Biing-Shiun Huang

Prognostic value of the new International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society lung adenocarcinoma classification on death and recurrence in completely resected stage I lung adenocarcinoma.

Objective: This study investigated the prognostic value of the new International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society (IASLC/ATS/ERS) lung adenocarcinoma classification in resected stage I lung adenocarcinoma. Methods: Histological classification of 283 patients undergoing surgical resection for stage I lung adenocarcinoma was determined according to the IASLC/ATS/ERS classification after comprehensive histological subtyping with recording of the percentage of each histological component (lepidic, acinar, papillary, micropapillary, and solid) in 5% increments. Their impact on overall survival, recurrence, and postrecurrence survival was investigated. Results: The 5-year overall survival and recurrence-free rates were 81.6% and 76.9%, respectively. During follow-up, 57 (20.1%) patients developed recurrence. The 2-year postrecurrence survival rate was 72.3%. The solid predominant group is associated with significant more male sex, higher smoking exposure, larger tumor size, and more poorly differentiated histological grade. Lepidic predominant group had significantly better overall survival (P = 0.002). Micropapillary and solid predominant groups had significantly lower probability of freedom from recurrence (P = 0.004). Older age (P = 0.039), visceral pleural invasion to the surface (PL2) (P = 0.009), and high grade (micropapillary/solid predominant) of the new classification (P = 0.028) were predictors of recurrence in multivariate analysis. The solid predominant group tends to have significantly worse postrecurrence survival (P = 0.074). Conclusions: The new adenocarcinoma classification has significant impact on death and recurrence in stage I lung adenocarcinoma. Patients with PL2 and micropapillary/solid predominant pattern have significant higher risk for recurrence. This information is important for patient stratification for aggressive adjuvant chemoradiation therapy.

Predictive Value of the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society Classification of Lung Adenocarcinoma in Tumor Recurrence and Patient Survival

PURPOSE This study investigated the pattern of recurrence of lung adenocarcinoma and the predictive value of histologic classification in resected lung adenocarcinoma using the new International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification system. PATIENTS AND METHODS Histologic classification of 573 patients undergoing resection for lung adenocarcinoma was determined according to the IASLC/ATS/ERS classification system, and the percentage of each histologic component (lepidic, acinar, papillary, micropapillary, and solid) was recorded. The pattern of recurrence of those components and their predictive value were investigated. RESULTS The predominant histologic pattern was significantly associated with sex (P < .01), invasive tumor size (P < .01), T status (P < .01), N status (P < .01), TNM stage (P < .01), and visceral pleural invasion (P < .01). The percentage of recurrence was significantly higher in micropapillary- and solid-predominant adenocarcinomas (P < .01). Micropapillary- and solid-predominant adenocarcinomas had a significantly higher possibility of developing initial extrathoracic-only recurrence than other types (P < .01). The predominant pattern group (micropapillary or solid v lepidic, acinar, or papillary) was a significant prognostic factor in overall survival (OS; P < .01), probability of freedom from recurrence (P < .01), and disease-specific survival (P < .01) in multivariable analysis. For patients receiving adjuvant chemotherapy, solid-predominant adenocarcinoma was a significant predictor for poor OS (P = .04). CONCLUSION In lung adenocarcinoma, the IASLC/ATS/ERS classification system has significant prognostic and predictive value regarding death and recurrence. Solid-predominant adenocarcinoma was also a significant predictor in patients undergoing adjuvant chemotherapy. Prognostic and predictive information is important for stratifying patients for aggressive adjuvant chemoradiotherapy.

Predictors of Death, Local Recurrence, and Distant Metastasis in Completely Resected Pathological Stage-I Non–Small-Cell Lung Cancer

Objective: This study investigated the factors predicting recurrence and death in patients with resected stage-I non–small-cell lung cancers according to the 7th edition of tumor, node, metastasis (TNM) classification for lung cancer. Methods: All patients undergoing surgical resection for pathological stage-I non–small-cell lung cancers at Taipei Veterans General Hospital between 1980 and 2000 were retrospectively reviewed. Those undergoing sublobar resection were excluded. The factors predicting overall survival (OS), overall recurrence, local recurrence, and distant metastasis were investigated. Results: A total of 756 patients were eligible. The 5-year OS rate and probability of freedom from recurrence were 57.3% and 70.2%, respectively. The 2-year local-recurrence–free and distant-metastasis–free rates were 90.7% and 82.1%, respectively. In multivariable analysis, the new T descriptor (T1a, T1b, and T2a) was the common factor that significantly affected OS (p = 0.003), overall recurrence (p = 0.004), and distant metastasis (p < 0.001). Smoking index more than 20, and number of mediastinal lymph nodes dissected/sampled of 15 or fewer were common factors that significantly predicted worse OS (p < 0.001, p < 0.001, respectively), lower probability of freedom from overall recurrence (p = 0.025, p = 0.009, respectively), and higher risk of local recurrence (p < 0.001, p = 0.030, respectively). Non–squamous-cell histology predicted higher risk of distant metastasis (p = 0.006). Conclusions: Risks of death and recurrence increase as the T descriptor upgrades in the new TNM system. The combination of risk factors can be used to identify high-risk subgroups of local recurrence and distant metastasis.

Management of Primary Chest Wall Tumors: 14 Years' Clinical Experience

Background: Primary chest wall tumor is rare but it encompasses tumors of various origins. We analyzed our experience with primary chest wall tumors with emphasis on its demographic presentation and management. Methods: From 1991 to 2004, 62 patients with the diagnosis of primary chest wall tumors were enrolled. Lipoma, chest wall metastasis, direct invasion from nearby malignancy, infection, and inflammation of chest wall were excluded. The clinical features, management, and the outcome of these patients were retrospectively reviewed. Results: There were 37 males and 25 females. Malignant and benign tumors were equally distributed. Chondrosarcoma and lymphoma were the 2 most common types of malignant chest wall tumors. The most common clinical symptoms were palpable mass (54.8%) and pain (40.3%). Nine of 31 patients (29.0%) with benign chest wall tumors were free of symptoms whereas patients with malignant chest wall tumors were all symptomatic (p = 0.002). A definite diagnosis was obtained in 21 of 26 patients (80.7%) who received nonexcision biopsy. All patients with primary chest wall tumors, except 6 who had medical treatment only, underwent surgical resection. Patients with malignant chest wall tumors were older than those with benign tumors (p < 0.001). The mean largest diameter of tumors was also larger in malignant tumors than in benign tumors (p = 0.04). Conclusion: Patients with primary malignant chest wall neoplasm were older than those with benign tumors. The mean size of malignant tumors was larger than that of benign tumors. Adequate surgical resection remains the treatment of choice for patients with primary chest wall tumors. Nonexcision biopsy should be reserved for patients with a past history of malignancy, suspicion of hematologic disease, and with high operative risk. For patients with isolated chest wall lym‐phoma, surgical resection followed by chemotherapy can be considered to obtain a better outcome.

Is Thymectomy Necessary in Nonmyasthenic Patients with Early Thymoma

Background: In thymoma patients without myasthenia gravis, it is debatable whether thymectomy should be performed in addition to thymomectomy, the procedure in which the thymoma alone is resected. In this study, we proposed to compare the surgical results in early-stage nonmyasthenic thymoma patients who underwent thymomectomy with and without extended thymectomy. Methods: A total of 95 patients without clinical evidence of preoperative myasthenia gravis, who underwent surgery for early-stage thymoma (stages I and II), were selected for the study. Thymomectomy with extended thymectomy was performed through median sternotomy on 42 patients, whereas thymomectomy without thymectomy was carried out through video-assisted thoracoscopic surgery (VATS) or thoracotomy in 53 patients. Outcomes and surgical complications were compared between the two patient groups. Results: The median duration of the follow-up was 57 months (6–121 months). Three patients, one in the thymomectomy group (1.9%) and two in the thymomectomy with thymectomy group (4.5%), developed tumor recurrences. Tumor recurrence rates between the two groups were not significantly different. During the follow-up period, we did not document the development of postoperative myasthenia gravis in any of the patients enrolled. Postoperative opioid use, the number of days of drainage, and hospitalization length were lower in patients undergoing thymomectomy through thoracotomy or VATS. Conclusions: In early-stage nonmyasthenic thymoma patients, thymomectomy without thymectomy through thoracotomy or VATS was associated with lower morbidity and shorter hospitalization, than thymomectomy with extended thymectomy. Postoperative myasthenia gravis did not develop in any of the patients enrolled in our study during the 57-month median follow-up period. Overall tumor recurrence rates were not significantly different between these two patient groups. On the basis of our results, we conclude that thymomectomy without thymectomy through thoracotomy or VATS is justified for early-stage nonmyasthenic thymoma patients, and longer follow-up is needed to investigate the necessity of thymectomy in this group.

Reconstruction of the esophagus with the left colon

This report reviews our experience with 96 patients with benign or malignant stricture of the esophagus who underwent interposition of the left colon with or without esophageal resection from July 1982 to June 1987. There were 67 male and 29 female patients ranging in age from 8 to 80 years. Thirty-seven patients had fibrotic stricture secondary to corrosive injury of the esophagus, 42 had cancer of the esophagus, and 17 had cancer of the gastric cardia. The incidence of postoperative complications and surgical mortality, respectively, was 16.2% and 2.7% for patients with corrosive stricture of the esophagus, 35.7% and 11.9% for patients with cancer of the esophagus, and 35.2% and 5.8% for patients with cancer of the gastric cardia. Reconstruction resulted in good function in 75.6% of the patients with corrosive stricture of the esophagus, 66.6% of the patients with cancer of the esophagus, and 70.5% of patients with cancer of the gastric cardia. The morbidity and mortality were higher in the group with malignant esophageal strictures because of advanced age, poor general condition of the patient, and extent of the surgical procedure needed. Cervical anastomotic leakage was the most frequently encountered complication (13.5%), and all the poor-function results were caused by this complication. In our experience, reconstruction of the esophagus with left colon is a satisfactory method that can be accomplished with acceptable morbidity and mortality. The left colon is a durable and functional substitute.

Time Trends of Overall Survival and Survival after Recurrence in Completely Resected Stage I Non-small Cell Lung Cancer

Introduction: The seventh edition of the tumor, node, metastasis classification for lung cancer has been published in 2009. The aim of this study is to evaluate time trends of surgical outcomes and clinicopathologic factors in patients with pathological stage I non-small cell lung cancer according to the seventh edition of the tumor, node, metastasis classification. Methods: We retrospectively reviewed the clinicopathologic characteristics of 1249 patients with pathological stage I non-small cell lung cancer from Taipei Veterans General Hospital between January 1980 and December 2006, during the three periods of 1980–1990, 1991–2000, and 2001–2006. The overall survival, disease-specific survival, and postrecurrence survival were analyzed. Results: The 5-year overall survival rates during the three periods improved significantly: 53.7, 59.9, and 69.3%, respectively (p < 0.001). The 2-year postrecurrence survival rates during the three periods improved significantly: 10.6, 25.4, and 43.2%, respectively (p < 0.001). The percentage of female patients increased during each period: 15.4, 24.9, and 32.0%, respectively (p < 0.001). The percentage of adenocarcinoma also increased during each period: 51.2, 62.2, and 74.9%, respectively (p < 0.001). Tumor size during each period was 3.2, 3.2, and 2.8 cm, tending to be smaller when diagnosed in the last period (p < 0.001). The overall survival in patients with squamous cell carcinoma and those undergoing pneumonectomy or bilobectomy did not improve over time. Conclusions: Stage migration, improved postrecurrence survival, increased frequencies of female gender and adenocarcinoma, and decreased tumor size lead to improved overall survival over the past three decades.

Video-assisted thoracoscopic surgery versus sternotomy in treating myasthenia gravis: Comparison by a case-matched study

PurposeTo clarify the effi cacy of a right-sided videoassisted thoracoscopic extended thymectomy (RtVATET) as a surgical alternative for myasthenia gravis (MG) and to determine the optimal timing for a thymectomy.MethodsThirty-three patients who underwent RtVATET in two institutes were enrolled in this study. Another 66 paired, traditional trans-sternal extended thymectomy (TET) patients from the registered database were used to compare these two surgical modalities for MG.ResultsMean blood loss was 88.5 ml in RtVATET and 226.8 ml in TET group patients (P < 0.001). Mean operation duration was 207.3 min for RtVATET and 172.8 min for TET patients (P = 0.003). Complete stable remission (CSR) rates and total improvement rates for the RtVATET and TET patients were 42.4% vs 60.6% (P = 0.087) and 87.9% vs 90.1% (P = 0.637), respectively. Furthermore, when we focused on the minor grades (classes I and IIa), TET groups showed signifi cantly better CSR than the RtVATET groups (P = 0.012), but there was no statistically signifi cant difference for the more severe grades (classes IIb and III, P = 0.827).ConclusionBoth RtVATET and TET are effective for treating MG, although this study does indicate an advantage for TET. We suggest that a thymectomy should therefore be performed earlier, or that the procedures should be extensive enough to remove all of the tissue that contains thymic tissue.

Pure Red Cell Aplasia and Hypogammaglobulinemia in a Patient with Thymoma

Both pure red cell aplasia (PRCA) and hypogammaglobulinemia are rarer conditions than myasthenia gravis (MG) in thymoma patients. Several articles have discussed the relation between PRCA and thymoma or hypogammaglobulinemia and thymoma, and their proper treatments. Instances of both PRCA and hypogammaglobulinemia in a thymoma patient are few and reported sporadically in the literature. We discuss a 46-year-old woman with thymoma and simultaneous PRCA and hypogammaglobulinemia who achieved complete remission from PRCA after perioperative steroid administration and extended thymectomy, and review the literature.

Analysis of outcomes following surgical treatment of thymolipomatous myasthenia gravis: comparison with thymomatous and non-thymomatous myasthenia gravis

OBJECTIVES Although significant improvement in myasthenic symptoms has been reported following the removal of thymolipomas, information on surgical outcomes among patients with thymolipomatous myasthenia gravis (MG) is limited. METHODS This was a retrospective review of patients who underwent extended thymectomy for treatment of MG. RESULTS From 1995 to 2010, 267 patients with MG underwent extended thymectomy, including 104 with thymomatous MG, 151 with non-thymomatous MG and 12 (4.4%) with thymolipoma. The mean duration of myasthenic symptoms before surgery was greatest in the thymolipomatous group (P < 0.001). The lowest mean age (36.1 years old, P < 0.001) and the lowest preoperative serum anti-acetylcholine receptor antibody titre (P = 0.015) occurred in the non-thymomatous group. More thymic and adipose tissue was removed from the thymolipomatous group compared with the non-thymomatous group (P < 0.001). Regarding surgical outcomes, the rate of stable remission was higher in the non-thymomatous (42.3%) and thymolipomatous (41.7%) groups compared with the thymomatous group (28.8%, P = 0.029). No instances of postoperative exacerbation of MG or tumour recurrence were noted during the postoperative follow-up of patients treated for thymolipoma. CONCLUSIONS Our results suggest that patients with myasthenia thymolipomatous have surgical outcomes similar to those of patients with non-thymomatous MG and have a mean age at the time of surgery similar to that of patients with thymomatous MG.