論文

OBJECTIVES. Cases of severe pectus excavatum presenting with worsening cardiopulmonary symptoms in the upright position have been reported. However, the underlying mechanism remains unclear. We evaluated posture-related morphological changes of the thorax in patients with pectus excavatum. METHODS. Chest morphology was evaluated preoperatively using upright and supine computed tomography in 21 patients with pectus excavatum and 35 healthy volunteers. The minimum anterior–posterior thoracic diameter, depression depth, and Haller index on horizontal sections, as well as the T6-12 plumb line distance on sagittal sections, were compared between the 2 positions. RESULTS. In patients with pectus excavatum (median age, 22 years; 18 males and 3 females), the minimum anterior–posterior diameter was smaller (4.5 vs 5.1 cm, P < 0.001) and the Haller index was greater (10.1 vs 6.4, P < 0.001) in the upright position than in the supine position. The T6-T12 plumb line distance was longer in the upright position (2.4 vs 0.8 cm, P < 0.001), while the depression depth showed no significant difference. Healthy volunteers exhibited similar changes. The degree of spinal curvature increased in the upright position due to the anterior shift of the lower thoracic vertebrae, resulting in a shorter anterior–posterior diameter, irrespective of chest wall deformity. One patient with dyspnoea only in the upright position exhibited compression of the right inferior pulmonary vein only on upright computed tomography. CONCLUSIONS. The minimum anterior–posterior diameter is shorter in the upright position. This may explain the worsening of cardiopulmonary symptoms in patients with severe pectus excavatum when in an upright position.

OBJECTIVES: The Nuss procedure, a minimally invasive surgery for pectus excavatum, has undergone various improvements. However, the impact of using multiple bars on thoracic shape changes and surgical outcomes remains unclear. METHODS: We retrospectively evaluated patients who underwent the Nuss procedure for pectus excavatum between August 2014 and September 2021. We divided the patients into 2 groups based on the number of bars placed and identified differences in surgical outcomes and morphological characteristics. RESULTS: A total of 225 patients were evaluated, of whom 132 were classified into the ≤2 bar group (using 1 or 2 bars) and 93 into the ≥3 bar group (using 3 or more bars). There was no difference in the preoperative Haller index [median (interquartile range), 4.59 (3.67–6.16) vs 4.67 (4.12–6.14), P ¼ 0.227], and asymmetric excavatum was more frequently observed in the ≥3 bar group (81% vs 51%, P < 0.001). The preoperative sternal torsion angle was larger in the ≥3 bar group, but no difference was found between the 2 groups postoperatively. The incidence of postoperative complications (≥grade 3) was comparable between groups (10% vs 17%, P ¼ 0.105); however, postoperative pleurisy was more frequently observed in the ≥3 bar group (12% vs 4%, P ¼ 0.021). In univariable and multivariable analyses, ≥3 bar placement was the only risk factor for postoperative pleurisy. CONCLUSIONS: The placement of multiple bars (≥3 bars) is useful for the correction of asymmetric pectus excavatum, but attention should be paid to the potential risk of postoperative pleurisy.

Purpose: Salvage surgery for primary lung cancer is expected to become increasingly common. This study aimed to clarify the survival impact of pathologic characteristics after salvage surgery. Methods: Consecutive patients who underwent salvage surgery following definitive chemoradiotherapy or systemic therapy for initially unresectable lung cancer from 2010 to 2020 were enrolled in this study. The tumor slides were reviewed to determine the size of the tumor bed and the proportions of viable tumor, necrosis, and stroma. Results: A total of 23 patients were evaluated, and 18 had clinical stage IIIB–IV disease. Six received chemoradiotherapy and 17 received systemic therapy alone. A major pathologic response (MPR, ≤ 10% of viable tumor) was observed in 6 patients, and 4 patients achieved a pathological complete response. The 3-year overall and recurrence-free survival rates (OS and RFS) were 78.6% and 59.2%, respectively. There was no significant difference in OS between patients with and without MPR, and even non-MPR patients achieved a favorable 3-year OS of 70.2%. Meanwhile, patients with high (≥ 30%) stroma showed significantly better OS than those with low (< 30%) stroma (3-year OS: 100% vs. 23.3%, p < 0.001). Conclusions: This study showed that the proportion of stroma can be useful for predicting long-term survival after salvage surgery. Further large-scale studies are warranted to confirm the current findings.

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弯の進行を認めた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度の軽度側弯があり，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，側弯はCobb角34.2度に増悪した．術後早期に側弯の進行を認めたため，側弯症に対して装具治療を行った．術後4ヵ月で側弯の改善がみられ，現在経過観察中である．側弯症を合併する漏斗胸の場合，漏斗胸治療により側弯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弯変形を招いた可能性が示唆された．

症例は51歳，女性．潰瘍性大腸炎に対して19年前より薬物療法が開始され，寛解が維持されていた．胸部CT検査で左肺下葉に内部に低吸収域を伴う腫瘤影を認めた．増大傾向を認め，原発性肺癌が疑われたため左肺下葉切除術を施行した．病理組織所見では悪性所見は認めず，高度な炎症性細胞浸潤，膿瘍形成，杯細胞減少など潰瘍性大腸炎活動期の腸管病変に類似した所見であったため，臨床経過と併せて潰瘍性大腸炎合併肺肉芽腫と診断した．潰瘍性大腸炎を含めた炎症性腸疾患はさまざまな臓器に腸管外合併症を認めることがあり，炎症性腸疾患に合併する肉芽腫は肺癌との画像診断は困難である．病理組織学的にも多彩な所見を示すため，少量の検体量では確定診断は困難な場合が多く，手術検体を用いた病理組織学的診断が必要となることがある．

2012年1月～2022年12月に手術を施行した肺原発MALTリンパ腫7例(男性2例、女性5例、年齢中央値70歳)の臨床病理学的特徴および画像的特徴について検討した。術前胸部CT所見はすりガラス結節影4例、単発腫瘤影1例、充実性結節影1例、両肺に多発するすりガラス結節影1例であり、腫瘍辺縁の境界は不明瞭で、5例で腫瘍内部に気管支透亮像を確認した。FDG-PETでは1例を除き有意な集積を認めなかった。術前にMALTリンパ腫と診断されていた単発腫瘤影例は左肺上区域切除を施行し、多発結節影を認めた1例では診断目的に肺部分切除を施行し、原発性肺癌疑いの5例は開胸生検目的に肺部分切除を施行した。多発肺結節に対する生検例1例を除く6例で完全切除が施行され、7例全例で病理組織学的にMALTリンパ腫と診断した。術後在院日数の中央値は5日であり、2例に術後補助治療としてrituximabを投与した。術後生存期間の中央値は52ヵ月で、6例が生存中である。

Objectives: Advances in drug therapy and radiotherapy for non-small cell lung cancer resulted in an increased number of salvage surgeries for initially unresectable tumors. This study aimed to evaluate the safety and efficacy of salvage surgery for non-small cell lung cancer. Methods: We defined salvage surgery as (1) surgery for local recurrence/residual tumor after definitive chemoradiotherapy/radiotherapy (salvage surgery in a narrow sense) or (2) conversion surgery after non-surgical treatment. We retrospectively analyzed patients who underwent salvage surgery at four Keio University-affiliated hospitals. Results: Forty-six patients were included. The initial clinical stage was I in 4 patients (9%), III in 19 (41%), and IV in 23 (48%). Initial treatment before salvage surgery was chemoradiotherapy in 10 patients (24%), radiotherapy in 4 (9%), and drug therapy in 32 (67%). Pneumonectomy, lobectomy, segmentectomy, and wedge resection were performed in 2 (4%), 37 (80%), 3 (7%), and 4 (9%) patients, respectively. Complete resection was achieved in 41 patients (89%). Postoperative complications occurred in 11 patients (24%). Initial chemoradiotherapy/radiotherapy was an independent predictor of postoperative complications (odds ratio 10, p = 0.03). The 30- and 90-day mortality rates were 0 and 2%, respectively. The 5-year overall and progression-free survival rates were 66 and 30%, respectively. Conclusion: The safety and efficacy of salvage surgery for non-small cell lung cancer were acceptable. Salvage surgery was a viable treatment option for selected patients with recurrent/residual tumors after non-surgical treatments.

Background: Unilateral diaphragmatic paralysis is a condition in which the unilateral diaphragm is paralyzed and elevated. Orthopnea due to lung compression by an elevated diaphragm in the supine position is common in patients with unilateral diaphragmatic paralysis. Although its symptom is posture-dependent, the effect of posture on lung function in unilateral diaphragmatic paralysis has not been studied. Computed tomography (CT) can be used to assess lung volume. However, conventional CT cannot be performed in the upright position. A pulmonary function test can be performed in both upright and supine positions. However, it cannot evaluate the function of each lung separately. Case presentation: We report a case of a 79-year-old man with unilateral diaphragmatic paralysis. He presented with difficulty in inspiration, specifically in the supine position, and underwent both conventional supine CT and newly developed upright CT to assess the effect of posture on the function of each lung. The difference between expiratory and inspiratory lung volumes on CT in the supine position was less than that in the upright position by 46% and 4% on affected and healthy sides, respectively. We previously reported that the difference between expiratory and inspiratory lung volumes on CT correlated with inspiratory capacity on the pulmonary function test. A 46% decline in inspiratory capacity on the affected side in the supine position likely caused orthopnea in this patient. Conclusions: Supine/upright CT is helpful to assess the influence of posture on unilateral lung function in patients with unilateral diaphragmatic paralysis.

Background: The prevalence of salvage surgeries after drug therapy for non-small cell lung cancer (NSCLC) has risen, mainly due to recent progress in molecular-targeted drugs and immune checkpoint inhibitors for NSCLC. While the safety and effectiveness of salvage surgery after drug therapy for NSCLC have been studied, its indications remain unclear. We aimed to identify the prognostic factors affecting survival in patients with advanced-stage (stages III–IV) NSCLC treated with salvage surgery after drug therapy. Methods: A retrospective investigation was conducted on patients who received salvage surgery after drug therapy at four hospitals between 2007 and 2020. Salvage surgery was defined as surgery after drug therapy for local progression, tumor conversion to resectable status, and discontinuation of prior drug therapy owing to serious complications. Results: Thirty-two patients received cytotoxic agents alone (n = 12 [38%]), tyrosine kinase inhibitors (TKIs; n = 16 [50%]), or immune checkpoint inhibitors (n = 4 [13%]) as prior drug therapy. In 11 (34%) and 21 (66%) patients, the clinical stage before treatment was III or IV, respectively. The median initial and preoperative serum carcinoembryonic antigen (CEA) levels were 10.2 (range, 0.5–1024) ng/mL and 4.2 (range, 0.6–92.5) ng/mL, respectively. Among the patients, 28 (88%) underwent lobectomy, 2 (6%) underwent segmentectomy, and 2 (6%) underwent wedge resection. Complete resection of the primary lesion was accomplished in 28 (88%) patients. Postoperative complications were documented in six (19%) patients. Mortality rates were 0% at 30 days and 3% at 90 days post-operation. The 5-year overall survival rate stood at 66%, while the 5-year progression-free survival rate was 21%. Multivariate analyses showed that prior TKI therapy and preoperative serum CEA level < 5 ng/mL were prognostic factors influencing overall survival (hazard ratio [95% confidence interval]: 0.06 [0.006–0.68] and 0.03 [0.002–0.41], respectively). The 5-year overall survival in the 11 patients with both favorable prognosticators was 100%. Conclusions: In this study, prior TKI therapy and preoperative serum CEA level < 5 ng/mL were favorable prognostic factors for overall survival in patients with NSCLC treated with salvage surgery. Patients with these prognostic factors are considered good candidates for salvage surgery after drug therapy.

Objective: The quality of life (QOL) and psychological states of patients with pectus excavatum (PE) have yet to be well understood. This study aimed to evaluate the health-related QOL (HRQOL), psychological states, and personality traits of patients with PE, alongside the associations of these factors with the severity of PE. Methods: A cross-sectional evaluation was prospectively performed in patients scheduled to undergo PE repair surgery between July 2019 and April 2021. The primary outcome was the patients’ HRQOL, and the secondary outcomes were depression, social anxiety, self-efficacy, and personality traits. Results: In total, 129 patients were subjected to analyses. Patients' HRQOL had a lower role component summary score (mean ± standard deviation: 41.8 ± 12.8, P < .001) than the general population controls. Patients' HRQOL had a significantly better physical component summary (54.0 ± 10.4, P < .001) and mental component summary (53.3 ± 8.8, P < .001) than that of the general population. Fourteen patients' (10.9%) and 56 patients' (43.4%) scores indicated the presence of depression and social anxiety disorder, respectively. Patients’ self-efficacy (46.1 ± 11.4, P, .001) and level of extraversion (46.5 ± 11.8, P < .001) were lower than those of the general population. No significant correlation was found between the severity of PE and these scores. Conclusions: Our study revealed that patients with PE had decreased social-role QOL, depressive tendencies, increased social anxiety, lower self-efficacy, and introversion. No correlation between the severity of PE and the patients’ psychological outcomes leads us to conclude that surgical implications of PE should not be decided solely by a physical index.

Background: Sarcomatoid carcinoma of the lung is a rare histological type of non-small cell lung cancer with a poor prognosis. We aimed to investigate the clinicopathological characteristics and prognostic factors of surgically resected sarcomatoid carcinoma of the lung. Methods: We retrospectively reviewed 14999 patients who underwent surgical resection for non-small cell lung cancer accumulated by the Japanese Joint Committee of Lung Cancer Registry in 2010. Clinicopathological characteristics and survival were compared between the sarcomatoid carcinoma and other non-small cell cancer groups. The prognostic factors in the sarcomatoid carcinoma group were identified using a multivariate Cox proportional hazard model. Results: Patients with sarcomatoid carcinoma comprised 1.4% of all patients. The sarcomatoid carcinoma group demonstrated a more aggressive pathology with presentation at more advanced stages, requiring more frequent extensive surgical resections. The sarcomatoid carcinoma group had remarkably poorer overall and recurrence-free survival than the other non-small cell lung cancer group. Adjuvant chemotherapy was associated with improved survival for pathological stage II–III sarcomatoid carcinoma cases rather than for pathological stage I disease. In the multivariate analysis, larger tumor size, lymphatic permeation, and no adjuvant chemotherapy were associated with the sarcomatoid carcinoma group’s overall and recurrence-free survival. Conclusions: Surgically resected sarcomatoid carcinoma of the lung has a higher aggressive and metastatic potential and a worse prognosis than other non-small cell lung cancers. Adjuvant chemotherapy, which was associated with enhanced survival in patients with pathological stage II–III of the disease, could be considered for treating patients with pathological stage II–III sarcomatoid carcinoma of the lung.

背景．挿管後気管狭窄に対する治療は，外科的な気管切除・再建術が長期開存性に優れるとされ推奨されてきた．一方，近年内視鏡機器・技術の進歩に伴い，内視鏡下拡張術の報告も増加しているが，その適応や長期成績は十分検討されていない．症例．患者は23歳，女性．1年前に交通外傷で他院に搬送され，意識障害に対して5日間の経口気管内挿管，人工呼吸管理が施行された．抜管40日後より，咳嗽と呼吸困難を自覚し，喘息として治療されたが軽快しないため，精査・加療目的に当院へ紹介受診となった．胸部CT画像および気管支鏡検査所見上，狭窄長2.1 cmの瘢痕性気管狭窄を認め，挿管後気管狭窄の診断の元，緊急で硬性気管支鏡による拡張術を施行した．しかし，その後に再狭窄が生じ，硬性鏡下に拡張術を再度行ったが再々狭窄を認めたため，気管管状切除・端々吻合術を施行した．術後2年6カ月経過した現在，再狭窄の徴候は認めていない．結論．瘢痕性の挿管後気管狭窄に対し，硬性鏡下での拡張術を複数回施行したものの再狭窄を繰り返したため，外科的気道再建術を行い良好な経過を得た1例を経験した．

© 2020 Wiley Periodicals LLC Background: The aim of this study was to investigate the clinicopathological and prognostic features of operable non-small cell lung cancer (NSCLC) patients with diabetes mellitus (DM). Methods: A total of 1231 surgically resected NSCLC patients were retrospectively reviewed. Clinicopathological characteristics were compared between patients with DM (DM group, n = 139) and those without DM (non-DM group, n = 1092). The clinical factors associated with postoperative complications and prognostic factors were identified. Results: The DM group had distinct clinicopathological features. No significant differences in histological invasiveness or stage were found. The presence and control status of DM were independent predictors of postoperative complications. No significant differences in recurrence-free survival or cancer-specific survival were observed; however, the DM group had worse overall survival (OS). The DM group had a higher number of deaths from other diseases than the non-DM group, and these patients had significantly higher postoperative hemoglobin A1c levels than patients with cancer-related death. Conclusion: The presence and control status of preoperative DM are useful predictors of both postoperative complications and OS in operable NSCLC patients. Concomitant diabetes-related complications have a negative effect on long-term survival in diabetic NSCLC patients, and long-term glycemic control is important to prolong OS.

Debulking surgery, also called cytoreductive surgery, is a resection of the tumor as much as possible and an intended incomplete resection for unresectable malignant tumors. Since the most important principle in surgical oncology is complete R0 resection, debulking surgery goes against the basic principle and obscures the concept of operability. However, debulking surgery has been advocated for various types of advanced malignant tumors, including gynecological cancers, urological cancers, gastrointestinal cancers, breast cancers and other malignancies, with or without adjuvant therapy. Positive data from randomized trials have been shown in subsets of ovarian cancer, renal cell carcinoma, colorectal cancer and breast cancer. However, recent trials for renal cell carcinoma, colorectal cancer and breast cancer have tended to show controversial results, mainly according to the survival improvement of nonsurgical systemic therapy alone. On the other hand, debulking surgery still has a therapeutic role for slow-growing and borderline malignant tumors, such as pseudomyxoma peritonei and thymomas. The recent understanding of tumor heterogeneity and clonal evolution responsible for malignancy and drug resistance indicates that select patients may obtain prolonged survival by the synergistic effect of debulking surgery and novel systemic therapy. This review aimed to describe the current status and evidence of debulking surgery in a cross-organ manner and to discuss future perspectives in the current era with advances in systemic therapy.

Background: Although completion lobectomy is the treatment of choice for local recurrence of non-small cell lung cancer after segmentectomy, few cases have been reported. We report four patients who underwent completion lobectomies for staple line recurrence after segmentectomy for stage I non-small cell lung cancer. Case presentation: Three women aged 65, 82, and 81 years underwent completion lower lobectomy after superior segmentectomy of the same lobe for local recurrence of stage I non-small cell lung cancer. A 67-year-old man, who had a tumor recurrence on the staple line after apical segmentectomy with superior mediastinal nodal dissection for stage I non-small cell lung cancer, underwent completion right upper lobectomy. These four patients underwent segmentectomy because of comorbidities or advanced age. Local recurrence was confirmed by computed tomography-guided needle biopsy. The interval between the two operations was 37, 39, 41, and 16 months, respectively. Although minimal hilar adhesion was seen for the three completion lower lobectomies, tight adhesions after apical segmentectomy made completion right upper lobectomy quite difficult to dissect, which led to injury of the superior pulmonary vein. No recurrence was recorded after completion lobectomies for 62, 70, 67, and 72 months, respectively. Conclusions: Although completion lobectomy is one of the most difficult modes of resection, among several completion lobectomies, completion lower lobectomy after superior segmentectomy without superior mediastinal nodal dissection was relatively easy to perform because of fewer hilar adhesions.