Norihiko Kawate

Photodynamic therapy for multiple primary bronchogenic carcinoma

In recent years, multiple primary lung cancers have been reported with greater frequency, partly as a result of technologic advances in the detection of lung cancer and therapeutic achievements in its management. Photodynamic therapy (PDT) is a relatively new therapy used with increasing frequency in the treatment of a wide variety of malignancies, including central lung cancers. In PDT, the differential retention of an injected photosensitizer by malignant tissue is exploited by treatment with a low‐power laser beam delivered endoscopically. Since 1980, 145 patients with central lung cancers, including 35 cases of endoscopically evaluated early‐stage lesions were treated with PDT at Tokyo Medical College. Thirteen of these 145 patients had multiple primary bronchogenic carcinomas, five cases of which were synchronous with the rest, metachronous. Three of 13 patients with multiple tumors had early‐stage lesions and were treated with endoscopic PDT alone. In the other ten cases, PDT was used to treat accessible early‐stage foci although operative excision was required for advanced lesions. Mean survival after PDT, alone or in combination with surgery, was 38 months (range, 14 to 87 months), and seven patients remain alive to date. It was concluded that PDT is useful in extending the therapeutic options for, and improving the prognosis of patients with, multiple primary bronchogenic carcinomas.

Cine MRI enables better therapeutic planning than CT in cases of possible lung cancer chest wall invasion

THE OBJECTIVE To evaluate the hypothesis that lung cancer treatment planning (whether or not to use induction therapy) can be improved if respiratory dynamic cine magnetic resonance imaging (RD MR) is used. METHOD We studied 100 lung cancer patients, 76 men and 21 women, scheduled for thoracotomies between May 1997 and December 2006 wherein it was unclear preoperatively whether chest wall invasion would be found. We evaluated the accuracy of RD MR as compared with the findings at operation and postoperative pathology. The accuracy of RD MRI for evaluating chest wall invasion was compared with the efficacy of CT and MRI within our own group of patients and with data from the studies of other investigators. RESULTS Concerning the evaluation of chest wall invasion, conventional computed tomography (CT) had 43.9% specificity, 60.0% sensitivity and 47.1% accuracy, while RD MR had 68.5% specificity, 100.0% sensitivity and 77.0% accuracy. RD MRI was particularly useful in the evaluation of cancers around 5 cm in diameter that were located adjacent to the diaphragm. Postoperative evaluation of superior sulcus tumor cases that had received induction therapy also showed that the RD MR procedure enabled an accurate decision in 87.5% of cases, and there were no false negative cases. CONCLUSIONS RD MR is more useful than CT or standard MRI for evaluating thoracic wall invasion. This noninvasive method enhances the reliability of deciding whether induction therapy should be employed.

Extended indications for robotic surgery for posterior mediastinal tumors

Previously, we evaluated use of the da Vinci Surgical System for anterior and middle mediastinal tumors in clinical cases, focusing on feasibility, safety, and appropriate settings. In this study, we evaluated extending the indications for robotic surgical treatment of posterior mediastinal tumors to include those located adjacent to the upper vertebrae or aorta. Three patients with mediastinal tumors located immediately adjacent to the vertebrae or aorta, underwent resection with the da Vinci Surgical System. All resected tumors were benign histologically. Robotic surgery enabled treatment of tumors located in the posterior mediastinum, which are very difficult to reach, making resection with the conventional video-assisted thoracoscopic surgery technique extremely difficult. All procedures were performed safely, smoothly, and extremely precisely. Crucial to the success of these operations were the appropriate placement and angle of the special da Vinci surgical ports in relation to the target and the patient’s position, which varied according to the tumor location.

Recurrence at the bronchial stump after resection of lung cancer.

ObjectiveRecurrence at the bronchial stump frequently is difficult to diagnose before the disease progresses. Patients with recurrence at the bronchial stump after surgical treatment were studied to clarify characteristics. Summary Background DataReports on this type of recurrence are few. MethodsBetween January 1979 and December 1988, 625 primary lung cancers were resected. Fourteen patients (2.2%). in whom recurrence occurred at the bronchial stump, were studied pathologically and clinically. ResultsEight tumors (57.1%) were squamous cell carcinomas, five (35.7%) were adenocarcinomas, and one (7.1 %) was small cell carcinoma. Pathologically, six tumors (42.9%) were stage I, four (28.6%) were stage II, two (14.3%) were stage IIIA, and two (14.3%) were stage IV. Eight patients had bloody sputum at recurrence; two cases were asymptomatic. Submucosal tumors were observed bronchoscopically at recurrence in 11 patients. Considering lymphadenopathy on chest x-ray, the submucosal type recurrence may have been direct invasion from metastatic lymph nodes. The periods from the operation to the recurrence were 7 to 102 months (mean 28.8 months). In 8 of 14 patients, recurrence was observed within 24 months. All but one patient died within 24 months of recurrence detection. ConclusionsLong survival could be expected only if there were no metastases in the mediastinal lymph nodes. If the tumors were detected earlier, it was possible to cure the tumors by intensive therapy, even in submucosal type recurrence. Regular bronchoscopic examination is needed to diagnose the recurrence at the bronchial stump as early as possible.

Appropriate set-up of the da Vinci® Surgical System in relation to the location of anterior and middle mediastinal tumors

The da Vinci® Surgical System (dV) and its later version [da Vinci S® Surgical System (dVS)] have been used only in very few cases in selected thoracic surgical areas in Japan. Recently, we used the dV and dVS for various types of anterior and middle mediastinal tumors in clinical practice. We report our experience, and review the settings which depended on tumor location. Six patients gave written informed consent to undergo robotic surgery using the dV or dVS. We evaluated the feasibility, safety and appropriate settings of this system for the surgical treatment of mediastinal tumors. Tumor dissection was performed by two specialists in thoracic surgery certified to use the dV and dVS, and another specialist who acted as an assistant. We were able to access difficult-to-reach areas like the mediastinum. All the resected tumors were classified as benign tumors histologically. Crucial to the success of these operations was the set-up of the dV, which varied according to the location of mediastinal tumors. Robotic surgery enables various types of mediastinal tumor dissection more safely and easily than conventional video-assisted thoracoscopic surgery (VATS). The dV requires the appropriate set-up configuration, which varies according to the location of the mediastinal tumor.

Early experience using the da Vinci Surgical System for the treatment of mediastinal tumors

PurposeThe da Vinci Surgical System has been used in only a few cases for treating mediastinal tumors in Japan. Recently, we used the da Vinci Surgical System for various types of anterior and middle mediastinal tumors in clinical practice. We report our early experience using the da Vinci Surgical System.MethodsSeven patients gave written informed consent to undergo robotic surgery for mediastinal tumor dissection using the da Vinci Surgical System. We evaluated the safety and feasibility of this system for the surgical treatment of mediastinal tumors.ResultsTwo specialists in thoracic surgery who are certified to use the da Vinci S Surgical System and another specialist acted as an assistant performed the tumor dissection. We were able to access difficult-to-reach areas, such as the mediastinum, safely. All the resected tumors were classified as benign tumors histologically. The average da Vinci setting time was 14.0 min, the average working time was 55.7 min, and the average overall operating time was 125.9 min. The learning curve for the da Vinci setup and manipulation time was short.ConclusionRobotic surgery enables mediastinal tumor dissection in certain cases more safely and easily than conventional video-assisted thoracoscopic surgery and less invasively than open thoracotomy.

Cost-Benefit Performance of Robotic Surgery Compared with Video-Assisted Thoracoscopic Surgery under the Japanese National Health Insurance System

BACKGROUND Medical economics have significant impact on the entire country. The explosion in surgical techniques has been accompanied by questions regarding actual improvements in outcome and cost-effectiveness, such as the da Vinci(®) Surgical System (dVS) compared with conventional video-assisted thoracic surgery (VATS). OBJECTIVE To establish a medical fee system for robot-assisted thoracic surgery (RATS), which is a system not yet firmly established in Japan. METHODS This study examines the cost benefit performance (CBP) based on medical fees compared with VATS and RATS under the Japanese National Health Insurance System (JNHIS) introduced in 2012. RESULTS The projected (but as yet undecided) price in the JNHIS would be insufficient if institutions have less than even 200 dVS cases per year. Only institutions which perform more than 300 dVS operations per year would obtain a positive CBP with the projected JNHIS reimbursement. CONCLUSION Thus, under the present conditions, it is necessary to perform at least 300 dVS operations per year in each institution with a dVS system to avoid financial deficit with current robotic surgical management. This may hopefully encourage a downward price revision of the dVS equipment by the manufacture which would result in a decrease in the cost per procedure.

Interventional management for benign airway tumors in relation to location, size, character and morphology

OBJECTIVE To select minimally stressful methods for patients with benign bronchial tumors, and evaluate interventional strategies in relation to location, size, character and morphology. METHODS We reviewed the indications and efficacy of various interventional bronchology techniques at our institution, including individual or combined laser resection, electrocautery, argon plasma coagulation and high radiofrequency snaring for the treatment of various types of benign bronchial tumors. RESULTS It is essential to treat endoscopically that the tumor is visible and has a stalk and not invade beyond bronchial wall. By using combined techniques, no complications or recurrences were encountered. CONCLUSIONS Interventional bronchology techniques for benign bronchial tumors can be simple and safe, and therapeutic strategies should be designed in relation to location, size, character and morphology of tumors.

Evaluation of a new solution containing trehalose for twenty-hour canine lung preservation.

We examined the efficacy of two new preservation solutions containing trehalose-an extracellular type (ET-K) of solution and an intracellular type (IT-K) of solution — in relation to that of Euro-Collins (EC) solution in 20-h canine lung preservation. Canine lungs were flushed with one of the three solutions (n=5 for each solution) after pretreatment with PGE1 (20 μg/kg) and were stored for 20 h at 4°C. The left lungs were transplanted and evaluated to 6 h post transplant. In the ET-K group, the arterial oxygen tension after reperfusion was significantly higher than in the IT-K and EC groups. The pulmonary vascular resistance, wet/dry weight ratio, and histological evaluation of each transplanted lung in the ET-K group were also better than in the IT-K and EC groups. This indicates that ET-K solution is useful for 20-h preservation of canine lung grafts.

Maximizing Use of Robot-Arm No. 3 in Da Vinci–Assisted Thoracic Surgery

We have previously reported on the importance of appropriate robot-arm settings and replacement of instrument ports in robot-assisted thoracic surgery, because the thoracic cavity requires a large space to access all lesions in various areas of the thoracic cavity from the apex to the diaphragm and mediastinum and the chest wall. (1 - 3) Moreover, it can be difficult to manipulate the da Vinci Surgical System using only arms No. 1 and No. 2 depending on the tumor location. However, arm No. 3 is usually positioned on the same side as arm No. 2, and sometimes it is only used as an assisting-arm to avoid conflict with other arms ( Fig. 1 ). In this report, we show how robot-arm No. 3 can be used with maximum effectiveness in da Vinci-assisted thoracic surgery. [Figure: see text].