The impact of statins treatments for plaque characteristics in stable angina pectoris patients with very low and high low-density lipoprotein cholesterol levels: an intracoronary optical coherence tomography study

Low-density lipoprotein cholesterol (LDL-C) levels are recommended according to the patient's risk factors based on guidelines. In patients achieving low LDL-C levels, the need for statins is uncertain, and the plaque characteristics of patients not treated with statins are unclear. In addition, the difference in plaque characteristics with and without statins is unclear in similarly high LDL levels. We evaluate the impact of statins on plaque characteristics on optical coherence tomography (OCT) in patients with very low LDL-C levels and high LDL-C levels. A total of 173 stable angina pectoris patients with 173 lesions undergoing OCT before percutaneous coronary intervention were evaluated. We divided the LDL-C levels into three groups: < 70 mg/dL (n = 48), 70 mg/dL ≤ LDL-C < 100 mg/dL (n = 71), and ≥ 100 mg/dL (n = 54). Among patients with LDL-C < 70 mg/dL, patients not treated with statins showed a significantly higher C-reactive protein level (0.27 ± 0.22 mg/dL vs. 0.15 ± 0.19 mg/dL, p = 0.049), and higher incidence of thin-cap fibroatheromas (TCFAs; 44% [7/16] vs. 13% [4/32], p = 0.021) than those treated with statins. Among patients with LDL-C level ≥ 100 mg/dL, patients treated with statins showed a significantly higher prevalence of familial hypercholesterolemia (FH) (38% [6/16] vs. 5% [2/38], p = 0.004), lower incidence of TCFAs (6% [1/16] vs. 39% [15/38], p = 0.013), healed plaques (13% [2/16] vs. 47% [18/38], p = 0.015), and higher incidence of fibrous plaques (75% [12/16] vs. 42% [16/38], p = 0.027) than patients not treated with statins. While patients achieved a low LDL-C, patients not treated with statins had high plaque vulnerability and high systemic inflammation. While patients had a high LDL-C level with a high prevalence of FH, patients treated with statins had stable plaque characteristics.

Clinical Outcomes of Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Interventions with a Novel Dynamic Coronary Roadmap System

Dynamic coronary roadmap (DCR) is a novel technology that creates a real-time overlay of the coronary arteries in percutaneous coronary intervention (PCI) and has the potential to reduce the contrast volume. However, the efficacy of DCR in terms of clinical outcomes in patients with chronic kidney disease (CKD) remains to be fully elucidated.This single center retrospective study enrolled 275 patients with CKD who underwent PCI, and divided them into a DCR group (n = 124) and Non-DCR group (n = 151). Propensity score matching was performed to minimize the differences in baseline characteristics in 113 patient pairs. The primary endpoint was a composite outcome of all-cause death, hospitalization for heart failure, nonfatal myocardial infarction, or the introductory rate of dialysis within 2 years. The secondary endpoints were contrast medium volume, the incidence of contrast-induced acute kidney injury (CI-AKI), and the introductory rate of dialysis within 2 years.Although there was no significant difference in the success rate (DCR group: 99.1% versus Non-DCR group: 98.2%; P = 0.561), contrast volume (92.20 mL versus 115.97 mL; P = 0.002) was significantly lower in the DCR group. CI-AKI incidence was 0.9% versus 6.2% in the DCR and Non-DCR groups, respectively (P = 0.031). The composite outcome defined as primary endpoint occurred in 10 patients in the DCR group and 20 patients in the Non-DCR group (8.8% versus 17.7%; P = 0.049).From the perspective of acute and long-term clinical outcomes, DCR use may be effective for patients with CKD.

Predictive value of lipoprotein(a) for assessing the prevalence and severity of lower-extremity peripheral artery disease among patients with acute coronary syndrome

Lipoprotein(a) [Lp(a)] is a reliable lipid marker for atherosclerosis. However, the clinical relevance of Lp(a) to lower-extremity peripheral artery disease (LE-PAD) and coronary artery disease (CAD) in the same patient has not been investigated. Patients who received primary percutaneous coronary intervention for the acute coronary syndrome (ACS) were enrolled. Patients who received hemodialysis, required multidisciplinary treatments, or had incomplete medical history were excluded. A total of 175 patients were divided into two groups according to whether they had LE-PAD (n = 21) or did not (n = 154), and three multivariable logistic regression models were used to assess if Lp(a) level is associated with LE-PAD prevalence. In addition, serum Lp(a) levels were compared among three groups according to the severity of LE-PAD (none, unilateral, or bilateral) and CAD. Serum Lp(a) levels were significantly higher in patients with LE-PAD than in those without (31.0 mg/dL vs. 13.5 mg/dL, p = 0.002). After adjusting for confounding factors, higher Lp(a) levels were independently associated with the prevalence of LE-PAD in all three models (p < 0.001 for all). With respect to LE-PAD severity, serum Lp(a) levels were significantly higher in the bilateral LE-PAD groups than in the group with no LE-PAD (p = 0.005 for all), whereas Lp(a) was not associated with CAD severity. Though Lp(a) levels are associated with the prevalence and severity of LE-PAD, are not associated with the severity of CAD among patients with ACS.

Healed neointima of in-stent restenosis lesions in patients with stable angina pectoris: an intracoronary optical coherence tomography study

The phenomenon to heal neointimal rupture or thrombus after coronary stenting occurs as well as in native coronary artery. We investigated clinical characteristics and neointimal vulnerability of healed neointima by optical coherence tomography (OCT). We treated 67 lesions by percutaneous coronary intervention for in-stent restenosis (ISR) and conducted OCT examinations. Healed neointima was defined as neointima having one or more layers with different optical densities and a clear demarcation from underlying components. ISR with healed neointima was found in 49% (33/67) of the lesions. Compared to ISR without healed neointima, ISR with healed neointima showed significantly longer stent age (102 ± 72 vs. 31 ± 39 months, P < 0.001), lower frequency of dual antiplatelet therapy [42% (14/33) vs. 74% (25/34), P = 0.017], lower use of angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (ACE-I or ARB) [61% (20/33) vs. 91% (31/34), P = 0.028], lower usage of second-generation drug-eluting stents (DESs) [36% (12/33) vs. 63% (22/34), P = 0.029], higher usage of thick-strut stents [42% (14/33) vs. 15% (5/34), P = 0.012], larger neointimal area (6.8 ± 2.6 vs. 5.2 ± 1.8 mm², P = 0.005), higher incidence of thin-cap fibroatheroma [58% (19/33) vs. 21% (7/34), P = 0.002], neointimal rupture [45% (15/33) vs. 9% (3/34), P = 0.001], and lower incidence of stent underexpansion [15% (5/33) vs. 44% (15/34), P = 0.010]. In conclusions, ISR with healed neointima was associated with neointimal vulnerability, stent age, stent type, stent strut thickness, stent expansion, antiplatelet therapy, and use of ACE-I or ARB.

Clinical usefulness of Lipoprotein(a) for the prevalence and severity of peripheral artery disease among patients with acute coronary syndrome

Background

Lipoprotein(a) [LP(a)] is known to be a robust lipid marker associated with cardiovascular events. Though coronary artery disease and peripheral artery disease (PAD) are often coexist, little is known about the relationship between LP(a) and PAD among patients with acute coronary syndrome (ACS).

Purpose

The purpose of this study is to examine if LP(a) is of predictive value for PAD among ACS patients in Japanese population.

Methods

Of consecutive 238 ACS patient who received successful primary PCI, a total of 175 patients were enrolled in the current study. We excluded the patients who received hemodialysis (n=10), required multidisciplinary treatment (n=36) and incomplete data (n=17). PAD was diagnosed as ankle brachial index &lt;0.9. Multiple lipid biomarkers [LP(a), low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), malondialdehyde-modified LDL (MDA-LDL), docosahexaenoic acid and arachidonic acid] were compared between patients with PAD (n=21) and without PAD (n=154). Further, multivariable logistic regression models were used to assess if LP(a) was associated with PAD. In addition, serum LP(a) level were compared between 3 groups according to pattern of PAD [none (n=154), unilateral (n=10) and bilateral PAD (n=11), respectively].

Results

Compared to patients without PAD, those with PAD were older (74.4 vs. 65.4 years, p=0.003), and had a higher prevalence of chronic kidney disease (CKD) (61.9% vs. 20.1%, p&lt;0.001), diabetes mellitus (DM) (66.7% vs. 27.3%, p&lt;0.001). Serum LP(a) level was significantly higher in patients with PAD (36.4 vs. 18.5 mg/dl, p&lt;0.001), whereas LDL-C and MDA-LDL were significantly lower in PAD (92.0 vs. 109.5 mg/dl, p=0.015 and 98.6 vs. 119.5 mg/dl, p=0.046, respectively). After adjusting for LDL-C and MDA-LDL, LP(a) &gt;30 mg/dl was independently associated with a presence of PAD (OR 5.67, 95% CI 2.09–15.4, p=0.0006). When adjusting for CKD and DM in a different model, LP(a) &gt;30 mg/dl was similarly associated with PAD (OR 4.98, 95% CI 1.66–14.9, p=0.004). Serum LP(a) levels were significantly higher in bilateral PAD group compared to none PAD group (Figure).

Conclusion

LP(a) was a useful lipid biomarker for the prevalence and severity of PAD among patients with ACS in Japanese population.

Funding Acknowledgement

Type of funding source: None

The relationship between coronary artery calcium density and optical coherence tomography-derived plaque characteristics

BACKGROUND AND AIMS

Although coronary artery calcium (CAC) density has been associated with plaque stability, pathological evidence is lacking. We investigated the relationship between coronary computed tomography (CCT)-derived CAC density and multiple calcified and high-risk plaque (HRP) characteristics using optical coherence tomography (OCT).

METHODS

We analyzed 83 plaques from 33 stable angina patients who underwent both CCT and OCT. CAC density was measured at calcium plaques with ≥90 Hounsfield units (HU) and ≥130 HU using custom CT software. The correlation between median CAC density and OCT-derived calcium size (thickness and area) was assessed. To investigate whether median CAC densities measured at the 90 HU threshold were associated with plaque vulnerability, OCT-derived plaque characteristics and HRP characteristics were compared between the low (90-129 HU), intermediate (130-199 HU) and high (≥200 HU) CAC HU groups.

RESULTS

Median CAC densities at 130 HU were moderately associated with calcium thickness (R = 0.573, p < 0.001) and area (R = 0.560, p < 0.001). Similar results were observed at 90 HU (thickness, R = 0.615, p < 0.001; area, R = 0.612, p < 0.001). Among groups with low, intermediate and high HU levels, calcium thickness (0.42 ± 0.14 mm, 0.60 ± 0.17 mm and 0.77 ± 0.19 mm, respectively; p < 0.001) and area (0.55 ± 0.29 mm², 1.20 ± 0.58 mm² and 1.78 ± 0.87 mm², respectively; p < 0.001) were significantly greater in the high HU group. HRP characteristics, however, did not differ among the three groups.

CONCLUSIONS

OCT-derived calcium size, but not HRP characteristics, were associated with CAC density, suggesting that CAC density is driven mainly by calcified plaque size but not local plaque vulnerability.

Heart Rate After Resuscitation From Out-of-Hospital Cardiac Arrest due to Acute Coronary Syndrome Is an Independent Predictor of Clinical Outcome

BACKGROUND

Heart rate (HR) is a useful predictor of cardiovascular disease, especially in acute coronary syndrome (ACS). However, it is unclear whether there is an association between HR and clinical outcomes after resuscitation from out-of-hospital cardiac arrest (OHCA) due to ACS. The aim of this study was to investigate the impact of HR on clinical outcome in individuals resuscitated from OHCA due to ACS.Methods and Results:Data from 3,687 OHCA patients between October 2002 and October 2014 were retrospectively analyzed. We divided 154 patients diagnosed with ACS into 2 groups: those with tachycardia (HR >100 beats/min, n=71) and those without tachycardia (HR ≤100 beats/min, n=83) after resuscitation. The primary endpoint was 1-year mortality and the secondary endpoint was neurological injury at discharge according to cerebral performance category score. Overall, mean HR was 95.6 beats/min. There were several significant differences in patient characteristics, indicating poor general condition of patients with tachycardia. Mortality at 1-year was 41.6%, and neurological injury at discharge was observed in 44.1% of individuals. In the multivariate analysis, tachycardia after resuscitation was an independent predictor of both 1-year mortality (hazard ratio, 2.66; 95% CI: 1.20-5.85; P=0.03) and neurological injury at discharge (odds ratio, 2.65; 95% CI: 1.27-5.55; P=0.04).

CONCLUSIONS

In patients who recovered from OHCA due to ACS, tachycardia after resuscitation predicted poor clinical outcome.

A Case Demonstrating the Ribaroxaban Therapy for Paradoxical Embolism

A paradoxical embolism is defined as a systemic arterial embolus due to passage of a venous thrombus through a right to left shunt. In recent years, vitamin K antagonists and aspirin are used as anticoagulant medications for the secondary prevention of paradoxical embolism. We describe a case of subacute right upper limb ischemia due to paradoxical embolism. We first started treatment with urokinase, intravenous (IV) injection and unfractionated heparin (continuous IV). As her condition and the serum D-dimer level showed improvement, we started catheterization on day 7 after admission; however the right brachial artery thrombus did not disappear. For her outpatient care, based on the viewpoint of providing rapid anticoagulation therapy within the therapeutic range, having longest periods of initial intensive therapy we chose the treatment using ribaroxaban. Recanalization of her right brachial artery was achieved with this therapy. Here, we report the effective results of initial intensive therapy using ribaroxaban for paradoxical embolism.

Efficacy of Intravenous Administration of Landiolol in Patients With Acute Heart Failure and Supraventricular Tachyarrhythmia

BACKGROUND

Patients with acute heart failure (HF) complicated by supraventricular tachyarrhythmia (SVT) often receive continuous intravenous infusion of landiolol or diltiazem for rate control. It is unclear whether the interval from initiation of infusion to commencement of oral beta-blocker (BB) therapy differs for these two drugs.

METHODS

From January 2013 to July 2015, 94 consecutive patients were hospitalized for acute HF complicated by SVT. After 35 patients were excluded, the remaining 59 were divided into groups treated with diltiazem or landiolol. We investigated the blood pressure, heart rate, New York Heart Association classification, brain natriuretic peptide, chest X-ray film, echocardiographic findings (ejection fraction (EF)), time until commencement of oral BB therapy, and hospital stay.

RESULTS

There were no significant between-group differences of heart rate, blood pressure, or the severity of HF. The time until commencing oral BB therapy was significantly shorter in the landiolol group compared with the diltiazem group (median: 2 vs. 4 days, P = 0.002), but there was no significant difference in hospital stay. This interval was significantly shorter in patients with a reduced EF in the landiolol group (median: 2 days) compared with those with a reduced EF in the diltiazem group (median: 5 days, P = 0.008), and patients with a preserved EF in the landiolol group tended to have a shorter interval (median: 2 days) than those with a preserved EF in the diltiazem group (median: 4 days, P = 0.092).

CONCLUSIONS

Switching to oral BBs was accomplished earlier with landiolol than with diltiazem.

A 2,7-diamino-1,4,8-triazanaphthalene derivative selectively binds to cytosine bulge DNA only at a weakly acidic pH

The synthesis and properties of 2,7-diamino-1,4,8-triazanaphthalene (azaDANP) are described. AzaDANP is protonated only at a weakly acidic pH to bind to the cytosine bulge DNA duplex selectively. Upon binding of azaDANP to the cytosine bulge DNA, a new absorption band at 407 nm appears, and the absorption change of azaDANP on binding to the target is very sensitive to environmental pH with a bell-shaped pH-absorption profile.

Digital Subtraction Angiography in Takayasu Arteritis

The usefulness and limitation of digital subtraction angiography (DSA) in Takayasu arteritis were investigated in 32 patients. Intravenous DSA was particularly useful in the follow-up of patients with an established diagnosis of Takayasu arteritis. Pulmonary arterial involvement could also be demonstrated with intravenous DSA as obstructive arterial changes and lack of accumulation of contrast medium in the pulmonary parenchyma. Detailed information concerning the site and extent of vascular involvement and development of collateral vessels were obtained with intraarterial DSA. Thickening of the thoracic aortic wall, however, could not be recognized with either intravenous or intraarterial DSA. Conventional angiography of the descending thoracic aorta is still required as an initial examination, particularly when there is no aortic arch involvement. However, there is no doubt that DSA has the potential to become the diagnostic procedure of choice in Takayasu arteritis.

Paravertebral Arteriovenous Malformation with Venous Connection to Left Iliac Vein

An unusual systemic arteriovenous malformation arising from the left 9th intercostal artery, taking a caudal course through the left paravertebral veins, eventually drained into the left ascending lumbar vein, as illustrated at computed tomography and angiography. An embryologic maldevelopment of the azygos venous system is not the only possible explanation for venous drainage in the caudal direction. We believe that predominant venous drainage can take place in either direction because of the potentially bidirectional flow in the vertebral venous systems.

Common Bile Duct Cancer with Massive Necrosis Mimicking Choledochal Dilatation on CT

Carcinomas of the common bile duct are usually seen as dilatation of the bile duct proximal to a solid mass on CT. In the case reported here, the common bile duct cancer itself mimicked dilated common bile duct on CT because of massive necrosis. In a case of simulating dilated common bile duct on CT, and discrepancy between CT and ultrasonography or endoscopic retrograde cholangiopancreatography, a common bile duct cancer with massive necrosis should be included in the differential diagnosis.

How to Embolize Wide-Necked Aneurysms?

Novel endovascular approaches are needed for safer and more definitive treatment of wide-necked aneurysms, to overcome the limitations of the Guglielmi detachable coil (GDC) system and further, the application of this technique.

The double GDC technique (DGT), for embolization of wide-necked aneurysms, and the combination of stent placement and coil deposition (CTSC) for management of fusiform aneurysms have been developed and their usefulness is reviewed. The DGT involves scaffolding of a GDC coil to form a stabilizing frame inside the aneurysmal neck and then positioning of a second coil to reinforce the first coil. After confirming the absence of coil herniation in the parent artery, both coils are released together. A patient with a wide-necked large aneurysm of the left internal carotid artery was treated using this technique, and followed up angiographically and clinically for a period of three months. The follow-up angiograms revealed complete embolization of the aneurysm.

The patient had no neurological changes or adverse events during the procedure. The CTSC involves reconstructing the artery with a stent and packing the aneurysm lumen with GDCs through the stent interstices. A patient with a dissecting fusiform aneurysm of the vertebral artery associated with hypoplasia of the contralateral vertebral artery was treated using this technique to prevent rebleeding. His clinical course was uneventful over a six-month follow-up period. Angiography performed two months after the procedure confirmed excellent flow through the right vertebral artery and absence of filling of the daughter aneurysm.

A simplified pull-through angioplasty technique without a snare device. A technical note

The pull-through angioplasty technique allows stable wire tension and stabilization of the device during the procedure. In this technique, a guide wire is passed from one sheath to another, usually with the aid of a snare device. We describe the treatment of occlusive subclavian artery disease and lesion at the origin of the vertebral artery employing a brachiofemoral pull-through technique without using a snare device. In this technique, the guide wire is advanced from the femoral artery to the brachial artery. The guide wire is directly inserted into the sheath placed at the brachial artery. The brachial artery is compressed proximal to the point of sheath insertion to prevent bleeding. The sheath is extracted temporally and the guide wire is caught outside of the body. The sheath is then introduced again through the guide wire. We used the pull-through technique without a snare device in seven cases, and we were able to build the pull-through system in six of these cases without a snare device. This pull-through technique without a snare device is not difficult to use, and may reduce the time and cost of angioplasty procedures.

The use of docosahexaenoic acid supplementation to ameliorate the hyperactivity of rat pups induced by in utero ethanol exposure

It has been demonstrated thatin utero ethanol (EtOH) exposure induces hyperactive behavior and learning disturbances in offspring. In order to investigate the effects of docosahexaenoic acid (DHA) on these neurobehavioral dysfunctions of rat pups induced byin utero EtOH exposure, pregnant Wistar rats were divided into four treatment groups depending on the type of oil added to the diet and drinking water as follows; (a) 5% safflower oil with tap water (TW/n-6), (b) 3% safflower oil and 2% DHA with tap water (TW/n-3), (c) 5% safflower oil with 10%-EtOH (ET/n-6), (d) 3% safflower oil and 2% DHA with 10%-EtOH (ET/n-3) at gestational day (GD) 7.10%-EtOH was administered to dams in ET/n-6 and ET/n-3 groups from GD 7 to the pups' weaning (postnatal week 4), and all pups were fed with the same diet that was given to their dams during the entire examination period. The open-field test and the water E-maze test were conducted for all pups, and a spontaneous motor activity test and the Sidman electric shock avoidance test were performed for some of male pups. Amounts of monoamine metabolites in striatum were then determined, and fatty acid analyses of total brain lipids were performed.The male pups in the ET/n-6 group showed significandy more rearing and square-crossing movements in the open-field test, and significandy higher spontaneous motor activity during the dark period in the daily cycle compared to the males in the TW/n-6 group. The male pups in the ET/n-3 group showed fewer of these behaviors in the open-field test compared to the ET/n-6 group males, and a normal pattern of spontaneous motor activity.Learning disturbance induced byin utero EtOH exposure was not observed in the E-shaped water maze, but was observed in the avoidance rates in the Sidman electric shock avoidance test. However, there was no significant modifying effect of DHA on the avoidance rates in EtOH exposed pups.The analysis of the fatty acid composition of total lipids in the brains of the pups revealed high levels of DHA in the diet reflected an increased level of brain DHA and caused a decreased level of the brain arachidonic acid. Retroco nversion from DHA to eicosapentaenoic acid was also observed. However, there was no significant effect of DHA on the levels of monoamine metabolites.These results support the hypothesis that DHA can counteract the attention deficit hyperactivity disorder.

[Descending necrotizing mediastinitis]

We treated of 3 patients with descending necrotizing mediastinitis that is often to be fatal. There are 3 important issues regarding the treatment of this disease. First, the precise sites of abscess should be determined by computed tomography (CT) scans from the neck to diaphragm. Second, effective drainage of the neck and mediastinal abscess should be carried out immediately when the sites of abscess are determined. Third, drainage under video-assisted thoracic surgery (VATS) is an appropriate treatment because VATS is less invasive and provides an easier placement of the drainage tubes at abscess sites.

[Complete resection of an advanced mediastinal nonseminomatous germ cell tumor with multiple distant metastases after down-staging by chemotherapy]

A mediastinal nonseminomatous germ cell tumor was completely resected after down-staging by chemotherapy despite the presence of multiple distant metastases. A 22-year-old female was admitted for superior vena cava (SVC) syndrome. Her SVC was obstructed by a large anterior mediastinal tumor; she also exhibited distant metastases on a left rib, in the liver, and multiple in the lung. The blood alpha-fetoprotein (AFP) level was extremely elevated to 57,530 ng/ml. Four courses of BEP therapy [cisplatin (CDDP), bleomycin (BLM), etoposide (VP-16)] and a high dose chemotherapy followed by a peripheral blood stem cell transplantation made the tumor become smaller and effected its down-staging. Residual mediastinal tumor with an intravascular tumor in SVC was completely resected. The SVC was reconstructed by an artificial vessel graft. A mediastinal nonseminomatous germ cell tumor, even though it has multiple distant metastases, can achieve down-staging and complete resection by a chemotherapy based on scientific evidence.

Retinal nerve fibre layer assessment in myopic glaucomatous eyes: comparison of GDx variable corneal compensation with GDx enhanced corneal compensation

Aim:

To compare the results of scanning laser polarimetry (GDx) with variable corneal compensation (VCC) and enhanced corneal compensation (ECC) when applied to myopic glaucomatous eyes.

Methods:

Forty glaucoma eyes with moderate myopia (between −3 and −6 D) and 35 glaucoma eyes with high myopia (−8 D or greater) were enrolled in this study. GDx VCC, GDx ECC and standard automated perimetry (SAP) were performed. The prevalence of an atypical retardation pattern (ARP), the typical scan score (TSS) and retinal nerve fibre layer (RNFL) thickness were compared between VCC and ECC in both groups of myopic subjects. A correlation analysis between RNFL thickness and visual sensitivity was also conducted.

Results:

In both myopic groups, the mean TSS is significantly lower (p<0.0001), and the prevalence of ARP was significantly higher (p<0.0001) by VCC scans than by ECC scans. Temporal, superior, nasal, inferior, temporal (TSNIT) average and temporal average thickness showed significantly higher values (p<0.001) by VCC than by ECC. A statistically significant association was observed between TSNIT average and mean deviation of SAP by ECC scan.

Conclusions:

ECC scans showed a better retardation pattern and structure–function relationship than did VCC, and ECC appeared to be more suitable for RNFL assessment in glaucomatous eyes that are moderately to highly myopic.

[Congenital bronchoesophageal fistula in an adult; an undiscribed mechanism of symptom tolerance]

We present a case of a congenital bronchoesophageal fistula in a 61-year-old woman. She was referred to hospital because of postprandial heart burn. Three-dimensional (3D) computed tomography (CT) demonstrated an anastomosis between her right intermediate bronchus and esophagus. In spite of direct communication between her bronchus and esophagus, she has never suffered severe infection. We visualized the orifice of fistula closed with mucosal flap in swallowing by means of a bronchofiberscope. The delay of a diagnosis was explained by symptom tolerance. Some theories as to the symptom tolerance are found in literatures, but we supposed to find an undiscribed mechanism; closure of the orifice in swallowing. The fistula was surgically closed.

Carotid artery stenting for calcified lesions

BACKGROUND AND PURPOSE

Our aim was to assess the feasibility of carotid artery stent placement (CAS) for calcified lesions.

MATERIALS AND METHODS

Using embolic protection devices (EPDs), we performed 51 CAS procedures in 43 patients with severe carotid artery stenosis accompanied by plaque calcification. Before intervention, all lesions were subjected to multidetector-row CT. The arc of the circumferential plaque calcification was measured on axial source images at the site of maximal luminal stenosis, and the total volume of the plaque calcification was determined. The angiographic outcome immediately after CAS, and intra- and postoperative complications were recorded.

RESULTS

The mean arc of calcification was 201.1 +/- 72.3 degrees (range, 76-352 degrees ), and the mean of the total calcification volume was 154.9 +/- 35.4 mm(3) (range, 92-2680 mm(3)). Balloon rupture occurred in 1 procedure (2.0%) at predilation angioplasty; all 51 CAS procedures were successful without clinical adverse effects. Although there was a correlation between the arc of plaque calcification and residual stenosis (r = 0.6, P < .001), excellent dilation with residual stenosis < or =30% was achieved in all lesions. There was no correlation between the total volume of calcification and residual stenosis. None of the patients developed stroke or death within 30 days of the CAS procedure.

CONCLUSION

CAS by using EPDs to treat lesions with plaque calcification is feasible even in patients with near-total circumferential plaque calcification.

[Comparison of the images in virtual bronchoscopy under different conditions]

OBJECTIVE

We report herein the comparison of the virtual bronchoscopy (VB) images which were constructed with 2 different computed tomography (CT) scanners combined with 3 different applications in 2 healthy adult volunteers.

METHODS

CT scanners were multi-detector row CT (MDCT) [64 detectors] and MDCT (16 detectors). Applications, by which VB images were made, were Leonardo (Leo), Ziostation (Zio), and Plus XNVZ2 (Plus). The image quality was evaluated by 3 expert bronchoscopists.

RESULTS

The change of the threshold value was necessary in Leo for practical use in subsegmental bronchi and more distal area, but unnecessary in Plus or Zio. When Plus was used, the VB images from the data obtained with MDCT (16 detectors) and MDCT (64 detectors) had almost equal quality.

CONCLUSIONS

Although the process to construct VB images was different in each application, it was regarded that Plus was not inferior to Zio or Leo in VB image quality.

Mechanisms of perianeurysmal edema following endovascular embolization of aneurysms

SUMMARY

After coil embolization for an aneurysm, edema surrounding the aneurysm revealed by magnetic resonance imaging (MRI) is rarely seen and is usually associated with neurological symptoms. Perianeurysmal edema was found by postoperative MRI in three out of 182 patients with cerebral aneurysm, which was treated with Guglielmi Detachable Coil (GDC), and neurological symptoms developed simultaneously. In cases where neurological symptoms improved with conservative medical treatment, a temporary increase in the volume of an aneurysm, due to coil and thrombus formation, may result in edema. In cases where symptoms were not alleviated with conservative medical treatment, persistent water-hammer effect against the residual lumen of the aneurysm as well as an increase in the volume of aneurysm by hemorrhage in the aneurysmal wall may contribute to the development of perianeurysmal edema. Consideration of the mechanism of edema development by neurological symptoms, MRI findings, and angiographic findings is needed in order to select appropriate treatment.

Direct superficial temporal vein approach for dural carotid cavernous fistula

SUMMARY

We present an alternative endovascular approach to treat dural carotid cavernous fistulae (dural CCF) that drain only into the superior ophthalmic vein. Four cases of cavernous dural AVFs that could not be treated via the inferior petrosal vein were accessed via the direct superficial temporal vein approach through the superior ophthalmic vein. Successful embolization was documented radiographically and clinically in all patients. The trans-superficial temporal vein approach is safe and useful for inaccessible dural CCFs through the inferior petrosal sinus.

Direct carotid puncture for the endovascular treatment of anterior circulation aneurysms

We report the usefulness of Guglielmi detachable coil (GDC) embolization by direct carotid puncture for anterior circulation aneurysms. For all 27 patients, GDC embolization by direct carotid puncture was safely performed by using a 5F sheath introducer 5 cm long and a Tracker-38 catheter. Neurologic deficits and hemorrhage were not found in any patient during the follow-up period. If the transfemoral approach cannot be applied, GDC embolization should be considered as an alternative method.

The significance of incomplete stent apposition in patients undergoing stenting of internal carotid artery stenosis

BACKGROUND AND PURPOSE

Incomplete stent apposition after carotid angioplasty and stent placement (CAS) is often seen but little is known about how the incomplete attachment goes after stent placement. For example, some may change into restenosis around the stent edge and some may remain unchanged. The purpose of this study is to clarify the morphologic prognosis of an incomplete stent apposition at the stent edge.

METHODS

CAS was attempted on 135 consecutive stenotic lesions (124 patients). Angiograms were then evaluated immediately after the procedure. An incomplete stent apposition at stent edge was found in 15 patients, and all of them were followed up by angiography and MR imaging with antiplatelet therapy.

RESULTS

No ischemic event caused by the lesions occurred during the mean follow-up period of 11 months (from 4 to 32 months). The angiography findings of 15 lesions at a mean of 8.8 months (from 2 to 28 months) after CAS showed that all remained unchanged. No patients required any additional intervention. No new ischemic lesions were detected in any of the 15 patients who underwent follow-up MR imaging at a mean of 10 months (from 2 to 32 months) after CAS.

CONCLUSION

In this study, the existence of a segment of incomplete stent apposition had no adverse morphologic or clinical effect.

[Pulmonary actinomycosis developing diffuse phregmone after pneumonectomy]

The patient was a 75-year-old male who consulted the department of respiratory tract internal medicine in our hospital for left chest pain occurring from the beginning of December 2003. Chest X-ray indicated a tumorous shadow in the left lower lung field. A chest CT also revealed an irregularly shaped mass shadow in the left lower lobe. Since bronchoscopy failed to establish a definitive diagnosis, the patient was referred to our department for surgery to undertake thoracotomy. After left pneumonectomy being performed based on a suspicion of lung abscess, pathological examination of specimen from the resected left lung showed sulfur granules which led to the diagnosis of pulmonary actinomycosis. Because of the diffuse phregmone developing around the surgical wound, benzylpenicillin potassium administration was started, and was continued for a further 6 months on an outpatient basis. Pulmonary actinomycosis is a relatively rare chronic pulmonary infection. It is often difficult to distinguish pulmonary actinomycosis from other pulmonary disease such as lung cancer because of the similarity of their appearance on X-ray or CT, and almost all cases of pulmonary actinomycosis are diagnosed by thoracotomy.

[Large cell carcinoma with chest wall infiltration combined with contralateral giant bulla]

A 48-year-old male consulted the department of respiratory medicine for right precordial pain occurring from the beginning of May 2004. Chest X-ray indicated a tumorous shadow in the right upper lung field and a large left lung cyst. Although chest wall infiltration was suspected based on computed tomography (CT) demonstrating a mass lesion in the right S2, there was no significant swelling of the mediastinal lymph node. On the left side, the lung was markedly compressed by a large cyst in the left upper lobe. Since bronchoscopy failed to establish a definitive diagnosis, the patient was referred to our department for surgery based on a suspicion of malignant pulmonary tumor. Considering both the risk of perioperative complications due to the left cystic lesion at surgery for right lung lesion and the improvement of respiratory function by removing cystic lesion of the left lung, the left side operation was preceded by the right side. Although postoperative examinations of respiratory function did not demonstrate any particular improvement, the results of selective right pulmonary artery obstruction test supported the possibility of pulmonary lobectomy. Therefore, the right upper lobectomy and ND 2a mediastinal dissection combined with chest wall resection was subsequently performed. Postoperative pathological diagnosis revealed that the tumor was a stage IIB large cell carcinoma of pT3N0M0 with costal infiltration.

Spontaneous improvement of persistent ulceration after carotid artery stenting

BACKGROUND AND PURPOSE

Because carotid plaque ulceration is associated with an increased risk of cerebral embolism, residual carotid plaque ulceration directly around a stent (persistent ulceration) after carotid angioplasty and stent placement (CAS) could still be a risk factor for a stroke. The purpose of this study is to understand the morphologic and clinical prognosis of persistent ulceration.

PATIENTS AND TECHNIQUES

CAS was attempted on 91 consecutive stenotic lesions (80 patients). Of these, 54 lesions (48 patients) had ulceration before CAS. Angiograms were evaluated immediately after the procedure. Persistent ulceration was found in 34 lesions (30 patients). The mean depth and length of persistent ulcers were 2.1 mm (range, 1-4.7 mm) and 8.9 mm (range, 1.5-22 mm), respectively. All patients with persistent ulceration were followed with antiplatelet therapy.

RESULTS

No ischemic event due to the lesions occurred during the mean follow-up period of 25.5 months (range, 3-48 months). Angiography on 25 lesions (21 patients) at a mean of 5.8 months (range, 1-21 months) after CAS showed that persistent ulceration disappeared in 12 lesions (48%), improved in 11 lesions (44%), and remained unchanged in 2 lesions (8%). Nine lesions (36%) showed restenosis, which were < or =30% and did not require any additional intervention. New ischemic lesions were not detected in any of the 14 patients (17 lesions) who underwent follow-up MR imaging at a mean of 9 months (range, 1-32 months) after CAS.

CONCLUSION

We conclude that persistent ulceration after CAS improves spontaneously and is not a risk factor for cerebral embolism.

[Abdominal organ infarction encountered immediately after surgery of primary lung cancer]

Very rare cases of abdominal organ infarction after surgery of primary lung cancer were reported. Case 1: Patient 1 was a 70-year-old man who underwent left upper lobectomy and ND 2a in June 1999 based on the clinical diagnosis of stage IA lung cancer. On the 4th postoperative day, the patient developed fever and right flank pain. Abdominal computed tomography (CT) demonstrated a specific finding compatible with renal infarction. The etiology could not be determined. The patient was treated conservatively. However, severe atrophy of right kidney was demonstrated by following CT performed 3 years later. Case 2: Patient 2 was a 70-year-old woman who underwent left upper lobectomy and ND 2a in December 2002 based on the clinical diagnosis of stage IA lung cancer. On the 4th postoperative day, the patient developed abdominal pain in the left upper quadrant, nausea and vomiting which had lasted for 10 days. Abdominal CT demonstrated a wedge-shaped filling defect at spleen compatible with splenic infarction. The etiology could not be determined. The patient was treated conservatively with prophylactic antibiotic therapy and followed closely. Partial atrophy of spleen was demonstrated by following CT performed 4 months later.

[Simultaneous spontaneous pneumomediastinum caused by vocal exercise; report of 2 cases]

Two cases of spontaneous pneumomediastinum caused by vocal exercise were reported. Two 18-year-old men were admitted to our hospital simultaneously in April 2003, because of cervical discomfort and chest pain after vocal exercise of self introduction as a event of freshman in their college. Their chest X-ray film and chest computed tomography (CT) demonstrated typical pneumomediastinum. One of them also showed thoracic epidural emphysema without any particular neurological deficit. Both cases completely recovered by only conservative therapy within 5 days. Spontaneous pneumomediastinum which occurs frequently in young men is thought to be a relatively rare disease showing a good prognosis. It seems important to consider this rare condition when the young man complaints chest pain and discomfort around their neck. We thought that there must be a high possibility of this disease being overlooked as a mere chest pain in young man of unknown reason until now. It is our conclusion that spontaneous pneumomediastinum is a really benign condition that requires no specific examination nor therapy.

[A clinical evaluation of the practical reliability in video-assisted thoracic surgery for right primary lung cancer]

Recently, lobectomy by video-assisted thoracic surgery (VATS lobectomy: VL) has been widely applied to peripheral lung cancer because of its less invasive approach compared to standard thoracotomy (ST). However, the appropriate approach in VL still remains to be solved. The aim of this study was to evaluate the practical reliability of our technical devices in VL for right primary lung cancer. For the VATS procedures, a mini-thoracotomy measuring about 6-7 cm was made in the fourth or fifth intercostal space (ICS) under the auscultatory triangle without rib resection. Two access holes 12 mm in size were also made in the fourth ICS at the anterior axillary line and in the seventh ICS at the posterior axillary line, respectively. These access holes were used for insertion of thoracoscope, endoscopic stapler or retracting instrument according to operative procedure. After stapling of the vessels and bronchus, the resected pulmonary lobe was removed from the thorax using a plastic retrieval bag. The present study showed the technical feasibility of this unique thoracoscopic approach in the standard lobectomy with systematic nodal dissection for right lung cancer.

Clinicopathological Investigation of AVMs Embolized with HEMA-MMA. A New Non-Adhesive Liquid Material

SUMMARY

We have recently developed a non-adhesive liquid embolic agent, hydroxyethylmethacrylate methylmethacrylate copolymer (HEMA-MMA), and used it for arteriovenous malformations (AVMs) in the central nervous system. To evaluate the toxicity and usefulness of this agent, we made a clinicopathological study of AVMs that were embolized with it and then excised surgically. This study includes ten cases: nine with pial AVM and one with scalp AVM. In a pathological study, special attention was paid to vascular and perivascular inflammation, angionecrosis, recanalization of the embolized vessels, and foreign body reactions. Inflammation was absent or very mild regardless of the interval between embolization and excision. There was no angionecrosis. Recanalization could be expected to occur in the partially occluded vessel. Foreign body reactions such as infiltration of monocytes or giant cells, and proliferation of fibroblasts or capillaries were also not seen in any case. It was concluded that HEMA-MMA is an excellent embolic material that is easy to handle, less vasotoxic than other agents, and highly histocompatible.

[Ultrasonographical approach for the diagnosis on the depth of invasion in early bronchogenic squamous cell carcinoma]

It is important to evaluate the depth of invasion to determine the appropriate treatment for roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC). In order to evaluate the actual significance of TUS as a diagnostic tool of intraluminal carcinoma invasion, we have conducted a prospective trial. TUS was performed on 29 lesions of ROSCCs. We ultrasonographically classified the degree of the depth of intraluminal invasion into 2 groups; A: "inside of cartilaginous layer" and B: "cartilaginous layer or over". The patients were treated by irradiation, photodynamic therapy (PDT) or surgical resection. Clinicopathological findings and response to the treatment were compared with this ultrasonographical classification. In the evaluation of invasion within cartilage, the sensitivity was 88.2%, the specificity was 77.8%, the accuracy was 84.6%, and the positive predictive value was 88.2%. With TUS, the decision of treatment modality would be more appropriate.

[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.

Diagnostic validity of computed tomography for mediastinitis after cardiac surgery

BACKGROUND

Optimal treatment based on appropriate early diagnosis is essential in managing mediastinitis after cardiac surgery. We evaluated the accuracy of thoracic computerised tomography (CT) in the diagnosis of mediastinitis.

METHODS

Forty-one patients in whom we performed CT after cardiac surgery were classified into two groups as follows; Six cases had mediastinitis requiring a redo surgical intervention (Group M). Thirty-five cases recovered without mediastinitis (Group C). Comparisons of CT findings in both groups were made retrospectively.

RESULTS

In group M, CT and re-operations were performed 6.3+/-2.5 days and 8.0+/-5.2 days after previous operation, respectively. All but one of redo surgical procedures were mediastinal lavage and omental transplantation. Two patients died due to septic shock and multiple organ failure. CT in group M showed a soft tissue mass with contrast enhancement in 4 patients, bilateral pleural effusion in 5, free gas appearance in 4, and sternal dehiscence or destruction in 2 patients. Consequently, we regarded 4 of the 6 patients in this group as showing postoperative mediastinitis radiographically. In group C, CT performed 16.6+/-7.1 days after operations revealed findings suggestive of mediastinitis in 6 patients. Therefore, in terms of the validity of CT for the diagnosis of mediastinitis, the sensitivity was 67% and the specificity was 83%.

CONCLUSION

The sensitivity of CT for diagnosis of mediastinitis after cardiac operations is unsatisfactory. Diagnosis by seeking infective changes in a multidisciplinary way is important in dealing with mediastinitis.

Allelic loss on 17p13 (TP53) and allelic loss on 3p21 in early squamous cell carcinoma of the lung

Roentgenographically occult bronchogenic squamous cell carcinomas are early lung cancers that localize in the bronchial wall, and are thought to be a good model to elucidate the carcinogenesis of lung cancer. In the present study, we analyzed the incidence of allelic losses on chromosome regions 3p21 and 17p13 in 40 cases of roentgenographically occult bronchogenic squamous cell carcinomas, using three microsatellite dinucleotide polymorphic markers. We also investigated the relationship between such allelic loss and the clinicopathological findings of those cases. These chromosome regions showed frequent losses. Moreover, the incidence of loss on 17p13 increased gradually along with the advance of the depth of invasion, while the incidence of loss on 3p21 increased along with the advancing length of the longitudinal extension. These results suggested that these chromosome regions play different roles in lung cancer progression, i.e., the 3p21 chromosome region was related to the longitudinal extension of the carcinoma while the 17p13 (p53) region was related to the depth of invasion.

MDM2 expression is associated with progress of disease and WAF1 expression in resected lung cancer

Although MDM2, p21/WAF1, and p53 are considered as regulating each other based on in vitro studies, the relation in human lung cancer is not fully understood. The expressions of these proteins were examined immunohistochemically in 112 resected non-small cell lung cancer specimens and the correlation between them were analyzed. MDM2 was expressed in 45% of all lung cancers. In advanced stage, MDM2-positive cases were observed more frequently than in early stage, showing significant difference. No significant difference was observed in the prognosis of the patients regardless of the expression of any protein. Although no correlation was observed between MDM2 expression and p53 expression, or between p21/WAF1 expression and p53 expression, MDM2 expression was strongly related with p21/WAF1 expression. Therefore, MDM2 expression may relate to the progress of the stage of lung cancer, and MDM2 expression and p21/WAF1 expression may be associated not through the p53-related pathway.

Inhibitory effect of natural and environmental estrogens on thymic hormone production in thymus epithelial cell culture

The present study was carried out to assess the direct effect of natural estrogen and environmental estrogens on thymus epithelial cell (TEC) production/secretion of the thymic hormone thymosin-alpha 1 by using the technique of quantitative high-performance liquid chromatography. The presence of estrogen receptors in the TECs was also investigated. Murine TECs were cultured in the experimental DMEM medium containing various concentrations of natural or environmental estrogens, which was followed by determining the production of thymosin-alpha 1. The production of thymosin-alpha 1 by TECs was significantly inhibited by increasing concentrations of 17beta-estradiol (natural estrogen) over 3 x 10(-11) M, genistein (phytoestrogen) over 3 x 10(-9) M, coumestrol (phytoestrogen) over 3 x 10(-9) M, alpha-zearalanol (livestock anabolic) over 3 x 10(-7) and bisphenol-A (plastic) over 3 x 10(-6) M. Small amounts of estrogen receptor were present in the TECs. The above results clearly indicate that natural and environmental estrogens directly modulate TECs to produce thymic hormone probably through an estrogen receptor mechanism. Furthermore, our finding may be useful for evaluating biological effects of chemicals with estrogenic activity.

The effects of lesions in the nucleus basalis of Meynert and physostigmine on rat frontal cortex acetylcholine level

To clarify the relationship between acetylcholine (ACh) level in the frontal cortex and the area of lesion in the nucleus basalis of Meynert (nbM), we used ibotenic acid to bilaterally lesion the substantia innominata (SI), including the nbM, in rats and measured extracellular ACh by microdialysis. Baseline level of ACh (ACh-baseline) averaged 0.14 +/- 0.07 ng/40 microl/20 min (n=13) in the steady state. We also measured the size of the lesioned areas in the SI (nbM-lesion) by using a computed image analysis system. Both ACh level and nbM-lesion varied widely among animals. The bilateral nbM-lesion averaged 28 +/- 30% (n=13). The correlation coefficient between ACh-baseline and bilateral nbM-lesion was -0.871 (p<0.01). After intraperitoneal injection of physostigmine, maximum ACh levels increased to 0.18 +/- 0.06 ng/40 microl/20 min, and deltaACh (ACh-max/ACh-baseline) averaged 132 +/- 19% (n=8). There was no apparent correlation between deltaACh and bilateral nbM-lesion. These results show that the size of lesioned area in the bilateral SI was strongly correlated with the baseline ACh level in the frontal cortex, and indicate that the nbM is the major functional source of ACh in the frontal cortex. Our results also suggests that physostigmine possibly affects not only spared nbM-originated cholinergic fibers but also non-nbM-originated cholinergic fibers in the rat with the bilateral nbM lesion.

Immunohistochemical study on tumor angiogenic factors in non-small cell lung cancer

BACKGROUND

In order to elucidate the roles of tumor angiogenesis in lung carcinogenesis, the expressions of several angiogenic factors in lung carcinoma tissues were examined.

MATERIALS AND METHODS

Tissue specimens from 112 cases of resected non-small cell lung cancer (NSCLC) were studied. The expressions of platelet-derived endothelial cell growth factor (PD-ECGF) and vascular endothelial growth factor (VEGF) were examined immunohistochemically. Microvessel density (MVD) was also evaluated.

RESULTS

VEGF-positive cases were observed more frequently in advanced stage lung cancers than in early cancers, and VEGF-positive tumors had higher MVD than VEGF-negative tumors, while such differences were not observed for PD-ECGF. In squamous cell carcinoma, the patients with high-MVD tumor had significantly worse survival than those with low-MVD tumor.

CONCLUSIONS

Our results suggest that VEGF plays an important role in angiogenesis of lung cancers, while the contribution of PD-ECGF may be limited.

Leiomyoma of the parapharyngeal space

A rare case of leiomyoma of the prestyloid parapharyngeal space is reported together with computed tomographic and magnetic resonance imaging findings. The tumor appeared as a well-circumscribed ovoid mass with some calcifications and lobulations. Because the attenuation, signal intensity, and shape of the mass were not specific and were similar to those of a pleomorhic adenoma, the most common tumor of the prestyloid parapharyngeal space, radiological differentiation of leiomyoma from pleomorphic adenoma of the prestyloid parapharyngeal space was difficult.

Involvement of the #12u lymph nodes around the upper lobe bronchi in patients with lung cancer of the right middle lobe, right lower lobe, or left lower lobe

In Japan, the lymph nodes around the upper lobe bronchi, known as the #12u nodes, are not included in the nodes recommended for dissection in patients with right middle lobe carcinoma, right lower lobe carcinoma, or left lower lobe carcinoma. However, histologic examination has revealed involvement of these nodes in pneumonectomy patients whose carcinoma originated in the right lower lobe. We histologically examined the lymph nodes from 152 patients with lung cancer to determine the incidence of involvement of the #12u lymph nodes. These nodes were found to be involved in 14 (9.2%) of the 152 patients. The rate of involvement was significantly higher in those with T2-T4 disease than in those with T1 disease, and was also significantly higher in patients with N2 disease than in those with N1 disease. There were two long-term survivors without recurrence, and one other patient who lived for more than 5 years before succumbing to the disease. In conclusion, to ensure removal of all the cancer tissue, it is recommended that the #12u lymph nodes be included in the nodes routinely dissected in patients with right lower lobe carcinoma, right middle lobe carcinoma, or left lower lobe carcinoma.

Expression of Bcl-2, Bax, and p53 proteins in carcinogenesis of squamous cell lung cancer

BACKGROUND

Apoptosis is regulated by many genes, including bcl-2, p53, and bcl-2 family genes. The expression of Bcl-2, p53, and Bax in very early lung cancers or precancer lesions is not been fully understood.

MATERIALS AND METHODS

The expression of these proteins was examined immunohistochemically in 11 normal bronchial epithelia, 23 dysplasias, and 40 roentgenographically occult squamous cell lung cancers (ROCs).

RESULTS

The expression of the Bcl-2 and p53 protein increased along with the advance of the morphological atypia in bronchial epithelial cells, whereas no difference in the Bax expression. The patients with Bcl-2 positive ROCs had a better prognosis than those with Bcl-2 negative ROCs.

CONCLUSIONS

Bcl-2 and p53 proteins play important roles in early steps of carcinogenesis in squamous cell lung cancer of central type. The Bcl-2 protein could be a prognostic marker in ROCs.