Optimal timing of thoracoscopic drainage and decortication for empyema

BACKGROUND

Although video-assisted thoracic surgery (VATS) pleural drainage and decortication have been proven to be effective treatments in the early stages of empyema, the optimal timing of VATS is still not clear. To assess the effectiveness of early VATS drainage and decortication, we reviewed the records of patients who underwent VATS and open decortication for empyema.

METHODS

One hundred twenty-eight patients with empyema were treated with VATS and open decortication over 8 years at Korea University Anam Hospital. The VATS patients (120 patients) were divided into 3 groups based on the interval between the onset of chest symptoms and the time of operation (group 1: <2 weeks; group 2: 2 to 4 weeks; group 3: >4 weeks). Additional 8 open decortication patients with symptom durations greater than 4 weeks were compared with group 3 patients.

RESULTS

Groups 1 and 2 showed shorter chest tube duration, postoperative hospital stay, surgical procedure time, and fewer prolonged air leaks than group 3. No significant difference was noted between groups 1 and 2; and no difference was noted in the length of postoperative intensive care unit stays or the reintervention and reoperation rates among the 3 groups. In chronic empyema patients, group 3 showed shorter chest tube duration than the open decortication group.

CONCLUSIONS

Patients with symptom durations of less than 4 weeks showed better early results than those with symptom durations greater than 4 weeks. Thus, symptom duration can be considered a reliable preoperative factor in deciding the surgical management of empyema or cases involving loculated pleural effusion.

Targeting of the Hedgehog signal transduction pathway suppresses survival of malignant pleural mesothelioma cells in vitro

OBJECTIVE

The present study sought to determine whether the Hedgehog (Hh) pathway is active and regulates the cell growth of cultured malignant pleural mesothelioma (MPM) cells and to evaluate the efficacy of pathway blockade using smoothened (SMO) antagonists (SMO inhibitor GDC-0449 or the antifungal drug itraconazole [ITRA]) or Gli inhibitors (GANT61 or the antileukemia drug arsenic trioxide [ATO]) in suppressing MPM viability.

METHODS

Selective knockdown of SMO to inhibit Hh signaling was achieved by small interfering RNA in 3 representative MPM cells. The growth inhibitory effect of GDC-0449, ITRA, GANT61, and ATO was evaluated in 8 MPM lines, with cell viability quantified using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Cell death was determined by annexinV/propidium iodide staining and flow cytometry.

RESULTS

SMO small interfering RNA mediated a two- to more than fivefold reduction of SMO and Gli1 gene expression as determined by real-time quantitative reverse-transcriptase polymerase chain reaction, indicating significant Hh pathway blockade. This was associated with significantly reduced cell viability (34% ± 7% to 61% ± 14% of nontarget small interfering RNA controls; P = .0024 to P = .043). Treating MPM cells with Hh inhibitors resulted in a 1.5- to 4-fold reduction of Gli1 expression. These 4 Hh antagonists strongly suppressed MPM cell viability. More importantly, ITRA, ATO, GANT61 induced significant apoptosis in the representative MPM cells.

CONCLUSIONS

Hh signaling is active in MPM and regulates cell viability. ATO and ITRA were as effective as the prototypic SMO inhibitor GDC-0449 and the Gli inhibitor GANT61 in suppressing Hh signaling in MPM cells. Pharmaceutical agents Food and Drug Administration-approved for other indications but recently found to have anti-Hh activity, such as ATO or ITRA, could be repurposed to treat MPM.

Analgesia in patients undergoing thoracotomy: epidural versus paravertebral technique. A randomized, double-blind, prospective study

BACKGROUND

Pain control after thoracotomy prevents postsurgical complications and improves respiratory function. The gold standard for post-thoracotomy analgesia is the epidural catheter. The aim of this study was to compare it with a new technique that involves placement of a catheter in the paravertebral space at the end of surgery under a surgeon's direct vision.

METHODS

From November 2011 to June 2012, 52 patients were randomized into 2 groups depending on catheter placement: an epidural catheter for group A and a paravertebral catheter for group B. At 12, 24, 48, and 72 hours after surgery, the following parameters were recorded: (1) pain control using the patient's completion of a visual analog scale module, (2) respiratory function using forced expiratory volume in 1 second and ambient air saturation, and (3) blood cortisol values as an index of systemic reaction to pain.

RESULTS

Statistically significant differences (P < .05) were found in favor of group B for both cough and rest pain control (P = .002 and .002, respectively) and respiratory function in terms of forced expiratory volume in 1 second and ambient air saturation levels (P = .023 and .001, respectively). No statistically significant differences were found in blood cortisol trends between the 2 groups (P > .05). Collateral effects such as vomiting, nausea, low pressure, or urinary retention were observed only in group A. No collateral effects were recorded in the paravertebral group.

CONCLUSIONS

According to our data, drugs administered through a paravertebral catheter are very effective. Moreover, it does not present contraindications to its positioning or collateral effects. More studies are necessary to confirm data we collected.

Chylothorax complicating pulmonary resection for lung cancer: effective management and pleurodesis

BACKGROUND

Chylothorax associated with pulmonary resection for lung cancer, although rare, must be considered as a potential complication during thoracic surgery. In the present study, we investigated the effectiveness of a conservative approach (diet or pleurodesis) to the management of chylothorax.

METHODS

Between January 2000 and December 2010, 3,120 consecutive patients underwent pulmonary resection and mediastinal lymph node dissection at our institution. Among them, 67 patients with confirmed chylothorax were retrospectively reviewed.

RESULTS

Right-sided chylothorax was more common than left-sided chylothorax (p=0.033). All patients were initially treated with nil per os (NPO; n=46) or a low long-chain triglyceride (LCT) diet (n=21). In the NPO group, 24 patients were successfully treated with diet alone and 20 underwent pleurodesis. In the LCT group, 10 patients were successfully treated with diet alone; of the 11 remaining patients, 4 patients improved after NPO. The 7 patients who did not improve with NPO underwent pleurodesis. No significant differences in chest tube output before and after initial treatment, length of stay, or success rate were observed between patients initially treated with NPO and those receiving low LCT. All 32 pleurodeses performed in 27 patients were successful. Two patients underwent surgery without pleurodesis after dietary treatment failure. Postoperative air leakage or drainage for 5 days greater than 21.6 mL/kg were independent risk factors for dietary treatment failure.

CONCLUSIONS

Conservative treatment, including pleurodesis, should be the first choice of treatment for chylothorax complicating pulmonary resection.

The rate of pleural fluid drainage as a criterion for the timing of chest tube removal: theoretical and practical considerations

Clinicians place chest tubes approximately 1 million times each year in the United States, but little information is available to guide their management. Specifically, use of the rate of pleural fluid drainage as a criterion for tube removal is not standardized. Absent such tubes, pleural fluid drains primarily through parietal pleural lymphatics at rates approaching 500 mL of fluid per day or more for each hemithorax. Early removal of tubes does not appear to be harmful. A noninferiority randomized trial currently in progress comparing removal without considering the drainage rate to a conservative threshold (2 mL/kg body weight in 24 hours) may better inform tube management.

Clinical indications and results after chest wall resection for recurrent mesothelioma

OBJECTIVE

The ipsilateral hemithorax is the most common site of recurrence after surgical resection for malignant pleural mesothelioma. Salvage treatment has generally been ineffective. We reviewed the outcomes after resection of isolated ipsilateral chest recurrence after cytoreductive surgery in patients with malignant pleural mesothelioma.

METHODS

Patients with malignant pleural mesothelioma who underwent initial surgical resection at our institution from 1988 to 2011 and were subsequently treated for localized recurrence with an additional chest resection were identified and their data retrospectively reviewed.

RESULTS

A total of 1142 patients underwent either extrapleural pneumonectomy (n = 794) or pleurectomy/decortication (n = 348). Of the patients who returned for follow-up, 47 (4.1%) had chest wall recurrence amenable to resection. The location of recurrence was predominantly incisional (49%) and/or costophrenic (38%). The median time to recurrence after either extrapleural pneumonectomy or pleurectomy/decortication was 16.1 months (range, 2.7-58.2). No 30-day mortality was found for chest wall resection, and the median length of stay in the hospital was 3 days (range, 0-12). The median overall survival duration after chest wall resection correlated positively with the time to recurrence (epithelial: median, 8.9, 17.2, and 35.8 months for a time to recurrence of <12, 12 to <24, and ≥24 months, respectively; biphasic: median, 2.7 and 15.9 months for a time to recurrence of <10 and ≥10 months, respectively).

CONCLUSIONS

Chest wall resection is a safe and effective therapeutic option in the management of localized chest wall recurrence of malignant pleural mesothelioma. The time to recurrence appears to be predictive of the expected survival benefit in both epithelial and biphasic malignant pleural mesothelioma.

A novel surgical approach to refractory hepatic hydrothorax

Hepatic hydrothorax is defined as the presence of a pleural effusion in a patient with liver cirrhosis in the absence of cardiopulmonary disease, and it is a devastating complication impairing quality of life in the end stage of liver disease. The management of the effusion is challenging, and chest tube drainage can sometimes cause more serious complications by removing massive amounts of protein-rich fluid. Though the most plausible mechanism is the influx of ascites to the pleural cavity through a small diaphragmatic defect, the defect often cannot be found. Hepatic hydrothorax could be controlled by repairing an invisible defect of the diaphragm. With pneumoperitoneum after intraperitoneal administration of indocyanine green, the defect, clearly dyed green, appeared on the diaphragm. This novel combination technique could be useful for ensuring the surgical repair of an invisible diaphragmatic defect.

The Anti-inflammatory Effect of Soluble Epoxide Hydrolase Inhibitor and 14, 15-EET in Kawasaki Disease Through PPARγ/STAT1 Signaling Pathway

Soluble epoxide hydrolase (sEH) is responsible for rapid degradation of 14, 15-EET, which is one of the isomers of EETs and plays an important role in cardiovascular diseases. In this study, we investigated the mechanism by which sEH inhibitor AUDA played an anti-inflammatory effect in HCAECs. Our results indicated that AUDA treatment promoted PPARγ expression, while knockdown of PPARγ blocked the cell growth and STAT1 expression inhibition induced by 100 μmol/L AUDA in HCAECs. AUDA also inhibited the overexpression of TNF-α, IL-1 β, and MMP-9 induced by KD sera in HCAECs. Moreover, 30 blood samples from children with Kawasaki disease (KD) were collected with 30 healthy children as the control group. QPCR and ELISA assays were used to detect the level of 14, 15-EET, TNF-α, IL-1β, and MMP-9. We found that the level of 14, 15-EET was higher in peripheral blood of children with KD compared with healthy controls (P < 0.05). In comparison to KD children with non-coronary artery lesion (nCAL), the level of 14, 15-EET was higher in peripheral blood of KD children with coronary artery lesion (CAL) (P < 0.05). Compared with healthy control group, the expression levels of TNF-α, IL-1β, and MMP-9 in patients with KD were significantly up-regulated. Compared with nCAL KD children, the expression levels of TNF-α, IL-1β, and MMP-9 in CAL children were abnormally high (P < 0.05). Our study indicated that AUDA played an anti-inflammatory effect in HCAECs through PPARγ/STAT1 signaling pathway, and 14, 15-EET is up-regulated in children with KD, suggesting that 14, 15-EET involved in the progression of KD.

A comparison of the usefulness of nuclear beta-catenin in the diagnosis of desmoid-type fibromatosis among commonly used anti-beta-catenin antibodies

Desmoid-type fibromatosis (DF) is a locally aggressive but non-metastatic (myo)fibroblastic neoplasm. A hallmark of the tumor is nuclear positivity for beta-catenin in immunohistochemistry due mostly to CTNNB1 mutations. However, a recent study has reported that even beta-catenin 'nuclear-negative' DFs can harbor CTNNB1 mutations and that the positive ratio of nuclear beta-catenin in DF is different among antibodies. Here, we reviewed soft tissue lesions for which the possibility of DF was considered and compared the sensitivity and specificity of nuclear beta-catenin for the diagnosis of DF among commonly used anti-beta-catenin antibodies, i.e., clone beta-catenin 1, 17C2 and 14. We analyzed 26 cases of DF, 28 cases of benign fibroblastic lesions, and 27 cases of other soft tissue tumors. The sensitivity and specificity of nuclear beta-catenin for the diagnosis of DF were different among antibodies; 54% and 98% in clone beta-catenin 1, 85% and 84% in 17C2, and 96% and 62% in 14. IHC of LEF1 showed comparable results with IHC of beta-catenin, with a sensitivity of 88% and specificity of 76%. Additionally, when beta-catenin 1 was used, DFs showed characteristic dotted cytoplasmic staining, often appearing as rings. Our results might be helpful for making a correct diagnosis of DF.

Video-guided tube thoracostomy with use of an electrical nonfiberoptic endoscope

PURPOSE

Tube thoracostomy is a common and generally safe procedure. However, potential hazards can occur during placement of the chest tube. Inasmuch as unexpected injuries may arise from tube thoracostomy, we propose a novel video-guided method.

DESCRIPTION

We used an independent complementary metal oxide semiconductor image sensor with a processing chip to obtain a front view image of the chest cavity. The device is connected to an aluminum shaft with four small light-emitting diode crystals in the tip, and a detachable small monitor with a battery inside. The apparatus is small and can be used to direct vision-guided tools in tube thoracostomy.

EVALUATION

We performed video-guided tube thoracostomy in 6 patients with pleural adhesions. All patients experienced good tolerance to the procedure and had no immediate adverse events. The thoracostomies were performed by a single surgeon with good acceptability, and each procedure was completed in less than 10 minutes.

CONCLUSIONS

In some cases of pleural adhesion, the video-guided thoracostomy may be a safer alternative to non-image guided tube thoracostomy.

Huge inflammatory myofibroblastic tumor of pleura with concomitant nuchal fibroma

Inflammatory myofibroblastic tumor (IMT) is a rare benign neoplasm. It is a challenging disease because the symptoms and radiologic findings are diverse and nonspecific. Although pulmonary IMT is the most common form, pleural origin is an extremely rare clinical entity. Nuchal fibroma (NF) is another rare benign neoplasm. We report herein a case of pleural IMT with concomitant NF in a 15-year-old girl. To the best of our knowledge, this is the first report suggesting an association between IMT and NF, and our case had the largest reported intrathoracic IMT. Moreover, we found a possible association between IMT and increased CA-125 levels.

14,15-Epoxyeicosatrienoic Acid Protect Against Glucose Deprivation and Reperfusion-Induced Cerebral Microvascular Endothelial Cells Injury by Modulating Mitochondrial Autophagy via SIRT1/FOXO3a Signaling Pathway and TSPO Protein

Neurovascular system plays a vital role in controlling the blood flow into brain parenchymal tissues. Additionally, it also facilitates the metabolism in neuronal biological activities. Cerebral microvascular endothelial cells (MECs) are involved in mediating progression of the diseases related to cerebral vessels, including stroke. Arachidonic acid can be transformed into epoxyeicosatrienoic acids (EETs) under the catalysis by cytochrome P450 epoxygenase. We have reported that EETs could protect neuronal function. In our research, the further role of 14,15-EET in the protective effects of cerebral MECs and the potential mechanisms involved in oxygen glucose deprivation and reperfusion (OGD/R) were elucidated. In our study, we intervened the SIRT1/FOXO3a pathway and established a TSPO knock down model by using RNA interference technique to explore the cytoprotective role of 14,15-EET in OGD/R injury. Cerebral MECs viability was remarkably reduced after OGD/R treatment, however, 14,15-EET could reverse this effect. To further confirm whether 14,15-EET was mediated by SIRT1/FOXO3a signaling pathway and translocator protein (TSPO) protein, we also detected autophagy-related proteins, mitochondrial membrane potential, apoptosis indicators, oxygen free radicals, etc. It was found that 14,15-EET could regulate the mitophagy induced by OGD/R. SIRT1/FOXO3a signaling pathway and TSPO regulation were related to the protective role of 14,15-EET in cerebral MECs. Moreover, we also explored the potential relationship between SIRT1/FOXO3a signaling pathway and TSPO protein. Our study revealed the protective role and the potential mechanisms of 14,15-EET in cerebral MECs under OGD/R condition.

MYC/BCL2 double- and MYC/BCL2/BCL6 triple-hit follicular lymphomas associated with t(8;14;18)(q24;q32;q21)

We describe two follicular lymphoma (FL) patients with MYC/BCL2 double- and MYC/BCL2/BCL6 triple-hit translocations. The first patient (case 1) was a man in his 30s who presented with stage IV disease with leukemic manifestation. The second patient (case 2) was a man in his 60s who presented with relapsed FL, but his disease was in a limited stage. Histopathology of the lymph node biopsies revealed grade 3A FL in both cases. MYC positivity and the Ki-67-labeling index were 60-70 and 20% in case 1 and 30 and 50% in case 2, respectively. G-banding revealed t(8;14;18)(q24;q32;q21) in both cases and fluorescence in situ hybridization using MYC, IGH, and BCL2 break-apart probes confirmed t(8;14;18)(+5'BCL2,-3'MYC;+3'MYC,-5'IGH;+5'IGH,-5'BCL2). In case 2, additional materials of der(8)t(8;14;18) were duplicated and translocated to chromosome Y, and t(3;16)(q27;p13)/BCL6::CIITA was identified. We obtained BCL2-major breakpoint region::IGHJ5::IGHG1 and MYC exon 2::IGHA2 fusion sequences by long-distance polymerase chain reaction in case 1, and proposed that t(8;14;18) was generated by two-step translocations and that BCL2::IGH and MYC::IGH involved the same IGH allele. Both patients responded to the standard chemotherapy for FL. We suggest that the presence of t(8;14;18) in FL does not immediately indicate high-grade transformation and aggressive clinical behavior requiring intensive chemotherapy.

Cytokeratin 8 depicts nodal metastasis in head and neck squamous cell carcinoma

Background

Nodal involvement in squamous cell carcinoma is an important feature directly associated with the poor prognosis in patients with head and neck squamous cell carcinoma (HNSCC). There are no clear cut indicators available currently to identify the lymph node metastases and overall prognosis in HNSCC. Thus, the current study was conducted to correlate the immunoexpression of cytokeratins (CK) 8, 10, and 14 with lymph node metastases and tumour differentiation in patients with HNSCC.

Material and Methods

The study population included 61 retrospective cases of HNSCC with lymph node metastases (n = 31) and without lymph node metastases (n = 30). Expression of CK 8, 10, and 14 was assessed by immunohistochemical staining procedure. Using Pearson's Chi-square test and Spearman's correlation coefficient, the correlation of these markers with lymph node metastases and tumour differentiation was statistically analysed.

Results

The expression of CKs in HNSCC cases was higher than in controls. In nodal metastasis cases, CK 8 expression was noted in >50% of the tumour cells at the invasive tumour front (ITF) (P value 0.008), and in cases without nodal metastasis, <1% or negative expression was noted. CK 10 expression gradually decreased as the tumour grade increased. Association of CK 10 expression and tumour differentiation exhibited statistically significant results (P value 0.03). CK 14 expression was noted in the entire epithelium and at the ITF, strongly in most cases; however, CK 14 did not correlate with the lymph node metastasis and tumour differentiation as well.

Conclusion

We found a strong correlation of CK 8 expression with nodal metastasis in HNSCC, and it can be utilised as a reliable prognostic indicator.