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Background: The usefulness of autologous blood pleurodesis for air leak after pulmonary resection is well known; however, factors predicting the therapeutic efficacy are poorly understood. Herein, we aimed to examine the predictors of early autologous blood pleurodesis for air leak following pulmonary resection., Methods: Patients who underwent pulmonary resection and autologous blood pleurodesis with thrombin for postoperative air leak between January 2016 and October 2022 were retrospectively analyzed. Patients received 50-100 mL of autologous blood and 20,000 units of thrombin on postoperative days 1-4. If necessary, the same procedure or pleurodesis with other chemical agents was repeated until the air leak stopped. Patients were divided into single-dose and multiple-dose groups based on the number of times pleurodesis had occurred before the air leak stopped and were statistically analyzed. Logistic regression analysis was performed to identify predictors of treatment efficacy., Results: Of the 922 patients who underwent pulmonary resection, 57 patients (6.2%) were included and divided into single-dose ( n  = 38) and multiple-dose ( n  = 19) groups. The amount of air leaks was identified as a significant predictor of multiple dosing, with a cutoff of 60 mL/min, in multivariate logistic regression analyses (odds ratio 1.13, 95% CI 1.03-1.24, p  = 0.0065). The multiple-dose group showed a significantly higher recurrence of air leak ( p  = 0.0417)., Conclusions: The amount of air leaks after pulmonary resection is the only significant factor predicting whether multiple autologous blood pleurodesis is required, and the recurrence rate of pneumothorax is significantly higher in such cases., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This study was performed to compare the outcome of pleurectomy/decortication (P/D) with that of extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM)., Methods: Patients with MPM underwent either P/D or EPP from August 2008 to December 2014. Various clinicopathological factors were analyzed to identify differences between the two procedures., Results: P/D was performed in nine patients and EPP in 30 patients. Most of the patients' background characteristics were not significantly different between the groups. The surgery time (680 vs. 586 min, p = 0.0034) and bleeding volume (4050 vs. 2110 mL, p = 0.002) were significantly greater in P/D than in EPP; however, grade ≥3 complications (44% vs. 33%, p = 0.54) and length of postoperative hospital stay (29 vs. 37 days, p = 0.26) were not significantly different. The median survival time and 2- and 3-year survival rates in all patients were 16.7 months, 28.5%, and 15.3%, respectively. The median survival time and 2- and 3-year survival in the P/D and EPP groups were 22.5 months, 43.8%, and 43.8% and 16.5 months, 24.0%, and 14.4%, respectively (p = 0.13)., Conclusion: Survival of patients with MPM remains poor despite multidisciplinary treatment. P/D is comparable with EPP and could be a safe and another surgical treatment for patients with MPM.

Purpose: The aim of this study was to compare the outcomes of surgery and stereotactic body radiotherapy (SBRT) for elderly clinical stage I non-small cell lung cancer (NSCLC) patients., Methods: Patients ≥80 years of age with clinical stage I NSCLC between August 2008 and December 2014 were treated either surgery or SBRT. Propensity score matching was performed to reduce bias in various clinicopathological factors., Results: Surgery was performed in 57 cases and SBRT in 41 cases. In the surgery group, the operations included 34 lobectomies and 23 sublobar resections. In the SBRT group, 27 cases were given 48 Gy in 4 fractions, and 14 were given 60 Gy in 10 fractions. Similar characteristics were identified in age (82 years), gender (male:female ratio 2:1), tumor size (2.2 cm), carcinoembryonic antigen (3.6 ng/ml), Charlson comorbidity index (1), Glasgow prognostic scale (0), and forced expiratory volume in 1 s (1.7 L) after matching. Before matching, the 5-year overall survival (OS) in surgery (68.3%) was significantly better than that in SBRT (47.4%, p = 0.02), and the 5-year disease-specific survival (DSS) (94.1%, 78.2%, p = 0.17) was not significantly different between the groups. The difference in the 5-year OS became non-significant between the matched pairs (57.0%, 49.1%, p = 0.56)., Conclusions: The outcomes of surgery and SBRT for elderly patients with the early stage NSCLC were roughly the same.

Purpose: Several studies have reported that an acute exacerbation (AE) of idiopathic interstitial pneumonia (IIP) can occur after lung resection in patients with non-small cell lung cancer (NSCLC); however, the perioperative management strategy is controversial., Methods: The data of lung cancer patients at Nagasaki University Hospital from June 1994 to October 2013 were retrospectively reviewed., Results: Among all 1701 NSCLC patients who underwent lung resection, 59 (3.5%) had IIP. Five patients (8.5%) had an AE of IIP following lung resection, three (60%) of whom died in hospital. Univariate and multivariate analyses were performed to identify possible risk factors for AE. The univariate analyses identified LDH and the volume of blood loss as risk factors. The multivariate analysis identified no factors. The treatment for an AE included steroid pulse therapy and neutrophil elastase inhibitor therapy. Direct hemoperfusion with polymyxin B immobilized the fiber column and immunosuppressant therapy was attempted in some of the patients who did not respond to these treatments., Conclusion: Patients with lung cancer and IIP have a higher risk of chest surgery and a poor prognosis. Very careful surgery and perioperative management are needed, because AEs are often difficult to AE predict.

A 66-year-old woman underwent right lower lobectomy and partial resection of the middle lobe for Stage I A double lung cancer. Five years after the operation, a routine computed tomography (CT) scan showed a mass on the staple line at the middle lobe. The mass was enlarged on CT scan after 6 months. A definitive diagnosis could not be made by bronchoscopic examination and fluoro-2-deoxy-glucose(FDG)/positron emission tomography( PET)-CT showed FDG uptake in the mass( early phase:SUVmax=3.24, late phase:SUVmax=4.31). Local recurrence of lung cancer was not completely denied, and right middle lobectomy was performed. Histopathologically, the resected specimen revealed granuloma with foreign body reaction. We should keep in mind the possibility of granuloma as differential diagnosis of lung cancer when using stapler.

Purpose: Unexpected intraoperative bleeding during thoracoscopic surgery, necessitating emergency conversion to thoracotomy, is gradually being reported. We reviewed our experience of encountering unexpected bleeding during thoracoscopic surgery., Methods: We defined "unexpected intraoperative bleeding" as the need for hemostatic procedures with angiorrhaphy, with or without a sealant. The location, cause, and management of injured vessels, and perioperative outcomes were investigated and compared with those for patients without injured vessels., Results: Between 2007 and 2014, a total of 241 thoracoscopic anatomical pulmonary resections were performed at our hospital. Twenty (8.3 %) of these patients required hemostatic procedures with angiorrhaphy, with or without a sealant. The main injured vessels were the pulmonary artery (n = 13) and vein (n = 3) and the main causes of injury were related to technical issues with energy devices and staplers. There were no morbidities related to intraoperative bleeding. The operation time and blood loss were significantly greater in the patients with vessel injury than in those without vessel injury, but perioperative morbidities and the duration of chest tube insertion (4.5 vs. 3.5 days, average, p = 0.20) and postoperative hospital stay (12.7 vs. 11.0 days, average, p = 0.08) were not significantly different., Conclusions: The frequency of unexpected bleeding was relatively high in this series, but its management and outcomes were satisfactory in terms of safety.

Objectives: Sublobar resection procedures, such as segmentectomy and wedge resection, can be used for resectable lung cancer when the cancer is small or the condition of the patient is poor. In such cases, intraoperative lymph node (LN) exploration is necessary to avoid incomplete resection of potential N1 or N2 disease. The semi-dry dot-blotting (SDB) method was developed to detect intraoperative LN metastasis as a quick, cost-effective procedure that does not require special technical expertise. This study examined whether SDB can sufficiently identify LN metastasis in lung cancer patients., Methods: This study prospectively examined 147 LNs from 50 lung cancer patients who underwent surgery at Nagasaki University Hospital between April 2011 and June 2013. The SDB method uses antigen-antibody reactions with anti-pancytokeratin as the primary antibody and detects cancer cells using chromogen. To identify LN metastases, each LN was examined by the SDB method during surgery along with intraoperative pathological diagnosis (ope-Dx) and permanent pathological diagnosis (permanent-Dx)., Results: Compared with permanent-Dx, SDB offered 94.7% sensitivity, 97.7% specificity and 97.2% accuracy, while ope-Dx exhibited 84.2% sensitivity, 100% specificity and 98.0% accuracy. For 3 cases, micrometastases were detected by the SDB method but not by ope-Dx. Three LNs from lobar stations showed pseudo-positive results by the SDB method because of the presence of alveolar epithelium., Conclusions: The SDB method offers acceptably high accuracy in detecting LN metastasis, especially for mediastinal LNs, and represents a potential alternative for the intraoperative diagnosis of LN metastasis, even in the absence of a pathologist., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The purpose of this study was to evaluate the factors contributing to the outcomes of bronchoplasty for lung cancer by analysing a single institution's data for a 30-year period., Methods: A retrospective review of 213 patients who underwent bronchoplasty for lung cancer between 1980 and 2010 was undertaken. The patients were divided into two groups by the date of surgery: the first period was 1980-95, and the second period was 1996-2010., Results: Bronchoplasty and broncho-angioplasty were performed in 100 (75.8%) and 32 (24.2%) patients, respectively, in the first period and 61 (75.3%) and 20 (24.7%) patients, respectively, in the second period. Overall 90-day operative morbidity and mortality rates were 25.8 and 9.8%, respectively, in the first period and 45.7 and 2.5%, respectively, in the second period. Thirty-day mortality rates were 6.8% in the first period and 0% in the second period. Five-year survival was 41.1% (n = 132) in the first period and 61.5% (n = 81) in the second period (P = 0.0003). Comparing bronchoplasty and broncho-angioplasty, the 5-year survival was 45.6 and 26.5%, respectively, in the first period (P = 0.0048) and 60.9 and 62.1%, respectively, in the second period (P = 0. 8131). Using multivariate analysis to identify potential prognostic factors, the type of operation (broncho-angioplasty), postoperative complications and histology (non-squamous cell carcinoma) were significant factors affecting survival in the first period, but none of the factors significantly affected survival in the second period. When the rates of pN2 or N3 histological type disease were compared in each period, the rate of pN2 or N3 disease in non-squamous cell carcinoma was 51.4% in the first period and 45.5% in the second period; both were significantly higher than in squamous cell carcinoma (31.6 and 16.9%, respectively; P = 0. 0365 and 0.0073)., Conclusions: The present study suggests that progress in the preoperative staging system and perioperative medical management, as well as surgery, has contributed to current improvements in patients undergoing bronchoplasty and broncho-angioplasty. However, since nodal status in non-squamous cell carcinoma is not precisely evaluated before the operation, the indication for bronchoplasty should be considered carefully., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Lung cancer surgery in octogenarians has already become common in Japan due to the high proportion of elderly people and the progress in perioperative management, including anesthesia and video-assisted thoracic surgery. However, there have been few reports about the surgical treatment of lung cancer in nonagenarians. Five cases (mean age: 91.2 years; 3 men, 2 women) of non-small cell lung cancer in nonagenarians in whom pulmonary resection was performed are reported. All were adenocarcinomas; three were clinical stage IA, and two were IB. Three patients underwent lobectomy, and two underwent wedge resection. Mediastinal lymph node dissection was omitted in all patients. There were no fatal postoperative complications. During follow-up, one patient died due to fatal arrhythmia, and one patient who underwent wedge resection had local recurrence, but the others are alive in good condition. Pulmonary resection of lung cancer is possible for highly selected, nonagenarian patients without lymph node metastasis.

A rare case of a patient with primary adenocarcinoma of the middle lobe bronchus that was successfully treated with rigid bronchoscopy followed by middle sleeve lobectomy is reported. The patient was a 75-year-old man who presented with low-grade fever and cough. Chest computed tomography showed obstructive pneumonia of the lower lobe and a polypoid lesion in the truncus intermedius. Middle sleeve lobectomy and mediastinal lymphadenectomy were performed following recovery of respiratory function after partial resection of the tumor with rigid bronchoscopy. There was no sign of tumor recurrence and metastasis over 32 months of follow-up. We should be aware of tracheal or bronchial tumor in patients with prolonged asthma-like symptoms. Palliative resection with rigid bronchoscopy was useful to make the correct diagnosis, evaluate the extent of the tumor, and protect the right lower lobe.

Surgery for lung cancer involving the carina is challenging as it requires special surgical techniques and airway management. We report how we successfully treated carinal invasion of primary lung cancer by performing left sleeve pneumonectomy through a clamshell incision, as bilateral thoracotomy through a transverse sternotomy. Without a cardiopulmonary assist device, adequate ventilation and oxygenation were maintained across the operative field with a spinal tube. Tracheo-bronchial anastomosis was relatively easy to perform, with an excellent surgical view. The patient had an uneventful postoperative course and was discharged from hospital without oxygen support. There was no evidence of complications at the anastomosis on chest computed tomography and no sign of recurrence during 6 months of follow-up. The clamshell incision approach provided an excellent surgical view without the need to change the position of the patient during the operation. Thus, it could prove a useful procedure for carinal surgery; especially left sleeve pneumonectomy.

Video-assisted thoracoscopic treatment of intralobar pulmonary sequestration in an obese (120 kg, body mass index 42) young man is described. Two aberrant arteries originating from the descending thoracic aorta were transected with a vascular stapler, and a left lower lobectomy was successfully performed thoracoscopically. Three-dimensional chest computed tomography was used to identify the aberrant vessels. Video-assisted thoracoscopic lobectomy is useful and minimally invasive for treating pulmonary sequestration, especially in obese patients.

This study reports the efficacy of adjuvant chemotherapy in stage IA non-small cell lung cancer (NSCLC) with vessel invasion (Vi). We sub-divided 322 patients with surgically resected pathological stage IA NSCLC into two groups according to Vi [non-Vi (n=237) and Vi (n=85)]. Both groups were compared with regard to age, gender, performance status, smoking habits, serum carcinoembryonic antigen level, extent of surgery, tumour size, histopathology, recurrence sites, and survival. The overall 5-year survival rates of non-Vi and Vi groups were 89.6% and 71.8% (P<0.001), respectively. Distant metastasis was observed more frequently in the Vi group (P<0.001, risk ratio: 9.06). Univariate and multivariable analyses identified poor performance status, squamous cell carcinoma, tumour size>or=15 mm and Vi as poor prognostic factors (P<0.05). The overall 5-year survival rate of stage IA Vi group nearly overlapped with that of patients with stage IB NSCLC. Retrospectively, oral uracil-tegafur chemotherapy increased the overall 5-year survival rate of stage IA Vi group by more than 25% (P=0.036). In conclusion, vessel invasion is a poor prognostic factor in patients with stage IA NSCLC. Prognosis of patients with Vi-stage IA NSCLC is similar to that of patients with stage IB NSCLC and is improved significantly by postoperative oral uracil-tegafur chemotherapy. Our preliminary study suggests that stage IA Vi group benefits from adjuvant chemotherapy.

Background: Lymphovascular invasion (LVI), which includes vascular or lymphatic invasions, is a representative prognostic factor even in patients with resected stage IA non-small cell lung cancer (NSCLC). Because tegafur-uracil is effective on cancers with LVI, we conducted a multi-center single-arm phase II study to estimate the efficacy of adjuvant tegafur-uracil in patients with LVI-positive stage IA NSCLC.Methods: Patients with completely resected LVI-positive stage IA NSCLC were registered. LVI was diagnosed by consensus of two of three pathologists. Adjuvant chemotherapy consisted of 2 years of oral tegafur-uracil at 250 mg/m2/day. Fifty-five patients from 7 institutions were enrolled from June 2007 to September 2012.Results: Among the 52 eligible patients, 36 (69.2%) completed the treatment course. There were 39 male and 13 female patients. The observation period was calculated as 562 to 3107 days using the reverse Kaplan-Meier method. The 5-year overall and relapse free survival rates were 94.2 and 88.5% respectively, which were significantly better than that of any other studies conducted on patients with LVI-positive stage IA NSCLC. Notably, the overall survival rate was 15% better than that of our prior retrospective study. The retrospective analysis of stage IA NSCLC patients who had received an operation in the same period revealed that the 5-year overall survival rate of the LVI positive group was 73.6% when adjuvant chemotherapy was not applied. Among 55 safety analysis sets, 4 cases of grade 3 hepatic function disorder (9.1%) and 5 cases of grade 2 anorexia (10.9%) were most frequently observed. No grade 4 adverse effects were encountered.Conclusion: A 2-year course of oral tegafur-uracil administration is feasible and might have a significant benefit in the adjuvant treatment of LVI-positive stage IA NSCLC.Trial Registration: UMIN identifier: UMIN000005921 ; Date of enrolment of the first participant to the trial: 19 June 2007; Date of registration: 5 July 2011 (retrospectively registered). [ABSTRACT FROM AUTHOR]