Makoto Kurai

Intraoperative ultrasonographic localization of pulmonary ground-glass opacities

OBJECTIVES Ground-glass opacities are typically difficult to inspect and to palpate during video-assisted thoracic surgery. We therefore examined whether ultrasonographic assessments could localize ground-glass opacities and help to achieve adequate resection margins. METHODS An intraoperative ultrasonographic procedure was prospectively performed on 44 patients harboring ground-glass opacities of less than 20 mm in diameter to localize these lesions and to achieve adequate margins. We also examined whether there were any complications resulting from the intraoperative ultrasonogram, such as lung injury, heart injury, or arrhythmia. We excluded patients with both asthma and chronic obstructive pulmonary disease from this study inasmuch as the intraoperative ultrasonographic procedure is more difficult to interpret when residual air is present in the lung. RESULTS A total of 53 ground-glass opacities were successfully identified by intraoperative ultrasonography without any complications. Of the 20 mixed ground-glass opacities that we examined, 15 were found on palpation. However, only 4 (12.1%) of the 33 pure ground-glass opacities could be palpated. In all instances in which complete collapse of the lung was achieved (30/53 of these cases), high-quality echo images were obtained. Additionally, a strong correlation was found between the resection margins measured by ultrasonogram and the margins determined by histologic examination in the resected lung specimens (r(2) = 0.954, P < .001). CONCLUSIONS Intraoperative ultrasonography can both safely and effectively localize pulmonary ground-glass opacities in a completely deflated lung. This procedure is also useful for the evaluation of surgical margins in a resected lung. Hence, ultrasonography may assist surgeons to perform minimally invasive lung resections with clear surgical margins during the treatment of solitary lung ground-glass opacity.

Methotrexate stimulates lung epithelial cells to release inflammatory cell chemotactic activities.

Methotrexate-induced pneumonitis has been reported as an infrequent but potentially serious complication of therapy in a variety of malignant and benignconditions. Because inflammatorycell infiltration is concerned with the development of methotrexate-induced pneumoinitis, and because airway epithelial cells participate in the orchestration of lung inflammation, the authors determined whether methotrexate might stimulate airway epithelial cells (A549 cells) to release neutrophil, monocyte, and eosinophil chemotactic activities (NCA, MCA, and ECA). A549 cells released NCA, MCA, and ECA in a dose- and time-dependent manner in response to methotrexate. Partial characterization revealed the heterogeneity of NCA, MCA, and ECA. The release of chemotactic activity was blocked by lipoxygenase inhibitors and cycloheximide. NCA was inhibited by leukotriene (LT) B 4 receptor antagonist, and anti-interleukin (IL)-8 and granulocyte colony-stimulatingfactor (G-CSF) antibodies. MCA was attenuated by LTB 4 receptor antagonist, and anti-monocyte chemoattractant protein (MCP)-1 and granulocyte-macrophage CSF (GM-CSF) antibodies. ECA was attenuated by LTB 4 receptor antagonist, and anti-IL-8 and GM-CSF antibodies. The release of IL-8, G-CSF, MCP-1, GM-CSF, and LTB 4 from A549 cells significantly increased in response to methotrexate. The mRNA expression of IL-8 and MCP-1 was augmented by methotrexate stimulation. These data suggest that type II epithelial cells may modulate inflammatory cell recruitment into the lung by releasing NCA, MCA, and ECA in response to methotrexate.

Different efficacy of CT screening for lung cancer according to histological type: Analysis of Japanese-smoker cases detected using a low-dose CT screen

The efficacy of CT screening for lung cancers is still a controversial issue, although one of the recently publicized large randomized controlled trials of this methodology, the National Lung Screening Trial (NLST), reported a decrease in the lung cancer-specific mortality for heavy smokers. We here performed case-matched comparative analyses, as a retrospective study, of three lung cancer arms detected by CT screen, X-ray screen, and by individual analysis of the clinicopathological features and outcomes in smokers from a symptomatic-prompted group of patients. We also considered the impacts of various potential biases in this cohort. The total study cohort comprised 136 patients in the CT screen group, 263 in the X-ray screen group and 254 in the symptomatic-prompted group. The ratio of stage IA cancers in the CT screen group was 67.7% and the ratio of advanced cases (i.e. stages IIIB+IV) was 12.5%. The percentage of bronchioloalveolar carcinoma (BAC) was 28.7% in the CT screen group. The 5-year survival rates were 82.4% in the CT screen group, 38.0% in the X-ray screen group and 17.8% in the symptomatic-prompted group. CT screening was found to be an independent prognostic factor for lung cancer even when BAC cases were eliminated (HR 0.35, P<0.01). Based on our sub-analysis by individual histological sub-type, CT screen lung cancer cases had a better survival rate than non-screened patients, which included adenocarcinoma, squamous cell carcinoma and large/small cell carcinoma. However, by multi-variant analysis a CT scan would not be expected to reduce the risk of lung cancer mortality in patients with large/small cell carcinoma, although would be expected to reduce the risk of lung cancer death by 80% in cases of both adenocarcinoma and squamous cell carcinoma. In conclusion, our current findings indicate that CT screening for lung cancer is an effective strategy for smokers and that patients with adenocarcinoma and squamous cell carcinoma of all variant histological types may benefit from this test. In this regard, early stage large/small cell carcinomas are insufficiently detected by the existing annual screening system.

Clinical features of lung cancer in smokers with light and mild chronic obstructive pulmonary disease: a retrospective analysis of Japanese surgical cases.

OBJECTIVES We estimated the influence of chronic obstructive pulmonary disease (COPD) upon the clinicopathological characteristics of lung cancer (LC) in Japanese surgical cases by comparing LC cases in non-COPD smokers. METHOD A consecutive cohort comprising 157 COPD patients (78 in Global Initiative for Obstructive Lung Disease-1 (GOLD-1) and 79 in GOLD-2) and 374 non-COPD smoker-LC patients were enrolled in this study. Comparative analyses of the clinicopathological features of these two groups, including clinical outcomes, were performed. RESULTS By analyzing all cases, we found that LC patients with COPD were older on average, more likely to be male, and heavier smokers than LC patients without COPD. In sub-analysis involving matched patient backgrounds, histological differentiation grade of LC in smokers with COPD was lower than in LC smokers without COPD, although distribution of clinical stages and histological types of LCs did not differ between smokers with and without COPD. The 5-year-survival rate in COPD patients was poorer than in non-COPD smokers in terms of both overall (38% vs 54%) and cancer-related mortality (45% vs 63%). By single-variant risk analysis, COPD became a prognostic factor. CONCLUSION We concluded from our analysis that COPD-related LC may have a higher malignant potential than LC in non-COPD smokers, as the histological differentiation grade and clinical outcomes were poorer.

Multiple Schwannomas of the Bilateral Mediastinal Vagus Nerves

Multiple schwannomas arising from the mediastinal vagus nerve are very rare, but herein we report a case with such lesions involving the bilateral intrathoracic vagus nerves. A 43-year-old man presented with multiple mediastinal tumors during a check-up. A chest computed tomographic scan revealed multiple lesions that appeared strung together like beads along the right vagus nerve. Three small tumors were also evident on the left side of the esophagus. We performed a complete resection of the bilateral mediastinal tumors through right thoracoscopic surgery. The pathologic diagnosis for each of these tumors was a schwannoma without malignant components.

Benefits of video-assisted thoracic surgery for repeated pulmonary metastasectomy

PurposeThe use of repeated pulmonary resection for metachronous pulmonary metastasis has increased. We assessed whether video-assisted thoracic surgery (VATS) produced greater benefits than classic thoracotomy for repeated pulmonary metastasectomy procedures.MethodsA total of 46 patients who had undergone two or more pulmonary metastasectomies from 1995 to 2008 were analyzed in this study. These patients were classified into four groups as follows: group A (previous VATS/present VATS); group B (previous VATS/present thoracotomy); group C (previous thoracotomy/present VATS); group D (previous thoracotomy/present thoracotomy). The clinical features of these four groups were then compared.ResultsThe operating time and the duration of thoracic drainage were longer in group D than in group A or B. The operating time was also longer in group C than in group A. Intraoperative bleeding was greater in group D patients than in other three groups. There were no discernible morbidities resulting from VATS in groups A or C. No differences were found in the occurrence of relapse among the groups. The mean interval from the previous to the present pulmonary metastasectomy also did not differ significantly among groups.ConclusionVATS can result in a shortened operating time, reduced intraoperative bleeding, and generally fewer complications compared with repeated classic thoracotomy. VATS is also potentially a curative procedure as it is not inferior to classic thoracotomy in terms of the relapse rate after repeated pulmonary metastasectomy.

Colchicine as an effective treatment for postpericardiotomy syndrome following a lung lobectomy

Postpericardiotomy syndrome (PPS) is a frequent complication of various cardiac procedures that involve entry into the pericardium, but rarely occurs after pulmonary surgery because the pericardium is usually preserved during this procedure. The standard treatment for PPS is the administration of non-steroidal anti-inflammatory drugs (NSAIDs). Recent studies have indicated however, that colchicine may be useful for the treatment and prevention of this syndrome. Here, we describe the successful use of colchicine to treat PPS in a lung cancer patient who developed this complication following a lung lobectomy. A 64-year-old woman with a stage IA lung tumor underwent a left upper lobectomy with a mediastinal lymph node dissection. Severe precordial pain occurred 10 days after surgery, and accumulations of pericardial and pleural fluid were revealed by chest X-ray, echocardiogram, and chest computed tomography. These symptoms were not alleviated by antibiotics, thoracic cavity drainage, or NSAIDs. However, the administration of colchicine (initial dose of 1.0 mg and maintenance dose of 0.5 mg daily for three months) in combination with NSAIDs resolved these symptoms immediately after the first dosage. In addition, the patient remains free of any recurrent pericarditis at six months after this episode.

Occurrence of a Simultaneous Bilateral Spontaneous Pneumothorax Due to a Pleuro-Pleural Communication

Herein we present a case of a simultaneous bilateral spontaneous pneumothorax caused by a pleuro-pleural communication. A 70-year-old man with a history of esophagectomy presented with dyspnea. A chest roentgenogram revealed a bilateral pneumothorax and bilateral chest drainage procedures were performed. A left bullectomy was also performed 3 days later due to persistent air leakage on the left side. During surgery, a small fistula was detected in the anterior mediastinal pleura and was found to be in communication with the bilateral pleural spaces.

Efficacy of CT screening for lung cancer in never-smokers: Analysis of Japanese cases detected using a low-dose CT screen

CT-screening for lung cancer is fairly widely used for both smokers and never-smokers in East Asia because the mortality rate for never-smokers due to this cancer is relatively high in this region. We performed comparative analyses, as a retrospective study, on three lung cancer arms detected by CT-screen, X-ray-screen, and via analysis of clinicopathological features and outcomes in never-smokers from a symptomatic-prompted group of patients. The total study cohort comprised 218 patients in CT group, 160 in X-ray group, and 82 in symptomatic-prompted group. The percentage of bronchioloalveolar carcinoma (BAC) was 65.1% in CT-screen group. The ratio of stage IA tumors in CT-screen group was 88.5% and the ratio of advanced cases (i.e. stages IIIB+IV) was 2.3%. The 5-year-survival rates were 95.0% in CT-screen, 73.0% in X-ray-screen and 40.0% in symptomatic-prompted group. We performed further sub-analysis which excluded pure BACs (i.e. Noguchi types A and B) or pure GGOs within a 10mm diameter because this is indicative of a very favorable prognosis. Based on this sub-analysis the number of the subjects in each group became 76 in CT group; 140 in X-ray group and 77 in symptomatic-prompted group. The principal characteristics of the patients such as age and sex became almost even in the three arms. In CT-screen subgroup, the ratio of stage IA cancer was 69.7% and of advanced cases was 6.6%. This advanced ratio was lower than both X-ray-screen (22.1%) and symptomatic-prompted (61.9%) groups. The 5-year-survival rates were 89.9% among CT-screen group patients, 72.6% for X-ray screen cases and 39.1% in symptomatic-prompted group. A CT-screen was found to be one of the independent prognostic factors for lung cancer (HR, 0.28; 95% CI, 0.12-0.72) and based on this would be expected to reduce the risk of lung cancer death by 78% compared with non-screened cases. In conclusion, CT will improve the survival rate and decrease the rate of advanced cancers in never-smokers via the existing annual screening system. CT-screening is also an independent prognostic improvement factor in never-smokers, and will therefore reduce the risk of lung cancer death.

Localized nodular amyloidosis of the lung

Pulmonary localized nodular amyloidosis is a rare disorder and is not associated with primary systemic amyloidosis. We herein report a patient with a growing lung nodule who underwent thoracic surgery and was diagnosed with this condition. This case study suggests that localized nodular amyloidosis should be considered during a differential diagnosis of growing lung nodules and that a histological examination should be performed to distinguish this disorder from lung malignancies.