Randomized Phase III Study of Pemetrexed Plus Cisplatin Versus Vinorelbine Plus Cisplatin for Completely Resected Stage II to IIIA Nonsquamous Non-Small-Cell Lung Cancer.

PURPOSE: To evaluate the efficacy of pemetrexed plus cisplatin versus vinorelbine plus cisplatin as postoperative adjuvant chemotherapy in patients with pathologic stage II-IIIA nonsquamous non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: We performed a randomized, open-label, phase III study at 50 institutions within 7 clinical study groups in Japan. Patients with completely resected pathologic stage II-IIIA (TNM 7th edition) nonsquamous NSCLC were randomly assigned to receive either pemetrexed (500 mg/m2, day 1) plus cisplatin (75 mg/m2, day 1) or vinorelbine (25 mg/m2, days 1 and 8) plus cisplatin (80 mg/m2, day 1) with stratification by sex, age, pathologic stage, EGFR mutation, and institution. These treatments were planned to be given every 3 weeks for 4 cycles. The primary end point was recurrence-free survival in the modified intent-to-treat population, excluding ineligible patients. RESULT: Between March 2012 and August 2016, 804 patients were enrolled (402 assigned to vinorelbine plus cisplatin and 402 assigned to pemetrexed plus cisplatin). Of 784 eligible patients, 410 (52%) had stage IIIA disease and 192 (24%) had EGFR-sensitive mutations. At a median follow-up of 45.2 months, median recurrence-free survival was 37.3 months for vinorelbine plus cisplatin and 38.9 months for pemetrexed plus cisplatin, with a hazard ratio of 0.98 (95% CI, 0.81 to 1.20; 1-sided P = .474). Grade 3-4 toxicities reported more frequently for vinorelbine plus cisplatin than for pemetrexed plus cisplatin were febrile neutropenia (11.6% v 0.3%, respectively), neutropenia (81.1% v 22.7%, respectively), and anemia (9.3% v 2.8%, respectively). One treatment-related death occurred in each arm. CONCLUSION: Although this study failed to show the superiority of pemetrexed plus cisplatin for patients with resected nonsquamous NSCLC, this regimen showed a better tolerability as adjuvant chemotherapy.

Optimal sublobar resection for c-stage I non-small cell lung cancer: significance of margin distance to tumor size ratio and margin cytology (Supplementary analysis of KLSG-0801): complete republication.

BACKGROUND: Sublobar resection for lung cancer is associated with a higher risk of recurrence than that of lobectomy; we evaluated the factors considered to be predictors of recurrence. METHODS: By analyzing multicenter prospective studies of sublobar resection for patients with c-stage I non-small lung cancer who were unable to undergo lobectomy (KLSG-0801), we investigated the relationship between (1) tumor location (TL) and margin distance from the stump (MD), (2) the MD/tumor size (TS) ratio and prognosis, (3) and the margin cytology (MC) and prognosis. RESULTS: The correlation between TS and MD was statistically significant in cases of easily resectable regions defined by Lewis' classification (n = 18). However, there was no correlation in difficult-to-resect regions (n = 14). Among cases of recurrence, the MD/TS ratio was less than 1. The 3-year survival rate was 100% for patients with MD/TS > 1 (n = 12), 59.7% for patients with MD/TS ≤ 1 (n = 20) (p = 0.06), 88.1% in cases of negative MC (n = 18), and 20% in cases of positive MC (n = 5) (p = 0.001). CONCLUSION: Cases with positive MC had a significantly worse prognosis than those with negative MC. It may be difficult to secure an MD greater than the TS in a difficult-to-resect region according to Lewis' classification.

Postoperative empyema following lung cancer surgery.

Postoperative empyema following lung cancer surgery is a serious complication. Occurrence rate of postoperative empyema following lung cancer surgery, patient background, surgical procedures, date of empyema onset, treatment, and prognosis of 4772 patients who underwent lung cancer surgery between 2008 and 2012 were investigated. Postoperative empyema following lung cancer surgery was found in 43 patients (0.9%). The occurrence rate of postoperative empyema was significantly higher in patients with the following factors: male gender, extended surgery such as pneumonectomy, bi-lobectomy and thoracotomy, squamous cell carcinoma, and an advanced pathologic stage of II and above. Chest drainage, video-assisted thoracic surgery debridement, fenestration, and thoracoplasy were performed, where 29 patients were cured (67.5%) and 5 patients (11.6%) died from thoracic empyema-related complications. Nine patients were not cured and died due to cancer or other diseases during treatment. When comparing cured and non-cured patients, it is indicated that squamous cell carcinoma, administration of steroids, history of interstitial pneumonia, presence of bronchial stump fistula, exacerbation of interstitial pneumonia and presence of non-fermenting Gram-negative bacilli led to a significantly low prognosis. The five-year overall survival rate was 34.9%.

Overall Survival Results of the Feasibility Study of Adjuvant Chemotherapy With Docetaxel Plus Cisplatin Followed by Long-term Single-agent Administration of S-1 in Patients With Completely Resected Non-Small Cell Lung Cancer: Thoracic Oncology Research Group (TORG) 0809.

OBJECTIVES: The TORG0809 study was a multicenter feasibility study of long-term single-agent therapy with S-1 after docetaxel plus cisplatin therapy in patients with completely resected stage II or stage IIIA non-small cell lung cancer. We report the results of the final overall survival (OS) analysis. PATIENTS AND METHODS: A total of 129 eligible patients received 3 cycles of docetaxel (60 mg/m, day 1) plus cisplatin (80 mg/m, day 1), followed by S-1 at 40 mg/m twice daily for 14 consecutive days, for >6 months (maximum, 1 y). RESULTS: At the cutoff date of April 13, 2016, the median follow-up time was 6.0 years. Of the 129 patients, 43 had died, and 74 patients developed disease recurrence or died. The median OS had not been reached. The 5-year OS rate was 71% [95% confidence interval (CI), 62-78]. The 5-year OS rates in the patients with stage II and stage IIIA were 76% and 68%, respectively. The median recurrence-free survival (RFS) duration was 3.4 years (95% CI, 2.3-5.7). The 5-year RFS rate was 44% (95% CI, 36-53). The 5-year RFS rates in patients with stage II and stage IIIA disease were 57% and 38%, respectively. Disease recurrence occurred in 68 patients, and 62 of these patients received second-line chemotherapy. The most common sites of recurrence were the brain (n=22) and mediastinal lymph nodes (n=22). CONCLUSION: The survival data obtained from this study are promising and comparable to those reported from a previous study conducted in Japan.

Surgical Outcome and Prognostic Stratification for Pulmonary Metastasis From Colorectal Cancer.

BACKGROUND: This study investigated recent clinical outcomes and prognostic factors of metastasectomy for pulmonary metastasis (PM) from colorectal cancer. METHODS: Data for 785 patients with PM from colorectal cancer who underwent curative resection, including 376 patients treated with postmetastasectomy adjuvant chemotherapy, between 2004 and 2008, were collected from 46 Japanese hospitals. Disease-free and overall survival was analyzed. Potential prognostic factors were assessed. RESULTS: The 5-year disease-free and overall survival rates (95% confidence interval) of all patients were 37.1% (33.7% to 40.9%) and 68.1% (64.6% to 71.8%), respectively, over a median follow-up of 65 months. On multivariable analysis, no survival benefit for postmetastasectomy adjuvant chemotherapy was observed (hazard ratio, 0.85; 95% confidence interval, 0.65 to 1.12; p = 0.25), and the independent poor prognostic factors for overall survival (hazard ratio, 95% confidence interval) were age 70 years and older (1.50, 1.15 to 1.97), disease-free interval of less than 2 years (1.76, 1.31 to 2.35), extrathoracic metastatic lesion treated curatively before PM resection (1.35, 1.01 to 1.79), abnormal carcinoembryonic antigen level (1.99, 1.53 to 2.58), and three or more PMs (1.72, 1.20 to 2.45). The 5-year overall survival rates (95% confidence interval) of the low-risk (no prognostic factor, n = 87), moderate-risk (1 to 2 factors, n = 539), and high-risk (≥3 factors, n = 159) groups were 89.4% (82.2% to 98.2%), 72.5% (68.3% to 76.8%), and 48.9% (41.7% to 57.3%), respectively. CONCLUSIONS: Metastasectomy of PM from colorectal cancer was associated with a favorable prognosis. Patients could be classified into three risk groups using five prognostic factors. This grouping may be useful for identifying an optimal treatment strategy according to risk in future studies.

Heterogeneity of Tumor Sizes in Multiple Pulmonary Metastases of Colorectal Cancer as a Prognostic Factor.

BACKGROUND: The number of metastatic lesions is closely correlated with prognosis in most cancers. The aim of this study was to clarify the relationship between individual heterogeneity of metastatic tumor sizes and prognosis in patients with multiple pulmonary metastasis of colorectal cancer who received surgical treatment. METHODS: Clinical data for patients who had pulmonary metastasis from colorectal cancer and underwent curative resection at 46 Japanese institutions between January 2004 and December 2008 were collected. Among 898 patients eligible considering these inclusion criteria, 247 patients had multiple metastases and were analyzed. A difference between the maximum and minimum tumor diameters (Dmax-min) on pathologic findings was used to evaluate size heterogeneity. RESULTS: The overall survival rate was 75% at 3 years and 58% at 5 years, with a median follow-up period of 65 months (range, 0 to 112). When Dmax-min of 5 mm was set as a cutoff value, overall survival was significantly different between small (≤5 mm, n = 95) and large (>5 mm, n = 152) tumor groups (5-year survival rates, 66.5% and 53.3%, respectively; log rank test, p = 0.025). Multivariate analysis using a Cox proportional hazards model revealed that disease-free interval from resection of primary lesion, serum carcinoembryonic antigen level, number of pulmonary metastases, and Dmax-min were independent prognostic factors. CONCLUSIONS: The heterogeneity of metastatic tumor sizes may be an indicator for prognosis in patients with multiple pulmonary metastases of colorectal cancer who underwent resection.

Does Repeated Lung Resection Provide Long-Term Survival for Recurrent Pulmonary Metastases of Colorectal Cancer? Results of a Retrospective Japanese Multicenter Study.

BACKGROUND: The purpose of this study was to clarify the long-term survival outcomes after repeated lung resection (RLR) of pulmonary metastases from colorectal cancer (PM-CRC) using data from a Japanese nationwide investigation. METHODS: Among 898 patients who underwent R0 resection of PM-CRC at 46 Japanese institutions between 2004 and 2008, we analyzed the data of 216 patients who experienced recurrence limited to the lung after initial resection of PM-CRC. Overall survival (OS) after RLR was analyzed, and prognostic factors were explored using a multivariate Cox analysis. RESULTS: Of a total 216 patients, 132 (61%) received RLR, and their 5-year OS rate was 75.3%. Twenty-two patients underwent a second RLR, and 2 patients underwent a third RLR; a favorable survival outcome was observed even after a second RLR (5-year OS rate, 55.1%). The prognostic factors associated with worse survival after RLR were concomitant liver metastasis, which had been completely resected or ablated at the initial lung metastasectomy (hazard ratio [HR], 4.84; 95% confidence interval [CI], 1.48-14.8) and location of the primary tumor in the rectum (HR, 3.16; 95% CI, 1.17-9.35). Patients without these 2 poor prognostic factors (n = 58) showed a 5-year OS rate of 82.6% after RLR. CONCLUSIONS: This nationwide database study showed that RLR for resectable lung-limited recurrence after PM-CRC resection could provide favorable survival, especially for patients with colon cancer without liver metastases at the initial PM-CRC resection.

Outcomes of segmentectomy and wedge resection for pulmonary metastases from colorectal cancer.

Objectives: Although wedge resection is the most common surgical procedure for pulmonary metastases from colorectal cancer, there are few reports about segmentectomy for colorectal metastasectomy. Methods: This was a subset analysis of a Japanese nationwide retrospective study of resected pulmonary metastases from colorectal cancer. The study included 553 patients who underwent segmentectomies ( n = 98) or wedge resections ( n = 455) without preoperative chemotherapy between January 2004 and December 2008. Recurrence patterns, recurrence-free survival and overall survival were analysed for each procedure. Results: As for the patients' background factors, only the median size of resected metastases was different between patients with segmentectomies (median 18 mm, range 5-50 mm) and wedge resections (14 mm, 5-51 mm) ( P < 0.001). Prolonged air leak developed more frequently in those undergoing segmentectomy compared with wedge resection (5.1% vs 1.8%) ( P = 0.048). The resection-margin recurrence rate was higher in patients who underwent wedge resection compared with segmentectomy (7.3% vs 2.0%; P = 0.035). The 5-year recurrence-free survival was 48.8% in patients with segmentectomy and 36.0% in patients with wedge resections. The 5-year overall survival was 80.1% in patients with segmentectomy and 68.5% in patients with wedge resection. Multivariable analysis revealed that the surgical procedure, segmentectomy, was a significant favourable factor for recurrence (hazard ratio: 0.63, 95% confidence interval: 0.44-0.87, P = 0.005), but not for overall survival (hazard ratio: 0.65, 95% confidence interval: 0.38-1.05, P = 0.080). Conclusions: Segmentectomy demonstrated a good efficacy with less resection-margin recurrence in patients with resectable pulmonary-limited metastasis from colorectal cancer.

Multicenter prospective study of sublobar resection for c-stage I non-small cell lung cancer patients unable to undergo lobectomy (KLSG-0801): complete republication.

BACKGROUND: Local therapy for stage I non-small cell lung cancer (NSCLC) is divided into surgical and radiation treatment, and given to patients unable to tolerate a lobectomy. A prospective phase II study of cases that received stereotactic body radio therapy (SBRT) (JCOG0403) revealed an overall 3-year survival rate (3-YSR) of 76.0 %, 3-year relapse free survival rate (3-YRFS) of 69.0 %, and rate of morbidity of grade 3 or greater of 9 %. However, few prospective multicenter studies have reported regarding surgery for high-risk stage I NSCLC patients. METHODS: We investigated this issue in the setting of a prospective multicenter observational study. Thirty-two high-risk NSCLC patients (30 males, 2 females; median age 74 years, 61-85 years) were analyzed. RESULTS: Two (6.3 %) showed morbidity of grade 3 or greater, though there were no postoperative deaths. The margin local control rate was 97.0 % (surgical margin recurrence, 1) and local recurrence control rate was 75.0 % (ipsilateral thorax recurrence, 8), while the 3-YSR and 3-YRFS was 79.0 and 75.9 %, respectively. CONCLUSION: A sublobar pulmonary resection for patients unable to tolerate a lobectomy with stage I NSCLC was shown to be safe and provided results comparable with those of SBRT.

Lobectomy Versus Segmentectomy in Radiologically Pure Solid Small-Sized Non-Small Cell Lung Cancer.

BACKGROUND: The indication for limited resection of radiologically pure solid non-small cell lung cancer (NSCLC) is controversial owing to its invasive pathologic characteristics. This study was performed to compare the outcomes after lobectomy and segmentectomy in these NSCLC patients. METHODS: We retrospectively reviewed 251 patients with radiologically pure solid cT1a N0 M0 NSCLC who underwent lobectomy or segmentectomy, and the preoperative characteristics of the patients treated with the two operative techniques were matched using propensity score methods. Overall survival (OS) and disease-free survival (DFS) curves were compared using the log rank test, and differences in survival were also evaluated by the McNemar test. The preoperative factors and surgical procedure were analyzed with the multivariate Cox proportional hazards regression model to identify independent predictors of poor OS and DFS. RESULTS: In the propensity score matched lobectomy and segmentectomy groups (87 patients per group), the 5-year and 10-year OS rates were 85% versus 84% and 66% versus 63%, respectively; and the 5-year and 10-year DFS rates were 80% versus 77% and 64% versus 58%, respectively. There were no significant differences between the two groups in OS or DFS by the log rank test, and also no significant differences in 3-year, 5-year, or 7-year OS or DFS by the McNemar test. Although age, smoking status, pulmonary function, and carcinoembryonic antigen were identified as significant predictors of both OS and DFS, the surgical procedure was not identified. CONCLUSIONS: Similar oncologic outcomes after lobectomy and segmentectomy were indicated among patients with radiologically pure solid small-sized NSCLC.

Lobectomy and limited resection in small-sized peripheral non-small cell lung cancer.

BACKGROUND: Although lobectomy is the standard surgical procedure for non-small cell lung cancer (NSCLC), recent studies show favorable outcomes after limited resection in patients with small-sized peripheral tumors. We conducted a randomized controlled trial of such patients to estimate postoperative outcomes and pulmonary function following these surgical techniques. METHODS: Between 2005 and 2008, eligible patients with tumors of 2 cm or less were randomly assigned 1:1 to undergo lobectomy or limited resection; 32 and 33 NSCLC patients in each group, respectively, were analyzed. The primary end points were 5-year overall survival (OS) and disease-free survival (DFS), while the secondary end points were postoperative pulmonary function including forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). RESULTS: The 5-year OS rates were 93.8% and 90.9% in the lobectomy and limited resection groups, respectively (P=0.921). The 5-year DFS rates were 93.8% and 90.9% in the lobectomy and limited resection groups, respectively (P=0.714). These rates did not differ significantly between the two resection groups. The median postoperative/preoperative FVC ratios were 84.1% and 90.0% in the lobectomy and limited resection groups, respectively, while the median postoperative/preoperative FEV1 ratios were 81.9% and 89.1%, respectively. Both ratios were significantly higher in the limited resection group (P=0.032 and P=0.005 for FVC and FEV1 ratios, respectively). CONCLUSIONS: A similar outcome, with more preserved postoperative pulmonary function, was observed in patients who underwent limited resection compared to those who underwent lobectomy. Ongoing large-scale multi-institutional prospective randomized trials of lobar versus sublobar resection in patients with small peripheral NSCLCs will hopefully provide definitive information about intentional limited resection of small peripheral tumors.

[Pulmonary Resection for Malignant Tumor after Stereotactic Radiation Therapy].

We describe our experience with 14 patients who underwent surgery for a recurrent malignant lung tumor following stereotactic radiation therapy (SRT). The reasons for selecting SRT were patients'decision in 7 patients, advanced age in 3, reduced lung function in 3, and comorbidity in 1. Eight patients had primary lung cancer and 6 had metastatic lung cancer. Tumor recurrence was diagnosed by chest computed tomography in all patients except for one. The median period from SRT to surgery was 12.2 months. All 14 patients were deemed fit for surgery;5 patients underwent lobectomy, and 9 underwent limited resection. In 13 patients, complete resection was possible. In all 14 patients, lung resection was performed safely, and postoperative course was uneventful. No patients died of cancer during follow-up. Informed consent should be obtained from patients for post-recurrence treatment because tumor recurrence can occur after SRT.

[Chest wall reconstruction after resection of chest wall tumors].

Between 1994 and 2012, chest wall resection and reconstruction were performed 15 patients (16 cases) with primary chest wall tumors, metastatic tumors. and chest wall recurrence of breast carcinoma. In all the patients, reconstruction of the chest wall was performed using layers of polypropylene Marlex mesh sheets. In 9 patients, only Marlex mesh sheets were used. The post-operative course was uneventful, and neither paradoxical respiration nor respiratory failure was observed. In 2 patients, reconstructions of the sternum was performed using a Marlex mesh sandwich. A full thickness chest wall defect was reconstructed using Marlex mesh and a pedicled latissimus dorsi musculocutaneous flap. Chest wall recurrence of breast cancer and primary leiomyosarcoma of the chest wall were observed in 4 and 1 patient, respectively. In conclusion, polypropylene Marlex mesh sheets arranged in a layered form appear to be a stable prosthetic material for chest wall reconstruction.

Risk factor analysis of locoregional recurrence after sublobar resection in patients with clinical stage IA non-small cell lung cancer.

OBJECTIVE: Although lobectomy is the standard surgical procedure for operable non-small cell lung cancer (NSCLC), sublobar resection also has been undertaken for various reasons. The aim of this study was to identify risk factors of locoregional recurrence and poor disease-specific survival in patients with clinical stage IA NSCLC undergoing sublobar resection. METHODS: We retrospectively reviewed 328 patients with clinical stage IA NSCLC who underwent segmentectomy or wedge resection. Demographic, clinical, and pathologic factors were analyzed using the log-rank test as univariate analyses, and all factors were entered into a Cox proportional hazards regression model for multivariate analyses to identify independent predictors of locoregional recurrence and poor disease-specific survival. RESULTS: The 5- and 10-year locoregional recurrence-free probabilities were 84.8% and 83.6%, respectively, and the 5- and 10-year disease-specific survivals were 83.6% and 73.6%, respectively. Four independent predictors of locoregional recurrence were identified: wedge resection (hazard ratio [HR], 5.787), microscopic positive surgical margin (HR, 3.888), visceral pleural invasion (HR, 2.272), and lymphatic permeation (HR, 3.824). Independent predictors of poor disease-specific survival were identified as follows: smoking status (Brinkman Index; HR, 1.001), wedge resection (HR, 3.183), microscopic positive surgical margin (HR, 3.211), visceral pleural invasion (HR, 2.553), and lymphatic permeation (HR, 3.223). All 4 predictors of locoregional recurrence also were identified as independent predictors of poor disease-specific survival. CONCLUSIONS: Segmentectomy should be the surgical procedure of first choice in patients with clinical stage IA NSCLC who are being considered for sublobar resection. Patients having tumors presenting with no suspicious of pleural involvement would be suitable candidates for sublobar resection.

Predictive risk factors for mediastinal lymph node metastasis in clinical stage IA non-small-cell lung cancer patients.

INTRODUCTION: Even for patients with clinical N0 non-small-cell lung cancer (NSCLC), several invasive tests are available to pathologically confirm the presumptive mediastinal stage by radiologic modalities. The aim of this study was to determine a high-risk population for mediastinal nodal metastasis in patients with clinical stage IA NSCLC, which would be suitable for mediastinal staging by invasive modalities, such as mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration. METHODS: We retrospectively reviewed peripheral clinical stage IA NSCLC patients who had undergone surgical resection with systematic mediastinal lymphadenectomy from 1998 to 2011. To identify predictors for mediastinal nodal metastasis, univariate and multivariate logistic regression analyses were performed. For the significant factors, optimal cutoff points were determined with a receiver operating characteristic analysis. RESULTS: Among the 894 patients eligible for this study, the overall prevalence of mediastinal nodal metastasis was 7.5%. The following four predictors for mediastinal nodal metastasis were identified: age, preoperative serum carcinoembryonic antigen level, tumor size on preoperative radiologic findings, and consolidation/tumor ratio on high-resolution computed tomography. Of the patients with all four predictors identified by the multivariate analyses and receiver operating characteristic analyses (age ≤ 67 years, carcinoembryonic antigen ≥ 3.5 ng/ml, tumor size ≥ 2.0 cm, and consolidation/tumor ratio ≥ 89%), the prevalence of mediastinal nodal metastasis was 33.8%. CONCLUSIONS: Among the clinical stage IA NSCLC patients in whom all four predictors were identified, one third of the patients showed mediastinal nodal metastasis, and thus, those patients should be a target for mediastinal node assessment by invasive modalities, such as mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration.

Prognostic predictors in non-small cell lung cancer patients undergoing intentional segmentectomy.

BACKGROUND: Despite recent studies reporting on the results of prospective intentional sublobar resection for patients with small non-small cell lung cancer (NSCLC), few studies have investigated predictors for prognosis or recurrence exclusively in patients undergoing intentional sublobar resection. METHODS: We retrospectively reviewed 223 patients with small (2 cm or less) peripheral NSCLC who underwent intentional segmentectomy at the Niigata Cancer Center Hospital between 1992 and 2009. The significant demographic, clinical, and pathologic factors identified with the log rank test in univariate analyses were analyzed with the Cox proportional hazards regression model to examine independent predictors for prognosis and recurrence in multivariate analysis. RESULTS: The 5-year and 10-year overall survival rates were 89.6% and 81.0%, respectively, and the 5-year and 10-year recurrence-free probabilities were 91.1% and 91.1%, respectively. Eight patients had locoregional recurrence, and 12 had distant recurrence. Multivariate analyses revealed that age more than 70 years (hazard ratio [HR] 2.389), male (HR 2.750), more than 75% consolidation/tumor ratio on high-resolution computed tomography (HR 2.750), and lymphatic permeation (HR 5.618) were independent poor prognostic factors, and lymphatic permeation (HR 16.257) was an independent predictor for recurrence. CONCLUSIONS: The factors related to upstaging on pathologic diagnosis were not identified as independent predictors; therefore, the current patient selection criterion seems reasonable. If lymphatic permeation is present on pathologic findings, careful follow-up is recommended. The predictors identified in this study will support assessment and interpretation of the results of ongoing prospective randomized trials of lobar versus sublobar resection in patients with small peripheral NSCLC.

Factors influencing long-term survival and surgical indications for pulmonary metastasectomy for metastases from colorectal cancer.

BACKGROUND: This study examined the prognostic factors and surgical indications for pulmonary metastasectomy for metastases from colorectal cancer. METHODS: We retrospectively reviewed 142 patients treated between 1985 and 2005 who had undergone complete resections of pulmonary metastases from colorectal cancer. RESULTS: Overall 5-year and 10-year survival rates were 42.4% and 32.0%, respectively. The 5-year survival rate for patients with a solitary metastasis was 55.1%, compared with 24.0% for patients with multiple metastases (P= 0.013). The 5-year survival rate for patients with a disease-free interval (DFI) ≥ 1000 days was 55.1%, compared with 31.6% for patients with a DFI < 1000 days (P= 0.008). No significant differences in survival rate according to the location of the primary lesion, maximum tumor size, preoperative serum carcinoembryonic antigen level, or surgical procedure were observed. Prior resection for liver metastases and repeated resection for recurrent pulmonary metastases did not influence the survival rate. A multivariate analysis demonstrated that the number of metastases was an independent, significant prognostic factor for survival. The survival rate of patients with three or more metastases was significantly lower than that of patients with two or fewer metastases. CONCLUSIONS: The number of metastases is an independent prognostic factor after pulmonary metastasectomy for metastases from colorectal cancer. Patients with a solitary pulmonary metastasis benefit the most from pulmonary metastasectomy. The pulmonary resection of three or more metastases is associated with a reduced survival rate. Pulmonary metastasectomy is recommended even for patients with a prior hepatic metastasectomy or patients with recurrent pulmonary metastases.

Diagnostic yield of preoperative computed tomography imaging and the importance of a clinical decision for lung cancer surgery.

PURPOSE: This study aimed to evaluate the diagnostic yield of preoperative computed tomography (CT) imaging and the validity of surgical intervention based on the clinical decision to perform surgery for lung cancer or suspected lung cancer. METHODS: We retrospectively evaluated 1755 patients who had undergone pulmonary resection for lung cancer or suspected lung cancer. CT scans were performed on all patients. Surgical intervention to diagnose and treat was based on a medical staff conference evaluation for the suspected lung cancer patients who were pathologically undiagnosed. We evaluated the relation between resected specimens and preoperative CT imaging in detail. RESULTS: A total of 1289 patients were diagnosed with lung cancer by preoperative pathology examination; another 466 were not pathologically diagnosed preoperatively. Among the 1289 patients preoperatively diagnosed with lung cancer, the diagnoses were confirmed postoperatively in 1282. Among the 466 patients preoperatively undiagnosed, 435 were definitively diagnosed with lung cancer, and there were 383 p-stage I disease patients. There were 38 noncancerous patients who underwent surgery with a diagnosis of confirmed or suspected lung cancer. Among the 1755 patients who underwent surgery, 1717 were pathologically confirmed with lung cancer, and the diagnostic yield of preoperative CT imaging was 97.8%. Among the 466 patients who were preoperatively undiagnosed, 435 were compatible with the predicted findings of lung cancer. CONCLUSION: Diagnostic yields of preoperative CT imaging based on clinical evaluation are sufficiently reliable. Diagnostic surgical intervention was acceptable when the clinical probability of malignancy was high and the malignancy was pathologically undiagnosed.

A case of rapidly growing pulmonary carcinosarcoma.

We report herein a case of rapidly growing pulmonary carcinosarcoma, a rare and highly malignant lung neoplasm characterized by a biphasic histopathological pattern consisting of both epithelial and sarcomatous components, and we also summarize the clinical features of this entity based on previously reported cases. A 65-year-old man was referred for further examination of a lung tumor after a routine chest X-ray (CXR) showed a tumor shadow in the right upper lung zone. Chest computed tomography (CT) found a 2.0 cm pulmonary mass with suspected chest wall invasion in the right upper lobe, although cytological evidence of malignancy could not be obtained despite repeated preoperative bronchoscopy. The tumor grew rapidly, indicating the possibility of lung cancer. A right upper lobectomy with chest wall excision was performed. The postoperative definitive diagnosis was carcinosarcoma consisting of adenocarcinoma and chondrosarcoma. The pathological stage was p-T3N0M0. The patient subsequently received adjuvant chemotherapy with cisplatin and vinorelbine. Routine follow-up chest CT 7 months after the surgery showed pleural dissemination. Consequently he underwent radiotherapy, but the disseminated tumors enlarged further while he received this treatment. The patient is receiving best supportive care at present. Findings based on previously reported cases and our case suggest that early surgical intervention and combined therapeutic strategy are the most important aspects of treatment for pulmonary carcinosarcoma.

Long-term survival after removal of a malignant peripheral nerve sheath tumor originating in the anterior mediastinum.

Malignant peripheral nerve sheath tumors (MPNSTs; malignant schwannomas) rarely occur in the anterior mediastinum, and their prognosis is poor. A 75-year-old man was referred to our hospital for examination of an anterior mediastinal tumor. A computed tomography-guided percutaneous needle biopsy revealed only fibrosis. The tumor was completely excised via a median sternotomy with partial resection of the pericardium and right upper lobe of the lung. Thereafter, the tumor was diagnosed as a storiform-pleomorphic type of malignant fibrous histiocytoma. At 1 year after the surgery, a distant metastasis was found in the interlobular space between the right middle and lower lobes. The tumor was completely excised via a right posterolateral thoracotomy. Reexamination of the primary and secondary tumors revealed an MPNST. No recurrence was found up to 5 years after the second surgery without adjuvant chemotherapy or radiation therapy. However, he died from multiple lung metastases after 6 years.