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In recent years, the number of surgical cases involving patients with comorbidities has been increasing due to the aging society. Such patients may have a higher risk of postoperative morbidity or mortality. Therefore, surgeons are required to evaluate the current control status of the comorbidity, and perform appropriate perioperative management to decrease perioperative risk. This article focuses on the preoperative evaluation and management, as well as intraoperative and postoperative management of diabetes mellitus, thyroid dysfunction, which are frequently encountered among patients with metabolic and endocrine disorders, and paraganglioma, which is a rare disease but requires special attention in the field of thoracic surgery.

Long-term survival after living-donor lobar lung transplantation (LDLLT) is hampered by the development of chronic lung allograft dysfunction( CLAD), similar to the clinical courses seen in some recipients of cadaveric lung transplantation( CLT). CLAD after bilateral LDLLT has been shown to be characterized by the development in the unilateral lung due to differences in the immunological features of the two donors. Based on this characteristic, we found that lung perfusion scintigraphy, which can show a perfusion shift to the contralateral unaffected lung with the development of CLAD, had the potential to predict unilateral CLAD after bilateral LDLLT. Moreover, we found that CLAD, especially restrictive allograft syndrome, developed significantly later after bilateral LDLLT than after bilateral CLT, although the CLAD-free survival and overall survival after bilateral LDLLT were similar to those after bilateral CLT. We describe our experience of CLAD after bilateral LDLLT since the first case of LDLLT in Japan.

The mediastinum contains large blood vessels, airways, and spinal cord, which are anatomically important parts of the human body because they survive by injury, obstruction, and compression, and are involved in activities of daily living( ADL). Therefore, even benign tumors have been indicated for aggressive surgical intervention. Dissection procedures from these anatomically important structures is extremely risky and difficult in reoperation for recurrence of mediastinal tumors, so careful consideration and attention must be paid to the surgical indications and methods. In this paper, we have described the points to be noted and points regarding the reoperation of mediastinal tumors with some review of the literature, including our own cases.

The development of specialized training programs for medical personnel, particularly nurses, clinical laboratory technicians, and pharmacists, is considered critical for the promotion of genomic medicine throughout Japan. Specifically, medical personnel skilled at analyzing and understanding high-throughput genomic data are in high demand. In this symposium, we will introduce the basic knowledge and skills necessary for processing genomic data.

The management of locally advanced non-small cell lung cancer (LA-NSCLC) is still controversial, because of complicated patient status and poor prognosis. The purpose of this study was to evaluate the treatment results for induction chemoradiotherapy (iCRT) followed by surgery for LA-NSCLC. From 1999 to 2016, 157 patients were surgically treated after iCRT in our hospital, and their median follow-up was 43 months. Overall survival( OS) was 66.8%, and relapse-free survival( RFS) was 52.0%. The poor prognostic factor in OS by multivariate analysis was lower-lobe origin, incomplete radiotherapy, reoperation, and RFS was lower-lobe origin. The result of our hospital was feasible compared with definitive CRT. The definitive CRT is mainstream for treatment of LA-NSCLC and adjuvant anti-programmed death ligand 1 antibody will influence the treatment strategy, however there are some patients who can get benefit only by iCRT followed by surgery. iCRT followed by surgery is one of the feasible treatment for LA-NSCLC.

In the end of last year, the US Food and Drug Administration has announced the authorization of MSK-IMPACT(TM), clinical test based on multiplex cancer panel profiling for genetic mutations and other alterations in patients' tumors, while in Japan, NCC Oncopanel, domestic multiplex cancer panel, is scheduled to be clinically implemented as advanced medical care B in this coming spring, chasing the state of the art technology for cancer treatment. In this article, we outline a recently published roadmap for precision medicine in Japan, together with our years of experience on cancer diagnosis and treatment based on multiplex cancer panel at Okayama University Hospital and Okadai Biobank.

Perioperative assessment and care, such as enhanced recovery after surgery (ERAS), is very important for improving the clinical outcomes of patients who have undergone surgery. However, professional assessments and care cannot be achieved through the actions of only 1 surgical department. We established a perioperative management center(PERIO) comprised of surgeons, dedicated nurses, anesthesiologists, dentists, physiotherapists, pharmacists, and nutritionists to perform intensive cross-sectoral perioperative management. In this manuscript, we investigated the impact of PERIO on the clinical outcomes of 127 elderly patients who underwent thoracic surgery for the resection of non-small cell lung cancer (NSCLC). We categorized these 127 patients into 3 groups:① those treated before the introduction of PERIO (between January 2006 to August 2008), ② those treated during the early phase after PERIO introduction (September 2008 to December 2011), and ③ those treated during the late phase after PERIO introduction( January 2012 to December 2014). Radical operations were performed significantly more frequently after PERIO introduction than before PERIO introduction, while the postoperative complication rates were similar among the 3 groups. The duration of postoperative hospitalization was reduced after the introduction of PERIO, and the hospital surplus increased after the introduction of PERIO. In conclusion, PERIO may play an important role in improving the clinical outcomes of thoracic surgery, especially for elderly patients with NSCLC.

Recent advances in cancer research have revealed that noncoding RNAs such as microRNAs and long noncoding (lnc) RNAs play important roles in various cancers including lung cancer. Noncoding RNAs have the potential to become new biomarkers of cancer in the clinical setting, that is, they may be useful for the early detection, prognostic prediction, and prediction of sensitivity to chemotherapy and radiotherapy. It is also expected that noncoding RNAs can become new therapeutic targets. Aberrant expression of several microRNAs and lncRNAs has been reported in lung cancer, and there is a possibility of the identification of new therapeutic targets in the near future. To contribute to improved outcomes of lung cancer treatment, it is necessary to detect patients who are candidates for surgery in an earlier stage to increase the number undergoing radical surgery and to select those who are at high risk of recurrence postoperatively to increase opportunities for treatment to prevent it. Thus, it is important to discover new biomarkers for lung cancer. Surgeons can take the initiative in research, as they have easy access to specimens from lung cancer patients.

18F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT)imaging is valuable in biopsy guidance, response assessment, grading, follow-up and prognostication for soft-tissue sarcoma. In liposarcoma, the maximum standardized uptake value (SUVmax) on PET/CT scan is correlated with the histological subtypes. We briefly review the role of FDG PET/CT in liposarcoma, and describe a case of chest wall liposarcoma treated based on the assessment with PET/CT. A 76-year-old man, with a 10-cm tumor at the thoracic outlet of the right chest wall, underwent the complete resection of the tumor according to the assessment with PET/CT that showed high FDG uptakeonly in the central area of the tumor with SUVmax of 5.89, but low uptake in the peripheral area. In accordance with the PET/CT findings, pathological examination revealed dedifferentiated liposarcoma in the central area and well-differentiated liposarcoma in the peripheral area. Pretherapy PET/CT should be performed for the appropriate treatment of liposarcoma.

Treatment for primary mediastinal lymphoma generally involves chemotherapy and radiotherapy, and treatment regimens depend on histologic subtypes of lymphoma. The histologic subtype of lymphoma is mostly determined by computed tomography (CT)-guided core-needle biopsy or surgical procedures, including thoracotomy, thoracoscopy and mediastinoscopy. We describe the clinicopathologic features and diagnostic procedures of 8 cases of primary mediastinal lymphoma. The male-to-female ratio was 1:1, and median age at diagnosis was 27 years. The median size of the primary mediastinal tumor on CT was 8.5 cm. Five patients were diagnosed by CT-guided core-needle biopsy, 1 by open biopsy and 2 by surgery. Three patients were diagnosed with nodular sclerosis Hodgkin lymphoma, 3 with mediastinal diffuse large B-cell lymphoma, 1 with precursor T-lymphoblastic leukemia/lymphoma and 1 with thymic extranodal marginal zone B-cell lymphoma. According to their histological subtypes, 5 patients were treated with chemoradiotherapy, 2 patients with chemotherapy and 1 patient of thymic extranodal marginal zone B-cell lymphoma with surgery alone. All patients survived in the median follow-up of 34.5 months. Appropriate biopsy procedure should be performed in patients with suspected mediastinal lymphoma.

Invading apical lung cancers are generally the non-small-cell lung cancers (NSCLCs) which involve the apex of the chest wall. These tumors should be classified into 2 types based on the main location of tumor because of the difference of involved surrounding structures ; (1) the superior sulcus tumor origi nally termed Pancoast tumor which involves posterior region of the apex and (2) the anterior apical tumor which involves anterior region of the apex. Previously, these NSCLCs were considered to be inoperable showing a dismal prognosis. With the development of combined modality therapies for locally advanced NSCLCs, the prognosis of invading apical NSCLCs has been improved, especially since intro duction of the neoadjuvant chemoradiotherapy. Surgical resection for invading apical NSCLCs is 1 of challenging procedures for thoracic surgeons. The point is the anatomical complication of the small apex surrounding vital structures. Several approaches have been developed such as the posterior Paul-son's approach or anterior Masaoka's approach. In particular, the approach from anterior chest has been modified or devised to achieve safe and complete resection of tumors invading anterior structures like subclavian vessels. In this article, we reviewed our 13 cases of invading apical NSCLCs, especially from the view point of surgical approach. Thoracic surgeons should understand the properties of each approach and master them for complete resection avoiding serious complications.