In cases of right upper and lower bilobectomy, careful manipulation is required to avoid lung torsion, as only the right middle lobe remains in the right thoracic cavity. We report a case of successful right upper and lower bilobectomy with no torsion of the middle lobe. Our technique prevents postoperative lung torsion by fixing the lung to the chest wall and pericardial fat with silk threads. In situations where lung torsion is a concern after lung resection, fixing the remaining lungs with silk thread is effective in preventing lung torsion.

BACKGROUND:The nodal classification of lung cancer is determined by the anatomical location of metastatic lymph nodes (mLNs). However, prognosis can be heterogeneous at the same nodal stage, and the current classification system requires improvement. Therefore, we investigated the correlation between the number of mLNs and prognosis in patients with non-small cell lung cancer.METHODS:Using a multicenter database in Japan, we retrospectively reviewed the records of patients who underwent complete resection for lung cancer between 2010 and 2016. Kaplan-Meier curves were used to determine recurrence-free and overall survival. Multivariate analyses were performed using the Cox proportional hazards model.RESULTS:We included 1,567 patients in this study. We could show a statistically significant difference in recurrence-free survival between pN2 patients with 1 mLN and pN2 patients with ≥2 mLNs (P=0.016). Patients with a combination of pN1 (≥4 mLNs) plus pN2 (1 mLN) had a poorer prognosis than pN1 patients (1-3 mLNs) (P=0.061) and a better prognosis than pN2 patients (≥2 mLNs) patients (P=0.007). Multivariate analysis showed that the number of mLNs was independently associated with cancer recurrence in patients with pN1 and pN2 disease (P=0.034 and 0.018, respectively).CONCLUSIONS:Nodal classification that combines anatomical location and the number of mLNs may predict prognosis more accurately than the current classification system. Our study provides the concept that supports the subdivision of nodal classification in the upcoming revision of the tumor, node, and metastasis staging system.

OBJECTIVES:The objective of this study was to determine the variation in intrapleural pressure (IPP) with and without air leakage using a digital chest drainage system (DCS) for each pressure setting. METHODS:In this retrospective single-centre study, we analysed 49,553 h of air leakage after anatomical lung resection in 714 patients between 2018 and 2020. The transition of mean IPP and mean air leak flow was monitored using DCS, and the association between mean IPP and mean air leak flow was examined. The relationship between the transition of mean IPP and air leakage according to the varying suction pressures on DCS was also investigated. RESULTS:Overall, 272 patients (38.1%) showed air leakage after surgery. The mean IPP in patients without air leakage was -12.0 ± 2.9 cmH2O and maintained at about -12 cmH2O constantly, while the mean IPP in patients with air leakage was -8.3 ± 1.9 cmH2O, which changed to -12 cmH2O instantly if air leakage disappeared (P < 0.001). Among patients with air leakage, the mean IPP changed more distinctly in patients with mild suction management than in those with conventional suction management (-5.0 ± 2.6 to -11.5 ± 4.2 and -8.8 ± 1.3 to -12.1 ± 2.5 cmH2O, respectively; P < 0.001). CONCLUSIONS:The change in IPP on a DCS is useful for detecting air leakage. Furthermore, management with a mild suction setting on DCS makes it easy to recognize the disappearance of postoperative air leakage.

Objectives This study was designed to investigate whether the outcomes of adjuvant chemotherapy are affected by the lung adenocarcinoma predominant (AP) in stage IB according to the 8 th UICC staging system. Methods From 2008 through 2015, 293 patients with pathological stage IB who were ≤ 75-year-old and underwent lobectomy were studied. The relations of clinicopathological factors were investigated by propensity score matching. Results The median follow-up period was 66.0 months. The cases of AP were followed: lepidic 96, acinar 71, papillary 54, solid 45, micropapillary 3 and others 17. Adjuvant chemotherapy with UFT was performed in 70 cases (23.9%). Recurrence-free survival at 5 years (RFS) was 72.2%. Lymph vessel invasion (ly+), vascular vessel invasion (v+), pleural invasion (pl+) and non-lepidic statistically affected RFS. Multivariate analysis showed that only AP (non-lepidic) was significant (hazard ratio; HR=2.006 (1.104-3.644)). Overall survival (OS) rate at 5 years was 83.5%. ly+, v+, pl+, EGFR mutation status and AP affected OS. In multivariate analysis, only non-lepidic was left (HR=2.888 (1.231 - 6.774)). After matching AP, adjuvant chemotherapy did not have an impact on RFS or OS (p=0.992, 0.616). In lepidic, both adjuvant and non-adjuvant had excellent outcomes in RFS (84.8% and 92.9%, p=0.574) and OS (100% vs 100%, p=0.361). In non-lepidic group, adjuvant therapy tended to show slightly, but not significantly better RFS (71.5% vs, 60.6%, p=0.177). Conclusion Lepidic predominant showed excellent outcomes, adjuvant chemotherapy is not necessary. For non-lepidic predominant, UFT remains standard adjuvant chemotherapy in Japan.

BACKGROUND:The Oncomine Dx Target Test (ODxTT) is a next-generation sequencing-based companion diagnostic test which has been recently developed; however, its analysis success rate could be improved, especially for small samples. The aim of this study was to identify the pathological factors associated with biopsy specimens that affect the analysis success rate of ODxTT. METHODS:We retrospectively investigated 119 cases subjected to ODxTT at Kanagawa Cancer Center. Data pertaining to the results of BRAF V600E mutation analysis in ODxTT and pathological factors based on microscope slides were collected. Pathological factors including tissue surface area, tumor cell count, and tumor content rate were assessed. We constructed receiver operating characteristic curves and determined the optimal cutoff values of each pathological factor. Multivariate logistic analysis was used to identify significant factors. RESULTS:A total of 98 of 119 samples were successfully analyzed (75.6%). The tissue surface area and tumor cell count were significantly higher in the group associated with analysis success (P < 0.001 and P = 0.011, respectively), and their optimal cutoff values were 1.04 mm2 and 375 cells, respectively. A tissue surface area > 1.04 mm2 and tumor cell count >375 cells had a positive effect on the analysis success rate of ODxTT (odds ratio [OR] 0.10; 95% confidence interval [CI]: 0.03-0.35; P < 0.001 and OR 0.25; 95% CI: 0.07-0.90; P = 0.033, respectively). CONCLUSIONS:Selecting samples with a tissue surface area > 1.04 mm2 and a tumor cell count >375 cells might improve the analysis success rate of ODxTT. KEY POINTS:Significant findings of the study: We found that a tissue surface area > 1.04 mm2 and tumor cell count >375 cells had a positive effect on the analysis success rate of ODxTT in the analysis of biopsy tissue samples. WHAT THIS STUDY ADDS:It is sometimes necessary to assess genetic alterations with a small biopsy sample in daily practice. The criteria mentioned above will help to determine which tests should be performed, ODxTT or multiple single-gene testing.

Background: Bronchopleural fistula (BPF) remains a serious complication after surgery for lung cancer with bronchial resection. A free pericardial fat pad (FPFP) is applied in high-risk cases to reduce BPF frequency. BPF may occur 6 months after surgery. Thus, we evaluated the residual FPFP volume at 6 months after surgery to estimate the residual FPFP ratio and determine the amount of FPFP to be harvested during surgery. Methods: We retrospectively investigated 40 patients who underwent lobectomy with bronchial stump coverage using FPFP. During surgery, the volume of the harvested FPFP was measured and the FPFP was affixed to the bronchial stump. Further, 6 months after surgery, the residual volume of the installed FPFP was analyzed using a three-dimensional volume analyzer and the residual ratio was calculated. We also evaluated clinicopathological factors influencing the resected FPFP and residual ratio. Results: The median resected FPFP volume was 11 [3-40] mL. During multivariate analysis, body mass index and surgical approach were found to be significant factors associated with the resected FPFP volume. The median residual FPFP volume was 4.3 (0.4-15.5) mL. The median residual ratio was 0.39 (0.13-0.66). The resected FPFP volume was significantly associated with the residual volume (P<0.001) but not with the residual ratio (P=0.811). No factor was associated with the residual ratio. Conclusions: In all cases, residual FPFP was confirmed at 6 months after surgery and the residual ratio was 40%. It is necessary to determine the volume of FPFP to be harvested while carefully considering the shrinkage ratio.

Background The category of grade 3 neuroendocrine tumor (NET G3) was newly introduced in the 2017 World Health Organization (WHO 2017) classification of neuroendocrine neoplasms of the pancreas. Pancreatic NET G3 shows a carcinoid-like morphology with high proliferative activity and the prognosis is intermediate between NET G2 and neuroendocrine carcinoma. There is no category corresponding to NET G3 in the current WHO 2015 classification of lung tumors. Herein, we report two cases of lung neuroendocrine carcinoma with carcinoid morphology that correspond to NET G3. Case presentation Case 1: An abnormal chest shadow was detected in a 78-year-old female never-smoker during a routine medical examination. She was asymptomatic. The radiological assessment revealed a mass in the peripheral S4 segment of the right lung. She underwent right middle lobectomy for the mass preoperatively diagnosed as non-small cell lung carcinoma. Postoperative histological examination revealed a neuroendocrine tumor with carcinoid morphology and a mitotic count of 15/2 mm 2 . Case 2: An abnormal chest shadow was detected in a 74-year-old female never-smoker undergoing follow-up for another disease. She was asymptomatic. The radiological assessment revealed a mass in the peripheral S3 segment of the right lung. She underwent right upper lobectomy for the mass suspected to be lung carcinoma. Postoperative histological examination revealed a neuroendocrine tumor with carcinoid morphology with mitotic count of 13/2 mm 2 . Both of these tumors showed carcinoid morphology but with a mitotic count exceeding 10/2 mm 2 ; thus, we diagnosed them as small cell lung carcinomas according to the current WHO 2015 classification. Conclusions Our tumors occurred in female never-smokers and their histology showed carcinoid morphology without extensive necrosis. Moreover, proliferative abilities of them were extremely low compared to small cell lung carcinoma. The clinical and pathological features of our tumors appeared to be different from those of small cell lung carcinoma. Although there is no category corresponding to NET G3 in the current classification of lung tumors, we consider that our tumors may correspond to NET G3 and identification of this subset is relevant for therapeutic management.

ObjectivesThe aim of this study was to analyze the accuracy of computed tomography (CT) and F-18 fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) to distinguish lepidic growth adenocarcinoma (LGA), including adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), and lepidic-predominant adenocarcinoma, all of which have favorable survival outcomes, from the more aggressive and invasive non-LGA subtypes.Materials and MethodsWe identified 225 patients with c-0/I adenocarcinoma of the lung who underwent PET/CT and 3DCT followed by complete resection. Maximum standardized uptake values (SUVmax) of FDG and several histogram parameters were analyzed. Histological grades were classified according to the predominant subtype (G1: lepidic; G3: micropapillary or solid; and G2: subtypes other than G1/G3).ResultsThe proportion of pathological invasive factors (lymphatic vessel involvement/blood vessel invasion/pleural invasion/lymph node metastasis) of patients with preinvasive adenocarcinoma, G1, G2, and G3 tumors were 0%, 3.6%, 48.0%, and 100%, respectively; p <  0.001). Multivariate analysis with CT-related parameters demonstrated that 75th percentile CT attenuation value (75th%, p <  0.001) and maximum CT attenuation value (maxCT, p =  0.009) were associated with incidence of non-LGA, whereas the value of SUVmax demonstrated a significant correlation (p <  0.001). When all patients were dichotomized according to ground-glass opacities (GGO)/solid-dominancy for CT maximum diameter, a significant correlation with non-LGA was shown in patients with solid-dominant tumor on SUVmax (p <  0.001) and with GGO-dominant tumor on 75th% (p =  0.006) and maxCT (p =  0.007). The combination of one of the two significant histogram parameters and SUVmax revealed higher predictive performance for pathological high malignant features (positive pathological invasive factors, non-LGA, and the highly malignant subtype covering G2 with moderately or poorly-differentiated carcinoma and G3) than the individual use of either factor.ConclusionThe 75th%, maxCT, and SUVmax were highly useful in distinguishing LGA from non-LGA in c-0/I adenocarcinoma.

Fire in the operation room is an example of a never event, which should never happen. An oxidizer, fuel, and ignition source are necessary for a fire and these all exist in the operating room (1). General anesthesia requires the use of 100% oxygen.

Background: The second-generation photosensitizer NPe6 has strong anti-tumor effects with a much shorter photosensitive period than the first-generation photosensitizer Photofrin. Although photosensitive period has been reduced, skin photosensitivity is still a major side effect of photodynamic therapy (PDT). Therefore, we conducted a prospective study to investigate whether the NPe6 fluorescence intensity in skin after PDT could be measured effectively in human patients to improve the management of a patient's photosensitive period. Methods: The NPe6 fluorescence measurements using a constructed fluorescence sensing system at the inside of the arm were acquired prior to and 5 and 10 min after NPe6 administration as well as at the time of PDT (4-5 h after administration), at discharge (2 or 3 days after PDT), and at 1 or 2 weeks after PDT. Participants were interviewed as to whether they had any complications at 2 weeks after PDT. Results: Nine male patients and one female patient entered this study. Nine patients were inpatients and one patient was an outpatient. All of the measurements of NPe6 fluorescence in the skin could be obtained without any complications. The spectral peak was detected at the time of discharge (2-3 days after administration) in most cases and it decreased at 1 or 2 weeks after PDT. Conclusions: The fluorescence of NPe6 in the skin could be detected feasibly using the fluorescence sensing system in human patients. Measuring the relative concentration of NPe6 in the skin indirectly by measuring fluorescence intensity might be useful to predict the period of skin photosensitivity after PDT.