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While the PD-L1 expression and neutrophil-to-lymphocyte ratio (NLR) are prognostic biomarkers for lung cancer, few studies have considered their interaction. We hypothesized that the product of the PD-L1 expression (tumor proportion score) and NLR (PD-L1×NLR) might be a postoperative prognostic marker reflecting the immune microenvironment of lung cancer. We analyzed the association between PD-L1×NLR and the postoperative recurrence-free survival in 616 non-small-cell lung cancer patients using multivariable Cox proportional hazards models. In the analysis of PD-L1×NLR as a categorical variable, the group with PD-L1×NLR ≥ 25.8 had a significantly higher hazard ratio (HR) than the group with

Background Pulmonary pleomorphic carcinoma (PPC) is a rare type of non-small cell lung cancer characterized by high malignancy and a poor prognosis. PPC is associated with a high frequency of postoperative relapse, and shows resistance to chemotherapy. The high malignancy of cancers is associated with genomic instability, which is related to mutations of tumor suppressor genes, such as tumor protein p53 (TP53) and ataxia-telangiectasia mutated (ATM). In addition, signaling pathways involving the oncogenes such as phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) and epidermal growth factor receptor (EGFR) are associated with resistance to chemotherapy. However, the association of PPC with these gene mutations remains unknown. We investigated the impact of TP53, ATM, PIK3CA, and EGFR mutations on the postoperative prognosis of PPC. Methods Fifty-five patients with PPC who underwent complete resection were studied. A gene mutation analysis was performed using next-generation sequencing. Postoperative overall survival of patients with gene mutations was evaluated using a multivariable Cox proportional hazards model in which the explanatory variables were the presence of each gene mutation, and the confounding factors were pathological stage and age. The robustness of the results was evaluated by a sensitivity analysis. Results The frequencies of pathogenic mutations in TP53, ATM, PIK3CA, and EGFR were 47, 0, 7, and 9%, respectively. A multivariable analysis adjusted for pathological stage and age showed a significant difference for only PIK3CA mutations. The hazard ratio (HR) for overall survival in cases with pathogenic mutations of PIK3CA for wild type or non-pathogenic mutations was 4.5 (95% confidence interval [CI] 1.1–18.8). Likewise, sensitivity analyses adjusted for pathological stage and sex (HR, 7.5; 95% CI 1.7–32.4) and for age and sex (HR, 5.4; 95% CI 1.4–21.7) resulted in similar findings. Although three patients with pathogenic mutations of PIK3CA that recurred postoperatively were treated by chemotherapy or immunotherapy, they survived for less than 2 years. Conclusions The postoperative prognosis of PPC with PIK3CA pathogenic mutations is particularly poor. Pathogenic mutations of PIK3CA may be a postoperative prognostic marker. Inhibition of signaling pathways associated with PIK3CA mutations may also be a target for chemotherapy after relapse of PPC.

Objectives: For patients with multiple small-sized pulmonary cancers, a lobectomy can disrupt future therapeutic options for other lesions. It was recently reported that limited pulmonary resections were not inferior to lobectomy for the management of selected peripheral small-sized pulmonary adenocarcinomas. Patients with adenocarcinoma in situ or minimally invasive adenocarcinoma, as proposed by the International Association for the Study of Cancer classification, have been reported to have 100% survival after 5 years. However, that classification can be applied postoperatively. Since 2005, we have been intentionally performing limited pulmonary resection procedures for small-sized adenocarcinoma cases based on intraoperative imprint cytological diagnosis and our classification (Nakayama-Higashiyama's classification). Materials and Methods: A total of 120 consecutive cases were included in this study. Lung tumors were removed intraoperatively by wedge resection, and stump smear cytology was performed, from which the cases were classified into 5 groups based on our classification. When the tumor was classified as Group I or II, the operation was finished. When diagnosed as a more advanced classification, a lobectomy and lymph node dissection were additionally performed. Results: The 5-year survival rate for Group I and II was 100%, while those for Group III and IV-V were 95.8% and 94.4%, respectively. The 5-year disease-free survival rates for Group I and Group II were 100% and 97.1%, respectively, and for Group III and IV-V they were 100% and 94.1%, respectively. Conclusion: Use of cytological findings along with Nakayama-Higashiyama's classification for determining operation procedure is effective for treatment of patients with small-sized pulmonary adenocarcinoma.

Objectives: Small-size lung lesions suspected of being cancer are now often being identified on computed tomography. Correspondingly, a new lung cancer staging system has been proposed by the International Association for the Study of Lung Cancer (IASLC), in which the T1 factor and adenocarcinoma are re-subclassified. Previously, we proposed an intraoperative cytological diagnosis and its classification of small-size lung adenocarcinoma, which correlated significantly with clinical malignancy, to be used for selecting the surgical strategy. In the current study, the correlation of our intraoperative cytological classification with the new 8th IASLC classification was investigated. Materials and Methods: A total of 139 consecutive small-size lung adenocarcinoma cases were surgically resected from 2000 to 2006 and included in this study. Intraoperative stump imprint cytology using these specimens was performed, and the cases were classified into 5 groups based on our classification. The cytological classification was compared with the IASLC classification and the WHO histopathological grading. Results: According to our classification, 32 patients were in Group I, 38 in Group II, 24 in Group III, 27 in Group IV, and 18 in Group V. Compared with the IASLC classification, most of Group I was pTis or pT1mi, and most of Group II was pT1mi or pT1a (p

We report a case of anal canal cancer with Pagetoid spread without a macroscopic skin lesion. A 54-year-old man was admitted to a hospital with complaints of bloody stools. Endoscopic examination revealed a polyp in the anal canal, and endoscopic mucosal resection was performed. Pathological examination revealed an adenocarcinoma accompanied by Pagetoid spread and the positive surgical margin. We additionally performed trans-anal resection twice, but the resected horizontal margin was positive. Mapping biopsy of rectal mucosa and perianal skin revealed adenocarcinoma in only rectal mucosa. Abdominoperineal resection was performed. Histopathological examination showed invasive adenocarcinoma with pagetoid spread and that the surgical margin was negative. Pagetoid spread of anal canal adenocarcinoma usually showed macroscopic abnormal findings, but in this case, there was no skin lesion. It suggests that preoperative mapping biopsy is helpful for determining the excision range. It is necessary to keep in mind that anal canal adenocarcinoma with no skin lesion may cause Pagetoid spread.

Intrapulmonary hematomas are collections of blood within alveolar and interstitial spaces. They occur mainly following thoracic trauma. Typically, intrapulmonary hematomas without bleeding or infection spontaneously disappear after several weeks to 6 months. In the current case, the patient presented with an intrapulmonary nodule 17 months after a chest injury. The size of the nodule had not changed at 4 months after the first visit. Consequently, the patient was diagnosed with an intrapulmonary hematoma by surgical resection. To our knowledge, there are no previous studies that described the cause of the persistent intrapulmonary hematoma. This study reports the case of a patient who underwent surgical resection of a persistent traumatic intrapulmonary hematoma., Highlights • Intrapulmonary hematoma occurs with a chest injury, anticoagulants, thrombocytopenia, and congenital diseases. • Differential diagnoses should include intrapulmonary hematoma when considering medical history. • Patients are generally placed under observation when intrapulmonary hematoma is suspected. • This is the first report on the cause of persistent intrapulmonary hematoma.

We report a case of recurrent hepatocellular carcinoma(HCC)successfully treated by radiation therapy. A 79-year-old woman was diagnosed with HCC and underwent liver resection. Seven months after resection, CT and MRI detected a new HCC, and she had a surgery again. One year after the surgery, CT and MRI detected local recurrence, and she underwent the third operation. Three months after the operation, the third liver recurrence was treated by transcatheter arterial chemoembolization( TACE). Four months later, a new lesion was detected and treated by stereotactic body radiation therapy(SBRT) twice. She remains alive without recurrence 27 months after the last radiation therapy. Very few evidence is reported of radiation therapy for HCC, but this case suggests that radiation therapy provides a benefit for patients with HCC after other treatments.

A 68-year-old woman was presented with anorexia. Upper gastrointestinal endoscopy revealed type 4 gastric cancer at corpus of the stomach. Peritoneal metastasis was detected by staging laparoscopy. After a diagnosis of cT4aN1M1, cStage ⅣB advanced gastric cancer, we performed chemotherapy(SOX regimen; S-1 100 mg/body on day 1-14, followed by 7 days of rest, oxaliplatin 130 mg/m2 on day 1). After the 3 courses of chemotherapy, the primary tumor had been reduced. Second staging laparoscopy revealed no peritoneal metastasis. Then, we performed total gastrectomy with D2 lymph node dissection. Histopathological examination revealed no residual cancer cells, indicating a pathological complete response (Grade 3). We report a case of advanced gastric cancer with peritoneal metastasis achieved pathological complete response by chemotherapy.

Background: Recently, therapeutic strategies for a metastasectomy from colorectal carcinoma after chemo-targeted therapy with bevacizumab have been presented, with which some uncommon but serious adverse events have been reported. However, only few reports have investigated the safety of lung resection after such therapy or the histological effects. We retrospectively analyzed the both of them at our institute. Methods: Of 69 colorectal carcinoma patients who underwent pulmonary metastasectomy procedures from 2009 to 2014, we investigated 11 who also received chemo-targeted therapy prior to surgery. Results: In addition to bevacizumab, 5 fluorouracil (FU)/leucovorin + oxaliplatin or capecitabine was given in 6 cases and 5 FU/leucovorin + irinotecan in 5 cases. The mean period from the end of chemo-targeted therapy to surgery was 2.7 ± 0.9 months. The response to therapy shown in imaging findings was progressive disease in 6, stable disease in 3, and partial response in 2 (response rate, 18.2%). The operation modes were wedge resection (n = 8, 72.3%), segmentectomy (n = 2, 1 in bilateral lobes, 1 in the right lobe, 18.2%), and lobectomy (n = 1, left lower lobectomy, 9.1%). All patients safely underwent a complete resection. As for postsurgical complications, chylothorax occurred in 1 case and prolonged pulmonary air leakage in 1 case. The histological effects of chemo-targeted therapy were slight. There was no relationship between histological findings with imaging findings obtained prior to the operation (p = 0.63). The 5-year disease-free survival rate after metastasectomy was 10.9%. Conclusions: Pulmonary metastasectomy after chemo-targeted therapy for colorectal carcinoma patients obtained acceptable results. In addition, there was no correlation between imaging and histopathologic results following chemo-targeted therapy.

The impact of in vitro chemosensitivity test-guided platinum-based adjuvant chemotherapy on the surgical outcomes of patients undergoing complete resection for locally advanced non-small cell lung cancer (NSCLC) has yet to be elucidated. In the present study, the utility of adjuvant chemotherapy based on the collagen gel droplet embedded culture drug sensitivity test (CD-DST) in patients with p (pathology)-stage IIIA NSCLC was retrospectively analyzed. A series of 39 patients that had received platinum-based adjuvant chemotherapy following complete resection between 2007 and 2012 were enrolled. Their surgical specimens were subjected to the CD-DST. The patients were subsequently classified into two groups on the basis of in vitro anti-cancer drug sensitivity data obtained using the CD-DST: The sensitive group (25 patients) were treated with regimens including one or two of the anti-cancer drug(s) that were indicated to be effective by the CD-DST, whereas the non-sensitive group (14 patients) were treated with chemotherapy regimens that did not include any CD-DST-selected anti-cancer drugs. There were no significant differences in the background characteristics of the two groups [including in respect of the pathological TN (tumor-lymph node) stage, tumor histology, epidermal growth factor receptor mutation status, the frequency of each chemotherapy regimen, and the number of administered cycles]. The 5-year disease-free survival (DFS) rate of the sensitive group was 32.3%, whereas that of the non-sensitive group was 14.3% (P=0.037). In contrast, no difference in overall survival (OS) was observed (P=0.76). Multivariate analysis revealed that adjuvant chemotherapy based on the CD-DST had a significant favorable effect on the DFS (P=0.01). Therefore, the present study has demonstrated that CD-DST data obtained from surgical specimens aid the selection of effective platinum-based adjuvant chemotherapy regimens for patients undergoing complete resection for p-stage IIIA NSCLC. The use of CD-DST-guided platinum-based regimens may have a beneficial impact on the DFS of such patients.

Background We retrospectively compared the oncologic outcome after segmentectomy versus lobectomy in patients with clinical (c-) T1a N0 M0 non-small cell lung cancer (NSCLC) detected as a part-solid ground-glass nodule or purely solid nodule on thin-section computed tomography. Methods From 1997 to 2010, 312 patients with c-T1a N0 M0 NSCLC were determined to require a surgical approach categorized as segmentectomy or lobectomy. Preoperatively available data were collected using logistic regression analysis, and propensity matching was performed. Factors affecting local-regional recurrence were assessed by Cox proportional hazards regression analysis and Kaplan-Meier estimates. Results The 5-year and 10-year overall survival rates for the 80 patients who underwent segmentectomy were 97.5% and 83.5%, respectively, compared with 87.75% and 75.0%, respectively, for the 232 patients who underwent lobectomy (p = 0.019). Local-regional recurrence as the first relapse site was found in 3 the 80 segmentectomies (3.8%) of and in 15 of the 232 lobectomies (6.5%). The difference in local-regional recurrence-free survival in patients undergoing segmentectomy compared with lobectomy was not significant (p = 0.304). In 69 propensity score-matched pairs, there was no significant difference in the overall survival (p = 0.442) or local-regional recurrence-free survival (p = 0.717) between the two groups. Multivariate analysis using the Cox proportional hazards regression model identified lymphatic invasion as the only independent factor predicting local-regional recurrence (relative risk, 10.764; 95% confidence interval, 2.98 to 57.68). Conclusions Our results suggest that the oncologic outcome of segmentectomy vs lobectomy is similar in this cohort of c-T1a N0 M0 NSCLC patients. These results will be validated by large-scale, prospective, randomized trials.

The AminoIndexTM Cancer Screening (AICS) system, a plasma-free amino acid (PFAA)-based multivariate discrimination index, is a blood screening test for lung cancer based on the comparison of PFAA concentrations between patients with lung cancer and healthy controls. Pre- and post-operative AICS values were compared among 72 patients who underwent curative resection for lung cancer. Post-operative changes in PFAA concentrations were also evaluated. AICS values were classified as rank A (0.0–4.9), B (5.0–7.9), or C (8.0–10.0). Rank B–C patients were evaluated for outcomes and post-operative changes in their AICS values. Twenty-three of the 44 pre-operative rank B–C patients experienced post-operative reductions in AICS rank. Only one patient experienced cancer recurrence. Post-operative changes in PFAA concentrations were associated with the risk of post-operative cancer recurrence (p = 0.001). Multivariate analysis revealed that the absence of a post-operative reduction in AICS rank independently predicted cancer recurrence (hazard ratio: 14.28; p = 0.012). The majority of patients had high pre-operative AICS values and exhibited a reduction in AICS rank after curative resection. However, the absence of a post-operative reduction in AICS rank was associated with cancer recurrence, suggesting that AICS rank may be a sensitive marker of post-operative recurrence.

Summary: Objective: To evaluate the diagnostic usefulness of performing a preoperative water-soluble contrast enema (WSCE) before emergency surgery for colorectal perforation. Methods: We retrospectively reviewed 68 consecutive patients who underwent a preoperative WSCE before emergency surgery for colorectal perforation during the period from January 2011 to December 2017. Clinical characteristics and inflammatory biomarkers were compared between patients with Hinchey I–II versus those with Hinchey III–IV. Results: WSCE leakage occurred in 27 of 68 patients (39.7%). Univariate analysis showed that the two groups (Hinchey I–II and Hinchey III–IV) significantly differed regarding age, perforation site, cause of perforation, American Society of Anesthesiologists grade, presence or absence of WSCE leakage, and white blood cell count. Multivariable analysis revealed that WSCE leakage was a predictor of Hinchey III–IV, with an odds ratio of greater than 24 (P = 0.002). The sensitivity and specificity of WSCE leakage for differentiating those with Hinchey III–IV from those with Hinchey I–II were 76.5% and 97.1%, respectively. Conclusions: This retrospective study indicates that preoperative WSCE before emergency surgery is a useful tool for predicting the presence of Hinchey III–IV in patients with colorectal perforation. Keywords: Colorectal perforation, Water-soluble contrast enema (WSCE), Emergency surgery

According to a recent report by the Committee for Scientific Affairs of the Japanese Association for Thoracic Surgery, pulmonary metastasectomy accounted for as many as 10.2 % of all entry cases of general thoracic surgery, and its use is increasing year by year. Accordingly, many studies have examined the surgical procedures used during pulmonary metastasectomy for metastases from primary tumors affecting various organs as well as the outcomes of and indications for such procedures, but some problems remain. In this article, the following questions related to the surgical approach and the type of resection used during pulmonary metastasectomy are reviewed: (1) Wedge resection--what is a safe margin for preventing local recurrence? (2) What is the clinical significance of node sampling/dissection during pulmonary metastasectomy? and (3) When is segmentectomy necessary? In addition, we discuss: (4) open thoracotomy vs. video-assisted thoracoscopic surgery (VATS), (5) repeated metastasectomy for pulmonary metastases, (6) the surgical approach for bilateral pulmonary metastasectomy, (7) pneumonectomy, and (8) pulmonary metastasectomy combined with resection of the neighboring organs.

This report presents a case of malignant pleural mesothelioma (MPM) producing granulocyte colony-stimulating factor (G-CSF) that was treated by tumor resection. A 76-year-old male presented with a huge right-side chest wall tumor, along with a slight fever and chest wall pain. Laboratory findings showed an increased white blood cell count (64600 cells/μL) and C-reactive protein level (20.57 mg/dL). The patient underwent surgical removal of the tumor along with tissue from the chest wall and histopathological analysis led to a diagnosis of sarcomatous type of MPM. Immunohistochemical findings for both anti-human G-CSF and interleukin-6 monoclonal antibodies were positive. Although the general condition of the patient quickly improved after surgery, local recurrence occurred two months later and he died of respiratory failure seven months after the operation, though surgery provided symptom relief. G-CSF-producing MPMs usually show a poor prognosis, though less-invasive surgery may be considered for relief of symptoms.

Background Treatment strategies for brain metastasis from lung cancer have been making progress. The aim of this retrospective analysis was to investigate the post-recurrent prognostic factors in patients with brain metastasis after complete resection of non-small cell lung cancer (NSCLC). Methods We retrospectively reviewed the medical records of 40 patients found to have postoperative brain metastasis from NSCLC in our institution from 2002 to 2008. All patients had undergone radical pulmonary resection for the lung cancer. The impact of numerous variables on survival were assessed, including gender, age, carcinoembryonic antigen (CEA), tumor size, N status, histological type, number of brain metastases, tumor size of brain metastasis, presence of symptoms from the brain tumor(s), and use of perioperative chemotherapy. Results The median follow-up was 20.6 months (range, 3.4–66 months). The five-year survival rate from the diagnosis of brain recurrence was 22.5%. In univariate analysis, the favorable prognostic factors after brain recurrence included a normal range of CEA, no extracranial metastasis, no symptoms from the brain metastasis, brain metastasis (less than 2 cm), and radical treatment (craniotomy or stereotactic radiosurgery [SRS]). The multivariate Cox model identified that a small brain metastasis and radical treatment were independent favorable prognostic factors. Conclusions This study found that the implementation of radical therapy for metastatic brain tumor(s) when the tumor is still small contributed to an increase in patients' life expectancy.

Background Activating EGFR mutations, HER2, and HER3 are implicated in lung cancer; however, with the exception of EGFR gene amplification in lung adenocarcinoma harboring EGFR mutations, their involvement in disease progression during the early stages is poorly understood. In this paper, we focused on which receptor is correlated with lung adenocarcinoma progression in the presence or absence of EGFR mutation from stage 0 to IA1. Methods HER2 and HER3 expression and activating EGFR mutations in surgically resected lung adenocarcinoma exhibiting ground glass nodules on chest computed tomography and re‐classified to stage 0 and IA1 were examined by immunohistochemistry and peptide nucleic acid‐locked nucleic acid PCR clamp method, respectively. Results HER2 and HER3 expression was detected in 22.2% and 86.1% of samples, respectively. The frequency of EGFR mutation was 45.7% and was not significantly different between stage 0 and IA1 (40.0% and 48.0%, respectively), suggesting that EGFR mutation does not correlate with cancer progression from stage 0 to IA1. HER2 expression also did not correlate to progression. However, not only the frequency, but also the intensity of HER3 expression was increased in stage IA1 lung adenocarcinoma, particularly in lung adenocarcinoma without EGFR mutation. Conclusion HER3 tends to be intensively expressed during the progression of lung adenocarcinoma without EGFR mutation from carcinoma in situ to invasive carcinoma.

As well as its local effects, radiotherapy leads to the delayed regression of distant non-irradiated lesions. These abscopal effects are most likely mediated by the innate immune system. Patient 1, a 74-year-old male, had concomitant left supraclavicular lymph node metastases and multiple lung metastases 2 years after complete resection of pathological stage IIA (T1bN1M0) lung adenocarcinoma. He received radiation therapy (RT) of 58 Gy for the supraclavicular lymph node metastases and then innate immunotherapy using the cell wall skeleton of Mycobacterium bovis bacillus Calmette–Guerin (BCG-CWS). Three months after the RT and 2 months after the immunotherapy, all lung metastases disappeared on computed tomography scans. Patient 2, a 40-year-old female, underwent stereotactic body RT (SBRT) for metastasis from a deep-seated urothelial carcinoma in the right upper lobe of the lung. Twenty-one months after the SBRT, we started administration of BCG-CWS to two new lesions that had appeared in the left lung. As a result, after 3 months, the lesions completely disappeared. Complete response was maintained for more than 1 year in both patients. We believe that an optimal combination of RT and immunotherapy will elicit abscopal effects that can be employed to attain a systematically achievable, rather than anecdotal, therapeutic goal.

Background To prevent postoperative middle lobe torsion after a right upper lobectomy, we introduced a novel technique of interlobar fixation using collagen fleece coated with fibrin. In this study, the prophylactic effects of this method on the incidence of postoperative pulmonary torsion were analyzed. Methods Between April 2001 and December 2015, 3786 pulmonary resection procedures (excluding total pneumonectomy) were performed in our institution, and prophylactic interlobar fixation was selectively applied when intraoperative examination indicated that the patient was at high risk of postoperative pulmonary lobe torsion. As a control group, 842 patients who underwent pulmonary resection procedures between January 1996 and April 2001 were reviewed. Results During the study period, 10 (0.3%) patients underwent prophylactic middle lobe fixation (to the lower lobe after a right upper lobectomy in 9, and to the upper lobe after a right lower lobectomy in one). Pulmonary lobar (middle lobe) torsion occurred in only one patient (after right upper lobectomy); thus the incidence of this complication was 0.1% among patients who underwent a right upper lobectomy and 0.03% among all pulmonary resection procedures. The rates during the study period were marginally significantly lower than those in the control period (1.3% and 0.24%, respectively; p = 0.071 and p = 0.087, respectively). Conclusion Prophylactic middle lobe fixation might be useful for preventing postoperative pulmonary middle lobe torsion.

Background There are two forms of staple cartridge available for lung cancer operations, the flat face with equal height staples and the stepped face with graduated height staples. The objective of the study was to evaluate their stapling ability in lobectomy. Methods A randomized prospective study was conducted to compare two types of stapling reloads for bronchial closure. Stapling ability was evaluated by the staple formation on the resected bronchial stump. The stumps were sliced along the staple line, and the shapes of the staples were recorded by roentgenogram. Then, the staple formation was scored as 0 to 4 points with 4 approximating a perfect B-shaped staple. Results A total of 61 patients were randomly assigned to the equal height staples (n = 30) or the graduated height staples (n = 31). From 61 patients, 183 staple lines, which included 1,144 staples, were evaluated. The case scores were significantly lower in the equal height staples than in the graduated height staples (2.17 versus 2.88, p = 0.0003), respectively. The percentage of staples that formed a complete "B" shape was significantly higher in the graduated height staples than in the equal height staples (25.3% versus 10.0%, p = 0.000). No considerable difference was found between the two groups concerning postoperative complications. No bronchopleural fistula was observed. Conclusions The graduated height staples had significantly higher scores of the staple formation on the bronchia stump than the equal height staples. From the clinical point of view, both the equal height staples and the graduated height staples showed acceptable performance in the stapling ability.

Gastrointestinal metastasis is not common in recurrent non-small-cell lung cancer (NSCLC) patients. There is thus limited information on clinical outcome for these patients. This report presents the clinical characteristics and outcomes of patients with gastrointestinal metastasis after pulmonary resection. The study retrospectively analyzed nine NSCLC patients with gastrointestinal metastases. Gastrointestinal metastases were observed in the small intestine (n = 4), colon or rectum (n = 4), and stomach (n = 1). All of the patients were symptomatic. The median survival after gastrointestinal recurrence was 10.8 months. Gastrointestinal surgery was performed in five patients, whereas no cancer treatment was indicated in the remaining four patients. Three patients who underwent surgery for a solitary metastasis survived for more than 2 years after surgery with no other recurrence. Surgical resection of gastrointestinal metastasis is indicated not only for symptom relief but also for providing a potentially long-term survival if the patients are properly selected.

Background The outcomes after repeat pulmonary resection for colorectal cancer (CRC) and the factors associated with the prognosis of these patients remain uncharacterized. Methods Data on 156 patients who underwent curative resection of pulmonary metastasis from CRC were reviewed. Repeat pulmonary resection was performed in 25 patients; the present study examined the outcomes and factors associated with prognosis after repeat pulmonary resection. Results The 5-year survival rate after the first pulmonary resection was 56.2%. A multivariate analysis identified a histological type other than well-differentiated adenocarcinoma, a high prethoracotomy serum carcinoembryonic antigen (CEA) level, and the presence of hilar or mediastinal lymph node metastasis as poor prognostic factors for the first pulmonary resection. The 5-year survival rate after repeat pulmonary resection was 42.1%. Hilar or mediastinal lymph node metastasis at the time of the repeat resection was significantly associated with poor survival. Conclusions Repeat pulmonary resection for metastatic CRC provides satisfactory outcomes. Hilar or mediastinal lymph node involvement is consistently associated with a poor prognosis after the first and repeat pulmonary resections.

Objective: Despite the report of new treatment options, surgery remains the best treatment for pulmonary metastases from renal cell carcinoma (RCC). Repeat resection is also an effective means for recurrent pulmonary metastases. The aim of the present study was to define the prognostic factors for survival after pulmonary metastasectomy from RCC based on a 25-year single-centre experience. Methods: Between 1973 and 2008, 59 thoracotomies on 48 patients (38 men, 10 women) were performed in our hospital. Repeat resections were performed in eight patients.Theclinicopathologicalandsurgicaldataofthesepatientsobtainedfromthemedicalrecordswereanalysed.Thetimeintervalbetween lung resection and death, or latest follow-up, ranged from 3 to 177 months (median 39 months). Survival analysis was conducted by the Kaplan— Meier method and log-rank test. Multivariate analysis was performed using the Cox multivariate proportional hazard model. Results: The cumulative 3-, 5- and 10-year survival rates were 60%, 47% and 18%, respectively. Multivariate analysis identified disease-free interval (DFI) (2 years) and complete resection as significant prognostic factors for survival. Among eight patients, who underwent repeat resection, two remain alive with no evidence of disease. These two patients had long DFI and long DFI-2 (time from first pulmonary metastasectomy to diagnosis of recurrent pulmonary metastasis). Conclusions:The results showed that (1) surgical resection of pulmonary metastasis from RCC has a favourable outcome in selected patients, (2) DFI and completeness of resection are prognostic markers for survival after pulmonary metastasectomy and (3) repeat lung resection for metastatic RCC is a safe procedure that provides satisfactory patient outcomes. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

The discovery of a distinct subtype of non-small cell lung cancer (NSCLC) positive for rearrangement of the anaplastic lymphoma kinase gene (ALK) has had a substantial impact on personalized therapy for this disease. The clinical features associated with metastasis in individuals with ALK rearrangement-positive NSCLC remain to be fully characterized, however. We now describe a case of ovarian metastasis from NSCLC with ALK rearrangement. A 39-year-old woman underwent a right middle lobectomy for acinar-type adenocarcinoma of the lung (pT2aN2M0, stage IIIA). Fluorescence in situ hybridization (FISH) analysis of the resected tumor tissue revealed the presence of an ALK rearrangement. Twenty months later, a large intrapelvic mass was detected in the patient at follow-up. She underwent both left salpingo-oophorectomy and right ovarian cystectomy. Histological examination of the ovarian tumors showed acinar adenocarcinoma, and FISH analysis revealed the presence of ALK rearrangement, confirming a diagnosis of ALK rearrangement-positive NSCLC with ovarian metastasis. Although the ovary is an uncommon site for metastasis from lung cancer, physicians should be aware of the possibility for such metastasis during follow-up for female patients with ALK rearrangement-positive NSCLC. Further investigation is warranted to clarify the incidence of ovarian metastasis in NSCLC patients with ALK rearrangement.

Objective Diaphragm plication is used to improve lung function and respiratory insufficiency in patients suffering from diaphragm paralysis. We assessed the efficacy of intra-operative unilateral diaphragm plication for prevention of postoperative pulmonary complications in patients, who underwent a phrenicotomy due to extended surgical intervention. Methods Intra-operative unilateral diaphragm plication was performed in 13 patients, who underwent a unilateral phrenicotomy during an extended thoracic operation. Six patients had lung cancer, six had a mediastinal tumour and one had a mesothelioma. We retrospectively observed the postoperative clinical courses in the perioperative period and lung function results at 1 year after operation. The postoperative lung function was compared with the predicted postoperative lung function. In addition, we observed clinical symptoms and radiological findings of the follow-up period. Results Ten (77%) of the cases revealed no postoperative complications, while three (23%) had pulmonary complications and two (15%) required prolonged mechanical ventilation. Diaphragm paralysis was not shown clinically and radiologically during the follow-up period. Postoperative lung function was similar to predicted postoperative lung function. Conclusion Unilateral diaphragm plication in a patient undergoing a unilateral phrenicotomy during an extended thoracic operation is effective to prevent postoperative pulmonary complications and to preserve postoperative lung function.

Sublobar resection is indicated for early-stage non-small cell lung cancer in patients with a perioperative risk associated with impaired medical conditions. This study was conducted to investigate the clinical impact of this procedure in the elderly.The patients who underwent complete resection for stage IA non-small cell lung cancer from 1990 and 2007 were enrolled (n = 764). Two age groups were defined as elderly (≥75 years) and younger (75 years) patients. The 5-year survival, recurrence, and postoperative complications after sublobar resection were compared with those after standard lobectomy according to age group.There were 133 elderly patients (79 standard lobectomies and 54 sublobar resections) and 631 younger patients (539 standard lobectomies and 92 sublobar resections). While the 5-year survival after sublobar resection was significantly inferior to that after standard lobectomy in the younger group (64.0% and 90.9%, respectively, p0.0001), however, no substantial difference was observed in the elderly (67.6% and 74.3%, p = 0.92). Locoregional recurrence rates were higher in patients after sublobar resection than those after standard lobectomy in both the elderly (11.1% vs 1.3%) and the younger (12.0% vs 1.5%) groups. No significant difference in postoperative complications was observed between the types of surgery in the elderly.Sublobar resection for stage IA is considered to be an appropriate treatment in the elderly patients as this procedure provides an equivalent long-term outcome in comparison with lobectomy. A larger scale study with matching patients is necessary to confirm the noninferiority of sublobar resection in comparison with standard lobectomy in this population.

A 23-year-old woman was admitted to our hospital because of an intrapulmonary mass that had been observed for 7 years. Chest computed tomography revealed a 3.5-cm well-defined mass with enhancement in the left lower lobe. During the 7 years of observation, she had been asymptomatic and the tumor size was unchanged. She underwent surgical resection for diagnosis and treatment. Histological examination revealed Castleman's disease of the hyaline vascular type. We present this rare case of solitary Castleman's disease arising from an intrapulmonary lymph node.

外科的切除にて診断された肺過誤腫23例の臨床像を検討した．性別は男性12例，女性11例で，年齢は28～71歳，平均53.5歳であった．20例は無症状であったが，3例は症状を有し，そのうち2例は胸痛，1例は咳嗽であった．病変は，22例が単発性で，1例のみ多発性であった．腫瘍径は0.5～3.0cmで，平均1.5cmであった．画像上，石灰化を6例に認めたが，明らかなポップコーン様ではなかった．石灰化を有する症例は，腫瘍径が有意に大きかった．17例に気管支鏡が施行されたが，確定診断できず，全例が悪性疾患を否定できないため手術に至った．術式は，6例に核出術，16例に部分切除術，1例に葉切除術が施行され，そのうち17例に胸腔鏡下手術が施行された．肺過誤腫の術前診断は困難であるが，悪性疾患との鑑別が問題となる場合，外科的切除にて診断することを考慮すべきである．

症例は53歳，女性．人間ドックの胸部CTにて前縦隔腫瘍を指摘され入院となった．術前診断では，胸腺腫または胸腺嚢胞を疑い，手術を施行した．手術は胸腔鏡補助下に腫瘍を摘出した．病理診断は胸腺内発生の気管支原性嚢胞であった．気管支原性嚢胞が前縦隔胸腺内に発生することは稀であり報告する．

Mediastinal lymphangiomatosis in a 70-year-old woman was diagnosed on a medical checkup. The tumor was resistant to sclerotherapy with OK432 or bleomycin. The patient continued on a downhill course and died approximately 3 years after the initial diagnosis. Autopsy revealed a large tumor mass occupying the anterior mediastinum and firmly adhered to the pericardium and the pleura. The tumor consisted of two intermingled lesions: dilated vessels lined with D2-40-positive lymphatic endothelium and CD5-positive atypical cell nests with focal keratinization. The former was diagnosed as lymphangiomatosis and the latter as thymic squamous cell carcinoma. Vascular endothelial growth factor (VEGF)-C, a growth factor for lymphatic endothelial cells, was expressed by the carcinoma, and VEGF-C receptor was expressed by the endothelium of lymphangiomatosis. These findings suggested that VEGF-C derived from the thymic carcinoma induced the lymphangiomatosis lesion in a paracrine manner.

Following thoracic surgery, patients often suffer from persistent coughing. There is speculation regarding the cause. However, since few studies of that following pulmonary resection have been reported, we conducted an observational and empiric study of this issue.A cross-sectional assessment of 240 patients who had undergone a pulmonary resection was performed using a questionnaire regarding postsurgical persistent coughing. Further, therapy based on empiric results was given to 20 patients who had undergone a lobectomy and mediastinal lymph node resection for nonsmall cell lung cancer.Seventy patients were surveyed within 1 year following surgery (subchronic phase), of whom 35 (50%) suffered from coughing, as compared to 30 (18%) of 170 whose postoperative time was 1 year or more (p0.0001). Presence of lung cancer, mediastinal lymph node resection, and gastroesophageal reflux (GER) symptoms were significant factors in the group of subchronic patients. Of the 20 patients who received empiric therapy, 90% saw their coughing symptoms improve after the course of medication.In the present patients, mediastinal lymph node resection may have contributed to coughing after the procedure, which tended to improve after 1 year following the operation. Further, a secondary change, such as GER, caused by surgical intervention may also be a contributing factor in the subchronic phase.

BACKGROUND Elevated serum carcinoembryonic antigen (CEA) levels are sometimes attributable to the production of CEA by malignant cells, and in turn, the antigen itself can enhance the metastatic potential of malignant cells. The authors speculated that low serum CEA levels might be indicative of relatively low levels of malignant cells and a low probability of disease recurrence. This hypothesis led them to investigate whether low CEA levels in serum represented a useful prognostic factor for patients with pathologic Stage IA nonsmall cell lung carcinoma. METHODS Between 1993 and 2001, 724 patients underwent surgery for NSCLC at Toneyama National Hospital (Toyonaka, Japan). Of these patients, the 242 who were diagnosed with pathologic Stage IA disease were included in the current study. Smoking behavior, gender, age, tumor diameter, disease histology, and preoperative and postoperative serum CEA levels were chosen as study variables, with the cutoff level between subnormal and normal serum CEA levels set at 2.5 ng/mL and the cutoff level between normal and high serum CEA levels set at 5.0 ng/mL. Prognostic indicators were evaluated using a Cox hazard model. In addition, survival probabilities were calculated using the Kaplan–Meier method, and differences in survival were assessed by log-lank analysis. RESULTS Subnormal postoperative serum CEA levels were found to be an independent prognostic indicator (hazard ratio, 2.3; 95% confidence interval, 1.1–4.7; P = 0.03 for comparison with patients who had normal CEA levels) on multivariate analysis. Furthermore, the 5-year survival rate was 87% for patients with subnormal postoperative CEA levels (n = 146), compared with 75% for patients with normal postoperative CEA levels (n = 80) and 53% for patients with high postoperative CEA levels (n = 16) (P < 0.0001). CONCLUSIONS Among patients with pathologic Stage IA NSCLC, those who had an extremely favorable prognosis were distinguished by their subnormal postoperative serum CEA levels. Cancer 2004. © 2004 American Cancer Society.

肺全摘術後の急性膿胸は難治性の重篤な合併症である.肺癌に対する左肺全摘術後に発症し嫌気性菌を起因菌とした急性無瘻性膿胸に対し, 再開胸掻爬術に引き続きクリンダマイシンを用いた胸腔持続洗浄を行い治癒せしめた症例を経験したので報告する.症例は60才, 男性.肺化膿症をともなった左肺扁平上皮癌の診断で左肺全摘術を施行.術後7日目にドレーンを抜去したが, 術後11日目に肺化膿症の起因菌であった嫌気性菌 (Bacteroides) による皮下膿瘍と膿胸を発症し再胸腔ドレナージを施行.術後36日目に再開胸し胸腔鏡併用下掻爬術を行い, その翌日からクリンダマイシンによる2週間の胸腔内持続洗浄と5日間の全身投与を行い膿胸は治癒した.肺全摘後の急性無瘻性膿胸に対する再開胸掻爬術とそれに続く胸腔持続洗浄は, 確実に感染をともなったフィブリン塊を除去でき効果的な治療手段のひとつと思われる.

Background Treatment strategies for brain metastasis from lung cancer have been making progress. The aim of this retrospective analysis was to investigate the post-recurrent prognostic factors in patients with brain metastasis after complete resection of non-small cell lung cancer (NSCLC). Methods We retrospectively reviewed the medical records of 40 patients found to have postoperative brain metastasis from NSCLC in our institution from 2002 to 2008. All patients had undergone radical pulmonary resection for the lung cancer. The impact of numerous variables on survival were assessed, including gender, age, carcinoembryonic antigen (CEA), tumor size, N status, histological type, number of brain metastases, tumor size of brain metastasis, presence of symptoms from the brain tumor(s), and use of perioperative chemotherapy. Results The median follow-up was 20.6 months (range, 3.4–66 months). The five-year survival rate from the diagnosis of brain recurrence was 22.5%. In univariate analysis, the favorable prognostic factors after brain recurrence included a normal range of CEA, no extracranial metastasis, no symptoms from the brain metastasis, brain metastasis (less than 2 cm), and radical treatment (craniotomy or stereotactic radiosurgery [SRS]). The multivariate Cox model identified that a small brain metastasis and radical treatment were independent favorable prognostic factors. Conclusions This study found that the implementation of radical therapy for metastatic brain tumor(s) when the tumor is still small contributed to an increase in patients' life expectancy.

We report a case of esophageal schwannoma in a 46-year-old woman who presented with rapidly progressive dyspnea and dysphagia. Chest computed tomography showed a large mediastinal mass, which was extrinsically compressing the trachea, widely adjacent to the upper thoracic esophagus. We performed an axillary right thoracotomy to enucleate the tumor, which was located in the esophageal muscle layer. A definite diagnosis of esophageal schwannoma was made from the pathologic findings, which included positive immunohistochemical staining for S-100 protein and negative staining for c-kit and CD34.