Non-small cell lung cancer with pathological complete response: predictive factors and surgical outcomes.

OBJECTIVES: When induction therapy followed by surgery for locally advanced non-small cell lung cancer results in pathological complete response, the prognosis is excellent; however, relapses can occur. We analyzed the predictive factors for achieving pathological complete response and reviewed the clinicopathological features and surgical outcomes of locally advanced non-small cell lung cancer with pathological complete response. METHODS: Between March 2005 and January 2015, 145 resections after induction therapy for locally advanced non-small cell lung cancer were performed; 38 cases achieved pathological complete response. Predictive factors for achieving pathological complete response were analyzed, and the clinicopathological features and surgical outcomes of 38 cases with pathological complete response were retrospectively reviewed. RESULTS: Of 145 patients, 98 underwent induction chemoradiation and 47, induction chemotherapy. Squamous cell carcinoma occurred most frequently (n = 64), followed by adenocarcinoma (n = 53). Only squamous cell carcinoma was positively associated with achieving pathological complete response (p = 0.009). Of 38 patients with pathological complete response, 33 were men and the mean age was 67.0 ± 6.3 years; the clinical stages were IIA (n = 3), IIB (n = 2), IIIA (n = 26), and IIIB (n = 3). One patient died within 30 days post-surgery (2.6%). Eight recurrences occurred during the follow-up period; brain metastasis occurred most frequently. The 5-year overall and recurrence-free survival rates were 79.5% and 72.6%, respectively. CONCLUSIONS: Squamous cell carcinoma was identified as a positive predictive factor for achieving pathological complete response. Among patients undergoing lung cancer surgery after induction therapy with pathological complete response, brain metastasis occurred most frequently.

Comparing Part-Solid and Pure-Solid Tumors in the TNM Classification of Lung Cancer (Eighth Edition).

BACKGROUND: In the eighth edition of the TNM classification, the lung tumors that have the same solid components are categorized either as part-solid or pure-solid tumors. However, this is debatable since the tumors in the same T component categories were evaluated without considering this categorization, and was based on a more malignant behavior and a poorer prognosis of pure-solid tumors. The aim of this study was to investigate and compare the prognosis between part-solid and pure-solid tumors. METHODS: We retrospectively analyzed 530 patients who were diagnosed with clinical-T1a-cN0M0 non-small-cell lung cancer (NSCLC) and were treated surgically. The subjects were divided into part-solid and pure-solid tumor groups using thin-section computed tomography. The prognosis was compared between the groups. RESULTS: Although relapse-free survival (RFS) was significantly shorter in the pure-solid tumor group (p = 0.016), no significant differences were observed in the overall survival (OS) between the two groups (p = 0.247). In 137 propensity score-matched pairs, including variables such as age, gender, Brinkman index, body mass index, forced expiratory volume in 1 second/forced vital capacity, Charlson comorbidity index, carcinoembryonic antigen levels, clinical-T status, surgical procedure, and extent of surgery, no significant differences were seen in the RFS and OS between the two groups (p = 0.709 and p = 0.517, respectively). CONCLUSION: In the eighth edition of the TNM classification of clinical-T1a-cN0M0 NSCLC, the prognosis of part-solid and pure-solid tumors showed no significant differences. Solid component size of the tumor is considered important prognostic factor in early-stage NSCLC.

[Induction Chemoradiotherapy Followed by Surgery in Non-small-cell Lung Cancer;a Retrospective Study].

OBJECTIVE: The aim of this study is to investigate the outcomes of induction chemoradiotherapy (ICRT) followed by surgery in patients with non-small cell lung cancer( NSCLC). METHODS: We retrospectively analyzed consecutive patients with NSCLC who underwent ICRT followed by surgery at our hospital between January 2006 and December 2015. RESULTS: A total of 102 patients were eligible for evaluation (cStage/I B/II A/II B/III A/III B, 1/8/14/75/4). The median age was 66 years. Forty-one patients had adenocarcinoma, 42 patients had squamous cell carcinoma, and 19 patients had others. The regimen consisted of carboplatin and paclitaxel in 94 patients, and the others in 8 patients plus concurrent radiation at a dose of 28 Gy in 1 patient, 30 Gy in 28 patients, 40 Gy in 42 patients, 45 Gy in 3 patients, and 50 Gy in 28 patients. Major response was obtained in 84 patients. Grade 3/4 toxicity of ICRT reported in 57 patients. The 5-year relapse-free and overall survival rate was 51.4% and 62.7%, respectively. CONCLUSION: ICRT (carboplatin and paclitaxel plus concurrent standard radiation) followed by surgery in NSCLC can be safely performed and may contribute to satisfactory outcomes in locally advanced NSCLC. It is likely that 28~50 Gy radiation dose contributes to satisfactory outcomes in ICRT.

Surgical outcomes and complications of pneumonectomy after induction therapy for non-small cell lung cancer.

OBJECTIVES: Although surgical resection after induction therapy (IT) for locally advanced non-small cell lung cancer (NSCLC) is a possible treatment option, pneumonectomy may be avoided owing to high-surgical risks. However, reports exist that pneumonectomy after IT has acceptable safety and favorable outcomes. We reviewed pneumonectomies after IT in terms of surgical outcomes, perioperative management, and complications. METHODS: Between April 2004 and March 2015, 15 consecutive pneumonectomies were performed for locally advanced NSCLC after IT. Surgical outcomes, perioperative management, and complications were retrospectively reviewed. RESULTS: Thirteen patients were men, and 6 pneumonectomies were right-sided. One pneumonectomy was performed after induction chemotherapy and 14 followed induction chemoradiation. In all 15 cases the bronchial stumps were covered with autologous tissues. Pedunculated mediastinal fat pad and pedunculated intercostal muscles were used in 4 and 11 cases, respectively. Although postoperative complications were seen in 12 patients (80.0%), with major complications (Clavien-Dindo classification ≥ IIIa) in 5 patients (33.3%), there were no deaths within 30 days after pneumonectomy. Overall 3- and 5-year survivals were 80.0 and 57.1%, respectively. CONCLUSIONS: Owing to high-surgical risks and complication rates, careful surgical technique and postoperative management are essential for successful pneumonectomy after IT.

Surgery for Intralobar Pulmonary Sequestration Using Indocyanine Green Fluorescence Navigation: A Case Report.

A 38-year-old man with bilateral Pryce III intralobar sequestration was admitted. At first, left lower lobectomy and division of the aberrant artery were performed because of continuous hemoptysis after admission. Two months later, we planned a video-assisted thoracoscopic wedge resection of the right sequestration and a division of the 2 aberrant arteries. We chose indocyanine green fluorescence navigation because of the small volume of the right sequestration, with a goal to reduce respiratory functional loss as much as possible. After the aberrant arteries and the small pulmonary vein of the sequestration were transected, the boundary of the sequestration was observed clearly using infrared thoracoscopy. In patients with a small sequestration with recurrent episodes of infections and low respiratory function, indocyanine green fluorescence navigational technique is considered useful.

Right extrapleural completion pneumonectomy for fibrocavitary nontuberculous mycobacterial lung disease.

We report a case of a 76-year-old man with fibrocavitary nontuberculous mycobacterial (FC-NTM) lung disease, who was successfully treated with right extrapleural completion pneumonectomy. Right extrapleural completion pneumonectomy with careful coverage of the bronchial stump might be effective in patients with FC-NTM lung disease.

Stapler-Based Thoracoscopic Basilar Segmentectomy.

Thoracoscopic S9-10 segmentectomy is more difficult than other segmentectomies because of the complexity of the peripheral pulmonary anatomies and the difficulty of dividing the intersegmental plane. In S9-10 segmentectomy, the intersegmental plane between segments S6 and S8 near the major fissure impedes division of the plane between segments S6 and S9-10, or S8 and S9-10. Dividing the intersegmental plane between segments S6 and S8 with stapling is difficult, because peripheral pulmonary anatomies are not exposed clearly. Herein, we describe the technique of stapler-based thoracoscopic S9-10 segmentectomy under indocyanine green fluorescence navigation.

Adjuvant chemotherapy for elderly patients with non-small-cell lung cancer.

Background Adjuvant chemotherapy after complete surgical resection is currently the standard of care for patients with stage IB, II, or IIIA non-small-cell lung cancer. However, the generalizability of this treatment to elderly patients is controversial. We investigated the effects of adjuvant chemotherapy in patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer. Methods We retrospectively analyzed 246 consecutive patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer who underwent standard lung cancer surgery between January 2001 and December 2015. They were divided into 102 who had adjuvant chemotherapy and 144 who had none (control group). The outcomes were compared between the two groups, and prognostic factors were evaluated. Results Relapse-free survival and overall survival were significantly shorter in the control group than the chemotherapy group ( p = 0.006 and p = 0.008, respectively). In multivariable analyses, adjuvant chemotherapy was found to be an independent prognostic factor for relapse-free survival and overall survival (hazard ratio = 0.594, 95% confidence interval: 0.396-0.893, p = 0.012; and hazard ratio = 0.616, 95% confidence interval: 0.397-0.957, p = 0.031, respectively). After inverse-probability-of-treatment weighting adjustment using the propensity score for baseline characteristics, chemotherapy almost improved relapse-free survival and overall survival (hazard ratio = 0.652, 95% confidence interval: 0.433-0.981, p = 0.040; and hazard ratio = 0.657, 95% confidence interval: 0.429-1.004, p = 0.052, respectively). Conclusions Adjuvant chemotherapy improved the prognosis after standard lung cancer surgery in patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer.

Surgical and survival outcomes of lung cancer patients with intratumoral lung abscesses.

BACKGROUND: Intratumoral lung abscess is a secondary lung abscess that is considered to be fatal. Therefore, surgical procedures, although high-risk, have sometimes been performed for intratumoral lung abscesses. However, no studies have examined the surgical outcomes of non-small cell lung cancer patients with intratumoral lung abscesses. The aim of this study was to investigate the surgical and survival outcomes of non-small cell lung cancer patients with intratumoral lung abscesses. METHODS: Eleven consecutive non-small cell lung cancer patients with intratumoral lung abscesses, who had undergone pulmonary resection at our institution between January 2007 and December 2015, were retrospectively analysed. The post-operative prognoses were investigated and prognostic factors were evaluated. RESULTS: Ten of 11 patients were male and one patient was female. The median age was 64 (range, 52-80) years. Histopathologically, 4 patients had Stage IIA, 2 patients had Stage IIB, 2 patients had Stage IIIA, and 3 patients had Stage IV tumors. The median operative time was 346 min and the median amount of bleeding was 1327 mL. The post-operative morbidity and mortality rates were 63.6% and 0.0%, respectively. Recurrence of respiratory infections, including lung abscesses, was not observed in all patients. The median post-operative observation period was 16.1 (range, 1.3-114.5) months. The 5-year overall survival rate was 43.3%. No pre-operative, intra-operative, or post-operative prognostic factors were identified in the univariate analyses. CONCLUSION: Surgical procedures for advanced-stage non-small cell lung cancer patients with intratumoral lung abscesses, although high-risk, led to satisfactory post-operative mortality rates and acceptable prognoses.

Comparison of the outcomes of stereotactic body radiotherapy and surgery in elderly patients with cT1-2N0M0 non-small cell lung cancer.

BACKGROUND: This study aimed to compare the outcomes of stereotactic body radiotherapy (SBRT) and surgery in elderly patients with cT1-2N0M0 non-small cell lung cancer (NSCLC). METHODS: Elderly patients (≥75 years) with cT1-2 (≤5 cm) N0M0 NSCLC who were treated with SBRT (n=35) or surgery (n=183) between January 2001 and December 2011 were analyzed. RESULTS: The following radiation doses were administered: 48 Gy/4-6 fractions in 12 patients; 50 Gy/4-5 fractions in 20; and 60 Gy/8 fractions in 3. The following surgical methods were performed: pneumonectomy in 2 patients, lobectomy in 154, segmentectomy in 23, and wedge resection in 4. Patients in the SBRT group had a higher mean age, a worse performance status, and a lower percentage of forced expiratory volume in 1.0 s than those in the surgery group. The overall 5-year survival rates were 43.8% and 67.6% for the SBRT and surgery groups, respectively (p=0.057, log-rank test). Regarding tumor diameter, patients in the surgery group survived significantly longer than did those in the SBRT group (>20-mm tumors, p=0.027; >30-mm tumors p=0.043), whereas survival did not differ significantly between the groups for ≤20-mm tumors (p=0.982). Multivariate analysis confirmed the improved survival in the surgery group compared to the SBRT group for all tumors (p=0.034) and for >20-mm tumors (p=0.016). CONCLUSIONS: Post-therapeutic survival among elderly patients might be better with surgery than with SBRT in NSCLC patients with tumors >20 mm.

Spontaneous whole-lung torsion after massive pleural effusion and atelectasis.

We present a case of whole-lung torsion after massive pleural effusion and atelectasis. A 79-year-old woman with a history of recent pneumonia and pleurisy presented to our hospital and complained of left leg edema and pain that was considered to be vasculitis. A sagittal computed tomography (CT) scan showed that her whole right lung had a 120-degree counterclockwise torsion toward the hilum. We obtained and compared a CT image from the previous doctor. By comparing the CT scans, we determined that lung torsion had progressed gradually. To our knowledge, this is the first report that confirms the progress of whole-lung torsion with CT images.

[Plication of diaphragm for eventration of diaphragm caused by megacolon; report of a case].

A 70-year-old woman with severe respiratory distress was admitted to our hospital by ambulance. Chest X-ray revealed marked elevation of left diaphragm and invagination of megacolon. Colectomy was performed to improve the respiratory distress, but continuous mechanical ventilation was necessary after operation due to hypoxia and hypercapnea. Therefore, plication of diaphragm was additionally performed. With 10 rows of nonabsorbable sutures, 6 to 8 pleats were formed. The following day of operation, she was successfully relieved from the ventilator.

Teratoma with naturally occurring malignant transformation in a child.

We present a 12-year-old girl with a teratoma with malignant transformation (TMT) of the mediastinum. Computed tomography showed a cystic mass (5.0 cm × 4.0 cm) with a thick solid portion, in the anterior mediastinum. Six months later, the solid portion of the mass had enlarged, and surgical resection was performed. The resected tumor was 7.0 × 5.0 × 4.0 cm in size. The cystic portion was a mature teratoma, and the solid portion predominantly comprised a viable embryonal rhabdomyosarcoma. There were no immature teratomatous elements or other germ-cell components. The histopathologic diagnosis was a mature teratoma with embryonal rhabdomyosarcoma, a so-called TMT. The tumor recurred, despite adjuvant chemotherapy. The patient died of progressive disease 16 months postoperatively. To the best of our knowledge, no naturally occurring TMT of the mediastinum has previously been reported in a child. Surgical resection at an early stage is necessary.

Localized malignant pleural mesothelioma showing a thoracic mass and metastasizing to the stomach.

Malignant mesothelioma typically shows either diffuse tumors or multiple pleura-based nodules. Localized malignant mesothelioma is rare. In this case report, a 70-year-old man with left chest wall tumor underwent tumor resection, and the lesion was pathologically diagnosed as biphasic malignant mesothelioma. Tumor recurrence was detected in the stomach due to vomiting of blood, and also spread to the mediastinal lymph node, and bone 3 months postoperatively. Total gastrectomy was performed and the histopathological diagnosis of metastasis of mesothelioma was made. In the previously reported cases, all of the localized malignant mesothelioma arose in the pleural space and there was no metastasis of localized malignant mesothelioma to the stomach. In the present case, gross and histological examinations were performed for both the primary lesion and gastric metastatic tumor. Though it was very difficult to distinguish mesothelioma from sarcoma and other chest wall tumors, immunochemical staining was able to facilitate making the diagnosis. This case suggests that localized malignant mesothelioma is capable of showing multiple forms and a variety of clinical courses. Localized malignant mesothelioma can arise primarily from the chest wall.

Surgical treatment for non-small cell lung cancer in octogenarians--the usefulness of video-assisted thoracic surgery.

The purpose of this study was to investigate whether surgical treatment for non-small cell lung cancer (NSCLC) confers a survival benefit in octogenarians, and whether video-assisted thoracic surgery (VATS) is effective in terms of postoperative morbidity, mortality, and quality of life (QOL). Among 1684 patients with primary NSCLC who underwent pathologically complete resection, 95 were octogenarians. Operation was performed by the VATS approach (VATS group, n=58) or the standard thoracotomy (ST group, n=37). Although postoperative cardiopulmonary complications occurred in 20 cases (21.1%), all were manageable. In the ST group cardiopulmonary complications occurred more frequently than in the VATS group (P=0.030). The overall 5-year survival rate of the 95 octogenarians, including deaths from all causes, was 54.4%. The overall 5-year survival rate of patients with stage IA disease was 65.2%. These outcome data were not significantly worse than those for patients aged 79 years or under (P=0.136). There was no significant difference in overall 5-year survival rates between the ST group and the VATS group (P=0.144). The VATS approach for pulmonary resection is recommended for octogenarians with NSCLC. Surgical resection is the optimal treatment for stage IA NSCLC, and therefore, advanced age is not a contraindication for curative resection.

Evaluation of the new TNM staging system proposed by the International Association for the Study of Lung Cancer at a single institution.

OBJECTIVE: The seventh TNM Classification of Malignant Tumours will be published in 2009. The International Association for the Study of Lung Cancer has proposed a revision of the current pathologic staging system. We illustrated the effects of this new system and pointed out potential problems using a retrospective study of surgical cases of non-small cell lung cancer at our institution. METHODS: Subjects were 1532 patients for whom current pathologic staging was possible. These data were migrated into the new staging system. The numbers of patients at various stages determined by using the current and new staging systems were, respectively, as follows: IA (n = 700, n = 700), IB (n = 338, n = 249), IIA (n = 49, n = 164), IIB (n = 129, n = 116), IIIA (n = 204, n = 234), IIIB (n = 77, n = 17), and IV (n = 35, n = 52). Prognoses were compared by using the current and the new systems. RESULTS: By using the new staging system, 5-year survivals by T classifications were as follows: T1a, 82.6%; T1b, 73.3%; T2a, 63.5%; T2b, 50.1%; T3, 40.6%; and T4, 34.6%. There were significant differences between the new T1a and T1b (P = .0026), T1b and T2a (P = .0027), and T2a and T2b (P = .0062) classifications. In the current system 5-year survivals based on pathologic stages were as follows: IA, 84.8%; IB, 72.9%; IIA, 53.8%; IIB, 53.7%; IIIA, 31.8%; IIIB, 34.0%; and IV, 27.1%. There were significant differences between stages IA and IB (P < .0001) and stages IIB and IIIA (P = .0006). In the new system these were as follows: IA, 84.8%; IB, 75.2%; IIA, 62.4%; IIB, 52.1%; IIIA, 32.4%; IIIB, 15.2%; and IV, 30.6%. There were significant differences between stages IA and IB (P = .0004), IB and IIA (P = .0195), IIA and IIB (P = .0257), IIB and IIIA (P = .0040), and IIIA and IIIB (P = .0399). CONCLUSION: Although the outcomes for stages IIIB and IV were reversed, the new pathologic staging system was considered valid based on our single-institution evaluation.

Rapidly expanding extrapleural hematoma.

We present a rare case of extrapleural hematoma due to chest trauma in an anticoagulated male patient. Chest computed tomography revealed multiple left rib fractures and a D-shaped opacity in the upper left side of the thorax suggesting extrapleural hematoma, which was caused from continuous bleeding. His past history included alcoholic liver cirrhosis, which caused thrombocytopenia and coagulopathy. Therefore, the hematoma was expanding, causing circulatory and ventilatory disturbance and severe anemia despite the difficulty of expanding in the extrapleural space. As the bleeding did not stop, even after intercostal artery angiography with embolization was performed, surgical treatment was undertaken to control the bleeding and evacuate the huge hematoma. The problems associated with the diagnosis and treatment of an extrapleural hematoma are discussed in the light of this case.

Postrecurrence survival in patients with stage I non-small cell lung cancer.

OBJECTIVE: Postoperative recurrence is a major obstacle to achieving a cure and long-term survival in patients with non-small lung cancer. However, prognostic factors and the efficacy of therapy after recurrence remain controversial. We evaluated the clinical outcomes of patients with resected lung cancer for postrecurrence prognostic factors. METHODS: Patients who underwent complete resection with systematic lymph node dissection for stage I non-small cell lung cancer were selected. Cases of low-grade malignancy, preoperative therapy, history of previous malignancy or death within 30 days of operation were excluded. A total of 397 patients were retrospectively reviewed. RESULTS: Out of 87 patients who had recurrence after surgery, 45 had symptoms at the initial recurrence. The initial recurrent site was local in 30 patients and distant in 57. Single-site recurrence was detected in 48 patients and multiple-site recurrence was seen in 39. The recurrent site was the ipsilateral thorax in 49 patients, the contralateral thorax in 32, the cervico-mediastinum in 15, brain in 12 and bone in 11. Surgery was performed in 20 patients, whereas non-surgical therapy was performed in 55 (chemotherapy, 16; radiation therapy, 33; chemo-radiation therapy, 6). Prognostic analysis of factors related to recurrent status demonstrated that symptoms at the initial recurrence, cervico-mediastinal metastasis, liver metastasis and postrecurrence therapy were significant prognostic factors in both univariate and multivariate analysis. CONCLUSIONS: Symptoms at the initial recurrence, cervico-mediastinal metastasis and liver metastasis were worse prognostic factors after recurrence. Postrecurrence therapy for the initial recurrence may prolong survival after recurrence.

Pediculate mucinous cystadenoma difficult to differentiate from pleural tumor.

We present a case of benign pediculate mucinous cystadenoma in a 60-year-old man. The tumor, which was connected with the lung parenchyma, was difficult to distinguish from a pleural tumor radiographically. Initially, computed tomographic-guided needle aspiration biopsy was performed to confirm the diagnosis, but this was unsuccessful. Therefore, surgical resection was performed to diagnose and treat the tumor, and pathologic examination of the specimen revealed mucinous cystadenoma. The problems associated with the diagnosis and treatment of pediculate mucinous cystadenoma are discussed in light of this case.

Solitary fibrous tumor of the pleura with a minute malignant component and diaphragmatic vascular supply: report of a case.

We resected a fist-sized, solitary fibrous tumor of the pleura (SFTP) with a minute malignant component, following percutaneous embolization of its feeding artery. The tumor had macroscopic characteristics of a benign SFTP, and most parts of it were microscopically benign. However, further careful pathological examination revealed a minute malignant component in its periphery. We report this case to show that large and mostly benign SFTPs may contain malignant components, which can be overlooked. Thus, large SFTPs should be resected in consideration of this possibility.