1 patients develop hyperparathyroidism, it should be kept in mind that this condition can be treated by thymectomy and concurrent parathyroidectomy.

Non-circumferential tracheal resection with muscle flap reconstruction for adenoid cystic carcinoma.

Circumferential airway resection with primary anastomosis has been widely adopted as a treatment for adenoid cystic carcinoma (ACC) of the trachea. However, carinal resection is a complicated procedure with high mortality and morbidity rates. We describe a technique of non-circumferential tracheal resection performed to treat ACC arising from the lower membranous trachea adjacent to the carina. The tumor was resected while preserving the tracheo-carinal cartilage. A silicone Y-stent was placed at the bifurcation to ensure airway patency before closing the defect. The airway defect, measuring 4 × 2.5 cm, was closed using an autologous pericardial patch and pedicled latissimus dorsi muscle flap. These procedures were technically easy, and no postoperative airway complication occurred.

[Giant malignant solitary fibrous tumor successfully resected via clamshell incision and lower door open thoracotomy].

We report a case of a giant intrathoracic tumor successfully resected via clamshell incision and lower door open thoracotomy. A 62-year-old woman presented with cough and dyspnea on exertion. A chest computed tomography (CT) revealed a giant mass occupying nearly whole of the right hemithorax. Since the tumor infiltrated deeply into the lung parenchyma, we performed a right pneumonectomy. The 1st thoracotomy was performed at 4th intercostal clamshell incision. Then we divided lower sternum vertically and opened the right lower chest wall laterally. These procedures provided wide operative view from the apex to the diaphragm and excellent access to hilar constructions, and enabled enbloc resction of giant tumor with the right lung. The resected specimen was 25×19×12 cm in size, 2,830 g in weight, and histologically diagnosed as a malignant solitary fibrous tumor. We conclude that this approach is effective for excision of giant intrathoracic tumor.

[Reconstruction of the superior vena cava by artificial graft bypass between right brachiocephalic vein and right atrial appendage preserving azygos vein circulation for mediastinal non-seminomatous germ cell tumor].

A 24-year-old man was admitted to our hospital for surgical resection of mediastinal non-seminomatous germ cell tumor after 4 courses of BEP therapy (cisplatin, bleomycin, etoposide). Although it became markedly smaller after chemotherapy, the tumor invaded the superior vena cava (SVC) and the left brachiocephalic vein (LBCV). Venogram demonstrated SVC obstruction above the azygos vein and missing LBCV. A blood return from the left upper limb was shown through thoracodorsal vein, intercostal vein, and accessory hemi-azygos continuation. Excision of residual tumor with SVC and LBCV was done through a median sternotomy. Vascular reconstruction was performed between the right brachiocephalic vein and the right atrial appendage with ringed polytetrafluoroethylene graft. SVC was sutured just above the azygos vein to preserve collateral circulation. LBCV reconstruction was abandoned because distal end of LBCV was entirely surrounded by postchemotherapy scar tissue. Venous occlusive symptoms were not seen in both intraoperative and postoperative period.

Pulmonary hypertension confirmed histologically five months prior to scleroderma renal crisis onset.

A 69-year-old man presented shortness of breath and acute renal failure. He had undergone pulmonary partial resection for lung cancer 5 months prior. On examination, severe hypertension, skin sclerosis of his forearms, and anticentromere antibody were observed. A renal biopsy specimen showed characteristic findings for scleroderma renal crisis, and a right heart catheterization revealed severe pulmonary arterial hypertension. Re-examination of the resected lung specimen revealed sclerodermatous vascular involvement was present.

[Sleeveresection of the left main bronchus for bronchogenic carcinoid for preserving lung parenchyma].

UNLABELLED: We performed bronchoplasty for a bronchogenic tumor of low-grade malignancy without lung parenchyma resection. A 69-year-old man visited our hospital in March 2008 because of cough. Chest computed tomography (CT) revealed atelectasis of the entire left upper lobe and a 2-cm mass with strong contrast enhancement in the lumen of the left main bronchus. Bronchoscopy identified a polypoid mass in the left main bronchus, about 3 cm distal to carina, obstructing the lumen. Biopsy led to a diagnosis of typical carcinoid tumor. Surgery : Thoracotomy showed complete atelectasis of the left upper lobe. After lymph node dissection, resection of the left main bronchus including the site of tumor origin was performed. From the extent of expansion, the left upper lobe was decided to be possible to be spared, and end-to-end anastomosis of the bronchus was performed. Postoperative respiratory rehabilitation resulted in improved aeration of the left upper lobe and markedly improved respiratory function. CONCLUSION: The judgment of whether the long-standing atelectatic left upper lobe could be spared or not was a key in choosing this procedure.

[Radical surgery using modified open door method for anterior apical tumor].

The approach that should be used for an anterior apical tumor still remains controversial. Since a modified open door method was very useful for the widening of the surgical field in a recent patient with an anterior apical tumor, an outline of this case is reported. The patient was a 66-year-old male with squamous cell carcinoma of the anterior apical region of the right lung (suspected to be invading the thoracic wall, cT3N1M0). After a midline sternal incision with a right unilateral collar incision, the medial half of the right clavicle and a few cm of the right 1st rib on the sternal side were resected to sufficiently expose the area from the right brachiocephalic trunk to around the subclavicular artery and vein, where invasion was suspected. This treatment facilitated widening of the visual field around the site of tumor invasion and made safe right upper lobectomy + combined thoracic wall resection + ND2a possible. In this patient, anterolateral incision at the 4th intercostal level, which is made using the original open door method, could be avoided, probably minimizing surgical invasion.

[Reoperation for left main bronchial stump fistula developing after pneumonectomy].

We report the case of a 71-year-old male patient who underwent reoperation for bronchial stump fistula developing after left pneumonectomy for adenocarcinoma of the left lung (clinical stage IIB). After surgery, he developed persistent, severe cough and chest X-ray films taken on the 23rd postoperative day showed a drop in the air-fluid level in the left lung field, which, along with bronchoscopic findings, strongly suggested the bronchial stump fistula and subsequent reoperation was performed. Both superior pulmonary vein and main pulmonary artery were dissected again proximally in pericardium, and the left main bronchus was separated from the surrounding tissue. Bronchial stump was closed with a stapler as close to the carina as possible, and additional resection was performed. After reoperation, the patient had an uneventful course, and was discharged in the second postoperative week. Shorter length of bronchial stump may be the most important factor to prevent the bronchial stump fistula developing after pneumonectomy.

[Median approach for upper lobe lung cancer patients with suspected anterior mediastinal invasion].

We report the usefulness of a median approach to the mediastinum for the treatment of lung cancer with possible mediastinal invasion. Patient was a 74-year-old man with left S3 squamous cell carcinoma suspected of anterior mediastinal invasion (cT4N0M0) because of hoarseness before surgery. A median sternotomy with partial collar incision was chosen for surgery. The tumor was widely adherent to the anterior mediastinum, invading the common carotid artery and the origin of the left subclavian artery. Left upper lobectomy with ND2a by incomplete resection of the invading portion followed by postoperative radiotherapy was performed. For upper lobe lung cancer with possible mediastinal invasion, a median approach seems to be useful, because it facilitates both easy approach to the anterior mediastinum and the management of invasion of large vessels.