A case of trichilemmal carcinoma with distant metastases in a kidney transplantation patient

Transplant recipients receiving immunosuppressants are at a high risk of cancer, especially skin cancer. Trichilemmal carcinoma is comparatively rare compared with other skin cancers. We report here a first case of trichilemmal carcinoma arising in a kidney transplant recipient. A 63-year-old man who had undergone a living donor renal transplantation at the age of 50 years presented with a 15 × 10 mm lesion on his forehead. The pathological diagnosis after resection was trichilemmal carcinoma. Distant metastases involving the lymph nodes, lung, and liver occurred, and the patient died. Given that trichilemmal carcinoma generally has an indolent clinical course and a low metastatic potential, the present case of trichilemmal carcinoma with an aggressive course resulting in distant metastases is rare.

Soft x-ray intensity profile measurements of electron cyclotron heated plasmas using semiconductor detector arrays in GAMMA 10 tandem mirror

Temporally and spatially resolved soft x-ray analyses of electron cyclotron heated plasmas are carried out by using semiconductor detector arrays in the GAMMA 10 tandem mirror. The detector array has 16-channel for the measurements of plasma x-ray profiles so as to make x-ray tomographic reconstructions. The characteristics of the detector array make it possible to obtain spatially resolved plasma electron temperatures down to a few tens eV and investigate various magnetohydrodynamic activities. High power electron cyclotron heating experiment for the central-cell region in GAMMA 10 has been started in order to reduce the electron drag by increasing the electron temperature.

Evaluation of lower-starch diets for lactating Holstein dairy cows

The objective of this experiment was to measure ruminal and lactational responses of Holstein dairy cows fed diets containing 3 different starch levels: 17.7 (low; LS), 21.0 (medium; MS), or 24.6% (high; HS). Twelve multiparous cows (118 ± 5 d in milk) were assigned randomly to dietary treatment sequence in a replicated 3 × 3 Latin square design with 3-wk periods. All diets were fed as total mixed rations and contained approximately 30.2% corn silage, 18.5% grass silage, and 5.0% chopped alfalfa hay. Dietary starch content was manipulated by increasing dry ground corn inclusion (% of dry matter) from 3.4 (LS) to 10.1 (MS) and 16.9 (HS) and decreasing inclusion of beet pulp and wheat middlings from 6.7 and 13.4 (LS) to 3.4 and 10.1 (MS) or 0 and 6.8 (HS). In vitro 6-h starch digestibility of the diet increased as nonforage sources of fiber replaced corn grain (% of dry matter; 73.6, HS; 77.3, MS; 82.5, LS) resulting in rumen-fermentable starch content by 14.6, 16.2, and 18.1% for the LS, MS, and HS diets, respectively. Diets had similar neutral detergent fiber from forage and particle size distributions. Dry matter intake, solids-corrected milk yield, and efficiency of solids-corrected milk production were unaffected by diet, averaging 26.5 ± 0.8, 40.8 ± 1.6, and 1.54 ± 0.05 kg/d, respectively. Reducing dietary starch did not affect chewing time (815 ± 23 min/d), mean ruminal pH over 24h (6.06 ± 0.12), acetate-to-propionate ratio (2.4 ± 0.3), or microbial N synthesized in the rumen (585 ± 24 g/d). Total tract organic matter digestibility was higher for HS compared with MS and LS diets (69.2, 67.3, and 67.0%, respectively), but crude protein, neutral detergent fiber, and starch digestibilities were unaffected. As dietary starch content decreased, in vitro ruminal starch fermentability increased and, consequently, the range between HS and LS in rumen-fermentable starch (3.5 percentage units) was less than the range in starch content (6.9 percentage units). Under these conditions, dietary starch content had no measurable effect on ruminal fermentation or short-term lactational performance of high-producing Holstein dairy cows.

The new IASLC-ATS-ERS lung adenocarcinoma classification: what the surgeon should know

In 2011, a new histologic classification of lung adenocarcinomas was proposed from a joint working group of the International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society, based on the recommendation of an international and multidisciplinary panel. This classification proposed a method of comprehensive histologic subtyping (lepidic, acinar, papillary, micropapillary, and solid pattern) based on semiquantitative assessment of histologic patterns (in 5% increments), with the ultimate goal of choosing a single, predominant pattern. Prognostic subsets could then be described for the classification. Patients with completely resected adenocarcinoma in situ and minimally invasive adenocarcinomas experienced low risk of recurrence. Patients with micropapillary or solid predominant tumors have a high risk of recurrence or cancer-related death. Patients with acinar and papillary predominant tumors comprise an intermediate-risk group. Herein, we review the outline of the proposed International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society classification, a summary of published validation studies of this new classification, and then discuss the key surgical issues; we mainly focused on limited resection as an adequate treatment for early-stage lung adenocarcinomas, as well as preoperative and intraoperative diagnoses. We also review the published studies that identified the importance of histologic subtypes in predicting recurrence, both rates and patterns, in early-stage lung adenocarcinomas. This new classification for the most common type of lung cancer is useful for surgeons, as its implementation would require only hematoxylin-and-eosin histology slides, which is the common type of stain used in hospitals. It can be implemented with routine pathology evaluation and with no additional costs.

NADPH Regeneration by Glucose Dehydrogenase fromGluconobacter scleroidesforl-Leucovorin Synthesis

A new process for (6S)-tetrahydrofolate production from dihydrofolate was designed that used dihydrofolate reductase and an NADPH regeneration system. Glucose dehydrogenase from Gluconobacter scleroides KY3613 was used for recycling of the cofactor. The reaction mixture contained 200 mM dihydrofolate, 220 mM glucose, 2 mM NADP, 14.4 U/ml dihydrofolate reductase, and 14.4 U/ml Glucose dehydrogenase, and the reaction was complete after incubation at pH 8.0, and 40 degrees C for 2.5 hr. With (6S)-tetrahydrofolate as the starting material, l-leucovorin was synthesized via a methenyl derivative. The purity of the l-leucovorin was 100%, and its diastereomeric purity was greater than 99.5% d.e. as the (6S)-form.

Usefulness of vessel-sealing devices for ≤7 mm diameter vessels: a randomized controlled trial for human thoracoscopic lobectomy in primary lung cancer

OBJECTIVES

Vessel-sealing devices (VSDs) are widely used for various surgical procedures, including thoracoscopic surgery, but very few reports have compared their safety and usefulness with human thoracoscopic lobectomy procedures not employing VSDs.

METHODS

Primary lung cancer patients for whom a thoracoscopic lobectomy involving mediastinal lymph node dissection was planned in our department from April 2011 to March 2013 were recruited for the study. Patients were randomly allocated to a control group (n = 14) or a VSD group (n = 44), which comprised three sub-groups, namely EnSeal (n = 17), LigaSure (n = 15) and Harmonic (n = 12). The control group comprised patients undergoing surgery solely with ligation and conventional electrocautery. EnSeal, LigaSure and Harmonic were chosen because they are the three most popular disposable VSDs used in Japan. In the VSD groups, the proximal side of pulmonary artery stumps (≤7 mm diameter) were ligated and then treated with respective devices. Primary end-points were burst pressure of the pulmonary artery stump (measured using resected specimens), operative time, intraoperative blood loss, instances of endostapler use, intraoperative surgeon stress (assessed by visual analogue scale) and postoperative drainage volume and duration. As a secondary objective, the individual VSD groups were also compared with each other.

RESULTS

The burst pressure of ligation-treated pulmonary artery stumps was higher than that of VSD-treated stumps (P <0.0001). The burst pressure of <5-mm-wide VSD-treated stumps was higher than that of ≥5-mm-wide stumps (P = 0.0421). However, the burst pressure for all groups and all vessel diameters was sufficient to withstand the physiological pulmonary artery pressure. The VSD group demonstrated reduced intraoperative blood loss (P = 0.0241), surgeon stress (P = 0.0002), postoperative drainage volume (P = 0.0358) and shortened postoperative drainage duration (P = 0.0449). Operative time and the instances of endostapler use did not significantly differ. Comparison between each of the VSD groups revealed no significant differences. None of the patients experienced serious perioperative complications or died because of surgery.

CONCLUSION

VSD is simple and safe to use in thoracoscopic lobectomy involving mediastinal lymph node dissection for primary lung cancer. Furthermore, none of the VSDs used in this study presented any observable differences in quality that could lead to clinical problems.

Pulmonary artery reconstruction with a prosthetic conduit in lung cancer

In radical pulmonary resection for advanced lung cancer, reconstruction of the pulmonary artery (PA) can preserve the lung parenchyma. Reconstruction techniques have gained acceptance because they enable the surgeon to avoid pneumonectomy. Various techniques have been documented, such as direct suturing, end-to-end anastomosis, and a patch or conduit reconstruction. We present two lobectomy cases in which the patients underwent PA reconstruction with prosthetic conduits because they were unfit for other procedures. In both cases, the conduits showed good postoperative patency. When interposition of a conduit is required for PA reconstruction, the use of a prosthetic conduit should be considered in selected cases.

Tumor size and computed tomography attenuation of pulmonary pure ground-glass nodules are useful for predicting pathological invasiveness

Objectives

Pulmonary ground-glass nodules (GGNs) are occasionally diagnosed as invasive adenocarcinomas. This study aimed to evaluate the clinicopathological features of patients with pulmonary GGNs to identify factors predictive of pathological invasion.

Methods

We retrospectively evaluated 101 pulmonary GGNs resected between July 2006 and November 2013 and pathologically classified them as adenocarcinoma in situ (AIS; n = 47), minimally invasive adenocarcinoma (MIA; n = 30), or invasive adenocarcinoma (I-ADC; n = 24). The age, sex, smoking history, tumor size, and computed tomography (CT) attenuation of the 3 groups were compared. Receiver operating characteristic (ROC) curve analyses were performed to identify factors that could predict the presence of pathologically invasive adenocarcinomas.

Results

Tumor size was significantly larger in the MIA and I-ADC groups than in the AIS group. CT attenuation was significantly greater in the I-ADC group than in the AIS and MIA groups. In ROC curve analyses, the sensitivity and specificity of tumor size (cutoff, 11 mm) were 95.8% and 46.8%, respectively, and those for CT attenuation (cutoff, −680 HU) were 95.8% and 35.1%, respectively; the areas under the curve (AUC) were 0.75 and 0.77, respectively. A combination of tumor size and CT attenuation (cutoffs of 11 mm and −680 HU for tumor size and CT attenuation, respectively) yielded in a sensitivity and specificity of 91.7% and 71.4%, respectively, with an AUC of 0.82.

Conclusions

Tumor size and CT attenuation were predictive factors of pathological invasiveness for pulmonary GGNs. Use of a combination of tumor size and CT attenuation facilitated more accurate prediction of invasive adenocarcinoma than the use of these factors independently.

Hilar lymph node metastasis of amelanotic malignant melanoma of unknown origin

We report a case of hilar lymph node metastasis of amelanotic malignant melanoma of unknown origin. A left pulmonary nodule was detected during a check-up in a 58-year old woman. Chest computed tomography indicated a large left hilar mass located between the upper and lower lobes. She underwent left pneumonectomy with mediastinal lymph node dissection, and the tumour was diagnosed as hilar lymph node metastasis of an amelanotic malignant melanoma; however, the primary lesion could not be detected. Thus, the possibility of spontaneous regression of the primary lesion and the amelanotic subtype of malignant melanomas should be considered in clinical practice.

Feasibility of using a vessel sealing system in a human pulmonary lobectomy: a retrospective comparison of this procedure with or without a vessel sealing system

OBJECTIVE

Despite recent advances in video-assisted thoracoscopic lobectomy, some technical limitations still remain. Our current study purpose was to determine if the vessel sealing system (VSS) has utility in this procedure.

METHOD

112 patients who underwent an anatomic pulmonary lobectomy at our institute were evaluated retrospectively. The burst pressure of pulmonary vessels, which was divided into VSS (VSS group; n = 44) or manual ligature (ligature group; n = 53) groups, was measured experimentally in transected lungs. Perioperative clinical data was also retrospectively evaluated in patients treated with (VSS group) or without using VSS (n-VSS group).

RESULTS

Burst pressures achieved adequate strength in both the VSS (600.0 ± 436.8 mmHg) and ligature (1057.4 ± 462.3 mmHg) groups. Compared with the n-VSS group, the VSS group patients showed lower intraoperative blood loss (115.4 ± 181.1 vs. 183.3 ± 159.1 ml), lower chest fluids by 3rd post-operative day (POD) (533.8 ± 264.8 vs. 705.3 ± 339.3 ml) and a shorter period of chest tube duration (4.1 ± 1.2 vs. 5.4 ± 2.4 days). No serious complications or perioperative (30 days) deaths occurred in either group.

CONCLUSION

The VSS device has the advantage in pulmonary lobectomy procedures, especially those involving video-assisted thoracic surgery (VATS).

Lung re-expansion following one-lung ventilation induces neutrophil cytoskeletal rearrangements in rats

PURPOSE

To investigate the morphological and functional behavior of neutrophils during and after one-lung ventilation (OLV).

METHODS

We utilized an OLV rat model system and performed 3 hours of OLV followed by either re-expansion (RE) and 30 minutes of two-lung ventilation (TLV) (RE group), only two-lung ventilation (TLV group), or only OLV (OLV group). Cytoskeletal rearrangements of circulating neutrophils were assessed by determining the localization of filamentous actin (F-actin). In addition, the number of sequestered neutrophils in the lung capillary and the cytokine-induced neutrophil chemoattractant 1 (CINC-1) levels in the plasma were determined.

RESULTS

The F-actin rimmed neutrophils in the RE group increased after RE, but did not increase in the other groups. In the RE group, the sequestered neutrophils in the ventilated lung were significantly more numerous, and the plasma CINC-1 levels were significantly higher than in the other groups.

CONCLUSIONS

Lung RE following OLV induces cytoskeletal rearrangements in circulating neutrophils and would thereby promote their sequestration in the lung capillaries. The plasma CINC-1 elevation after RE can be involved in neutrophil recruitment.

Pulmonary pure ground-glass opacity lesions: Use of computed tomography attenuation for predicting tumor progression

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Background: Cases with pure ground-glass opacity (GGO) are increasing with the use of computed tomography (CT). In some cases, pure GGO on follow-up CT may represent tumor enlargement or the presence of solid components. We evaluated the natural progression of pure GGO lesions during a long-term follow-up period of more than 2 years. Methods: We retrospectively investigated 95 patients with pure GGO lesions detected between February 2003 and December 2010, in whom these lesions were monitored using CT for more than 2 years. Results: The median follow-up period was 64.7 months (range, 24–114 months). During the follow-up period, areas showing GGO increased in size or appeared to have solid components in 49 patients (group 1) and showed no change in 46 patients (group 2). We compared patient characteristics and tumor properties between the 2 groups. Mean CT attenuation values of the tumors differed significantly between groups 1 (-639.9 ± 88.9 HU) and 2 (-709.2 ± 60.9 HU). In contrast, no significant differences were noted with regard to age, gender, smoking history, lung cancer history, tumor size, and total numbers of GGO lesions between the 2 groups. The difference in the time to tumor growth according to the initial mean CT attenuation value was estimated using the Kaplan–Meier method. The growth incidence at 114 months for lesions with a mean CT attenuation value of -650 HU or more (n = 35) and less than -650 HU (n = 60) were estimated to be 96% and 48%, respectively. The difference between the 2 Kaplan–Meier curves was statistically significant (p < 0.0001). The usefulness of the mean CT attenuation value in predicting the growth of GGO lesions was evaluated using receiver operating characteristic analysis. The sensitivity and specificity was 63% and 87%, respectively, for a mean CT attenuation cutoff value of -650 HU. The area under the curve was 0.76. Conclusions: Many pure GGO lesions have potential for growth as seen during long-term follow-up. CT attenuation is useful in predicting the growth of GGO lesions.