Development of a multivariable prediction model for prolonged air leak after lung resection.

OBJECTIVES: Prolonged air leak (PAL) is a common complication of lung resection. Research on predictors of PAL using a digital drainage system (DDS) remains insufficient. In this study, we investigated the predictive factors of PAL to establish a novel early postoperative prediction model for PAL. METHODS: A retrospective cohort study and validation study were conducted. We examined patients who underwent lung resection with DDS at our institute. The relationship between the clinical factors and measurements of the DDS, including the difference between the set and measured intrapleural pressure (named: additional negative pressure [ANP]) at postoperative hour (POH) 3, with PAL was analyzed. RESULTS: A total of 494 patients were enrolled, 29 of whom had PAL. Percent forced expiratory volume in 1 s <60%, ANP <1 cmH2O, air leak flow >20 mL/min and pleural adhesion findings at surgery were independent predictors of PAL according to a multivariable analysis. The PAL rate was clearly stratified according to our novel risk scoring system, which simply notes the presence of the above four factors, that is, the rate increases when the score increases. The area under the curve (AUC) of the receiver operating characteristic (ROC) analysis for this scoring system was 0.818. Analysis of the validation cohort (n = 133) revealed that this scoring system showed a sufficient ability to predict PAL. CONCLUSIONS: ANP at POH 3 is an independent predictor of PAL. Thus, the risk-scoring system proposed in this study is useful for predicting PAL in the early postoperative period.

[Dealing with Pleural Adhesion in Video-assisted Thoracoscopic Surgery].

The adhesion between the visceral and parietal pleura makes video-assisted thoracoscopic surgery (VATS) difficult or impossible. When performing VATS without conversion to thoracotomy due to pleural adhesion, it is important to( ⅰ) evaluate the presence and extent of the adhesion preoperatively, (ⅱ) carefully perform detachment, and( ⅲ) adequately repair the injured visceral pleura. We evaluate visceral sliding with the help of chest ultrasonography and plan the best approach to make utility inci-sions, camera port, and third-port incisions. Considering the difficulty in repairing the injured visceral pleura under VATS, we perform extra-pleural detachment of adhesions around the injured visceral pleura, which can facilitate the repair of the pleural injury. For repairing pleural injury, we use free mediastinal fat tissue as biological pledgets to support suturing. In this report, we present the approaches and techniques we follow to perform VATS for patients with pleural adhesion.

The Impact of Kinlessness on Survival in Patients With Advanced Non-small Cell Lung Cancer: A Single-Center Retrospective Study.

Objectives Among patients with advanced non-small cell lung cancer (NSCLC), there are those who do not have a spouse, family members, or friends to support them in their cancer treatment and daily life: the kinless patients. Therefore, we designed an exploratory study of kinlessness and the prognosis of advanced NSCLC. Methods We retrospectively analyzed the prognosis of clinical factors and treatment and kinlessness in patients with advanced NSCLC with wild-type or unknown status for epidermal growth factor receptor/anaplastic lymphoma kinase (EGFR/ALK) and who visited our hospital from November 2018 to February 2023. In addition to the survival analysis by kinlessness, a multivariable analysis of survival was performed for all clinical factors. In a secondary analysis, a multivariable analysis of the choice of best supportive care (BSC) was performed for all clinical factors. Results One hundred forty-four patients are included in our cohort. There were 131 patients with kin, with a median survival of 1.34 years (95% CI of 1.01-1.79 years). There were 13 patients has no kin, with a median survival of 0.53 years (95% CI 0.23-0.76 years). The log-rank analysis showed that kinless patients had significantly shorter overall survival than patients who have kin. A Cox regression analysis showed that age, distant metastasis, performance status, and kinlessness were associated with overall survival. Secondary analysis showed that there was no statistical association between kinlessness and the choice of BSC in our cohort. Conclusions Kinless patients had shorter survival than patients who have kin in our single-center, retrospective study of patients with advanced NSCLC with wild-type or unknown status for (EGFR/ALK). Further research to evaluate the clinical impact of kinlessness in the treatment of advanced NSCLC is needed.

Outcomes and prognostic factors of repeat pulmonary metastasectomy.

OBJECTIVES: Information on prognostic factors after repeat pulmonary metastasectomy (PM) is limited, and outcomes after a third PM are not well documented. METHODS: A single-institute retrospective study was conducted. Between 2000 and 2020, 68 patients underwent repeat PM for pulmonary metastases from various cancers. Outcomes and prognostic factors for the second PM and outcomes after the third PM were analysed. RESULTS: This study included 39 men and 29 women. The mean age at second PM was 53.2 years old. The primary tumours were soft tissue sarcoma in 24 patients, colorectal cancer in 19 and osteosarcoma in 10. The interval between the first PM procedure and detection of pulmonary metastasis after the first PM (months) was ≤12 in 37 patients and >12 in 31 patients. At the second PM, 20 patients underwent lobectomy or bilobectomy, and 48 underwent sublobar resection. Complete resection was achieved in 60 patients, and 52 patients experienced recurrence after the second PM. The 5-year relapse-free survival and overall survival rates after the second PM were 27% and 48%, respectively. Multivariable analysis revealed that the interval between the first PM and the subsequent detection of pulmonary metastasis (≤12 months) was a poor prognostic factor for both relapse-free survival and overall survival after the second PM. Seventeen patients underwent a third PM, 3 of whom achieved a 3-year disease-free survival. CONCLUSIONS: Patients with a period of >12 months between the first PM and the subsequent detection of pulmonary metastases showed favourable outcomes and are thus considered good candidates for second PM. A third PM may be beneficial for selected patients.

Surgical indication of pulmonary metastasis arising from osteosarcoma or soft tissue sarcoma.

OBJECTIVES: Metastasectomy is often the local treatment for pulmonary metastases arising from osteosarcoma or soft tissue sarcoma. However, there have been few investigations on the outcomes of patients who undergo this procedure. In this study, we identified prognostic factors in patients with pulmonary metastases arising from osteosarcoma and soft tissue sarcoma to determine more appropriate eligibility criteria for metastasectomy. METHODS: We retrospectively examined 37 patients who underwent metastasectomy of pulmonary nodules arising from osteosarcomas or soft tissue sarcomas at our institute between 2005 and 2020. Overall and recurrence-free survival intervals were determined using univariate and multivariate analyses. RESULTS: A tumor doubling time > 1 month and a primary tumor histological type of osteosarcoma were independent predictors of longer overall survival on multivariate analysis (hazard ratios: 3.618 and 2.979, p = 0.00986 and 0.0373, respectively). Moreover, a > 1-month tumor doubling time and > 10-cm diameter of the primary tumor were independent predictors of longer recurrence-free survival (hazard ratios: 3.293 and 2.67, p = 0.0121 and 0.0134, respectively). Patients who underwent repeat pulmonary metastasectomy after complete resection of sarcoma-derived pulmonary metastases had significantly longer overall survival than those who did not (median: 5.91 years vs. 0.81 years, p < 0.0001). CONCLUSIONS: Tumor doubling time is a significant predictor of clinical outcomes in patients who undergo resection of pulmonary metastases originating from sarcomas. The surgical indication for this procedure should be decided carefully, particularly for patients with metastatic lesion doubling times ≤ 1 month.

Small-sized type A thymoma with pulmonary metastasis: a case report.

BACKGROUND: Type A thymomas comprise a homogenous population of neoplastic epithelial cells that are characterized by a spindle/oval shape without nuclear atypia. They may be accompanied by few non-neoplastic lymphocytes. Most type A thymomas are detected in the earlier Masaoka stages. Compared to other thymoma subtypes, they rarely metastasize or recur. There have been some reports of patients with type A thymomas with pulmonary metastasis; however, these thymomas were 20 mm or more in size. Herein, we report the case of a patient who underwent surgical resection for a small-sized type A thymoma (12 mm) with pulmonary metastasis. CASE PRESENTATION: A 62-year-old patient presented with an abnormal shadow in the left lung on plain chest radiography during a medical checkup. Chest computed tomography revealed a 12-mm tumor in the anterior mediastinum and a 13-mm nodule in the left lower lobe. 18F-fluorodeoxyglucose positron emission tomography/computed tomography revealed uptake in the anterior mediastinal tumor, but did not show a significant uptake in the pulmonary nodule. The patient underwent surgical resection on two separate occasions, and was diagnosed with an atypical type A thymoma and pulmonary metastasis. The TNM classification was p-T1aN0M1b stage IVb, and it was stage IVb according to the Masaoka staging system. No recurrence was observed during the follow-up. CONCLUSIONS: We report a case of the smallest type A thymoma with pulmonary metastasis. Pulmonary metastasis secondary to a type A thymoma should be considered even if the thymoma is small in size (< 20 mm).

Thymic Metastasis of Ovarian Cancer 33 Years After Primary Surgery.

This report describes a case of an extremely late recurrence of thymic metastasis after radical resection of ovarian cancer. Chest computed tomography demonstrated anterior mediastinal nodules with a smooth marginal area in a 56-year-old woman who had undergone an oophorectomy for ovarian cancer 33 years earlier. Because imaging findings suggested a thymic epithelial tumor, a partial thymectomy was performed. Histopathologic results led to the diagnosis of thymic metastasis of ovarian cancer. In patients with a medical history of ovarian cancer, thymic metastasis should be considered in the differential diagnosis of thymic tumor.

Thoracoscopic diaphragm repair using abdominal insufflation in a patient with hepatic hydrothorax.

Hepatic hydrothorax refers to significant serous pleural effusion induced by liver cirrhosis, and some reports have suggested that this entity is ascites transferred to the thoracic cavity via a small hole in the diaphragm. There have been a few reports describing radical diaphragmatic repair by suturing the defect. We performed thoracoscopic diaphragmatic repair under abdominal insufflation to clarify the defect points. Air leakage at the diaphragmatic tissue was clearly noted and closed by suturing with polytetrafluoroethylene (PTFE) pledgets. The patient's postoperative course was uneventful, and no recurrence of ascites or hydrothorax has been noted.

Novel imprint cytological classification is correlated with tumor spread through air spaces in lung adenocarcinoma.

OBJECTIVES: Spread through air spaces (STAS) is a risk factor for local recurrence after sublobar resection in lung cancer patients. We recently proposed the novel Nakayama-Higashiyama imprint cytological classification (N-H classification) based on small-sized lung adenocarcinoma surgical specimens, which correlated with histological patterns and nodal involvement. This study aimed to evaluate the correlation between STAS and the N-H classification and to validate the N-H classification as an intraoperative predictor of the presence of STAS. MATERIALS AND METHODS: We retrospectively analyzed 164 intraoperative imprint cytologies and their paired histologic specimens from patients undergoing surgical resection for lung adenocarcinoma in our institute in 2017-2019. Using the NH classification, imprint cytological findings were classified into 5 groups (Groups I to V) based on cell cluster shape, cell and nucleus size, and the existence of necrosis. We examined the characteristics of imprint cytology and STAS in the resected tissues and analyzed the relationship between them. RESULTS: Tumor STAS was observed in 29 (17.7 %) cases. The presence of STAS was significantly associated with the NH classification (P < 0.0001). STAS was present in 6 of 57 cases (10.5 %) in NH classification Group II, 11 of 42 cases (26.2 %) in Group III, and 12 of 28 cases (42.9 %) in Group IV/V; STAS was not observed in any case in Group I. Logistic regression analysis revealed that tumors with a ground glass opacity rate of <50 % on computed tomography (P = 0.00867) and Groups III-V of the NH classification (P = 0.00201) were significant independent predictors for STAS. CONCLUSION: Intraoperative imprint cytology with the N-H classification for lung adenocarcinoma is well correlated with the STAS status of the tumor and might have applications as an intraoperative predictive marker of STAS. This classification may be useful for intraoperative detection of STAS and in the decision-making process for the surgical procedure.