Current Advancements in General Thoracic Surgery Charles Heim Current Advancements in General Thoracic Surgery "This page is Intentionally Left Blank" Current Advancements in General Thoracic Surgery Edited by Charles Heim Current Advancements in General Thoracic Surgery Edited by Charles Heim Published by Learning Press, 5 Penn Plaza, 19th Floor, New York, NY 10001, USA © 2018 Learning Press International Standard Book Number: 978-1-9789-0518-4 The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy. Furthermore, the publisher ensures that the text paper and cover boards used have met acceptable environmental accreditation standards. Trademark Notice: Registered trademark of products or corporate names are used only for explanation and identification without intent to infringe. This book contains information obtained from authentic and highly regarded sources. Copy- right for all individual chapters remain with the respective authors as indicated. A wide variety of references are listed. Permission and sources are indicated; for detailed attribu- tions, please refer to the permissions page. Reasonable efforts have been made to publish reliable data and information, but the authors, editors and publisher cannot assume any responsibility for the validity of all materials or the consequences of their use. Copyright of this ebook is with Learning Press, rights acquired from the original print publisher, Foster Academics. Contents Preface VII Chapter 1 Primary Lung Cancer Coexisting with Lung Metastases from Various Malignancies 1 Noritoshi Nishiyama Chapter 2 Malignant Pulmonary Solitary Nodules: High Resolution Computed Tomography Morphologic and Ancillary Features in the Differentiation of Histotypes 11 Michele Scialpi, Teresa Pusiol, Irene Piscioli, Alberto Rebonato, Lucio Cagini, Lucio Bellantonio, Marina Mustica, Francesco Puma, Luca Brunese and Antonio Rotondo Chapter 3 Short and Long Term Results of Major Lung Resections in Very Elderly People 25 Cristian Rapicetta, Massimiliano Paci, Tommaso Ricchetti, Sara Tenconi, Salvatore De Franco and Giorgio Sgarbi Chapter 4 The Acute Stress Reaction to Major Thoracic Surgery 49 Lucio Cagini, Jacopo Vannucci, Michele Scialpi and Francesco Puma Chapter 5 Robot Assisted Thoracic Surgery (RATS) 65 Naohiro Kajiwara, Masatoshi Kakihana, Jitsuo Usuda, Tatsuo Ohira, Norihiko Kawate and Norihiko Ikeda Chapter 6 Risk Prediction and Outcome Analysis 77 Constance K. Haan Chapter 7 Valved Conduits Right Ventricle to Pulmonary Artery for Complex Congenital Heart Defects 101 Antonio F. Corno ______________WORLD TECHNOLOGIES ______________ Chapter 8 Surgical Management of the Aortic Root 113 B. Goslin and R. Hooker Chapter 9 Thoracic Reconstruction 147 Christodoulos Kaoutzanis, Tiffany N.S. Ballard and Paul S. Cederna Chapter 10 Robotic Resection of Left Atrial Myxoma 179 José Francisco Valderrama Marcos, María Teresa González López and Julio Gutiérrez de Loma Chapter 11 Thoracic Trauma 197 Slobodan Milisavljević, Marko Spasić and Miloš Arsenijević Chapter 12 Thoracic Vascular Trauma 239 Nicolas J. Mouawad, Christodoulos Kaoutzanis and Ajay Gupta Chapter 13 Localized Drug Delivery for Cardiothoracic Surgery 263 Christopher Rolfes, Stephen Howard, Ryan Goff and Paul A. Iaizzo Chapter 14 Endoscopic Clipping and Application of Fibrin Glue for an Esophago-Mediastinal Fistula 289 Hiroshi Makino, Hiroshi Yoshida and Eiji Uchida Permissions List of Contributors VI Contents ______________WORLD TECHNOLOGIES ______________ Preface This book was inspired by the evolution of our times; to answer the curiosity of inquisitive minds. Many developments have occurred across the globe in the recent past which has transformed the progress in the field. The purpose of this book is to provide a concise analysis of various topics in the field of general thoracic surgery. It consists of a compilation of contributions from several renowned authors who present their knowledge and experiences from across the globe. The broad spectrum of subjects presented in this book ranges from CT examination of solitary pulmonary and metastatic nodules to prospective analyses of drug delivery in thoracic surgery including surgical risk prediction, robotic pulmonary and cardiac processes, stress reaction, vascular and thoracic reconstruction methodologies, mediastinal fistula and thoracic trauma. It represents an improvement in the knowledge and in the involvement of individuals associated with these areas of analysis. This book was developed from a mere concept to drafts to chapters and finally compiled together as a complete text to benefit the readers across all nations. To ensure the quality of the content we instilled two significant steps in our procedure. The first was to appoint an editorial team that would verify the data and statistics provided in the book and also select the most appropriate and valuable contributions from the plentiful contributions we received from authors worldwide. The next step was to appoint an expert of the topic as the Editor-in-Chief, who would head the project and finally make the necessary amendments and modifications to make the text reader-friendly. I was then commissioned to examine all the material to present the topics in the most comprehensible and productive format. I would like to take this opportunity to thank all the contributing authors who were supportive enough to contribute their time and knowledge to this project. I also wish to convey my regards to my family who have been extremely supportive during the entire project. Editor ______________WORLD TECHNOLOGIES ______________ "This page is Intentionally Left Blank" ______________WORLD TECHNOLOGIES ______________ Chapter 1 Primary Lung Cancer Coexisting with Lung Metastases from Various Malignancies Noritoshi Nishiyama Additional information is available at the end of the chapter 1. Introduction Various tumors metastasize to the lung, and they are often detected as multiple nodules. Advances in computed tomography (CT) have made it possible to detect small tumors. Even for multiple pulmonary nodules with previous malignancy, surgical removal is often required when the primary sites are well controlled and no other sites are involved. However, preoperative differential diagnosis of coexisting primary lung cancer is usually difficult for such small nodules [1]. Here, three cases of lung metastases that coexisted with primary lung cancer, confirmed by postoperative histological examination, are presented. In addition, a case with a proven lung cancer that coexisted with small nodules in the ipsilateral lung, one of which was pathologically diagnosed as a metastasis from rectal cancer, is presented. Further, the importance of active tissue diagnosis including surgery is discussed. 2. A: Lung metastases from various malignancies coexisting with primary lung cancer 2.1. Case 1 A 53-year old woman was diagnosed by needle biopsy as having a myxoid liposarcoma in the right thigh. A chest CT scan revealed small bilateral pulmonary nodules, which were diagnosed as pulmonary metastases; and the patient underwent two courses of preoperative chemotherapy with ifosfamide and adriamycin. There was a partial response to the chemotherapy for both the primary tumor and pulmonary metastases. Surgical resection of the primary tumor in the right thigh and bilateral pulmonary metastasectomy via sequential small axillary thoracotomies under video assistance (one in the right lower ______________WORLD TECHNOLOGIES ______________ lobe and one in the left upper lobe measuring 3 and 5 mm, respectively, and two in the left lower lobe measuring 5 and 8 mm) (Figure 1) was simultaneously performed in January 2008. Figure 1. Preoperative chest computed tomography (CT) images showing tumors (arrows): one in the right lower lobe and one in the left upper lobe measuring 3 and 5 mm, respectively (a, white arrows), and two in the left lower lobe measuring 5 and 8 mm (b, white arrow; c, black arrow). (d) Magnified image of (c). Postoperative pathological examination revealed that the tumor shown in panels (c) and (d) was a well differentiated adenocarcinoma. (From Nishiyama, Iwata, Nagano et al. Lung metastases from various malignances combined with primary lung cancer. Gen Thorac Cardiovasc Surg 2010; 58: 539. With permission) Current Advancements in General Thoracic Surgery 2 ______________WORLD TECHNOLOGIES ______________ A postoperative pathological examination revealed that one of the resected pulmonary tumors in the left lower lobe, measuring 8 mm in diameter, was a well differentiated adenocarcinoma (Noguchi type F) [2], and there were no viable tumor cells in the remaining three nodules; the resected tumor in the right thigh was finally diagnosed as a myxoid liposarcoma. Carcinoembryonic antigen (CEA), squamous cell carcinoma-related antigen (SCC), cytokeratin 19 fragment (CYFRA), and Sialyl Lewisx (SLX) were within normal ranges. No distant metastasis was found, and the patient was diagnosed with clinical stage IA primary lung cancer [3]. The risks and benefits for lobectomy and observation were explained to the patient. After informed consent was obtained, a left lower lobectomy via a left axillary thoracotomy was performed 17 days after the initial surgery. The patient recovered uneventfully, and a postoperative pathological examination revealed no lymph node metastasis. She was discharged with a treatment plan involving postoperative adjuvant chemotherapy for the liposarcoma. 2.2. Case 2 A 70-year old woman was referred to our hospital in June 2008 for further treatment of pulmonary metastases due to colon cancer. A chest CT scan revealed bilateral small pulmonary nodules: three in the right upper lobe and two in the left upper lobe (Figure 2). The patient underwent right hemicolectomy for stage IIIB transverse colon cancer in October 2005, followed by adjuvant chemotherapy with oral tegafur and leucovorin for 18 months postoperatively. Bilateral pulmonary metastases appeared in June 2007, but were markedly diminished in January 2008 when chemotherapy with 17 courses of 5-fluorouracil (5-FU), leucovorin and oxaliplatin was completed. However, the tumors re-grew and were diagnosed in May 2008. Serum CEA and CA 19-9 were within normal ranges. Bilateral pulmonary metastasectomy via sequential small axillary thoracotomies under video assistance (three in the right upper lobe measuring 12, 12 and 20 mm, and two in the left upper lobe measuring 5 and 12 mm) was carried out in June 2008. A postoperative pathological examination revealed that one of the resected pulmonary tumors in the left upper lobe, measuring 5 mm in diameter, was Noguchi type B bronchioloalveolar carcinoma [2]. The remaining four tumors were diagnosed as metastatic tubular adenocarcinoma from colon cancer. No distant metastasis was found, and the patient was diagnosed with clinical stage IA primary lung cancer [3]. She recovered uneventfully and was discharged with a plan of postoperative adjuvant chemotherapy for the colon cancer. 2.3. Case 3 A 69-year old man was referred to our hospital in October 2011 for further treatment of pulmonary metastases due to renal cell carcinoma. He underwent left nephrectomy for a left renal cell carcinoma (T1a, G1, INFα) in June 2007. A chest CT scan revealed two small pulmonary nodules in segments S8 and S9 of the right lower lobe that appeared in 3 Primary Lung Cancer Coexisting with Lung Metastases from Various Malignancies ______________WORLD TECHNOLOGIES ______________ November 2010 and increased in size in September 2011 (Figure 3). Serum CEA, CYFRA and SLX were within normal ranges, but SCC was slightly elevated to 2.1 ng/ml (normal range < 1.5 ng/ml). Although lung metastases were suspected, tissue diagnosis through bronchoscopy was unsuccessful and pulmonary metastasectomy via a small axillary thoracotomy was conducted under video assistance in October 2011. Figure 2. Preoperative chest CT images showing tumors (arrows): three in the right upper lobe measuring 12, 12 and 20 mm (a, b, c, white arrows), and two in the left upper lobe measuring 5 mm (black arrow) and 12 mm (white arrow) (d). (e) Magnified image of panel (d) (black arrow). Postoperative pathological examination revealed that the tumor shown in panel (e) was a Noguchi type B bronchioloalveolar carcinoma. The remaining four tumors were diagnosed as metastatic tubular adenocarcinoma from colon cancer. (From Nishiyama, Nagano, Izumi et al. Lung metastases from various malignances combined with primary lung cancer. Gen Thorac Cardiovasc Surg 2010; 58: 540. With permission) Current Advancements in General Thoracic Surgery 4 ______________WORLD TECHNOLOGIES ______________ Figure 3. Preoperative chest CT images showing tumors in the right lower lobe (black arrows): one in the S8 segment measuring 8 mm (a), and the other in the S9 segment measuring 7 mm (b). (c) Thin slice image of (b). An intra-operative pathological examination revealed that the tumor in the S9 segment was adenocarcinoma and postoperative pathological examination revealed that the tumor shown in panel (a) in the S8 segment was a metastatic clear cell carcinoma from renal cell carcinoma. An intra-operative pathological examination revealed that one of the pulmonary tumors in segment S9 measuring 7 mm in diameter was adenocarcinoma and a right lower lobectomy was performed. A postoperative pathological examination revealed that the tumor in segment S9 was Noguchi type A bronchioloalveolar carcinoma [2], and the other tumor measuring 8 mm in segment S8 of the resected lobe was metastatic clear cell carcinoma from renal cell carcinoma. No lymph node metastasis or distant metastasis was found, and the patient was diagnosed with clinical stage IA primary lung cancer [3]. He recovered uneventfully and was discharged with a plan of postoperative adjuvant chemotherapy for the renal cell carcinoma. 5 Primary Lung Cancer Coexisting with Lung Metastases from Various Malignancies ______________WORLD TECHNOLOGIES ______________ 3. B: Primary lung cancer coexisting with lung metastases from other malignancies 3.1. Case 4 A 62-year old man was referred to our hospital for further examination of a suspicious primary lung cancer in the left upper lobe, measuring 23 mm in diameter on a chest CT. In addition, the chest CT scan revealed other two nodules, one beside the tumor in the left upper lobe measuring 5 mm and the other in the left lower lobe measuring 10 mm (Figure 4). The patient had undergone surgery for stage IIIA rectal cancer followed by postoperative adjuvant chemotherapy 6 years ago, and stage IA gastric cancer 3 years ago. Trans-bronchial curettage cytology of the larger tumor in the left upper lobe revealed adenocarcinoma. CEA 13.2 ng/ml, SCC 2.0 ng/ml and SLX 47 U/ml (normal range <5.0 ng/ml, 1.5 ng/ml and 38 U/ml, respectively) serum tumor markers were elevated. Clinical diagnosis of primary lung cancer was established by cytology and chest CT, leaving a differential diagnosis of pulmonary metastasis from rectal cancer or gastric cancer. Preoperative tissue diagnosis of the other two nodules was unobtainable because of small lesions. The patient was advised on the risks and benefits of surgery for disease with metastases from lung cancer, rectal cancer or gastric cancer. After obtaining informed consent the patient underwent left upper lobectomy with mediastinal lymph node dissection, combined with partial resection of the left lower lobe in April 2008. A postoperative pathological examination using immunohistological staining revealed the tumor and the nodule in the left lower lobe as being poorly differentiated adenocarcinoma, which was cytokeratin (CK) 7 positive and CK 20 negative, CEA positive, surfactant apoprotein negative and thyroid transcription factor-1 (TTF-1) positive. Metastasis in the resected hilar lymph node was also diagnosed. Definitive pathological diagnosis of primary lung cancer with pulmonary metastasis in the ipsilateral lung and hilar lymph node metastasis (pT4N1M0, stage IIIA) [3] was established. The remaining nodule besides the tumor in the left upper lobe was diagnosed as metastasis from rectal cancer, and was CK 7 negative and CK 20 positive, CEA positive, surfactant apoprotein negative and TTF-1 negative. The patient recovered uneventfully and was discharged with a treatment plan involving postoperative chemotherapy for lung cancer. 4. Discussion Recent advances in CT have obviously contributed to the diagnosis of small pulmonary nodules and ground-glass opacity components which indicate possible primary lung cancer [4]. The preoperative differential diagnosis of either metastatic or primary lung cancer is usually difficult, because with the exception of surgery, it is not possible to obtain sufficient tissue from these small neoplasms. A retrospective assessment of case 1 suggested that a careful review of the CT scans could lead to a diagnosis of possible primary lung cancer because they demonstrated an unclear-bordered nodule with pleural indentation. In addition, the nodule, which was different from the others, did not reduce Current Advancements in General Thoracic Surgery 6 ______________WORLD TECHNOLOGIES ______________