Kentaroh Miyoshi

Prognostic impact of intratumoral vessel invasion in completely resected pathologic stage I non–small cell lung cancer

OBJECTIVE Intratumoral vessel invasion of non-small cell lung cancer is a readily available tumor-related factor that provides direct evidence of microscopic tumor invasion. We assessed the prognostic influence of intratumoral vessel invasion and its ability to provide a differential prediction of prognosis for completely resected pathologic stage I non-small cell lung cancer. METHODS We analyzed 258 patients with non-small cell lung cancer who underwent complete resection between January of 1996 and December of 2005 and were diagnosed with pathologic stage I disease. In addition to the conventional staging factors, intratumoral vessel invasion in the primary lesion was histologically evaluated by both hematoxylin-eosin and elastic staining. We examined the significance of intratumoral vessel invasion in prognosis and compared the outcomes between patients with and without this factor with stage IA and IB disease, respectively. RESULTS Intratumoral vessel invasion was found in 124 patients (48%). Five-year survival of patients with or without intratumoral vessel invasion was 74% and 93%, respectively. On multivariate analysis, intratumoral vessel invasion and pleural invasion were shown to be independent prognostic factors. Subgroup analyses suggested that patients with pathologic-stage IA with intratumoral vessel invasion and patients with pathologic-stage IB with both intratumoral vessel and pleural invasion had significantly worse prognosis than patients with the same pathologic stage without these factors. CONCLUSION The current study indicated that intratumoral vessel invasion and pleural invasion are independent prognostic factors. Intratumoral vessel invasion status can complement the size-dependent TNM staging system in pathologic stage I non-small cell lung cancer.

Suppression of Inflammatory Cytokines During Ex Vivo Lung Perfusion With an Adsorbent Membrane

BACKGROUND Lung grafts can be perfused ex vivo for 2 hours without edema formation; however, prolonged ex vivo lung perfusion (EVLP) eventually induces lung injury. This study evaluated the change in proinflammatory cytokines of the perfusate during EVLP and investigated the effect of cytokine removal using an adsorbent membrane. METHODS Porcine heart-lung blocks were harvested after electrically induced cardiac arrest and underwent 12-hour EVLP with an adsorbent membrane (membrane group: n = 5) and without an adsorbent membrane (control group: n = 6). RESULTS In the control group, both tumor necrosis factor-alpha and interleukin 8 levels were elevated in the perfusate 2 hours after perfusion. Although tumor necrosis factor-alpha and interleukin 8 levels were significantly lower in the membrane group than in the control group during the EVLP period, there was no significant difference in oxygenation, pulmonary vascular resistance, edema formation, or myeloperoxidase activity between the two groups. CONCLUSIONS Tumor necrosis factor-alpha and interleukin 8 levels of the perfusate were elevated during EVLP. Although adverse effects of these inflammatory cytokines were anticipated, removal of inflammatory cytokines by the adsorbent membrane did not improve lung function during prolonged EVLP. Factors other than the cytokines may play a major role in causing lung injury during EVLP. Further research is needed to investigate the real mechanism of lung graft injury during prolonged EVLP and to establish longer EVLP duration for graft treatment. This strategy could contribute to the salvage of potentially damaged lungs, especially from cardiac death donors, and to expansion of the donor pool.

Abnormal fluorine-18-fluorodeoxyglucose uptake in benign esophageal leiomyoma

A benign esophageal leiomyoma with abnormally increased fluorine-18-fluorodeoxyglucose uptake on positron emission tomography (PET) was resected thoracoscopically. The tumor, of which the maximum standardized uptake value of the lesion was 4.7, was well defined and 38 mm in diameter. Neither mitotic activity nor degeneration was found histologically; and immunoreactivity for CD34, CD117, MIB-1, and glucose transporter-1 was negative immunohistochemically. A diagnosis of gastrointestinal stromal tumor was ruled out by an oncogenic kinase gene mutation study. This case cautions against PET-dependent evaluation for malignant potential of esophageal submucosal tumors.

Extracorporeal Membrane Oxygenation Bridging to Living-Donor Lobar Lung Transplantation

A 21-year-old man with pulmonary fibrosis and a 27-year-old woman with idiopathic pulmonary hypertension, who were in pulmonary hypertensive crisis, were successfully treated by using venoarterial extracorporeal membrane oxygenation, followed by living-donor lobar lung transplantation. In both of the patients, bridging time of extracorporeal membrane oxygenation to lung transplantation was 2 days, and both could be weaned from cardiopulmonary support immediately after transplantation in the operating room. No major complications were seen, including primary graft dysfunction. The cardiopulmonary functions of these patients markedly improved after living-donor lobar lung transplantation.

A novel technique for identification of the lung intersegmental plane using dye injection into the segmental pulmonary artery

Patient 2 A 48-year-old man was referred to Yamaguchi University hospital for surgical treatment of a superior mediastinal tumor. A chest CT scan showed that the tumor was located mainly adjacent to the apical thoracic vertebra, but partially above the thoracic inlet (Figure 2, C). Magnetic resonance imaging showed low intensity on the T1-weighted sequence and high intensity on the T2-weighted sequence, which mimicked schwannoma. We attempted to perform totally thoracoscopic resection of the tumor. Careful manipulation was necessary for dissecting the tumor from sympathetic nerve and brachial plexus in the thoracic inlet. We dissected the tumor from the nerves carefully using scissors and an ultrasonic scalpel. The operation was completed totally thoracoscopically with no complications. The operation time was 122 minutes, and intraoperative blood loss was 150 mL. The patient was discharged on postoperative day 3. Pathologic examination revealed that the tumor was a schwannoma of the brachial plexus. A CT scan performed 5 months after the operation showed no evidence of recurrence of the tumor.

Early effects of the ex vivo evaluation system on graft function after swine lung transplantation

OBJECTIVES Ex vivo lung evaluation (ex vivo) has been developed as a useful method by which to assess lungs from donation-after-cardiac death (DCD) donors prior to transplant. However, the safety of the ex vivo circulation itself with respect to grafts has not been fully investigated. The aim of this study is to evaluate the effects of the ex vivo circuit using a swine lung transplant model. METHODS Lungs with or without 2-h warm ischemia were used. To assess post-transplant graft function, the left lung was transplanted after 2-h ex vivo or cold preservation; blood gas analysis of the left pulmonary vein (partial pressure of oxygen, PO(2)) was performed during the 6-h post-transplant follow-up period. Data were compared between the ex vivo (+) and ex vivo (-) groups. RESULTS Partial pressure of oxygen/ inspired oxygen fraction (PO(2)/FiO(2)) in the ex vivo (-) group was significantly greater than that in the ex vivo (+) group until 3h after transplant. The PO(2)/FiO(2) levels in both groups then increased and became similar at 6 h after transplant, regardless of whether ischemic or non-ischemic lungs (p<0.001 and p=0.004, respectively) were used. CONCLUSIONS Negative effects of the ex vivo system were limited and seen only in the immediate post-transplant period. Therefore, in DCD swine lung transplantation, the ex vivo system appears to be safe.

Prolonged administration of twice-daily bolus intravenous tacrolimus in the early phase after lung transplantation

BACKGROUND Although administration of tacrolimus, whether by the enteric, sublingual, or continuous intravenous routes, has some limitations, twice-daily bolus intravenous tacrolimus administration has been shown to be beneficial in optimizing efficacy and safety after lung transplantation. However, at present, the duration of bolus intravenous tacrolimus administration is limited, and the effects of prolonged bolus intravenous tacrolimus administration remain unknown. Our study was aimed at assessing the safety and efficacy of prolonged twice-daily bolus intravenous tacrolimus administration in the early phase after lung transplantation. MATERIAL AND METHODS We retrospectively investigated the data of 62 recipients of lung transplantation who had received twice-daily bolus intravenous administration of tacrolimus, followed by oral tacrolimus, after lung transplantation at our institution between January 2011 and October 2015. RESULTS The median duration of bolus intravenous tacrolimus administration was 19 days (4-72 days). The target trough level was achieved in 89% of the patients by day 3. Acute kidney injury occurred in 27% of the patients during bolus intravenous tacrolimus. Two patients (3%) had neurotoxicity, necessitating discontinuation of tacrolimus. Suspected acute rejection requiring steroid pulse therapy occurred in 21% of patients during the follow-up period. Eight patients (13%) developed chronic lung allograft dysfunction during the follow-up period. The 1-year and 5-year survival rates after lung transplantation were 95% and 76%, respectively. CONCLUSIONS These results suggest that prolonged bolus intravenous tacrolimus administration in the early phase after lung transplantation is a safe and effective alternative to enteric, sublingual, or continuous intravenous administration.

Living related donor middle lobe lung transplant in a pediatric patient

From the Department of Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmacological Sciences, Okayama, Japan. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Aug 13, 2014; revisions received Oct 20, 2014; accepted for publication Oct 25, 2014; available ahead of print Nov 27, 2015. Address for reprints: Takahiro Oto, MD, 2-5-1, Shikata-cho, Kita-ku, Okayama 7008558, Japan (E-mail: oto@md.okayama-u.ac.jp). J Thorac Cardiovasc Surg 2015;149:e42-4 0022-5223/

Extended sleeve lobectomy after induction chemoradiotherapy for non-small cell lung cancer

36.00 Copyright 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2014.10.102

Intrathoracic irrigation with arbekacin for methicillin-resistant Staphylococcus aureus empyema following lung resection

AbstractPurpose Extended sleeve lobectomy is a challenging surgery. While induction chemoradiotherapy (ChRT) followed by surgery is one of the therapeutic strategies used for locally advanced non-small cell lung cancer (NSCLC), ChRT can impair the anastomotic healing potential. We herein present our experience with cases who underwent an extended sleeve lobectomy after induction ChRT.MethodsThe medical records of patients who underwent a surgery for NSCLC after ChRT were reviewed.ResultsBetween December 2007 and January 2013, nine patients underwent an extended sleeve lobectomy; the left lingular division and lower lobe in four patients, the right upper lobe and trachea in one patient, the carina and trachea in one patient, the right middle and lower lobes in one patient, the right upper and middle lobes and carina in one patient and the right upper lobe and superior segment of the lower lobe in one patient. While no postoperative 90-day deaths occurred, one case developed a bronchopleural fistula on postoperative day (POD) 25 and one case developed a bronchovascular fistula on POD 163. No cases of local recurrence developed.ConclusionsOur experience suggests that an extended sleeve lobectomy after induction ChRT is feasible, but careful patient selection and perioperative management are mandatory.