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Objectives: To demonstrate the differences in clinical outcomes between lobectomy and segmentectomy for non-small cell lung cancer using propensity score matching., Methods: A single-centre, retrospective, matched cohort study was conducted in clinical T1N0M0 non-small cell lung cancer patients treated by surgery between 2012 and 2019. Differences in freedom from recurrence, overall survival, postoperative complications, chest drainage and preservation of pulmonary function between lobectomy and segmentectomy were evaluated using the propensity score model. Matched variables of patients were age, sex, comorbidity index and pulmonary function. Matched variables of tumours were tumour size, T-stage, fluorodeoxyglucose uptake on positron emission tomography, histopathology, lobe site and tumour distance ratio from the hilum., Results: Of the 112 patients treated by lobectomy and 233 patients treated by segmentectomy, 93 patients each from both groups were selected after the matching. The median tumour distance ratio from hilum was 0.7 in lobectomy and 0.8 in segmentectomy group (P = 0.59), i.e. almost outer third tumour location. There were no significant differences in freedom from recurrence (P = 0.38), overall survival (P = 0.51), postoperative complications (P = 0.94), drainage period (P = 0.53) and prolonged air leakage (P = 0.82) between the two. Median preservation of pulmonary function was 93.2% after segmentectomy, which was significantly higher than 85.9% after lobectomy (P < 0.001)., Conclusions: Freedom from recurrence, overall survival, postoperative complications and chest drainage were similar between segmentectomy and lobectomy. Segmentectomy could be one of the options for clinical T1N0M0 non-small cell lung cancer located outer third as well as being able to preserve pulmonary function better than lobectomy., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Adjuvant oral uracil-tegafur (UFT) has led to significantly longer postoperative survival among patients with non-small-cell lung cancer (NSCLC). Gemcitabine (GEM) monotherapy is also reportedly effective for NSCLC and has minor adverse events (AEs). This study compared the efficacy of GEM- versus UFT-based adjuvant regimens in patients with completely resected pathological stage (p-stage) IB-IIIA NSCLC., Patients and Methods: Patients with completely resected p-stage IB-IIIA NSCLC were randomly assigned to GEM or UFT. The primary endpoint was overall survival (OS); secondary endpoints were disease-free survival (DFS), and AEs., Results: We assigned 305 patients to the GEM group and 303 to the UFT group. Baseline factors were balanced between the arms. Of the 608 patients, 293 (48.1%) had p-stage IB disease, 195 (32.0%) had p-stage II disease and 121 (19.9%) had p-stage IIIA disease. AEs were generally mild in both groups, and only one death occurred, in the GEM group. After a median follow-up of 6.8 years, the two groups did not significantly differ in survival: 5 year OS rates were GEM: 70.0%, UFT: 68.8% (hazard ratio 0.948; 95% confidence interval 0.73-1.23; P = 0.69)., Conclusion: Although GEM-based adjuvant therapy for patients with completely resected stage IB-IIIA NSCLC was associated with acceptable toxicity, it did not provide longer OS than did UFT., (© 2021. Japan Society of Clinical Oncology.)

Background: This study sought to clarify the extent of segmentectomy that achieves greater lung preservation than lobectomy., Methods: This was a single-center retrospective cohort study involving 374 patients with lung cancer who were treated with either lobectomy or segmentectomy between 2013 and 2018. The percentage of preserved pulmonary function (%PPF) after surgery was compared among patients who underwent lobectomy (n = 164), segmentectomy of 2 or more segments (Seg ≥2S; n = 42), and segmentectomy of less than 2 segments (Seg <2S; n = 168). Using perfusion scintigraphy, forced expiratory volume in 1 second of the preserved target lobe was measured to examine its effect on the %PPF. The number of resected subsegments (SSs) in segmentectomy that made the %PPF higher than that observed with lobectomy was also examined., Results: Mean %PPF was lowest in those patients who underwent lobectomy (86%), followed by Seg ≥2S (89%) and Seg <2S (95%) (P < .001), but the difference between the lobectomy and Seg ≥2S was not significant (P = .21). The forced expiratory volume in 1 second of the preserved target lobe was significantly lower in the Seg ≥2S group than in the Seg <2S group (P < .001). The number of resected SSs was 6 to 12 in lobectomy, 4 to 7 in Seg ≥2S, and 1 to 4 in Seg <2S. Although the %PPF after segmentectomy of less than 5 SSs (Seg <5SS) was significantly higher than that after lobectomy (P < .001), the %PPF after segmentectomy of 5 or more SSs (Seg ≥5SS) was not significantly different from that after lobectomy (P = .68)., Conclusions: Both the Seg ≥2S and Seg ≥5SS groups did not differ from lobectomy in %PPF because of the low function of preserved target lobe., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study was aimed to examine the significance of fluorodeoxyglucose positron emission tomography in predicting prognosis after segmentectomy in lung cancer., Methods: This was a retrospective cohort study, including 227 patients with cT1N0M0 nonsmall cell lung cancer who underwent positron emission tomography followed by segmentectomy between 2012 and 2019. Significance of tumor histology, T-stage, tumor size, and standardized uptake value on positron emission tomography in relation to recurrence-free survival were examined using Cox's proportional hazard analysis. Median follow-up period was 56 months (range: 1-95 months)., Results: Tumor stages were Tis in 25 patients, T1mi/T1a in 51, T1b in 98, and T1c in 53. Twenty-six patients (11%) experienced recurrences, including local ( n  = 8) and distant ( n  = 18). Multivariate analysis showed that the significant variables for recurrence-free survival were T-stage and standardized uptake value ( p  = 0.002 and 0.015, respectively), whereas tumor histology and tumor size were not significant ( p  = 0.28 and 0.44, respectively). When tumor size was divided into ≤2 cm and >2 cm for analysis, it was not significant again ( p  = 0.49), whereas standardized uptake value remained significant ( p  = 0.008). While standardized uptake value of tumors with recurrences was significantly higher than those without (4.9-2.8 and 2.6-2.5, respectively, p  < 0.001), there was no significant difference between local and distant recurrences ( p  = 0.32). Cut-off value of standardized uptake value for recurrences was 3.2. Five-year recurrence-free survival rates in tumors with standardized uptake value <3.2 and ≥3.2 were 86 and 65%, respectively ( p  < 0.001)., Conclusion: Positron emission tomography could predict the prognosis after segmentectomy better than tumor size., Competing Interests: None declared, (Thieme. All rights reserved.)

Objectives: To evaluate local control and complications of cryoablation for T1N0M0 non-small cell lung cancer using liquid nitrogen., Methods: This is a retrospective observational study on 101 patients with T1N0M0 NSCLC who underwent cryoablation between 2013 and 2019. Exclusion criteria included tumors without pathological diagnosis. The study population was divided into 4 groups according to the quartile of maximum tumor diameter. The study outcomes included local control, recurrence-free survival (RFS), treatment complications, and change in pulmonary function. Median follow-up period was 35 months., Results: Tumor diameter was divided into ≤0.9 cm (n = 21), 1.0-1.2 (n = 29), 1.3-1.7 (n = 24), and ≥1.8 (n = 27). Ten patients experienced local recurrences, which were observed none in both the groups of ≤0.9 cm and 1.0-1.2 cm (0%), one in the group of 1.3-1.7 cm (4%), and the other 9 in the group of ≥1.8 cm (33 %), indicating the local control to be better in smaller tumors (p < 0.001). The 3-year RFS was 86 % in ≤0.9 cm, 97 % in 1.0-1.2 cm, 92 % in 1.3-1.7 cm, and 53 % in≥1.8 cm, indicating the survival to be better in smaller tumors (p < 0.001). No patient had treatment-related mortality. The most frequent complication was pneumothorax, with a rate of 24 %. Forced expiratory volume in 1 s at 6 months after cryoablation was 97 ± 10 % of the pretreatment one., Conclusion: The local control and recurrence-free survival of cryoablation for T1N0M0 NSCLC was satisfactory for tumors <1.8 cm. While main complication was pneumothorax, the decrease of pulmonary function was just 3%., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: To investigate local control and survival after bronchial artery embolization (BAE) using N-butyl-2-cyanoacrylate (NBCA) for pulmonary hilar or mediastinal tumors that are refractory to chemotherapy or chemoradiotherapy., Method: This is a single center retrospective study involving 42 patients treated between 2015 and 2018 for pulmonary hilar or mediastinal tumors (primary tumors in 5 and metastatic ones in 37). Tumor histology was sarcoma in 22 and carcinoma in 20 patients. All patients had shown tumor progression regardless of previous chemotherapy (n = 37) or chemoradiotherapy (n = 5). Thirty-seven patients (88 %) had respiratory symptoms, such as cough, dyspnea, and hemoptysis. BAE was performed using NBCA to shrink tumors for extending life expectancy. Target tumors were followed with computed tomography at 1,3, and 6 months after BAE. Endpoints included the best tumor response within 6 months as well as overall survivals in patients with and without tumor responses., Results: Best local responses within 6 months were complete response (CR) in 1 patient, partial response (PR) in 16, stable disease (SD) in 24, and progressive disease (PD) in 1; the CR/PR rate was 40 % (17/42). Median follow-up period was 13 months (range:1-43). Overall survival in patients with CR/PR was significantly better than in those with SD/PD (p = 0.006); with 3-year survival rates of 45 % (8/17) and 0% (0/25), respectively., Conclusions: BAE using NBCA has potential promise for shrinking hilar and/or mediastinal tumors that are refractory to chemotherapy or chemoradiotherapy, and may also improve overall survival in patients who respond., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Non-small cell lung cancer (NSCLC) involving the chest wall is usually treated with en bloc rib resection or parietal pleurectomy; however, the former causes chest wall deformity and the latter is associated with local recurrence. To prevent both these sequalae, we performed the "ribcage" procedure for tumors involving the chest wall after induction chemoradiotherapy., Methods: This was a single center retrospective study conducted from 2012 to 2018. The "ribcage" procedure is designed to preserve the ribs of patients with lung tumors involving chest wall and involves peeling the intercostal muscles and periosteum from the ribs, resulting in a birdcage-like appearance. Seventeen patients with NSCLC clearly involving the chest wall, but not destroying the ribs, were treated with induction chemoradiotherapy, followed by the ribcage procedure. A negative margin at the ribs was confirmed by intraoperative frozen sections in 16 of these patients, who then underwent the ribcage procedure., Results: Complete resection was achieved in all 16 patients, none of whom experienced major postoperative complications. After a median follow-up period of 37 months, there was no evidence of local recurrence in any of the patients., Conclusion: Our findings suggest that the ribcage procedure is the preferable surgical option as it can prevent chest wall deformities as well as local recurrence.

Purpose: The aim was to investigate the relationship of age for recovery of six-minute walking distance (6MWD), pulmonary function, and health-related quality of life (HRQOL) after lung cancer surgery., Methods: Primary outcome was the 6MWD recovery until 6 months after surgery. Secondary outcome was the recoveries of forced expiratory volume in 1 s (FEV 1 ) and HRQOL until 6 months after surgery. Linear mixed-effects model was used to estimate the association of age to the outcomes., Results: A total of 311 lung cancer patients were included. All the 6MWD, FEV 1 , and HRQOL decreased after surgery (- 32 m, - 0.39L, and - 2 scores, respectively, p = 0.027-p < 0.001). While 6MWD increased every month after surgery (5 m/month, 95% confidence interval (CI); 4-7, p < 0.001), the recovery decreased, as the age increased 1 standard deviation (SD) (i.e., 9 years) (- 2 m/month; 95% CI - 3 to - 1, p < 0.001). While FEV 1 increased every month after surgery (0.03 L/month; 95% CI 0.02-0.03, p < 0.001), the recovery increased, as the age increased by 1 SD (0.01 L/month; 95% CI 0.00-0.01, p = 0.003), which was opposite to the 6MWD recovery. While the postoperative HRQOL recovered every month (2 score/month; 95% CI 1-2, p < 0.001), there was no significant association between the recovery and age (0 score/month; 95% CI - 1 to 0, p = 0.5)., Conclusions: The 6MWD recovery delayed in elderly patients, which was not related to their FEV 1 -and HRQOL recoveries. Postoperative walking training would be important for the elderly lung cancer patients.

Background: To predict pathological response and survival in T3/T4 non-small cell lung cancer after induction chemoradiotherapy by assessing fluorodeoxyglucose uptake with positron emission tomography., Methods: In this retrospective observational study, standard uptake values of whole tumors and extrapulmonary involvement sites were measured after induction chemoradiotherapy. The values were then compared with pathological responses and recurrence-free survival., Results: Fifty-seven patients with clinical T3/T4 tumors were treated by chemoradiotherapy followed by surgery. Pathological complete response was observed in 33% of patients (19 of 57). With the cutoff value of 3.3 for whole tumor fluorodeoxyglucose uptake for estimating complete response, 38% patients (9 of 24) with values lower than the cutoff value were false-negative. Tumor remission at extrapulmonary involvement sites was observed in 82% patients (47 of 57), and the cutoff value of the extrapulmonary uptake was 3.0 without any false negatives. Recurrence-free survival was significantly better in patients with values lower than both the whole- and extrapulmonary-uptake cutoff values than in patients with higher values (P = .016 and P = .001, log-rank test, respectively). Among 7 patients who avoided en bloc resections of involved structures because of lowered extrapulmonary uptakes and negative findings in intraoperative frozen sections, none experienced margin recurrence., Conclusions: Even when whole tumor uptakes in patients with T3/T4 tumors markedly decrease after induction chemoradiotherapy, surgical treatment is still indicated because of possible residual tumors. Tumor remission at extrapulmonary involvement sites could be predicted by extrapulmonary uptake values. Both whole- and extrapulmonary-uptake values after induction chemoradiotherapy could be used to predict prognosis., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Prognosis beyond 5 years after segmentectomy for non-small cell lung cancer (NSCLC) has not been well studied., Methods: This study is a retrospective analysis of a previous prospective cohort study of patients with peripheral cT1 N0 M0 NSCLC who underwent segmentectomy between 2005 and 2009. Exclusion criteria were right middle lobe tumors, multiple tumors in same lobe, patients having considerable risk for segmentectomy, and patients requesting lobectomy rather than segmentectomy. The median follow-up period was 108 months. Study outcomes included overall survival, recurrence-free probability, and local recurrence., Results: Of 179 patients with cT1 N0 M0 who were treated by segmentectomy, clinical T stages were Tis in 57 patients, T1mi or T1a in 34, T1b in 57, and T1c in 31. All tumors were pathologic N0 tumors. The 10-year recurrence-free probability rates in each clinical stage were 100% in Tis, 97% in T1mi or T1a, 90% in T1b, and 69% in T1c, which were significantly lower in advanced T stages (p < 0.001). Fourteen patients (8%) experienced recurrences after segmentectomy; these were local in 8 patients (five recurrences at the surgical margin and three in the preserved lobe) and nonlocal in 6 patients. Six of the eight local recurrences developed more than 5 years after segmentectomy. All eight local recurrences were treated by local therapy, resulting in 6 patients surviving without disease at 55 months of median follow-up after the additional treatments., Conclusions: Although segmentectomy may be a viable curative option for treating T1 N0 M0 NSCLC, monitoring for local recurrence should be continued beyond 5 years after segmentectomy to avoid missing opportunities to effect a cure., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Our study aim was to determine whether there are differential changes in whole-lung and regional lung functions after lobectomy for lung cancer between propensity score-matched patients treated with and without induction chemoradiotherapy, by using single-photon emission computed tomography lung perfusion., Methods: This study was a retrospective matched cohort study of consecutively acquired data. Pulmonary function test and perfusion scintigraphy were conducted before lobectomy and 6 months after lobectomy in patients treated with induction therapy (n = 72) and in those not treated (n = 170), for measuring functional changes of whole lung, contralateral lung, and lobes. After exact matching on resected lobe site, propensity scores for age, smoking status, preoperative pulmonary functions, and predicted postoperative pulmonary function were used to match the groups., Results: After the matching, 46 patients were selected from the groups. Standardized mean differences of the 5 matched variables were <0.1. Whole lung function significantly decreased after lobectomy in the induction therapy group than in the noninduction therapy group (P < .001). Although ipsilateral preserved lobe function before surgery was not different between the groups (P = .33), postoperative value was significantly lower in the induction therapy group than in the noninduction therapy group (P < .001). Although both groups showed a significant increase of contralateral lung function after lobectomy (P < .01), the increases were not significantly different between the groups (P = .81)., Conclusions: Induction chemoradiotherapy was associated with reduced pulmonary function after lobectomy because of a decrease in ipsilateral preserved lobe function, which could be caused by the chronic effects of the induction chemoradiotherapy., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To clarify differences in postoperative changes in systemic and regional pulmonary functions between segmentectomy and lobectomy in patients with lung cancer, we compared the 2 procedures using lung perfusion scintigraphy with a fusion image of single-photon emission computed tomography and computed tomography., Methods: This study is a retrospective matched cohort study of consecutively acquired data. Pulmonary function tests and perfusion single-photon emission computed tomography/computed tomography were conducted before surgery and 6 months after surgery to measure changes in forced expiratory volume in 1 s of a whole lung, contralateral lung and a lobe. After exactly matching the site of the resected lobe between the 2 procedures, propensity scores for age, sex, smoking status and pulmonary function were used to match them., Results: Of the 184 patients treated with segmentectomy and the 208 patients treated with lobectomy between 2013 and 2016, 103 patients were selected from each group after the matching. Whole lung function was significantly more preserved after segmentectomy than after lobectomy (P < 0.001). Segmentectomy preserved the function of the operated lobe with 48 ± 21% of the preoperative function. The function of the ipsilateral non-operated lobe increased after segmentectomy (P = 0.003) but not after lobectomy (P = 0.97). Contralateral lung function increased after both procedures (P < 0.001)., Conclusions: Our data suggest that segmentectomy preserved whole lung function better than lobectomy, because it not only preserved the lobe but also increased the function of the ipsilateral non-operated lobe. Lobectomy did not result in an increase of ipsilateral non-operated lobe function. Contralateral lung function increased after both procedures. The postoperative increase in regional functions could be the result of compensatory lung growth., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

It is often difficult to expose the pulmonary artery buried in a scar tissue, especially in lung cancer patients that responded well to neoadjuvant chemoradiotherapy. Difficulty to access pulmonary artery branches may lead to potentially unnecessary pneumonectomy. To complete lobectomy in such cases, a technique with preceding bronchial cutting for exposure of the pulmonary artery is presented. After dissecting the pulmonary vein, the lobar bronchus is cut from the opposite side of the pulmonary artery with scissors. The back wall of the lobar bronchus is cut using a surgical knife from the luminal face, which can expose the pulmonary artery behind the bronchial stump and then complete lobectomy. Fourteen patients have been treated using the present technique, enabling complete resection by lobectomy (including sleeve lobectomy in 3 patients) without major bleeding. The present procedure can expose pulmonary artery buried in scar tissue, resulting in making the lobectomy safer.

Purposes: To assess whether a video-assisted thoracoscopic surgery (VATS) procedure is superior to limited thoracotomy (LT) for segmentectomy; postoperative pain was compared between VATS-lobectomy (VATS-L) and LT-segmentectomy (LT-S). Widely opened anterolateral thoracotomy segmentectomy (WT-S) was used as a control., Methods: This study was a retrospective analysis of prospectively collected data for 220 consecutive patients with stage I NSCLC treated between 2012 and 2015 at a single institute using VATS-L (n = 58), LT-S (n = 93), or WT-S (n = 69). Pain scores from postoperative days (POD) 1-4 were measured using a visual analog scale three times a day. Chronic pain was assessed by the need for analgesics at 1, 2, and 3 months postoperatively., Results: No significant differences in pain from POD 1 to 4 were observed between VATS-L and LT-S, whereas WT-S showed significantly higher pain scores than these two procedures (p = 0.0001-0.02). Chronic pain did not differ significantly among the procedures., Conclusion: Postoperative pain does not differ significantly between VATS-L and LT-S. LT may be preferable to VATS for segmentectomy to identify the anatomy, dissect the hilar nodes, and establish surgical margins.

Purposes: One of the limitations of fluorodeoxyglucose-positron emission tomography (PET) for N-staging in non-small cell lung cancer (NSCLC) is false-positive results due to lymphadenitis. This study was performed to examine whether DWI can correctly identify false-positive nodes on PET in NSCLC., Methods: Both PET and DWI were performed in 157 patients before surgery, which involved dissection of 1033 nodal stations. Of the 157 patients, 26 patients had pathological N1 or N2 disease. Each nodal station was classified as positive or negative on PET and DWI according to the cutoff value determined by the receiver operating characteristic curve. Short-axis diameters of lymph nodes were measured on computed tomography., Results: While hilar nodes did not show significant differences in the number of false-positives between PET and DWI, DWI showed fewer false-positives than PET in the mediastinum (p = 0.011). Of the 43 false-positive mediastinal nodes on PET, 35 (81 %) were negative on DWI. The mean size of the 43 false-positive nodes on PET was 9 ± 1 mm, which was significantly larger than mean size of 7 ± 3 mm of the 24 false-positive nodes on DWI (p = 0.002)., Conclusions: DWI can correctly identify false-positive nodes on PET in the mediastinum. The larger size of false-positive nodes on PET could be due to enlargement by lymphadenitis.

Objective: Segmentectomy includes numerous kinds of procedures that may result in decreased postoperative pulmonary function. This causes controversy regarding the functional advantage of segmentectomy over lobectomy. To clarify the difference between the procedures, systemic and regional pulmonary functions of the resected segments must be examined., Methods: Pulmonary function tests and lung perfusion single-photon emission computed tomography (SPECT) were prospectively conducted before and after segmentectomy in 117 patients who were divided into groups based on resection of <2 segments (n = 83), ≥2 segments (n = 20), and left upper division (LUD) (n = 14). Left upper lobectomy (n = 13) was used as a control for the LUD group. Forced expiratory volume in 1 second (FEV1) of segment and lobe were measured from a fusion image of SPECT and computed tomography., Results: Percentage of postoperative/preoperative pulmonary function was the highest in the <2 segments group (97% ± 10%), which was followed by the ≥2 segments group (90% ± 9%), LUD group (84% ± 7%), and left upper lobectomy group (83% ± 7%), and the differences between the segmentectomy groups were significant (P < .001-.03), although there was no difference between the LUD and lobectomy groups. Whereas actual FEV1 of preserved lobes were significantly lower than the predicted value in all segmentectomy groups (P < .001), the percentage of actual/predicted value in the LUD group (43% ± 19%) was significantly lower than those in the <2 (72% ± 23%) and ≥2 segments (68% ± 30%) groups (P < .001 and P = .02, respectively)., Conclusions: Segmentectomy decreased the pulmonary function with increasing number of resected segments. LUD segmentectomy decreased both systemic and lobar function significantly due to not only large resection, but also marked depression of the preserved lobe, resulting in similar decrease as lobectomy., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purposes: Sentinel node identification using indocyanine green (ICG) is not only simpler, but also more cost-effective, than using radioisotope tracers. We herein examined the utility and pitfalls of sentinel node (SN) identification using ICG during segmentectomy in patients with cT1N0M0 non-small cell lung cancer (NSCLC)., Methods: ICG was injected around the tumor after thoracotomy, followed by segmentectomy and lymph node dissection, in 135 patients with cT1N0M0 NSCLC. The dissected nodes were examined using an ICG fluorescence imaging system., Results: SNs could be identified in 113 patients (84 %). The mean number of SNs was 2.3 ± 1.3. The percentages of being an SN were 57 % for both stations #12 and #13, which was significantly higher than the 18 % for #10 and 22 % for #11 (p < 0.001). Fourteen patients had N1 or N2 disease. Of these, the SNs were true positive (i.e., SNs contained metastasis) in 11 patients (79 %) and false negative (i.e., SNs did not contain metastasis, while non-SNs contained metastasis) in three patients (21 %). Of the three patients with false-negative results, all non-SNs containing metastases were at station #12 or #13., Conclusion: While ICG makes it simple to identify SNs during segmentectomy for cT1N0M0 NSCLC, stations #12 and #13 should be submitted for frozen sections along with the identified SNs to avoid missing true SNs.

Purposes: To examine whether diffusion-weighted magnetic resonance imaging (DWI) is as useful as fluorodeoxyglucose positron emission tomography (FDG-PET) for discriminating between malignant and benign pulmonary nodules measuring less than 3 cm in size, as well as for predicting tumor aggressiveness., Methods: PET and DWI were carried out on 87 pulmonary nodules measuring from 1 to 3 cm in size (66 NSCLCs and 21 benign nodules). The signal intensity (SI) of DWI was measured by the contrast ratio (CR) between the lesions and spinal cord, i.e., SI-CR. The maximum standard uptake value (SUV) of PET was measured by CR between the lesions and contralateral lung, i.e., SUV-CR., Results: DWI and PET showed sensitivities of 0.86 and 0.71, and specificities of 0.90 and 0.81, respectively. While there was no significant difference in the specificity between the two, DWI showed a significantly higher sensitivity than PET (p = 0.013). While the difference in the sensitivity was significant in lung adenocarcinoma (p = 0.012), there was no difference in the other histological types. Both the SI-CR and SUV-CR were significantly higher in the tumors with either histological invasiveness or lymphatic metastasis than in those without., Conclusions: DWI is thus considered to be useful, not only to diagnose NSCLCs, especially in lung adenocarcinoma, but also for predicting tumor aggressiveness as well as FDG-PET.

Background: Diffusion-weighted magnetic resonance imaging (DWI) frequently shows heterogeneity of signal intensity (SI) in non-small cell lung cancer (NSCLC). The purpose of our study was to examine the association of SI and DWI patterns with histology, tumor invasiveness, lymph node metastasis, and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) uptake in NSCLC., Methods: One hundred forty-five patients with NSCLC underwent preoperative DWI and FDG-PET. DWI patterns were visually classified as homogenous (HOM) (n = 81) or heterogeneous (HET) (n = 64). The former was further classified as faint (faint-HOM) (n = 27) or dark (dark-HOM) (n = 54) according to a cutoff value of SI. Associations of SI and DWI patterns with tumor histology, lymphatic or vascular invasion, pleural invasion, lymph node metastasis, and FDG uptake were evaluated., Results: All faint-HOM tumors were well-differentiated adenocarcinoma, whereas dark-HOM and HET tumors were less-differentiated adenocarcinoma or non adenocarcinoma. Although the dark areas in HET tumors showed a dense aggregation of tumor cells, their faint areas showed abundant fibrovascular stroma or necrosis, or a well-differentiated part of adenocarcinoma. Tumor size and the frequencies of lymphatic or vascular invasion, pleural invasion, and nodal metastasis were highest in HET tumors, followed by dark-HOM and faint-HOM (P = .1-P < .001) tumors. Sixty-five tumors having at least 1 of the invasions or metastasis showed significantly higher SI than the 81 tumors without (P < .001). HET tumors had the highest FDG uptake, followed by dark-HOM and faint-HOM tumors; differences between the groups were significant (P < .01 to P < .001)., Conclusions: The SI and heterogeneity of DWI reflect the histologic heterogeneity, tumor aggressiveness, and FDG-PET uptake in NSCLC., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: A procedure of modified trap-door thoracotomy and our 25 years' experience in 33 patients with tumors invading the anterior superior sulcus are presented., Methods: The modified portion of the original trap-door thoracotomy is the disconnection of the first rib from inside the thorax. Tumors consisted of lung cancer in 13 patients, thyroid cancer in 10, thymic tumor in 5, neurogenic tumor in 3, germ cell tumor in 1, and metastatic tumor in 1. Of the 33, 16 patients underwent a combined resection of the invaded organs, which included the brachiocephalic and subclavian veins in 4 patients, brachiocephalic vein in 3, thoracic wall in 6, trachea in 2, and trachea and brachiocephalic artery in 1. Combined resections of the trachea in the total 3 patients were treated with a sleeve resection and reconstruction, and those of the brachiocephalic and subclavian veins in 2 patients and brachiocephalic artery in 1 were reconstructed by a vessel graft., Results: Compared with the original trap-door thoracotomy, the additional disconnection of the first rib from inside the thorax provided a more adequate opening in the chest wall and more extensive exposure of the entire superior sulcus region, which enabled the complete resection of the tumors in all patients. A postoperative complication occurred in 1 patient, who had chylothorax., Conclusions: A trap-door thoracotomy modified with a disconnection of the first rib enabled a sufficient approach for resection of tumors invading the anterior superior sulcus., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

While the use of segmentectomy to treat lung cancer remains controversial, it has recently gained status as a radical surgery for cT1aN0M0 non-small cell lung cancer. I herein review the literature regarding segmentectomy and present my data to discuss the following issues: the prognosis after segmentectomy; local recurrence; the area required for lymph node dissection at the hilum and mediastinum; the technique used to cut the intersegmental plane; the selection of the lymph nodes for frozen sections; the postoperative pulmonary function; the role of completion lobectomy after radical segmentectomy for cT1N0M0/pN1-2; expectations and concerns regarding the randomized controlled trial JCOG0802; and the future of segmentectomy.

Resistance to erlotinib in lung cancer cases includes T790M mutant epidermal growth factor receptor and c-Met gene amplification, but other unknown mechanisms account for about 30% of the resistance. Activation of the nuclear factor kappa B (NFkappaB)-related pathways in association with the reduction in ikappaB level may be one of such potential mechanisms. It is known that curcumin inhibits the inducible activation of NFkappaB at least in part by sustaining ikappaB expression level. Therefore, we evaluated the effects of coadministration of erlotinib and curcumin on lung cancer cells. We found that erlotinib and curcumin augmentatively reduced cell viability. Studies in PC9 cells showed that induction of apoptosis was involved. Expression of ikappaB was elevated in PC9 cells by curcumin administration, and pretreatment with siRNAs for ikappaB significantly attenuated the reduction in cell viability after coadministration of erlotinib and curcumin. Furthermore, coadministration of erlotinib and/or curcumin augmentatively attenuated the growth of PC9 tumors in mice. These results suggested the existence of an augmentative tumor growth inhibitory effect between erlotinib and curcumin, and this effect was at least in part mediated by the increase in the expression of ikappaB induced by curcumin., (Copyright © 2013 John Wiley & Sons, Ltd.)

A 64-year-old man with primary lung cancer (cT1aN0M0) was diagnosed as having partial anomalous pulmonary venous connection (PAPVC) in the same lobe by preoperative chest computed tomography (CT). The anomalous vein originated from left upper lobe pulmonary vein and flowed into the left brachiocephalic vein. Although the patient was asymptomatic, cardiac catheterization revealed that pulmonary-systemic blood flow ratio (Qp/Qs ratio) was 2.0, and his pulmonary arterial pressure was marginally elevated (60/18 mmHg). We performed left upper lobectomy as the definitive treatment for both lung cancer and PAPVC. His pulmonary arterial pressure decreased after lobectomy (33/16 mmHg). He is living well without relapse of lung cancer 56 months after surgery. Although PAPVC is detectable on computed tomography, out of 7 previous reports of PAPVC associated with lung cancer, only 2 cases were diagnosed preoperatively. The presence of PAPVC should be kept in mind before major lung resections.

Objective: We aimed to identify prognostic factors after pulmonary metastasectomy for colorectal cancer and propose the clinical application of them. Furthermore, we endeavored to provide a rationale for pulmonary metastasesectomy., Background: Several prognostic factors have been proposed, but clinical application of them remains unclear. Moreover, there is no theoretical evidence that pulmonary metastasectomy is indicated for colorectal cancer., Methods: We retrospectively analyzed 1030 patients who underwent pulmonary metastasectomy for colorectal cancer from 1990 to 2008. Prognostic factors were identified and the relationship of recurrent sites after pulmonary resection to pulmonary tumor size was assessed., Results: Overall 5-year survival was 53.5%. Median survival time was 69.5 months. Univariate analysis showed tumor number (P < 0.0001), tumor size (P < 0.0001), prethoracotomy serum carcinoembryonic antigen (CEA) level (P < 0.0001), lymph node involvement (P < 0.0001), and completeness of resection (P < 0.0001) to significantly influence survival. In multivariate analysis, all remained independent predictors of outcome. In patients whose recurrent sites extended downstream from the lung via hematogenous colorectal cancer spread, pulmonary tumor size was significantly larger than in those with recurrent sites confined to the lung and regions upstream from the lung., Conclusions: We should utilize these prognostic factors to detect patients who might benefit from surgery. Therefore, we should periodically follow up advanced colorectal cancer patients by chest computed tomography to detect small pulmonary metastases before serum CEA elevation. Metastases to the lung or organs upstream from the lung are regarded as semi-local for colorectal cancer. This concept provides a rationale for validating surgical indications for pulmonary metastases from colorectal cancer.

Objective: During cryoablation, cells are destroyed at temperatures less than -20°C. The determining factors for local cancer control in pulmonary cryoablation were assessed using computed tomography (CT), isothermal curves, and histologic findings in pigs. Experimental findings were compared with clinical CT findings and were extrapolated to local cancer control outcomes., Methods: Cryoablation was performed with thermal monitoring, and the ablated areas were divided into 3 zones: less than -20°C, -20°C to 0°C, and greater than 0°C and were compared with histologic findings. CT findings with multiplanar reconstruction in 36 nodules were compared with the porcine histologic findings. The relationship between CT findings and 3-year local cancer control was evaluated in 98 nodules., Results: The 3 concentric thermal zones correlated with histologic findings as follows: less than -20°C zone, complete tissue destruction (zone D); -20°C to 0°C zone (which surrounded zone D), hemorrhage with air trapping and maintenance of alveolar structures (zone H); and greater than 0°C zone (outermost), edema with sustained alveolar structures (zone E). The CT findings in 36 nodules showed a central solid zone, a surrounding air-containing zone, and an outside solid zone, corresponding to zones D, H, and E, respectively. Local cancer control at 3 years in 80 nodules contained within the central solid zone was significantly greater compared with the 18 nodules that were not (82% vs 33%, P = .0002)., Conclusions: Pulmonary cryoablation should be performed such that tumors are contained within the central solid zone on CT, which represents the less than -20°C zone., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Here, we report a case of hepatoblastoma metastasis to the left pulmonary artery which was resected by left lingular segmentectomy plus left lower lobectomy in 5-year-old girl. She had previously undertaken right upper lobectomy and multiple lung partial resections on bilateral lungs as hepatoblastoma metastatectomies. Prediction of postoperative pulmonary function based on perfusion scan merged with CT image and the measurement by CT volumetry, showed that left lingular segmentectomy plus left lower lobectomy could preserve 78% of the preoperative functional values and resection was done. Three weeks after the operation, her condition recovered to the preoperative level. Pathological examination showed that the metastasis was tumor embolism of hepatoblastoma which extended into the pulmonary arterial wall, which to our knowledge, has not been previously reported.

Salvage surgery after gefitinib therapy in a 66-year-old female with cT4N1M1a lung adenocarcinoma in the right middle lobe, which had gene mutation of epidermal growth factor receptor, is presented. The patient had bulky hilar lymph nodes, pleural dissemination, and pulmonary metastases in the ipsilateral lobes. After 3 courses of chemotherapy, the patient was treated with gefitinib, resulting in partial response, i.e. only the primary tumor and the middle lobe atelectasis remained. We performed the middle lobe lobectomy aimed at local control and pathological confirmation of the remaining tumor. Because the hilum of the middle lobe was occupied with scar tissue, its pulmonary vein had to be cut within the pericardium and its pulmonary artery and bronchus had to be transected simultaneously with a stapler. Pathological stage was yp-T2aN0N0 with Ef 2. For salvage surgery after good response to gefitinib therapy, it should be taken care to expose pulmonary vessels.

A 66-year-old male was diagnosed with inoperable non-small cell lung cancer, and underwent chemoradiotherapy, to which he achieved a partial response. During subsequent follow-up, positron emission tomography showed a fluorodeoxyglucose uptake lesion within the primary tumor, without evidence of metastatic foci elsewhere in the body. As local disease progression was most suspected, cryoablation was performed for the lesion with high fluorodeoxyglucose uptake. After treatment, there has been no evidence of recurrence for 12 months. Herein, we present a case of percutaneous cryoablation as a salvage therapy for recurrent lung cancer after chemoradiotherapy., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the present study was to identify the modern surgical results of pathologic T3 lung cancer and to examine the heterogeneity of this group from the nationwide database., Methods: The registered data of 11,663 cases from the Japanese Joint Committee of Lung Cancer Registry conducted in 2010 were analyzed, which included patients with resected lung cancer during 2004. Of these patients, 531 with invasive T3 lung cancer constituted the study population., Results: Of the 531 patients, 466 were men and 65 women, with a mean age of 65.9 years. The 3- and 5-year survival rates and median survival time was 54.0%, 44.9%, and 46 months, respectively. A multivariate analysis showed incomplete resection, N2 disease, and no adjuvant therapy were independent prognostic factors of a poor outcome. However, pneumonectomy and N1 disease were not significantly associated with the prognosis. In terms of each involved structure, we detected 407 patients with T3 tumors involving the chest wall, 56 involving the mediastinal pleura, 45 with involvement of the bronchus within 2 cm of the carina, 31 involving the diaphragm, and 20 involving the pericardium. The corresponding 5-year survival rates were 43.2%, 40.1%, 55.2%, 42.6%, and 54.2%., Conclusions: The modern 5-year survival rates of patients with T3 lung cancer involving any neighboring structures have been 40% to 55%, and the current pT3 group was proved to have a relatively uniform prognosis., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: To describe the computed tomographic (CT) appearance of lung tumors treated with cryoablation to establish a reliable reference profile., Materials and Methods: CT images of 56 patients who underwent follow-up CT for at least 1 year for treatment with cryoablation of 79 tumors from 2003 to 2010 were retrospectively reviewed. Patients had a follow-up CT scan immediately after the procedure; 1 day, 1 week (two-phase dynamic CT), and 1 month later; and then at 3-month intervals. The appearance of ablation zones on CT images was classified into five patterns, and bidimensional diameters and other imaging features were evaluated., Results: Seventy-eight percent of ablation zones (62 of 79) showed transformation similar to the following: a consolidation or nodular pattern was seen within the 1-week follow-up, involution and a "stripe" pattern was shown at 1 month or later, and zones later became indistinct. Eighty percent of cases of local progression (eight of 10) arose from the stripe pattern on follow-up CT 6 months or later, after the ablation zones showed a transformation opposite the aforementioned pattern. Ice balls could not always be visualized exactly because of dense peritumoral hemorrhage. Internal and marginal enhancement of the ablation zone within the 3-month follow-up did not show a direct relationship with local progression. In total, cavitation and peritumoral ground-glass opacity were seen in 35% (n = 28) and 85% (n = 66) of ablation zones, respectively., Conclusions: The reference profile of CT appearance, which is mandatory for follow-up, has been established. No single indicator of complete ablation was proven throughout this study. Careful long-term follow-up with CT is indispensable., (Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.)

Background: To examine whether segmentectomy is radical for cT1N0M0 non-small cell lung cancer (NSCLC), a prospective single-arm study was performed at a single institution., Methods: The criteria for segmentectomy were as follows: (1) peripheral-type cT1N0M0 NSCLC; (2) intraoperative frozen sections of sentinel nodes identified with isotope showing no metastasis; (3) surgical margins greater than 2 cm; (4) patient choice for segmentectomy; and (5) exclusion of right middle lobe tumors. From 2005 to 2009, of 245 patients with cT1N0M0 NSCLC, 195 (80%) were enrolled in the present study. Of these 195 patients, 179 ultimately underwent segmentectomy with systematic lymph node dissection. Of these 179 patients, 134 (75%) had tumors 2 cm or smaller, and 45 (25%) had tumors 2.1 cm to 3 cm. The median follow-up period was 43 months., Results: All 181 tumors from 179 patients were stage pN0. Of the 179 patients, 6 developed distant site recurrence and 3 local recurrence (ie, 1 developed pulmonary metastases within the same lobe 21 months after segmentectomy and 2 developed local recurrence at the surgical margin 60 and 62 months after segmentectomy, respectively). The 5-year overall survival was 94% for patients with tumors 2 cm or smaller and 81% for those with 2.1-cm to 3-cm tumors. Postoperative pulmonary function was preserved at 90% ± 12% of preoperative levels., Conclusions: Segmentectomy with systematic lymph node dissection with a sufficient surgical margin could be a radical treatment for selected cT1N0M0/pN0 NSCLC while preserving pulmonary function. The surgical margin should be monitored for the development of local recurrence for a long period after segmentectomy., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Anatomic sublobar resection is being assessed as a substitute to lobectomy for primary lung cancers. However, persistent air leak after anatomic sublobar resection is prevalent and increasing surgical morbidity and costs. The use of electrocautery is being popularized recently in anatomic sublobar resection. We have retrospectively evaluated the safety and efficacy of intersegmental plane dissection using electrocautery., Methods: Between April 2009 to September 2010, 47 patients were treated with segmentectomy for clinical T1N0M0 non-small cell lung cancers. The intersegmental plane was dissected using electrocautery alone or in combination with staplers. We evaluated the methods of dividing intersegmental plane (electrocautery alone or combination with electrocautery and staplers), intraoperative blood loss, duration of chest tube placement, duration of surgery, preoperative FEV1.0%, incidence of prolonged air leak, length of postoperative hospital stay, postoperative pulmonary function at 6 months after surgery and the cost for sealing intersegmental plane., Results: Among the 47 patients, 22 patients underwent intersegmental plane dissection with electrocautery alone and 25 patients did in combination with electrocautery and staplers. The mean number of stapler cartridges used was only 1.3 in electrocautery and staplers group. Mean age, gender, number of patients whose FEV1% < 70% were similar between two groups. There was no statistical difference between electrocautery alone and combination with electrocautery and staplers group in duration of surgery (282 vs. 290 minutes), intraoperative blood loss (203 vs.151 ml), duration of chest tube placement (3.2 vs. 3.1 days), postoperative hospital stay (11.0 vs.10.0 days), postoperative loss of FEV1.0 (13 vs.8 %), loss of FVC (11 vs. 6 %) or incidence of minor postoperative complications [9 % (2/22) vs. 16 % (4/25), p = 0.30)]. However, incidence of prolonged air leak was higher in electrocautery alone group than in combination with electrocautery and staplers group [14 % (3/22) vs. 4 % (1/25), p = 0.025)]. The cost of materials for sealing air leaks amounted to €964 per patient in the electrocautery alone group and €1594 per patient in combination with electrocautery and staplers group., Conclusions: The number of patients with prolonged air leak was higher in the electrocautery alone group. The use of staplers in addition to electrocautery may lead to reduced prolonged air leak. However, the use of electrocautery for intersegmental plane dissection appeared to be safe with acceptable postoperative complications and effective in reducing costs.

Background: The role of surgery in the treatment of non-small-cell lung cancer (NSCLC) with clinically manifested mediastinal node metastasis is controversial even in resectable cases because it is often accompanied by systemic micrometastasis. However, surgery is occasionally indicated for cases with single-station N2 disease or within multimodal treatment regimens, and in clinical trials. The aim of this study is to evaluate surgical outcomes in a modern cohort of patients with clinical (c-) stage IIIA-N2 NSCLC whose nodal metastasis was confirmed by pathology (cN2/pN2)., Methods: From the central database of lung cancer patients undergoing surgery in 2004, which was founded by the Japanese Joint Committee for Lung Cancer Registration, data of patients having all conditions of NSCLC, c-stage IIIA, cN2, and pN2 were extracted, and the clinicopathologic profile of patients and surgical outcomes were evaluated., Results: Among 11,663 registered NSCLC cases, 436 patients (3.8%) (332 men and 104 women) had been extracted. Their mean age was 65 years, and histologic types included adenocarcinoma (n = 246), squamous cell carcinoma (n = 132), and others (n = 58). The proportion of R0 resection was 82.5% and the proportion of the hospital deaths among the cause of death was 2.3%. The 5-year survival rate was 30.1% for the selected group of patients. The postoperative prognosis was significantly better than those of corresponding populations extracted from the 1994 (p = 0.0001) and 1999 databases (p = 0.0411). Men and women experienced a significantly different survival outcome (p = 0.025) with 5-year survivals of 27.5% and 37.8%, respectively. Single-station N2 cases occupied 60.9 % of the cohort and showed a significantly better prognosis than multistation N2 (p = 0.0053, 35.8 % versus 22.0 % survival rate at 5 years)., Conclusions: The surgical outcomes of c-stage IIIA-cN2/pN2 NSCLC patients in 2004 were favorable in comparison with those ever reported.

Objective: To examine the role of radical segmentectomy, defined as a segmentectomy with extensive hilar/mediastinal lymph node dissection and a sufficient surgical margin, for local control in cT1 N0 M0/pN1-2 non-small cell lung cancer (NSCLC), we examined the following: (1) whether metastases were observed in specimens additionally resected by completion lobectomy undertaken after segmentectomy because of pN1-2 disease and (2) prognostic outcome in patients whose operations were completed with segmentectomy regardless of pN1-2., Methods: Of 275 patients with cT1 N0 M0 NSCLC who were scheduled to undergo radical segmentectomy, 15 (6%) had a diagnosis of pN1 or N2 disease. Of these patients, 10 were additionally treated with completion lobectomy, whereas the operations of the remaining 5 were completed with segmentectomy., Results: None of the 10 patients who underwent completion lobectomy showed residual metastases in the specimens additionally resected by completion lobectomy. Two of the 5 patients whose operations were completed with segmentectomy, regardless of N1 or N2 disease, had tumor recurrence, but their first recurrence was not local., Conclusions: Radical segmentectomy, with extensive hilar/mediastinal lymph node dissection and a sufficient surgical margin, may play a role in local control in patients with cT1 N0 M0/pN1-2 NSCLC., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

A 47-year-old woman with a lung adenocarcinoma of 1.3 cm located in the left S9+10 was treated by S9+10 segmentectomy with sentinel node (SN) identification using radioisotopes. During segmentectomy, frozen section of the segmental nodes at S9+10 and S6, identified as SNs, did not show metastasis; however, postoperative immunohistochemical staining with cytokeratin revealed isolated tumor cells in the segmental node at S6. None of the other dissected nodes, including the hilar, interlobar, and mediastinal nodes, showed metastasis, even with immunohistochemical staining. Completion lobectomy was conducted 6 days after segmentectomy, and the resected specimens did not show further metastasis. The final pathological diagnosis was adenocarcinoma with pT1aN0(i+)M0 stage A. The present case was indicative of the importance of dissecting the segmental lymph node located not only at the tumor-bearing segment but also at the neighboring segment, especially the one located between the primary tumor and the lobar bronchi.

Purpose: To evaluate the safety and feasibility of cryoablation for lung tumors as well as the incidence of, and risk factors for, complications., Materials and Methods: This study included 193 cryoablation sessions for 396 lung tumors in 117 consecutive patients. Univariate and multivariate analyses were performed to assess risk factors for common complications. Changes in laboratory values were analyzed the day after cryoablation., Results: Pneumothorax, pleural effusion, and hemoptysis occurred after 119 (61.7%), 136 (70.5%), and 71 (36.8%) sessions, respectively. Phrenic nerve palsy, frostbite, and empyema occurred after one session each (0.52%). Proximal tumor implantation was observed in one of 471 punctures (0.20%). Of 119 sessions with pneumothorax, 21 (17.6%) required chest tube insertion and two (1.7%) required pleurodesis. Delayed and recurrent pneumothorax occurred in 15 of 193 sessions each (7.8%). A greater number of cryoprobes was a significant (P = .001) predictor of pneumothorax. Male sex (P = .047) and no history of ipsilateral surgery (P = .012) were predictors for the need for chest tube insertion, and no history of ipsilateral surgery (P = .021) was a predictor for delayed/recurrent pneumothorax. Greater number of cryoprobes (P = .001) and no history of ipsilateral surgery (P = .004) were predictors for pleural effusion. Greater number of cryoprobes (P < .001) and younger age (P = .034) were predictors for hemoptysis. Mean changes in white blood cell count, platelet count, hemoglobin level, and C-reactive protein level were 2,418/μL ± 2,260 (P < .001), -2.0 × 10(4)/μL ± 3.2 (P < .001), -0.77 mg/dL ± 0.89 (P < .001), and 3.0 mg/dL ± 2.9 (P < .001), respectively., Conclusions: Percutaneous cryoablation could be performed minimally invasively with acceptable rates of complications., (Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.)

We report a case of lung cancer producing granulocyte-macrophage colony-stimulating factor (GM-CSF). The patient, a 55-year-old woman, was found to have leukocytosis (leukocytes 28.8 × 10(3)/mm3) with eosinophilia (eosinophils 24.5%) without any evidence of infection or allergy. The serum concentration of GM-CSF was elevated to 44 pg/ml (normal range <2.0 pg/ml), which might have induced the leukocytosis and eosinophilia. We performed left pneumonectomy and diagnosed a pleomorphic carcinoma with p-T2bN0M0, based on histological examination of the resected tumor. Immunohistochemical examination revealed GM-CSF. The serum level of GM-CSF decreased to within the normal range 8 days after surgery. At the time of writing, 16 months after the surgery, she was alive without disease. To our knowledge, this represents the first case report of a GM-CSF-producing tumor effectively treated by surgical resection.

Background: To evaluate the midterm results of percutaneous cryoablation for medically inoperable stage I non-small cell lung cancer., Methodology/principal Findings: Between January 2004 and June 2010, 160 patients underwent computer tomography guided percutaneous cryoablation for lung tumors at our institution. Of these patients, histologically proven stage I lung cancer patients with more than one year of follow-up, were retrospectively reviewed. All of these patients were considered to be medically inoperable with Charlson comorbidity index of 3 or greater. Follow-up was based primarily on computed tomography. There were 22 patients with 34 tumors who underwent 25 sessions of cryoablation treatment. Complications were pneumothoraces in 7 treatments (28%, chest tube required in one treatment), and pleural effusions in 8 treatments (31%). The observation period ranged from 12-68 months, average 29±19 months, median 23 months. Local tumor progression was observed in one tumor (3%). Mean local tumor progression-free interval was 69±2 months. One patient died of lung cancer progression at 68 months. Two patients died of acute exacerbations of idiopathic pulmonary fibrosis which were not considered to be directly associated with cryoablation, at 12 and 18 months, respectively. The overall 2- and 3-year survivals were 88% and 88%, respectively. Mean overall survival was 62±4 months. Median overall survival was 68 months. The disease-free 2- and 3-year survivals were 78% and 67%, respectively. Mean disease-free survival was 46±6 months. Pulmonary function tests were done in 16 patients (18 treatments) before and after cryoablation. Percentage of predicted vital capacity, and percentage of predicted forced expiratory volume in 1 second, did not differ significantly before and after cryoablation (93±23 versus 90±21, and 70±11 versus 70±12, respectively)., Conclusions/significance: Although further accumulation of data is necessary regarding efficacy, cryoablation may be a feasible option in medically inoperable stage I lung cancer patients.

Treatment strategies for synchronous, multiple peripheral lung cancers remain controversial. Bilobectomy for multiple lung cancers could cause pulmonary function impairment. We report two patients with synchronous multiple peripheral non-small cell lung cancers, who underwent multiple segmentectomy simultaneously. This is the first report of consecutive segmentectomy of two segments.

We describe our innovative technique for performing segmentectomy of the posterior segment of the lower lobe of the lung, being segment number 10 (S¹⁰). In segmentectomy of S¹⁰, it is difficult to identify A¹⁰ from the interlobar fissure because the pulmonary artery to S¹⁰ (A¹⁰) branches from A(9+10) and runs dorsally and deeply into the lung tissue. Moreover, to reach S¹⁰ from the interlobar fissure, the lung tissue should be cut between S⁶ and S⁸, because S¹⁰ is not located beside the interlobar fissure. However, it is difficult to identify the boundary between the S⁶ and S⁸ without a route marker. To solve these difficulties, we divided S⁶ and S¹⁰ from each other at the beginning of the procedure, which enabled A¹⁰ to be identified easily from the dorsal side. Because S⁶ and S(8-10) should be divided in S¹⁰ segmentectomy at the end, the division between S⁶ and S(8-10) at the beginning of procedure is not only reasonable, but makes the procedure simple.

Objective: A risk of tumor seeding after percutaneous needle biopsy has been reported in various organs, including the lung. This study retrospectively evaluated the proportion of ipsilateral pleural recurrence after computed tomography-guided needle biopsy (CTNB) in p-stage I lung cancer patients., Methods: Of the 321 patients diagnosed with p-stage I lung cancer, 124 underwent CTNB before surgery, while 197 underwent non-CTNB procedures, including bronchoscopic biopsy in 188 patients and thoracoscopic wedge resection in 9. These patients were retrospectively analyzed., Results: While the tumor size was significantly larger in the non-CTNB group (25 ± 9 mm) in comparison to the CTNB group (19 ± 9 mm) (p<0.001), percentage of pleural, vascular, or lymphatic invasions were comparable between the two groups. Eight patients developed ipsilateral pleural recurrences, one (1%) in the CTNB group, and 7 (4%) in the non-CTNB group. Of these, 3 patients developed pleural recurrence only at first, 1 (1%) in the CTNB group, and 2 (1%) in the non-CTNB group. The differences in the proportions of these pleural recurrences between the 2 groups were not significant. Subgroup analyses by baseline characteristics such as tumor size, pT stage, or microscopic pleural invasion, showed that proportions of pleural recurrences in CTNB group were not high compared with non-CTNB group in each subgroup. Analysis of progression-free survival showed that recurrences in CTNB were not high compared with non-CTNB., Conclusions: The pleural recurrence was not significantly increased after CTNB in p-stage I lung cancer patients in this particular study.

Lung cancers in the residual lungs of patients who have undergone pneumonectomies are often unresectable, primarily because of the risks of overt pulmonary function losses. Percutaneous cryoablation of lung tumors is a potentially minimally invasive technique that has recently been used in the treatment of lung cancers and metastatic lung tumors. Here, we present two patients who had previously undergone pneumonectomies, in whom lung cancers in the residual lungs were treated by cryoablation. In both patients, the procedures were performed safely without any complications, such as airway bleeding, hemothoraces, or pneumothoraces. The changes in pulmonary functions after the procedures were minimal: % vital capacity (-1% and -4%), and %FEV(1) (-1% and +10%) in the first and second patients, respectively. The performance statuses were maintained at zero in both patients after cryoablation. In the first patient, local control has been maintained for 4 years. In the second patient, local control was maintained for 2 years until the patient died of distant metastases. This is, to our knowledge, the first reported case of lung cryoablation in residual lungs of patients who have previously undergone pneumonectomies. Application of percutaneous cryoablation may represent a new treatment option for lung tumors in patients who have previously undergone pneumonectomies.

We report two cases of needle-tract seeding after percutaneous cryoablation for lung metastases of colorectal cancer. The targeted lung tumor was solitary in both cases. In patient 1, cryoablation was performed with a single cryoprobe, which was removed without freezing the cryoprobe tract. In patient 2, cryoablation was performed with two cryoprobes, both of which were removed after freezing of the cryoprobe tract. The seeding nodule appeared 5 and 7 months after cryoablation on the follow-up computed tomographic scan, respectively. In both cases, the seeding nodules were solitary and existed primarily in the subcutaneous to chest muscle layer, and could be completely resected under local anesthesia. Both lesions were pathologically confirmed as metastases from colorectal cancer. Local control was maintained in patient 1 for 4 years, until death due to progressive lung metastases. Patient 2 is alive without recurrences 8 months after resection., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A technique for combined resection of S(2)(b) (horizontal subsegment of the posterior segment) and S(3)(a) (lateral subsegment of the anterior segment) of the right upper lobe of the lung is presented. Although both the S(2)(b) and S(3)(a) should be resected from the interlobar fissure, an approach for the artery and bronchus of S(3)(a) (A(3)(a) and B(3)(a), respectively) is easier from the ventral side of the hilum rather than from the interlobar fissure, because B(3) runs in back of V(2) at the interlobar fissure. To resolve this contradiction, we devised a procedure as follows: (1) A(2)(b) and B(2)(b) are cut at the interlobar fissure; (2) A(3)(a) and B(3)(a) are cut from the ventral side of hilum; (3) the peripheral stumps of A(3)(a) and B(3)(a) are transferred to the interlobar fissure; and (4) subsegments of S(3)(a) and S(2)(b) are resected with the peripheral stumps of A(2)(b), B(2)(b), A(3)(a), and B(3)(a) from the side of the interlobar fissure. We believe this procedure makes the combined resection of S(2)(b) and S(3)(a) easy.

Introduction: Cancer tissue is composed of various stromal cells forming cancer-specific microenvironments. Peritumoral stroma is reportedly composed of activated fibroblasts that can influence the biological properties of tumor cells, mainly their local aggressiveness and their ability. The aim of this study was to examine whether the histological properties of peritumoral stroma are correlated with squamous cell carcinoma (SqCC) aggressiveness and clinical outcome., Methods: A series of 220 pathological stage I lung SqCC were categorized into two types according to the histological properties of the peritumoral stroma, "fibrous stroma type" (n = 85), and "thin stroma type" (n = 135), and compared the prognostic significance. Furthermore, we compared the immunohistochemical properties of the SqCC cells surrounded by "fibrous stroma" with those of the SqCC cells surrounded by "thin stroma.", Results: The prognosis of the patients with fibrous stroma-type tumors was significantly poorer than that of the thin stroma type with regard to both recurrence-free survival (p = 0.005) and overall survival (p = 0.008). A multivariate analysis showed that the presence of a fibrous stroma was an independent prognostic factor (p = 0.030). Compared with the SqCC cells with a thin stroma, the SqCC cells with a fibrous stroma exhibited reduced expression of E-cadherin (55.9 versus 126.0, p < 0.001) and an increased expression of laminin-5γ2 (94.6 versus 25.0, p = 0.001), matrix metalloproteinase-7 (26.0 versus 3.50, p = 0.009), and c-Met (64.0 versus 36.5, p = 0.033)., Conclusion: SqCC with a fibrous stroma displayed higher invasive phenotype and were associated with a significantly poor prognosis. The current results suggest that the microenvironment created by both SqCC cells and the peritumoral fibroblasts may facilitate cancer aggressiveness.

Objective: The diagnostic performance of percutaneous core needle lung biopsy under multi-CT fluoroscopic guidance for ground-glass opacity (GGO) pulmonary lesions was evaluated., Materials and Methods: Out of 90 patients who underwent CT fluoroscopy-guided core needle biopsy of GGO lesions at our institution, the biopsy results and the final diagnoses were retrospectively compared in 67 patients with available data (one lesion per patient). Diagnostic performance was also compared according to the lesion size (≤ 10 mm (n=8) versus 11-20mm (n=42) versus >20mm (n=17)), the percentage of GGO component (50-90% (n=31) versus >90% (n=36)), and the length of needle path (≤ 7 cm (n=45) versus > 7 cm (n=22)). Finally, all 90 cases were reviewed for complications., Results: The overall sensitivity, specificity, and accuracy were 97%, 100%, and 97%, respectively. The diagnostic sensitivity and accuracy tended to be lower in smaller lesions (≤ 10 mm; 86 and 88%, 11-20mm; 97 and 98%, >20mm; 100 and 100%, respectively, p>0.05), and in lesions with lower percentage of GGO component (50-90%; 93 and 94%, >90%; 100 and 100%, respectively, p=0.21), but statistical significances were not reached. The sensitivity and accuracy were not significantly affected by the length of needle path (≤ 7 cm; 98 and 98%, > 7 cm; 95 and 96%, respectively, p=1.00). Fourteen patients (16%) developed pneumothoraces, and 13 patients (14%) experienced mild hemoptysis, all of which resolved conservatively., Conclusion: The diagnostic performance was satisfactory, and it was considered that the procedure was appropriate for GGO lesions regardless of lesion size, the percentage of GGO component, or the length of needle path. The procedure was also feasible without any major complications., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Systemic chemotherapy remains the standard treatment for metastatic transitional cell carcinoma (TCC) of the urinary tract. For pulmonary metastases of several malignancies, surgical therapy for selected patients has become a treatment of choice to achieve cure. However, data on pulmonary metastasectomy for urinary TCC remain limited., Methods: From 1990 to 2005, 2,288 patients who underwent pulmonary metastasectomy for all types of malignancy were registered in the Metastatic Lung Tumor Study Group of Japan. Of these, we extracted 32 patients with TCC who underwent pulmonary metastasectomy with a curative intent from the database. We investigated the surgical outcomes of the patients, focusing on long-term progression-free survival (PFS) and modified PFS as a parameter for achieving a cure. In modified PFS, when the disease-free status had continued for longer than two years after repeated resection at the last follow-up, the first recurrence was not considered as an event., Results: The five-year overall survival and PFS rates were 50% and 26%, respectively. Including 3 patients who underwent a second pulmonary metastasectomy for recurrence, 9 patients survived without recurrence for more than 5 years, resulting in a modified five-year PFS rate of 40%. Multivariate analysis revealed that a pulmonary metastasis greater than 3 cm was a significantly poor prognostic factor. The modified five-year PFS rate for patients with a pulmonary metastasis smaller than 3 cm in diameter was 65%., Conclusions: Pulmonary metastasectomy may have a curative role in the treatment of metastatic TCC in appropriately selected patients, especially those with a small solitary pulmonary metastasis., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Although segmentectomy is attempted for small non-small cell lung cancer (NSCLC) tumors, no reports have so far described how many of these tumors can be candidates for a successful resection by single segmentectomy., Methods: In all, 135 patients with peripheral p-T1N0M0 NSCLC were examined. The tumors were classified into five groups divided by every 0.5-cm increase in size. Tumor locations were classified into two groups - limited to within one segment and extended beyond one segment - based on the identification of whether pulmonary vessels and the bronchi were involved in the tumors on high-resolution computed tomography. Differences in the proportion of tumors limited within one segment between tumors smaller and larger than each class of tumor size were assessed., Results: The tumor sizes were 0-1.0 cm in 8 tumors, 1.1-1.5 cm in 27, 1.6-2.0 cm in 35, 2.1-2.5 cm in 34, and 2.6-3.0 cm in 31 tumors. Of these 135 tumors, 92 (65%) were limited to one segment, whereas 48 (35%) had extended beyond one segment. When the tumor size was less than 30 mm, the proportion of tumor limited within one segment did not show any significant difference depending on the size of the tumor., Conclusions: More than one-third of p-T1N0M0 NSCLC tumors extended beyond one segment, irrespective of size. It is therefore noteworthy that resection of up to two segments or lobectomy should be undertaken for prevention of local recurrence in patients with p-T1N0M0 peripheral NSCLC.

Background and Objective: Both Krebs von den Lungen-6 (KL-6) and carcinoembryonic antigen (CEA) are known to be tumour markers in non-small cell lung cancer (NSCLC). The aim of the present study was to assess whether or not intrabronchial epithelial lining fluid (ELF) levels of these markers predicted tumour response better than serum levels in patients with advanced NSCLC treated with gefitinib., Methods: ELF samples were obtained both from near the tumour and from the contralateral lung using a bronchoscopic microsampling technique, before and 2 weeks after the start of gefitinib treatment. Serum samples were taken concurrently. Among the 22 patients enrolled in the study, 14 (64%) showed partial responses or stabilization of disease with gefitinib treatment (treatment responders), while 8 (36%) showed progression of disease (treatment non-responders), 4 weeks after the start of treatment., Results: ELF KL-6 levels near the tumour decreased significantly after 2 weeks in the treatment responders group (P = 0.011), whereas there was a marginal increase in the treatment non-responders group (P = 0.049). ELF CEA levels near the tumour decreased significantly after 2 weeks in the treatment responders group (P = 0.004), whereas there was no significant change in the treatment non-responders group. For both markers, neither the serum levels nor the levels in contralateral ELF showed any significant changes in either group of patients., Conclusions: Both KL-6 and CEA levels in ELF near the tumour predicted tumour response in NSCLC patients treated with gefitinib, whereas serum levels did not., (© 2011 The Authors. Respirology © 2011 Asian Pacific Society of Respirology.)