Yoshito Yamada

Severity of chronic obstructive pulmonary disease and its relationship to lung cancer prognosis after surgical resection.

OBJECTIVEnThe purpose was to determine the rates of postoperative pulmonary complications, and to clarify the impact of COPD on long-term survival in lung cancer patients after surgical resection.nnnMETHODSnA retrospective chart review was performed on 1,461 patients who had undergone pulmonary resection for lung cancer from 1990 to 2005. Classification of COPD severity was based on spirometric guidelines of the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Postoperative complication rates among the four COPD groups were compared and long-term overall and disease-specific survivals were analyzed.nnnRESULTSnThe frequencies of all pulmonary complications in three COPD groups were higher than in the non-COPD group (all p < 0.05). Overall and disease-specific survivals were significantly worse in relation to higher COPD grades (all p ≤ 0.05). Significant prognostic factors were age, body mass index, positive smoking history, tumor size, pneumonectomy, pathologic stage, and COPD grade (p < 0.05).nnnCONCLUSIONnHigher COPD grades had higher rates of postoperative pulmonary complications and poorer long-term survivals because of higher rates of cancer-related deaths.

Trends of bacterial colonisation and the risk of postoperative pneumonia in lung cancer patients with chronic obstructive pulmonary disease

BACKGROUNDnLung cancer patients with chronic obstructive pulmonary disease (COPD) have a high risk of developing postoperative pneumonia (POP). This study aims to investigate the impact of COPD on POP and the trends for perioperative bronchial colonisation by micro-organisms.nnnMETHODSnA retrospective chart review was made for 626 patients who underwent lung cancer surgeries at the Chiba University Hospital between 1996 and 2005. The patients were categorised as non-COPD (n=475) and COPD (forced expiratory volume in 1s/forced vital capacity (FEV1/FVC) <70%; n=151). All the patients had sputum and bronchial bacterial cultures examined for potentially pathogenic micro-organisms (PPMs). Risk factors for POP and mortality were analysed.nnnRESULTSnPatients with COPD had a significantly higher incidence of POP (23/151, 15.2%) than those without COPD (17/475, 3.6%) (p<0.0001). Preoperative bronchial bacterial examinations showed that 50 of 475 patients without COPD (10.5%) had positive cultures, while the results for 30 of 151 patients with COPD (19.9%) were positive (p=0.0111). Only 31 of 548 patients (5.7%) who did not show any preoperative PPMs had POP, while nine of 78 patients (11.5%) who presented preoperative PPMs had POP (p=0.0469). The PPMs that emerged postoperatively were primarily Staphylococcus aureus (and Gram-negative bacilli (94.4% of PPMs), while they were seen less frequently preoperatively (46.5% of PPMs). Multivariate analysis demonstrated that advanced age and FEV1/FVC were independent risk factors for POP. Patients with POP had significantly worse long-term survivals than those without POP (p=0.0004).nnnCONCLUSIONnCOPD was a risk factor for POP. Staphylococcus aureus and Gram-negative bacilli should be targets for postoperative prophylactic antibiotic selection. Patients with POP had poor long-term survivals.

Long-term Surgical Outcome in Patients with Lung Cancer and Coexisting Severe COPD

BACKGROUNDnThe functional criteria for curative surgery for patients with non-small cell lung cancer (NSCLC) and coexisting chronic obstructive pulmonary disease (COPD) remain controversial. We aimed to clarify long-term outcomes after resection.nnnMETHODSnBetween January 1990 and April 2005, 36 consecutive patients with NSCLC and severe COPD underwent pulmonary resection. All had severe (30-50 % pred FEV1) or very severe COPD (30 % > pred FEV1) preoperatively. Survival, short- and long-term complications were analyzed retrospectively. Prognostic factors were also analyzed.nnnRESULTSnThe 5-year survival rate of these patients was significantly worse than that of patients with better pulmonary function (50 % < pred FEV1) ( P < 0.0001). Patients with interstitial pneumonia (IP) had a significantly poorer prognosis ( P = 0.0099). With regard to long-term complications three months after surgery, 30 % of patients reported worsening of dyspnea, and 20 % experienced pneumonia recurrence. No deaths were related to COPD progression.nnnCONCLUSIONnPatients with stage IA NSCLC and severe COPD may undergo curative surgical resection; however, postoperative complications and long-term survival remain unsolved problems. IP is a contraindication for surgery in patients with severe COPD.

Efficacy of perioperative high-dose prednisolone therapy during thymectomy in myasthenia gravis patients

BackgroundThis study aimed to investigate the benefits of administering perioperative high-dose prednisolone in conjunction with thymectomy in patients with myasthenia gravis.MethodsWe retrospectively reviewed data from patients with Myasthenia Gravis Foundation of America Clinical Class I to IIIB who had undergone an extended thymectomy between 1992 and 2009. Perioperative high-dose prednisolone was administered at starting doses of 10 to 20xa0mg and escalated up to 100xa0mg on alternate days. The treatment group comprised 70 patients receiving perioperative high-dose prednisolone, whereas the control group included 61 patients not treated with preoperative steroids. The two groups were compared with respect to baseline clinical characteristics, incidence of postoperative complications, and follow-up disease status.ResultsPrednisolone-treated patients presented with more advanced disease compared to controls (Class IIB or greater, 42 [60.0%] versus 7 [11.3%], respectively; Pu2009<u20090.001). Mean preoperative%FVC was lower and FEV1.0% was higher in treated patients than in controls (%FVC: 92.4u2009±u20092.3% versus 99.5u2009±u20092.4%, respectively; Pu2009=u20090.037, FEV1.0%: 85.2u2009±u20091.3% versus 81.4u2009±u20090.9%, respectively; Pu2009=u20090.017). The groups were similar in other variables including presence of thymoma, and operative procedure. In the treatment group, disease status was significantly improved only by the induction of high-dose prednisolone before the surgery (Pu2009<u20090.001), and these patients discontinued anti-cholinesterase therapy more frequently than controls (Pu2009<u20090.001). Moreover, the treatment group demonstrated markedly lower rates of postoperative crisis (12.2% versus 2.9%, respectively; Pu2009=u20090.045). The incidence of infection, wound dehiscence, and diabetes mellitus were comparable between groups. Survival analysis demonstrated higher rates of treated patients with improved disease status at three and five years (92% and 96%, respectively) compared to controls (57% and 76%, respectively; Pu2009<u20090.001). Likewise, significantly greater proportions of treated patients achieved complete stable remission or pharmacologic remission at three, five, and ten years (23%, 42%, and 72%, respectively) compared to controls (10%, 20%, and 44%, respectively; Pu2009=u20090.002).ConclusionsPerioperative high-dose prednisolone therapy is a safe, promising strategy for managing patients with myasthenia gravis and may reduce the incidence of postoperative crisis while improving disease status.

Risk factors for developing postthymectomy myasthenia gravis in thymoma patients

BACKGROUNDnThymoma patients with no prior history of myasthenia gravis (MG) occasionally have MG after thymectomy. This study aimed to identify risk factors for developing postthymectomy MG.nnnMETHODSnWe retrospectively reviewed the characteristics and clinical outcomes of thymoma patients without preoperative MG who underwent a thymectomy at our institute.nnnRESULTSnOf the 229 thymoma patients who underwent surgery from 1991 to 2011, 123 had no history of MG. The serum of all patients was analyzed for acetylcholine receptor antibodies (AchR-Ab), and 33 patients had detectable levels (greater than 0.2 nmol/L). Ten seropositive patients had MG develop postoperatively within 3 to 2,859 days, whereas 90 seronegative patients did not. Univariate analysis showed that a positive result for serum AchR-Ab (p < 0.001), type B1/B2/B3 thymoma histology (pxa0= 0.025), and incomplete resection (pxa0= 0.008) were risk factors for the development of MG. In patients with post-thymectomy MG, the AchR-Ab levels at the onset of MG were significantly higher than the preoperative levels (pxa0= 0.036). The analysis of the 33 antibody-positive patients showed a significant correlation between antibody levels and the onset of disease (pxa0= 0.003). The analysis of 12 patients with incomplete resection revealed that perioperative chemotherapy or radiotherapy reduced the risk of development of MG (pxa0= 0.009).nnnCONCLUSIONSnA positive result for serum AchR-Ab, type B1/B2/B3 thymoma histology, and incomplete resection were considered risk factors for the development of postthymectomy MG. Preoperative levels of serum AchR-Ab should be examined in all thymoma patients. Perioperative chemotherapy or radiotherapy for the patients with incomplete resection might reduce the risk of MG development.

Surgical Outcomes of Patients With Stage III Thymoma in the Japanese Nationwide Database.

BACKGROUNDnTo investigate the clinical characteristics and therapeutic outcomes of patients who underwent surgery for stage III thymoma in Japan.nnnMETHODSnUsing the Japanese nationwide database, which contains the records of 2,835 patients with thymic epithelial tumors who underwent treatment between 1991 and 2010, we extracted and analyzed the records of those who underwent surgery for stage III thymoma.nnnRESULTSnA total of 310 patients (170 males, 140 females; median age, 58 years) were analyzed. Involved sites were the lung in 194 (62.6%), the pericardium in 151 (48.7%), the great vessels in 126 (40.6%), the phrenic nerve in 84 (27.1%), and the chest wall in 7 (2.3%). Complete resection (R0) was achieved in 247 (79.7%) cases. Induction therapies were administered to 42 (13.5%) patients, and postoperative therapies were administered to 147 (47.4%). In R0 cases, 68 (27.5%) experienced recurrence. The pleural space was the most frequent site of recurrence (46; 18.6%). The 10-year overall and disease-free (in R0) survival rates were 80.2% and 51.6%, respectively. Multivariate analyses revealed that age (pxa0= 0.002), male sex (pxa0= 0.017), induction therapy (p < 0.001), and type B histology (pxa0= 0.037) were independent adverse predictors for overall survival. Chest wall invasion was the only independent adverse predictor for disease-free survival, although the factor analysis was marginal for overall survival.nnnCONCLUSIONSnThe outcomes of surgery for patients with stage III thymoma were favorable unless chest wall invasion was present; however, the role of complete resection and appropriate multimodal treatment plan require further investigation.