Purpose
We aimed to assess the clinical usefulness of the fissureless technique, which avoided dissection of the lung parenchyma over the pulmonary artery, in preventing prolonged air leak after ...video-assisted thoracic surgery right upper lobectomy (VATS RUL).
Methods
Perioperative outcomes, including the frequency of prolonged air leak after fissureless technique or traditional fissure dissection technique, which dissected the lung parenchyma through the fissure, were compared in patients who underwent VATS RUL (
n
= 213) between January 2016 and March 2020. We adopted our fissural grade to evaluate the degree of fused fissure ranging from II (light incomplete fissure) to IV (severe incomplete fissure), which covered all fissural grades in 213 patients.
Results
Fifty-four and 159 patients underwent fissureless and traditional techniques, respectively. Significant differences in the incidence of prolonged air leak (
p
= 0.037), time to air leak cessation (
p
= 0.047), and duration of chest tube placement (
p
= 0.017) were observed between fissureless and traditional technique groups. On multivariable analysis, traditional technique (
p
= 0.005), and greater fissural grade (III vs II,
p
= 0.020; IV vs II, p = 0.001) were significantly associated with prolonged air leak.
Conclusions
Fissureless technique during VATS RUL can be a superior alternative to the traditional technique to prevent prolonged air leak in treating incomplete fissures.
The aim of this study was to evaluate the effectiveness of 3-dimensional computed tomography (3D-CT) software in short-term surgical outcomes and the assessment of variations of pulmonary vessel ...branching patterns on performing video-assisted thoracic surgery (VATS).
The study included 179 consecutive patients who had undergone VATS anatomical lung resection, of which 172 were lobectomies (96%) and 7 were segmentectomies (4%), from May 2011 through January 2013. There were 124 patients (69%) in whom 3D-CT was performed and 55 patients (31%) who had not undergone 3D-CT. Observed actual pulmonary vessel branching patterns by intraoperative findings or footage were compared with the 3D image findings. Various surgical outcomes, including the occurrence of postoperative complications, in this study defined as those of Grade 2 or above under the Clavien-Dindo classification system, and total operative time, were retrieved from available clinical records.
Among the 124 patients with preoperative 3D imaging, there were 5 (4%) conversions from VATS to thoracotomy. The incidence rate of patients with postoperative complications was 8% (n = 10), and there were no 30-day or 90-day mortalities. Pulmonary artery (PA) branches were precisely identified for 97.8% (309 of 316) of branches on 3D images, and the sizes of the seven undetected branches (five in the right upper lobe, two in the left upper lobe) ranged from 1 to 2 mm. The 3D images accurately revealed 15 cases (12%) of anomalous or unusual PA branches and 5 cases (4%) of variant pulmonary veins. Multivariate logistic regression analysis of the association with postoperative complications and operative time in 165 lung cancer patients demonstrated that male gender was the only statistically significant independent predictor of complications (risk ratio: 5.432, P = 0.013), and patients without 3D imaging tended to have operative complications (risk ratio: 2.852, P = 0.074), whereas conducting the 3D-CT (risk ratio: 2.282, P = 0.021) as well as intraoperative bleeding amount (risk ratio: 1.005, P = 0.005) had significant association with operative time.
High-quality 3D-CT images clearly revealed the anatomies of pulmonary vessels, which could play important roles in safe and efficient VATS anatomical resection.
Although tracheobronchial stents are widely used for tracheal obstruction due to malignant or benign stenosis, stent migration has been reported as a major postoperative complication. A ...self-expandable metallic stent (SEMS) is more easily introduced compared with silicone stents. However, it is also difficult to remove or replace without complications. We report a new technique for successful SEMS adjustment using a flexible bronchoscope with two biopsy forceps.
Purpose
Sarcopenia influences postoperative outcomes of patients with non-small cell lung cancer (NSCLC). Imaging tools for evaluating and diagnosing sarcopenia have developed, and a novel method of ...psoas volume index (PVI) obtained by measuring bilateral psoas major muscle volume has been reported. However, the relationship between sarcopenia based on PVI and clinical outcomes has not been fully investigated for patients with early-stage NSCLC. This study aimed to clarify the utility of PVI values in assessing the relationshipe between sarcopenia and clinical outcomes.
Methods
This study included 645 patients with stage I-II NSCLC who underwent curative lung resection between 2012 and 2017. Bilateral psoas major muscle volumes were calculated semi-automatically using a three-dimensional workstation. The cutoff value of PVI for defining sarcopenia was < 60.5 cm
3
/m
3
for men and < 43.6 cm
3
/m
3
for women.
Results
The avrage time to obtaine PVI was only 25 s with the 3D system, and interobserver agreements for evauating sarcopenia on PVI was 1. A total of 159 patients (24.7%) were preoperatively diagnosed with sarcopenia. On multivariate analysis, sarcopenia was an independent prognostic factor for overall survival (OS,
p
< 0.001), recurrence-free survival (RFS, p < 0.001), and lung cancer-specific survival (LCS,
p
< 0.001). The 5-year OS, RFS, and LCS were significantly worse in sarcopenic patients than non-sarcopenic patients (88.8 vs. 72.4%,
p
< 0.001; 80.1 vs. 65.0%,
p
< 0.001; 92.4 vs. 78.9%,
p
< 0.001, respectively).
Conclusion
Sarcopenia diagnosed using PVI is an independent prognostic predictor of OS, RFS, and LCS in early-stage NSCLC.
Emphysema is one of the main causes of respiratory complications in patients operated on for lung cancer. We have used three-dimensional computed tomography (3D CT) for surgical simulations, as well ...as for depicting emphysematous areas as low attenuation areas (LAAs) and visual scores based on the Goddard classification (Goddard score), which is a visual scale of the area of vascular disruption and LAA for each lung field. This study aimed to investigate the effectiveness of the 3D CT function for assessing emphysema severity and its association with respiratory complications.
The study included 504 lung cancer patients who had preoperative 3D CT from October 2010 to March 2015. Goddard score and LAA% (LAA/total lung volume) were measured using 3D CT data. The relationship between respiratory complications and independent variables was investigated.
Postoperative respiratory complications were observed in 69 (13.6%) patients. The receiver operating characteristic curves for respiratory complications determined using the Goddard score and LAA% dichotomized at each cut-off level (1 and 0.7%, respectively) showed that the events were observed in 32% of the patients with a Goddard score ≥1 and in 25% of the patients with an LAA% ≥0.7. On multivariable analyses, the Goddard score was significantly correlated with postoperative respiratory complications (P < 0.001).
Preoperative measurement of the Goddard score and LAA% using 3D CT in patients with lung cancer, particularly with the coexistence of emphysema, was beneficial for predicting postoperative respiratory complications.
•Appropriate evaluation of solid component of early-stage lung cancer is crucial.•A new volumetric analysis technique based on artificial intelligence was developed.•Artificial intelligence was more ...powerful prognostic factor than conventional methods.
The size of the solid part of a tumor, as measured using thin-section computed tomography, can help predict disease prognosis in patients with early-stage lung cancer. Although three-dimensional volumetric analysis may be more useful than two-dimensional evaluation, measuring the solid part of some lesions is difficult using this methods. We developed an artificial intelligence-based analysis software that can distinguish the solid and non-solid parts (ground-grass opacity). This software calculates the solid part volume in a totally automated and reproducible manner. The predictive performance of the artificial intelligence software was evaluated in terms of survival or recurrence-free survival.
We analyzed the high-resolution computed tomography images of the primary lesion in 772 consecutive patients with clinical stage 0-I adenocarcinoma. We performed automated measurement of the solid part volume using an artificial intelligence-based algorithm in collaboration with FUJIFILM Corporation. The solid part size, the solid part volume based on traditional three-dimensional volumetric analysis, and the solid part volume based on artificial intelligence were compared.
Higher areas under the curve related to the solid part volume were provided by the artificial intelligence-based method (0.752) than by the solid part size (0.722) and traditional three-dimensional volumetric analysis-based method (0.723). Multivariate analysis demonstrated that the solid part volume based on artificial intelligence was independently correlated with overall survival (P = 0.019) and recurrence-free survival (P < 0.001).
The solid part volume measured by artificial intelligence was superior to conventional methods in predicting the prognosis of clinical stage 0-I adenocarcinoma.
Abstract
OBJECTIVES
The measurement of part-solid and whole tumour sizes in patients with non-small-cell lung cancer (NSCLC) using computed tomography (CT) has been widely accepted for assessing ...clinical outcomes. Although the volume doubling time (VDT) of a tumour is useful for distinguishing high-risk nodules from low-risk ones, it remains to be clarified whether separate calculation of whole-tumour VDT and solid-part tumour VDT (SVDT) greatly affects the survival rate of patients with radiologically node-negative part-solid or solid NSCLC.
METHODS
The study included 258 patients with NSCLC who had radiologically node-negative, part-solid or solid tumours and who had at least 2 preoperative CT scans taken more than 30 days apart followed by radical lobectomy and systemic lymph node dissection between January 2012 and December 2015. Univariable and multivariable analyses of recurrence-free survival were performed using the Cox proportional hazards regression model.
RESULTS
The mean whole-tumour VDT and SVDT were 375 and 458 days, respectively. Multivariable analyses demonstrated that whole-tumour VDT (P = 0.003), SVDT (P < 0.001), solid-part tumour size, whole-tumour size and comorbidities significantly affected the recurrence-free survival. Using the receiver operating characteristic curve, the cut-off value of the SVDT for recurrence was 215 days, and the 5-year recurrence-free survival rates for patients with SVDT >215 days and those with SVDT <215 days were 85.7% and 43.0%, respectively (P < 0.001).
CONCLUSION
The calculation of SVDT in patients with node-negative, part-solid or solid NSCLC is highly useful for predicting postoperative survival outcomes.
Abstract
OBJECTIVES
Indications of limited resection, such as segmentectomy, have recently been reported for patients with solid-predominant lung cancers ≤2 cm. This study aims to identify ...unfavourable prognostic factors using three-dimensional imaging analysis with artificial intelligence (AI) technology.
METHODS
A total of 157 patients who had clinical N0 non-small cell lung cancer with a radiological size ≤2 cm, and a consolidation tumour ratio > 0.5, who underwent anatomical lung resection between 2011 and 2017 were enrolled. To evaluate the three-dimensional structure, the ground-glass nodule/Solid Automatic Identification AI software Beta Version (AI software; Fujifilm Corporation, Japan) was used.
RESULTS
Maximum standardized uptake value (SUVmax) and solid-part volume measured by AI software (AI-SV) showed significant differences between the 139 patients with adenocarcinoma and the 18 patients with non-adenocarcinoma. Among the adenocarcinoma patients, 42 patients (30.2%) were found to be pathological upstaging. Multivariable analysis demonstrated that high SUVmax, high carcinoembryonic antigen level and high AI-SV were significant prognostic factors for recurrence-free survival (RFS; P < 0.05). The 5-year RFS was compared between patients with tumours showing high SUVmax and those showing low SUVmax (67.7% vs 95.4%, respectively, P < 0.001). The 5-year RFS was 91.0% in patients with small AI-SV and 68.1% in those with high AI-SV (P = 0.001).
CONCLUSIONS
High AI-SV, high SUVmax and abnormal carcinoembryonic antigen level were unfavourable prognostic factors of patients with solid-predominant lung adenocarcinoma with a radiological size ≤2 cm. Our results suggest that lobectomy should be preferred to segmentectomy for patients with these prognostic factors.
Recent developments in imaging modalities and the widespread use of low-dose helical computed tomography (CT) for the detection of lung cancer have contributed to the increase in the detection rate of small pulmonary lesions 1.
Cancer-associated inflammation develops resistance to the epidermal growth-factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in non-small cell lung cancers (NSCLCs) harboring oncogenic EGFR ...mutations. Stat3-mediated interleukin (IL)-6 signaling and Smad-mediated transforming growth factor-β (TGF-β) signaling pathways play crucial regulatory roles in cancer-associated inflammation. However, mechanisms how these pathways regulate sensitivity and resistance to EGFR-TKI in NSCLCs remain largely undetermined. Here we show that signal transducer and activator of transcription (Stat)3 represses Smad3 in synergy with the potent negative regulators of TGF-β signaling, c-Ski and SnoN, whereby renders gefitinib-sensitive HCC827 cells resistant. We found that IL-6 signaling via phosphorylated Stat3 induced gefitinib resistance as repressing transcription of Smad3, whereas TGF-β enhanced gefitinib sensitivity as activating transcription of Smad3 in HCC827 cells with gefitinib-sensitizing EGFR mutation. Promoter analyses showed that Stat3 synergized with c-Ski/SnoN to repress Smad2/3/4-induced transcription of the Smad3 gene. Smad3 was found to be an apoptosis inducer, which upregulated pro-apoptotic genes such as caspase-3 and downregulated anti-apoptotic genes such as Bcl-2. Our results suggest that derepression of Smad3 can be a therapeutic strategy to prevent gefitinib-resistance in NSCLCs with gefitinib-sensitizing EGFR mutation.
•STAT3-mediated IL-6 signaling induces gefitinib resistance in HCC827 cells.•Phosphorylated STAT3 cooperates with c-Ski and SnoN to repress Smad3.•Repression of Smad3 renders gefitinib-sensitive HCC827 cells resistant.
PDF
