Low suction on digital drainage devices promptly improves post-operative air leaks following lung resection operations: a retrospective study.

BACKGROUND: We investigated the most effective suction pressure for preventing or promptly improving postoperative air leaks on digital drainage devices after lung resection. METHODS: We retrospectively analyzed the postoperative data of 242 patients who were monitored with a digital drainage system after pulmonary resection in our institution between December 2017 and June 2020. We divided the patients into three groups according to the suction pressure used: A (low-pressure suction group: - 5 cm H2O), B (intermediate-pressure group: - 10 cm H2O), and C (high-pressure suction group: - 20 cm H2O). We evaluated the duration of air leaks, timing of chest tube replacement, the amount of postoperative air leak, volume of fluid drained before chest tube removal, and the total number of air leaks during drainage. RESULTS: In total, 217 patients were included in this study. The duration of air leaks gradually decreased with significant difference between the groups, the highest decrease in A, the lowest decrease in C (P = 0.019). Timing of chest tube replacement, on the other hand, did not significantly differ between the three groups (P = 0.126). The number of postoperative air leaks just after surgery did not significantly differ between the three groups (P = 0.175), but the number of air leaks on postoperative day 1 were fewest in group A, then B, and greatest in group C (P = 0.033). The maximum amount of air leaks during drainage was lowest in A, then B, and highest in C (P = 0.036). Volume of fluid drained before chest tube removal did not significantly differ between the three groups (P = 0.986). CONCLUSION: Low-pressure suction after pulmonary resection seems to avoid or promptly improve postoperative air leaks in digital drainage devices after lung resection. TRIAL REGISTRATION: This is a single-institution, retrospective analysis-based study of data from an electronic database. Study protocol was approved by the Akashi Medical Center Institutional Research Ethics Board (approval number: 2020-9).

Extended-spectrum ß-lactamase-producing Escherichia coli rib osteomyelitis with debridement and vacuum-assisted closure.

Rib osteomyelitis is a rare disease, comprising 1% or less of all osteomyelitis. Treatment of rib osteomyelitis includes prolonged antibiotic therapy and surgical intervention. Indications for surgical treatment of rib osteomyelitis remain unclear, however, because of few reported cases. We report the first known case of extended-spectrum ß-lactamase-producing Escherichia coli rib osteomyelitis caused by urosepsis. The 69-year-old male patient remains free of recurrence and symptoms after rib resection and vacuum-assisted closure treatment with antibiotic therapy. Rib osteomyelitis should be considered as differential diagnosis when patients report chest pain after bacteraemic infection. We recommend surgical treatment for patients with drug-resistant bacterial rib osteomyelitis.

Surgical repair of hepatic hydrothorax caused by diaphragmatic fistula.

A 65-year-old woman visited our hospital complaining of dyspnea several days before admission. A chest X-ray showed massive right-sided pleural effusion, which was not observed 1 month previously. Although the patient had never been diagnosed with cirrhosis at regular visits, the patient was diagnosed with primary biliary cholangitis at admission. Hepatic hydrothorax was suspected because pleural effusion was transudative. A diaphragmatic fistula was confirmed and closed by thoracoscopy. Pleural effusion did not reappear after this procedure. Existence of a diaphragmatic defect should be confirmed under direct vision if pleural effusion accumulates acutely or becomes beyond control.

Pulmonary arteriovenous fistula ruptured in an adolescent girl 1 week after her mother's rupture: a report of a case.

A 14-year-old girl was diagnosed with hemothorax associated with pulmonary arteriovenous fistula rupture, and emergency surgery was performed. One week before her surgery, her mother at 32 weeks of gestation underwent emergency surgery for hemothorax caused by pulmonary arteriovenous fistula rupture. Both were diagnosed with hereditary hemorrhagic telangiectasia. The indications for treatment of pulmonary arteriovenous fistulas in young patients remain controversial because the risk of complications concerning pulmonary arteriovenous fistula is lower in young patients than in adult patients. We recommend that aggressive treatment should be performed for pulmonary arteriovenous fistulas in patients with hereditary hemorrhagic telangiectasis with a family history of pulmonary arteriovenous fistula rupture even if the patient is asymptomatic and young, because such patients may have a high risk of pulmonary arteriovenous fistula rupture.

[Pulmonary Epithelial-myoepithelial Carcinoma;Report of a Case].

A 30-year-old female was admitted for diagnosis of an abnormal shadow on chest X-ray. A computed tomography scan showed honeycombing in bilateral dorso-basal segments of the lung and a tumor obstructing the orifice of right middle lobe bronchus. Resection of the tumor by a bronchofiberscope was performed. However, a part of the tumor remained in the bronchus. Histlogical examination confirmed the tumor to be epithelial-myoepithelial carcinoma. In order to assure a complete resection of the tumor, we performed right middle wedge bronchoplastic lobectomy. The patient is doing well, without recurrence 5 years after surgery.

Psf3 as a possible biomarker of postoperative chemotherapy for patients with early pulmonary adenocarcinoma.

BACKGROUND: Partner of Sld five 3 (Psf3) is a member of the heterotetrameric complex that consists of SLD5, Psf1, Psf2, and Psf3. We have shown in previous studies that high Psf3 expression was a poor prognostic marker for pulmonary adenocarcinoma. Here, we statistically evaluated the relationship between clinicopathologic factors and Psf3 expression in stage I pulmonary adenocarcinoma. METHODS: A total of 583 patients who had undergone complete resection of stage I pulmonary adenocarcinoma from January 2002 to December 2009 were included in the study. Tissue microarrays were performed, and the resected tumors were divided into groups according to Psf3 expression. RESULTS: Of 583 patients, high expression of Psf3 was observed in 211 (36.2%) and low expression of Psf3 observed in 372 (63.8%) patients. Among stage I patients, the five-year survival rate was 76.7% in the Psf3 high expression group and 90.9% in the Psf3 low expression group (P < 0.0001). On multivariate analysis, Psf3 was found to be the independent prognostic factor. Among stage I patients in the Psf3 high expression group, a significantly greater five-year survival rate was observed in patients who received postoperative chemotherapy with tegafur-uracil than in those who underwent surgery alone (P < 0.0001). In contrast, among stage I patients in the Psf3 low expression group, no difference was found in the five-year survival, regardless of the presence or absence of tegafur-uracil (P = 0.873). CONCLUSION: The Psf3 expression was an independent prognostic factor and could be a biomarker of adjuvant tegafur-uracil for stage I pulmonary adenocarcinoma. KEY POINTS: Significant findings of the study: The Psf3 expression could be a biomarker of adjuvant tegafur-uracil administration for stage I pulmonary adenocarcinoma. WHAT THIS STUDY ADDS: Appropriate patients of adjuvant chemotherapy for stage I pulmonary adenocarcinoma using Psf3 expression could be selected.

Psf3 is a prognostic biomarker in lung adenocarcinoma: a larger trial using tissue microarrays of 864 consecutive resections.

OBJECTIVES: Partner of Sld five (Psf) 3 is a member of the evolutionarily conserved heterotetrameric complex GINS (Go-Ichi-Ni-San). We previously reported that Psf3 could serve as a biomarker of poor prognosis in lung adenocarcinoma. Here, we used tissue microarrays to analyse Psf3 expression in lung adenocarcinoma and investigated whether its expression is associated with survival outcomes. METHODS: The study included 864 consecutive patients with lung adenocarcinoma who underwent complete resection at Hyogo Cancer Center between January 2002 and December 2009. Tissue microarrays were prepared, and Psf3 was detected using mouse antihuman Psf3 primary monoclonal antibodies. The status of Psf3 expression was determined using these microarrays. RESULTS: Of the 864 patients, 375 had high-positive Psf3 expression and 489 had low-positive expression. Psf3 expression was significantly associated with age, sex, T factor, lymph node metastasis, stage and P factor. The 5-year disease-free survival (DFS) rate was significantly lower in patients with high-positive Psf3 expression than in those with low-positive expression, and Psf3 expression, sex, age, T factor and lymph node metastasis were identified as independent and significant prognostic determinants. Among patients with Stage I adenocarcinoma, the 5-year DFS rate was significantly lower in those with high-positive Psf3 expression than in those with low-positive expression, and Psf3 expression was the most powerful survival predictor. CONCLUSIONS: The present findings strengthened our previous data demonstrating that high Psf3 expression in primary lung adenocarcinoma plays an important role in disease progression and is a prognostic indicator, particularly in early-stage adenocarcinoma.

Ruptured thymoma causing a hemothorax: A case report.

A thymoma is a neoplasm that arises from the epithelial cells of the thymus, and may cause various signs and symptoms dependent upon its local extent. A non-traumatic hemothorax is extremely rare. The present study reports the case of a 77-year-old female who presented with an acute onset of chest pain. Imaging procedures revealed a mass occupying the anterior mediastinum and left hemithorax, and a left pleural effusion. Progressive anemia was noted following admission. Left hemothorax due to rupture of the anterior mediastinal mass was suspected, and emergency surgery was performed. Hemorrhage was observed on the cut surface of the tumor. An analysis of frozen sections indicated a thymoma, and a thymo-partial thymectomy was subsequently performed to remove as much of the hematoma as possible. The patient was discharged on post-operative day 13 following an uneventful recovery. The present case suggests that in previously healthy individuals, sudden-onset dyspnea and chest pain co-occurring with an acute widening of the mediastinum observed on roentgenograph may be indicative of a ruptured thymoma.

Efficacy of adjuvant chemotherapy for lung adenocarcinoma patients with positive pleural lavage cytology findings.

OBJECTIVES: Positive pleural lavage cytology (PLC) findings are considered to be predictive of a poor prognosis in patients with non-small-cell lung cancer (NSCLC). We investigated the clinical benefit of adjuvant chemotherapy for lung adenocarcinoma patients with positive PLC findings. METHODS: We retrospectively reviewed the medical records of lung adenocarcinoma patients who underwent tumour resection and had positive PLC findings between January 2000 and December 2009. RESULTS: Fifty-three patients (4.8%) of 1114 patients with lung adenocarcinoma had positive PLC findings. The median follow-up period was 33.6 months. Adjuvant chemotherapy was administered to 24 patients (adjuvant chemotherapy group); 7, 8 and 9 patients had pathological Stage I, II and III, respectively . The surgery-alone group comprised 29 patients; 12, 8 and 9 patients had pathological Stage I, II and III, respectively. The 5-year recurrence-free survival (RFS) rates were 34.6 and 15.7% (P < 0.01) in adjuvant chemotherapy and surgery-alone groups, respectively. The rate of distant recurrence was significantly reduced in the adjuvant chemotherapy group (25.0 and 58.6%; P = 0.01). Even for Stage I cases, adjuvant chemotherapy tended to improve the 5-year RFS rate compared with surgery alone (60.1 and 29%; P = 0.11). Multivariate analysis for RFS revealed that adjuvant chemotherapy [hazard ratio (HR), 0.45; P = 0.03], tumour size >30 mm (HR, 2.23; P = 0.02) and lymph node metastasis (HR, 2.67; P < 0.01) were significant independent prognostic factors for recurrence. CONCLUSIONS: Adjuvant chemotherapy for lung adenocarcinoma patients with positive PLC findings significantly improved recurrence-free survival.

Outcomes of segmentectomy for cT1bN0M0 lung adenocarcinoma and squamous cell carcinoma: a possible association with pathological invasion.

OBJECTIVES: We evaluated the clinical benefit of segmentectomy for patients with cT1bN0M0 lung cancer. METHODS: We retrospectively reviewed the medical records of 178 patients who underwent lobectomy or segmentectomy for cT1bN0M0 lung adenocarcinoma and squamous cell carcinoma from January 1995 to December 2005. We investigated the association of surgical outcomes with the presence of pathological invasion. RESULTS: The median follow-up period was 93.4 months. Of 178 patients, 37 were scheduled for segmentectomy, but 6 of these patients were switched to receive lobectomy due to surgical N1 or N2 in 3 patients and insufficient surgical margins in 3 patients. In total, 31 patients underwent segmentectomy, and 147 underwent lobectomy. The 5-year overall survival (OS) was similar between the patients who underwent lobectomy (5-year OS, 81.6%) and segmentectomy (5-year OS, 77.4%, P = 0.73). Among pN0 patients without pathological invasion, there was no difference in OS between patients who underwent lobectomy (5-year OS, 89.9%) and segmentectomy (5-year OS, 88.9%, P = 0.80). In contrast, among pN0 patients with pathological invasion, OS was greater in patients who underwent lobectomy (5-year OS, 80.9%) than in those who underwent segmentectomy (5-year OS, 54.6%; P = 0.19). Moreover, a significantly higher rate of local and local + distant recurrence was observed in patients who underwent segmentectomy (45%) than in those who underwent lobectomy (15%) in this group (P = 0.02). CONCLUSIONS: The results of our study suggest that segmentectomy may not be recommended for cT1b tumours if pathological invasion is suspected before surgery.

Pleural lavage cytology as an independent prognostic factor in non-small-cell lung cancer patients with stage I disease and adenocarcinoma.

We previously reported that cancer cells may be detected through pleural lavage cytology (PLC). In this study, we sought to re-examine the prognostic significance of the PLC status based on an extended dataset with an additional follow-up period. Pleural lavage following thoracotomy was cytologically examined in 1,317 consecutive patients who were diagnosed with NSCLC between 1987 and 2004 at the Thoracic Surgery Units of Kobe University Graduate School of Medicine and Hyogo Cancer Center. Among the investigated patients, 46 exhibited positive cytological findings. The prognosis of these patients was significantly worse compared to that of patients without positive PLC. Of the 844 pathological stage I patients, 18 had a positive PLC status and their prognosis was significantly worse compared to that of patients with stage I disease without positive PLC. In conclusion, positive PLC findings were associated with a poor prognosis and this finding was significant for patients with stage I disease. These results suggest the need for PLC status evaluation during staging and treatment planning in patients with NSCLC.

Pulmonary large cell neuroendocrine carcinoma exhibiting extensive pagetoid spread in the bronchial epithelium: A case report.

Pulmonary large cell neuroendocrine carcinoma (LCNEC) is a rare and aggressive malignant tumor, which was proposed as a novel type of neuroendocrine tumor in 1991. Although it is categorized as a non-small cell lung carcinoma, the precise pathological condition is unknown due to its rare occurrence. The present study outlines the case of a patient presenting with an LCNEC that exhibited pagetoid spread from the region of the primary tumor to the bronchial epithelium (distance, >30 mm). The pagetoid spread was unconfirmed preoperatively, however, was identified by intraoperative rapid diagnosis. This caused us to suffer the perioperative decision of additional resection and resulted in an incomplete resection, as suture of the bronchus was not possible. Pagetoid spread, which is often apparent in the breast, presents as a rare pattern of infiltration of cancer cells when a massive carcinoma is identified beneath the intraepithelial spread. Although preoperative diagnosis of pagetoid spread is difficult due to its rarity and undefined clinical features, it is important for surgeons and pathologists treating lung cancer patients to be aware of potential pagetoid spread in the thoracic region.

Clinical significance of the 'not otherwise specified' subtype in candidates for resectable non-small cell lung cancer.

The histological subtype of non-small-cell lung cancer (NSCLC) is a significant factor when selecting treatment strategies. However, cases are occasionally encountered that are diagnosed as 'not otherwise specified' (NOS) prior to surgery, due to an uncertain histological subtype. The present study investigated the prognostic significance of the NOS subtype for patients with resectable NSCLC. Between 2001 and 2011, 1,913 patients were diagnosed with NSCLC using transbronchial biopsy and underwent surgical resection at two facilities in Japan. Of these patients, 151 (7.9%) were pre-operatively diagnosed with NSCLC-NOS (NOS group) and the remainder had confirmed histological subtypes (confirmed group). The present study compared the clinicopathological features and prognoses of these groups. Analyses of resected specimens revealed that pleomorphic cell carcinoma, large cell neuroendocrine cell carcinoma, large cell carcinoma and adenosquamous carcinoma were significantly more common in the NOS group than in the confirmed group (P<0.001, P=0.002, P=0.019 and P=0.014, respectively). The five-year survival rate was significantly poorer in the NOS group (60.5 vs. 67.1%; P=0.010), particularly for stage I disease (70.8 vs. 80.7%; P=0.007). The results of a multivariate analysis of overall survival indicated that NOS was a significant independent prognostic factor (hazard ratio, 1.40; 95% confidence interval, 1.02-1.86; P=0.041). These results indicated that pre-operative NOS was significantly associated with poorer survival, including for stage I disease. In conjunction with other clinicopathological parameters, NOS can be a useful prognostic factor when deciding on a treatment strategy for NSCLC.

The efficacy of 320-detector row computed tomography for the assessment of preoperative pulmonary vasculature of candidates for pulmonary segmentectomy.

OBJECTIVES: The purpose of this study was to compare the efficacy of 320-detector row computed tomography (CT) with that of 64-detector row CT for three-dimensional assessment of pulmonary vasculature of candidates for pulmonary segmentectomy. METHODS: We included 32 patients who underwent both 320- and 64-detector CT before pulmonary segmentectomy, which was performed by cutting the pulmonary artery and bronchi of the affected segment followed by dissection of the intersegmental plane along the intersegmental vein. Before the operation, three-dimensional pulmonary vasculature images were obtained for each patient, and the arteries and intersegmental veins of the affected segments were identified. Two thoracic surgeons independently assessed the vessels with visual scoring systems, and kappa analysis was used to determine interobserver agreement. The Wilcoxon signed-rank test was used to compare the visual scores for the assessment of the visualization capabilities of the two methods. In addition, the final determination of pulmonary vasculature at a given site was made by consensus from thoracic surgeons during operation, and receiver operating characteristic analysis was performed to compare their efficacy of pulmonary vasculature assessment. Sensitivity, specificity and accuracy of either method were also compared by means of McNemar's test. RESULTS: Of the 32 cases, there were no operative complications, but 1 patient died of postoperative idiopathic interstitial pneumonia. Visualization scores for the pulmonary vessels were significantly higher for 320- than those for 64-detector CT (P < 0.0001 for the affected arteries and P < 0.0001 for the intersegmental veins). As for pulmonary vasculature assessment, the areas under the curve showed no statistically significant differences in between the two methods, while the specificity and accuracy of intersegemental vein assessment were significantly better for 320- than those for 64-detector row CT (P < 0.05). Interobserver agreement for the assessment yielded by either method was almost perfect for all cases. CONCLUSIONS: Three hundred and twenty-detector row CT is more useful than conventional 64-detector row CT for preoperative three-dimensional assessment of pulmonary vasculature, especially when we identify the intersegmental veins, in candidates for pulmonary segmentectomy.

The role of Necl-5 in the invasive activity of lung adenocarcinoma.

Nectin-like molecule-5 (Necl-5) is an immunoglobulin-like molecule that was originally identified as a poliovirus receptor and is often upregulated in cancer cells. It has been said that Necl-5 plays a role in not only cell-cell adhesion, but also cell migration, proliferation, and metastasis. In this study, we used a bronchioloalveolar carcinoma (BAC) cell line and fibroblasts to assess the expression of Necl-5 in the development of cancer-stroma communication by using an easy-to-prepare double-layered collagen gel hemisphere (DL-CGH) system that enables visualization of cell migration during invasion. The expression of Necl-5 was higher in BAC cells than in fibroblasts. This tendency didn't change even when the BAC cells were mixed with fibroblasts. To assess the role of Necl-5 in the invasive activity of the BAC cells, we knocked down its expression using RNA interference (RNAi). The invasion assay with DL-CGH revealed that inhibition of Necl-5 expression in the BAC cells was associated with suppressed invasiveness. In addition, Necl-5 knockdown inhibited the movement and proliferation of the BAC cells. Necl-5 expression in lung cancer cells is crucial for their invasiveness in the cancer-stromal interaction, suggesting that Necl-5 could be a favorable molecular target for the suppression of invasiveness in lung adenocarcinoma.

Significance of microscopic invasion into hilar peribronchovascular soft tissue in resection specimens of primary non-small cell lung cancer.

INTRODUCTION: The significance and handling of microscopic invasion of non-small cell lung cancer (NSCLC) into hilar peribronchovascular soft tissue (SHEATH+) have not been defined in the TNM classification by AJCC/UICC; nevertheless, SHEATH+ may be equivalent to spread into the mediastinum. Also, assessment of the margin of peribronchial resection is challenging because of the technical difficulty of inking, and intraoperative and postoperative artifacts. METHODS: Records of 592 consecutive Asian patients with primary NSCLC (excluding adenocarcinoma in situ) who had, without any preoperative therapy, undergone lobectomy, sleeve lobectomy and pneumonectomy were examined. SHEATH+, simply defined as invasion of hilar peribronchovascular soft tissue, without categorizing any invasive patterns, and its significance were statistically analyzed. RESULTS: Forty-four SHEATH+ cases demonstrated significantly advanced TNM stages, and were statistically associated with central occurrence, pN1-3, and vascular invasion, as assessed by logistic regression analysis. No statistically significant differences were observed between TNM stage-adjusted frequency of recurrence and recurrence-free intervals. Kaplan-Meier's estimates of the rate of overall and recurrence-free survival after surgery showed no statistically significant differences between SHEATH+ and SHEATH-. Cox's multivariate analysis suggested SHEATH was not a statistically independent prognostic factor under the TNM classification by AJCC/UICC (7th edition). CONCLUSIONS: SHEATH+ in NSCLC was simply associated with central occurrence and advanced TNM stages. To the best of our knowledge, this is the first report on the significance of SHEATH+ in NSCLC.

Associations among bronchioloalveolar carcinoma components, positron emission tomographic and computed tomographic findings, and malignant behavior in small lung adenocarcinomas.

OBJECTIVE: The aggressiveness of small adenocarcinomas has not been fully evaluated using integrated positron emission tomography/computed tomography. We investigated malignant aggressiveness according to positron emission tomography/computed tomography, high-resolution computed tomographic findings, and the proportions of pathologically defined bronchioloalveolar carcinomas in cT1N0M0 lung adenocarcinoma. METHODS: Sixty consecutive patients with cT1N0M0 lung adenocarcinomas of 3 cm or less in diameter underwent fluorodeoxyglucose-positron emission tomograph/computed tomography, and high-resolution computed tomography, followed by complete tumor resection. Correlations between the proportion of bronchioloalveolar carcinoma and maximum standardized uptake value on positron emission tomographic scan/computed tomographic scan, ground-glass opacity, and tumor shadow disappearance rate were investigated and the findings were compared with clinicopathologic features. RESULTS: Lymphatic and vascular invasion occurred in 18 (30%) and 13 (22%) patients, respectively, whereas hilar or mediastinal lymph nodes occurred in 8 patients (13%). Maximum standardized uptake value generally seemed the most valuable predictor of lymphatic invasion, vascular invasion, and nodal metastasis compared with ground-glass opacity, tumor shadow disappearance rate, and bronchioloalveolar carcinoma ratios. Although the association was significant between the bronchioloalveolar carcinoma ratio versus maximum standardized uptake value, ground-glass opacity ratio, and tumor shadow disappearance rate (all P < .0001), maximum standardized uptake value (R2 = 0.245) was less correlated with the bronchioloalveolar carcinoma ratio than was the ground-glass opacity ratio (R2 = 0.554) and tumor shadow disappearance rate (R2 = 0.671). CONCLUSIONS: The malignant behavior of small adenocarcinomas with a lower maximum standardized uptake value and a greater proportion of ground-glass opacity, tumor shadow disappearance rate, and bronchioloalveolar carcinoma was less aggressive. Maximum standardized uptake value was a more powerful clinical predictor of biologic tumor performance, independent of pathologic bronchioloalveolar carcinoma proportion. Preoperative assessment of maximum standardized uptake value on positron emission tomographic/computed tomographic findings, in addition to the ground-glass opacity ratio and tumor shadow disappearance rate on high-resolution computed tomographic scans, might be useful to guide treatment strategies for small adenocarcinomas.