Thoracic Surgery

Introduction
The Division of Thoracic Surgery deals with various kinds of neoplasms in the thorax: lung tumors both primary and metastatic, mediastinal, pleural, and chest wall tumors. Surgical treatment of pulmonary carcinoma employing various surgical techniques has been the major challenge for the division. The modes of surgical treatment for the carcinoma include limited resection (wedge or segmental resection), simple resection (lobectomy or pneumonectomy) with or without systematic lymph node dissection, to more complex approaches such as bronchoplasty, combined resection with adjacent structures, perioperative adjuvant treatment and thoracoscopic surgery.
The division includes three attending surgeons. We usually have 4 residents. One of the two years of our of our junior residency course is devoted to the study of pathology, endoscopy, image diagnosis and medical oncology, depending on each residentis interest. This rotation system in the related oncologic specialties provides our residents with a better understanding of the fields.
The number of patients who undergo surgical intervention for primary lung cancer at our division is one of the largest three in Japan, second to the National Cancer Center Hospital Tokyo. 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 physicians and pathologists every Tuesday evening to determine their treatment modalities. Selected
patients among those who underwent resection are radiologically and cyto-pathologically reviewed every Friday morning.
Primary pulmonary carcinomas of non-small cell histology in clinical stages I and II, IIIA without bulky mediastinal nodes and those of small cell histology in clinical stage I are usually indicated surgical resection for cure. In an attempt to improve the poor prognosis of patients with bulky or clinically and histologically proven mediastinal lymph node metastases, with invasive disease to the neighboring vital structures or with small cell cancer, the optimal treatment modalities are sought for in clinical trial settings.
Resection of metastatic lung tumors has been attempted on Thomfoldis criteria with slight modification upon consultation with the patient. Histologically, metastases from colorectal carcinoma constitute 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
Changes in the national health insurance system prompted us to employ video thoracoscopic assistance in almost all pulmonary resection cases. This enabled us to detect pleural dissemination with ease and high accuracy. Standard thoracotomy incision has shortened to a 10 to 15 cm range in length, and the serrartus anterior muscle is almost always preserved.National Cancer Center Hospital East Annual Report
These factors contributed considerably to reducing surgical invasiveness. The postoperative hospital stay is 4 days in the shortest and 7 days on average. Operative mortality occurred in one patient due to Lyellis syndrome during the past 1 year. Ongoing Clinical Trials
1. Preoperative chemotherapy and irradiation followed by surgery for superior sulcus tumor [phase II]
2. Induction chemotherapy and irradiation for advanced thymic epithelial tumor [phase II]
3. Limited resection for small peripheral adeno-carcinoma of Noguchiis types A and B [phase II]
4. A randomized, double-blind, placebo-controlled, phase III multi-center trial to assess the survival of ZD1839 (IRESSA(tm)) 250 mg/day versus placebo with completely resected Non Small Cell lung Cancer

K. NAGAI
J. YOSHIDA

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