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Background: Although sublobar resection (wedge resection [Wed] or segmentectomy [Seg]) has become a standard operative procedure for clinical stages IA1 and IA2 non-small cell lung cancer (NSCLC) in Japan, the impact of this procedure on the prognosis and postoperative complications in real-world clinical practice is unknown., Methods: This study retrospectively analyzed risk factors for a poor prognosis and postoperative complications of 470 patients with clinical stage ≤ IA2 NSCLC who underwent surgery from 2012 to 2021., Results: Among the patients with a consolidation-to-tumor ratio (CTR) higher than 0.5, the 5-year relapse-free survival (RFS) rate was significantly lower in the Wed group (72.1%) than in the Seg (85.8%) and Lob (86.8%) groups (p < 0.01), but the difference between the Seg and Lob groups was not significant. Among patients with a CTR of 0.5 or lower, the 5-year RFS rate did not differ significantly among the three groups. Multivariable analysis of RFS showed that the prognosis was significantly worse in the Wed group than in the Lob group (hazard ratio, 2.83; p < 0.01), but the difference between the Wed and Seg groups or the between Seg and Lob groups was not significant. Multivariable analysis of postoperative complications showed a significantly lower risk in the Wed group than in the Seg group (odds ratio, 0.31; p < 0.01)., Conclusions: Seg could become the standard operative procedure for clinical stages IA1 and IA2 NSCLC patients. Wed is suggested to be an option for patients with a CTR of 0.5 or lower and has the advantage of avoiding postoperative complications., Competing Interests: Disclosures: There are no conflicts of interest., (© 2024. Society of Surgical Oncology.)

BACKGROUND Coagulopathy caused by trauma itself is defined as trauma-induced coagulopathy (TIC). The pathophysiology of TIC is considered to consist of coagulation activation, hyperfibrinolysis, and consumption coagulopathy, similar to disseminated intravascular coagulation (DIC). This report describes a 68-year-old man with a history of epilepsy presenting with TIC associated with multiple traumatic fractures and hemothorax. CASE REPORT A 68-year-old man with a history of epilepsy fell while working on a second-floor roof and had right rib fractures (6th to 12th rib), right hemothorax, right clavicle fracture, right elbow fracture, and pelvic fractures. The right hemothorax became exacerbated and he went into shock. We performed the emergency surgery 5 hours after the trauma. Although circulation dynamics became stable and the discharge of chest drainage became thinned at postoperative day (POD) 1 while administering blood transfusions and tranexamic acid, hemoglobin remained below 8 g/dl, platelet count was below 60 000/µl, and prothrombin time - international normalized ratio (1.22) remained prolonged. Furthermore, the right hemothorax became exacerbated and re-operation was performed on the evening of POD2. Oozing hemorrhages from multiple rib fractures were observed. Although hemostatic management was performed with electrocautery and ultrasound energy devices, the hemorrhage could not be completely managed, so hemostasis was secured using hemostatic materials. CONCLUSIONS The pathophysiologic mechanism of TIC has been emphasized as being different from that of DIC, and management of severe traumatic patients with TIC should be based on an understanding of the pathophysiology of TIC.

Introduction and Clinical Importance: Solitary fibrous tumours of the pleura (SFTPs) are rare, often benign, localized fibrous tumours. SFTPs are surgically excised after discovery. Herein, we report a rare case in which the tumour doubling time (TDT) was measured., Case Presentation: A 71-year-old male patient with a history of cataract surgery presented with back pain and dyspnoea on exertion. Chest radiography revealed a large mass in the left thorax measuring 135 × 80-mm, after pleural effusion drainage. A thoracic tumour had been identified on a preoperative medical examination for cataract surgery 4 years previously; however, the patient did not opt for treatment. Chest radiography revealed a 43 × 22-mm mass. The TDT calculated using the Schwarz method, was 284 days. The tumour was resected and diagnosed as an SFTP. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. No evidence of recurrence was observed one year and three months postoperatively., Clinical Discussion: The malignant form of SFTPs remains unclear. The TDT of malignant SFPTs tends to be shorter than that of benign SFTPs in previous reports. However, in this case, despite the diagnosis of malignant SFT, the TDT was 284 days, which was longer than in previous reports., Conclusions: Compared with previous reports, there appeared to be no correlation between the risk of metastases and TDT. Few reports have calculated the TDT of SFPTs, and further accumulation of cases is desirable., Competing Interests: Conflict of interest statement All authors declare that they have no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Bronchial bifurcation abnormalities are often discovered incidentally on chest computed tomography or bronchoscopy. As this condition is asymptomatic, it has little effect on the disease course of patients with lung cancer. However, this abnormality must be considered when performing lung resection., Case Presentation: Patient 1 was a 73-year-old man with suspected simultaneous triple lung cancers [cT1c (3) N0M0, Stage IA3] in the right and left upper lobes. He was initially scheduled to undergo right upper lobectomy and systematic nodal dissection. Chest computed tomography revealed a displaced B 3 that arose from the right middle lobe bronchus. V 1+2 was transected first, followed by the superior truncus of the pulmonary artery, and B 1+2 , respectively. After the branches of V 3 were ligated, B 3 was identified smoothly. Finally, the incomplete interlobar fissure between the upper and middle lobes was separated using an auto-stapler. No vascular abnormalities were observed. Patient 2 was a 62-year-old woman with suspected lung cancer (cT1cN0M0, Stage IA3) in the right upper lobe, and was scheduled to undergo right upper lobectomy and lobe-specific nodal dissection. Chest computed tomography revealed a right top pulmonary vein and a displaced B 1 that arose from the right main bronchus independently. Because V 1+3 was resected simultaneously during upper and middle lobe resection during robot-assisted thoracic surgery, the procedure was cool-converted to video-assisted thoracic surgery. An independently A 1 was observed, followed by A 2 b and A 3 , which branched off as a common stem. A right top pulmonary vein was smoothly detected. Each blood vessel was transected using an auto-stapler. B 2+3 was transected first using an auto-stapler, followed by B 1 ., Conclusions: The displaced anomalous bronchus is often accompanied by pulmonary arterial or venous abnormalities and an incomplete interlobar fissure. A "hilum first, fissure last" technique is often useful. Preoperative evaluation and surgical planning are important., (© 2024. The Author(s).)

Background/aim: The outcomes of lung cancer treatment have improved over time. However, in contrast to other treatments, the clinical outcomes of salvage surgery are seldom reported because the follow-up periods after salvage surgery are short., Patients and Methods: We conducted a comprehensive study involving consecutive patients who underwent salvage surgery at two different institutions. Our analysis encompassed the exploration of clinicopathological features, perioperative variables, and surgical outcomes. Additionally, we employed propensity score matching to compare the long-term survival of patients with non-small cell lung cancer (NSCLC) who underwent salvage surgery with those who received induction chemoradiotherapy prior to surgery., Results: Twenty-five patients underwent salvage procedures, while 113 patients received induction chemotherapy followed by surgery during the same study period. When assessing the overall survival (OS) from the registration date to the initial treatment date, the five-year OS rates were 73.8% in the induction group and 70.5% in the salvage surgery group (p=0.674). No significant differences were identified between the two groups in a cohort of 48 patients with NSCLC who were matched using propensity scores., Conclusion: In patients who underwent salvage surgery, reasonable long-term survival was achieved with outcomes comparable to those of induction chemotherapy followed by surgical resection., (Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: The relationship between risk factors of common postoperative complications after pulmonary resection, such as air leakage, atelectasis, and arrhythmia, and patient characteristics, including nutritional status or perioperative factors, has not been sufficiently elucidated., Methods: One thousand one hundred thirty-nine non-small cell lung cancer patients who underwent pulmonary resection were retrospectively analyzed for risk factors of common postoperative complications., Results: In a multivariate analysis, male sex (P = 0.01), age ≥ 65 years (P < 0.01), coexistence of chronic obstructive pulmonary disease (COPD) (P < 0.01), upper lobe (P < 0.01), surgery time ≥ 155 min (P < 0.01), and presence of lymphatic invasion (P = 0.01) were significant factors for postoperative complication. Male sex (P < 0.01), age ≥ 65 years (P = 0.02), body mass index (BMI) < 21.68 (P < 0.01), coexistence of COPD (P = 0.02), and surgery time ≥ 155 min (P = 0.01) were significant factors for severe postoperative complication. Male sex (P = 0.01), BMI < 21.68 (P < 0.01), thoracoscopic surgery (P < 0.01), and surgery time ≥ 155 min (P < 0.01) were significant risk factors for postoperative air leakage. Coexistence of COPD (P = 0.01) and coexistence of asthma (P < 0.01) were significant risk factors for postoperative atelectasis. Prognostic nutrition index (PNI) < 45.52 (P < 0.01), lobectomy or extended resection more than lobectomy (P = 0.01), and surgery time ≥ 155 min (P < 0.01) were significant risk factors for postoperative arrhythmia., Conclusion: Low BMI, thoracoscopic surgery, and longer surgery time were significant risk factors for postoperative air leakage. Coexistence of COPD and coexistence of asthma were significant risk factors for postoperative atelectasis. PNI, surgery time, and surgical procedure were revealed as risk factors of postoperative arrhythmia. Patients with these factors should be monitored for postoperative complication., Trial Registration: The Institutional Review Board of Kanazawa Medical University approved the protocol of this retrospective study (approval number: I392), and written informed consent was obtained from all patients., (© 2024. The Author(s).)

Background: Lung cancer is associated with a high mortality rate worldwide. Non-small-cell lung cancer (NSCLC) is a major subtype of lung cancer. Carboplatin (CBDCA) plus nab-paclitaxel (PTX) has become a standard treatment for advanced unresectable NSCLC. However, treatment with nab-PTX has not been established as a standard therapy for resectable locally advanced (LA)-NSCLC., Methods: We conducted a comprehensive study involving consecutive patients with locally advanced NSCLC who underwent induction therapy including nab-PTX followed by surgical resection. Fifteen patients with locally advanced NSCLC underwent induction therapy including nab-PTX followed by surgical resection. Concurrent chemoradiotherapy (CRT) consisted of weekly administration of nab-PTX (50 mg/m 2 ) plus CBDCA (area under the plasma concentration time curve (AUC) 2) and thoracic radiotherapy (50 Gy/25 fractions)., Results: The clinical stages were as follows: IIB (n =1), IIIA (n =12), and IIIC (n =2). Downstaging was observed in 73% (11/15) of patients on comparison with the clinical stage before concurrent CRT. Adverse drug reactions were observed in seven patients. Complete resection was performed in all patients. The re-evaluated pathological stage after pretreatment was diagnosed as stage 0 in three patients, stage IA1 in six, stage IA2 in one, and stage IIIA in five. The pathological effects of previous therapy were as follows: Ef3 (n =3), Ef2 (n =9), and Ef1a (n =3)., Conclusion: The therapeutic effect of induction therapy including nab-PTX was promising. Induction CRT, including nab-PTX, followed by resection, may be a viable alternative treatment option for locally advanced NSCLC., (© 2024. The Author(s).)

Purpose: Diabetes mellitus (DM) is a common comorbidity of lung cancer. We hypothesized that severe DM is associated with increased complications after surgical resection of non-small-cell lung cancer (NSCLC)., Methods: A review of our retrospective thoracic database identified 1139 consecutive surgical resections for NSCLC from 2002 to 2021. Our analysis included the exploration of clinicopathological features, perioperative variables, and surgical outcomes., Results: In addition to lung cancer, 170 patients (14.9%) had DM. The patients included 132 (77.6%) men and 38 (22.4%) women, with a median age of 72 (range, 51-93) years old. The median preoperative fasting blood glucose and HbA1c levels were 135 mg/dL (range, 57-303) and 6.9% (range, 5.1-14.8), respectively. Eighty-one patients had DM as a single comorbidity, and 89 patients had other comorbidities or a relevant medical history. A total of 144 patients were prescribed these drugs. There were 107 patients (62.9%) who consulted a specialist diabetes endocrinology department preoperatively and 118 patients (69.4%) who required sliding-scale insulin during the perioperative period. Forty-seven patients (27.6%) developed post-operative complications. No cases of bronchopleural fistula were noted. A univariate analysis showed that the sex (p = 0.017), body mass index (BMI) (p = 0.0032), surgical procedure (p = 0.017), surgical time (p = 0.002), and lymphatic invasion (p = 0.011) were significantly different among patients stratified by postoperative complications. A multivariate analysis showed that a low BMI (odds ratio [OR]: 0.413, 95% confidence interval [CI]: 0.196-0.870, p = 0.018), long surgical time (OR: 2.690, 95% CI: 1.190-6.082, p = 0.015), and presence of lymphatic invasion (OR: 2.849, 95% CI: 1.319-6.135, p = 0.007) were risk factors for postoperative complications. In contrast, severe preoperative DM did not have a significant negative effect on the incidence of postoperative complications., Conclusion: In modern respiratory surgery, severe DM does not affect the short-term outcomes under strict preoperative treatment., (© 2024. The Author(s).)

Background: Among a cohort of patients who underwent chest wall resection and reconstruction by rigid prosthesis, 6% required removal of the prosthesis, and in 80% of these cases the indication for prosthesis removal was infection. Although artificial prosthesis removal is the primary approach in such cases of infection, the usefulness of vacuum-assisted closure (VAC) has also been reported., Case Presentation: A 64-year-old man with diabetes mellitus underwent right middle and lower lobectomy with chest wall (3rd to 5th rib) resection and lymph node dissection because of lung squamous cell carcinoma. The chest wall defect was reconstructed by an expanded polytetrafluoroethylene (PTFE) sheet. Three months after surgery, the patient developed an abscess in the chest wall around the PTFE sheet. We performed debridement and switched to VAC therapy 2 weeks after starting continuous drainage of the abscess in the chest wall. The space around the PTFE sheet gradually decreased, and formation of wound granulation progressed. We performed wound closure 6 weeks after starting VAC therapy, and the patient was discharged 67 days after hospitalization., Conclusions: We experienced a case of chest wall reconstruction infection after surgery for non-small cell lung cancer that was successfully treated by VAC therapy without removal of the prosthesis. Although removal of an infectious artificial prosthesis can be avoided by application of VAC therapy, perioperative management to prevent surgical site infection is considered essential., (© 2024. The Author(s).)

Background: Lung abscess treatment results the treatment results improved with the development of antibiotics; however, surgical treatment is indicated when pyothorax is present, surgical treatment is indicated. When a lung abscess ruptures, pyothorax and fistula occur, which are difficult to treat., Case Presentation: A 74-year-old woman who experienced exacerbated dyspnea and left back pain for 10 days was diagnosed with a lung abscess caused by an odontogenic infection. The patient's medical history included hypertension, angina pectoris, untreated dental caries, and periodontitis. Despite administration of meropenem for 5 days, inflammatory markers increased. Chest radiography revealed pleural effusion exacerbation; therefore, the patient immediately underwent chest drainage and surgery was planned. Thoracic debridement and parietal and visceral decortication were performed. However, the lung abscess in the lateral basal segment ruptured during visceral decortication. As the tissue was fragile and difficult to close with sutures, free pericardial fat was implanted in the ruptured abscess cavity and fixed with fibrin glue, and sutured to the abscess wall. No signs of postoperative air leakage or infection of the implanted pericardial fat were observed. All drainage tubes were removed by postoperative day 9. The patient was discharged on postoperative day 12 and underwent careful observation during follow-up as an outpatient. At 1 year and 2 months after surgery, empyema recurrence was not observed., Conclusions: A lung abscess that ruptured intraoperatively was successfully and effectively treated by implantation of free pericardial fat in the abscess cavity., (© 2024. The Author(s).)

Introduction: Although histological subtype in lung adenocarcinoma has been reported as a poor prognostic factor in several studies, its utility has not yet been revealed as an adaptation criterion of postoperative adjuvant chemotherapy., Methods: Four hundred ninety-four lung adenocarcinoma patients were enrolled in this retrospective study. A subanalysis was performed in 420 lung adenocarcinoma patients with pathological stage 0-I disease for risk factors of postoperative recurrence., Results: Maximum standardized uptake value (SUVmax) (p &lt; 0.01), pathological stage ≥II (p &lt; 0.04), and adjuvant chemotherapy (p &lt; 0.01) were risk factors for recurrence in the multivariate analysis, whereas histological subtype was not a significant factor for recurrence at all stages. In the subanalysis, univariate analysis showed that carcinoembryonic antigen expression (p &lt; 0.01), prognostic nutrition index (p = 0.03), SUVmax (p &lt; 0.01), lymphatic invasion (p &lt; 0.01), vascular invasion (p &lt; 0.01), grade 3-4 differentiation (p &lt; 0.01), pathological stage ≥IA3 (p &lt; 0.01), and histological subtype (p = 0.03) were significant risk factors of recurrence. SUVmax (p &lt; 0.01) was the only risk factor for recurrence in the multivariate analysis, whereas histological subtype was not (p = 0.07). Relapse-free survival (RFS) was significantly worse in the micropapillary- and solid-predominant subtype groups than in the other subtypes (p = 0.01). On the other hand, RFS with or without uracil-tegafur as adjuvant chemotherapy in lung micropapillary- or solid-predominant adenocarcinoma patients with pathological stage IA-IB disease was not significantly different., Conclusion: This study suggested that histological subtypes, such as micropapillary- or solid-predominant pattern, are risk factors for recurrence in pathological stage 0-I lung adenocarcinoma and may be necessary adjuvant chemotherapy instead of uracil-tegafur., (© 2023 S. Karger AG, Basel.)

Introduction: Few studies have investigated the prognostic factors for non-adenocarcinoma of the lung. We retrospectively evaluated the prognostic factors on the basis of histological type of non-adenocarcinoma of the lung treated by pulmonary resection., Methods: We enrolled 266 patients with non-adenocarcinoma of the lung in this retrospective study: 196 with squamous cell carcinoma (SCC) and 70 with non-SCC., Results: Relapse-free survival (RFS) did not differ significantly between SCC and non-SCC patients (p = 0.33). For SCC patients, RFS differed significantly between patients who underwent wedge resection and non-wedge resection (p &lt; 0.01) and between patients with Clavien-Dindo grade ≥3a and 0-2 postoperative complications (p &lt; 0.01). For non-SCC patients, RFS rates were significantly different in the groups divided at neutrophil-to-lymphocyte ratio = 2.40 (p = 0.02), maximum standardized uptake value (SUVmax) = 8.39 (p &lt; 0.01), between patients with pathological stage (pStage) 0-I and with pStage more than II (p &lt; 0.01). For SCC patients, male sex (p = 0.04), wedge resection (p = 0.01), and Clavien-Dindo grade ≥3a (p = 0.02) were significant factors for RFS in multivariate analysis. For non-SCC patients, neutrophil-to-lymphocyte ratio &gt;2.40 (p &lt; 0.01), SUVmax &gt;8.39 (p = 0.01), and pStage ≥II (p = 0.03) were significant factors for RFS in multivariate analysis., Conclusion: RFS did not differ significantly differently between SCC and non-SCC patients. It is necessary to perform more than segmentectomy and to avoid severe postoperative complications for SCC patients. SUVmax might be an adaptation criterion of adjuvant chemotherapy for patients with non-adenocarcinoma and non-SCC of the lung., (© 2024 S. Karger AG, Basel.)

Purpose: We aimed to elucidate the functions and clinical relevance of sodium-glucose cotransporter 2 (SGLT2) in resected lung adenocarcinoma., Methods: The protein expression of SGLT2 in tumor samples from 199 patients with lung adenocarcinoma was analyzed by immunohistochemistry, and the protein expression, clinical variables, and survival outcomes were compared., Results: The median SGLT2 expression was significantly higher in advanced-stage and more aggressive adenocarcinomas. Age ≥70 (p &lt; 0.01), BI ≥600 (p &lt; 0.01), PRDX4 &lt;25 (p &lt; 0.01), and SGLT2 ≥12% (p = 0.03) were significant factors for RFS in multivariate analysis. Significant differences were observed in the RFS rates of the groups divided using the cutoff value of SGLT2 ≥12% (5-year RFS: 72.6% vs. 90%) (p &lt; 0.01)., Conclusion: The expression of SGLT2 was more frequently detected in advanced-stage and more aggressive adenocarcinomas with aggressive biological behavior than in their counterparts. The survival analysis revealed that the strong expression of SGLT2 was associated with poorer RFS. The SGLT2 expression predicts postoperative recurrence in lung adenocarcinoma patients., (© 2024 S. Karger AG, Basel.)

Introduction: It is unclear whether a lower lobe origin is a risk factor for early recurrence of non-small cell lung cancer (NSCLC) in patients who underwent pulmonary resection., Methods: The risk factors for early recurrence, defined as recurrence occurring within 1 year after surgery, were analyzed in 476 patients with NSCLC who underwent pulmonary resection without wedge resection., Results: The proportion of men, Brinkman's index, carcinoembryonic antigen levels, and the maximum standardized uptake value (SUVmax) were significantly higher in patients with early recurrence than in those without early recurrence. Furthermore, the rates of lower lobe origin, extended resection beyond lobectomy, lymphatic invasion, vascular invasion, and advanced-stage disease were significantly higher in patients with early recurrence. Age (odds ratio [OR] = 4.46, p &lt; 0.01), SUVmax (OR = 5.78, p = 0.02), a lower lobe origin (OR = 3.06, p = 0.01), and pathological stage (OR = 3.34, p = 0.01) were risk factors for early recurrence in multivariate analysis. Furthermore, only early recurrence (OR = 3.34, p = 0.01) was a risk factor for overall survival in multivariate analysis, and overall survival outcomes and prognoses significantly differed between patients with and without early recurrence (p &lt; 0.01)., Conclusion: Age, SUVmax, a lower lobe origin, and pathological stage are risk factors for early recurrence. These results suggest that for patients with NSCLC who underwent pulmonary resection, SUVmax and a lower lobe origin are important for deciding the indication for adjuvant chemotherapy in addition to pathological stage., (© 2023 S. Karger AG, Basel.)

Introduction: The relative efficacies of epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) and immune checkpoint inhibitors (ICIs) for the treatment of recurrent non-small cell lung cancer (NSCLC) after surgery remain unclear., Methods: Among 801 patients with NSCLC who underwent pulmonary resection at Kanazawa Medical University between 2017 and 2021, sixty-four patients had recurrence. We retrospectively compared the efficacies of EGFR-TKIs and ICIs in these patients with recurrent NSCLC who underwent pulmonary resection., Results: The 3-year overall survival rates after recurrence were 79.3% in patients who received EGFR-TKIs, 69.5% in patients who received ICIs, and 43.7% in patients who received cytotoxic agents. There was no significant difference in overall survival between patients treated with EGFR-TKIs and ICIs (p = 0.14) or between patients treated with ICIs and cytotoxic agents (p = 0.23), but overall survival was significantly higher in patients treated with EGFR-TKIs compared with cytotoxic agents (p &lt; 0.01). The probabilities of a 2-year response were 88.5%, 61.6%, and 25.9% in patients treated with EGFR-TKIs, ICIs, and cytotoxic agents, respectively. There was no significant difference in response periods between patients treated with EGFR-TKIs and ICIs (p = 0.18), but the response period was significantly better in patients treated with EGFR-TKIs (p &lt; 0.01) or ICIs (p = 0.03) compared with cytotoxic agents. Percent-predicted vital capacity (p = 0.03) and epidermal growth factor receptor gene mutation (p &lt; 0.01) were significant factors affecting the overall response to chemotherapy in multivariate analysis., Conclusion: EGFR-TKIs and ICIs are effective for treating recurrent NSCLC after surgery. Although adjuvant chemotherapy for completely resected pathological stage II to IIIA NSCLC, atezolizumab or osimertinib, has also been recently approved as adjuvant chemotherapy, there is a risk that patients who relapse after adjuvant chemotherapy will have less choice., (© 2023 S. Karger AG, Basel.)

Background: Several risk factors for postoperative recurrence of spontaneous pneumothorax have been reported, but the identified risk factors differed among studies., Methods: A total of 183 primary spontaneous pneumothorax patients were enrolled in this retrospective study, and the risk factors for postoperative recurrence were evaluated., Results: Among the patients, more than 80% with ipsilateral postoperative recurrence (IPR) relapsed within 3 years and more than 80% with contralateral postoperative recurrence relapsed within 4 years. Compared with patients without IPR, patients with IPR had significantly more cases with history of pneumothorax (P<0.10), more cases without preoperative drainage (P=0.02), more cases with intraoperative adhesion (P<0.01), greater upward lung volume (P=0.04), more numbers of automatic sutures (P=0.04), and more cases with contralateral recurrence (P<0.01). Furthermore, compared with patients without adhesion, patients with adhesion had significantly older age (P<0.01), and more cases with adhesion on CT images (P<0.01). Patients with adhesion also had significantly greater upward lung volume (P<0.01), more cases that received covering with polyglycolic acid (PGA) sheet covering with fibrin glue (P=0.01), and more cases that received re-do surgery (P=0.04). IPR was significantly more common in the adhesion group (P<0.01), while contralateral postoperative recurrence did not differ significantly between the groups with and without adhesion (P=0.06). Univariate analyses showed that body mass index (BMI) <15.6 kg/m 2 (P<0.01), history of pneumothorax (P=0.01), intraoperative adhesion (P<0.01), upward lung volume >80% (P=0.02), lateral lung volume >80% (P=0.02), 3 fire or more of automatic sutures (P=0.03), and contralateral recurrence (P=0.01) were significant risk factors for IPR. BMI <15.6 kg/m 2 (odds ratio: 20.89; 95% confidence interval: 1.55-280.70; P=0.02) and intraoperative adhesion (odds ratio: 25.58; 95% confidence interval: 1.91-342.39; P=0.01) were identified as risk factors for IPR in a multivariate analysis., Conclusions: The present findings suggest that low BMI and intraoperative adhesion are risk factors for postoperative recurrence of spontaneous pneumothorax. For such patients, additional intraoperative procedures, such as covering with PGA sheet absorbable oxidized cellulose may be required to reduce postoperative recurrence., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1127/coif). The authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Background: Antiphospholipid syndrome causes systemic arterial and venous thromboses due to the presence of antiphospholipid antibodies. Adrenal insufficiency is a rare complication of antiphospholipid syndrome that may result in fatal outcomes if left untreated. Therefore, we report adrenal insufficiency as a rare complication of bilateral adrenal infarction associated with antiphospholipid syndrome and trauma surgery., Case Presentation: A 64-year-old male patient underwent surgery for a left traumatic hemothorax. He concurrently had antiphospholipid syndrome and was receiving warfarin. Postoperatively, the patient complained of severe lumbar back pain despite resuming anticoagulation therapy, and he experienced paralytic ileus and shock. Abdominal contrast-enhanced computed tomography revealed adrenal swelling and increased surrounding retroperitoneal adipose tissue density. Diffusion-weighted abdominal magnetic resonance imaging showed high-intensity areas in the bilateral adrenal glands. Cortisol and adrenocorticotropic hormone levels were 3.30 μg/dL and 185.1 pg/dL, respectively. Subsequently, the patient was diagnosed with bilateral adrenal infarction and acute adrenal insufficiency, and hydrocortisone was immediately administered. Adrenal insufficiency improved gradually, and the patient was discharged after initiating steroid replacement therapy., Conclusions: The timing of postoperative anticoagulant therapy initiation remains controversial. Therefore, adrenal insufficiency due to adrenal infarction should be monitored while anticoagulant therapy is discontinued in patients with antiphospholipid syndrome., (© 2023. The Author(s).)

Purpose: Cancer-inflammation prognostic index (CIPI) is calculated by multiplying the concentration of carcinoembryonic antigen by neutrophil-to-lymphocyte ratio. CIPI has been reported as a prognostic factor for colorectal cancer. Although carcinoembryonic antigen and neutrophil-to-lymphocyte ratio have been reported as prognostic factors for non-small cell lung cancer (NSCLC), it has not been investigated whether CIPI is a useful marker., Methods: We analyzed the prognostic factors, including CIPI, in 700 NSCLC patients treated by pulmonary resection. We also analyzed a subgroup of 482 patients with pathological stage I NSCLC., Result: CIPI > 14.59 (P < 0.01), maximum standardized uptake value (SUV max ) > 5.35 (P < 0.01), lymphatic invasion (P = 0.01), and pathological stage (P < 0.01) were significant factors for relapse-free survival (RFS) in multivariate analysis. SUV max  > 5.35 (P < 0.01) and pathological stage (P < 0.01) were revealed as significant factors for overall survival in the multivariate analysis. In the subanalysis, CIPI > 14.88 (P = 0.01) and SUV max  > 5.07 (P < 0.01) were significant factors for RFS of pathological stage I NSCLC in multivariate analysis., Conclusion: CIPI was a significant factor for RFS in NSCLC patients treated surgically, even in those with pathological stage I disease. SUV max was also a significant factor for RFS and overall survival in NSCLC patients treated surgically, and for RFS in patients with pathological stage I NSCLC., Trial Registration: The Institutional Review Board of Kanazawa Medical University approved the protocol of this retrospective study (Approval Number: I392), and written informed consent was obtained from all patients., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Although rigid bronchoscopy may lead to tracheal injury, the incidence is unknown. A 59-year-old woman diagnosed with clinical stage IV esophageal cancer was scheduled to undergo placement of a silicon Y-stent by rigid bronchoscopy to address tracheal stenosis. When the tumor was cored out by rigid bronchoscopy, perforation of the lower trachea occurred, and a silicon Y-stent was inserted to cover the tracheal fistula. Chest X-ray revealed right pneumothorax, and chest drainage was performed. When spontaneous ventilation was confirmed, the patient was weaned from the ventilator in the operating room. Chest computed tomography immediately after surgery showed an air space on the right side of the stent. The space gradually disappeared over time, and no air leakage was observed. The chest drain was removed on postoperative Day 12. Conservative treatment using a silicon Y-stent for iatrogenic tracheal injury due to rigid bronchoscopy is safe., Competing Interests: All authors confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2023.)

Background: A recent study reported the effect of preoperative hyponatremia on postoperative outcomes of patients with non-small cell lung cancer. However, the influence of postoperative hyponatremia on postoperative outcomes has not been completely investigated., Methods: We retrospectively studied 75 octogenarians who underwent pulmonary surgery for non-small cell lung cancer between 2009 and 2018. We divided them into hyponatremic and non-hyponatremic groups, depending on preoperative and immediate postoperative serum sodium levels, and investigated their clinicopathological characteristics and outcomes. Disease-specific survival and cumulative incidence of relapse rates between the two groups were calculated and compared using the stratified Kaplan-Meier method. Univariable and multivariable analyses were performed to identify prognostic factors., Results: Preoperative hyponatremia was associated with 66.7% of postoperative respiratory and 88.9% of non-cardiovascular complications. The long-term prognosis of the postoperative hyponatremic group was significantly worse than that of their counterpart. The 3-year disease-specific survival and 3-year cumulative incidence of relapse rate were 55.9% and 46.2%, respectively, and the median observation period after surgery was 37.4 (interquartile range, 23.7-51.0) months for the entire cohort. Kaplan-Meier curves showed that hyponatremia was associated with worse disease-specific survival and cumulative incidence of relapse. Multivariable analysis identified hyponatremia as a factor that predicted unfavorable disease-specific survival and cumulative incidence of relapse., Conclusions: Immediate postoperative hyponatremia is an independent predictor of non-small cell lung cancer outcomes among octogenarians. Preoperative hyponatremia was associated with a high frequency of postoperative respiratory and non-cardiovascular complications. Surgical indications in older patients with hyponatremia should be carefully considered with follow-up., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Tension pyopneumothorax is a rare and life-threatening complication of pneumonia, lung abscess, and empyema, and immediate thoracic drainage or surgery is required. A 70-year-old man presented to another hospital 2 weeks after exacerbation of dyspnea and anorexia. Chest X-ray imaging revealed leftward deviation of the mediastinum, pleural effusion, and collapse of the right lung. The patient was referred to our hospital for surgical treatment. He underwent chest drainage immediately after the transfer. The patient's blood pressure was elevated after drainage. Chest X-ray imaging showed improvement in the mediastinal deviation, but expansion failure of the lung occurred. Debridement and parietal and visceral decortications were performed under thoracotomy. The thoracic cavity was irrigated using a pulse lavage irrigation system with 12,000 mL of saline. The patient underwent fibrinolytic therapy with intrathoracic urokinase postoperatively because of persistent high inflammatory marker levels and multilocular pleural effusion. Parvimonas micra was detected in the preoperative pleural fluid culture. He was discharged on postoperative day 22 and followed up as an outpatient afterwards. Two years have passed since the surgery, and there has been no recurrence of empyema. Decortication of the parietal and visceral pleura and irrigation using a pulse lavage irrigation system were effective., (© 2023. The Author(s).)

Background: In the post-intubation period, laryngeal edema is one of the most severe complications, which can cause significant morbidity and even death. Herein, we report a case in which we performed a temporary tracheostomy during surgery because of the risk of postoperative laryngeal edema, successfully avoiding post-intubation laryngeal edema complications., Case Presentation: A 78-year-old man underwent surgery for left upper lobe lung cancer. He had a history of chemoradiotherapy for laryngeal cancer, bronchial asthma, and chronic obstructive pulmonary disease. He was diagnosed with grade 1 laryngeal edema using computed tomography, and there was a risk of developing post-intubation laryngeal edema. Additionally, there was a decrease in laryngeal and pulmonary functions; therefore, postoperative aspiration pneumonia was judged to be a fatal risk. A temporary tracheostomy was performed during surgery to avoid postoperative intubation laryngeal edema. He was found to have exacerbated laryngeal edema, which is a serious complication of airway stenosis., Conclusions: Temporary tracheostomy should be considered to avoid airway stenosis due to post-intubation laryngeal edema in patients with laryngeal edema after radiotherapy., (© 2023. The Author(s).)

Purpose: Although targeting programmed death-1 (PD-1) and its ligand, programmed death-ligand 1 (PD-L1), is an established treatment modality for non-small cell lung cancer (NSCLC), the prognostic relevance of PD-L1 expression in NSCLC patients who undergo pulmonary resection is controversial., Methods: Two hundred thirty-seven NSCLC patients who underwent pulmonary resection were enrolled and the relationship between PD-L1 and various clinicopathological factors, as well as the prognostic relevance of PD-L1, was evaluated., Results: PD-L1 expression was significantly higher in male patients (p < 0.01), lymphatic invasion (p < 0.01), vascular invasion (p < 0.01), grade 3-4 differentiation (p < 0.01), squamous cell carcinoma (p < 0.01), and pathological stage > II (p < 0.01), but significantly lower in those who were epithelial growth factor receptor (EGFR) mutation negative (p < 0.01). Relapse-free survival was significantly worse in patients with PD-L1 expression (p = 0.04). Univariate analysis showed that male sex (p = 0.04), carcinoembryonic antigen expression (CEA) (p < 0.01), maximum standardized uptake value (p < 0.01), lymphatic invasion (p < 0.01), vascular invasion (p < 0.01), grade 3-4 differentiation (p < 0.01), lower lobe disease (p = 0.04), PD-L1 expression (p = 0.03), and pathological stage (p < 0.01) were significant risk factors of recurrence. In multivariate analysis, CEA expression (p = 0.01), lymphatic invasion (p = 0.04), and pathological stage (p < 0.01) were risk factors for recurrence, whereas PD-L1 expression was not a significant factor of recurrence (p = 0.62)., Conclusion: PD-L1 expression was not a risk factor of recurrence but tumor progression tended to increase PD-L1 expression., Trial Registration: The Institutional Review Board of Kanazawa Medical University approved the protocol of this retrospective study (approval number: I392), and written informed consent was obtained from all patients., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Percutaneous or transbronchial markings are performed to localize pulmonary nodules preoperatively. We present a novel intraoperative procedure that utilizes virtual thoracoscopic imaging-assisted pleural marking. In this procedure, a virtual thoracoscopic image is created preoperatively, and the coordinates of the pleural point above the tumor are determined. The pleural marker is intraoperatively placed on the coordinates, and dye is transferred to the visceral pleura with two lung ventilations. We present the specific procedures and countermeasures for cases when nodules are not palpable. Additionally, we present a comparison between the various methods of preoperative marking and this method.

Background: Video-assisted thoracic surgery (VATS) procedures for non-small cell lung cancer (NSCLC) have steadily increased and have become the gold standard, but their prognostic advantage compared with thoracotomy has not been elucidated. This study retrospectively evaluated perioperative characteristics of VATS for NSCLC over time., Methods: We collected the clinical data of 760 patients with NSCLC who underwent pulmonary resection over the past decade, classifying patients into early (2011-2015) and late (2016-2020) periods. Changes in NSCLC patient characteristics, surgical approaches, perioperative factors, postoperative morbidities, and prognoses were analyzed., Results: Patients in the late period were older (p = 0.01), had more comorbidities (p = 0.01), and had earlier-stage cancer (p < 0.01) than those in the early period. The late period had significantly fewer surgical procedures for lobectomy or extended resection beyond lobectomy (p < 0.01), open thoracotomies (p < 0.01), postoperative (p = 0.02) and severe morbidities (p < 0.01), and a significantly shorter postoperative hospital stay than the early period. Surgical procedures of lobectomy or extended resection beyond lobectomy (p < 0.01) were significant risk factors for postoperative morbidity, and being in the early period (p < 0.01) and surgical procedures of lobectomy or extended resection beyond lobectomy (p < 0.01) were significant risk factors for severe postoperative morbidities. The overall survival prognosis significantly differed between the groups (p = 0.02) but progression-free survival did not (p = 0.89)., Conclusions: The incidence of postoperative morbidities decreased over time in older patients and patients with more comorbidities. The prognosis of patients with NSCLC did not change with increasing VATS or sublobar resection., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Although the consolidation diameter of a tumor on computed tomography (CT) is an adaptation criterion for limited resection in early-stage non-small cell lung cancer (NSCLC), whether the maximum standardized uptake value (SUVmax) is also an adaptation criterion for limited resection has not been evaluated., Methods: In total, 478 NSCLC patients with clinical stage IA disease were analyzed, among whom 383 were used to perform a sub-analysis., Results: Multivariate analysis showed that consolidation diameter (odds ratio [OR]: 3.05, p = 0.01), SUVmax (OR: 10.74, p = 0.02), and lymphatic invasion (OR: 10.34, p &lt; 0.01) were risk factors for lymph node metastasis in clinical stage IA NSCLC patients. Furthermore, age (OR: 2.98, p = 0.03), SUVmax (OR: 13.07, p = 0.02), and lymphatic invasion (OR: 5.88, p = 0.02) were risk factors for lymph node metastasis in clinical stage IA lung adenocarcinoma patients according to multivariate analysis., Conclusion: Consolidation diameter of a tumor on CT, SUVmax, and lymphatic invasion are risk factors for lymph node metastasis. However, SUVmax was a risk factor for lymph node metastasis rather than consolidation diameter on CT in lung adenocarcinoma patients. These results suggest that for early-stage lung adenocarcinoma patients, SUVmax is more important for deciding the indication of limited resection than consolidation diameter of the tumor on CT., (© 2023 S. Karger AG, Basel.)

Background: Abnormal tumor vascularization and escalating tumor size represent two major impediments that make cancer surgery impossible or complicated., Case Presentation: Herein, we report the case of a giant thymoma (type AB) in a 58-year-old woman who presented with cough and yellow sputum. The thymoma grew extensively from the neck to the upper mediastinum. The patient exhibited an aberrant right subclavian artery and a non-recurrent inferior laryngeal nerve. Intraoperative nerve monitoring facilitated the identification and preservation of vital nerves spanning the neck and chest, including the non-recurrent inferior laryngeal nerve. Furthermore, the tumor was divided naturally along the constriction, and a good field of view was acquired to identify abnormal right subclavian arteries and nerves that ran deep in the tumor and surgical field. The tumor was safely removed without complications using intraoperative nerve monitoring, and the thymoma that grew extensively from the neck to the upper mediastinum and was associated with an aberrant right subclavian artery was resected., Conclusion: Intraoperative nerve monitoring was helpful in identifying the non-recurrent inferior laryngeal nerve and left recurrent laryngeal nerve., (© 2022. The Author(s).)

Background: Thrombosis of the pulmonary vein stump is a common complication after a left upper lobectomy and can be a source of embolism in various organs, such as the kidneys. A renal infarction, on the other hand, is a rare and often lethal condition that is usually diagnosed postmortem. Here, we present a case of renal infarction associated with pulmonary vein stump thrombosis after a left pneumonectomy, which was treated successfully with edoxaban., Case Presentation: A 73-year-old man was diagnosed with squamous cell lung cancer (cT1miN0M0 stage IA1). Due to pneumoconiosis, extensive lymph node infiltration into the pulmonary artery was noted and necessitated an open thoracotomy. Ultimately, a left pneumonectomy was performed. Atrial fibrillation occurred on postoperative day 3, and the patient complained of left-sided abdominal pain. Contrast-enhanced computed tomography revealed a left upper pulmonary vein thrombosis and a left renal infarction. Anticoagulant therapy was immediately initiated with heparin and warfarin. On postoperative day 13, warfarin was replaced with the direct oral anticoagulant edoxaban since the patient's compliance and drug response to warfarin were poor. On postoperative day 19, contrast-enhanced computed tomography revealed a reduction in pulmonary vein stump thrombosis and improvement in renal infarction. Subsequently, the patient was discharged. Three months post-surgery, no infarct lesions or reduced renal function was observed on imaging., Conclusions: The direct oral anticoagulant edoxaban could be effective in preventing recurrence or exacerbation of pulmonary vein thrombosis associated with renal infarction without bleeding complications., (© 2022. The Author(s).)

Background: Lobectomy may be a challenging treatment option in lung cancer with inflammatory lymph node infiltration. Moreover, the en-masse lobectomy technique, which involves the simultaneous ligation or stapling of pulmonary vessels and bronchi at the hilar area, is controversial., Case Presentation: We report the case of a 75-year-old woman who presented with lung cancer and lymph node infiltration from the posterior ascending pulmonary artery (A2) to the superior pulmonary artery (A6). A nodule was observed in her right upper lobe on chest computed tomography while treating her for a myocardial infarction 3 months prior; hence, a radical lobectomy was planned. Her main pulmonary artery could be constricted using surgical tape, but this was not possible in the peripheral pulmonary artery of the ascending A2 due to widespread lymph node infiltration. Intraoperative frozen sections confirmed the absence of metastases in the hilar lymph nodes. Pulmonary angioplasty was aborted because the cardiac function had not fully recovered from the previous procedure. The ascending A2 and upper lobe bronchus were collectively treated using an auto-stapler. Two months postoperatively, computed tomography showed no pulmonary artery aneurysm., Conclusions: This report highlights that the en-masse technique may be recommended as an alternative for A2 treatment during lobectomy in cases with inflammatory lymph node infiltration. Surgeons should consider switching to thoracotomy, in such cases, to avoid fatal intraoperative complications., (© 2022. The Author(s).)

Background: Although the utility of segmentectomy for early-stage non-small cell lung cancer (NSCLC) has been reported, the adaptation criterion for segmentectomy is unclear., Methods: In total, 171 NSCLC patients who underwent segmentectomy or lobectomy with a consolidation tumor diameter on computed tomography of ≤20 mm were analyzed., Results: Consolidation diameter (p = 0.01), consolidation to tumor ratio (CTR) (p < 0.01), maximum standardized uptake value (SUV max ) (p < 0.01), and segmentectomy (p = 0.01) were significantly different upon univariate analysis among patients stratified by recurrence. Positive correlations were observed between the consolidation diameter on CT and CEA (correlation coefficient; r = 0.19, p = 0.01), SUV max (r = 0.48, p < 0.01), and CTR (r = 0.83, p < 0.01). Because there was a significant correlation among the consolidation diameter of tumors on CT, CTR, and SUV max in this study, we integrated these factors into one. Consolidation, CTR, and SUV max (hazard ratio [HR]: 3.77, 95% confidence interval [CI]: 1.35-11.29, p = 0.01) and segmentectomy (HR: 0.24, 95% CI: 0.03-0.90, p = 0.03) were risk factors for recurrence in a multivariate analysis. There was a significant difference between the segmentectomy and lobectomy groups (5-year relapse-free survival [RFS] 96.5% vs. 80.7%, p = 0.02)., Conclusions: Consolidation tumor diameter on CT, CTR, and SUV max is a risk factor for recurrence. These results suggest that for patients with small-sized early stage NSCLC, this combined factor is important for determining the indication for segmentectomy., (© 2022 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: Although T factor is defined as the size of invasive area rather than total tumor size in the eighth edition of the TNM classification, whether the pathological invasive area to tumor ratio (ITR) is a prognostic factor has not yet been evaluated., Methods: In total, 432 lung adenocarcinoma patients were analyzed, among which 266 patients with pathological stage IA were used to perform a subanalysis., Results: Smoking status (odds ratio [OR]: 0.43, p = 0.01), neutrophil-to-lymphocyte ratio (NLR) (OR: 1.97, p = 0.03), maximum standardized uptake value (SUV max ) (OR: 3.62, p < 0.01), and ITR (OR: 6.76, p < 0.01) were significantly different in univariate analysis. Smoking status (OR: 0.34, p < 0.01), SUV max (OR: 3.05, p < 0.01), and ITR (OR: 5.44, p < 0.01) were risk factors for recurrence in multivariate analysis. In patients with pathological stage IA disease, smoking status (OR: 0.34, p = 0.03), NLR (OR: 2.30, p = 0.04), SUV max (OR: 3.63, p < 0.01), pathological invasive area (OR: 4.00, p < 0.01), and ITR (OR: 6.03, p < 0.01) were significantly different in univariate analysis. Smoking status (OR: 0.27, p = 0.02), SUV max (OR: 3.93, p < 0.01), and ITR (OR: 4.38, p < 0.01) were significant risk factors for recurrence in multivariate analysis., Conclusions: SUV max and ITR are risk factors for recurrence. These results suggest that SUV max is important for deciding the indication for limited resection or adjuvant chemotherapy, and ITR is an adaptation criterion for adjuvant chemotherapy for early-stage lung adenocarcinoma patients., (© 2022 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: Primary hyperparathyroidism is a disease caused by the secretion of excess parathyroid hormone (PTH) owing to the enlargement of the parathyroid gland. Ectopic parathyroid glands exist in the mediastinum in approximately 1-2% of cases, which is relatively rare. Intraoperative monitoring of serum PTH level is important to assess whether the source of hyperparathyroidism has been eliminated., Case Presentation: A 53-year-old asymptomatic woman was diagnosed with ectopic mediastinal parathyroid adenoma. A three-port robotic partial resection of the thymus containing the tumor was attempted, but bleeding from a swollen pericardial diaphragmatic vein led to the addition of an assist port along the way. The PTH level was measured intraoperatively. After confirming that the 15-min PTH level after removal of the tumor was less than 50% of the baseline value, the operation was completed. The tumor was positive for PTH and was diagnosed as an ectopic mediastinal parathyroid adenoma. Some small ectopic parathyroid gland tissues were observed in other parts of the thymic tissue. Serum calcium and PTH levels decreased and normalized., Conclusions: We report the usefulness of robotic resection for ectopic mediastinal parathyroid adenoma with PTH monitoring. However, histopathologically, small parathyroid gland tissues may remain in the surrounding thymus. Hence, we believe that a strict follow-up is required for parathyroid function in the future., (© 2022. The Author(s).)

A female underwent a right middle lobectomy for a pulmonary adenocarcinoma (AD). She eventually died of a right malignant pleural mesothelioma (MPM; sarcomatoid type) 4 years and 7 months after the removal of the AD even though she did not have any history of asbestos exposure, smoking, or radiation exposure. Her chest CT revealed multiple pulmonary nodules and bilateral pleural effusion with a right pleural tumor directly invading into the abdominal cavity. The genomics of tumor origin and characteristics were examined for the AD and the MPM. As a result, 50 somatic variants were detected in the AD, and 29 somatic variants were detected in the MPM. The variants which were common in both the AD and the MPM were not present, which suggested that the AD and the MPM had occurred independently in different origins. The MPM had two driver oncogenes of TP53 and EP300 , but the AD did not. Two driver oncogenes of TP53 and EP300 were hypothesized to make the MPM aggressive. The speed at which the MPM progressed without the patient having a history of asbestos exposure, smoking, or radiation exposure was alarming., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Usuda, Niida, Ishikawa, Iwai, Yamagata, Iijima, Motono, Yamada and Uramoto.)

Background: Although the risk calculator of the National Clinical Database (RC-NCD) has been widely used to predict the occurrence of mortality and major morbidity in Japan, it has not been demonstrated whether a correlation between the calculated RC-NCD risk score and the actual occurrence of mortality and severe morbidity exists., Methods: The clinical data of 585 patients who underwent pulmonary resection for non-small cell lung cancer were collected, and the risk factors for postoperative morbidity were analyzed to verify the validity of the RC-NCD., Results: The coexistence of asthma (p = 0.02), nutrition lymphocyte ratio (p = 0.04), and pulmonary lobe (p < 0.01) were significant risk factors for postoperative morbidity in the present study, and the percent-predicted vital capacity (p < 0.01), pulmonary lobe (p = 0.03), and type of operative procedure (p = 0.01) were significant risk factors for severe postoperative morbidity. Furthermore, in patients received lobectomy, coexistence of asthma (p = 0.01) and pulmonary lobe (p < 0.01) were identified as significant risk factors for postoperative morbidity. Meanwhile, male sex (p = 0.01), high BMI (p < 0.01), low vital capacity (p = 0.04), and pulmonary lobe (p = 0.03) were identified as significant risk factors for severe postoperative morbidity., Conclusions: Given that the pulmonary lobe was a significant risk factor for postoperative morbidity in patients received pulmonary resection and for severe postoperative morbidity in patients received lobectomy, the RC-NCD for postoperative morbidity needs to be modified according to high-risk lobes., Trial Registration: The Institutional Review Board of Kanazawa Medical University approved the protocol of this retrospective study (approval number: I392), and written informed consent was obtained from all patients., (© 2022. The Author(s).)

Background: This study aimed to determine outcomes and prognostic factors associated with octogenarians who underwent pulmonary resection for lung cancer., Methods: From 2009 to 2018, 76 octogenarians who underwent pulmonary surgery for lung cancer were enrolled in this study. We divided them into two groups, namely overweight and non-overweight, and investigated their clinicopathological characteristics and outcomes. Disease-specific survival (DSS) rates were determined using Kaplan-Meier curves. Univariate and multivariate analyses were performed to identify prognostic factors., Results: Although perioperative morbidity and mortality in octogenarians were not significantly different between the two groups, the long-term prognosis of the overweight group was significantly worse than that of the non-overweight group. The 3-year DSS rate was 56.5%. The median observation period after surgery was 37.5 (8.9-112.3) months for the entire cohort postoperatively. Kaplan-Meier curves showed that being overweight (body mass index ≥ 25) was associated with worse survival rates in all pathological stages (0 to III) and stage 0/I (DSS, p = 0.036 and p = 0.003, respectively). Multivariate analysis identified overweight as an unfavorable prognostic factor for DSS in patients with stage 0/I lung cancer (hazard ratio 2.240, 95% confidence intervals 1.052-4.564, p = 0.037)., Conclusions: Overweight is an independent risk factor, especially in pathological stage 0/I lung cancer. Indications for surgery should be carefully considered in elderly patients with obesity. However, owing to the limitations of this retrospective single-center study, future studies involving multiple institutions are required to confirm our findings., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Although several prognostic factors in patients undergoing pulmonary resection with early-stage non-small cell lung cancer (NSCLC) have been reported, the risk factors are varied and have not been consistent among reports., Methods: Clinical data of 540 patients with pathological stage IA NSCLC were analyzed. Patient factors, such as the sex, age, comorbidities, carcinoembryonic antigen (CEA) level, and smoking history, and surgical factors, such as the operative approach and procedure, were collected and analyzed., Results: There were significant prognostic differences in the relapse-free survival (RFS) depending on the presence of interstitial lung disease (P<0.0001), CEA level (P=0.007), and wedge resection (P=0.002). There were significant prognostic differences in the overall survival (OS) depending on the presence of interstitial lung disease (P=0.0015), CEA level (P<0.0001), and smoking history (P=0.0003). Interstitial lung disease [hazard ratio (HR): 7.725, P=0.003], the CEA level (HR: 1.923, P=0.045), and operative procedure (HR: 2.086, P=0.025) were risk factors for the RFS in a multivariate analysis. The smoking history (HR: 2.539, P=0.002) and CEA level (HR: 2.464, P=0.002) were risk factors for the OS in a multivariate analysis., Conclusions: Interstitial lung disease, the CEA level, and operative procedure were risk factors for the RFS, while the smoking history and CEA level were risk factors for the OS., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1757/coif). The authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Background: Anomalous systemic arterial supply to normal basal lung segments is a rare congenital malformation, in which aberrant arteries arising from the systemic circulation flow into the basal segment of the lung and return to normal pulmonary veins without abnormal bronchial branching. It presents a left-to-right shunt, resulting in volume overload of the pulmonary circulation, and consequently, pulmonary hypertension. Therefore, nearly all cases require surgery. Herein, we present a case, in which indocyanine green was used to demarcate the lung segment perfused by an anomalous systemic artery., Case Presentation: A 15-year-old boy was diagnosed with an anomalous artery originating from the celiac artery and supplying the right dorsobasal lung segment (S 10 ). Via three-port video-assisted thoracoscopic surgery, the anomalous artery was ligated and processed with an auto-stapler. Indocyanine green was injected intravenously to identify the tissue perfused by the anomalous artery, and the lung was resected., Conclusions: With anomalous systemic arterial supply to normal basal lung segments, indocyanine green can be particularly helpful in identifying the boundaries of the perfused area. Then, the affected tissue can be resected by thoracoscopic surgery., (© 2022. The Author(s).)

Introduction and Importance: Bronchial arterial racemose hemangioma is considered to be a type of pulmonary arteriovenous malformation (PAVM). We encountered an extremely rare case of racemose hemangioma, which was identified because of massive bleeding during lung cancer surgery., Case Presentation: A 71-year-old man was suspected of having lung cancer and underwent a right upper lobectomy. During the dissection of the peribronchial connective tissue around the upper lobe bronchus, a sudden massive hemorrhage occurred after separation of the pulmonary artery and vein. Hemostasis was difficult to achieve with compression hemostasis and the point of bleeding was unknown; thus, we were called in to search for the source of the bleeding, which was identified as the bronchial artery. Postoperatively, a racemose hemangioma was diagnosed via preoperative chest computed tomography and imaging analysis with the Ziostation2® (Ziosoft Inc. Tokyo, Japan)., Clinical Discussion: Racemose hemangioma has weaker blood vessel walls than normal blood vessels. Once bleeding occurs, it is very difficult to stop. However, once the bleeding point was identified, hemostasis via suturing and cutting was possible., Conclusion: As hemorrhaging from a racemose hemangioma is very difficult to stop, preoperative imaging retrieval is very important., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Detecting distant metastases when staging lung cancer is critical to avoid unnecessary surgery and provide appropriate multidisciplinary treatment. However, it is controversial as to whether staging studies should be performed routinely for patients with early-stage lung cancer who have no evidence of distant metastasis. Thus, this study aimed to examine the need for extrathoracic metastasis screening in patients with clinical stage IA non-small cell lung cancer, understand the association between extrathoracic metastasis and other clinical features, and evaluate the diagnostic efficiency of imaging screening for preoperative extrathoracic metastasis in patients with early-stage lung cancer., Methods: From 2010 to 2019, 510 patients diagnosed with clinical T1N0 lung cancer, excluding contralateral lung metastases, pleural dissemination, malignant pleural effusion, and malignant pericardial effusion, were treated for primary lung cancer. Patients were divided into two groups, and their clinicopathological characteristics were investigated., Results: Five patients (1.0%) had extrathoracic metastases. The histological types were adenocarcinoma in three of the cases, and squamous cell carcinoma and large cell neuroendocrine carcinoma in the other two cases. The T factor was T1b in one case and T1c in four cases. Four patients had solid tumors and one had a solid predominant tumor with an average tumor diameter of 23.0 ± 2.9 mm. The size of solid tumors with extrathoracic metastases was larger than their counterparts., Conclusion: When evaluating stage IA non-small cell lung cancer with a solid component diameter < 22 mm, or clinical T1mi-1bN0 in computed tomography evaluation, screening for preoperative extrathoracic metastasis may be omitted.

Background: Congenital pericardial defects are rare congenital anomalies, often asymptomatic and incidentally detected during thoracic surgery., Case Presentation: A 74-year-old man with primary lung cancer (cT1cN0M0, Stage IA3) underwent thoracoscopic radical lobectomy. At the time of thoracotomy, a pericardial defect was found on the ventral side of the hilar region, and the left atrial appendage was exposed. Due to concern that contact between the bronchial stump and the left atrial appendage may lead to postoperative bleeding and heart hernia, the pericardial defect was closed with an expanded polytetrafluoroethylene GoreTex® membrane. Preoperative computed tomography was reanalyzed with a 1 mm slice, congenital pericardial defect was detected as the pericardium had penetrated under the left atrial appendage., Conclusions: In congenital partial pericardial defect, contact between the left atrial appendage and bronchial stump, due to movement of the lung or heart, increases the risk of bleeding after lung resection. Therefore, closure of the defect should be considered. Although it is difficult to diagnose congenital partial pericardial defect preoperatively, computed tomography taken with a slice thickness of 1 mm is useful for diagnosis., (© 2021. The Author(s).)