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国立がん研究センター 中央病院

Home > Clincal depts. > Department of Thoracic Surgery

Department of Thoracic Surgery

Shun-ichi Watanabe, Hiroyuki Sakurai, Kazuo Nakagawa, Keisuke Asakura, Kyohei Masai, Shigeki Suzuki

Introduction

The Department of Thoracic Surgery deals with various kinds of neoplasms and allied diseases in the thorax, with the exception of the esophagus. These include both primary and metastatic lung tumors, mediastinal tumors, pleural tumors (mesotheliomas), and chest wall tumors. The surgical management of lung cancer patients has been the main clinical activity of the division, as well as the subject of most of its research activities. In addition to continuing to improve procedures, such as the combined resection of neighboring vital structures and minimally invasive techniques (video-assisted thoracic surgery, VATS), it has become increasingly important to define the role of surgery in multimodality treatment for patients with a poor prognosis.

Routine activities

The Department has four attending surgeons. Attending surgeons and residents perform all of the inpatient care, operations, examinations, and outpatient care. In 2015, we performed a total of 664 operations; for lung cancer in 492 patients, metastatic tumor in 82, mediastinal tumor in 24, and others in 66.

The treatment strategy for patients with lung cancer is based on tumor histology (non-small cell vs. small cell), extent of disease (clinical stage), and 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 histology and clinical stages I with small cell histology. However, to improve the poor prognosis of patients with clinically and histologically proven mediastinal lymph node metastasis or with invasion to the neighboring vital structures, optimal treatment modalities are sought in a clinical trial setting. Recently, adjuvant chemotherapy is often given to the patient with advanced lung cancer even after complete pulmonary resection.

For metastatic lung tumors, resection has been attempted on the basis of Thomford's criteria: eligible patients are those who are at good risk, with no extrathoracic disease, with the primary site in control, and with completely resectable lung disease. Metastasis from colorectal carcinomas is the most common disease.

For mediastinal tumors, thymic epithelial tumors are most commonly encountered for resection. In the mediastinum, where a variety of tumor histologies can arise, the treatment must be carefully determined by the cytologic/histologic diagnosis before surgery. For this purpose, CT-guided needle biopsy is replacing the formerly common biopsy under X-ray fluoroscopy. For patients with thymoma, we have already adopted video-assisted resection (VATS) of the tumor. VATS resection of mediastinal tumor is indicated exclusively for small thymomas.

As for meetings, there are two division meetings. One is for the preoperative evaluation and postoperative inpatient review on Friday and the other is for the journal club on Tuesday. In addition, on Thursday the chest group has a plenary meeting to share basic information about the current issues for diagnosis and treatment of patients with lung malignancy.

Research activities

Lymph node dissection for lung cancer has been a major issue in lung cancer treatment, and has been extensively studied in our division. We continue to improve the surgical technique of dissection based on oncological and surgical considerations: 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 surgery with the thoracoscope for thoracic malignancies is also an important challenge in our division. In particular, the indications and surgical techniques of video-assisted surgery for early lung cancer are of special interest because of the increased incidence of such minute tumors due to improvements in CT devices and CT screening.

Clinical trials

Due to the advent of new technologies in CT scanning, small-sized lung cancers are being found in a screening setting and also by chance. They are usually present as “ground-glass opacity (GGO)” on CT, and pathologically they are considered early adenocarcinoma. The surgical management of such GGO-type lung cancer remains undetermined in terms of the extent of pulmonary parenchymal resection and lymph node dissection. Some cases might be followed up with careful monitoring by CT, since indolent tumors are known to exist. We are seeking the appropriate way to manage these patients. A clinical trial to determine the appropriateness of limited resection for early adenocarcinoma had been planned in the Japan Clinical Oncology Group (JCOG) – Lung Cancer Study Group, and two clinical trials (a phase III trial, JCOG 0802; a phase II trial, JCOG 0804) have been conducted since the end of 2009. In addition, another phase II trial (JCOG1211), a confirmatory trial of segmentectomy for clinical T1N0 lung cancer dominant with GGO, was started in 2013. The accrual for JCOG 0804 trial has already closed. The accrual for JCOG0802 was closed in 2014. The accrual for JCOG 1211 was closed in November 2015.

As for postoperative adjuvant therapy, a phase III clinical trial to compare the effectiveness of UFT with that of TS-1 for stage IA of more than 2 cm and IB NSCLC planned in JCOG (JCOG 0707) has been conducted since 2008. This trial completed the full accrual of 960 patients in 2013. A phase III clinical trial (JCOG 1205) to compare Irinotecan/ Cisplatin with Etoposide/Cisplatin for adjuvant chemotherapy of resected pulmonary high-grade neuroendocrine carcinoma was started in 2013.


Table 1. Number of patients in 2015 Table 2. Type of procedure in 2015 Table 3. Survival rates for primary lung cancer patients after surgery

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. Sakurai H. Reply. Ann Thorac Surg, 100:2413, 2015
  3. Yoshida A, Kamata T, Iwasa T, Watanabe S, Tsuta K. Myocardial Sleeve Tissues in Surgical Lung Specimens. Am J Surg Pathol, 39:1427-1432, 2015
  4. Sato T, Soejima K, Arai E, Hamamoto J, Yasuda H, Arai D, Ishioka K, Ohgino K, Naoki K, Kohno T, Tsuta K, Watanabe S, Kanai Y, Betsuyaku T. Prognostic implication of PTPRH hypomethylation in non-small cell lung cancer. Oncol Rep, 34:1137-1145, 2015
  5. Katsuya Y, Yoshida A, Watanabe S, Tsuta K. Tumour-to-tumour metastasis from papillary thyroid carcinoma with BRAF mutation to lung adenocarcinoma with EGFR mutation: the utility of mutation-specific antibodies. Histopathology, 67:262-266, 2015
  6. Kamata T, Yoshida A, Kosuge T, Watanabe S, Asamura H, Tsuta K. Ciliated muconodular papillary tumors of the lung: a clinicopathologic analysis of 10 cases. Am J Surg Pathol, 39:753- 760, 2015
  7. Sakurai H, Nakagawa K, Watanabe S, Asamura H. Clinicopathologic features of resected subcentimeter lung cancer. Ann Thorac Surg, 99:1731-1738, 2015
  8. Katsuya Y, Fujita Y, Horinouchi H, Ohe Y, Watanabe S, Tsuta K. Immunohistochemical status of PD-L1 in thymoma and thymic carcinoma. Lung Cancer, 88:154-159, 2015
  9. 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
  10. Kitazono S, Fujiwara Y, Tsuta K, Utsumi H, Kanda S, Horinouchi H, Nokihara H, Yamamoto N, Sasada S, Watanabe S, Asamura H, Tamura T, Ohe Y. Reliability of Small Biopsy Samples Compared With Resected Specimens for the Determination of Programmed Death-Ligand 1 Expression in Non--Small-Cell Lung Cancer. Clin Lung Cancer, 16:385-390, 2015
  11. Kakinuma R, Moriyama N, Muramatsu Y, Gomi S, Suzuki M, Nagasawa H, Kusumoto M, Aso T, Muramatsu Y, Tsuchida T, Tsuta K, Maeshima AM, Tochigi N, Watanabe S, Sugihara N, Tsukagoshi S, Saito Y, Kazama M, Ashizawa K, Awai K, Honda O, Ishikawa H, Koizumi N, Komoto D, Moriya H, Oda S, Oshiro Y, Yanagawa M, Tomiyama N, Asamura H. Ultra-high-resolution computed tomography of the lung: image quality of a prototype scanner. PLoS One, 10:e0137165, 2015
  12. Kakinuma R, Moriyama N, Muramatsu Y, Gomi S, Suzuki M, Nagasawa H, Kusumoto M, Aso T, Muramatsu Y, Tsuchida T, Tsuta K, Maeshima AM, Tochigi N, Watanabe SI, Sugihara N, Tsukagoshi S, Saito Y, Kazama M, Ashizawa K, Awai K, Honda O, Ishikawa H, Koizumi N, Komoto D, Moriya H, Oda S, Oshiro Y, Yanagawa M, Tomiyama N, Asamura H. Correction: Ultra-high-resolution computed tomography of the lung: image quality of a prototype scanner. PLoS One, 10:e0145357, 2015
  13. Saito M, Shimada Y, Shiraishi K, Sakamoto H, Tsuta K, Totsuka H, Chiku S, Ichikawa H, Kato M, Watanabe S, Yoshida T, Yokota J, Kohno T. Development of lung adenocarcinomas with exclusive dependence on oncogene fusions. Cancer Res, 75:2264-2271, 2015
  14. Ito J, Yoshida A, Maeshima AM, Nakagawa K, Watanabe S, Kobayashi Y, Fukuhara S, Tsuta K. Concurrent thymoma, thymic carcinoma, and T lymphoblastic leukemia/lymphoma in an anterior mediastinal mass. Pathol Res Pract, 211:693-696, 2015