Background and objective: The prognostic nutritional index (PNI) is based on the serum albumin level and lymphocyte count, and is a useful predictor of survival in various cancers. However, the utility of PNI in lung cancer has not been examined. The aim of this study is to assess PNI as a prognostic factor in elderly patients after surgery for primary lung cancer. Methods: A retrospective review was performed in 131 elderly patients (>= 75 years old) with lung cancer who underwent curative operations at our hospital from July 2008 to December 2014. Survival was calculated by the Kaplan-Meier method. The effects of PNI and clinicopathological factors on survival were evaluated in univariate and multivariate Cox regression analyses. Results: The 5-year cancer-specific survival (CSS) rates of patients with PNI >= 45 and < 45 were 76.2% and 47.8%, respectively (P = 0.0166), and the 5-year overall survival (OS) rates were 61.9% and 39.8%, respectively (P = 0.0275). Among patients who died within 5 years, mortality due to other diseases was 31%. Univariate analysis identified gender (P = 0.003), serum carcinoembryonic antigen (CEA) (P = 0.009), PNI (P = 0.027), c-stage (P = 0.005), histological type (P = 0.001) and p-stage (P < 0.001) as prognostic factors. In multivariate analysis, CEA (HR 2.487, P = 0.0169), PNI (HR 2.737, P = 0.0289) and p-stage (HR 3.294, P = 0.007) were independent prognostic factors in elderly patients after curative surgery for lung cancer. Conclusions: CEA, PNI and p-stage are independent prognostic factors in elderly patients after surgery for primary lung cancer. Therefore, determination of preoperative PNI may be useful for treatment planning in elderly patients with lung cancer.

A 48-year-old man presenting with cough, dysphagia and chest pain was diagnosed with advanced inoperable squamous cell carcinoma located in the right S2 with mediastinal lymph node metastases invading the oesophagus (c-T4N2M0 stage IIIB). Concurrent chemoradiotherapy (66 Gy) was planned, but he developed a tracheo-oesophageal fistula during the chemoradiotherapy course (26 Gy). A right sleeve pneumonectomy with oesophagectomy, cervical oesophagostomy and enterostomy were performed. Although bilateral recurrent nerve palsy occurred, he recovered via enhanced rehabilitation and was discharged 28 days after the salvage surgery. Three months after the initial surgery, staged reconstruction surgery of the stomach was performed. Intensive rehabilitation resulted in restored swallowing ability. He is alive with recurrent disease 12 months after surgery. This is the first report of salvage surgery for advanced lung cancer with tracheo-oesophageal fistula during concurrent chemoradiotherapy.

Background: Robot-assisted thoracic surgery (RATS) for mediastinal tumors is a minimally invasive approach that offers three-dimensional magnified visualization, tremor filtration, and articulated instruments. Although it is expected to reduce postoperative pain compared with open surgery, pain may still arise from intercostal ports, subxiphoid incisions and chest tubes. Therefore, a consistent multimodal analgesic strategy is needed from the intraoperative to the postoperative period, tailored to the surgical approach and port placement. Objective: This review aims to characterize the mechanisms underlying postoperative pain after RATS for mediastinal tumors and to examine the current evidence and clinical indications for systemic analgesics and regional analgesic techniques, including thoracic epidural analgesia (TEA), peripheral nerve blocks, and local wound infiltration. Conclusions: Routine use of TEA may not be necessary for all patients undergoing RATS for medi-astinal tumors. In most cases, a multimodal analgesic regimen based on acetaminophen, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2 selective inhibitors, supplemented with a single-shot regional block or local wound infiltration according to the surgical approach and port placement, appears reasonable. However, individualized analgesic strategies incorporating continuous regional analgesia should be considered in patients undergoing extensive thymectomy, those requiring ports across multiple intercostal spaces, those at risk of conversion to open surgery, and those with severe preoperative pain or an increased risk of chronic postoperative pain.