Thoracic Surgery
Introduction
The Division of Thoracic Surgery deals surgically with various kinds of neoplasms in the thorax: lung tumors both primary and metastatic, mediastinal, pleural (mesotheliomas) and chest wall tumors. The surgical treatment of pulmonary carcinoma with various surgical techniques has been the major challenge of the division. The modes of surgical treatment for the carcinoma included simple resection (wedge resection, segmentectomy, lobectomy and pneumonectomy) to more complex approaches such as combined resection with neighboring structures, perioperative treatment and thoracoscopic surgery.
The Division includes four attending staff surgeons, 1 senior resident and 2 to 4 residents. One of the two years of our senior residency program in general thoracic surgery is dedicated to research work. One of the three years of our residency course is devoted to the study of pathology, endoscopy, image diagnosis and medical oncology depending on each resident's interest. This system of rotation in the related oncological specialties provides our senior residents and residents with a better understanding of the fields.
The number of patients who undergo surgical intervention in our Division is one of the 3 largest in Japan, and we have been one of the most active leaders in this field since its establishment in 1992.
Routine Activities
All possible candidates for surgical intervention are presented at our conference with the thoracic oncology group every Tuesday evening to determine their treatment modalities. Selected patients of those who underwent resection are radiologically and pathologically reviewed every Friday morning.
Pulmonary carcinomas of non-small cell histology in clinical Stages I, II, and IIIa and of small cell histology in clinical Stages I and II are usually indicated for surgical resection for cure. However, in an attempt to improve the poor prognosis of patients with clinically and histologically proven mediastinal lymph node metastases, with invasion to the neighboring vital structures or with small cell cancer, the optimal treatment modalities are sought in clinical trial settings. Resection of metastatic lung tumors has been attempted on Thomfold's criteria with a slight modification upon consultation with the patient. Histologically, metastases from colorectal carcinoma are the majority of the cases. The majority of mediastinal tumors were thymic epithelial tumors, and we did not attempt to use a thoracosopic procedure in these patients.
New Developments
In an attempt to reduce the surgical invasiveness, especially in elderly or high-risk patients, major or conservative pulmonary resection with thoracoscopic assistance is being attempted, but in a small number of patients.
Standard thoracotomy has changed from cutting apart both the latissimus dorsi and serratus anterior muscles to preserving the serrartus anterior muscle. The length of the thoracotomy incision shortened from about 20 cm to 15 cm.
Research Activities
Ongoing Clinical Trials
1. Preoperative chemotherapy and irradiation followed by surgery for histologically proven cN2 non-small cell lung carcinoma (phase II).
2. Induction chemotherapy and irradiation for advanced thymic epithelial tumor (phase II).
3. Limited resection for small peripheral adenocarcinoma of Noguchi's types A and B (phase II).
Statistics
| 1995 | 1996 | 1997 | 1998 | |
| Lung carcinoma | 155 | 188 | 176 | 180 |
| Metastatic lung tumor | 26 | 14 | 23 | 28 |
| Mediastinal tumor | 18 | 19 | 18 | 20 |
| Esophageal carcinoma | 16 | 24 | 23 | 21 |
| Others | 46 | 21 | 38 | 42 |
| Total | 261 | 266 | 278 | 291 |
| 1995 | 1996 | 1997 | 1998 | |
| Lung resection | 137 | 167 | 161 | 172 |
| Pneumonectomy | 4 | 7 | 9 | 12 |
| Lobectomy | 127 | 151 | 147 | 145 |
| (Bronchoplasty) | (8) | (3) | (4) | (11) |
| Conservative resection | 6 | 9 | 5 | 15 |
| Thoracoscopic resection | 16 | 30 | 16 | 20 |
| Others | 13 | 10 | 15 | 10 |
| Stage | 3-yr survival rate (%) | 5-yr survival rate (%) |
| Ia | 92.5 | 87.6 |
| Ib | 85.1 | 73.3 |
| IIa | 84.5 | 74.0 |
| IIb | 55.9 | 42.9 |
| IIIa | 53.7 | 25.3 |
| IIIb | 51.6 | 19.0 |
(K. Nagai, J. Yoshida)
