Haruko Suzuki

Characteristics of Subsolid Pulmonary Nodules Showing Growth During Follow-up With CT Scanning

OBJECTIVE The positive results of a screening CT scan trial are likely to lead to an increase in the use of CT scanning, and, consequently, an increase in the detection of subsolid nodules. Noninvasive methods including follow-up with CT scanning, to determine which nodules require invasive diagnosis and surgical treatment, should be defined promptly. METHODS Between 2000 and 2008, from our database of . 60,000 examinations with CT scanning, we identified 174 subsolid nodules, which showed a ground-glass opacity area . 20% of the nodule and measured 2 cm in diameter, in 171 patients. We investigated the clinical characteristics and CT images of the subsolid nodules in relation to changes identified during the follow-up period. RESULTS The nodule sizes ranged from 4 mm to 20 mm at the fi rst presentation. Nonsolid nodules numbered 98. During the follow-up period, 18 nodules showed resolution or shrinkage, and 41 showed growth of 2 mm or more in diameter. The time to 2-mm nodule-growth curves calculated by Kaplan-Meier methods indicated that the 2-year and 5-year cumulative percentages of growing nodules were 13% and 23% in patients with nonsolid nodules and 38% and 55% in patients with part-solid nodules, respectively. Multivariate analysis disclosed that a large nodule size ( . 10 mm) and history of lung cancer were significant predictive factors of growth in nonsolid nodules. CONCLUSIONS An effective schedule for follow-up with CT scanning for subsolid nodules should be developed according to the type of subsolid nodule, initial nodule size, and history of lung cancer.

Pathologic stage I non–small cell lung cancer with high levels of preoperative serum carcinoembryonic antigen: Clinicopathologic characteristics and prognosis

OBJECTIVE Surgery alone remains the standard therapy for patients with stage I non-small cell lung cancer. Although the preoperative serum level of carcinoembryonic antigen has been shown to be an independent prognostic factor, it has not yet been included in the staging system and does not alter the treatment strategy, especially in the selection of patients for adjuvant chemotherapy. METHODS From 1986 to 2003, preoperative and postoperative serum carcinoembryonic antigen levels were measured in 455 patients with completely resected pathologic stage I non-small cell lung cancer. We compared the clinicopathologic characteristics and outcomes among patients who had preoperative serum carcinoembryonic antigen levels within the normal range (N group, n = 323), patients who had high carcinoembryonic antigen levels before surgery but normal levels after surgery (HN group, n = 112), and patients who had high carcinoembryonic antigen levels before and after surgery (HH group, n = 20). RESULTS The significant characteristics of the HN group included the male sex, greater age, smoking, squamous cell histology, T2 status, lymphatic invasion, vascular invasion, and pleural invasion. Adenocarcinomas in patients of the HN group were more likely to be moderately to poorly differentiated. The 5-year survivals in the HN and HH groups were significantly lower (56.2% and 43.1%, respectively) than those in the N group (85.9%). Multivariate analysis revealed that greater age, non-adenocarcinoma histology, pleural invasion, and the carcinoembryonic antigen in the HN and HH groups were independent prognostic factors. CONCLUSION Patients with resected pathologic stage I non-small cell lung cancer and high preoperative serum carcinoembryonic antigen levels are a subgroup with a distinctly poor prognosis who display smoking-related clinicopathologic characteristics.

Multimodality Therapy for Patients With Invasive Thymoma Disseminated Into the Pleural Cavity: The Potential Role of Extrapleural Pneumonectomy

BACKGROUND The optimal treatment method for thymoma with pleural dissemination remains controversial. We analyzed our experience with a multimodality approach and evaluated the role of extrapleural pneumonectomy (EPP) in the treatment of disseminated thymoma. METHODS Multimodality therapy was used to treat 11 consecutive patients with invasive thymoma disseminated into the pleural cavity. Disease was stage IVa in 9 and stage IVb disease with lymph node metastasis in 2. Our treatment strategy for those patients was induction chemotherapy with cisplatin, doxorubicin, and methylprednisolone (CAMP therapy), followed by thymectomy combined with resection of the visible disseminated nodules and postoperative radiotherapy. EPP was applied for 4 patients who had chemoresistant tumors or pleural refractory recurrence. RESULTS Eight patients underwent induction chemotherapy. The response rate to CAMP was 85%. Thymectomy with or without the resection of disseminated pleural tumors was performed in 7 patients and EPP in 3. Postoperative radiotherapy was administered in 6. All patients except 1 with EPP had recurrence: pleural recurrence in 7, lung in 1, and multiple organs in 2. Nine patients were retreated with chemotherapy, radiotherapy, pulmonary metastasectomy, or pleurectomy. One underwent EPP for pleural recurrence. Consequently, among the 7 patients without EPP, only 1 was alive without disease and 4 were alive with pleural recurrence. In contrast, 3 of the 4 patients with EPP had no local failure and were alive without recurrence. CONCLUSIONS In multimodality therapy for thymoma with pleural dissemination, EPP offers good local control and may lead to cure.

Comparison of Three Measurements on Computed Tomography for the Prediction of Less Invasiveness in Patients With Clinical Stage I Non–Small Cell Lung Cancer

BACKGROUND A greater proportion of ground-glass opacity (GGO) is well known to be strongly associated with less invasive lung adenocarcinoma. Recently, the solid area diameter has also been reported to be a simple and better marker for the same purpose compared with the whole nodule diameter. METHODS From 1997 to 2009, 383 patients with clinical T1-2N0M0 non-small cell lung cancer (NSCLC) with a solid area of 3 cm or less underwent surgical resection, and their preoperative high-resolution computed tomographic images were preserved in Digital Imaging and Communications in Medicine format. Less invasive lung cancer was defined as having no vascular, lymphatic, or pleural invasion or lymph node metastasis. We compared the solid area and whole nodule diameters and proportion of GGO, with the objective of predicting less invasive lung cancer. RESULTS Among the 383 patients, 187 were men, 335 had adenocarcinoma histologic type, 242 had less invasive lung cancer, and 43 experienced recurrence. Receiver operating characteristic (ROC) analysis to predict less invasive lung cancer showed that the area under the curve of proportion of GGO was the highest (0.848; 95% confidence interval [CI], 0.810-0.886), followed by the solid area diameter (0.785; 95% CI, 0.740-0.829), and then whole nodule diameter (0.621; 95% CI, 0.565-0.677). Multiple logistic regression analyses revealed that proportion of GGO was the only significant predictor of less invasive lung cancer. The proportion of GGO was also found to be a significant prognostic factor of disease-free survival (DFS) along with solid area diameter by multivariate analysis. Regardless of the solid area diameter, no patient with a greater proportion of GGO (> 50%) experienced recurrence. CONCLUSIONS Proportion of GGO remains important for predicting less invasive lung cancer.

Postoperative radiotherapy for patients with completely resected pathological stage IIIA-N2 non-small cell lung cancer: focusing on an effect of the number of mediastinal lymph node stations involved

Postoperative radiotherapy (PORT), especially using modern technology, for patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) is controversial. We retrospectively investigated 112 patients with stage IIIA-N2 NSCLC who underwent complete resection of the lung tumor in our institution from 1986 through 2003. Among the 91 patients determined suitable candidates for PORT postoperatively, 45 patients received PORT (PORT group) and 46 did not (non-PORT group). We analyzed the correlation between PORT use and clinicopathological characteristics, number of involved mediastinal lymph node stations, recurrence, and survival. Five-year and 10-year survival rates of PORT group were 53.2% and 40.0%, which were superior, however, not statistically different, to those (39.3% and 27.5%) of non-PORT group (P=0.6284). According to the number of mediastinal lymph node stations, PORT was more effective for multiple station metastasis than single station metastasis. The disease-free survival of PORT group was significantly better than that of non-PORT group among the patients with multiple station metastasis. Five-year disease-free survival rate of PORT group and non-PORT group were 41% and 5.9%, respectively (P=0.0220). PORT using modern techniques can reduce local recurrence and improve overall survival especially for patients with multiple station N2. Prospective randomized control trials are warranted.

Can non-performance of radical systematic mediastinal lymphadenectomy be justified in elderly lung cancer patients? An evaluation using propensity-based survival analysis

OBJECTIVES The increasing age of the population has raised the importance of determining the minimally required surgical treatment for elderly lung cancer patients. Despite a number of previous studies, the therapeutic impact of a radical mediastinal lymphadenectomy (RLA) associated with a pulmonary resection for lung cancer remains controversial. Herein, we investigated the impact of lymph node dissection on the overall survival for elderly lung cancer patients and assessed whether the non-performance of an RLA could be justified in the surgical treatment for these elderly patients. METHODS We analysed the data for 160 patients aged 70 years and older (113 males, 47 females) who underwent curative-intent surgery for non-small-cell lung cancer. They were divided into two groups, according to the method used for the intra-operative mediastinal lymph node dissection, the radical systematic lymphadenectomy (RLA, n=76) and the non-radical lymphadenectomy (NLA, n=94) groups. A Cox proportional hazards model and the Kaplan-Meier method were used for the survival analyses. Propensity-based analyses were also used to reduce the effect of non-randomisation and possible bias in indication of treatment between the two groups. RESULTS RLAs had no protective effect on mortality; the hazard ratio for the RLA group in comparison to the NLA group was 0.97 (95% confidence interval (CI): 0.32-2.89) in the multivariate analysis and 1.43 (95% CI: 0.42-4.91) in the propensity-based stratifying analysis. The 3-year survival probability was 81.3% (95% CI: 67.1-89.8) for the NLA group, which was marginally better than that of the RLA group (77.5% (95% CI: 63.3-86.8)). There was no significant difference in the overall survival between the two groups (p=0.26). The 3-year survival probability of the NLA group at each quartile of the propensity score also tended to be better than that of the RLA group, which did not show any significant difference. CONCLUSIONS There was no survival benefit shown for RLA associated with pulmonary resections in the present cohort, even in the propensity-based analyses. Although some reports recommend a systematic mediastinal lymphadenectomy for proper staging and better survival, a pulmonary resection with non-performance of radical lymphadenectomy could be an acceptable surgical treatment for the increasing number of elderly lung cancer patients.

Arterial Air Embolism: A Rare but Life-Threatening Complication of Percutaneous Needle Biopsy of the Lung

1 F 51-year-old man was admitted to our hospital for examination of a nodule on chest roentgenograms. or pathologic diagnosis, a transthoracic needle biopsy of he nodule was performed with computed tomographic, uoroscopic guidance using an automatic cutting needle Monopty, 16 gauge; Bard Radiology, Covington, GA). The atient was positioned in a right lateral decubitus position. mmediately after the procedure, the patient coughed up pproximately 1 to 2 tablespoons of bloody sputa and soon ecame unresponsive, showing upward gaze fixation and ild right hemiparesis. To exclude tension pneumothorax, omputed tomographic scans were immediately obtained, hich disclosed an air-fluid level in the descending aorta Fig 1). Subsequent brain computed tomographic scans also emonstrated air emboli of the cerebral vessels in the left arietal sulci (Fig 2). The patient’s consciousness began to lear approximately 30 minutes after the incident, and he as transferred to another hospital to receive hyperbaric xygen therapy. The patient recovered fully without any

Late breast metastasis from resected lung cancer diagnosed by epidermal growth factor receptor gene mutation

Primary lung cancer metastasizes to various organs, but rarely metastasizes to the breast. We report a case of breast metastasis from primary lung cancer, which was confirmed by the detection of the same epidermal growth factor receptor (EGFR) gene mutation.

Transmanubrial osteomuscular sparing approach for lung cancer invading the anterior part of the thoracic inlet

Standard treatment for lung cancer presenting as a superior sulcus tumor is induction chemoradiotherapy followed by surgery, which yields rates of about 70% complete resection and 50% 5-year survival rate. However, the surgical technique to achieve complete resection for superior sulcus tumor invading major anatomical sites including the subclavian artery is challenging. The anterior transcervical thoracic approach applied by Dartevelle and colleagues provides excellent exposure of the subclavian vessels. Grunenwald and associates have improved on this approach to preserve the clavicle and sternoclavicular joint. We applied the transmanubrial osteomuscular-sparing approach in two patients. In both cases, exposure of the subclavian vessels was excellent. In one case, the subclavian artery was resected and reconstructed with a polytetrafl uoroethylene graft. This patient has continued to show recurrence-free survival for more than 5 years. We outline our experience and review the literature on the surgical approach for superior sulcus tumor invading the anterior part of the thoracic inlet.