Outcomes of surgical resection for pulmonary metastasis from pancreatic cancer

PURPOSE

As the number of long-term survivors of pancreatic cancer is expected to increase thanks to recent advances in multidisciplinary treatment and earlier diagnoses of pancreatic cancer, we are likely to encounter more cases of postoperative pulmonary nodules. We analyzed the clinical course and prognosis of resection of pulmonary metastases from pancreatic cancer to clarify the prognostic implication of pulmonary metastasectomy for pancreatic cancer.

METHOD

We retrospectively analyzed 35 patients who underwent resection of lung metastases after pancreatic cancer surgery. Short- and long-term outcomes and factors associated with the prognosis were analyzed.

RESULTS

The observation period was 20 (range, 1-101) months, with 3- and 5-year survival rates of 88.3% and 64.5% from pancreatectomy and 44.1% and 28.3% from lung resection, respectively. A univariate analysis revealed that a period from pancreatic cancer resection to pulmonary nodule shadow detection of < 15 months was associated with a significantly lower overall survival from pancreatic resection than a longer period. Conversely, histological type, stage, size of lung metastases, and resection technique were not associated with the overall survival.

CONCLUSION

A long-term prognosis may be expected in some cases with a disease-free interval of ≥ 15 months. Our findings suggest that the disease-free interval may influence the prognosis.

Sarcoid-Like Granulomatosis of the Lung Related to Durvalumab After Chemoradiation for Pulmonary Squamous Cell Carcinoma

Sarcoid-like granulomatosis is a unique immune-related adverse event (irAE) in cancer patients treated with immune checkpoint inhibitors (ICIs). This irAE is infrequent, reported to range from 2% to 22.2% of melanoma treated with ICI. In a case of granulomatosis localized in the lung, it is difficult to differentiate granulomatosis from cancer progression or metastases. Herein, we report a case of ICI-induced sarcoid-like granulomatosis of the lung, which was confusable with localized recurrence of the primary lung cancer. A 56-year-old woman with c-stage IIIA of pulmonary squamous cell carcinoma in the right lower lobe received chemo-radiotherapy with two courses of cisplatin and vinorelbine and concurrent thoracic irradiation, followed by 1-year durvalumab consolidation therapy. The tumor in the right S₆ grew and presented abnormal uptake by fluorodeoxyglucose positron emission tomography (FDG-PET), 1.5 years after durvalumab. Neither computed tomography (CT) nor FDG-PET found mediastinal and distant metastases. She underwent right lower lobe lobectomy. Histopathologically, the tumor and sampled lymph nodes contained no residue of carcinoma cells but presented diffuse epithelioid granuloma with infiltration of inflammatory cells, partial necrotic lesions and many multinucleated giant cells. In immunohistochemical stains, CD3⁺ and CD8⁺ T cells predominantly infiltrated, while there were few CD4⁺ T cells and a small number of CD20⁺ B cells. We followed her without steroid and other immunosuppressant drug. We should pay attention to the development of sarcoid-like granulomatosis as a rare irAE, which is difficult to be differentiated from cancer progression.

Efficacy of pleural coverage with polyglycolic acid sheet after bullectomy for postoperative recurrence of spontaneous pneumothorax in young patients: a multi-institutional cohort study

OBJECTIVE

Various surgical procedures have been performed to decrease the recurrence of primary spontaneous pneumothorax after video-assisted thoracic surgery. This study aimed to examine the efficiency of pleural coverage for the prevention of postoperative recurrence in relatively young patients.

METHODS

Between January 2008 and December 2012, a total of 357 cases of 345 patients (age 15-29 years) with primary spontaneous pneumothorax who underwent bullectomy at 13 institutions were enrolled in this multi-institutional retrospective cohort study. A concurrent bilateral operation was counted as two cases. Polyglycolic acid sheets were used in 238 cases, and oxidized regenerated cellulose sheets were used in 37 cases to cover the visceral pleura, with no pleural coverage in 82 cases. The average observation period was 4.2 ± 2.0 years.

RESULTS

Postoperative recurrence was observed in 50 cases (14.0%) after video-assisted thoracic surgery. Twenty-six cases (10.9%) in the polyglycolic acid group, eight (21.6%) in the oxidized regenerated cellulose group, and sixteen (19.5%) in the non-coverage group experienced postoperative recurrence. Kaplan-Meier analysis revealed that the rate of freedom from postoperative recurrence in the polyglycolic acid group was significantly higher than that in the non-coverage group. Multivariate analysis showed that age ≥ 20 years and coverage with polyglycolic acid sheets were associated with reduced risk factors for postoperative recurrence.

CONCLUSION

Pleural coverage with a polyglycolic acid sheet is suggested to be effective in preventing postoperative recurrence of pneumothorax compared with non-coverage in relatively young patients.

Pigmented spindle cell variant of a thymic atypical carcinoid in an octogenarian

Background

A pigmented carcinoid is an extremely rare variant of carcinoid characterized by melanin pigmentation of the tumor, with only five cases described in the literature. In addition, thymic carcinoids are rare in elderly patients and their prognosis after resection of the carcinoid tumor is unclear.

Case presentation

An anterior mediastinal tumor was incidentally found in an 82-year-old man who had been diagnosed with acute thoracic empyema. The tumor was considered most likely to be a noninvasive thymoma or thymic carcinoma for which surgery was indicated after the resolution of the empyema. The tumor was completely resected 4 months after the empyema surgery, and the patient had an uneventful postoperative course. A cut surface of the resected specimen was extensively pigmented and appeared dark-brownish, with abundant melanin pigmentation later confirmed in the spindle-shaped tumor cells. Based on the histologic examination and immunohistochemical study, melanoma was eliminated as a differential diagnosis and the tumor was diagnosed as a pigmented atypical carcinoid of the thymus.

Conclusions

This report provides additional knowledge on thymic pigmented carcinoids and thymic atypical carcinoids in elderly patients.

Outcomes of surgical resection for pulmonary metastasis from ovarian cancer

Background

Due to its rarity, information on pulmonary metastasectomy for pulmonary metastasis from ovarian cancer is limited.

Methods

Cases of pulmonary metastasectomy for ovarian cancer were collected in a multi-institutional setting and the outcomes were analyzed.

Results

Among 1508 cases in which pulmonary resection was performed to treat pulmonary metastasis from tumors of various organs, 6 cases (0.4%) involved pulmonary metastasis from ovarian cancer. The mean age was 61 years (range, 39–75 years). The histological types were undifferentiated carcinoma in 2 patients, and clear cell adenocarcinoma, serous papillary cystadenocarcinoma, serous adenocarcinoma, and endometroid adenocarcinoma in 1 patient each. One patient (17%) had a history of liver metastasis at the time of pulmonary resection. The median disease-free interval was 22 months (range, 0 [synchronous]-188 months). The tumor was solitary in 5 patients (83%). The mean tumor size was 15 mm (range, 5–23 mm). All 6 patients underwent complete resection. The type of resection was wide wedge resection in 3 patients, segmentectomy in 2 patients, and lobectomy in 1 patient. Four patients (67%) received postoperative chemotherapy. Thus far, 4 patients (67%) have experienced recurrence after pulmonary resection. In terms of outcomes, 1 patient who had synchronous pulmonary metastasis with the primary tumor died in the early period after pulmonary resection, 1 patient is alive without recurrence after a short follow-up period (5 months), 3 patients have achieved mid- to long-term survival and are alive with disease (38–61 months), and 1 patient achieved long-term (61 months) disease-free survival.

Conclusions

Patients with pulmonary metastasis from ovarian cancer who fulfill the eligibility criteria for pulmonary metastasectomy are rare. Pulmonary metastasectomy for ovarian cancer can provide favorable outcomes in highly selected patients. Patients with synchronous pulmonary metastasis from ovarian cancer are not good candidates for pulmonary metastasectomy.

Prognosis of patients with recurrence after pulmonary metastasectomy for colorectal cancer

OBJECTIVES

We investigated the prognosis of patients with recurrence of pulmonary metastases (PM) from colorectal cancer (CRC) after resection.

METHODS

We reviewed our surgical series of 101 CRC patients with PM who underwent R0 resection with curative intent. The overall survival (OS) and disease-free survival (DFS) rates after metastasectomy as well as the prognostic factors of survival were analyzed.

RESULTS

Fifty-five patients (54%) experienced recurrence, of whom 21 had developed extrapulmonary metastasis (EPM) before lung resection. Multivariate analysis restricted to patients with recurrence identified a disease-free interval (DFI) shorter than a year as an adverse prognosticator of OS (HR, 2.68; 95% CI 1.40-5.51; P < 0.01) and DFS (HR, 8.54; 95% CI 3.0-24.6; P < 0.001). EPM was also identified as an adverse prognosticator of OS for patients with recurrence (HR, 3.16; 95% CI 1.64-5.88; P < 0.001). There was a significant difference in the 5-year OS rate between patients with and without EPM (27.9% vs 64.9%, P < 0.001), and between those with a DFI shorter and longer than a year (40.0% vs 75.0%, P < 0.01). Among these, 31 patients (56%) bore lung-limited recurrence after their first lung resection, of whom 20 (36%) underwent a total of 29 repeat pulmonary metastasectomies, which resulted in a 5-year OS rate of 71.3% after the second lung resection.

CONCLUSIONS

Our findings indicate that CRC patients with PM whose DFI is shorter than a year after lung resection or those with prior EPM more frequently experience multisite recurrence.

Long-Term Outcomes of Pulmonary Metastasectomy for Uterine Malignancies: A Multi-institutional Study in the Current Era

BACKGROUND

Information on pulmonary metastasectomy (PM) for uterine malignancies in the current era is limited. In the present study, we analyzed the clinical course and results of PM for uterine malignancies in the era of modern imaging diagnostics to clarify the role of PM in the current era in a multi-institutional setting.

METHODS

Fifty-seven patients who underwent PM for uterine malignancies between 2006 and 2015 were retrospectively reviewed. The short- and long-term outcomes, along with factors associated with the prognosis, were analyzed. Details of the clinical course after PM were described.

RESULTS

The mean age of patients was 59.4 years. The primary tumor was located in the uterus corpus in 34 cases (60%) and in the uterus cervix in 23 cases (40%). The median disease-free interval (DFI) was 32 months. Forty patients (70%) received fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography before PM, and complete resection was achieved in 52 patients (91%). Postoperative complications occurred in 4 patients (7%). Of the 52 patients who underwent complete resection of pulmonary metastases, 28 experienced recurrence, and among these, 17 (60%) underwent local therapy, including six repeat PMs. Among the 52 patients who underwent complete resection, the 5-year relapse-free survival rate was 40.7% and the 5-year overall survival (OS) rate was 68.8%. The univariate analysis revealed that a DFI of ≤ 24 months was associated with significantly poorer OS.

CONCLUSIONS

PM for uterine malignancies is safe and provides favorable long-term outcomes in selected patients. Patients with a DFI of > 24 months have better OS and are good candidates for PM.

Feasibility of postoperative adjuvant chemotherapy using carboplatin plus S-1 in completely resected non-small cell lung cancer patients

Feasibility is one of the major concerns during adjuvant chemotherapy in patients with completely resected non-small cell lung cancer. A phase II clinical trial of adjuvant chemotherapy with four courses of carboplatin (AUC 5 at day 1) and S-1 (80 mg/m²/day for 2 weeks followed by a 2-week rest) was performed to evaluate the feasibility (UMIN 9101). The primary endpoint was the completion rate and the secondary endpoints were adverse events, 2-year overall survival and disease-free rates. Thirty-five non-small cell lung cancer patients were enrolled. The adjuvant chemotherapy completion rate was 85.3% (29/34); 17/34 (50%) patients completed 4 courses without dose reduction. There were no treatment-related deaths, and Grade 3/4 adverse events included neutropenia (38.2%), leukocytopenia (14.7%), anemia (20.6%), thrombocytopenia (20.6%), anorexia (5.9%), fatigue (5.9%), and oral mucositis (2.9%). Two-year overall and disease-free survival rates were 96.3% and 53.3%, respectively. Adjuvant chemotherapy with carboplatin plus S-1 is safe and feasible.

Upfront surgery in patients with clinical skip N2 lung cancer based on results of modern radiological examinations

Background

Direct lymphatic drainage from a primary tumor to the right paratracheal or aortic window lymph nodes is often noted in pN2 disease. This multi-institutional retrospective study investigated the outcomes of upfront surgery in patients with clinical skip N2 disease (N2 disease without N1 disease) and a tumor in the right upper lobe or left upper segment based on results of modern radiological examinations, including positron emission tomography (PET).

Methods

We identified 143 patients with cN2 disease who underwent upfront surgery in 12 institutions under the Thoracic Surgery Study Group of Osaka University between January 2006 and December 2013. Among 143 patients, 94 who underwent PET were analyzed. We classified these patients into Group A (n=39; clinical skip N2 disease and a tumor in the right upper lobe or left upper segment) and Group B (n=55; other).

Results

The median follow-up was 56.5 months. Among the 94 patients, 50 (53.2%) had skip N2 disease and 65 (69.1%) had a tumor in the right upper lobe or left upper segment. The 5-year overall survival (OS) rates of the 94 patients with cN2 disease was 47.9%. The 5-year OS rates for the cN2pN0/1 (n=22) and cN2pN2 (n=70) groups were 74.9% and 41.2%, respectively (P=0.034). The univariate analysis of OS revealed no significant differences in age, sex, histology, carcinoembryonic antigen (CEA) level, tumor size, PET findings, and number of metastatic lymph nodes when these parameters were dichotomized. A significantly better 5-year OS rate was observed in Group A than in Group B (64.0% vs. 37.0%; P=0.039). The multivariate analysis of OS revealed that Group A was a significantly prognostic factor (P=0.030).

Conclusions

Patients with cN2 disease in Group A had a more favorable prognosis. Upfront surgery may be a treatment option for such selected patients with non-small lung cancer in the specific group.

Aggressive cribriform-morular variant of papillary thyroid carcinoma: Report of an unusual case with pulmonary metastasis displaying poorly differentiated features

The cribriform-morular variant of papillary thyroid carcinoma (CMV-PTC) is a rare morphologic entity in which metastasis rarely occurs. Until now, only three cases of metastasis by CMV-PTC have been reported. We present a rare sporadic case of CMV-PTC with multiple lung metastases in a 28-year-old female, 3 years after total thyroidectomy. The lung tumor was not encapsulated but well-circumscribed and showed a mixture of cribriform, papillary, and solid patterns of growth with necrosis. The tall columnar carcinoma cells did not display the typical nuclear features of PTC. Carcinoma cells were positive for thyroid transcription factor 1, paired-box gene 8, estrogen receptor, progesterone receptor, and adenomatous polyposis coli, and showed positive nuclear and cytoplasmic staining for β-catenin. Carcinoma cells were negative for thyroglobulin and CDX-2, and the Ki-67 labeling index was 22.1%. This immunoprofile suggests a pathological diagnosis of metastasis by a CMV-PTC displaying poorly differentiated features. To the best of our knowledge, our case is the first report of CMV-PTC with pulmonary metastasis that was confirmed by histological and immunohistochemical examinations. The present case suggests that CMV-PTC with a high Ki-67 labeling index may cause visceral metastasis.

A rare case of ectopic papillary thyroid carcinoma transformed into squamous cell carcinoma

A rare case of a metastatic ectopic papillary thyroid carcinoma (PTC) of the lung that transformed into a squamous cell carcinoma (SCC) that resembles pulmonary SCC is reported. A subcutaneous ectopic PTC in the left anterior neck area, together with a normal thyroid gland, were excised. The ectopic PTC showed thyroglobulin, TTF-1 and PAX-8 immunoreactivity and a BRAF V600E mutation. During the post-operative follow-up period, a rapidly growing 2 cm nodular lesion in the lower left lobe of the lung was detected. The lung tumor consisted of solid sheets and nests of squamous cells but without the nuclear features of PTC. Neither papillary nor follicular structures of cancer cells were identified. Carcinoma cells were positive for TTF-1, PAX-8, p40, CK14, and p63, while showing a high Ki-67 labeling index and a BRAF V600E mutation. These results support our interpretation of a PTC that originated from ectopic thyroid tissue in the left anterior neck and that developed a lung metastasis showing squamous cell differentiation.

[Invasive thymoma with extensive growth in the superior vena cava;report of a case]

An anterior mediastinal tumor was incidentally found in a 58-year-old asymptomatic woman on a medical checkup. Computed tomography (CT) demonstrated a large tumor plugging the almost entire lumen of the superior vena cava (SVC), and 3 nodules in the bilateral lungs. The tumor seemed most likely an advanced thymoma or thymic carcinoma extending into the SVC and presenting with lung metastases. The patient underwent a combined resection of the invasive tumor and the SVC under cardiopulmonary bypass (CPB), and lung wedge resection for the nodules. The bilateral brachiocephalic veins were reconstructed with the separate grafts. The invasive tumor and the lung nodules were histologically confirmed as thymoma. Resection and reconstruction of the SVC was successfully performed under CPB for extirpation of an invasive thymoma with extensive intracaval growth. Combination chemotherapy for the relapsing lung metastases finally achieved complete response 41 months after surgery.

Combination of morphological feature analysis and immunohistochemistry is useful for screening of EML4-ALK-positive lung adenocarcinoma

BACKGROUND

A subset of lung cancers harbours the fusion gene echinoderm microtubule-associated protein-like-4-anaplastic lymphoma kinase (EML4-ALK). Recently, immunohistochemistry for ALK has shown sensitivity for the detection of EML4-ALK-positive lung adenocarcinoma almost equal to that of the fluorescence in situ hybridisation (FISH) assay.

AIMS

To study the clinicopathological features of EML4-ALK-positive lung adenocarcinoma in a large number of surgically resected samples using immunohistochemistry, in order to establish a useful screening method for EML4-ALK-positive lung adenocarcinoma.

METHODS

Immunohistochemistry for ALK was used to screen for EML4-ALK-positive lung adenocarcinomas in 254 cases of surgically resected samples.

RESULTS

EML4-ALK-positive cases were detected in 3.1% of lung adenocarcinomas (8/254). EML4-ALK-positive lung adenocarcinomas showed significant associations with intra- and/or extra-cytoplasmic mucin (p=0.0001), and cribriform pattern with excessive extracytoplasmic mucin (p<0.0001). Signet-ring cell appearance alone lacked significance (p=0.149).

CONCLUSION

EML4-ALK-positive lung adenocarcinoma has a tendency to express a characteristic morphological pattern. The combined use of morphological feature analysis and immunohistochemistry may be a useful and cost effective screening method for EML4-ALK lung adenocarcinoma.

[An autopsied case of giant small cell carcinoma of the pancreas]

A 58-year-old man who complained of an abdominal tumor was admitted to our hospital. Abdominal CT scan showed that a 15-cm tumor occupied the entire right upper abdomen and that there were ascites and liver metastases. A liver biopsy was performed. The liver biopsy showed a small cell carcinoma pattern, but no definitive origin of the tumor was determined. Considering the extensive peritoneal invasion and multiple liver metastases, he received 2 / courses of cisplatin/etoposide chemotherapy, but his tumor became larger with concomitant abdominal pain and nausea. The patient suddenly died due to multiple organ failure caused by tumor necrosis. The autopsy revealed a pathological diagnosis of primary small cell carcinoma of the pancreas.

Pheochromocytoma of the posterior mediastinum undiagnosed until the onset of intraoperative hypertension

An asymptomatic 42-year-old man was diagnosed with a posterior mediastinal mass, most likely a nonfunctioning, benign, neurogenic tumor for which thoracoscopic surgery was initially indicated. However, the systemic blood pressure rapidly increased to a critical level immediately after starting the surgical manipulation of the tumor, which was suggestive of a hyperfunctioning pheochromocytoma. The tumor was removed after controlling the blood pressure and was histologically diagnosed as a pheochromocytoma. The patient had an uneventful course, and the tumor was proven to be sporadic through further postoperative investigations. The possibility of extraadrenal pheochromocytoma should be considered in the preoperative diagnosis of an intrathoracic paraaortic tumor, even in an asymptomatic patient.

Wide resection of the upper right hemithorax combined with amputation of the right arm for a recurrent desmoid tumor

A 66-year-old woman had a recurrent desmoid tumor in the right thoracic apex. The tumor infiltrated the brachial plexus and eventually rendered the upper right extremity functionless. The tumor was removed by aggressive wide resection of the right upper hemithorax with simultaneous amputation of the functionless right arm. Reconstruction of the chest wall was accomplished, utilizing the soft tissues of the remnant arm as a pedicled flap to cover the full-thickness defect. Aggressive wide resection of the chest wall with limb amputation is technically challenging but unavoidable in some cases of recurrent desmoid tumor.

Pulmonary lymphoma of mucosa-associated lymphoid tissue type followed as a long-standing indeterminate lesion in immunoglobulin M-type paraproteinemia

An 82-year-old woman with monoclonal immunoglobulin (Ig) M-type paraproteinemia had a large opacity in the right lung field. The abnormal shadow on roentgenogram had persisted for more than 6 years since the initial diagnosis of paraproteinemia, which had been diagnosed as Waldenström's macroglobulinemia (WM). Computed tomography revealed the lesion as a pulmonary tumor which was finally diagnosed as a marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) after surgical removal. MALT lymphoma constitutes the majority of primary pulmonary lymphomas and is often associated with monoclonal IgM-type paraproteinemia as well as WM, a distinctive lymphoproliferative disorder. Pulmonary MALT lymphoma should frequently be suspected in case of an indeterminate pulmonary tumor with IgM-type paraproteinemia.

Non-small-cell lung cancer associated with non-thymomatous myasthenia gravis

A non-small-cell lung cancer without distant metastases was incidentally found in a 77-year-old man who had suffered from myasthenia gravis (MG) without thymoma. The patient's condition was stabilized by oral pyridostigmine bromide which he had taken during the past 6 years. He simultaneously underwent thymectomy and left lower lobectomy with regional lymph node dissection. Although postoperative myasthenic crisis occurred, mechanical ventilation and intravenous steroid pulse relieved the patient and the symptoms improved thereafter. Cases of operable lung cancer with non-thymomatous MG have rarely been reported and the appropriate therapeutic strategy for such cases remains to be debated. Their causal association remains to be identified, whereas some studies have implied that immune disorder due to the abnormal thymus might possibly enhance the oncogenesis of extrathymic malignancies. Myasthenic crisis should also be taken into account in postoperative management of MG patients who simultaneously undergo thymectomy and lobectomy for synchronous lung cancer.

Pulmonary Artery Dissection Complicating Lung Transplantation for Primary Pulmonary Hypertension

We report a case of pulmonary artery (PA) dissection complicating lung transplantation. A 30-year-old man with primary pulmonary hypertension underwent bilateral single lung transplantation. Thirty hours postoperatively he had signs of obstruction of the right main pulmonary artery develop due to dissection demonstrated on transesophageal echocardiography and pulmonary arteriography. Surgical repair of the dissection with reanastomosis of the pulmonary artery was successfully carried out, and the patient subsequently improved to a favorable condition. Pulmonary hypertension is a risk factor of pulmonary artery dissection; our case suggested that underlying chronic pulmonary hypertension might have led to this rare and life-threatening anastomotic problem after lung transplantation.

Metastatic somatostatinoma of the chest wall

A 72-year-old male was diagnosed as having a thoracic tumor in the left chest wall five years after resection of primary pancreatic somatostatinoma. The tumor was suggestive of metastasis to the chest wall or to the left lung from the previously resected somatostatinoma based on the abnormally elevated serum somatostatin level. Percutaneous biopsy confirmed that the lesion was an islet cell tumor and thoracotomy demonstrated metastasis to the left third rib without involvement of the left lung. Our case represents a rare documentation of somatostatinoma metastatic to the chest wall for which complete resection was performed.

A Novel Procedure Using a Tissue Expander for Management of Persistent Alveolar Fistula After Lobectomy

We treated a patient with postlobectomy persistent alveolar fistula using a tissue expander, which is a prosthesis widely used in plastic surgery. The patient had thoracic empyema develop after right bilobectomy for lung cancer, and consequently underwent drainage of empyema followed by muscle flap closure for alveolar fistula. A residual space remained, and air leak persisted. However, implanting and expanding a tissue expander enabled us to tightly fix the flap on the raw pulmonary surface, which eventually solved the air leak. The tissue expander greatly contributed to muscle flap closure for a persistent alveolar-pleural fistula with a large remaining thoracic space.

Solitary fibrous tumor of the pleura presenting as an aneurysm-like lesion with the strongly contrasted tumor stain by angiography

We treated a patient with solitary fibrous tumor of the pleura (SFT) whose angiograms demonstrated its feeders and strongly contrasted tumor stain. Although no one has clearly identified the specific features of SFT on angiograms, SFT can be suspected in the clinical setting if a localized chest wall tumor presents with the feeders and strongly contrasted tumor stain shown by angiography.

Thoracoscopic parasternal lymph node dissection for the staging of breast cancer

With the advent of advanced thoracoscopic techniques, new applications have been expanding their roles in thoracic surgery. The aim of this paper is to introduce our new thoracoscopic approach in performing parasternal lymph node dissection of advanced breast cancer for its staging. This technique does not need the removal of any costal cartilage which is usually done in the conventional classical technique after radical mastectomy. Thoracoscopic procedure, in which wide and complete parasternal lymph node dissection is done, is minimally invasive and easy to perform. Therefore, the thoracoscopic technique may be a suitable alternative to the conventional approach in the future.

Hepatocyte growth factor stimulates proliferation of respiratory epithelial cells during postpneumonectomy compensatory lung growth in mice

Although it is known that the lung undergoes compensatory growth after pulmonary resection, mechanisms by which lung cells exhibit compensatory proliferation are not well defined. We investigated the involvement of hepatocyte growth factor (HGF) in postpneumonectomy compensatory lung regeneration in mice, because HGF has mitogenic and morphogenic actions on lung epithelial cells. Following left pneumonectomy, alveolar and airway epithelial cells underwent compensatory DNA synthesis, reaching maximal levels 5 d after the surgery. Before changes in DNA synthesis in lung epithelial cells, expression of HGF mRNA and protein levels in the remaining lung, liver, and kidney were changed in response to left pneumonectomy, and these changes were associated with postoperative increases in plasma HGF levels. c-Met/HGF receptor expression was localized predominantly in alveolar type II and airway epithelial cells, whereas c-Met/HGF receptor mRNA expressions were transiently upregulated before the peak in lung DNA synthesis. Neutralization of endogenous HGF by an antibody in pneumonectomized mice suppressed the compensatory DNA synthesis in lung epithelial cells, whereas administration of recombinant HGF to pneumonectomized mice stimulated DNA synthesis in lung epithelial cells. These results strongly suggest that HGF has a role as a pulmotrophic factor in postpneumonectomy compensatory lung regeneration.

Mediastinal liposarcoma appearing as a tumor arising in the esophageal wall

We report a case of mediastinal liposarcoma, a relatively uncommon neoplasm, in which the mass also appeared as a tumor arising in the esophageal wall. A 76-year-old man diagnosed with a posterior mediastinal mass had the tumor extirpated in local esophageal myectomy due to its unclear margin on the esophageal wall. The resected specimen was diagnosed as well-differentiated liposarcoma. Preoperative angiography showed the tumor received its blood supply from a branch of the left gastric artery, suggesting it arose in the lower esophageal segment close to the hiatus and extended to the mediastinum. Since this tumor's growth pattern differed completely from esophageal liposarcoma described in previous case reports, we concluded that it was mediastinal liposarcoma.

Enantioselective rhodium(I)-catalyzed hydrogenation of trifluoromethyl ketones

[figure: see text] The asymmetric hydrogenation of trifluoromethyl ketones to yield chiral alpha-trifluoromethyl alcohols with enantiomeric excesses up to 98% was achieved in the presence of chiral rhodium-(amidephosphine-phosphinite) complexes.

A comparison of the new preservation solution Celsior to Euro-Collins and University of Wisconsin solutions in lung reperfusion injury

BACKGROUND

The lung is particularly susceptible to reperfusion injury, both experimentally and clinically after transplantation. The extracellular-type preservation solution Celsior, which has been predominantly studied in cardiac preservation, has components designed to prevent cell swelling, free radical injury, energy depletion, and calcium overload. Using an isolated blood-perfused rat lung model, we investigated whether Celsior would decrease preservation injury and improve lung function after cold ischemic storage and reperfusion compared to Euro-Collins (EC) and University of Wisconsin (UW) solutions.

METHODS

Lewis rat lungs were isolated, flushed with the respective cold preservation solution, and then stored at 4 degrees C for 6 or 12 hr. After ischemic storage, the lung block was suspended from a force transducer, ventilated with 100% O2, and reperfused for 90 min with fresh blood via a cannula in the pulmonary artery. Lung compliance, alveolar-arterial oxygen difference, and outflow oxygen tension were all measured. The capillary filtration coefficient (Kf), a sensitive measure of changes in microvascular permeability, was determined.

RESULTS

For 6 hr of cold storage, lungs stored in Celsior had lower Kf values than those stored in EC, indicating decreased microvascular permeability. No other significant differences were noted between Celsior and EC or UW. For 12 hr of cold storage, Celsior provided increased oxygenation, decreased alveolar-arterial O2 differences, increased compliance, and decreased Kf values as compared to both EC and UW.

CONCLUSIONS

Celsior provides better lung preservation than EC or UW as demonstrated by increased oxygenation, decreased capillary permeability, and improved lung compliance, particularly at 12-hr storage times. These results are highly relevant, inasmuch as EC and UW are the most common clinically used lung preservation solutions. Further studies of Celsior in experimental and clinical lung transplantation, as well as in other solid organs, are indicated.

[Effect of unilateral superior cervical sympathetic ganglionectomy on the contralateral ganglion in rat]

The effect of unilateral superior cervical sympathetic ganglionectomy on the contralateral ganglion was investigated in Sprague-Dawley male rats employing histological and morphometrical procedures. Neuronal cells showed cell enlargement and no change in the nuclear size and the cell number. Neuronal hypertrophy was due to innervation by some fibers of the contralateral half of organs which had been innervated by the ipsilateral ganglion.

[Pathohistological changes of the superior cervical ganglion after 99.5% ethyl alcohol injection]

The authors attempted to clarify the histological changes of superior cervical ganglion (SCG) cells in chronological order. Adult rat SCGs were injected with ethyl alcohol and were examined under light microscopy after fixation and histological processes. All neurons showed the so-called coagulation necrosis. Inflammatory reactions characterized by cellular invasion were delayed in contrast to ethyl alcohol exposure from outside of the ganglion capsule.

Addition of aprotinin to organ preservation solutions decreases lung reperfusion injury

BACKGROUND

Organ preservation injury is associated with endothelial cell damage, destabilization of mitochondrial and cell membranes, and the release of proteolytic enzymes. In addition to its well-known clinical effect of reducing perioperative blood loss, aprotinin has antiproteolytic and membrane-stabilizing properties. We hypothesized that adding aprotinin to Euro-Collins (EC) and University of Wisconsin (UW) solutions would decrease preservation injury in cultured endothelial cells and a whole organ rat lung model.

METHODS

Bovine aortic endothelial cells were cultured and stored in the respective solution at 4 degrees C for 12 or 48 hours. Endothelial cell viability after storage was assessed by dimethylthiazole tetrazolium cytotoxicity assay. In the whole organ model, rat lungs were isolated, flushed with the respective solution, and stored at 4 degrees C for 6 or 12 hours. The lungs were ventilated with 100% O2 and reperfused with fresh blood. Alveolar-arterial O2 difference, O2 tension, capillary filtration coefficient, and compliance were determined.

RESULTS

Endothelial cell viability was optimized with the addition of aprotinin to EC and UW at a dose of 150 KIU/mL (0.02 mg/mL). In the isolated perfused lung model, after 6 hours of ischemic storage, aprotinin-enhanced (100 KIU/mL [0.014 mg/mL]) EC and UW decreased alveolar-arterial O2 difference, increased O2 tension, and decreased capillary filtration coefficient compared with EC and UW alone. After 12 hours of ischemic storage, aprotinin-enhanced EC and UW decreased alveolar-arterial O2 difference, increased O2 tension, decreased capillary filtration coefficient, and increased compliance compared with EC and UW alone.

CONCLUSIONS

The addition of aprotinin to EC and UW solutions increases endothelial cell viability in hypoxic cold storage conditions. In terms of whole organ function, aprotinin improves lung preservation as demonstrated by increased oxygenation and compliance, and decreased capillary permeability. This study is clinically applicable as there is already extensive experience with the use of aprotinin in heart and lung transplant recipients, in addition to its routine use in conventional cardiac operations.

Addition of a mast cell stabilizing compound to organ preservation solutions decreases lung reperfusion injury

OBJECTIVE

Research in lung transplant preservation has generally focused on free radicals and enzyme release from neutrophils, parenchymal cells, macrophages, and endothelium. The lung has a large resident population of mast cells that, when activated, release potent inflammatory mediators. We hypothesized that adding an inhibitor of mast cell degranulation, lodoxamide tromethamine (10 micromol/L), to Euro-Collins and University of Wisconsin preservation solutions, would decrease lung preservation injury.

METHODS

Rat lungs were isolated, flushed with the respective solution, and stored at 4 degrees C for 6 or 12 hours. The lungs were reperfused with fresh blood and ventilated with 100% oxygen. Alveolar-arterial oxygen difference, oxygen tension, capillary filtration coefficient, and compliance were determined.

RESULTS

After 6 hours of ischemic storage: lodoxamide tromethamine-enhanced Euro-Collins solution decreased alveolar-arterial oxygen difference from 539 to 457 (p = 0.004), increased oxygen tension from 119 to 205 mm Hg (p = 0.006), and decreased capillary filtration coefficient from 3.9 to 2.0 (p < 0.001); lodoxamide tromethamine-enhanced University of Wisconsin solution decreased alveolar-arterial oxygen difference from 546 to 317 (p < 0.001), increased oxygen tension from 166 to 335 mm Hg (p < 0.001), and decreased capillary filtration coefficient from 3.0 to 1.7 (p < 0.001). After 12 hours of ischemic storage, lodoxamide tromethamine-enhanced Euro-Collins solution decreased alveolar-arterial oxygen difference from 588 to 485 (p < 0.001), increased oxygen tension from 100 to 161 mm Hg (p = 0.012), decreased capillary filtration coefficient from 6.2 to 2.6 (p < 0.001), and increased compliance from 0.12 to 0.21 (p < 0.001); lodoxamide tromethamine-enhanced University of Wisconsin solution decreased alveolar-arterial oxygen difference from 478 to 322 (p < 0.001), increased oxygen tension from 214 to 335 mm Hg (p < 0.001), decreased capillary filtration constant from 4.2 to 2.0 (p < 0.001), and increased compliance from 0.20 to 0.25 (p < 0.001).

CONCLUSIONS

Addition of lodoxamide tromethamine to Euro-Collins or University of Wisconsin solution results in a marked decrease in lung reperfusion injury as demonstrated by increased oxygenation, decreased microvascular permeability, and increased compliance. These results are relevant as Euro-Collins and University of Wisconsin solutions are the most common clinically used lung preservation solutions. This study also highlights the deleterious role of resident mast cells in preservation injury.

Thoracoscopic treatment of esophagobronchial fistula with esophageal diverticulum

Thoracoscopic fistulectomy and diverticulectomy for esophagobronchial fistula with esophageal diverticulum were performed on a 49-year-old-woman. The neck of the diverticulum and the fistula were divided with endo-stapling technique. Intraoperative esophagoscopy was found to be useful for the definite localization and complete excision of the fistula and the diverticulum and the avoidance of stenosis of the esophagus. To avoid the recurrence of fistula, a pedicle of viable mediastinal pleura was interposed between esophageal and bronchial closures. Postoperative course was uneventful, and the complete relief of symptom was experienced for a period of 10 months after the operation. It is to be considered that the present thoracoscopic procedure with intraoperative esophagoscopy can be used as a standard operative procedure for esophagobronchial fistula with esophageal diverticulum.

Histopathological study on bone changes induced by recombinant granulocyte colony-stimulating factor in rats

Histopathological bone changes were examined in growing rats intravenously administered with high doses (100 and 1000 micrograms/kg/day) of recombinant human granulocyte colony-stimulating factor (rG-CSF) for 28 days. The changes were observed in the region where physiological bone resorption actively occurs in the growth phase, that is the trabeculae of metaphyseal spongy bone and the endosteum region of diaphyseal compact bone. Histologically, the changes involved accelerated osteoclastic bone resorption and osteogenesis due to intramembranous ossification. While osteoclastic bone resorption was observed in almost all lesions, about half of which were accompanied by osteogenesis. Bone changes which appeared after administration of rG-CSF were characterized by frequent occurrence at the site of highly osteoclastic activity and by initial osteoclastic resorption followed by osteogenesis due to intramembranous ossification. These results suggest that the main action of rG-CSF on bone may be an acceleration of osteoclastic bone resorption.

The age-related difference in bone changes in rats induced by recombinant human granulocyte colony-stimulating factor

We examined the bone changes in recombinant granulocyte colon-stimulating factor (rhG-CSF)-treated young and young adult rats in order to investigate the effect of age-related conditions of bone growth on the bone changes induced by rhG-CSF. Recombinant human G-CSF (100 and 1,000 micrograms/kg/day) was given to rats by daily intravenous injection for 28 days starting at the age of either 6 or 14 wk, and the hindlimb bones were evaluated histopathologically. In the young rats, bone lesions were observed in the 100- and 1,000-micrograms/k groups. In the young adult rats, lesions were found only in the 1,000-micrograms/kg group. The lesions involved accelerated osteoclastic bone resorption and osteogenesis due to intramembranous ossification and there was no age-related difference in these histopathological findings. However, both the incidence of bone involvement and the severity of lesions were greater in the young rats than in the dose-matched young adult rats. The results suggest that the higher dose of rhG-CSF may intrinsically induce bone lesions of a particular histopathological nature in rats regardless of their age, and the action of rhG-CSF on bone may be stronger in young growing rats than in young adults.

Thoracoscopic surgery combined with a supraclavicular approach for removing superior mediastinal tumor

This report introduces our new technique of thoracoscopic surgery combined with a supraclavicular approach for removing superior mediastinal tumor. A 68-year-old woman noticed a tumor palpable in the left supraclavicular fossa. The patient had no pain around the neck and shoulder. A radio-opaque shadow 6 cm in diameter was detected in her left apical lung field on chest roentgenogram. Chest CT and MRI showed that the tumor was located in the superior mediastinum, extending up to the thoracic inlet, and there was no invasion of the surroundings. At first, a thoracoscopic examination was performed to assess the possibility of the excision. After dissecting the tumor from the mediastinal tissue and the first costovertebrae as far as possible by thoracoscopic surgery, a supraclavicular approach was used to enter the thoracic cavity. Complete resection of the tumor was successfully performed by thoracoscopic surgery combined with a supraclavicular approach. The tumor was removed in a plastic bag through the supraclavicular defect. Postoperative histopathology revealed that the tumor was a benign neurogenic one. A satisfactory follow-up of 5 postoperative days was observed without any complications, and the patient was discharged. The procedure was safe, easy, and minimally invasive to perform. Moreover, the supraclavicular approach could be used to add trocar port if needed.

Rapid induction of more malignant tumors by various genotoxic carcinogens in transgenic mice harboring a human prototype c-Ha-ras gene than in control non-transgenic mice

In this study, we investigated the carcinogenic response of transgenic mice carrying the human prototype c-Ha-ras gene, namely Tg rasH2/CB6F1 mice, to various genotoxic carcinogens and compared it with that of control non-transgenic CB6F1 mice (non-Tg mice). The present studies were conducted as the first step in the evaluation of the Tg rasH2/CB6F1 mouse as a model for the rapid carcinogenicity testing system. Short-term (< or = 6 months) rapid carcinogenicity tests of various genotoxic carcinogens, 4-nitroquinoline-1-oxide, cyclophosphamide, N,N-diethylnitrosamine, N-methyl-N-nitrosourea, N-methyl-N'-nitro-N-nitrosoguanidine and methylazoxymethanol, revealed that Tg rasH2/CB6F1 mice are more susceptible to these genotoxic carcinogens than control non-Tg mice. Tg rasH2/CB6F1 mice developed tumors more rapidly compared with non-Tg mice. Malignant tumors were observed only in the carcinogen-treated Tg rasH2/CB6F1 mice, but not in non-Tg mice treated with the same carcinogens. Each carcinogen induced tumors in corresponding target tissues of the Tg rasH2/CB6F1 mice. Only a very few lung adenomas but no other tumors were seen as spontaneous tumors during the 6 months of carcinogenicity tests. These results demonstrate that more rapid onset and higher incidence of more malignant tumors can be expected with high probability after treatment with various genotoxic carcinogens in the Tg rasH2/CB6F1 mice than in control non-Tg mice. The Tg rasH2/CB6F1 mouse seems to be a promising candidate as an animal model for the development of a rapid carcinogenicity testing system.

Effects of a calcium channel blocker, nicardipine, on pressure-natriuresis in Dahl salt-sensitive rats

The effects of a calcium channel blocker, nicardipine, on pressure-natriuresis responses were studied in Dahl salt sensitive (DS) and resistant (DR) rats. Differences in the neural and endocrine background were minimized by renal denervation and by holding plasma vasopressin, aldosterone, corticosterone, and norepinephrine levels constant by intravenous infusion. The renal plasma flow (RPF) and glomerular filtration rate (GFR) of DS rats were disautoregulated in the low renal perfusion pressure range, while those of DR rats were autoregulated. Administration of nicardipine (0.3 microgram/kg/min) into the renal artery significantly increased RPF and GFR and abolished the autoregulation in both strains of rats. Nicardipine also sharpened the pressure-natriuresis responses in both strains without changes in fractional excretion of sodium. These findings suggest that nicardipine increased GFR and thereby improved the pressure-natriuresis responses of DS rats.

Contribution of prostaglandins to pressure natriuresis in Dahl salt-sensitive rats

To examine the role of prostaglandins on pressure natriuresis in Dahl salt-sensitive (DS) rat, the pressure-natriuresis relationships in DS and Dahl salt-resistant (DR) rats were characterized with or without indomethacin (2 mg/kg/h) by utilizing an in vivo renal perfusion study. When untreated, in the DS rat the pressure-natriuresis curve was blunted (P less than .05) and excretion of prostaglandin E2 (38 +/- 11 to 109 +/- 43 pg/min) was decreased in comparison to the DR rat. With indomethacin, the pressure-natriuresis curve in the DR rat was blunted, while no significant changes were observed in the DS rat. Plasma renin activity and concentration of atrial natriuretic peptide were not changed by the treatment of indomethacin in both strains. These results suggest that the decrease in renal prostaglandins, at least in prostaglandin E2, plays some role in blunting pressure natriuresis in DS rat.

Different effects of low and high doses of endothelin on haemodynamics and hormones in the normotensive conscious dog

The effects of low-dose endothelin on systemic haemodynamics and vasoactive hormones were examined in conscious dogs. In addition, we examined the effects of endothelin on pressor responses to noradrenaline and angiotensin II and the baroreflex regulation of heart rate in conscious dogs. Continuous infusion of 40 fmol/kg per min endothelin for 40 min induced a mild but significant reduction in mean arterial pressure from 89.1 +/- 1.7 to 82.7 +/- 2.0 mmHg (P less than 0.05), associated with decreases in total peripheral resistance 20 min later. A 400 fmol/kg per min dose of endothelin, on the other hand, induced a gradual elevation of mean arterial pressure from 89.2 +/- 2.3 to 96.8 +/- 2.0 mmHg (P less than 0.05), associated with increases in total peripheral resistance over 30 min. The 40 fmol/kg per min dose of endothelin infusion induced a significant reduction in plasma arginine vasopressin (AVP; P less than 0.05) and elevations of plasma atrial natriuretic peptide (ANP; P less than 0.05), plasma prostaglandin E2 (PGE2; P less than 0.05) and plasma 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha; P less than 0.05). The 400 fmol/kg per min dose produced elevations of AVP, ANP, PGE2 and 6-keto-PGF1 alpha (P less than 0.05). Pressor responses to noradrenaline and angiotensin II were significantly attenuated during continuous infusion of 40 fmol/kg per min endothelin, whereas 400 fmol/kg per min endothelin did not induce any significant changes compared with the control. Furthermore, baroreflex sensitivity was attenuated with 40 fmol/kg per min endothelin but did not show any significant changes at 400 fmol/kg per min.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcitonin gene-related peptide modulates adrenal hormones in conscious dogs

The effects of a small dose (2 pmol/kg) of human calcitonin gene-related peptide I on plasma renin activity and hormones, including, aldosterone, ACTH, cortisol, AVP and ANH, were investigated in 14 conscious dogs. In addition, we studied the effects of calcitonin gene-related peptide on aldosterone secretion when it is stimulated by angiotensin II and ACTH. An intravenous bolus injection of 2 pmol/kg of calcitonin gene-related peptide raised plasma renin activity (by 216%, p less than 0.05), ACTH (by 85%, p less than 0.05), AVP (by 89%, p less than 0.05), and ANH (by 36%, p less than 0.05). Despite the elevation of plasma renin activity, aldosterone was decreased (by 52%, p less than 0.05). Cortisol did not change significantly. Infusion of 1 pmol.kg-1.min-1 of angiotensin II produced an elevation of aldosterone (by 186%, p less than 0.01), which was completely inhibited by pretreatment with an injection of 2 pmol/kg of calcitonin gene-related peptide. On the other hand, aldosterone secretion stimulated by ACTH was not altered significantly by pretreatment with an injection of 2 pmol/kg of calcitonin gene-related peptide. These results suggest that calcitonin gene-related peptide inhibits aldosterone secretion, especially when aldosterone is stimulated by angiotensin II. In addition, calcitonin gene-related peptide may be involved as an endocrine modulator in the physiological control of other several hormones closely related to the hemodynamics.

[Six-month intraperitoneal toxicity study of cefpirome sulfate in rats]

A six-month intraperitoneal chronic toxicity study of cefpirome sulfate (CPR) in rats as well as a two-month recovery study were carried out at dose levels of 51.2, 128, 320 and 800 mg/kg/day. The results are as follows. 1. CPR caused no remarkable clinical signs in the general condition of the animals. 2. Body weight gain was depressed in males and females given 800 mg/kg/day. Food consumption, however, was not afected at any dose level. Water consumption increased in males and females at dose of greater than or equal to 320 mg/kg/day. 3. Except an increase in urine volume in males at 800 mg/kg/day, no abnormalities in urinary parameters were found. 4. Frequent decreases in erythrocyte count, hematocrit and hemoglobin concentration were seen in males and females of the 800 mg/kg/day group. At this dose, certain males and females also showed an increase in the reticulocyte count. 5. The serum-biochemical examinations showed a very slight or slight decrease in total cholesterol in males and females given 320 mg/kg/day or more, and increases in uric acid and inorganic phosphorus concentration in some males and females given 800 mg/kg/day. 6. Very slight or slight increases in spleen weight in males and females at a dose of greater than or equal to 320 mg/kg/day, in thyroid weight in females at a dose of greater than or equal to 320 mg/kg/day and in kidney weight in males given 320 mg/kg/day or more as well as in females at 800 mg/kg/day were measured. Further, a decrease in thymus weight was seen in females of the 800 mg/kg/day group. 7. At autopsy, very slight or slight reddish browning of the thyroid was seen in males given 320 mg/kg/day or more and in females given 800 mg/kg/day.(ABSTRACT TRUNCATED AT 400 WORDS)

A case of pseudotumor cerebri following glucocorticoid therapy in which warfarin prevented recurrence

A patient with nephrotic syndrome developed pseudotumor cerebri following glucocorticoid therapy. Diagnosis of pseudotumor cerebri was based on satisfaction of four criteria proposed by Ahlskog and O'Neill. The symptoms of pseudotumor cerebri disappeared within 10 days. After a three-week interval of remission, relapse occurred. Glycerol and urokinase produced rapid resolution of the symptoms and warfarin prevented further recurrence of pseudotumor cerebri for one year. These results suggest that the pathogenesis of pseudotumor cerebri might be associated with the hypercoagulable state which was induced by glucocorticoid therapy and nephrotic syndrome.

Swelling of the Golgi apparatus and decrease of galactosyltransferase in polyamine-deficient bovine lymphocytes and epithelium of mouse small intestine

When bovine small lymphocytes stimulated by concanavalin A were treated with inhibitors (alpha-difluoromethylornithine (5 mM) and ethylglyoxal bis(guanylhydrazone) (100 microM)] of polyamine biosynthesis, swelling of the Golgi apparatus was observed. This was accompanied by decreases in the amount of the Golgi apparatus and of the specific activity of galactosyltransferase. Both spermidine and spermine, at physiological concentrations, stimulated galactosyltransferase activity 2-3-fold. When mice were treated with these inhibitors, the following changes were observed in the epithelial cells of small intestine: swelling of the Golgi apparatus; decrease in the amount of the Golgi apparatus; and decrease of galactosyltransferase activity.