Yoshifumi Miyamoto

Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy.

OBJECTIVE The purpose of this study was to compare the outcomes after sleeve lobectomy and pneumonectomy for patients with non-small cell lung cancer distributed according to their nodal involvement status. METHODS Of 1172 patients in whom primary non-small cell lung carcinoma, including mediastinal lymph nodes, was completely excised, 151 patients underwent sleeve lobectomy and 60 underwent pneumonectomy. For bias reduction in comparison with a nonrandomized control group, we paired 60 patients undergoing sleeve lobectomy with 60 patients undergoing pneumonectomy by using the nearest available matching method. RESULTS The 30-day postoperative mortality was 2% (1/60) in the pneumonectomy group and 0% in the sleeve lobectomy group. Postoperative complications occurred in 13% of patients in the sleeve lobectomy group and in 22% of those in the pneumonectomy group. Local recurrences occurred in 8% of patients in the sleeve lobectomy group and in 10% of those in the pneumonectomy group. The overall 5- and 10-year survivals for the sleeve lobectomy group were 48% and 36%, respectively, whereas those for the pneumonectomy group were 28% and 19%, respectively (P =.005). Multivariable analysis showed that the operative procedure, T factor, and N factor were significant independent prognostic factors and revealed that survival after sleeve lobectomy was significantly longer than that after pneumonectomy (P =.03). CONCLUSIONS These data suggest that sleeve lobectomy should be performed instead of pneumonectomy in patients with non-small cell lung cancer regardless of their nodal status whenever complete resection can be achieved because this is a lung-saving procedure with lower postoperative risks and is as curative as pneumonectomy.

Operative approach for multiple primary lung carcinomas

Of 908 patients who underwent operation for primary lung cancer between January 1985 and June 1996, we considered 57 (6.3%) to have a second primary lung cancer, which was synchronous in 28 cases (3.1%) and metachronous in 29 cases (3.2%). Five-year survival for patients with synchronous and metachronous disease from initial treatment of cancer was 70.3% and 66.0%, respectively. Survival after the development of a metachronous lesion was 32.9% at 5 years. Sixteen of the synchronous second tumors (57%) were detected on preoperative radiography or bronchoscopy and 11 (39%) at the time of operation. Survival of patients at stage I or II from treatment of a synchronous lesion (p = 0.002) and of a metachronous second lesion (p = 0.028) was significantly better compared with those at stage III or IV. Therefore it is important to carefully examine a synchronous lesion before and during the operation of a primary lung cancer and to perform close follow-up surveillance for early detection of a metachronous lesion. In treating multiple lung carcinomas consideration should always be given to performing precise staging, aggressive operative approach for early stage, and oncologically sound parenchymal sparing procedures.

Proposal for reasonable mediastinal lymphadenectomy in bronchogenic carcinomas: Role of subcarinal nodes in selective dissection

OBJECTIVE The aims of this study were to reveal the characteristics of skipping N2 lung cancer and to develop a more reasonable approach for dissecting mediastinal lymph nodes. METHODS Of consecutive 956 patients who were operated on for primary lung cancer from 1986 through 1996, 760 (79.5%) had a diagnosis of non-small cell carcinoma and were subjected to complete resection of the tumor together with hilar and mediastinal lymphadenectomy. RESULTS Of 141 patients with N2 disease, 53 (37.6%) had skipping metastases. Among 78 patients with N2 cancer of the upper lobe, 37 (47.4%) had skipping metastases affecting upper or aortic mediastinal nodes whereas none of them had skipping metastases affecting lower mediastinal nodes. Among 47 patients with N2 cancer of the lower lobe, 13 (27.7%) had skipping metastases affecting mediastinal nodes. Of these 13 patients, 11 (84.6%) had skipping metastases affecting the subcarinal node. The remaining 2 patients had a huge primary tumor. CONCLUSIONS Dissection of the upper part of the mediastinum including the aortic regions should be performed regardless of the operative appearance when cancer is located in the upper lobe, but it is not required for lower lobe tumors with negative hilar and subcarinal nodes. Dissection of the subcarinal node in patients with an upper lobe tumor is not routinely needed when the nodes in both the hilum and upper mediastinum are intact. We consider that the subcarinal node is of significance and skipping metastases should be defined as metastases that skip the subcarinal node in addition to N1 nodes.

Prognosis of completely resected pn2 non–small cell lung carcinomas: What is the significant node that affects survival?☆☆☆★

OBJECTIVE We analyzed the effect of the station of mediastinal metastasis with regard to the location of the primary tumor on the prognosis in patients with non-small cell lung cancer. METHODS Of 956 consecutive patients who underwent operation for primary lung carcinoma between 1986 and 1996, 760 patients (79.5%) were diagnosed as having non- small cell carcinoma and were subjected to complete removal of hilar and mediastinal lymph nodes together with the primary tumor. RESULTS The status of lymph node involvement was N0 in 480 patients (63.2%), N1 in 139 patients (18.3%), and N2 in 141 patients (18.6%). The 5- and 10-year survival of patients with N2 disease were 26% and 17%, respectively. Neither cell type nor the extent of procedure was a significant survival determinant. Patients having involvement of subcarinal nodes from upper-lobe tumors had a significantly worse prognosis than those patients with metastases only to the upper mediastinal or aortic nodes (P =.003). Patients with nodal involvement of the upper mediastinum from lower-lobe tumors had a significantly worse survival than those patients with metastases limited to the lower mediastinum (P =.039). Furthermore, patients with involvement of the aortic nodes alone from left upper-lobe tumors had a significantly better survival than those patients with metastasis to the upper or lower mediastinum beyond the aortic region (P =.044). CONCLUSIONS When mediastinal metastasis is limited to upper nodes from upper-lobe tumor, to lower nodes from lower-lobe tumor, or to aortic nodes from left upper-lobe tumor, acceptable survival could be expected after radical resection.

Extended sleeve lobectomy for lung cancer: The avoidance of pneumonectomy

OBJECTIVE We have tried atypical bronchoplasties in patients with noncompromised lung function with centrally located cancers to avoid pneumonectomy. We evaluated the efficacy of extended sleeve lobectomy in such patients. METHODS Among 157 patients undergoing bronchoplasty for primary non-small cell lung carcinoma, 15 patients underwent extended sleeve lobectomy. RESULTS According to the mode of reconstruction, the 15 patients were classified into 3 groups: (A) anastomosis between the right main and lower bronchi with resection of the upper and middle lobes (n = 6), (B) anastomosis between the left main and basal segmental bronchi with resection of the upper lobe and superior segment of the lower lobe (n = 4), and (C) anastomosis between the left main and upper division bronchi with resection of the lingular segment and lower lobe (n = 5). The tumors were completely resected in all patients. Pulmonary angioplasty was carried out in 8 patients. Bronchial reconstruction was successful in all patients. Pulmonary vein thrombosis resulting from overstretching of the inferior pulmonary vein occurred in 1 patient of group A and was relieved by completion pneumonectomy. There was neither operative mortality nor local recurrence. Although all patients with stage IIB disease and half of patients with stage IIIA disease were alive without recurrence (12-106 months), half of the patients with stage IIIA disease died of distant metastases within 1 year. CONCLUSIONS We suggest that this extended sleeve lobectomy, which is technically demanding, should be considered in patients with centrally located lung cancer, because this lung-saving operation is safer than pneumonectomy and is equally curative.

Evaluation of TMN classification for lung carcinoma with ipsilateral intrapulmonary metastasis

BACKGROUND Staging for lung cancer based on the TNM classification is an important predictive factor for prognosis. Recently, lung cancer with ipsilateral intrapulmonary metastasis (PM) was reclassified according to the revision of the TNM classification. To evaluate the prognostic importance of the new staging system for PM, we analyzed the postoperative survival of patients with non-small cell lung carcinoma. METHODS Of 1,002 consecutive patients who underwent operation for primary lung cancer between June 1984 and December 1996, we reviewed the medical record of 889 patients who underwent complete resection for non-small cell lung cancer. RESULTS We considered 89 patients (10.0%) to have synchronous ipsilateral PM. After reclassification to the former staging system revised in 1992, 5 patients were classified as stage I, 29 as stage IIIA, 48 as stage IIIB, and 7 as stage IV. In the new staging system revised in 1997, 48 patients were recategorized as stage IIIB, and 41 as stage IV. The 5-year survival of patients without PM (49.5%) was significantly better than that of patients with PM in primary-tumor lobe (29.6%, p = 0.002) or in nonprimary-tumor ipsilateral lobe (23.4%, p = 0.0002). Although the survival of patients with stage IV cancer without PM was significantly worse than that of patients with the new (1997) stage IV cancer with PM (p = 0.02), it was similar to that of patients with the former (1992) stage IV cancer with PM. The survival of PM patients with N0 or N1 disease was significantly better than that of PM patients with N2 or N3 disease (p = 0.001). Furthermore, in patients with the new (1997) stage IIIB cancer, the survival of N0 disease was better than that of N2 disease (p = 0.007). CONCLUSIONS Inasmuch as the prognosis of non-small cell carcinoma in patients with PM strongly correlated with N factor rather than PM factor, N factor should be reflected in a staging designation. We therefore consider the new TNM classification for PM reclassified in 1997 to be less acceptable for surgical-pathologic staging than the revision in 1992.

Role of pleural lavage cytology before resection for primary lung carcinoma.

OBJECTIVE To investigate the role of pleural lavage cytology (PLC) in resection for primary lung carcinoma. SUMMARY BACKGROUND DATA The prognostic significance of PLC before manipulation is still controversial. METHODS Cytology of pleural lavage immediately after thoracotomy but before any manipulation of the lung was examined in 500 consecutive patients with lung cancer with no pleural effusion who underwent pulmonary resections. Eighteen patients who already had pleural dissemination were excluded from this study. RESULTS Eighteen of 482 patients (3.7%) had positive cytologic findings. The positivity of PLC was significantly correlated with histology, extension of tumor to pleura, and presence of lymphatic permeation or vascular involvement by tumor. Positive lavage findings were seen only in adenocarcinoma. Because 6.3% of the patients with adenocarcinoma had positive cytologic findings, it is vital to perform PLC before curative resections for lung cancer, especially adenocarcinoma. The 5-year survival rates of the patients having negative and positive lavage findings were 52.9% and 14.6%, respectively. The prognosis of the patients with positive lavage findings was as poor as that of the patients with stage IIIB disease and that of the patients with malignant effusion. CONCLUSIONS Positive findings on PLC indicate exfoliation of cancer cells into the pleural cavity, which is an essential prognostic factor. In addition, we should regard positive cytologic findings as a subclinical malignant pleural effusion that is pathologic stage T4.

How should interlobar pleural invasion be classified? Prognosis of resected T3 non-small cell lung cancer.

BACKGROUND The results of surgical treatment for non-small cell lung cancer with interlobar pleural involvement and direct invasion of the other lobe have seldom been documented. METHODS Of 1,130 consecutive patients who were operated on for primary bronchogenic carcinoma between 1984 and 1997, we studied 132 patients who had complete resection of T3 non-small cell carcinoma. RESULTS The structures involved were as follows: parietal pleura, 49 patients; chest wall, 45; interlobar pleura, 19; main bronchus within 2 cm of the carina, 11; mediastinal pleura, 6; and diaphragm, 1. Patients with N2 disease had a significantly worse survival than those with N0 (p = 0.0054) and N1 disease (p = 0.0165). The survival of patients with involvement of the interlobar pleura was significantly worse than that of patients with T1 (p = 0.0001) or T2 disease (p = 0.0484), and was similar to that of patients with T3 disease (p = 0.9821). CONCLUSIONS In patients with T3 disease, mediastinal lymph node involvement influenced survival significantly. Patients with involvement of the interlobar pleura should be regarded as having T3 lesions.

Surgical treatment for chronic pleural empyema

Various surgical procedures have been developed in an attempt to alleviate the significant problems caused by chronic pleural empyema. The present study evaluates our 11-year experience of employing a number of therapeutic approaches for chronic empyema. Between 1987 and 1997, 45 consecutive patients underwent treatment for chronic empyema at our hospitals. They comprised 21 patients (47%) presenting with post-tuberculosis, 11 (24%) receiving cancer therapy including pulmonary resection, and 13 (29%) with postpneumonic empyema. Omentopexy, lung resection, and thoracoscopic surgery were performed in 10 (22%), 5 (11%), and 4 (9%) patients, respectively. Poor results of treatment were observed in two of the patients with post-tuberculous empyema, and three of the patients treated for cancer died of recurrence. The other 40 patients remain symptom-free. An improvement in quality of postoperative life was revealed by the exercise test rather than by static spirometry. Optimal therapy for chronic empyema requires selection of the most appropriate first and staged procedures for each patient. Moreover, lung resection should be minimal. In a critical state, open thoracostomy must be performed as the first procedure, while omentopexy or thoracoplasty should be restricted to selected cases. Dead space and minor air leakage may safely be left behind. A video-assisted procedure can be selected for postpneumonia empyema.

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.