[Sleeve Resection for Right Upper Lobe Non-small Cell Lung Cancer After Systemic Chemotherapy and Immune Checkpoint Inhibitor Administration]

A man in his 50s was diagnosed with right upper lobe non-small-cell lung cancer (cT3N1M0, stage ⅢA) on bronchoscopy. The tumor was located at the right hilum and was bordered extensively on the pulmonary artery. We observed significant tumor shrinkage (ycT1bN1M0, stage ⅡB), following three cycles of systemic chemotherapy combined with an immune checkpoint inhibitor and performed right upper sleeve lobectomy + ND2a-2 via thoracotomy for radical resection. Postoperative histopathological examination showed no residual tumor cells, and the patient was deemed to have a histopathologic complete response. Currently, the patient is being followed up without adjuvant chemotherapy. Several recent studies have reported the usefulness of systemic chemotherapy combined with immune checkpoint inhibitor administration as preoperative induction chemotherapy. However, the role of adjuvant immunotherapy in patients with a histopathologic complete response remains unclear, and careful treatment decision-making is important.

Mediastinal lymph node evaluation, especially at station 4L, in left upper lobe lung cancer

Background

Mediastinal lymph node (LN) dissection during lung resection is essential for accurate staging. Station 4L dissection is anatomically difficult. Therefore, care should be taken to avoid complications. We investigated the importance of mediastinal LN dissection in left upper lobe lung cancer and evaluated intraoperative videos to identify relevant steps during dissection.

Methods

We retrospectively reviewed 151 consecutive patients with left upper lobe lung cancer. Finally, 139 patients were enrolled to examine the survival effects of clinical factors of metastatic LN stations. The association between risk factors or surgical procedures and recurrent laryngeal nerve palsy was analyzed.

Results

LN dissection of the left upper lobe revealed station 4L LN metastasis in nine patients, three of whom were node-negative on mediastinoscopy. Station 4L LN status was confirmed intraoperatively in 12 of 33 patients. Twenty patients had recurrent laryngeal nerve palsy, four of whom were complicated with aspiration pneumonia. Station 4L LN dissection was an independent risk factor for recurrent laryngeal nerve palsy (P=0.03). The use of an energy device near the recurrent laryngeal nerve was a significant risk factor for recurrent laryngeal nerve palsy. Incidentally, pathological N stage ≥2 was an independent prognostic factor for disease-free survival (DFS) (P=0.005) herein.

Conclusions

In patients with left upper lobe lung cancer, pathological N2 disease is an important predictor of recurrence. Therefore, accurate mediastinal LN dissection, including at station 4L, should be performed. We propose to standardize the dissection procedure at each institution to avoid complications, such as recurrent laryngeal nerve palsy.

The risk of footswitch misstep during robot-assisted thoracoscopic surgery: a case report

The Da Vinci Surgical System is an ergonomically devised and excellent surgical support device. However, surgeon skill is of paramount importance since human error cannot be completely eliminated. We report a case of bleeding from the pulmonary artery due to a footswitch misstep. A 72-year-old male with suspected right upper lobe lung cancer underwent robot-assisted thoracoscopic surgery (RATS). While avoiding the pulmonary artery with the right arm spatula and trying to cauterize V2t with the left arm bipolar-forceps, the footswitch was accidently activated and the spatula was energized, resulting in pulmonary artery trauma and blood loss. After this case, we changed the surgical procedure from a monopolar-bipolar combination use to a bipolar-only use and noted no significant difference in the console duration, and less intraoperative blood loss. Human errors can occur anytime. Especially for surgeons new to RATS, simplified foot management should be considered until RATS mastery is achieved.

[Experience of Treatment for Pneumothorax with Coronavirus Disease 2019( COVID-19) Pneumonia]

A 73 years old male patient with the past history of kidney transplantation was admitted to our hospital for treatment of coronavirus disease 2019 (COVID-19) pneumonia. On the 25th day after the onset of symptoms when his condition was improving, he suddenly developed pneumothorax. Chest tube drainage was performed and connected the tube to the drainage device using a high efficiency particulate air (HEPA) filter. Because of the improvement of infection, the HEPA filter was removed from the drainage device on day 28. Chest tube drainage was continued by day 35, and he was discharged and introduced home oxygen therapy on day 51.

Perioperative changes in respiratory impedance in lobectomy and their clinical impact

Background

Respiratory function declines after lung resection. However, perioperative changes in respiratory impedance and their clinical significance are unclear. The forced oscillation technique can measure respiratory impedance during quiet breathing and possibly early after surgery. We investigated respiratory impedance changes before and after lung lobectomy and examined the correlation of impedance with clinical factors.

Methods

We prospectively included patients who underwent lobectomy between February 2018 and March 2020 and measured respiratory impedance by forced oscillation preoperatively and postoperative days 1 and 7. We statistically analyzed changes in perioperative forced oscillation measurements and their correlation with clinical factors, including subjective symptoms. The modified British Medical Research Council scale and the chronic obstructive pulmonary disease (COPD) assessment test were used for scoring subjective symptoms.

Results

Forty-four subjects were included, in whom respiratory impedance could be measured from postoperative day 1. The respective mean values for forced oscillation measurements preoperatively and at postoperative days 1 and 7 were as follows: respiratory resistance, 5 Hz: 2.28, 2.77, and 2.75; respiratory resistance, 20 Hz: 2.00, 2.36, and 2.32; difference in respiratory resistance at 5 and 20 Hz: 0.28, 0.40, and 0.43; respiratory reactance, 5 Hz: -0.31, -0.65, and -0.56; resonant frequency: 7.45, 10.41, and 9.81; and low-frequency reactance area: 1.33, 3.27, and 2.84. These changes were statistically significant (P<0.01). Besides the difference in respiratory resistance at 5 and 20 Hz, all other measurements on postoperative day 7 were relatively weakly correlated with the modified Medical Research Council scale score at this time point (all P<0.05). Respiratory complications correlated with the respiratory resistance difference, respiratory reactance, and resonant frequency on day 7 (R =0.415, -0.421, and 0.441), while the latter also correlated with postoperative hypoxemia on day 1 (R =0.433).

Conclusions

Respiratory impedance was measurable even early after surgery and significantly changed postoperatively. As the sample size was small and appeared to be biased, assessing respiratory impedance and clinical factors in detail was difficult. Since respiratory impedance is suggested to be associated with clinical factors that affect the postoperative course, it is necessary to accumulate cases and observe them over longer periods.

Dynamic perfusion digital radiography for predicting pulmonary function after lung cancer resection

Background

Accurate prediction of postoperative pulmonary function is important for ensuring the safety of patients undergoing radical resection for lung cancer. Dynamic perfusion digital radiography is an excellent and easy imaging method for detecting blood flow in the lung compared with the less-convenient conventional lung perfusion scintigraphy. As such, the present study aimed to confirm whether dynamic perfusion digital radiography can be evaluated in comparison with pulmonary perfusion scintigraphy in predicting early postoperative pulmonary function and complications.

Methods

Dynamic perfusion digital radiography and spirometry were performed before and 1 and 3 months after radical resection for lung cancer. Correlation coefficients between blood flow ratios calculated using dynamic perfusion digital radiography and pulmonary perfusion scintigraphy were then confirmed in the same cases. In all patients who underwent dynamic perfusion digital radiography, the correlation predicted values calculated from the blood flow ratio, and measured values were examined. Furthermore, ppo%FEV1 or ppo%DLco values, which indicated the risk for perioperative complications, were examined.

Results

A total of 52 participants who satisfied the inclusion criteria were analyzed. Blood flow ratios measured using pulmonary perfusion scintigraphy and dynamic perfusion digital radiography showed excellent correlation and acceptable predictive accuracy. Correlation coefficients between predicted FEV1 values obtained from dynamic perfusion digital radiography or pulmonary perfusion scintigraphy and actual measured values were similar. All patients who underwent dynamic perfusion digital radiography showed excellent correlation between predicted values and those measured using spirometry. A significant difference in ppo%DLco was observed for respiratory complications but not cardiovascular complications.

Conclusions

Our study demonstrated that dynamic perfusion digital radiography can be a suitable alternative to pulmonary perfusion scintigraphy given its ability for predicting postoperative values and the risk for postoperative respiratory complications. Furthermore, it seemed to be an excellent modality because of its advantages, such as simplicity, low cost, and ease in obtaining in-depth respiratory functional information.

Trial registration

Registered at UMIN on October 25, 2017. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_his_list.cgi?recptno=R000033957

Registration number: UMIN000029716

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02158-w.

Survival and prognostic factors in patients undergoing extended pulmonary metastasectomy

Extended pulmonary metastasectomy has become feasible in patients with extrapulmonary metastases and multiple or bilateral pulmonary metastases. Even peritoneal dissemination is considered to be curable in modern medicine. Therefore, it is necessary to analyze the prognosis of patients undergoing complete pulmonary metastasectomy. A total of 80 patients who underwent pulmonary resection for lung metastases were retrospectively analyzed. The eligibility criteria for the present study were as follows: i) the primary tumor was controlled; ii) if extrapulmonary metastases (including peritoneal dissemination) existed, these were controlled by local treatment or such treatment was planned; iii) the one to three months follow-up computed tomography (CT) following the first assessment revealed no increase of pulmonary metastatic disease; iv) pulmonary metastases could be resected completely. The overall 5- and 10-year survival rates were 71.7 and 41.5%, respectively. Applying the extended criteria for surgery, the present study demonstrated that pulmonary metastasectomy resulted in a good patient prognosis.

Sarcopenia predicts poor postoperative outcome in elderly patients with lung cancer

PURPOSE

Sarcopenia gradually progress with age; hence, it is necessary to define sarcopenia to predict postoperative outcomes in elderly patients with lung cancer. The purpose of this study is to propose a definition of sarcopenia in elderly patients with lung cancer, and to demonstrate the post operative outcomes.

METHODS

Using computed tomography scans, the cross-sectional area (cm²) of the psoas muscle at the third lumbar vertebral level was measured. The psoas area was normalized for height. The psoas muscle mass index was calculated as total psoas muscle area at L3 level/height² (cm²/m²).

RESULTS

A total of 173 patients aged > 75 years of age received lobectomy for non-small cell lung cancer in our hospital. We defined sarcopenia as the psoas muscle mass index under 3.70 cm²/m² in males and 2.50 cm²/m² in females, based on the morbidity rate. The postoperative complication rate was significantly higher in patients with sarcopenia (62.5%) than in those without sarcopenia (22.7%). The 5-year survival rate was 26.5% in patients with sarcopenia, and 66.3% in patients without sarcopenia.

CONCLUSIONS

In elderly lung cancer patients, sarcopenia was observed to be a high risk for morbidity and predicted poor prognosis.

Patient Survival after Surgical Management in Intrathoracic Pseudomyxoma peritonei

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare disease, characterized by mucinous ascites and deposits diffusely present on the peritoneal surfaces. However, extension of PMP to the thoracic cavity is extremely rare. Although there are a few case reports on the long-term postoperative prognosis of intrathoracic lesions, whether surgical resection of these lesions can improve patient prognosis remains unclear.

METHODS

We reviewed 17 patients with PMP who underwent resection of intrathoracic lesions after abdominal cytoreductive surgery and examined their clinical outcome after surgery.

RESULTS

Direct extension into the pleural cavity was identified in 11 patients. Extrapleural pneumonectomy of the lesions followed by hyperthermic intrathoracic chemotherapy (HITOC) was performed in four patients, parietal pleurectomy and visceral tumor resection followed by HITOC in four patients, resection of all disseminated pleural and visceral lesions followed by HITOC in one patient, resection of a single disseminated lesion in one patient, and composite resection of basal segment with the diaphragm in one patient. Pulmonary metastases were found in six patients. Partial resection was performed in four patients, segmentectomy in one patient, and lobectomy in one patient. We could perform macroscopic resection of the tumor in all the cases. The 5-year overall survival rate after thoracic surgery for the 17 patients was 46.1% and relapse-free survival was 34.9%.

CONCLUSIONS

Resection of intrathoracic lesions of PMP after abdominal cytoreductive surgery achieved 5 years survival in at least 46.1% of the patients. Aggressive tumor resection should be considered for patients with PMP extending to thoracic cavity.

Aneurysm of the gastroduodenal artery

We report a case of gastroduodenal arterial aneurysm incidentally discovered by abdominal ultrasonogram, in which three-dimensional computed tomography (3D-CT) was useful for diagnosis. An 85-year-old man was hospitalized because of fever and liver dysfunction. Carcinoma of the papilla of Vater was diagnosed by endoscopic retrograde cholangio-pancreatography, while abdominal ultrasonogram and CT scan revealed a round mass measuring 6.2x4.1 cm on the ventral side of the pancreatic head. Three-dimensional CT demonstrated that the mass arose from a branch of the common hepatic artery and projected downward, indicating a gastroduodenal arterial aneurysm. During pancreatoduodenectomy and aneurysmectomy, it was confirmed that this aneurysm arose from the gastroduodenal artery.

[Perfusion study of the pulmonary hilar region by SPECT--normal cases]

Alveoli in the hilar region comprise the peripheral area containing daughter branches from subsegmental or one more divisional peripheral bronchi. Pulmonary perfusion in hilar region was examined by SPECT (single photon emission CT) in ten normal volunteers. ROI (region of interest) in the axial images were set in the hilar region, the upper, middle and lower lung fields with 10.8 mm thickness. Counts/one pixel (C/P) were calculated in these ROI. There was a tendency of C/P increase from upper to lower lung field. And there were no significant differences in C/P increase between hilar region and other axial fields. In the chronic obstructive pulmonary diseases, however, ventilation studies in the previous reports using Xe dynamic CT or PET (positron emission tomography) showed differences between outer region and hilar region. This method will be expected to evaluate the pulmonary perfusion not only in the whole lung but in different lung areas, including the hilar region in the chronic obstructive pulmonary diseases.