Kentaro Anami

Video-assisted thoracoscopic indocyanine green fluorescence imaging system shows sentinel lymph nodes in non-small-cell lung cancer.

OBJECTIVE The primary objective was to assess the feasibility and accuracy of intraoperative sentinel lymph node mapping by using a video-assisted thoracoscopic indocyanine green fluorescence imaging system in patients with clinical stage I non-small-cell lung cancer. METHODS Thirty-one patients who underwent operation between January 2009 and September 2009 were investigated for sentinel node biopsy. Indocyanine green fluorescence imaging was applied by an infrared light charge-coupled device, and sentinel nodes were identified intraoperatively and dissected. Histologic examination by hematoxylin-eosin staining was used to evaluate metastases. RESULTS Sentinel lymph nodes were identified by segmentectomy in 11 of 14 patients (78.5%) and by lobectomy in 14 of 17 patients (82.4%). The total identification rate was 80.7% (25/31 patients), the false-negative rate was 0% (0/24 patients), and the overall accuracy rate was 80.7% (25/31 patients). CONCLUSION Video-assisted thoracoscopic indocyanine green fluorescence image-guided surgery is feasible for sentinel node biopsy and may be a powerful tool to eliminate unnecessary lymph node dissection in patients with lung cancer.

Sentinel Node Navigation Surgery by Thoracoscopic Fluorescence Imaging System and Molecular Examination in Non-Small Cell Lung Cancer

PurposeThe application of sentinel node navigation surgery in non-small cell lung cancer (NSCLC) is not popular because of the difficulty of sentinel node identification and the low incidence of complications after systemic lymph node dissection. We report the intraoperative assessment of sentinel node metastasis by thoracoscopic ICG fluorescence imaging system and real-time reverse transcription-polymerase chain reaction (RT-PCR).MethodsSixty-one patients who underwent surgery between January 2009 and December 2010 were investigated for sentinel node biopsy. ICG fluorescence imaging was applied by an infrared light CCD system, and sentinel nodes were identified and dissected. Intraoperative real-time quantitative RT-PCR to determine the expression of cytokeratin 19 (CK-19) was performed for evaluation of metastasis and finally histologic examination of hematoxylin and eosin-stained, paraffin-embedded sections.ResultsSixteen (80%) of 20 patients with segmentectomy and 33 (80.5%) of 41 with lobectomy were identified for sentinel lymph nodes. The total identification rate was 80.3% (49 of 61). The false-negative rate was 2.1% (1 of 49). The overall accuracy rate was 78.7% (48 of 61 patients). Disease of four of these patients was upstaged to stage IIA by RT-PCR for CK-19 expression, which was positive for sentinel nodes and micrometastases.ConclusionsThese results demonstrated that thoracoscopic ICG fluorescence imaging-guided surgery and real-time quantitative RT-PCR were useful for sentinel node biopsy and might be a powerful tool for more focused pathologic or molecular evaluation for staging.

Thoracoscopic segmentectomy for T1 classification of non-small cell lung cancer: a single center experience

OBJECTIVES Segmentectomy is one of the treatment options for small-sized non-small cell lung cancer (NSCLC). Although growing results support the feasibility and efficacy, it still remains unclear in segmentectomy. The International Association for the Study of Lung Cancer recommended a revised classification of TNM staging in 2009 (the seventh edition) and multidisciplinary classification of adenocarcinoma. We report here the outcome of totally thoracoscopic segmentectomy and lobectomy for T factor and adenocarcinoma. METHODS Ninety patients with Stage IA NSCLC underwent thoracoscopic segmentectomy between September 2003 and June 2011. A total of 124 patients were referred as a control group to compare the peri-operative outcome, local recurrence rate and survival. These survivals were analysed using the Kaplan-Meier method with the log-rank test and propensity score analyses. RESULTS The peri-operative outcome, including operative time, blood loss, duration of chest tube drainage and length of hospital stay, was not significantly different between groups. The number of dissected lymph nodes with segmentectomy was less than that with lobectomy. Morbidity and mortality were not significantly different between groups. Seven patients relapsed in each group and propensity score analysis in disease-free and overall survivals showed no differences between two groups in Stage IA. Subclass analyses revealed that disease-free and overall survivals in T1a and T1b were not significantly different between the two groups. CONCLUSIONS Our study demonstrated that thoracoscopic segmentectomy was feasible with regard to peri-operative and oncological outcomes for Stage IA NSCLC, especially T1a and carefully selected T1b descriptor.

Clinical Impact of Segmentectomy Compared with Lobectomy Under Complete Video-Assisted Thoracic Surgery in the Treatment of Stage I Non-Small Cell Lung Cancer

BACKGROUND Segmentectomy for small or early stage non-small cell lung cancer (NSCLC) has been controversial. Further, video-assisted thoracic surgery (VATS) for lung cancer was accepted during the past decade. We here compared the outcome between VATS segmentectomy and VATS lobectomy for stage I NSCLC. METHODS In the retrospective study, 109 consecutive patients in stage I underwent surgery at Oita University Hospital (Oita, Japan) between September 2003 and October 2008. VATS segmentectomy was performed in 38 patients and VATS lobectomy with systemic lymphadenectomy was performed in 71 patients. After clinicopathologic factors were compared in both groups, local recurrence rates and survivals were compared. RESULTS Five of 38 VATS segmentectomy and eight of 71 VATS lobectomy patients relapsed during the follow-up period (median 27.5 mo). In the relapsed patients after VATS segmentectomy, three (7.9%) were local recurrences and two (5.3%) were distant metastases. On the other hand, four (5.6%) were local recurrence and four (5.6%) were distant metastases in the VATS lobectomy group. There was no significant difference between the two groups. Furthermore, there was no difference in recurrence-free and overall survival between segmentectomy and lobectomy. CONCLUSIONS Although the sample size is small, VATS segmentectomy is one of the appropriate procedures for stage I NSCLC.

Combination of p53AIP1 and survivin expression is a powerful prognostic marker in non-small cell lung cancer

Backgroundp53AIP1 is a potential mediator of apoptosis depending on p53, which is mutated in many kinds of carcinoma. High survivin expression in non-small cell lung cancer is related with poor prognosis. To investigate the role of these genes in non-small cell lung cancer, we compared the relationship between p53AIP1 or survivin gene expression and the clinicopathological status of lung cancer.Materials and methodsForty-seven samples from non-small cell lung cancer patients were obtained between 1997 and 2003. For quantitative evaluation of RNA expression by PCR, we used Taqman PCR methods.ResultsAlthough no correlation between p53AIP1 or survivin gene expression and clinicopathological factors was found, the relationship between survivin gene expression and nodal status was significant (p = 0.03). Overall survival in the p53AIP1-negative group was significantly worse than in the positive group (p = 0.04); however, although survivin expression was not a prognostic factor, the combination of p53AIP1 and survivin was a significant prognostic predictor (p = 0.04). In the multivariate cox proportional hazard model, the combination was an independent predictor of overall survival (p53AIP1 (+) survivin (+), HR 0.21, 95%CI = [0.01–1.66]; p53AIP1 (+) survivin (-), HR 0.01, 95%CI = [0.002–0.28]; p53AIP1 (-) survivin (-), HR 0.01, 95%CI = [0.002–3.1], against p53AIP1 (-) survivin (+), p = 0.03).ConclusionThese data suggest that the combination of p53AIP1 and survivin gene expression may be a powerful tool to stratify subgroups with better or worse prognosis from the variable non-small cell lung cancer population.

Contralateral mediastinal lymph node micrometastases assessed by video-assisted thoracoscopic surgery in stage I non-small cell left lung cancer

OBJECTIVES Survival of patients with left-sided stage I non-small cell lung cancer (NSCLC) is unsatisfactory, probably because of the high incidence of contralateral mediastinal node involvement. In this study, occult micrometastases to the right upper mediastinal nodes were retrospectively investigated in patients with left-sided stage I NSCLC. METHODS Nineteen patients with clinical stage I NSCLC underwent video-assisted thoracoscopic lobectomy and bilateral mediastinal node dissection (BMD). Clinical data and survival of patients with BMD were compared with those of 25 left-unilateral mediastinal node dissection (UMD) patients. Occult micrometastases were detected using the cytokeratin 19 mRNA reverse transcription-polymerase chain reaction method. RESULTS Pathological N2 disease was found in 1 patient, and 18 had pN0 disease. The operative time, blood loss, duration of chest tube drainage and duration of postoperative hospital stay were not different between BMD and UMD patients. Nodal micrometastases were detected in 11/19 (57.8%) patients. Skip micrometastases to the level N3 nodes without N1 and N2 node involvement were observed in 8/11 (72.7%) patients. Patients with BMD are all alive and have had no recurrence during the median follow-up period of 21.4 months. Overall 3-year survival and disease-free 3-year survival were not significantly different between the two groups. CONCLUSION In this preliminary study, occult micrometastases to the level N3 nodes occurred frequently in patients with left-sided clinical N0 stage I NSCLC. Postoperative survival of patients with occult micrometastases to the level N3 node does not appear to be poor. Further follow-up and work are needed.

Expression of dual-specificity tyrosine-(Y)-phosphorylation–regulated kinase 2 (DYRK2) can be a favorable prognostic marker in pulmonary adenocarcinoma

OBJECTIVES We investigated the possibility of DYRK2, a dual-specificity tyrosine-(Y)-phosphorylation-regulated kinase gene, to predict survival for patients with pulmonary adenocarcinoma. PATIENTS AND METHODS One hundred forty-four patients with pulmonary adenocarcinoma underwent surgery in our institute from 2000 to 2008. We used immunohistochemical analysis and real-time reverse-transcriptase polymerase chain reaction to determine the expression of DYRK2 and compared this with the clinicopathologic factors and survival. RESULTS We found no correlation between DYRK2 expression by immunohistochemical and clinicopathologic factors; however, a negative nodal status and negative lymphatic invasion were significantly associated with DYRK2 expression by reverse-transcriptase polymerase chain reaction. Five-year disease-free survival in the DYRK2-positive group (75.4%) was significantly different from that in the negative group (55.4%; P = .03) by immunohistochemical analysis. The 5-year overall survival of 89.2% in the DYRK2-positive group was better than the 66.3% survival of the DYRK2-negative group (P = .01). Quantitative real-time reverse-transcriptase polymerase chain reaction analyses showed a significant difference between positive and negative expressions for disease-free survival (P = .003) and overall survival (P = .007). In multivariate Cox regression analysis, negative DYRK2 protein and messenger RNA expression showed a worse prognostic value of survival (hazard ratio [HR] = 4.7, 95% confidence intervals [CI] = 1.5-14.5, P=.007; HR = 2.5, 95% CI = 1.1-6.1, P = .04, respectively). When we analyzed adenocarcinoma cases except for bronchioloalveolar carcinoma, we found a close correlation between DYRK2 expression by immunohistochemical analysis and nodal status (P = .03). Furthermore, disease-free survivals between positive and negative groups of DYRK2 expression by immunohistochemistry (P = .03) and reverse-transcriptase polymerase chain reaction (P = .02) without bronchioloalveolar carcinoma were significantly different. Overall survivals in both groups showed significant differences by immunohistochemistry (P = .02) but not by reverse-transcriptase polymerase chain reaction (P = .08). CONCLUSIONS These data showed that DYRK2 expression is associated with a favorable prognosis.

Successful Application of Subcutaneous Adipose Tissue With Fibrin Glue in Conservative Treatment of Tracheobronchial Rupture

An 84-year-old woman underwent aortic and mitral valve replacement. After weaning from cardiopulmonary bypass, hemorrhage was observed in the endobronchial tube. The bleeding bronchus was isolated to protect the airway using the blocker cuff of a Univent tube (Fuji Systems Corp, Tokyo, Japan). Computed tomography showed a pulmonary pseudoaneurysm in the left upper lobe. She underwent selective pulmonary angiography and embolization of the pseudoaneurysm. Bronchoscopy revealed a 5-mm bronchial rupture at the left upper lobe bronchus. The laceration was filled with adipose tissue and fibrin glue. Bronchoscopy showed a completely reepithelialized membrane, and she was discharged 38 days postoperatively.

Branching patterns of segmental bronchi and arteries in the medial basal segment.

Background:We investigated the branching patterns of B7 and A7 on computed tomography. Methods:The study population was 2150 patients. The branching patterns were classified into 5 types. Results:Pattern 1 [the entire S7 segment was ventral to the inferior pulmonary vein (IPV), and A7 branched from the basal segmental artery (Aba) and ran on the ventral side of the basal bronchus (Bba)] was found in 1373 patients, pattern 2 (B7 showed double branching into the dorsal and ventral sides of the IPV. A7 flowed into the lung on the dorsal side of the IPV and ran on the dorsal side of the Bba after branching from the Aba) in 226, pattern 3 (B7 showed double branching into the dorsal and ventral sides of the IPV. A7 ran on the ventral side of the Bba after branching from the Aba) in 170, pattern 4 (the entire S7 was dorsal to the IPV, and A7 ran on the dorsal side of the Bba after branching from the Aba) in 99, and pattern 5 (although the entire S7 was dorsal to the IPV, A7 either ran on the dorsal side of the Bba after branching from the Aba or ran on the ventral side of the Bba after branching from the Aba) in 24. Conclusions:Because segmentectomy of the basal segment is anticipated to become more frequent, the results of this study may serve as useful reference data.

Successful Use of Mediastinal Repositioning Employing PTFE Sheet for Right-Sided Post-Pneumonectomy Syndrome

Post-pneumonectomy syndrome (PPS) is a rare late complication of pneumonectomy, and diverse treatments have been employed. We herein present a useful technique for right-sided PPS. The patient was a 53-year-old female who underwent a right pneumonectomy for locally advanced squamous cell lung cancer (pT2N2M0). Mild dyspnea and stridor developed and progressed 1 year after surgery. A chest roentgenogram and computed tomography (CT) scan showed a right-sided mediastinal shift. Under local anesthesia, a chest tube with a balloon was inserted into the right thoracic cavity, and the balloon was inflated with air. Dyspnea and stridor improved and disappeared as the balloon expanded. Then, mediastinal fixation was performed under general anesthesia. Mediastinal fixation involved a PTFE (polytetrafluoroethylene) sheet which was sewn on the sternum and costal cartilage anteriorly, on the vertebra posteriorly, and covered the azygos vein level superiorly and two thirds of the pericardium inferiorly using nonabsorbable sutures. A post-operative chest roentgenogram and CT scan showed improvement of the right-sided mediastinal shift. The post-operative course was uneventful, and dyspnea and stridor were improved and became stable. In conclusion, the presented method is a useful procedure for right-sided PPS.