Sakashi Fujimori

Safe and Effective Minimally Invasive Approaches for Small Ground Glass Opacity

BACKGROUND Popularized computed tomography physical check up results in an increasing number of patients with ground glass opacity (GCO) lesions of which management has not been established yet. METHODS From January 2004 to December 2008, 738 patients underwent pulmonary resection for primary lung cancer, and 96 (13.0%) with resected GGO lesions were included in this study. Pure GGO lesions sized less than 10 mm are monitored until they grow bigger or develop a core. Three-port video-assisted thoracic lobectomy with systematic lymph node dissection is indicated when the lesion diameter exceeds 15 mm or is invasive, and segmentectomy is indicated when the tumor diameter is 10 to 15 mm. Wedge resection is indicated when the tumor is peripherally located. RESULTS There was no procedurally related mortality or morbidity. There were 9 papillary adenocarcinomas or invasive bronchioloalveolar carcinomas, 75 noninvasive bronchioloalveolar cell carcinomas, 7 atypical adenomatous hyperplasias, and 5 organizing pneumonias. No local recurrence was observed. CONCLUSIONS Several pathologies are included in GGO lesions, and the video-assisted thoracic approach seems to be one of the best options in their management.

Video-assisted thoracic surgery for pulmonary aspergilloma

The purpose of this retrospective study was to review our experience with video-assisted thoracic surgery (VATS) for pulmonary aspergilloma. The patients (n=20) were aged 62+/-12 years, and eight (40%) were aged 70 years or more. The disease types were simple aspergilloma (SA) in six patients and complex aspergilloma (CA) in 14. The surgical procedures performed were lobectomy in 14 patients, segmentectomy in two, and wedge resection in four. The operation time was shorter (143+/-69 min vs. 216+/-85 min; P=0.08) and the blood loss was less (10+/-17 ml vs. 307+/-346 ml; P<0.01) for patients with SA than those with CA. Postoperative death occurred in one patient with CA who developed a bronchial stump fistula (30-day mortality; 5.0%). During follow-up, three patients died from other non-disease-related causes, and the remaining 17 patients survived without recurrence. The 5-year survival rate was 89%. In suitable cases, VATS for pulmonary aspergilloma may not be inferior to open surgery with regard to safety and efficacy. In particular, SA is considered to be a good indication for VATS.

Locoregional Control of Thoracoscopic Lobectomy With Selective Lymphadenectomy for Lung Cancer

BACKGROUND In this retrospective study, we review our experience with video-assisted thoracic surgery (VATS) lobectomy with selective lymphadenectomy for clinical stage I lung cancer and report the long-term results. METHODS From April 1999 to December 2006, 355 patients with clinical stage I lung cancer underwent a VATS lobectomy. The perioperative data, morbidity, mortality, and long-term survival of each patient were reviewed. RESULTS A thoracoscopic lobectomy was performed successfully in 348 patients (T1 N0, 237 patients; T2 N0, 111 patients), and a selective lymphadenectomy was performed in 268. Seven procedures (2.0%) were uneventfully converted to a thoracotomy and were excluded. The median operation time was 192 minutes, and the median blood loss was 100 mL. The median postoperative stay was 6 days. There were no intraoperative deaths; 2 patients died within 30 days of operation (mortality; 0.6%); 1 died of bacterial pneumonia and the other of postoperative interstitial pneumonia exacerbation. Postoperative complications occurred in 54 patients (16% morbidity). Major complications included prolonged air leak (3.7%), bacterial pneumonia (3.4%), and mild arrhythmia (3.4%). Pathologic upstaging was noted in 67 patients (19%). At a median follow-up of 43 months, total recurrence occurred in 66 cases (26 locoregional and 40 distant). The locoregional recurrence rate was 0.021 per person per year. The overall and 5-year locoregional recurrence-free survival rates were 78.5% and 76.6%, respectively. CONCLUSIONS Our findings suggest that performing VATS lobectomy with selective lymphadenectomy for clinical stage I lung cancer is safe and results in acceptable locoregional control.

Semiquantitative Assessment of Tumor Spread through Air Spaces (STAS) in Early-Stage Lung Adenocarcinomas

Introduction: Tumor spread through air spaces (STAS) has recently been reported as a form of tumor invasion having an unfavorable prognosis, but the significance of a small amount of STAS is not known. The aim of this study was to perform a semiquantitative assessment of STAS. Methods: Small (≤2 cm) stage I lung adenocarcinomas surgically resected at our institution between 2003 and 2009 were assessed semiquantitatively in the most prominent area as no STAS, low STAS (1–4 single cells or clusters of STAS), or high STAS (≥5 single cells or clusters of STAS) by using a 20× objective and a 10× ocular lens. A statistical analysis was performed to determine the impact of clinicopathologic parameters on STAS and to clarify the relationship between STAS and patient survival. Results: STAS was assessed as no STAS in 109 of 208 cases (52.4%), as low STAS in 38 cases (18.3%), and as high STAS in 61 cases (29.3%). There were statistically significant associations between higher STAS and solid predominant invasive adenocarcinoma (p < 0.001), pleural invasion (p < 0.001), lymphatic invasion (p < 0.001), vascular invasion (p < 0.001), and tumor size of 10 mm or more (p = 0.037). There was a significant association between increasing STAS and shorter recurrence‐free survival (RFS) in univariate analysis (no STAS, 154.2 months; low STAS, 147.6 months; and high STAS, 115.6 months). In a multivariate Cox proportional hazards model, only STAS (p = 0.015) remained a significant predictor of RFS. Conclusions: We found that one‐third of resected small adenocarcinomas had high STAS. Higher STAS was predictive of worse RFS.

Single-stage video-assisted thoracoscopic surgery: Right upper lobectomy and left lower lobectomy for synchronous bilateral lung cancers

Highlights • Single-stage bilateral radical surgery for synchronous bilateral multiple lung cancers has strong advantages.• A case of single-stage bilateral radical lobectomy with a good result is reported.• Single-stage bilateral VATS-lobectomy could be a feasible surgical option in selected patients.

Bronchial bleeding caused by recurrent pneumonia after radical esophagectomy for esophageal cancer.

We herein report a case of bronchial bleeding after radical esophagectomy that was treated with lobectomy. A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis. After the esophagectomy, bilateral vocal cord paralysis was observed, and the patient suffered from repeated episodes of aspiration pneumonia. Bronchoscopy revealed hemosputum in the right middle lobe bronchus, and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus. Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis, the procedures were unsuccessful. Right middle lobectomy was therefore performed via video-assisted thoracic surgery. Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen. The patient recovered uneventfully and was discharged on postoperative day 14.