Department of Thoracic Surgery

 

Shun-ichi Watanabe, Kazuo Nakagawa, Yukihiro Yoshida, Masaya Yotsukura, Yu Okubo, Masahiro Higashiyama, Yuji Muraoka 

 

Training Program for Doctors

The National Cancer Center Hospital (NCCH) is a leading hospital for cancer treatment in Japan. We conducted 684 operations and 227 segmentectomies for primary lung cancer in 2020. The number of segmentectomies at NCCH has been increasing due to the frequent detection of small lung adenocarcinoma in the periphery with ground-glass opacity on high-resolution computed tomography. Visitors are also able to learn sophisticated techniques of lymph node dissection for primary lung cancer. We have also been accepting thoracic surgeons who want to view our surgery and study surgical techniques with us. One-day visits are also welcome.

If you want to visit our hospital, or if you have any questions, please contact the Office of International Affairs: https://www.ncc.go.jp/en/about/training_prog/index.html

Voices from Visitors

 From Dr HOU, Guangjie

Dear my NCC friends

On the first day of 2020, I wanna say happy new year to all my NCC friends. During my three months’ visit to NCC, I received warm-hearted greeting and help, I am really grateful for that.

Thanks to my tutors Dr. Daiko and Dr. Watanabe, who gave me key instructions and showed wonderful skills in esophagus and thoracic surgery. Also, thanks to Dr. Kanamori, Dr. Okubo, they are young but really good-skilled surgeons. Special thanks to Dr. Yoshida, who were my best friend in Japan and helped me a lot in my learning and gave me much deeper understanding in Japanese medical system and  treatment guideline of lung cancer .I will always cherish my experiences at NCC, Japan. I will always cherish friendships with all my Japanese tutors and friends. And Best wishes to them.

Hope I will revisit Japan in near future.

Sincerely

Dr. Guangjie Hou

Dr HOU, Guangjie

Henan Provincial People's Hospital, China

(Department of Esophageal Surgery: March 11 to April 5, 2019)

(Department of Thoracic Surgery: April 8 to June 6, 2019)

 From Dr. Percy Enrique Serrano Carvajal

I want to thank very much the hospitality of the entire thoracic surgery service of the NCC, I have felt very well and very welcome all the time that I have been an observer, I am infinitely grateful to all the doctors especially with Dr. Yoshida, the human quality Your staff is unique, their professionalism is an example, I can't find words to express my gratitude.

As a fifth-year resident of the thoracic surgery specialty, I saw it as an incomparable opportunity to ask them to accept me as an observer, my goal was fundamentally to learn the best way to perform sublobar pulmonary resections (anatomical segmentectomies). Start by reviewing the Illustrated Anatomical Segmentectomy

For Lung Cancer, a book from your country, inform me through a specialty partner, is Lorena from the Gregorio Marañon hospital in Madrid who went to your hospital in 2018.

In this year 2020 I finish the specialization in Spain and I will probably return to my country Bolivia to practice the profession, with this I want to tell you that the knowledge that I have acquired when attending the NCC is of great value to me, to exercise the profession taken as a great example of work to such magnificent professionals as Dr. Watanabe, Dr. Yoshida and the entire thoracic surgery team. Many of the knowledge that I have learned with you I am currently applying in my daily practice. In addition, I have been able to transmit everything I have learned to my colleagues from my current service at the Ramón y Cajal hospital. The gratitude I have for all of you is infinite, to know Japan, a wonderful country, with a unique human quality, has been an experience that I will never forget, I hope to return one day, I hope with all my heart to see the team members again. Please send an affectionate solution to everyone. What I have learned from you is invaluable to me.

Thank you ¡¡¡

Dr. Percy Enrique Serrano Carvajal

University Hospital Ramón y Cajal Thoracic Surgery Service, Madrid, Spain

(October 1 to 31, 2019)

From  Dr. Lorena Martin-Albo Caballero

NCC is a world reference center in the surgical treatment of lung cancer.

I have always been interested in surgical advances in the treatment of lung cancer, in fact I knew about the clinical trías JCOG 0802 and I wanted to see the performance of segmentectomy in live and nobody better than Dr. Watanabe's team.

It has been a wonderful experience, I have learned a lot and I hope to visit you again in the near future.

 

Introduction

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. As well as continuing to improve procedures, such as the combined resection of neighboring vital structures using minimally invasive techniques (video-assisted thoracic surgery, VATS), it has become increasingly important to define the role of surgery in multimodal treatment for patients with poor prognoses.  

Our team and what we do

Our department has four attending surgeons and attending and resident surgeons perform all of the inpatient care, surgeries, examinations and outpatient care. In 2020, we performed a total of 889 operations; for lung cancer in 684 patients, metastatic tumors in 85, mediastinal tumors in 60, malignant pleural mesothelioma in 12 and others in 48 (Tables 1 and 2).

Table 1. Number of patients in 2020

Primary lung cancer	684
Metastatic lung tumor	85
Mediastinal tumor	60
Malignant pleural mesothelioma	12
Other	48
Total	889

Table 2. Type of procedures in 2020

Pulmonary resection	794
Lobectomy	338
Pneumonectomy	1
Segmentectomy	248
Wedge resection	207
Tracheal resection	0
Surgery for mediastinal tumors	61
Surgery for pleural tumors	11
Surgery for chest wall tumors	12
Others	11
Total	889

 

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 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 of vital neighboring structures, optimal treatment modalities are sought in a clinical trial setting. Recently, adjuvant chemotherapy has often been given to patients 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 under 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 meanwhile, where various tumor histologies can arise, treatment must be carefully determined by cytologic/ histologic diagnosis before surgery. For patients with thymoma, we have already adopted video-assisted resection (VATS) for the tumor. 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 Tuesdays. In addition, on Thursdays, the chest group holds a plenary meeting to share basic information about current issues for diagnosing and treating 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 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 video-assisted surgery 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 2020, we performed the largest number of segmentectomies as well as lung cancer surgeries in Japan.

Clinical trials

Our department has played an important role as a leading hospital in the Japan Clinical Oncology Group (JCOG) – Lung Cancer Surgical Study Group (LCSSG). As mentioned below, the LCSSG conducted more clinical trials for lung cancer surgery in 2020 than ever. The advent of new technologies in CT scanning means more small-sized lung cancers are being found in screening settings and by chance. They usually present as “ground-glass opacity (GGO)” on CT and are considered as early adenocarcinoma in pathological terms. The surgical management of such GGO-type lung cancers 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, given indolent tumors are known to exist and we are seeking how best to manage such patients. Three clinical trials to determine the appropriateness of limited resection for early lung cancer (JCOG 0802, JCOG 0804, and JCOG1211) have been conducted since the end of 2009 in the JCOGLCSSG. The accrual of these three trials is complete and has achieved the planned number of patients. We now await maturation of the follow-up data regarding recurrence and prognosis. More recently, a prospective evaluation of watchful waiting for early-stage lung cancer with ground-glass opacity: a single arm confirmatory multicenter study (JCOG1906), 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 non-small cell lung cancer (NSCLC), opened to accrual in January 2017. To investigate 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. Regarding adjuvant therapy, postoperative radiotherapy (PORT) for pathological N2 NSCLC with adjuvant chemotherapy: a randomized phase III trial (JCOG1916), opened to accrual in January 2021. A prospective observational study of daily living activities in elderly patients having undergone lung cancer surgery (JCOG1710A) completed the full accrual of 986 patients. We await maturation of follow-up data. The results of two clinical trials for postoperative adjuvant therapy were published in 2020: a phase III clinical trial to compare the effectiveness of UFT with that of TS-1 for stage IA exceeding 2 cm and IB NSCLC (JCOG 0707) and a phase III clinical trial to compare irinotecan/ cisplatin with etoposide/cisplatin for adjuvant chemotherapy of resected pulmonary high-grade neuroendocrine carcinoma (JCOG1205); they have both had a considerable impact on routine clinical practice. The LCSSG in the JCOG continues to try to establish ideal surgical treatment strategies for lung cancer.

List of papers published in 2020

Journal

1. Yotsukura M, Okubo Y, Yoshida Y, Nakagawa K, Watanabe SI. Indocyanine green imaging for pulmonary segmentectomy. JTCVS Techniques, 2021
2. Yotsukura M, Okubo Y, Yoshida Y, Nakagawa K, Watanabe SI. Fissureless trans-pericardial left upper lobectomy of the lung: a technique to avoid pneumonectomy. Gen Thorac Cardiovasc Surg, 69:778-780, 2021
3. Hattori A, Suzuki K, Takamochi K, Wakabayashi M, Aokage K, Saji H, Watanabe SI. Prognostic impact of a ground-glass opacity component in clinical stage IA non-small cell lung cancer. J Thorac Cardiovasc Surg, 161:1469-1480, 2021
4. Shirasawa M, Yoshida T, Horinouchi H, Kitano S, Arakawa S, Matsumoto Y, Shinno Y, Okuma Y, Goto Y, Kanda S, Watanabe R, Yamamoto N, Watanabe SI, Ohe Y, Motoi N. Prognostic impact of peripheral blood neutrophil to lymphocyte ratio in advanced-stage pulmonary large cell neuroendocrine carcinoma and its association with the immune-related tumour microenvironment. Br J Cancer, 124:925-932, 2021
5. Kenmotsu H, Niho S, Tsuboi M, Wakabayashi M, Eba J, Asamura H, Ohe Y, Watanabe SI. Reply to J. L. Derks et al. J Clin Oncol, 39:1509-1510, 2021
6. Yamaguchi M, Nakagawa K, Suzuki K, Takamochi K, Ito H, Okami J, Aokage K, Shiono S, Yoshioka H, Aoki T, Tsutani Y, Okada M, Watanabe SI. Surgical challenges in multimodal treatment of N2-stage IIIA non-small cell lung cancer. Jpn J Clin Oncol, 51:333-344, 2021
7. Shimoyama R, Nakagawa K, Ishikura S, Wakabayashi M, Sasaki T, Yoshioka H, Hashimoto T, Kataoka T, Fukuda H, Watanabe SI. A multi-institutional randomized phase III trial comparing postoperative radiotherapy to observation after adjuvant chemotherapy in patients with pathological N2 Stage III nonsmall cell lung cancer: Japan Clinical Oncology Group Study JCOG1916 (J-PORT study). Jpn J Clin Oncol, 51:999-1003, 2021
8. Shirasawa M, Yoshida T, Takayanagi D, Shiraishi K, Yagishita S, Sekine K, Kanda S, Matsumoto Y, Masuda K, Shinno Y, Okuma Y, Goto Y, Horinouchi H, Hamada A, Kohno T, Yamamoto N, Watanabe SI, Ohe Y, Motoi N. Activity and Immune Correlates of Programmed Death-1 Blockade Therapy in Patients With Advanced Large Cell Neuroendocrine Carcinoma. Clin Lung Cancer, 2021
9. Hamada K, Tian Y, Fujimoto M, Takahashi Y, Kohno T, Tsuta K, Watanabe SI, Yoshida T, Asamura H, Kanai Y, Arai E. DNA hypermethylation of the ZNF132 gene participates in the clinicopathological aggressiveness of 'pan-negative'-type lung adenocarcinomas. Carcinogenesis, 42:169-179, 2021
10. Aokage K, Suzuki K, Wakabayashi M, Mizutani T, Hattori A, Fukuda H, Watanabe SI. Predicting pathological lymph node status in clinical stage IA peripheral lung adenocarcinoma. Eur J Cardiothorac Surg, 2021
11. Shibayama T, Makise N, Motoi T, Mori T, Hiraoka N, Yonemori K, Watanabe SI, Esaki M, Morizane C, Okuma T, Kawai A, Ushiku T, Yatabe Y, Yoshida A. Clinicopathologic Characterization of Epithelioid Hemangioendothelioma in a Series of 62 Cases: A Proposal of Risk Stratification and Identification of a Synaptophysin-positive Aggressive Subset. Am J Surg Pathol, 45:616-626, 2021
12. Nishida T, Matsumoto Y, Sasada S, Tanaka M, Nakai T, Fukai R, Ohe Y, Watanabe SI, Motoi N. Feasibility study of cryobiopsy for practical pathological diagnosis of primary lung cancer including immunohistochemical assessment. Jpn J Clin Oncol, 51:271-278, 2021
13. Uchida S, Yoshida Y, Yotsukura M, Nakagawa K, Watanabe SI. Correction to: Factors Associated with Unexpected Readmission Following Lung Resection. World J Surg, 45:1583- 1584, 2021
14. Nakagawa K, Yoshida Y, Yotsukura M, Watanabe SI. Pattern of recurrence of pN2 non-small-cell lung cancer: should postoperative radiotherapy be reconsidered? Eur J Cardiothorac Surg, 59:109-115, 2021
15. Yotsukura M, Nakagawa K, Suzuki K, Takamochi K, Ito H, Okami J, Aokage K, Shiono S, Yoshioka H, Aoki T, Tsutani Y, Okada M, Watanabe SI. Recent advances and future perspectives in adjuvant and neoadjuvant immunotherapies for lung cancer. Jpn J Clin Oncol, 51:28-36, 2021
16. Suda K, Mitsudomi T, Shintani Y, Okami J, Ito H, Ohtsuka T, Toyooka S, Mori T, Watanabe SI, Asamura H, Chida M, Date H, Endo S, Nagayasu T, Nakanishi R, Miyaoka E, Okumura M, Yoshino I. Clinical Impacts of EGFR Mutation Status: Analysis of 5780 Surgically Resected Lung Cancer Cases. Ann Thorac Surg, 111:269-276, 2021
17. Nakagawa K. Reply to Ding et al. Eur J Cardiothorac Surg, 59:925-926, 2021
18. Shintani Y, Okami J, Ito H, Ohtsuka T, Toyooka S, Mori T, Watanabe SI, Asamura H, Chida M, Date H, Endo S, Nagayasu T, Nakanishi R, Miyaoka E, Okumura M, Yoshino I. Clinical features and outcomes of patients with stage I multiple primary lung cancers. Cancer Sci, 112:1924-1935, 2021
19. Shirasawa M, Yoshida T, Matsumoto Y, Shinno Y, Okuma Y, Goto Y, Horinouchi H, Yamamoto N, Watanabe SI, Ohe Y, Motoi N. Impact of chemoradiotherapy on the immune-related tumour microenvironment and efficacy of anti-PD-(L)1 therapy for recurrences after chemoradiotherapy in patients with unresectable locally advanced non-small cell lung cancer. Eur J Cancer, 140:28-36, 2020
20. Kenmotsu H, Niho S, Tsuboi M, Wakabayashi M, Ishii G, Nakagawa K, Daga H, Tanaka H, Saito H, Aokage K, Takahashi T, Menju T, Kasai T, Yoshino I, Minato K, Okada M, Eba J, Asamura H, Ohe Y, Watanabe SI. Randomized Phase III Study of Irinotecan Plus Cisplatin Versus Etoposide Plus Cisplatin for Completely Resected High-Grade Neuroendocrine Carcinoma of the Lung: JCOG1205/1206. J Clin Oncol, 38:4292-4301, 2020
21. Fukumoto K, Mori S, Shintani Y, Okami J, Ito H, Ohtsuka T, Toyooka S, Mori T, Watanabe SI, Asamura H, Chida M, Date H, Endo S, Nagayasu T, Nakanishi R, Miyaoka E, Okumura M, Yoshino I. Impact of the preoperative body mass index on the postoperative outcomes in patients with completely resected non-small cell lung cancer: A retrospective analysis of 16,503 cases in a Japanese Lung Cancer Registry Study. Lung Cancer, 149:120-129, 2020
22. Tanaka K, Tsutani Y, Wakabayashi M, Mizutani T, Aokage K, Miyata Y, Kuroda H, Saji H, Watanabe SI, Okada M. Sublobar resection versus lobectomy for patients with resectable stage I non-small cell lung cancer with idiopathic pulmonary fibrosis: a phase III study evaluating survival (JCOG1708, SURPRISE). Jpn J Clin Oncol, 50:1076-1079, 2020
23. Watanabe S, Shimomura A, Kubo T, Sekimizu M, Seo T, Watanabe SI, Kawai A, Yamamoto N, Tamura K, Kohno T, Ichikawa H, Yoshida A. BRAF V600E mutation is a potential therapeutic target for a small subset of synovial sarcoma. Mod Pathol, 33:1660-1668, 2020
24. Shimoyama R, Tsutani Y, Wakabayashi M, Katayama H, Fukuda H, Suzuki K, Watanabe SI. A multi-institutional randomized phase III trial comparing anatomical segmentectomy and wedge resection for clinical stage IA non-small cell lung cancer in high risk operable patients: Japan Clinical Oncology Group Study JCOG1909 (ANSWER study). Jpn J Clin Oncol, 50:1209-1213, 2020
25. Watanabe SI. How we should tailor the nodal staging for various types of lung cancer? J Thorac Dis, 12:3890-3892, 2020
26. Yoshida Y, Yotsukura M, Nakagawa K, Watanabe H, Motoi N, Watanabe SI. Surgical Results in Pathological N1 Nonsmall Cell Lung Cancer. Thorac Cardiovasc Surg, 2020
27. Miyanaga A, Masuda M, Motoi N, Tsuta K, Nakamura Y, Nishijima N, Watanabe SI, Asamura H, Tsuchida A, Seike M, Gemma A, Yamada T. Whole-exome and RNA sequencing of pulmonary carcinoid reveals chromosomal rearrangements associated with recurrence. Lung Cancer, 145:85-94, 2020
28. Yotsukura M, Asamura H, Suzuki S, Asakura K, Yoshida Y, Nakagawa K, Sakurai H, Watanabe SI, Motoi N. Prognostic impact of cancer-associated active fibroblasts and invasive architectural patterns on early-stage lung adenocarcinoma. Lung Cancer, 145:158-166, 2020
29. Kobayashi AK, Horinouchi H, Nakayama Y, Ohe Y, Yotsukura M, Uchida S, Asakura K, Yoshida Y, Nakagawa K, Watanabe SI. Salvage surgery after chemotherapy and/or radiotherapy including SBRT and proton therapy: A consecutive analysis of 38 patients. Lung Cancer, 145:105-110, 2020
30. Makise N, Mori T, Kobayashi H, Nakagawa K, Ryo E, Nakajima J, Kohsaka S, Mano H, Aburatani H, Yoshida A, Ushiku T. Mesenchymal tumours with RREB1-MRTFB fusion involving the mediastinum: extra-glossal ectomesenchymal chondromyxoid tumours? Histopathology, 76:1023-1031, 2020
31. Onishi Y, Ito K, Motoi N, Morita T, Watanabe SI, Kusumoto M. Ciliated muconodular papillary tumor of the lung: 18F-FDG PET/CT findings of 15 cases. Ann Nucl Med, 34:448-452, 2020
32. Yotsukura M, Asamura H, Suzuki S, Asakura K, Yoshida Y, Nakagawa K, Sakurai H, Watanabe SI, Motoi N. Histological and prognostic data on surgically resected early-stage lung adenocarcinoma. Data Brief, 31:105785, 2020
33. Onishi Y, Kusumoto M, Motoi N, Watanabe H, Watanabe SI. Ciliated Muconodular Papillary Tumor of the Lung: Thin-Section CT Findings of 16 Cases. AJR Am J Roentgenol, 214:761-765, 2020