Sternal resection for metastasis from thyroid carcinoma and reconstruction with the sandwiched Marlex and stainless steel mesh

A case of 69-year-old woman with a solitary sternal bone metastasis from thyroid carcinoma undergoing surgical therapy was reported here. On admission, most part of the body of the sternum was destroyed by tumor. Subtotal sternectomy was performed and a part of the major pectoral muscles adherent to the sternal tumor was also resected. The chest wall defect was reconstructed with a sandwiched Marlex and stainless steel mesh. Pathological examination of the resected specimen revealed metastatic papillary carcinoma of the thyroid. Her postoperative course was uneventful. The reconstruction with Marlex and stainless steel mesh seemed to be an appropriate procedure to prevent paradoxical movement of the thorax and protect the intrathoracic organs. Stainless steel mesh compensated for limited resiliency of Marlex mesh and remained rigid in all directions.

Postoperative Respiratory Complications of Video-assisted Thoracic Surgery for Lung Cancer

PURPOSE

We analyzed the risk factors predisposing patients to develop postoperative respiratory complications (PRCs) in VATS lobectomy and segmentectomy for lung cancer, retrospectively.

METHODS

Both univariate and multivariate analyses of PRCs were performed in seventy-five patients who had undergone VATS lobectomy and segmentectomy for lung cancer from November 1994 to December 2000.

RESULTS

Univariate analysis of the development of PRCs revealed that the significant risk factors were age, ppo%VC, ppo%FEV, ppoFEV, poor pulmonary function, and duration of surgery. Multivariate logistic regression test in regard to the development of PRCs revealed that duration of surgery was the most significant risk factor. On the basis of the receiver operator characteristic analysis, duration of surgery more than 297 min had a sensitivity of 70% and a specificity of 66% for the development of PRCs.

CONCLUSIONS

The duration of surgery should be less than five hours not to lose advantages of VATS lobectomy and segmentectomy. Therefore, if the duration of surgery is more than five hours for any reasons, conversion to limited thoracotomy or muscle-sparing methods is recommended.

Video-assisted Thoracic Surgery for Pulmonary Aspergilloma in Patients with Anorexia Nervosa

We report a case of pulmonary aspergilloma in a 27-year-old woman with anorexia nervosa who underwent a video-assisted thoracic surgery (VATS) lobectomy. On admission, she had lost 38% of her original weight but the laboratory data were normal. She had refused treatment for anorexia nervosa for nine years ago and may have been predisposed to opportunistic conditions. The aspergilloma was developed in a simple bulla formed in the course of healing of a lung abscess and a VATS lobectomy was safely and cosmetically performed. Wedge resection was difficult due to the size of the lesion. The residual lobes expanded very well and the postoperative course was uneventful. VATS is considered to be an efficient method in the treatment of pulmonary aspergilloma in patients with better lung function and localized pulmonary disease.

Video-assisted lobectomy for a lung cancer patient with chronic obstructive pulmonary disease

OBJECTIVES

This retrospective study was conducted to see whether a video-assisted lobectomy is beneficial in lung cancer patients with chronic obstructive pulmonary disease regarding preservation of pulmonary function compared to lobectomy by standard thoracotomy.

SUBJECTS AND METHODS

Between 1982 and 2002, 67 patients who underwent lobectomy for primary lung cancer showed 55% or less of preoperative forced expiratory volume in one second/vital capacity. Among them, 25 patients were enrolled in this retrospective study. The remaining 42 patients were excluded because of no presence of a postoperative pulmonary function test. Nine of 25 patients underwent a video-assisted lobectomy between 1994 and 2002 and the remaining 16 patients who underwent a lobectomy by standard thoracotomy between 1982 and 1994 were employed as a historical control. Perioperative conditions and changes in pulmonary function were compared between two groups.

RESULTS

A parameter of chest wall damage was minor in video-assisted lobectomy compared to that in lobectomy by standard thoracotomy. Changes between pre- and postoperative percent of vital capacity, forced expiratory volume in one second and maximal ventilatory volume showed significantly minor deterioration or even improvement in video-assisted lobectomy patients. Predicted postoperative pulmonary function tended to be underestimated for postoperative values in video-assisted lobectomy patients.

CONCLUSIONS

Video-assisted lobectomy seemed to be profitable in preservation of pulmonary function in lung cancer patients with chronic obstructive pulmonary disease. Prediction of postoperative pulmonary function should be revised due to the underestimation for postoperative values in video-assisted lobectomy, which could offer profitable surgical treatment for lung cancer patients with chronic obstructive pulmonary disease.

[The evaluation of the complications and its management in 800 patients who underwent the thoracoscopic surgery]

Thoracoscopy has been applied to almost all thoracic surgery as shown (table 1). Besides an opportunity to follow and encounter a trouble during surgery using thoracoscopy, so that it is necessary to become skilled in the prediction and management of complication. Nowadays, there are two options on surgery using thoracoscopy, thoracoscopic surgery (TS) is performed only on in a port and on a mini-thoracotomy with a few ports (video-assisted thoracoscopic surgery: VATS). When changing into emergency or converting into open thoracotomy, a muscle sparing thoracotomy could be available. The symptoms which occurred in the thorax are fundamentally similar during both TS and VATS procedure. However, peculiar dangerous factor existed according to the difference in internal organs, procedures, and diseases. Critical complications during surgery were as follows, i.e., injury of pulmonary vessels and bronchus, tension pneumothorax of the opposite lung and tumor implantation of the chest wall. Basically, standard practice is the most important to avoid an accident and determine whether converting to open thoracotomy should be employed. In the present commentary, we would like to present our experiences and propose regarding management.

Lobectomy by video-assisted thoracic surgery for lung cancer patients aged 80 years or more

To clarify the usefulness of video-assisted lobectomy for lung cancer patient aged 80 years old or more, a retrospective study was conducted to evaluate the clinical outcome. Between 1982 and 2001, 914 patients underwent surgery for primary lung cancer at the Nippon Medical School Hospital. Among them, 32 patients underwent lobectomy, including 17 with a mean age of 82 years (range, 80 to 91 years) who underwent video-assisted lobectomy and 15 with a mean age of 82 years (range, 80 to 86 years) who underwent lobectomy by standard thoracotomy. Of these 32 patients, clinical outcome was evaluated retrospectively. Mortality was 4 (12.5%) of 32 patients consisting of 3 (20%) of 15 who underwent lobectomy by standard thoracotomy and 1 (5.9%) of 17 who underwent video-assisted lobectomy. Single variate analyses revealed that the presence of preoperative cardiopulmonary disease, 0.6 L or more of predicted postoperative forced expiratory volume in one second/m(2), 700 ml or more of blood loss, five hours or more of duration of operation and two or more of postoperative complications were considered as risk factors regarding mortality within three months postoperation. Among the patients who underwent lobectomy with mediastinal lymph node dissection, the 5-year survival rate at stage I (IA+IB) was 55.6% for patients who underwent video-assisted lobectomy and 0% for patients who underwent lobectomy by standard thoracotomy (IA=2, IB=2). Video-assisted lobectomy for lung cancer patients aged 80 years or more is considered to offer an acceptable clinical outcome. However, further observation on prognosis is necessary.

Prognostic suggestion in the evaluation of solid component in poorly differentiated adenocarcinoma of the lung

Pulmonary adenocarcinoma composed of pure or predominant solid components is reported to be a highly malignant tumor. However, the existence of solid components and its connection with biological behavior have not been well documented. To answer this question, we histologically subclassified poorly differentiated adenocarcinoma (P/D Ad Ca) into solid type and non-solid type, and compared the biological behavioral characteristics.

MATERIAL AND METHODS

All histological specimens of surgically resected primary lung carcinoma diagnosed as P/D Ca or large cell carcinoma in Nippon Medical School Hospital were re-evaluated according to the 1999 WHO manual. The cases re-evaluated as P/D Ad Ca were further divided into solid type and non-solid type according to our original definition: the solid type contains solid components where a glandular structure is not recognized in more than one high-power field, while in the non-solid type, a small glandular structure is observed in every high-power field. The differences in the occurrence of lymph node metastasis were assessed by Fisher's exact test.

RESULTS

Among 109 cases satisfying both histological and clinical investigation, 45 cases were re-evaluated as P/D Ad Ca; solid type (n=22), and non-solid type (n=23). Lymph node metastases occurred at a higher rate in the solid type than in the non-solid type (p<0.01).

CONCLUSION

Patients with solid type Ad Ca have reached a more advanced stage than patients having non-solid type due to high metastatic rate to lymph nodes. These results suggest that we should not overlook solid components even if the solid components are the focal lesion. This sub-typing alerts clinicians to survey metastases, and may contribute to therapeutic strategies in the future.

Functional mediastinal parathyroid cyst: report of a case

We report herein a rare case of a functional mediastinal parathyroid cyst. A mediastinal tumor was detected by a chest X-ray film and subsequent computed tomography (CT) scan in a 68-year-old woman who was asymptomatic. Biochemical examination revealed that her serum calcium and intact-parathyroid hormone (i-PTH) levels were above the normal range. The findings of chest CT and magnetic resonance imaging suggested a cystic mass. The mass, which adhered tightly to its surrounding structures, was resected through a median sternotomy. The patient had an uneventful postoperative course, and her serum calcium and i-PTH levels rapidly returned to within the normal range.

A case of chronic expanding hematoma presenting as a huge mass in the pleural cavity

We report a case of a huge chronic expanding hematoma completely removed by surgery. A 71-year-old man was found to have a 3-cm-diameter round nodule in the posterior mediastinum seven years previously. He was not administered any treatment because he did not have any other serious symptoms. There was nothing in his history that could be related to his present condition, such as thoracic surgical treatment or tuberculosis. The massive tumor in the left pleural cavity grew, compressing the left lung and heart gradually in the past seven years. Cytological examination of a needle biopsy specimen showed only erythrocytes with a few infiltrating inflammatory cells. Moreover, his preoperative histopathological analysis did not reveal any significant findings. Therefore, he underwent complete resection of the hematoma including the fibrous capsule and left lower lobectomy. Severance of abundant new vascularizations caused massive bleeding. The postoperative course was uneventful. There was no recurrence in the two years. In cases of gradual growth of a mass without indications of malignancy, we should consider the existence of a chronic expanding hematoma even in patients without a history of thoracic operation or tuberculosis.

Thoracoscopic approach for congenital bronchoesophageal fistula in an adult

We present a case of a congenital bronchoesophageal fistula in an adult male who underwent video-assisted thoracic surgery for a resection of the fistula. The patient had not suffered from any serious respiratory infection since the adolescence. However, at 49 years old, the patient experienced persistent cough and back pain. An abnormal shadow in the right lower lobe was observed on a chest X-ray. Chest computed tomography scanning indicated bronchiectasia in the lower superior segment and an abnormal air duct in the posterior mediastinum. Esophagography revealed a 4-cm-long and 1-cm-diameter fistula between the midesophagus and the right lower lobe. Esophagoscopy and bronchoscopy revealed the orifice of the fistula. Three-dimensional computed tomography scanning demonstrated that there was no abnormal artery supplying blood to the affected lung. He underwent video-assisted thoracic surgery, and was uneventfully discharged. Thoracoscopy offered excellent anatomical visualization of the fistula and safe surgical resection.

Pneumothorax manifesting primary lung cancer

Pneumothorax is a rare lung cancer manifestation. We report 2 patients in which pneumothorax occurred as a first manifestation of lung cancer. Postoperative lung tissue examination after pneumothorax showed lung cancer by chance. One patient had dissemination suspected due to ruptured bulla with adenocarcinoma. Both immediately underwent additional lobectomy with mediastinal lymphadenectomy after lung cancer was diagnosed, but we detected lung cancer recurrence in the bottom of the pleural cavity on the same side some 11 months after radical surgery in the patient suspected of dissemination. We could resect it completely, followed by adjuvant radiotherapy. The possibility of lung cancer should thus be considered in pneumothorax patients, even if middle-aged.

Prediction of the postoperative pulmonary function and complication rate in elderly patients

We analyzed the risk factors predisposing elderly patients to develop postoperative respiratory complications (PRCs) and investigated the possibility of predicting the postoperative pulmonary function and PRC rate. The postoperative pulmonary functions were predicted according to a simplified system, which we developed using plain chest roentgenograms from patients with primary lung cancer. Both univariate and multivariate analyses of PRCs were performed in 39 elderly patients with lung cancer from July 1982 to March 1991 (the early period). Based on the results obtained, the permissible extent of lung resection to achieve a predicted postoperative % forced expiratory volume in 1 s (ppo%FEV1.0) and a predicted postoperative % vital capacity (ppo%VC) of more than 55% was selected as the basic criteria for undergoing such an operation after April 1991 (the recent period). A ppo%FEV1.0 and/or ppo%VC of 55% or less was the most significant risk factor for developing PRCs. The PRC rate decreased from 33.3% to 9.8% (P = 0.0251) and the operative mortality rate decreased from 10.3% to 0%. The survival rates for stage I, II. and III cases were not significantly different between the early and recent periods. Decisions made on the operability and the permissible extent of lung resection based on our system using plain chest roentgenograms therefore appeared to reduce the PRC rate and operative mortality rate in elderly patients.

Preclinical evaluation of a new hollow fiber silicone membrane oxygenator for pediatric cardiopulmonary bypass: ex-vivo study

Based on the results of many experimental models, a hollow fiber silicone membrane oxygenator applicable for long-term extracorporeal membrane oxygenation (ECMO) was developed. For further high performance and antithrombogenicity, this preclinical model was modified, and a new improved oxygenator was successfully developed. In addition to ECMO application, the superior biocompatibility of silicone must be advantageous for pediatric cardiopulmonary bypass (CPB). An ex vivo short-term durability test for pediatric CPB was performed using a healthy miniature calf for six hours. Venous blood was drained from the left jugular vein of a calf, passed through the oxygenator and infused into the left carotid artery using a Gyro C1E3 centrifugal pump. For six hours, the O2 and CO2 gas transfer rates were maintained around 90 and 80 ml/min at a blood flow rate of 2 L/min and V/Q=3, respectively. The plasma free hemoglobin was maintained around 5 mg/dl. These data suggest that this newly improved oxygenator has superior efficiency, less blood trauma, and may be suitable for not only long-term ECMO but also pediatric CPB usage.

A case of dumbbell tumor of the superior mediastinum removed by combined thoracoscopic surgery

We report a case of a neurogenic dumbbell tumor in the superior mediastinum resected completely by the combined application of thoracoscopy and neurosurgery performed by an orthopedic surgeon. A 54-year-old female was admitted because her chest X-ray showed a superior mediastinal mass. Computed tomography and magnetic resonance imaging revealed that the tumor was extradural dumbbell-shaped and compressed the spinal cord through the intervertebral foramen between Th2 and Th3. First, she underwent laminectomy of the vertebrae (Th1similarTh3) and separation of the tumor from the dura mater and the root of the second left intercostal nerve in the right semilateral position. Then in the same position, three thoracic ports were placed and the tumor was resected completely using thoracoscopy in a one-stage operation. The pathological diagnosis was neurilemmoma. There has been no sign of serious neurologic deficits or of recurrence four years after the operation. Thus, the procedure is a minimally invasive approach, which is both safe and useful.

Video-assisted lobectomy in elderly lung cancer patients

OBJECTIVES

We evaluated the pre-, intra- and postoperative outcome of video-assisted thoracic surgery lobectomy in elderly lung cancer patients to determine what factors may be disadvantageous.

METHODS

From June 1982 to May 2000, 707 patients underwent pulmonary resection for primary lung cancer. Of these, 87 patients with t1-2 peripheral lung cancer underwent lobectomy and postoperative pulmonary function tests and postoperative conditions at an average of 2.3 months postoperatively. Of these, 52 underwent video-assisted thoracic surgery lobectomy since 1994 and 35 lobectomy by standard thoracotomy.

RESULTS

Video-assisted thoracic surgery lobectomy offered advantages in blood loss, chest wall damage, and minimal performance deterioration status. The percent vital capacity, percent forced expiratory in 1 second, and percent maximum ventilatory volume were well preserved in patients who underwent video-assisted thoracic surgery lobectomy. Multivariate logistic regression analysis identified operation duration as an independent risk factor in morbidity and operative procedure as an independent risk factor in performance deterioration. In stage IA and IB patients, 3-year-survival was 92.9% and 5-year survival 53.8% in those undergoing lobectomy by standard thoracotomy and 84.2% at 3 years and 60.1% at 5-years in those undergoing video-assisted thoracic surgery lobectomy.

CONCLUSION

We thus consider video-assisted thoracic surgery lobectomy in this age group to be an effective procedure, but the long surgical duration is a risk factor in a poor clinical outcome.

Transcriptional regulation of Mesp1 and Mesp2 genes: differential usage of enhancers during development

Mesp1 and Mesp2 encode bHLH-type transcription factors, Mesp1 and Mesp2, respectively. The expression of both genes is observed in the nascent mesoderm, and subsequently in the rostral presomitic mesoderm. To determine the regulatory mechanism for gene expression, we attempted to identify enhancer elements by transient transgenic analysis. At least two enhancers, which are responsible for the expression of the two genes in the early mesoderm (early mesodermal enhancer, EME) and the presomitic mesoderm (PSM enhancer, PSME), and one suppressor, which is responsible for the rostrally restricted expression in the presomitic mesoderm, were identified. Deletion studies of these enhancer elements indicate that either gene may use the same enhancer for early mesoderm development, whereas both genes may utilize separate enhancers to regulate their expression in the presomitic mesoderm.

Legionnaires' disease associated with habitual drinking of hot spring water

A 57-year-old man presented with pneumonia, respiratory distress, and myelodysplastic syndrome. A diagnosis of Legionnaires' disease due to Legionella pneumophila (L. pneumophila) was established. The patient had long been drinking tap water via a conduit from a hot spring resource, from which L. pneumophila was also isolated. Both the patient's strain and the water strain of L. pneumophila were identified as serogroup 1, and the genetic relatedness between the two strains as seen by pulsed-field gel electrophoresis was 87%. The patient was successfully treated with erythromycin, fluoroquinolone, and rifampicin. This case raises an important issue on public health represented by legionellosis in Japan.

Comparison of changes in hemodynamics between unilateral and bilateral lung volume reduction for pulmonary emphysema

This study was aimed to compare changes in hemodynamics between unilateral (UL) or simultaneous bilateral (BL) lung volume reduction surgery (LVRS) for chronic obstructive lung disease. Sixteen patients underwent LVRS by stapler resection with neodymium: yttrium-alminum-garnet (Nd: YAG) laser ablation; five underwent BL-LVRS (four by median sternotomy and one by thoracoscopy) and 11 underwent UL-LVRS by thoracoscopy. Four patients had multiple bullae within pulmonary emphysema. At preoperation and 6, 12, 24, and 48 hours postoperatively, hemodynamics and right ventricular performance were evaluated. UL- and BL-LVRS reduced afterload of the right and left ventricle postoperatively. Although the pulmonary arterial resistance increased after surgery, the total pulmonary resistance decreased (p=0.001) in association with the reduced systemic vascular resistance (p=0.001). These reductions improved cardiopulmonary circulation, resulting in increased stroke volume and cardiac output (p=0.003). The right ventricular ejection fraction showed minimal change 48 hours postoperation. Two patients died of pneumonia caused by persistent air leakage. In conclusion, both the UL- and BL-LVRS showed similar effectiveness in terms of improvement in the systemic and cardiopulmonary circulation after LVRS, if there were no postoperative complications. We concluded that we had to reduce and repair the persistent air leakage after LVRS.

A retroviral-derived immunosuppressive peptide activates mitogen-activated protein kinases

The highly conserved region within the retroviral transmembrane envelope proteins has been implicated in a number of retrovirus-associated mechanisms of immunosuppression. CKS-17, a synthetic peptide representing the prototypic sequence of the immunosuppressive domain, has been found to suppress numerous immune functions, disregulate cytokines, and elevate intracellular cAMP. In this report we show that using a human monocytic cell line THP-1, CKS-17 activates mitogen-activated protein (MAP) kinases extracellular signal-regulated kinase 1 and 2 (ERK1/2). Kinetic studies show that CKS-17 induces an acute increase of ERK1/2 activity followed by a rapid decrease and then a second sustained increase of ERK1/2. CKS-17 also activates MAP kinase/ERK kinase (MEK) with a similar induction pattern. Mutant THP-1 cells isolated in our laboratory, in which CKS-17 exclusively fails to activate cAMP, did not show the transient decrease of CKS-17-induced ERK1/2 phosphorylation. Pretreatment of THP-1 cells or mutant THP-1 cells with cAMP analog or forskolin followed by treatment with CKS-17 showed no activation of MEK or ERK1/2. These results indicate that CKS-17 activates the MEK/ERK cascade and that there is a cross-talk between CKS-17-mediated MEK/ERK cascade and cAMP in that the MEK/ERK cascade is negatively regulated by cAMP. These data present a novel molecular mechanism(s) by this highly conserved retroviral immunosuppressive component.

High survival rate of 6 cases of pulmonary large cell neuroendocrine carcinoma formerly classified as small cell carcinoma

In the revised WHO classification of lung cancer, published in 1999, large cell neuroendocrine carcinoma (LCNEC) was employed as a new histological entity. LCNEC is generally considered a high-grade malignant lung cancer, and appropriate treatment remains to be determined. Before its new classification, LCNEC had long been classified into several entities. Advancing the review of previous cases in Nippon Medical School Hospital, we noticed that some LCNEC patients were formally diagnosed as having small cell lung cancer (SCLC), and they showed long-term survival.

MATERIAL AND METHODS

All histological specimens of surgically resected SCLC in Nippon Medical School Hospital were reclassified according to the 1999 WHO classification manual. Their neuroendocrine differentiations were confirmed by the use of immunostainings with chromogranin A and synaptophysin.

RESULTS

Fourteen cases satisfied the qualifications for both histological and clinical reevaluation. Among them, 6 patients were reclassified as LCNEC, and their stage distribution was as follow: IA; 1, IB; 2, IIIA; 2, and IIIB; 1. Their survival term ranged from 33.8 to 78.0 months; 5 were still alive, and 1 (IIIB) died 57.6 months after surgery.

DISCUSSION

According to this study, all the LCNEC patients who were treated as SCLC patients showed more favorable prognoses than patients described in published studies, even overall lung cancer. Therefore, it is suggested that multimodality therapy for SCLC may improve the prognoses of patients with LCNEC.

Immunologic reconstitution following bone marrow transplantation for X-linked hyper IgM syndrome

X-linked hyper IgM syndrome (XHIM), caused by mutations of the CD40 ligand (CD40L) gene, is characterized by recurrent bacterial and opportunistic infections, an increased incidence of autoimmunity and malignancies, and immunodeficiency due to abnormal T/B cell interaction. Because of poor long-term prognosis, bone marrow transplantation (BMT) has been proposed as an alternative treatment. An 8-month-old boy with XHIM and a splice site mutation of CD40L underwent BMT using a fully matched sibling donor. Markers of engraftment and immunologic reconstitution were measured serially. After BMT, activated T cells expressed functional CD40L, and genomic DNA obtained from circulating white cells contained predominantly wild-type CD40L sequences. Serum immunoglobulin levels including IgE and antibody responses to recall antigens normalized, and immunization with the T-cell-dependent neoantigen, bacteriophage &phi;X174, demonstrated amplification of the response and isotope switching. BMT provides a permanent cure for XHIM if a fully matched sibling donor is available and the procedure is performed before complications have occurred.

Involvement of a herbimycin A-sensitive protein tyrosine kinase in extracellular action of HIV-1 Nef

Extracellular Nef which has been implicated in disease progression and development of AIDS induces IL-10, a potent immunosuppressive cytokine, in vitro. The present study was designed to examine whether the action of extracellular Nef is a protein tyrosine kinase (PTK)-dependent event. Anti-phosphotyrosine immunoblotting reveals that recombinant HIV-1 Nef induces rapid tyrosyl phosphorylation of several cellular proteins in human peripheral blood mononuclear cells. Pre-treatment of cells with herbimycin A, but not with genistein, significantly abolishes the Nef-induced tyrosine phosphorylation of cellular proteins. Furthermore, ELISA and RNase protection assays show that herbimycin A significantly blocks Nef-induced production of IL-10 at both the protein and the mRNA level. Genistein and aminogenistein have a much less blocking effect on the ability of Nef to induce IL-10. These results provide evidence for the involvement of a herbimycin A-sensitive PTK in the signal transduction pathway for exogenous HIV-1 Nef.