Is video-assisted thoracoscopic surgery suitable for resection of primary lung cancer?

We investigated the validity of thoracoscopic surgery-in patients with primary lung cancer undergoing lobectomy. 14 primary lung cancer patients treated by typical VATS lobectomy and one by anatomical segmentectomy, were compared with 56 patients with Stage-I lung cancer undergoing standard lobectomy (control group), the results focusing on the lymph-nodes dissected. All 14 lobectomy patients showed primary lesions of size less than 3 cm. Following classification of the lymph-nodes into groups I (hilar lymph node) and II (mediastinal lymph node), we compared results according to the sites of the lobectomies conducted. Numbers of dissected lymph-nodes were similar in patients whether undergoing standard thoracotomy or VATS lobectomy. We also investigated what histological types of cancer should be treated by VATS lobectomy by comparing preoperative and operative staging in the control group. The results showed that in most patients with squamous-cell carcinoma judged as T1 N0 M0 the staging corresponded, the other patients actually being in N1 (Stage II). Of Patients with adenocarcinoma of T1 N0 M0, however, 14% had lymph-node metastasis even into the superior mediastinum, i.e., Stage III. The overall findings suggest at present that VATS lobectomy should be applied preferably to patients with a histological typing such as squamous cell carcinoma or alveolar cell carcinoma of relatively early stage, i.e. preoperative Stage I.

The augmenting effect of OK432-stimulated B cells on the in vitro generation of anti-tumor cytotoxic T lymphocytes from tumor-draining lymph node cells: the possible role of interleukin-12

Effect of a local injection with a streptococcal preparation OK432 on the in vitro generation of anti-tumor cytotoxic T lymphocytes (CTLs) from tumor-draining lymph nodes (LN) was investigated. A peritumoral injection with OK432 on days 2, 4, 6 and 8 significantly increased both the total cell number and the proportion of B cells in the draining LN cells on day 10 after a subcutaneous inoculation with B16 melanoma. In an in vitro proliferative assay, OK432 showed a stimulatory effect on both normal splenic T and B cells. In a cytolytic assay, the OK432-injected B16-draining LN cells showed a higher level of anti-B16 CTL activity than the B16-draining LN cells after in vitro restimulation. This augmenting effect of OK432 was dependent on the B cells. Moreover, nonadherent cells from the OK432-injected B16-draining LN cells showed a low but significantly higher level of anti-B16 CTL activity than those from the B 16-draining LN cells after in vitro restimulation, whereas this augmenting effect of OK432 was abolished by the in vitro addition of anti-interleukin (IL)-12 monoclonal antibody. Collectively, these findings suggest that the augmenting effect of a local injection with OK432 on the potential of tumor-draining LN cells to turn into anti-tumor CTLs after in vitro restimulation was at least in part due to IL-12 derived from the OK432-stimulated B cells.

Carinal resection and reconstruction for recurrent lung cancer

A patient with a recurrent tumor in the trachea adjacent to the right main bronchus was treated by surgical resection 19 months after undergoing surgery for the primary cancer. The patient had previously undergone right upper lobectomy for T1N0M0 stage I squamous cell carcinoma. A carinal resection was performed which included 4 rings of the trachea, 2 rings of the right main bronchus, and 1 ring of the left main bronchus. Reconstruction consisted of an end-to-end anastomosis of the trachea and left main bronchus, and an end-to-side anastomosis of the right and left main bronchi. The postoperative course was uneventful, and at present the patient is healthy 12 months following reoperation.

Thoracoscopic approach to the diagnosis and treatment of diaphragmatic disorders

Thoracoscopy was used in the diagnosis and treatment of three patients with diaphragmatic disorders, including traumatic injury of the diaphragm, partial eventration of the diaphragm, and catamenial pneumothorax (endometriosis of the diaphragm). An excellent view of the diaphragm was obtained by using thoracoscopy. The diaphragmatic injury was repaired primarily, the eventration plicated, and the focal endometriosis resected. Recovery was rapid and uneventful in all three patients. Thoracoscopic surgery, although relatively new, may be an acceptable alternative to the conventional operative management of diaphragmatic disorders and may actually reduce the morbidity and mortality associated with thoracotomy.

[Combined treatment with resection, intraoperative hypotonic and post-operative systemic chemotherapy using cis-platinum for a mediastinal yolk sac tumor: a case report]

Generally yolk sac tumor in the mediastinum is a rare and highly malignant neoplasm. We report a case of yolk sac tumor, which was treated with resection, and then intraoperative hypotonic and postoperative systemic chemotherapy. A 33-year-old man was diagnosed as a mediastinal tumor with chest X-ray and chest CT findings. At operation he had mediastinal tumor which invaded to the part of the right upper lobe and pericardium, disseminated on the right diaphragm. A large tumor was removed with partial pericardiectomy and wedge resection of the right upper lobe. After resection hypotonic chemotherapy with cis-platinum was performed. This tumor had endodermal sinus structure, Schiller-Duval body, and eosinophilic hyaline globolus which were histological characteristics of yolk sac tumor, and the value of serum alpha-fetoprotein (AFP) was high. After operation with this diagnosis systemic chemotherapy consisted of cis-platinum, etoposide were performed. Patient was discharged uneventfully 8 months later.

Medroxyprogesterone acetate treatment reduces serum interleukin-6 levels in patients with metastatic breast carcinoma

BACKGROUND

The serum interleukin (IL)-6 concentration was very low in patients with metastatic breast carcinoma who had received oral medroxyprogesterone acetate (MPA) treatment as compared with those who had not. Accordingly, the authors conducted a prospective study to determine whether MPA treatment reduces the serum level of IL-6 in patients with this disease.

METHODS

In 21 consecutive Japanese patients who were scheduled to receive oral MPA treatment at doses of 600, 800 or 1200 mg/day, serum concentrations of IL-6 were determined with a sensitive enzyme-immunoassay prior to the administration of MPA and again at 4 weeks after the treatment was started. In addition, plasma levels of MPA were determined by high-performance liquid chromatography (HPLC).

RESULTS

Four weeks after the oral MPA therapy was started, serum IL-6 levels decreased in all 21 patients regardless of whether or not they responded to the treatment. Although the extent of decrease in the serum IL-6 (delta IL-6) did not correlate with the daily dose of MPA, it correlated closely with the plasma MPA level in these patients. Subjective improvement in appetite and weight gain were more frequent in the delta IL-6 > 3 pg/mL group compared with the delta IL-6 < or = 3 pg/mL group (80% vs. 45% and 70% vs. 45%, respectively). Similar results were obtained for improvement in patients' sense of well-being (100% vs. 55%).

CONCLUSIONS

Oral MPA treatment reduces serum IL-6 concentration in patients with metastatic breast carcinoma, but the decrease is not associated with response to MPA. This observation may indicate a potential of this agent for producing subjective improvement.

[Indications and techniques for surgical treatment of pulmonary emphysema]

We compared two surgical treatments for pulmonary emphysema: unilateral thoracoscopic surgery and bilateral volume reduction (pneumectomy). There were no significant complications with either technique. Symptoms were relieved and pulmonary function improved with both. Post-operative pain was more severe and postoperative blood loss was greater after pneumectomy, but the improvement in pulmonary function was also greater. Possible advantages of bilateral thoracoscopic surgery over pneumectomy should be studied.

Reconstruction of trachea and carina with immediate or cryopreserved allografts in dogs

BACKGROUND

Grafting is required when primary reconstruction of a tracheocarinal defect is not feasible. To determine the viability of and the nature of the healing process occurring in the cryopreserved graft, we performed tracheocarinal transplantation in dogs.

METHODS

We performed 32 tracheocarinal reconstructions in dogs using autotransplanted, immediately transplanted, or cryopreserved allografts. The viability of each graft was evaluated serially by fiberoptic macroexamination and by measurement of the tracheal mucosal blood flow using a hydrogen clearance method. In group A (n = 8), the tracheal carina was removed and reimplanted immediately. In group B (n = 8), the tracheocarina was allotransplanted immediately after harvest. In group C (n = 8), allotransplantations were performed using grafts cryopreserved for 1 to 3 weeks by freeze-drying. In group D (n = 8), we attempted to achieve immunosuppression-free transplantation with the cryopreserved allografts.

RESULTS

Sufficient viability and good healing (6/8, 75%) occurred in the dogs with cryopreserved tracheocarinal allotransplants. Three of 8 dogs (38%) with cryopreserved allotransplants survived for 25 to 57 days without immunosuppression.

CONCLUSIONS

The cryopreservation of tracheocarinal allografts for 3 weeks without the use of a preservative solution was shown to be feasible. Cryopreservation prolonged the survival of nonimmunosuppressed allotransplants in dogs.

[Dynamic stent useful for trachocarinal stenosis due to lung cancer]

In this study, a new tracheobronchial stent was used for treating a patient with tracheocarinal stenosis due to lung cancer. The patient was 41 year-old male with lung mass in the right upper lobe and metastatic mediastinal lymph node which caused tracheocarinal stenosis. The stent was introduced under general anesthesia with a jet ventilator. The respiratory condition of the patient could be controlled fairly well, and the ventilation tube didn't interfere with the stenting. The stent was a tracheobronchial silicone stent provided with a flexible posterior membrane and tracheal cartilage-shaped steel struts. Coughing is less difficult than other stents owing to better design. This patient has been able to cough up sputum from the day of the operation and there has been no need for bronchoscopic examination for removal of secretions.

Increased expression of membrane-associated phospholipase A2 in the lower respiratory tract of asymptomatic cigarette smokers

Group II phospholipase A2 (membrane-associated phospholipase A2, M-PLA2) hydrolyses the 2-acyl position of a glycerophospholipid. The concentrations of M-PLA2 in serum and bronchoalveolar lavage fluid (BALF) were measured in 13 asymptomatic cigarette smokers without clinically detectable lung disease, and the results were compared with those in 13 healthy non-smokers, using a specific radioimmunoassay. In addition, Northern blot analysis of M-PLA2 mRNA was performed in preparations of total RNA extracted from the cell pellet of BALF from two smokers and two non-smokers. No significant difference was found in serum M-PLA2 levels between 13 smokers (mean +/- SD, 3.48 +/- 1.21 ng ml-1) and 13 non-smokers (3.12 +/- 1.06 ng ml-1). The smokers' BALFs contained significantly greater levels of M-PLA2 compared with the non-smokers', whether expressed in terms of BALF volume (0.59 +/- 0.34 vs. 0.12 +/- 0.09 ng ml-1, P < 0.001) or protein content (7.22 +/- 3.17 vs. 2.31 +/- 1.48 ng mg-1 protein, P < 0.001). Northern analysis showed that the levels of M-PLA2 mRNA in two smokers were greater than those in two non-smokers. Thus, cigarette smoking was associated with increased levels of M-PLA2 in BALF. This enzyme may be involved in the pathogenesis of pulmonary disease associated with cigarette smoking.

Thoracoscopic diagnosis of Goodpasture's syndrome

Goodpasture's syndrome is a rare glomerulonephritis that is associated with or preceded by hemoptysis. An 11-year-old boy who demonstrated hematuria and hemosputum was successfully and definitely diagnosed as having Goodpasture's syndrome by thoracoscopic resection, although most cases generally require an open thoracotomy. The patient's postoperative course was uneventful. Thoracoscopy appears to be a safe and effective modality for the diagnosis of Goodpasture's syndrome.

Nodular lymphoid hyperplasia in the lung

We describe an immunocompetent adult patient presenting with cough and hemoptysis who was found to have a pulmonary mass localized to the right upper lobe. Lobectomy was performed and pathological examination revealed nodular lymphoid hyperplasia (pseudolymphoma) of the bronchus-associated lymphoid tissue.

Apoptosis and proliferation in gastric carcinoma: the association with histological type

We examined apoptosis in 33 gastric carcinomas using the terminal deoxynucleotydil transferase mediated dUTP-digoxigenin nick end labelling technique (TUNEL). Of the tumours, nine were well-differentiated, 13 moderately differentiated and 11 poorly differentiated. In addition, we also analysed MIB-1, a cell proliferation antigen. Morphologically, apoptotic tumour cells were more frequently observed in well-differentiated tumours. In addition, apoptotic signals of the TUNEL method were seen even in the nuclei of tumour cells which did not show apoptosis. The nick end labelling index was 51.0 +/- 26.3 in the well-differentiated and moderately differentiated tumours and 28.0 +/- 18.8 in poorly differentiated tumours. The mean of apoptotic body index and nick end labelling index were both significantly higher in well-differentiated and moderately differentiated tumours than in the poorly differentiated type (P < 0.0001, P = 0.008). The MIB-1 labelling index and higher in poorly differentiated tumours than in the well-differentiated or moderately differentiated tumours, and labelled cells were more numerous in the superficial region than in the middle and deep regions of tumours. No apparent correlation was found between the nick end labelling index and the MIB-1 labelling index. The high number of apoptotic cells (the high Nick end labelling index) and low proliferation potentiality (the low MIB-1 labelling index) in well-differentiated gastric carcinomas may thus be related to their natural tendency to demonstrate slow growth.

Local increase in polymorphonuclear leukocyte elastase is associated with tumor invasiveness in non-small cell lung cancer

The production of tumor cell proteases is implicated in tumor cell invasion and metastasis. To determine whether lung cancer cells can produce polymorphonuclear leukocyte elastase (PMN-E), we measured the concentration of immunoreactive (ir)-PMN-E in the conditioned medium of seven lines of non-small cell lung cancer cells, EBC-1, LC-1sq, LK-2, A-549, PC-3, RERF-LC-MS, and RERF-LC-OK, and three normal lung epithelial cell lines, CCD-8Lu, WI-1003, and LL-24, by using a recently developed enzyme immunoassay (EIA). We measured the concentration of ir-PMN-E in extracts of 40 non-small cell lung cancers, and evaluated its association with the clinicopathologic findings in these patients. The ir-PMN-E level in the culture medium increased with time in six of the seven lines of lung cancer cells; the exception was PC-3. No detectable ir-PMN-E was secreted into the culture medium of the three lines of normal lung epithelial cells. The ir-PMN-E was detected in tissue extracts from 34 to 40 specimens at concentrations ranging from 0.11 to 15.5 micrograms/100 mg of protein. When 40 specimens of lung cancer were categorized by clinical stage of disease, the ir-PMN-E concentration was significantly higher in stage IIIB vs stages I, II, or IIIA. Similarly, the ir-PMN-E concentration was significantly higher in stage IIIA than in stage I. Evaluation of correlations between the ir-PMN-E concentration and patient characteristics showed that the ir-PMN-E level was significantly higher in T3 and T4 tumors than in T1 or T2 tumors. Analysis of prognostic factors in a group of 101 patients with non-small cell lung cancer demonstrated that those with high ir-PMN-E had a significantly shorter overall survival vs those with a low ir-PMN-E at the cutoff point of 3.5 micrograms/100 mg of protein. Multivariate analysis showed that ir-PMN-E was a significant porgnostic factor for early death (hazard ratio, 4.04; 95% confidence interval, 1.65 to 9.95) (p = 0.005), suggesting it was an independent marker for prognosis. Results suggest that the local production of PMN-E may be involved in the tumor invasion associated with a poor prognosis in patients with non-small cell lung cancer.

[Lung volume reduction surgery (VRS) for lung diffuse emphysema]

The lung volume reduction surgery is now being accepted for patients with lung diffuse emphysema. The basic concept of this procedure is based on reducing overall lung volume by multiple pneumectomy. The lungs are resected on both pathologic and non-pathologic lesions. As a result, elastic pull on the small airway may be achieved and normal underlying compressed lung can be re-expanded. Additionally, the compliance of thoracic wall is ameliorated with normalized thoracic volume. On the other hand, laser ablation of emphysematous lung with bullaectomy under video assisted thoracoscopy (VATS) has been performed recently. This procedure is based on reducing the non-functional air volume due to bullae underlying the pleural surface. Both procedures have still having been under consideration in last three years. In this report, the latest result of both methods in the USA are reported and discussed. Additionally, comparative data with lung transplantation, the other surgical strategy for lung emphysema, is also discussed.

Immunohistochemical analysis of bcl-2 and p53 protein in breast carcinoma

We analyzed the expression of bcl-2 and p53 in relation to clinicopathological features and estrogen receptor (ER) status in breast carcinomas from a series of 67 women who were treated surgically. Fifty and 23 cases showed positive immunostaining for bcl-2 and p53 protein, respectively. Thirty-five cases were ER-positive. A positive relationship was observed between bcl-2 and ER (p<0.05). Furthermore, an inverse relationship was observed between bcl-2 and p53 (p<0.01), which suggests that overexpression of p53 may down-regulate bcl-2 expression in breast carcinoma tissue, as has been described in a breast carcinoma cell line.

[Thoracoscopic surgery versus axillary thoracotomy for spontaneous pneumothorax]

From October 1974 through March 1995, 453 patients with spontaneous pneumothorax admited to our institution and 416 patients underwent an operation. Among them, except bilateral pneumothorax, 204 patients under sixty years of age underwent an axillary incision (Group Ax) and 80 patients underwent a thoracoscopic surgery (Group Ts). In Group Ax, 178 male and 26 female, median age was 26.6 years old and in Group Ts, 68 male and 12 female, median age was 24.6 years old. The median operating time was significantly shorter for patients in Group Ts than for those in Group Ax (73.2 versus 111.3 minutes; p < 0.05). The median intraoperative blood loss was significantly less in Group Ts than in Group Ax (5.4 versus 65.6 g; p < 0.01). There was no significant difference in the duration of intercostal drain placement between the two groups (2.1 versus 2.7 days) but the median postoperative hospital stay was significantly shorter in Group Ts than in Group Ax (8.0 versus 12.5 days; p < 0.01). 58.9% of the patients needed postoperative analgesia in Group Ts, while 82.3% of the patients in Group Ax, and it was significantly less in Group Ts. The rate of recurrent pneumothorax was more in Group Ts (5.0% versus 2.9%), because of fail to notice the bulla under the thoracoscopy. Recently we observe the thoracic cavity using electric bronchoscope in order that we may not miss the bulla, and we take laser treatment for bullous emphysema with much effect.

A case of bronchopleural fistula detected by monitoring plasma endothelin-1

Levels of endothelin (ET)-1 peptide are transiently increased after major physical stress. While studying sequential changes in plasma ET-1 levels during various types of stress, we noticed that the level of plasma ET-1 began to rise 10 days post-operatively in one patient with lung cancer who had undergone a left lower lobectomy. 35 days postoperatively a bronchopleural fistula became clinically manifest. The case is presented and the use of plasma ET-1 as an indicator is discussed.

[Resection of sternal lesion and its reconstruction]

Our experience of seven cases with resection and reconstruction of sternum were introduced. The lesions were 1 chondrosarcoma, 1 malignant fibrous histiocytoma, 1 myeloma, 1 fibrous dysplasia, 1 thymic carcinoma and 2 recurrent breast carcinomas. Partial resection of sternum was performed in 6 and subtotal resection in 1. In reconstruction of sternum we have used frequently Marlex mesh for prosthetic material, and pedicled pectoralis major muscle flap and/or rectus abdominis musculocutaneous flap for overlying the prosthesis. All patients are living and well for except one case.

The induction of cytotoxicity by a bispecific antibody against CEA positive cell line, in vitro

A mouse anti-human carcinoembryonic antigen (CEA) x anti-human CD3 bispecific antibody, AB5C10*UCHT1, was developed. This antibody-heteroconjugate was chemically prepared by cross-linking the AB5C10 monoclonal antibody reactive with human CEA with the monoclonal antibody, UCHT1, which binds to CD3 on human T-lymphocytes. The AB5C10*UCHT1 recognized both CEA expressed on the KATOIII cell line and CD3 expressed on T-lymphocytes, as determined using flowcytometry. Next, AB5C10*UCHT1-mediated cytolysis was analyzed by 51Cr-release assay. When 51Cr-labeled target KATOIII cells were incubated for 6 h with effector cells that had been pretreated with AB5C10*UCHT1 for 60 min at 4 degrees C, the percentage specific lysis was significantly increased compared to that of untreated effector cells. Using peripheral blood mononuclear cells (PBMC) and lymphokine-activated killer (LAK) cells pretreated with AB5C10*UCHT1 for effector cells, the percentage specific lysis was determined to be 16.3% and 57.4% at effector: target (E:T) ratios of 100:1 and 12.5:1, respectively. On the other hand, the percentage specific lysis of untreated PBMC and LAK cells determined to be 3.0% and 35.8% at E:T ratios of 100:1 and 12.5:1, respectively. The minimum effective dose of AB5C10*UCHT1 required for antibody-mediated cytotoxicity was 0.1 mu g/ml. The results of this study suggest that AB5C10*UCHT1 could be useful for augmenting the cytotoxicity of CD3-positive T-cells against CEA-positive target cells in vitro.

The unusual presentation of mucinous carcinoma in the colon making preoperative diagnosis difficult: report of a case

A 51-year-old man was admitted to our hospital for investigation of fever, lower abdominal pain, and pain on micturition. Barium enema and endoscopic findings revealed an extracanal large cavity of the rectosigmoid colon, which suggested an abscess caused by penetration. Histological examination of the endoscopic biopsy specimen demonstrated no malignancy. A preoperative diagnosis of malignant lymphoma was strongly suspected from the imaging findings; however, intraoperative inspection revealed a large tumor invading the urinary bladder. An intraoperative incisional biopsy was performed and histological examination demonstrated mucinous carcinoma. The patient subsequently underwent pelvic exenteration about 1 week later followed by adjuvant chemotherapy and radiotherapy.

A new approach for bronchoplastic procedures in the treatment of bronchial carcinoid tumors

Usually patients with typical carcinoid tumors originating in a segmental bronchus undergo segmentectomy with or without a bronchoplastic procedure. We have performed only sleeve resection of the bronchus for a bronchial carcinoid tumor located in the left basal bronchus thus preserving the lung tissue. This was made possible by transecting and reanastomosing the pulmonary artery.

Plasma endothelin-1 as a marker for doxorubicin cardiotoxicity

The use of doxorubicin is often limited by cardiotoxicity that can lead to congestive heart failure (CHF). Although various techniques have been used to predict its cardiotoxicity, none has proven useful. We reported 2 patients in whom the level of plasma endothelin (ET)-1 rose progressively during doxorubicin treatment of breast cancer, and who subsequently developed CHF. Accordingly, we conducted a prospective study of 30 consecutive patients, 23 with breast cancer and 7 with small-cell lung cancer, who were treated with doxorubicin. Serial changes in plasma ET-1 during doxorubicin treatment were measured by a specific radioimmunoassay, and plasma levels of atrial natriuretic peptide (ANP) were determined by a sensitive immunoradiometric assay. M-mode echocardiography was performed serially to monitor the fractional shortening (FS) and the left ventricular ejection fraction (LVEF). The plasma concentrations of ET-1 rose progressively in 5 of the 30 patients during doxorubicin treatment. Two of the 5 patients developed clinically overt CHF after developing cumulative doses of doxorubicin of 500 and 480 mg/m2. Serial measurement of plasma levels of ANP, FS and LVEF showed no abnormalities until the development of CHF. Another 25 patients who had received doxorubicin (cumulative doses ranging from 400 to 660 mg/m2) and had not developed CHF showed no appreciable change in plasma ET-1 or other markers. This prospective study suggests that plasma ET-1 may be useful for predicting the risk of doxorubicin-induced cardiotoxicity.

Postoperative chylothorax following partial resection of mediastinal lymphangioma: report of a case

We report herein the rare case of a 20-year-old man in whom a mediastinal lymphangioma was incidentally detected by a chest roentgenogram taken during a routine health examination. Both computed tomography and magnetic resonance imaging confirmed a mass measuring 3 x 7 cm in diameter in the left anterior mediastinum. A thoracoscopic exploration was done, which confirmed a diagnosis of mediastinal lymphangioma, and 3 days later a sternotomy was performed. However, the tumor could not be completely extirpated due to partial invasion. Following the thoracoscopic procedure, a chylous discharge developed which was difficult to treat conservatively and he continued to drain 700-1,000 ml of chyle daily 2 weeks following the tumor extirpation. Therefore, a right thoracotomy with ligation of the thoracic duct was performed which resolved the chylothorax. The patient remains well without any regrowth of the regional tumor 9 months after his operation.