Shinji Nakashima

Is lung cancer resection indicated in patients with idiopathic pulmonary fibrosis

OBJECTIVE The purpose of this study was to determine the implication of idiopathic pulmonary fibrosis on the surgical treatment for primary lung cancer. METHODS Between January 1994 and June 2006, 870 patients with primary lung cancer were surgically treated. Fifty-six (6.4%) of 870 patients had complications with idiopathic pulmonary fibrosis, and their data were retrospectively reviewed. There were 50 men and 6 women with an average age of 68 years. The incidence of squamous cell carcinoma was 28 (50.0%). Surgical procedures consisted of 7 wedge resections of the lung, 5 segmentectomies, 43 lobectomies, and 1 bilobectomy. RESULTS Surgery-related hospital mortality was higher in patients with idiopathic pulmonary fibrosis than in patients without (7.1% vs 1.9%; P = .030). Four (7.1%) of these 56 patients had acute postoperative exacerbation of pulmonary fibrosis and died because of this complication. No factors such as pulmonary function, serologic data, operative data, and histopathologic data were considered predictive risk factors for the acute exacerbation. The postoperative 5-year survival for pathologic stage I lung cancer was 61.6% for patients with idiopathic pulmonary fibrosis and 83.0% for patients without (P = .019). The causes of late death were the recurrence of cancer or respiratory failure owing to idiopathic pulmonary fibrosis. CONCLUSIONS Although idiopathic pulmonary fibrosis causes high mortality after pulmonary resection for lung cancer and poor long-term survival, long-term survival is possible in patients with these two fatal diseases. Therefore, in selected patients, idiopathic pulmonary fibrosis may not be a contraindication to pulmonary resection for stage I lung cancer.

Is video-assisted thoracoscopic surgery a feasible approach for clinical N0 and postoperatively pathological N2 non-small cell lung cancer?

OBJECTIVE It remains controversial whether video-assisted thoracoscopic surgery (VATS) major pulmonary resection (VMPR) with systematic node dissection (SND) is a feasible approach for clinical N0 and pathological N2 non-small cell lung cancer (cN0-pN2 NSCLC). We compared the clinical outcome of patients who underwent VMPR with SND for cN0-pN2 NSCLC with the outcome of patients who underwent MPR with SND by thoracotomy. We conducted this study to determine the feasibility of VMPR for cN0 and pN2 NSCLC patients and intraoperative node staging by node sampling. METHODS Between 1997 and 2006, 770 patients underwent MPR with SND for NSCLC, wherein 450 patients had VMPR and 320 were subjected to open thoracotomy. There were 673 clinical N0 patients. Among them, we retrospectively reviewed 69 patients (10.3%) with cN0-pN2 NSCLC of which the greatest tumor dimension ranged from 20 to 50mm. These patients were divided into two groups: 37 patients under group V, who underwent VMPR, and 32 patients under group T, who underwent MPR by thoracotomy, for cN0-pN2 NSCLC. The majority of the patients underwent postoperative chemotherapy. RESULTS There were no differences between the two groups regarding preoperative data or the number of nodes dissected. The rate of nodal metastasis (number of metastatic nodes/number of dissected nodes) was similar between the two groups (group V vs group T, 0.24 vs 0.24 in total nodes dissected, 0.24 vs 0.23 in mediastinal nodes dissected). The 3-year and 5-year recurrence-free survivals were similar (60.9% vs 49.6% and 60.9% vs 49.6%), as well. Most of the pattern of recurrence was due to remote metastasis. In like manner, the 3-year and 5-year survivals were similar (67.6% vs 57.7% and 45.4% vs 41.1%). CONCLUSIONS This study demonstrates that VMPR with SND is a feasible surgical therapy for cN0-pN2 NSCLC without loss of curability. It is unnecessary to convert the VATS approach to thoracotomy in order to do SND even if pN2 disease is revealed during VMPR.

Feasibility of video-assisted thoracoscopic surgery segmentectomy for selected peripheral lung carcinomas

OBJECTIVE Segmentectomy for non-small cell lung cancer (NSCLC) is believed to increase the rates of recurrence and postoperative air leak. We sought to present our clinical data and outcome of VATS (video-assisted thoracoscopic surgery) segmentectomies with systematic node dissection for selected NSCLC patients. METHODS Inclusion criteria were clinical T1N0M0 peripheral NSCLC measuring <or=2 cm (n=38) and NSCLC with interlobar invasion, which cause positive surgical margin with malignancy after lobectomy of a primary lesion and only partial resection of invasion site (n=3). Outcome variables include hospital course, complications, mortality, recurrence patterns and survival. The intersegmental border was identified using the intersegmental veins as landmark and the demarcation between the resected (inflated) and preserved (collapsed) lungs. The intersegmental plane was divided by an endoscopic stapler and electrocautery. RESULTS The mean operative time and intraoperative bleeding were 220 min (range 100-306) and 183 ml (30-730), respectively. The number of stapler cartridges used for intersegmental division was 2 (1-5). Postoperative air leak (>7 days), which required no surgical intervention, occurred in two patients. The chest tube drainage duration was 3 days. There were no in-hospital deaths. The numbers of resected subsegments and reserved subsegments in comparison with lobectomy were 5 (2-13) and 5 (3-13), respectively. The FEV1.0 after VS was higher than the predictive FEV1.0 after lobectomy, if the latter was performed as standard procedure. We experienced four cases of distant metastasis after segmentectomy, but there was no case of local recurrence. The 5-year survival and recurrence-free survival rates in pathological stage IA NSCLC were 89.9% and 93.3%, respectively. CONCLUSIONS VATS segmentectomy with systematic node dissection is a reasonable treatment option for selected peripheral NSCLC.

Need for Preoperative Computed Tomography-Guided Localization in Video-Assisted Thoracoscopic Surgery Pulmonary Resections of Metastatic Pulmonary Nodules

BACKGROUND Preoperative localization of pulmonary nodules is sometimes necessary when they are too small or distant from the surface of the visceral pleura to be detected during video-assisted thoracoscopic surgery. This study aims to present the criteria for localization and to evaluate the accuracy of the criteria. METHODS From April 2001 to March 2008, 178 patients with 224 nodules who underwent wedge resection of pulmonary metastatic nodules by video-assisted thoracoscopic surgery were reviewed retrospectively. Thirty-one patients (17.4%) including 35 nodules underwent thoracoscopic resection immediately after computed tomography-guided localization using hook wires. Criteria for preoperative localization were (1) maximum diameter of the nodule of 5 mm or less, (2) maximum diameter to minimum distance between the visceral pleura and inferior border of nodule of 0.5 or less, and (3) nodule with low-density image by computed tomography after chemotherapy. The accuracy of these inclusion criteria was statistically evaluated. RESULTS All 224 nodules were removed by wedge resection or additional segmentectomy. Nineteen nodules (54.3%) were detected in the thoracic cavity with preoperative localization. Sensitivity, specificity, positive predictive value, and negative predictive value were 11.1%, 99.5%, 66.7%, and 92.8%; 88.9%, 93.2%, 53.3%, and 99.0%; and 88.9%, 90.8%, 45.7%, and 98.9% in each preoperative finding of which a nodule met all (3 nodules), two or more (30 nodules), and one or more (35 nodules) of the three criteria, respectively. CONCLUSIONS This study suggests that preoperative localization should be considered before video-assisted thoracoscopic surgery operation if the pulmonary nodule meets two or more of our criteria.

C4d Deposition and Cellular Infiltrates as Markers of Acute Rejection in Rat Models of Orthotopic Lung Transplantation

Background. C4d is a useful marker of antibody-mediated rejection in cardiac and renal transplants, but clinical studies examining correlations between circulating alloantibodies, C4d deposition, and rejection in lung transplants have yielded conflicting results. Methods. We studied circulating alloantibody levels and C4d deposition in two rat models of lung transplantation: Brown Norway (BN) to Wistar-Kyoto (WKY) and PVG.R8 to PVG.1U lung allografts. The availability of C6 deficient (C6−) and C6 sufficient (C6+) PVG 1U rats allowed evaluation of the effects of the terminal complement components on graft injury and C4d deposition. Results. The lung allografts had histologic features resembling human posttransplant capillaritis, characterized by neutrophilic infiltration of alveoli, edema, and hemorrhage. Immunoperoxidase stains on cross sections of allografts showed intense, diffuse, C4d deposition in a continuous linear pattern on the vascular endothelium. C4d deposits were found in both BN to WKY and PVG R8 to 1U allografts, whereas no staining was detectable in WKY to WKY isografts or native lungs. Complement deposition was associated with vascular disruption in C6+, but not in C6− recipients. The presence of circulating donor-specific alloantibodies was verified by flow cytometry. Cell-specific staining revealed perivascular accumulation of macrophages and T lymphocytes whereas neutrophils were sequestered in the intravascular and alveolar capillary compartments. Conclusions. The deposition of C4d on vascular endothelium as well as the coincident presence of alloantibodies is consistent with previous findings in antibody-mediated rejection of renal and cardiac transplants. Furthermore, the histological features of our allografts support the concept that posttransplant capillaritis is a form of humoral rejection.

Thoracoscopic Mediastinal Lymph Node Dissection for Lung Cancer

In lung cancer, mediastinum lymphatic spread occurs. We review our technique and experience of thoracoscopic mediastinal lymphnode dissection (MLND). Between 1997 and 2011, 992 patients with primary lung cancer underwent thoracoscopic major pulmonary resection with MLND. Initially we used a combination of electrocautery and clips to divide blood vessels and lymphatic channels; our current technique relies on a vessel sealing system (VSS) which is expeditious and leads to less lymphorrhea. Furthermore, dissection of station 7 nodes is performed after each main bronchus or right intermediate bronchus is taped with a 0 silk suture, which is then brought out of the thorax through the access incision for antero-lateral retraction of the tracheal carina. We dissect between 3 and 4 N2 lymph node stations and a total of approximately 20 N2 lymph nodes. Postoperative complications related to MLND occurred in 35 of 992 patients (3.5%), 15 (1.5%) for recurrent laryngeal nerve injury, 3 (0.3%) for bilateral vagal injury, 14 (1.4%) for chylothorax and 3 (0.3%) for airway injury. However, none were lethal. Thoracoscopic mediastinal dissection is safe and feasible in treating lung cancer. We believe our technique and VSS are very useful for thoracoscopic MLND.

Feasibility and safety of postoperative management without chest tube placement after thoracoscopic wedge resection of the lung

PurposeThe aim of the present study was to assess the feasibility and safety of several improved criteria to avoid chest tube placement after thoracoscopic wedge resection of the lung.MethodsFrom 2000 to 2009, 333 patients who underwent thoracoscopic wedge resections of the lung were reviewed. The patients were classified into two groups: (1) the no chest tube group (NCT), consisting of 132 patients in whom chest tubes were not placed because no air leakage or bleeding during intraoperative alternative sealing test was confirmed, and (2) the chest tube placement (CTP) group, consisting of 201 patients in whom chest tubes were placed because the criteria for the nonplacement of a chest tube were not met. The clinical data and postoperative morbidity were assessed between the two groups.ResultsThe number of specimens (1.3 vs 1.5) and the endostapler cartridges used (2.5 vs 3.3), and the duration of the postoperative hospital stay (4.6 vs 6.7 days) in the NCT group were significantly lower than in the CTP group. One patient from the NCT group required chest tube insertion due to the development of late pneumothorax. However, no significant differences were found between the two groups.ConclusionsOur improved criteria are therefore considered to positively contribute to a safe and definite clinical decision regarding postoperative patient management.

Impact of MHC class II incompatibility on localization of mononuclear cell infiltrates to the bronchiolar compartment of orthotopic lung allografts.

Chronic pathological changes in transplanted lungs are unique because they center on the airways. We examined the relative role of MHC class I and II antigens in causing bronchial pathology in orthotopic lung transplants to rats maintained on cyclosporin A (CsA). Transplants mismatched for MHC class II antigens had significantly more peri‐bronchiolar infiltrates than MHC class I incompatible transplants. No significant increase in infiltrates was found in lung transplants incompatible for MHC class I plus II antigens compared to MHC class II antigens alone. Immunohistochemistry demonstrated that MHC class II antigen expression was confined to macrophages in MHC class I incompatible transplants, but was upregulated on bronchial epithelium in transplants with MHC class II incompatibilities. Vascular endothelium was notably devoid of MHC class II antigen expression in all transplants. However, both peri‐bronchial and peri‐vascular infiltrates were frequently cuffed by alveolar macrophages and type II pneumocytes that expressed MHC class II antigens. PCR analysis demonstrated that IFN‐γ and regulated on activation, normal T cells expressed and secreted (RANTES) were upregulated in MHC class II incompatible transplants. Thus, MHC class II incompatible orthotopic lung transplants in rats maintained on CsA immunosuppression undergo a bronchiolcentric upregulation of alloantigens.

Advantages of preoperative three-dimensional contrast-enhanced computed tomography for anomalous pulmonary artery in video-assisted thoracoscopic segmentectomy

A 74-year-old man, who was diagnosed with primary lung adenocarcinoma, underwent video-assisted thoracoscopic left segment 6 segmentectomy. Preoperative three-dimensional contrast-enhanced computed tomographies (Fig. 1) guided the surgeons in avoiding injury to the anomalous A6c, and in distinguishing the latter from the lower basal dorsal pulmonary artery during VATS segmentectomy (VATS, videoassisted thoracoscopic surgery; Fig. 2). www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 38 (2010) 388

Right hydrothorax found soon after introduction of continuous ambulatory peritoneal dialysis: thoracoscopic surgery for pleuroperitoneal communication

Hydrothorax due to pleuroperitoneal communication is a rare complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). One of the problems of this complication is the need to cease CAPD, which means that the patient must shift completely to hemodialysis. Therefore, a quick, minimally invasive, and complete surgical repair of the pleuroperitoneal communication is required. We recently treated a patient who had developed a right hydrothorax soon after the introduction of CAPD. Clinical examination led to a diagnosis of pleuroperitoneal communication. The patient was successfully treated by complete thoracoscopic repair of the communication. We could precisely identify the defective site on the diaphragm using the dye-added CAPD solution method. CAPD was restarted 5 days after the operation, and there was no recurrence of hydrothorax after the operation.