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Department of Thoracic Surgery

Masahiro Tsuboi, Junji Yoshida, Tomoyuki Hishida, Keiju Aokage, Masahito Naito, Tomohiro Miyoshi

Introduction

The Department of Thoracic Oncology has three missions: surgical treatment, surgical resident training, and clinical research. Thoracic surgeries involve the treatment of thoracic neoplasms, primary and metastatic lung tumors, as well as mediastinal, pleural, and chest wall tumors. The Department specializes in the surgical treatment of pulmonary carcinomas. Routine surgical treatment modalities for carcinomas 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 broncho-/angio-plasty, combined resection with adjacent structures, and perioperative adjuvant treatment.

Since its establishment in 1992, the Department has been one of the most active leaders in the field of lung cancer in Japan. Moreover, it has been an active participant in international and national scientific venues. This year, in addition to 13 scientific papers published in English, the Department made 31 presentations: 4 international, 23 national, and 4 regional.

Routine activities

The Department is presently composed of four consultant surgeons and five or six residents.

The Department has adopted a team approach in patient treatment and resident training. Potential surgical intervention candidate cases are presented every Tuesday evening at a multidisciplinary team conference of thoracic surgeons, oncology physicians, radiologists and residents. Each case is thoroughly and vigorously reviewed and discussed. To improve the English fluency of staff members and residents in preparation for international presentations, and to better involve visiting physicians from other countries, treatment modality discussions are conducted in English. Moreover, selected patients' records are radiologically and cytopathologically reviewed every Friday morning. These reviews aim to improve the interpretation of radiologic indications to pathology findings, accurately evaluate surgical indications, and upgrade knowledge on rare histologies. The Department believes that these activities improve the knowledge base, treatment indications, and surgical treatment.

For non-small cell histology, primary pulmonary carcinomas in clinical stages I/II and IIIA without bulky or multistation-involved mediastinal nodes, and primary pulmonary small cell carcinomas in clinical stage I, surgical resection is indicated for the cure. Optimum treatment modalities are being sought via clinical trials with the aim of improving the poor prognosis of patients with bulky or clinically and histologically proven multistation mediastinal lymph node metastases, with disease invading the neighboring vital structures, or with small cell cancers in clinical stage II and later.

Resection of metastatic lung tumor is attempted based on modified Thomfold's criteria after consultation with the patient. The majority of these cases are metastases from colorectal carcinomas, while most of the mediastinal tumors are thymic epithelial tumors.

The surgical procedures of the Department have generally remained similar for the past decade, but we have employed port-access thoracoscopic surgery more often for the last several years. Approximately 20% of the surgeries are completed via a 3-port access, and 70% of the surgeries are video-thoracoscopically assisted. To date, the average postoperative hospital stays of patients in the Department have improved and became shorter; three days being the shortest with a median of seven days for cases of primary lung cancer. These shorter hospital stays are achieved with a slightly better complication rate than the normal rate. This year, 30-day operative mortality occurred in 2 patients undergoing surgery for primary lung cancer.

Research activities

Research in the area of combined treatments, especially immunotherapy, has now advanced to clinical trials. It is a goal of researchers in the Department to acquire a basic understanding of the cellular and molecular mechanisms leading to the development and progression of lung cancer and apply these findings to further the development of immunotherapy-based prevention and treatment strategies

Clinical trials

  1. Surgical margin lavage cytology examination in limited resection for primary and metastatic lung cancer patients [observational].
  2. Primary investigator and a member of an organized trial of TS-1 vs. UFT adjuvant chemotherapy for completely resected pathologic stage I (> 2 cm) non-small cell lung cancer [JCOG0707, phase III, patient accrual completed].
  3. Primary investigator and a member of an organized trial of sublobar resection for peripheral GGO dominant cT1aN0M0 lung adenocarcinomas [JCOG0804, phase II, patient accrual completed].
  4. Study coordinator and a member of an organized trial of segmental resection vs. lobectomy for peripheral T1aN0M0 non-small cell lung cancers [JCOG0802, phase III, patient accrual completed].
  5. Study coordinator and a member of an organized trial of sublobar resection for peripheral GGO dominant cT1bN0M0 lung adenocarcinomas [JCOG1211, phase III, patient accrual completed]
  6. Primary investigator and a member of an organized trial of Cisplatin/Pemetrexed vs. Cisplatin/Vinorelbine adjuvant chemotherapy for completely resected pathologic stage II-IIIA
  7. A member of an organized trial of Human Atrial Natriuretic Peptide during perioperative period for completed resectable non-small cell lung cancer [JANP, randomized phase II, patient accrual ongoing].
  8. A member of an organized trial of postoperative maintenance adjuvant immunotherapy with S-588410 for completed resected stage II-IIIA non-small cell lung cancer [S-588410, phase II, patient accrual ongoing]

Education

Our educational program is to educate residents by expanding their knowledge and technical skills in the treatment of lung cancer, other thoracic malignancies and benign tumors, such as hamartoma and mediastinal cystic lesions. In addition, we seek to instill in the trainee a desire for continued introspection and self-education, open communication between all health care providers, while maintaining a respectful and professional demeanor.

Future prospects

Treatment advances in thoracic cancers including lung, mesothelioma, thymic malignancies and lung metastases have been slow to develop, even though these cancers are among the most common clinical problems. This clinical and laboratory research is vital to making progress.

  • Table 1. Number of patients Table 2. Type of procedure - primary lung cancer
  • Table 3. Overall survival

List of papers published in 2015

Journal

  1. Suzuki K, Watanabe S, Mizusawa J, Moriya Y, Yoshino I, Tsuboi M, Mizutani T, Nakamura K, Tada H, Asamura H, Japan Lung Cancer Surgical Study Group (JCOG LCSSG). Predictors of non-neoplastic lesions in lung tumours showing groundglass opacity on thin-section computed tomography based on a multi-institutional prospective study†. Interact Cardiovasc Thorac Surg, 21:218-223, 2015
  2. Sugiyama E, Umemura S, Nomura S, Kirita K, Matsumoto S, Yoh K, Niho S, Ohmatsu H, Tsuboi M, Ohe Y, Goto K. Impact of single nucleotide polymorphisms on severe hepatotoxicity induced by EGFR tyrosine kinase inhibitors in patients with non-small cell lung cancer harboring EGFR mutations. Lung Cancer, 90:307-313, 2015
  3. Omori T, Tajiri M, Baba T, Ogura T, Iwasawa T, Okudela K, Takemura T, Oba MS, Maehara T, Nakayama H, Tsuboi M, Masuda M. Pulmonary Resection for Lung Cancer in Patients With Idiopathic Interstitial Pneumonia. Ann Thorac Surg, 100:954-960, 2015
  4. Haruki T, Aokage K, Miyoshi T, Hishida T, Ishii G, Yoshida J, Tsuboi M, Nakamura H, Nagai K. Mediastinal nodal involvement in patients with clinical stage I non-small-cell lung cancer: possibility of rational lymph node dissection. J Thorac Oncol, 10:930-936, 2015
  5. Mimae T, Suzuki K, Tsuboi M, Nagai K, Ikeda N, Mitsudomi T, Saji H, Okumura S, Okumura M, Yoshimura K, Okada M. Surgical Outcomes of Lung Cancer in Patients with Combined Pulmonary Fibrosis and Emphysema. Ann Surg Oncol, 223:1371-1379, 2015
  6. Yoshida J, Ishii G, Hishida T, Aokage K, Tsuboi M, Ito H, Yokose T, Nakayama H, Yamada K, Nagai K. Limited resection trial for pulmonary ground-glass opacity nodules: case selection based on high-resolution computed tomography-interim results. Jpn J Clin Oncol, 45:677-681, 2015
  7. Hamanaka R, Yokose T, Sakuma Y, Tsuboi M, Ito H, Nakayama H, Yamada K, Masuda R, Iwazaki M. Prognostic impact of vascular invasion and standardization of its evaluation in stage I non-small cell lung cancer. Diagn Pathol, 10:17, 2015
  8. Hishida T, Tsuboi M, Shukuya T, Takamochi K, Sakurai H, Yoh K, Ohashi Y, Kunitoh H. Multicenter observational cohort study of post-operative treatment for completely resected non-smallcell lung cancer of pathological stage I (T1 >2 cm and T2 in TNM classification version 6). Jpn J Clin Oncol, 45:499-501, 2015
  9. Noma D, Morohoshi T, Adachi H, Natsume I, Ookouchi M, Tsuura Y, Tsuboi M, Masuda M. A resected case of combined small cell lung carcinoma with carcinosarcoma. Pathol Int, 65:332-334, 2015
  10. Udagawa H, Ishii G, Morise M, Umemura S, Matsumoto S, Yoh K, Niho S, Ohmatsu H, Tsuboi M, Goto K, Ochiai A, Ohe Y. Comparison of the expression levels of molecular markers among the peripheral area and central area of primary tumor and metastatic lymph node tumor in patients with squamous cell carcinoma of the lung. J Cancer Res Clin Oncol, 141:1417-1425, 2015
  11. Adachi H, Tsuboi M, Nishii T, Yamamoto T, Nagashima T, Ando K, Ishikawa Y, Woo T, Watanabe K, Kumakiri Y, Maehara T, Morohoshi T, Nakayama H, Masuda M. Influence of visceral pleural invasion on survival in completely resected non-smallcell lung cancer. Eur J Cardiothorac Surg, 48:691-7; discussion 697, 2015
  12. Koriyama H, Ishii G, Yoh K, Neri S, Morise M, Umemura S, Matsumoto S, Niho S, Ohmatsu H, Tsuboi M, Goto K, Ochiai A. Presence of podoplanin-positive cancer-associated fibroblasts in surgically resected primary lung adenocarcinoma predicts a shorter progression-free survival period in patients with recurrences who received platinum-based chemotherapy. J Cancer Res Clin Oncol, 141:1163-1170, 2015
  13. Samejima J, Tajiri M, Ogura T, Baba T, Omori T, Tsuboi M, Masuda M. Thoracoscopic lung biopsy in 285 patients with diffuse pulmonary disease. Asian Cardiovasc Thorac Ann, 23:191-197, 2015
  14. Arai H, Inui K, Watanabe K, Watanuki K, Okudela K, Tsuboi M, Masuda M. Lung abscess combined with chronic osteomyelitis of the mandible successfully treated with video-assisted thoracoscopic surgery. Clin Respir J, 9:253-256, 2015
  15. Matsumura Y, Umemura S, Ishii G, Tsuta K, Matsumoto S, Aokage K, Hishida T, Yoshida J, Ohe Y, Suzuki H, Ochiai A, Goto K, Nagai K, Tsuchihara K. Expression profiling of receptor tyrosine kinases in high-grade neuroendocrine carcinoma of the lung: a comparative analysis with adenocarcinoma and squamous cell carcinoma. J Cancer Res Clin Oncol, 141:2159-2170, 2015
  16. Morise M, Hishida T, Takahashi A, Yoshida J, Ohe Y, Nagai K, Ishii G. Clinicopathological significance of cancer stem-like cell markers in high-grade neuroendocrine carcinoma of the lung. J Cancer Res Clin Oncol, 141:2121-2130, 2015
  17. Suzuki S, Ishii G, Matsuwaki R, Neri S, Hashimoto H, Yamauchi C, Aokage K, Hishida T, Yoshida J, Kohno M, Nagai K, Ochiai A. Ezrin-expressing lung adenocarcinoma cells and podoplanin-positive fibroblasts form a malignant microenvironment. J Cancer Res Clin Oncol, 141:475-484, 2015
  18. Kinoshita T, Yoshida J, Ishii G, Hishida T, Wada M, Aokage K, Nagai K. The availability of pre- and intraoperative evaluation of a solitary pulmonary nodule in breast cancer patients. Ann Thorac Cardiovasc Surg, 21:31-36, 2015
  19. Yano M, Yoshida J, Koike T, Kameyama K, Shimamoto A, Nishio W, Yoshimoto K, Utsumi T, Shiina T, Watanabe A, Yamato Y, Watanabe T, Takahashi Y, Sonobe M, Kuroda H, Oda M, Inoue M, Tanahashi M, Adachi H, Saito M, Hayashi M, Otsuka H, Mizobuchi T, Moriya Y, Takahashi M, Nishikawa S, Matsumura Y, Moriyama S, Nishiyama T, Fujii Y, Japanese Association for Chest Surgery. Survival of 1737 lobectomy-tolerable patients who underwent limited resection for cStage IA nonsmall-cell lung cancer. Eur J Cardiothorac Surg, 47:135-142, 2015
  20. Tsubokawa N, Mimae T, Aokage K, Hattori A, Suzuki K, Nagai K, Tsuboi M, Okada M. Surgical outcomes of non-small-cell lung carcinoma in patients previously treated for gastric cancer. Eur J Cardiothorac Surg, 47:648-652, 2015