Takamitsu Maehara

Decreased invasiveness via two methods of thoracoscopic lobectomy for lung cancer, compared with open thoracotomy.

Background and objective:  Video‐assisted thoracic surgery (VATS) lobectomy for primary lung cancer is considered minimally invasive. However, different procedures may be used for the VATS lobectomy, from complete videoscopic (CV) surgery to a technique similar to the muscle‐sparing thoracotomy. We divided patients into two groups based on the surgical approach and analysed the outcomes.

Correlation between lymph node micrometastasis and histologic classification of small lung adenocarcinomas, in considering the indication of limited surgery

The validity of limited surgery for lung carcinomas have not been clearly established. Several reports suggest that not only tumor size but also the histological findings may be of importance in this role. By conducting immunohistochemical examinations of lymph node micrometastases from small lung adenocarcinomas, we considered the suitability of limited surgery for especially localized bronchioloalveolar carcinoma (LBAC) without active fibroblastic proliferation (Noguchis histologic classification types A and B). In this study, we enrolled 54 patients with lung adenocarcinoma smaller than 2 cm in diameter. Lymph node involvement was demonstrated in 11 (20.4%) patients. Lymph node micrometastasis was present in 11 (25.6%) of the 43 patients at pN0 disease. However, 13 patients with LBAC without active fibroblastic proliferation (types A and B) had neither lymph node involvement nor micrometastasis. Our results indicate that limited pulmonary resection may be acceptable procedure for LBAC without active fibroblastic proliferation.

Endobronchial hamartoma treated by an Nd-YAG laser: Report of a case

Endobronchial hamartomas are only rarely encountered. They cause irreversible lung damage due to bronchial obstruction if not diagnosed early and treated properly. Among the various treatments for this rare disease, a surgical resection remains the most popular. We herein report a case of a 53-year-old man presenting with an endobronchial hamartoma which was successfully excised by laser irradiation via a rigid bronchoscope, along with a review of 113 patients with this disease reported in the literature.

Influence of visceral pleural invasion on survival in completely resected non-small-cell lung cancer

OBJECTIVES Although the prognostic implications of visceral pleural invasion (VPI) are well established, it remains controversial whether the extent of VPI affects survival in patients with completely resected non-small-cell lung cancer (NSCLC). In addition, the impact of VPI according to nodal status is unclear. We evaluated the influence of the extent of pleural invasion on survival by analysing a multicentre retrospective database of patients who had undergone surgery for NSCLC. METHODS We retrospectively reviewed the clinicopathological characteristics and outcomes of 639 patients with NSCLC who underwent anatomic complete resection from 2005 to 2007 at nine hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons. RESULTS The median follow-up was 65.0 months. The extent of pleural invasion was PL0 in 462 patients, PL1 in 135 and PL2 in 42. The 5-year overall survival rate was significantly higher in patients with PL0 tumours (75.9%) than in those with PL1 (63.6%) or PL2 tumours (54.1%). On subgroup analysis according to nodal status, PL0 was associated with a higher survival rate than that of PL1 or PL2 tumours in patients with N0 or N1 metastasis, but not in those with N2 metastasis. There was no difference between PL1 and PL2 in any subgroup. CONCLUSIONS Our results suggest that the presence of VPI, rather than the extent, has an impact on postoperative survival in patients with NSCLC who have N0 or N1 metastasis. Because very few previous studies have addressed the effects of VPI in patients with N1 disease, further re-evaluation of the prognostic impact of VPI is necessary in this subgroup of patients.

Lobe-Specific Lymph Node Dissection as a Standard Procedure in Surgery for Non–Small Cell Lung Cancer: A Propensity Score Matching Study

Introduction: Systematic lymph node dissection (SND) is the standard procedure in surgical treatment for NSCLC, but the value of this approach for survival and nodal staging is still uncertain. In this study, we evaluated the potential of lobe‐specific lymph node dissection (L‐SND) in surgery for NSCLC by using a propensity score matching method. Methods: From 2005 to 2007, 565 patients with cT1a–2b N0–1 M0 NSCLC underwent lobectomy with lymph node dissection at our 10 affiliated hospitals. Patients were classified into groups that underwent nodal sampling, L‐SND, and systematic dissection SND on the basis of pathological data for the number and extent of nodal resection. A total of 77 patients with insufficient pathological data were excluded from the study. Results: Overall, survival did not differ significantly among the groups (p = 0.552), but the rate of detection of pN2 in the SND group (13.1%) was significantly higher than in the nodal sampling (3.3%) and L‐SND (9.0%) groups (p = 0.010). However, given the many confounding factors in the patient characteristics in each group, outcomes were reevaluated using a propensity score matching method for the L‐SND and SND groups. After matching, the two groups had no significant differences in 5‐year overall survival (73.5% for L‐SND versus 75.3% for SND, p = 0.977) and pN2 detection (8.2% in both groups, p = 0.779). Conclusions: These results suggest that lobe‐specific lymph node dissection has the potential to be a standard procedure in surgical treatment for NSCLC.

Postoperative follow-up strategy based on recurrence dynamics for non-small-cell lung cancer

OBJECTIVES Our study was designed to visually represent recurrence patterns after surgery for non-small-cell lung cancer (NSCLC) with the use of event dynamics and to clarify postoperative follow-up methods based on the times of recurrence. METHODS A total of 829 patients with NSCLC who underwent complete pulmonary resection from 2005 to 2007 in 9 hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons were studied. Event dynamics, based on the hazard rate, were evaluated. Only first events involving the development of distant metastases, local recurrence or both were considered. The effects of sex, histological type, pathological stage and age were studied. RESULTS The hazard rate curve displayed an initial surge that peaked about 6-8 months after surgery. The next distinct peak was noted at the end of the second year of follow-up. On non-parametric kernel smoothing, the maximum peak was found 6-8 months after surgery in men. In women, the highest peak occurred 22-24 months after surgery, which was about 16 months later than the peak in men. The peak timing of the hazard curve was not affected by histological type, pathological stage or age in either sex. CONCLUSIONS Our results suggest that the timing of recurrence after surgery for lung cancer is characterized by a bimodal pattern, and the times with the highest risk of recurrence were suggested to differ between men and women. Postoperative follow-up strategies should be based on currently recommended follow-up programmes, take into account the recurrence patterns of lung cancer, and be modified as required to meet the needs of individual patients.

Video-assisted thoracoscopic surgery for pulmonary arteriovenous malformations: report of five cases

We experienced five cases of pulmonary arteriovenous malformations (PAVMs) that were successfully treated by video-assisted thoracoscopic surgery. Four malformations were treated by local wedge resection and one was treated by segmentectomy. Criteria for patient selection for surgery were peripheral and solitary lesions, with feeding arteries larger than 3 mm. Postoperative hospital stays were 1–7 days (median, 2 days). All patients showed unchanged or increased values of PaO2 in arterial blood after operation. No major postoperative complication occurred in any patient, but a persistent air leak for 5 days occurred in the one patient who was treated by segmentectomy. No growth of accessory vessels or untreated malformations were seen in any patient throughout the follow-up period of 14–54 months. Thoracoscopic surgical resection for well-selected patients provides a high certainty of eliminating fistulae and was associated with lower morbidity, lower mortality, and shorter hospital stays.

Assessment of spontaneous hemopneumothorax: Indications for surgery.

Background Although spontaneous hemopneumothorax is rare, emergency surgery may be necessary if massive bleeding is present. Methods We examined therapeutic strategies and outcomes as well as background factors in 16 patients with spontaneous hemopneumothorax treated at our hospital between April 2002 and August 2013. Results Emergency surgery was performed in 3 patients, all of whom were hemodynamically unstable. Elective surgery was performed in 7 patients, all of whom showed continuous bleeding from a pleural cavity drain. The surgery consisted of intrapleural hematoma removal, hemostasis, and bullectomy; 3-port thoracoscopy was used in all of the surgical cases. Six patients, none of whom showed continuous bleeding, recovered with conservative therapy. Comparing the conservative therapy and surgery groups revealed the mean continuous bleeding volume and total blood loss to be significantly greater in the latter, but no significant difference was noted between the two groups in terms of the initial bleeding volume following tube thoracostomy. None of the cases required a blood transfusion. Conclusions Spontaneous hemopneumothorax is not necessarily an indication for surgery, and even when the initial volume of blood drained through the chest tube is large, some patients can still be treated conservatively with careful monitoring of vital signs and continuous bleeding volumes. However, it is important not to miss the optimal timing of surgery in order to avoid administering unnecessary blood transfusions to young patients.

Gender Differences in the Recurrence Timing of Patients Undergoing Resection for Non-Small Cell Lung Cancer

Objective: This study was designed to visually represent postoperative recurrence patterns using event dynamics and to assess sex-based differences in the timing of recurrence for non-small cell lung cancer. Methods: We studied 829 patients (538 men, 291 women) with NSCLC who underwent complete pulmonary resection in 9 hospitals. Event dynamics with the use of life-table methods were evaluated, and only first events (distant metastases or local recurrence) were considered. The effects of sex, histological type, pathological stage, and smoking history were studied. Result: The resulting smoothed hazard rate curves indicated that the recurrence risk pattern definitely correlated with sex, with a sharp peak in the first year in men and a broad peak during the first 2 to 3 years in women. These findings were also confirmed by analyses according to pathological stage, histological type, and smoking history. Conclusion: The peak times of recurrence differed considerably between men and women. The delayed time of peak recurrence in women, associated with a longer disease-free interval within subsets of patients with similar disease stage, histological type, and smoking status, might account for the better survival in women.

Mediastinal lymph node dissection in surgical treatment for early stage non-small-cell lung cancer: lobe-specific or systematic?

The standard surgical treatment for early stage non-small-cell lung cancer (NSCLC) is lobectomy or pneumonectomy with systematic lymph node dissection (SND) (1,2). In 2006, the European Society of Thoracic Surgeons (ESTS) released guidelines for intraoperative lymph node staging in NSCLC, in which intraoperative procedures for lymph nodes were classified into five groups; selected lymph node biopsy, (systematic) sampling, lobe-specific lymph node dissection (L-SND), SND, and extended lymph node dissection; and it was recommended to provide SND in all cases of complete resection of NSCLC (3).