Ryuta Fukai

Safety and reproducibility of virtual-assisted lung mapping: a multicentre study in Japan†

Abstract OBJECTIVES: Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multispot dye-marking technique using virtual images. The purpose of this study was to evaluate the safety, efficacy and reproducibility of VAL-MAP among multiple centres. METHODS: Selection criteria included patients with pulmonary lesions anticipated to be difficult to identify at thoracoscopy and/or those undergoing sub-lobar lung resections requiring careful determination of resection margins. Data were collected prospectively and, if needed, compared between the centre that originally developed VAL-MAP and 16 other centres. RESULTS: Five hundred patients underwent VAL-MAP with 1781 markings (3.6 ± 1.2 marks/patient). Complications associated with VAL-MAP necessitating additional management occurred in four patients (0.8%) including pneumonia, fever and temporary exacerbation of pre-existing cerebral ischaemia. Minor complications included pneumothorax (3.6%), pneumomediastinum (1.2%) and alveolar haemorrhage (1.2%), with similar incidences between the original centre and other centres. Marks were identifiable during operation in approximately 90%, whereas the successful resection rate was approximately 99% in both groups, partly due to the mutually complementary marks. The contribution of VAL-MAP to surgical success was highly rated by surgeons resecting pure ground glass nodules (P < 0.0001), tumours ≤ 5 mm (P = 0.0016), and performing complex segmentectomy and wedge resection (P = 0.0072). CONCLUSIONS: VAL-MAP was found to be safe and reproducible among multiple centres with variable settings. Patients with pure ground glass nodules, small tumours and resections beyond conventional anatomical boundaries are considered the best candidates for VAL-MAP. Clinical Trial Registration Number: UMIN 000008031. University Hospital Medical Information Network Clinical Trial Registry (http://www.umin.ac.jp/ctr/).

Complete resection via medial sternotomy for non-small cell lung cancer in the right upper lobe

Background:  Right upper lobectomy with right cervical and bilateral mediastinal lymph node dissection via a median approach was performed for non‐small cell lung cancer.

A dedifferentiated liposarcoma of the anterior mediastinum

Dedifferentiated liposarcoma was first described in 1979, and its definition has been recently extended. We found an undiagnosed anterior mediastinal mass in a 56- year-old man for whom we performed a complete tumor resection through median sternotomy. Microscopic examination revealed that the mass was primarily a low-grade, dedifferentiated liposarcoma, with a partial high-grade area. Occurrence of dedifferentiated liposarcoma in the anterior mediastinum is rare. We did not perform any adjuvant therapy. Three years after the surgery, the patient is alive without disease. In lipoma-like, well-differentiated liposarcoma cases, we should consider the possibility of dedifferentiated liposarcoma if a mild, atypical spindle cell component is found.

Effect of virtual-assisted lung mapping in acquisition of surgical margins in sublobar lung resection

Objective Virtual‐assisted lung mapping is a preoperative bronchoscopic multi‐spot dye‐marking technique. This study aimed to examine the efficacy of virtual‐assisted lung mapping for obtaining sufficient surgical margins in sublobar lung resection. Methods The multicenter, prospective, single‐arm study was conducted from September 2016 to July 2017 in 19 registered centers. Patients who required sublobar lung resection and careful determination of resection margins underwent virtual‐assisted lung mapping followed by thoracoscopic surgery. Successful resection was defined as resection of the lesion with margins greater than the lesion diameter or 2 cm using the preoperatively planned resection without additional resection. We defined the primary goal of the study as achieving successful resection in 95% of lesions. Results The resection of 203 lesions (average diameter, 9.6 ± 5.3 mm) was intended in 153 patients. The lesions included pure and mixed ground‐glass nodules (75 [35.9%] and 36 [17.2%], respectively), solid nodules (91 [43.5%]), and others (7 [3.3%]). Surgical procedures included wedge resection (131, 71.2%), segmentectomy (51, 27.7%), and others (2, 1.1%). Successful resection was achieved in 178 lesions (87.8% [95% confidence interval, 82.4‐91.9%]), and virtual‐assisted lung mapping markings successfully aided in the identification of 190 lesions (93.6% [95% confidence interval, 89.3‐96.5%]). Multivariable analysis showed that the most significant factor affecting resection success was the depth of the necessary resection margin (P = .0072). Conclusions This study showed that virtual‐assisted lung mapping has reasonable efficacy, although the successful resection rate did not reach the primary goal. The depth of the required margin was the most significant factor leading to resection failure. Graphical abstract Figure. No Caption available.

The role of virtual-assisted lung mapping in the resection of ground glass nodules

Background Virtual-assisted lung mapping (VAL-MAP), a bronchoscopic multi-spot dye-marking technique, was tested for its ability to resect ground glass nodules (GGNs) in sublobar lung resections. Methods All patients were prospectively registered in the multi-institutional lung mapping (MIL-MAP) study using VAL-MAP. The data were retrospectively analyzed, focusing on GGNs. GGN characteristics, pathological findings, operation type, and the surgical contribution of VAL-MAP were evaluated. Results The 370 GGNs in 299 patients included 257 pure and 113 mixed GGNs. There were 146 wedge resections (43.6%), 99 simple segmentectomies (29.6%), and 60 complex segmentectomies (18.0%). The largest number of marks were used in complex segmentectomy (4.05±0.74), followed by simple segmentectomy (3.35±0.97) and wedge resection (2.96±0.80). The overall successful resection rate was 98.6%. Multiple [2-5] GGNs were concurrently targeted by VAL-MAP in 53 patients (17.7%) with 123 GGNs. Two concurrent resections were conducted in 36 patients (12.1%), most commonly wedge resection and segmentectomies (21 patients). Among 190 sub-centimeter GGNs, 24 out of 51 GGNs ≤5 mm in diameter (47.1%) and 113 of 139 GGNs >5 mm in diameter (81.3%) were primary lung cancer (P<0.0001). Regarding the contribution of VAL-MAP to successful resection, wedge resection and pure GGNs were graded higher than both other resection types and mixed GGNs. Conclusions VAL-MAP enabled thoracoscopic limited resection of GGNs. Its multiple marks facilitated resections of multi-centric GGNs. Resected suspicious GGNs >5 mm in diameter are likely to be lung cancer. VAL-MAP may impact decision-making regarding the indications and type of surgery for suspicious small GGNs.

Urgent surgical treatment for a huge metastatic tumor of the right lung via plastron thoracotomy: A case report

For an extremely large intrathoracic tumor, which almost occupies a unilateral thoracic cavity, it is likely that salvage surgery would provide benefit. Nevertheless, the operative risk of such salvage surgery is very high, plus the surgery itself often becomes challenging. The choice of surgical approach presents another problem, as the presence of a large tumor mass often makes it difficult to secure a workable surgical field. Our patient was a 63-year old man with a huge right lung metastasis from a left crural myxofibrosarcoma. We performed an urgent salvage surgery: a right pneumonectomy with assisted circulation via plastron thoracotomy. The patient lived a year and two months after the operation. We believe that plastron thoracotomy can be one of the available choices for surgical approach for resection of a giant thoracic tumor. Correspondence to: Ryuta Fukai, Department of General Thoracic Surgery, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanagawa, 247-8533, Japan, Tel: +81 467 46 1717; Fax: +81 467 47 8243; E-mail: ryuta.f@ hotmail.co.jp

Pneumonic-type Adenocarcinoma with Dissemination Similar to That of Bronchioloalveolar Carcinoma

背景．気道を介した病変の多発・両側性進展（aerogenous dissemination）は細気管支肺胞上皮癌に典型的であるが，腺癌でも同様の進展を示す場合があり，肺炎型肺腺癌として報告されている．症例．65歳，男性．血痰を主訴に受診，喀痰細胞診で腺癌と診断された．胸部X線写真で，右下葉に一致した肺炎様硬化像を認め，胸部CTでは右下葉内に嚢胞性変化を伴った病変であり，中葉にもわずかに陰影がみられた．術中所見で肉眼的に中葉に異常を認めず，右下葉切除，リンパ節郭清を施行，pT2N0M0，ステージIB期であった．術後UFTを内服していたが，4ヵ月目で中葉病変が拡大し，対側にも病変が出現したため化学療法を開始した．しかしその後も病変は拡大し，レジメンを変更して化学療法を継続したが治療抵抗性であり，術後1年5ヵ月で癌死した．結論．腺癌には，肺胞上皮癌と同様の進展を示す肺炎型肺腺癌が存在する．特異的な臨床経過を示し，予後不良なため注意が必要である．