Katsunari Matsuoka

Long-term survival after video-assisted thoracic surgery lobectomy for primary lung cancer.

BACKGROUND Despite its feasibility and safety, use of video-assisted thoracic surgery (VATS) lobectomy for malignancies has spread slowly during the past decade because no definitive conclusions have been reached regarding the oncologic validity of this approach for malignancies. Thus, the purpose of this study was to analyze the indications and long-term results of VATS major pulmonary resections for primary lung cancers. METHODS Of 502 patients who had surgical resections for primary lung cancers at the National Hospital Organization Himeji Medical Center from May 2000 to December 2003, the cases of the 325 patients who were originally scheduled for VATS major pulmonary resections (pneumonectomy, bilobectomy, lobectomy, and segmentectomy) were retrospectively reviewed. At this hospital, after an initial learning-curve period, indications for VATS were extended to all cases for which this approach was thought possible. For better analysis of long-term survival rates, patients whose follow-up periods were more than 5 years after surgery were analyzed. RESULTS Of the 325 scheduled VATS resections, 21 procedures (6.4%) were eventually converted to open thoracotomies. In-hospital death occurred in 1 patient (0.3%). The average follow-up period for all censored cases was 66 months. Overall and disease-free 5-year survival rates were 85% and 83% for stage Ia (192 cases), 69% and 64% for stage Ib (50 cases), 48% and 37% for stage II (27 cases), and 29% and 19% for stage III (50 cases), respectively (p < 0.0001). Patients who were operated on using the VATS approach increased year by year, especially after 2002, when indications for using this method were extended (ratio of VATS to total cases, approximately 50% in the first 2 years and more than 80% in the latter 2 years). Long-term survival rates during the entire study period were comparable, especially in early stage lung cancer cases. CONCLUSIONS Use of VATS major pulmonary resection for primary lung cancer is feasible, with long-term patient survival comparable to that of conventional thoracotomy. Thus, it is possible that this approach might become the standard in experienced surgical centers, especially for early stage lung cancer cases. Further investigation at multiple centers is required.

Prognostic value of thymidylate synthase expression in patients with p-stage I adenocarcinoma of the lung

We investigated thymidylate synthase (TS) expression in tumor tissues and examined the relationship between TS expression and post-operative survival in patients with p-stage I adenocarcinoma of the lung. A total of 104 patients, who underwent complete resection for p-stage I adenocarcinoma of the lung, were retrospectively reviewed. TS expression in tumor tissues was evaluated by immunohistochemical staining using rhTS polyclonal antibody. The intensity of immunohistochemical staining was classified into four categories using a visual grading system from 0 to 3. The percentage of each grade of TS staining was 9.6% for Grade 0, 18.3% for Grade 1, 35.6% for Grade 2 and 36.5% for Grade 3. Five-year survival rates of patients with Grade 0 to Grade 3 were 90.0, 83.9, 70.3 and 73.7%, respectively with no significant difference among all groups (P=0.236). When divided into two groups, according to the intensity of the grade, 5-year survival rates of TS low expression group (Grade 0 and Grade 1) and TS high expression group (Grade 2 and Grade 3) were 86.1 and 72.0%, respectively, with a significant difference (P=0.048). In conclusion, high level of TS expression was associated with poor prognosis. Immunohistochemical evaluation of TS expression may be useful to predict survival after complete resection in p-stage I adenocarcinoma of the lung.

Prognostic Factors in Patients with Pathologic T1-2N1M0 Disease in Non-small Cell Carcinoma of the Lung

Introduction: Patients with stage II non-small cell lung carcinoma (NSCLC) represent a heterogeneous subgroup with variable 5-year survival rates. The influence of the type of lymph node involvement on survival and recurrence was investigated. Methods: A total of 128 consecutive patients who underwent complete tumor resection and mediastinal lymph nodes dissection for pT1-2N1M0 NSCLC between July 1991 and December 2003 were retrospectively reviewed. Results: The overall 5-year survival of patients with T1-2N1M0 disease was 42.2%. Although pT status, histology, surgical procedure, and adjuvant therapy did not affect survival for pT1-2N1M0 patients, the 5-year survival rate differed significantly according to the type of lymph node involvement. The 5-year survival rate for patients with main bronchial lymph node involvement, interlobar and lobar lymph node involvement, and segmental bronchial lymph node involvement was 19.7%, 39.8%, and 59.7%, respectively. The survival curves of these three groups had significant differences. Fifty-five patients had cancer recurrence, and the type of lymph node involvement did not affect the pattern of cancer relapse. Conclusions: In patients with stage II NSCLC, survival differs according to the type of lymph node involvement: patients with only segmental lymph node involvement have a better prognosis and the disease seems to be at an early stage, whereas patients with main bronchial lymph node involvement have a poorer prognosis, and main bronchial lymph node involvement represents more advanced disease. Patients with pN1 disease represent a heterogeneous group that may be subdivided according to the level of the involved N1 station, not pT factor.

Video-Assisted Thoracoscopic Pneumonectomy: Retrospective Outcome Analysis of 47 Consecutive Patients

BACKGROUND Although video-assisted thoracoscopic surgery (VATS) lobectomy is widely accepted, VATS pneumonectomy remains an uncommon procedure in patients with complicated diseases. METHODS Of 47 consecutive patients who were planned to undergo VATS pneumonectomy from May 2000 to May 2012 at the National Hospital Organization Himeji Medical Center, VATS pneumonectomy was completed successfully in 46 patients (2.1% conversion rate). Appropriate tissue retraction and cooperative dissection of hilum structures under only thoracoscopic visualization were applied to all candidates. We retrospectively reviewed morbidity, mortality, local disease control, and surgical considerations to evaluate the validity of this procedure. RESULTS All patients had malignant tumors, including 45 with primary lung cancer. One patient with a severe adhesion around a tumor required conversion to open thoracotomy, with no subsequent specific complications. Of 46 patients in whom VATS pneumonectomy was completed, the mean operation time was 159 minutes and the mean blood loss was 258 g. Surgery-related death occurred in 1 patient (mortality rate: 2.2%) with recurrent heart failure after discharge. Seven patients (15.2%) had major complications defined as grade 3 or higher (Common Terminology Criteria for Adverse Effects, version 4.0) within 30 days postoperatively; however, no patients exhibited secretion retention that required bronchoscopy. There were no patients with locoregional recurrence within usual lymph node dissection areas and the ipsilateral thoracic cavity among 44 patients with primary lung cancer who underwent VATS pneumonectomy, with the median follow-up time of 27 months. CONCLUSIONS Video-assisted thoracoscopic surgery pneumonectomy has developed into a common procedure with acceptable damage and lower morbidity among selected patients with complicated diseases.

Inflammatory endobronchial stenosis

We encountered a 71-year-old woman with inoperable bronchial stenosis of the right main bronchus, which was caused by inflammatory granulation infected with Pseudomonas aeruginosa in posttuberculous bronchiectasis. Two months after placement of self-expanding nitinol stents, fiberoptic bronchoscopic examination to investigate hemosputum revealed endobronchial granuloma formation. Endobronchial granulation has disappeared with long-term oral administration of tranilast.

Severe Mediastinitis and Pericarditis After Transbronchial Needle Aspiration.

Endobronchial ultrasonographically guided transbronchial needle aspiration (EBUS-TBNA) is now widely performed for mediastinal lymph node staging of lung cancer. Although this procedure is less invasive than mediastinoscopy, some infectious complications have been reported. We report the successful use of pericardial and mediastinal drainage in a case of acute severe mediastinitis with pericarditis after EBUS-TBNA.

Clinical results of bronchial stump coverage using free pericardial fat pad

OBJECTIVES Bronchial fistula is a severe complication after thoracic surgery. Although many methods of coverage using various autologous tissues including pedicled pericardial fat pad have been reported to be useful for the prevention of bronchial fistula, the ideal roles of these approaches and the coverage techniques yielding the best results still remain unclear. The clinical use of an autologous free fat graft has been reported in the various surgical fields including otolaryngology, orthopaedics and plastic surgery. Therefore, we have used a free pericardial fat pad (FPFP) as the material for covering the bronchial stump instead of a pedicled pericardial fat pad. METHODS Between January 2009 and December 2013, 1134 patients with lung cancer underwent pneumonectomy or lobectomy without bronchoplasty at our institution. Among them, 46 patients underwent bronchial stump coverage using a FPFP and we investigated the clinical results obtained retrospectively. RESULTS Bronchial fistula occurred in 5 patients during the study period. Although we performed bronchial stump coverage mainly in patients with several risk factors for bronchial fistula, no bronchial fistula developed in this group. To investigate the viability of the FPFP, we examined the fat tissue around the bronchial stump demonstrated by chest computed tomography retrospectively. Although fat tissue at the bronchial stump gradually decreased in size, it remained evident for 5 months and was identified in almost half of the patients even at 1 year after surgery. CONCLUSIONS No bronchial fistula developed in the FPFP group. Although the FPFP is a free flap, it remains viable for many months after surgery and may contribute to good wound healing of the bronchial stump by offering a wet environment. A pericardial fat pad is easy to make, can be used anywhere in the thoracic cavity and may be useful for bronchial stump reinforcement.

Four Cases of Contralateral Pneumothorax After Pneumonectomy

Contralateral pneumothorax after pneumonectomy (CPAP) is a rare but potentially fatal condition. Therefore, when treating CPAP prevention of recurrence is very important. Despite a number of case reports about CPAP, its management is still controversial. We describe 4 cases of CPAP that were treated successfully by bullectomy and coverage with absorbable polyglactin mesh.

Video-assisted thoracoscopic surgery for nontuberculous mycobacterial infection.

Background The number of patients with nontuberculous mycobacterium infection is increasing in Japan, and therefore surgical treatment is also being applied with increasing frequency. Although the effectiveness of surgery for nontuberculous mycobacterium disease has been established and reported by a number of authors, the role of video-assisted thoracoscopic surgery in the surgical treatment of nontuberculous mycobacterium disease has not been sufficiently investigated. Patients and methods We retrospectively investigated 10 patients, comprising 5 males and 5 females, who underwent video-assisted thoracoscopic lobectomy or segmentectomy for nontuberculous mycobacterium disease at our institution between February 2006 and November 2012. The average patient age was 59.5 years (range 53–65 years). We performed lobectomy in 6 cases and segmentectomy in 4. Results All surgical procedures were completed under video-assisted thoracoscopic surgery and none required conversion to thoracotomy. Postoperatively, air leakage continuing for 7 days occurred in 2 patients but there was no severe postoperative complication. The median periods of postoperative drainage and hospitalization were 4.0 and 5.5 days, respectively. Among 8 cases followed up at our institution, reactivation of nontuberculous mycobacterium disease occurred in one case 4 years after surgery. Conclusion Video-assisted thoracoscopic surgery is a safe and useful procedure for lobectomy and segmentectomy in patients with nontuberculous mycobacterium disease.

Tracheal Stenosis After Metal Stent Insertion Treated Successfully With a T-Tube

Tracheal stenosis after intubation is a fairly common complication, and treatment of such cases can be difficult. A 52-year-old woman was admitted to our hospital because of severe dyspnea. Seven years previously, she had suffered tracheal stenosis after tracheal intubation and had undergone tracheal resection and placement of a self-expandable metal stent. In this case, tracheal restenosis had occurred and we successfully treated the patient by insertion of a silicone T-tube after tracheotomy. Use of a T-tube is safe and effective for relief of tracheal restenosis after self-expandable metal stent placement.