Department of Thoracic Surgery
Shun-ichi Watanabe, Kazuo Nakagawa, Yukihiro Yoshida, Masaya Yotsukura, Masahiro Higashiyama, Yuji Muraoka
The Department of Thoracic Surgery deals with various kinds of neoplasms and allied diseases in the thorax, except the esophagus. These include both primary and metastatic lung tumors, mediastinal tumors, pleural tumors (mesotheliomas) and chest wall tumors. The main clinical activity of our department and the subject of most of its research activities has been the surgical management of lung cancer patients.
The Team and What We Do
Our department has 4 attending surgeons and resident surgeons perform all the inpatient care, surgeries, examinations, and outpatient care. In 2022, we performed a total of 736 operations: for lung cancer in 649 patients, metastatic tumors in 8, mediastinal tumors in 50 and other tumors in 29 (Tables 1 and 2).
The treatment strategy for patients with lung cancer is based on tumor histology (non-small cell vs. small cell), the extent of the disease (clinical stage) and the physical status of the patient. In lung cancer patients, surgical resection is usually indicated for clinical stages I, II and some IIIA with non-small cell lung cancer [NSCLC] and clinical stage I with small cell lung cancer [SCLC]. However, to improve the poor prognosis of patients with clinically and histologically proven mediastinal lymph node metastasis or with invasion of vital neighboring structures, optimal treatment modalities are sought in a clinical trial setting. In addition, adjuvant therapy has often been given to patients with advanced lung cancer, even after complete resection.
For metastatic lung tumors, resection has been attempted based on Thomford’s criteria: eligible patients are those who are at good risk, with no extrathoracic disease, with the primary site under control and with completely resectable lung disease. For mediastinal tumors, thymic epithelial tumors are most commonly encountered for resection. In the mediastinum meanwhile, where various tumor histologies can arise, treatment must be carefully determined by cytologic/histologic diagnosis before surgery. VATS resection of mediastinal tumor is indicated exclusively for small thymomas.
As for meetings, there are two department meetings. One is for the preoperative evaluation and postoperative inpatient review on Fridays and the other is for the journal club on Wednesdays.
Table 1. Details of resected disease
|Primary lung cancer||649|
|Metastatic lung tumor||8|
|Malignant pleural mesothelioma||5|
Table 2. Details of surgical procedures
|Surgery for mediastinal tumors||50|
|Surgery for pleural tumors||5|
|Surgery for chest wall tumors||5|
Lymph node dissection for lung cancer has been a major issue in lung cancer treatment and has been extensively studied in our department. We continue to improve our surgical dissection technique, taking oncological and surgical aspects into consideration: a more effective and less invasive lymph node dissection called “selective mediastinal/hilar dissection”, according to the location of the primary tumor by the lobe.
Minimally invasive open surgery (MIOS), using a thoracoscope for thoracic malignancies, is also an important challenge in our department. Indications and surgical techniques of VATS for early lung cancer are of special interest given the increased incidence of such minute tumors due to improvements in CT devices and CT screening.
Recently, the role of segmentectomy has become more important because the rate of detection for early-stage lung cancer is increasing. We have actively performed segmentectomy for early-stage lung cancer in recent years. In 2022, we performed the largest number of segmentectomies as well as lung cancer surgeries in Japan.
Our department has played an important role as a leading hospital in the Japan Clinical Oncology Group (JCOG) - Lung Cancer Surgical Study Group (LCSSG). To date, the LCSSG has conducted a lot of clinical trials for lung cancer surgery.
In terms of the mode of surgical resection, lobectomy has been the standard mode of resection since 1960. However, with the increased frequency of CT screening and advances in diagnostic modalities, the early detection rate of small-sized or ground-glass opacity (GGO) lung tumors has increased and the significance of limited resection, particularly, segmentectomy is a more important issue in lung cancer surgery now than ever before. In addition, GGO lung tumors are well known to have an indolent behavior, so some cases might be followed up with careful monitoring by CT. Accordingly, we are seeking how best to manage such patients with not only resection but also observation. Three clinical trials to determine the appropriateness of limited resection for early-stage lung cancer (JCOG0802, JCOG0804, and JCOG1211) have been conducted since the end of 2009. Among these three trials, the results of JCOG0802 (a phase III randomized trial of lobectomy versus segmentectomy for small [≤ 2 cm] peripheral NSCLC) were published in the Lancet in 2021. The JCOG0802 study not only confirmed non-inferiority of segmentectomy but also showed superiority in overall survival. These three trials from the JLCSSG could lead to major shifts in clinical practice towards limited resection for early-stage NSCLC. More recently, a single arm confirmatory multicenter study (JCOG1906), a prospective evaluation of watchful waiting for early-stage lung cancer with GGO, opened to accrual in June 2020.
As for lymph node dissection, a randomized phase III trial (JCOG1413), lobe-specific versus systematic nodal dissection for c-stage I/II NSCLC, completed the full accrual of 1507 patients. We await maturation of follow-up data.
Investigating the appropriate mode of resection for compromised patients is also crucial. Two clinical trials are ongoing. A phase III study (JCOG1708), sublobar resection versus lobectomy for patients with resectable stage I NSCLC with idiopathic pulmonary fibrosis, opened to accrual in May 2018, and a randomized phase III trial (JCOG1909), anatomical segmentectomy versus wedge resection in high-risk operable patients with clinical stage IA NSCLC, opened to accrual in April 2020. In addition, a prospective observational study (JCOG1710A), daily living activities in elderly patients having undergone lung cancer surgery, completed the full accrual of 986 patients.
Regarding adjuvant or neoadjuvant therapy, a randomized phase III trial (JCOG1916), postoperative radiotherapy (PORT) for pathological N2 NSCLC with adjuvant chemotherapy, opened to accrual in January 2021. More recently, a phase III trial (JCOG1807C), efficacy and safety of durvalumab before and after operation or durvalumab as maintenance therapy after chemoradiotherapy against superior sulcus NSCLC, opened to accrual in September 2020.
The LCSSG in the JCOG continues to try to establish ideal surgical treatment strategies for lung cancer.
List of papers published
- Nakagawa K. Minimally invasive sleeve lobectomy: it is important to pass excellent techniques to the next generation. J Thorac Dis. 2023 Mar 31;15(3):946-949. PMID:37065577. PMCID:PMC10089855. DOI: 10.21037/jtd-23-71. Epub 2023 Feb 22.
- Sugawara H, Yatabe Y, Watanabe H, Akai H, Abe O, Watanabe SI, Kusumoto M. Radiological precursor lesions of lung squamous cell carcinoma: Early progression patterns and divergent volume doubling time between hilar and peripheral zonesLung Cancer. 2023 Feb;176:31-37. PMID:36584605. DOI: 10.1016/j.lungcan.2022.12.007. Epub 2022 Dec 19... Online ahead of print.
- Yotsukura M, Muraoka Y, Yoshida Y, Nakagawa K, Shiraishi K, Kohno T, Yatabe Y, Watanabe SI. ASO Visual Abstract: Long-Term Prognosis and Prognostic Indicators of Stage IA Lung Adenocarcinoma. Ann Surg Oncol. 2023 Feb;30(2):859-860. PMID: 36472783. DOI: 10.1245/s10434-022-12718-3.
- Yotsukura M, Muraoka Y, Yoshida Y, Nakagawa K, Shiraishi K, Kohno T, Yatabe Y, Watanabe SI. Long-Term Prognosis and Prognostic Indicators of Stage IA Lung Adenocarcinoma. Ann Surg Oncol. 2023 Feb;30(2):851-858. PMID: 36260144. DOI: 10.1245/s10434-022-12621-x. Epub 2022 Oct 19.
- Yoshino I , Moriya Y, Suzuki K, Wakabayashi M, Saji H, Aokage K, Suzuki M, Ito H, Matsumoto I, Kobayashi M, Okamoto T, Okada M, Yamashita M, Ikeda N, Nakamura S, Kataoka T, Tsuboi M, Watanabe SI, on behalf of the West Japan Oncology Group (WJOG) and Japan Clinical Oncology Group (JCOG). Long-term Outcome of Patients with Peripheral Ground Glass Opacity Dominant Lung Cancer after Sublobar Resections. The Journal of Thoracic and Cardiovascular Surgery. Published:January 24, 2023 DOI: https://doi.org/10.1016/j.jtcvs.2023.01.019. (JCOG0804)
- Akamine T, Yotsukura M, Yoshida Y, Nakagawa K, Yatabe Y, Watanabe SI. Feasibility and effectiveness of segmentectomy versus wedge resection for clinical stage I non-small cell lung cancer. Eur J Cardiothorac Surg. 2023 Mar 1;63(3):ezad018. PMID: 36708001 DOI: 10.1093/ejcts/ezad018.
- Ohishi T, Kaneko MK, Yoshida Y, Takashima A, Kato Y, Kawada M. Current targeted therapy for metastatic colorectal cancer. Int J Mol Sci. 2023 Jan 15;24(2):1702.
- Matsuzaki J, Kato K, Oono K, Tsuchiya N, Sudo K, Shimomura A, Tamura K, Shiino S, Kinoshita T, Daiko H, Wada T, Katai H, Ochiai H, Kanemitsu Y, Takamaru H, Abe S, Saito Y, Boku N, Kondo S, Ueno H, Okusaka T, Shimada K, Ohe Y, Asakura K, Yoshida Y, Watanabe SI, Asano N, Kawai A, Ohno M, Narita Y, Ishikawa M, Kato T, Fujimoto H, Niida S, Sakamoto H, Takizawa S, Akiba T, Okanohara D, Shiraishi K, Kohno T, Takeshita F, Nakagama H, Ota N, Ochiya T; Project Team for Development and Diagnostic Technology for Detection of miRNA in Body Fluids. Prediction of tissue-of-origin of early stage cancers using serum miRNomes. JNCI Cancer Spectr. 2023 Jan 3;7(1):pkac080. PMID: 36426871 PMCID: PMC9825310. DOI: 10.1093/jncics/pkac080.
- Kajiyama A, Ito K, Watanabe H, Mizumura S, Watanabe SI, Yatabe Y, Gomi T, Kusumoto M. Consistency and prognostic value of preoperative staging and postoperative pathological staging using 18F-FDG PET/MRI in patients with non-small cell lung cancer. Ann Nucl Med. Ann Nucl Med. 2022 Dec;36(12):1059-1072. PMID: 36264439. DOI: 10.1007/s12149-022-01795-9. Epub 2022 Oct 20.
- Kobayashi AK, Nakagawa K, Nakayama Y, Ohe Y, Yotsukura M, Uchida S, Asakura K, Yoshida Y, Watanabe SI. Salvage Surgery Compared to Surgery After Induction Chemoradiation Therapy for Advanced Lung Cancer. Ann Thorac Surg. 2022 Dec;114(6):2087-2092. PMID: 34843695. DOI: 10.1016/j.athoracsur.2021.10.036. Epub 2021 Nov 26.
- Kashima J, Hashimoto T, Yoshida A, Goto Y, Ushiku T, Ohe Y, Watanabe SI, Yatabe Y. Insulinoma-associated-1 (INSM1) expression in thymic squamous cell carcinoma. Virchows Arch. 2022 Dec;481(6):893-901. PMID: 36305944. DOI: 10.1007/s00428-022-03437-x. Epub 2022 Oct 28.
- Yotsukura M, Nakagawa K, Takemura C, Yoshida Y, Ito K, Watanabe H, Kusumoto M, Yatabe Y, Watanabe SI. Aggressive histological component in subsolid lung adenocarcinoma: priority for resection without delay. Jpn J Clin Oncol. 2022 Nov 3;52(11):1321-1326. PMID: 35975671 DOI: 10.1093/jjco/hyac131.
- Ishiguro Y, Uchimura K, Furuse H, Imabayashi T, Matsumoto Y, Watanabe SI, Tsuchida T. Esophageal submucosal tumor diagnosed with EBUS-guided transbronchial mediastinal cryobiopsy: A case report. Thorac Cancer. 2022 Nov;13(21):3068-3072. PMID: 36100954 DOI: 10.1111月17日59-7714.14650. Epub 2022 Sep 13.
- Higashiyama M, Kobayashi Y, Kashima J, Muraoka Y, Watanabe H, Kusumoto M, Watanabe SI, Yatabe Y. Invasive Mucinous Adenocarcinoma of the Lung with a Mural Nodule-like Lesion. Am J Surg Pathol. 2022 Nov 1;46(11):1524-1532. PMID: 35939825 DOI: 10.1097/PAS.0000000000001938. Epub 2022 Aug 2.
- Yamauchi Y, Kawamura M, Okami J, Shintani Y, Ito H, Ohtsuka T, Toyooka S, Mori T, Watanabe SI, Asamura H, Chida M, Endo S, Kadokura M, Nakanishi R, Miyaoka E, Suzuki H, Yoshino I, Date H. Hazard Function Analysis of Recurrence in Patients with Curatively Resected Lung Cancer: Results from the Japanese Lung Cancer Registry in 2010. Cancers (Basel). 2022 Oct 19;14(20):5119. PMID: 36291903 PMCID: PMC9600058 DOI: 10.3390/cancers14205119.
- Yoshida Y, Saeki N, Yotsukura M, Nakagawa K, Watanabe H, Yatabe Y, Watanabe SI. Visualization of patterns of lymph node metastases in non-small cell lung cancer using network analysis. JTCVS Open. 2022 Oct 13;12時41分0-425. doi: 10.1016/j.xjon.2022.10.003. eCollection 2022 Dec.
- Kojima N, Komiyama M, Shinoda Y, Watanabe SI, MD, Yatabe Y, MD, Kawai A, Yoshida A. Liposarcoma With Hibernoma-like Histology: A Clinicopathologic Study of 16 Cases. Am J Surg Pathol. 2022 Oct 1;46(10):1319-1328. PMID: 35475774. DOI: 10.1097/PAS.0000000000001911. Epub 2022 Apr 27.
- Kawakubo N, Hishiki T, Arakawa A, Nakajima M, Kumamoto T, Nakagawa K, Kawai A, Ogawa C. Surgical treatment for pneumothorax and tumor-bronchial fistula secondary to pulmonary metastasis of osteosarcoma in pediatric and adolescent patients. J Pediatr Hematol Oncol. 2022 Oct 1;44(7):393-397. PMID: 35091523. DOI: 10.1097/MPH.0000000000002416 .
- Nakayama S, Kobayashi E, Nishio J, Toda Y, Yotsukura M, Watanabe SI, Yamamoto T, Kawai A. Prognostic Factors of Pulmonary Metastasectomy for Soft Tissue Sarcomas Arising in the Trunk Wall and Extremities. Cancers (Basel). 2022 Jul 8;14(14):3329. PMID: 35884389. PMCID: PMC9322058. DOI: 10.3390/cancers14143329.
- Inoue M, Yotsukura M, Yoshida Y, Nakagawa K, Watanabe SI. A case of cardiac herniation after right pneumonectomy Show less. Asian Cardiovasc Thorac Ann. 2022 Jul;30(6):737-740. PMID: 35503409. DOI: 10.1177/02184923221097841. Epub 2022 May 3.
- Saito T, Murakawa T, Shintani Y, Okami J, Miyaoka E, Yoshino I, Date H; Japanese Joint Committee of Lung Cancer Registry. Preoperative renal dysfunction and long-term survival after surgery for non-small cell lung cancer. J Thorac Cardiovasc Surg. 2022 Jul;164(1):227-239.e6. PMID:34600766. DOI: 10.1016/j.jtcvs.2021.09.008. Epub 2021 Sep 10..
- Soh J, Toyooka S, Shintani Y, Okami J, Ito H, Ohtsuka T, Mori T, Watanabe SI, Asamura H, Chida M, Endo S, Nakanishi R, Kadokura M, Suzuki H, Miyaoka E, Yoshino I, Date H; Japanese Joint Committee of Lung Cancer Registry. Limited resection for stage IA radiologically invasive lung cancer: a real-world nationwide database study. Eur J Cardiothorac Surg. 2022 Jun 15;62(1):ezac342. PMID: 35678584. DOI: 10.1093/ejcts/ezac342.
- Ruffini E, Rami-Porta R, Huang J, Ahmad U, Appel S, Bille A, Boubia S, Brambilla C, Cangir AK, Cilento V, Detterbeck F, Falkson C, Fang W, Filosso PL, Giaccone G, Girard N, Guerrera F, Infante M, Kim DK, Lucchi M, Marino M, Marom EM, Nicholson AG, Okumura M, Rimner A, Simone CB 2nd, Asamura H; IASLC Staging and Prognostic Factors Committee and of the Advisory Boards. The International Association for the Study of Lung Cancer Thymic Epithelial Tumor Staging Project: Unresolved Issues to be Addressed for the Next Ninth Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol. 2022 Jun;17(6):838-851. PMID: 35321838. DOI: 10.1016/j.jtho.2022.03.005. Epub 2022 Mar 20.
- Fujikawa R, Muraoka Y, Kashima J, Yoshida Y, Ito K, Watanabe H, Kusumoto M, Watanabe SI, Yatabe Y. Clinicopathologic and Genotypic Features of Lung Adenocarcinoma Characterized by the IASLC Grading System. J Thorac Oncol. 2022 May;17(5):700-707. PMID: 35227909. DOI: 10.1016/j.jtho.2022.02.005. Epub 2022 Feb 25.
- Muraoka Y, Yoshida Y, Nakagawa K, Ito K, Watanabe H, Narita T, Watanabe SI; Tsukiji Lung Cancer Working Group, Yotsukura M, Motoi N, Yatabe Y. Maximum standardized uptake value of the primary tumor does not improve candidate selection for sublobar resection. J Thorac Cardiovasc Surg. 2022 May;163(5)1656-1665.e3. PMID: 34275620. DOI: 10.1016/j.jtcvs.2021.06.053. Online ahead of print.
- Takemura C, Kashima J, Hashimoto T, Ichikawa H, Honma Y, Goto Y, Watanabe SI, Yatabe Y. A mimic of lung adenocarcinoma: a case report of histological conversion of metastatic thyroid papillary carcinoma. Histopathology. 2022 May;80(6):1004-1007. PMID: 34843113. DOI: 10.1111/his.14607. Epub 2022 Jan 28.
- Saji H, Okada M, Tsuboi M, Nakajima R, Suzuki K, Aokage K, Aoki T, Okami J, Yoshino I, Ito H, Okumura N, Yamaguchi M, Ikeda N, Wakabayashi M, Nakamura K, Fukuda H, Nakamura S, Mitsudomi T, Watanabe SI, Asamura H; West Japan Oncology Group, Japan Clinical Oncology Group. Segmentectomy Versus Lobectomy in Small-Sized Peripheral Non-Small Cell Lung Cancer (JCOG0802/WJOG4607L): A Multicentre, Randomised, Controlled, Phase 3 Trial. Lancet. 2022 Apr 23;399(10335):1607-1617. PMID: 35461558. DOI: 10.1016/S0140-6736(21)02333-3.
- Kawakubo N, Okubo Y, Yotsukura M, Yoshida Y, Nakagawa K, Yonemori K, Watanabe H, Yatabe Y, Watanabe SI. Assessment of Resectability of Mediastinal Germ Cell Tumor Using Preoperative Computed Tomography. J Surg Res. 2022 Apr;272:61-68. PMID: 34936913. DOI: 10.1016/j.jss.2021.11.002. Epub 2021 Dec 20.
- Aokage K, Tsuboi M, Zenke Y, Horinouchi H, Nakamura N, Ishikura S, Nishikawa H, Kumagai S, Koyama S, Kanato K, Kataoka T, Wakabayashi M, Fukutani M, Fukuda H, Ohe Y, Watanabe SI; Lung Cancer Surgical Study Group of the Japan Clinical Oncology Group. Study protocol for JCOG1807C (DEEP OCEAN): a interventional prospective trial to evaluate the efficacy and safety of durvalumab before and after operation or durvalumab as maintenance therapy after chemoradiotherapy against superior sulcus non-small cell lung cancer. Jpn J Clin Oncol. 2022 Apr 6;52(4):383-387. PMID: 34999817. PMCID: PMC8985519. DOI: 10.1093/jjco/hyab208.