Omission of mediastinal lymph node dissection in lung cancer: its techniques and diagnostic procedures.

To reduce or omit a mediastinal lymph node dissection in the patients with clinical stage I non-small cell lung cancer (NSCLC), several authors examined the prevalence of metastatic sites of lymph nodes. Because lymphatic drainage usually heads for the upper mediastinum in upper lobe cancer and for the lower mediastinum in lower lobe cancer, upper and lower mediastinal lymph node dissection could be reduced in lung cancers of lower lobe and upper lobe. By using sentinel node (SN) navigation surgery, it is possible to omit mediastinal lymph node dissection. Radiological findings are also useful to determine reduction of mediastinal lymph node dissection. In clinical stage Ia adenocarcinomas that show ground glass opacity (GGO) findings on computed tomography (CT) or negative for fluorodeoxyglucose accumulation on positron emission tomography (PET), mediastinal lymph node dissection can be omitted, because these types of adenocarcinomas rarely metastasize to the lymph nodes. By using these procedures, mediastinal lymph node dissection can be reduced or omitted with little risk of local recurrence.     

Use of technetium-99m tin colloid for sentinel lymph node identification in non-small cell lung cancer

BACKGROUND: To test the reliability of sentinel lymph node identification in non-small cell lung cancer, sentinel nodes were localized with a radioactive colloid in patients undergoing surgery. METHODS: Forty-six patients with non-small cell lung cancer undergoing curative resection with mediastinal lymph node dissection were examined. The day before surgery, technetium-99m ((99m)Tc) tin colloid was injected into the peritumoral region. At operation, the radioactivity of the lymph nodes was counted with a handheld gamma counter before (in vivo) and after (ex vivo) dissection. Lymph nodes with an ex vivo radioactive count more than 10 times the background value were identified as sentinel nodes. The correlation between the in vivo and ex vivo results was examined. RESULTS: Lymphoscintigraphy revealed that it took longer than 6 hours for sufficient (99m)Tc tin colloid to reach the sentinel nodes. Sentinel nodes could be identified in 40 patients (87%). Patients whose sentinel nodes could not be identified had a significantly lower ratio of forced expiratory volume in 1 second to forced vital capacity than did those with identifiable sentinel nodes (P =.03). No false-negative sentinel nodes were detected in 14 patients with N1 or N2 disease (0%). In the hilar lymph node stations, the lobar lymph nodes were most frequently identified as sentinel nodes (as often as 85% of the time). Fourteen patients (35%) had sentinel nodes in the mediastinum, the distribution of which depended on the lobe. In vivo and ex vivo counting showed 88% concurrence for the identification of sentinel nodes in mediastinal lymph node stations. CONCLUSION: The identification of sentinel nodes with (99m)Tc tin colloid is a reliable method of establishing the first site of nodal metastasis in non- small cell lung cancer. Sentinel nodes could be hardly identified in patients with a low ratio of forced expiratory volume in 1 second to forced vital capacity because of such conditions as chronic obstructive pulmonary disease. In vivo identification of sentinel nodes in the mediastinum could be useful approach to guide mediastinal lymph node sampling or dissection.     

Bougienage and balloon dilation using a conventional tracheal tube for tracheobronchial stenosis before stent placement

In order to achieve urgent restoration of the airways in tracheobronchial stenosis and to make stent placement simpler and safer, we developed a method that allows combined bougienage and balloon dilation via the use of a conventional tracheal tube. Fifteen patients with tracheobronchial stenosis underwent bougienage and balloon dilation using a tracheal tube with a cuff attached, inserted via a tracheostomy, before stent placement. The conventional tracheal tube was inserted via a tracheostomy, the cuff was expanded at the stenotic site, and the tube was fixed to the tracheostomy and left in place for a few days until sufficient dilation was achieved. This procedure was conducted on the trachea in 10 patients, the left main bronchus in three patients, and the right main bronchus in two patients. In all patients, the procedure immediately relieved the obstructive symptoms and dilated the stenosis sufficiently. Thereafter, Dumon stents were inserted in 10 patients, dynamic stents in four patients, and an expandable metallic stent in one patient. The stents were introduced easily with no other dilation procedure after a mean of 5 days from the start of the procedure. For tracheobronchial stenosis, bougienage and balloon dilation using a tracheal tube with an integral cuff via a tracheostomy is a simple and safe method for achieving both urgent relief of airway stenosis and dilation before stent placement. Received: 20 May 1999/Accepted: 17 December 1999/Online publication: 25 April 2000     

A case of lung cancer with extensive pleural adhesion, which could be resected by a thoracoscopic middle lobectomy

A thoracoscopic middle lobectomy was performed for a 78-year-old male with lung cancer associated with extensive pleural adhesion. After peeling off the area of pleural adhesion surrounding the surgical ports by finger, the thoracoscope was inserted into the thorax and then the area of adhesion in the other area was also peeled off under thoracoscope. A pulmonary vein was resected using a stapler. Due to adhesion at the fissures between the lobes, a pulmonary artery and bronchus of the middle lobe were cut from the front of the lung hilum. After that, the fissures between the lobes were also cut using a stapler thus resulting in a complete middle lobectomy. The operation time was 5 hours and 28 minutes, and the intraoperative bleeding was 200 ml. There was no postoperative air leakage, and the chest drain could be removed the day after surgery. In conclusion, even for lung cancer with extensive pleural adhesion, a thoracoscopic lobectomy can still be successfully performed. When a fissure between the lobes is found to adhere, the approach to pulmonary artery and bronchus from the front of the lung hilum is useful for performing a thoracoscopic middle lobectomy.     

How can sentinel navigation surgery abbreviate mediastinal lymph node dissection for lung cancer?

Sentinel nodes (SNs) were examined for 101 patients who had peripheral type non-small cell lung cancer less than 5 cm and had undergone systemic mediastinal lymph node dissection. The surgical procedure was lobectomy in 91, pneumonectomy in 3, and segmentectomy with lymph node dissection in 7. In the CT room, the site for RI injection was marked on the skin, and the angle and depth of the needle required to reach the peritumoral region was determined. The RI was then injected in the RI room. The radioactivity in the lymph nodes was counted before dissection (in vivo counting), and after dissection that (ex vivo counting). SNs were defined as any node for which the count was > or = 10 times than the background count. SN identification was finally based on ex vivo data. Of the 101 patients, SNs could be identified in 80 patients (80%). Patients whose SNs could not be identified had a significantly lower FEV1/FVC than those with identifiable SNs (p=0.025). Twenty six patients (33%) had SN in the mediastinum, the distribution of which depended on the lobe, ie the #4 lymph node station in the right upper lobe, the #4 in the right middle lobe, the #4 and 7 in the right lower lobe, the #5 in the left upper lobe, and the #7 in the left lower lobe. One false negative SN was detected in 25 patients with N 1 or N 2 disease (4%). In vivo and ex vivo counting showed 73% concurrence for the identification of SNs in mediastinal lymph node stations, of which rate was significantly higher than 40% in hilar lymph node stations (p<0.001). Conclusion: The SNs were identifiable in 80% of lung cancer patients, with 4% false negative by using a Tc-99 m tin-colloid. SNs were difficult to identify in patients with a low level of FEV1/FVC, such as those with chronic obstructive pulmonary disease. The in vivo identification of mediastinal SNs was reliable as much as the ex vivo. Therefore, the in vivo identification of SNs in the mediastinum could be useful approach to guide mediastinal lymph node sampling or dissection.     

Histogram analysis of computed tomography numbers of clinical T1 N0 M0 lung adenocarcinoma, with special reference to lymph node metastasis and tumor invasiveness

PURPOSE: To predict lymph node metastasis and tumor invasiveness in lung adenocarcinoma from computed tomography findings, we examined computed tomography number histograms of clinical T1 N0 M0 lung adenocarcinomas. PATIENTS AND METHODS: Histograms of pixel computed tomography numbers were made for 100 patients with clinical T1 N0 M0 lung adenocarcinoma. Pathological tumor stages were N0 in 80 patients, N1 in 7, N2 in 9, and T4 due to intrapulmonary metastasis in 4. RESULTS: The histogram showed 3 patterns: 1 peak at a low computed tomography number (n = 18), 1 peak at a high computed tomography number (n = 54), and 2 peaks at both low and high computed tomography numbers (n = 28). Histologically, adenocarcinoma with 1 peak at a low computed tomography number showed a large area of bronchioloalveolar carcinoma-like spread with little area of solid growing tumor or central fibrosis, whereas those with 1 peak at a high computed tomography number showed a large area of solid growing tumor or central fibrosis with little bronchioloalveolar carcinoma-like spread. Adenocarcinomas with 2 peaks had both types of areas. Lymph node or pulmonary metastases were seen in none (0%) of the adenocarcinomas with 1 peak at a low computed tomography number, in 1 (4%) with 2 peaks, and in 20 (37%) with 1 peak at a high computed tomography number. The former 2 types had metastases less frequently than those with 1 peak at a high computed tomography number (P <.01). In the 79 patients with pathological T1 N0 M0, tumor involvement of the intratumoral vessels or pleura was seen in 1 of 18 (6%) adenocarcinomas with 1 peak at a low computed tomography number, which was significantly less frequent than the 18 of 34 (53%) with 1 peak at a high computed tomography number (P <.001) and 10 of 27 (37%) with 2 peaks (P <.05). CONCLUSION: Clinical T1 N0 M0 adenocarcinomas with 1 peak at a low computed tomography number on histogram seldom had lymph node metastasis or tumor involvement of vessels or pleura. Limited surgical resection could be indicated for this type of adenocarcinoma, especially for elderly patients or patients with poor pulmonary function.     

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.     

Difference in the Impairment of Vital Capacity and 6-Minute Walking After a Lobectomy Performed by Thoracoscopic Surgery,an Anterior Limited Thoracotomy,an Anteroaxillary Thoracotomy,and a Posterolateral Thoracotomy

Purpose: Postoperative vital capacity (VC) and the 6-min walking (6MW) test were used to compare the differences in impairment of the pulmonary function and walking capacity in patients undergoing a lobectomy by video-assisted thoracoscopic surgery (VATS), an anterior limited thoracotomy (ALT), an anteroaxillary thoracotomy (AAT), or a posterolateral thoracotomy without muscle sparing (PLT). Methods: The study was a retrospective analysis. Lung cancer patients who underwent a lobectomy by VATS, ALT, AAT, or PLT (28 in each group) were matched by sex and age (±5 years). VC was measured before surgery and at 1, 2, 4, 12, and 24 weeks after surgery. The distance covered during the 6MW test (6MWD) was measured before surgery and in a postoperative test 1 week after surgery. Results: Compared with the VATS, ALT, and AAT groups, PLT patients showed a significant impairment of VC from 1 to 24 weeks after surgery (P < 0.05–0.001) and also a significant impairment of 6MWD 1 week after surgery (P < 0.01–0.001). The AAT group showed a significant impairment of 6MWD 1 week after surgery compared with the VATS and ALT groups (P < 0.001 and P < 0.05, respectively). There was no significant difference in the impairment of either VC or 6MWD between VATS and ALT. Conclusions: The PLT without a muscle sparing procedure therefore cannot be recommended for general lung cancer surgery because of the impairment of both walking capacity and pulmonary function which continues long after surgery. VATS and ALT are better procedures than AAT regarding the recovery of walking capacity early after surgery. VATS and ALT are similar to each other regarding the impairment of pulmonary function and walking capacity after surgery. Received: October 15, 2001 / Accepted: July 2, 2002 Reprint requests to: H. Nomori     

Pain-relieving posterior rod fixation with segmental sublaminar wiring for Pancoast tumor invading the vertebrae

We describe the case of a 44-year-old male patient with Pancoast lung cancer invading the vertebrae. Because irradiation did not relieve his symptoms, we conducted tumor resection with posterior rod fixation with segmental sublaminar wiring of the vertebrae. This enabled the patient to walk and to discontinue morphine immediately after surgery. Although the tumor recurred within the region of the fixation 4 months after surgery, the patient complained of no pain until his death. Although Pancoast lung cancer with extensive vertebral invasion cannot be cured surgically, posterior rod fixation with segmental sublaminar wiring with tumor resection can improve a patient's quality of life by providing immediate, long-term pain relief.     

Modified trap-door thoracotomy for mediastinal metastasis of thyroid carcinoma invading the right brachiocephalic vein.

The patient was a 65-year-old female with metastasis of thyroid papillary carcinoma at the right upper mediastinum. The tumor, which invaded almost the entire length of the right brachiocephalic vein, was resected via a modified trap-door thoracotomy. The modification was the additional resection of the first rib from inside the thorax, which provided a sufficient exposure from the distal side of the brachiocephalic and subclavian vein. Because the subclavian and internal jugular veins could be clamped under this thoracotomy, the entire right brachiocephalic vein could be reconstructed by graft without excessive difficulty. Modified trap-door thoracotomy is a useful approach in the resection of malignancies which invade the brachiocephalic and subclavian vein.