Effect of gravitation for detection of bronchioloalveolar carcinoma on computed tomography.

A 64-year-old female was found to have localized ground-glass opacity (GGO) in the middle lobe on a chest computed tomography (CT) for screening. Middle lobectomy with video-assisted thoracoscopic surgery (VATS) was undertaken, and pathological diagnosis was a bronchioloalveolar carcinoma (BAC) in stage IA. A follow-up CT a year following the surgery revealed localized GGO in area S6 of the left lung. However, it disappeared during the gravitation-dependent gradient in the observation period. The patient was scanned again under prone position to exclude the gravitational effect, resulting in definite detection of the GGO. Left extended S6 segmentectomy with VATS was performed, and pathological diagnosis was a BAC in stage IA. As GGO existing in a gravitation-dependent area may be masked by the gravitation-dependent density, a change of the scanning position may lead to a proper detection of the tumor for the diagnosis of BAC.     

A rational approach of limited resection for small peripheral lung adenocarcinoma with curative intent; analyses of multiple primary adenocarcinomas

Hundred and forty-one small peripheral adenocarcinomas 2 cm or less in diameter were retrospectively studied to determine the rationale of limited resection with curative intent. We used a conventional computed tomography (CT) which used 2.5 mm thick sections to examine only the main tumor during from March 1985 to May 1999 and a spiral CT which produced 2.5 mm thick sections of the entire lung field during from June 1999 to July 2003. The incidence of small peripheral adenocarcinoma significantly increased from 12.6% to 29.1%, suggesting an increase in the rate of detection with spiral CTs. During the spiral CT era, the percentage of females, pathological stage I a tumors, predominant ground-glass opacity (GGO) tumors and limited resection were significantly higher. The incidence of multiple adenocarcinomas 2 cm or less in diameter significantly increased 2.6% to 14.1%. It increases to 21.9% in small adenocarcinomas and 63.6% in predominant GGO type, when minute GGO lesion which have been followed in 5 patients by a watch and wait policy would be bronchioloalveolar carcinoma (BAC). In conclusion, a paradigm shift of the treatment for small peripheral adenocarcinoma should be warrant, because localized BAC as noninvasive cancer is not rare and often found as multiple BACs.     

A clinicopathological study of resected pulmonary nodules with focal pure ground-glass opacity.

OBJECTIVE: Pulmonary lesions with focal ground-glass opacity (GGO) have been detected increasingly by low-dose helical computed tomography (CT). However, the strategy of treatment for focal pure GGO lesions is still undecided. This study evaluates clinicopathological characteristics of resected pulmonary nodules with focal pure ground-glass opacity. METHODS: Between January 1997 and December 2005, 26 patients (35 lesions) with pure GGO lesions underwent pulmonary resection. The data on patient age, lesion size, pathology, carcinoembryonic antigen (CEA) level and palpability of the tumor in the resected specimen were evaluated. RESULTS: The histological diagnosis was bronchioloalveolar carcinoma (BAC) in 10 patients (12 lesions), atypical adenomatous hyperplasia (AAH) in 15 patients (22 lesions), and focal scar in 1 patient (1 lesion). There were no significant differences in age, sex, tumor size, and CEA level between the patients with BAC, AAH, and focal scar. However, the lesions >10mm in size were all BAC. Palpability of the tumor in the resected specimen was significantly more frequent in BAC cases than in AAH cases (p<0.01). For BAC, lobectomy was performed for four lesions, and limited resection for eight. None of the BACs showed lymphatic or vascular invasion upon pathological examination. At the median follow-up point of 44 months (range: 4-84 months), no recurrences were observed. CONCLUSIONS: BAC and AAH cannot be discriminated by their size. In the resected specimen, BAC lesions are more frequently palpable than AAH lesions. Thoracoscopic surgery is recommended for focal pure GGO after repeated CT even if the GGO lesion is small. Partial resection is a sufficient treatment for pure GGO.     

Pulmonary nodules 10 mm or less in diameter with ground-glass opacity component detected by high-resolution computed tomography have a high possibility of malignancy

Objectives: For the histological diagnosis of small lung cancers of 10 mm or less in diameter (≤10), resection by video-assisted thoracic surgery (VATS) with computed tomography (CT)-guided marking is feasible. One problem is that a small number of these pulmonary nodules are malignant. We retrospectively analyzed CT images of pulmonary nodules to find better criteria to select candidates for resection among patients with small pulmonary nodules. Methods: Ninety-four patients with indeterminate peripheral pulmonary nodules underwent wedge resection by VATS. High-resolution CT using a 1.25 mm slice included the area of lesions. Nodules were classified by size (≤10, 11 to 22,>20 mm) and whether they had a ground-glass opacity (GGO) component. Results: The histology of all 94 nodules showed 52 primary lung cancers, 6 metastatic tumors, 5 benign tumors, 8 intrapulmonary lymph nodes, and 23 inflammatory nodules. Ninety-three percent of nodules larger than 20 mm, 75% of nodules 10 to 20 mm, and 43% of nodules ≤10 mm were malignant. Introducing a classification according to GGO component to nodules, malignancy was detected in 88% of nodules with a GGO component and in 30% of nodules without a GGO component among nodules ≤10 mm. Nodules ≤10 mm with a GGO component showed a statistically significant (p<0.01) correlation with malignancy. Conclusions: Pulmonary nodules ≤10 mm with GGO should be considered to have a high possibility of malignancy and to be candidates for resection by VATS.     

Procedure for lung resection in patients with small-sized lung cancer and mid-term results

Sublobar resection and the optimum approach for small-sized lung cancer remain controversial. We defined the criteria for the selection of cT1aN0M0 patients for thoracoscopic lung surgery and the criteria for other patients for open lung surgery in 2004. Limited resection for small-sized lung cancer was performed when the diameter of the solid lesion was less than 20% the diameter of lesions of groundglass opacity( GGO). The 5-year overall survival and 5-year disease-free survival( 5Y-DFS) was 89.9% and 91.7%, respectively. The 5Y-DFS according to the pathological stage was as follows:stage IA, 96.5%;IB, 100%;IIA, 50%;IIIA, 66.7%;and stage IV, 100%. According to computed tomography (CT) findings, the 5Y-DFS was as follows:pure GGO lesion, 100%;mixed GGO lesion, 100%;and solid lesion, 84.6%. Lymph node metastases and recurrence were noticed only in patients with a solid lesion. Thus, patients with GGO lesions are considered good candidates for thoracoscopic sublobar resection. In addition, thoracoscopic segmentectomy was performed in cT1bN0M0 patients with GGO lesions, and good prognostic results were obtained;therefore, these patients are also considered good candidates for the procedure.     

Pulmonary nodules 10 mm or less in diameter with ground-glass opacity component detected by high-resolution computed tomography have a high possibility of malignancy

OBJECTIVES: For the histological diagnosis of small lung cancers of 10 mm or less in diameter (< or =10), resection by video-assisted thoracic surgery (VATS) with computed tomography (CT)-guided marking is feasible. One problem is that a small number of these pulmonary nodules are malignant. We retrospectively analyzed CT images of pulmonary nodules to find better criteria to select candidates for resection among patients with small pulmonary nodules. METHODS: Ninety-four patients with indeterminate peripheral pulmonary nodules underwent wedge resection by VATS. High-resolution CT using a 1.25 mm slice included the area of lesions. Nodules were classified by size (< or =10, 11 to 20, >20 mm) and whether they had a ground-glass opacity (GGO) component. RESULTS: The histology of all 94 nodules showed 52 primary lung cancers, 6 metastatic tumors, 5 benign tumors, 8 intrapulmonary lymph nodes, and 23 inflammatory nodules. Ninety-three percent of nodules larger than 20 mm, 75% of nodules 10 to 20 mm, and 43% of nodules < or =10 mm were malignant. Introducing a classification according to GGO component to nodules, malignancy was detected in 88% of nodules with a GGO component and in 30% of nodules without a GGO component among nodules < or =10 mm. Nodules < or =10 mm with a GGO component showed a statistically significant (p < 0.01) correlation with malignancy. CONCLUSIONS: Pulmonary nodules < or =10 mm with GGO should be considered to have a high possibility of malignancy and to be candidates for resection by VATS.     

Objective definition and measurement method of ground-glass opacity for planning limited resection in patients with clinical stage IA adenocarcinoma of the lung

Objective: The standard operation for patients with stage IA lung adenocarcinoma is considered to be a lobectomy. Recently, some researchers have reported that patients with tumors showing greater proportions of ground-glass opacity (GGO) at computed tomography (CT) could be candidates for limited resection, because of its less aggressive nature. However, the lack of a precise definition or standard measuring method of GGO prevents its general use as an index for planning limited resection. Therefore, we attempted to define GGO based on CT number and measured it more objectively. Methods: Between 1998 and 2001, 90 patients with clinical stage IA adenocarcinoma, who underwent standard or intentional limited resection and whose images of chest high-resolution CT were preserved in Digital Imaging and Communications in Medicine (DICOM) format, constituted the study population. The tumor shadow seen on the solid window (WL, −160 HU; WW, 2 HU) was regarded as the central solid area of the tumor seen on the lung window, and GGO was defined as the whole tumor area with the exception of the central solid area. Each area was measured using Scion Image (Scion Corp., Frederick, MD). We analyzed the relationship between the proportion of GGO and both of pathologic findings and recurrence. Results: Among the 90 tumors, 31 (34.4%) were calculated to have a GGO area greater than or equal to 50%. Of these, 27 (87%) tumors were bronchioloalveolar carcinoma. Lymphatic and vascular invasions, or nodal involvement were found only in patients with a smaller proportion of GGO (<50%) (P<0.05). During the follow-up period (median 36 months), recurrences occurred in eight patients who were diagnosed as having tumors showing smaller proportion of GGO (<50%). Conclusions: Tumors with a greater proportion of GGO measured by our method are thought to have a less invasive nature. Our objective measuring method of GGO could be useful for future multicenter trials to elucidate the value of limited resection for clinical stage IA adenocarcinoma based on the proportion of GGO.     

Video-assisted S6b-subsegmental resection after computed tomography guided localization of pulmonary nodules

A 38-year-old man, who had undergone surgery for gastric cancer one year previously, was found to have two pulmonary nodules (PNs: 10mm in diameter) on chest radiography. Computed tomography (CT) revealed one of these nodules to be located near the B⁶b in the right lung hilus, while the other was located in the superficial region of the left lower lobe. Video-assisted thoracic surgery (VATS) was performed, for both diagnostic and therapeutic purposes. In this procedure, after preoperative CT-guided marking, simultaneous subsegmental resection of the right S⁶b and VATS wedge resection of the left lower lobe were performed successfully with adequate surgical margin. Histological diagnosis was compatible with metastatic pulmonary tumor from a gastric carcinoma primary. This case demonstrates that preoperative CT-guided localization can facilitate safe VATS subsegmental resection of a small deep pulmonary nodule.     

Video-assisted S<Superscript>6</Superscript>b-subsegmental resection after computed tomography guided localization of pulmonary nodules

A 38-year-old man, who had undergone surgery for gastric cancer one year previously, was found to have two pulmonary nodules (PNs: 10mm in diameter) on chest radiography. Computed tomography (CT) revealed one of these nodules to be located near the B⁶b in the right lung hilus, while the other was located in the superficial region of the left lower lobe. Video-assisted thoracic surgery (VATS) was performed, for both diagnostic and therapeutic purposes. In this procedure, after preoperative CT-guided marking, simultaneous subsegmental resection of the right S⁶b and VATS wedge resection of the left lower lobe were performed successfully with adequate surgical margin. Histological diagnosis was compatible with metastatic pulmonary tumor from a gastric carcinoma primary. This case demonstrates that preoperative CT-guided localization can facilitate safe VATS subsegmental resection of a small deep pulmonary nodule.     

Preoperative marking of a submillimeter metastatic pulmonary tumor using a mobile computed tomography scan with a navigation system: A case report

Introduction and importancePreoperative localization of non-palpable lung nodules plays an important role in video assisted thoracic surgery (VATS). Although percutaneous computed tomography (CT)-guided hook wire marking has become widely accepted, it is accompanied by rare but fatal complications such as air embolisms. We herein report a case of a submillimeter pulmonary nodule successfully localized by a mobile CT scan with a navigation system.Case presentationA 40-year-old-man presented with the two right pulmonary nodules 4 years after a radical left nephrectomy for a renal clear cell carcinoma. One of the nodules was too small to palpate and preoperative marking was applied using a mobile CT scan with a navigation system. We successfully performed VATS wedge resection for both nodules and confirmed a pathological diagnosis of a metastasis from the renal cell carcinoma. The maximum pathological size of the smaller nodule was 500 μm.Clinical discussionPreoperative marking of the lower lobe lesion in the present case was essential for VATS. Our novel technique was helpful for the precise marking without any morbidity.ConclusionPreoperative marking using a mobile CT scan with a navigation system is safe and easily applicable. It might be a useful option for VATS of non-palpable lung nodules.     

One-dimensional mean computed tomography value evaluation of ground-glass opacity on high-resolution images

Objective  

Differentiation of atypical adenomatous hyperplasia (AAH), bronchioloalveolar carcinoma (BAC), and invasive carcinoma on computed tomography (CT) is useful for determining “follow-up or resection” strategies for lesions displaying ground-glass opacity (GGO). The purpose of this study is to evaluate one-dimensional quantitative CT values of GGO on high-resolution CT (HRCT) images using computer-aided diagnosis.     

Small peripheral lung adenocarcinoma: Clinicopathological features and surgical treatment

The clinical use of high-resolution computed tomography (CT) has greatly advanced diagnosis of small peripheral lesions of the lung. In CT images, these lesions often exhibit ground-glass opacity (GGO). Ground-glass opacity is typical of noninvasive bronchioloalveolar carcinoma (BAC), which is characterized by a lepidic pattern of cells that line the alveoli but do not invade neighboring structures. Bronchioloalveolar carcinoma is classified as a subset of lung adenocarcinoma, but has distinct clinical and pathological features and a favorable prognosis. Most small peripheral lung lesions, including BAC, probably originate in the epithelium of the peripheral airway. As with other subsets of non-small cell lung cancer, surgical resection is a potentially curative treatment. However, it is questionable whether a lobectomy is necessary for small lesions that exhibit GGO, particularly when they are <1 cm in diameter. Although several Japanese investigators have suggested that a limited resection, including a wedge resection and a segmentectomy without nodal dissection, is an appropriate treatment for small lung adenocarcinomas, this approach should be validated by clinical trials.     

Prospective study of thoracoscopic limited resection for ground-glass opacity selected by computed tomography

BACKGROUND: With recent advances in low-dose helical computed tomography (CT), detection of ground-glass opacity (GGO) has increased. The aim of this study was to correlate high-resolution CT (HRCT) findings with pathologic features and to evaluate the efficacy of thoracoscopic limited resection for focal GGO, which were selected based on HRCT findings. METHODS: Focal GGO lesions were classified into two subtypes based on HRCT findings: pure type and mixed type. Ninety-six patients with persistent GGO 2 cm or less in diameter underwent pulmonary resection from January 1997 to December 2001. Among these, thoracoscopic wedge resection was performed prospectively between June 2000 and December 2001 in 33 patients with pure GGO lesions that were 1 cm or less. RESULTS: Thoracoscopic wedge resection was completed with complete safety. The histologic diagnoses of these 33 lesions were adenocarcinoma in 1, bronchioloalveolar carcinoma (BAC) in 23, and atypical adenomatous hyperplasia (AAH) in 9. No patients have had any evidence of tumor recurrence to date. Of the total 96 GGO lesions, 93.0% (53/57) of pure GGO 1 cm or less were BAC or AAH, whereas 38.5% (15/39) of pure GGO larger than 1 cm or mixed GGO were adenocarcinoma. CONCLUSIONS: Pure GGO 1 cm or less was characteristic of noninvasive lesions. Thoracoscopic limited resection for small GGO lesions selected by HRCT was valid.     

Video-assisted thoracic surgery for lung cancer

Objective|The objective of this study was to confirm the safety and feasibility of video-assisted thoracic surgery (VATS) for primary lung cancer and to compare prognoses with that of conventional procedures, and then to examine whether VATS would supplant a conventional thoracotomy for stage I lung cancer. Methods: From September 1995 through March 2002, 144 patients with primary lung cancer, included 118 patients with postoperative state I, underwent VATS lobectomy. We reviewed the previous cases whether they could be candidates for VATS lobectomy according to present indications. 166 cases were supposed to be candidates for VATS, and 121 cases of postoperative stage I disease were recruited into the “conventional thoracotomy” group. Results: There was no mortality or major complication except one case, and mean follow-up was 31.8 months in VATS. The number of removed lymph nodes was not significantly less than the number by conventional thoractomy (p=0.061). Five-year survival for patients with pathological stage IA adenocarcinoma was 92.4% (n=66) in VATS and 86.9% (n=50) in conventional thoracotomy, and a statistical significance could not be recognized (p=0.980). The length of hospital stay was significantly short in VATS lobectomy (p<0.0001). Conclusions: VATS lobectomy for stage I lung cancer can be performed safely with minimal morbidity, satisfying survival comparable with that of lobectomy through conventional thoractomy. VATS approach is a feasible surgical technique for patients with stage I lung cancer.     

电视胸腔镜手术在肺恶性肿瘤合并气胸诊断和治疗中的应用

目的探讨电视胸腔镜手术（video-assisted thoracoscopic surgery,VATS）对肺恶性肿瘤合并气胸的诊断和治疗价值。方法 2002年4月～2008年5月,19例术前胸部CT提示单侧周围型肺肿瘤合并气胸,术前均无明确病理诊断,行VATS手术探查,术中取肺肿瘤组织快速冰冻切片,根据病理结果和病人情况决定手术方式,同时处理肺脏漏气部位。结果全胸腔镜肺肿瘤楔形切除10例,胸腔镜辅助小切口手术9例（其中原发肺癌根治4例,肺肿瘤射频消融5例）。14例肺转移瘤均行胸膜摩擦固定。均手术顺利,均明确病理诊断。手术时间45～90 min（平均51.4 min）,术中出血量50～280 ml（平均150 ml）,胸管引流时间3～8 d（平均4.5 d）。术后2例轻度漏气,无特殊处理自愈,无围手术期死亡。术后所有患者肺复张良好。19例术后随访2～49个月,平均23个月,仅1例气胸复发,行胸腔闭式引流治愈。结论 VATS对明确周围型肺肿瘤病理诊断有重要作用,同时及时有效治疗气胸和肺恶性肿瘤,值得推荐。     

Differentiating between atypical adenomatous hyperplasia and bronchioloalveolar carcinoma using the computed tomography number histogram

BACKGROUND: Both atypical adenomatous hyperplasia (AAH) and bronchioloalveolar carcinoma (BAC) appear as ground glass opacity (GGO) lesions by computed tomography (CT) and are sometimes difficult to differentiate. To aid distinction between the two, we examined their CT number histograms. METHODS: Histograms of pixel CT numbers were made for AAH (n = 9) and nonmucinous BAC (n = 8), and the peak and mean CT numbers on the histogram were quantified. RESULTS: Although there was no significant difference in lesion size between AAH and BAC, all AAHs were less than or equal to 1 cm in diameter. All AAHs and BACs manifested one histogram peak. Both the peak and mean CT numbers on the histogram were significantly lower for AAH than for BAC (p < 0.001). However, the degree of overlap between AAH and BAC was less for the peak CT number than for the mean CT number. CONCLUSIONS:The peak CT number on the histogram can help the radiologic differentiation between AAH and BAC. GGO lesions less than or equal to 1 cm in diameter that are diagnosed as AAH from the CT number histogram can be safely followed by CT.     

Pathological Diagnosis and Cytoreduction of Cardiophrenic Lymph Node and Pleural Metastasis in Ovarian Cancer Patients Using Video-Assisted Thoracic Surgery

Background  The aim of this study was to assess the benefit of video-assisted thoracic surgery (VATS) in pathological diagnosis and intrathoracic cytoreduction of cardiophrenic lymph node (CPLN) and pleural metastasis on computed tomography (CT) in patients with ovarian cancer. Methods  We reviewed a database of ovarian cancer patients who underwent VATS from June 2007 to November 2008. The criterion for suspicion of malignancy on CT was either a CPLN with short-axis dimension >5 mm or multinodular pleural thickening. Seven patients with primary ovarian cancer and five patients with recurrent ovarian cancer were identified and evaluated. Results  Twelve patients met the criterion for suspicious malignancy on CT, with CPLN metastasis and pleural metastasis in nine and five patients, respectively. CPLN metastasis was identified in two of four patients with primary ovarian cancer and in all five patients with recurrent ovarian cancer who had CPLN >5 mm on CT. Pleural metastasis was identified in three of five patients with suspicious pleural metastasis and in one of seven patients without suspicious pleural metastasis on preoperative CT. The median operation time for VATS was 65 min and estimated blood loss was less than 20 ml in all cases. All visible intrathoracic diseases were completely resected without major complications, and VATS did not delay planned treatment. Conclusion  VATS enables the accurate pathological diagnosis and intrathoracic resection of pleural and CPLN metastasis in patients with ovarian cancer with acceptable morbidity. Further studies are needed to confirm the impact of VATS on survival in patients with ovarian cancer.     

Video-assisted thoracoscopic lobectomy vs. conventional lobectomy via open thoracotomy in patients with clinical stage IA non-small cell lung carcinoma

The aim of this study was to evaluate our personal experience with video-assisted thoracoscopic lobectomy and compare survival between this procedure and conventional lobectomy via open thoracotomy in patients with clinical stage IA non-small cell lung carcinoma. Between May 1997 and December 2004, 140 patients with clinical stage IA non-small cell lung carcinoma had either VATS lobectomy (VATS group, 84 patients) or standard lobectomy via open thoracotomy (open group, 56 patients) performed in our hospital. We compared overall survival, disease-free survival and recurrence between the two groups. The overall survival rate five years after surgery was 72% in the open group and 82% in the VATS group. There were no significant differences in the overall survival rate between the two groups. The disease-free survival rate five years after surgery was 68% in the open group and 80% in the VATS group. There were no significant differences in the disease-free survival rate between the two groups. Five patients in the open group developed distant recurrence, whereas one patient developed regional recurrence. In the VATS group six patients developed distant recurrence, whereas one patient developed regional recurrence. We consider VATS lobectomy to be one of the therapeutic options in patients with clinical stage IA non-small cell lung carcinoma.     

Pulmonary cryptococcosis diagnosed by video-assisted thoracoscopic surgery with CT-guided localization: report of a case

We report a case of pulmonary cryptococcosis diagnosed by video-assisted thoracoscopic surgery (VATS) with CT-guided localization. A 61-year-old man was admitted to our hospital for the precise diagnosis of a solitary mass in the left upper lung. Because the mass was too small to be detected under VATS, we tried CT-guided localization for surgery. One day before VATS, we placed a marking device besides the lesions after percutaneous puncture. We used a Naruke point marker as a marking device. After this procedure, the wedge resection was performed. The pathological diagnosis was cryptococcosis of the lung. The identification of small lesions in the lung has frequently been detected by helical and thin slice CT. Therefore, CT-guided localization procedure may be the most reliable technique to employ before surgery.     

Thoracoscopic resection of localized fibrous tumor of the pleura; report of a case and review of the Japanese literature

A 61-year-old female was admitted with abnormal shadow on chest X-ray. Chest computed tomography (CT) showed a clearly localized flat tumor at the peripheral region of the left lung. We suspected localized fibrous tumor of the pleura (LFTP) and performed video-assisted thoracic surgery (VATS). Under the thoracoscopy, the tumor was connected to the visceral pleura with a short pedicle and completely resected with safety margin. Pathological findings, including immunohistochemical examination, definitely revealed benign LFTP. VATS is a good indication for the diagnosis and treatment of LFTP. This case was reported together with some reviews of the literature.