A 54-year-old Japanese man with a 30 pack-year smoking history was referred to a medical institution due to pain and paresthesia from the ulnar surface of the right forearm to the small finger of the right hand in the distribution of the C8 and T1 dermatomes that had persisted for approximately 2 months. He had no remarkable medical history. The patient’s laboratory data revealed an elevation carcinoembryonic antigen (CEA) level of 8.4 ng/ml. A chest X-ray showed a tumoral shadow at the right apex of the upper-lung field. (Fig. 1a). On a computed tomography (CT) of the chest, a 56 × 30 × 25-mm mass was discovered at the right superior sulcus (Fig. 1b–e). The mass was suspected to have invaded the chest wall of the right first and second intercostal space (Fig. 1b–d). Additionally, the disruption of blood flow of the subclavian vein, which was suspected to be due to tumor invasion, was confirmed (Fig. 1d). Fluorodeoxyglucose-positron emission tomography (FDG-PET) demonstrated high FDG uptake (SUVmax 13.5) in the mass at the right lung apex (Fig. 1f). Bone scintigraphy and cerebral magnetic resonance imaging (MRI) showed no evidence of distant metastasis. The histopathological diagnosis of a bronchoscopic biopsy specimen was non-small cell lung cancer-suspected adenocarcinoma. The tumor was classified as cStage IIB (cT3N0M0). The patient was referred to our hospital for the treatment. We decided to perform neoadjuvant chemoradiotherapy followed by right upper lobectomy.
We induced chemotherapy with cisplatin 80 mg/m2 on day 1, plus vinorelbine 20 mg/m2 on days 1 and 8. Two cycles of chemotherapy were scheduled every 21 days. Concurrent thoracic radiation therapy (40 Gy in 20 fractions of 2 Gy each) was performed. Chest CT after chemoradiotherapy indicated remarkable reduction of the tumor (Fig. 1g, h). Also, it revealed a partial response in which tumor volume decreased by 65.2% (Fig. 1h). In addition, most of the contact between the tumor and the chest wall was released (Fig. 1h). We assessed the patient at stage ycT1bN0M0 and ycStage IA2. The pain and paresthesia from the ulnar aspect of the right forearm to the little finger were much improved. The laboratory data showed that the CEA level had decreased to 6.9 ng/ml. Because there was no evidence of distant metastasis or local progression, we planned to perform right upper lobectomy 4 weeks after the completion of the chemoradiotherapy. Because chest CT after chemoradiotherapy indicated the remarkable shrinkage of the tumor, we decided to attempt thoracoscopic right upper lobectomy. When firm adhesion is observed between the tumor and chest wall, our policy is to perform open thoracotomy with chest wall resection.
The patient was positioned in the left lateral decubitus position. First, we observed the right thoracic cavity using a thoracoscopy through a 10-mm trocar in the sixth intercostal space on the midaxillary line. Because only partial adhesion of the chest wall apex was observed (Fig. 2a), we judged that tumor resection could be accomplished by complete VATS. We inserted a 7.5-mm trocar in the fourth intercostal space on the posterior axillary line and a 3-cm wound retractor in the same intercostal space on the anterior axillary line. Partial parietal pleurectomy was performed with the resection of the extra parietal pleural fatty tissue of the site of tumor adhesion (Fig. 2b). We confirmed that the extra parietal pleural fatty tissue was a safe margin, ensuring (by an intraoperative diagnosis) that it contained no viable cancer cells. Subsequently, we performed right upper lobectomy with lymph node dissection (ND2a-1) through complete VATS.
A postoperative pathological examination revealed no viable cancer cells in the resected tumor. The pathological effect of induction therapy was classified as a pathologically complete cell death, Ef 3. However, extensive fibrotic lesions with hyaline degeneration were confirmed in the resected specimen as the evidence of the effect of chemoradiotherapy. Parietal pleural invasion of the tumor was suggested on histopathological images of the resected specimen in which elastic fibers disappeared and were replaced by connective tissue. We reexamined the preoperative bronchoscopic biopsy specimen, which had been diagnosed as non-small cell lung cancer. A histopathological examination revealed the absence of morule formation (Fig. 3a). Immunohistochemistry revealed that the tumor cells were positive for p53 protein (Fig. 3b), oncofetal protein (SALL4 and Glypican3), and β-catenin (Fig. 3c–e). With respect to β-catenin staining, membranous expression patterns were observed (Fig. 3e). As for neuroendocrine markers, the specimen was positive for CD56 but negative for chromogranin A and synaptophysin. These immunohistochemistry results supported a pathological diagnosis of adenocarcinoma with fetal features (high grade). We decided not to perform adjuvant chemotherapy because of the pathological complete response to neoadjuvant chemoradiotherapy.
The patient was discharged without postoperative complications on the 14th day after the surgery. He receives clinical and radiologic assessments every 3 months. No recurrence was observed at 2 years of follow-up.
