Michiyo Miyawaki

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.

Prognostic significance of HE4 expression in pulmonary adenocarcinoma

We investigated the possibility of human epididymis 4(HE4) to predict survival for patients with pulmonary adenocarcinoma. One hundred and thirty-seven patients with pulmonary adenocarcinoma underwent surgery in our institute from 2000 to 2008. We used immunohistochemical analysis to determine the expression of HE4 and compared with the clinicopathological factors and survival. Serum levels of HE4 in lung adenocarcinoma were investigated by enzyme immunometric assay. Fifty-seven of 137 cases (41.6%) were HE4 positive. It was found that there was no correlation between HE4 expression by immunohistochemistry and clinicopathological factors, however, adenocarcinoma subtype was significantly associated with HE4 expression. Sera in lung adenocarcinoma were significantly higher than in healthy control. Five-year disease-free survival in the HE4-positive group (44.6%) was significantly different from that in the negative group (82.3%, p = 0.001) by immunohistochemistry. The five-year overall survival rate was 60.1% in the HE4-positive group, as compared with 90.8% in the HE4-negative group (p = 0.001). In multivariate Cox regression analysis, positive HE4 protein expression was a worse prognosis factor of disease-free and overall survival (HR = 3.7, 95%CI = [1.7–8.4], p = 0.001; HR = 5.5, 95%CI = [1.8–17.2], p = 0.003, respectively), in addition to nodal status as a powerful value. When HE4 expression in adenocarcinoma cases except the BAC were analyzed, nodal status and HE4 expression were independent prognostic factors in disease-free and overall survivals. These data showed that HE4 expression is associated with a worse prognosis and is a possible prognostic factor of lung adenocarcinoma.

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.

Spontaneous hemothorax in patients with von Recklinghausen's disease

Spontaneous massive intrathoracic bleeding is rare except for the rupture of aortic aneurysm or pleural adhesions in association with pneumothorax. We encountered two cases of critical massive hemothorax in patients with von Recklinghausens disease (type I neurofibromatosis). Case 1; a 59-year-old female suddenly experienced severe back pain followed by syncope and shock. The hemothorax was caused by a bleeding of diffuse type neurofibroma of the parietal pleura and she underwent thoracotomy and surgical ligation of the bleeding vessels. Case 2; a 46-year-old male suddenly suffered back pain and fainted while driving. An intercostal aneurysmal rupture caused a spontaneous hemothorax and he underwent chest tube drainage followed by endovascular coil embolization. We reviewed 23 cases reported in the literature, including our two cases. Spontaneous hemothorax in patients with von Recklinghausens disease is a life-threatening syndrome and may require emergency surgical or endovascular embolization.

Phosphorylation status of epidermal growth factor receptor is closely associated with responsiveness to gefitinib in pulmonary adenocarcinoma

Twenty-one cases of primary lung carcinoma were analyzed for correlations between the presence of somatic mutations of the epidermal growth factor receptor (EGFR) gene and the phosphorylation status of EGFR, which was analyzed by immunohistochemistry with antibodies recognizing the phosphorylated form of EGFR. Somatic mutations were detected in 11 (52.4%) of the 21 cases. Immunohistochemistry with an antibody recognizing EGFR phosphorylated at tyrosine (pEGFR-tyr) 992 and an antibody recognizing EGFR phosphorylated at tyrosine 1173 (pEGFR-tyr1173) revealed that 12 (57.1%) and 21 (100%) of the 21 cases were positive, respectively. Interestingly, the mutation status of the EGFR gene was strongly correlated with immunoreactivity for pEGFR-tyr992 (P = .0019). pEGFR-tyr992 immunoreactivity was significantly correlated with clinical responsiveness to gefitinib (P = .0011). These findings suggest that immunohistochemical evaluation with anti-pEGFR-tyr992 antibody is useful for prediction of responsiveness to gefitinib.

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.

Enhanced phosphorylation of the epidermal growth factor receptor at the site of tyrosine 992 in esophageal carcinomas

This study aimed to determine whether epidermal growth factor receptor (EGFR), which has been reported to be frequently overexpressed in esophageal carcinoma cells, is actually activated in the cells. Paraffin‐embedded specimens of 39 cases of esophageal carcinoma were analyzed immunohistochemically with anti‐EGFR polyclonal antibody (α‐EGFR Ab) and also an anti‐phospho‐EGFR‐specific polyclonal antibody (α‐p‐EGFRTyr992 Ab) that specifically recognizes phosphorylated tyrosine 992 of EGFR. All of the 39 cases were found to express EGFR, but the expression levels were not significantly higher than those in basal cells of the normal esophageal epithelium. In 38 of the 39 cases, α‐p‐EGFRTyr992 immunoreactivity was evident. Interestingly, the positively stained carcinoma cells were not distributed diffusely, and strongly immunostained cells tended to be localized in areas of severe dysplasia and in microinvasive foci just adjacent to the main invasive carcinoma. However, the deeply invasive front never exhibited positive immunoreactivity. The present findings suggest that phosphorylation of EGFR Tyr992 may play some specific functional role in esophageal carcinomas besides promotion of cell proliferation.

Bronchial stump aspergillosis after stapled lobectomy for lung cancer.

Aspergillus causes several pulmonary complications, but bronchial stump aspergillosis (BSA) is very rare. To date, 31 cases of bronchial stump aspergillosis have been reported in the English, German, and Japanese literature. The bronchial stump was closed by hand-sewn suturing in most cases, but we report herein two cases of BSA that developed after stapled closure of the bronchial stump.