Hiroaki Nomori

A 64-year-old man with primary lung cancer (cT1aN0M0) was diagnosed as having partial anomalous pulmonary venous connection (PAPVC) in the same lobe by preoperative chest computed tomography (CT). The anomalous vein originated from left upper lobe pulmonary vein and flowed into the left brachiocephalic vein. Although the patient was asymptomatic, cardiac catheterization revealed that pulmonary-systemic blood flow ratio (Qp/Qs ratio) was 2.0, and his pulmonary arterial pressure was marginally elevated (60/18 mmHg). We performed left upper lobectomy as the definitive treatment for both lung cancer and PAPVC. His pulmonary arterial pressure decreased after lobectomy (33/16 mmHg). He is living well without relapse of lung cancer 56 months after surgery. Although PAPVC is detectable on computed tomography, out of 7 previous reports of PAPVC associated with lung cancer, only 2 cases were diagnosed preoperatively. The presence of PAPVC should be kept in mind before major lung resections.

The interactions of tumor cells with stromal fibroblasts influence tumor biology, but the exact mechanisms involved are still unclear. In the present study, we evaluated the effects of a human lung fibroblast cell line, TIG-3, on Lewis lung carcinoma (LLC) cells both in vitro and in vivo. LLC and TIG-3 cells were co-cultured/co-implanted in vitro and in vivo. Cell invasion was assayed. Local tumor growth, as well as lung metastasis, were evaluated after subcutaneous cell co-implantation into NOD/SCID/γ-null (NOG) mice. LLC, and TIG-3 cells were pre-treated with either SB431542, a small molecule TGF-β receptor antagonist, or siRNA for transforming growth factor (TGF)-β before co-culture or co-implantation, and the effects of pre-treatments were compared both in cell culture and in mice. Subcutaneous LLC tumor growth (L group) in NOG mice was significantly increased by co-implantation of TIG-3 cells (L+T group) at four weeks. The number of macroscopic lung metastases was also significantly increased in the L+T group in comparison to the L group. In vitro cell invasion was significantly increased in the L+T group in comparison to the L group. In vitro expression of phosphorylated-SMAD3 was significantly increased in the L+T group in comparison to the L group. Furthermore, pre-treatment with either SB431542 or siRNA for TGF-β reduced the invasiveness both in culture and in mice. This study suggested that in vitro as well as in vivo progression of LLC was facilitated by co-culture/co-implantation with TIG-3 cells, and that this process was at least in part dependent on TGF-β-mediated interactions.

A 47-year-old woman with a lung adenocarcinoma of 1.3 cm located in the left S9+10 was treated by S9+10 segmentectomy with sentinel node (SN) identification using radioisotopes. During segmentectomy, frozen section of the segmental nodes at S9+10 and S6, identified as SNs, did not show metastasis; however, postoperative immunohistochemical staining with cytokeratin revealed isolated tumor cells in the segmental node at S6. None of the other dissected nodes, including the hilar, interlobar, and mediastinal nodes, showed metastasis, even with immunohistochemical staining. Completion lobectomy was conducted 6 days after segmentectomy, and the resected specimens did not show further metastasis. The final pathological diagnosis was adenocarcinoma with pT1aN0(i+)M0 stage A. The present case was indicative of the importance of dissecting the segmental lymph node located not only at the tumor-bearing segment but also at the neighboring segment, especially the one located between the primary tumor and the lobar bronchi.

CT1aN0M0非小細胞肺癌において，肺区域切除を肺葉切除と同等の根治性のある手術とするための要点は，十分な切離断端の確保と肺門リンパ節の郭清であることは容易に想像がつく．しかしこの2点は意外と容易ではない．ここに我々が日常心がけている切離断端確保と肺門縦隔リンパ節郭清の方法および手技を紹介する．切離断端の確保のためには腫瘍をリング状の鉗子で掴み込み，リング状鉗子よりさらに離して肺を切離する．肺門リンパ節郭清のためには肺門の血管・気管支にそれぞれテーピングして，肺門を展開しリンパ節を切除する．これらの重要性を症例提示しながら紹介する．

We describe our innovative technique for performing segmentectomy of the posterior segment of the lower lobe of the lung, being segment number 10 (S¹⁰). In segmentectomy of S¹⁰, it is difficult to identify A¹⁰ from the interlobar fissure because the pulmonary artery to S¹⁰ (A¹⁰) branches from A⁹⁺¹⁰ and runs dorsally and deeply into the lung tissue. Moreover, to reach S¹⁰ from the interlobar fissure, the lung tissue should be cut between S⁶ and S⁸, because S¹⁰ is not located beside the interlobar fissure. However, it is difficult to identify the boundary between the S⁶ and S⁸ without a route marker. To solve these difficulties, we divided S⁶ and S¹⁰ from each other at the beginning of the procedure, which enabled A¹⁰ to be identified easily from the dorsal side. Because S⁶ and S^8–10 should be divided in S¹⁰ segmentectomy at the end, the division between S⁶ and S^8–10 at the beginning of procedure is not only reasonable, but makes the procedure simple.

A technique for combined resection of S² _b (horizontal subsegment of the posterior segment) and S³ _a (lateral subsegment of the anterior segment) of the right upper lobe of the lung is presented. Although both the S² _b and S³ _a should be resected from the interlobar fissure, an approach for the artery and bronchus of S³ _a (A³ _a and B³ _a, respectively) is easier from the ventral side of the hilum rather than from the interlobar fissure, because B³ runs in back of V² at the interlobar fissure. To resolve this contradiction, we devised a procedure as follows: (1) A² _b and B² _b are cut at the interlobar fissure; (2) A³ _a and B³ _a are cut from the ventral side of hilum; (3) the peripheral stumps of A³ _a and B³ _a are transferred to the interlobar fissure; and (4) subsegments of S³ _a and S² _b are resected with the peripheral stumps of A² _b, B² _b, A³ _a, and B³ _a from the side of the interlobar fissure. We believe this procedure makes the combined resection of S² _b and S³ _a easy.

Background: For small peripheral c-T1N0M0 non-small cell lung cancers involving multiple segments, we have conducted a resection of subsegments belonging to different segments, i.e. combined subsegmentectomy (CSS), to avoid resection of multiple segments or lobectomy. Tumor size, location of tumor, and forced expiratory volume in 1 second (FEV₁) of each preserved lobe were compared among the CSS, resection of single segment, and that of multiple segments. Methods: FEV₁ of each preserved lobe were examined in 17 patients who underwent CSS, 56 who underwent resection of single segment, and 41 who underwent resection of multiple segments, by measuring pulmonary function and lung-perfusion single-photon-emission computed tomography and computed tomography before and after surgery. Results: Tumor size in the CSS was significantly smaller than that in the resection of multiple segments (1.4 ± 0.5 vs. 2.0 ± 0.8 cm, p = 0.002). Tumors in the CSS were located in the right upper lobe more frequently than those in the resection of multiple segments (53% vs. 5%, p < 0.001). Postoperative of FEV₁ of each lobe after the CSS was higher than that after the resection of multiple segments (0.3 ± 0.2 vs. 0.2 ± 0.2 l, p = 0.07). Mean FEV₁ of each preserved lobe per subsegment after CSS was significantly higher than that after resection of multiple segments (0.05 ± 0.03 vs. 0.03 ± 0.02 l, p = 0.02). There was no significant difference of these factors between the CSS and resection of single segment. Conclusions: The CSS is effective for preserving pulmonary function of each lobe, especially for small sized lung cancer involving multiple segments in the right upper lobe, which has fewer segments than other lobes.

A 34-year-old woman was diagnosed as primary mediastinal diffuse large B-cell lymphoma, treated by cyclophosphamide, doxorubicin, vincrisitne, prednisolone (CHOP) chemotherapy and radiation therapy, and received high-dose ranimustine, cytarabine, etoposide, cyclophosphamide (MCVAC) chemotherapy with autologous peripheral blood stem cell transplantation. Seven years after complete remission was achieved, she recognized dyspnea and was diagnosed secondary interstitial pneumonitis caused by chemotherapy and/or radiotherapy. Because her symptoms and pulmonary function got worsen gradually, she underwent lung transplantation from a brain death donor when she was 47-year-old. She has successfully rehabilitated and returned to her life without oxygen inhalation therapy.

The efficacy of fluorodeoxyglucose-positron emission tomography (FDG-PET) for predicting pathological tumor response and prognosis after neoadjuvant chemoradiotherapy followed by surgery in locally advanced nonsmall cell lung cancer (NSCLC) was compared to the predictive value of tumor size as determined by computed tomography (CT). Thirty-seven consecutive NSCLC patients who received FDG-PET and CT scans both before and after neoadjuvant chemoradiotherapy were enrolled in this study. The percentage point changes in maximum standard uptake value (SUV) on PET and tumor size on CT after neoadjuvant treatment were defined as the SUV ratio and the size ratio, respectively, and were compared with pathological tumor response and prognosis after surgery. A major pathological response was defined as residual viable tumor cells corresponding to less than one-third the size of the original tumor. Nineteen and 18 patients showed major and minor pathological responses, respectively, after neoadjuvant treatment. The optimal cutoff values for predicting a major pathological response were 0.6 for the SUV ratio and 0.79 for the size ratio. The SUV ratio predicted the pathological tumor response with higher accuracy than the size ratio did (P = 0.04). Neither the SUV ratio nor the size ratio predicted prognosis after surgery. For predicting the pathological tumor response after neoadjuvant chemoradiotherapy, the SUV ratio on FDG-PET is superior to the size ratio on CT in patients with NSCLC. However, neither the SUV ratio nor the size ratio could predict prognosis.