Surgical Stump Research Articles

Hydropneumothorax in a non‐small cell lung cancer patient after lobectomy due to surgical stump air leak

Key messageHydropneumothorax following lobectomy or pneumonectomy is relatively uncommon, with an incidence of 1%–5%. It involves air and fluid in the pleural cavity, often due to intraoperative injury, infection, bronchopleural fistula, or mechanical ventilation. Careful management, including drainage and addressing the underlying cause, is essential to prevent serious outcomes.

The existence of biliary intraepithelial neoplasia at resection margin is not a risk factor for recurrence of biliary tract cancer

Abstract Background Invasive carcinoma or dysplasia (biliary intraepithelial neoplasia [BilIN]) is often found in the surgical stumps of biliary tract cancer. We investigated whether the presence of BilIN at the surgical margin is a risk factor for recurrence. Materials and Methods Seventy-five consecutive patients who underwent curative resection for biliary tract cancer were included in this study. We retrospectively evaluated the surgical margin status (negative, BilIN, or positive) and analyzed the postoperative disease recurrence rate and recurrence pattern by the status. Results The disease-free survival rate was significantly worse in the positive margin group than in the negative margin group (11 vs 18 months, P = 0.027). There were no statistical differences between the BilIN-positive group and the other two groups. In the multivariate analysis, infiltrative growth c (hazard ratio [HR], 3.348; 95% confidence interval [CI], 1.368–8.195; P = 0.008) and pathological exhumed margin (HR, 2.670; 95% CI, 1.097–6.495; P = 0.030) were independent recurrence factors. The margin status of BilIN was not associated with recurrence (HR, 0.867; 95% CI, 0.491–2.946; P = 0.687). Conclusions The BilIN component at the surgical margin was not associated with short-term recurrence, but the pathological exhumed margin positive and infiltrative growth c were. Infiltrative growth c may be a potential predictive factor for recurrence.

Radiation therapy for pelvic recurrent colorectal or gynecological cancer: is whole pelvic irradiation necessary?

Preoperative whole pelvic radiation therapy (RT) is used commonly for rectal cancer and is the standard field postoperatively in gynecological cancer. However, the ideal field (local vs. whole pelvis) has not been determined for local recurrence of these cancers. We retrospectively reviewed the data for 52 patients who developed local tumor recurrence of rectal or gynecological cancer treated from 2013 to 2021. The initial treatment for all patients was total excision of the primary tumors without radiation therapy. Radiation therapy targets were surgical stumps, perianastomosis sites, and pelvic lymph nodes, classified according to the pelvic nodal volume atlas for radiation therapy. Patients were divided into the local recurrent tumor only radiation therapy group and the whole pelvis radiation therapy group. Whole pelvis radiation therapy included the common iliac lymph nodes or prophylactic lymph nodes below the L5/S1 junction. We recorded second recurrence after RT and the affected site(s) in each group. We also compared disease-specific survival using uni- and multivariate analyses. We found no significant differences between the groups regarding second recurrence or regarding the site(s) of recurrence. We also found no significant differences in disease-specific survival between the two RT groups. However, patients who did not receive chemotherapy after the initial surgery and before RT had significantly longer survival (P=0.015). In patients with locally recurrent rectal or gynecological cancer, we found no significant difference in second recurrence or survival between the local tumor only RT field and the whole pelvic RT field.

A review of the first wave of lower limb amputees from the Great March of Return in Gaza: Taking stock and preparing for the task ahead

AimBallistic injuries during the Great March of Return (GMR) protests in Gaza have resulted in young, civilian amputees. This article defines this unique population, their injuries and clinical variables that impacted on amputation. MethodA multidisciplinary team (MDT) assessed 103 lower limb amputees (104 stumps). Individualized prescriptions of care were formulated and applied for both stump and prosthesis management.The cohort's health state was assessed at screening by applying the EQ-5D-L5 questionnaire. The EQ-5D-L5 will be repeated on completion of the prescription of care. ResultsThe population is predominantly young, male, suffering unilateral amputation with an equal ratio of above knee (AKA) to below knee (BKA) amputations. 18% were amputated immediately and 82% with delay. Most amputations occur within 15 days of gunshot wound (GSW).All tissue elements were affected by the severe, ballistic injury. Division, gapping and tissue loss consolidated the decision for amputation rather than limb salvage. Knee zone injury was common, influencing the high numbers AKAs.Primary injury ramified beyond the amputated leg: 38% have contralateral leg injuries. 20% had physiological challenges requiring Intensive care unit (ICU) admissions. Infection was reported in 49% of amputees with 12% reporting acute sepsis. Psychologically, 49% reported severe, or extreme, anxiety and depression.AKAs were associated with greater morbidity: amputees are significantly younger, have more proximal vascular injuries, receive delayed amputations and experience longer time intervals to stump healing. ICU care and contralateral leg injuries were more frequent.One third of amputees used their prostheses’, one third did not and one third do not have a prosthesis yet. The limiting factor for repair was supply of materials. 11% of amputees needed no adjustment to stump or prosthesis. Surgical stump revision was recommended in 26% of stumps and prosthetic management in 41%. A further 22%, subject to the success or failure of prescribed prosthetic adjustment, could require stump revision. ConclusionYouth, proximal injury, high numbers of AKA, psychosocial issues and the need for stump and prosthetic support define this group of amputees. Unifying expertise within a National MDT will promote continuity of care necessary for decades to come.The ultimate aim is an evidence-based amputee care system in Gaza, with lower limb specialists promoting best outcomes, judicious allocation of funds and maximising amputee quality of life.

Intraoperative computed tomography of a resected lung inflated with air to verify safety surgical margin.

During sublobar resection for small, indistinct lung cancer, surgeons may be uncertain as to whether or not the target lesion has been resected and the surgical margin is sufficient. We herein report our procedure for confirming the success of sublobar resection without incising the resected specimen. We reviewed our initial experience of 12 patients with intrapulmonary lesions (consolidation diameter ≤1 cm) who underwent thoracoscopic pulmonary wedge resection using autostapler. Six patients had primary adenocarcinoma showing part solid lesion, and remaining six patients had metastatic carcinoma showing purely solid lesion. Intraoperatively, the resected specimen was inflated with air and subjected to computed tomography (CT). The maximum tumor diameter and surgical margin length were measured intraoperatively on CT and postoperatively on formalin-fixed specimen. Surgical stump cytology was also done to verify surgical margin. According to the intraoperative CT, complete resection was confirmed in all patients. The intraoperative CT-based maximum tumor diameter closely correlated with the macroscopically measured one (r=0.971, P<0.0001). However, the tumor shrunk after formalin-fixation by 16.0% in patients with primary lung cancer (P<0.01), but not in patients with metastatic lung cancer. The intraoperative CT-based margin length closely correlated with the macroscopically measured one (r=0.984, P<0.0001). However, the margin shrunk after formalin-fixation in both patients with primary lung cancer and metastatic lung cancer, by 15.1% and 15.7%, respectively. Stump cytology was negative in all patients. Consequently, no recurrence was found during postoperative follow-up of 23 months (range, 14-31 months). Intraoperative CT is reliable for diagnosing the presence of a target lesion within the resected specimen as well as for estimating the surgical margin length in patients undergoing sublobar resection for intrapulmonary indistinct lesions.

An Emerging Infection: Streptococcal Toxic Shock-Like Syndrome Caused By Group B Streptococcus (GBS), Streptococcus Agalactiae

Abstract Introduction/Objective Streptococcus agalactiae, Group B Streptococcus (GBS), is a major cause of neonatal sepsis and infections in pregnant women. However, incidence of invasive GBS infections has more than doubled in the last two decades with highest risk in adults 65 years or older. Other risk factors are diabetes, malignancy, and immunocompromised state. Bacteremia and skin soft tissue infections are the most common invasive infections in nonpregnant adults. Rarely GBS infection has a fulminating pyrogenic exotoxin-mediated course characterized by acute onset, multiorgan failure, shock, and sometimes death, referred to as toxic shock-like syndrome. Methods A 77-year-old hypertensive female with uncontrolled type 2 diabetes mellitus and a history of bilateral foot ulcers presented to the hospital in probable septic shock. Clinical diagnosis of necrotizing fasciitis was made and she underwent bilateral lower limb amputations. Results Grossly soft tissue appeared gray. Microscopically fascia was necrotic without neutrophils present and Gram stain revealed sheets of Gram positive cocci. These findings reflected histopathologic Stage III necrotizing fasciitis, which is associated with 47% mortality. Autopsy showed a similar histology of Stage III necrotizing fasciitis involving the surgical stump. Erythema and desquamation of the upper limbs bilaterally and multi-organ failure met the clinical picture of Streptococcal Toxic Shock Syndrome (STSS) and fulfilled the criteria for TSS due to Group A Streptococcus (GAS), defined by The Working Group on Severe Streptococcal Infections. Conclusion Group B Streptococcal Toxic Shock-Like Syndrome may have a similar outcome to STSS caused by GAS and other pathogens and, in limited studies, mortality has been 30% or greater.

Form-Vessel Classification of Cholangioscopy Findings to Diagnose Biliary Tract Carcinoma's Superficial Spread.

We aimed to evaluate a newly developed peroral cholangioscopy (POCS) classification system by comparing classified lesions with histological and genetic findings. We analyzed 30 biopsied specimens from 11 patients with biliary tract cancer (BTC) who underwent POCS. An original classification of POCS findings was made based on the biliary surface’s form (F factor, 4 grades) and vessel structure (V-factor, 3 grades). Findings were then compared with those of corresponding biopsy specimens analyzed histologically and by next-generation sequencing to identify somatic mutations. In addition, the histology of postoperative surgical stumps and preoperative POCS findings were compared. Histological malignancy rate in biopsied specimens increased with increasing F- and V-factor scores (F1, 0%; F1, 25%; F3, 50%; F4, 62.5%; p = 0.0015; V1, 0%; V2, 20%; V3, 70%; p < 0.001). Furthermore, we observed a statistically significant increase of the mutant allele frequency of mutated genes with increasing F- and V-factor scores (F factor, p = 0.0050; V-factor, p < 0.001). All surgical stumps were accurately diagnosed using POCS findings. The F–V classification of POCS findings is both histologically and genetically valid and will contribute to the methods of diagnosing the superficial spread of BTC tumors.

EP1.08-06 Postoperative Oligo-Recurrence of Non-Small Cell Lung Cancer

Postoperative recurrences of non-small cell lung cancer (NSCLC) are usually disseminated and systemic. The concept of oligo-recurrence, defined as a small number of new lesions at a distant site theoretically curable by local therapy, has recently been proposed for several cancers. The aim of this study was to clarify clinical features and outcomes of patients with postoperative oligo-recurrence of NSCLC. From 364 patients who underwent resection for NSCLC between January 2008 and December 2017 at our hospital. A total of 43 patients who developed recurrence were included in this study. Oligo-recurrence was defined as 1-2 loco-regional or distant recurrence lesions restricted to a single organ. Other recurrences were classified as poly-recurrence. Local therapy included surgery, stereotactic radiotherapy and radiotherapy. Oligo-recurrence was identified in 12 (27.9%) patients, mainly as a solitary recurrence (n=11, 91.7%) in regional lymph nodes (n=1), surgical stump (n=2), brain (n=5), lung (n=1), bone (n=2) and liver (n=1). Primary tumor histopathological types included 9 cases of adenocarcinoma, one case of squamous cell carcinoma, one case of pulmonary pleomorphic carcinoma and one case of large cell neuroendocrine carcinoma.The patients with oligo-recurrence had a longer time to recurrence than those with poly-recurrence (median: 23.5 months, 11.0 months). A case of mediastinal lymph node recurrence was performed radiation therapy. A case of surgical stump recurrence underwent lobectomy and other case was performed concurrent chemo-radiotherapy. 4 case of brain metastasis were underwent tumor resection and were performed stereotactic radiotherapy, one case of brain metastasis was performed stereotactic radiotherapy only. A case of lung metastasis underwent wedge resection and was used EGFR-TKI. A case of bone recurrence was performed radiation therapy and was used EGFR-TKI, other case was performed concurrent chemo-radiotherapy. A case of liver metastasis underwent tumor resection. 7 of 12 cases confirmed re-recurrence after local therapy. But 9 patients were alive between 30.4 and 110.0 months after local therapy, whereas three of 5 brain metastatic patients died between 24.9 and 71.8 months. The 5 year overall survival rates after local therapy were 81.5%. The presence of oligo-recurrence can predict a favorable prognosis in patients with NSCLC treated with aggressive local therapy.

A resected case of recurrent ITPN in the remnant pancreas after pancreatoduodenectomy

BackgroundSince intraductal tubulopapillary neoplasm (ITPN) is a rare disease, the clinical features of ITPN, especially the characteristics related to recurrence, have not been revealed. We performed a total remnant pancreatectomy for a patient whose ITPN recurred 16 months after pancreatoduodenectomy (PD). We report useful findings to clarify how ITPN reoccurs based on this experience and previously reported cases.Case presentationA 61-year-old male patient was diagnosed with pancreatic cancer and underwent PD. However, a postoperative pathologic examination diagnosed ITPN with invasive cancer. After receiving adjuvant chemotherapy, he was hospitalized for pancreatitis 16 months after the operation. He was diagnosed as having recurrence near the pancreato-jejunal anastomosis based on detailed examinations and underwent a remnant total pancreatectomy. From the results of the histopathological examination, he was found to have a recurrence of ITPN as a polypoid mass without invasion distant from the surgical stump of the first operation. Furthermore, tumor cells floating in the main pancreatic duct distant from the main tumor were observed at three locations.Review of the literatureIncluding our case, five cases of recurrence in the remnant pancreas after surgery for ITPN have been reported. Recurrence in the main pancreatic duct was observed in four of these five cases. The primary tumor, which recurred in the remnant pancreas after surgery, was characterized as being relatively small and less invasive; however, Ki-67 labeling index was high. In immunohistochemical examination, the expression of MUC6, which is not one of characteristics of ITPN, tended to be positive.ConclusionIn this case, tumor cells were floating inside the pancreatic duct at several locations. From the results of this case and a review of previous reports, the cause of ITPN recurrence in this case seemed to be due to tumor cells leaving the tumor and implanting into the pancreatic duct.

Is there any different risk factor for clinical relevant pancreatic fistula according to the stump closure method following left-sided pancreatectomy?

Backgrounds/AimsConsistency on risk factors for postoperative pancreatic fistula (POPF) after left-sided pancreatectomy (LP) according to the stump closure methods has not been revealed. Appropriate surgical stump closure method after LP is still in debate. This study investigates risk factors for POPF according to the closure methods in LP.MethodsA total of 49 consecutive patients underwent LP with a stapler closure (ST) or hand-sewn closure (HS) between June 2001 and September 2016. The risk factors of pancreatic fistulas were investigated in 49 LPs according to stump closure methods, HS (n=19), and ST (n=30).ResultsThere was no significant difference in the incidence of overall POPF (HS 42.1% vs. ST 50.0%) and clinical relevant POPF (CR-POPF) (HS 5.3% vs. ST 6.7%) between two groups. In the ST group, the pancreas was significantly thick in patients with CR-POPF (27 mm vs. 17 mm) and the tumor was also larger (58 mm vs. 27 mm). In the HS group, the operation time was longer in CR-POPF group (515 min vs 292 min). In univariate analysis, wider diameter of the pancreatic duct (27 mm vs 16 mm) was associated with POPF in the HS group. There was no meaningful risk factor for POPF in the ST group.ConclusionsIncidence of overall POPF between the ST and HS group were clinically insignificant in this study. The thickness of the pancreas and the tumor diameter are factors significantly associated with CR-POPF in the ST group. Long operation time was the only factor associated with CR-POPF in the HS group.

Hemangiossarcoma primário intrauterino em um macaco aranha de cara vermelha (Ateles paniscus)

Hemangiosarcoma is a common neoplasm in dogs and less frequently seen in cats. In nonhuman primates, this tumor is rarely reported. A 17 year-old female spider monkey ( Ateles paniscus) was submitted an ultrasound exam due to gestation suspicion, which was seen a circular mass intra-uterine measuring 1.3 cm. New exams shown increase of the mass to 4.4 x 3.0 cm associated with a viable fetus. Was realized cesarean with ovariohysterectomy and excision of the mass; however the animal died in less than 24 hours after the surgery. In the necropsy, severe hemoabdomen was evidenced, although the surgical stumps were properly ligated and the complete sutures. Macroscopically, the uterine mass was soft, dark heterogeneous and measuring 5.0 cm in diameter. Histologically was visualized proliferation of spindle cells that form vascular channels replete of erythrocytes a nd some with thrombus, marked pleomorphism, nucleolus evident, binucleated cells and mitotic figures were rare. The immunohistochemistry (IHC) was performed, using streptavidin-biotin peroxidase technique (Dako Cytomation, USA) with the use of antibodies CD31 (clone JC/70A), CD34 (clone QB-END/10). The IHC showed a specific antigen-antibody reaction for CD31. According to localization, morphology and IHC, the present study reports a primary uterine hemangiosarcoma in a spider monkey that caused hemostatic abnormalities and consequent death of the animal.

Cost and morbidity of surgical management of resectable gallbladder cancer (GBC): Results from the National Inpatient Sample database.

e15663 Background: GBC is the most common biliary tract cancer. Based on a retrospective, single-institution data, extended cholecystectomy (EXT) has been recommended over simple cholecystectomy (CHOL) in tumors T2 and above. Retrospective data indicate increased morbidity/mortality with removal of more than 3 segments of the liver compared to CHOL and the effect on long-term survival is unclear. Therefore, we sought to identify short-term outcomes of hospitalization, such as cost and morbidity, for surgical treatment of GBC. Methods: The National Inpatient Sample/Healthcare Cost and Utilization Project (NIS/HCUP) for years 2010, 2011, 2012 and 2013 was surveyed for GBC hospitalizations. Hospitalizations for non-surgical management of GBC were excluded. Results: We identified 5,612 cases; mean age in EXT was 66.8 years vs. 72.4 in CHOL (p&lt;0.001). Patients insured through Medicare were less likely to have EXT (OR: 1.5, 95% CI 1.125-2.064; p=0.007). No difference based on race (OR: 1.14, 95% CI 0.854-1.519; p=0.38). Surgical/Medical morbidity is presented in Table 1. In-hospital mortality was 3.3 vs. 4.1% for EXT and CHOL, respectively (p=0.55). Mean length of stay was higher in the EXT group (9.8 vs. 8.3 days, p=0.03), cost ($32,782 vs. 22,667.3, p=0.003) and total charges ($111,714.7 vs. 81,432.9, p&lt;0.001). Conclusions: EXT for resectable GBC is associated with higher cost of care, probably related to higher risk for surgical site infection and stump leak. Until more evidence for overall survival benefit from EXT in this rare tumor emerges, referral of patients to high-volume centers with the hepatobiliary surgery expertise is recommended. [Table: see text]

Factors influencing survival and recurrence and potential significance of postoperative radiotherapy and adjuvant chemotherapy for stage ⅢA-N2 non-small cell lung cancer

Objective: To investigate the survival, recurrence patterns and risk factors in patients with stage ⅢA-N2 NSCLC treated with curative surgery and adjuvant chemotherapy and to explore the significance of postoperative radiation therapy. Methods: The clinical data of 290 patients with pathologically diagnosed stage ⅢA-N2 NSCLC after curative resection and adjuvant chemotherapy from January 2010 to December 2014 at our department were retrospectively analyzed. The survival and recurrence patterns were observed, and the factors affecting locoregional recurrence were analyzed. Results: The median survival time was 31.5 months. The 1-, 3-and 5-year survival rates were 88.3%, 46.0% and 33.2%, respectively. The median locoregional control time was 38.5 months. The 1-, 3-and 5-year locoregional control rates were 78.6%, 55.2% and 41.0%, respectively. The median distant metastasis-free survival was 26.8 months. The 1-, 3-and 5-year distant metastasis-free survival rates were 76.4%, 45.5% and 39.5%, respectively. The median progression-free survival was 19.1 months. The 1-, 3-and 5-year progression-free survival rates were 64.1%, 32.5% and 23.8%, respectively. Univariate analysis showed that clinical N status, histological type, pathological T stage, operation mode, the number of positive N2 lymph nodes and the number of positive N2 lymph node stations had a significant influence on overall survival; clinical N status, histological type, the number of positive N2 lymph nodes and the number of positive N2 lymph node stations had a significant influence on locoregional control. Multivariate analysis demonstrated that the number of N2 positive lymph nodes (P= 0.017) was an independent factor for overall survival of stage ⅢA-N2 patients; the number of N2 positive lymph nodes (P=0.009) and histological type (P=0.005) were independent factors for locoregional recurrence. For left-sided lung cancer, the lymph node station failure sites were mostly in 2R, 4R, 5, 6 and 7, and the contralateral mediastinum was frequently involved. For right-sided lung cancer, the lymph node station failure sites were mostly in 2R, 4R, 7, 10R and surgical stump. Conclusions: Clinical N2, squamous cell carcinoma, positive N2 nodes of more than 3 and multiple positive N2 stations are poor prognostic factors for locoregional recurrence. Locoregional recurrence of left lung cancer frequently involves the contralateral mediastinum, while that of the right lung cancer usually locates in the ipsilateral mediastinum.

Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy

BackgroundThe appropriate surgical stump closure after distal pancreatectomy (DP) is still controversial. This study investigated the benefits and risks of stapler closure during DP. MethodsThe risk factors of pancreatic fistulas were investigated in 122 DPs among 3 types of stump closure: hand-sewn suture (n = 32), bipolar scissors (n = 45), and stapler closure (n = 45). ResultsThere was no significant difference in the incidence of pancreatic fistula between the 3 types of stump closure (hand-sewn suture [44%] vs bipolar scissors [37.7%] vs stapler closure [35.5%]). By using receiver operating characteristics curves, 12 mm was the best cutoff value of the thickness of the pancreas for pancreatic fistulas after DP using stapler closure. Three factors (ie, male sex, body mass index >25 kg/m2, and stapler closure) were independent risk factors of pancreatic fistulas after DP with a pancreas thicker than 12 mm. ConclusionsA pancreas thicker than 12 mm significantly increased the incidence of pancreatic fistulas after DP using stapler closure.

Breast Conserving Surgery and Sentinel Lymph Node Biopsy under Local Anesthesia for Breast Cancer

Background: Breast conserving surgery and sentinel lymph node biopsy has become the standard operation for early breast cancer. This operation has been performed under local anesthesia for patients that would like short-term admission or for those not indicated for general anesthesia due to complications. This report presents the outcomes of breast conserving surgery and sentinel lymph node biopsy under local anesthesia. Patients and Methods: The study included 61 patients with breast cancer that were all definitely diagnosed before surgery. The indications were preoperatively diagnosed localized DCIS, invasive carcinoma measuring less than 3 cm in tumor diameter on ultrasound, and tumors with negative axillary lymph nodes. The surgical procedures included breast conserving surgery associated with sentinel lymph node navigation biopsy. Results: The surgery could be performed under local anesthesia in all 61 patients, and no patient was converted to general anesthesia. Four patients had sentinel lymph node metastasis. Surgical stumps were positive in 18 patients (29.5%). Ten Gy of boost irradiation of the tumor bed was added to the conventional breast irradiation for these patients. There were no serious complications associated with surgery. Conclusion: Breast conserving surgery and sentinel lymph node biopsy for early breast cancer can be performed safely under local anesthesia. This procedure contributes to shortening the length of hospitalization and thereby saving medical resources without deceasing the quality of treatment.

Massive haemothorax after pulmonary endostapling preloaded with bioabsorbable tissue reinforcement material

Reinforced endostapling can prevent postoperative air leakage from surgical stumps. We herein present a 58-year old woman with idiopathic interstitial pneumonia who developed lethal haemothorax after a thoracoscopic lung biopsy with the use of an endostapler preloaded with bioabsorbable tissue reinforcement material. This lethal haemothorax, which occurred on the day after the lung biopsy, required an emergency operation. The bleeding point was an intercostal artery of the inferior chest wall adjacent to the surgical stump. The operative findings suggested that the reinforced material on the surgical stump scratched the chest wall through respiratory movement.

Preoperative localization of small peripheral pulmonary nodules by percutaneous marking under computed tomography guidance

The outcome of computed tomography (CT)-guided percutaneous marking for the preoperative localization of small peripheral pulmonary nodules was analyzed retrospectively. This procedure, in which 21-gauge markers were placed near nodules under local anesthesia on the day of surgery, concerned the patients who received video-assisted thoracoscopic surgery as a primary operative technique. The study included all the 57 patients who underwent CT-guided percutaneous marking before pulmonary resection. The mean nodule size was 1.1 cm. Pneumothorax and pulmonary bleeding were observed in 28 and 17 patients, respectively. Other complications included pain (four), subcutaneous bleeding (two) and dislodgment of the marker (one). Wedge resection during thoracotomy was necessary in seven patients because of severe adhesions (four), multiple wedge resections (one), dislodgment of the marker (one) and difficulty in identifying a nodule (one). Pathological studies revealed 24 metastatic lung tumors, 19 bronchioloalveolar carcinomas (BACs), five adenocarcinomas with mixed subtypes, three granulomas, two atypical adenomatous hyperplasias and six miscellaneous others. Wedge resection for malignancy was performed in 39 patients with 41 lesions. The median follow-up period was 46 months. A positive surgical margin and recurrence at the surgical stump were observed in one case each. In conclusion, preoperative CT-guided marking was safe and effective, although marker dislodgment, positive surgical margin and recurrence at the surgical stump were observed infrequently.

A case of maxillary osteosarcoma with epuloid growth

This report presents a case of maxillary osteosarcoma that was initially considered to be granulomatous epulis. A pedunculated mass was found on the buccal gingiva in the right maxillary molar region in a 45-year-old male patient at the initial examination. The clinical and pathological findings indicated that the mass was an epulis. However, a partial maxillectomy was performed under general anesthesia because the rapidly enlarged mass was clinically diagnosed as a maxillary tumor. A pathological examination of the resected specimen revealed that the maxillary tumor was osteosarcoma with a partially positive surgical stump. A total resection of the maxilla was performed under general anesthesia because recurrence was observed at 3 years postoperatively. Recurrence of a tumor that invaded into the cranial base was found at 2.5 years after reoperation despite three courses of adjuvant chemotherapy. Heavy particle radiotherapy was administered. Unfortunately, the patient died at 6 years and 2 months after the first operation due to tumor growth and a gradual worsening of his general condition. The experience from the present case suggested that an early diagnosis and an appropriate surgical therapy is very important for a satisfactory treatment outcomes of the jawbone osteosarcoma.

Local failure after complete resection of N0–1 non-small cell lung cancer

Purpose To estimate the risk of local–regional failure (LRF) after surgery for operable NSCLC, and the effect of clinical/pathologic factors on this risk. Methods Records of 335 patients undergoing complete resection (lobectomy, pneumonectomy) for pathological T1–4 N0–1 NSCLC (without post-operative radiation) from 1996 to 2006 were reviewed. Crude and actuarial estimated failure rates were computed; local–regional sites included ipsilateral lung, surgical stump, hilar, mediastinal, or supraclavicular nodes. Failure times in sub-groups were calculated with the Kaplan-Meier method and compared via log-rank test. Independent factors adversely affecting LRF were determined with Cox regression. Results The median follow-up duration for event-free surviving patients was 40 months (range: 1–150). The crude and actuarial 5-year probability of any failure (LR or distant) were 33% and 43%, respectively. Of all failures; 37% were LR only, 35% LR and distant and 28% distant only. The 5-year crude and actuarial probability of LRF were 24% and 35% (95% CI: 29–42%). Five-year crude LRF rates for T1–2N0, T1–2N1, T3–4N0 and T3–4N1 disease were 19% (41/216), 27% (16/59), 37.5% (15/40) and 40% (8/20), respectively. The corresponding actuarial estimates were T1–2N0 28%, T1–2N1 39%, T3–4N0 50% and T3–4N1 67%. In Cox multiple regression analysis, lymphovascular space invasion ( p = 0.03, HR: 1.7) and tumor size ( p = 0.01, HR: 1.67 for 5 cm increment) were associated with an increased risk of LRF. Conclusion Five-year LRF rates are ≥19% in essentially all patient subsets.

Optimal sampling methods for margin cytology examination following lung excision☆

Local recurrence of the tumor after lung excision often occurs in cases with positive cytology results at the surgical stump. Some reports have described the efficacy of margin cytology examinations with various sampling procedures, though an optimum method has not been established. In the period between 2005 and 2008, 58 patients underwent a lung excision followed by a margin cytology examination at our hospital, of whom 49 were finally diagnosed with malignancy. Cytology samples were obtained by scratching the staple lines of both resected and residual lungs, and collecting lavage from washed stapler cartridges used in the procedure, with the results compared. Of the 49 cases with malignancy, 44 underwent both sampling techniques, of which four had positive results, three detected in lavage samples and one by the scratching method. Since neither technique detected all positive cases, it is recommended that samples be obtained using both techniques to avoid missing malignancy.