Anesthetic and analgesic techniques and perioperative inflammation may affect the timing of recurrence after complete resection for non-small-cell lung cancer.

Introduction: It has been widely recognized that both surgery and anesthesia may increase the risk of cancer recurrence by inducing an inflammatory response and immunosuppression in various cancer operations. The present study explored using hazard curves how anesthetic and analgesic techniques regarding the host inflammation status affect the risk of recurrence over time in patients with non-small-cell lung cancer (NSCLC). Material and Methods: Clinicopathological data from patients who underwent complete pulmonary resection with pathological I-IIIB stage NSCLC from 2010 to 2020 were collected. The inflammation-based scores, including the C-reactive protein-to-albumin ratio (CAR), systemic immune-inflammation index (SII), Glasgow prognostic score (GPS), and modified GPS (mGPS), were calculated before surgery, and hazard curves indicating the changes in hazards over time were evaluated. Results: A total of 396 patients were eligible for the analysis. The median follow-up was 42.3 months. In total, 118 patients (29.8%) experienced recurrence, and 66.9% of those occurred within 24 months after surgery. According to the multivariate Cox regression analysis, volatile anesthesia (VA) (hazard ratio [HR], 1.69; 95% confidence interval [CI], 1.05-2.71), and elevated CAR (HR, 1.88; 95% CI, 1.18-2.99) were associated with a worse recurrence-free survival. The resulting hazard curve revealed that a delayed peak of recurrence was present in patients with a low CAR in the VA group and in those with intravenous flurbiprofen axetil administration in the propofol-based total intravenous anesthesia group (30 and 24 months after surgery, respectively). Discussion: Choosing anesthetic and analgesic techniques while taking inflammation-based scores into account may be useful for reducing the risk of and/or delaying recurrence in patients undergoing resection for NSCLC.

Preoperative inflammation-based scores predict early recurrence after lung cancer resection.

BACKGROUND: Inflammation in the tumor microenvironment is hypothesized to have a major role in cancer invasiveness, progression, and metastases. The purpose of this study was to evaluate the prognostic value of preoperative inflammation-based scores in terms of estimating the timing of recurrence by hazard curves in a cohort of operable, early-stage non-small cell lung cancer (NSCLC) patients. METHODS: A total of 387 patients with NSCLC who underwent complete pulmonary resection from 2010 to 2019 had their C-reactive protein-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), Glasgow prognostic score (GPS), modified GPS, systemic immune-inflammation index (SII), and advance lung cancer inflammation index (ALI) measurements taken before surgery. Hazard curves indicating changes in hazards over time were evaluated. RESULTS: Median follow-up was 39.2 months. In total, 105 patients (27.1%) experienced recurrence. The resulting hazard curve with elevated CAR, SII, GPS, and mGPS, values displayed an initial high peak during the first year. Multivariate analyses showed that an elevated CAR [hazard ratio (HR), 1.987; 95% confidence interval (CI), 1.202-3.284] independently predicted the recurrence-free survival. Even in stage I disease, patients with elevated CAR and SII values showed an earlier peak of recurrence, which was about 12 to 16 months earlier than those with low values. CONCLUSIONS: Even after complete resection of stage I NSCLC, patients with elevated CAR and SII values retain a high risk of early recurrence. Preoperative inflammation-based scores can be an objective, simple, and cost-effective measurement for predicting early recurrence of NSCLC.

Unique pathological findings of lung adenocarcinoma after unexpected nivolumab treatment, possible different effects on the primary lesion and metastatic lymph nodes: case report.

A 69-year-old man was diagnosed with cT1aN2M0-stage IIIA lung adenocarcinoma. Chemoradiotherapy, the standard treatment for cN2, stage IIIA adenocarcinoma, was considered impossible due to his renal functional impairment. So surgery was the only radical treatment option and therefore planned. However, a preoperative chest computed tomography (CT) scan performed three months after the first scanning revealed apparent shrinking of the pulmonary nodule. We performed left upper lobectomy and mediastinal lymph node dissection. Pathologically, we confirmed no adenocarcinoma cells in the resected lung specimen. Alternatively, a foreign body granuloma composed of foamy macrophages and cholesterol clefts was observed among fibrous tissue, suggesting a trace of lost tumor after some treatment, whereas viable adenocarcinoma cells remained in the lymph nodes. Six weeks after surgery, the patient developed hypothyroidism as a side effect and confessed to having undergone a preoperative treatment with nivolumab 20 mg per body twice before surgery. Unexpected preoperative nivolumab treatment was effective only on the primary lesion possibly due to intratumoral heterogeneity or insufficient dosage. We present an extremely rare case with unique pathological findings of lung adenocarcinoma after unexpected preoperative nivolumab treatment that was followed by surgery. We histologically confirmed the tumor cells disappearing only at the primary site and remaining at the lymph node. This case report may provide a clue to the future development of induction therapy using nivolumab and surgery.

[Video-assisted Thoracoscopic Pericardial Fenestration for Pericardial Effusion in a Patient with Crow-Fukase Syndrome].

A 65-year-old woman was referred to our department with recurrent pericardial effusion. Her serum vascular endothelial growth factor was high, serum M-protein was positive, and nerve conduction velocity of extremities was decreased. Therefore, she was diagnosed with Crow-Fukase (polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes:POEMS) syndrome, which is characterized by the presence of plasma cell dyscrasia with them. We performed video-thoracoscopic pericardial fenestration with 4×4 cm window. The postoperative course was uneventful, and the pericardial effusion completely disappeared. Video-assisted thoracoscopic pericardial fenestration was a safe and effective treatment for recurrent pericardial effusion.

Prognostic Effect of Lymphovascular Invasion on TNM Staging in Stage I Non-Small-cell Lung Cancer.

INTRODUCTION: Lymphovascular invasion (LVI) is a known adverse prognostic factor for early-stage non-small-cell lung cancer (NSCLC). Nonetheless, the prognostic effect of LVI on TNM staging of stage I NSCLC remains inconclusive. We thus hypothesized that it might be better to upstage pathologic stage IA NSCLC with LVI to pathologic stage IB NSCLC. PATIENTS AND METHODS: Using a Cox proportional hazards model, we examined the effect of LVI on disease-specific survival (DSS) in stage IA versus stage IB disease in 660 consecutive patients with stage I NSCLC (598 with adenocarcinoma, 62 with squamous cell carcinoma) who had undergone complete resection. RESULTS: On univariable analysis of stage IA cases, vascular invasion (VI) was significantly associated with inferior DSS (univariable hazard ratio [HR], 3.39; 95% confidence interval [CI], 1.46-7.89; P = .005). In contrast, lymphatic invasion exhibited a tendency toward inferior DSS (univariable HR, 2.90; 95% CI, 0.97-8.66; P = .056). Multivariable analysis of DSS in stage IA cases identified VI as an independent significant prognostic factor (multivariable HR, 2.86; 95% CI, 1.58-5.18; P = .007). With VI, DSS was significantly poorer for stage IB than for stage IA patients without VI (univariable HR, 3.44; 95% CI, 1.67-7.09; P < .001). In contrast, no difference was observed between patients with stage IA and VI and stage IB patients (P = .97). CONCLUSION: The presence of VI independently and significantly affects DSS in patients with stage IA NSCLC. We found that stage IA with VI and stage IB disease had equivalent prognostic outcomes. Our results suggest that stage IA with VI should be upstaged to IB in the TNM classification of NSCLC.

Pulmonary chondromatous hamartoma with pleural dissemination: report of a case.

We herein describe a very rare case of pulmonary hamartoma with pleural dissemination. A 77-year-old male was referred to our department for a further investigation of an abnormal chest radiograph. Chest computed tomography showed a 15 mm nodule in the left lung with small pleural nodules. Thoracoscopic resection of the nodules was performed, as the possibility of malignancy could not be ruled out. The intraoperative findings revealed a white nodule with a lumpy surface in the left lower lobe that had penetrated the visceral pleura. Several smaller nodules were found on the pleural surface. Pathologically, the pulmonary and pleural nodules were chondromatous hamartomas.

Spontaneous bilateral pneumothorax resulting from iatrogenic buffalo chest after the nuss procedure.

We describe a case of iatrogenic buffalo chest resulting in spontaneous bilateral pneumothorax in a 14-year-old boy with pectus excavatum in the late postoperative period after the Nuss procedure. The patient presented with a sudden onset of dyspnea 2 months after the Nuss procedure, and a chest roentgenogram showed a bilateral pneumothorax. We performed an emergency operation and found a communication between the chest cavities and a ruptured bulla in the left lung. This case highlights the potential development of simultaneous bilateral pneumothorax caused by a communication between the chest cavities after the Nuss procedure.

Metal allergy to titanium bars after the Nuss procedure for pectus excavatum.

The Nuss procedure requires the placement of metal bars in the chest cage to repair pectus excavatum. Metal allergies are one of the complications associated with this procedure. Given that titanium is a biocompatible metal, it induces few allergic symptoms. Therefore, titanium bars are recommended for patients with metal sensitivity. We report the case of a 17-year-old boy with pectus excavatum who had a metal allergy to titanium bars, which occurred after the Nuss procedure. The administration of oral steroids is useful for treating metal allergies. Metal allergies to titanium bars are very rare; however, they can still occur.