Background: To determine factors predicting indocyanine green (ICG) visualization during fluorescence imaging for segmental plane formation in thoracoscopic anatomical segmentectomy.Methods: Intraoperatively, the intravenous ICG fluorescence imaging system during thoracoscopic anatomical segmentectomy obtained fluorescence emitted images of its surfaces during lung segmental plane formation after the administration of 5 mg/body weight of ICG. The subtraction of regularization scale for calculating the exciting peaks of ICG between the planned segments to resect and to remain was defined as ΔIntensity (ΔI). Variables such as the ratio of forced expiratory volume in 1 s to forced vital capacity (%FEV 1.0 ), smoking index (SI), body mass index (BMI), and low attenuation area (LAA) on computed tomography (CT) took a leading part.Results: The formation of the segmental plane was successfully accomplished in 98.6% segments and/or subsegments. SI and LAA significantly affected ΔI levels. The area under the receiver operating characteristic curve for the %FEV 1.0 , SI, and LAA was 0.56, 0.70, and 0.74, respectively. SI >800 and LAA >1.0% were strong predictors of unfavorable ICG visibility (P=0.04 and 0.01, respectively).Conclusions: Fluorescence imaging with ICG was a safe and effective method for segmental plane formation during thoracoscopic anatomical segmentectomy. In spite of its high success rate, unfavorable visibility may potentially occur in patients who are heavy smokers or those with a LAA (>1.0%) on CT. margin. Misunderstanding of anatomical structures may cause unnecessary bleeding or postoperative air leakage and inadequate resection of a non-palpable tumor in the remaining lobe. Several methods to identify the lung demarcation line have been reported (3,4). Intriguingly, methods based on lung ventilation frequently require that the intersegmental plane be approached along the inflation-deflation (ID) line at the peripheral site, while the intersegmental vein serves as a landmark at the central portion around the hilum. The ID lines, also known as segmental lines, sometimes overlap due to the existence of the pores of Kohn at the lung periphery. For methods that use the ID line to detect the segmental plane, the degree of difficulty becomes higher in patients with emphysematous lung. In such a case, the surgeons' experience and skills are required, particularly in thoracoscopic surgery (TS).The technique of visualizing the demarcation line based on fluorescence imaging with indocyanine green (ICG) during thoracotomy or thoracoscopy was recently developed and used by surgeons, with relatively high success rates (3,5). From our experiences during anatomical segmentectomy by TS, we noticed that ICG brightness varied in every case, depending on the blood flow or presence of anthracosis; therefore, there is a doubt on the accuracy of ICG fluorescence imaging in demarcating the segmental plane. The ICG visualization tended to be hard in patients with heavy anthracosis compared with those with light-to-middle an...

Background The incidence of postoperative atrial fibrillation (POAF) after pulmonary lobectomy ranges from 6.4 to 12.6%. This study aimed to analyze the postoperative risk factors and prognosis for POAF in lobectomy for lung cancer. Methods Data were collected from patients undergoing pulmonary lobectomy from April 2010 to March 2019. We analyzed risk factors for POAF among perioperative factors and compared postoperative complications or overall survival between POAF and non‐POAF groups. We classified POAF as either the temporary or non‐temporary type and compared perioperative factors, postoperative complications, and overall survival. Results POAF was identified in 49 (5.2%) of the 947 lobectomies. The POAF group included more males, patients with poor performance status (PS), history of paroxysmal atrial fibrillation (AF), chronic obstructive pulmonary disease (COPD), and intraoperative blood transfusions. Poor PS, COPD, previous paroxysmal AF, and intraoperative blood transfusion were independent risk factors for POAF in multivariate analysis. The POAF group had a poorer prognosis than the non‐POAF group (p = 0.0045). POAF was divided into 29 temporary and 20 non‐temporary types. The onset date of non‐temporary‐type POAF was significantly later than that of the transient type (P < 0.01), and diabetes mellitus was significantly higher in non‐temporary‐type POAF. Non‐temporary‐type POAF had a significantly poorer prognosis in terms of overall survival (p = 0.005). Conclusions Poor PS, COPD, history of PAF, and intraoperative blood transfusion were independent risk factors for POAF. Non‐temporary‐type POAF occurred significantly later than transient type and caused poorer prognosis after lobectomy for lung cancer.

Comprehensive genetic panel testing generally requires that the analyzed tissues have a percent tumor nuclei (%TN) content of 20% or more to achieve assay performance comparable to the validated specifications. Pathologists play a crucial role in ensuring that the optimal results are achieved by accurately assigning %TN content of the available specimens and selecting the best material to submit for sequencing. This study addresses the issues in evaluating %

ObjectivesThere have been few studies that have fully elucidated the relationship between genomic mutations in pulmonary adenocarcinomas and occult lymph node (LN) metastases (pN1-2) despite a preoperative clinical N0 stage (cN0). It is well known that anaplastic lymphoma kinase (ALK) rearrangements are more likely to occur in younger patients with high grade tumors. The aim of this study was to investigate the genomic status, examine the clinicopathologic features, and evaluate whether ALK mutations are associated with occult LN metastases.Materials and methodsWe retrospectively evaluated 459 Japanese patients who underwent pulmonary resection of cN0 adenocarcinomas between January 2012 and December 2015. The clinicopathologic characteristics, including age, sex, smoking index, tumor maximum diameter and consolidation/tumor ratio on computed tomography (CT), maximum standardized uptake value on positron emission tomography (PET) and gene mutations (epidermal growth factor receptor [EGFR], ALK, and kirsten ras genes (KRAS), were evaluated.ResultsALK and EGFR and KRAS mutations were all mutually exclusive. Among 324 patients found to have mutations, ALK was involved in 19 (5.9%), EGFR in 266 (82.1%), and KRAS in 39 (12.0%). The incidence of occult LN metastases did not differ significantly between those with or without mutations (p=0.27). On univariate and multivariate analyses, tumors with ALK were more likely to have occult LN metastases (p=0.03). In cN0 tumors with ALK, pN1 was diagnosed in 26.3% and pN2 in 10.5%, whereas pN1 or pN2 stage was found in <10.0% in those with EGFR or KRAS mutations or with no mutations at all. No significant difference was found in the 2-year disease-free survival among those with gene mutations (p=0.08).ConclusionThis study highlights the frequency of PET- and CT-negative occult LN metastases in resected adenocarcinomas with ALK rearrangement. Our multivariate analysis showed that ALK rearrangements were associated with a significantly higher incidence of occult LN metastasis compared with ALK-negative adenocarcinomas.

Background The incidence of postoperative delirium after anatomical lung resection ranges from 5 to 16%. This study aimed to analyze the risk factors and prognosis of postoperative delirium in anatomical lung resection for lung cancer. Methods This study included 1351 patients undergoing anatomical lung resection between April 2010 and October 2020. We analyzed the perioperative risk factors of postoperative delirium. We also compared postoperative complications and survival between the delirium and non-delirium groups.Results Postoperative delirium was identified in 44 (3.3%) of 1351 patients who underwent anatomical lung resection for lung cancer. Age, peripheral vascular disease, depression, and current smoking status were independent risk factors for postoperative delirium in the multivariate analysis. The percentage of postoperative delirium was 0.6% in never smokers and 6.0% in current smokers. The delirium and non-delirium groups showed significant differences in overall survival (p = 0.0144) and non-disease-specific survival (p = 0.0080). After propensity score matching, the two groups did not significantly differ in overall survival (p = 0.9136), non-disease-specific survival (p = 0.8146), or disease-specific survival (p = 0.6804). Conclusions Age, peripheral vascular disease, depression, and current smoking status were considered independent risk factors for postoperative delirium in anatomical lung resection for lung cancer. Smoking cessation for at least four weeks before surgery is recommended for reducing incidence of post-operative delirium.