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Objectives: This study aimed to evaluate the safety and feasibility of early chest tube removal after anatomic pulmonary resection, regardless of the drainage volume., Methods: We conducted a multicenter, randomized, controlled, noninferiority trial. Patients with greater than 300 mL drainage volume during postoperative day 1 were randomly assigned to group A (tube removed on postoperative day 2) and group B (tube retained until drainage volume ≤300 mL/24 hours). The primary end point was the frequency of respiratory-related adverse events (grade 2 or higher based on the Clavien-Dindo classification) within 30 days postoperatively., Results: Between April 2019 and October 2021, 175 patients were assigned to group A (N = 88) or group B (N = 87). One patient in group B who experienced chylothorax was excluded from the study. Respiratory-related adverse events were observed in 10 patients (11.4%) in group A and 12 patients (14.0%) in group B (P = .008). The frequencies of thoracentesis or chest tube reinsertion were not significantly different (8.0% and 9.3% in groups A and B, respectively, P = .752). Additionally, the duration of chest tube placement was significantly shorter in group A than in group B (median, 2 vs 3 days; P < .001). No significant difference between groups A and B was found in postoperative hospital stay (median, 6 vs 7 days, P = .231)., Conclusions: Early chest tube removal, regardless of drainage volume, was safe and feasible in patients who underwent anatomic pulmonary resection., Competing Interests: Conflict of Interest Statement K.T.: honoraria from AstraZeneca, Chugai, Ono, Nippon Kayaku, Johnson & Johnson, and Covidien. T.H.: payment or honoraria from Intuitive Surgical and Johnson and Johnson. M.T.: payment or honoraria Johnson & Johnson Japan, AstraZeneca KK, Eli Lilly Japan, Chugai Pharmaceutical Co, Ltd, Taiho Pharma, Medtronic Japan, Ono Pharmaceutical Co, Ltd, MSD, Bristol-Myers Squibb KK, and Novartis. N.O.: payment or honoraria from Johnson & Johnson. N.I.: payment or honoraria from Taiho Pharma, Bristol Myers, Chugai Pharma, Fuji Film Nihon Mediphysics, MSD, Daiichi-Sankyo, Boehringer Ingelheim, Shionogi, Medtronic, Johnson & Johnson, Olympus, Roche, and Ono Pharma. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Clinical stage IA non-small cell lung cancer (NSCLC) showing a pure-solid appearance on computed tomography is associated with a worse prognosis. This study aimed to develop and validate machine-learning models using preoperative clinical and radiomic features to predict overall survival (OS) in clinical stage IA pure-solid NSCLC., Methods: Patients who underwent lung resection for NSCLC between January 2012 and December 2020 were reviewed. The radiomic features were extracted from the intratumoral and peritumoral regions on computed tomography. The machine-learning models were developed using random survival forest and eXtreme Gradient Boosting (XGBoost) algorithms, whereas the Cox regression model was set as a benchmark. Model performance was assessed using the integrated time-dependent area under the curve (iAUC) and validated by 5-fold cross-validation., Results: In total, 642 patients with clinical stage IA pure-solid NSCLC were included. Among 3748 radiomic and 34 preoperative clinical features, 42 features were selected. Both machine-learning models outperformed the Cox regression model (iAUC, 0.753; 95% confidence interval [CI], 0.629-0.829). The XGBoost model showed a better performance (iAUC, 0.832; 95% CI, 0.779-0.880) than the random survival forest model (iAUC, 0.795; 95% CI, 0.734-0.856). The XGBoost model showed an excellent survival stratification performance with a significant OS difference among the low-risk (5-year OS, 100.0%), moderate low-risk (5-year OS, 88.5%), moderate high-risk (5-year OS, 75.6%), and high-risk (5-year OS, 41.7%) groups (P < .0001)., Conclusions: A radiomics-based machine-learning model can preoperatively and accurately predict OS and improve survival stratification in clinical stage IA pure-solid NSCLC., Competing Interests: Conflict of Interest Statement K.T. receives personal fees from Johnson & Johnson, AstraZeneca, Eli Lilly, Chugai, Taiho, Medtronic, and Ono. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the influence of simple preoperative exercise tests as prognostic factors for early-stage lung cancer., Methods: This single-institution retrospective study included consecutive patients who underwent pulmonary resection for stage 0 to I lung cancer between April 2017 and December 2019. Before surgery, 7 metabolic equivalents of task in the double Master 2-step test were loaded into the exercise echocardiogram. The relationship between prognosis and exercise stress test results in terms of availability, symptoms, and saturation of percutaneous oxygen was investigated., Results: This study included 862 patients with pathological stage 0 to I lung cancer. Among the 862 patients, 673 patients (78.1%) who were able to complete 7 metabolic equivalents of task exercise for 3 minutes without assistance were classified into the complete group. The 5-year survival of the complete group was significantly better than that of the incomplete group. Multivariable analysis revealed that age (hazard ratio, 1.06; P = .008), male sex (hazard ratio, 2.23; P = .011), carcinoembryonic antigen level >5 ng/mL (hazard ratio, 2.33; P = .011), and inability to complete 7 metabolic equivalents of task exercise (hazard ratio, 3.90; P < .001) were the prognostic factors. Patients in the older group who had the ability to complete exercise had a better prognosis than those in the younger group without the ability (P = .003)., Conclusions: Preoperative exercise ability is a prognostic factor for early-stage lung cancer. Patients who can tolerate an exercise load of 7 metabolic equivalents of task, even if they are aged 70 years or older, have a better prognosis than patients younger than age 70 years without exercise tolerance., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: We evaluated the clinicopathological and oncological characteristics of epidermal growth factor receptor-mutated clinical stage IA radiological pure-solid lung adenocarcinoma and compared them with those of a ground-glass opacity component., Methods: Between 2008 and 2020, data from 1014 surgically resected clinical stage 0-IA epidermal growth factor receptor-mutated lung adenocarcinomas were evaluated. Oncological outcomes were assessed using multivariable analysis. Overall survival was estimated using Kaplan-Meier analysis and the log-rank test. The cumulative incidence of recurrence was estimated using the Gray's test., Results: Of these, 233 (23%) were radiologically pure-solid tumors, which demonstrated a higher proportion of nodal metastasis, micropapillary component, spread through alveolar space, and Ex19 subtype compared with those of tumors with ground-glass opacity (P < .001). Multivariable analysis revealed that the presence of ground-glass opacity was an independently significant factor for overall survival (P = .037) and cumulative incidence of recurrence (P < .001). In cases where the oncological outcomes were stratified by the presence of ground-glass opacity component, the 5-year overall survival was excellent at more than 90% in tumors with ground-glass opacity despite clinical-T categories (P = .2044); however, tumor size significantly affected survival only in pure-solid tumors (T1a, 100%; T1b, 77.7%; T1c, 68.5%; P = .0056). Furthermore, the cumulative incidence of recurrence was low in tumors with ground-glass opacity despite the clinical-T categories, whereas tumor size significantly affected the cumulative incidence of recurrence only in pure-solid tumors (5-year cumulative incidence of recurrence: T1a-b, 18.9%; T1c, 41.3%; P < .001)., Conclusions: Oncologic behavior and prognosis of radiologically pure-solid tumors were significantly poorer than those of tumors with ground-glass opacity among patients with epidermal growth factor receptor-mutated early-stage lung adenocarcinoma. These findings imply distinct tumorigenesis based on the presence of ground-glass opacity, even in tumors with epidermal growth factor receptor mutations., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Pulmonary artery (PA) reconstruction is performed to avoid pneumonectomy for non-small cell lung cancer (NSCLC). Our objective was to assess the safety and efficacy of performing PA reconstruction without systemic heparinization during resections of NSCLC., Methods: Among 3537 patients with resected NSCLC between 2008 and 2019, 130 (3.7%) patients underwent PA reconstruction to avoid pneumonectomy without intraoperative systemic heparinization. We investigated surgical outcome. The median follow-up time was 37 months., Results: As to PA reconstruction, tangential suture, patch closure (autologous pericardium), end-to-end anastomosis, and conduit were performed in 56, 26, 32, and 16 patients (autologous pericardium, 13; resected pulmonary vein, 3), respectively. Combined bronchial sleeve resection was performed in 68 (52%) patients. The mean operative time was 261 minutes. The procedure-related complications were 2 PA thromboses with pericardial conduit requiring completion pneumonectomy and 2 massive hemoptysis of a bronchopulmonary fistula leading to death (operative mortality, 1.5%). PA bending and mechanical stenosis were due to the lengthening by the conduit. Seventy-five patients had other complications, the most frequent being arrhythmia. One patient was at stage 0 after induction chemoradiotherapy; 26, stage I (9 IA and 17 IB); 43, stage II (19 IA and 24 IB), 55 stage III (49 IIIA and 6 IIIB); and 5, stage IV. Five-year overall survival, cancer-specific survival, and recurrence-free survival rates were 49.2%, 61.8%, and 37.1%, respectively., Conclusions: PA reconstruction without intraoperative systemic heparinization during resections of NSCLC was performed with a very low risk of thrombosis as well as perioperative bleeding., (Copyright © 2022. Published by Elsevier Inc.)

Background: Personalized Induction Therapy-1 is a multicenter, randomized phase II selection design trial of the efficacy and safety of platinum-doublet induction chemotherapy plus angiogenesis inhibitors/concurrent thoracic radiotherapy (TRT) followed by surgery for stage IIIA (N2) nonsquamous non-small cell lung cancer (NSCLC)., Methods: Patients with pathologically proven stage IIIA (N2) nonsquamous NSCLC were assigned at random to 1 of 2 arms. Patients received (1:1) induction therapy with pemetrexed 500 mg/m 2 and cisplatin 75 mg/m 2 plus bevacizumab 15 mg/kg intravenously every 3 weeks for 3 cycles (bevacizumab arm) or concurrent TRT (45 Gy in 25 fractions; TRT arm) before surgery. The primary endpoint was the 2-year progression-free survival (PFS) rate., Results: Eighty-two patients were treated, including 42 in the bevacizumab arm and 40 in the TRT arm. Thirty-eight patients (90%) in the bevacizumab arm and 37 patients (93%) in the TRT arm underwent surgery. The objective response rates in the 2 groups were 50% and 60%, respectively (P = .36). The 2-year PFS and overall survival rates were 37% (95% confidence interval [CI], 22.4%-51.2%) and 50% (95% CI, 33.8%-64.2%) (hazard ratio [HR], 1.34; P = .28), respectively, and 81% (95% CI, 64.7%-89.7%) and 80% (95% CI, 64.0%-89.5%) (HR, 1.10; P = .83), respectively. Although grade 5 toxicity did not occur during induction therapy, 2 patients in the bevacizumab arm died due to bronchopleural fistula., Conclusions: Although not significant, the 2-year PFS rate was higher in the TRT arm than in the bevacizumab arm. Fatal surgical complications were observed only in the bevacizumab arm. Therefore, pemetrexed-cisplatin with concurrent TRT was chosen as the investigational induction treatment strategy for future phase III trials., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Non-small cell lung cancers with a ground-glass opacity component have better prognosis than those with solid nodules of equivalent consolidation size. However, the impact of small ground-glass opacity components on prognosis is unknown. Therefore, we aimed to evaluate the significance of a small ground-glass opacity component in solid-dominant clinical stage IA non-small cell lung cancers., Methods: We reviewed the cases of 543 surgically resected solid-dominant c-stage IA non-small cell lung cancers, which was defined as a tumor with consolidation tumor ratio of 0.75 or more on computed tomography. The patients were classified into 2 groups: 0.75 or less consolidation tumor ratio less than 1 (n = 126) and consolidation tumor ratio of 1 (n = 417). The prognoses were compared between the 2 groups., Results: Among the 543 cases, multivariable analyses revealed that pure-solid appearance was a predictor of worse overall survival (hazard ratio, 2.051; 95% confidence interval, 1.044-4.028). Compared with the part-solid group, the pure-solid group was associated with poor survival in c-stages IA2 (5-year overall survival: 91.5% vs 76.8%, hazard ratio, 2.942; 95% confidence interval, 1.402-6.173; recurrence-free survival: 89.0% vs 68.8%, hazard ratio, 3.439; 95% confidence interval, 1.776-6.669) and IA3 (5-year overall survival: 93.5% vs 63.0%, hazard ratio, 5.110; 95% confidence interval, 1.607-16.241; recurrence-free survival: 80.5% vs 54.1%, hazard ratio, 2.789; 95% confidence interval, 1.290-6.027). The T categories significantly affected 5-year overall survival only in the pure-solid group (cT1a, 89.3%; cT1b, 76.8%; cT1c, 63.0%)., Conclusions: A small ground-glass opacity component has an impact on the prognosis of patients with solid-dominant c-stage IA non-small cell lung cancer. Therefore, c-stage IA non-small cell lung cancers should be evaluated separately for tumors with ground-glass opacity and pure-solid tumors., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: We investigated the surgical outcomes of repeated pulmonary resection for metachronous ipsilateral second non-small cell lung cancer (NSCLC)., Methods: A retrospective review identified 104 (3.6%) patients who underwent surgical resection for ipsilateral metachronous second NSCLC. Repeated anatomical (reanatomical) resection was defined as a metachronous anatomical surgery for secondary NSCLC after ipsilateral primary major lung resection for NSCLC. Operative morbidity or other clinicopathologic factors were analyzed by a multivariable model. Overall survival (OS) was evaluated using Cox proportional hazard model., Results: Seventy-seven (74%) patients were diagnosed as second primary cases. The 3-year OS after metachronous surgery for ipsilateral second NSCLC was 80.1%, and that of reanatomical resection was equivalent to the other procedures (reanatomical: 81.8%, others: 78.2%, P = .816), whereas reanatomical resection (n = 56) was a significant predictor of postoperative severe morbidity after ipsilateral second pulmonary resection (P = .036) that was found in 23 (41%) patients. When this procedure was classified into 2 groups, ie, completion pneumonectomy (CP; n = 26) and other reanatomical resection to avoid CP (non-CP; n = 32), non-CP was significant on the right side (P = .011), whereas intrapericardial procedure was employed frequently for both (CP: 85%, non-CP: 47%). In contrast, the oncologic outcome (3-year OS; 75.8% vs 87.1%, P = .881) and several surgical outcomes including morbidities were similar between CP and non-CP., Conclusions: Reanatomical pulmonary resection showed acceptable oncologic outcomes for metachronous ipsilateral second NSCLC. The non-CP procedure was technically challenging; however, both oncologic and surgical results were feasible compared with the CP. This procedure might be a promising novel strategy for properly selected ipsilateral second NSCLC., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We performed a validation study to confirm the prognostic importance of the presence of a ground-glass opacity component based on data of the Japan Clinical Oncology Group study, JCOG0201, which was a prospective observational study to predict the pathological noninvasiveness of clinical stage IA lung cancer in Japan., Methods: Among the 811 patients registered in JCOG0201, 671 were confirmed eligible by study monitoring and a central review of computed tomography. Registered c-stage IA lung cancer was less than 30 mm in maximum tumor size, which was classified into a with ground-glass opacity group (pure ground-glass opacity and part-solid tumor) or solid group based on the status of a ground-glass opacity component. T staging was reassigned in accordance with the 8th edition of the TNM staging system. To validate the prognostic impact, overall survival was estimated., Results: Of the cases, 432 (64%) were in the with ground-glass opacity group and 239 (36%) were in the solid group with a median follow-up time of 10.1 years. The 5-year overall survival was significantly different between the with ground-glass opacity group and solid group (95.1% vs 81.1%). The 5-year overall survival was excellent regardless of the solid component size in the with ground-glass opacity group (c-T1a or less: 97.2%, c-T1b: 93.4%, c-T1c: 91.7%). In contrast, prognostic impact of the tumor size was definitive in the solid group (c-T1a: 87.5%, c-T1b: 85.9%, c-T1c: 73.7%)., Conclusions: Favorable prognostic impact of the presence of a ground-glass opacity component was demonstrated in JCOG0201. The presence or absence of a ground-glass opacity should be considered as an important parameter in the next clinical T classification., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Vascular sealing with an energy vessel sealing system during lung resection may allow surgeons to treat small vessels with minimal dissection, possibly decreasing likelihood of injury. Few large prospective trials have examined the proximal sides of vessels not ligated in addition to sealing during surgery. We therefore assessed feasibility of an energy device to seal pulmonary artery and vein branches without further ligation., Methods: This prospective, preoperative registration study at 2 institutions evaluated safety of energy sealing with the LigaSure (Medtronic, Minneapolis, Minn), with no additional reinforcing material such as suture ligation, for pulmonary vessels as large as 7 mm during anatomic lung resection (cohort 1 study). A postoperative hemorrhage occurred in the 128th case, so a cohort 2 study proceeded after we changed inclusion criterion for pulmonary arteries from a maximum of 7 mm to a maximum of 5 mm., Results: In cohort 1 (n = 128) and cohort 2 (n = 200), 216 and 250 pulmonary arteries and 189 and 213 pulmonary veins, respectively, were treated with energy sealing. Overall postoperative hemorrhage rate was 0.3% (1/328 patients); however, no serious postoperative complications were associated with energy sealing among the 200 patients in cohort 2. Subsequent inspection of the torn artery stump confirmed that the bleeding in the 128th case was in an area adjacent to the sealing zone., Conclusions: Energy sealing without reinforcement allows secure treatment during lung resection of pulmonary arteries as large as 5 mm in diameter and pulmonary veins as large as 7 mm., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate whether a digital thoracic drainage system (group D) is clinically useful compared with a traditional thoracic drainage system (group T) in chest tube management following anatomic lung resection., Methods: Patients scheduled to undergo segmentectomy or lobectomy were prospectively randomized before surgery to group D or T. A stratification randomization was performed according to the following air leak risk factors: age, sex, smoking status, and presence of emphysema and/or chronic obstructive pulmonary disease. The primary end point was the duration of chest tube placement., Results: No statistically significant differences were found between groups D (n = 135) and T (n = 164) with regard to the duration of chest tube placement (median, 2.0 vs 3.0 days; P = .149), duration of hospitalization (median, 6.0 vs 7.0 days; P = .548), or frequency of postoperative adverse events (25.1% vs 20.7%; P = .361). In subgroup analyses of the 64 patients with postoperative air leak (20 in group D and 44 in group T), the duration of chest tube placement (median, 4.5 vs 4.0 days; P = .225) and duration of postoperative air leak (median, 3.0 vs 3.0 days; P = .226) were not significantly different between subgroups., Conclusions: The use of a digital thoracic drainage system did not shorten the duration of chest tube placement in comparison to a traditional thoracic drainage system after anatomic lung resection., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether solid component size and the presence of a ground glass opacity (GGO) component are independently associated with survival outcomes in patients with early-stage non-small cell lung cancer (NSCLC) using the eighth edition Lung Cancer Stage Classification., Methods: We retrospectively evaluated 1029 surgically resected early-stage NSCLCs. T categories were assigned based on solid component size using the eighth classification. All tumors were classified into 1 of 2 groups: the GGO group or the solid group. We evaluated the prognostic impact of several clinicopathological variables in clinical T classification using a Cox proportional hazard model., Results: On multivariable analysis, the presence of a GGO component (hazard ratio [HR], 0.314; 95% confidence interval [CI], 0.181-0.529: P < .001) and solid component size (HR, 1.021; 95% CI, 1.006-1.036; P = .006) were identified as independently significant prognostic factors of overall survival. However, after accounting for the presence of a GGO component, neither maximum tumor size nor solid component size added to the prediction of long-term survival. Moreover, tumor size significantly affected survival outcome only in the solid group (HR, 1.020; 95% CI, 1.006-1.034; P = .004). Survival was excellent at ≥90% despite the revised T categories, provided that the tumor had a ground glass appearance. Meanwhile, tumor size significantly affected survival only in the solid group (P < .001)., Conclusions: The presence of a GGO component is a significant prognostic factor in early-stage NSCLC. External validation is required to assess whether it should be adopted as a novel factor in clinical T staging., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Epidermal growth factor receptor (EGFR) gene mutation status is a well-established predictor of the efficacy of EGFR tyrosine-kinase inhibitor (TKI) therapy in patients with non-small cell lung cancer. Recently, differences in EGFR mutation subtypes have been reported to be associated with the efficacy of EGFR-TKI therapy. The prognostic impact of EGFR mutation status and subtypes remains controversial, however., Methods: We retrospectively reviewed 939 patients with surgically resected adenocarcinomas who underwent EGFR mutation status analysis between January 2010 and December 2014. Overall survival (OS) and recurrence-free survival (RFS) were compared according to pathological stage, EGFR mutation status, and EGFR mutation subtype using the log-rank test. Independent prognostic factors for OS and RFS were identified by multivariate analysis using the Cox proportional hazards model., Results: The median duration of follow-up was 48 months. We found that positive EGFR mutation status was significantly associated with longer OS and RFS in all patients and was associated with longer OS in patients in pathological stage I; however, there were no significant differences in OS and RFS between patients with exon 21 L858R mutations and those with exon 19 deletions. In a Cox regression model for OS, EGFR mutation status was a significant prognostic factor that was independent of well-established prognostic factors, including age, pathological stage, vascular invasion, lymphatic permeation, and serum carcinoembryonic antigen level., Conclusions: Positive EGFR mutation status is a favorable prognostic factor in patients with surgically resected lung adenocarcinomas; however, EGFR mutation subtype (exon 21 L858R mutation or exon 19 deletion) exhibits no prognostic impact., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to identify clinical factors associated with lepidic growth in resected clinical stage IA radiologic pure-solid lung adenocarcinoma for identifying a possible sublobar resection candidate in the population., Methods: Clinicopathologic data were reviewed for 200 surgically resected clinical stage IA pure-solid lung adenocarcinomas. Radiologic pure-solid tumor was defined as a tumor without a ground-glass opacity component, that is, a consolidation tumor ratio equal to 1.0. Lepidic predominant adenocarcinoma included adenocarcinomas in situ, minimally invasive adenocarcinomas, and lepidic predominant invasive adenocarcinomas., Results: A total of 57 patients (29%) had lepidic predominant adenocarcinoma. The 5-year overall survival of clinical stage IA pure-solid adenocarcinoma was 83.4% and that of lepidic predominant adenocarcinoma and nonlepidic predominant adenocarcinoma was 98.1% versus 76.6% (P = .0012). A multivariate analysis revealed that maximum standardized uptake value was an independently significant variable of lepidic predominant adenocarcinoma (P < .0001) and a significant prognostic factor (P = .034). The predictive criterion of lepidic predominant adenocarcinoma was maximum standardized uptake value 3.3 or less based on a receiver operating characteristic curve, and 77 patients (39%) who met this criterion showed less pathologic invasiveness regarding lymphatic (P = .0012) and vascular (P < .0001) invasions, nodal metastasis (P = .0007), and better overall survival than those who did not (maximum standardized uptake value ≤3.3 vs >3.3 rates being 91.7% vs 78.6%, P = .0031). Moreover, the 3-year locoregional recurrence-free survival of the sublobar resection arm was significantly worse than that of the lobectomy arm when the tumor showed maximum standardized uptake value greater than 3.3 (62.7% vs 82.9%, P = .0281)., Conclusions: Higher maximum standardized uptake value may be useful for identifying patients with clinical stage IA radiologic pure-solid lung adenocarcinoma in whom sublobar resection should not be considered, even if technically feasible., (Copyright © 2017. Published by Elsevier Inc.)

Objective: We reviewed our experience with iatrogenic chylothorax after pulmonary resections for lung cancer to evaluate our treatment strategy and to identify factors that predict the need for reoperation., Methods: From July 1992 through February 2000, a total of 1110 patients underwent pulmonary resection (at least lobectomy) and systematic mediastinal lymph node dissection for lung cancer at our division. Twenty-seven patients (2.4%) had postoperative chylothorax develop. We initially treated 26 of these patients conservatively with complete oral intake cessation and total parenteral nutrition, and these patients constituted the subjects in this study., Results: There were 21 men and 5 women with a median age of 62 years (range 44 to 80 years). The initial procedures were pneumonectomy in 2 cases, bilobectomy in 1 case, and lobectomy in 23 cases. Twenty-one patients (81%) had the condition cured with conservative treatment. These patients resumed a normal diet at a median of 8 days after chylothorax diagnosis (range 4-35 days). The remaining 5 patients (19%) underwent reoperation at a median of 14 days after diagnosis (range 5-35 days). Chest tube drainage of less than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition predicted a cure with conservative treatment., Conclusion: Although most cases of chylothorax after pulmonary resection with systematic mediastinal lymph node dissection can be cured with a conservative strategy, early surgical intervention may be indicated if chest tube drainage is more than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition.

Objectives: The reliability of computed tomographic scanning in evaluating mediastinal node involvement is controversial because of the high false result rate. We attempted to identify significant factors responsible for false-positive and false-negative scans., Methods: From August 1992 through April 1997, 401 patients with lung cancer who underwent major lung resection and systematic lymph node dissection were enrolled in this study. We retrospectively examined mediastinal node size, tumor location, maximum tumor dimension, the presence or absence of obstructive pneumonia, atelectasis, pulmonary fibrosis, and lymph node calcification on contrast-enhanced computed tomographic scans. We identified clinical and radiologic factors responsible for the false results by using univariate and multivariable analysis., Results: Central tumor location proved to be a significant factor of false-positive scans. Elevated carcinoembryonic antigen level and larger tumor dimension were significant factors of false-negative scans. In patients with a peripheral tumor smaller than 40 mm and normal levels of serum carcinoembryonic antigen, sensitivity, specificity, positive predictive value, and negative predictive value were 6%, 93%, 8%, and 90%, respectively. The reliability of computed tomographic scanning in this low-risk subgroup was high in detecting N0-1 disease but low in diagnosing N2 disease., Conclusion: It is not possible to accurately diagnose N2 disease by using lymph node size on computed tomographic scanning alone, especially in patients with a central tumor, an elevated serum carcinoembryonic antigen level, or a tumor of 40 mm or larger. A preoperative invasive staging procedure is indicated in these populations and may not be indicated in the population with normal computed tomographic scan results without any of these risk factors.