Thoracic Surgery Division

Clinical Activities

The Division of Thoracic Surgery has three missions: surgical treatment, surgical resident training, and clinical research.
After more than 7 years, a new consultant surgeon joined the Division. At the end of July, the Division welcomed Dr. Tomoyuki Hishida, one of our former senior residents. The Division currently has four consultant surgeons and four or five residents. However, since the Division chief, Dr. Nagai, was promoted to hospital management in April and spends more time on administration, the Division still needs more consultant surgeons.
Thoracic surgeries involve treatment of neoplasms of the thorax, primary and metastatic lung tumors, and mediastinal, pleural, and chest wall tumors. The Division specializes in surgical treatment of pulmonary carcinomas. The routine carcinoma surgical treatment modalities include limited resection (wedge or segmental resection) and simple resection (lobectomy or pneumonectomy) with or without systematic lymph node dissection. Thoracoscopic assistance is almost always used. Non-routine surgical procedures involve complex approaches such as bronchoplasty, combined resection with adjacent structures, and perioperative adjuvant treatment.
The Division of Thoracic Surgery, National Cancer Center Hospital East ranks second in Japan, providing surgical treatment of primary lung cancer, following the National Cancer Center Tokyo. Since its establishment in 1992, the Division has been one of the most active leaders in the lung cancer field in Japan. The Division of Thoracic Surgery has been an active participant in international and national scientific venues. This year, in addition to 13 published papers: 10 in English and 3 in Japanese; the Division made 39 presentations: 9 international, 18 national, and 12 regional.

Routine Activities

The Division has adopted a multidiscipline approach in patient treatment and resident training. Every Tuesday evening, potential surgical intervention candidate cases are presented at a multidisciplinary team conference of the thoracic surgeons, oncology physicians, radiologists, pathologists, and Division’s residents. Each case is thoroughly and vigorously reviewed and discussed. To improve the English fluency of staff members and residents, preparing them for international presentations, and to better involve visiting physicians from other countries, the treatment modality discussions are conducted in English. Every Friday morning, selected patients’ records are radiologically and cyto-pathologically reviewed. These reviews are conducted to better interpret radiologic indications to the pathology findings, evaluate surgery indications, and learn more of rare histologies. The Division believes this improves our knowledge base, treatment indications, and surgical treatment.
For non-small cell histology, primary pulmonary carcinomas in clinical stages I/II, and IIIA without bulky mediastinal nodes, and small cell primary pulmonary carcinomas in clinical stage I, surgical resection is indicated for cure. The optimum treatment modalities are being sought via clinical trials, attempting to improve the poor prognosis of patients with bulky, or clinically and histologically proven, ediastinal lymph node metastases, with disease invading the neighboring vital structures, or with small cell cancers in clinical stage II and later.
Metastatic lung tumor resection is attempted based on modified Thomfold's criteria after consultation with the patient. The majority of these cases are metastases from colorectal carcinomas.
The majority of mediastinal tumors are thymic epithelial tumors.
The Division’s surgical procedures have remained mostly constant for the past several years. Fifteen percent of the surgeries are completed via a 3-port access, and 80% of the surgeries are thoracoscopically assisted. While some attempt thoracoscopic　surgical resection, the Division deems such an approach as inappropriate due to the limited access and little difference in surgical invasiveness. The Division’s patients had shorter than average postoperative hospital stays, with the shortest being three days and averaging seven for primary lung cancer cases. These shorter stays are achieved with a slightly better than normal complication rate. This year only one 30-day operative mortality occurred.

Number of Patients Surgically Treated
  2003 2004 2005 2006 2007
Lung carcinoma 291 317 286 314 320
Metastatic lung tumor 31 41 38 52 46
Mediastinal tumor 23 21 19 16 14
Esophageal carcinoma 29 57 64 78 87
Others 58 33 45 37 36
Total 432 469 452 497 503
While there has been an upward trend in patient treatment, NCCHE has reched its limits based on operating rooms and anesthesiologists.

Primary Lung Carcinoma - Operative Method
  2003 2004 2005 2006 2007
Pneumonectomy 12 17 18 8 16
Lobectomy 217 233 221 237 255
(Bronchoplasty)  (5) (6) (8) (3) (5)
Limited resection 37 36 31 45 34
Lung resction 266 286 270 290 305

Survival Rates for Resected Primary Lung Carcinoma
P-Stage 3-year survival rate(%) 5-year survival rate(%)
ⅠA 94.2 87.2
ⅠB 80.9 67.7
ⅡA 75.4 54.6
ⅡB 62.5 51.0
ⅢA 50.4 38.3
ⅢB 50.1 37.5
While we do not have other institutions data for detailed patient characteristics analysis and comparison, our  results appear to be slightly better than the national averages.

Research Activities

In November 2003, the Division initiated a new limited resection trial for small pulmonary ground-glass opacity (GGO) lesions. Patient selection is based solely on high-resolution CT (HRCT) findings: a pure or mixed GGO lesion 2 cm or smaller in the lung periphery with a tumor disappearance ratio (TDR) 0.5 or greater on HRCT. TDR is defined as 1－ DM/DL, where DM is the maximum tumor diameter on mediastinal setting and DL on lung setting. The Department of Thoracic Oncology, Kanagawa Cancer Center Hospital, Yokohama, Kanagawa, Japan, joined the trial in November 2006. The enrollment pace has more than doubled, and we think we will reach our 100 patient target within two years. The Division is developing a new GGO lesion treatment trial protocol employing non-surgical modalities such as stereotactic radiation.
The Division is performing a new negative resection margin technique trial, using lavage cytology examination for primary and metastatic lung cancer patients treated by limited resection. This method involves washing the used stapler cartridges and then intraoperative cytological evaluation of the washed saline sediment.

Ongoing Clinical Trials

1. Surgical margin lavage cytology examination in limited resection for primary and metastatic lung cancer patients [observational].
2. Limited resection trial for small ground-glass opacity (GGO) lung tumors [phase II].
3. Member of an organized trial of combined chemotherapy with cisplatin and irinotecan for large cell neuroendocrine carcinoma [phase II].
● K. Nagai, J. Yoshida ●
Table of Contents