Hiroyuki Adachi

Influence of visceral pleural invasion on survival in completely resected non-small-cell lung cancer

OBJECTIVES Although the prognostic implications of visceral pleural invasion (VPI) are well established, it remains controversial whether the extent of VPI affects survival in patients with completely resected non-small-cell lung cancer (NSCLC). In addition, the impact of VPI according to nodal status is unclear. We evaluated the influence of the extent of pleural invasion on survival by analysing a multicentre retrospective database of patients who had undergone surgery for NSCLC. METHODS We retrospectively reviewed the clinicopathological characteristics and outcomes of 639 patients with NSCLC who underwent anatomic complete resection from 2005 to 2007 at nine hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons. RESULTS The median follow-up was 65.0 months. The extent of pleural invasion was PL0 in 462 patients, PL1 in 135 and PL2 in 42. The 5-year overall survival rate was significantly higher in patients with PL0 tumours (75.9%) than in those with PL1 (63.6%) or PL2 tumours (54.1%). On subgroup analysis according to nodal status, PL0 was associated with a higher survival rate than that of PL1 or PL2 tumours in patients with N0 or N1 metastasis, but not in those with N2 metastasis. There was no difference between PL1 and PL2 in any subgroup. CONCLUSIONS Our results suggest that the presence of VPI, rather than the extent, has an impact on postoperative survival in patients with NSCLC who have N0 or N1 metastasis. Because very few previous studies have addressed the effects of VPI in patients with N1 disease, further re-evaluation of the prognostic impact of VPI is necessary in this subgroup of patients.

Lobe-Specific Lymph Node Dissection as a Standard Procedure in Surgery for Non–Small Cell Lung Cancer: A Propensity Score Matching Study

Introduction: Systematic lymph node dissection (SND) is the standard procedure in surgical treatment for NSCLC, but the value of this approach for survival and nodal staging is still uncertain. In this study, we evaluated the potential of lobe‐specific lymph node dissection (L‐SND) in surgery for NSCLC by using a propensity score matching method. Methods: From 2005 to 2007, 565 patients with cT1a–2b N0–1 M0 NSCLC underwent lobectomy with lymph node dissection at our 10 affiliated hospitals. Patients were classified into groups that underwent nodal sampling, L‐SND, and systematic dissection SND on the basis of pathological data for the number and extent of nodal resection. A total of 77 patients with insufficient pathological data were excluded from the study. Results: Overall, survival did not differ significantly among the groups (p = 0.552), but the rate of detection of pN2 in the SND group (13.1%) was significantly higher than in the nodal sampling (3.3%) and L‐SND (9.0%) groups (p = 0.010). However, given the many confounding factors in the patient characteristics in each group, outcomes were reevaluated using a propensity score matching method for the L‐SND and SND groups. After matching, the two groups had no significant differences in 5‐year overall survival (73.5% for L‐SND versus 75.3% for SND, p = 0.977) and pN2 detection (8.2% in both groups, p = 0.779). Conclusions: These results suggest that lobe‐specific lymph node dissection has the potential to be a standard procedure in surgical treatment for NSCLC.

Postoperative follow-up strategy based on recurrence dynamics for non-small-cell lung cancer

OBJECTIVES Our study was designed to visually represent recurrence patterns after surgery for non-small-cell lung cancer (NSCLC) with the use of event dynamics and to clarify postoperative follow-up methods based on the times of recurrence. METHODS A total of 829 patients with NSCLC who underwent complete pulmonary resection from 2005 to 2007 in 9 hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons were studied. Event dynamics, based on the hazard rate, were evaluated. Only first events involving the development of distant metastases, local recurrence or both were considered. The effects of sex, histological type, pathological stage and age were studied. RESULTS The hazard rate curve displayed an initial surge that peaked about 6-8 months after surgery. The next distinct peak was noted at the end of the second year of follow-up. On non-parametric kernel smoothing, the maximum peak was found 6-8 months after surgery in men. In women, the highest peak occurred 22-24 months after surgery, which was about 16 months later than the peak in men. The peak timing of the hazard curve was not affected by histological type, pathological stage or age in either sex. CONCLUSIONS Our results suggest that the timing of recurrence after surgery for lung cancer is characterized by a bimodal pattern, and the times with the highest risk of recurrence were suggested to differ between men and women. Postoperative follow-up strategies should be based on currently recommended follow-up programmes, take into account the recurrence patterns of lung cancer, and be modified as required to meet the needs of individual patients.

Giant Desmoid Tumor of the Chest Wall

A 21-year-old man was referred to our hospital because of a right thoracic mass detected on a medical checkup. He was asymptomatic. There was no history of trauma or Gardner syndrome. Computed tomography revealed that the chest wall tumor involved the right first and second ribs (Figure 1A). The tumor occupied the right hemithorax and displaced the mediastinum to the left (Figure 1B). A combined clamshell incision and median sternotomy were performed. The tumor was resected en bloc with portions of the first rib, second rib, sternum, musculus pectoralis major, and clavicle. The chest wall was reconstructed with a 1-mm composite mesh (polypropylene/polytetrafluoroethylene). Mechanical ventilation was required for 2 weeks postoperatively because of respiratory failure. However, the patient recovered without any functional deficit. Histopathological examination confirmed a desmoid tumor measuring 23.5 18 11 cm and weighing 2800 g. The specimen showed proliferations of spindle-shaped cells with slight atypia in a collagenous stroma. The surgical margins were free of tumor (Figure 2). Desmoid tumors are relatively rare tumors derived from fascial or musculoaponeurotic structures. Pathologically they are benign but grow locally aggressive. If feasible, surgical resection of the tumor is the treatment of choice, but a high incidence of local recurrence has been reported.1,2 Reoperation and positive margins are associated with a high risk of local recurrence.1 Therefore, it is essential to achieve local control by wide resection with tumor-free margins on initial treatment.

An Improved Technique for Esophagojejunostomy after Total Gastrectomy with a Novel Anvil Grasping Forceps

D T i t c e t t n t c c a F i ircular stapler anastomosis has been widely used in esophgojejunostomy after total gastrectomy. Because tearing f an esophagojejunostomy can result in lethal complicaions, this anastomosis occupies an important step during he reconstruction procedure of total gastrectomy. But echnical problems associated with the procedure of the nastomosis remain because of the anatomic features round the abdominal esophagus, which is located in a eep and narrow region at the bottom of the upper abdomnal cavity. We present a new technique for esophagojejuostomy using a novel anvil grasping forceps, which has a orn head (Fig. 1).