Outpatient thoracoscopic limited sympathectomy for hyperhidrosis palmaris

Thoracoscopic sympathectomy is considered the most effective treatment for hyperhidrosis palmaris. We have treated 1,043 cases of this disease by this method. We have developed an outpatient technique of thoracoscopic sympathectomy using electrocautery. This procedure has been used in 47 patients with hyperhidrosis palmaris. The early results have been favorable. We describe this fast, safe, economic, and effective method for the treatment of hyperhidrosis palmaris.

Resympathectomy for palmar and axillary hyperhidrosis

BACKGROUND

The aim was to analyse patterns of failure or symptom recurrence after primary sympathectomy for palmar or axillary hyperhidrosis, and to carry out tactical problem-solving for resympathectomy and review the operative findings.

METHODS

Over a 2-year period, 20 patients (six men and 14 women) underwent resympathectomy for palmar hyperhidrosis (13 patients, 20 sides) or axillary hyperhidrosis (seven patients, ten sides). T2-3 sympathectomy for palmar hyperhidrosis or T4-5 sympathectomy for axillary hyperhidrosis was performed during the repeat procedure. Criteria for evaluation by means of patient questionnaire included good (more than 80 per cent), fair (50-80 per cent) and poor (less than 50 per cent) improvement.

RESULTS

Operative findings included inadequate sympathectomy on 19 sides, nerve regeneration on eight sides and no evidence of previous sympathectomy on three sides. One patient had Kuntz fibre in addition to inadequate sympathectomy. In the palmar hyperhidrosis group, good results were obtained in all 13 patients on all 20 sides after resympathectomy. In the axillary hyperhidrosis group, six of seven patients, or eight of ten sides, showed good results after resympathectomy.

CONCLUSION

The main cause of primary sympathectomy failure was inadequate surgery, and recurrence of palmar or axillary hyperhidrosis was seldom caused by nerve regeneration. The key factor for preventing failed sympathectomy or recurrent palmar or axillary hyperhidrosis is a first-time sympathectomy that is both accurate and adequate. Most patients with recurrent symptoms can be cured by resympathectomy.

Color Doppler ultrasound pulsatile flow signals of thoracic lesions: comparison of lung cancers and benign lesions

Color Doppler ultrasound (US) was performed in 153 patients (including 102 with lung cancer and 51 with benign lesions) to assess pulsatile flow signals in thoracic lesions. The values of resistive index (RI) and pulsatility index (PI) of color Doppler US pulsatile flow signals in lung cancers and benign lesions were measured, analyzed, and compared. In the enrolled 153 patients with thoracic lesions, 61 lung cancers and 34 benign lesions had detectable color Doppler US pulsatile flow signals, and lung cancers had lower RI and PI values than benign lesions (RI: 0.70+/-0.03 vs. 0.79+/-0.04, p < 0.05; PI: 1.61+/-0.15 vs. 2.44+/-0.25, p < 0.005). However, overlapping RI and PI values in lung cancers and benign lesions somewhat limited color Doppler US pulsatile flow signals to differentiate lung cancers from benign lesions. Further analysis of RI and PI values in subgroups of lung cancers [squamous cell carcinoma (SCC, n = 34), adenocarcinoma (AC, n = 18), and small-cell lung cancer (SCLC, n = 6)] and benign lesions [cavitary benign lesions (CBL, n = 8), and noncavitary benign lesions (NCBL, n = 26)] revealed that all different cell types of lung cancers (SCC, AC, and SCLC), indeed, had lower RI and PI values than NCBL (for RI, all p < 0.01; for PI, all p< or =0.001). Moreover, the mean RI and PI values showed a significant incremental decrease from NCBL (mean RI, PI = 0.88, 2.94) toward SCC and AC (for SCC, mean RI, PI = 0.71, 1.68; for AC, mean RI, PI = 0.68, 1.67) and, finally, to SCLC (mean RI, PI = 0.62, 1.05). In contrast, CBL had relatively lower RI and PI values than AC and SCLC (for CBL, mean RI, PI = 0.53, 0.80; both p > 0.05 for RI and PI), and even a significant difference from SCC (p < 0.05 for RI and PI). We conclude that color Doppler US pulsatile flow signal is somewhat limited to differentiate lung cancers from benign lesions, but provides a noninvasive in vivo model to assess the neovascularity intensity of lung cancers.

Beta cyclodextrins enhance adenoviral-mediated gene delivery to the intestine

PURPOSE

In general, the intestinal epithelium is quite refractory to viral and non-viral methods of gene transfer. In this report, various cyclodextrin formulations were tested for their ability to enhance adenoviral transduction efficiency in two models of the intestinal epithelium: differentiated Caco-2 cells and rat jejunum.

METHODS

Transduction efficiency of replication-deficient adenovirus type 5 vectors encoded with either the E. coli beta-galactosidase or the jellyfish green fluorescent protein gene was assessed by X-gal staining or visualization of fluorescence 48 hours after infection. In vivo experiments were performed using an intestinal loop ligation technique.

RESULTS

Several formulations of neutral and positively charged beta cyclodextrins significantly enhanced adenoviral-mediated gene transfer in the selected models. The cyclodextrin formulations studied increased adenoviral transduction in the intestine by enhancing both viral binding and internalization. Viral binding was significantly increased on cell membranes treated with positively charged cyclodextrins, as seen with confocal microscopy and rhodamine-labeled virus. Permeability studies and TEER readings revealed that the most successful formulations gently disrupt cell membranes. This enhances internalization of viral particles and results in increased levels of gene expression.

CONCLUSIONS

These formulations can be of value in gene transfer to cells and tissues in which adenoviral infection is limited due to a lack of fiber and alpha(v) integrin receptors. They are simple to prepare and do not affect the ability of the virus to transduce target cells.

Overexpression of human intestinal oligopeptide transporter in mammalian cells via adenoviral transduction

PURPOSE

Our goals are to establish an in vitro screening system and to evaluate a new approach in improving oral absorption of peptides and peptide-like drugs by overexpression of the human intestinal oligopeptide transporter (hPepT1). This study characterizes the expression of hPepT1 in human intestinal Caco-2 cells, rat intestinal epithelial cells (IEC-18), and human cervix epithelial cells (Hela) after adenoviral transduction.

METHODS

A recombinant replication-deficient adenovirus carrying the hPepT1 gene was made and used as a vector for the expression of hPepT1. The increase in the uptake permeability of cephalexin and Gly-Sar was determined. The effects of time, dose, apical pH, and substrate specificity were evaluated.

RESULTS

A significant increase in the uptake permeability of Gly-Sar and cephalexin was found in all three cell lines after viral transduction. The increase of Gly-Sar permeability in Hela. IEC-18, and Caco-2 cells was 85-, 46-, and 15-fold respectively. Immunoblotting using an antibody against hPepT1 detected high levels of a 85-98-kDa protein in all three infected cell lines. Substrate permeability was dependent on time of infection, inward pH gradients, and multiplicity of infection (MOI). Decreased infectivity and lower hPepT1 expression were observed in differentiated Caco-2 cells. The uptake was inhibited by dipeptides and beta-lactam antibiotics but not amino acids.

CONCLUSIONS

Adenoviral infected Hela cells displayed a pronounced level of hPepT1 expression with a low background and high specificity to dipeptides. These features make this system a useful tool for screening of potential substrates. The success of overexpression of hPepT1 in Caco-2 and IEC-18 cells may lead to a novel approach in improving oral absorption of peptides and peptidornimetic drugs.

Intracerebral hemorrhage in a young woman with arteriovenous malformation after taking diet control pills containing phenylpropanolamine: a case report

Administration of phenylpropanolamine (PPA) is a rare cause of intracerebral hemorrhage. We present the case of a young female patient with arteriovenous malformation who suffered an intracerebral hemorrhage after ingestion of diet pills containing PPA. The literature on PPA-related intracerebral hemorrhage is also reviewed. This is the first report of PPA-associated intracerebral hemorrhage in a patient with pathology-proven arteriovenous malformation of the brain. Because intracerebral hemorrhage may develop as a side effect of PPA when patients take the manufacturer's recommended dose, especially in patients with vascular abnormalities, we conclude that this medicine should be prescribed carefully and patients should be closely monitored by experienced physicians. Furthermore, its use should be contraindicated in patients who have, or possibly have, a family history of vascular abnormalities.

Differential tyrosine phosphorylation/activation of oncogenic proline-directed protein kinase F(A)/GSK-3alpha in well and poorly differentiated human prostate carcinoma cells

Computer analysis of protein phosphorylation site sequences revealed that transcriptional factors and viral oncoproteins are prime targets for regulation of proline-directed protein phosphorylation, suggesting an association of the proline-directed protein kinase (PDPK) family with neoplastic transformation and tumorigenesis. In this report, an immunoprecipitate activity assay of proline-directed protein kinase F(A)/glycogen synthase kinase-3alpha (PDPK F(A)/GSK-3alpha) has been optimized to demonstrate significantly increased (p < 0.01) activity in poorly differentiated human prostate carcinoma PC-3 cells (55.5+/-3.8 units/mg) when compared to well-differentiated LNCaP cells (28.1+/-2.3 units/mg). Immunoblotting analysis revealed that increased activity of this PDPK in PC-3 cells is due not to overexpression of the protein, but to enhanced tyrosine phosphorylation of the kinase. When treated with genistein (a protein tyrosine kinase PTK inhibitor), the enhanced tyrosine phosphorylation/activation of the kinase in PC-3 cells can be blocked. Conversely, when treated with vanadate (a protein tyrosine phosphatase PTP inhibitor), the phosphotyrosine content of PDPK F(A)/GSK-3alpha in LNCaP cells can be promoted to the level of PC-3 cells. In sharp contrast, the PTK inhibitor has little effect on the tyrosine phosphorylation level of the kinase in LNCaP cells, whereas the PTP inhibitor has little effect on the tyrosine phosphorylation level of the kinase in PC-3 cells. Taken together, the results provide initial evidence that the tyrosine phosphorylation/activation levels of this oncogenic PDPK can be differentially regulated in well- and poorly differentiated prostate carcinoma cells.

Acute inductive effects on oncogenic proline-directed protein kinase FA/GSK-3 alpha in NIH 3T3 cells by ethanol and cadmium

Exposure of NIH 3T3 cells to 375 mM ethanol at 37 degrees C for 20 min could induce a rapid increase in the protein level and cellular activity of oncogenic proline-directed protein kinase FA/glycogen synthase kinase-3 alpha (PDPK FA/GSK-3 alpha), up to approximately 300% of the control level, in a time- and concentration-dependent manner. The maximal inductive effect on PDPK FA/GSK-3 alpha also occurred within 40 min when cells were treated with only 100 mM ethanol. Similarly, exposure of NIH 3T3 cells to 100 microM cadmium for 2 h could induce a rapid increase in the protein level and cellular activity of PDPK FA/GSK-3 alpha, up to approximately 250% of the control level, in a time- and concentration-dependent manner. The maximal inductive effect on this kinase reached within 3 h when cells were treated with only 50 microM cadmium. The results demonstrate that PDPK FA/GSK-3 alpha may not represent a constitutively active/mitogen-inactivated protein kinase as previously conceived. Taken together with the previous report that PDPK FA/GSK-3 alpha is a heat-inducible protein kinase, the results further demonstrate that PDPK FA/GSK-3 alpha may represent a typical cellular stresses-inducible protein kinase subject to early induction by heat, ethanol and cadmium.

Clinical experience in radical lymphadenectomy for adenocarcinoma of the gastric cardia

OBJECTIVES

We evaluated the pattern of nodal metastasis and its prognosis after radical lymphadenectomy in adenocarcinoma of the gastric cardia.

METHODS

We conducted a retrospective cohort study of 70 patients (52 men and 18 women; mean age 63.6 years) with adenocarcinomas of the gastric cardia who underwent extended gastrectomy (65 total gastrectomies and 5 proximal gastrectomies) and radical lymphadenectomy (D2 to D4) at Taichung Veterans General Hospital between 1989 and 1995.

RESULTS

Twenty-four complications developed in 22 (31.4%) patients, and seven (10.0%) hospital deaths occurred. An overall 5-year cumulative survival of 37.6% was obtained. Lymph node metastases were identified in 53 (75.7%) patients. Nodal involvement was closely related to the depth of tumor invasion (p = 0.005). When the gastric wall invasion was limited to the subserosal layer (T1 and T2, n = 15), no patient had N4 group nodal metastasis. Once the serosal layer had been involved (beyond T3), N4 group nodal metastasis was frequently seen (30.9%, 17 of 55 patients). A multivariable analysis revealed that the level of nodal involvement, the depth of tumor invasion, and the presence of complications were independent prognostic factors. Cumulative 5-year survivals of curability A (n = 12), B (n = 19), and C (n = 32) resections were 100%, 21.2%, and 27.5%, respectively (p = 0.0001). The long-term survival of the patients after resection was also closely related to their pTNM stages (p = 0.0004).

CONCLUSIONS

We conclude that gastrectomy accompanied by radical lymphadenectomy provides a reasonable long-term survival expectancy that is closely related to the stage of the disease and the curability of resection.

High rate of hepatitis C virus infection in an isolated community: persistent hyperendemicity or period-related phenomena?

We investigated underlying risks for hyperendemic hepatitis C virus (HCV) infection among the 1853 inhabitants of a mountainous village in Eastern Taiwan with high prevalence of HCV and hepatitis B virus (HBV). Among the 80 selected adults, we found that having resided away from the village before 1985 was protective against HCV infection, while residing in the village after 1985 posed little risk for HCV infection to children and young adults < 30 years of age. Among the 559 school children 7 through 14 years of age, anti-HCV prevalence was 1.9%, and the HBV carrier rate was 29%. Following up 270 children 1 year later, we found that new HCV infection occurred in 0.74% and new or repeated HBV infection occurred in 6.5% of the children, indicating distinct transmission patterns between HBV and HCV. Children of anti-HCV-positive mothers were either anti-HCV-negative or were infected by distinct genotypes of HCV from those infecting their mothers; most married couples in whom both were infected, were infected by HCV of discordant genotypes, indicating negligible importance of sexual or vertical HCV transmission. A case-control study comparing 13 anti-HCV-positive and 53 anti-HCV-negative children showed that having received parenteral medication in local clinics was a significant risk for HCV infection. Our data indicate that, unlike the case of HBV, HCV transmission by vertical or sexual route, or through casual contact are extremely inefficient, and our data further suggest that HCV hyperendemicity is unlikely to persist as a result of the more stringent practice of parenteral precautions in nearly all aspects of daily life.

Esophageal reflux after total or proximal gastrectomy in patients with adenocarcinoma of the gastric cardia

OBJECTIVES

To demonstrate gastroesophageal reflux induced by proximal gastrectomy and to report preventive measures, such as total gastrectomy followed by Roux-en-Y esophagojejunostomy.

METHODS

Thirteen patients underwent proximal gastrectomy (PG), and six patients underwent total gastrectomy (TG). Two of the 13 patients who received PG later underwent completion total gastrectomy. All patients were followed with endoscopy, radionuclide scintigraphy, and 24-h pH monitoring.

RESULTS

Endoscopic examination revealed evidence of esophagitis in all PG group patients; however, none of the TG group had esophagitis. Prolonged esophageal transit was observed in 11 patients (10 in the PG group, one in the TG group). Increased residual fraction was found in 10 patients (nine in the PG group, one in the TG group). An increase in the retrograde index was found in 14 cases (11 in the PG group, three in the TG group). Positive enterogastroesophageal reflux was identified in 11 patients (eight in the PG group, three in the TG group). Twenty-four hour pH monitoring resulted in 10 positives (10 in the PG group, none in the TG group).

CONCLUSIONS

Frequently, proximal gastrectomy will lead to significant gastroesophageal reflux and, subsequently, to varying degrees of esophagitis. The clinical symptoms are usually characteristic. However, the severity of esophagitis and the mechanism of reflux can be determined only by integrated interpretation of a reflux study. The study should include endoscopy, radionuclide scintigraphy, and 24-h pH monitoring. Although a total gastrectomy with Roux-en-Y diversion can reduce the incidence of acid reflux, neutral enteroesophageal reflux may be observed during a radioactive isotope study. Fortunately, neutral refluxes rarely cause esophagitis. A proximal gastrectomy should be avoided in adenocarcinoma of the gastric cardia, except in early cancer. Symptomatic palliation can be relieved by medication. However, completion total gastrectomy is the only effective method for eradicating unrelenting symptoms.

Surgical treatment and its long-term result for caustic-induced prepyloric obstruction

OBJECTIVE

To present our long-term results of the treatment of caustic-induced prepyloric obstruction, and to set out guidelines for the management of such patients.

DESIGN

Retrospective study.

SETTING

General hospital (medical centre), Taiwan.

SUBJECTS

30 patients (8 male and 22 female, mean age 34 years, range 13-62) who developed prepyloric obstruction out of 271 treated for caustic injuries of the upper gastrointestinal tract.

INTERVENTIONS

Gastrojejunostomy (n = 24), antrectomy and Billroth I reconstruction (n = 4), and antrectomy and Billroth II reconstruction (n = 2). Four patients required second operations: oesophageal reconstruction for stricture (n = 3), and gastrojejunostomy for restenosis of Billroth I anastomosis (n = 1).

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

No patient died postoperatively, and there were three complications--wound infection, internal bleeding, and stenosis of the Billroth I anastomosis. 21 patients were able to enjoy their normal diet postoperatively, 5 required periodic dilatation of oesophageal strictures, and 4 required further operations.

CONCLUSIONS

Gastrojejunostomy gives good long term results as long as there is no oesophageal stricturing, and morbidity and mortality are low. The long term outcome is dependent on the degree of oesophageal involvement.

Detection of k-ras point mutations in codons 12 and 13 in non-small cell lung cancers

Point mutations of the K-ras gene have been reported in a wide variety of human tumors. By using polymerase chain reaction followed by direct DNA sequencing, we screened for point mutations at codons 12 and 13 of the K-ras gene in specimens obtained from fresh frozen tumors in 38 patients with non-small cell lung cancers. Point mutations were detected in two of 38 (5.3%) resected non-small cell lung cancers. Both of them were G to T transversions. One patient was found to have a K-ras codon 13 point mutation (GGC to TGC, gly to cys), while the other had a codon 12 point mutation (GGT to GTT, gly to val). Based on the limited numbers in this study, we found that the frequency of K-ras point mutations in codons 12 and 13 among Asian patients with lung adenocarcinomas was lower than that detected among Caucasian patients.

Change of lower esophageal sphincter pressure in rabbits by Teflon injection

BACKGROUND

The mechanically incompetent lower esophageal sphincter (LES) plays a key role in patients with gastroesophageal reflux disease. The purpose of the study was to assess the pressure changes of LES in rabbits by intraabdominal injection of Teflon paste (Polytetrafluoroethylene) at the gastroesophageal junction.

METHODS

New Zealand white breed of rabbits were used in these studies. The anesthetized rabbit was injected with a 21-gauge needle and a syringe loaded with Teflon paste. The injection sites were around the gastroesophageal junction. LES pressure was measured by conventional methods using a water-filled infused system. The pressure gradient was measured immediately before and after the injection as well as by a weekly measurement over four weeks. The histologic characteristics of the injection sites were studied four weeks later.

RESULTS

The mean pressure gradient of LES of twelve rabbits of immediate preinjection and post-injection was 29.71 +/- 8.10 mmHg and 37.58 +/- 10.69 mmHg (mean +/- S.D.), respectively (p value, 0.0329) Animals were followed upifor from one to four weeks, and were then sacrificed. The mean pressure gradient of LES of the twelve rabbits in the first week, the second week, the third week and the fourth week was 37.80 +/- 11.36 mmHG, 35.77 +/- 3.54 mmHg, 33.42 +/- 4.95 mmHg and 32.68 +/- 4.62 mmHg (mean +/- S.D.), respectively. Compared to pre-injection data, a significant difference was found in the first week and the second week (p value, 0.0342 and 0.0281, respectively). Gross examination of the gastroesophageal regions showed a welldefined Teflon mass of firm consistency at the site of the injection. Histological examination showed encapsulation of the implant by a thin layer of fibrous tissue and a benign foreign body granulomatous reaction with round cells surrounding the implant.

CONCLUSIONS

It is technically feasible to produce experimentally pressure changes of LES in rabbits by intraabdominal injection of Teflon paste. Nevertheless, the clinical validity on patients with gastroesophageal reflux induced by the incompetence of LES remains to be verified.

Color Doppler ultrasound signals of thoracic lesions. Correlation with resected histologic specimens

Sixty-eight patients with thoracic lesions (48 with lung cancer and 20 with benign lesions) underwent color Doppler ultrasound (US) examinations. Of those, 21 patients (13 with lung cancer and eight with benign lesions) also received resections, and the correlation between color Doppler US signals and resected histologic specimens was evaluated. Our results showed that three patterns of color Doppler US signals could be detected and confirmed: pulsatile flow (artery), constant flow, and triphasic flow (pulmonary vein). Among the 48 patients with lung cancer, pulsatile flow, constant flow, and/or triphasic flow were detected in 34 (71%), 24 (50%), and 14 (29%), respectively. Among the 20 patients with benign lesions, only pulsatile flow and/or triphasic flow were detected in nine (45%) and eight (40%), respectively. From the correlation between color Doppler US signals and histologic specimens, constant flow was representative of the true neovascularity of lung cancers, and it was valuable for differentiating lung cancers from benign lesions (p = 0.00008, sensitivity = 0.50, and specificity = 1.0). Although color Doppler US still had some limitations in detecting blood vessels in thoracic lesions, the correlation between the vascularity represented by color Doppler US signals and histologic specimens was excellent. We conclude that color Doppler US is a valuable method for assessing blood flow in thoracic lesions and differentiating lung cancers from intrapulmonary benign lesions.

Surgical experience in treating T4 lung cancer: its resectability, morbidity, mortality and prognosis

Extensive experience in the treatment of locally advanced lung cancers is rare. The aim of this study is to show the rationality and effectiveness of an aggressive surgical approach in T4 lung cancers. Between 1984 and 1994, 111 consecutive cases of T4 lung cancers were operated on. The patients included 91 males and 20 females, with mean ages of 61.8 years and 55.3 years, respectively. The cell types included 57 squamous cell carcinomas, 42 adenocarcinomas, and 12 miscellaneous malignancies. Fifty-three (47.7%) procedures were non-resectional. The remaining 58 (52.3%) procedures had various extents of pulmonary resection. These surgical procedures included 24 (21.6%) pulmonary resections with gross residual tumour (R2), nine (8.1%) pulmonary resections with microscopic residual tumour (R1), and 25 (22.5%) curative pulmonary resections without residual tumour (R0). Post-operative adjuvant therapy included radiotherapy ( > or = 3000 rads) in 53 patients (47.7%), and cisplatin-based chemotherapy in 15 patients (13.5%). The overall median survival time of these 111 patients was 9.1 months. The overall cumulative survival rates at 1, 2, 3 and 5 years were 38.0%, 20.4%, 15.3%, and 5.5%, respectively. There were 24 (21.6%) complications and eight (7.2%) hospital mortalities. Most of the pleural seedings were caused by adenocarcinomas, while most of the curatively resected tumours were squamous cell carcinomas. Our data demonstrate that: (1) Almost a quarter (22.5%) of T4 lung cancers could be curatively resected, and the cumulative 5-year survival rate was 23.4%; (2) squamous cell carcinoma had a higher curative resection rate (P = 0.0381), while adenocarcinoma showed higher possibility of pleural seeding (P = 0.0000); (3) the prognosis of T4 lung cancers did not relate to their nodal status (P = 0.7978), and cell type (P = 0.4169); (4) complete surgical resection provided the best rates for long-term survival (P = 0.0263); (5) the complication rate was higher in the resectional group (P = 0.0221); (6) post-operative irradiation did not lengthen survival times (P = 0.1720); and (7) post-operative chemotherapy did not improve survival (P = 0.1577). We conclude that surgery to T4 lung cancers should only be performed in highly selected patients due to their poor prognosis, and the associated high complication and mortality rates.

Oesophageal squamous cell carcinoma after gastrectomy for benign ulcer disease

Of 684 patients treated for squamous cell carcinoma of the oesophagus in 1982-1993, 19 (2.8%) had previously undergone partial gastrectomy for benign ulcer disease. The average interval between gastrectomy and diagnosis of oesophageal carcinoma was 14 years. In six of the 19 (31.6%) cases the carcinoma was in the lower thoracic oesophagus, an incidence not significantly higher than the 25% in the total series. The oesophageal resectability rates were 52.6% in the gastrectomized patients and 44.4% in the total series (intergroup difference not significant). Of the ten gastrectomized patients who underwent oesophageal resection, only one had oesophagitis at the oesophagogastric junction, without significant histologic characteristics. The relationship between oesophageal squamous cell carcinoma and previous gastrectomy for benign ulcer disease may be incidental.

Pleural non-Hodgkin's lymphoma arising in a patient with a chronic pyothorax

A 69 year old man with a chronic left pyothorax was treated by decortication. Although the treatment rapidly improved respiratory function, histopathological examination revealed a diffuse large B cell non-Hodgkin's lymphoma. Subsequent bone marrow biopsy samples disclosed bone marrow involvement. It is possible that non-Hodgkin's lymphoma may develop from a chronic pyothorax.

Diagnostic video-assisted thoracoscopic procedures

OBJECTIVE

The authors evaluated the effectiveness and the limitations of video-assisted diagnostic thoracoscopy.

SUMMARY BACKGROUND DATA

The initial successes achieved with the use of video-assisted diagnostic thoracoscopic techniques has lead to an enthusiastic propagation of its use by thoracic surgeons as well as by some pulmonologists. However, detailed analyses of the diagnostic yield and potential limitations of this technique in relation to the roentgenographic and pathologic presentations of the patients are necessary to ensure its safe and effective application.

METHODS

From July 1991 to December 1993, 102 diagnostic video-assisted thoracoscopic procedures were performed. All patients received other preoperative diagnostic workups without a definitive diagnosis. The initial roentgenographic presentations of these patients included 42 pulmonary nodules, 23 interstitial processes, 11 parenchymal infiltrates, 6 pleural effusions, 10 mediastinal tumors, and 10 mediastinal lymphadenopathies. If the procedure was completed without minithoracotomy or extension of any port site, then it was defined as an exclusive thoracoscopic biopsy (ETB); if the procedure was completed with the assistance of minithoracotomy (4-6 cm), then it was defined as a supplementary thoracoscopic biopsy (STB).

RESULTS

Ninety-two of the pathology reports (90.2%) were interpreted as conclusive. Of these, 35 tumors were malignant and 67 benign. Ten pathology reports were inconclusive and on initial roentgenography had presented as pulmonary infiltrates (4 cases), pulmonary nodule (2), pleural effusion (2), interstitial process (1), and mediastinal lymphadenopathy (1). Seventy-six procedures (74.5%) were completed thoracoscopically and were classified as ETB. The remaining 26 procedures (25.5%) were completed with minithoracotomy and were classified as STB. The underlying diseases in the STB group were carcinoma (8 cases), Hodgkin's lymphoma (3), sarcoidosis (3), tuberculosis (2), interstitial pneumonitis (2), organizing pneumonia (2), mesothelioma (1), and miscellaneous disease (5). The reasons given for minithoracotomy were diffuse intrapleural adhesion (10 cases), technical inexperience (8), inability to localize the lesion (5), problems with anesthesia (1), poor patient tolerance (1), and unknown (1). Four patients (3.9%) experienced complications and three (2.9%) died while in the hospital.

CONCLUSIONS

Diagnostic thoracoscopy provides high diagnostic yield with very low risk. However, 25.5% of the procedures require minithoracotomy to obtain adequate tissue for definitive diagnosis. This finding supports the assertion that diagnostic thoracoscopy should be performed only by experienced thoracic surgeons who can extend the procedure when indicated.

Bronchioloalveolar carcinoma

Bronchioloalveolar carcinoma is a subtype of adenocarcinoma of the lung with a relatively better prognosis. We reviewed the cases of 50 consecutive patients with bronchioloalveolar carcinoma treated during a 10-year period and attempted to analyze factors related to prognosis. During the 10-year study period, the prevalence of bronchioloalveolar carcinoma relative to adenocarcinoma of the lung remained steady. The subjects included 32 male and 18 female patients with mean ages of 64.7 years and 55.1 years, respectively (p = 0.0030). The preoperative radiographic findings included 40 cases of localized and 10 cases of diffuse bronchioloalveolar carcinoma. The clinicopathologic TNM staging included 20 patients with stage I cancer, 4 with stage II cancer, 11 with stage IIIa cancer, 3 with stage IIIb cancer, and 12 with stage IV cancer. Forty patients with clinical stage I, II, or III disease underwent operation (operability 80%). The resectability rate was 90% (36 of 40). Thirty-four procedures were considered as curative. The overall cumulative survival at 5 years was 22.2% (46.4% for stage I). Different TNM stages showed significant differences in survival time (p = 0.0001). The median survival times were 64.6 months for stage I, 48.0 months for stage II, 24.7 months for stage IIIa, 9.0 months for stage IIIb, and 4.5 months for stage IV disease. The median survival time for localized bronchioloalveolar carcinoma was 27.5 months, and the median survival time for diffuse bronchioloalveolar carcinoma was 4.3 months (p = 0.0002). The median survival time for the curative resection group was 30.6 months, and the median survival time for the noncurative resection or nonresection group was 5.8 months (p = 0.0001). On the basis of this study we conclude that (1) the prevalence of bronchioloalveolar carcinoma is quite steady, (2) bronchioloalveolar carcinoma presents at an earlier age in women, (3) bronchioloalveolar carcinoma frequently presents with lymphatic spread or systemic metastasis at diagnosis, (4) most localized bronchioloalveolar carcinomas are resectable and the prognosis with this type is better than that of the diffuse type, and (5) long-term survival correlates closely with initial roentgenographic appearance, TNM stage, and completeness of surgical resection.

Prediction of probability of pneumonectomy for lung cancer using Tc-99m MAA perfusion lung imaging

Pulmonary perfusion scintigraphy with Tc-99m MAA was performed on 182 patients, on whom either pneumonectomy or lobectomy was performed, because of primary nonsmall-cell lung carcinoma. Among them, 76 underwent pneumonectomy, and 106 underwent lobectomy. The mean value of the perfusion fraction (PF) of the affected lung of the patients undergoing pneumonectomy was 32.3 +/- 13.6% (range, 4%-50%) and was less than that of the patients undergoing lobectomy, 43.5 +/- 4.5% (range, 27%-50%). The difference was statistically significant (t-test, t = 6.82; P < 0.001). Among the 28 patients whose PF of the affected lung was equal to or less than 30%, 26 underwent pneumonectomy and only 2 had a lobectomy. Among the 154 patients whose PF of the affected lung was more than 30%, 50 underwent pneumonectomy and 104 had a lobectomy. These result suggest that "30%" can be a cutoff value (Yates correction X(2) test, X2 = 33.09; P < 0.001).

Video-assisted thoracoscopic T2 sympathectomy for hyperhidrosis palmaris

BACKGROUND

Hyperhidrosis palmaris is a functionally and socially disabling problem. Thoracic sympathectomy of the T2 ganglion has proved to be the time-honored treatment modality.

STUDY DESIGN

The results of this study demonstrate the effectiveness of video-assisted thoracoscope for treatment of hyperhidrosis palmaris. The possibility to apply different anesthetic techniques and to measure surface temperature change of the hand were documented as well.

RESULTS

Eighty consecutive cases (159 procedures) of essential hyperhidrosis palmaris were treated by video-assisted thoracoscopic T2 sympathectomy between January 1991 and December 1992. The surgical results were classified as excellent (much improved, very dry) in 88.1 percent, good (improved, minimal wet) in 9.4 percent, and fair (slightly improved, still wet) in 2.5 percent of the patients. The postoperative complications included one prolonged air leakage, one hemothorax, two wound infections, and 15 cases of facial anhidrosis. There were no recurrent cases (mean follow-up, 14.5 months). Fifty-six patients had concomitant hyperhidrosis pedum. Interestingly enough, through unknown mechanism, 64.3 percent of the patients with concomitant hyperhidrosis pedum were cured after this procedure.

CONCLUSIONS

Video-assisted thoracoscopy provides magnified surgical fields, which make thoracoscopic sympathectomy for hyperhidrosis palmaris an effective, safe, easy to use, and time-saving procedure. This technique is also excellent for teaching purposes and allows the assistant to participate in the operation.

Thymic carcinoma. Ten years' experience in twenty patients

Thymic carcinoma is a rare neoplasm with extremely poor prognosis. To evaluate the outcome of treatment in thymic carcinoma, we reviewed a 10-year (1982 to 1992) experience with 20 consecutive patients in Taichung Veterans General Hospital. There were 9 men and 11 women: ages ranged from 34 to 70 years old (mean 51.4 years). None of these patients had concomitant myasthenia gravis. All of the patients received surgical intervention, and the diagnosis was made by pathologic study. Postoperative staging was made according to the modified Masaoka staging system. None of our patients were in stage I. One patient (5%) had stage II disease, 12 (60%) stage III, and 7 (35%) stage IV. The pathologic subtypes of thymic carcinoma included eight squamous cell carcinomas, seven undifferentiated carcinomas, one lymphoepithelioma-like carcinoma, one clear-cell carcinoma, 1 mucoepidermoid carcinoma, and two carcinoid tumors. Curative resection could be done in seven patients (35%). The overall cumulative survival was 45.9% at 3 years and 34.4% at 5 years. The median survival times for patients with complete and incomplete resection were 39.0 months and 14.3 months, respectively (p = 0.1752). The median survival times of patients with postoperative radiotherapy and without postoperative radiotherapy were 39.3 months and 15.0 months, respectively (p = 0.0738). The median survival times of patients with squamous cell carcinoma and undifferentiated carcinoma were 25.4 months and 11.3 months, respectively (p = 0.1464). Our data show that complete resection, postoperative radiotherapy, and squamous cell carcinoma do not indicate a significantly favorable result, even though they result in longer median survival times. Yet a positive trend of favorable outcome in patients who received postoperative radiotherapy is ambiguously shown.

Sclerosing hemangioma of the lung: a clinicopathologic study

The clinical and pathological features of 11 cases with sclerosing hemangiomas of the lung seen between 1982, and 1992 were reviewed. There were 1 male and 10 female patients aged 15 to 74 years (mean age, 53 years) at operation. Among the 11, 4 were asymptomatic, with the tumor discovered only on routine chest roentgenograms. All 11 patients had a solitary tumor showing as a well-defined homogeneous round or oval shadow on chest x-rays. Microscopically, 8 of the 11 tumors consisted of a mixture of the four major patterns: hemorrhagic, sclerotic, papillary and solid. Five patients received enucleation; four, wedge resection; one, segmentectomy and one, lobectomy. Since this tumor is usually clinically benign and surgically curative, thoracotomy and complete removal of the tumor by limited resection is recommended.

[Carcinosarcoma of the esophagus]

Carcinosarcoma of the esophagus is a rare neoplasm of the esophagus, composes both of carcinomatous and sarcomatous elements. From Oct. 1982 to Sept. 1991, there were 516 neoplasms of the esophagus, 2 (0.39%) carcinosarcoma, treated at our hospital. The first patient was a 62-year-old man, pathological stage III (T3N2M0). The second patient was a 68-year-old man, pathological stage I (T1N0M0). The tumors were polypoid and located at the middle portion of the esophagus. They had received subtotal esophagectomy, mediastinal lymph node dissection and cervical esophagogastrostomy, retrosternally. The first patient has still lived disease free for seven years. The second patient died one year after the operation due to intra-abdominal lymphadenopathy, liver metastasis and massive ascites. As epidermoid carcinoma, radical esophagectomy with lymph node dissection is the standard procedure for carcinosarcoma of the esophagus.