論文

INTRODUCTION: Anomalous systemic arterial supply to the basal segments (ASABS) is a rare congenital pulmonary anomaly. Considering the associated complications of pulmonary hypertension or hemoptysis, surgical lung resection is recommended. However, there is a lack of standardized surgical management guidelines. We report a case of ASABS with an aneurysmal aberrant artery, in which imaging findings suggested an increased risk of rupture. Thoracic endovascular aortic repair (TEVAR) was first performed to achieve inflow control; this strategy provided a secure setting for subsequent pulmonary resections.CASE PRESENTATION: A 56-year-old woman presented with an abnormal chest shadow. Contrast-enhanced chest CT revealed an aberrant artery arising from the descending aorta supplying the left basal segment with an irregular aneurysm measuring 33 mm. Non-contrast chest CT demonstrated intraluminal hyperattenuation consistent with acute thrombosis, raising concerns regarding an increased risk of rupture. The absence of a normal pulmonary arterial supply to the basal segment and normal bronchial and pulmonary venous anatomy confirmed the diagnosis of ASABS. Given the radiologic findings suggestive of an increased risk of rupture of an aberrant artery, preoperative TEVAR was performed to control the inflow to the aberrant artery. After 18 days, video-assisted left lower lobectomy with division of the aberrant artery was performed safely. The postoperative course was uneventful, and the patient was discharged 10 days after surgery. Pathology revealed disruption of the elastic fibers and thinning of the media, supporting aneurysmal degeneration at the risk of rupture. Contrast-enhanced CT performed 6 months after surgery confirmed the absence of an endoleak or stump aneurysm.CONCLUSIONS: The TEVAR-first approach for inflow control enabled safe pulmonary resection in ASABS with an aneurysmal aberrant artery. To the best of our knowledge, this is the first reported case for this condition where histopathological findings suggested an increased risk of rupture. Further investigation is needed to determine which patients benefit the most from this strategy and to understand the long-term outcomes.

Background: Surgical resection is the standard treatment for pulmonary metastases from colorectal cancer, but its safety and long-term efficacy in medically inoperable patients remain limited. Percutaneous cryoablation is a minimally invasive alternative to surgical resection and has gained increasing attention in recent years. Aims: This retrospective study aimed to evaluate complication rates, local tumor control, and overall survival associated with percutaneous cryoablation for pulmonary metastases from colorectal cancer. Methods and Results: We retrospectively reviewed patients treated with percutaneous cryoablation from 2002–2017. Complications were defined as adverse events ≥ grade 2 per Common Terminology Criteria for Adverse Events version 5.0. In total, 126 metastatic pulmonary tumors in 48 patients were treated across 73 sessions. Complications occurred in 18 sessions (24.7%), including 2 grade ≥ 3 events (2.7%). No treatment-related deaths occurred within 30 days. With a median follow-up of 9.7 months (maximum, 155.4 months), local tumor control rates at 1, 3, and 5 years were 74.5%, 58.8%, and 56.4%, respectively. Median overall survival was 3.8 years, with 1-, 3-, 5-, and 10-years rates of 86.8%, 60.4%, 41.9%, and 36.6%, respectively. The relatively short median follow-up should be considered when interpreting these long-term local control estimates. Six patients achieved 10-years survival. Conclusion: Percutaneous cryoablation is a safe, minimally invasive option that provides favorable local tumor control and encouraging long-term survival outcomes.

Objectives: The aim of this review was to clarify the differences in therapeutic intent and indications for salvage surgery following treatment with epidermal growth factor receptor tyrosine kinase inhibitor versus definitive chemoradiotherapy. Unresolved issues in molecular targeted therapy, including the optimal surgical procedure, timing of surgical intervention, and the relationship between surgery and radiotherapy, were examined to provide practical guidance for integrating systemic and local treatment in advanced lung cancer. Methods: This focused narrative review was developed by conducting a targeted PubMed search through October 2025 using terms associated with epidermal growth factor receptor, tyrosine kinase inhibitors (TKIs), and salvage or conversion surgery. Relevant studies were selectively examined to explore indications, patient selection, timing of surgery, extent of resection, and comparisons with radiotherapy as an alternative local treatment. Results: Salvage surgery following definitive chemoradiotherapy is intended to cure isolated intrathoracic recurrences and typically excludes patients with uncontrolled distant metastases or unresectable lymph node disease. Conversely, salvage surgery following TKI therapy is increasingly included in strategies for systemic disease control. Its objectives include removing local lesions resistant to systemic treatment, prolonging the effectiveness of systemic therapy, and gathering pathological and genomic information. Importantly, the primary therapeutic goal is to prolong overall survival when performed after TKI therapy, rather than improve disease-free survival. Conclusions: As molecular targeted treatments advance, the role of salvage surgery following TKI therapy is expected to expand. Further evidence is required to guide patient selection, timing of intervention, and surgical strategy.

Patients with giant mediastinal tumors often experience worsened dyspnea in the supine position due to central airway stenosis, which can become life-threatening during the induction of general anesthesia with muscle relaxants. However, posture-related changes in airway morphology in such cases have not been quantitatively evaluated. A 34-year-old male with a giant mediastinal tumor presented with dyspnea in the supine position. The recently developed upright and supine multi-detector computed tomography (MDCT) scans revealed a significant decrease in airway luminal areas from the upright to the supine position: 42.5%, 36.8%, and 40.4% in the trachea, right, and left main bronchi, respectively. These reductions were significantly greater than the 4%-9% changes previously reported in healthy individuals, suggesting that tumor weight worsened airway stenosis. To prevent airway collapse during general anesthesia, awake intubation was performed in the supine position prior to surgical resection. Airway luminal areas in patients with giant mediastinal tumors can significantly decrease from the upright to the supine position, which is considered to cause worsened dyspnea. Upright and supine MDCT enables safe and quantitative assessment of posture-related airway stenosis and may serve as an adjunctive imaging modality for evaluating patients who experience dyspnea in the supine position.

The technical complexity of salvage lung resection after epidermal growth factor receptor (EGFR)–tyrosine kinase inhibitor (TKI) therapy remains unclear, in contrast to the well-recognized technical difficulty of salvage surgery after chemoradiotherapy. We retrospectively reviewed 15 patients with Stage IIIB/IV lung cancer who underwent anatomical lung resection after EGFR–TKI therapy and compared perioperative outcomes according to clinical nodal (cN) status (cN − vs. cN+). Although postoperative complication rates were similar, cN+ cases demonstrated greater technical complexity, including longer operative time (median increase, 66%), greater blood loss (median increase, 138%), and more frequently requiring bronchovascular reconstruction (30% vs. 0%). These findings may warrant caution for thoracic surgeons when operating on TKI-treated patients with cN+ disease, even when the primary tumor appears surgically favorable.

Lung tumor with polypoid extension into the left atrium (LA) poses a high systemic tumor embolism risk. We report a rare case of a woman with pulmonary metastasis from a retroperitoneal leiomyosarcoma extending into the LA as a polypoid mass through the left superior pulmonary vein. To minimize the risk of fatal embolization, complete resection was performed under cardiopulmonary bypass using a bilateral transseptal approach, enabling excellent visualization and precise intracardiac tumor resection before left upper lobectomy. She has remained recurrence free for 1 year. This approach safely manages lung tumors with polypoid LA invasion while mitigating catastrophic tumor embolism risk.

Loeys-Diez症候群(LDS)はMarfan症候群類縁の先天性結合織疾患で,骨格系の異常として漏斗胸を併存することが知られている.我々は漏斗胸手術後に側彎の進行を認めたLDSの一例を経験した.患者は9歳,男児.5歳時に遺伝子検査でLDSと診断された.Haller index 9.81の高度漏斗胸とCobb角8.5度の軽度側彎があり,漏斗胸に対してRavitch法とNuss法を組み合わせた術式(Combined Ravitch and Nuss Procedure:CRN法)を施行した.左右の肋軟骨を一部分節切除した後に2本のチタンバーを挿入し胸骨挙上術を施行した.術後のHaller indexは3.57となり,漏斗胸の改善が得られたが,側彎はCobb角34.2度に増悪した.術後早期に側彎の進行を認めたため,側彎症に対して装具治療を行った.術後4ヵ月で側彎の改善がみられ,現在経過観察中である.側彎症を合併する漏斗胸の場合,漏斗胸治療により側彎の進行を認める可能性がある.本症例では結合組織の脆弱性が背景にあり,漏斗胸の矯正が過度の側彎変形を招いた可能性が示唆された.(著者抄録)

2024年4月から医師の働き方改革が始まっているが、医師の中でも他の診療科の医師に比べ労働時間が長いことが知られている外科医の幸せな働き方の検討に資することを目的に、本学および関連病院に所属する医師を対象に、前野らが開発した「はたらく人の幸せ診断」を用いたWebアンケートを実施し、436名(男性336名、女性100名、平均卒後年数12年、うち、外科医は92名)より回答を得た(回収率16%)。「はたらく人の幸せ診断」は働くことの幸せ実感を7因子(自己成長、リフレッシュ、チームワーク、役割認識、他者承認、他者貢献、自己裁量)に分けて測定する質問票で、全7因子の平均点(7点満点:幸せ指数)により労働者の幸せを評価可能である。その結果、外科医は非外科医と比べ、労働時間が有意に長かったが、卒後3年目および9～19年目で非外科医より幸せ指数が有意に高かった。どの卒後年数の外科医の幸せ指数(4.54～5.54)も、先行研究による一般の全職種の平均(4.42)より高く、全般的に外科医の幸せ実感は高いと考えた。主に大学病院で修練を積む卒後5～8年目の外科医の幸せ指数が相対的に低いことが課題として認識され、「はたらく人の幸せの7因子」のそれぞれを高める施策が必要と考えられた。

The next-generation sequencing (NGS)–based Oncomine Dx Target Test (ODxTT) is the standard tool for guiding postoperative adjuvant therapy in patients with non-small cell lung cancer (NSCLC) in Japan. To advance precision oncology, we evaluated the clinical utility of an in-house comprehensive genomic profiling (CGP) assay, Rapid-Neo, as a complementary approach to ODxTT in surgically resected NSCLC. Patients with pathological stage II–III NSCLC who underwent anatomical surgical resection between December 2019 and May 2024 were included. Resected specimens underwent genomic analysis using both ODxTT and Rapid-Neo CGP. We evaluated the mutational concordance and the frequency of additional actionable alterations identified by CGP. Among 68 eligible patients, driver mutation results were concordant in 64 (94.1%) cases. Crucially, CGP rescued one patient for targeted therapy by detecting an EGFR mutation where ODxTT failed due to insufficient DNA. CGP also identified rare EGFR variants not covered by ODxTT in two cases, although it failed to detect a RET fusion in one patient. Furthermore, CGP revealed additional actionable alterations, such as tumor suppressor gene mutations, in 57 patients (83.8%). Our in-house CGP shows high concordance with ODxTT and serves as a powerful complementary tool. These findings support a strategic testing algorithm where CGP is incorporated for patients with negative or inconclusive ODxTT results, or at the time of recurrence, to maximize opportunities for individualized therapy in resected NSCLC.

Introduction: Thymic neuroendocrine tumors (TNETs) are rare malignancies characterized by aggressive clinical behavior and limited therapeutic options. In small cell lung cancer (SCLC), molecular subtypes based on the expression of lineage-defining transcription factors (TFs)—ASCL1, NEUROD1, POU2F3, and YAP1—have been proposed. However, the TF landscape of TNETs remains poorly defined. Given the pathological similarities among neuroendocrine tumors across organs, we aimed to investigate whether the TF-based classification system used in SCLC is applicable to TNETs. Methods: Sixteen pathologically confirmed TNETs—including large cell neuroendocrine carcinoma (LCNEC), thymic small cell carcinoma (TSCC), atypical carcinoid (AC), and typical carcinoid (TC)—were retrospectively analyzed. Immunohistochemistry was performed to evaluate classical neuroendocrine (NE) markers (synaptophysin, chromogranin A, CD56) and TFs (ASCL1, NEUROD1, POU2F3, YAP1). H-scores were calculated, and tumors were categorized according to TFs expression profiles. Results: Synaptophysin was strongly expressed in all cases, while chromogranin A and CD56 showed variable expression, with reduced levels in LCNEC and TSCC. The combined NE score was significantly higher in carcinoid tumors compared to LCNEC and TSCC. For TFs, ASCL1 expression was observed in 93.8 % of cases, whereas NEUROD1 and POU2F3 were rarely or not expressed. YAP1 expression was confined to LCNEC cases, all of which co-expressed ASCL1 and YAP1. Based on H-scores, TNETs were classified into three subgroups: (1) ASCL1-positive/YAP1-negative (n = 12, 75 %), (2) ASCL1/YAP1 double-positive (n = 3, 19 %), and (3) double-negative (n = 1, 6 %). Conclusion: This study reveals molecular heterogeneity among TNETs. Notably, ASCL1 and YAP1 co-expression characterizes all LCNEC cases, making a distinct TF landscape in high-grade TNETs.

Sublobar resection is an established surgical option for early-stage non-small cell lung cancer. However, evidence remains limited regarding its use for tumours >20 mm in real-world settings. We evaluated characteristics and outcomes of limited resection in this context and identified predictors of local recurrence. We retrospectively analysed 165 patients with clinical stage I non-small cell lung cancer with tumours >20 mm who underwent limited resection between 2007 and 2017. Clinical, pathological, and radiological data were reviewed. The primary end-point was local recurrence, assessed using competing risk analysis. Overall survival and disease-free survival were estimated using Kaplan-Meier and Cox models. We analysed 165 patients with 13 local recurrence events. Among them, 146 (88.5%) had identifiable reasons for not undergoing lobectomy. Segmentectomy and wedge resection were performed in 59% and 41% of cases, respectively. Lymph node dissection was performed in all segmentectomies and in 20% of wedge resections. The 5-year overall and disease-free survival rates were 64.0% and 62.1%. Local recurrence occurred in 8%, more frequently after wedge resection than segmentectomy (13% vs 4%, P = .04). Solidpredominant tumours with a consolidation-to-tumour ratio greater than 0.5 accounted for 76% and were independently associated with lower disease-free survival (hazard ratio, 2.65; P = .05) and higher local recurrence (hazard ratio: infinite; P < .001). No local recurrence was observed in tumours with a ground-glass opacity-predominant pattern. Limited resection showed acceptable outcomes in lung cancers >20 mm, especially with ground-glass opacity; solidpredominant CT patterns were strongly linked to recurrence.

Surgical approaches for giant middle mediastinal tumors are challenging owing to the surrounding great vessels and vital organs. Here, we report the resection of a giant middle mediastinal tumor with feeding vessels from the coronary artery causing exertional dyspnea. Surgical resection involved a clamshell incision and temporary transection of the ascending aorta and right pulmonary artery under cardiopulmonary bypass to achieve optimal visualization. The tumor, diagnosed as unicentric Castleman disease, was safely excised with good postoperative outcomes. This method—the transaortopulmonary arterial approach—offers a favorable surgical tool for giant mediastinal tumors.