[Management of surgical approach for intractable secondary spontaneous pneumothorax]

Secondary spontaneous pneumothorax (SSP) such as lymphangioleiomyomatosis (LAM), bronchiolitis obliterans (BO) is intractable or repeated the recurrence of pneumothorax. The most effective chemical pleurodesis for intractable pneumothorax is talc poudrage and so on that is associated with a reduction in the rate of pneumothorax recurrence. However, severe and broad pleural adhesion due to the pleural interventional procedures sometimes cause serious bleeding when the patients undergo lung transplantation. We must be considered for new approaches to these intractable secondary pneumothoraces which replaced traditional conservative and surgical approaches. We had proposed new 2 approaches of total pleural covering (TPC) and awake surgical intervention (ASI) for intractable pneumothorax. We applied the TPC modified with coverage of air leak points with polyglycolic acid (PGA) sheet to 5 patients with intractable bilateral pneumothorax to reduce the risk of excessive bleeding by chemical pleurodesis in lung transplantation. The bilateral pneumothorax was well controlled, and no recurrence has been observed. TPC is reliable procedure for management intractable bilateral SSP. For 12 high-risk patients with other underling pulmonary diseases on general poor conditions, a surgical intervention was performed in awake condition. The air leaks were stopped in 11 cases except for 1 case. The recurrence of pneumothorax after surgery was 2 cases. ASI for intractable secondary pneumothorax can be applicable to selected patients with deteriorated general condition.

Dedifferentiated chondrosarcoma of the chest wall: reconstruction with polypropylene mesh using a transverse rectus abdominis myocutaneous flap

We report a case of dedifferentiated chondrosarcoma of the chest wall. After resection, the chest wall defect was reconstructed using polypropylene mesh and a transverse rectus abdominis myocutaneous flap. A 61-year-old woman presented with a 16-year history of a slow-growing mass underneath the right chest wall. After percutaneous biopsy, preoperative cytopathological examination of the large mass revealed dedifferentiated chondrosarcoma. The tumor was resected with a wide margin along with the chest wall including skin, the right seventh to tenth ribs, and part of the diaphragm. The chest wall defect was reconstructed with a polypropylene (Marlex) mesh sheet followed by a left-side transverse rectus abdominis myocutaneous flap.

An experience with the modified total pleural covering technique in a patient with bilateral intractable pneumothorax secondary to lymphangioleiomyomatosis

We present a case of bilateral intractable pneumothorax associated with a modified form of lymphangioleiomyomatosis (LAM), successfully treated with a previously reported surgical procedure, the total pleural covering (TPC) technique, under video-assisted thoracic surgery. The patient was a 28-year-old woman with bilateral pneumothorax secondary to LAM who had undergone thoracoscopic surgery in another hospital. We performed bilateral TPC modified with a preceding coverage of air leak points with polyglycolic acid sheets for reinforcement. Although a minor air leak after the surgery necessitated a mild pleurodesis on the right side, the bilateral pneumothorax was well controlled, and no recurrence has been observed for 9 months. We believe that TPC is a safe and reliable procedure for the management of intractable pneumothorax secondary to LAM. It also has the potential to reduce risk of excessive bleeding in lung transplantation.

Transbronchial human interleukin-10 gene transfer reduces acute inflammation associated with allograft rejection and intragraft interleukin-2 and tumor necrosis factor-alpha gene expression in a rat model of lung transplantation

BACKGROUND

The ability to express genes with potential immunoregulatory capacity could reduce allograft rejection (AR). This study examined the effect of ex vivo lipid-mediated transbronchial human interleukin-10 (hIL-10) gene transfer on AR and the intragraft cytokine profile in a rat model of lung transplantation.

METHODS

Left single lung transplants were performed between a highly histoincompatible combination of inbred rats. The donor left lung was extracted and intrabronchially instilled with a plasmid encoding hIL-10 (IL-10 group) or Escherichia coli beta-galactosidase (control group), mixed with a cationic lipid. At 3 and 6 days after transplantation, the degree of AR was graded histologically (stage 1-4) and several pathologic categories of inflammation were scored on a scale of 0 to 4 according to the percentage of involvement. Intragraft cytokine profile was examined by real-time reverse transcription polymerase chain reaction.

RESULTS

The stage of AR (3.1 +/- 0.4 vs 3.8 +/- 0.4) and the pathologic scores for edema (2.3 +/- 0.8 vs 3.2 +/- 0.4), intraalveolar hemorrhage (0.3 +/- 0.5 vs 2.2 +/- 0.8), and necrosis (0.3 +/- 0.5 vs 1.2 +/- 0.4) in the IL-10 group were significantly decreased compared with the control group at Day 6. IL-2 and tumor necrosis factor-alpha messenger RNA expression levels on Day 3 were significantly decreased in the IL-10 group.

CONCLUSIONS

Ex vivo lipid-mediated transbronchial hIL-10 gene transfer attenuated acute inflammation associated with AR, which was related to decreased levels of proinflammatory cytokine gene expression in a rat model of lung transplantation.

[Experience of a vascular stent placement under bronchoscopy for a severe airway stenosis like a pinhole]

The patient was a 32-year-old woman. She suffered repeated hemoptysis due to a congenital right pulmonary artery deficiency and underwent right pneumonectomy at 19 years of age. Immediately after the operation, postpneumonectomy syndrome appeared. The left main bronchus was compressed and almost obstructed, and so metallic stent was urgently installed. However, she subsequently suffered from repeated stenosis due to granulation and repeated obstructive pneumonia. She underwent 7 stent installations, laser therapy, low dose radiotherapy, and ballooning to treat her airway stenosis. However, her left main bronchus gradually became a severe stenosis like a pinhole. When she admitted to our hospital due to obstructive pneumonia last time, it was impossible to install usual airway stents because of extreme kinking of airway and severe stenosis. Therefore, a vascular stent for iliac artery was chosen to treat her airway stenosis and the stent was placed to regain good patency. As a result of the treatment, she had immediate relief of symptoms and survived obstructive pneumonia.

[Pleomorphic liposarcoma in anterior mediastium]

The patient was 70-year-old man. He had complained of general fatigue and hoarseness for 5 months. Chest computed tomography scan demonstrated a large anterior mediastinal tumor. The diagnosis of high grade malignant sarcoma was established with needle biopsy and the complete resection through median sternotomy was conducted. The tumor was histopathologically diagnosed pleomorphic liposarcoma. Six months after operation, right supraclavicular lymph node metastasis was noted. Radiotherapy was performed, but the liver metastasis appeared subsequently 16 months after operation. Pleomorphic type is considered one of the poorest prognostic liposarcoma and should be required special attention.

[Surgical approaches for superior sulcus tumor]

Surgical approach is one of the most crucial aspects in the treatment of superior sulcus tumor (SST). Posterior approach as described by Paulson and coworkers is appropriate for the resection of SST invading posterior part of the 1st rib and the vertebrae, whereas anterior approaches as described by Masaoka, Dartevelle, Grunenwald, or Rusca are suitable for resection of SST involving subclavian vessels. We present 2 cases of SST who underwent complete resection through the posterior approach and a modified hemi-clamshell approach, respectively. We also discuss the surgical approaches for SST with referring to literatures.

[Experience of postoperative adjuvant chemotherapy of lung cancer at outpatient department]

In late years the cancer adjuvant chemotherapy shifts from an inpatient care to an outpatient treatment. For operated lung cancer patients, outpatient chemotherapy center has been working since October 2005 in our hospital. Chemotherapy regimens were carboplatin (CBDCA) + paclitaxel (PTX), CBDCA + gemcitabine (GEM), docetaxel (DTX) + tegaful-gimeracil-oteracil potassium (S-1), and GEM + vinorel bine (VRE). CBDCA was chosen instead of cisplatin (CDDP) and non-platinum doublets are also used because of less toxicity and more time saving. Adjuvant chemotherapy has been performed for a total of 25 outpatients. Twenty-two out of 25 completed chemotherapy. Neutrophilopenia was the most common toxicity and grade 3 or 4 neutrophilopenia was seen in 6 patients. Adjuvant chemotherapy of outpatients can be completed safely by the choice of a safe regimen, supportive therapy for the toxicity, and cooperation with the community medicine organization. Our chemotherapy regimen are thought to be feasible for postoperative lung cancer outpatients.

[Video recording system of endoscopic procedures for digital forensics]

Recently, endoscopic procedures including surgery, intervention, and examination have been widely performed. Medical practitioners are required to record the procedures precisely in order to check the procedures retrospectively and to get the legally reliable record. Medical Forensic System made by KS Olympus Japan offers 2 kinds of movie and patient's data, such as heart rate, blood pressure, and Spo, which are simultaneously recorded. We installed this system into the bronchoscopy room and have experienced its benefit. Under this system, we can get bronchoscopic image, bronchoscopy room view, and patient's data simultaneously. We can check the quality of the bronchoscopic procedures retrospectively, which is useful for bronchoscopy staff training. Medical Forensic System should be installed in any kind of endoscopic procedures.

Results of long-term follow-up of photodynamic therapy for roentgenographically occult bronchogenic squamous cell carcinoma

BACKGROUND

Photodynamic therapy (PDT) is considered a useful and minimally invasive modality for treating centrally located early lung cancer. To date, there has been limited information on the long-term outcome of patients treated with PDT, especially those who are medically operable.

METHODS

Beginning in 1994, patients with roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC) who met our criteria underwent PDT at Tohoku University Hospital and were followed up through 2006. Our criteria were as follows: (1) ROSCC without distant metastasis; (2) medically operable by means of lobectomy or further resection; (3) longitudinal tumor length of <or= 10 mm; and (4) superficial bronchoscopic tumor findings.

RESULTS

A total of 48 patients with ROSCC underwent PDT. The complete response (CR) rate was 94% (45 of 48 of patients). Nine patients (20%) had local recurrence after CR. A total of 11 deaths was observed, with 6 resulting from multiple primary lung cancer and only 1 from the original ROSCC. The 5-year and 10-year overall survival rates for all 48 patients were 81% and 71%, respectively. The Cox proportional hazard model showed that only metachronous multiple primary lung cancer was an independent poor prognostic factor.

CONCLUSIONS

PDT is thought to be a first-line modality for patients who have ROSCC with a tumor length of <or= 10 mm, even if the tumor is medically operable. Most local recurrence can be cured by active therapy such as surgery, radiotherapy, or PDT. Multiple primary lung cancer subsequent to PDT is an important issue from the viewpoint of survival.

Immunocytochemical evaluation of large cell neuroendocrine carcinoma of the lung

OBJECTIVE

To examine whether immunocytochemistry can distinguish pulmonary large cell neuroendocrine carcinoma (LCNEC) among non-small cell lung cancers (NSCLCs).

STUDY DESIGN

Tumor touch imprint cytologic specimens of 109 lung cancers were studied. Immunocytochemistry was done using a total of 8 primary antibodies: chromogranin A, synaptophysin, neural cell adhesion molecule, neuron specific enolase, CK34betaE12, thyroid transcription factor-1, cytokeratin 18 and E-cadherin.

RESULTS

If 2 or 3 antibodies of chromogranin A, synaptophysin and neural cell adhesion molecule were stained positive and CK34betaE12 was not stained, pulmonary LCNEC can be selected accurately among other NSCLCs with 100% sensitivity and 100% specificity.

CONCLUSION

This study reveals that immunocytochemistry can help distinguish LCNEC of the lung from other NSCLCs.

An analysis of the horizontal burrow morphology of the oriental mole cricket (Gryllotalpa orientalis) and the distribution pattern of surface vegetation

Food acquisition in animals that construct burrows for foraging is influenced by burrow structure associated with food distribution and searching patterns. The burrowing patterns of the oriental mole cricket ( Gryllotalpa orientalis Brumeister, 1838) (Orthoptera: Gryllotalpidae) were investigated based on analyses of the relation between burrow morphology and plant distribution. To assess differences between horizontal burrows (HB) with and without vertical burrows (VB), the number of branching points, the length of the horizontal parts, the plant ratio of the burrow area, and the burrow fractal dimension were compared. The size of the burrow area was positively related to the degree of branching. Cyperaceae and Gramineae occurred less frequently, whereas Hydrocotyle sibthorpioide Lam. and areas with no plants were more frequent in the burrow area than in the quadrat area. Juncaceae and Persicaria thunbergii (Siebold and Zucc.) H. Gross ex Nakai occurred more frequently and Lindernia crustacea (L.) F. Muell. occurred less frequently in HB without VB than in HB with VB. The ratio of burrow length to the number of branching points was not significantly different between HB with or without VB. HB with VB had a nearly planar structure (higher burrow fractal dimension) than that of HB alone. HB structure and plant composition of the burrow area differed depending on the presence of VB.

The methylation status of FBXW7 beta-form correlates with histological subtype in human thymoma

FBXW7 is reported to be a tumor suppressor gene, and the functional inactivation of FBXW7 has been reported in various human tumors. In this study, we investigated the FBXW7 gene in human thymoma; although no mutations were evident, a significantly high frequency of methylation in the FBXW7 beta-form promoter was observed in types B1 or higher (P=0.014). We propose a novel mechanism for the pathogenesis of thymoma by FBXW7 beta-form and hypothesize that expressional suppression plays an important role in the malignant potential of thymoma.

[Clinical analysis of bronchoplastic surgery for lung cancer after 2000]

We investigated surgical complications and prognosis of bronchoplasty and bronchoplasty with pulmonary angioplasty (broncho-angioplasty) for lung cancer. Between October 2000 and October 2007, 37 bronchoplastic procedures were done in 572 patients who underwent lung resections for lung cancer. Eleven (29.7%) bronchoplasties were done with pulmonary angioplasty. There was no operative mortality and 1 hospital mortality (2.7%) causing by myocardial infarction. Six of 11 postoperative complications were bronchial complications and 2 additional lung resections were needed. The 5-year survival for all patients was 55.2% and for bronchoplasty was 57.8%. Though the 5-year survival of broncho-angioplasty was not able to calculate at present, the 3-year survival of which was 72.9%. There was no death of patients with adenocarcinoma after introduction of pre-operative assessment by FDG-PET for lymph node metastasis. These data suggest that bronchoplasty and broncho-angioplasty are safe operative procedures and could provide acceptable intermediate survivals with modern multimodality diagnostic and therapeutic tools.

[Adjuvant concurrent chemoradiotherapy for resected locally advanced lung cancer outpatients]

Recently, adjuvant chemoradiotherapy showed possible survival advantage in the western prospective studies. A feasibility study was conducted. Adjuvant concurrent chemoradiotherapy with carboplatin (CBDCA) + paclitaxel (PTX) was performed to 4 outpatients with resected locally advanced lung cancer. A total of 60 Gy was given during about 7 weeks, and concurrent CBDCA 2 mg/AUC + PTX 45 mg/m2 was administered weekly. Grade 2 neutropenia was seen in 2 patients, grade 2 esophagitis was seen in 1, and grade 2 peripheral neuritis was in 1. Grade 3 or more toxicity was never seen. One patient had to be hospitalized because of esophagitis, but other 3 patients had completed all course of the therapy as outpatients. Adjuvant concurrent chemoradiotherapy with CBDCA + PTX was thought to be feasible to the resected locally advanced lung cancer patients. Prospective study will be conducted to examine the efficacy of this treatment.

[Problems in donor lung evaluation for transplantation with regard to airway infection]

The shortage of donor organs has been 1 of the major obstacles to solid organ transplantation. Typical lung donor criteria include clear lung field on chest radiograph, adequate oxygenation, acceptable lung compliance, and satisfactory bronchoscopic findings. To extend usage of available donors, liberalization of donor lung selection criteria has been facilitated, however, marginal donor lungs must be used with discretion, because donor lung injury, especially that related to infection, has a potential leading to early post-operative death of the recipient. From March 2000 to December 2006, we evaluated 15 braindead donors and at least 1 of the lungs from 9 donors was judged suitable for transplantation. One of 9 recipients developed severe pneumonia cased by carbapenems-resistant Pseudomonas aeruginosa possibly originating from the donor lungs, eventually leading to death. The chest radiograph and oxygenation of the donor had been satisfactory, however, a moderate amount of mucopurulent secretions was observed by bronchoscopic inspection and the donor had been given a cefozopran for 9 days before the procurement operation. Remaining 8 recipients were free from air-way infection in the early postoperative period. We discuss the status and problems of donor lung evaluation for transplantation with regard to donor lung infection.

Identification and Characterization of Genetic Variation in the Folylpolyglutamate Synthase Gene

Folylpolyglutamate synthase (FPGS) catalyzes the polyglutamation of folic acid, methotrexate, and pemetrexed to produce highly active metabolites. To characterize genetic variation in the FPGS gene, FPGS, have resequenced the gene in four different ethnic populations. Thirty-four single nucleotide polymorphisms were identified including five nonsynonymous coding single nucleotide polymorphisms that altered the FPGS protein sequence: F13L and V22I polymorphisms in the mitochondrial isoform of FPGS, and R466/424C, A489/447V, and S499/457F polymorphisms, which exist in both the mitochondrial and cytosolic isoforms. When expressed in AuxB1 cells, the A447V cytosolic variant was functionally similar to the wild-type cytosolic (WT Cyt) allozyme, whereas the R424C and S457F cytosolic variants were reduced by approximately 2-fold in protein expression compared with WT Cyt (P < 0.01). The intrinsic clearance of glutamate was reduced by 12.3-fold (R424C, P < 0.01) and 6.2-fold (S457F, P < 0.01), whereas the intrinsic clearance of methotrexate was reduced by 4.2-fold (R424C, P < 0.05) and 5.4-fold (S457F, P < 0.05) in these two cytosolic variants when compared with the WT Cyt isoform. Additionally, the in vitro enzyme velocity at saturating pemetrexed concentrations was reduced by 1.6-fold (R424C, P < 0.05) and 2.6-fold (S457F, P < 0.01) compared with WT Cyt. AuxB1 cells harboring these same cytosolic variant allozymes displayed significant increases in the EC(50) for folic acid and in the IC(50) values for both methotrexate and pemetrexed relative to the WT Cyt form of FPGS. These observations suggest that genetic variations in FPGS may alter the efficacy of antifolate therapy in cancer patients.

[Endobronchial ultrasonography (EBUS) for evaluation of the depth of invasion of central type early lung cancer]

It may be essential for taking appropriate therapeutic decisions in cases with early central-type lung cancer, to know the depth of tumor invasion of the bronchial wall at the laminar level. When a tumor penetrates the cartilaginous layer, photodynamic therapy (PDT) may no longer effective. For optimal therapeutic outcome, the physicians should know accurately whether or not the lesion has invaded the cartilaginous layer. Endobronchial ultrasonography (EBUS) is the sole tool available currently for depicting the laminar structure of the bronchial wall in clinical use. But mastery is required for judging the extent of tumor invasion of the bronchial wall from the ultrasonogram. Even experienced interpreters have to depend on their subjective judgment. We employed image analysis software to digitize the EBUS image. This allowed us to draw a plot of the EBUS data from the bronchial wall and perform statistical analysis for an objective assessment. In this study, we examined the ultrasound images of the bronchial wall structure using 20 MHz and 30 MHz transducers. The results showed that the 30 MHz transducer was significantly more useful for delineating the bronchial wall layers than the 20 MHz probe. Our image analysis is an objective evaluation, and any examiner should arrive at the same results.

[Bronchoplasty without lung resection for the complete transection of the left main bronchus due to blunt trauma]

Blunt bronchial injury is rare but crucial injury. A 17-year-old female was admitted due to traumatic injury. She was diagnosed with bilateral lung contusion, multiple rib fractures, spleen damage and the suspicion about the complete transection of the left main bronchus on X-ray and computed tomography (CT). She was brought to our hospital at 30 hours later from injury. Bronchoscopy revealed the complete transection and the edema of the left main bronchus. She underwent a resection of the disrupted portion and end-to-end anastomosis of left main bronchus without lung resection. We should be an immediate and accurate diagnosis of tracheobronchial disruption by X-ray, CT and bronchoscopy whenever we evaluate patients with blunt chest trauma.