Repeat resection of pulmonary metastasis is beneficial for patients with colorectal carcinoma

BACKGROUND

The role for repeat pulmonary metastasectomy for colorectal carcinoma has not been well defined. To identify the class of patients who benefit from pulmonary resection of recurrent pulmonary metastases, we herein reviewed our institutional experience.

METHODS

Between 1990 and 2007, 84 patients with pulmonary metastases from colorectal carcinomas underwent complete pulmonary resection, and 22 of them (26%) later underwent complete resection for repeat pulmonary metastasis. Various perioperative variables were investigated retrospectively in these patients to confirm a role for repeat metastasectomy and analyze prognostic factors after repeat pulmonary metastasectomy.

RESULTS

Overall survival and disease-free survival after repeat pulmonary metastasectomy were, respectively, 61 and 32% at 5 years. On univariate analysis, male gender and less than 1 year of disease-free status after the first pulmonary metastasectomy demonstrated significantly adverse overall survival (p = 0.01 and p = 0.009, respectively). Elevated preoperative serum carcinoembryonic antigen (CEA) level and maximum tumor size larger than 3 cm were also significantly adverse prognostic factors for disease-free survival (p = 0.03 and p = 0.04, respectively). The overall survival curve after repeat pulmonary metastasectomy was almost identical with that after complete resection of the first pulmonary metastasis.

CONCLUSIONS

Patients with more than 1 year of disease-free status after the first pulmonary metastasectomy demonstrated a significantly better overall survival. Normal preoperative serum CEA level and maximum tumor size <3 cm were significantly adverse prognostic factors for disease-free survival. Our data imply that repeat pulmonary metastasectomy might be beneficial as it can salvage a subset of patients with colorectal carcinoma who retain favorable prognostic determinants.

Surgical management of bronchopulmonary typical carcinoid tumors: an institutional experience

Bronchopulmonary typical carcinoid tumors are well known as low-grade malignant tumors with fairly benign behaviors; however, distant metastasis after complete resection and multiple carcinoid tumors in the resected lungs have been sporadically reported. Lesser resections are preferred including lung-sparing surgery, while the importance of major surgical resections is also emphasized. For better understanding of bronchopulmonary typical carcinoid tumors, we reviewed our institutional experience. Eight patients with bronchopulmonary typical carcinoid tumors underwent complete pulmonary resection. Various perioperative variables and postoperative survival were investigated retrospectively. All patients were alive after surgery. Seven patients received more than a lobectomy and one underwent a segmentectomy for a peripheral small nodule. In all patients, systemic nodal dissection was performed. In one patient who received a lobectomy for a peripheral nodule, multiple carcinoid tumors were found in the resected specimen. No patients received any adjuvant chemotherapy or radiotherapy after pulmonary resection. In one patient, tumors recurred at the bronchial stump and in the liver approximately five years after complete pulmonary resection. Despite a small number of cases, our study supported the idea that bronchopulmonary typical carcinoid tumors might require major surgical procedures and that complete pulmonary resection of typical carcinoid tumors could expect long-term survival.

Large solitary fibrous tumor with overexpression of insulin-like growth factor-2

We present the case of a 66-year-old woman in whom a large solitary fibrous tumor (SFT) in the right thoracic cavity caused intermittent symptoms of hypoglycemia. A diagnosis was made of non-islet cell tumor hypoglycemia on the basis of the presence of hypoglycemia requiring continuous glucose infusion, elevated serum insulin-like growth factor-2 (IGF-2), and a large well-defined tumor in the right thoracic cavity. The patient underwent complete resection of the tumor. Histological examination revealed spindle tumor cells with a hemangiopericytoma-like vascular pattern. Mitotic figures and necrotic areas were rare, and cellular atypia and nuclear pleomorphism were mild. Under immunohistochemical examination, the tumor cells were positive for CD34. Overexpression of IGF-2 mRNA in the tumor was detected by reverse-transcription polymerase-chain reaction. The diagnosis of SFT with IGF-2 production was confirmed. Immediately after surgery, her serum glucose level was normalized (without the need for glucose infusion) and serum IGF-2 level was decreased. Two years after surgery, the patient remains alive and well, with no signs of recurrence or hypoglycemia.

Perioperative assessment of oversized lobar graft downsizing in living-donor lobar lung transplantation using three-dimensional computed tomographic volumetry

A 15-year-old boy with bronchiolitis obliterans after bone marrow transplantation successfully underwent bilateral living-donor lobar lung transplantation (LDLLT) with segmentectomy of the superior segment of an oversized right lower lobe graft. As the recipient was small for his age, the predicted value of his functional vital capacity of the recipient was difficult to determine preoperatively. Three-dimensional computed tomography (CT) volumetry revealed that the ratio of donor graft volume to recipient hemithorax volume was 159% on the right side and 82% on the left side. The patient is alive and well 7 months after transplantation, and three-dimensional CT volumetry revealed that the right and left donor lungs were still compressed to 73% and 84% of the original size, respectively. In LDLLT, segmentectomy of the superior segment of the lower lobe is a useful option for downsizing an oversized graft and three-dimensional CT volumetry can provide meaningful data for size matching.

Post-ischemic infusion of atrial natriuretic peptide attenuates warm ischemia-reperfusion injury in rat lung

BACKGROUND

The serious shortage of organs for transplantation, especially lungs, has drawn increasing attention to donation after cardiac death and protection of organs against warm ischemic injury. Atrial natriuretic peptide (ANP) activates guanylate cyclase receptors and increases cyclic guanosine monophosphate (cGMP) levels, which decrease in the lung during ischemia. In this study we investigated the effect on lung ischemia-reperfusion injury of administering synthetic ANP (carperitide) at the onset of reperfusion after warm ischemia.

METHODS

An isolated rat lung perfusion model was used. The rats were allocated into three groups: the control group; the ANP group; and the sham group. In the control and ANP groups, the heart-lung block was exposed to 60 minutes of ischemia at 37 degrees C, and subsequently reperfused for 60 minutes. At the onset of reperfusion, either saline or ANP was added to the perfusate. In the sham group, lungs were continuously perfused without ischemia and only saline was added to the perfusate.

RESULTS

ANP significantly reduced pulmonary vascular resistance and pulmonary edema, and improved oxygenation. It also significantly increased cGMP levels in reperfused lungs. Histologically, lungs in the ANP group showed significantly fewer signs of injury and fewer cells demonstrated apoptotic changes or single-stranded DNA than lungs in the control group.

CONCLUSIONS

Our results indicate that ANP administered at the onset of reperfusion increases cGMP in lung tissue and attenuates warm ischemia-reperfusion injury in isolated perfused rat lung.

Repeat resection of pulmonary metastasis is beneficial for patients with osteosarcoma of the extremities

Pulmonary metastasectomy in osteosarcoma can lead to long-term survival, but the role for repeat pulmonary metastasectomy is undefined. To confirm the value of repeat pulmonary resection of recurrent pulmonary metastases, we herein reviewed our institutional experience. Between 1989 and 2007, 25 patients with pulmonary metastases from osteosarcomas of the extremities underwent pulmonary resection, and 14 patients underwent repeat pulmonary metastasectomy. Ten of 14 patients underwent complete resection. Various perioperative variables were investigated retrospectively in these patients to confirm a role for repeat metastasectomy and analyze prognostic factors for overall survival (OS) after repeat pulmonary metastasectomy. OS rate after repeat pulmonary metastasectomy was 43% at two years and 19% at five years. On multivariate analysis, patients with complete resection presented significantly favorable OS (P=0.02). Interestingly enough, survival curve of patients with complete resection after the first pulmonary metastasectomy was almost the same as that of patients with complete resection after the second pulmonary metastasectomy. In conclusion, patients with complete resection for recurrent pulmonary metastasis show a significantly better prognosis after repeat pulmonary metastasectomy. Our data imply that repeat pulmonary metastasectomy might be beneficial because it can salvage a subset of patients with osteosarcoma who retain favorable prognostic determinants.

Use of totally implantable central venous access port via the basilic vein in patients with thoracic malignancies

BACKGROUND

For patients with a thoracic malignancy whose peripheral veins are not suitable for blood access for chemotherapy, we evaluated a totally implantable central venous access port, in which the port is implanted in the ulnar side of the arm and the catheter is introduced via the basilic vein into the superior vena cava (TIAP-BV).

METHODS

Twenty-five patients (21 with lung cancer, 2 with malignant pleural mesothelioma, and 2 with thymoma) receiving TIAP-BV were included. Indications, surgical complications, and long-term complications were analyzed.

RESULTS

Indications for TIAP-BV were: chemotherapy (17 patients) and chemotherapy with parenteral nutrition (8 patients). The following surgical complications occurred: arrhythmia due to misplacement of the tip of catheter (1 patient); intraoperative conversion from the left to right arm (2 patients); and hematoma at the implantation site (1 patient). Short-term problems were: death 1 week after implantation without the use of TIAP-BV (2 patients). Long-term complications were: skin ulcer at the port site (1 patient); early removal of TIAP-BV because of port site infection (1 patient); catheter occlusion (1 patient); and venous thrombosis of basilic vein (2 patients). In the 22 patients who did not die early or have the device withdrawn early, the median duration of TIAP-BV use was 7 months (range, 1 to 20 months) without any break to the port system, leakage of drugs, or catheter-related infections.

CONCLUSION

TIAP-BV can be employed for long-term use for chemotherapy and parenteral nutrition. However, a patient's expected prognosis and infectious disease status at the time of implantation surgery should be considered before the surgery proceeds.

Value of FOXP3 expression in peripheral blood as rejection marker after miniature swine lung transplantation

BACKGROUND

Outcome for highly immunogenic lung transplantation remains unsatisfactory despite the development of potent immunosuppressants. The poor outcome may be the result of a lack of minimally invasive methods to detect early rejection. There is emerging clinical evidence that, paradoxically, expression of forkhead box P3 (FOXP3, a specific marker for the regulatory T cells) is upregulated within rejecting grafts.

METHODS

Orthotopic lung transplantation was performed using miniature swine without immunosuppression. Rejection was monitored by chest radiography and open lung biopsy. Expressions levels of FOXP3, perforin, Fas-L and IP-10 mRNA were quantified in the peripheral blood. In addition, rescue immunosuppressive therapy (steroid plus tacrolimus) was administered on post-operative day (POD) 4 or 6.

RESULTS

Early rejection was detected by open lung biopsy, but misdiagnosed by chest radiography on POD 4. Expression of FOXP3 in the peripheral blood reached its highest value as early as POD 4, followed by a decline. Such an increase of FOXP3 was not observed in recipients given high-dose tacrolimus. Neither perforin, Fas-L or IP-10 in the peripheral blood exhibited significant fluctuations in the early phase of rejection. Rescue immunosuppressive therapy from POD 4, when peak FOXP3 was seen, prolonged graft survival (27.2 days, versus 9.1 days without immunosuppression, p < 0.001), in contrast to POD 6, when rejection was suspected by chest radiography (11.5 days, p = not statistically significant [NS]).

CONCLUSIONS

In a miniature swine lung transplantation model, the FOXP3 mRNA level in the peripheral blood was upregulated at an early phase of rejection. The clinical implication of this finding remains to be elucidated.

Potential for pulmonary protection by nebulized milrinone during warm ischemia

OBJECTIVE

A method to compensate for the donor shortage may be the utilization of donation after cardiac death. The control of lung injury against warm ischemia is crucial in manipulating donors after cardiac death. Nebulization is a simple and feasible drug delivery route after cardiac death. Herein we have examined the potential effect of nebulized milrinone, a phosphodiesterase III inhibitor, on pulmonary warm ischemia.

MATERIALS AND METHODS

Deeply anesthetized rats were euthanized by exsanguination. Lungs were exposed to warm ischemia with ventilation up to 2 hours. Milrinone was nebulized for 10 minutes at the beginning of warm ischemia (n = 5). In the control group (n = 5), normal saline was nebulized for the same time. At given intervals, the lungs were partially resected to measure adenine nucleotide and cyclic adenosine monophosphate levels.

RESULTS

In both groups, lung tissue cyclic adenosine monophosphate levels decreased significantly at 2 hours after warm ischemia; however, there was no significant difference between the groups. Lung tissue adenosine triphosphate levels significantly decreased at 2 hours after ischemia in the control group, while they did not drop up to 2 hours in the milrinone group. Further, lung tissue adenosine triphosphate levels at 2 hours after ischemia were higher in the milrinone group than the control group.

CONCLUSIONS

Our results confirmed that milrinone nebulization during warm ischemia maintained lung tissue adenosine triphosphate levels. Therefore, milrinone nebulization may have potential for lung protection against warm ischemia.

Successful sub-zero non-freezing preservation of rat lungs at -2 degrees C utilizing a new supercooling technology

BACKGROUND

A lower temperature, namely below 0 degrees C, has been thought to be desirable for organ preservation because of the lower rate of metabolism; however, its benefits are still poorly understood. Supercooling is a non-freezing state of liquid below the freezing point, and the new development of a refrigerator for supercooling has now made it possible to preserve organs at sub-zero temperatures in a non-frozen state without cryoprotectants.

METHODS

Rat lungs were ventilated and perfused for 60 minutes in the 3 groups (n = 7 each): (1) the fresh group, in which the lungs were reperfused immediately after harvesting; (2) the 4 degrees C group, in which the lungs were stored after harvesting in ET-Kyoto solution at 4 degrees C for 17 hours before reperfusion; and (3) the supercooling group, in which lungs were preserved in ET-Kyoto solution at -2 degrees C for 17 hours.

RESULTS

Ischemia-reperfusion injury was significantly attenuated in the supercooling group, with a decrease in the pulmonary artery pressure (p < 0.02) and weight gain (p < 0.001), and an increase in the tidal volume (p = 0.001) and arterial oxygen tension (p < 0.001) compared with the 4 degrees C group. In the supercooling group, most of these indicators were equivalent to the fresh lung, with less damage to the endothelial cells of the pulmonary arteries and higher levels of adenosine triphosphate than in the 4 degrees C group.

CONCLUSIONS

Lungs stored using this new supercooling method of lung preservation showed better organ function than conventional storage at 4 degrees C.

Peripheral primitive neuroectodermal tumour of the chest wall invading lung with regional lymph node metastasis

Here we present the case of a 26-year-old man in whom peripheral primitive neuroectodermal tumour of chest wall origin invaded the left lung with regional lymph node metastasis. He underwent initial resection of the left chest wall tumour with combined left lower lobectomy, left S5 segmentectomy, and lymph node dissection in order to facilitate a definitive diagnosis and also to obviate the risk of fatal bleeding due to tumour invasion of the pulmonary artery. Histological examination of the resected sample revealed small round cell proliferation with neural differentiation, and confirmed lymph node involvement within the left lower lobe. EWS/FLI-1 fusion gene transcripts were detected by the reverse-transcription polymerase-chain reaction. Diagnosis of peripheral primitive neuroectodermal tumour was confirmed. After surgery, combination chemotherapy with cyclophosphamide, vincristine, doxorubicin, ifosphamide, and etoposide was given. Five years after resection, the patient remains alive and well, with no signs of recurrence.

ET-Kyoto solution plus dibutyryl cyclic adenosine monophosphate is superior to University of Wisconsin solution in rat liver preservation

ET-Kyoto solution (ET-K) is an extracellular-type organ preservation solution containing the cytoprotective disaccharide, trehalose. A previous study reported the supplement of dibutyryl cyclic adenosine monophosphate (db-cAMP) in conventional ET-K to attenuate lung ischemia-reperfusion injury. In this study, the efficacy of this modified ET-K for liver preservation was investigated by comparison with University of Wisconsin solution (UW). ET-K was supplemented with db-cAMP (2 mmol/L). Lewis rats were randomly assigned to two groups, and liver grafts were flushed and stored at 40C for 24 h with ET-K or UW before syngeneic liver transplantation. The graft function and histological changes at 4 h posttransplant as well as 7-day survival were evaluated. Recipient rat survival rate was significantly higher in the ET-K group than in the UW group. Preservation in ET-K resulted in a significant reduction in serum parenchymal transaminase level and promotion of bile production in comparison with UW. The serum hyaluronic acid level, an indicator of sinusoidal endothelial cell injury, was significantly lower after ET-K preservation than that in UW. Histologically, at 4 h after transplantation, the liver grafts preserved in UW solution demonstrated a greater degree of injury than those in ET-K, which appeared to be apoptosis, rather than necrosis. The continuity of the sinusoidal lining was better preserved in ET-K than in UW. In conclusion, ET-K supplemented with db-cAMP is superior to UW in rat liver preservation. This modified ET-K might therefore be a novel candidate for the procurement and preservation of multiple organs.

Prognostic factors of pulmonary metastasectomy for osteosarcomas of the extremities

BACKGROUND

Factors affecting recurrence and survival after pulmonary resection for metastatic osteosarcomas are controversial. To confirm a role for resection of pulmonary metastases for such tumors, we herein reviewed our institutional experience.

METHODS

Between 1989 and 2007, 23 patients with pulmonary metastases from osteosarcomas of the extremities underwent pulmonary resection. Various perioperative variables were investigated retrospectively to confirm a role for metastasectomy and to analyze prognostic factors for overall survival and disease-free survival after metastasectomy.

RESULTS

Overall survival rate after metastasectomy was 31% at 5 years. Disease-free survival rate was 19% at 5 years after pulmonary resection. On multivariate analysis, patients with less than five pulmonary metastases and patients without pulmonary metastases identified during pre- and postoperative chemotherapy presented significantly favorable overall survival (p=0.015 and 0.0082, respectively). Furthermore, the number of pulmonary metastases less than five was the only significantly favorable prognostic factor for disease-free survival on univariate analysis (p=0.0055).

CONCLUSIONS

Current practice of pulmonary metastasectomy for osteosarcomas in our institution was well justified. The number of pulmonary metastases more than five and the advent of pulmonary metastases during pre- and postoperative chemotherapy seemed relevant to a worse prognosis.