Designer umbilical cord-stem cells induce alveolar wall regeneration in pulmonary disease models

Background

Researchers are focusing on cellular therapy for chronic obstructive pulmonary disease (COPD) using mesenchymal stem cells (MSCs), with human bone marrow-derived MSCs (hBM-MSCs) leading the way. However, BM-MSCs may not be as optimal as therapeutic cells owing to their low growth potential, invasive harvesting, and high expression of aging-related genes with poor differentiation potential. Consequently, umbilical cord-derived MSCs (hUC-MSCs), which have many excellent features as allogeneic heterologous stem cells, have received considerable attention. Allogeneic and heterologous hUC-MSCs appear to be promising owing to their excellent therapeutic properties. However, MSCs cannot remain in the lungs for long periods after intravenous infusion.

Objective

To develop designer hUC-MSCs (dUC-MSCs), which are novel therapeutic cells with modified cell-adhesion properties, to aid COPD treatment.

Methods

dUC-MSCs were cultured on type-I collagen gels and laminin 411, which are extracellular matrices. Mouse models of elastase-induced COPD were treated with hUC-MSCs. Biochemical analysis of the lungs of treated and control animals was performed.

Results

Increased efficiency of vascular induction was found with dUC-MSCs transplanted into COPD mouse models compared with that observed with transplanted hUC-MSCs cultured on plates. The transplanted dUC-MSCs inhibited apoptosis by downregulating pro-inflammatory cytokine production, enhancing adhesion of the extracellular matrix to alveolar tissue via integrin β1, promoting the polarity of M2 macrophages, and contributing to the repair of collapsed alveolar walls by forming smooth muscle fibers. dUC-MSCs inhibited osteoclastogenesis in COPD-induced osteoporosis. hUC-MSCs are a promising cell source and have many advantages over BM-MSCs and adipose tissue-derived MSCs.

Conclusion

We developed novel designer cells that may be involved in anti-inflammatory, homeostatic, injury repair, and disease resistance processes. dUC-MSCs repair and regenerate the alveolar wall by enhancing adhesion to the damaged site. Therefore, they can contribute to the treatment of COPD and systemic diseases such as osteoporosis.

Curved Axillary Incision with Video-Assisted Thoracoscopic Surgery: An Alternative Approach for Teenage Female with Large Apical Chest Wall Tumor

Primary chest wall tumors are rare, their common clinical features are not well known, and surgical resection remains the main treatment. Apical chest wall tumors require large skin incisions and dissection of the chest wall muscles, making it difficult to maintain cosmetic appearance, respiratory function, and support of the upper extremity. There are few treatment options and no studies have reported on thoracotomy that spares muscles and preserves cosmetic superiority. However, in benign chest wall tumors in young patients, it is necessary to consider radicality, cosmetic superiority, and muscle sparing. We used a combined axillary incision and thoracoscopic approach to treat a massive myxoid neurofibroma at the apical chest wall in a 14-year-old female and were able to preserve the chest wall, upper limb function, and cosmetic aspects. This report provides a detailed description of the combined axillary incision and thoracoscopic approach for apical chest wall tumors.

Adipose-Derived Mesenchymal Stem Cells Attenuate Immune Reactions Against Pig Decellularized Bronchi Engrafted into Rat Tracheal Defects

Decellularized scaffolds are promising biomaterials for tissue and organ reconstruction; however, strategies to effectively suppress the host immune responses toward these implants, particularly those without chemical crosslinking, remain warranted. Administration of mesenchymal stem cells is effective against immune-mediated inflammatory disorders. Herein, we investigated the effect of isogeneic abdominal adipose-derived mesenchymal stem/stromal cells (ADMSCs) on xenogeneic biomaterial-induced immunoreactions. Peripheral bronchi from pigs, decellularized using a detergent enzymatic method, were engrafted onto tracheal defects of Brown Norway (BN) rats. BN rats were implanted with native pig bronchi (Xenograft group), decellularized pig bronchi (Decellularized Xenograft), or Decellularized Xenograft and ADMSCs (Decellularized Xenograft+ADMSC group). In the latter group, ADMSCs were injected intravenously immediately post implantation. Harvested graft implants were assessed histologically and immunohistochemically. We found that acute rejections were milder in the Decellularized Xenograft and Decellularized Xenograft+ADMSC groups than in the Xenograft group. Mild inflammatory cell infiltration and reduced collagen deposition were observed in the Decellularized Xenograft+ADMSC group. Additionally, ADMSC administration decreased CD8+ lymphocyte counts but increased CD163+ cell counts. In the Decellularized Xenograft+ADMSC group, serum levels of vascular endothelial growth factor and IL-10 were elevated and tissue deposition of IgM and IgG was low. The significant immunosuppressive effects of ADMSCs illustrate their potential use as immunosuppressive agents for xenogeneic biomaterial-based implants.

A novel ex vivo lung cancer model based on bioengineered rat lungs

Introduction: Two-dimensional cell cultures have contributed substantially to lung cancer research, but 3D cultures are gaining attention as a new, more efficient, and effective research model. A model reproducing the 3D characteristics and tumor microenvironment of the lungs in vivo, including the co-existence of healthy alveolar cells with lung cancer cells, is ideal. Here, we describe the creation of a successful ex vivo lung cancer model based on bioengineered lungs formed by decellularization and recellularization. Methods: Human cancer cells were directly implanted into a bioengineered rat lung, which was created with a decellularized rat lung scaffold reseeded with epithelial cells, endothelial cells and adipose-derived stem cells. Four human lung cancer cell lines (A549, PC-9, H1299, and PC-6) were applied to demonstrate forming cancer nodules on recellularized lungs and histopathological assessment were made among these models. MUC-1 expression analysis, RNA-seq analysis and drug response test were performed to demonstrate the superiority of this cancer model. Results: The morphology and MUC-1 expression of the model were like those of lung cancer in vivo. RNA sequencing revealed an elevated expression of genes related to epithelial-mesenchymal transition, hypoxia, and TNF-α signaling via NF-κB; but suppression of cell cycle-related genes including E2F. Drug response assays showed that gefitinib suppressed PC-9 cell proliferation equally well in the 3D lung cancer model as in 2D culture dishes, albeit over a smaller volume of cells, suggesting that fluctuations in gefitinib resistance genes such as JUN may affect drug sensitivity. Conclusions: A novel ex vivo lung cancer model was closely reproduced the 3D structure and microenvironment of the actual lungs, highlighting its possible use as a platform for lung cancer research and pathophysiological studies.

Spontaneous pleural aspergillosis in an immunocompetent young adult treated with minimally invasive surgery

Spontaneous cases of pleural aspergillosis in healthy adults are rare, and the optimal therapeutic approach has not been established. Here we report a rare case of spontaneous pleural aspergillosis in an otherwise healthy young adult. Two-stage surgery with decortication and cavernostomy, followed by systemic antifungal therapy, finally resulted in a successful resolution of his empyema without any serious complications. In young patients with good pulmonary compliance, less invasive procedures, such as thoracoscopic decortication and/or carvernotomy, is a potential treatment option.

Timing of Mesenchymal Stromal Cell Therapy Defines its Immunosuppressive Effects in a Rat Lung Transplantation Model

Cell therapy using mesenchymal stromal cells (MSCs) is being studied for its immunosuppressive effects. In organ transplantation, the amount of MSCs that accumulate in transplanted organs and other organs may differ depending on administration timing, which may impact their immunosuppressive effects. In vitro, adipose-derived mesenchymal stem cells (ADMSCs) suppress lymphocyte activation under cell-to-cell contact conditions. However, in vivo, it is controversial whether ADMSCs are more effective in accumulating in transplanted organs or in secondary lymphoid organs. Herein, we aimed to investigate whether the timing of ADMSC administration affects its immunosuppression ability in a rat lung transplantation model. In the transplantation study, rats were intramuscularly administered half the usual dose of tacrolimus (0.5 mg/kg) every 24 h after lung transplantation. ADMSCs (1 × 106) were administered via the jugular vein before (PreTx) or after (PostTx) transplantation. Cell tracking using quantum dots was performed. ADMSCs accumulated predominantly in the lung and liver; fewer ADMSCs were distributed in the grafted lung in the PreTx group than in the PostTx group. The rejection rate was remarkably low in the ADMSC-administered groups, particularly in the PostTx group. Serum tumor necrosis factor-α (TNF-α), interferon-γ, and interleukin (IL)-6 levels showed a greater tendency to decrease in the PreTx group than in the PostTx group. The proportion of regulatory T cells in the grafted lung 10 days after transplantation was higher in the PostTx group than in the PreTx group. PostTx administration suppresses rejection better than PreTx administration, possibly due to regulatory T cell induction by ADMSCs accumulated in the transplanted lungs, suggesting a mechanism different from that in heart or kidney transplantation that PreTx administration is more effective than PostTx administration. These results could help establish cell therapy using MSCs in lung transplantation.

Donor and Recipient Adipose-Derived Mesenchymal Stem Cell Therapy for Rat Lung Transplantation

BACKGROUND

Mesenchymal stem cells (MSCs) are beginning to be proven as immunosuppressant in the field of organ transplantation. However, the effects of MSC origin (donor or recipient) on immunosuppression are not clear. Hence, we investigated the effects of recipient and donor adipose-derived MSCs (ADMSCs) on immunosuppression in a rat lung transplantation model.

METHODS

Subjects were divided into no treatment, tacrolimus administration, recipient ADMSC administration, donor ADMSC administration, and mixed donor and recipient ADMSC administration groups. ADMSC-administered groups were also treated with tacrolimus. Histologic study, immunofluorescence, immunohistochemistry, enzyme-linked immunosorbent assay, and polymerase chain reaction were used for various analyses.

RESULTS

Fluorescently labeled ADMSCs were predominant in the grafted donor lung, but not in the recipient lung, on day 5. On day 7, the pathologic rejection grades of the grafted donor lung were significantly lower in the ADMSC-administered groups (P < .05) and did not differ among these groups. Although serum hepatocyte growth factor and vascular endothelial growth factor levels did not differ among the groups, interleukin 10 level was slightly higher in the ADMSC-administered groups. The numbers of infiltrating regulatory T cells in the grafted lung were significantly higher in the ADMSC-administered groups (P < .05) but did not differ with cell origin. Transcriptional analysis suggested interleukin 6 suppression to be the main overlapping immunosuppressive mechanism, regardless of origin. Therefore, a donor or recipient origin may not influence the immunosuppressive efficacy of ADMSCs in our rat lung transplantation model.

CONCLUSIONS

Collectively, the results indicate that allogenic ADMSCs, regardless of their origin, may exert similar immunosuppressive effects in clinical organ transplantation.

[Airway Complications after Lung Transplantation]

Lung transplantation is the only option for patients with end-stage pulmonary diseases. During recent years, satisfactory results in terms of long-term survival and quality of life have been achieved with improvements in perioperative management, surgical technique, and immunosuppression. Airway complications after lung transplantation are associated with significant morbidity and mortality. Common airway complications after lung transplantation include anastomotic granulation, airway stenosis, bronchomalacia, fistulas, and anastomotic infection. These airway complications often result in repeated hospitalisations and interventions. If bronchoscopic interventions are not effective, other alternatives like surgical intervention or re-transplantation become necessary. While numerous strategies for airway complications have been proven effective, there are still some issues that to be solved. Further research is necessary to reduce mortality and improve quality of life of these patients.

Anticancer agent α-sulfoquinovosyl-acylpropanediol enhances the radiosensitivity of human malignant mesothelioma in nude mouse models

Malignant pleural mesothelioma (MPM) is a highly malignant disease that develops after asbestos exposure. Although the number of MPM cases is predicted to increase, no effective standard therapies have been established. The novel radiosensitizer α-sulfoquinovosyl-acylpropanediol (SQAP) enhances the effects of γ-radiation in human lung and prostate cancer cell lines and in animal models. In this study, we explored the radiosensitizing effect of SQAP and its mechanisms in MPM. The human MPM cell lines MSTO-211H and MESO-4 were implanted subcutaneously into the backs and thoracic cavities of immunodeficient KSN/Slc mice, then 2 mg/kg SQAP was intravenously administered with or without irradiation with a total body dose of 8 Gy. In both the orthotopic and ectopic xenograft murine models, the combination of irradiation plus SQAP delayed the implanted human MSTO-211H tumor growth. The analysis of the changes in the relative tumor volume of the MSTO-211H indicated a statistically significant difference after 8 Gy total body combined with 2 mg/kg SQAP, compared to both the untreated control (P = 0.0127) and the radiation treatment alone (P = 0.0171). After the treatment in each case, immunostaining of the harvested tumors revealed decreased cell proliferation, increased apoptosis and normalization of tumor blood vessels in the SQAP- and irradiation-treated group. Furthermore, hypoxia-inducible factor (HIF) 1 mRNA and protein expression were decreased, indicating reoxygenation in this group. In conclusion, SQAP improved hypoxic conditions in tumor tissue and may elicit a radiosensitizing effect in malignant mesothelioma models.

Successful pulmonary artery stenting for occlusion at a constructed pericardial conduit after right upper double sleeve lobectomy

The patient was a 53-year-old man. His chief complaint was a cough and dyspnea on exertion. Computed tomography (CT) showed a 3-cm-diameter tumor in the right upper lobe with invasion from hilar lymph nodes to the superior vena cava, right main bronchus, and pulmonary artery. After being diagnosed with non-small cell lung cancer, the patient underwent preoperative induction radiochemotherapy. At surgery, right upper double sleeve lobe lobectomy was performed. The right main pulmonary artery was reconstructed using a pericardial conduit. CT 1 week after surgery showed impaired blood flow in the right pulmonary artery. A metal vascular stent was inserted into the narrow part of the constructed pulmonary artery in the hybrid operating room because thrombectomy was unsuccessful. After surgery, contrast CT showed that blood flow was maintained. The patient is currently well without any recurrence 3 years after surgery.

Mirogabalin treatment of postoperative neuropathic pain after thoracic surgery: study protocol for a multicenter, randomized, open-label, parallel-group, interventional trial

Background

Intercostal nerve damage due to thoracotomy or thoracoscopic manipulation is a major contributor to chronic postsurgical pain after pulmonary resection. Chronic postsurgical pain may last for months or years and can negatively impair physical functioning and daily activities. Global consensus on severe postoperative pain management is lacking, and chronic pain incidence after thoracic surgery remains high. Many patients report neuropathic pain, which can be difficult to treat with currently available therapies. The efficacy and safety of mirogabalin have been demonstrated for other types of neuropathic pain; thus, this study was planned to investigate the efficacy and safety of mirogabalin to treat neuropathic pain after thoracic surgery.

Methods

In this multicenter, randomized, open-label, parallel-group, interventional study, patients who are diagnosed with neuropathic pain following removal of a chest drain after lung resection will receive conventional therapy (non-steroidal anti-inflammatory drugs and/or acetaminophen) with or without the addition of a clinical dose of mirogabalin for 8 weeks. For patient stratification, a visual analog scale pain intensity score at baseline of <60 vs. ≥60 mm will be used. Treatment efficacy and safety with and without the addition of mirogabalin will be assessed using a questionnaire evaluating postoperative changes in pain severity and activity. The primary study endpoint is the change in pain intensity from baseline to Week 8, measured by the visual analog scale. Additionally, the presence of chronic pain at 12 weeks after enrollment in each treatment group will be recorded.

Discussion

This protocol has been reviewed and approved by the Clinical Research Review Board of Nagasaki University. Study data will be published in the Japan Registry of Clinical Trials database and peer-reviewed journals. Mirogabalin is already approved for the treatment of other types of neuropathic pain. It is anticipated that this study will provide data to elucidate the impact of mirogabalin treatment, in combination with conventional therapy, to benefit patients with neuropathic pain following thoracic surgery.

Trial Registration

Japan Registry of Clinical Trials Identifier: jRCTs071200053.

Primary mucinous adenocarcinoma of the thymus; a rare type of thymic carcinoma. Case Report

Mucinous adenocarcinoma of the thymus is a particularly rare type among thymic carcinomas. Here, we report a patient who underwent complete surgical resection of the primary mucinous adenocarcinoma of the thymus. She was 74 years old and presented with a 60-mm multilocular cystic tumor in her right anterior mediastinum. We performed extended thymo-thymectomy with partial resection of the right upper lobe and pathologically diagnosed the patient with Masaoka stage II mucinous adenocarcinoma of the thymus. Immunohistochemistry showed the absence of PD-L1, suggesting that immune check point inhibitors targeting PD-1/PD-L1 might not be effective in this case. The increased preoperative serum levels of CA19-9 decreased after the operation. CA19-9 is a biomarker for disease status. Future reports should help elucidate the pathogenesis of this disease.

Enhanced airway stenting using a preoperative, three-dimensionally printed airway model simulation

Three-dimensionally printed organ models that facilitate preoperative simulations have the potential to improve outcomes of surgical procedures. Here, we report a case involving a 54-year-old man diagnosed with lung cancer of the right upper bronchus that was invading the right main bronchus. A right upper lobectomy with carinoplasty was performed. Although complete excision of the tumor was achieved, exertional dyspnea redeveloped 4 months post-surgery. Chest computed tomography revealed that airway stenosis caused by granulation had deformed the airway. Ablation of the granulation and airway stenting was required to improve the patient's symptoms. Prior to performing airway stenting, a three-dimensionally printed airway model was constructed, and the Y-shaped silicone stent used was modified in accordance with the model. After stenting, both the right and left bronchi were preserved, and the patient's symptoms improved. The three-dimensional printed airway model enhanced the accuracy and safety of the airway stenting procedure performed.

Cephalic Vein Cut-down for Totally Implantable Central Venous Access Devices With Preoperative Ultrasonography by Surgical Residents

BACKGROUND/AIM

Cephalic vein (CV) cut-down for totally implantable central venous access devices (TICVADs) is not frequently used due to its low success rate. We compared the outcomes of CV cut-down using preoperative ultrasonography (US) performed by experienced surgeons versus surgical residents.

PATIENTS AND METHODS

From December 2015 to December 2017, 10 surgeons implanted 212 TICVADs using CV cut-down with preoperative US. The surgeons were divided into two groups of five each: surgical residents (Group A, n=124 procedures) and experienced surgeons (Group B, n=88 procedures). Duration of operation time, completion rate, and complications were retrospectively analyzed.

RESULTS

The completion rate was significantly higher in Group A (98.4% versus 92.0%, p=0.04). Duration of operation time (45.2±14.5 versus 42.0±13.1 minutes, p=0.22), rates of early complications (1.6% versus 1.1%, p=0.77) and late complications (3.2% versus 2.3%, p=0.68) were equivalent between the two groups. No fatal complications occurred in either group.

CONCLUSION

CV cut-down can be safely performed by surgical residents under the use of preoperative US.

Lung Microvascular Niche, Repair, and Engineering

Biomaterials have been used for a long time in the field of medicine. Since the success of "tissue engineering" pioneered by Langer and Vacanti in 1993, tissue engineering studies have advanced from simple tissue generation to whole organ generation with three-dimensional reconstruction. Decellularized scaffolds have been widely used in the field of reconstructive surgery because the tissues used to generate decellularized scaffolds can be easily harvested from animals or humans. When a patient's own cells can be seeded onto decellularized biomaterials, theoretically this will create immunocompatible organs generated from allo- or xeno-organs. The most important aspect of lung tissue engineering is that the delicate three-dimensional structure of the organ is maintained during the tissue engineering process. Therefore, organ decellularization has special advantages for lung tissue engineering where it is essential to maintain the extremely thin basement membrane in the alveoli. Since 2010, there have been many methodological developments in the decellularization and recellularization of lung scaffolds, which includes improvements in the decellularization protocols and the selection and preparation of seeding cells. However, early transplanted engineered lungs terminated in organ failure in a short period. Immature vasculature reconstruction is considered to be the main cause of engineered organ failure. Immature vasculature causes thrombus formation in the engineered lung. Successful reconstruction of a mature vasculature network would be a major breakthrough in achieving success in lung engineering. In order to regenerate the mature vasculature network, we need to remodel the vascular niche, especially the microvasculature, in the organ scaffold. This review highlights the reconstruction of the vascular niche in a decellularized lung scaffold. Because the vascular niche consists of endothelial cells (ECs), pericytes, extracellular matrix (ECM), and the epithelial-endothelial interface, all of which might affect the vascular tight junction (TJ), we discuss ECM composition and reconstruction, the contribution of ECs and perivascular cells, the air-blood barrier (ABB) function, and the effects of physiological factors during the lung microvasculature repair and engineering process. The goal of the present review is to confirm the possibility of success in lung microvascular engineering in whole organ engineering and explore the future direction of the current methodology.

A case of emergent operation for a life-threatening infectious mediastinal cyst

PURPOSE

Congenital mediastinal cysts are an uncommon but important diagnostic group. Most of these cysts are benign and asymptomatic in adults. However, some of them are clinically problematic due to the compression of neighboring organs, infection, or perforation.

CASE PRESENTATION

A 20-year-old man presented with severe dyspnea. Imaging revealed a mediastinal cyst in the subcarinal space compressing his right pulmonary artery and airway, which was later diagnosed as a bronchogenic cyst. Due to quick symptom exacerbation, emergent cyst wall fenestration was performed through video-assisted thoracic surgery with "stand-by" extracorporeal membrane oxygenation. Complete cyst resection was difficult owing to adhesion of the cyst to the surrounding organs. The symptoms immediately resolved after surgery and the postoperative course was uneventful.

CONCLUSION

Mediastinal bronchogenic cysts with life-threatening complications are rarely reported in adults. However, this case was life-threatening due to airway and vascular compression; emergent surgical care should be considered in such cases.

[Resection of Lung Cancer with Chest Wall Invasion Using Posterior Paramedian Incision]

We report a case of lung cancer with chest wall invasion resected with the posterior paramedian incision. A man in his 60s exhibited hemosputum and cough. Chest X-ray revealed a large mass below the right hilum. A 6.3 cm soft tissue mass with central cavity invading to the lower posterior chest wall was found on chest computed tomography( CT). The tumor was diagnosed as squamous cell carcinoma by transcutaneous lung biopsy( TCLB). Thoracoscopic hilar dissection of the right lower lobe with dissection of the mediastinal lymph nodes were preceded to the en-bloc resection of the invaded chest wall with less invasive manner by the posterior paramedian incision.

Cosmetic benefits of a novel biomimetic lamellar formulation containing niacinamide in healthy females with oily, blemish-prone skin in a randomized proof-of-concept study

OBJECTIVE

A randomized study was designed to evaluate the potential cosmetic benefit of a biomimetic, niacinamide-containing moisturizing cream in oily, blemish-prone skin.

METHODS

Healthy adult women with oily, blemish-prone skin were randomized to one of three treatment groups: test, control, or positive control. In the test group, subjects used the test product (containing 4% niacinamide), plus the standard cleanser (Simple® Kind to Skin Moisturizing Facial Wash). In the control group, subjects received no moisturizer but used the standard cleanser. In the positive control group, subjects used Vivatinell Acnecinamide^® Gel Cream (containing 4% niacinamide) as a moisturizer and Neutrogena Visibly Clear^® Spot Clearing Facial Wash (containing 2% salicylic acid) as a cleanser. The positive control regimen was included to provide a comparison for estimates of effect size. The primary objective was to evaluate skin moisturization as a change from baseline in corneometer values at 8 h for the test regimen vs. the control regimen. Analysis of covariance was applied for the primary efficacy analysis.

RESULTS

A total of 132 subjects were randomized with 44 included in each treatment group. A significant difference was observed in the primary endpoint for the test regimen compared with the control regimen (least-squares mean difference [95% CI]: 3.12 [0.68, 5.56], P = 0.0128). A trend was observed in favour of the positive control regimen compared with the control regimen. Secondary measurements of moisturization supported the primary efficacy outcome. Assessment of blemishes showed a significant difference between the test regimen vs. the control regimen for change from baseline in mean total blemish count at Week 8 (least-squares mean difference [95% CI]: -1.80 [-3.41, -0.19], P = 0.0290). No statistical comparisons between the positive control group and the test group were performed.

CONCLUSION

This study provides proof-of-concept evidence that a novel lamellar lipid moisturizer containing niacinamide, in combination with a standard cleanser, can help moisturize the skin and provide an overall improvement in the complexion appearance of people with blemish-prone skin.

STUDY REGISTRATION

NCT03093181.

Replacement of Rat Tracheas by Layered, Trachea-Like, Scaffold-Free Structures of Human Cells Using a Bio-3D Printing System

Current scaffold-based tissue engineering approaches are subject to several limitations, such as design inflexibility, poor cytocompatibility, toxicity, and post-transplant degradation. Thus, scaffold-free tissue-engineered structures can be a promising solution to overcome the issues associated with classical scaffold-based materials in clinical transplantation. The present study seeks to optimize the culture conditions and cell combinations used to generate scaffold-free structures using a Bio-3D printing system. Human cartilage cells, human fibroblasts, human umbilical vein endothelial cells, and human mesenchymal stem cells from bone marrow are aggregated into spheroids and placed into a Bio-3D printing system with dedicated needles positioned according to 3D configuration data, to develop scaffold-free trachea-like tubes. Culturing the Bio-3D-printed structures with proper flow of specific medium in a bioreactor facilitates the rearrangement and self-organization of cells, improving physical strength and tissue function. The Bio-3D-printed tissue forms small-diameter trachea-like tubes that are implanted into rats with the support of catheters. It is confirmed that the tubes are viable in vivo and that the tracheal epithelium and capillaries proliferate. This tissue-engineered, scaffold-free, tubular structure can represent a significant step toward clinical application of bioengineered organs.

Sodium hydroxide based non-detergent decellularizing solution for rat lung

Lung transplantation is the last option for the treatment of end stage chronic lung disorders. Because the shortage of donor lung organs represents the main hurdle, lung regeneration has been considered to overcome this hurdle. Recellularization of decellularized organ scaffold is a promising option for organ regeneration. Although detergents are ordinarily used for decellularization, other approaches are possible. Here we used high alkaline (pH12) sodium hydroxide (NaOH)-PBS solution without detergents for lung decellularization and compared the efficacy on DNA elimination and ECM preservation with detergent based decellularization solutions CHAPS and SDS. Immunohistochemical image analysis showed that cell components were removed by NaOH solution as well as other detergents. A Collagen and GAG assay showed that the collagen reduction of the NaOH group was comparable to that of the CHAPS and SDS groups. However, DNA reduction was more significant in the NaOH group than in other groups (p < 0.0001). The recellularization of HUVEC revealed cell attachment was not inferior to that of the SDS group. Ex vivo functional analysis showed 100% oxygen ventilation increased oxygen partial pressure as artificial hemoglobin vesicle-PBS solution passed through regenerated lungs in the SDS or NaOH group. It was concluded that the NaOH-PBS based decellularization solution was comparable to ordinal decellularizaton solutions and competitive in cost effectiveness and residues in the decellularized scaffold negligible, thus providing another potential option to detergent for future clinical usage.

Transplantation of bioengineered rat lungs recellularized with endothelial and adipose-derived stromal cells

Bioengineered lungs consisting of a decellularized lung scaffold that is repopulated with a patient's own cells could provide desperately needed donor organs in the future. This approach has been tested in rats, and has been partially explored in porcine and human lungs. However, existing bioengineered lungs are fragile, in part because of their immature vascular structure. Herein, we report the application of adipose-derived stem/stromal cells (ASCs) for engineering the pulmonary vasculature in a decellularized rat lung scaffold. We found that pre-seeded ASCs differentiated into pericytes and stabilized the endothelial cell (EC) monolayer in nascent pulmonary vessels, thereby contributing to EC survival in the regenerated lungs. The ASC-mediated stabilization of the ECs clearly reduced vascular permeability and suppressed alveolar hemorrhage in an orthotopic transplant model for up to 3 h after extubation. Fibroblast growth factor 9, a mesenchyme-targeting growth factor, enhanced ASC differentiation into pericytes but overstimulated their proliferation, causing a partial obstruction of the vasculature in the regenerated lung. ASCs may therefore provide a promising cell source for vascular regeneration in bioengineered lungs, though additional work is needed to optimize the growth factor or hormone milieu for organ culture.

[Granuloma by Foreign Body Reaction to the Stapler Used for Partial Resection of the Lung]

A 66-year-old woman underwent right lower lobectomy and partial resection of the middle lobe for Stage I A double lung cancer. Five years after the operation, a routine computed tomography (CT) scan showed a mass on the staple line at the middle lobe. The mass was enlarged on CT scan after 6 months. A definitive diagnosis could not be made by bronchoscopic examination and fluoro-2-deoxy-glucose(FDG)/positron emission tomography( PET)-CT showed FDG uptake in the mass( early phase:SUVmax=3.24, late phase:SUVmax=4.31). Local recurrence of lung cancer was not completely denied, and right middle lobectomy was performed. Histopathologically, the resected specimen revealed granuloma with foreign body reaction. We should keep in mind the possibility of granuloma as differential diagnosis of lung cancer when using stapler.

Is early postoperative administration of pregabalin beneficial for patients with lung cancer?-randomized control trial

BACKGROUND

Post-thoracotomy pain is an obstacle for lung-cancer patients even after introduction of less invasive surgical procedures. The aim of this prospective study was to evaluate if early postoperative administration of pregabalin is beneficial for patients with non-small cell lung cancer (NSCLC).

METHODS

We conducted a randomized open control trial. Patients with NSCLC were allocated randomly to epidural and nonsteroidal anti-inflammatory drug (NSAID) use for analgesia (control group) or pregabalin use (pregabalin group). Primary endpoint was the frequency of additional administration of a NSAID. Secondary endpoints were intensity of ongoing pain, frequency of neuropathic pain, and pain catastrophizing.

RESULTS

Seventy-two patients were registered and allocated. Thirty-four cases in the control group and 33 in the pregabalin group were assessed. Age, sex, body mass index (BMI), type of surgical procedure, type of lymph-node dissection, operation time, bleeding, duration of chest-tube insertion, and postoperative hospital stay between the two groups was not significantly different. Frequency of additional NSAID use between the control group (2±4 suppositories) and pregabalin group (2±3 suppositories) was not significantly different (P=0.62). Numeric Rating Scale (NRS) for the intensity of ongoing pain, frequency of neuropathic pain, and Pain Catastrophizing Scale (PCS) between each group were not significantly different at any time until 3 months after surgery.

CONCLUSIONS

Early postoperative administration of pregabalin is not beneficial for patients with NSCLC.

Ratio of C-reactive protein to albumin is a prognostic factor for operable non-small-cell lung cancer in elderly patients

PURPOSE

The aim of this retrospective study was to evaluate inflammation-based scoring as a prognostic factor for operable non-small-cell lung cancer (NSCLC) in elderly patients.

METHODS

We collected preoperative data from 108 patients aged above 80 years with NSCLC. Inflammation-based scoring systems, including the C-reactive protein to albumin ratio (CAR) and the Glasgow prognostic score (GPS), as well as other clinicopathological factors, were evaluated as potential prognostic factors.

RESULTS

The median patient age was 82 (range 80-93) years and the 5-year overall and disease-specific survival rates were 49.7 and 73.9%, respectively. The cut-off value for CAR was calculated using a receiver operator characteristics analysis and patients were dichotomized accordingly. Patients with a low CAR had significantly higher overall survival than those with a high CAR (<0.028; 65.2% vs. ≥0.028; 31.0%, respectively; p < 0.01). In univariate analysis, female gender, a low Charlson comorbidity index of 0 or 1 and a low CAR were significantly identified in overall survival. On multivariate analysis, a low CAR (p = 0.03, hazard ratio: 2.13, 95% confidence interval 1.074-4.295) was identified as a significant prognostic factor.

CONCLUSIONS

The preoperative CAR is a useful predictor of overall survival and could be a simple prognostic tool to help identify resectable NSCLC in elderly patients.

[Anastomotic Airway Complications after Lung Transplantation]

Anastomotic airway complications still remain an important issue after lung transplantation. Most of the complications are stenosis and anastomotic leakage. Stent insertion is one option for the stenosis. We review the anastomotic airway complications and report our recent experience of stent insertion using 3-dimensional printed airway model.

Ventilation-Based Decellularization System of the Lung

The demand for donated organs greatly exceeds the availability. Alternatives to organ donation, such as laboratory-engineered organs, are therefore being developed. One approach is to decellularize the organ and reseed it with selected cells, ideally from the organ recipient. Organ decellularization has typically been attempted by the administration of detergents into vessels such as the portal vein in the liver. However, in the case of the lung, the airway provides another potential administration route, because it has a wide contact area between cells and detergents in the tracheal tree and alveoli. In the present study, we introduce a novel ventilation-based decellularization system for the lung and compare its efficacy to ordinary decellularization systems administering detergent through the pulmonary artery. Rat lungs were decellularized using 500 mL of 3-[(3-cholamidopropyl) dimethylammonio]-1-Propanesulfonate (CHAPS) decellularization solution administrated through the pulmonary artery (vessel group) or through the trachea (airway group). The vessel group was infused CHAPS solution using a gravitational pressure head of 20 cmH2O. The airway group was infused with the detergent using negative pressure and positive end-expiratory pressure, for a volume 10cc with each inspiration in a bioreactor. Pathological and immunohistochemical findings indicated that components of the extracellular matrix (ECM), including proteoglycans, elastic fibers, fibronectin, and laminin, were more decreased in the airway group than in the vessel group. Western blot analysis showed that MHC class I antigen and β-actin were not detected in both decellularized groups. A collagen assay showed that collagen was 70% preserved in both groups compared to native lung. Glycosaminoglycan (GAG) and DNA assays showed that GAG and DNA contents were strongly diminished in both decellularized groups, but those contents were smaller in the airway group than in the vessel group. Accordingly, the alveolar wall was thinner on electron microscopy, and DNA remnants were not observed in the airway group. Infusion of red blood cells indicated that capillary walls were preserved without blood leakage in both groups. In conclusion, we describe a novel approach for decellularization through the airway that represents a more stringent method for both DNA and ECM removal, with capillary wall preservation.

Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience

PURPOSE

Unexpected intraoperative bleeding during thoracoscopic surgery, necessitating emergency conversion to thoracotomy, is gradually being reported. We reviewed our experience of encountering unexpected bleeding during thoracoscopic surgery.

METHODS

We defined "unexpected intraoperative bleeding" as the need for hemostatic procedures with angiorrhaphy, with or without a sealant. The location, cause, and management of injured vessels, and perioperative outcomes were investigated and compared with those for patients without injured vessels.

RESULTS

Between 2007 and 2014, a total of 241 thoracoscopic anatomical pulmonary resections were performed at our hospital. Twenty (8.3 %) of these patients required hemostatic procedures with angiorrhaphy, with or without a sealant. The main injured vessels were the pulmonary artery (n = 13) and vein (n = 3) and the main causes of injury were related to technical issues with energy devices and staplers. There were no morbidities related to intraoperative bleeding. The operation time and blood loss were significantly greater in the patients with vessel injury than in those without vessel injury, but perioperative morbidities and the duration of chest tube insertion (4.5 vs. 3.5 days, average, p = 0.20) and postoperative hospital stay (12.7 vs. 11.0 days, average, p = 0.08) were not significantly different.

CONCLUSIONS

The frequency of unexpected bleeding was relatively high in this series, but its management and outcomes were satisfactory in terms of safety.

[Important factors surrounding chest surgery for the patients complicated with digestive disease]

OBJECTIVE

Important factors surrounding chest surgery for the patients complicated with digestive disease were discussed according to the experiences of clinical settings.

METHODS

Check points regarding each context, preoperative, perioperative, postoperative, and outpatient care were considered independently.

RESULTS

If digestive diseases are uncontrolled, the operation should be postponed until they are appropriately cared. Dental problems such as teeth caries or denture insufficiency should be cleared preoperatively. Dysphagia after the head and neck surgery must be evaluated and alternative feeding methods should be established. The patients with digestive tract disorder have malabsorption and are prone to malnutrition. According to the appropriate assessments of digestion and absorption, an enteral nutrition or a total parenteral nutrition should be considered before and after operation, to improve nutrition status. Immunonutrition is particularly beneficial to reduce the postoperative infection or various stresses of invasive operations in the chest surgery. Chronic pancreatitis is characterized by absorption impairment and pancreatic diabetes. They should also be controlled before the operation using digestive enzymes and an exogenous insulin.

CONCLUSION

Teeth problems, dysphagia, malabsorption, malnutrition and pancreatic diabetes should be assessed and cared appropriately before and after the chest surgery using compensative therapy.

[A review of cases of surgery for acute empyema]

We retrospectively reviewed cases of acute empyema treated surgically in our hospital from April 2005 to April 2010. Patients comprised 10 men and 4 women, with a mean age of 62.5 years( range, 23~ 80 years). One case required open thoracotomy and decortication, and was in the organized phase at the time of operation( duration of symptoms before surgery, 44 days). The remaining 13 cases were in the fibropurulent phase at the time of operation and underwent video-assisted thoracoscopic surgery (VATS). In 6 of these 13 remaining cases, we performed mini-thoracotomy combined with the thoracoscopic operation due to the presence of severe intrathoracic adhesions. Median durations of postoperative drainage and postoperative stay were 5 days( range, 2~7 days) and 13.5 days( range, 6~17 days), respectively. Postoperative complications of subcutaneous abscess, drug-induced hepatitis, pseudomembranous enterocolitis and reexpansion pulmonary edema were observed in 1 case each, but all patients survived to discharge without perioperative deaths. VATS is a safe and effective method for the management of acute empyema, and is favorable to perform in the fibropurulent phase. Appropriate combination with mini-thoracotomy was useful in accomplishing surgery in cases with dense adhesion.

Factors contributing to cure in T2 pancreatic cancer

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Background: It is crucial to determine whether cancer therapy achieves cure or merely prolongs time to death from cancer (failure time). Unfortunately, conventional survival tests such as log-rank test and Cox regression fail to distinguish between cure and prolonged failure time, both making a great difference in survival benefit. In 1994, Gamel extended the Boag model to three regressions, allowing us to study whether prognostic factors have significant effect on cure rate or failure time. Using the Gamel-Boag regressions, we study curative effects of clinicopathological factors in pancreatic cancer.

Methods: Follow-up data from 452 patients who underwent pancreatectomy for T2 ductal cell cancer were analyzed. The prognostic factors to be studied were converted to binary variables, which include sex, age (<=60 or >60 years), tumor size (<=2 or >2 cm) lymphnode metastasis, and six types of invasions, i.e., serosal, retroperitoneal, portal vain, common bile duct and duodenal invasions. By calculating coefficients of the three regressions and their confidence intervals, we evaluated whether each (or combinations) of these variables are associated with increased cure rate or prolonged failure time.

Results: Tthere were 11 relapse-free 5-year survivors. Except for tumor size (TS) and lymphnode metastasis (N), no factors were significantly associated with increased cure rate or prolonged failure time. The only factor found to significantly affect cure was TS; the estimated cure rate being 44% for patients with TS <= 2 cm and 4% otherwise (p=0.0001). This effect was not influenced by N and other factors. Only N significantly accelerated failure time; the median failure time being 11.9 months when N was negative and 6.7 months otherwise (p<0.0001). Thus, both TS and N affected the prognosis significantly but in different ways. By contrast the Cox regression showed that both TS and N were significantly associated with hazard reduction (p=0.003 and p<0.001, respectively), which, however, did no reveal a qualitative difference in survival outcome between TS and N.

Conclusions: In T2 pancreatic cancer, a highly significant increase in cure rate is found when TS≤2 cm. This increase is not affected by N or tumor extension to nonpancreatic tissues.

No significant financial relationships to disclose.

A randomised phase III trial comparing gemcitabine with surgery-only in patients with resected pancreatic cancer: Japanese Study Group of Adjuvant Therapy for Pancreatic Cancer

BACKGROUND

This multicentre randomised phase III trial was designed to determine whether adjuvant chemotherapy with gemcitabine improves the outcomes of patients with resected pancreatic cancer.

METHODS

Eligibility criteria included macroscopically curative resection of invasive ductal carcinoma of the pancreas and no earlier radiation or chemotherapy. Patients were randomly assigned at a 1 : 1 ratio to either the gemcitabine group or the surgery-only group. Patients assigned to the gemcitabine group received gemcitabine at a dose of 1000 mg m(-2) over 30 min on days 1, 8 and 15, every 4 weeks for 3 cycles.

RESULTS

Between April 2002 and March 2005, 119 patients were enrolled in this study. Among them, 118 were eligible and analysable (58 in the gemcitabine group and 60 in the surgery-only group). Both groups were well balanced in terms of baseline characteristics. Although heamatological toxicity was frequently observed in the gemcitabine group, most toxicities were transient, and grade 3 or 4 non-heamatological toxicity was rare. Patients in the gemcitabine group showed significantly longer disease-free survival (DFS) than those in the surgery-only group (median DFS, 11.4 versus 5.0 months; hazard ratio=0.60 (95% confidence interval (CI): 0.40-0.89); P=0.01), although overall survival did not differ significantly between the gemcitabine and surgery-only groups (median overall survival, 22.3 versus 18.4 months; hazard ratio=0.77 (95% CI: 0.51-1.14); P=0.19).

CONCLUSION

The current results suggest that adjuvant gemcitabine contributes to prolonged DFS in patients undergoing macroscopically curative resection of pancreatic cancer.

Adjuvant 5-fluorouracil and folinic acid vs observation for pancreatic cancer: composite data from the ESPAC-1 and -3(v1) trials

The ESPAC-1, ESPAC-1 plus, and early ESPAC-3(v1) results (458 randomized patients; 364 deaths) were used to estimate the effectiveness of adjuvant 5FU/FA vs resection alone for pancreatic cancer using meta-analysis. The pooled hazard ratio of 0.70 (95% CI=0.55-0.88) P=0.003, and the median survival of 23.2 (95% CI=20.1-26.5) months with 5FU/FA vs 16.8 (95% CI=14.3-19.2) months with resection alone supports the use of adjuvant 5FU/FA in pancreatic cancer.

Characteristics of cognitive function in patients after traumatic brain injury assessed by visual and auditory event-related potentials

OBJECTIVE

Using auditory and visual stimuli including facial affective stimuli, we analyzed the P300 components of event-related potentials (ERPs) in patients after traumatic brain injury (TBI) to assess their cognitive characteristics.

DESIGN

Twenty TBI patients and 32 age-matched control subjects were recruited. Using conventional oddball paradigms, visual ERPs were recorded using images of crying and smiling babies as visual stimuli. Auditory ERPs were obtained using 2-kHz tones as stimuli without affective stimuli. The peak amplitude and latency for P300, and the latency for N200, were recorded.

RESULTS

: In visual ERPs, the P300 amplitudes were significantly smaller in patients than in controls for the crying baby, but the amplitudes were similar between groups for the smiling baby. Controls showed smaller P300 amplitudes for the smiling baby than for the crying baby, but patients showed no difference. In patients, the P300 latency for both smiling and crying babies was longer than in the controls. Patients' auditory ERPs showed smaller P300 amplitudes but similar P300 latencies compared with controls. The N200 latency in patients was significantly longer than in controls only for the crying baby.

CONCLUSIONS

Visual ERPs are a potentially useful marker for evaluating cognitive dysfunction in patients after TBI.

The retrospective analysis of single agent gemcitabine for biliary tract cancers

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Background: At present, outcomes of advanced biliary tract cancers are dismal despite the prognosis of other many cancers are improving. Methods: We retrospectively analyzed survivals of 46 advanced biliary tract cancer patients, who were diagnosed between January 2001 and June 2005, and treated with gemcitabine 600–1,000 mg/m2 as an intravenous 30-min infusion on days 1, 8, and 15 for every 28 days, thereafter. Results: The median age was 63 (range 41–76) with 28 males and 18 females. Twenty-nine (63.0%) had no prior chemotherapy and 18 (30.4%) patients were inoperable cases. One (2.2%) achieved complete response; 5 (10.9%) achieved partial responses; 25 (54.3%) had stable diseases; 9 (19.6%) had progressive disease; and 6 (13.0%) were not evaluated for response. The median survival time and the 1 year-survival of all advanced biliary cancer patients were 8.6 months and 43.9%, respectively, those of the patients, who had the recurrence or residual cancer lesions after surgical resection were 13.5 months and 68.8%, and those of the inoperable patients were 5.4 months and 8.3%. Patients reported grade 3/4 neutropenia/leucopenia (4.3%) and grade 3 thrombocytopenia (2.2%). Grade 3 non-hematologic toxicities were general fatigue (4.3%) and renal failure (2.2%). Multivariate analysis demonstrated that history of surgical resection with tumor recurrence or with residual tumor was the independent predictors for survival. Moreover, except the features of the history of surgical resection, the prognosis of patients with low levels of serum albumin (< 3.7 g/dl) or ≥ 70 ages was worse than that of high levels of serum albumin (≥ 3.7 g/dl) or < 70 ages. Conclusions: In the treatment of biliary tract cancer, it seems that surgical resection even with possible residual tumor is beneficial for patients with good surgical candidate. The present study also suggests the possibility that the prognosis of patients with low levels of serum albumin (< 3.7 g/dl) or ≥ 70 ages might be worse than that of high levels of serum albumin (≥ 3.7 g/dl) or < 70 ages.

No significant financial relationships to disclose.

Expression of the gene for a membrane-bound fatty acid receptor in the pancreas and islet cell tumours in humans: evidence for GPR40 expression in pancreatic beta cells and implications for insulin secretion

AIMS/HYPOTHESIS

G protein-coupled receptor 40 (GPR40) is abundantly expressed in pancreatic beta cells in rodents, where it facilitates glucose-induced insulin secretion in response to mid- to long-chain fatty acids in vitro. However, GPR40 gene expression in humans has not been fully investigated, and little is known about the physiological and pathophysiological roles of GPR40 in humans. The aim of this study, therefore, was to examine GPR40 expression and its clinical implications in humans.

METHODS

GPR40 mRNA expression in the human pancreas, pancreatic islets and islet cell tumours was analysed using TaqMan PCR.

RESULTS

GPR40 mRNA was detected in all human pancreases collected intraoperatively. It was enriched approximately 20-fold in isolated islets freshly prepared from the pancreases of the same individuals. The estimated mRNA copy number for the GPR40 gene in pancreatic islets was comparable to those for genes encoding sulfonylurea receptor 1, glucagon-like peptide 1 receptor and somatostatin receptors, all of which are known to be expressed abundantly in the human pancreatic islet. A large amount of GPR40 mRNA was detected in insulinoma tissues, whereas mRNA expression was undetectable in glucagonoma or gastrinoma. The GPR40 mRNA level in the pancreas correlated with the insulinogenic index, which reflects beta cell function (r=0.82, p=0.044), but not with glucose levels during the OGTT, the insulin area under the OGTT curve or the index for the homeostasis model assessment of insulin resistance (HOMA-IR).

CONCLUSIONS/INTERPRETATION

The present study provides evidence for GPR40 gene expression in pancreatic beta cells and implicates GPR40 in insulin secretion in humans.