Postoperative bronchial fistula and anastomotic stenosis remain significant concerns in lung cancer surgery requiring bronchial reconstruction. Previous studies have shown that basic fibroblast growth factor (bFGF)-induced cartilage regeneration could stabilize anastomosis sites and replace conventional tissue coverage. To inform the optimal configuration of bFGF-based protocols, this study evaluated the relative mechanical effects of varying the number and arrangement of regeneration sites. We developed a mechanically equivalent two-dimensional finite element model based on rabbit tracheal anatomy, with material properties calibrated against quasi-static tensile measurements on whole-trachea component specimens. Stress distributions and principal stress directions were analyzed across configurations of 0, 2, 4, and 8 sites under two loading scenarios: 50% strain (postoperative environment) and 100% strain (surgical upper bound). Across both conditions, as few as two sites were sufficient to eliminate compressive stress at the anastomotic plane, redistribute hydrostatic and principal shear stresses to anchor the cartilage regions, and reduce the angular deviation of the maximum principal stress from the longitudinal axis by approximately 35-36%. Additional sites beyond two showed marginal benefit. The model further predicted that regenerated cartilage progressively suppresses tension-induced anastomotic contraction, with the loaded anastomotic diameter rising from approximately 79% of the cartilage diameter without regeneration to 91% with two sites and 95% with eight sites. While two sites provided sufficient mechanical support in this idealized analysis, the trachea-bronchial system's anatomical complexity suggests a four-point approach warrants further preclinical investigation. These findings provide a mechanical basis for validating cartilage regeneration protocols addressing both anastomotic stability and stenosis prevention.

Background: Predicting long-term outcomes after pulmonary metastasectomy for colorectal cancer remains challenging because existing prognostic methods lack precision. We developed and validated a prognostic scoring system derived from a major international meta-analysis to improve risk stratification and to evaluate the benefit of adjuvant chemotherapy across risk groups. Methods: Using a Japanese registry of 819 patients who underwent lung resection between 2010 and 2019, we constructed a 0-13-point score based on eight variables including tumor size, number, biological markers, and intrathoracic lymph node status, which may require intraoperative or pathological confirmation. Granular data on chemotherapy regimens, timing, and duration were unavailable. Patients were classified as low, intermediate, or high risk. The primary analysis used inverse probability of treatment weighting to adjust for baseline imbalances; however, only 819 of 1657 patients (49.4%) had complete prognostic data, introducing potential selection bias. Results: The score separated patients into three groups with distinct five-year survival rates: 81.1% (low), 67.8% (intermediate), and 59.1% (high). In high-risk patients, chemotherapy was associated with improved overall survival but did not delay recurrence. In low-risk patients, chemotherapy correlated with reduced recurrence-free survival, a finding that persisted after adjustment. Conclusions: This validated scoring system aids individualized surgical decision making by identifying patients unlikely to benefit from routine postoperative chemotherapy. Observed survival advantages in high-risk patients may reflect selection of fitter individuals rather than direct treatment effects, underscoring the need to address selection bias in future trials.

Hyalinizing clear cell carcinoma of lung is rare. In recent years, the increased numbers of case reports and its inclusion in the WHO 2021 classification have led to growing recognition of this tumor. However, it remains unclear whether there are associated underlying conditions, as histological observation around the tumor have not been documented in previous reports. We report a case of a bronchial hyalinizing clear cell carcinoma under suspicion of allergic bronchopulmonary aspergillosis (ABPA). At the distal side of tumor, we found eosinophil-rich mucoid impaction and eosinophilic pneumonia, and also a lesion with intermediate morphology between hyalinizing clear cell carcinoma and basal cells within bronchial inflammatory polyp-like tissue.

Pancreatic carcinoma (PC) and biliary tract carcinoma (BTC) may metastasize to the lungs, and surgical resection of these metastases should be considered in selected patients with controlled primary disease. This study evaluated the survival outcomes and prognostic factors in patients who underwent pulmonary metastasectomy for pancreatobiliary carcinoma. Seventy-eight patients who underwent lung metastasectomy between 1993 and 2019 were included in the Metastatic Lung Tumor Study Group of the Japan database. The clinicopathological characteristics including overall survival (OS), pulmonary metastasis-free survival (PmFS), and disease-free interval (DFI) from primary surgery to lung metastasectomy were analyzed. We included 41 men and 37 women with a mean age of 67 years. The primary cancers included 56 PC and 22 BTC cases. Partial resection was performed in 52 patients, segmentectomy in 16, and lobectomy in 10. Five-year OS was 38.3

PURPOSE:To evaluate the incidence, characteristics, and perioperative outcomes of pulmonary artery (PA) injury during lung cancer surgery using data from the Japanese National Clinical Database (NCD). METHODS:We analyzed patients who underwent lobectomy or segmentectomy for clinical stage I-III primary lung cancer registered in the NCD between 2018 and 2021. The clinicopathological features and perioperative outcomes were compared between patients with and without PA injury. Subgroup analyses were performed according to blood loss categories and the causes of mortality. RESULTS:PA injury occurred in 1,325 of 142,343 patients (0.9%). It was more frequent in older patients, those with a higher BMI, advanced-stage disease, and left upper lobe resections. PA injury was associated with longer operative duration, greater blood loss, and higher transfusion rates. Postoperative complications were more frequent in the PA injury group. Thirty-day mortality (1.2% vs. 0.4%) and operative mortality (1.5% vs. 0.6%) rates were higher. Mortality was notably higher when intraoperative blood loss exceeded 2000 mL, regardless of PA injury. A female sex, obesity, and cN0 status were more common among patients with PA injury-related mortality. CONCLUSIONS:Intraoperative PA injury occurred in nearly 1% of resections and it was associated with poor outcomes. A hemorrhage exceeding 2000 mL may therefore be a critical mortality marker.

Forgotten childhood foreign body aspiration may present in adulthood as chronic bronchial obstruction, creating substantial diagnostic challenges. A 45-year-old man with a history of recurrent pneumonia in childhood had an abnormal chest shadow on routine examination without recollection of choking episodes. Chest computed tomography demonstrated complete obstruction of the right basal bronchus with atelectasis. Bronchoscopy revealed inflammatory changes and an occluded bronchus with viscous secretions. Differential diagnosis included pulmonary sequestration, bronchial atresia, and malignancy. Right middle and lower bilobectomy was performed because malignancy could not be excluded. Pathological examination unexpectedly identified a 12-mm plastic air pistol pellet encapsulated by thick fibrous tissue, indicating retention exceeding 30 years. Foreign body aspiration should remain in the differential diagnosis of chronic bronchial obstruction even when patient history and all preoperative diagnostic modalities fail to suggest this aetiology, particularly in patients with childhood respiratory illness.

Ablation therapy is a minimally invasive local treatment that destroys tumor tissue. It has attracted attention as a treatment option for early-stage lung cancer and metastatic lung tumors. In this review, we provide an overview of the current status of treatment, technical characteristics, indications, and treatment results for three ablation methods for peripheral lung lesions: radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation (PCT). RFA is relatively simple to perform, but its therapeutic effect is limited in tumors near blood vessels due to the influence of heat diffusion by blood vessels and bronchi. MWA enables wide-range ablation in a short time compared to RFA and has the advantage of being less affected by blood vessels and bronchi. PCT enables easy confirmation of the ablation range because it can be visualized as an ice ball on computed tomography (CT) fluoroscopy and is less painful for the patient. It is characterized by the induction of tumor cell death by apoptosis and the preservation of tissue structure. The indications for ablation therapy are mainly early-stage non-small cell lung cancer (NSCLC) that is difficult to surgically resect. Patients with high surgical risk, such as elderly patients and patients with serious complications, are targeted. The combination of ablation therapy and immunotherapy is expected to have a therapeutic effect, and systemic antitumor effects through the release of tumor-associated antigens can be expected. In the future, further expansion of treatment options for lung cancer is expected with the development of optimal combination methods with immunotherapy and the development of transbronchial approaches.

Objectives: This study was aimed to identify risk factors for persistent air leak after chest tube placement for secondary spontaneous pneumothorax and to determine the optimal timing of treatment. Methods: We retrospectively analyzed 221 cases of secondary spontaneous pneumothorax in patients aged ≥50 years who were treated with chest tube drainage. Patients were categorized into the observation group or additionally treated group based on whether they received interventional treatment beyond chest tube drainage. Air leak resolution patterns were analyzed using hazard function analysis. Risk factors were evaluated using univariate and multivariate analyses. Results: Hazard function analysis revealed that the probability of air leak resolution decreased by approximately 50% within the first 5 days after the initiation of chest tube drainage, with only 33% of cases resolving by day 7. Beyond days 7–10, resolution probability stabilized at a minimal level. Multivariate analysis identified previous pneumothorax history (HR: 0.422, p = 0.007) and low geriatric nutritional risk index (GNRI) (HR: 2.521, p < 0.001) as significant independent risk factors for persistent air leak. Further analysis of early resolution (within 7 days) identified female sex (HR: 0.24, p = 0.003), absence of previous pneumothorax (HR: 0.21, p = 0.003), and higher GNRI values (HR: 1.04, p = 0.008) as positive predictors. Conclusions: Risk stratification based on pneumothorax history and nutritional status enables the optimization of the timing of intervention for persistent air leak. We recommend considering additional treatment between days 7 and 10 of chest tube drainage, with earlier intervention for high-risk patients. This approach may improve patient outcomes while avoiding unnecessarily prolonged conservative management.

Perilipin 2 expression is related to poor prognosis of patients with various malignant tumors. It exists on the surface of lipid droplets (LDs), which store lipids that can be used as an energy source during cancer progression. However, the underlying mechanism of lipid metabolism involving LDs in the progression of lung adenocarcinoma is unclear. This study investigated the role of perilipin 2 in the regulation of lipid metabolism in lung adenocarcinoma, as well as patient prognosis. In clinicopathologic analyses, high perilipin 2 expression in adenocarcinomas was significantly associated with poor differentiation, blood vessel and pleural invasion, advanced cancer stage, and large tumor size relative to perilipin 2-negative cases. Furthermore, patients with high perilipin 2 expression had significantly shorter recurrence-free survival times. LD accumulation was significantly reduced in A549 and PC-9 lung adenocarcinoma cells with clustered regularly interspaced short palindromic repeats/CRISPR-associated protein 9 (CRISPR/Cas9) genome editing-mediated knockout of PLIN2 expression. Treatment of these cells with extracellular oleic acid induced accumulation of LDs, but the total amount of accumulated LDs was low in PLIN2 knockout cells compared with control cells. Cell proliferation and migration ability was also significantly reduced in PLIN2 knockout cells. Together, these results suggest that perilipin 2 mediates aggressive cancer progression in lung adenocarcinoma by regulating LD accumulation, and thus may represent a potential target for suppressing lung adenocarcinoma.

Accurate measurement of lung adenocarcinoma is crucial for determining treatment plan and predicting prognosis. However, interobserver variability and display conditions can affect these measurements. We compared tumor size measurements between radiologists and commercially available AI-based software using preoperative CT images from 307 cases and evaluated their predictive value for lymph node metastasis, disease-free survival, and overall survival. We concluded that while radiologist measurements showed interobserver variability, AI-based software provided accurate and reproducible prognostic indicators. Purpose: To compare the variability of quantitative values from lung adenocarcinoma CT images independently assessed by 2 radiologists and AI-based software under different display conditions, and to identify predictors of pathological lymph node metastasis (LNM), disease-free survival (DFS), and overall survival (OS). Methods: Preoperative CT images of 307 patients were displayed under 4 conditions: lung-1, lung-2, mediastinum-1, and mediastinum-2. Two radiologists (R1, R2) measured total diameter (tD) and the longest solid diameter (sD) under each condition. The AIbased software automatically detected lung nodules, providing tD, sD, total volume (tV), and solid volume (sV). Results: All measurements by R1 and R2 with AI-based software were identical. Four out of the 8 measurements showed significant variation between R1 and R2. For LNM, multivariate logistic regression identified significant indicators including sD at mediastinum-2 of R1, sD at mediastinum-1 and mediastinum-2 of R2, tV, and the proportion of sV to tV (sV/tV) of AI-based software. For DFS, multivariate Cox regression identified sD at lung-1 of R1, the proportions of sD to tD at lung-2 of R1, sD at lung-2 and mediastinum-1 of R2, tV, and sV/tV of AI-based software as significant. For OS, multivariate Cox regression identified sD at lung-1 and mediastinum-2 of R1, tD at lung-2 of R2, sD at mediastinum-1 of R2, sV, and sV/tV of AI-based software as significant. Conclusion: Radiologists' CT measurements were significant predictors of LNM and prognosis, but variability existed among radiologists and display conditions. AI-based software can provide accurate and reproducible indicators for predicting LNM and prognosis.

Background/Objectives: Although surgeries employing cone-beam computed tomography (CBCT) for small lung lesions have been reported, the association between CBCT scan frequency and patient radiation exposure remains unclear. This study aimed to investigate patient radiation doses from CBCT during thoracic surgeries, and the patient radiation doses were compared with those from other preoperative marking methods. Methods: This multicenter prospective study included 81 patients who underwent surgery for small lung lesions requiring marking between January 2021 and June 2024 at three institutions. CBCT-guided surgeries involved the use of metal clips in a hybrid operating room with 1–4 scans, depending on the lesion. For other preoperative marking methods, hook-wire or virtual-assisted lung mapping (VAL-MAP) was used. Patient radiation doses were measured using wearable dosimeters at five anterior thorax sites, and the total dose was compared across methods. Results: The study included 81 patients: CBCT (n = 61), VAL-MAP (n = 10), and hook-wire (n = 10). CBCT cases were distributed as follows: single scan (n = 10), double scans (n = 34), triple scans (n = 15), and quadruple scans (n = 2). The radiation doses were 86.9 ± 61.7 mGy for hook-wire, 39.8 ± 27.5 mGy for VAL-MAP, and 11.0 ± 6.5 mGy for single-scan CBCT, 17.3 ± 7.8 mGy for double scans, 23.1 ± 14.0 mGy for triple scans, and 22.7 ± 0.1 mGy for quadruple scans. Although radiation exposure increased with more CBCT scans, performing up to triple scans resulted in significantly lower exposure compared to other methods. Conclusions: Intraoperative CBCT is a feasible and safe technique for identifying small lung lesions, providing lower radiation exposure compared to other preoperative localization methods.

BACKGROUND:The optimal management of pneumothorax remains controversial, with evolving evidence challenging the conventional approach of routine chest drainage. METHODS:We analyzed data of 1773 patients (956 with primary spontaneous pneumothorax [PSP], 817 with secondary spontaneous pneumothorax [SSP]) from a nationwide Japanese database. Multivariate and propensity score matching analyses identified factors associated with drainage requirement and compared outcomes between drainage and non-drainage groups. RESULTS:Pneumothorax grade was the most significant determinant of chest drainage requirement in both PSP (moderate: odds ratio [OR] 12.5, severe: OR 22.6 vs. mild, p < 0.001) and SSP patients (moderate: OR 16.1, severe: OR 26.9 vs. mild, p < 0.001), with chronic obstructive pulmonary disease being an additional factor in SSP (OR 3.04). PSP patients without drainage had shorter hospital stays (median: 6.0 vs. 8.0 days, p < 0.001) and more frequently underwent surgery. SSP patients without drainage had lower ICU admission rates and shorter hospitalization (median: 11.0 vs. 14.0 days, p < 0.001). The benefits of non-drainage were observed across all pneumothorax grades in PSP, while in severe SSP, drainage was associated with better outcomes. After matching for pneumothorax grade, non-drainage PSP patients had shorter stays in both non-surgical (median: 2 vs. 6 days, p < 0.001) and surgical subgroups (median: 5 vs. 8 days, p < 0.001). Mortality rates were comparable between groups. CONCLUSIONS:While pneumothorax grade remains the key determinant for chest drainage, carefully selected patients may be successfully managed without drainage, with shorter hospital stays without compromising outcomes. Refined criteria for non-drainage management could improve resource utilization and patient experience.

OBJECTIVES:Non-small-cell lung cancer (NSCLC) lesions appearing solid on imaging are highly likely to be malignant. However, "solid" has a subjective definition. This study aimed to determine whether artificial intelligence (AI)-based imaging analysis can offer a more objective and clinically meaningful definition of solid tumours, specifically in regards to lymph node metastasis and prognosis. METHODS:This study included 216 patients with cN0 lung adenocarcinoma (pathological invasive diameter ≤ 30 mm) who underwent lobectomy with lymph node dissection. AI software was used to calculate the consolidation-to-tumour diameter (cD/tD) and volume (cV/tV) ratios, which were then compared with radiologist-defined cD/tD. To determine the optimal cutoff values, correlations between the pathological invasive diameter/tumour diameter ratio (PathoiD/tD) and lymph node metastasis were evaluated. Subsequently, these values were applied to a subset of tumours measuring ≤20 mm (n = 117) to determine their potential use in candidate selection for limited resection. RESULTS:A cV/tV cutoff value of ≥0.72 accurately predicted lymph node metastasis and improved concordance between AI and radiologist solid tumour assessment while maintaining a similar PathoiD/tD to the conventional (cD/tD = 1.0) threshold. Among tumours measuring ≤20 mm in the low solid-component group (cV/tV <0.72), lymph node metastases were not observed; the 5-year recurrence-free survival rate was 100%. CONCLUSIONS:An AI-based volumetric analysis using a cV/tV threshold of ≥0.72 showed potential for predicting lymph node metastasis in this single-centre retrospective study of lung adenocarcinoma ≤30 mm. External validation in diverse, multicentre cohorts is essential before clinical implementation.

Background/objectives: The efficacy of lung metastasectomy in patients with urothelial carcinoma remains inconclusive, as there is only limited evidence from small studies. In this study, we aimed to assess the prognostic outcomes of excising pulmonary metastases from urothelial carcinoma. Methods: In this study, we utilized data from the Metastatic Lung Tumor Study Group of Japan database, a multi-institutional prospective database of pulmonary metastasectomies. We examined the data of patients who had undergone pulmonary metastasectomy for urothelial carcinoma between 1985 and 2021. Exclusion criteria included insufficient clinical information and follow-up of <3 months. Results: The study cohort comprised 100 patients (63 bladder cancer, 37 renal pelvic and ureteral cancer), with a median follow-up of 34 months. There were 70 male and 30 female patients of average age 66.5 ± 10.4 years at lung metastasectomy. The median interval from treatment of the primary lesion to metastasectomy was 19 months and the maximum tumor diameter was 21 ± 15 mm. Three- and five-year overall survival rates were 69% and 59%, respectively. Three- and five-year disease-free survival rates were 56% and 46%, respectively. Multivariate analysis identified larger tumor diameter (hazard ratio: 1.62, 95% confidence interval: 1.21–2.17) and distant metastases at the time of treatment of the primary cancer (hazard ratio: 4.23; 95% confidence interval: 1.54–11.6) as significant adverse prognostic factors for overall survival. Conclusions: To our knowledge, this is the largest published case series of pulmonary resection for metastatic urothelial carcinoma, providing benchmark data for the assessment of long-term outcomes of this rare entity.

Background: Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors are powerful molecular targeted therapeutic agents for lung cancer. We recently developed an original immunocytology and glass slide-based circulating tumor cell (CTC) detection platform for both CTC enumeration and EGFR mutation analysis with DNA extracted from CTCs. Methods: Using this platform, we conducted a pilot clinical study for CTC enumeration in peripheral blood (PB), pulmonary arterial blood (PA), and pulmonary venous blood (PV) from 33 patients with lung cancer (Stage I–III) who underwent surgery, followed by digital PCR-based EGFR mutation analysis of CTCs in PV from 12 patients. Results: The results showed that CTC levels were significantly higher in PV and PA than in PB (p < 0.05, p < 0.01. respectively), with a notably greater number of small and large CTC clusters (p < 0.01). Genetic analysis of EGFR mutations of CTCs from PV (n = 12) revealed six mutations, including three Exon19del and three L856R, in CTCs and eight EGFR mutations, including five Exon19del and three L856R, in lung tumor tissue. CTC mutation status matched that of tissue samples in nine patients, was unmatched in two patients, and controversial in one patient, indicating a sensitivity of 0.75 (6/8) and specificity of 1.0 (4/4) with some false-negative results for the mutation analysis of CTCs. Conclusions: This immunocytology-based CTC detection platform is a convenient method for detecting both CTC number and EGFR mutation status under microscopy, suggesting its potential as a liquid biopsy tool in the hospital for patients with lung cancer in some clinical settings.

Systemic arterial blood supply to a normal lung is a rare anatomical abnormality. Surgery is usually indicated because this abnormality leads to pulmonary hypertension. Herein, we report our experience and ideas for safe vessel dissection. Case 1 was a woman in her 50s. We performed a left lower lobectomy following percutaneous coil embolization. The aberrant artery with emboli was confirmed intraoperatively by cone-beam computed tomography (CBCT) to safely dissect under thoracoscopic surgery (TS). Case 2 was a man in his 40s. Following percutaneous endovascular plug occlusion, we performed a left partial resection using indocyanine green fluorescence navigation. Intraoperatively, CBCT imaging demonstrated the aberrant artery and exact position of the emboli. This combination technique of interventional radiology and TS with CBCT imaging was considered safe and more secure for the treatment of anomalous systemic arterial blood supply to a normal lung.

Several methods can be used to intraoperatively identify pulmonary lesion using radiation technology. However, little is known about patient radiation exposure during chest surgery. We aimed to measure patients’ radiation exposure from cone-beam computed tomography (CBCT) used in a hybrid operating room. This retrospective study included patients who underwent surgical treatment in a hybrid operating room between April 2019 and December 2023 at the Teikyo University Hospital. All data was obtained prospectively, but the study was approved by the IRB as a retrospective study because of repeated extensions of study period in order to collect more cases. Skin radiation exposure was measured using five wearable dosimeters per patient. The measurements were compared to cumulative Air Kerma. Furthermore, the radiation exposure dose on the surgical side, which cannot be measured, was estimated by computer simulation. Among 182 patients who underwent surgery in a hybrid operating room, radiation exposure measurements were conducted on 67 patients. The patients’ mean age was 60.7 years. The average number of CBCT scans was 2.1 (1–5) and the intraoperative identification rate was 100

Surgery is the most effective treatment for early-stage lung cancer; however, it poses a higher physical burden than other treatment options. Therefore, understanding the perioperative course of patients is important. Using the Short Form Health Survey 36, we prospectively measured the physical quality of life of patients who underwent anatomical pulmonary resection for non-small cell lung cancer at Shonan Kamakura General Hospital, Kanagawa, Japan (n = 87). In the preoperative setting, patients who had lower performance status and lived alone had significantly worse physical quality of life scores on multivariate analysis (regression coefficient (95% confidence interval), −9.37 (−13.43–−5.32) and −10.22 (−13.74–−7.40), respectively, p < 0.0001 for both). At 6 months postoperatively, patients who stopped smoking within 1 year preoperatively (stopped smoking within 1 year vs. remote or never smokers, 41.0 ± 10.5 vs. 48.6 ± 7.2, p = 0.002), had lower performance status (0 vs. 1–2, 49.3 ± 6.6 vs. 38.6 ± 9.6, p < 0.0001), lived alone (living alone vs. living with somebody, 41.6 ± 9.7 vs. 48.1 ± 7.9, p = 0.021), and had higher comorbid burden (Charlson comorbidity index <3 vs. ≥3, 48.2 ± 6.9 vs. 39.1 ± 14.7, p = 0.003) had significantly worse physical quality of life scores on univariate analysis. More recent smoking (regression coefficient (95% confidence interval), −4.90 (−8.78–1.0), p = 0.014), lower performance status (8.90 (5.10–12.70), p < 0.0001), living alone (5.76 (1.39–10.13), p = 0.01), and higher comorbid burden (−6.94 (−11.78–−2.10), p = 0.006) were significant independent predictors of worse postoperative physical quality of life on multivariate analysis. Therefore, patients with these conditions might need additional support to maintain their physical condition after anatomical lung cancer surgery.

Diaphragmatic eventration causes respiratory distress with the development of severe diaphragmatic compression of lung volume. While non-surgical treatment, such as physical therapy and pulmonary rehabilitation, is adequate for mild cases, surgical intervention is critical for severe diaphragmatic eventration. A 45-year-old man with respiratory fatigue was diagnosed with left diaphragmatic eventration and underwent surgery with diaphragmatic plication with double-row stapling under a video-assisted approach. Thoracoscopy with laparoscopic image display avoided visceral tissue involvement, and the double-stapling technique prevented diaphragmatic rupture and lowered the diaphragmatic level. The procedure improved the patient's respiratory function by reducing respiratory fatigue. This procedure is safe and effective for the thin and vulnerable diaphragmatic muscle.