Surgical strategy for patients with papillary thyroid carcinoma invading the trachea: a comparison of tracheal sleeve resection with end-to-end anastomosis and window resection with tracheocutaneous fistula

Background

Sleeve resection with end-to-end anastomosis (Procedure A) and window resection with a tracheocutaneous fistula (Procedure B) are the major surgical procedures for patients with papillary thyroid carcinoma (PTC) exhibiting transluminal tracheal invasion. For each procedure, the indications, postoperative course, and treatment results were examined retrospectively.

Methods

Of 1,456 patients with PTC (maximum tumor diameter >1 cm) who received initial treatment between 1993 and 2013, we reviewed 51 patients. Of these 51 cases, 45 showed full-layer tracheal invasion, and 6 did not reach the tracheal mucosa, but required full-layer tracheal resection. Twenty-four patients underwent Procedure A, and 27 patients underwent Procedure B.

Results

Regarding surgical procedure selection, Procedure B was selected significantly more frequently than Procedure A for cases with preoperative recurrent laryngeal nerve (RLN) palsy, tumor invasion of the esophagus, clinical lymph node metastasis, or a large number of resected tracheal rings. Postoperative airway-related complications were not significantly different between the procedures, but decreased with the use of intraoperative neuromonitoring (IONM). The postoperative hospital stay was significantly longer for Procedure B than for Procedure A. In addition, the rate of a permanent postoperative tracheostoma was higher with Procedure B than with Procedure A. Local recurrence-free survival (LRFS) and cause-specific survival (CSS) did not differ significantly between the two procedures.

Conclusions

Certain patients may benefit from Procedure A with IONM in terms of a shorter hospital stay and avoiding the need for a permanent tracheostoma. Although Procedure B was indicated for patients with more advanced disease than Procedure A, treatment outcomes were similar.

Correlation between low expression of protein disulfide isomerase A3 and lymph node metastasis in papillary thyroid carcinoma and poor prognosis: a clinicopathological study of 1,139 cases with long-term follow-up

The incidence of papillary thyroid carcinoma (PTC) is increasing worldwide. The biomarkers to identify aggressive types of PTC are limited, illustrating the need to establish reliable novel biomarkers. Protein disulfide isomerase A3 (PDIA3) is a chaperone protein that modulates the folding of newly synthesized glycoproteins and stress-responsive proteins in the endoplasmic reticulum. Although the role of PDIA3 in various cancers such as breast, uterine cervix, head and neck, and gastrointestinal tract has been examined, its expression in thyroid cancer has not been reported. We retrospectively reviewed accumulated data with long-term follow-up of 1,139 PTC patients, and investigated the correlation between immunohistochemical expression of PDIA3 in PTC patients and clinicopathological features and prognosis. PDIA3 expression was significantly lower in PTCs compared to normal thyroid tissues (NTT; n = 80, p = 0.002). In PTCs, correlation between low PDIA3 expression and lymph node metastasis (p = 0.018) and the number of positive nodes (p = 0.004) was observed. Patients with low PDIA3 expression exhibited worse cause-specific survival compared to those with high PDIA3 expression (p = 0.013). Our findings indicate that low PDIA3 expression is related to poor clinical outcome in PTC patients, and that PDIA3 may potentially be a novel ancillary biomarker. Further clarification of the biological role of PDIA3 in PTC is warranted for the future clinical application.

Multifocality and Progression of Papillary Thyroid Microcarcinoma During Active Surveillance

BACKGROUND

Prospective trials of active surveillance (AS) have shown low rates of progression in low-risk papillary thyroid microcarcinoma (PTMC; T1aN0M0). However, the significance of multifocality as a prognostic factor remains controversial.

METHODS

Data from 571 patients (mean age, 53.1 years; 495 females) who underwent AS were reviewed. PTMC was unifocal in 457 patients (80.0%) and multifocal in 114 patients (20.0%), with 2-5 lesions each (261 tumors in total). Tumor progression was defined as tumor size enlargement ≥ 3 mm and/or development of clinically evident lymph node metastasis (LNM).

RESULTS

After a mean duration of AS of 7.6 years, 53 patients (9.3%) showed tumor enlargement and 8 patients (1.4%) developed LNM. The 10-year progression rate was 13.1%. Age, sex, and calcification pattern did not differ significantly between uni- and multifocal diseases. However, anti-thyroglobulin antibody and/or anti-thyroid peroxidase antibody was more frequently positive with multifocal PTMCs (46.7%) than with unifocal disease (34.4%, p = 0.024). Patients with uni- and multifocal disease showed no significant differences in 10-year rate of tumor enlargement (11.4% vs. 14.8%), LNM development (1.1% vs. 2.4%), or progression (12.4% vs 15.9%). Multivariate analysis of predictors for progression showed multifocality was not a significant risk factor (odds ratio, 1.45; 95% confidence interval, 0.79-2.54; p = 0.22). Eventually, 9 patients (7.9%) with multifocal PTMCs underwent surgery and 7 needed total thyroidectomy, although 7 still showed T1N0M0 low-risk cancer.

CONCLUSIONS

Even patients with multiple PTMCs (T1amN0M0) are good candidates for AS. Many patients can avoid total thyroidectomy and subsequent surgical complications.

TERT Promoter Mutation and Extent of Thyroidectomy in Patients with 1-4 cm Intrathyroidal Papillary Carcinoma

There are concerns regarding overtreatment in papillary thyroid carcinoma (PTC). BRAF V600E and TERT promoter mutations play important roles in the development of PTC. However, initial surgical approaches for PTC based on genetic characteristics remain unclear. The present study aimed to identify genetic mutations as predictors of prognosis and to establish proper indications for lobectomy (LT) in patients with 1–4 cm intrathyroidal PTC. Prospectively accumulated data from 685 consecutive patients with PTC who underwent primary thyroid surgery at the Cancer Institute Hospital, Tokyo, Japan, between 2001 and 2012 were retrospectively reviewed. Of the 685 patients examined, 538 (78.5%) had BRAF V600E mutation and 133 (19.4%) had TERT promoter mutations. Patients with TERT promoter mutations displayed significantly worse outcomes than those without mutations (10-year cause-specific survival (CSS): 73.7% vs. 98.1%, p < 0.001; 10-year disease-free survival (DFS): 53.7% vs. 93.3%, p < 0.001). As for extent of thyroidectomy among TERT mutation-negative patients with 1–4 cm intrathyroidal PTC, patients who underwent LT showed no significant differences in 10-year CSS and 10-year DFS compared to patients who had total thyroidectomy (TT) under propensity score-matching. Avoiding TT for those patients indicates a possible pathway to prevent overtreatment and reduce postoperative complications.

Evaluation of the 8th Edition TNM Classification for Anaplastic Thyroid Carcinoma

Background: The tumor–node–metastasis (TNM) classification system to categorized anaplastic thyroid cancer (ATC) was revised. Methods: The revised system was evaluated using a large database of ATC patients. Results: A total of 757 patients were analyzed. The proportion and median overall survival values (OS: months) for each T category were T1 (n = 8, 1.1%, 12.5), T2 (n = 43, 5.7%, 10.9), T3a (n = 117, 15.5%, 5.7), T3b (n = 438, 57.9%, 3.9), and T4 (n = 151, 19.9%, 5.0). The OS of the N0 and N1 patients were 5.9 and 4.3, respectively (log-rank p < 0.01). Sixty-three (58.3%) patients migrated from stage IV A to IV B by revision based on the existence of nodal involvement and 422 patients (55.7%) were stratified into stage IV B, without a worsening of their OS (6.1), leaving 45 patients (5.9%) in stage IV A with fair OS (15.8). The hazard ratios for the survival of the patients of stage IV B compared to stage IV A increased from 1.1 to 2.1 by the revision. No change was made for stage IV C (n = 290, 38.8%, 2.8). Conclusion: The revised TNM system clearly indicated the prognoses of ATC patients by extracting rare patients with fair prognoses as having stage IV A disease and categorized many heterogeneous patients in stage IV B.

Active Surveillance for T1bN0M0 Papillary Thyroid Carcinoma

BACKGROUND

Prospective trials of active surveillance for asymptomatic papillary microcarcinoma (T1aN0M0) since the 1990s have shown progression rates of only 5-10%. Late rescue surgery after progression had no deleterious effects on mortality and morbidity. The 2015 American Thyroid Association guidelines approved active surveillance for very low-risk papillary thyroid carcinoma (PTC) as an alternative method to immediate surgery. However, there is no study that evaluates long-term active surveillance for T1b tumors.

METHODS

A prospective trial of active surveillance with 360 very low-risk PTC (T1aN0M0) patients has been conducted since 1995. Of the 392 T1bN0M0 patients, 61 selected active surveillance over surgery and eventually participated in this trial, while the remaining 331 patients underwent surgery. To find an appropriate management strategy for patients with T1bN0M0 PTC, the outcomes of active surveillance for T1bN0M0 to T1aN0M0 PTC were investigated and compared, and the outcomes of surgery for T1bN0M0 PTC were studied.

RESULTS

After a mean of 7.4 years of active surveillance, 29 (8%) T1aN0M0 tumors and four (7%) T1bN0M0 tumors had increased in size (p = 0.69). Development of lymph node metastasis was seen in three (0.8%) patients and two (3%) patients, respectively (p = 0.10). No significant difference in progression rate was seen between groups. Among T1bN0M0 tumors, weak calcification and rich vascularity were risk factors for tumor-size increase, and younger age was a predictor for the development of lymph node metastasis. Mean initial tumor size was significantly greater in T1bN0M0 patients who underwent immediate surgery (14.5 ± 2.8 mm) than it was in patients who chose observation (11.7 ± 1.1 mm; p < 0.0001). No postoperative recurrence was seen in patients with tumor <15 mm in diameter.

CONCLUSIONS

Active surveillance is an option for selected patients with T1bN0M0 PTC.

Stromal tiny black dots, like "sugar-coated", of von Kossa stain is a diagnostic clue to hyalinizing trabecular tumor of the thyroid gland

Hyalinizing trabecular tumor (HTT) is a rare low-grade tumor, and a prominent feature is the basement membranous stroma. We assume that such characteristic stromal findings of HTT are related to calcium deposition, and examined HTT samples by von Kossa special staining. There has been no report describing von Kossa special staining for such stroma. We collected 12 cases of HTT and 30 cases of papillary thyroid carcinoma (PTC) that had matched age, gender, tumor size, and surgical procedure characteristics as a control group. We compared the staining pattern and degree of von Kossa positivity between HTT and PTC, and a grading system of von Kossa stain was adopted to highlight differences between them. On von Kossa staining, all HTT revealed many tiny black dots around vessels in the hyalinized stroma, like "sugar-coated", and a high degree of calcium deposition in most cases, whereas PTC showed sparse stromal calcification in some cases. The degree of von Kossa staining was significantly different between the two groups. This is the first report describing abundant tiny black dots, like a "sugar-coated" appearance, of von Kossa stain in HTT. Here, we propose this finding can be a useful diagnostic clue to HTT.

Natural History of Asymptomatic Papillary Thyroid Microcarcinoma: Time-Dependent Changes in Calcification and Vascularity During Active Surveillance

BACKGROUND

Prospective trials of non-surgical observation have shown progression rates of only 5-10% in patients with asymptomatic papillary microcarcinoma (PMC). This study investigated time-dependent changes in calcification patterns and tumor vascularity on ultrasonography (US) to clarify the natural course of PMC.

METHODS

We examined calcification patterns and tumor vascularity for 480 lesions in 384 patients. Calcification patterns were classified as: (A) none; (B) micro; (C) macro; or (D) rim. Tumor vascularity was classified as rich or poor via color Doppler US.

RESULTS

After a mean of 6.8 years of observation, 29 lesions (6.0%) had increased in size. Mean age for initial calcification pattern was 52.1 years for A (n = 135), 54.2 years for B (n = 235), 56.3 years for C (n = 96), and 60.1 years for D (n = 14), and the incidence rates of tumor enlargement were 9.6, 5.5, 3.2, and 0%, respectively. The cumulative rate of upgrade in calcification pattern was 51.8% at 10 years. Lesions with initially rich vascularity (n = 70) had significantly higher rate of tumor enlargement than those with poor vascularity (n = 410); however, the majority of tumor (61.4%) with initially rich vascularity had decreased their blood supply during the follow-up. Multivariate analysis showed that strong calcification (C or D) and poor vascularity at last examination correlated significantly with non-progressive disease.

CONCLUSIONS

PMCs in older patients showed significantly stronger calcification patterns and poorer vascularity. Both consolidation of calcification and loss of vascularity occurred in a time-dependent manner during observation and were significant indicators for non-progressive disease.

Common carotid artery rupture during treatment with lenvatinib for anaplastic thyroid cancer

Anaplastic thyroid cancer is a fatal disease for which no effective therapeutic strategies exist. Lenvatinib, a tyrosine-kinase inhibitor that targets vascular endothelial growth factor receptor, has recently been approved in Japan for the treatment of patients with unresectable thyroid cancer including anaplastic thyroid cancer. Although lenvatinib, like the other tyrosine-kinase inhibitors, sunitinib and sorafenib, might also confer a risk of bleeding, fatal bleeding as a result of lenvatinib treatment for anaplastic thyroid cancer has not been described. A 61-year-old woman presented with a 7-cm mass in the right lobe of the thyroid, lymph node metastases to the neck and multiple lung metastases. Fine needle aspiration revealed that the tumor was anaplastic thyroid cancer. The TNM classification was T4aN1bM1, stage IVC. Shortly after local curative surgery, a tumor recurred in her neck that was treated with lenvatinib (24 mg/day). Nineteen days later, the common carotid artery ruptured and the lenvatinib was stopped. She received the best possible supportive care but died 40 days after stopping the lenvatinib. Autopsy findings showed that the tumor had invaded the adventitia of the common carotid artery at the region of the neck surgery, and an aneurysm had developed. However, the adventitia of the common carotid artery was preserved at the non-dissected area. Lenvatinib might confer risk for fatal bleeding in patients with recurrent anaplastic thyroid cancer after neck surgery, particularly with dissection around the common carotid artery.

[Total Glossolaryngectomy of an Advanced Oropharyngeal and Tongue Squamous-Cell Carcinoma: A 29-Case Series Study]

We report herein on 29 patients with advanced oropharyngeal and tongue squamous-cell carcinoma who underwent a total glossolaryngectomy at the Cancer Institute Hospital of the JFCR between July 2005 and June 2013. In this study, we tried to evaluate associations between several variables of the primary tumor and prognosis in these 29 patients. The cause-specific 5-year survival rate with the Kaplan-Meier method was 45% in all patients. Tumor recurrence occurred in 15 patients. Four patients had recurrence in the primary site, 11 patients in neck lymph nodes or in the lungs or bone. The multivariate analysis revealed that the number of neck lymph node metastases, age and alcohol drinking were poor prognostic markers for patients undergoing a total glossolaryngectomy. Cause-specific survival was compared between patients with salvage surgery and initial surgery using Kaplan-Meier survival curves with log-rank tests. There was no significant association with survival (log-rank test: p = 0.13). The overall local control rate was 69% in all patients. Regarding salvage surgery, 9 of 16 patients had no recurrence in the primary site or neck lymph nodes. The limitations of this study include the small number of patients especially regarding the prognosis study and may have included a selection bias regarding undergoing a total glossolaryngectomy.

A Clinical Study of Pharyngolaryngectomy with Total Esophagectomy: Postoperative Complications, Countermeasures, and Prognoses

OBJECTIVE

Patients with advanced hypopharyngeal or cervical esophageal cancer have a comparatively high risk of also developing thoracic esophageal cancer. Pharyngolaryngectomy with total esophagectomy is highly invasive, and few reports about it exist. We examined the postoperative complications and respective countermeasures and prognoses of patients who underwent pharyngolaryngectomy with total esophagectomy.

STUDY DESIGN

Case series with chart review.

SETTING

Department of Head and Neck Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Japan.

SUBJECTS AND METHODS

We examined the postoperative complications and respective countermeasures and prognoses of 40 patients who underwent pharyngolaryngectomy with total esophagectomy in our hospital.

RESULTS

Postoperative complications were observed in 23 patients (57.5%) and consisted of 8 groups: tracheal region necrosis in 5 patients; neck abscess formation/wound infection in 5; fistula in 4; tracheostomy suture leakage in 2; ileus in 2; lymphorrhea in 2; pulmonary complications in 2; and other complications, including hemothorax, tracheoinnominate artery fistula, temporary cardiac arrest due to intraoperative mediastinum operation, methicillin-resistant Staphylococcus aureus enteritis, and sepsis, in 1 patient each. A lethal complication-brachiocephalic vein hemorrhage due to tracheostomy suture leakage and hemorrhagic shock due to tracheoinnominate artery fistula-occurred in 2 (5%) patients. The crude 5-year survival rate was 48.6%.

CONCLUSIONS

Serious postoperative complications were related to tracheostomaplasty. Although pharyngolaryngectomy with total esophagectomy is highly invasive, we believe that our outlined treatment method is the most appropriate for cases of advanced hypopharyngeal or cervical esophageal cancer that also requires concurrent surgery for esophageal cancer.

[The role of postoperative radiotherapy in non-small cell lung cancer; a retrospective analysis of our experience]

Sixty-one patients with completely resected non-small cell lung cancer followed by postoperative radiotherapy were retrospectively reviewed. Forty-six patients were male and 15 were female. Ages ranged 34-79 (median 64) years. Squamous cell carcinoma (scc) in 28, adenoca. in 31, large cell ca in 1 and adenoid cystic ca. in 1. Pathological stage was IIA in 1, IIB in 9, IIIA in 41 and IIIB in 10. Over-all 5-year survival rate (OS) was 56.0%, and 5-year disease-free survival rate (DFS) was 39.7%. For IIB, IIIA, IIIB patients, OS were 77.8%, 55.4%, 24.0% respectively. According to purpose of radiotherapy, patients divided into 3 types as local invasion (LI) group (T3-4N0-1, n = 12), lymphnode metastases (LN) group (T1-2N2-3, n = 38) and both advanced (BA) group (T3-4N2-3, n = 8). OS were 71.6%, 50.7%, 46.9% and DFS were 68.6%, 31.0%, 42.9% respectively. In LN group, half of patients with scc had no relapse, but about half of non-scc had distant metastases. All N2 patients divided 2 types as single-station N2 and multi-station N2. OS were 71.8%, 40.0% and DFS were 53.5%, 21.1% respectively. DFS was significantly different (p = 0.04). The advantage was remarkable in patients with scc-single-station N2 (OS was 88.9%, DFS was 77.8%). The effectiveness of postoperative radiotherapy is not showed, but our results suggest the possibility for existence of subgroup benefited from postoperative radiotherapy.

[Recurrence and pulmonary metastasis of extradural paraganglioma in thoracic vertebral canal: report of a case]

A 70-year-old female was operated on for extradural spinal cord tumor in 1982. Microscopic examination revealed the tumor as paraganglioma. Tumor recurred at paravertebral twice in 1985 and 1989, and they were also resected. In 1995, her chest X-ray film showed round tumor in the right upper field. Exploratory open lung biopsy was performed in 1996, and right upper lobectomy was performed according to for malignant lung tumor because intra-operative microscopic findings showed carcinoid or lung metastasis of paraganglioma. Chest wall tumor at paravertebral was resected at the same time. Postoperative microscopic examination revealed the tumors were same as operated paraganglioma. The 2nd thoracotomy was done in 1999, and two chest wall tumors and a pulmonary nodule in right S8 segment were resected. They were recurrence and pulmonary metastasis of paraganglioma. Now 18 years after initial operation, she is out of hospital in tumor free.

Bronchioloalveolar carcinoma arising in a bronchogenic cyst

We report the case of a 37-year-old woman with a radiographically cystic lung lesion. Lobectomy was performed. Histopathologic examination showed a bronchioloalveolar carcinoma arising in a bronchogenic cyst. This suggests that epithelial cells of bronchogenic cysts can undergo malignant transformation. It may be prudent to recommend complete resection of any bronchogenic cyst.

Imaging of optical disc using reflection-mode scattering-type scanning near-field optical microscopy

A phase-change optical disc was observed using a reflection-mode scattering-type scanning near-field optical microscope (RS-SNOM). In an a.c.-mode SNOM image, the 1.2 microm x 0.6 microm recording marks were successfully observed although the data were recorded on the groove. In contrast, no recording marks could be resolved in a d.c.-mode SNOM image. These results are in good agreement with those from a numerical simulation using the finite difference time domain method. The resolution was better than 100 nm with a.c.-mode SNOM operation and the results indicate that recording marks in phase-change optical media can be directly observed with the RS-SNOM.

[Pulmonary veno-occlusive disease developed in a man given long-term treatment with anticancerous agents]

A 67-old man was referred to our hospital because of dyspnea on exertion and severe hypoxia. He had been given, tegafur and OK 432 for seven years following an operation for gastric cancer. Pulmonary hypertension was noted by right heart catheterization. The findings of a transbronchial lung biopsy resulted in a diagnosis of pulmonary veno-occlusive disease. Pulmonary hemodynamic studies were performed for five different agents: nifedipine, beroprast sodium (PGI2), nitroglycerin, theophylline, and isosorbide dinitrate. However, none of these agents showed significant effects on pulmonary arterial pressure or pulmonary vascular resistance. Treatment with glucocorticoid relieved the patient's symptoms without any apparent effect on pulmonary hemodynamics. The long-term administration of anticancerous agents (tegafur) were thought to have caused pulmonary veno-occlusive disease to develop in this patient.

[Excision of a chronic expanding hematoma developing after thoracoplasty: a case report]

The patient was a 56-year-old woman who had undergone thoracoplasty for right pulmonary tuberculosis 31 years previously. She consulted her local physician complaining of right shoulder pain. Chest X-rays revealed a mass of the thoracic wall, and the patient was referred to our department. Because of the difficulty in making a diagnosis by needle biopsy and of increased pain, operation was done. The mass was covered by a fibrous capsule, and its center was composed of structure-less material including fibrin and blood cells. A diagnosis of chronic expanding hematoma developing after thoracoplasty was made. Beneath the hematoma, a 5 mm diameter hole communicated with the thoracic cavity. Chronic inflammation at this site appeared to have caused the hematoma.

[Retroperitoneal fibrosis with involvement up to the mediastinal space]

A 60-year-old man presented with sudden palpitations in September 1993, and was admitted to hospital with a diagnosis of atrial fibrillation and heart failure. The patient was suspected of having collagen disease, because of a positive test for antinuclear antibodies and a high sedimentation rate. He was referred to lou hospital. Chest radiographic findings were suggestive of cardiomegaly and cardiac murmurs were audible, which indicated the presence of heart disease. A chest Ct scan revealed a lesion surrounding the intramediastinal large vessels and the heart from the level of the confluence of the left brachiocephalic vein and the superior vena cava. Suspicion of a mediastinal tumor led the patient to be admitted to the respiratory department. Percutaneous needle biopsy with a Trucut needle revealed non-specific chronic inflammation. An abdominal CT scan showed that the lesion surrounding the descending aorta traversed the diaphragm, reached the renal pelvis along both renal arteries, and caused narrowing of the ureter and left hydronephrosis. Based on these findings, retroperitoneal fibrosis was diagnosed. Treatment with steroids caused the lesion to shrink.

[A case of multiple inthorathoracic neurilemmoma with cutaneous lesions]

A 33-year-old man with right inguinal mass was admitted to our hospital because of an abnormal shadow on his chest X-ray film. Surgery was performed. These tumors originating from the right 7th, 8th intercostal and right cutaneous femoralis nerve were removed. Histologically, excised tumors were diagnosed as neurilemmoma. There had been only 4 cases of inthorathoracic multiple neurilemmoma with skin lesion, in Japan. We reviewed and discussed the Japanese literature.

Mucociliary clearance in pulmonary vascular disease

The mucociliary clearance function was studied by radioaerosol inhalation lung cinescintigraphy and its quantification in 8 patients with pulmonary vascular diseases; pulmonary embolism, 5 cases, and right pulmonary artery hypoplasia, pulmonary arteriovenous fistulas, aortitis syndrome, 1 case each. The mucociliary clearance function was found to be well maintained in pulmonary vascular diseases unless ventilation was disturbed. There was no difference in the mucociliary clearance function between pulmonary embolism and other pulmonary vascular diseases.

Effect of bronchodilation on the deposition and clearance of radioaerosol in bronchial asthma in remission

Radioaerosol inhalation lung cine-scintigraphy and lung function tests were performed on ten patients with bronchial asthma in remission before and after inhalation of salbutamol following intravenously administered aminophylline. Radioaerosol inhalation lung cine-scintigraphy was very useful in revealing the changes not only in the deposition patterns of inhaled aerosol in the lungs but also in the dynamic transport of mucus on the airways. The bronchodilating effect of the combined treatment was significant; the inhaled aerosol deposited more homogeneously and less centrally in the lungs, the "penetration index" and the alveolar deposition ratio (ALDR) increased from 31 +/- 3 to 49 +/- 7%, and from 29 +/- 2% to 39 +/- 1%, respectively, while the airway deposition ratio (ADR) decreased from 72 +/- 2 to 61 +/- 1% immediately after the treatment. Lung function data including FVC, FEV 1.0, FEV 1.0%, MMF, V50 and Vp significantly improved after the treatment. There was, however, little visual or quantitative improvement in mucociliary clearance after the treatment.

Effect of oral salbutamol on mucociliary clearance mechanisms in the lungs

The purpose of the study was to investigate whether or not orally administered salbutamol would affect mucociliary clearance function in the lungs. Salbutamol, 4 mg, was given orally 3 times a day for 7 days to 10 and 9 patients with various chest diseases in stable stage, respectively; the former were also currently taking other medications and the latter, none. Lung function tests, chest x-rays and radioaerosol inhalation lung cine-scintigraphy were performed before and after the administration of salbutamol. There was little qualitative or quantitative difference in mucociliary clearance function in either group before and after the administration of oral salbutamol, although it induced some increases in VC and FEV1.0 and a decrease in RV/TLC ratio in the former and some increases in FEV1.0, FEV1.0% and MMF in the latter. Oral salbutamol seems little to affect the mucociliary clearance function in the lungs.

Estimation of a drug effect by a simplified radioaerosol inhalation lung cine-scintigraphy: bromhexine on mucociliary clearance mechanisms

A proposed simplification of radioaerosol inhalation lung cine-scintigraphy, namely 60 min measurement of radioactivity without repeating measurement at 24 hr later and calculation of alveolar deposition ratio (ALDR) by the regression formula of ALDR = -48.08 + 0.47 X FEV1.0% + 0.59 X LRR60, was found useful and applicable even to the evaluation of a drug on mucociliary clearance mechanisms. The simplified method indicated a very similar evaluation of the effect of bromhexine on airway clearance efficiency with those actually revealed by the original method.

Mucociliary clearance mechanism in interstitial lung disease

To evaluate mucociliary clearance mechanisms of the lungs, 14 patients with pulmonary interstitial fibrosis and 8 with sarcoidosis were studied by lung function tests and radioaerosol inhalation lung cine-scintigraphy. Although all these patients showed interstitial densities on chest x-rays, only the patients with pulmonary interstitial fibrosis indicated restrictive and diffusion abnormalities by lung function tests and those with sarcoidosis did not show either of these functional abnormalities. Mucociliary clearance mechanisms were well maintained qualitatively and quantitatively in these patients with interstitial lung disease.

Estimation of alveolar deposition ratio of inhaled radioaerosol

The lung retention ratio (LRR) and the alveolar deposition ratio (ALDR) are mandatory to calculate the other three indices for quantitatively evaluating mucociliary clearance function of the ciliated airways; the airway deposition ratio (ADR), the airway retention ratio (ARR) and the airway clearance efficiency (ACE). According to our original method, the LRR required 2-hr continuous measurement of radioactivity in the thorax and the ALDR a repeat measurement at 24-hr after radioaerosol inhalation. The 2-hr continuous measurement is, however, too long for a clinical examination and the 24-hr repeat measurement cumbersome. The purpose of the study was to find a way to get the ALDR by calculation without repeating the 24-hr measurement and by counting radioactivity for the shortest possible period and yet without sacrificing the visual evaluation by compiling radioaerosol inhalation lung cine-scintigraphy. By using the derived formulae listed in Table 1, the ALDR was calculable. Forced expiratory volume (FEV) in one sec divided by FEV in per cent (FEV1.0%), the initial 60 min measurement of radioactivity without repeating 24-hr measurement, and smoking history were the minimum requirements to calculate the ALDR. The calculated ALDR appeared reliable enough to estimate the other indices.

Lung clearance mechanisms in obstructive airways disease

Using radioaerosol inhalation lung cinescintigraphy, pulmonary clearance mechanisms were studied in 21 patients with obstructive airways disease. In none of them did we find homogeneous deposition of inhaled radioaerosol in the lungs, or a steady, constant, axial, and cephalad transport of radioactivity in the major airways. Of the 21 patients, 14 showed temporary but frequent stopping and starting of radioactivity in the airways in the course of lung clearance; in ten there was reversal of flow; in five migration of radioactivity from one bronchus into the opposite, bypassing the trachea and often followed by shuttling between right and left bronchi; and in four there was spiral or zigzag transport of radioactivity. The overall lung retention ratio in the first 2 hr was not abnormal, but the airway deposition ratio was significantly above normal, and airway clearance efficiency was below. The alveolar deposition ratio was also significantly smaller in these patients.

Mucociliary clearance mechanism in smoking and nonsmoking normal subjects

Mucociliary clearance mechanisms were evaluated in 17 normal subjects visually and qualitatively by radioaerosol inhalation cinescintigraphy of the lung, and quantitatively by calculating the following indices: (a) overall or regional lung retention ratio; (b) airway deposition ratio; (c) airway retention ratio; (d) airway clearance efficiency; and (e) alveolar deposition ratio. The inhaled aerosol deposited homogeneously throughout the lungs, and mucus transport was always cephalad in direction and constant in velocity, although a temporary stasis of mucus was seen in smokers. Overall lung retention ratio was significantly smaller and airway deposition ratio was significantly larger in the smokers than in nonsmokers, but there was no difference between the groups in airway retention ratio or airway clearance efficiency. There was an inverse relationship between alveolar deposition ratio and cigarette consumption. Mucociliary clearance mechanisms were well maintained in the normal subjects, but in the smokers inhaled aerosol tended to deposit more proximally.

[Clinical trial of butorphanol tartrate in cancer patients: evaluation for analgesic effects and safety on the basis of long term administration]

Twenty-eight cancer patients were treated with intramuscular butorphanol tartrate, a new non-narcotic analgesic, for investigating its clinical benefits in controlling cancer pain. Remarkable analgesic effects were observed approximately 30 minutes after administration by the single dose of either 1 or 2 mg of butorphanol. The effects lasted actively for 3 to 4 hours. Tolerance or drug dependency was rarely recognized even in the cases receiving repeated injections of the drug. Adverse effects, such as dizziness, nausea, thirst, numbness of the hands etc, observed in 5 patients were transient and required no medication. The above results may warrant a long-term administration of the drug for controlling varieties of pain in the cancer patients.

Radioaerosol inhalation lung cine-scintigraphy: a preliminary report

"Radioaerosol inhalation lung cine-scintigraphy", a cinematographic display of the lungs following radioaerosol inhalation has been found to be extremely helpful not only to the visual assessment of mucociliary clearance in the lungs but also to the setting of regions of interest and to the interpretation and analysis of clearance curves over the regions of interest in the lungs. It is expected that this procedure offers an important means to the study of mucociliary clearance in health and disease in man.

Effect of isoproterenol on regional pulmonary perfusion and its blockade by propranolol

Effects of isoproterenol and propranolol on regional pulmonary perfusion were assessed in the dog. In each experiment the right upper lobe was isolated in vivo by a balloon catheter and artificially ventilated with nitrogen, air or 60% oxygen in nitrogen before and after administration of the medicaments listed above. The rest of the lungs kept breathing air spontaneously. Following administration of isoproterenol regional pulmonary perfusion increased in the hypoxic right upper lobe induced by artificial ventilation with nitrogen, but the increase was not observed when isoproterenol was administered following pretreatment with propranolol. Administration of propranolol alone did not induce any change in regional pulmonary perfusion distribution. When artificial ventilation was done in the right upper lobe either with air or 60% oxygen in nitrogen, thus inducing regional less hypoxia or hyperoxia, no change in regional perfusion was observed with any of the medication. Thus isoproterenol reversed regional hypoxic pulmonary vasoconstriction, but its action was blocked by pretreatment with propranolol. Propranolol per se, however, showed no effect on pulmonary vascular responses to the different alveolar oxygen tensions.

Effect of dopamine on regional pulmonary perfusion

Dopamine effect on regional pulmonary perfusion in the right upper lobe was studied in 6 dogs in which the lobe was isolated by a balloon catheter and artificially ventilated with nitrogen, air or 60% oxygen in nitrogen, while the rest of the lungs was allowed spontaneous air respiration. Dopamine was administered at the rate of 20 micrograms/kg/min. Each dog served as its own control. There was no change in the regional vascular responses to the different alveolar oxygen tensions in the right upper lobe before and after dopamine administration.