Diversity of gene expression in adenocarcinoma of the lung

The global gene expression profiles for 67 human lung tumors representing 56 patients were examined by using 24,000-element cDNA microarrays. Subdivision of the tumors based on gene expression patterns faithfully recapitulated morphological classification of the tumors into squamous, large cell, small cell, and adenocarcinoma. The gene expression patterns made possible the subclassification of adenocarcinoma into subgroups that correlated with the degree of tumor differentiation as well as patient survival. Gene expression analysis thus promises to extend and refine standard pathologic analysis.

Advances in the staging of intrathoracic malignancies

Conventional staging of lung and esophageal tumors has consisted of a thorough history and physical examination, screening laboratory studies, computed tomography, and radionuclide imaging. Newer modalities including positron emission scanning, endoscopic ultrasonography, minimally invasive surgery (laparoscopy and thoracoscopy), and immunohistochemical staining of lymph node tissue. The role of these techniques are subject to much current debate, and they may ultimately add information that is valuable for staging and optimally treating patients with intrathoracic malignancies.

The current role of transhiatal esophagectomy

Transhiatal esophagectomy is gaining increasing use as the preferred technique for esophagectomy. In this article, the indications, diagnostic evaluation, and technical details of the operative procedure for transhiatal esophagectomy are reviewed. Results of large clinical series are discussed and the potential pitfalls and risks of the procedure are reviewed. Current controversies and future trends are also discussed.

Primary non-small-cell lung cancer: determining the suitability of the patient and tumor for resection

Choosing resective surgery for patients with bronchogenic carcinoma requires assessments of tumor suitability and patient suitability. Tumor suitability is largely dependent on the assessed stage of the tumor complex, based on characteristics of the primary tumor, detection of lymph node metastases, and detection of distant metastases. Imaging tests that assist in the determination of tumor stage include computed tomographic scans and positron emission tomographic (PET) scans. PET scans are more sensitive and specific than computed tomography. PET is also helpful in screening for distant metastases. Mediastinoscopy is required in most cases of mediastinal adenopathy. Patient suitability is assessed by predicting short-term surgical mortality, and the likelihood of crippling long-term respiratory failure. There is no single test that provides such information. Pulmonary function tests can be used to calculate the "predicted postoperative" function, and several algorithmic approaches have been devised to predict surgical risk. Assessments of regional pulmonary function are obtained with quantitative perfusion scintiscans. Cardiac function is also an important factor.

Dobutamine stress echocardiography for the preoperative evaluation of patients undergoing lung volume reduction surgery

BACKGROUND

Lung volume reduction surgery has been proposed as a bridge to lung transplantation and as definitive therapy for advanced chronic obstructive lung disease. However, patient selection criteria and optimal preoperative assessment have not been clearly defined.

OBJECTIVE

We investigated the feasibility, safety, and value of dobutamine stress echocardiography as a predictor of major early cardiac events in patients who underwent lung volume reduction surgery.

METHODS

The study population consisted of 46 patients (21 men and 25 women, mean age 59 +/- 9 years) who underwent dobutamine stress echocardiography (maximum dose 40 microg. kg(-1). min(-1) plus atropine if needed) 180 days or less before lung volume reduction surgery. Adverse cardiac events were prospectively defined and tabulated during hospitalization after the operation and at subsequent outpatient visits.

RESULTS

Dobutamine stress echocardiography was interpretable in 45 of 46 (98%) patients. There were no adverse events during testing. The studies revealed normal left ventricular systolic function at rest in all patients and normal right ventricular function in all patients but one. Thirteen patients had right ventricular enlargement. Estimated right ventricular systolic pressure was mildly elevated (>40 mm Hg) in 5 patients. Four patients (9%) had stress tests positive for ischemia. There were no perioperative deaths. Follow-up was available for 44 of 45 patients at a duration of 20.0 +/- 7.0 months. Two major adverse cardiac events occurred in the same patient in whom the results of dobutamine stress echocardiography were positive for ischemia (positive predictive value 25%, 95% confidence interval 0% to 83%; negative predictive value 100%, 95% confidence interval 90 to 100%).

CONCLUSION

Despite end-stage chronic obstructive lung disease and poor ultrasound windows, dobutamine stress echocardiography is feasible and safe in patients undergoing evaluation for lung volume reduction surgery. It yields important information on right and left ventricular function and has an excellent negative predictive value for early and late adverse cardiac events.

Heart-lung transplantation for primary pulmonary hypertension

BACKGROUND

The operation of choice for primary pulmonary hypertension remains controversial, as heart-lung transplantation, single-lung transplantation, and double-lung transplantation have all been advocated.

METHODS

We reviewed our institution's experience with heart-lung transplantation for primary pulmonary hypertension.

RESULTS

Thirty-nine patients had heart-lung transplantation for primary pulmonary hypertension. Operative mortality rate was 18%, and actuarial survival was 72% at 1 year, 67% at 2 years, and 42% at 5 years. Freedom from obliterative bronchiolitis was 91% at 1 year, 83% at 2 years, and 70% at 5 years. Freedom from obliterative bronchiolitis-related death was 100% at 1 year, 90% at 2 years, and 87% at 5 years. Freedom from accelerated graft coronary disease was 92% at 5 years. The most frequent causes of death were infection, obliterative bronchiolitis, and accelerated graft coronary disease.

CONCLUSIONS

Heart-lung transplantation results in survival comparable to that reported for single or double lung transplantation. Obliterative bronchiolitis is a significant cause of late death but seems to occur less frequently with heart-lung transplantation than with lung transplantation alone. Accelerated coronary graft disease is rare in the first 5 years after transplantation.

Preoperative echocardiographic evaluation of patients referred for lung volume reduction surgery

BACKGROUND

The most efficient preoperative assessment for lung volume reduction surgery (LVRS) in patients with advanced emphysema is undefined. This study analyzed the preoperative assessment of patients by surface echocardiography (without and with dobutamine infusion), the results of which were used to exclude patients with significant pre-existing cardiac disease, a contraindication to LVRS, from the surgery.

SETTING

A university-based, tertiary care referral center.

METHODS

Patients with emphysema who met initial LVRS screening criteria underwent resting and stress surface echocardiography with Doppler imaging. Patients were evaluated prospectively for perioperative cardiac complications.

RESULTS

Between July 1994 and December 1996, 503 candidates for LVRS were evaluated. Of these, 207 patients (81.8%) who had echocardiography performed at our institution formed the primary study group. Images were adequate for the analysis of chamber sizes and function in 206 patients (99.5%) undergoing resting echocardiography, and the images were adequate for wall motion analysis in 172 of 174 patients (98.9%) undergoing functional testing. Right heart abnormalities were common (40.1%). Significant pulmonary hypertension (> 35 mm Hg) was uncommon (5 patients, 5.4%) among the 92 patients who subsequently underwent right heart catheterization. Occult ischemia, left ventricular dysfunction, and valvular abnormalities also were uncommon. Thus, although Doppler imaging estimates of right ventricular systolic pressure were imperfect, echocardiographic findings of normal right heart anatomy and function excluded significant pulmonary hypertension. Ninety patients (43%) eventually underwent LVRS (70 bilateral and 20 unilateral). A total of 13 perioperative cardiac events occurred in 10 patients, 6 of whom had undergone preoperative echocardiography. No patient suffered acute myocardial infarction or cardiac death.

CONCLUSIONS

Despite potential limitations due to severe obstructive lung disease, surface echocardiographic imaging is a feasible, noninvasive tool in this patient population to identify patients with evidence of cor pulmonale that suggests pulmonary hypertension. The routine use of surface resting and stress echocardiography for preoperative screening obviates the need for invasive right heart catheterization in many patients and results in a low incidence of significant perioperative cardiac complications.

Combined lung volume reduction and mitral valve reconstruction

Combined lung volume reduction and mitral valve reconstruction was performed in a 66-year-old man with end-stage emphysema and severe mitral regurgitation. Quality of life, pulmonary function, 6-minute walk, echocardiographic degree of mitral regurgitation, and New York Heart Association heart failure classification all improved substantially. A lung volume reduction operation can safely be combined with complex cardiac operations for patients with disabling dyspnea of a multifactorial nature.

Idiopathic pulmonary fibrosis: predicting response to therapy and survival

Idiopathic pulmonary fibrosis (IPF) is associated with significant morbidity and mortality despite aggressive therapy. Thirty-eight patients with biopsy-proven IPF were studied to identify pretreatment features that could be used to predict short-term improvement in pulmonary function and improved longer term survival. In all patients, a pretreatment clinical (dyspnea), radiographic (chest radiograph), and physiologic (pulmonary function including exercise saturation) score was generated (CRP). A high-resolution CT scan (HRCT) was independently scored by four radiologists for ground glass (CT-alv) and linear opacity (CT-fib) on a scale of 0-4. Open lung biopsy samples were scored for cellular infiltration, interstitial fibrosis, desquamation, and granulation by an experienced pulmonary pathologist. All patients were treated with 3 mo of high-dose steroids and the CRP scoring repeated. Patients were divided into three groups: responders with a greater than 10-point drop in CRP (n = 10); stable with +/- 10 point change in CRP (n = 14); and nonresponders with > 10 point rise in CRP or death (n = 14). Those responding to steroids were treated for 18 mo in a tapering fashion. In all others, steroids were tapered quickly and oral cyclophosphamide prescribed. Responders (10 of 38) had a lower age (45.1+/-4.3 yr) than nonresponders (61.4+/-3.5 yr) or those remaining stable (53.1+/-3.3 yr) (p = 0.01). Pretreatment CRP was higher in responders (58.8+/-5.6) than nonresponders (40.5+/-4.7) or stable individuals (37.6+/-4.7) (p = 0.01). Cellular infiltration score of the open lung biopsies was higher in responders (7.6+/-0.6) than stable individuals (5.7+/-0.5) (p = 0.04). The CT-alv scores were higher and CT-fib scores were lower in responders than nonresponders. Receiver operating curve (ROC) analysis was employed to identify pretreatment features of longer term survival (follow-up of 29.1+/-2.3 mo). Only CT-fib (p = 0.009) and pathology fibrosis score (p = 0.03) were able to predict mortality. A pretreatment CT-fib score > or = 2.0 demonstrated 80% sensitivity and 85% specificity in predicting survival. Those patients who did not respond to initial steroid therapy demonstrated a worse long-term survival and greater likelihood of decreased pulmonary function. We demonstrate that pretherapy pulmonary function, pathologic and radiographic parameters are different in individuals who respond to initial prednisone therapy. Only HRCT imaging and pathologic fibrosis were able to reliably predict long-term survival in patients with biopsy-proven IPF.

Functional outcome after surgical treatment of esophageal perforation

BACKGROUND

The functional results after treatment of intrathoracic esophageal perforations have been poorly documented.

METHODS

A retrospective review of 42 patients who underwent treatment of intrathoracic esophageal perforation associated with benign esophageal disease was performed.

RESULTS

Of 42 patients treated for esophageal perforation, 25 underwent primary repair, 15 underwent esophagectomy and reconstruction, 1 underwent cervical esophagostomy and drainage followed by esophageal resection, and 1 had drainage alone followed by primary repair. Among the patients treated with primary repair, at least one additional operation was required in 13 patients. Of the 15 patients treated with esophagectomy and reconstruction, none required further operative treatment. Follow-up averaged 3.7 years, and of the 36 survivors available for follow-up, 18 (50%) required at least one esophageal dilation postoperatively, and 3 (8.3%) have required regular dilations. Subjectively, 19 of 36 patients (53%) indicate that their swallowing is better than before perforation, it was the same in 12 (33%), and worse in 4 (11%).

CONCLUSIONS

In conclusion, approximately one third of patients surviving primary repair of esophageal perforations have continued difficulty with swallowing, which often requires esophageal dilations or esophageal reconstructive procedures, or a combination of both. Optimal long-term results are achieved when primary repair is performed in patients with motor disorders or a "normal" esophagus. Esophagectomy is a better option in those patients with strictures or diffuse esophageal disease.

Mycophenolate mofetil for obliterative bronchiolitis syndrome after lung transplantation

BACKGROUND

The development of obliterative bronchiolitis after lung transplantation portends a poor long-term outcome because of progressive decline in allograft function. There are currently no effective means of treating this condition.

METHODS

Thirteen patients in whom obliterative bronchiolitis syndrome developed after lung transplantation were treated with mycophenolate mofetil, an antimetabolite immunosuppressant, at a dose of 1.5 g orally twice daily. Patients were followed up clinically and with pulmonary function testing.

RESULTS

Duration of mycophenolate mofetil therapy ranged from 1 week to 24 months (mean duration, 11.4 months). Pulmonary function test results stabilized in the majority of patients with no significant further decline in forced expiratory volume in 1 second. Two patients died of progressive obliterative bronchiolitis, 1 patient is alive with progressive disease, and 1 patient died of an acute infection. The drug was discontinued in 2 additional patients. In no patient did severe leukopenia or cytomegalovirus infection develop; 1 patient had a fungal infection, and 7 patients experienced gastrointestinal side effects.

CONCLUSIONS

In the setting of obliterative bronchiolitis syndrome, mycophenolate mofetil is generally well tolerated and is associated with stabilization of pulmonary function test results. These findings suggest that the otherwise progressive process of obliterative bronchiolitis can be slowed.

Thin-section CT obtained at 10-mm increments versus limited three-level thin-section CT for idiopathic pulmonary fibrosis: correlation with pathologic scoring

OBJECTIVE

The purpose of our study was to determine if three-level thin-section CT depicts idiopathic pulmonary fibrosis (IPF) pathology as accurately as CT obtained at 10-mm increments throughout the entire lungs.

SUBJECTS AND METHODS

Thin-section (1.0- to 1.5-mm) images at 10-mm increments were obtained and scored prospectively in 25 consecutive patients with newly diagnosed IPF who were participating in a Special Center of Research grant for interstitial lung disease. Each patient's lobe was scored by four thoracic radiologists on a scale of 0-5 for both ground-glass attenuation and fibrosis. The radiologists used three images (limited CT) and also used the entire data set (complete CT). CT scores were compared with pathology scores from 67 open and thoracoscopic biopsies. Limited and complete scores were compared with each other (Pearson correlation coefficient). Interobserver variation in the CT scoring system was assessed using kappa values.

RESULTS

CT fibrosis scores strongly correlated with pathology fibrosis scores for complete (r = .53, p = .0001) and limited (r = .50, p = .0001) CT. CT ground-glass scores correlated with the histologic inflammatory scores for each lobe on complete (r = .27, p = .03) and limited (r = .26, p = .03) CT. The desquamative subcomponent of the pathology inflammatory score had the highest correlation with the CT ground-glass scores (complete: r = .29, p = .01; limited: r = .33, p = .007). Good interobserver agreement existed for both the alveolar and fibrosis components of the CT scoring system (kappa values ranging from .51 to .83) for each lobe of the lung on limited and complete CT.

CONCLUSION

Limited thin-section CT reveals the pathologic changes associated with IPF as well as CT obtained at 10-mm increments. An added advantage of limited thin-section CT is that it exposes patients to less radiation.

The CXC chemokines, IL-8 and IP-10, regulate angiogenic activity in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic and often fatal disorder. Fibroplasia and deposition of extracellular matrix are dependent, in part, on angiogenesis. We postulated that an imbalance exists in the expression of angiogenic (IL-8) vs angiostatic (IFN-gamma-inducible protein (IP-10)) CXC chemokines, which favors net angiogenesis in IPF. To test this hypothesis, we obtained open lung biopsies either from normal patients undergoing thoracic surgery for reasons other than interstitial lung disease (control) or from patients with IPF. We found that levels of IL-8 were greater from tissue specimens of IPF patients then from those of controls. In contrast, IP-10 levels were higher from tissue specimens obtained from control subjects than from those from IPF patients. When IL-8 or IP-10 was depleted from IPF tissue specimens, tissue-derived angiogenic activity was markedly reduced or enhanced, respectively. Immunolocalization of IL-8 demonstrated that the pulmonary fibroblast (PF) of IPF lung was the predominant cellular source of IL-8. Isolated PF from IPF patients constitutively produced more IL-8 and less IP-10 than control PF. Conditioned media from IPF-PFs demonstrated constitutive angiogenic activity that was attributable, in part, to IL-8. Depletion of IP-10 from IPF-PF CM resulted in an increase in corneal neovascularization. These findings support the notion that IL-8 and IP-10 are important factors that regulate angiogenic activity in IPF.

The CXC chemokines, IL-8 and IP-10, regulate angiogenic activity in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic and often fatal disorder. Fibroplasia and deposition of extracellular matrix are dependent, in part, on angiogenesis. We postulated that an imbalance exists in the expression of angiogenic (IL-8) vs angiostatic (IFN-gamma-inducible protein (IP-10)) CXC chemokines, which favors net angiogenesis in IPF. To test this hypothesis, we obtained open lung biopsies either from normal patients undergoing thoracic surgery for reasons other than interstitial lung disease (control) or from patients with IPF. We found that levels of IL-8 were greater from tissue specimens of IPF patients then from those of controls. In contrast, IP-10 levels were higher from tissue specimens obtained from control subjects than from those from IPF patients. When IL-8 or IP-10 was depleted from IPF tissue specimens, tissue-derived angiogenic activity was markedly reduced or enhanced, respectively. Immunolocalization of IL-8 demonstrated that the pulmonary fibroblast (PF) of IPF lung was the predominant cellular source of IL-8. Isolated PF from IPF patients constitutively produced more IL-8 and less IP-10 than control PF. Conditioned media from IPF-PFs demonstrated constitutive angiogenic activity that was attributable, in part, to IL-8. Depletion of IP-10 from IPF-PF CM resulted in an increase in corneal neovascularization. These findings support the notion that IL-8 and IP-10 are important factors that regulate angiogenic activity in IPF.

Pulmonary smooth muscle proliferation occurring after lung transplantation

We report the first example of smooth-muscle proliferations occurring in an allograft lung implanted in a recipient who had end-stage emphysema. Smooth-muscle proliferations were detected 46 months following transplantation in a 53-year-old woman. The lesions involved the airways and were bronchoscopically undetectable. Posttransplant smooth-muscle tumors have been described in liver transplant patients and are thought to be due to Epstein-Barr virus. Evidence of virus infection was not found in the current case.

Lung-volume reduction improves dyspnea, dynamic hyperinflation, and respiratory muscle function

Lung-volume reduction surgery (LVRS) improves static lung elastic recoil in selected patients with severe chronic obstructive pulmonary disease (COPD). This explains the increase in FEV1 in many COPD patients who undergo LVRS, but fails to explain clinical improvement in those without changes in FEV1. We prospectively evaluated 17 patients after pulmonary rehabilitation but prior to and again at least 3 mo after bilateral LVRS done via median sternotomy. In addition to pulmonary function, lung elastic recoil, walking distance, and exercise capacity, we evaluated static and dynamic respiratory muscle (RM) function, and dyspnea. In 12 patients we also quantified dynamic hyperinflation (end-expiratory and end-inspiratory lung volume [EELV and EILV, respectively]). After LVRS, FEV1 rose from 26.7 +/- 1.8 to 39.0 +/- 3.7% predicted (p < 0.004), whereas TLC dropped from 134.7 +/- 4.8 to 118.3 +/- 4.4% predicted (p < 0.0002), and RV from 239.6 +/- 14.8 to 180.3 +/- 8.7% predicted (p < 0.0002). Isowork dyspnea decreased as assessed with a visual analogue scale (VAS) (79.6 +/- 5.2 versus 49.3 +/- 7.5 mm, p < 0.005) and the Borg scale (7.1 +/- 0.6 versus 3.5 +/- 0.6, p = 0.002). Walking distance improved significantly and, in the 12 patients in whom they were measured, EELV and EILV decreased at rest and at isowork. Maximal transdiaphragmatic pressure rose from 67.1 +/- 8.3 to 92.0 +/- 7.5 cm H2O (p < 0.03). Resting RM function changed little, but at isowork improved significantly after LVRS. Excluding one outlier, there was a strong linear correlation between the change in Borg-scale score at equivalent work loads before and after LVRS and the change in EELV (% predicted TLC, r = 0.75, p < 0.001), as well as between the change in Borg-scale score and the absolute decrease in end-expiratory pleural pressure (Ppl(e)) (r = 0.78, p = 0.004). Successful LVRS improves not only lung recoil, but also respiratory muscle function, and reduces dynamic hyperinflation. These changes help explain the decreased dyspnea and improved exercise capacity seen after LVRS, and add to current understanding of the mechanisms by which this procedure may help selected patients with severe emphysema.

Bronchoalveolar lavage neutrophilia is associated with obliterative bronchiolitis after lung transplantation: role of IL-8

Obliterative bronchiolitis (OB) is a devastating complication in lung transplantation. We postulated that the pathogenesis of OB is mediated, in part, by neutrophils. We serially collected bronchoalveolar lavage (BAL) fluid from lung transplant recipients. Patients were divided into two groups depending on the presence or absence of OB. Samples from patients who never developed OB were further divided according to whether rejection was present. These samples were labeled healthy or rejection. Samples from patients who developed OB were divided according to whether the sample was obtained before (future OB) or at the time of diagnosis of OB (OB). The OB group, as compared with the healthy and rejection group, had significantly elevated neutrophil counts (3.9 x 10(5) +/- 1.8 x 10(5) vs 0.3 x 10(5) +/- 0.07 x 10(5) and 0.4 x 10(5) +/- 0.1 x 10(5), respectively, p < 0.01 for both) and levels of IL-8 (3131 +/- 1468 pg/ml vs 240 +/- 62 pg/ml and 172 +/- 47 pg/ml, p < 0.01 for both). Furthermore, we demonstrated immunolocalization of IL-8 associated with alpha smooth muscle actin-positive cells in the peribronchial region of OB. To confirm that the IL-8 present in BAL fluid from patients with OB was bioactive, we performed neutrophil chemotaxis experiments that showed that IL-8 accounted for a significant amount of the neutrophil chemotactic activity. We also found a trend toward higher levels of neutrophils and IL-8 in BALs from the future OB as compared with the healthy group (7.1 x 10(4) +/- 4.2 x 10(4) vs 3.4 x 10(4) +/- 0.7 x 10(4) and 500 +/- 306 pg/ml vs 240 +/- 62 pg/ml). In conclusion, we have provided the novel observation that in lung transplant recipients with OB, neutrophilia is present and highly correlated with the presence of IL-8.

Detection of Barrett's adenocarcinoma of the gastric cardia with sucrase isomaltase and p53

BACKGROUND

Routine surveillance for dysplastic epithelium in patients with Barrett's esophagus has markedly improved prognosis. Many patients with short segments of Barrett's mucosa near the esophagogastric junction remain undiagnosed and at risk for the development of Barrett's adenocarcinomas (BA). Sucrase isomaltase (SI), an intestinal enzyme, is highly expressed in intestinal-type Barrett's mucosa and frequently expressed in dysplastic Barrett's mucosa and BA. Sucrose isomaltase is not expressed in normal esophageal or gastric mucosa. Alterations in the p53 tumor suppressor gene are frequent events in dysplastic Barrett's mucosa and BA and result in nuclear protein accumulation. The purpose of this study was to determine the presence or absence of these markers of Barrett's mucosa in adenocarcinoma of the esophagogastric junction or cardia.

METHODS

Expression of SI and p53 were examined in 40 BAs and 25 cardia adenocarcinomas using immunohistochemical techniques.

RESULTS

Sucrose isomaltase analysis revealed positive staining in 55% (22/40) of the BAs and 44% (11/25) of the cardia adenocarcinomas. Of 14 cardia adenocarcinomas that were SI negative, 100% (14/14) had no associated Barrett's mucosa. However, in 21 cardia adenocarcinomas with no associated Barrett's mucosa, 7/21 (33%) were SI positive. This suggests that SI-positive tumors may represent BA without the standard definition of Barrett's esophagus being met. P53 was present in 65% of BAs and 64% of cardia adenocarcinomas, demonstrating the importance and similarity of this gene alteration in both tumor types. Staining was positive for SI or p53 in 77% (50/65) of all tumors. Tumors of lower stage expressed SI more often than higher stage tumors.

CONCLUSIONS

These data suggest that a subset of cardia adenocarcinomas represent BAs. Surveillance endoscopy incorporating additional esophagogastric junction biopsies and assessment of SI or p53 may improve detection of intestinalized Barrett's mucosa and early dysplastic changes.

Bronchoalveolar lavage neutrophilia is associated with obliterative bronchiolitis after lung transplantation: role of IL-8

Obliterative bronchiolitis (OB) is a devastating complication in lung transplantation. We postulated that the pathogenesis of OB is mediated, in part, by neutrophils. We serially collected bronchoalveolar lavage (BAL) fluid from lung transplant recipients. Patients were divided into two groups depending on the presence or absence of OB. Samples from patients who never developed OB were further divided according to whether rejection was present. These samples were labeled healthy or rejection. Samples from patients who developed OB were divided according to whether the sample was obtained before (future OB) or at the time of diagnosis of OB (OB). The OB group, as compared with the healthy and rejection group, had significantly elevated neutrophil counts (3.9 x 10(5) +/- 1.8 x 10(5) vs 0.3 x 10(5) +/- 0.07 x 10(5) and 0.4 x 10(5) +/- 0.1 x 10(5), respectively, p &lt; 0.01 for both) and levels of IL-8 (3131 +/- 1468 pg/ml vs 240 +/- 62 pg/ml and 172 +/- 47 pg/ml, p &lt; 0.01 for both). Furthermore, we demonstrated immunolocalization of IL-8 associated with alpha smooth muscle actin-positive cells in the peribronchial region of OB. To confirm that the IL-8 present in BAL fluid from patients with OB was bioactive, we performed neutrophil chemotaxis experiments that showed that IL-8 accounted for a significant amount of the neutrophil chemotactic activity. We also found a trend toward higher levels of neutrophils and IL-8 in BALs from the future OB as compared with the healthy group (7.1 x 10(4) +/- 4.2 x 10(4) vs 3.4 x 10(4) +/- 0.7 x 10(4) and 500 +/- 306 pg/ml vs 240 +/- 62 pg/ml). In conclusion, we have provided the novel observation that in lung transplant recipients with OB, neutrophilia is present and highly correlated with the presence of IL-8.

Interferon-gamma-inducible protein 10 (IP-10) is an angiostatic factor that inhibits human non-small cell lung cancer (NSCLC) tumorigenesis and spontaneous metastases

The success of solid tumor growth and metastasis is dependent upon angiogenesis. Neovascularization within the tumor is regulated, in part, by a dual and opposing system of angiogenic and angiostatic factors. We now report that IP-10, a recently described angiostatic factor, as a potent angiostatic factor that regulates non-small cell lung cancer (NSCLC)-derived angiogenesis, tumor growth, and spontaneous metastasis. We initially found significantly elevated levels of IP-10 in freshly isolated human NSCLC samples of squamous cell carcinoma (SCCA). In contrast, levels of IP-10 were equivalent in either normal lung tissue or adenocarcinoma specimens. The neoplastic cells in specimens of SCCA were the predominant cells that appeared to express IP-10 by immunolocalization. Neutralization of IP-10 in SCCA tumor specimens resulted in enhanced tumor-derived angiogenic activity. Using a model of human NSCLC tumorigenesis in SCID mice, we found that NSCLC tumor growth was inversely correlated with levels of plasma or tumor-associated IP-10. IP-10 in vitro functioned as neither an autocrine growth factor nor as an inhibitor of proliferation of the NSCLC cell lines. Reconstitution of intratumor IP-10 for a period of 8 wk resulted in a significant inhibition of tumor growth, tumor-associated angiogenic activity and neovascularization, and spontaneous lung metastases, whereas, neutralization of IP-10 for 10 wk augmented tumor growth. These findings support the notion that tumor-derived IP-10 is an important endogenous angiostatic factor in NSCLC.

Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma

BACKGROUND

It is important to diagnose distant metastases disease in patients with newly diagnosed esophageal carcinoma, so that unwarranted surgery and its attendant risks are avoided. The purpose of this study was to determine (1) the percentage of esophageal cancer patients with distant metastases (M1) at presentation, (2) the locations of these distant metastases, and (3) how the metastases were diagnosed.

METHODS

All patients at the University of Michigan Medical Center with newly diagnosed esophageal cancer between 1982 and July, 1993, were identified. Records for these 838 patients were reviewed, and patients were classified as having M0 or M1 disease at presentation. For patients with M1 disease, the locations of distant metastases and the methods of diagnosis were recorded.

RESULTS

One hundred forty-seven of 838 (18%) patients had M1 disease. In 110 of 147 (75%) patients, M1 disease was detected before surgery via imaging or physical examination, including 102 of 147 (69%) via chest or abdominal computed tomography (CT). In no case staged as M0 by abdominal and chest CT was M1 disease detected on bone scan or head CT. Distant metastases were most commonly diagnosed in abdominal lymph nodes (45%), followed by liver (35%), lung (20%), cervical/supraclavicular lymph nodes (18%), bone (9%), adrenal (5%), peritoneum (2%), brain (2%), and stomach, pancreas, pleura, skin/body wall, pericardium, and spleen (each 1%).

CONCLUSION

A significant percentage of patients with esophageal cancer have M1 disease at presentation. Imaging of the chest and abdomen is an effective method of screening such patients for M1 disease before treatment.

Distribution of distant metastases from newly diagnosed non-small cell lung cancer

BACKGROUND

The purpose of our study was to determine the incidence and locations of M1 disease at presentation in patients with non-small cell lung cancer to help design appropriate preoperative imaging algorithms.

METHODS

All patients with non-small cell lung cancer seen between 1991 and 1993 were identified, and records were reviewed. For patients with M1 disease, the sites of distant metastases and the methods of diagnosis were recorded.

RESULTS

Of 348 patients identified, 276 (79%) had M0 disease and 72 (21%) had M1 disease. In 40 of 72 patients (56%), M1 disease was detected via chest or abdominal computed tomography (CT). Brain, bone, liver, and adrenal glands were the most common sites of metastatic disease, in decreasing order. Brain metastases often occurred as an isolated finding, although isolated liver metastases were uncommon.

CONCLUSIONS

M1 disease was common at presentation, and was often detectable via chest CT. The incremental yield of abdominal CT over chest CT was very small, and therefore abdominal CT is not an effective method of screening for metastases if chest CT has been performed.

Lung mechanics and dyspnea after lung transplantation for chronic airflow obstruction

Single lung transplantation (SLT) is widely used to treat chronic airflow obstruction (CAO). During exercise the native lung should increase end-expiratory lung volume (EELV) and result in a different respiratory sensation compared with double lung transplantation (DLT). Eight SLT recipients and 12 DLT recipients demonstrated a similar maximal work load and achieved VO2. VEmax/MVV was 67.2 +/- 4.0% in SLT recipients and 48.5 +/- 3.6% in DLT recipients (p = 0.003). All SLT recipients demonstrated an increase in EELV during exercise, which was seen in only three of 12 DLT recipients. The change in absolute EELV from rest to peak exercise was different between SLT recipients (+0.37 +/- 0.10 L) and DLT recipients (-0.10 +/- 0.06, p = 0.0002). Tidal flow volume loop analysis demonstrated encroachment of the expiratory limb in four of seven SLT patients but in only one of 12 DLT recipients. A lesser peak breathlessness in DLT recipients approached statistical significance (p = 0.051), although the relation of respiratory sensation versus VE or VO2% predicted did not differ between the two groups. EELV increases in SLT recipients at peak exercise, although overall aerobic response is preserved and respiratory sensation is similar.

Restricted V beta usage by T cells infiltrating rejecting human lung allografts

TCR expression was evaluated in lung transplant patients to determine whether T cells infiltrating rejecting lung allografts employed restricted V beta elements. Serial bronchoalveolar lavage (BAL) specimens were obtained from six lung transplant recipients at approximately 3 wk, 6 wk, and 3 mo post-transplant. T cell lines were established by culturing lavage cells with irradiated donor splenocytes in the presence of low dose IL-2 for 3 wk, and TCR V beta usage was determined by quantitative reverse transcriptase-PCR. Patients were grouped into three categories based on TCR V beta profiles and the clinical status of the allograft. 1) In one patient, BAL-derived T cells expressed heterogeneous V beta repertoires at all time points evaluated. This patient did not experience graft rejection during the 16-mo period of observation, though respiratory infections were diagnosed. 2) In three patients, V beta usage by BAL-derived T cells was restricted during allograft rejection episodes, but was heterogeneous in the absence of rejection and during respiratory infections. In one of these patients, similar V beta repertoires were employed by BAL cells during multiple rejection episodes. 3) In two patients, restricted V beta usage by BAL-derived T cells was observed before and during rejection episodes. Collectively, these data illustrate that human lung allograft rejection, but not pulmonary infection, is associated with T cells expressing a limited number of V beta families. Restricted V beta usage by graft-reactive T cells may allow for the selective elimination of these cells using TCR-specific reagents, thereby promoting allograft-specific tolerance.

Restricted V beta usage by T cells infiltrating rejecting human lung allografts

TCR expression was evaluated in lung transplant patients to determine whether T cells infiltrating rejecting lung allografts employed restricted V beta elements. Serial bronchoalveolar lavage (BAL) specimens were obtained from six lung transplant recipients at approximately 3 wk, 6 wk, and 3 mo post-transplant. T cell lines were established by culturing lavage cells with irradiated donor splenocytes in the presence of low dose IL-2 for 3 wk, and TCR V beta usage was determined by quantitative reverse transcriptase-PCR. Patients were grouped into three categories based on TCR V beta profiles and the clinical status of the allograft. 1) In one patient, BAL-derived T cells expressed heterogeneous V beta repertoires at all time points evaluated. This patient did not experience graft rejection during the 16-mo period of observation, though respiratory infections were diagnosed. 2) In three patients, V beta usage by BAL-derived T cells was restricted during allograft rejection episodes, but was heterogeneous in the absence of rejection and during respiratory infections. In one of these patients, similar V beta repertoires were employed by BAL cells during multiple rejection episodes. 3) In two patients, restricted V beta usage by BAL-derived T cells was observed before and during rejection episodes. Collectively, these data illustrate that human lung allograft rejection, but not pulmonary infection, is associated with T cells expressing a limited number of V beta families. Restricted V beta usage by graft-reactive T cells may allow for the selective elimination of these cells using TCR-specific reagents, thereby promoting allograft-specific tolerance.

Endobronchial ultrasound-guided needle aspiration of mediastinal adenopathy

We conducted a randomized, controlled trial to prospectively confirm that ultrasound-directed transbronchial needle aspiration (USTBNA) results in: (1) improved sensitivity for detecting lymph nodes involved with neoplasm, and (2) a decreased number of aspirates needed to achieve a diagnosis as compared with standard transbronchial needle aspiration (TBNA). The study was conducted in a tertiary medical center on patients undergoing fiberoptic bronchoscopy in the evaluation of enlarged mediastinal lymph nodes. USTBNA or TBNA were followed by rapid, on-site cytopathology examination of the collected specimens. Measurements included the (1) age and sex of the patient, prior diagnosis of cancer, nodal short-axis diameter and node location as determined by computerized tomography (CT), and endobronchial abnormalities at bronchoscopy; (2) number, order, and location of transbronchial aspirates and results of on-site evaluation; (3) results of surgical exploration in patients with negative transbronchial needle aspiration; (4) sensitivity, specificity, and diagnostic accuracy of USTBNA and TBNA; (5) number of aspirates required for successful lymph node aspiration as well as for a diagnosis of cancer for both USTBNA and TBNA; and (6) multiple logistic regression analysis to determine the significance of combinations of clinical predictors and needle aspirate results. Eighty-two bronchoscopic examinations were performed on 80 patients. We found no significant difference between USTBNA and TBNA in sensitivity (82.6% versus 90.5%, respectively), specificity (100% for both), or diagnostic accuracy (86.7% versus 91.7%, respectively). The sensitivity, specificity, and diagnostic accuracy of USTBNA and TBNA were similarly high, regardless of node location (paratracheal or subcarinal). A decrease in the number of aspirates required for lymph node sampling approached statistical significance for all USTBNAs as compared with TBNAs (2.03 +/- 0.19 versus 2.62 +/- 0.25, p = 0.06), but this was not demonstrated for the number required to confirm cancer (1.95 +/- 0.47 versus 2.68 +/- 0.21, p = 0.17). The number of aspirates to successful lymph node aspiration decreased with USTBNA versus TBNA in paratracheal lymph nodes (2.00 +/- 0.20 versus 2.91 +/- 0.34, p = 0.03), but not to a diagnosis of cancer (1.93 +/- 0.25 versus 3.00 +/- 0.58, p = 0.11). No difference was seen in the number of aspirates for subcarinal nodes. The number of TBNA attempts for paratracheal lymph node sampling was inversely correlated with node size (r = 0.48, p = 0.02). No such relation was seen with USTBNA of paratracheal nodes (r = 0.09, p = 0.66), TBNA of subcarinal nodes, or USTBNA of subcarinal nodes. A similar relation was seen between the number of aspirates to a diagnosis of cancer. On multiple logistic regression analysis, a positive transbronchial aspirate was associated only with a larger lymph node and history of prior cancer. We conclude that: (1) in the setting of on-site cytopathology, transbronchial needle aspiration has a high sensitivity, specificity, and diagnostic accuracy in the evaluation of enlarged mediastinal lymph nodes suspected of harboring malignancy; (2) mediastinal anatomy, including vascular structures and lymph nodes, is clearly imaged with endobronchial ultrasonography; (3) a greater short-axis diameter of the mediastinal lymph node and history of a prior malignancy increase the likelihood of a positive transbronchial aspiration; (4) USTBNA exhibits a similarly high diagnostic yield to TBNA in the setting of rapid on-site cytopathology evaluation; (5) USTBNA decreases the number of aspirates required for paratracheal lymph node sampling, which may be particularly useful in sampling smaller paratracheal nodes or at institutions that do not utilize rapid on-site cytopathology evaluation.

Transthoracic needle aspiration in patients with severe emphysema. A study of lung transplant candidates

PURPOSE

To describe the risks of transthoracic needle aspiration (TTNA) in a population of patients with severe lung disease: candidates for lung transplantation.

MATERIALS AND METHODS

Eight of 190 patients evaluated for lung transplantation underwent TTNA of nine pulmonary nodules (mean diameter, 14 mm; range, 0.8 to 2.2 cm). We evaluated pneumothorax rate, chest tube rate, duration of placement, and pulmonary function test results.

RESULTS

All patients had emphysema; two had alpha 1-antitrypsin deficiency. The mean FEV1 of all patients was 0.64 L (22% of predicted; range, 17 to 28%), indicating severe air-flow obstruction. Six patients required a chest tube (50%); three chest tubes were placed emergently on the CT scanner table. Three patients required a second chest tube for persistent air leak. Tubes were in place for 1 to 22 days (mean, 10 days). One patient had chest tubes for 22 days and required intubation.

CONCLUSION

TTNA in patients with marked emphysema is complicated by a high incidence of pneumothorax, rapid development of tension pneumothorax and chest tube placement. Since nodules in lung transplant candidates may represent bronchogenic carcinoma, serial CT scans to demonstrate lesion stability or growth, or thoracoscopic resection should be considered as an alternate approach to TTNA to avoid the significant morbidity of the procedure in these patients.

Influence of sample number and biopsy site on the histologic diagnosis of diffuse lung disease

BACKGROUND

Although open biopsy is considered the optimal method for obtaining lung tissue for the diagnosis of diffuse infiltrative pulmonary disorders, there are no universally established guidelines concerning biopsy site selection and the ideal number of tissue samples. Relatively few investigations have been devoted to the influence exerted by the site and number of biopsy samples on the histologic diagnosis.

METHODS

Seventy-seven open biopsy samples obtained from different lobes of 28 patients with idiopathic pulmonary fibrosis were analyzed. The histopathologic features were evaluated semiquantitatively and the results from each sample compared with those of the other samples obtained from each patient.

RESULTS

Statistically significant differences in histopathologic features were not observed between samples.

CONCLUSIONS

A single generous (2 cm or greater diameter) sample, obtained from a representative region of the radiographically most involved lobe, will suffice for diagnostic and evaluation purposes.

Preoperative examination of lung transplant candidates: value of chest CT compared with chest radiography

OBJECTIVE

The purpose of our study was to determine the usefulness of CT in examining candidates for lung transplantation to detect cancer not visible on plain chest radiographs (a finding that would exclude a patient from transplantation) and to determine which lung is more severely diseased to aid in the decision of which side to transplant.

MATERIALS AND METHODS

We reviewed the chest radiographs and CT scans of 190 transplant candidates during a 3-year period for findings suggestive of neoplasm, including lung nodules and atelectasis; we also reviewed the symmetry of disease. In the latter category, patients with primary pulmonary hypertension, Eisenmenger's complex (pulmonary vascular, not parenchymal, disease), and cystic fibrosis (for which bilateral transplantation is performed) were excluded. A total of 190 plain chest radiographs, 180 thin-section CT scans, and 31 standard CT scans were reviewed retrospectively.

RESULTS

Plain chest radiographs revealed 20 noncalcified nodules; 13 were 8 mm or more in diameter, and 7 were less than 8 mm. CT scans revealed 66 noncalcified nodules; 37 were 8 mm or more in diameter, and 29 were less than 8 mm. Eight non-calcified nodules seen on plain chest radiographs were either absent on CT scans (and follow-up plain chest radiographs) or appeared calcified on CT scans. Solitary nodules in three patients proved to be bronchogenic carcinomas; two of these lesions were identified only on CT scans. CT prompted a change in the determination of which lung was more severely diseased from that made on the basis of plain radiography for 27 of 169 patients (16%) evaluated. Of the 45 patients who subsequently underwent transplantation, CT prompted a change in the determination of which side to transplant from that made on the basis of plain radiography for 4 patients (9%).

CONCLUSION

CT provides additional information to supplement plain radiography in the examination of lung transplant candidates. This information can alter patient management, particularly when bronchogenic carcinoma is detected, and enable a better determination of which lung is more severely diseased to aid in the decision of which lung to transplant for single-lung transplantation.

Catastrophic complications of the cervical esophagogastric anastomosis

Recent enthusiasm for the cervical esophagogastric anastomosis has arisen because of its perceived low morbidity. Although catastrophic complications of a cervical esophagogastric anastomosis are unusual, they can and do occur, and prevention is possible if the potential for them is recognized. Among 856 patients undergoing a cervical esophagogastric anastomosis after transhiatal esophagectomy, catastrophic cervical infectious complications occurred in 11 patients (1.3%): vertebral body osteomyelitis (1), epidural abscess with neurologic impairment (2), pulmonary microabscesses from internal jugular vein abscess (1), tracheoesophagogastric anastomotic fistula (1), and major dehiscence necessitating anastomotic takedown (6). These complications became manifest from 5 to 85 days after the esophageal resection and reconstruction (mean 19 days). Leakage from a gastric suspension stitch placed in the anterior spinal ligament over the vertebral bodies resulted in a posterior gastric leak and either osteomyelitis or an epidural abscess in three patients, none of whom had evidence of extravasation on the routine barium swallow 10 days after operation. Cervical exploration for a presumed anastomotic leak led to the unexpected discovery of an abscess formed by the stomach and the adjacent wall of the internal jugular vein, which was ligated and resected. One patient without symptoms who was discharged from the hospital with a contained anastomotic leak on the postoperative barium swallow was readmitted 7 days later with a cervical tracheoesophagogastric anastomotic fistula of which he ultimately died. In 6 patients (7% of those who had anastomotic leaks) there was sufficient gastric ischemia or necrosis, or both, to necessitate takedown of the anastomosis and intrathoracic stomach, cervical esophagostomy, and insertion of a feeding tube. As a result of this experience, it is recommended that cervical gastric suspension sutures either be omitted entirely or placed in the fascia over the longus colli muscles anterior to the spine, but not directly into the prevertebral fascia overlying the vertebral bodies or cervical disks. All but minute cervical anastomotic leaks, even if apparently contained, are best drained rather than treated expectantly. Patients who remain febrile and ill after bedside drainage of a cervical esophagogastric anastomosis leak should undergo cervical reexploration in the operating room; major gastric ischemia or necrosis, or both, may warrant takedown of the anastomosis and intrathoracic stomach.

Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma

BACKGROUND

It is important to diagnose distant metastases disease in patients with newly diagnosed esophageal carcinoma, so that unwarranted surgery and its attendant risks are avoided. The purpose of this study was to determine (1) the percentage of esophageal cancer patients with distant metastases (M1) at presentation, (2) the locations of these distant metastases, and (3) how the metastases were diagnosed.

METHODS

All patients at the University of Michigan Medical Center with newly diagnosed esophageal cancer between 1982 and July, 1993, were identified. Records for these 838 patients were reviewed, and patients were classified as having M0 or M1 disease at presentation. For patients with M1 disease, the locations of distant metastases and the methods of diagnosis were recorded.

RESULTS

One hundred forty-seven of 838 (18%) patients had M1 disease. In 110 of 147 (75%) patients, M1 disease was detected before surgery via imaging or physical examination, including 102 of 147 (69%) via chest or abdominal computed tomography (CT). In no case staged as M0 by abdominal and chest CT was M1 disease detected on bone scan or head CT. Distant metastases were most commonly diagnosed in abdominal lymph nodes (45%), followed by liver (35%), lung (20%), cervical/supraclavicular lymph nodes (18%), bone (9%), adrenal (5%), peritoneum (2%), brain (2%), and stomach, pancreas, pleura, skin/body wall, pericardium, and spleen (each 1%).

CONCLUSION

A significant percentage of patients with esophageal cancer have M1 disease at presentation. Imaging of the chest and abdomen is an effective method of screening such patients for M1 disease before treatment.

Helical computed tomography for the evaluation of tracheal stenosis

BACKGROUND

Helical computed tomography with multiplanar reconstruction (CT/MPR) was used to study proximal airway stenosis.

METHODS

Twenty-eight helical CT/MPR studies were obtained in 25 patients with known or suspected stenosis of the trachea or main bronchi. Computed tomographic results were compared with planar tomograms and bronchoscopic evaluation of the airway.

RESULTS

CT/MPR accurately demonstrated the site and degree of tracheal and main bronchial stenoses with a sensitivity of 93%, a specificity of 100%, and an accuracy of 94%. There was one false negative study in a patient with tracheomalacia. In a second patient, a tracheal web was only apparent on nonstandard viewing windows.

CONCLUSIONS

CT/MPR provides good anatomic detail and is an increasingly available technique. Potential drawbacks include the need for a longer breath-hold (15 to 45 seconds) and increased complexity of data compared with conventional tomograms. Helical CT/MPR is useful in the preoperative evaluation of these patients and, as experience accumulates, may replace the use of conventional tomograms.

Expression and activation of erbB-2 and epidermal growth factor receptor in lung adenocarcinomas

ErbB-2 and EGFR (epidermal growth factor receptor) are expressed in lung adenocarcinomas and associated with a poor prognosis. Immunocytochemical analysis revealed erbB-2 and EGFR coexperession as a characteristic feature of most lung adenocarcinomas, and at levels of receptor expression present in bronchial epithelial cells. In primary lung tumours and cell lines, erbB-2 detected using Western blot analysis demonstrated low-level phosphotyrosine staining of the 185 kDa band, as compared with breast cancer cell lines. A549 and A427 lung adenocarcinoma cells treated with neu differentiation factor (NDF) showed increased erbB-2 phosphotyrosine staining, but to a much lesser extent than breast cancer cells. The lung cells were examined for expression of the potential autocrine growth factors NDF and transforming growth factor alpha (TGF-alpha) by Northern blot analysis. Both NDF and TFG-alpha mRNA were abundantly expressed in the A549 cells. NDF mRNA was highest during active cell proliferation and decreased in confluent cells or after treatment with the growth-inhibitory steroid dexamethasone. Primary tumours and cell lines expressed EGFR, showing higher basal level phosphotyrosine staining than erbB-2. Treatment with NDF and EGF (epidermal growth factor) stimulated cell growth, and in A549 cells the presence of both factors provided an additive increase in cell growth. The growth stimulus that ligand-activated erbB-2 and EGFR provides to lung adenocarcinoma cells may establish a background of continued cell proliferation over which other critical transforming events may occur.

Stenosis of the central airways: evaluation by using helical CT with multiplanar reconstructions

PURPOSE

To assess the accuracy of helical computed tomography (CT) with multiplanar reconstructions (MPRs) in the evaluation of stenoses of the central airways.

MATERIALS AND METHODS

Thin-section axial CT and helical CT with MPRs were used to examine the central tracheobronchial tree for the presence of stenosis in 27 patients who underwent lung transplantation and 17 nontransplantation patients. The findings from these modalities were then compared with the findings obtained at conventional tomography and bronchoscopy, when available.

RESULTS

Axial CT alone was 91% accurate in depicting stenosis, CT with MPRs was 94% accurate, and conventional tomography was 89% accurate in the evaluation of bronchial anastomosis in transplant recipients. CT and CT scans with MPRs were each 91% accurate in depicting stenosis in nontransplantation patients; the single false-negative finding showed focal tracheomalacia at bronchoscopy.

CONCLUSION

CT with MPRs may be more accurate than thin-section axial CT in the demonstration of mild stenosis, the length of a stenosis, and horizontal webs.

Intrathoracic esophageal perforation. The merit of primary repair

Between 1976 and 1993, 22 patients with intrathoracic esophageal perforations, none associated with carcinoma, underwent primary repair regardless of the interval between perforation and the time of repair. Eighteen perforations were iatrogenic and four were spontaneous. The interval from perforation to operation was less than 12 hours in 10 patients, 12 to 24 hours in 3, and more than 24 hours in 9. Principles of repair included (1) a local esophagomyotomy proximal and distal to the tear to expose the mucosal defect and normal mucosa beyond, (2) debridement of the mucosal defect and closure over a bougie, and (3) reapproximation of the muscle. The repair was buttressed with muscle or pleura in five patients. Associated distal obstruction caused by reflux stricture was treated with dilation and fundoplication in four patients. Of the four patients with achalasia, two underwent esophagomyotomy with a fundoplication and one underwent myotomy alone. There was one death. The esophageal repair healed primarily in 17 patients (80%). Four patients, three of whom underwent repair more than 24 hours after the perforation, had leaks at the site of repair. All four fistulas eventually healed with drainage alone, two with simple tube thoracostomy and two with rib resection and empyema tube placement. In the absence of cancer or an irreversible distal obstruction, meticulous repair of an intrathoracic esophageal perforation is the preferred approach, regardless of the duration of the injury, inasmuch as primary healing is likely, and the morbidity associated with prolonged drainage or diversion may be avoided.

E-cadherin expression in primary and metastatic thoracic neoplasms and in Barrett's oesophagus

Reduced expression of E-cadherin, a Ca(2+)-dependent cell adhesion molecule present in normal epithelium, has been associated with invasive and metastatic cancer. Immunohistochemistry was used in examining the relationship between E-cadherin expression and stage in 59 oesophageal and 52 lung cancers. Advanced-stage oesophageal cancers were associated with both reduced and disorganised E-cadherin expression (P < 0.01). Advanced-stage lung adenocarcinomas generally exhibited disorganised or reduced E-cadherin expression, but no statistical association between expression pattern and stage was found (P > 0.05). No differences in stage were seen between tumours with reduced or disorganised E-cadherin expression. Altered E-cadherin expression was detected in dysplastic, non-invasive Barrett's oesophagus. Importantly, high-level E-cadherin expression was detected in 17 of 17 lymph nodes containing metastatic cancer. E-cadherin mRNA expression was decreased in tumours with reduced protein expression, but not in tumours with disorganised expression. Expression of alpha-catenin mRNA, an E-cadherin-associated protein, was detected in tissues with altered E-cadherin protein expression. Reduced and disorganised expression of E-cadherin appear to be related to transcriptional and post-translational events respectively, and both appear to represent altered cell adhesion associated with invasion and metastasis in thoracic neoplasms.

Extracorporeal life support after heart or lung transplantation

Extracorporeal life support (ECLS) has been used in 10 patients after heart (5 patients), lung (3 patients), and heart-lung (2 patients) transplantation. The age range was 7 months to 55 years. Cardiopulmonary failure leading to institution of ECLS was due to acute postoperative organ malfunction in 4 patients (2 survived), subacute organ malfunction in 3 patients (none survived), and late rejection or infection in 3 patients (2 survived). Neurologic complications occurred in 3 patients (1 survived) and bleeding, in 5 patients (2 survived). Six patients (60%) were successfully weaned from ECLS, and 4 (40%) survived to leave the hospital. Survival was associated with younger age, shorter duration of ECLS, and longer interval from operation to initiation of ECLS but not to reason for initiating ECLS. Extracorporeal life support is feasible for sustaining both adults and children after heart, lung, or heart-lung transplantation. Best results were obtained in patients with conditions that, in retrospect, were treatable and reversible within days. More experience is needed to predict preoperatively which patients will benefit most from ECLS.

Production of interleukin-10 by human bronchogenic carcinoma

Interleukin-10 (IL-10) is a recently characterized cytokine with suppressive activity against various aspects of the cellular immune response. Our laboratory has previously demonstrated that another anti-inflammatory cytokine, IL-1 receptor antagonist (IRAP) is produced and secreted by human bronchogenic carcinomas. We speculated that tumor production of IRAP may mitigate host responses and confer increased tumor viability. In this study, we investigated the capacity of human bronchogenic tumors to produce IL-10 as another possible mechanism to attenuate host defenses. We found increased levels of antigenic IL-10 in tissue homogenates of human bronchogenic carcinomas compared with normal lung tissue (13.69 +/- 2.87 versus 5.84 +/- 0.84 ng/mg total protein). Immunohistochemical staining of tumors illustrate primary localization of antigenic IL-10 to individual tumor cells. Analysis of supernatants of several unstimulated human bronchogenic cell lines in vitro demonstrated the ability of tumor cells to constitutively produce IL-10. Functional studies of mononuclear cells, cultured in the presence of conditioned medium from a bronchogenic cell line, demonstrated their increased tumor necrosis factor and IL-6 production with the addition of neutralizing antibodies to IL-10. These findings demonstrate that human bronchogenic carcinomas elaborate functional IL-10, which may significantly impair immune effector cell function and enable the tumor to evade host defenses.

Selective lung or heart-lung transplantation for pulmonary hypertension associated with congenital cardiac anomalies

Fixed pulmonary hypertension has been a contraindication to correction of congenital heart defects. Beginning in February 1991, we pursued a policy of performing single-lung transplantation with intracardiac repair for selected patients with this physiology, reserving heart-lung transplantation for those with unreconstructable heart disease. Of 7 patients treated under this protocol, 5 underwent single-lung transplantation and intracardiac repair. The cardiac anomalies included complete atrioventricular canal (1), aortopulmonary window (1), atrial septal defect (1), and ventricular septal defect (2). One patient died perioperatively. All 4 patients surviving operation remained alive through the first postoperative year, but 3 died 13, 17, and 22 months after operation. Two other patients with pulmonary hypertension (1 with tricuspid atresia, 1 after failed Mustard procedure) received a heart-lung transplant and are well 15 and 18 months after operation. This experience demonstrates that selected patients with major intracardiac defects and pulmonary hypertension may have good early results after cardiac repair and single-lung transplantation, but that long-term results are considerably less favorable.

Inhibition of interleukin 8 attenuates angiogenesis in bronchogenic carcinoma

We investigated the role of interleukin 8 (IL-8) in mediating angiogenesis in human bronchogenic carcinoma. Increased quantities of IL-8 were detected in tumor tissue as compared with normal lung tissue. Immunohistochemical staining of tumors revealed primary localization of IL-8 to individual tumor cells and demonstrated the capacity of tumor to elaborate IL-8. Functional studies that used tissue homogenates of tumors demonstrated the induction of both in vitro endothelial cell chemotaxis and in vivo corneal neovascularization. It is important to note that the addition of neutralizing antisera to IL-8 to these assays resulted in the marked and specific attenuation of these responses. Our observations definitively establish IL-8 as a primary mediator of angiogenesis in bronchogenic carcinoma and offer a potential target for immunotherapies against solid malignancies.