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Surgical resection is the accepted standard of care for patients with non-small cell lung cancer (NSCLC). Several imaging modalities play central roles in the detection and staging of the disease. The aim of this review is to evaluate the utility of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and PET/CT for NSCLC staging. Radiographic staging refers to the use of CT as a non-invasive diagnostic technique. However, while the vast majority of patients undergo only CT, CT is a notoriously inaccurate means of tumor and nodal staging in many situations. PET/CT clearly improves the staging, particularly nodal staging, compared to CT or PET alone. In addition, as a result of the increased soft-tissue contrast, MRI is superior to CT for distinguishing between tissue characteristics. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which is a minimally invasive technique, also has pathological diagnostic potential. Extensive research and the resultant improvements in the understanding of genetics, histology, molecular biology and oncology are transforming our understanding of lung cancer, and it is clear that imaging modalities such as CT, MRI, PET and PET/CT will have an important role in its preoperative management. However, thoracic surgeons should also be aware of the limitations of these techniques. [ABSTRACT FROM AUTHOR]

Purpose: This study investigated the actual rate or extent of lymph node metastasis or the survival outcomes among patients that underwent esophagectomy with lymph node dissection after ESD for clinical mucosal, but pathological submucosal, esophageal cancer. Methods: Seventeen patients that received esophagectomy with two- or three-field lymph node dissection as additional treatment after ESD for clinical mucosal, but pathological submucosal, esophageal cancer between 2006 and 2010 were analyzed. The rate and extent of lymph node metastasis and the patient outcomes were determined. Results: The tumor depths were diagnosed as SM1 in 8 (47 %) patients and SM2 in 9 (53 %), based on the analyses of resected specimens. Lymphatic invasion was evident in 13 (76 %) patients, while venous invasion was detected in 5 (29 %). Five (29 %) patients had pathologically detected lymph node involvement. Seven (0.8 %) of the 890 dissected nodes showed cancer involvement. Three patients had one involved node in the mediastinum or abdomen, and 2 patients had 2 involved nodes in the abdomen. The patients were followed up for 11-71 months (median 23 months), and all were alive without recurrence at the final follow-up. Conclusion: Twenty-nine percent of the patients diagnosed with clinically mucosal, but pathologically submucosal, thoracic squamous cell esophageal cancer after ESD had 1-2 cancer-involved lymph nodes in the lower mediastinum and abdomen. Esophagectomy with lymph node dissection is therefore considered to be a necessary and effective additional treatment for these patients. [ABSTRACT FROM AUTHOR]

Purpose: Lymphatic spread of lung carcinoma to the mediastinum is a key determinant of prognosis. The lymph flow often carries metastases from the pulmonary segment directly into the mediastinal lymph nodes, without passing through the hilar nodes. This phenomenon is termed as 'skip metastasis.' This study investigated the subpleural lymphatic flow to the mediastinum using indocyanine green (ICG) with a near-infrared fluorescence imaging system. Methods: Seventeen patients with lung cancer were enrolled in this study. A 0.3 ml sample of solution containing the fluorescent dye ICG (5 mg/ml) was injected into subpleural sites near the primary tumor. Fluorescence imaging was used to monitor the flow of ICG-containing lymph from the injection site for 5 min. The relationship between the anatomical segment of the primary tumor and the lymphatic flow was assessed. Results: The lymphatic vessels draining from the injection site were revealed by the bright ICG fluorescence in 14 of the patients (82.4 %). A direct lymphatic flow to the mediastinum was confirmed in 3 of those 14 (21.4 %). Conclusions: These findings confirm the direct flow of lymph to the mediastinum without passage through the hilum pulmonis intraoperatively. These preliminary results may provide a valuable clue for further investigations of the mechanisms underlying skip metastasis. [ABSTRACT FROM AUTHOR]

Purpose: Cancer cells reportedly produce C-reactive protein (CRP) locally within tumors. The aim of this study was to determine whether tumoral CRP is associated with clinical outcome and recurrence in thoracic esophageal squamous cell cancer. Methods: The subjects included 73 Japanese patients with thoracic esophageal squamous cell cancer (pathological Stage IIA-IV) that had not been treated preoperatively with either chemotherapy or radiotherapy. Tumoral CRP expression in resected specimens of tumor tissue was assessed by immunohistochemistry. The survival rate following surgery, the rates and patterns of recurrence, and the serum CRP levels before treatment and at recurrence were analyzed in patients with and without tumoral CRP expression. Results: Fifty-nine percent of the study participants (43/73) were positive for tumoral CRP expression, and the remaining 41% (30/73) were negative. No significant difference in clinicopathological factors was observed between the tumoral CRP-positive and CRP-negative groups; however, patients expressing tumoral CRP showed significantly poorer survival and recurrence rates. A multivariate analysis showed that tumoral CRP expression was an independent factor contributing to the likelihood of a poor outcome. Conclusion: Tumoral CRP is associated with a poor outcome in thoracic esophageal squamous cell cancer. Tumoral CRP could therefore be an important target for the treatment of this disease. [ABSTRACT FROM AUTHOR]

Benign esophageal strictures are generally treated with medication and balloon dilation; however, when repeated dilations fail, surgery is the only option. When performing surgery for benign esophageal stricture in young patients, it is important to consider not only the surgical stress and likelihood of complications but also digestive function after reconstruction, the durability of the reconstruction, and the potential for cancerous change in the reconstructed organs. We describe how we treated a 14-year-old boy with benign esophageal stricture by performing transhiatal esophagectomy assisted by mediastinoscopy, preserving the whole stomach and vagus nerve, and interposing pedicled jejunum between the cervical esophagus and stomach through a posterior mediastinal route, with good long-term results. [ABSTRACT FROM AUTHOR]

Purpose: The criteria for the diagnosis of lymph node metastasis (LNM) in non-small cell lung cancer were investigated using helical computed tomography (hCT). The conventional criterion (1-cm short axis threshold) is generally accepted; however, this criterion is based on conventional CT. New criteria for LNM were investigated because the resolution of hCT is better than that of conventional CT. Methods: Ninety-seven NSCLC patients examined with hCT were enrolled. Both the long axis (LA) and short axis (SA) of the nodes were measured using hCT. Results: Based on the receiver operating characteristic curves, the thresholds that gave optimal sensitivity and specificity for LNM were 13 mm for LA and 9 mm for SA. The LNM diagnosis was re-evaluated using the combination of cutoff values. When the LA was ≥13 mm and the SA was ≥9 mm, the sensitivity, specificity, and accuracy were 56.3%, 92.1%, and 88.1%, respectively. When the LA was ≥13 mm or SA was ≥9 mm, sensitivity, specificity, and accuracy were 75.0%, 74.7%, and 74.7%, respectively. These values were not so different from the conventional criterion recalculated from these data. Conclusion: The new criteria are considered to be useful for making a LNM diagnosis. The conventional criteria for the LNM diagnosis might therefore be applicable even for hCT. [ABSTRACT FROM AUTHOR]

Purpose: There is evidence that blood transfusion is associated with an increased rate of tumor recurrence. This study was conducted to assess the survival advantage of giving autologous blood instead of allogeneic blood during surgery for esophageal cancer. Methods: We retrospectively analyzed 62 patients who underwent esophagectomy for thoracic esophageal cancer between January 1991 and February 1995 and received allogeneic blood transfusion, and 61 patients operated on between March 1995 and February 1998, who received autologous blood transfusion. The clinicopathological factors and survival rates were compared between the two groups. Results: The clinicopathological factors that influenced prognosis were similar in the two groups; however, a definite survival advantage was evident in the autologous blood transfusion group. According to multivariate analyses, the transfusion of allogeneic blood was an independent prognostic factor ( P = 0.0222), as was the presence of metastatic lymph nodes. Patients who received allogeneic blood transfusions perioperatively had more than a twofold greater risk (Hazard ration 2.406) of death over patients who received autologous blood transfusions. Conclusion: Autologous blood transfusion appears to be an independent prognostic factor for the survival of patients with esophageal cancer. [ABSTRACT FROM AUTHOR]

We report herein two cases of thoracic esophageal cancer with a right aortic arch. Both cases were elderly males who complained of dysphagia. Computed tomography and aortography revealed a right aortic arch with a mirror-image branching and a diverticulum of the right descending aorta in both cases. They underwent an esophagectomy and a mediastinal lymph node dissection in a left thoractomy, and we also added a median sternotomy in the second case for a lymph node dissection in the right mediastinum. The ductus arteriosus was divided in the first case, but he died of a rupture of the aortic diverticulum 13 months later. In conclusion, for a successful esophagectomy and mediastinal lymph node dissection, a median sternotomy should be added to the left thoractomy, while careful attention should also be paid to the aortic diverticulum and the ductus arteriosus. [ABSTRACT FROM AUTHOR]

We describe a novel technique of using halo-vest-enforced immobilization to relieve anastomotic tension after tracheal sleeve resection. Immediately after the tracheal sleeve resection, four halo titanium pins were inserted in the skulls of the patients to secure the halo-vest. All patients fitted with halo-vests were able to eat and drink and their clinical course was good. Bronchoscopy confirmed the absence of anastomotic leaks and stenoses, and there were no complications associated with the halo-vest. We believe that ensuring neck flexion using a halo-vest after tracheal sleeve resection is an excellent way of relieving anastomotic tension that would predispose the wound to dehiscence. [ABSTRACT FROM AUTHOR]

C-reactive protein (CRP) produced locally within esophageal cancer is associated with the prognosis and the rate of recurrence. CRP genetic polymorphisms reportedly affect serum CRP concentrations; however, there are no reports of an association between genetic polymorphisms and tumoral CRP expression. This study enrolled 73 Japanese patients classified with Stage IIA-IV thoracic esophageal squamous cell cancer, and also investigated their CRP genetic polymorphisms using DNA extracted from their peripheral blood. The study then assessed the association between CRP genetic polymorphisms and tumoral CRP expression. The results revealed a significant association between the CRP 1846C>T genetic polymorphism and tumoral CRP expression. This finding suggests that tumoral CRP production controlled by CRP genetics significantly influences tumor behavior. [ABSTRACT FROM AUTHOR]

We describe a novel technique of using halo-vest-enforced immobilization to relieve anastomotic tension after tracheal sleeve resection. Immediately after the tracheal sleeve resection, four halo titanium pins were inserted in the skulls of the patients to secure the halo-vest. All patients fitted with halo-vests were able to eat and drink and their clinical course was good. Bronchoscopy confirmed the absence of anastomotic leaks and stenoses, and there were no complications associated with the halo-vest. We believe that ensuring neck flexion using a halo-vest after tracheal sleeve resection is an excellent way of relieving anastomotic tension that would predispose the wound to dehiscence.

Lymphangiomyoma is a rare benign hamartoma of lymphatic origin. A 70-year-old woman presented with a 6-month history of a cough and dyspnea on exertion. Computed tomography and magnetic resonance imaging of the chest showed a 10 x 9 x 4 cm multiloculated tumor in the anterior mediastinum. We resected the tumor successfully, preserving all vital structures, even though the tumor margin was partially indistinct. The tumor was diagnosed as lymphangiomyoma based on the pathological and immunohistological findings. Hamartomatous lymphangiomyoma is not expressed by markers for secondary lymphangiomyoma of lymphangioleiomyoma, including human-melanoma-black-45 and progesterone receptor. The terminology and relevant literature on lymphangiomyoma are reviewed following this case report.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign breast disease. Pseudoangiomatous stromal hyperplasia is characterized by a collagenous proliferation of mammary stroma, associated with capillary-like spaces. We herein report the case of a 48-year-old woman who presented with a huge mass in her right breast. Physical examination revealed a 20 x 23-cm mass, which was surgically excised. Histopathologically, the tumor was composed of abundant fibrous stroma containing non-vascular slit-like spaces and scattered ducts and lobules. Neither stromal nor epithelial cells showed atypia. We therefore diagnosed the tumor to be PASH.

We describe how we removed a giant pedunculated atypical lipomatous tumor, arising in the cervical to upper thoracic esophagus and occupying a region extending from the cervical to the middle thoracic esophagus, through a cervical esophagotomy without thoracotomy or laparotomy. We suggest that if the base of the tumor is located in the cervical portion of the esophagus, and if the tumor is not aggressive, the cervical approach is best, irrespective of the size of the tumor.

Purpose: The type of anastomosis and its outcome can affect postoperative morbidity, mortality, and quality of life after esophagectomy. We compared the outcomes of cervical hand-sewn anastomosis (CHS) and intrathoracic stapled anastomosis (ITS) performed after esophagectomy and gastric reconstruction., Methods: Thirty-two patients with middle or lower thoracic esophageal cancer were prospectively randomized to undergo CHS (n = 18) or ITS (n = 14) after esophagectomy. We compared clinical data, postoperative symptoms, and long-term survival in the two groups., Results: The rates of anastomotic leak and stricture in the CHS and ITS groups were 16.7% versus 7.1% and 0% versus 14.2%, respectively, which do not represent significant differences. The respective rates of recurrent laryngeal nerve palsy were 38.8% versus 7.1% (P < 0.05), and proximal esophageal resection was 15 mm longer (P < 0.05) in the CHS group. There were no significant differences in symptoms 6 months after surgery, or in the overall 5-year survival rates (72.2% and 85.7%, respectively)., Conclusions: The two methods of anastomosis yielded similar anastomotic outcomes. Although the incidence of recurrent laryngeal nerve injury was higher after CHS, and proximal esophageal resection was longer, this had little impact on postoperative symptoms and long-term survival.

A 55-year-old man underwent subtotal esophagectomy with extended three-field lymph node dissection for squamous cell carcinoma of the middle thoracic esophagus (histological stage pT3N4(3b)M0, pStage IVa). About 9 months later, contrast-enhanced computed tomography showed recurrence in several lymph nodes in the anterior mediastinum and the right side of the neck. We treated the recurrence by dissecting the affected nodes, followed by chemoradiotherapy. At the time of writing, 5 years later, the patient was well, without any further evidence of recurrence. Although the indications for resection of recurrent esophageal cancer are controversial and we cannot generalize about the best treatment for these patients, this case highlights the possibility of using salvage surgical resection to treat recurrent esophageal cancer with anterior mediastinal lymph node involvement in selected patients.

The conventional treatment for an epiphrenic diverticulum consists of diverticulectomy with or without myotomy via a left thoracic approach. We describe the resection of an epiphrenic esophageal diverticulum using a laparoscopic transhiatal approach after observing its rate of enlargement on routine chest X-rays done over a number of years. This approach eliminates the need for thoracotomy and pleural drainage, and permits a complete laparoscopic procedure, including diverticulectomy, myotomy, and antireflex surgery.

We report a case of mediastinal neurofibroma originating from the left phrenic nerve in a 42-year-old woman who was referred to us after a routine chest X-ray showed a smooth, round abnormal shadow in the left middle lung field adjacent to the heart. We resected a 25 x 20 x 20-mm tumor by video-assisted thoracic surgery. Histopathological examination confirmed that the lesion was a mediastinal neurofibroma originating from the left phrenic nerve without von Recklinghausen's disease. Neurogenic mediastinal tumors originating from the phrenic nerve are very rare, and to the best of our knowledge, no other case of a mediastinal neurofibroma originating from the phrenic nerve in a patient without von Recklinghausen's disease has ever been reported.

We successfully performed off-pump coronary artery bypass grafting (OPCAB) with concomitant esophagectomy in a 77-year-old man with esophageal cancer and severe stenosis of the anterior descending branch of the left coronary artery. Off-pump coronary artery bypass grafting was performed via median sternotomy and esophagectomy was done via the left thoracoabdominal approach. The patient was discharged with a patent graft 8 weeks after surgery. The benefits of OPCAB include that it is less invasive and heparinization can be avoided. This case report demonstrates that simultaneous OPCAB and esophagectomy is advantageous for a selected population with surgically correctable coronary artery disease and resectable esophageal cancer.

Purpose: Tissue factor (TF), an initiator of the extrinsic coagulation cascade, is also expressed in a wide range of cancer cells and plays an important role in cancer progression and metastasis, as well as in processes independent of the blood coagulation pathway. For example, by acting as an adhesion molecule enabling tissue invasion, TF may play a key role in the metastatic process and angiogenesis in non-small cell lung cancer (NSCLC)., Methods: To further investigate the role of TF on tumor cell invasion in NSCLC, we measured the TF mRNA expression in the tumors of 42 NSCLC patients using real-time quantitative reverse transcription - polymerase chain reaction carried out in a LightCycler. We then compared the TF mRNA expression with histological evidence of invasion of blood and lymphatic vessels by tumor cells., Results: Although there was no significant relationship between the TF mRNA expression and the invasion of lymphatic vessels, the TF mRNA expression was significantly higher in tumors that invaded blood vessels (Log(10) TF mRNA/GAPDH mRNA = 2.16 +/- 0.18) than in those that did not (1.59 +/- 0.16; P = 0.03)., Conclusion: These results suggest that TF plays a major role in blood vessel invasion by tumor cells in NSCLC.

Purpose: The mechanism underlying the immunomodulation caused by blood transfusion has yet to be elucidated. The aim of the present study was to determine whether the transfusion of a soluble or insoluble factor present in stored blood can induce immunomodulation, which would thereby promote solid tumor growth., Methods: C57Bl/6J mice were subcutaneously inoculated with B16-CG melanoma cells, which secrete beta-human chorionic gonadotropin (beta-hCG). Following inoculation, each of three different products of allogeneic and syngeneic blood were transfused on days 0 and 1: fresh whole blood, stored whole blood, and supernatants from the stored blood. Tumor growth was then monitored by measuring urinary beta-hCG. All mice were killed on day 15, and the tumor weight and volume were measured., Results: Transfusion of all allogeneic blood products enhanced tumor growth, as did the stored syngeneic whole blood. Neither fresh syngeneic blood nor the supernatant from stored syngeneic blood promoted tumor growth. Although the tumors were not visually detectable until day 10 after inoculation, by day 7 the levels of urinary beta-hCG were significantly higher in the mice that received allogeneic blood supernatant than in the mice that received saline., Conclusions: A soluble alloantigen enhances solid tumor growth, as does an insoluble factor present in stored syngeneic whole blood. The immunomodulation associated with this factor begins to enhance tumor growth within 7 days after transfusion.