Prognostic value of ground-glass opacity found in small lung adenocarcinoma on high-resolution CT scanning

OBJECTIVE

This study was undertaken to investigate the value of the ground-glass opacity (GGO) area found on high-resolution computed tomography (HRCT) scanning as a preoperative prognostic indicator.

PATIENTS AND METHODS

We studied 104 patients with small-sized lung adenocarcinoma, 20 mm or less in diameter, between 1995 and 1999. Three independent radiologists semi-quantitatively scored the extent of GGO on HRCT as greater than or less than 50%. Three independent pathologists semi-quantitatively scored the extent of the bronchioloalveolar carcinoma (BAC) component of the tumor on histologic examination as greater than or less than 50%. As no relapse occurred in patients with GGO greater than 50%, multivariate analysis of this prognostic factor was not possible.

RESULTS

Fifty patients were scored as having both BAC and GGO greater than 50%, 36 as both BAC and GGO less than 50%, and 16 as BAC greater than 50% and GGO less than 50%. In only two patients (1.9%), BAC less than 50% was overestimated on HRCT as GGO greater than 50%. The sensitivity and specificity of GGO to BAC were 76 and 95%, respectively. The 3 year-relapse-free survival rates in each group of 52 patients with GGO greater than and less than 50% were 100 and 72%, respectively, after a median follow-up of 24 months. Univariate analysis indicated that both GGO and BAC areas were significantly correlated with cancer relapse (P=0.005 and P=0.002). The multivariate analysis revealed an independent prognostic influence of the BAC area on relapse-free survival (P=0.015, relative risk=0.07).

CONCLUSIONS

To date there has been no relapse among the 52 patients with GGO greater than 50%. This novel classification based on the semiquantitative analysis of GGO area on HRCT should become an useful independent preoperative indicator when deciding on operative procedure, and to predict the potential of relapse in patients with small adenocarcinoma arising from the peripheral lung.

Body fatness and fat distribution as predictors of metabolic abnormalities and early carotid atherosclerosis

OBJECTIVE

To test the hypothesis that intra-abdominal fat plays a primary role over general adiposity for metabolic abnormalities and atherosclerosis.

RESEARCH DESIGN AND METHODS

We cross-sectionally studied 849 Japanese men aged 50.3 +/- 8.5 years (range 20-78) with BMI 23.5 +/- 2.9 kg/m(2). Intimal-medial thickness (IMT) of the carotid artery was measured by ultrasound. General adiposity was assessed by BMI. Waist circumference and waist-to-hip ratio (WHR) were used as a surrogate measure for abdominal fat. Abdominal subcutaneous fat area (ASF) and intra-abdominal fat area (IAF) were measured by computed tomography. Correlations between these measures and carotid IMT were analyzed. The interaction of generalized adiposity (BMI) and IAF in relation to metabolic variables, such as glucose tolerance, insulin resistance, and serum lipids, was also evaluated.

RESULTS

BMI, waist circumference, WHR, ASF, and IAF were all correlated with carotid IMT. Adjustment for BMI eliminated the associations between IMT and waist circumference, ASF, and IAF. In contrast, WHR retained a significant correlation with IMT. BMI and IAF were associated with insulin resistance, glucose tolerance, HDL cholesterol, and blood pressure independently of each other. IAF was an independent correlate for serum triglyceride, but BMI was not.

CONCLUSIONS

The primary importance of IAF over general adiposity for carotid atherosclerosis was not confirmed. Caution is recommended when using WHR as a measure of abdominal fat. The roles of IAF for metabolic abnormalities may be more limited than conventionally thought. BMI and WHR are simple and better clinical predictors for carotid atherosclerosis versus IAF.

Transmembrane TNF (pro-TNF) is palmitoylated

Human transmembrane tumor necrosis factor (pro-TNF) was examined for protein acylation. The cDNA encoding pro-TNF was expressed in both COS-1 cells and Sf9 cells and metabolic labeling with [(3)H]myristic or [(3)H]palmitic acid was attempted. The 17 kDa mature TNF secreted from the transfected cells was not labeled, whereas the 26 kDa pro-TNF was specifically labeled with [(3)H]palmitic acid. The [(3)H]palmitic acid labeling of pro-TNF was eliminated by treatment with hydroxylamine, indicating that the labeling was due to palmitoylation of a cysteine residue via a thioester bond. Site-directed mutagenesis of the two cysteine residues residing in the leader sequence of pro-TNF demonstrated that palmitoylation of pro-TNF occurs solely at Cys-47, located at the boundary between the transmembrane and cytoplasmic domains of pro-TNF. Thus, pro-TNF interacts with the plasma membrane via both its proteinaceous transmembrane domain and a lipid anchor.

Increased expression of transforming growth factor-beta1 in small airway epithelium from tobacco smokers and patients with chronic obstructive pulmonary disease (COPD)

Tobacco smoke is believed to cause small airway disease and then chronic obstructive pulmonary disease (COPD), but the molecular mechanisms by which small airway obstruction occurs remain unknown. To study the gene expression levels of transforming growth factor (TGF)-beta1, a potent fibrogenic factor, in small airway epithelium from smokers and patients with COPD, we harvested highly pure samples of epithelial cells from small airways under direct vision by using an ultrathin bronchofiberscope BF-2.7T (outer diameter 2.7 mm with a biopsy channel of 0.8 mm in diameter). The expression levels of TGF-beta1 were evaluated by reverse transcription-polymerase chain reaction (RT-PCR). The mRNA levels of TGF-beta1 corrected by beta-actin transcripts were significantly higher in the smoking group and patients with COPD than those in nonsmokers (p < 0.01). Furthermore, among smokers and patients with COPD, TGF-beta1 mRNA levels correlated positively with the extent of smoking history (pack-years) and the degree of small airway obstruction as assessed by measurements of flow-volume curves. Immunocytochemistry of the cells demonstrated more intense stainings for TGF-beta1 in samples from smokers and patients with COPD than from nonsmokers. Spontaneously released immunoreactive TGF-beta1 levels from cultured epithelial cells were more elevated in subjects with a history of smoking and patients with COPD than in nonsmokers. Our study showed a close link between smoking and expression of TGF-beta1 in small airways. Our results also suggested that small airway epithelial cells might be involved in obstructive changes found in smokers and patients with COPD.

Palladium-catalyzed cross-coupling reaction of organoindiums with aryl halides in aqueous media

[reaction: see text] Diaryl-, divinyl-, and dialkylindium proved to be stable in aqueous media and to undergo a palladium-catalyzed cross-coupling reaction with aryl halides in aqueous THF. Treatment of 3-iodophenol with diphenylindium compound, generated from indium trichloride and two equimolar amounts of a phenyl Grignard reagent, in aqueous media under palladium catalysis provided the corresponding coupling product in excellent yield. Divinyl- and diethylindium can be used for the coupling reaction in the presence of water. A wide range of functional groups, including a hydroxy group and a formyl group, are compatible with this reaction.

Transmediastinal approach to exploring the lung contralateral to the thoracotomy site

OBJECTIVE

The approach to contralateral lung through the mediastinum is assumed useful in managing oddly distributed bilateral lung tumors.

SUBJECTS AND METHODS

To remove a tumor located in the contralateral lung, a transmediastinal approach from the thoracotomy site to the contralateral lung was used in 6 patients having oddly distributed bilateral lung tumors, 1 of which was located in the contralateral lung close to the anterior or posterior mediastinum.

RESULTS

All cases were treated successfully. One patient required an additional small incision on the contralateral anterior chest wall to insert an endoscopic stapler without intraoperative postural change. The postoperative course was uneventful and, to date, no local recurrence has been seen at the resected margin of the contralateral lung.

CONCLUSION

This novel approach is useful, offering the advantages of reduced invasiveness and pain, shorter surgical duration, and favorable cosmetic results for patients with a tumor close to the mediastinum in the contralateral lung.

Benzene-extracted components are important for the major activity of diesel exhaust particles: effect on interleukin-8 gene expression in human bronchial epithelial cells

Epidemiologic and experimental studies suggest that diesel exhaust particles (DEPs) may be related to increasing respiratory mortality and morbidity. We have shown that DEPs augmented the production of inflammatory cytokines by human airway epithelial cells in vitro. To better understand the mechanisms of their proinflammatory activities, we studied the effects of several components extracted from DEPs on interleukin (IL)-8 expression in human bronchial epithelial cell line BEAS-2B and normal human airway epithelial cells obtained from very peripheral airways by an ultrathin bronchoscope. We used several agents active on signal transduction pathways in cytokine expression, such as the protein kinase C inhibitor staurosporin, antioxidant agents including N-acetyl cysteine (NAC) and pyrrolidine dithiocarbamate (PDTC), and p38 mitogen-activated protein kinase (MAPK) inhibitor SB203580. Benzene-extracted components showed effects mimicking DEPs on IL-8 gene expression, release of several cytokines (IL-8; granulocyte macrophage colony-stimulating factor; and regulated on activation, normal T cells expressed and secreted) and nuclear factor (NF)-kappa B activation. We also found that NAC, PDTC, and SB203580 suppressed the activities of DEPs and their benzene extracts, suggesting the roles of oxidants-mediated NF-kappa B activation and p38MAPK pathways. Finally, benzo[a]pyrene, one of the important compounds included in the benzene component, replicated the activities shown by DEPs.

Purification and characterization of goose type lysozyme from cassowary (Casuarius casuarius) egg white

A novel goose-type lysozyme was purified from egg white of cassowary bird (Casuarius casuarius). The purification step was composed of two fractionation steps: pH treatment steps followed by a cation exchange column chromatography. The molecular mass of the purified enzyme was estimated to be 20.8 kDa by SDS-PAGE. This enzyme was composed of 186 amino acid residues and showed similar amino acid composition to reported goose-type lysozymes. The N-terminal amino acid sequencing from transblotted protein found that this protein had no N-terminal. This enzyme showed either lytic or chitinase activities and had some different properties from those reported for goose lysozyme. The optimum pH and temperature on lytic activity of this lysozyme were pH 5 and 30 degrees C at ionic strength of 0.1, respectively. This lysozyme was stable up to 30 degrees C for lytic activity and the activity was completely abolished at 80 degrees C. The chitinase activity against glycol chitin showed dual optimum pH around 4.5 and 11. The optimum temperature for chitinase activity was at 50 degrees C and the enzyme was stable up to 40 degrees C.

Cisplatin-based chemotherapy for postoperative recurrence in non-small cell lung cancer patients: relation of the in vitro chemosensitive test to clinical response

The usefulness of the in vitro chemosensitivity test, the collagen gel droplet embedded culture drug- sensitivity test (CD-DST, Int J Oncol 11: 449, 1997), in cisplatin-based combined chemotherapy for postoperative recurrent tumors in non-small cell lung cancer (NSCLC) patients was retrospectively analyzed. CD-DST data for cisplatin (or carboplatin), etoposide, 5-fluorouracil, mitomycin C, and vindesine were obtained in 311 surgically resected primary lesions. Of them, 25 patients were practically treated with first-line cisplatin- or carboplatin-based chemotherapy for postoperative initial recurrence. Nine (36%) of them responded to the combined chemotherapy for recurrent lesions, including one with complete remission, whereas 16 did not, with no change in 5 and progression in 11. Seven (70%) of 10 patients receiving combined chemotherapy using two or three in vitro sensitive chemoagents showed good responses, whereas there was no responder among the patients receiving chemotherapy including no in vitro sensitive chemoagents. In particular, of 11 patients showing good sensitivity to cisplatin or carboplatin on CD-DST, 8 (73%) responded to chemotherapy, whereas only one (7%) of 14 patients showing cisplatin- or carboplatin-resistance on CD-DST was a responder. Thus, CD-DST results for the chemoagents, especially cisplatin or carboplatin, correlated with chemotherapeutic response, indicating that the CD-DST analysis of surgically resected primary NSCLC tumors is a practically useful indicator of the clinical effect of first-line cisplatin-based combined chemotherapy for postoperative recurrence.

Isolation of a novel human lung-specific gene, LUNX, a potential molecular marker for detection of micrometastasis in non-small-cell lung cancer

We have isolated a novel human lung-specific gene, LUNX (lung-specific X protein), by differential-display mRNA analysis. The full-length cDNA contained 1,015 nucleotides including an open reading frame of 768 nucleotides encoding 256 amino acids. We localized the gene to chromosomal region 20p11.1-q12 by radiation hybrid mapping. Using an RT-PCR assay specific for LUNX mRNA, 35 non-small-cell lung-cancer (NSCLC) tumors and 0 of 16 normal lymph nodes were positive. Furthermore, LUNX mRNA expression was enhanced in 26 (84%) of 31 NSCLC tumors vs. corresponding cancer-free lung tissues by semi-quantitative analyses with multiplex RT-PCR. We assessed the possibility of LUNX mRNA as a molecular marker for detection of micrometastasis in dissected lymph nodes obtained from 20 patients with NSCLC tumors. LUNX mRNA was detected in 16 (80%) of 20 histologically positive lymph nodes and 21 (25%) of 84 histologically negative lymph nodes. Comparative analyses of the conventional histological examination and the RT-PCR detection assay for LUNX mRNA showed that the detection rate of metastases in lymph nodes by the RT-PCR assay was higher in 12 and consistent in 6 of the total 20 NSCLC patients. We demonstrate that the LUNX RT-PCR assay is a potential diagnostic method for detection of micrometastases in lymph nodes of NSCLC patients.

Clinical value of pleural lavage cytological positivity in lung cancer patients without intraoperative malignant pleuritis. Recurrent pattern based on semiquantitative analysis of tumor cells in pleural lavage

OBJECTIVES

We recently developed pleural lavage cytology for lung cancer patients without intraoperative signs of malignant pleuritis (Ann Surg Oncol, 4: 409, 1997). We analyzed recurrent patterns in pleural lavage cytology-positive lung cancer patients without intraoperative signs of malignant pleuritis based on semiquantitative evaluation of tumor cell clusters in pleural lavage solution.

METHODS

Between December 1987 and December 1998, pleural lavage cytology-positive results after thoracotomy were obtained in 97 cases of lung cancer despite the lack of evidence of malignant pleuritis. Based on semiquantitative evaluation of the mean number of tumor cell clusters per slide in pleural lavage solution, patients were classified as Type I, in whom the mean number of clusters was < 1; Type II, in whom clusters numbered 1-10; and Type III, in whom clusters exceeded 10.

RESULTS

Type I patients numbered 37, Type II 40, and Type III 20. By September 1999, pleural recurrence had occurred in 17 patients (18%)--2(5%) Type I, 4 (10%) Type II, and 11 (55%) Type III. The incidence of pleural recurrence was significantly higher for Type III patients, i.e., 5 of 11 Type III patients with pleural recurrence showed no sign of distant metastasis. In contrast, the main recurrent patterns in the other 2 groups were extrathoracic, nodal, and/or intrapulmonary.

CONCLUSIONS

The semiquantitative evaluation of tumor cell clusters in pleural lavage cytology-positive patients provided useful information on postoperative recurrence. Since Type III patients are at high-risk for pleural recurrence, postoperative therapy targeting local control should be conducted in such patients.

[Prognostic assessment of resected lung cancer based on the new international staging system: analysis by histologic types]

The purpose of this study is to assess the validity of the new international staging system for lung cancer revised in 1997 and to clarify the prognostic value of histologic type. Of 1,042 patients with primary lung cancer who underwent resection from 1982 to 1995, 549 patients with adenocarcinoma (AD) and 363 with squamous cell carcinoma (SQ) were included in this study. Overall deaths including operative deaths were treated as the terminal event. For patients with AD, 5-year survival rates were 83% in T1N0M0, 70% in T2N0M0, 46% in T2N1M0, 45% in T3N0M0, 43% in T1N2M0, 32% in T1N1M0, 27% in T2N2M0, 25% in T3N1M0, and 10% in T3N2M0, respectively. For patients with SQ, 5-year survival rates were 80% in T1N0M0, 78% in T1N1M0, 67% in T1N2M0, 60% in T3N0M0, 56% in T2N0M0, 47% in T2N1M0, 36% in T3N1M0, 26% in T2N2M0, and 10% in T3N2M0, respectively. Survival of T1N2M0 was significantly better than that of T2N2M0 and similar to that of T3N0M0 and T2N1M0 both in AD and SQ. In AD survival was dominantly affected by N factor, while in SQ survival was strongly correlated with T factor. In conclusion, we propose that T1N1M0, T2N1M0, T3N0M0 and T1N2M0 should be classified as stage II and T3N2M0 be included into stage IIIB for AD. The TNM grouping for SQ is same as that for AD except setting T1N1M0 as stage IB and T2N0M0 as stage II.

[Use of percutaneous cardiopulmonary support (PCPS) for extended surgery in patients with T4 tumor]

Since 1991, we have performed operations for tumors invading the upper airway, left atrium or main pulmonary artery with percutaneous cardiopulmonary support (PCPS) stand by support available. Of 15 cases with PCPS stand by, 6 patients actually underwent operation using PCPS. There were three esophageal cancers invading the carina, two lung neoplasms with left atrial invasion and one neoplasm extending to the main pulmonary artery. One of three patients with esophageal cancer had massive bleeding in the trachea resulting in airway obstruction. For this patient, emergency PCPS was carried out followed by the total removal of the thoracic esophagus and combined resection of membranous portion of the carina. As a result, a substantial amount of time (6 hours) was required. The two patients with reconstruction of the carina due to esophageal cancer were also successfully treated by using PCPS. Two patients with malignant pulmonary neoplasms invading the left atrium underwent combined resection of the lung and left atrium using a combination of PCPS and ventricular fibrillation under normothermia. In conclusion, PCPS should be accepted as a standard technique for patients with advanced thoracic malignancies in whom cardiac arrest or ventilation support is thought to be necessary for the complete removal of the tumor.

Diesel exhaust particles up-regulate expression of intercellular adhesion molecule-1 (ICAM-1) in human bronchial epithelial cells

Epidemiological and experimental studies suggest that diesel exhaust particles (DEP) may play an active role in the increased respiratory mortality and morbidity. We have shown that DEP augmented the production of inflammatory cytokines by human airway epithelial cells in vitro. ICAM-1 has been shown to play an important role in the local accumulation of inflammatory cells. We studied the effect of DEP on ICAM-1 gene expression and surface expression in human bronchial epithelial cell line BEAS-2B. DEP (5-50 microg/ml) showed a stimulatory effect on ICAM-1 mRNA levels as evaluated by reverse transcription-polymerase chain reaction (RT-PCR). Flow cytometric analysis demonstrated an increased ICAM-1 expression on the epithelial cell surfaces. The soluble form of ICAM-1 molecules was also increased by the stimulation of DEP. In vitro neutrophil attachment onto DEP-stimulated epithelial cells was augmented, which was partially blocked by anti-ICAM-1 neutralizing antibody. Finally, these events were significantly inhibited by pretreatment with anti-oxidants pyrrolidine dithiocarbamate and N-acetyl cysteine, and p38 mitogen activated protein kinase (MAPK) inhibitor SB203580. These findings suggested that DEP induced up-regulation of ICAM-1 gene, and this process might be largely dependent on oxidant-mediated NF-kappaB activation and p38-MAPK pathways.

Increased expression of inflammatory mediators in small-airway epithelium from tobacco smokers

To study the inflammatory responses of small-airway epithelium in smokers, we harvested enough living epithelial cells (1.97 x 10(6) +/- 0.74 x 10(6)) with a new ultrathin fiberscope from the very peripheral airways of 22 current smokers and 17 subjects who never smoked after informed consent was obtained. The cells were keratin positive and composed mainly of nonciliated cells. The expression levels of inflammatory markers [interleukin (IL)-8 and intercellular adhesion molecule (ICAM)-1] were evaluated with RT-PCR. The magnitude of the mRNA levels corrected by beta-actin transcripts of IL-8 and ICAM-1 was significantly higher in the smokers than in the nonsmokers (P < 0.001). Furthermore, among current smokers, IL-8 mRNA levels correlated positively with the extent of smoking history [in pack. years (packs/day x no. of years of smoking); r = 0.754, P < 0.001]. Spontaneously released IL-8 and soluble ICAM-1 levels (n = 12) from cultured epithelial cells were elevated in subjects with a smoking history than in those without it (IL-8, 1,580 +/- 29.6 vs. 354 +/- 39.4 pg. 10(6) cells(-1). 24 h(-1); P < 0.001; soluble ICAM-1, 356.0 +/- 45.9 vs. 112.9 +/- 12.9 pg. 10(6) cells(-1). 24 h(-1); P < 0.01 by Student's t-test ). In contrast, the epithelial cells from the main bronchi did not show such differences between smokers and nonsmokers. Our study highlighted a close link between smoking and the expression of inflammatory mediators such as IL-8 and ICAM-1 in small airways. Our results also suggested that this new ultrathin bronchofiberscope promised a good approach for the evaluation of cellular changes in the small airways.

[Diagnosis and treatment of small peripheral lung cancer]

Recently, routine clinical use of CT scan has enabled the detection of many small pulmonary nodules. Concurrently, high-resolution CT(HRCT) has made great advances in the diagnosis of small peripheral lung cancer. In the tumor of adenocarcinoma, non-invasive bronchioloalveolar carcinoma(BAC) component having a replacement growth pattern of alveolar lining cells shows ground-glass opacity(GGO) on HRCT. On the basis of analysis of small peripheral adenocarcinoma (= < 2 cm), patients with tumors showing > = 50% GGO had no metastatic tendency. Therefore, simple wedge resection may be acceptable as a radical operation. On the other hand, since patients with tumors < 50% GGO had slight metastatic tendency depending upon the tumor size, segmentectomy with mediastinal lymph node sampling should be considered only for tumors = < 15 mm.

p53-regulated GML gene expression in non-small cell lung cancer. a promising relationship to cisplatin chemosensitivity

The GML gene (glycosylphosphatidylinositol-anchored molecule-like protein gene) is a novel gene specifically induced by wild-type p53, which may participate in cell cycle control or the cell apoptotic pathway. Recent experiments suggest that the expression of this novel gene in cancer cells is closely associated with sensitivity to certain anticancer drugs. To elucidate the role of the gene expression in cisplatin (CDDP) chemosensitivity of non-small cell lung cancer (NSCLC), 30 surgically resected materials were examined by reverse transcriptase-polymerase chain reaction (RT-PCR). GML gene expression was detected in 9 (30%) samples. Its incidence was significantly higher in immunohistochemically p53-negative (P=0.040) or wild-type p53 tissues (P=0.041). On in vitro chemosensitivity testing using 29 primary tissues, six samples with GML gene expression showed good sensitivity to CDDP. In particular, in tissues with immunohistochemically p53-negative accumulation, those with GML gene expression showed significantly better in vitro sensitivity to CDDP (P=0.012). Clinically a good response to CDDP-based chemo(thermo)therapy for NSCLC patients with tumour residue or recurrence, was observed only in those with p53-negative accumulation and GML gene expression, in agreement with in vitro results. Thus, although the number of tested samples was small, GML gene expression is commonly detected in immunohistochemically p53-negative NSCLCs in close association with good sensitivity to CDDP. GML gene expression analysis may serve as a predictor of CDDP-based chemotherapy for patients with NSCLC.

Ancient allelism at the cytosolic chaperonin-alpha-encoding gene of the zebrafish

The T-complex protein 1, TCP1, gene codes for the CCT-alpha subunit of the group II chaperonins. The gene was first described in the house mouse, in which it is closely linked to the T locus at a distance of approximately 11 cM from the Mhc. In the zebrafish, Danio rerio, in which the T homolog is linked to the class I Mhc loci, the TCP1 locus segregates independently of both the T and the Mhc loci. Despite its conservation between species, the zebrafish TCP1 locus is highly polymorphic. In a sample of 15 individuals and the screening of a cDNA library, 12 different alleles were found, and some of the allelic pairs were found to differ by up to nine nucleotides in a 275-bp-long stretch of sequence. The substitutions occur in both translated and untranslated regions, but in the former they occur predominantly at synonymous codon sites. Phylogenetically, the alleles fall into two groups distinguished also by the presence or absence of a 10-bp insertion/deletion in the 3' untranslated region. The two groups may have diverged as long as 3.5 mya, and the polymorphic differences may have accumulated by genetic drift in geographically isolated populations.

Combined resection of the aorta for an esophageal carcinoma invading the aorta through a right transthoracic approach

The prognosis of esophageal carcinoma invading the thoracic aorta has been extremely poor, as it has been either not resected or only palliatively resected. In recent years a remarkable improvement in survival has been achieved in advanced esophageal carcinoma through an aggressive dissection of the upper mediastinal lymph nodes. This implied that resection only of the aorta without lymph node dissection in these patients was not adequate for curability. Although a resection of the aorta would seem to be performed more easily through a left thoracotomy than through a right thoracotomy, the upper mediastinal lymph node dissection was unsatisfactory through a left thoracotomy. Therefore, we performed combined resection of the aorta using a temporary aorta-aorta bypass together with upper mediastinal lymph node dissection through a right thoracotomy for four patients with the esophageal carcinoma invading the thoracic aorta. This operative procedure was performed safely, and had the advantage that full observation on the extent of the carcinoma was attained together with subsequent radical lymph node dissection in the same field through only the right thoracic approach. This operation may provide a possibility for cure to patients with an esophageal carcinoma invading the aorta, who would otherwise receive only palliative treatment.

Prognostic value of bronchiolo-alveolar carcinoma component of small lung adenocarcinoma

BACKGROUND

Bronchiolo-alveolar carcinoma (BAC) is often observed in lung adenocarcinoma, but its clinicopathological and prognostic significance, especially in small peripheral lung adenocarcinoma, remains undetermined.

METHODS

We assessed 206 consecutive cases of surgically resected small peripheral lung adenocarcinoma (less than 2 cm in diameter) recorded between 1973 and 1997. According to the component area of well differentiated BAC within maximally cut surface specimens of tumor tissue, we semiquantitatively classified the tumors into four types: those in which the BAC component comprised 0% (type I), 1% to 49% (type II), 50% to 99% (type III), and 100% (type IV) of the tumor tissue.

RESULTS

Forty tumors were classified as type I, 75 as type II, 74 as type III, and 17 as type IV. The tumors with less BAC, especially type I and II, showed a significantly more aggressive nodal involvement and tumor stage, and consequently a worse prognosis, while type IV tumors had no nodal involvement and the most favorable prognosis. The patients with type III showed clinicopathological characteristics somewhere between those of type II and type IV patients. Among stage I patients, however, those with type II had the worst prognosis, while those with type I showed as good a prognosis as the other two groups.

CONCLUSIONS

This novel classification based on the degree of BAC involvement in small peripheral lung adenocarcinoma may reflect clinicopathological and prognostic characteristics. This classification may prove practical for planning therapeutic strategies, in particular surgical treatment.

Differential effects of troglitazone and D-chiroinositol on glucosamine-induced insulin resistance in vivo in rats

Troglitazone and D-chiroinositol have been shown to exert antidiabetic effects by either potentiating or mimicking insulin action. We studied whether pretreatment with these compounds can prevent the deleterious effects of glucosamine on insulin action that may play an important role in hyperglycemia-induced insulin resistance. Normal Wistar rats were pretreated with troglitazone (100 mg/kg/d), D-chiroinositol (100 mg/kg/d), or placebo (saline) for 7 days. Glucosamine (50 micromol/kg/min) was then infused for 210 minutes, and a euglycemic glucose clamp was performed during the last 120 minutes. Pretreatment with troglitazone or D-chiroinositol had no effect on fasting plasma glucose or insulin or basal hepatic glucose output (HGO). Under the euglycemic-hyperinsulinemic (956+/-93 pmol/L) clamp condition, HGO in glucosamine-infused placebo-treated rats was not suppressed, but instead was increased over the basal level, indicative of hepatic insulin resistance. In contrast, HGO failed to increase during glucosamine infusion in rats pretreated with troglitazone but was not normally suppressed. This may indicate a partial improvement in the hepatic insulin resistance. D-Chiroinositol pretreatment had no effect on the glucosamine-induced increase in HGO. The glucose disposal rate (GDR) was 25% lower in rats infused with glucosamine versus saline-infused rats (25.5+/-2.5 v 34.1+/-2.0 mg/kg/min), indicative of peripheral insulin resistance. Pretreatment with D-chiroinositol (34.5+/-2.3 mg/kg/min) prevented the glucosamine-induced decrease in the GDR, indicating an improvement in peripheral insulin resistance. Troglitazone (25.2+/-3.3 mg/kg/min) was without effect. In conclusion, (1) in normal control rats, glucosamine infusion induced hepatic and peripheral insulin resistance; (2) D-chiroinositol, but not troglitazone, pretreatment prevented glucosamine-induced peripheral insulin resistance; and (3) troglitazone, but not D-chiroinositol, partially blocked the glucosamine-induced hepatic insulin resistance. D-Chiroinositol may provide a novel pharmacological approach to hexosamine-induced peripheral insulin resistance.

Survival and postoperative complications after extended surgery for non-small-cell lung cancer. A retrospective study

OBJECTIVE

We evaluated survival after extended surgery in patients with non-small-cell lung cancer and the effects of induction therapy on results and complications.

SUBJECTS AND METHODS

Between April 1987 and March 1998, 127 patients with pathological T3 (pT3) or T4 (pT4) non-small-cell lung cancer underwent extended surgery combined with resection of neighboring organs. Of these, 35 received induction therapy. In the remaining 92, surgery preceded other therapy. Long-term results and postoperative respiratory complications were analyzed and compared between the patients with and without induction therapy.

RESULTS

Overall 5-year survival after extended surgery was 37%. Five-year survival rates in the pT3 was 41% and that in the pT4 group 28% (p = 0.030). Five-year survival rate in the pN0-1 was 46% and that in the pN2-3 group 26% (p = 0.003). No significant difference was observed in survival curves between patients with and without induction therapy. Induction therapy responders showed better survival than nonresponders. To prevent postoperative fatal complications due to bronchopleural fistula, we prophylactically covered the bronchial stump using autologous tissue in 31 induction therapy patients, and no mortality due to complications was seen in this group.

CONCLUSION

Long-term survival after extended surgery was observed in pT3 and pT4 patients, especially among those with a pN0-1 status. Induction therapy responders may be considered good candidates for extended surgery because of the favorable prognosis in contrast to that for nonresponders.

[Indications for intentionally limited resection for non-small-cell lung cancer]

Radiographically, there have been new advances in spiral computed tomography (CT) scanning are currently being studied as a screening tools. As a result, many cases of small-sized lung cancer have been discovered. Some are noninvasive or minimally invasive bronchioloalveolar carcinoma, which is characterized by a the unique sign of ground-glass opacity (GGO) on high-resolution CT (HRCT) scanning. In such cases, lymph node metastases are extremely rare. However, there is currently no definitive surgical modality for such lesions. To clarify the indications of limited resection (segmentectomy or wedge resection), preoperative tumor diameter, location, and, GGO area on HRCT were estimated in patients with clinical T1N0 disease. In patients whose tumor included > or = 50% GGO area and was 15 mm or less in diameter, or patients with pure GGO regardless of tumor size, wedge resection without lymph node dissection should be considered as an acceptable treatment. Video-assisted thoracic surgery is a useful approach for selected patients. On the other hand, in patients with tumors < 50% GGO area in the range of 10-15 mm in diameter, segmentectomy with systematic lymph node dissection or diligent lymph node sampling should be considered.