Phase III study of adjuvant gemcitabine compared with adjuvant uracil-tegafur in patients with completely resected pathological stage IB-IIIA non-small cell lung cancer (WJTOG0101).

BACKGROUND: Adjuvant oral uracil-tegafur (UFT) has led to significantly longer postoperative survival among patients with non-small-cell lung cancer (NSCLC). Gemcitabine (GEM) monotherapy is also reportedly effective for NSCLC and has minor adverse events (AEs). This study compared the efficacy of GEM- versus UFT-based adjuvant regimens in patients with completely resected pathological stage (p-stage) IB-IIIA NSCLC. PATIENTS AND METHODS: Patients with completely resected p-stage IB-IIIA NSCLC were randomly assigned to GEM or UFT. The primary endpoint was overall survival (OS); secondary endpoints were disease-free survival (DFS), and AEs. RESULTS: We assigned 305 patients to the GEM group and 303 to the UFT group. Baseline factors were balanced between the arms. Of the 608 patients, 293 (48.1%) had p-stage IB disease, 195 (32.0%) had p-stage II disease and 121 (19.9%) had p-stage IIIA disease. AEs were generally mild in both groups, and only one death occurred, in the GEM group. After a median follow-up of 6.8 years, the two groups did not significantly differ in survival: 5 year OS rates were GEM: 70.0%, UFT: 68.8% (hazard ratio 0.948; 95% confidence interval 0.73-1.23; P = 0.69). CONCLUSION: Although GEM-based adjuvant therapy for patients with completely resected stage IB-IIIA NSCLC was associated with acceptable toxicity, it did not provide longer OS than did UFT.

Robot-assisted single-port surgery for mediastinal tumors.

We successfully performed totally endoscopic single-port robotic surgery. A 50-year-old man with a mediastinal tumor underwent robot-assisted tumor resection. Only one port was placed on the right side of the chest, and a robotic endoscope and two robotic instruments were inserted through the port. The instruments were crossed while avoiding collision. Single-port robotic surgery for a mediastinal tumor using the cross-arm technique was safely achieved with good clinical results and excellent cosmetic results.

The Outcomes of a Limited Resection for Non-Small Cell Lung Cancer Based on Differences in Pathology.

OBJECTIVE: A precise preoperative diagnosis of in situ or minimally invasive carcinoma may identify patients who can be treated by limited resection. Although some clinical trials of limited resection for lung cancer have started, it will take a long time before the results will be published. We have already reported a large-scale study of limited resection. We herein report the data for a subclass analysis according to differences in pathology. METHODS: Data from multiple institutions were collected on 1710 patients who had undergone limited resection (segmentectomy or wedge resection) for cT1N0M0 non-small cell carcinoma. The disease-free survival (DFS) and recurrence-free proportion (RFP) were analyzed. Small cell carcinomas and carcinoid tumors were excluded from this analysis. Adenocarcinomas were sub-classified into four groups using two factors, the ratio of consolidation to the tumor diameter (C/T) and the tumor diameter alone. RESULTS: The median patient age was 64 (20-75) years old. The mean maximal diameter of the tumors was 1.5 ± 0.5 cm. The DFS and RFP at 5 years based on the pathology were 92.2 and 94.7 % in adenocarcinoma (n = 1575), 76.3 and 82.4 % in squamous cell carcinoma (SqCC) (n = 100), and 73.6 and 75.9 % in patients with other tumors (n = 35). The prognosis of adenocarcinoma in both groups A (C/T ≤0.25 and tumor diameter ≤2.0 cm) and B (C/T ≤0.25 and tumor diameter >2.0 cm) was good. In SqCC, only segmentectomy was a favorable prognostic factor. In the groups with other pathologies, large cell carcinomas were worse in prognosis (the both DFS and RFP: 46.3 %). CONCLUSION: Knowing the pathological diagnosis is important to determine the indications for limited resection. Measurement of the tumor diameter and C/T was useful to determine the indications for limited resection for adenocarcinoma. Limited resection for adenocarcinomas is similar with a larger resection, while the technique should be performed with caution in squamous cell carcinoma and other pathologies.

Intrathoracic vagus nerve tumor: case report and review of the literature.

We present the case of a 23-year-old female with benign intrathoracic vagal neurofibroma associated with von Recklinghausen's disease. We reviewed 87 other neurogenic tumors of the intrathoracic vagus nerve and discuss the incidence rate of complications, especially the relationship between tumor location, tumor size, and preservation of the nerve in this case report.

Simultaneous surgical correction of pectus excavatum and cardiac disease in two adults.

Thoracic reconstruction in patients with pectus excavatum with concomitant cardiac or aortic surgery poses a major clinical challenge. The report describes two cases of adult patients undergoing simultaneous surgical correction of cardiac disease and sternal deformity using one of two different techniques: a sterno-turnover method preserving the rectus muscle or a sternal elevation method with A-O plates.

Can Artificial Intelligence Replace Humans for Detecting Lung Tumors on Radiographs? An Examination of Resected Malignant Lung Tumors.

OBJECTIVE: Although lung cancer screening trials have showed the efficacy of computed tomography to decrease mortality compared with chest radiography, the two are widely taken as different kinds of clinical practices. Artificial intelligence can improve outcomes by detecting lung tumors in chest radiographs. Currently, artificial intelligence is used as an aid for physicians to interpret radiograms, but with the future evolution of artificial intelligence, it may become a modality that replaces physicians. Therefore, in this study, we investigated the current situation of lung cancer diagnosis by artificial intelligence. METHODS: In total, we recruited 174 consecutive patients with malignant pulmonary tumors who underwent surgery after chest radiography that was checked by artificial intelligence before surgery. Artificial intelligence diagnoses were performed using the medical image analysis software EIRL X-ray Lung Nodule version 1.12, (LPIXEL Inc., Tokyo, Japan). RESULTS: The artificial intelligence determined pulmonary tumors in 90 cases (51.7% for all patients and 57.7% excluding 18 patients with adenocarcinoma in situ). There was no significant difference in the detection rate by the artificial intelligence among histological types. All eighteen cases of adenocarcinoma in situ were not detected by either the artificial intelligence or the physicians. In a univariate analysis, the artificial intelligence could detect cases with larger histopathological tumor size (p < 0.0001), larger histopathological invasion size (p < 0.0001), and higher maximum standardized uptake values of positron emission tomography-computed tomography (p < 0.0001). In a multivariate analysis, detection by AI was significantly higher in cases with a large histopathological invasive size (p = 0.006). In 156 cases excluding adenocarcinoma in situ, we examined the rate of artificial intelligence detection based on the tumor site. Tumors in the lower lung field area were less frequently detected (p = 0.019) and tumors in the middle lung field area were more frequently detected (p = 0.014) compared with tumors in the upper lung field area. CONCLUSIONS: Our study showed that using artificial intelligence, the diagnosis of tumor-associated findings and the diagnosis of areas that overlap with anatomical structures is not satisfactory. While the current standing of artificial intelligence diagnostics is to assist physicians in making diagnoses, there is the possibility that artificial intelligence can substitute for humans in the future. However, artificial intelligence should be used in the future as an enhancement, to aid physicians in the role of a radiologist in the workflow.

Robotic Right Lower Lobectomy in a Patient With V2 and V4+5 Pulmonary Vein Variation Merging Into the Lower Pulmonary Vein: A Case Report.

Several variations of pulmonary vein (PV) branching patterns exist. Since robot-assisted thoracoscopic surgery (RATS) is performed with magnified vision, it is crucial to carefully identify the running pattern of blood vessels before and during surgery. We present a case of a 77-year-old male patient with right lower lobe lung cancer. Right lower lobectomy via RATS was scheduled. Chest CT before surgery confirmed that the middle lobe PV (V4+5) merged with the inferior PV. Three-dimensional multidetector CT (3D-MDCT) subsequently confirmed that not only V4+5 but also the posterior segmental vein of the upper lobe (V2) merged with the inferior PV. We should have taped the lower lobe PV only, but we also taped the V2 and the middle lobe vein. However, since the oblique fissure was separated before cutting the taped blood vessel, the cutting of the blood vessel to be preserved was avoided. Surgeons should have a detailed understanding of the running patterns of pulmonary blood vessels before surgery to perform the procedure safely. Preoperative 3D-MDCT is useful for identifying the running pattern of blood vessels. An abnormality involving V2 and V4+5 merging into the inferior PV can also occur; hence, during right lower lobe resection, by dividing the lower lobe PV after the oblique fissure division, the surgeon can avoid unexpected transection of anomalous PVs that should be preserved.

Demonstration of Japanese radiographic examination codes in establishing typical values for a wide variety of general radiography examinations.

The purpose of this study was to demonstrate Japanese radiographic examination codes JJ1017 in establishing typical values for a wide variety of general radiography. About 200,000 sets of examination data were collected, including exposure conditions, JJ1017 code applied, examination room numbers and patient information. Typical values for adults, children, and infants were calculated from the collected data, and the following items were examined: comparing typical values of general radiography in Japan DRLs 2015 and typical values in a facility; comparison of typical values between X-ray equipment for examinations of DRLs 2015; comparison of typical values for different procedures at the same anatomical site; identification of examination items associated with high radiation doses. The total numbers of JJ1017 codes applicable to the examinations were 45,372 for adults, 542 for children, and 2339 for infants. To calculate the typical values and compare these with the DRLs, we used a combination of JJ1017 anatomical codes, posture codes, and direction of radiation codes. The combination of these codes allowed the calculation of a typical value and comparison with DRLs 2015. Comparison between devices reveals differences in radiation doses and provides an opportunity to review the characteristics of the devices and their operation to suggest dose reductions. By calculating typical values for examination items for which the DRLs were not available, we were able to identify examination items with high doses in a facility and suggest items that should be audited in the facility.

Robotic Lobectomy with a Single Robotic Stapler from One 12-mm Port: A Multi-institutional Study.

Introduction of the robotic stapler has allowed robotic lobectomy to be performed from a surgical console in complete autonomy. The robotic stapler fits a 12-mm port, which is larger than the standard 8-mm port and increases the risk of postoperative pain. However, in many cases, to cover all possible angles of approach, two 12-mm ports are preferably used. However, limiting instrument inventory and simplifying surgical procedures are also desirable to reduce costs. In a multicenter study, we assessed the feasibility of robotic lobectomy with a single type of robotic stapler [SureForm45 Curved-Tip (SF45C); Intuitive Surgical Inc.] inserted through one 12-mm port placed at the anterior tip of the lower intercostal space. We also investigated the potential cost savings of using an additional 60-mm stapler for interlobar division. A total of 135 lobectomy cases were enrolled. In all cases, all stapling procedures were completed using the SF45C inserted from the designated 12-mm port. We found that it was potentially less expensive to use the SureForm60 stapler if more than six SF45C reloads were needed for interlobar division. However, in our series, only 1 case (0.7%) met this requirement. The use of a single type of stapler from one 12-mm port in a robotic lobectomy is technically feasible. This approach may be expected to allow for surgical simplification, minimize the risk of postoperative pain, and reduce inventory costs.

Needlescopic video-assisted wedge resection combined with the subcostal trans-diaphragmatic approach for undetermined peripheral pulmonary nodules.

BACKGROUND: Reduced mortality from lung cancer by computed tomography (CT) screening facilitates the use of video-assisted thoracic surgery (VATS) lung wedge resection to obtain a definite diagnosis and to treat tiny nodules. The authors evaluated their initial experience using novel needlescopic VATS wedge resection combined with the subcostal trans-diaphragmatic (SCTD) approach for managing undetermined peripheral pulmonary nodules. METHODS: Between 2009 and 2012, 35 patients who had 36 operations underwent needlescopic VATS wedge pulmonary resection with the SCTD approach. Preoperative percutaneous CT-guided marking of the nodule was performed. Two 3-mm miniports were placed in the thorax for the thoracoscopic camera and minigrasper. Just anterior to the 10th rib, a 2-cm subcostal incision was made, and a 12- or 15-mm port was placed trans-diaphragmatically into the chest cavity. Wedge resection of the lung was performed with endostaplers introduced through a subcostal port. RESULTS: The median tumor size was 1.1 cm. Localization of the tumor was widely distributed. The mean operation time was 51 min, and the mean blood loss was 4.2 mL. No patients required conversion to thoracotomy, and one patient required conversion to conventional VATS. Additional thoracic ports were placed in five patients, and the needlescopic incision was extended to 15 mm in one patient. The median duration of chest drainage was 1 day. Additional analgesia was not required for 22 patients and was used for less than 1 day for three patients, less than 2 days for seven patients, and less than 3 days for seven patients. The pathologic diagnosis of the nodules was malignant for 28 patients and benign for 8 patients. On postoperative day 7 or at admission, 34 patients were free of postoperative neuralgia. CONCLUSIONS: Needlescopic VATS wedge pulmonary resection combined with the SCTD approach is both safe and feasible and offers the specific advantages of minimal invasiveness and good cosmetic outcomes.

Outcome prediction of pulmonary metastasectomy can be evaluated using metastatic lesion in osteosarcoma patients.

BACKGROUND: We investigated whether molecular prognostic factors should be evaluated in specimens of the primary or the metastatic lesion and if the prognosis after initial pulmonary metastasectomy can be predicted based on evaluation of metastatic lesion specimens in osteosarcoma patients. METHODS: This retrospective study included 29 osteosarcoma patients with pulmonary metastases (19 males, 10 females; age 21 ± 10 years). Molecular prognostic factors were the levels of vascular endothelial growth factor type A (VEGF-A), VEGF type C (VEGF-C), and Ki67. Primary and pulmonary metastatic lesions could be compared in 18 patients regarding the values of marker expressions and the prognosis after initial pulmonary resection. Finally, the prognosis of all 29 cases was compared according to the molecular markers of the metastatic lesions. RESULTS: Evaluation of the metastatic lesions reflected the prognosis after pulmonary metastasectomy more than that of the primary lesions. In the metastatic lesions, positive expression of VEGF-A (n = 15), VEGF-C (n = 2), and Ki67 (n = 15) was associated with a significantly poorer prognosis (p = 0.0013, 0.0001, and 0.037, respectively). No patients with positive expression of both VEGF-A and Ki67 (n = 7) survived more than 5 years after the initial pulmonary resection. All patients who had negative reactions to both VEGF-A and Ki67 (n = 6) were alive at the end of the study. CONCLUSIONS: Molecular prognostic factors should be investigated in specimens of the metastatic lesion. Combined evaluation of VEGF-A and Ki67 and of VEGF-C using pulmonary metastatic lesion specimens in osteosarcoma patients effectively reflects survival after pulmonary metastasectomy.

[Re-thoracotomy for the management of postoperative complications after bronchoplastic and angioplastic reconstruction].

Bronchoplastic and angioplastic reconstructions have become a common procedure as an alternative to pneumonectomy and provide an improved quality of life, which maximize residual lung tissue. Anastomotic complications in these procedures, such as anastomotic stricture, dehiscence, and vascular thrombosis, remain a matter of concern and are often fatal. Several different therapeutic approaches for these complications have been reported. In this paper, the management with re-thoracotomy for postoperative complications after bronchoplastic and angioplastic reconstructions are described.

U-clip for airway reconstruction: an experimental study of the feasibility of a robot-assisted endoscopic procedure.

BACKGROUND: The U-clip anastomotic device was developed to facilitate interrupted anastomoses without the need to tie sutures. Recently, this technology has been expanded into various fields of surgery. However, in the field of airway reconstruction, there have been no previous reports of this technology being used. The present study examined the technical feasibility of performing safe and efficient robot-assisted endoscopic airway reconstruction using nitinol U-clips in rabbits. METHODS: A total of six tracheal anastomoses with S60 U-clips were performed using the da Vinci Surgical System. Anastomosis time and complications were recorded. The effectiveness of anastomoses was evaluated by postoperative observation of rabbits for 8 weeks and measurement of anastomotic strictures and pathological findings. RESULTS: All procedures were completed safely. Mean procedure time was 14 ± 1.8 min (mean ± SD). There were no perioperative complications; however, all animals died between postoperative days 14-27, and anastomotic stricture was the likely cause of death. All anastomoses had severe strictures; the mean stricture rate was measured as being 51.1 ± 33.3 (%). CONCLUSIONS: Although the technical feasibility of robot-assisted endoscopic airway reconstruction using U-clips has been demonstrated in rabbits, the safety of this technique has not been evaluated. Our data suggest that U-clips are not a feasible approach for airway reconstruction surgery because of the occurrence of severe postoperative anastomotic stricture.

Robot-assisted resection of multiple schwannomas of the neck and mediastinum through an axillary approach.

A 49-year-old woman was referred to our department for increased schwannoma of the right neck and mediastinum. We chose a robot-assisted endoscopic approach to minimize the operative trauma. After exposure of the thyroid through the right axilla, the neck tumor was resected using the da Vinci Surgical System. A mini-thoracotomy was then made in the left third intercostal space through the axillary incision, robotic instruments were introduced across the thoracic cavity, and the tumor was excised circumferentially using the robot. Histopathological examination of both specimens revealed schwannomas. This procedure has benefited the patient with good cosmetic results and allowed her to rapidly resume her daily activities.

Pattern and predictors of false positive lymph node involvement on positron emission tomography in patients with non-small cell lung cancer.

Objectives The aim of this study was to elucidate the optimal parameters for diagnosing false positive (FP) lymph nodes (LNs) in patients with non-small cell lung cancer.Methods We reviewed 292 patients with non-small cell lung cancer (NSCLC). Fluorodeoxyglucose positron emission tomography (FDG-PET) imaging was performed at 1 hour (early) post-FDG injection and repeated 2 hours (delayed) after injection. We analyzed the relationship between the pathology of LNs and the results of PET, and the percent change in the standardized uptake value (%ΔSUV) between the two time-points.Results Eighteen of 46 cases (39.1%) in the FP group showed higher SUVs for their LNs compared with those for primary tumor, whereas 13.2% in the true positive group (p = 0.032) had higher SUVs for their LNs. Thirty-four of 36 cases in the true positive group had %ΔSUV ranging from 0% to 61.5% compared with only 13 of 33 in the FP group. Twenty out of 22 cases (90.9%) where %ΔSUV was over 61.5% or under 0% were considered as FP.Conclusions Patients with higher SUVs for LNs than for primary tumors and patients with extremely high or low %ΔSUVs tended to have FP LNs.

Massive hemothorax due to diaphragmatic endometriosis after a laparoscopic cystectomy of an ovarian endometrioma in a patient without a history of thoracic endometriosis.

BACKGROUND: Severe hemothorax is a rare complication after laparoscopic surgery for endometriosis, and the causes and proper management are not well understood. CASE: We report here the extremely rare case with massive hemothorax after laparoscopic surgery for ovarian endometrioma. A 40-year-old woman, gravida 1, para 1, underwent laparoscopic cystectomy of ovarian endometrioma. On postoperative day 2, she had progressive anemia (Hb 5.3) as well as dyspnea. A chest X-ray and computed tomography showed massive fluid collection in the right thoracic cavity, suggestive of intrapleural bleeding. TREATMENT: Thoracoscopic operation was performed and a total of 930 ml of blood retention in the right thoracic cavity was found. Scattered small endometriotic lesions were present on the pleural surface of the right diaphragm; pulsatile active bleeding was confirmed from one of these. Furthermore, two endometriotic lesions had perforated into the intraperitoneal cavity. The diaphragm containing bleeding spots was thoracoscopically resected and sutured. After thoracoscopic surgery, the dyspnea and anemia resolved. On postoperative day 5, the patient left the hospital. CONCLUSION: The present report reminds us of the importance of paying special attention to postoperative-thoracic complications caused by diaphragmatic endometriosis if the patient shows respiratory symptoms.

[Total port-access robot-assisted lobectomy for lung cancer].

We reported 2 cases of total port-access right lower lobectomy with hilar and mediastinal lymph nodal dissection using the da Vinci surgical system through subcostal trans-diaphragmatic approach. In case 1, the operating time was 6 hours 00 minutes, and the total blood loss was little. In case 2, the operating time was 6 hours 30 minutes, and the total blood loss was little. The da Vinci surgical system provides a high-resolution stereoscopic image and allows remote, tremor-free, and scaled control of endoscopic surgical instruments with 7 degrees of freedom. Minimally invasive robot-assisted lobectomy is an effective procedure and may add benefits for both surgeon and patients.

[Rapid multidisciplinary therapy for an advanced lung cancer patient with severe tracheal stenosis resulting in long-term survival].

A 61-year-old female was admitted to our hospital due to dyspnea and facial edema. A chest CT scan showed stenosis of the trachea and superior vena cava due to a tumor around the trachea. She underwent partial resection of the tracheal tumor via a rigid bronchoscope introduced into the trachea, and placement of a Dumon Y-stent. Undifferentiated non-small cell lung cancer was diagnosed. After airway management, she underwent cisplatin-based chemoradiotherapy and total 56 Gy stereotactic radiotherapy for the tumor. The tumor size was reduced by 40% immediately after chemoradiotherapy. Six months after the tracheal stent insertion, bone metastases were pointed out, and we changed the chemotherapy regimen to gefitinib. She has been in good condition without tumor growth for more than six years after tracheal stent insertion.

The new method to make diagnosis and identify the location of leakage of pleuroperitoneal communication in peritoneal dialysis patients.

Pleuroperitoneal communication is a severe complication in peritoneal dialysis, and about half of the patients forced to discontinue peritoneal dialysis. The method of coloring dialysis solution by indocyanine green or CT peritoneography have been reported to make diagnosis of pleuroperitoneal communication, however sensitivity of these tests is not a satisfactory level. By repairing the pleural hole with thoracoscopic surgery, it is possible to resume peritoneal dialysis. However, the recurrence rate is very high unless precisely detecting the location of the pleural hole during surgery. We report three cases of pleuroperitoneal communication in peritoneal dialysis patients, in which we found the combination of contrast-enhanced ultrasonography and the indocyanine green fluorescence system are reliable method to make diagnosis and identify the location of leakage of pleuroperitoneal communication. By making definite diagnosis and precisely identifying the localization, we were able to close diaphragm holes by video-assisted thoracoscopic surgery.

Radiologic and nuclear medicine predictors of tumor invasiveness in patients with clinical stage IA lung adenocarcinoma.

BACKGROUND: The aim of this study was to analyze parameters to predict tumor invasiveness according to high-resolution computed tomography and positron emission tomography in patients with clinical stage IA lung adenocarcinoma. METHODS: A total of 122 patients with clinical stage IA lung adenocarcinoma were enrolled in the study. Receiver operating characteristic (ROC) curves were constructed for three factors--the degree of solid tumor component (solid%), maximum standard uptake value (SUVmax) and tumor size--and cutoff values were determined to reveal the highest sensitivity and specificity to diagnose tumor invasiveness. We created an algorithm for detecting tumor invasiveness (model 1). The data for the three factors were combined and their ROC curves constructed (model 2). A prospective study was conducted to validate the utility of these models. RESULTS: Multivariate analysis identified solid%, SUVmax, and tumor size as potentially important predictors of tumor invasiveness. In the ROC curve analysis, solid% (area under the curve was 0.882) had the largest area under the curve, followed by the SUV (0.867) and tumor size (0.747). The combination assay using all three factors had the highest sensitivity and specificity for prediction (0.902). Models 1 and 2 were applied to the prospectively enrolled cases, and their utility was reviewed. Both models showed 100% sensitivity, with model 2 showing a slightly higher diagnostic value than model 1. CONCLUSIONS: The solid portion ratio was a more powerful clinical predictor for lymphovascular invasion than the SUVmax. Our novel scoring model for tumor invasiveness can be employed for preoperative assessment of tumor invasiveness.