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Y. Tsushima



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    MO02 - General Thoracic and Minimally Invasive Surgery (ID 99)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Surgery
    • Presentations: 2
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      MO02.01 - Is Lower Zone Lymph Node Dissection always Mandatory in Patients with Lower Lobe Lung Cancer? (ID 1851)

      10:30 - 12:00  |  Author(s): Y. Tsushima

      • Abstract
      • Presentation
      • Slides

      Background
      The recent UICC-IASLC classification defines lower zone lymph node metastasis, i.e., paraesophageal and pulmonary ligament lymph nodes metastasis, as p-N2 disease. Due to the relatively rare incidence of lower zone nodal involvement, however, controversies still surround regarding the clinical characteristics and the possible pathway for lower zone lymph node in patients with lower lobe lung cancer.

      Methods
      From 2009 to 2013, 257 consecutive patients underwent lobectomy with mediastinal lymph node dissection for lower lobe lung cancer. For all patients, thin-section CT scan was reviewed to investigate maximum tumor size, location and consolidation status. In a current study, radiologically “solid” tumor was defined as a tumor which constructed only by consolidation without ground glass opacity (GGO) lesions on thin-section CT scan. Several clinical factors were evaluated to identify significant predictive factors of lower zone lymph node metastasis using a multivariate analysis.

      Results
      Twenty (7.8%) patients revealed lower zone lymph node metastasis. Twelve were men and 8 were women. Patients ranged in age from 33 to 81 y, with an average of 63 y. Among them, tumors distributed especially in Segment (S) 10 (50%). All patients showed solid appearance on thin-section CT scan. A univariate analysis revealed that tumor location (S 10 or not) and solid tumors with more than 30mm in diameter were the significant predictors for lower zone lymph node metastasis (p=0.011, 0.033). Based on a multivariate analysis, these two factors were also shown to be independent predictors for lower zone nodal metastasis in patients with lower lobe lung cancer. (p=0.014, 0.034). Furthermore, the frequency of lower zone lymph node metastasis was approximately 24% for patients with solid tumors more than 30mm located in S10. On the other hand, lower zone lymph node metastasis was never seen in patients with c-T1a-b lower lobe lung cancer with GGO component.

      Conclusion
      Although lower zone lymph node metastasis is included in N2 disease, these incidences are extremely rare even in patients with lower lobe lung cancer except for those with radiologically large-sized solid tumor located in S10 field. Thus, selective dissection for lower zone lymph node could be an appropriate operative strategy in patients with small-sized lower lobe lung cancer especially with GGO predominance.

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      MO02.03 - Surgical intervention strategy for postoperative chylothorax after lung resection - clinical analysis of fifty patients who developed postoperative chylothorax (ID 3321)

      10:30 - 12:00  |  Author(s): Y. Tsushima

      • Abstract
      • Presentation
      • Slides

      Background
      Chylothorax is a rare but well-known complication of general thoracic surgery. This study evaluated our treatment strategy for postoperative chylothorax and identified associated predictors.

      Methods
      We retrospectively reviewed 1235 patients who underwent lung resection and systematic mediastinal lymph node dissection for primary lung cancer at our department from January 2008 to September 2012. Postoperative chylothorax patients were analyzed. Chylothorax was diagnosed by the milky aspect of drainage fluid and confirmed by an elevated triglyceride level (>110 mg/dL) in the drainage fluid. We initially treated chylothorax patients conservatively with low fat diet (fat intake < 20 g/day). If this treatment was judged to be ineffective, we tried to do complete oral intake cessation or surgical intervention. Comparisons between conservative and surgical intervention groups were analyzed using Fisher’s exact test. Univariate and multivariate analysis of predictors for surgical intervention was performed using logistic regression analysis. Value of p<0.05 were considered statistically significant.

      Results
      Fifty patients (4.0%) developed postoperative chylothorax. There were 35 men and 15 women with a median age of 63 years (range 33 to 81 years). The operative procedures were pneumonectomy in 2 cases, bilobectomy in 5 cases, lobectomy in 32 cases, segmentectomy in 1 case, and sleeve lobectomy in 10 cases. Forty-one patients (82%) cured with conservative treatment. These patients continued a low fat diet for one month. The remaining 9 patients (8%) underwent surgical intervention at a median of 5.5 days after diagnosis (range 3 to 12 days). Postoperative chest tube drainage (ml/h) until first oral intake was significantly greater in the surgical intervention group than conservative group (37.4±15.7 ml/h vs. 24.7±9.7 ml/h; p=0.003). In multivariate analysis, postoperative chest tube drainage (ml/h) until first oral intake was significant predictor for the chylothorax patient required surgical intervention (p=0.012, Hazard Ratio 1.110, 95% Confidence Interval 1.024-1.205). Four patients (8%) had chest tube drainage exceeding 45 ml/h until first oral intake. Among them 3 patients (75%) required surgical intervention.

      Conclusion
      Postoperative chest tube drainage (ml/h) was independent predictor for surgical intervention in postoperative chylothorax patients. If postoperative chest tube drainage exceed 45 ml/h until first oral intake, we should suspect postoperative chylothorax and consider early surgical intervention.

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    P1.18 - Poster Session 1 - Pathology (ID 175)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Pathology
    • Presentations: 1
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      P1.18-011 - Is Visceral Pleural Invasion Significant Prognostic Factor in Lung Cancer Patients with Ground Glass Opacity on Thin-Section CT Scan? (ID 1919)

      09:30 - 16:30  |  Author(s): Y. Tsushima

      • Abstract

      Background
      Due to the recent amendment of lung cancer staging by the IASLC committee, pathological visceral pleural invasion (VPI) has been considered as a new prognostic factor and even pT1a-b lung cancers is included in pT2a, if the tumors have VPI. Basically, lung cancers with VPI are often revealed in patients with radiologically “pure-solid” appearance on thin-section CT scan. On the other hand, controversies still remain with regard to the prognostic significance of VPI in patients with radiologically early lung cancer with ground glass opacity (GGO) predominance.

      Methods
      Between 2004 and 2012, among 543 patients with surgically resected pN0 non-small cell lung cancer less than 30mm in diameter, 466 patients that revealed radiologically “part-solid” and “pure-solid” appearance on thin-section CT scan were retrospectively reviewed. Pure-solid tumors were defined as a tumor constructed only by consolidation without GGO, whereas part-solid tumors were defined as a focal nodular opacity that contained both consolidation and GGO on thin-section CT scan. Several clinicopathological factors were evaluated to elucidate the prognostic factors for each group using a multivariate analysis. Survivals for each group were calculated by Kaplan-Meier estimation.

      Results
      Among 466 eligible lung cancers, 209 (45%) were pure-solid and 237 (55%) were part-solid nodule on thin-section CT scan. In the group with pure-solid nodule, 128 patients were men and 81 were women with average age of 67 years. VPI was found in 79 (38%) patients. Based on a multivariate analysis, VPI, maximum tumor diameter and CEA level were significant prognostic factors in patients with pure-solid nodule (p=0.0071, 0.0278, 0.0314). The 5-year survival in patients with VPI (-) (81.3%) was significantly greater than that in VPI (+) (70.1%) (p=0.0051). While the group with part-solid nodule included 97 men and 140 women with average age of 66 years. VPI was found in 24 (10%) of the patients with part-solid nodule, however, it was not a significant prognostic factor in these lesions (p=0.4697). Furthermore, the 5-year survival in patients with VPI (-) was 94.9%, whereas that with VPI (+) was 85.6% (p=0.3798).

      Conclusion
      It is no doubt regarding the prognostic significance of visceral pleural invasion in patients with radiologically pure-solid lung cancer. On the other hand, even pleural invasion may not participate in the prognosis in patients with part-solid lung cancers. Thus, upgrading of TNM staging system and administration of postoperative chemotherapy due to pleural factor should be carefully considered in lung cancer patients with GGO predominance.

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    P1.19 - Poster Session 1 - Imaging (ID 179)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Imaging, Staging & Screening
    • Presentations: 1
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      P1.19-012 - The Quality Of Consolidation In Part Solid Nodule Could Be A Predictor Of Survival (ID 3253)

      09:30 - 16:30  |  Author(s): Y. Tsushima

      • Abstract

      Background
      The size of consolidation on thin-section computed tomography (CT) has been one of the most important preoperative prognostic factors in resected lung cancer. On the other hand, few reports mentioned the nature of consolidation as prognostic factor.

      Methods
      A retrospective study was conducted on 617 lung cancers of clinical stage IA which were resected between 2009 and 2012. Thin-section CT scans were available for all cohorts, which were reviewed by authors. Moreover authors divided lung cancers into three categories: ground glass opacity (GGO), part solid and pure solid. 235 cases are part solid nodule. We classified these 235 part solid lung cancers into two groups: homogeneous or heterogenous. The relationship between these consolidation statuses were evaluated using the chi-square test and Fisher’s exact test. The medical record of each patient was examined for investigating following clinicopathological factors: age, gender, smoking status (pack-year smoking), preoperative serum carcinoembryonic antigen (CEA), SUV max of the primary tumor on positron emission tomography (PET), pathological pleural, vascular, and lymphatic invasion. P-value <0.05 was considered statically significant.

      Results
      Ninety pts (38.3%) had homogeneous consolidation. There were 32 (35.6%) , and 56 (38.6%) men, 6 (14.6%), and tumor having 3 or more SUV max on PET was found in 6 (14.6%), 5 (10.4%), respectively. Based on univariate analysis, age, gender, and pack-year smoking were not statistically significant differences. In homogeneous consolidation group, 2 patients have nodal metastasis, however nodal metastasis were not observed in scattered consolidation group. (P=0.023) Vascular invasive was frequently found in homogeneous consolidation group. (P=0.04)

      Conclusion
      This result of our study shows that the quality of consolidation in part solid lung cancer could be the prognostic factor.

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    P1.20 - Poster Session 1 - Early Detection and Screening (ID 172)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Imaging, Staging & Screening
    • Presentations: 1
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      P1.20-011 - Retrospective Study of Lung Cancer Screening. (ID 3372)

      09:30 - 16:30  |  Author(s): Y. Tsushima

      • Abstract

      Background
      The lung cancer screening in Japan is only chest radiography now. But in 2011, the national lung screening trial research team was reported reduced lung-cancer mortality with low-dose computed tomographic screening. We studied lung cancer patients about a difference of a screening type, for example radiography and computed tomography.

      Methods
      From January 2008 through May 2013, we performed the operation of 1344 lung cancer patients. In those patients, 1018 patients were proved the type of screening.

      Results

      symptom radiography CT
      pt 146 340 378
      age 64±1 64±0.7 67±0.5
      cStage IA 50 199 296
      IB 22 66 42
      IIA 18 25 6
      IIB 15 13 8
      IIIA 25 21 12
      IIIB 6 4 2
      IV 7 3 1
      pStage IA 35 155 259
      IB 18 57 53
      IIA 12 31 13
      IIB 16 23 11
      IIIA 41 50 30
      IIIB 6 4 1
      IV 12 7 4
      The number of patients by symptom, radiography and computed tomography are 146 (14%), 340 (33%) and 378 (37%), respectively. The rate of clinical stage I (789, 78%) are 72 (7%), 265 (26%), 338 (33%), respectively. The rate of pathological stage I (672, 66%) are 53 (5%), 212 (21%), 312 (31%), respectively. On the other hand, the rate of clinical III are 31 (3%), 25(2%), 14 (1%), respectively. The rate of pathological III are 47 (5%), 54 (5%), 31 (3%), respectively. The difference of between clinical stage I and screening type are 0.000, 0.813, and 0.000, respectively. The difference of between pathological stage I and screening are 0.000, 0.081, and 0.000, respectively.

      Conclusion
      In the group of symptom and radiography, there are a lot of advanced lung cancer patients, while in the group of computed tomography, we can detect a lot of early lung cancer patients. Computed tomography is better than the other screening about the detecting lung cancer. We should use a computed tomography in screening of lung cancer.

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    P3.12 - Poster Session 3 - NSCLC Early Stage (ID 206)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P3.12-020 - Derailed analysis of lung cancer with scattered consolidation (ID 3236)

      09:30 - 16:30  |  Author(s): Y. Tsushima

      • Abstract

      Background
      Background: We have reported that the definition of lung cancer with scattered consolidation (LCSC) was difficult to measure the size of ground glass opacity (GGO) on thin section computed tomography (Matsunaga T, Suzuki K, et al. Interact Cardiovasc Thorac Surg. 2013).To add to clinicopathological features, We investigate in LCSC in detail.

      Methods
      Methods: Between Jan.2009 and Oct.2012, 590 consecutive patients underwent pulmonary resection for lung cancer with clinical stage IA and are performed on thin section computed tomography for preoperative evaluation. Among them, 79 patients (13.4%) who had lung cancers in which it was difficult to measure the size of consolidation tumor ratio (CTR) were investigated in this study. LCSC was divided into three categories: tumor with discontinuous consolidation like islands (small islands type); tumors with reticulate consolidation (reticulation type); tumors with denser GGO (denser type). The medical record of each patient was examined for the frequency of pathological nodal status, lymphatic invasion, vascular invasion, and adenocarcinoma in situ (AIS).

      Results
      Results: All of LCSC patients are adenocarcinoma. No nodal involvement was observed in all cohort. Pathological lymphatic invasion were found in 5 (17.2%) out of 29 pts with island type, 2 (7.4%) out of 27 patients with reticular type, 1 (4.3%) out of 23 patients with denser type.. Vascular invasion was found in 3 (11.5%), 2 (7.4%), and 0 (0%), respectively. AIS were included in 3 (11.5%), 5 (13.5%), and 2 (8.6%), respectively. There were no statistically significant differences.

      Conclusion
      Conclusions: There were no significant differences in the three categories as to pathological invasive factors among LCSC. Vascular and lymphatic invasions were frequently seen in island or reticular type compared with denser type. On the other hand, AIS was frequently seen in denser type.

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    P3.18 - Poster Session 3 - Pathology (ID 177)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Pathology
    • Presentations: 1
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      P3.18-009 - Clinicopathological characteristics of primary lung mucinous adenocarcinoma in surgically resected cases (ID 1850)

      09:30 - 16:30  |  Author(s): Y. Tsushima

      • Abstract

      Background
      Primary mucinous adenocarcinomas (MA) are relatively rare, and the clinicopathological characterisics have remained unclear. The aim of this study was to clarify the clinicopathological characteristics of MA.

      Methods
      We selected MA from 1450 cases of surgically resected primary lungWe selected MA from 1450 cases of surgically resected primary lung adenocarcinoma. The clinicopathological characteristics of MA (30 cases) were analyzed.

      Results
      MA showed a high rate (22/30, 73%) of tumor location in the lower lobe. Vascular invasion was observed in 6 cases (20%). Pulmonary metastasis was observed in 5 cases (17%). Lymphatic permeation was present in 1 case (3%). Pleural invasion was observed in no cases. Lymph node metastasis was present in 1 case (tumor size: 75mm, 3%). MA showed a significantly higher rate of cases aged 65 and over, tumor location in the lower lobe and pathological N0 stage cases, when compared with the other of adenocarcinoma. Furthemore, MA displayed a lower frequency of plural invasion, lymphatic permeation, and vascular invasion, and a high frequency of pulmonary metastasis. We compared the frequency of invasive cases in the two groups with respect to their size (tumor size; TS). In MA, the frequency of invasive cases in TS ≦ 3cm, 3cm < TS ≦ 5cm and TS > 5cm was 11% (2/18), 50% (2/4), 62% (5/8), respectively. In the other types of adenocarcinoma, the frequency of invasive cases in TS ≦ 3cm, 3cm < TS ≦ 5cm and TS > 5cm was 89% (918/1027), 98% (274/281), 100% (112/112), respectively. Therefore, even as TS became bigger, MA displayed lower invasive capacity. We compared the frequency of recurrence cases in the two groups.MA showed local recurrence in 3 of 30 cases (10%), no incidents of distant metastasis. The tumor size of all 3 cases showed more than 5 cm. Pulmonary metastasis showed 1 case (3%) in same side, 2 cases (7%) in the both side. MA showed a significantly lower rate of pulmonary metastasis and distant metastasis (P < 0.05), when compared with the other of adenocarcinoma.

      Conclusion
      The pathogenesis of MA might differ from that of lung adenocarcinoma without MA based on higher rate of tumor location in the lower lobe and recurrence of pulmonary metastasis. MA less than 5cm may be treated as a local disease and could omit mediastinum lymph node dissection.