Favourable surgical outcomes for either second primary lung cancer or intrapulmonary metastasis after resection of non-small-cell lung cancer.

OBJECTIVES: Metachronous lung cancer arising after resection of non-small-cell lung cancer is either a second primary lung cancer (SPLC) or intrapulmonary metastasis (IPM) of the initial lung cancer; however, differential diagnosis is difficult. We evaluated the surgical outcomes of metachronous lung cancer in a combined population of patients with SPLC and IPM. METHODS: A retrospective study of 3534 consecutive patients with resected non-small-cell lung cancer between 1992 and 2016 was conducted at 4 institutions. RESULTS: A total of 105 patients (66 males; median age, 70 years) who underwent a second pulmonary resection for metachronous lung cancer were included. Most patients (81%) underwent sublobar resection, and there was no 30-day mortality. All metachronous lung cancers were cN0, 5 were pN1-2. The postoperative comprehensive histologic assessment revealed SPLC (n = 77) and IPM (n = 28). The 5-year overall survival rate after the second resection was 70.6% (median follow-up: 69.7 months). A multivariable analysis showed that age >70 years at the second resection (P = 0.013), male sex (P = 0.003), lymph node involvement in metachronous cancer (P < 0.001), pathological invasive size of metachronous cancer >15 mm (P < 0.001) and overlapping squamous cell carcinoma histology of the initial and metachronous cancers (P = 0.003) were significant prognostic factors for poor survival after the second resection, whereas histological IPM was not (P = 0.065). CONCLUSIONS: Surgery for cN0 metachronous lung cancer is safe and shows good outcomes. There were no statistically significant differences in the SPLC and IPM results. Caution should be exercised when operating on patients with overlapping squamous cell carcinoma.

DAIR in treating chronic PJI after total knee arthroplasty using continuous local antibiotic perfusion therapy: a case series study.

BACKGROUND: Antimicrobial agents are administered via intramedullary antibiotic perfusion (iMAP)/intrasoft tissue antibiotic perfusion (iSAP) to infected lesions to control osteoarticular and soft tissue infections. Continuous local antibiotic perfusion (CLAP) has been reported to be useful. This study aimed to investigate the outcomes of DAIR combined with CLAP for chronic PJI after total knee arthroplasty performed at our hospital. SUBJECTS AND METHODS: Six patients (male; one case, female; five cases, mean age 79.5 years (70-94)) underwent CLAP for chronic PJI after TKA at our hospital between July 2020 and June 2022. They were followable for at least one year after surgery. Seven months (17-219), with a mean follow-up of 24.3 months (12-36). In addition to direct debridement and insert exchange, systemic antimicrobial treatment, and CLAP with gentamicin were performed using NPWT. We investigated the organisms causing the inflammation, the duration of iMAP/iSAP implantation, the maximum daily dose of GM, the maximum GM blood concentration, and the presence or absence of GM-induced adverse events. RESULT: Two of six patients had a recurrence of infection at five weeks and five months after initial CLAP and required repeat CLAP treatment, but all patients could preserve their components. The organisms responsible for the flare-ups were MSSA in three cases: ESBL-producing E. coli, mixed MSSA and streptococcal infection, Klebsiella pneumonia in one case each, and unknown pathogens in one case. CLAP therapy for all patients was administered eight times in 6 cases: iMAP, mean: 10.0 days (5-16); iSAP, mean: 19.3 days (15-28); GM dose, mean: 162.5 mg/day (80-240); and GM blood concentration, mean: 1.4 µg/mL (0.2-5.0). Adverse events included one case of reversible acute kidney injury during CLAP in a patient with recurrent infection. DAIR with CLAP for chronic post-TKA infection can be a useful treatment option to preserve components and allow the infection to subside, provided the implant is not markedly loosened.

High density and proximity of CD8+ T cells to tumor cells are correlated with better response to nivolumab treatment in metastatic pleural mesothelioma.

BACKGROUND: The efficacy of immune checkpoint inhibitors (ICIs) in pleural mesothelioma has recently been established. The response to ICIs can be predicted by quantitative analysis of cells and their spatial distribution in the tumor microenvironment (TME). However, the detailed composition of the TME in pleural mesothelioma has not been reported. We evaluated the association between the TME and response to ICIs in this cancer. METHODS: A retrospective analysis of 22 pleural mesothelioma patients treated with nivolumab in different centers was performed using surgical specimens. Four patients had a partial response to nivolumab (response group) and 18 patients had stable or progressive disease (nonresponse group). The number of CD4, CD8, FoxP3, CK, and PD-L1 positive cells, cell density, and cell-to-cell distance were analyzed by multiplex immunofluorescence. RESULTS: PD-L1 expression did not differ significantly between the response and nonresponse groups. The density of total T cells and of CD8+ T cells was significantly higher in the response than in the nonresponse group. CD8+ T cells were more clustered and located closer to tumor cells, whereas regulatory T cells were located further from tumor cells in the response than in the nonresponse group. CONCLUSIONS: High density and spatial proximity of CD8+ T cells to tumor cells were associated with better response to nivolumab, whereas the proximity of regulatory T cells to tumor cells was associated with worse response, suggesting that the distinct landscape of the TME could be a potential predictor of ICI efficacy in pleural mesothelioma.

Optimal Chest Drainage Method After Anatomic Lung Resection: A Prospective Observational Study.

BACKGROUND: Several methods for chest drainage after pulmonary resection of malignant lung tumors exist, but consensus on the ideal method has not been reached. METHODS: We conducted a multicenter prospective observational study. We enrolled 2200 patients who underwent lung resection for lung tumors. Of the 1470 patients who underwent anatomic resection, 347 showed air leak on the morning of postoperative day 1. They were assigned to 3 groups according to the chest drainage method on postoperative day 1. RESULTS: Of 347 patients with postoperative air leaks, 107 (30.8%), 179 (51.6%), and 61 (17.6%) were assigned to water seal, continuous suction, and digital drainage, respectively. The median postoperative air leak duration was significantly longer with digital drainage (4.0 days) than with either water seal (2.5 days) or continuous suction (3.0 days; P = .009). Chest tubes were required for significantly more days on average with digital drainage (6.0 days) than with water seal (4.0 days) or continuous suction (4.0 days; P = .003). Prolongation of air leak duration was significantly more likely to occur in patients with body mass index <18.5 kg/m2 (hazard ratio [HR], 1.6; 95% CI, 1.1-2.3), moderate or severe air leak on postoperative day 1 (HR, 2.0; 95% CI, 1.5-2.6), or digital drainage (HR, 1.4; 95% CI, 1.01-1.9). CONCLUSIONS: Water seal was associated with significantly shorter duration of postoperative air leak and chest drainage compared with continuous suction and digital drainage.

Malignant pleural mesothelioma in situ.

Although the diagnosis of malignant pleural mesothelioma at an in situ stage was traditionally challenging, it is now possible owing to advances in molecular biological methods such as P16 fluorescence in situ hybridization or BRCA1-associated protein 1 immunohistochemistry. Here, we report the first case, to our knowledge, of total parietal pleurectomy for mesothelioma in situ. Future follow-up and accumulation of cases are necessary to determine whether total parietal pleurectomy could be applied as a treatment for mesothelioma in situ or not.

Visuomotor Tracking Task for Enhancing Activity in Motor Areas of Stroke Patients.

Recovery of motor function following stroke requires interventions to enhance ipsilesional cortical activity. To improve finger motor function following stroke, we developed a movement task with visuomotor feedback and measured changes in motor cortex activity by electroencephalography. Stroke patients performed two types of movement task on separate days using the paretic fingers: a visuomotor tracking task requiring the patient to match a target muscle force pattern with ongoing feedback and a simple finger flexion/extension task without feedback. Movement-related cortical potentials (MRCPs) were recorded before and after the two motor interventions. The amplitudes of MRCPs measured from the ipsilesional hemisphere were significantly enhanced after the visuomotor tracking task but were unchanged by the simple manual movement task. Increased MRCP amplitude preceding movement onset revealed that the control of manual movement using visual feedback acted on the preparatory stage from motor planning to execution. A visuomotor tracking task can enhance motor cortex activity following a brief motor intervention, suggesting efficient induction of use-dependent cortical plasticity in stroke.

Potential of Continuous Local Antibiotic Perfusion Therapy for Fracture-Related Infections.

INTRODUCTION: Fracture-related infections (FRIs) are challenging for orthopedic surgeons, as conventional surgical treatment and systemic antimicrobial therapy cannot completely control local infections. Continuous local antibiotic perfusion (CLAP) is a novel and innovative therapy for bone and soft-tissue infections, and is expected to eradicate biofilms by maintaining a sustained high concentration of antimicrobial agents at the infected site. If CLAP therapy can eradicate infection even in cases with implants while preserving the implants, it would be an ideal and effective treatment for local refractory infections. This study aimed to evaluate the usefulness of novel CLAP therapy for FRIs. METHODS: Nine patients treated with CLAP therapy were retrospectively analyzed. The mean age was 65.9 (43-82) years, and the mean follow-up period was 14.9 (6-45) months. In all cases, the infected sites were related to the lower extremities (tibia, n = 6; fibula, n = 1; hip joint, n = 1; foot, n = 1). All patients underwent similar procedures for this therapy combined with negative-pressure wound therapy after thorough irrigation and debridement of infected tissues. RESULTS: The pathogens identified were Staphylococcus aureus (methicillin-resistant S. aureus, n = 5; methicillin-susceptible S. aureus, n = 1), Pseudomonas aeruginosa (n = 3), Enterococcus faecalis (n = 2), Corynebacterium (n = 1), and Enterobacter (n = 1); pathogens were not detected in one case. The mean duration of CLAP was 17.0 (7-35) days. In all cases, implants were preserved until bone union was achieved. Five cases relapsed; however, infection was finally suppressed in all cases by repeating this method. No side effects were observed. CONCLUSION: This novel case series presents treatment outcomes using CLAP therapy for FRIs. This method has the potential to control the infection without removing the implants, because of the sustained high concentration of antimicrobial agents at the infected site, and could be a valuable treatment option for refractory FRIs with implants, in which bone union has not been achieved.

Retrospective study of efficacy of adjuvant chemotherapy using tegafur-uracil in patients with non-small cell lung cancer with primary tumor size of 4.1-5.0 cm.

BACKGROUND: The staging of patients with a tumor of diameter 4.1-5.0 cm and no lymphatic/distant metastases have been up-graded to stage IIA in the latest 8th edition of the TNM staging system. However, the efficacy of adjuvant tegafur-uracil (UFT) therapy in these patients, which has been recommended in the guideline issued by The Japan Lung Cancer Society, remains unclear. We evaluated the efficacy of adjuvant UFT therapy among a cohort by retrospective analyses of multicentric database. METHODS: In 2005-2007, 130 patients with p-stage IB non-small cell lung cancer (NSCLC) (diagnosed according to the 7th edition of the TNM staging system) and tumor size of ≥3.1 cm underwent anatomic complete resection at nine of our affiliated hospitals. We retrospectively reviewed the clinicopathological characteristics and the outcomes among these patients. RESULTS: Ninety-eight patients had tumor size of 3.1-4.0 cm (T2a group), whereas 32 patients had tumor size >4.0 cm (T2b group). Overall, patients who received adjuvant UFT showed a tendency of better outcomes than patients who did not [hazard ratio (HR) 0.564; 95% confidence interval (CI), 0.257-1.238, P=0.147]. In subgroup analyses, patients who received adjuvant UFT also tended to show better outcomes than those who did not in both T2a group and T2b group (HR 0.504; 95% CI, 0.202-1.255, P=0.132 in T2a group and HR 0.855; 95% CI, 0.181-4.033, P=0.843 in T2b group, respectively). CONCLUSIONS: Our results suggest that adjuvant UFT therapy have the potential to improve postoperative outcomes even in patients with p-stage IIA disease, as classified according to the 8th edition of the TNM staging system.

Contralateral tension pneumothorax during video-assisted thorascoscopic surgery for lung cancer: a case report.

Contralateral tension pneumothorax during one-lung ventilation is a rare but catastrophic surgical complication. A 72-year-old Japanese male with lung cancer underwent right upper lobectomy with video-assisted thoracoscopic surgery. Despite use of various methods for maintaining oxygenation during one-lung ventilation, percutaneous oxygen saturation was unstable from the start of surgery and suddenly decreased with a drop in blood pressure. An intraoperative chest X-ray revealed a tension pneumothorax of the dependent lung. Insertion of a chest drain saved the patient's life. This case suggests that a contralateral tension pneumothorax should be considered as a possible cause when adequate oxygenation cannot be maintained during one-lung ventilation.

Evaluation of a digital drainage system (Thopaz) in over 250 cases at a single site: A retrospective case-control study.

PURPOSE: The aim of this study was to evaluate the efficacy of the Thopaz system, a new drainage system in management of general thoracic surgery, based on a review of our clinical practice and a comparison of the utility of the Thopaz device compared with a standard drainage system. METHODS: A review of 540 thoracic surgeries at our hospital was performed. These cases were divided into 275 treated with the Thopaz system from April 2014 to March 2015 and 265 treated with a standard system from April 2013 to March 2014. The characteristics of patients and outcomes after surgery were compared in these 2 groups. RESULTS: The characteristics of the patients were similar in the 2 groups. Outcomes after surgery, including types of operation, period of chest tube placement, chest tube reinsertion rate and clamping test rate also did not differ significantly between the groups. CONCLUSIONS: The non-inferiority of the Thopaz system compared to a standard system was verified statistically. With advantages of providing objective data as a small portable system, in addition to the quietness of the unit and the ease of setup and operation, Thopaz system is likely to become mainstream in postoperative management in general thoracic surgery.

Three years' experience with the first pediatric hospice in Asia.

OBJECTIVE: Pediatric hospice has been the adoption of several service provision models in highly developed countries such as UK, Germany, Australia or Canada for a few decades, yet it has seldom been the case in the Asian Continent. This study aimed to evaluate the newest challenge for the children with Life-threatening illness (LTI) and described the characteristic of pediatric palliative care at the first pediatric hospice in Japan. METHODS: A retrospective review of all patients at our pediatric hospice in these three years was conducted. Of the 294 cases reviewed, 269 cases were eligible for analysis. RESULTS: We reviewed 269 patients admitted during the first three years. Most patients required intensive medical intervention. Patients were hospitalized in our pediatric hospice not only for end-of-life care (EOL), but also for respite care. Only 7% of the patients were with cancer. To support children and family to make the most of their time together, we provided a range of medical and recreational care. It is expected that the pediatric hospice will extend and establish cooperation with other hospitals or community services. CONCLUSION: Three years' experience of pediatric palliative care at the first pediatric hospice in the Asian Continent is encouraging. Further experience and improved communication with other pediatric service providers as well as their education in palliative care will enhance the recognition of the capacity of our hospice and support the needs of more children. Furthermore, we would like to introduce the idea of pediatric hospice and spread it throughout the Asian Continent in the future.

Lobe-Specific Lymph Node Dissection as a Standard Procedure in Surgery for Non-Small Cell Lung Cancer: A Propensity Score Matching Study.

INTRODUCTION: Systematic lymph node dissection (SND) is the standard procedure in surgical treatment for NSCLC, but the value of this approach for survival and nodal staging is still uncertain. In this study, we evaluated the potential of lobe-specific lymph node dissection (L-SND) in surgery for NSCLC by using a propensity score matching method. METHODS: From 2005 to 2007, 565 patients with cT1a-2b N0-1 M0 NSCLC underwent lobectomy with lymph node dissection at our 10 affiliated hospitals. Patients were classified into groups that underwent nodal sampling, L-SND, and systematic dissection SND on the basis of pathological data for the number and extent of nodal resection. A total of 77 patients with insufficient pathological data were excluded from the study. RESULTS: Overall, survival did not differ significantly among the groups (p = 0.552), but the rate of detection of pN2 in the SND group (13.1%) was significantly higher than in the nodal sampling (3.3%) and L-SND (9.0%) groups (p = 0.010). However, given the many confounding factors in the patient characteristics in each group, outcomes were reevaluated using a propensity score matching method for the L-SND and SND groups. After matching, the two groups had no significant differences in 5-year overall survival (73.5% for L-SND versus 75.3% for SND, p = 0.977) and pN2 detection (8.2% in both groups, p = 0.779). CONCLUSIONS: These results suggest that lobe-specific lymph node dissection has the potential to be a standard procedure in surgical treatment for NSCLC.

Two surgical cases of thymic MALT lymphoma associated with multiple lung cysts: possible association with Sjögren's syndrome.

Thymic mucosa-associated lymphoid tissue (MALT) lymphoma is rare. Sjögren's syndrome (SjS) has strong association with thymic MALT lymphoma but the exact etiology is unknown. On the other hand, SjS is characterized by the complication of various lung manifestations, including lung cysts. The mechanism for these lesions is also unknown. But the underlying SjS could result in MALT lymphoma with lung cysts. Herein, we demonstrate two surgical cases of thymic MALT lymphoma associated with multiple lung cysts and the characterization of this rare tumor. During surgery, the tumors were found to be well capsuled and had no adhesion or invasion to the surrounding tissues consistent with its characteristics of low grade malignancy. When thymic MALT lymphoma is suspected clinically, video-assisted thoracoscopic surgery might be the best approach for diagnosis. We propose that radiological findings of a thymic tumor along with lung cysts are an indication of thymic MALT lymphoma.

Postoperative follow-up strategy based on recurrence dynamics for non-small-cell lung cancer.

OBJECTIVES: Our study was designed to visually represent recurrence patterns after surgery for non-small-cell lung cancer (NSCLC) with the use of event dynamics and to clarify postoperative follow-up methods based on the times of recurrence. METHODS: A total of 829 patients with NSCLC who underwent complete pulmonary resection from 2005 to 2007 in 9 hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons were studied. Event dynamics, based on the hazard rate, were evaluated. Only first events involving the development of distant metastases, local recurrence or both were considered. The effects of sex, histological type, pathological stage and age were studied. RESULTS: The hazard rate curve displayed an initial surge that peaked about 6-8 months after surgery. The next distinct peak was noted at the end of the second year of follow-up. On non-parametric kernel smoothing, the maximum peak was found 6-8 months after surgery in men. In women, the highest peak occurred 22-24 months after surgery, which was about 16 months later than the peak in men. The peak timing of the hazard curve was not affected by histological type, pathological stage or age in either sex. CONCLUSIONS: Our results suggest that the timing of recurrence after surgery for lung cancer is characterized by a bimodal pattern, and the times with the highest risk of recurrence were suggested to differ between men and women. Postoperative follow-up strategies should be based on currently recommended follow-up programmes, take into account the recurrence patterns of lung cancer, and be modified as required to meet the needs of individual patients.

Influence of visceral pleural invasion on survival in completely resected non-small-cell lung cancer.

OBJECTIVES: Although the prognostic implications of visceral pleural invasion (VPI) are well established, it remains controversial whether the extent of VPI affects survival in patients with completely resected non-small-cell lung cancer (NSCLC). In addition, the impact of VPI according to nodal status is unclear. We evaluated the influence of the extent of pleural invasion on survival by analysing a multicentre retrospective database of patients who had undergone surgery for NSCLC. METHODS: We retrospectively reviewed the clinicopathological characteristics and outcomes of 639 patients with NSCLC who underwent anatomic complete resection from 2005 to 2007 at nine hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons. RESULTS: The median follow-up was 65.0 months. The extent of pleural invasion was PL0 in 462 patients, PL1 in 135 and PL2 in 42. The 5-year overall survival rate was significantly higher in patients with PL0 tumours (75.9%) than in those with PL1 (63.6%) or PL2 tumours (54.1%). On subgroup analysis according to nodal status, PL0 was associated with a higher survival rate than that of PL1 or PL2 tumours in patients with N0 or N1 metastasis, but not in those with N2 metastasis. There was no difference between PL1 and PL2 in any subgroup. CONCLUSIONS: Our results suggest that the presence of VPI, rather than the extent, has an impact on postoperative survival in patients with NSCLC who have N0 or N1 metastasis. Because very few previous studies have addressed the effects of VPI in patients with N1 disease, further re-evaluation of the prognostic impact of VPI is necessary in this subgroup of patients.

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.

[A retrospective study of the relationship between bacterial numbers from central venous catheter tip cultures and blood cultures for evaluating central line-associated bloodstream infections].

Catheter-related bloodstream infection (CRBSI) is an infectious disease requiring special attention. It is a common cause of nosocomial infections; catheter insertion into the central veins particularly increases the risk of infection (CLA-BSI: central line-associated bloodstream infection). We examined the relationship between the number of bacterial colonies cultured from shredded central venous catheter (CVC) tips and from blood cultures in our hospital from 2011 to 2012. Coagulase-negative staphylococci topped the list of microbe isolated from the CVC tip culture, followed by Pseudomonas aeruginosa, Staphylococcus aureus, and Candida spp. S. aureus and Candida spp., with growth of over 15 colony-forming units in the CVC tip culture, were also detected at high rates in the blood culture. However, gramnegative bacilli (Enterobacteriaceae and P. aeruginosa) did not show a similar increase in colony number in the CVC tip culture. Because microbes adhering to shredded catheter tips are readily detected by culture, this method is useful as a routine diagnostic test. In addition, prompt clinical reporting of the bacterial number of serious CLA-BSI-causing S. aureus and Candida spp. isolated from CVC tips could contribute to earlier CLA-BSI diagnosis.