Feasibility and Safety of Uniportal Thoracoscopic Segmentectomy Using a Unidirectional Dissection Approach without Dissecting a Fissure.

Background: Few original articles describe the perioperative outcomes of uniportal thoracoscopic segmentectomy using a unidirectional dissection approach. In this retrospective study, we evaluated the feasibility and safety of this procedure. Methods: This study included 119 patients who underwent uniportal thoracoscopic segmentectomy in our department between February 2019 and December 2022. The patients were divided into unidirectional (group U, n = 28) and conventional (group C, n = 91) dissection approach groups. While the dominant pulmonary vessels and bronchi were transected at the hilum without dissecting a fissure in the unidirectional (U) group, the dominant pulmonary artery was exposed and divided at a fissure in the conventional (C) group. Patient characteristics and perioperative outcomes were compared between groups U and C. Results: The proportions of simple and complex segmentectomies were statistically similar between the groups. The operating time was shorter (group U: 110 [interqurtile range: 90-140] min, group C: 135 [interqurtile range: 105-166] min, p = 0.012) and there was less blood loss (group U: 0 [interqurtile range: 0-0] g, group C: 0 [interqurtile range: 0-50] g, p = 0.003) in group U than in group C. However, there were no significant intergroup differences in other perioperative outcomes. Conclusions: The unidirectional dissection approach in uniportal thoracoscopic pulmonary segmentectomy is safe and feasible and enables a smoother operation.

Right basal bronchial fistula due to amebic infection: a case report.

BACKGROUND: Pleuropulmonary amebiasis is the second most common form of extraintestinal invasive amebiasis, but cases that include bronchopleural fistula are rare. CASE PRESENTATION: A 43-year-old male was referred to our hospital for liver abscess, right pleural effusion, and body weight loss. He was diagnosed with a bronchopleural fistula caused by invasive pleuropulmonary amebiasis and human immunodeficiency virus (HIV) infection. After initial medical treatment for HIV infection and invasive amebiasis, he underwent pulmonary resection of the invaded lobe. Intraoperative inspection revealed a fistula of the right basal bronchus in the perforated lung abscess cavity, but the diaphragm was intact. The patient was discharged on postoperative day 3 and was in good condition at the 1-year follow-up. CONCLUSIONS: Clinicians should be aware that pleuropulmonary amebiasis can cause a bronchopleural fistula although it is very rare.

[Gefitinib Monotherapy Afforded Long-Term Survival of an Octogenarian Patient with a Postoperative Recurrence of a Pulmonary Adenocarcinoma-A Case Report].

An 83-year-old(at the time of postoperative recurrence)female clinically diagnosed with primary lung cancer underwent right upper lobectomy and lymph node dissection(ND2a-2). Postoperative pathological staging revealed a Stage ⅠB (pT2aN0M0)adenocarcinoma that was EGFR mutation-positive(exon 21: L858R). Fifty-one months after surgery, the patient developed a mediastinal lymph node metastasis, and radiotherapy was delivered. Next, gefitinib(250 mg daily)was prescribed as first-line therapy. She developed mild anemia but we took a wait-and-see approach. A complete response was evident after 58 months of monotherapy. However, she then developed grade 3 anemia(Hb 6.2 g/dL)and gefitinib was discontinued. She requested(and received)follow-up computed tomography. No progressive disease was evident, but she died of non-cancer disease 16 months after discontinuation of gefitinib(thus 125 months after surgery and 74 months after the postoperative recurrence). Thus, we here present an unusual case. Gefitinib monotherapy afforded long-term survival of an octogenarian patient with a postoperative recurrence of a pulmonary adenocarcinoma.

[Recurrent Postoperative Lung Cancer with Tumor Shrinkage after Discontinuation of Pembrolizumab-A Case Report].

Our patient was a 41-year-old man with non-small cell lung cancer of grade cT3N2M0 and clinical Stage ⅢA. After induction chemoradiotherapy(weekly CBDCA plus PTX[5 courses]and concurrent radiation of 50 Gy, left upper lobectomy with lymph node dissection(ND2a-1)was performed. The postoperative pathological findings were large cell carcinoma, ypT2aN2M0, Stage ⅢA, with complete resection; the PD-L1 tumor proportion score was 50 to 74%. Consolidation chemotherapy( triweekly CBDCA plus PTX, 1 course)followed. Twelve months after surgery, he developed mediastinal lymph node recurrence(#4L), and pembrolizumab was administered every 3 weeks as a first-line treatment. Complete response was evident after 3 courses; thus, we continued this monotherapy. After 35 courses(24 months)of pembrolizumab, we discontinued the regimen. Twenty-two months later, the disease has not progressed. The patient is being followed-up in our outpatient department. We report a case of recurrent postoperative lung cancer with continuous tumor shrinkage after discontinuation of pembrolizumab.

[Multidisciplinary Treatment for Postoperative Recurrent Patients-Report of a Long-Term Survivor].

We present a long-term survivor who received multidisciplinary treatment for a postoperative recurrence. A 52-year-old female who had been clinically diagnosed with primary lung cancer underwent a right lower lobectomy, middle lobe wedge resection, and lymph node dissection(ND2a-1), and was pathologically diagnosed with primary pulmonary papillary adenocarcinoma( pT3N0M0, Stage ⅡB)positive for a sensitizing EGFR mutation(L858R). The patient was given UFT as postoperative adjuvant chemotherapy for 2 years. During the follow-up, multiple pulmonary metastases occurred in postoperative month 44. Gefitinib was administered as the first-line treatment, which resulted in a complete response for 30 months. Then, stereotactic radiotherapy was administered for 3 brain metastases, and multiple pulmonary metastases were treated with cisplatin plus pemetrexed and carboplatin plus pemetrexed for PD, but an adverse event occurred. Therefore, pemetrexed monotherapy was administered as a fourth-line treatment for 5 months. Then, afatinib, nivolumab, docetaxel, osimertinib, S-1, pembrolizumab, and atezolizumab(11th-line treatment)were administered with each PD or new lesion. Finally, the best supportive care was administered and she died on postoperative month 134, which was post-recurrent month 90.

[Lung Cancer Cases with Spontaneous Regression].

Case 1 was a 79-year-old man. Computed tomography (CT) showed a nodule in the left upper lobe. Surgery was planned, but the regression of the nodule was noted and the surgery was postponed. Six months later, the nodule shadow increased again, and was surgically resected. Pathological diagnosis was adenocarcinoma. Case 2 was an 82-year-old man. CT showed a nodule in the right lower lobe and surgery was planned, but the nodule regressed. Three months later, it increased and was resected. It was pathological diagnosed as squamous cell carcinoma. Although spontaneous regression of lung cancer is rare, careful follow up of the regressed nodules shadow is required because of possible regrowth after the regression.

[Uniportal versus Multiportal Video-assisted Thoracic Surgery for Primary Lung Cancer].

OBJECTIVES: This study aimed to consider the safety and feasibility of uniportal video-assisted thoracic surgery( VATS)[ u-VATS] compared with multiportal VATS( m-VATS). METHODS: Sixty-two patients underwent anatomical lung resection for primary lung cancer via u-VATS between February 2019 and May 2020 at our institution. We performed propensity score matching of these cases versus anatomical lung resection cases under m-VATS performed from January 2017 to December 2019, and compared the perioperative results. RESULTS: In the u-VATS group, operation time( 142 minutes vs. 178 minutes, p<0.01) and postoperative drainage days( 1.6 days vs. 2.4 days, p=0.01) were significantly shorter. There were no differences in intraoperative blood loss, vascular damage, conversion rate, number of lymph nodes dissected, postoperative complications, and postoperative hospital stay. The number of pain complaints and the number of analgesics (non-steroidal anti-inflammatory drugs:NSAIDs) prescribed at the first outpatient clinic after discharge were significantly lower in the u-VATS group( 10 vs. 22, p=0.03). CONCLUSIONS: U-VATS shortened the operation time and postoperative drainage period compared with conventional m-VATS, and significantly reduced the use of analgesics. U-VATS is considered to be safe and less invasive surgical procedure based on the present study.

[Video-assisted Thoracoscopic Total Pleural Adhesiolysis:Tips and Pitfalls].

PURPOSES: Here, we present the tips and pitfalls of video-assisted thoracoscopic( VATS) total pleural adhesiolysis( TPA), determined on an empirical basis. PATIENTS AND METHODS: From 2012 to 2020, VATS-TPA was performed in 33 patients undergoing pulmonary anatomic lung resection at our institute. The basic procedure was as follows:after peeling off the area of pleural adhesion surrounding the surgical ports using the fingers, the thoracoscope was inserted into the thorax and the adhesions in other areas were peeled off under thoracoscopic guidance. RESULTS: The adhesiolysis group had a longer operating time, greater blood loss, and higher rate of conversion to thoracotomy compared to the non-adhesiolysis group. However, the results were acceptable considering the extra manipulation for adhesiolysis. CONCLUSIONS: VATS-TPA is a necessary component of the standard surgical procedure for general thoracic surgeons in cases of total pleural adhesion.

[Erlotinib plus Bevacizumab Therapy for Postoperative Recurrence of Adenosquamous Cell Carcinoma Harboring EGFR Mutation-A Case Report].

A 59-year-old man clinically diagnosed with primary lung cancer underwent left lower lobectomy and lymph node dissection( ND2a-2). The postoperative pathological stage was ⅠB(pT2aN0M0), and the lesion was positive for epidermal growth factor receptor(EGFR)exon 21 L858R mutation. Thirty months after surgery, the patient developed pleural dissemination and effusion in the left pleural cavity. Carboplatin(AUC=6, day 1, every 3 weeks)and nab-paclitaxel(100 mg/m2, day 1 and day 8, every 3 weeks)were administered as first-line therapy. Progressive disease was evident 10 months after 4 courses of first-line therapy. Pembrolizumab(200 mg, day 1, every 3 weeks)was then administered as second-line therapy. After 7 months(9 courses of therapy), the lung cancer had metastasized to the left third intercostal muscle, and the pleural nodules regrew. The former lesion was treated with radiotherapy owing to the development of pain in the chest. Erlotinib (150 mg once daily)and bevacizumab(15 mg/kg, day 1, every 3 weeks)were initiated as third-line therapy, resulting in complete response at 14 months(67 months after surgery, 37 months after postoperative recurrence). The prognosis of patients with EGFR-positive pulmonary adenosquamous carcinoma and undergoing treatment with EGFR-tyrosine kinase inhibitors(TKI)is reportedly poor. Herein, we report a rare case of adenosquamous carcinoma with EGFR mutation presenting complete response following treatment with EGFR-TKI.

[Alectinib for an Octogenarian Patient with Poor Performance Status and ALK Fusion Gene-Positive Lung Cancer-A Case Report].

An 89-year-old female who had been clinically diagnosed with primary lung cancer underwent right upper lobectomy and lymph node dissection(ND2a-2). Postoperative pathological staging revealed a stage ⅡA(pT1bN1M0)adenocarcinoma that was negative for an EGFR mutation. Nineteen months after surgery, the patient developed a mediastinal lymph node metastasis, and radiotherapy was prescribed. Thirty-eight months later, she developed new mediastinal/hilar lymph node metastases and was prescribed pemetrexed(500 mg on day 1 of each of 3 weeks)as the first-line therapy. A complete response was evident after 10 courses. However, she developed grade 3 nausea, and pemetrexed was discontinued. During 10 months of follow-up, no new lesion appeared; therefore, follow-up was discontinued. Ninety-three months after surgery, she was referred to our hospital because an abnormal shadow was apparent on chest roentgenography. A thorough examination revealed pleural dissemination, pulmonary metastases, mediastinal/hilar lymph node metastases, an adrenal metastasis, and bone metastases. Although her performance status(PS)was poor(grade 4), as the diagnosis was ALK fusion gene-positive adenocarcinoma, alectinib(600 mg once daily)was commenced as the second-line therapy. Complete response was achieved 14 months later(ie, 108 months after surgery and 89 months after postoperative recurrence). Thus, an octogenarian patient with poor PS and ALK fusion gene-positive adenocarcinoma exhibited a complete response after treatment with alectinib.

[Postoperative Recurrence of ROS1‒Positive Pulmonary Adenocarcinoma after 19 Years].

A 73‒year‒old woman underwent right lower lobectomy for Stage ⅠA(pathological Stage T1N0M0)pulmonary adenocarcinoma. After 19 years, she complained of dyspnea on exertion. Computed tomography revealed metastatic lesions in the bilateral supraclavicular, mediastinal, and hilar lymph nodes. Thoracoscopic lymph node biopsy showed recurrence of the adenocarcinoma, and immunohistochemical staining confirmed that the metastases were ROS1‒positive. The patient responded well to crizotinib therapy. The prognosis of non‒small‒cell lung cancer is considered favorable when it does not recur within 5 years, postoperation. However, few studies have reported the recurrence of ROS1‒positive pulmonary adenocarcinoma after a long disease‒free interval. Long‒term postoperative follow‒up is essential for patients with ROS1‒positive pulmonary adenocarcinomas.

[Docetaxel and Ramucirumab Combination Chemotherapy after Nivolumab Treatment for Pretreated Pulmonary Squamous Cell Carcinoma-A Successful Case].

For immune checkpoint inhibitor(ICI)-pretreated patients, docetaxel and ramucirumab(DTX plus RAM)combination therapy can be more effective than no treatment. Herein, we present the case of a patient who had been treated with ICIs and was thereafter successfully treated with DTX plus RAM. A 62-year-old man with primary pulmonary squamous cell carcinoma( PDL-1 tumor proportion score<1%)at clinical stage ⅠA2(cT1bN0M0)was treated as follows: 1)right upper lobectomy ND2a-2(pT1bN0M0, stage ⅠA2); 2)surgery for a solitary pleural metastasis 20 months later; 3)cisplatin plus vinorelbine for multiple pleural metastases as a first-line treatment 24 months after the initial surgery; and 4)nivolumab as a second-line treatment. However, progressive disease and an adverse event occurred after 5 courses of nivolumab, and DTX plus RAM were introduced as a third-line treatment. A complete response to 12 courses of combination therapy(41 months after surgery/29 months after recurrence)was determined. Unfortunately, the DTX plus RAM regimen had to be withdrawn because the patient developed drug-induced acute pneumonitis. The patient has been in remission since drug discontinuation and is receiving steroid and home-oxygen therapy.

[Malignant Solitary Fibrous Tumor of the Pleura;Report of a Case].

We report a rare case of a malignant solitary fibrous tumor of the pleura(SFTP). The patient was a 66-year-old man, who had an asymptomatic 25 mm nodule in the left upper lung field. We performed a wedge resection of the left lung by video-assisted thoracic surgery, and the tumor was diagnosed as a malignant SFTP. Although the recurrence has not been found for 26 months, long-term clinical follow-up is thought to be necessary because of the potential adverse biological behavior of this tumor.

[Late-Onset Acute Pneumonitis Caused by Pembrolizumab Used to Treat Postoperative Recurrence of Squamous Cell Carcinoma-A Case Report].

We present an unusual case of late-onset acute pneumonitis developing 21 months after pembrolizumab monotherapy. An 80-year-old male with primary, pulmonary, squamous cell carcinoma underwent right lower lobectomy and lymph node dissection(ND2a-2); the postoperative pathological stage was ⅢA(pT2bN2M0)and the PD-L1 tumor proportion score 70%. Six months after surgery, he developed mediastinal lymph node(#2R), bilateral pulmonary, and hepatic metastases; pembrolizumab was administered every 3 weeks as a first-line treatment. A partial response was evident after 3 courses; we thus continued the monotherapy. However, after 28 courses(21 months)of pembrolizumab, we discontinued the regimen because acute pneumonitis(Grade 3)developed; we prescribed prednisolone at 50 mg/day. The acute pneumonitis shadow improved and prednisolone was tapered over 2 months. The patient exhibited no new lesion and no progressive disease 6 months after pembrolizumab was discontinued.

[Pulmonary Adenocarcinoma Responding to Fourth-Line S-1 Monotherapy-A Case Report].

Herein, we report a case of unresectable lung cancer in which S-1 monotherapy contributed to an improvement in the patient's quality of life and to prolonged survival. A 44-year-old man with primary pulmonary adenocarcinoma(negative driver mutation and a PD-L1 tumor proportion score of 1-24%)of clinical stage ⅢA(cT4N0M0)underwent multidisciplinary treatment as follows: 1 ) weekly carboplatin and paclitaxel plus radiotherapy as induction chemoradiotherapy, 2 ) surgery that revealed that the lesion was unresectable, 3 ) cisplatin plus pemetrexed as second-line treatment, and 4 ) pembrolizumab as third-line treatment. However, the disease progressed after 19 courses of pembrolizumab, and the patient developed cachexia due to esophageal stenosis caused by tumor enlargement. He underwent percutaneous gastrostomy and was fed via a gastrostomy tube. S-1 monotherapy(2-week administration every 3 weeks)was introduced as fourth-line treatment. After 3 courses of S-1 monotherapy, the patient complained of regurgitation of stomach fluid. Computed tomography( CT)revealed that the primary tumor had decreased in size, and he developed the ability to drink water. After 6 courses of S-1, CT revealed progressive disease, so atezolizumab was administered as fifth-line treatment. However, after 2 courses, mediastinitis due to esophageal penetration into the mediastinum occurred. The patient died 28 months after the initial treatment.

[Wedge Resection as an Alternative Procedure for Primary Pulmonary Carcinoma in Poor-risk Patients].

BACKGROUND: We present wedge resection as an alternative procedure for primary pulmonary carcinoma in poor-risk patients. PATIENTS AND METHODS: We examined the overall survival of 94 patients who underwent wedge resection for pN0M0 primary pulmonary carcinoma over the last 20 years because of their intolerance of lobectomy. RESULTS: In the wedge resection group, the postoperative 5-year survival in all causes of death was 59.6%, indicating significantly better prognoses in patients with adenocarcinoma aged less than 75 years old. The 5-year survival in the lobectomy group was 77.5%, while the 5-year survival in terms of primary causes of death in the wedge resection and lobectomy groups was 89.3% and 88.0%, respectively. There was a significant difference between wedge resection and lobectomy in all causes of death, but not between groups in primary causes of death. CONCLUSION: Because there were many non-primary deaths in the wedge resection group, care should be taken to follow comorbidities that cause limited lung resection. Survival in the wedge resection group was not inferior to that in the lobectomy group in analyses of the primary causes of death. We suggest that wedge resection should be a favorable procedure for primary pulmonary carcinoma in poor-risk patients to obtain a large enough sample volume of tumor cells.

[Successful Treatment of a Mechanically Ventilated Patient with an Oncological Emergency Caused by Recurrence of Pulmonary Adenocarcinoma].

We successfully treated a mechanically ventilated patient with severe respiratory failure caused by airway stenosis; she recovered after radiotherapy and gefitinib administration. A 68-year-old female with a pulmonary adenocarcinoma underwent a radical operation(right middle-lower sleeve lobectomy and lymph node dissection). Forty-four months later, she was admitted to our hospital with severe dyspnea, and was placed on mechanical ventilation after tracheal intubation. Postoperative cancer recurrence was evident in the bronchial mucosa and the site of carinal stenosis. Pathological examination revealed an epidermal growth factor receptor-positive adenocarcinoma. After radiotherapy(a total of 30 Gy), gefitinib(250mg/day) was commenced. Respiratory function improved gradually, and ventilator weaning was successful 3 weeks after tracheal intubation. Computed tomography revealed a partial response; her recovery from the emergency oncological situation was remarkable. She was discharged 4 months after hospitalization. Although she took gefitinib every 2-to-7 days, she refused all examinations and possible treatments for 25 months after recurrence. Finally, she died of respiratory failure 29 months after recurrence and 73 months after the initial operation.

[Multidisciplinary Approach to Recurrence after Resection of Primary Lung Cancer].

BACKGROUND: The standard approach for treating recurrence after complete resection of primary non-small cell lung cancer has been controversial. We present here a multidisciplinary strategy for postoperative recurrence in patients with primary lung cancer. PATIENTS AND METHODS: Over the last 7 years, we examined the disease-free survival and overall survival of 70 patients who underwent multidisciplinary treatment for recurrence after surgical resection of primary lung cancer. RESULTS: The median overall survival was 32.3 months after surgery and 17.4 months after recurrence developed, indicating significantly better prognoses in females and in patients with adenocarcinoma, stage I disease, driver mutation positivity, a longer postoperative disease-free period, and never smokers. Eight patients survived more than 5 years after recurrence;of these patients, all had adenocarcinomas, 7 had oligometastases and/or tumor dormancy, and 5 received multiple-drug regimens. CONCLUSION: Multidisciplinary treatment for recurrence after resection of primary lung cancer was effective for patients receiving various drug regimens. In patients with oligometastases, disease control was achieved by a combination of local treatments targeting each involved organ. In patients with tumor dormancy, follow-up or a drug holiday was important to maintain the patient's quality of life.

Histology is a Prognostic Indicator After Pulmonary Metastasectomy from Renal Cell Carcinoma.

OBJECTIVES: There are only a few detailed reports concerning the prognosticators following surgical resection of pulmonary metastases (PMs) from renal cell carcinoma (RCC). We investigated the prognosis of patients with RCC PMs undergoing pulmonary metastasectomy and identified prognostic factors in a multi-institutional retrospective study. METHODS: We retrospectively evaluated 84 patients who underwent resection of PMs from RCC between 1993 and 2014. We assessed the clinicopathological characteristics, focusing on the histological findings of PMs. We classified the histology into three types: pure clear cell carcinoma (N = 68), clear cell carcinoma combined with other histology type (N = 8), and non-clear cell carcinoma (N = 8). We examined the relationship between these histological types and the prognosis of patients with PMs from RCC. RESULTS: Complete resection was achieved in 78 patients (93%). The 5-year overall survival rate after metastasectomy was 59.7%. In multivariate analysis, three factors were found to be independent favorable prognostic factors of overall survival after lung metastasectomy [tumor size <2 cm, hazard ratio (HR) = 0.31, 95% confidence interval (CI) 0.13-0.78, P = 0.012; clear cell type, HR = 0.37, 95% CI 0.16-0.83, P = 0.025; and complete resection, HR = 0.27, 95% CI 0.10-0.78, P = 0.015]. CONCLUSIONS: This study indicates that a histological finding of the clear cell type is a significant favorable prognostic factor in addition to complete resection and a tumor size <2 cm. Histological evaluation of PM lesions is important for predicting survival after metastasectomy.

A minimally invasive technique for stabilizing the diaphragm on the thoracic wall after blunt chest trauma: the "lifting-up method".

Most traumatic diaphragmatic tears are located centrally or radially and may be amenable to repair by direct suturing or suturing with a surgical patch. However, diaphragmatic tears, such as those immediately adjacent to the costal margin, are uncommon. We describe how we repaired this type of tear using a needle loop retractor to pass a 2-0 braided suture through the chest wall on both sides of the rib to suture the torn diaphragm to the chest wall. Our technique is more physiologically and anatomically consistent than previously reported techniques. We have termed this technique the "lifting-up method", which we believe to be an easy and useful technique for repairing traumatic diaphragmatic injuries with no seam allowance.