Background: Division of intersegmental planes is one of the important practical issues for segmentectomy to obtain feasible outcomes without relapse for clinical stage I non-small cell lung cancer. Almost all surgeons perform this procedure using a stapler. However, division of intersegmental planes for segmentectomy can also be performed by electrocautery. In this article, we demonstrate the merits and drawbacks of division of the intersegmental plane by electrocautery for segmentectomy. Methods: Of those 125 patients who underwent segmentectomy with clinical stage I primary lung cancer, we compared cautery cases (n=50) with stapler cases (n=75). The cautery group included 29 cases (58.0%) with partial use of a staple at the end of division. Results: Operative time was significantly longer in cautery cases (281±72 min) than stapler in cases (235±86 min; P=0.003). No difference in the duration of chest tube placement was evident between cautery (3.0±3.0 days) and stapler groups (2.8±1.7 days; P=0.613). However, delayed air leakage occurred significantly more frequently in cautery cases (14.0%) than in stapler cases (4.0%; P=0.048). Five-year overall survival (OS) in clinical stage I was 94.7% in cautery cases and 80.5% in stapler cases (log-rank P=0.047). Five-year disease-free survival (DFS) was 80.0% and 71.3%, respectively (log-rank P=0.075). Conclusions: The merits of cautery division include the ability to achieve meticulous division of the intersegmental plane and good preservation of the shape of residual segments. Conversely, the drawbacks include prolonged air leakage. Pleural suture or closure of residual segments may be useful to prevent delayed air leakage.

BackgroundA better understanding of the tumor immune microenvironment (TIME) will facilitate the development of prognostic biomarkers and more effective therapeutic strategies in patients with lung cancer. However, little has been reported on the comprehensive evaluation of complex interactions among cancer cells, immune cells, and local immunosuppressive elements in the TIME.MethodsWhole-exome sequencing and RNA sequencing were carried out on 113 lung cancers. We performed single sample gene set enrichment analysis on TIME-related gene sets to develop a new scoring system (TIME score), consisting of T-score (tumor proliferation), I-score (antitumor immunity) and S-score (immunosuppression). Lung cancers were classified according to a combination of high or low T-score, I-score, and S-scores (eight groups; G1-8). Clinical and genomic features, and immune landscape were investigated among eight groups. The external data sets of 990 lung cancers from The Cancer Genome Atlas and 76 melanomas treated with immune checkpoint inhibitors (ICI) were utilized to evaluate TIME scoring and explore prognostic and predictive accuracy.ResultsThe representative histological type including adenocarcinoma and squamous cell carcinoma, and driver mutations such as epidermal growth factor receptor and TP53 mutations were different according to the T-score. The numbers of somatic mutations and predicted neoantigens were higher in Thi (G5-8) than Tlo (G1-4) tumors. Immune selection pressure against neoantigen expression occurred only in Thi and was dampened in Thi/Ilo (G5-6), possibly due to a reduced number of T cells with a high proportion of tumor specific but exhausted cells. Thi/Ilo/Shi (G5) displayed the lowest immune responses by additional immune suppressive mechanisms. The T-score, I-score and S-scores were independent prognostic factors, with survival curves well separated into eight groups with G5 displaying the worst overall survival, while the opposite group Tlo/Ihi/Slo (G4) had the best prognosis. Several oncogenic signaling pathways influenced on T-score and I-scores but not S-score, and PI3K pathway alteration correlated with poor prognosis in accordance with higher T-score and lower I-score. Moreover, the TIME score predicted the efficacy of ICI in patients with melanoma.ConclusionThe TIME score capturing complex interactions among tumor proliferation, antitumor immunity and immunosuppression could be useful for prognostic predictions or selection of treatment strategies in patients with lung cancer.

BackgroundAlthough gastrointestinal involvement in patients with granulomatosis with polyangiitis is uncommon, it is associated with mild to severe life-threatening complications. We present a case of pneumatosis cystoides intestinalis in a patient with granulomatosis with polyangiitis that was treated successfully with hyperbaric oxygen.Case presentationA 70-year-old Japanese man with a 3-year history of granulomatosis with polyangiitis consulted our hospital with a complaint of severe back pain. Computed tomography showed a large amount of gas located in his bowel wall and mesentery. He underwent urgent exploratory laparotomy, which led to a diagnosis of pneumatosis cystoides intestinalis without intestinal perforation or necrosis. He consequently underwent 13 sessions of hyperbaric oxygen therapy and was discharged from our hospital without complications.ConclusionsSeveral previous reports have supported the efficacy of hyperbaric oxygen for treating pneumatosis cystoides intestinalis. The present case, however, is the first in which pneumatosis cystoides intestinalis in a patient with granulomatosis with polyangiitis was successfully treated with hyperbaric oxygen. We therefore suggest that hyperbaric oxygen therapy could be a candidate treatment for pneumatosis cystoides intestinalis in patients with granulomatosis with polyangiitis.

Objectives: Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) is a risk factor for surgical site infections (SSIs). However, few studies have evaluated the rate of nasal carriage of MRSA and its effect on SSIs in patients undergoing general thoracic surgery. We investigated the importance of preoperative screening for nasal carriage of MRSA in patients undergoing general thoracic surgery. Patients and Methods: We retrospectively analyzed 238 patients with thoracic diseases who underwent thoracic surgery. We reviewed the rates of nasal carriage of MRSA and SSIs. Results: Results of MRSA screening were positive in 11 of 238 patients (4.6%), and 9 of these 11 patients received nasal mupirocin. SSIs occurred in 4 patients (1.8%). All 4 patients developed pneumonia; however, MRSA pneumonia occurred in only 1 of these 4 patients. No patient developed wound infection, empyema, and/or mediastinitis. SSIs did not occur in any of the 11 patients with positive results on MRSA screening. Conclusions: The rates of nasal carriage of MRSA and SSIs were low in this case series. Surveillance is important to determine the prevalence of MRSA carriage and infection in hospitals, particularly in the intensive care unit. However, routine preoperative screening for nasal carriage of MRSA is not recommended in patients undergoing general thoracic surgery.

Necrotizing soft tissue infection (NSTI) is a rare but rapidly progressing soft-tissue infection. Few reports of NSTI caused by colon cancer have been published. We present a rare case of NSTI of the thigh associated the retroperitoneal spread of ascending colon cancer. A 64-year-old man had noticed right hip pain since 3 months before admission, he felt pain in the right thigh which was reddening, and he had difficulty in walking. He was referred to Yokosuka general hospital Uwamachi. Anterolateral aspect of his right thigh was reddening and swelling. The patient was diagnosed with a psoas abscess and a NSTI of the right thigh caused by penetration of ascending colon tumor. The patient underwent debridement of severely necrotized tissue in the right thigh, diverting ileostomy and subsequently a right hemicolectomy with reversal of the ileostomy were performed. He was discharged 70 days after the first surgery. Colon cancer can be a cause of retroperitoneal abscess accompanied by NSTI of the thigh. Two-stage surgery was an efficient option in this patient with NSTI of the thigh associated with locally advanced ascending colon cancer.

In this single-institution, propensity score-matched study, hybrid VATS showed a shorter operative time and similar outcomes compared with thoracoscopic lobectomy for clinical stage IA lung cancer.

Some reports suggest the positive correlation between Schistosoma japonicum infection and colorectal cancer, however the sufficient evidence that supports a causal relationship between them has not been established. Japan used be an endemic area of S. japonicum infection for 40 years ago. But now all of Japan is a non-endemic area of S. japonicum infection. We report a case of ascending colon cancer associated with deposited ova of S. japonicum in non-endemic area.

During segmentectomy, the most critical consideration is establishment of sufficient surgical margins around the cancer. Our hybrid approach that includes meticulous surgical manipulations may produce sufficient surgical margins.