Hyperacute experimental model of rat lung transplantation using a coronary shunt cannula.

BACKGROUND: Lung transplantation is a well-established treatment of end-stage lung disease. A rodent model is an inexpensive way to collect biological data from a living model after lung transplantation. However, mastering the surgical technique takes time owing to the small organ size. AIM: To conduct rat lung transplantation using a shunt cannula (SC) or modified cannula (MC) and assess their efficacy. METHODS: Rat lung transplantation was performed in 11 animals in the SC group and 12 in the MC group. We devised a method of rat lung transplantation using a coronary SC for coronary artery bypass surgery as an anastomosis of pulmonary arteriovenous vessels and bronchioles. The same surgeon performed all surgical procedures in the donor and recipient rats without using a magnifying glass. The success rate of lung transplantation, operating time, and PaO2 values were compared after 2-h reperfusion after transplantation. RESULTS: Ten and 12 lungs were successfully transplanted in the SC and MC groups, respectively. In the SC group, one animal had cardiac arrest within 1 h after reperfusion owing to bleeding during pulmonary vein anastomosis. The operating time for the removal of the heart-lung block from the donor and preparation of the left lung graft was 26.8 ± 2.3 and 25.7 ± 1.3 min in the SC and MC groups, respectively (P = 0.21). The time required for left lung transplantation in the recipients was 37.5 ± 2.8 min and 35.9 ± 1.4 min in the SC and MC groups, respectively (P = 0.12). PaO2 values at 2 h after reperfusion were 456.2 ± 25.5 and 461.2 ± 21.5 mmHg in the SC and MC groups, respectively (P = 0.63), without difference between the groups. CONCLUSION: A hyperacute rat lung transplantation model using a coronary SC was created using a simple technique. The MC was inexpensive, easy to prepare, and simple to operate.

[Surgical Treatment to Castleman's Disease after Embolization of Feeding Vessels].

A 48-year-old woman with an abnormal shadow on chest X-ray was referred to our institution. Contrast-enhanced chest computed tomography( CT) showed a large mass, 4.4 cm in diameter, in the right upper mediastinum. Castleman's disease was suspected, and several vessels flowing into the tumor were identified. Since severe intraoperative bleeding was expected, preoperative embolization of the feeding vessels was performed, followed by thoracotomy and tumor extirpation. The amount of blood loss was 50 ml. The pathological diagnosis was Castleman's disease, hyaline vascular type.

[Paradigm Shift in Respiratory Diagnosis: Current Status and Future Prospects of Dynamic Chest Radiography].

Dynamic chest radiography (DCR) is a flat-panel detector (FPD) -based functional X-ray imaging, which is performed as an additional examination in chest radiography. The large field of view of FPDs permits real-time observation of motion/kinetic findings on the entire lungs, right and left diaphragm, ribs, and chest wall; heart wall motions; respiratory changes in lung density; and diameter of the intrathoracic trachea. Since the dynamic FPDs had been developed in the early 2000s, we focused on the potential of dynamic FPDs for functional X-ray imaging and have launched a research project for the development of an imaging protocol and digital image-processing techniques for the DCR. The quantitative analysis of motion/kinetic findings is helpful for a better understanding of pulmonary function, because the interpretation of dynamic chest radiographs is challenging and time-consuming for radiologists, pulmonologists, and surgeons. Recent clinical studies have demonstrated the usefulness of DCR combined with the digital image processing techniques for the evaluation of pulmonary function and circulation. Especially, there is a major concern in color-mapping images based on dynamic changes in radiographic lung density, where pulmonary impairments can be detected as color defects, even without the use of contrast media or radioactive medicine. Dynamic chest radiography is now commercially available for the use in general X-ray room and therefore can be deployed as a simple and rapid means of functional imaging in both routine and emergency medicine. This review article describes the current status and future prospects of DCR, which might bring a paradigm shift in respiratory diagnosis.

Dynamic chest radiography: clinical validation of ventilation and perfusion metrics derived from changes in radiographic lung density compared to nuclear medicine imaging.

BACKGROUND: Dynamic chest radiography (DCR) is a type of non-contrast-enhanced functional lung imaging with a dynamic flat-panel detector (FPD). This study aimed to assess the clinical significance of ventilation and perfusion metrics derived from changes in radiographic lung density on DCR in comparison to nuclear medicine imaging-derived metrics. METHODS: DCR images of 42 lung cancer patients were sequentially obtained during respiration using a dynamic FPD imaging system. For each subdivided lung region, the maximum change in the averaged pixel value (Δmax), i.e., lung density, due to respiration and cardiac function was calculated, and the percentage of Δmax relative to the total of all lung regions (Δmax%) was computed for ventilation and perfusion, respectively. The Δmax% was compared to the accumulation of radioactive agents such as Tc-99m gas and Tc-99m macro-aggregated albumin (radioactive agents%) on ventilation and perfusion scans in the subdivided lung regions, by Spearman's correlation coefficient (r) and the Dice similarity coefficients (DSC). To facilitate visual evaluation, Δmax% was visualized as a color scaling, where larger Δmax values were indicated by higher color intensities. RESULTS: We found a moderate correlation between Δmax% and radioactive agents% on ventilation and perfusion scans, with perfusion metrics (r=0.57, P<0.001) showing a higher correlation than ventilation metrics (r=0.53, P<0.001). We also found a good or strong correlation (r≥0.5) in 80.9% (34/42) of patients for perfusion metrics (r=0.60±0.16) and in 52.4% (22/42) of patients for ventilation metrics (r=0.53±0.16). DSC indicated a moderate correlation for both metrics. Decreased pulmonary function was observed in the form of reduced color intensities on color-mapping images. CONCLUSIONS: DCR-derived ventilation and perfusion metrics correlated reasonably well with nuclear medicine imaging findings in lung subdivisions, suggesting that DCR could provide useful information on pulmonary function without the use of radioactive contrast agents.

Chest Dynamic-Ventilatory Digital Radiography in Chronic Obstructive or Restrictive Lung Disease.

OBJECTIVE: The aim of this study was to identify the relationships between parameters obtained from dynamic-ventilatory digital radiography (DR) and ventilatory disorders. METHODS: This study comprised 273 participants with respiratory diseases who underwent spirometry and functional residual capacity measurements (104 with normal findings on spirometry as controls, 139 with an obstructive lung disorder, 30 with a restrictive lung disorder) were assessed by dynamic-ventilatory DR. Sequential chest radiography images of the patient's slow and maximum breathing were captured at 15 frames per second by a dynamic flat-panel imaging system. The system measured the following parameters: lung area at maximum inspiration divided by height (lung area_in/height), changes in tracheal diameter due to respiratory motions, rate of tracheal narrowing, diaphragmatic motion, and rate of change in lung area due to respiratory motion. Relationships between these parameters and ventilatory disorders were analyzed. RESULTS: Lung area_in/height in patients with restrictive disorders showed significant decreases. Tracheal diameter change and tracheal narrowing rate in patients with obstructive disorders were significantly increased compared to both the control participants and patients with restrictive disorders. Patients with obstructive disorders and patients with restrictive disorders showed decreased diaphragmatic motion and lung area change rate. With the restrictive disorders as references, the area under the curve (AUC), sensitivity and specificity of lung area_in/height were 0.88, 0.77, and 0.88, respectively. With the obstructive disorders as references, the AUC, sensitivity and specificity of tracheal narrowing rate were 0.67, 0.53 and 0.81, respectively. CONCLUSION: Dynamic-ventilatory DR shows potential as a method for the detection and evaluation of ventilatory disorders in patients with respiratory diseases.

Predicting recurrence of non-small cell lung cancer based on mean computed tomography value.

BACKGROUND: The aim of this study was to assess the ability of using mean computed tomography (mCT) values to predict non-small cell lung cancer (NSCLC) tumor recurrence. METHODS: A retrospective study was conducted on 494 patients with stage IA NSCLC. Receiver operating characteristics analysis was used to assess the ability to use mCT value, C/T ratio, tumor size, and SUV to predict tumor recurrence. Multiple logistic regression analyses were performed to determine the independent variables for the prediction of tumor recurrence. RESULTS: The m-CT values were - 213.7 ± 10.2 Hounsfield Units (HU) for the recurrence group and - 594.1 ± 11.6 HU for the non-recurrence group (p < 0.0001). Recurrence occurred in 45 patients (9.1%). The tumor recurrence group was strongly associated with a high CT attenuation value, high C/T ratio, large solid tumor size, and SUV. The diagnostic value of mCT value was more accurate than the C/T ratio, excluding the pure ground-glass opacity and pure solid (0 < C/T ratio < 100) groups. The SUV and mCT are independent predictive factors of tumor recurrence. CONCLUSIONS: The evaluation of mCT values was useful for predicting recurrence after the limited resection of small-sized NSCLC, and may potentially contribute to the selection of suitable treatment strategies.

Assessment of pleural invasion and adhesion of lung tumors with dynamic chest radiography: A virtual clinical imaging study.

PURPOSE: Accurate preoperative assessment of tumor invasion/adhesion is crucial for planning appropriate operative procedures. Recent advances in digital radiography allow a motion analysis of lung tumors with dynamic chest radiography (DCR) with total exposure dose comparable to that of conventional chest radiography. The aim of this study was to investigate the feasibility of preoperative evaluation of pleural invasion/adhesion of lung tumors with DCR through a virtual clinical imaging study, using a four-dimensional (4D) extended cardiac-torso (XCAT) computational phantom. METHODS: An XCAT phantom of an adult man (50th percentile in height and weight) with simulated respiratory and cardiac motions was generated to use as a virtual patient. To simulate lung tumors with and without pleural invasion, a 30-mm diameter tumor sphere was inserted into each lobe of the phantom. The virtual patient during respiration was virtually projected using an x-ray simulator in posteroanterior (PA) and oblique directions, and sequential bone suppression (BS) images were created. The measurement points (tumor, rib, and diaphragm) were automatically tracked on simulated images by a template matching technique. We calculated five quantitative metrics related to the movement distance and directions of the targeted tumor and evaluated whether DCR could distinguish between tumors with and without pleural invasion/adhesion. RESULTS: Precise tracking of the targeted tumor was achieved on the simulated BS images without undue influence of rib shadows. There was a significant difference in all five quantitative metrics between the lung tumors with and without pleural invasion both on the oblique and PA projection views (P < 0.05). Quantitative metrics related to the movement distance were effective for tumors in the middle and lower lobes, while, those related to the movement directions were effective for tumors close to the frontal chest wall on the oblique projection view. The oblique views were useful for the evaluation of the space between the chest wall and a moving tumor. CONCLUSION: DCR could help distinguish between tumors with and without pleural invasion/adhesion based on the two-dimensional movement distance and direction using oblique and PA projection views. With anticipated improved image: processing to evaluate the respiratory displacement of lung tumors in the upper lobe or behind the heart, DCR holds promise for clinical assessment of tumor invasion/adhesion in the parietal pleura.

A method to identify pulmonary intersegmental planes with intravenous vitamin B2 injection.

PURPOSE: The present study investigated whether the pulmonary intersegmental planes could be identified with the intravenous injection of vitamin B2 using a fluorescent camera and whether this method can be used instead of the inflation-deflation technique or the intravenous indocyanine green (ICG) method. METHODS: In experiment 1, the vitamin B2 was intravenously injected to visualize the pulmonary intersegmental plane and perform segmentectomy, and the visualized pulmonary intersegmental line was then compared to the inflation-deflation line in six pigs. In experiment 2, using six pigs, the fluorescent area and duration of fluorescence were compared after the intravenous injection of vitamin B2 and ICG in the same animals. RESULTS: In all animals in experiment 1, it was possible to clearly detect yellow-green fluorescence in the lung, in segments other than the one intended for resection, for at least 60 min. Moreover, the line visualized with vitamin B2 fluorescence matched the inflation-deflation line in all animals. In experiment 2, the area of vitamin B2 fluorescence corresponded to the area of ICG fluorescence in each animal. CONCLUSIONS: The visualization of fluorescence after the intravenous injection of vitamin B2 using a fluorescent camera was a simple, safe, and accurate method for detecting intersegmental planes in a pig model. This method can be an alternative to the inflation-deflation technique and the intravenous ICG method.

Comparison of dynamic flat-panel detector-based chest radiography with nuclear medicine ventilation-perfusion imaging for the evaluation of pulmonary function: A clinical validation study.

PURPOSE: Dynamic chest radiography (DCR) is a flat-panel detector (FPD)-based functional lung imaging technique capable of measuring temporal changes in radiographic lung density due to ventilation and perfusion. The aim of this study was to determine the diagnostic performance of DCR in the evaluation of pulmonary function based on changes in radiographic lung density compared to nuclear medicine lung scans. METHODS: This study included 53 patients with pulmonary disease who underwent DCR and nuclear medicine imaging at our institution. Dynamic chest radiography was conducted using a dynamic FPD system to obtain sequential chest radiographs during one breathing cycle. The maximum change in the average pixel value (Δmax ) was measured, and the percentage ofΔmax in each lung region, calculated relative to the sum of all lung regions (Δmax %), was calculated for each factor (ventilation and perfusion). The Δmax % was compared with the accumulation of radioactive agents (radioactive agents%) on ventilation and perfusion scans in each lung and lung region using correlation coefficients and scatter plots. The ratio of ventilation to perfusion Δmax % was calculated and compared with nuclear medicine ventilation-perfusion (V/Q) findings in terms of sensitivity and specificity for V/Q mismatch in each lung region. RESULTS: There was a high correlation between Δmax % and radioactive agents% for each lung (Ventilation: r = 0.81, perfusion: r = 0.87). However, correlation coefficients were lower (0.37 to 0.80) when comparing individual lung regions, with the upper lung regions showing the lowest correlation coefficients. The sensitivity and specificity of DCR for V/Q mismatch were 63.3% (19/30) and 60.1% (173/288), respectively. Motion artifacts occasionally increased Δmax %, resulting in false negatives. CONCLUSIONS: Ventilation and perfusion Δmax % correlated reasonably with radioactive agents% on ventilation and perfusion scans. Although the regional correlations were lower and the detection performance for V/Q mismatch was not enough for clinical use at the moment, these results suggest the potential for DCR to be used as a functional imaging modality that can be performed without the use of radioactive contrast agents. Further technical improvement is required for the implementation of DCR-based V/Q studies.

Case report: uniportal video-assisted thoracoscopic resection of a solitary fibrous tumor preoperatively predicted visceral pleura origin using dynamic chest radiography.

BACKGROUND: Dynamic chest radiography (DCR) is a flat-panel detector (FPD)-based functional X-ray imaging, which is performed as an additional examination in chest radiography. DCR provides objective and quantifiable information, such as diaphragm movement, pulmonary ventilation and circulation, and is reasonable for detecting tumor invasion or adhesion. CASE PRESENTATION: We present a case of Solitary Fibrous Tumor of Pleura (SFTP), preoperatively predicted visceral pleura origin using Dynamic chest radiography (DCR) and surgically resected through single-access (uniportal) video-assisted thoracoscopic surgery (UVATS). CONCLUSIONS: UVATS may be a suitable surgical option for pedunculated SFTPs. Dynamic chest radiography provides information, such as tumor invasion or adhesion and helpful for predicting origin of the tumor.

Semi-comprehensive analysis of gene amplification in thymic malignant tumors using multiplex ligation-dependent probe amplification and fluorescence in situ hybridization.

Research on the amplification of oncogenes in thymic malignant tumor is limited. In this study, we aimed to determine the gene amplification status of receptor tyrosine kinases and other cell regulator genes in thymic malignant tumors, with a view toward the future introduction of molecular targeted therapy. In addition, we examined the usefulness of multiplex, ligation-dependent probe amplification (MLPA) in the semi-comprehensive detection of these gene amplifications. The participants of this study were nine patients with thymic carcinoma and one patient with atypical carcinoid who underwent resection at our department from 1999 to 2016. Twenty-four oncogenes (MDM4, MYCN, ALK, PDGFRA, KIT, KDR, DHFR, EGFR, MET, SMO, BRAF, FGFR1, MYC, ABL1, RET, CCND1, CCND2, CDK4, MDM2, AURKB, ERBB2, TOP2A, AURKA, AR) were analyzed for amplification by MLPA. In cases where amplification by MLPA was suspected, confirmation was performed by fluorescence in situ hybridization (FISH). Immunostaining for detected oncoproteins and p53 were performed in cases with confirmed oncogene amplification. MYC (2/10, 20%) and MDM2 (1/10, 10%) amplifications were detected using MLPA and FISH. Immunostaining in both cases was positive. The MDM2-amplified tumor relapsed and spread rapidly after operation despite the use of post-operative chemo-radiotherapy. MYC amplification may be involved in the carcinogenesis of thymic malignant tumors. In addition, MDM2 amplification may be a concern in the increased malignancy.

[Surgical Treatment of Pectus Excavatum in Patients with Marfan Syndrome Associated with Vertebral or Cardiovascular Disease].

Surgical treatment is often required in patients with Marfan syndrome presenting with scoliosis or cardioaortic disease. If these patients present with pectus excavatum, surgery for spinal deformity correction or chest wall closure during cardioaortic surgery can cause thoracic organ compression secondary to narrowing of the thorax resulting in hemodynamic and respiratory compromise. Cardiovascular complications serve as prognostic factors in patients with Marfan syndrome, and surgical treatment is often required in these cases. In our case series involving 4 patients, 2 patients with pectus excavatum and scoliosis underwent a Nuss procedure followed by safe and successful spinal correction surgery 6 months later. A Nuss procedure was also performed in a patient complicated with sinus of Valsalva dilatation, and thoracotomy was performed before cardioaortic surgery. Another patient with a complication of pectus excavatum and acute deterioration of cardiac status underwent concomitant repair with sternal elevation using an AO plate and cardioaortic surgery. In patients with Marfan syndrome presenting with pectus excavatum complicated by scoliosis or cardioaortic disease, it is necessary to consider concomitant or staged repair depending on the disease condition.

Dynamic-Ventilatory Digital Radiography in Air Flow Limitation: A Change in Lung Area Reflects Air Trapping.

OBJECTIVE: The aim of this study was to determine the utility of dynamic-ventilatory digital radiography (DR) for pulmonary function assessment in patients with airflow limitation. METHODS: One hundred and eighteen patients with airflow limitation (72 patients with lung cancer before surgery, 35 patients with chronic obstructive pulmonary disease [COPD], 6 patients with asthma, and 5 patients with asthma-COPD overlap syndrome) were assessed with dynamic-ventilatory DR. The patients were instructed to inhale and exhale slowly and maximally. Sequential chest X-ray images were captured in 15 frames per second using a dynamic flat-panel imaging system. The relationship between the lung area and the rate of change in the lung area due to respiratory motion with respect to pulmonary function was analyzed. RESULTS: The rate of change in the lung area from maximum inspiration to maximum expiration (Rs ratio) was associated with the RV/TLC ratio (r = 0.48, p < 0.01) and the percentage of the predicted FEV1 (r = -0.33, p < 0.01) in patients with airflow limitations. The Rs ratio also decreased in an FEV1-dependent manner. CONCLUSION: The rate of change in the lung area due to respiratory motion evaluated with dynamic DR reflects air trapping. Dynamic DR is a potential tool for the comprehensive assessment of pulmonary function in patients with COPD.

Vitamin B2 lung-marking method using black light irradiation.

BACKGROUND: Various approaches and markers for marking the lungs prior to lung tumor resection have been reported. In clinical practice, the hook wire localization method is often used owing to the simplicity of the technique. However, although rare, this method is associated with air embolism, which can be lethal. Because vitamin B2 is harmless to the body and fluorescent, it was applied to various methods for thoracic surgery. Using a pig model, we aimed to examine whether a lung-marking method involving the injection of vitamin B2 to peripheral small lung lesions and observing them under black light irradiation could replace the hook wire localization method. METHODS: We used a pig model to perform hook wire localization of the lungs and at the same time injected 1 mL of a vitamin B2 aqueous solution to the lung parenchyma at the hook wire puncture site under the visceral pleura. Subsequently, we measured the length of the fluorescent marked area and fluorescence intensity over time. Black light was used to assess the fluorescent marked area, and fluorescence intensity was quantified using image analysis software. RESULTS: Lung-marking was successful in all five pigs and we visualized the vitamin B2-marked area under black light irradiation. Measurements were taken immediately after thoracotomy (0 min) and 60 and 120 min thereafter. No changes in the length of the marked area (1.3±0.3/1.2±0.3/1.1±0.3 cm, 0/60/120 min, P=0.21) and fluorescence intensity (162.8±55.1/157.2±63.1/165.2±62.2, 0/60/120 min, P=0.96) were observed over time. Compared to the non-marked area (normal lungs), the marked area showed significantly higher fluorescence intensity (P=0.01/0.01/0.01, 0/60/120 min). CONCLUSIONS: Vitamin B2 lung-marking was performed safely and accurately using the pig model, providing good visibility of the marked area. This approach may replace the hook wire localization method. In the near future, we plan to conduct clinical trials to evaluate the applicability of this method in humans.

Dynamic chest radiography: Novel and less-invasive imaging approach for preoperative assessments of pleural invasion and adhesion.

Here, we report a case of lung cancer with preoperatively predicted invasion to the parietal pleura on dynamic chest radiography (DCR). An 82-year-old patient was referred for staging of a right lung tumor. Preoperative DCR revealed invasion or adhesion of the tumor to the chest wall, and intraoperative findings revealed invasion of the tumor to the parietal pleura. DCR provides objective and quantifiable information, including diaphragmatic movement, pulmonary ventilation, and circulation, as well as tumor invasion or adhesion and is less invasive compared to 3-dimensional chest computed tomography or cine magnetic resonance imaging. This study was our initial attempt at performing a quantitative assessment using DCR.

Prognostic factor and treatment strategy for clinical N1 non-small cell lung cancer.

OBJECTIVES: The aim of this study is to evaluate the surgical results of clinical N1 disease and to clarify the high-risk clinical N1 subgroup. METHODS: Between 1990 and 2012, 137 patients who were clinically diagnosed as having N1 disease were enrolled. Their medical records were reviewed to assess clinical characteristics, radiologic findings, pathologic results, postoperative outcomes, recurrence patterns, and survival. Logistic regression analysis was used to identify independent predictive factors for pathologic N2 upstaging. To determine which factors were significantly associated with survival, a multivariate analysis using a Cox proportional hazards model was performed. RESULTS: More cases were pathological N2 in adenocarcinoma than squamous cell carcinoma (p = 0.039). The overall survival rates at 5 years were 54.9%, 36.7% in group upper lobe, middle and lower lobe, respectively (p = 0.013). Logistic regression analyses revealed that #10 positive (p = 0.002, HR 4.625) and adenocarcinoma (p = 0.029, HR 1.544) were significant predictor of pathologic N2 disease. Multivariate analyses revealed that pathologic N2 (p = 0.007, HR 4.186), middle and lower lobe (p = 0.009, HR 2.045) and presence of #10 (p = 0.024, HR 1.871) were independent prognostic factors. Patients with upper lobe and absence of #10 showed a significantly higher 5-year survival rate than patients with middle and lower lobe and presence of #10 (62.1 vs 25.9%: p < 0.0001). CONCLUSIONS: Among patients with cN1, pathological N2 disease, tumor in middle and lower lobe and clinical #10 lymph node positive were high-risk subgroup. Further analyses using larger numbers of patients with N1 disease from multiple centers are necessary.

[A Recurrent Case of Thymic Adenocarcinoma Effectively Treated with S-1 Over a Long-Term Period].

A 61-year-old woman with an abnormal radiograph shadow in her anterior mediastinum was admitted to our hospital and underwent an extended thymectomy. The pathological diagnosis of the tumor was a non-papillary adenocarcinoma of the thymus in pathological stage IV b using the Masaoka classification owing to mediastinal lymph node metastasis. We found parasternal lymph node metastases 5 months after her first operation, and subsequently, she underwent surgery and adjuvant radiotherapy. We found systemic lymph node metastases and metastatic lesions in distant organs, including her lungs, brain, and kidney 27 months after her first operation. Systemic chemotherapy, such as carboplatin plus paclitaxel and an ADOC regimen were not very effective, so we performed immunohistochemical staining of the primary thymic adenocarcinoma. The levels of both thymidylate synthase and dihydropyrimidine dehydrogenase were low; therefore, we started S-1 100mg/body (2 weeks of administration, 1 week of withdrawal)31 months after her first operation. She entered complete remission 6 months after the initiation of S-1. We surgically resected her solitary lung metastasis 13 months after initiation of S-1, and then continued the S-1 treatment. There was no recurrence for more than 2 years after the lung surgery. We believe that when the expression levels of thymidylate synthase or dihydropyrimidine dehydrogenase are low in cases of recurrent thymic adenocarcinoma, S-1 may be able to induce an effective response.

Lymph node ratio as a prognostic factor in patients with pathological N2 non-small cell lung cancer.

BACKGROUND: The aim of this study was to investigate whether the lymph node ratio (LNR) was associated with the prognosis of patients, who underwent surgery for pathological N2 non-small cell lung cancer (NSCLC). METHODS: A total of 182 patients were diagnosed with pathological N2 disease and underwent complete resection surgeries with systematic lymphadenectomies. We counted the number of positives and removed lymph nodes to calculate a ratio between them (LNR). We also investigated the association between skip mediastinal lymph node metastasis and survival. RESULTS: Univariate analysis of survival in patients with N2 NSCLC showed that the T factor, clinical N factor, and LNR were significant prognostic factors. Multivariate analyses showed that the clinical N stage and LNR were significant independent prognostic factors for patients with pathological N2 NSCLC. Patients with a clinical lymph node status of 0 (cN0) and LNR ≤0.22 showed a significantly higher survival rate than patients with a cN1-2 and LNR ≥0.22 and 5-year survival rates were 47.1 and 10.3%, respectively (p < 0.0001). CONCLUSIONS: LNR is an important prognostic factor for poor outcome following surgery in patients with N2 disease. The combination of the LNR and cN status provides a valuable prognostic tool.

[Solitary pulmonary lesion developed after the resection of primary lung cancer].

The purpose of this study was to evaluate the characteristics of solitary pulmonary lesion developed after the resection of primary lung cancer and the outcome. Between 1990 and 2011, 1,004 patients underwent complete resection for primary lung cancer in our hospital and we retrospectively analyzed 53 patients with a history of primary lung cancer resection who had a solitary pulmonary lesion. Pulmonary resections were performed in 43 patients. Wedge resection and segmentectomy were performed in 42( 98%) of them. There was no operative death. The diagnosis was 2nd primary lung cancer in 28 patients, recurrent lesion in 9, and benign lesions in 6. Malignant tumor ratio of resected cases was 86%.Other unresected 10 cases were not diagnosed historogically and 9 of them underwent radiation therapy. The 5-year survival rate was 57.3% in those with 2nd primary lung cancer, 55.5% in those with recurrent lesion, and 64.3% in those with undiagnosed-unresected lesions( no significant difference). It is important to take a surgical approach for a diagnosis and to treat with standard therapy for both 2nd primary lung cancer and recurrent lesion. Sublobar resection may be adequate. In patients with a undiagnosed nodule who were not able to have 2nd surgery, radiation therapy may be permitted and effective.

Surgical treatment of bilateral coronary-to-pulmonary artery fistulas.

Bilateral coronary artery fistulas with the coronary artery stenosis are rare. In this case, we successfully performed closure of coronary artery fistulas with coronary artery bypass grafting. Furthermore, we were able to measure the flow in the coronary artery fistulas using transit-time flow measurement.