Toshihiko Sakamoto

Characteristics and prognosis of patients after resection of nonsmall cell lung carcinoma measuring 2 cm or less in greatest dimension

There remains ongoing controversy with regard to the optimal management strategy and the prognostic significance of small‐sized nonsmall cell lung carcinoma. Therefore, in the current study, the authors analyzed the clinical characteristics of patients who underwent complete resection of these lung tumors, the follow‐up data, and the significant prognostic factors.

Pleural lavage cytology in non-small cell lung cancer: Lessons from 1000 consecutive resections

OBJECTIVE Intraoperative pleural lavage cytology for lung cancer has not been widely accepted. The prognostic significance of this procedure has yet to be intensively analyzed because the reports published thus far have involved small patient populations. We therefore performed a large prospective trial of pleural lavage cytology to elucidate its importance. METHODS Cytologic status of pleural lavage fluid before any manipulation of the lung was examined in 1000 consecutive patients with non-small cell lung cancer but no pleural effusion who underwent tumor resection. RESULTS Forty-five (4.5%) of 1000 patients had positive cytologic findings. Positive cytologic findings were observed more frequently in patients with adenocarcinoma, advanced stage, higher involvement of lymph nodes, pleural involvement of the tumor, lymphatic permeation, vascular invasion, high level of serum carcinoembryonic antigen, and male sex. The survival rate for 5 years was 28% in patients with positive findings and 67% in patients with negative findings (P <.0001). Among 587 patients with stage I disease, 13 (2.2%) had positive findings, and their 5-year survival was 43%, which was significantly poor compared with that of patients with negative findings (81%, P =.0009). Multivariable analysis demonstrated that pleural lavage cytology was an independent prognostic determinant (P =.0290). Regarding the recurrence pattern in patients with positive findings, distant metastases (19/45 [42.2%]) were observed more frequently rather than local recurrences (19/45 [22.2%]). CONCLUSIONS Cytologic status of pleural lavage fluid immediately after thoracotomy, an independent significant prognostic factor, constitutes valuable information to detect patients at a high risk of recurrence. Therefore cytology should be performed at the time of curative resection for non-small cell lung cancer.

Discrepancy of computed tomographic image between lung and mediastinal windows as a prognostic implication in small lung adenocarcinoma

BACKGROUND There have been no proven preoperative indicators for postoperative survival of patients with an adenocarcinoma, the incidence of which has been increasing lately. METHODS Of 952 consecutive patients operated on for primary lung cancer between 1995 and 2002, 167 patients with a proven adenocarcinoma 3 cm or less in diameter underwent complete removal of the primary tumor. We examined their computed tomographic scans to estimate tumor shadow disappearance rate (TDR), which was defined as the ratio of the tumor area of the mediastinal window to that of the lung window, reviewed the clinical records, and evaluated their relation to prognosis. RESULTS On univariate analyses, size of the tumor (p = 0.0380), TDR (p = 0.0018), carcinoembryonic antigen (p = 0.0001) pathologic stage (p < 0.0001), nodal involvement (p < 0.0001), lymphatic invasion (p = 0.0001), and vascular invasion (p = 0.0017) were significantly associated with prognosis. Also, the outcomes of multivariate analyses for preoperative factors indicated that TDR (p = 0.0340) and carcinoembryonic antigen (p = 0.0047) are significant independent prognostic determinants. The 5-year survival was 48% in cases with a TDR of 0% to 25%, 87% in those with a TDR of 26% to 50%, 97% in those with a TDR of 51% to 75%, and 100% in those with a TDR of 76% to 100%. The incidence of lymphatic, vascular invasion, and nodal metastases was lower in patients with a higher TDR. CONCLUSIONS Small-sized adenocarcinomas with a higher TDR showed less lymphatic, vascular vessel invasion, or nodal involvement, and demonstrated longer survival, suggesting that TDR was associated with clinical-pathologic characteristics and tumor aggressiveness. Preoperative assessment of TDR may be useful to identify an appropriate candidate for a lesser pulmonary resection.

Long-term survival and prognostic factors of five-year survivors with complete resection of non-small cell lung carcinoma

OBJECTIVE We analyzed the long-term follow-up data on cancer-related death in 5-year survivors of complete resection of their non-small cell lung cancer and examined the prognostic factors having an impact on subsequent survival. METHODS Of 848 consecutive patients with proven primary non-small cell carcinoma who underwent complete removal of the primary tumor together with hilar and mediastinal lymph nodes, 421 patients (49.6%) survived 5 years or longer after the initial surgical treatment. Of all the data analyzed, only death related to cancer was treated as death. RESULTS The median follow-up of 5-year survivors was 84 months from the original treatment (range, 60 to 200 months). Their overall survival rate at 10 years was 91.0%. Multivariable Cox analysis demonstrated that although advanced surgical-pathological stage (P =.0001), nodal involvement (P =.0245), male gender (P =.0313), and non-squamous type of the tumor (P =.0034) were significant, independent, unfavorable prognostic determinants in all patients, none of the variables investigated significantly influenced the long-term survival of 5-year survivors. The rate of recurrence beyond 5 years was much lower compared with that within 5 years. In contrast, the rate of occurrence of new malignancies was unchanged throughout the long-term postoperative period. CONCLUSIONS Among 5-year survivors of complete resection of non-small cell lung cancer, neither stage, nodal status, sex, nor histologic condition further affected subsequent survival, suggesting that the 5-year interval might be sufficient to declare that a patient with lung cancer has been cured.

Bronchoscopic dye injection for localization of small pulmonary nodules in thoracoscopic surgery

A new method of marking small pulmonary nodules situated deep within the visceral pleura using a transbronchial approach has been developed. Once the tip of the sheath catheter has passed the tumor and reached the visceral pleura, as confirmed by computed tomography fluoroscopy, indigo carmine is injected through a bronchoscope into the lung parenchyma just beneath the visceral pleura. No complications related to the procedure were experienced. The dye-marking procedure enabled the nodules to be precisely located. This technique can provide appropriate guidance when used in conjunction with video-assisted thoracic operations.

Empyema necessitatis into the retroperitoneal space

Empyema necessitatis is a rare complication of tuberculous empyema. We present a very rare case of empyema necessitatis into the retroperitoneal space through the diaphragm. The fistula between the thoracic empyema cavity and the retroperitoneal abscess was clearly identified by magnetic resonance imaging.

TWO CASES OF SYNCHRONOUS MULTIPLE THYMOMA

We report two cases of synchronous double primary thymoma without myasthenia gravis. These cases suggest the possibility of multicentric thymoma and confirm the validity of a complete thymectomy.

Division of the Pulmonary Ligament After Upper Lobectomy is Less Effective for the Obliteration of Dead Space than Leaving It Intact

PurposeTo investigate whether division of the pulmonary ligament after upper lobectomy obliterates dead space.MethodsThirty-five patients scheduled to undergo upper lobectomy (23 right, 12 left) were randomly assigned to two groups, according to whether the inferior pulmonary ligament was divided (11 right, 12 left) or preserved (6 right, 6 left). To assess upward movement of the nonoperated lobes, plain chest X-ray films (posterior-anterior) were done at end-inspiration preoperatively and 1 month postoperatively, and the ratio of dead space in the longitudinal axis was measured. To assess the change in the angle of the main bronchus, chest X-ray tomography films were done preoperatively and 1 month postoperatively. The angles formed by the main bronchus and the truncus intermedius on the right side, and by the main bronchus and the lower bronchus on the left side, were measured, and the postoperative changes were calculated.ResultsThe dead space ratio did not differ significantly between the divided group and the preserved group (3.5% vs 5.5%) or between sides. The change in the angle of the main bronchus did not differ significantly between the two groups on either the right (36.4° vs 36.3°) or the left side (72.5° vs 60.0°).ConclusionDivision of the pulmonary ligament after upper lobectomy is less effective for the obliteration of dead space than leaving it intact.

Efficacy of a Pedicled Pericardial Fat Pad Fixed with Fibrin Glue on Postoperative Alveolar Air Leakage

Abstract The purpose of this randomized trail was to investigate the effect of using a pedicled pericardial fat pad fixed with fibrin glue on postoperative alveolar air leakage. Thirty consecutive patients with lung cancer, who had moderate alveolar air leaks after pulmonary resection, were randomized into two groups: in group A fibrin glue was applied onto the surface of the leaking raw lung and in group B, after applying fibrin glue in the same manner as in group A, a pedicled pericardial fat pad was immediately fixed to the leaking lung surface with fibrin glue. The duration of the postoperative air leakage and chest tube drainage was recorded. In 6 of 15 patients in group B the air leakage ceased within the first 24 h after pulmonary resection, while in group A only 1 of 15 patients showed a cessation of the air leakage, and a significant difference was noticed between the two groups (P = 0.0309). The duration of the postoperative air leakage was 4.8 ± 4.6 days in group A and 3.6 ± 3.4 days in group B. The pedicled pericardial fat pad fixed onto the surface of the leaking raw lung using fibrin glue was found to reduce alveolar air leakage after pulmonary resection.

Selective segmental jet injection to distinguish the intersegmental plane using jet ventilation

We used the selective jet injection method under bronchofiberscopy to distinguish the intersegmental plane. This method can reveal the intersegmental line clearly, quickly and easily with a good operative view even through a miniature utility thoracotomy or a thoracoscope, since only the burdened segment and not the entire lobe is inflated.