Regeneration of emphysematous lungs using gelatin sheets that release basic fibroblast growth factor.

PURPOSE: Basic fibroblast growth factor (bFGF) induces regeneration and neovascularization of the lungs. We conducted this study to demonstrate the regeneration of emphysematous lungs achieved by gelatin sheets that slowly release bFGF into the visceral pleura in a canine model. METHODS: Porcine pancreatic elastase was used to induce bilateral lower lobe pulmonary emphysema in dogs. Slow-release bFGF gelatin sheets were attached to the visceral pleura of the left lower lobe via thoracotomy. The subjects were divided into two groups: one treated with gelatin sheets containing slow-release bFGF (bFGF+ group, n = 5), and the other, treated with only gelatin sheets (bFGF- group, n = 5). The subjects were euthanized after 28 days and histologic lung assessment was performed. The results were evaluated in terms of the mean linear intercept (MLI) and microvessel count. RESULTS: The MLI was significantly shorter in the bFGF+ group than in the bFGF- group; (110.0 ± 24.38 vs. 208.9 ± 33.08 µm; P = 0.0006). The microvessel count was not significantly different between the bFGF+ and bFGF- groups (12.20 ± 3.007 vs. 5.35 ± 2.3425; P = 0.075); however, it was significantly higher in the bFGF-attached lungs than in the emphysema group (12.20 ± 3.007 vs. 4.57 ± 0.8896; P = 0.012). CONCLUSIONS: Attaching gelatin sheets with slow-release bFGF to the visceral pleura induced lung regeneration and vascularization in a canine pulmonary emphysema model.

[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.

[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.

[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.

[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.

[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.

[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.

[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.

High-Pressure Carbon Monoxide and Oxygen Mixture is Effective for Lung Preservation.

(1) Background: Heme oxygenase-1 (HO-1) degrades heme and generates carbon monoxide (CO), producing various anti-inflammatory, anti-oxidative, and anti-apoptotic effects. This study aimed to confirm the effects of CO on the ischemia-reperfusion injury (IRI) of donor lungs using a high-pressure gas (HPG) preservation method. (2) Methods: Donor rat and canine lungs were preserved in a chamber filled with CO (1.5 atm) and oxygen (O2; 2 atm) and were ventilated with either CO and O2 mixture (CO/O2 group) or air (air group) immediately before storage. Rat lungs were subjected to heterotopic cervical transplantation and evaluated after reperfusion, whereas canine lungs were subjected to allogeneic transplantation and evaluated. (3) Results: Alveolar hemorrhage in the CO/O2 group was significantly milder than that in the air group. mRNA expression levels of HO-1 remained unchanged in both the groups; however, inflammatory mediator levels were significantly lower in the CO/O2 group than in the air group. The oxygenation of graft lungs was comparable between the two groups, but lactic acid level tended to be higher in the air group. (4) Conclusions: The HO-1/CO system in the HPG preservation method is effective in suppressing IRI and preserving donor lungs.

[Intraoperative Navigation System during Thoracoscopic Segmentectomy for Non-palpable Pulmonary Tumors;Infrared Thoracoscopy (IRT)-Indocyanine Green (ICG) and Intraoperative Computed Tomography(CT)-assisted Method].

OBJECTIVES: Recently, the use of video-assisted thoracoscopic surgery (VATS) segmentectomy for pulmonary malignancies has increased. For non-palpable lesions, securing a sufficient surgical margin is more likely to be uncertain. The purpose of this study was to evaluate the usefulness of our intraoperative navigation system in combination with the infrared thoracoscopy (IRT)-indocyanine green (ICG) method and intraoperative computed tomography (CT) during VATS segmentectomy for non-palpable pulmonary malignancies. METHODS: This study involved 12 consecutive patients who underwent both IRT-ICG and intraoperative CT-assisted thoracoscopic segmentectomy. Identification of the intersegmental line on the visceral pleura was visualized using IRT-ICG. The intersegmental line was marked by clipping, and intraoperative CT scan was performed under bilateral lung ventilation. The intraoperative CT images were used by the surgeons to confirm the correct anatomic segmental border and to secure a sufficient resection margin. RESULTS: A well-defined intersegmental line was observed in 83.3% of the patients. The rate of concordance between 3-dimensional (3D)-CT images reconstructed from intraoperative CT and preoperative simulation 3D-CT imaging was 91.7%. The mean surgical margin assessed on gross examination by the pathologist was 22.3 ± 4.5 mm. Complete resection was achieved in all patients using this approach. CONCLUSIONS: Imaging support including preoperative simulation, IRT-ICG and intraoperative CT enables surgeons to perform definitive VATS segmentectomy for non-palpable lesions.

[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.

Effects of various types of anesthesia on hemodynamics, cardiac function, and glucose and lipid metabolism in rats.

Anesthesia can affect respiratory, circulatory, and endocrine systems but is necessary for certain experimental procedures such as echocardiography and blood sampling in small animals. We have now investigated the effects of four types of anesthesia [pentobarbital sodium (PENT), ketamine-xylazine (K/X), and low- or high-dose isoflurane (ISO)] on hemodynamics, cardiac function, and glucose and lipid metabolism in Sprague-Dawley rats. Aortic pressure, heart rate, and echocardiographic parameters were measured at various time points up to 45 min after the induction of anesthesia, and blood was then collected for measurement of parameters of glucose and lipid metabolism. Systolic aortic pressure remained constant in the PENT group, whereas it showed a biphasic pattern in the K/X group and a gradual decline in the ISO groups. Marked bradycardia was observed in the K/X group. The serum glucose concentration was increased and the plasma insulin level was reduced in the K/X and ISO groups compared with the PENT group. The concentrations of free fatty acids and norepinephrine in plasma were increased in the K/X group. Despite the metabolic effects of K/X and ISO, our results suggest that the marked bradycardic effect of K-X renders this combination appropriate for measurement of Doppler-derived indexes of left ventricular diastolic function, whereas the relative ease with which the depth of anesthesia can be controlled with ISO makes it suitable for manipulations or data collection over long time periods. On the other hand, PENT may be best suited for experiments that focus on measurement of cardiac function by M-mode echocardiography and metabolic parameters.

Restraint stress exacerbates cardiac and adipose tissue pathology via ß-adrenergic signaling in rats with metabolic syndrome.

Restraint stress stimulates sympathetic nerve activity and can affect adiposity and metabolism. However, the effects of restraint stress on cardiovascular and metabolic disorders in metabolic syndrome (MetS) have remained unclear. We investigated the effects of chronic restraint stress and ß-adrenergic receptor (ß-AR) blockade on cardiac and adipose tissue pathology and metabolic disorders in a rat model of MetS. DahlS.Z-Lepr(fa)/Lepr(fa) (DS/obese) rats, derived from a cross between Dahl salt-sensitive and Zucker rats. Rats were exposed to restraint stress (restraint cage, 2 h/day) for 4 wk from 9 wk of age with or without daily subcutaneous administration of the ß-AR blocker propranolol (2 mg/kg). Age-matched homozygous lean littermates of DS/obese rats (DahlS.Z-Lepr(+)/Lepr(+) rats) served as control animals. Chronic restraint stress exacerbated hypertension as well as left ventricular hypertrophy, fibrosis, diastolic dysfunction, and oxidative stress in a manner sensitive to propranolol treatment. Restraint stress attenuated body weight gain in DS/obese rats, and this effect tended to be reversed by propranolol (P = 0.0682). Restraint stress or propranolol did not affect visceral or subcutaneous fat mass. However, restraint stress potentiated cardiac and visceral adipose tissue inflammation in DS/obese rats, and these effects were ameliorated by propranolol. Restraint stress also exacerbated glucose intolerance, insulin resistance, and abnormal lipid metabolism in a manner sensitive to propranolol. In addition, restraint stress increased urinary norepinephrine excretion, and propranolol attenuated this effect. Our results thus implicate ß-ARs in the exacerbation of cardiac and adipose tissue pathology and abnormal glucose and lipid metabolism induced by restraint stress in this model of MetS.

Roles of oxidative stress and the mineralocorticoid receptor in cardiac pathology in a rat model of metabolic syndrome.

Oxidative stress and the mineralocorticoid receptor (MR) are implicated in the pathogenesis of salt-induced left ventricular (LV) diastolic dysfunction associated with metabolic syndrome (MetS). We recently characterized DahlS.Z-Lepr(fa) /Lepr(fa) (DS/obese) rats, derived from a cross between Dahl salt-sensitive and Zucker rats, as a new animal model of MetS. We investigated the pathophysiological roles of increased oxidative stress and MR activation in cardiac injury with this model. DS/obese rats were treated with the antioxidant tempol (1 mmol/L in drinking water) or the selective MR antagonist eplerenone (15 mg/kg per day, per os) for 5 weeks beginning at 10 weeks of age. The increased systolic blood pressure and LV hypertrophy that develop in untreated DS/obese rats were substantially ameliorated by eplerenone but not by tempol. Eplerenone also attenuated LV fibrosis and diastolic dysfunction more effectively than did tempol in DS/obese rats, whereas cardiac oxidative stress and inflammation were reduced similarly by both drugs. Both the ratio of plasma aldosterone concentration to plasma renin activity and cardiac expression of the MR and serum/glucocorticoid-regulated kinase 1 genes were decreased to a greater extent by eplerenone than by tempol. Our results indicate that both increased oxidative stress and MR activation in the heart may contribute to the development of LV remodeling and diastolic dysfunction in DS/obese rats. The superior cardioprotective action of eplerenone is likely attributable to its greater antihypertensive effect, which is likely related to its greater inhibition of aldosterone-MR activity in the cardiovascular system.

Role of surgery in multi-modality treatment for carcinomatous pleuritis in patients with non-small cell lung cancer.

OBJECTIVE: To evaluate the role of surgery in the treatment of the patients with non-small cell lung cancer with pleural dissemination. METHODS: The clinical records of 25 patients (mean age 69 years) diagnosed with carcinomatous pleuritis during a thoracotomy by pathological examination and followed by surgery between 1994 and 2012 were reviewed. The treatment modality, including surgery, the clinicopathologic characteristics and 5-year survival were analyzed. RESULTS: There were 16 adenocarcinomas, 6 squamous cell carcinomas and 3 large cell carcinomas. Surgery included resection of the main tumor by partial resection in 10 cases, segmentectomy in 2 cases, lobar resection in 12 cases and bilobectomy in 1 case. Intrathoracic irrigation was performed in 20 cases. The pathological N status was N0/N1/N2/Nx: 10/6/7/2. Fifteen patients received adjuvant therapy. The overall 5-year survival rate was 22.2 %. The 5-year survival rates of the N0, N1 and N2 groups were 36.0, 16.7 and 14.3 %, respectively (p = 0.0068). Nine patients lived more than 3 years including 5 in N0, 3 in N1 and 1 in N2. CONCLUSIONS: Surgery should not be excluded from the multi-modality treatment of patients with carcinomatous pleuritis because there are some patients who could benefit from surgery especially if they are in N0 status.