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Background: Advances in minimally invasive surgery and drainage systems have caused earlier chest-tube-removal. This retrospective study aimed to assess the safety of early chest tube removal using the institution's new criteria 6 hours after thoracic surgery., Methods: Elective thoracic surgery patients from 2017 to 2023 were reviewed for meeting or not meeting the newer institutional requirement for early chest tube removal; (I) no air leak detected under the digital drainage device observation; (II) no fluid drainage of ≥100 mL/h; (III) no ≥3 combined risks [male, chronic obstructive pulmonary disease (COPD), body mass index (BMI) of <18.5 kg/m 2 , severe pleural adhesion, upper lobe lobectomy, or left upper division segmentectomy]. The incidence of adverse events, including chest tube replacement, subcutaneous tube placement, and postoperative thoracentesis, were investigated for 1 month postoperatively. Perioperative outcomes and factors involved in conventional chest tube removal were also assessed., Results: Of the 942 patient charts reviewed, 244 (25.9%) met the criteria for chest tube removal within 6 hours postoperatively. This patient group did not experience adverse events. They also demonstrated shorter postoperative hospital stay (4 vs. 6 days, P<0.001), and lesser postoperative complications (7.4% vs. 25.6%, P<0.001) compared to those for whom early chest tube removal was not done. A correlation with thoracotomy, COPD, and steroid and/or immunosuppressant use was observed for patients in the conventional chest tube removal group., Conclusions: Early chest tube removal after 6 postoperative hours was deemed safe for a selected group of patients who met the criteria for early chest tube removal. This study would support the potential expansion of our early removal criteria., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1905/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Background: In this study we aimed to clarify the PD-L1 positive expression in lung adenocarcinoma, including various adenocarcinoma subtypes paying particular attention to its component., Methods: A total of 307 lung adenocarcinoma patients who underwent lobectomy or segmentectomy, as well as systematic lymph node dissection (ND2a), from February 2008 to March 2020 at our hospital, were enrolled into the study. A final diagnosis of adenocarcinoma was obtained from the resected lung specimens of all 307 patients to determine the histological type, adenocarcinoma subtype, and component of adenocarcinoma by ethics of 5%. PD-L1 was immunohistochemically stained using the murine monoclonal antibody clone 22C3., Results: When PD-L1 expression-positive was defined by tumor proportion score (TPS) ≥1%, the positive cases were 6/33 in adenocarcinoma (Ad) in situ (AIS), 2/26 in minimally invasive Ad (MIA), 12/60 in lepidic predominant Ad (LPA), 44/91 in papillary predominant Ad (PPA), 24/49 in acinar predominant Ad (APA), 23/28 in solid predominant Ad (SPA), 4/7 in micropapillary predominant Ad (MPA), and 0/13 in invasive mucinous Ad (IMA). In the high proportion group (APA, PPA, SPA, and MPA) of PD-L1 expression, SPA was the only subtype which was statistically significant when both PD-L1 expression-positive was defined by TPS ≥ 1% (p < 0.0001) and TPS ≧ 50% (p < 0.0001). We then considered the solid component. We investigated 279 cases of the other subtype group excluding SPA. The group containing a solid component (≥5%) tended to be PD-L1 expression-positive both when defined by TPS ≥1% (p < 0.0001) and TPS ≧50% (p = 0.0049)., Conclusions: The PD-L1 expression tended to be positive when a solid component was confirmed (≥5%) in specimens of lung adenocarcinoma patients., (© 2021 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Minichromosome maintenance (MCM) protein deregulation is associated with tumor formation, progression and malignant transformation. MCM2 is frequently expressed during premalignant lung cell proliferation and is a sensitive marker for the early detection of pulmonary malignant lesions. The present study was undertaken to investigate whether MCM2 expression is of clinical and prognostic value in patients who have undergone lung adenocarcinoma resection. Between January 2009 and December 2010, 102 consecutive patients underwent complete pulmonary resection (involving lobectomy or more extensive resection) for lung adenocarcinoma at St. Marianna Medical University Hospital (Kanagawa, Japan). Among those, 73 patients, who had a final pathological diagnosis of lung adenocarcinoma measuring ≥10 mm, were enrolled in the present study. High MCM2 expression was found in 35 patients (48.0%). Univariate analysis of the overall survival (OS) revealed that pathological stage and MCM2 expression were significant prognostic factors in lung adenocarcinoma (P<0.001 and P<0.002, respectively). Univariate analysis of the recurrence-free survival (RFS), the significant prognostic factors included pathological stage, EGFR mutation status and MCM2 expression (P<0.001, P<0.034 and P<0.003, respectively). On multivariate survival analysis, high MCM2 expression and pathological stage II-III were identified as independent strong prognostic factors (OS: HR=5.084, 95% CI: 1.715-15.080, P=0.003; RFS: HR=2.761, 95% CI: 1.090-6.998, P=0.032). Therefore, the findings of the present study demonstrated that MCM2 may serve as a potential biomarker and therapeutic target for lung adenocarcinoma., Competing Interests: All authors declare that they have no competing interests., (Copyright © 2020, Spandidos Publications.)

Background: The current study aimed to evaluate the significance of clinicopathological factors, particularly the immunohistochemistry of programed cell death ligand-1 (PD-L1), in eight cases each of pulmonary sarcomatoid carcinoma (PSC) and malignant pleural mesothelioma (MPM) at our hospital., Methods: From January 2004 to December 2020, a total of 16 consecutive patients (eight with PSC and eight with MPM diagnosed via surgical resection or biopsy) were included in this study. After retrospectively reviewing the patient characteristics, the associations between PD-L1 status and age, sex, stage, histological type, and prognosis were investigated., Results: PD-L1-positive staining was observed in four (50%) PSC cases and one (12.5%) MPM case. Among the four PD-L1-positive PSC cases, two showed high PD-L1 expression in the vimentin-positive sarcomatoid compartment. Moreover, among those with PSC, two survived for about 10 years, whereas the others died within 5 years. No clear correlation was found between PD-L1 expression and prognosis. Among the patients with MPM, four survived for more than 2 years, with the longest being 9 years. Among MPM cases who received nivolumab, one patient with positive PD-L1 staining in the sarcomatoid survived, whereas the other with negative PD-L1 staining did not., Conclusion: The present study showed that sarcomatoid carcinoma had a higher PD-L1 expression compared to non-small-cell lung cancer and that both PSC and MPM tended to exhibit PD-L1 positivity in the sarcomatoid compartment. Moreover, while immune checkpoint inhibitors may somewhat prolong the prognosis of both tumors, further studies with a larger cohort are necessary to confirm our results., (© 2021 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: This study aimed to determine the relationship of programmed death-ligand 1 (PD-L1) expression and standardized uptake values in fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) with prognosis in non-small-cell lung cancer (NSCLC)., Methods: We retrospectively analyzed 328 NSCLC patients who underwent lobectomy/segmentectomy with lymph node dissection. PD-L1 expression was detected by immunohistochemically stained using the murine monoclonal antibody clone 22C3. The preoperative maximum standardized uptake value (SUV max ) of FDG-PET/CT at the primary lesion; pathological factors including histological type, microscopic lymphatic, venous, and pleural invasion; and lymph node metastases in resected specimens was determined. Significant prognostic clinicopathologic factors were analyzed by univariate and multivariate analyses., Results: PD-L1 expression was higher in men, smokers, squamous cell carcinoma, advanced pathologic stages, positive venous invasion, positive pleural invasion, and high preoperative SUV max (≥3). Postoperative survival analysis showed that both PD-L1 expression and preoperative SUV max were significantly negative prognostic factors in univariate analysis for overall survival (OS) ( P = 0.0123 and P < 0.0001) and relapse-free survival (RFS) ( P = 0.0012 and P < 0.0001). Kaplan-Meier survival curves showed that the OS and RFS were the best in patients with negative PD-L1 expression and SUV max < 3, intermediate in patients with positive PD-L1 expression and SUV max < 3 and those with negative PD-L1 expression and SUV max ≥ 3, and poor in patients with positive PD-L1 expression and SUV max ≥ 3., Conclusion: Combining PD-L1 expression and preoperative FDG-PET/CT SUV max in primary tumor might help in accurate prediction of postoperative prognosis in NSCLC patients.

The relatively low toxicity profile of nab-paclitaxel plus carboplatin and its feasibility as an adjuvant administration was reported previously. This study aimed to evaluate the survival efficacy for completely resected patients with stage IB, II, and IIIA nonsmall cell lung cancer (NSCLC). Twenty-nine eligible patients with NSCLC who received surgical resection for pathological stage IB, II, or IIIA, followed by postoperative adjuvant chemotherapy with modified 3-week cycles of either nab-paclitaxel (nab-P) (100 mg/m) on days 1 and 8 followed by carboplatin area (area under the curve = 6) on day 1 were prospectively enrolled and assessed for survival outcomes against patients with the same stages who received other postoperative adjuvant chemotherapy regimens during the same period. There were no significant differences in clinicopathological features, including age, gender, smoking status, performance status, surgical procedures, tumor histology, and pathological stage between the two groups. The cumulative overall survival (OS) rates at 5 years of the experimental and control groups in pathological stage IB-IIIA were 85.4% and 63.9%, respectively (P = 0.598), while recurrence-free survival (RFS) rates in these groups at 5 years were 65.2% and 34.8%, respectively (P = 0.344). Moreover, the cumulative OS rates of the experimental and control groups in pathological stage II-IIIA were 83.6% and 63.6%, respectively (P = 0.970), while RFS rates in these groups at 5 years were 61.1% and 37.3%, respectively (P = 0.460). This new regimen was considered an attractive alternative postoperative adjuvant chemotherapy option with relatively low toxicity and moderate survival outcomes for completely resected NSCLC.

Purpose: Knowledge regarding programmed death-ligand 1 (PD-L1) expression in lung cancer is limited. We aim to clarify PD-L1-positive expression in non-small-cell lung cancer (NSCLC), including adenocarcinoma subtypes., Methods: In all, 90 NSCLC specimens containing various adenocarcinoma subtypes, in addition to squamous cell carcinoma and large-cell carcinoma were selected. PD-L1 was immunohistochemically stained by murine monoclonal antibody clone 22C3., Results: When PD-L1-positive expression was defined by tumor proportion score (TPS) ≥1%, the positive cases were 0/11 in adenocarcinoma in situ, 0/12 in minimally invasive adenocarcinoma, 1/10 in lepidic predominant adenocarcinoma, 1/13 in papillary predominant adenocarcinoma, 8/14 in acinar predominant adenocarcinoma, 6/11 in solid predominant adenocarcinoma, 0/3 in micropapillary predominant adenocarcinoma, 0/4 in invasive mucinous adenocarcinoma, 4/9 in squamous cell carcinoma, and 2/3 in large-cell carcinoma. PD-L1 positivity was higher in males, smokers, advanced pathologic stages, positive vessel invasion, and positive lymphatic invasion. Postoperative survival analysis revealed that PD-L1-positive expression was a significantly worse prognostic factor in univariate analysis for recurrence-free survival (RFS)., Conclusion: PD-L1-positive tumors were frequent in acinar predominant adenocarcinoma and solid predominant adenocarcinoma than other adenocarcinoma subtypes. PD-L1 expression seemed to increase according to pathologic tumor progression, suggesting a worse postoperative prognosis in NSCLC patients.

Background: The reliability of the cobas EGFR assay to detect epidermal growth factor receptor (EGFR) mutations in non-small-cell lung cancer (NSCLC) as an in vitro diagnostic test was compared with 3 laboratory-developed tests (LDTs)., Materials and Methods: After screening for EGFR mutations using formalin-fixed-paraffin-embedded NSCLC tissue sections using the cobas EGFR assay, 151 samples were further tested with 3 LDTs; the peptide nucleic acid-locked nucleic acid polymerase chain reaction (PCR) clamp, PCR invader, and Cycleave assays. The cobas EGFR assay performance was evaluated by determining the concordance rate and κ-coefficient between the assays. In samples exhibiting discrepancies in the EGFR mutation status in the 4 assays, next-generation sequencing was performed to confirm mutated sequences., Results: Concordance rates and κ-coefficients between the cobas EGFR assay and the other tests were 96.0% and 0.921 for the peptide nucleic acid-locked nucleic acid PCR clamp assay, 94.0% and 0.881 for the PCR invader assay, and 96.7% and 0.934 for the Cycleave assay, respectively. Data showed very good agreement with the other assays. Precise mutated sequences or exons in the EGFR gene matched in 137 samples (90.7%). Different results were obtained in 4 samples (2.6%), owing to systemic limitations of the assay. Next-generation sequencing of 10 (6.6%) samples with discordant results exhibited a concordance rate of 60% to 80% in each assay., Conclusions: The cobas EGFR assay showed high concordance rates and κ-coefficients between the 3 compared LDTs and can be used to select patients who would benefit from EGFR-tyrosine kinase inhibitors., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Routine clinical and pathological evaluations to determine the relationship between different lesions are often not completely conclusive. Interestingly, detailed genetic analysis of tumor samples may provide important additional information and identify second primary lung cancers. In the present study, we report cases of two synchronous lung adenocarcinomas composed of two distinct pathological subtypes with different EGFR gene mutations: a homozygous deletion in exon 19 of the papillary adenocarcinoma subtype and a point mutation of L858R in exon 21 of the tubular adenocarcinoma. The present report highlights the clinical importance of molecular cancer biomarkers to guide management decisions in cases involving multiple lung tumors., (© 2017 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: The impact of chronic obstructive pulmonary disease (COPD) severity on survival after curative resection of early-stage lung cancer (NSCLC) has not been sufficiently elucidated., Methods: We retrospectively reviewed 250 consecutive patients who underwent lobectomy with lymph nodal dissection for pathological stage I-II NSCLC., Results: Among the COPD patients, 28 were classified as Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1, 21 as GOLD 2, and one as GOLD 3. The cumulative overall survival (OS) of the non-COPD, GOLD 1, and GOLD 2-3 groups at five years was 90.7%, 85.7%, and 55.3%, respectively, (P < 0.0001), while recurrence-free survival (RFS) between the groups at five years was 84.7%, 80.7%, and 72.9%, respectively. Although RFS in the GOLD 2-3 group tended to indicate a poor prognosis, there was no statistical difference between the groups (P = 0.385). In multivariate analysis, age ≥75 years, pN1, and GOLD 2-3 COPD were independent factors for a poor prognosis (P = 0.034, P = 0.010, and P = 0.030, respectively)., Conclusions: Our results indicate that early stage NSCLC patients with COPD had a significantly increased risk of poorer OS and potentially an increased risk of poor RFS., (© 2017 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Purpose: The aim of this study was to compare the clinicopathologic prognostic factors between patients who underwent lung resection for adenocarcinoma (AD) and those with squamous cell carcinoma (SQ)., Methods: A database of patients with lung AD or SQ who underwent surgery with curative intent in our department from January 2008 to December 2014 was reviewed. Associations between various clinicopathologic factors, postsurgical recurrence-free survival (RFS), and overall survival (OS) were analyzed to find significant prognostic factors., Results: A total of 537 lung cancer patients (AD, 434; SQ, 103) were included in this study. Although RFS was similar in patients with AD and SQ, OS was significantly poorer in those with SQ. Multivariate analysis in patients with AD revealed that age (≥69 vs. <69), lymphatic invasion, and histologic pleural invasion (p0 vs. p1-3) were associated with RFS, while gender and pleural invasion were associated with OS. In SQ, however, smoking, clinical stage, and pulmonary metastasis were associated with RFS in the multivariate analysis., Conclusion: Since significant postoperative prognostic factors are quite different between lung AD and SQ, these two histologic types should be differently analyzed in a clinical study.

Background: A few investigators have suggested an association between lung cancer and pulmonary cavity. However, this clinical association and its carcinogenic correlations are not well recognized. This study aimed to clarify the clinical features and to demonstrate the associated survival outcomes after curative surgery in patients with early non-small cell lung cancer (NSCLC) adjoining pulmonary cavity formation., Methods: We retrospectively reviewed 275 patients with pathological stage I NSCLC by re-evaluating their chest computed tomography images. Among them, we detected NSCLC adjoining pulmonary cavity formation in 12 (4.4%) patients., Results: The median follow-up period for all 275 patients was 43.2 (range, 6.0-86.0) months. Of these patients, 6 (50.0%) in group CF (patients with NSCLC adjoining pulmonary cavity formation) and 19 (7.2%) in group C (the control group, n=263) died during the study period. Besides, 6 (50.0%) and 32 (12.2%) patients in groups CF and C, respectively, exhibited recurrence of the primary lung cancer. The cumulative overall survival (OS) in groups CF and C at 5 years was 37.0% and 91.7%, respectively (P<0.0001); the recurrence-free survival (RFS) in these groups at 5 years was 55.0% and 86.7%, respectively (P=0.001). Univariate analysis showed that male sex, smoking habits, non-adenocarcinoma, and presence of pulmonary cavity formation were associated with poor OS (P=0.008, P=0.001, P<0.0001, and P<0.0001, respectively). Multivariate analysis demonstrated that smoking, non-adenocarcinoma, and pulmonary cavity formation were independent prognostic factors predicting poor survival (P=0.043, P=0.004 and P<0.0001, respectively)., Conclusions: Our results suggest that patients with early-stage NSCLC adjoining pulmonary cavity formation have an increased risk of poor OS and RFS after surgical resection. Further prospective, multi-institutional investigations and substantial clinical studies are warranted., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

The aim of this study was to determine the feasibility of adjuvant administration of nab-paclitaxel (nab-P) plus carboplatin and for completely resected patients with stage IB, II, and IIIA non-small-cell lung cancer (NSCLC) (FAST-nab study, UMIN000011225). Twenty-nine eligible NSCLC patients received surgical resection for pathological stage IB, II, or IIIA, followed by postoperative adjuvant chemotherapy with modified 3-week cycles of either nab-P (100 mg/m) on days 1 and 8, followed by carboplatin area (area under the curve=6) on day 1. Twenty-two (75.9%) of the 29 patients enrolled completed four cycles of this regimen. The most common grade 3 or 4 adverse event experienced during the nab-P plus carboplatin was neutropenia (34.5%), followed by anemia (13.8%). No grade 3 or 4 nonhematologic adverse event was observed during this chemotherapy. The median time to disease recurrence survival was 21 (95% confidence interval: 16-26) months. The administration of modified nab-P plus carboplatin was considered an attractive alternative regimen that was safe and well tolerated as a postoperative adjuvant chemotherapy for completed resected NSCLC.

Background  To assess the reliability of maximum standardized uptake values (SUVmax) at the primary lesion in 18-fluorodeoxyglucose positron emission tomography combined with computed tomography ( 18 FDG-PET/CT) for identifying patients with lung cancer who were most likely to be cured by sublobar resection (SR). Methods  We retrospectively reviewed the medical records of 120 patients who underwent SR for clinical (c)-stage IA + IB lung cancer after 18 FDG-PET/CT. Various factors, including tumor size, SUVmax at the primary site, and microscopic tumor invasion, were examined to identify their association with postsurgical survival. Prognoses of patients undergoing SR were compared with those of 272 patients undergoing lobectomy and lymphadenectomy during the same period. Results  The 5-year recurrence-free survival (RFS) and overall survival (OS) rates in all patients undergoing SR for c-stage IA + IB disease were 79.5% and 82.2%, respectively. In multivariate analysis, a lack of microscopic pleural invasion and SUVmax ≤ 3.0 significantly correlated with better RFS and OS in patients undergoing SR. Though there were no significant differences in RFS and OS following SR and lobectomy for c-stage IA + IB or IA disease, RFS was significantly inferior in nonintentional SR (NISR) than in lobectomy in c-stage IA disease ( p  < 0.01). However, in NISR identified based on SUVmax ≤ 2.0, RFS was comparable to those in lobectomy ( p  = 0.5371). Conclusion  When certain subgroups of patients are accurately identified based on preoperative SUVmax, SR can be a highly curative surgical method for lung cancer., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: The authors have no conflicts of interest to declare.

Objectives: Epidermal growth factor receptor (EGFR) mutation rates in adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) were studied using both DNA analysis and mutation-specific immunohistochemistry., Materials and Methods: The peptide nucleic acid-locked nucleic acid polymerase chain reaction clamp method was used to detect mutations in exons 18, 19, 20, and 21 of the EGFR gene in DNA samples extracted from paraffin-embedded tissue sections. Simultaneously, immunohistochemical analysis with two EGFR mutation-specific monoclonal antibodies was used to identify proteins resulting from an in-frame deletion in exon 19 (E746&#95;A750del) and a point mutation replacing leucine with arginine at codon 858 of exon 21 (L858R)., Results: Forty-three tumors (22 AIS and 21 MIA) were examined. The EGFR mutation rate in AIS detected by DNA analysis was 27.3% (L858R, 5/22; exon 19 deletion,1/22), whereas that detected in MIA was 42.9% (L858R,4/21; exon 19 deletion,5/21). Mutations detected by immunohistochemical analysis included 22.7% (L858R, 4/22; exon 19 deletion, 1/22) in AIS and 42.9% (L858R, 4/21; exon 19 deletion, 5/21) in MIA. Although some results were contradictory, concordant results were obtained using both assays in 38 of 43 cases (88.4%)., Conclusion: DNA and immunohistochemical analyses revealed similar EGFR mutation rates in both MIA and AIS, suggesting that mutation-specific monoclonal antibodies are useful to confirm DNA assay results., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

According to the 2012 annual report of the Japanese Association for Thoracic Surgery, the total number of surgical procedures performed for the treatment of lung cancer had reached 35,667. Patients over 70 years of age comprised 52% of those surgical cases, and those over 80 years 12%. This tendency has been increasing annually. Although hospital mortality rates in elderly patients over 80 years of age and others were almost the same, 30% of elderly patients died from other diseases, as reported by the Japanese Joint Committee of the Lung Cancer Registry in 1999. Therefore, current preoperative physiological and oncological risk evaluations of elderly patients do not appear to be sufficient. The Japanese Association for Chest Surgery planned and performed a multiinstitutional prospective cohort study of elderly patients with lung cancer who underwent thoracic surgery to answer clinical questions surrounding such risk evaluations.

Purpose: Maximum standardized uptake values (SUVmax) at the primary lesions of non-small-cell lung cancer in (18)F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT), and the microscopic local extension of tumors were examined to develop reliable criteria to determine candidates for sublobar resection., Methods: We retrospectively analyzed 209 patients who underwent lobectomy, bilobectomy, or pneumonectomy with systematic lymph node dissection. Preoperative SUVmax at the primary lesion, microscopic lymphatic, venous, and pleural invasion in addition to lymph node metastases in the resected specimens were examined. Receiver operating characteristic analyses were used to predict an optimal cutoff for lymph node metastases., Results: With receiver operating characteristic analysis, the areas under the curve for SUVmax and tumor size were 0.693 and 0.545, respectively, suggesting SUVmax superiority for prediction of lymph node metastases with a cutoff of 2.9. When a tumor was ≤2.0 cm (n = 41, 19.6 %), the percentages of microscopic lymphatic invasion, venous invasion, pleural invasion, and lymph node metastases were 12.2, 7.3, 4.9, and 17.1 %, respectively. When SUVmax was <3.0 (n = 91, 43.5 %), these percentages were 15.4, 3.3, 7.7, and 8.8 %, showing that SUVmax could efficiently exclude nodal metastases in more cases than tumor size. The postoperative 5-year survival rate was 86.6 % in patients with SUVmax < 3.0 and 58.1 % in patients with SUVmax ≥ 3.0 (p < 0.001)., Conclusions: (18)F-FDG uptake value was more useful than tumor size for selecting patients with non-small-cell lung cancer suitable for intentional sublobar resection.

Introduction: The objective of this study was to evaluate the feasibility of thoracoscopic thymectomy (TT) for treatment of early-stage thymoma and to compare the outcomes with those after open thymectomy (OT)., Methods: A retrospective review of 98 patients who underwent TT or OT of Masaoka stage I-II thymoma without thymic cancer between 1996 and 2013 was performed., Results: Thoracoscopic thymectomy was performed in 67 patients, and OT was performed in 31 patients. The intraoperative blood loss amounts differed significantly between the TT group and OT group (100 vs 185 mL, P = 0.0070). The postoperative hospital stay was significantly shorter in the TT group than in the OT group (4 vs 12 days, P < 0.0001). No patient in the TT group underwent conversion to open surgery, and no surgical complications, such as massive bleeding, were observed. Two patients experienced recurrence in the TT group during the median postoperative follow-up period of 65 months. No significant differences were found in the 5-year disease-free survival rates between the two groups. There were no significant differences in disease-free survival as classified by Masaoka stage, World Health Organization type, and the extent of resection of the thymus., Conclusion: Our outcome showed that TT largely reduced the degree of invasiveness. The outcome was not inferior to that of OT. The results primarily demonstrated the feasibility of TT for treatment of early-stage thymoma., (© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

We report a case of retroesophageal parathyroid adenoma coexisting with an aberrant right subclavian artery (ARSA). A 63-year-old female presented with elevated serum calcium and intact parathyroid hormone levels. 99mTc-methoxyisobutylisonitrile scintigram and enhanced chest computed tomography (CT) revealed a mediastinal tumor measuring 25×15×7 mm located posterior to the esophagus. Three-dimensional CT provided accurate anatomical location of the tumor and the ARSA. We safely resected the ectopic parathyroid adenoma using video-assisted thoracic surgery owing to the accurate location of the adenoma and its relationship to the surrounding anatomical structures including the ARSA.

Lung segmentectomy with bronchial variation has rarely been reported. We report the case of a lung cancer patient with variant anatomy of the right upper lobe bronchus.Thoracoscopic posterior segmentectomy of the right upper lobe was performed. Variant bronchus and related blood vessels were confirmed preoperatively by three-dimensional multidetector computed tomography (3D-MDCT), which facilitated visualization of the patient's anatomy during surgery.

Background: Anomalous systemic arterial supply to the basal segments of the lung is a rare anomaly. This study aimed to evaluate the outcomes of thoracoscopic surgery for this anomaly., Methods: We reviewed patients who underwent thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung between October 2007 and September 2012 at our institution., Results: Four patients (mean age 37.5 years; range, 22 to 54) underwent thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung. The mean diameter of the anomalous arteries was 14 mm (range, 10 to 16 mm). Two patients underwent thoracoscopic segmentectomy, 1 of whom had a complicated anomaly that necessitated conversion to thoracotomy. The other 2 patients underwent thoracoscopic lower lobectomy of the left lung. One of them had an aneurysm in the anomalous artery; therefore, endovascular devices were kept on standby in case massive hemorrhage occurred. The anomalous arteries were divided uneventfully using a vascular stapler in all patients. No patient had severe postoperative complications., Conclusions: Thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung is feasible, safe, and minimally invasive, with confirmed effectiveness in typical cases., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Thoracoscopic thymectomy has gradually replaced conventional sternotomy for resection of thymoma; however, a thoracoscopic approach for thymoma remains controversial. We evaluated the oncological outcomes of thoracoscopic thymectomy for the treatment of stages I-III thymomas., Methods: Sixty-two patients who underwent thoracoscopic thymectomy for the treatment of thymoma were retrospectively reviewed between July 2005 and September 2011 at Jikei University Hospital. Surgical outcomes and pathological results between stages I+II and stage III were compared., Results: Twenty-nine patients had Masaoka stage I, 28 had stage II and 5 had stage III. Three stage III patients needed conversions to open surgery. Masaoka stage III comprised pathological type B3 in 3 patients and thymic carcinoma in 2. For all patients, the 5-year overall survival rate was 100%. Three recurrences, diagnosed as thymic carcinoma, were observed in the Masaoka stage II or III patients. The 5-year disease-free survival rate was 94.2% for all patients, 100% for Masaoka stage I, 96.1% for stage II and 37.5% (55 months) for stage III (P=0.002). The 5-year disease-free survival rate was 100% for the World Health Organization classification types A, AB and B1-3 and 0% for thymic carcinoma (P<0.0001). Significant differences were found in the 5-year disease-free survival stratified by the Masaoka stage or WHO classification, but not by surgical procedures., Conclusions: Thoracoscopic thymectomy for Masaoka stages I and II thymomas presented acceptable oncological outcomes. Further investigation in a large series with longer follow-up is required. Masaoka stage III thymoma requires careful consideration of the approaches, including median sternotomy.

We report a case of pulmonary bilateral multiple chondromas that were possibly an initial clinical presentation of Carney's triad. A 56-year-old Japanese non-smoking asymptomatic woman was admitted to the hospital for further examination of small, multiple, bilateral nodules in the lungs. Although chest radiological findings suggested that the nodules were possibly metastatic pulmonary tumors, the malignant origin was not detected. During diagnostic video-assisted thoracic surgery, wedge resections including the nodules were performed. Since pathological examination showed nodules were surrounded by fibrous and eosinophilic stroma, we diagnose the nodules as chondromas. These chondromas were possibly components of Carney's triad, because each nodule had a thin fibrous pseudocapsule and did not have an entrapped epithelium and fat. Some patients die of Carney's triad because of malignant alteration of lesions. Therefore, the patients with Carney's triad should be taken a medical check periodically. This patient was scheduled to undergo the check-up for several years.

We report a case of anomalous systemic arterial supply with three aberrant arteries supplying the basal segments of the right lung. There is no published report of a patient of anomalous systemic arterial supply to the basal segments with three aberrant arteries. Transverse computed tomography (CT) showed one aberrant artery in the right lower lobe, and preoperative three-dimensional CT showed three aberrant arteries, which provided detailed information and assisted in the thoracoscopic surgery. The patient underwent a complete thoracoscopic right lower lobectomy.

Although fewer lymph nodes are dissected with video-assisted thoracic surgery than with open lobectomy, thoracoscopic lobectomy is increasingly becoming the preferred surgical approach for early-stage lung cancers. The endoscopic surgical spacer SECUREA™ is a medical device that has been effectively employed in laparoscopic surgery, but no study has evaluated its efficacy in thoracoscopic surgery. In this report, we demonstrate the utility of SECUREA for complete thoracoscopic mediastinal lymph node dissection in patients with non-small cell lung cancer.

A 41-year-old woman complained of chest pain when coughing. Computed tomography and magnetic resonance imaging disclosed a homogenously enhanced tumor occupying the spinal canal at the Th7 level and extending into the right paravertebral space through the intervertebral foramen between Th7 and Th8. The tumor was successfully removed via a posterolateral approach using unilateral hemilaminectomy followed by thoracoscopic surgery. Since the tumor had a dumbbell shape, a combined approach was considered essential. The histological diagnosis was a thoracic neurinoma. Combined hemilaminectomy and thoracoscopic surgery may be a good alternative for the management of thoracic dumbbell-shaped tumors.

Purpose: This study aimed to evaluate the clinical outcomes of chest wall reconstruction using a relatively new expanded polytetrafluoroethylene prosthesis Gore-Tex(®) dual mesh., Methods: We reviewed charts of 11 patients who underwent bony chest wall resection from April 2006 to January 2011., Results: Six patients underwent three ribs resection, three patients underwent two ribs resection, and the other two patients underwent sternal resection. Of six patients after three ribs resection, three underwent reconstruction using 2 mm Gore-Tex(®) dual mesh, one using Gore-Tex(®), one using Bard composite E/X, and the remaining one used no prosthesis. Three patients who underwent two ribs resection underwent no chest wall reconstruction using prosthesis. Two patients who underwent sternal resection underwent chest wall reconstruction using dual mesh with or without a vascularized musculocutaneous pedicle flap. Immediate postoperative extubation was performed in all patients, except one who was extubated the following day. No postoperative deaths or cases with paradoxical respiration occurred., Conclusion: Chest wall reconstruction using Gore-Tex(®) dual mesh demonstrated acceptable durability.

Pulmonary metastases of benign meningiomas are extremely rare. The case of a 34-year-old man with bilateral parasagittal meningioma who developed pulmonary metastases is described. The meningioma was an enormous hypervascular tumor with invasion of the superior sagittal sinus. The tumor was resected completely and histologically diagnosed as transitional meningioma. The Ki-67 labeling index was 5%. Four months after operation, the patient subsequently developed bilateral multiple lung lesions later identified as metastases. The lung lesions were partially removed surgically and histologically diagnosed as meningothelial meningioma WHO grade I. The Ki-67 labeling index was 2%. The histological findings demonstrated that the tumor occupied the arterial lumen and the perivascular space, suggesting that pulmonary tumors might metastasize via the vascular route. The histopathological features and mechanisms of metastasizing meningiomas are reviewed and discussed.

In vitro tumor growth in a three-dimensional (3D) architecture has been demonstrated to play an important role in biology not only for developmental organogenesis and carcinogenesis, but also for analyses on reconstitution and maintenance in a variety of biological environments surrounding the cells. In addition to providing architectural similarity to living organisms, 3D culture with a radial flow bioreactor (RFB) can also closely mimic the living hypoxic microenvironment under which specific organogenesis or carcinogenesis occurs. The findings of the present study under the RFB culture conditions show that cancer cells underwent a shift from aerobic to hypoxic energy metabolism, in addition to protein expression to maintain the 3D structure. In RFB-cultured cells, protein stability of hypoxia-inducible factor 1 (HIF1) α, a subunit of HIF1, was increased without upregulation of its mRNA. Under these conditions, PHD2, HIF-prolyl-4-hydroxy-lase 2 and a HIF1 downstream enzyme, were stabilized without affecting the mRNA levels via downregulation of FK506-binding protein 8. PHD2 accumulation, which occurred concomitant with HIF1 stabilization, may have compensated for the lack of oxygen under hypoxic conditions to regulate the HIF levels. 3D-culture-induced overexpression of carbonic anhydrase (another representative HIF downstream enzyme) was found to occur independently of cell density in RFB--cultured cells, suggesting that the RFB provided an adequately hypoxic microenvironment for the cultured cells. From these results, it was hypothesized that the key factors are regulatory molecules, which stabilize and degrade HIF molecules, thereby activating the HIF1 pathway under a hypoxic milieu.

Purpose: Details with regard to the standard criteria for a therapeutic metastasectomy and the use of video-assisted thoracic surgery (VATS) remain elusive. To evaluate the feasibility of VATS using a tailor-made virtual lung for patients with pulmonary metastases after chemotherapy, we reviewed the following cases., Methods: Clinical data from October 2006 to April 2010 were obtained from patients who received chemotherapy before a pulmonary metastasectomy (lobectomy or segmentectomy). VATS was the primarily selected surgical approach except for treating hilar lesions. A lobectomy was performed when the metastasis was greater than 3.0 cm in diameter or located deeply in the lobe. Tailor-made virtual lungs were created using three-dimensional multidetector computed tomography before lobectomy on a routine basis. The virtual lung consisted of three-dimensional pulmonary vessels, a tracheobronchial tree, pulmonary parenchyma, and tumors., Results: Twelve operations, consisting of 1 segmentectomy, 10 lobectomies, and 1 wedge bronchoplasty upper lobectomy, were performed on 11 patients during the study period. VATS was completed in 10 of these 12 operations. The mean operative time for the lobectomies was 257 min, and the mean operative bleeding volume was 215 ml. Two cases experienced postoperative transient atrial fibrillation, and no mortalities associated with these operations were reported., Conclusion: VATS was performed safely in instances of metastasectomy after chemotherapy, and the tailor-made virtual lung assisted in lung orientation during the operation.

Various anatomical variants in pulmonary veins can have a serious effect on patients undergoing lung surgery. We present a case of a patient with an unusual pulmonary vein variation. Preoperative review of the patient's three-dimensional 64-row multidetector computed tomography imaging allowed us precise simulation and good orientation of the patient's vascular variant anatomy during surgery. Upper lobectomy through thoracoscopic approach was performed successfully in the case where the middle lobe vein might have been divided without preoperative anatomical evaluation by 3D CT images.

A 21-year-old adult with previously diagnosed Marfan syndrome (MS) was admitted to our hospital complaining of chest pains that resulted from a complete left spontaneous pneumothorax (SP). A chest roentgenogram showed a 70% pneumothorax on the left side. Because for 8 days chest tube drainage did not ameliorate the air leak, and also because a computed tomography (CT) scan showed many cystic opacities at the apical lung, a bullectomy was performed under video-assisted thoracic surgery (VATS). The patient's family history revealed that his father and two brothers had MS. Three family members had a unilateral SP, and his two siblings were treated under VATS and showed no evidence of recurrent pneumothorax. The simultaneous occurrence of MS and SP in these two patients suggests the possibility that both abnormalities in pulmonary connective tissue (e.g., collagen I) and the tall figure are responsible for the development of SP in MS patients. Because our patients and those in published reports are few in number, no definitive conclusion can be drawn about the relationship between SP and MS. Herein we describe a rare case of familial SP in two adult siblings with MS.

Variations in pulmonary veins can have a serious effect on patients undergoing lung surgery. But few clinicians are familiar with patients who have these variations, and few have been reported in the left pulmonary vein. We report the case of a lung cancer patient with a variant anatomy in the inferior segment of the lingular vein (V5) that drained into the left inferior pulmonary vein. A preoperative review of the patient's three-dimensional 64-row multidetector computed tomography (3D MDCT) imaging showed that the variant vein (V5) was draining from the inferior lingular segment into the upper side of the inferior pulmonary vein, which was also observed on conventional CT films. This variant anatomy was confirmed during a thoracoscopic left upper lobectomy. Furthermore, the superior segment (V6) of the inferior pulmonary vein drained into the basal part of the inferior pulmonary vein, but not into the superior side where V5 in this patient was drained. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. Preoperative 3D MDCT imaging of the pulmonary vein allowed good visualization of the patient's vascular variant during surgery, and it contributed to safe thoracic surgery, especially in a thoracoscopic operation.

There have been a few reports of pulmonary resection for lung cancer in patients on hemodialysis (HD), but no reports of video-assisted thoracoscopic surgery (VATS) in these patients have been submitted. We describe two patients on HD undergoing thoracoscopic resection for lung cancer. For the thoracoscopic operation, anatomies of the patients were confirmed by three-dimensional multidetector computed tomography (3D-MDCT). The first patient underwent a right lower lobectomy thoracoscopically, and the second patient underwent a resection of the superior segment of the right lower lobe thoracoscopically. They were discharged on postoperative days 10 and 4, respectively. A review of the literature reveals that morbidity and mortality for pulmonary resection on HD are 74% and 11%, respectively. Thoracoscopic operations for lung cancer patients on HD may minimize the operative invasiveness. Preoperative 3D-MDCT angiography was useful because it supports understanding of the patient's personal anatomy for VATS.