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, 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 included four attending surgeons, but one surgeon moved to a prefectural cancer center in April 2000 and no replacement has been found. We usually have 4 residents. One of the two years of our senior residency program in general thoracic surgery is dedicated to research work. One to two of the three years of our junior residency course is devoted to the study of pathology, endoscopy, image diagnosis and medical oncology depending on each resident's interest. This rotation system in the related oncological specialties provides our residents with a better understanding of the fields.
The number of patients who undergo surgical intervention for primary lung cancer in our division is one of the largest three in Japan, second to the National Cancer Center Hospital Tokyo. In 2002, however, patient numbers stayed almost the same compared to the previous year both at the East and Tokyo Hospitals. 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 in English 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. Starting in 2002, clinical stages IB and II patients are candidates for a randomized phase II induction chemotherapy trial.
Resection of metastatic lung tumors has been attempted on Thomfold's 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 in 2002
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. We started placing a single 19 Fr Blake Drain as a chest tube, which allows simple tube removal without suture-closure of the chest tube wound.
These factors contributed considerably to reducing surgical invasiveness. The postoperative hospital stay is 4 days in the shortest and 7 days on average. No operative morbidity occurred during the past 1 year.

Ongoing Clinica Triall
1. Induction chemotherapy and irradiation for advanced thymic epithelial tumor [phase II].
2. Limited resection for small peripheral adenocarcinoma of Noguchi's types A and B [phase II].
3. Induction chemotherapy for stages IB and II non-small cell lung cancer [randomized phase II].
4. Prospective study of radiologic-pathologic correlation for peripherally located lung cancer for radiologic definition of "early" peripheral lung cancer.
5. ZD1839 as adjuvant therapy for completely resected non-small cell lung cancer patients in pathologic stages IB, II, and IIIA [randomized, placebo-controlled phase III].

K. NAGAI
J. YOSHIDA

Operative Methods for Primary Lung Carcinoma (1996-2002)

	1997	1998	1999	2000	2001	2002
Pneumonectomy	9	12	5	7	8	15
Lobectomy	147	145	150	179	207	203
(Bronchoplasty)	(4)	(11)	(10)	(4)	(7)	(5)
Limited resection	5	15	36	24	30	12
Total	161	172	191	210	245	230

Survival Rates for Resected Primary Lung Carcinoma

Stage	3-year survival rate(%)	5-year survival rate(%)
IA	92.6	83.0
IB	80.4	69.3
IIA	70.9	42.8.
IIB	57.5	45.2
IIIA	52.8	33.0
IIIB	40.7	27.4

Table of Contents