The surgical Apgar score predicts postoperative complications and the survival in lung cancer patients.

PURPOSE: The surgical Apgar score (SAS)-calculated using the intraoperative variables estimated blood loss, lowest heart rate, and lowest mean systolic pressure-is associated with mortality in cancer surgery. We investigated the utility of the SAS in patients with lung cancer undergoing surgery. METHODS: We retrospectively analyzed the data of 691 patients who underwent surgery for primary lung cancer between 2015 and 2019 in a single institute and analyzed the impact of the SAS. RESULTS: Of the 691 patients, 138 (20%), 57 (8.2%), and 7 (1.0%) had postoperative complications of all grades, grades ≥ III, and grade V, respectively, according to the Clavien-Dindo classification. The C-index for postoperative complications of grades ≥ III was 0.605. A lower score (0-5 points) (odds ratio 3.09 against 8-10 points, P = 0.04) and a lower percentage of vital capacity (odds ratio 0.97, P = 0.04) were independent negative risk factors for major postoperative complications. Patients with a lower score (0-5 points) had poor 5-year overall and cancer-specific survival rates (60.1% and 72.3%, respectively; P < 0.05 for both). CONCLUSIONS: The surgical Apgar score predicted postoperative complications and the long-term survival. Surgeons may improve surgical results using the SAS.

[Radiofrequency Ablation for Pulmonary Metastasis of Ovarian Cancer Caused Iatrogenic Pneumothorax, Leading to Empyema].

A female patient in her 40s who underwent surgery for recurrent right lung metastasis from resected ovarian cancer was referred to our department because of the right pneumothorax due to radiofrequency ablation for multiple lung metastases. Methicillin-resistant Staphylococcus epidermidis( MRSE) was detected from the tip of the drainage catheter indicated persistent pulmonary fistula with right empyema, and surgical treatment was performed. A white coat of the whole lung surface and air leakage were observed at radiofrequency ablation (RFA) treated lesion and partial resection of the right lung, debridement, and irrigation were performed. A pathological examination revealed residual viable ovarian cancer cells and pleural fistula.

[Giant Bullae Misdiagnosed as Pneumothorax:Report of a Case].

A 46-year-old man was taken to a hospital by ambulance because of sudden onset of dyspnea, and was inserted chest drainage tube with a diagnosis of right-sided tension pneumothorax on chest X-ray. Since the chest drainage was not effective, he was transferred to our institute. Based on chest computed tomography (CT) findings, a diagnosis of giant bullae of the right lung was made, and surgical treatment was performed. Postoperatively, the improvement of respiratory function was confirmed.

[Multiple Metastatic Lung Tumors in the Left Upper Lobe Complicated with Hypoplasia and Chronic Atelectasis of the Left Lower Lobe:Report of a Case].

An 80-year-old man with surgical history of colon cancer was referred to our department for surgical treatment for multiple metastatic lung tumors in the left upper lobe. The patient had been showing complete atelectasis of the left lower lung lobe one year prior to the consultation. Six months after wedge resections for the pulmonary metastases, the left lower lobe was re-expanded, showing bronchiectasis with rudimentary pulmonary artery branches. Further, the ventilation-perfusion scintigraphy showed decreased uptake in the left lower lobe. These findings indicated that the patient had the hypoplasia of the left lower lobe.

Past, present, and future perspectives of pulmonary metastasectomy for patients with advanced colorectal cancer.

Over a half-century has passed since Thomford et al. proposed the selection criteria for pulmonary metastasectomy, and several prognostic factors have been identified. Although screening modalities and operations have changed dramatically, the important concepts of the selection criteria remain unchanged. Recent improvements in the survival outcomes of colorectal cancer patients undergoing pulmonary metastasectomy may be the result of strict adherence to the selection criteria for oligometastatic lung tumors, which can mimic local disease. Pulmonary metastasectomy has become an important option for selected patients with oligometastasis, based mainly on a large amount of retrospective data, but its effect on survival remains unclear. Curable pulmonary metastasis might be regarded as a "semi-local disease" under the spontaneous control of an acquired alteration in host immune status. The current practice of pulmonary metastasectomy for colorectal cancer focuses on selecting the most appropriate operation for selected patients. However, in the rapidly evolving era of immunotherapy, treatment-naïve patients for whom surgery is not suitable might be pre-conditioned by immunotherapy so that they may be considered for salvage surgery.

The predictive value of preoperative risk assessments and frailty for surgical complications in lung cancer patients.

PURPOSE: To assess the predictive value of frailty and risk assessments for postoperative complications in lung cancer patients, we reviewed various risk indicators: including FEV1, ppoFEV1, the Zubrod performance status, the American Society of Anesthesiologist score, and risk models based on the Japan National Clinical Database (NCD) and the European Society of Thoracic Surgeons (ESTS) database. METHODS: Patients who underwent elective surgery between April 2016 and May 2019 were enrolled. A statistical analysis was performed to compare any differences among the risk indicators. RESULTS: The total number of patients enrolled was 193. Thirteen patients (6.7%) were classified as frail and 28 (14.5%) as pre-frail. Among the various risk indicators, the risk models based on the Japan NCD and the ESTS database revealed statistically significant differences in patients with and without postoperative complications (p value < 0.0001 and 0.0049, respectively), although there were no significant differences in frailty. The area under the receiver operating characteristic curve for risk models based on the Japan NCD registry and the ESTS registry was 0.70 and 0.64, respectively. CONCLUSIONS: Our analyses of a series of lung cancer patients showed that frailty was not a significant predictor of postoperative outcomes, while risk models based on academic society databases were found to have a significant predictive value.

[Left Upper Lung Cancer with Mediastinal Inferior Lober Branch of Pulmonary Artery].

We herein report a rare case of an antero-basal pulmonary artery that was noticed during left upper lung lobectomy. A 61-year-old man underwent surgery and radiation for a brain tumor, which was diagnosed as a solitary metastasis of the primary lung cancer in the upper lobe of the left lung. He underwent left upper lobectomy for the lung cancer. During the operation, the left A4+5 and A8b+9+10 was found to be diverged from the main left pulmonary artery as the first branch, which descended between the left upper pulmonary vein and the left upper bronchus. The left upper lobe was successfully resected with preserving the A8b+9+10. This variation was not recognized preoperatively. Careful dissection along the pulmonary vessels is essential to prevent cutting off the unexpected aberrant anatomy.

[Pulmonary Nontuberculous Mycobacteriosis Difficult to Differentiate from Local Recurrence of the Metastatic Lung Tumor of the Uterine Cervix Cancer at the Staple-line:Report of a Case].

A 70-year-old woman underwent right S6 segmentectomy and left S6 partial resection for lung metastasis of uterine cervix cancer. Although she received adjuvant chemotherapy, chest computed tomography revealed a new pulmonary nodule on the staple stump of the right lung. We diagnosed the tumor as local recurrence at the stump and planned to continue chemotherapy. However, the size of the tumor increased, and we performed right middle and lower lobectomy. Based on the pathological and bacteriological examinations, an epithelioid cell granuloma infected by Mycobacterium avium was established.

[Pulmonary Benign Metastasizing Leiomyoma Found as Multiple Bilateral Lung Nodules 11 Years after Hysterectomy;Report of a Case].

Pulmonary benign metastasizing leiomyoma (PBML) is a rare entity. We herein report a case of PBML found as multiple bilateral lung nodules 11 years after total hysterectomy. The patient was a 53-year-old woman with past surgical history of abdominal total hysterectomy for a uterine leiomyoma at the age of 42. She was referred to our department for further evaluation of multiple pulmonary nodules detected by a chest radiography. A chest computed tomography revealed multiple bilateral small lung nodules less than 10 mm in diameter. 18-fluorodeoxyglucose (FDG) positron emission tomography showed no significant FDG accumulation to these nodules. The patient finally underwent video assisted thoracoscopic wedge resection of the lower lobe of the right lung for surgical biopsy. The final pathological diagnosis was PBML, based on the comparative evaluation of the surgical specimens from the lung and the uterus. No evidence of enlargement in the remaining pulmonary nodules was noted for 9 months after surgical lung biopsy.

Measurement of intrapleural pressure in patients with spontaneous pneumothorax: a pilot study.

BACKGROUND: The initial management of pneumothorax remains controversial, and we speculated that this might be because there is no method available for evaluation of air leak during initial management. We have developed a system for measurement of intrapleural pressure in pneumothorax to address air leak without the need for chest drainage. The aim of this clinical study was to confirm the ability of this measurement system and to determine the clinical impact of management of air leak. METHODS: Patients in whom need aspiration was indicated for spontaneous pneumothorax were enrolled in the study. The intrapleural pressure was measured during stable breathing and data recorded when patients were coughing were excluded. RESULTS: Eleven patients were enrolled in the study between December 2016 to July 2017. The patterns in change of intrapleural pressure varied widely depending on the state of the pneumothorax. The mean intrapleural pressure values on end-inspiration and end-expiration in patients with persistent air leak was significantly lower than those in patients without persistent air leak (p = 0.020). The number of negative mean pressure recordings in end-inspiration and end-expiration was significantly lower in patients with persistent air leak than in those without persistent air leak (p = 0.0060). CONCLUSIONS: In this study, we demonstrated that intrapleural pressure could be successfully measured and visualized in patients with pneumothorax. Whether or not the pressure value is a predictor of persistent air leak needs to be confirmed in the future.

[Outcome of Limited Resection for Early Stage Non-small Cell Lung Cancer].

OBJECTIVES: Recent advancement in detection of small-sized early-stage lung cancer has made limited lung resection with curative intent a practical and vital option. In this retrospective study, we investigated the validity of choice of procedures at our institute with examining the survival outcomes of lung cancer patients who underwent surgery. METHODS: Data from consecutive patients with cTanyN0M0 lung cancer who underwent surgery between January 2006 and December 2012 were extracted by chart review, and the overall and recurrence-free survivals of the patients operated by wedge resection, by segmentectomy and by lobectomy were compared using the univariate and multivariate Cox proportional hazard model. A stepwise backward elimination method with a probability level of 0.15 was used to select the most powerful sets of outcome predictors. For all analyses, a p-value<0.05 was considered statistically significant. RESULTS: Limited lung resection (wedge resection and segmentectomy) were selected for higher age patients, for lower respiratory function patients and for smaller size tumor than lobectomy group. By univariate and multivariate analysis, surgical procedure was not identified as independent risk factor for overall and recurrence-free survival. CONCLUSION: In this study cohort, mode of surgical procedure did not affect the relapse risk and prognosis. The choice of procedures at our institute in this study period seemed to be appropriate.

[Multilocular Thymic Cyst with Calcification;Report of a Case].

A female in her 40s was admitted with an abnormal shadow on chest X-ray. A chest computed tomography (CT) revealed an anterior mediastinal cystic mass with calcification. We suspected the tumor to be a teratoma, and surgery was performed. The tumor was connected with the thymus, and did not infiltrate to the surrounding tissues. Macroscopically, the cyst was multiloculated with fibrous walls. Microscopically, thymic tissue was noted in the cyst wall, with neither thymic epithelial tumor nor teratoma. The cyst wall contained collagen fibers, cholesterol clefts, and calcification. Based on these findings, the tumor was diagnosed as multilocular thymic cyst with calcification.

Ultraflexible, large-area, physiological temperature sensors for multipoint measurements.

We report a fabrication method for flexible and printable thermal sensors based on composites of semicrystalline acrylate polymers and graphite with a high sensitivity of 20 mK and a high-speed response time of less than 100 ms. These devices exhibit large resistance changes near body temperature under physiological conditions with high repeatability (1,800 times). Device performance is largely unaffected by bending to radii below 700 µm, which allows for conformal application to the surface of living tissue. The sensing temperature can be tuned between 25 °C and 50 °C, which covers all relevant physiological temperatures. Furthermore, we demonstrate flexible active-matrix thermal sensors which can resolve spatial temperature gradients over a large area. With this flexible ultrasensitive temperature sensor we succeeded in the in vivo measurement of cyclic temperatures changes of 0.1 °C in a rat lung during breathing, without interference from constant tissue motion. This result conclusively shows that the lung of a warm-blooded animal maintains surprising temperature stability despite the large difference between core temperature and inhaled air temperature.

A deep azygoesophageal recess may increase the risk of secondary spontaneous pneumothorax.

PURPOSE: The azygoesophageal recess (AER) is known as a possible cause of bulla formation in patients with spontaneous pneumothorax. However, there has been little focus on the depth of the AER. We evaluated the relationship between the depth of the AER and pneumothorax development. METHODS: We conducted a retrospective study of 80 spontaneous pneumothorax patients who underwent surgery at our institution. We evaluated the depth of the AER on preoperative computed tomography scans. RESULTS: Ruptured bullae at the AER were found in 12 patients (52.2%) with secondary spontaneous pneumothorax (SSP) and 8 patients (14.0%) with primary spontaneous pneumothorax (PSP) (p < 0.001). In patients with ruptured bullae at the AER, 10 SSP patients (83.3%) had a deep AER while only 2 PSP patients (25%) had a deep AER (p = 0.015). CONCLUSIONS: A deep AER was more frequently associated with SSP than with PSP. A deep AER may contributes to bulla formation and rupture in SSP patients.

[Postoperative Chylotholax;Intraoperative Prevention and Postoperative Management].

Postoperative chylothorax is a relatively rare but potentially fatal complication caused by iatrogenic injury to thoracic duct system, with an incidence ranging from 2 to 4% after major lung surgery or esophagectomy. The pathophysiologic features of chylothorax include dehydration, loss of nutrients and immunological components. Intraopreative prevention is the first step for the management, and treatment options include conservative therapy, percutaneous intervention, and redo-operation. Although the treatment algorithm has not been standardized, chylothorax which is refractory to conservative treatment, or that with high output greater than 1,000 ml/day should be treated aggressively with thoracic duct embolization or redo-operation in a timely fashion. We herein review the anatomy and physiology of thoracic duct system and describe the overview of prevention and each theapeutic options of postoperative chylothorax.

[Development of Personalized and Targeted Preventive Therapies for Chronic Lung Allograft Dysfunction Subtypes;A Novel Strategy].

Chronic lung allograft dysfunction (CLAD) is a major limitation to long-term success of lung transplantation. Restrictive allograft syndrome (RAS) is a recently discovered subtype of CLAD, showing distinct clinical, pathological and radiological features compared with the major CLAD subtype, bronchiolitis obliterans syndrome (BOS). Introduction of the novel CLAD classification system that differentiates CLAD into BOS and RAS has stimulated research activities aiming delineation of the underlying pathological mechanism in the 2 CLAD subtypes. Accumulating evidences suggest that BOS and RAS could be biologically distinct, indicating that optimal therapeutic strategy could be different. Further efforts in refinements in biologic profiling of BOS and RAS will lead to a better understanding of CLAD, as well as the development of personalized and targeted preventive therapies for underlying CLAD subtypes.

Long-term outcomes of open and video-assisted thoracoscopic lung lobectomy for the treatment of early stage non-small cell lung cancer are similar: a propensity-matched study.

BACKGROUND: Generally, in retrospective studies, favourable short- and long-term outcomes for patients after lung lobectomy for early stage non-small cell lung cancer (NSCLC) using video-assisted thoracoscopic surgery (VATS) have been reported. However, the interpretation of lung lobectomy outcomes may be biased in retrospective settings. METHODS: We retrospectively reviewed patients who underwent lung lobectomy for cT1-2N0M0 NSCLC from 2001 to 2010. The outcomes of patients who underwent VATS lobectomy were compared to those who underwent open lobectomy before and after performing propensity score matching. Preoperative covariates were entered when developing the propensity score-matching model. RESULTS: This study reviewed the outcomes of 101 VATS patients and 184 open lobectomy patients. Before propensity score matching, the VATS group had a higher mean age (p < 0.0001), smaller solid tumour size (p = 0.0042), similar whole tumour size (p = 0.2082), and larger tumour-disappearance ratio (p = 0.0007). The VATS group had a shorter mean operation time (p = 0.0002), less blood loss (p < 0.0001), shorter chest tube duration (p = 0.0002), and shorter hospital stay (p < 0.0001). As for long-term outcomes, the VATS group had higher disease-free, disease-specific, and overall survival rates (p values by log-rank test: 0.0049, 0.0154, and 0.032, respectively). After propensity score matching, all differences, except operation time, blood loss, chest tube duration, and hospital stay, were no longer significant. CONCLUSIONS: VATS lobectomy is less invasive than open lobectomy, but in terms of survival outcomes, VATS lobectomy was oncologically equivalent to open lobectomy. The oncological benefit of VATS reported by retrospective studies might be overestimated.

[Tracheal Resection and Reconstruction for a Squamous Cell Carcinoma of the Trachea;Report of a Case].

We report a case of tracheal resection and reconstruction for a squamous cell carcinoma of the trachea that was found in an 82-year-old male patient who had underwent right lower lobectomy for an adenosquamous cell carcinoma 3.5 years before. He noticed bloody sputum. Chest computed tomography (CT) revealed a 15 mm tumor in the anterior wall of the trachea. A transbronchial biopsy for the tracheal tumor showed a squamous cell carcinoma. Under right thoracotomy, we resected the tumor with 3 tracheal rings. Histologically a squamous cell carcinoma was diagnozed. As there was intraepithelial spread of cancer cells in the oral margin, the tracheal tumor was suspected to be a primary tracheal tumor rather than a metastasis from lung cancer. After the surgery, combination therapies of an external radiation therapy for 50 Gy and brachytherapy 2 times for totally 8 Gy were performed as a postoperative adjuvant therapy. He does not have any signs of recurrence in 1 year and 6 months after the surgery.

Acute respiratory distress syndrome (ARDS) treated successfully by veno-venous extracorporeal membrane oxygenation (ECMO) in a nearly drowned patient.

This report highlights about one acute respiratory distress syndrome (ARDS) case after near-drowning resuscitated using extracorporeal membrane oxygenation (ECMO). Few cases have been reported about ECMO use for near-drowning and in most of these cases, ECMO was initiated within the first week. However, in our report, we would like to emphasize that seemingly irreversible secondary worsening of ARDS after nearly drowned patient was successfully treated by ECMO use more than 1 week after near-drowning followed by discharge without home oxygen therapy, social support, or any complication. This is probably due to sufficient lung rest for ventilator-associated lung injury during ECMO use. Based on our case's clinical course, intensive care unit physicians must consider ECMO even in the late phase of worsened ARDS after near-drowning.

Outcomes of combined modality therapy for patients with stage III or IV mediastinal malignant germ cell tumors.

PURPOSE: The treatment of primary mediastinal germ cell tumors with cisplatin-based chemotherapy followed by surgery is an established practice; however, the prognosis has remained poor. This study reviews the survival outcomes of patients with primary mediastinal germ cell tumors to evaluate the efficacy of our treatment. METHODS: We retrospectively reviewed 11 consecutive patients with primary mediastinal germ cell tumors. RESULTS: We had treated four patients with seminomas and seven patients with non-seminomas. Ten patients had undergone cisplatin-based chemotherapy. All patients underwent complete resection. Two patients showed a failure of first-line chemotherapy and thus received salvage chemotherapies, including paclitaxel plus ifosfamide followed by high-dose carboplatin plus etoposide (TI-CE) with stem cell transplantation. One of them died of relapse 29 months later; while the other patient remained disease-free for 56 months postoperatively. The postoperative overall 3-year survival rates of the patients with non-seminomas and seminomas were 83 and 100%, respectively. CONCLUSION: Complete resection after establishing normalized or decreased at a low-level serum tumor markers plateau plays a crucial role in the management of patients with primary mediastinal malignant germ cell tumors.