Since Cahan proposed "radical lobectomy" in 1960, lobectomy or larger lung resection with regional hilar and mediastinal lymph node dissection has been globally recognized as a standard mode of surgery for non-small cell lung cancer (NSCLC). Systematic nodal dissection (SND), which involves the removal of mediastinal nodes from the superior to the inferior mediastinum compartmented by anatomical landmarks, has remained a standard mode mediastinal nodal dissection, irrespective of the tumor location. However, since the late 1990s, with the elucidation of the nodal spread pattern, we have included lobe-specific nodal dissection (LND) in our clinical practice. The indications for LND vary depending on institutions; however, the LND is currently a major mode of dissection, especially in Japan. An prospective trial is currently underway to evaluate the validity and clinical benefit of LND in comparison to SND. Recently, limited lung resection without lymph node dissection is indicated, especially for early lung adenocarcinoma with ground glass attenuation-dominant nodules. The improvement of imaging modalities and new technologies, including radiomics and deep learning will enable us to precisely predict the nodal status before surgery. In the near future, lymph node dissection will be more sophisticated and personalized than ever before. This review article outlines the clinical benefit, history, and future perspectives of lymph node dissection for operable NSCLC.
Objective. To clarify the influence of the COVID-19 pandemic on lung cancer management, and to overcome the pandemic and preserve the optimal management of lung cancer in Japan. Methods. Previously published studies concerning the influence of the COVID-19 pandemic on lung cancer management were reviewed, and clinical guidelines published from Japan and other countries-including one by the Japan Lung Cancer Society (JLCS)-were examined for their relevance and uniqueness. Results. COVID-19 infection in lung cancer seems patients tended to be more serious and mortal in comparison to the general population, whereas no information regarding the susceptibility of lung cancer patients to infection was found. It should be noticed, however, that all of the studies published to date have been non-Japanese retrospective observational studies, and have contained important confounding factors. It is not clear whether the observations from those studies are valid in Japan. Due to contradictory data, it is unclear whether specific treatments for lung cancer have an impact on the prognosis of patients with lung cancer and COVID-19. Conclusion. Containing the COVID-19 pandemic is crucial for preserving the standard of care for lung cancer patients. As patients and caregivers may be forced to alter the standard of care in the midst of COVID-19 pandemic, guidelines including the expert opinion of the JLCS, should be consulted to propose optimal compromises in lung cancer management.
Objective. Immune checkpoint inhibitors (ICIs) may cause immune system overactivation and subsequent immune-related adverse events (irAEs). The standard irAE manual aids in the diagnosis by starting from the disease name, followed by an examination and, finally, treatment. We developed a reverse manual for irAEs to facilitate suspicion of a disease based on the symptoms. Methods. We selected eight important irAE symptoms (fever, nausea, disturbed consciousness, fatigue, dyspnea, abdominal pain, headache, and limb weakness). When a patient presents with one of these suspected symptoms, additional questions can be asked, leading to a suspected disease name. Thereafter, we can use the standard irAE manual. We prepared eight virtual symptoms and the corresponding correct disease names and validated the effectiveness of our reverse manual for irAEs among four medical interns who were asked to answer the disease name with and without using the reverse manual for irAEs. Results. Without the reverse manual, the correct answer rate was low (0-25%), and the time to answer was long (6-12 min). In contrast, the use of the reverse manual resulted in a high correct answer rate (75-100%) and short time to answer (2-3 min). Conclusions. Our reverse manual for irAEs may be a useful tool for identifying a suspected disease name in a short time.
Background. Immune checkpoint inhibitors are considered the standard treatment for non-small cell lung cancer; however, they can cause immune-related adverse events (irAEs). However, neurological irAEs (nAEs) are rare. Case. A 64-year-old man was diagnosed with lung adenocarcinoma (cT3N3M0, stage IIIC) and received first-line chemotherapy with carboplatin, pemetrexed, and pembrolizumab. He showed a partial response, and the regimen was switched to pemetrexed and pembrolizumab maintenance therapy. After six cycles of maintenance therapy, chest radiography revealed consolidation in the left upper lung field, suggesting an immune-related pulmonary disorder (checkpoint inhibitor pneumonitis [CIP]). Maintenance therapy was discontinued; however, the CIP worsened, and steroid therapy was initiated, after which the consolidation subsided. Neurological symptoms, such as dysesthesia and limb weakness occurred during steroid tapering, suggesting an nAE. The patient was diagnosed with Guillain-Barré syndrome. Although the patient's dysesthesia improved with steroid pulse therapy, his limb weakness persisted. This improved following the initiation of high-dose immunoglobulin therapy. Conclusion. Although nAEs are observed relatively early after the administration of immune checkpoint inhibitors, patients require close monitoring during follow-up, as nAEs can be detected at any time after their administration.
Background. There are few reports of primary pulmonary angiosarcoma. We herein report a case of primary pulmonary angiosarcoma developing in the left upper lobe, which was involved in the radiation range of adjuvant therapy for breast cancer after surgery. Case. The patient was a 47-year-old woman, who had previously undergone partial resection for multiple breast cancer. She had received adjuvant chemoradiotherapy and continued to receive hormone therapy. An abnormality was detected on a chest radiograph obtained in a periodic health examination 8 years after surgery. Recurrence of breast cancer, primary lung cancer, and inflammatory change were considered in the differential diagnosis. A bronchoscopic examination and pleural fluid cytology did not provide us with malignant findings; thus, we decided to perform exploratory surgery. The intraoperative findings indicated a nodular lesion in the lingular segment, bloody effusion, and multiple lesions in the parietal pleura. We performed partial resection of the lung lesion and pleural biopsy, which were diagnosed as primary pulmonary angiosarcoma and pleural dissemination. Contrast CT performed 1 month after the operation revealed the progression of pleural dissemination and multiple lymph node and liver metastases. Chemotherapy was administered; however, the patient eventually died 6 months after the operation. Conclusion. We described a rare case of primary pulmonary angiosarcoma. In this case, we concluded that this angiosarcoma could be a radiation-induced sarcoma because it developed in the radiation range of radiotherapy administered after breast cancer surgery.
Background. There have been reports of small-cell lung cancer found in cases of hilar and mediastinal lymphadenopathy with no primary lesion. We experienced a case of T0N1M0 small-cell lung cancer. Case. A 61-year-old man had a history of endoscopic submucosal dissection (ESD) for middle esophageal cancer 8 years ago and for gastric cancer 5 years ago. The gastric cancer had been completely resected endoscopically according to the pathology. However, with regard to the esophageal cancer, he was requested to be followed up, although additional excision was advised due to the depth to the wall. The left main bronchial lymph node was found to be swollen at follow-up. This node was located near the esophageal cancer that had been treated with ESD, which initially suggested esophageal cancer metastasis. As no other lesions were found, including in the esophagus after ESD, the node was resected for a diagnosis. The left main bronchial lymph node was removed thoracoscopically. The pathological findings resulted in a diagnosis of lymph node metastasis of small-cell lung cancer. There was no apparent primary lesion on image findings or endoscopically, so it was assumed to be a lung primary tumor and judged to be T0N1M0 small-cell lung cancer. Conclusion. We experienced a case of small-cell lung cancer of unknown primary origin with hilar lymphadenopathy. We believe that additional treatment including chemotherapy will be necessary in the future.
Background. Primary lung cancer frequently arises from the wall of the emphysematous bullae, and the same is true for giant pulmonary bullae. Although the clinical course of a giant pulmonary bulla is diverse, it most often increases in size or remains unchanged. The natural regression of a giant pulmonary bulla is rare and the underlying mechanism is unknown. We herein report the case of a patient who experienced the sub-total regression of a giant pulmonary bulla in association with the development of primary lung cancer. Case. The patient was a 72-year-old man, whose main complaint was discomfort on the left side of his back. Computed tomography (CT) showed a 4-cm lung tumor on the apex of the left lung, which was suspected to be invading the parietal pleura. Ten years previously, chest CT had shown an 11-cm giant pulmonary bulla at the same location, which now presented as a 3-cm pulmonary bulla accompanied by a cancerous mass. Left upper lobectomy, with resection of the parietal pleura and lymph node dissection, was performed. The pathological and CT findings indicated that the pulmonary bulla had regressed due to the inhibition of airflow into the giant pulmonary bulla, as a consequence of the development of lung cancer on or near the bulla wall. Conclusion. The results of the CT examination and the pathological findings were indicative of the mechanism of regression of a giant pulmonary bulla in association with the development of primary lung cancer.
Background. Pulmonary epithelioid hemangioendothelioma (PEH) is a malignant tumor that is derived from the vascular endothelium. It is difficult to determine an appropriate treatment for this tumor because most PEHs are slow-growing. We herein report the case of a rapidly progressive PEH. Case. The patient was a 31-year-old female patient who was found to have an abnormal shadow on a chest radiograph taken during a health examination. Whole-body computed tomography and positron emission tomography revealed a nodule of 2.6 cm diameter in the right lower lobe and multiple small nodules in both lungs. We performed partial resection of the right lower lobe and diagnosed PEH with pleural invasion. At 6 months after surgery, the patient developed buttock pain, and recurrence was detected in the left and right iliac bones and in the resection stump of the right lung. At 10 months, metastasis was detected in the vertebral bones and left femur. Her pain improved after palliative irradiation of bone metastasis. At 13 months, the patient's dyspnea associated with right malignant pleural effusion worsened. We performed pleurodesis but could not control the pleural effusion. She died at 16 months after surgery. Conclusion. Most PEHs are slow-growing malignant tumors; however, rapid progression may occur, as was observed in this case. Patients with PEH require close follow-up and should be treated symptomatically.
Background. Primary peritoneal carcinoma, ovarian carcinoma, and fallopian tube carcinoma are known as mullerian adenocarcinoma. We herein report a case of peritoneal carcinoma with metastasis to the supradiaphragmatic lymph nodes. Case. The patient was a 78-year-old woman with dermatomyositis. Computed tomography (CT) performed to investigate interstitial pneumonia revealed a 34-mm mass on the right side and a 49-mm mass on the left side of the diaphragm, within the adipose tissue, as well as numerous masses around the inferior vena cava and iliac artery. Since positron emission tomography/CT (PET-CT) showed the accumulation of fluorodeoxyglucose (FDG) in the masses, malignant lymphoma was suspected. She was referred to our department for a biopsy and underwent thoracoscopic resection of the tumor on the right diaphragm. The pathological diagnosis was serous adenocarcinoma; thus, tumor metastasis from a gynecological organ was suspected. Laparoscopic bilateral adnexectomy and mesenteric tumor resection were performed in our gynecology department. A pathological examination revealed no malignant findings in the bilateral adnexa; however, the tumor in the mesentery was the same type as the tumor on the diaphragm. Ovarian cancer is reported to metastasize to the thoracic lymph nodes through the transdiaphragmatic route. In this case, the metastatic lesion on the diaphragm was thought to be the paracardiac group of superior diaphragmatic lymph nodes on the thoracic surface. Conclusion. When patients present with supradiaphragmatic swelling without lung lesions, in addition to malignant lymphoma, physicians should consider the possibility of metastasis of malignant tumors, such as primary peritoneal cancer.
Background. Antineutrophil cytoplasmic antibodies (ANCA) are highly specific for ANCA-related vasculitis and are used to assist in its diagnosis. Although ANCA may also be present in patients with malignant tumors, few studies have reported lung cancer patients with false-positive ANCA tests. Case. A 66-year-old man was admitted to our hospital with suspected refractory pneumonia and was diagnosed with small cell lung cancer by bronchoscopy. Although his serum was positive for PR3-ANCA, no findings of vasculitis were observed, suggesting the false-positive detection of PR3-ANCA. Chemotherapy was effective against his lung cancer, and a complete remission was obtained, at which point his PR3-ANCA levels became negative. There was no recurrence of lung cancer and his PR3-ANCA level remained negative. Conclusion. Although rare, lung cancer patients may show false-positive ANCA tests results and their disease status may be evaluated according to the change in their ANCA titer.