[Chest wall reconstruction after resection of malignant chest wall tumors]

Full-thickness chest wall resection is performed for complete removal of primary and secondary malignant chest wall tumors. Large defects of the chest wall after resection must be repaired to maintain adequate ventilation, to protect important intrathoracic structures, and to preserve cosmetic integrity. Various materials have been utilized over the years to replace the rigid chest wall. At present, Marlex mesh and a composite of Marlex mesh and methylmethacrylate are frequently used to reconstruct rigid chest wall defects. On the other hand, to replace the soft part of the chest wall and cover the rigid materials, pedicled muscle flaps, myocutaneous flaps, or omentum are used. Major pedicled flaps include the pectoralis major, rectus abdominis and latissimus dorsi muscular, and musculocutaneous flaps. Techniques are now available to repair any chest wall site, and to restore chest continuity in patients whose tumors are curatively resected.

[Long-term survival in terms of DNA-RNA contents in breast cancer]

Fifty-nine primary breast cancers were analyzed by flow cytometric cellular DNa-RNA contents stained by acridine orange simultaneous DNA-RNA double staining. Forty-three cases (72.9%) out of 59 had abnormal stemlines (DNA aneuploidy), and 16 normal ones (DNA diploidy). RNA indices widely ranged from 1.41 to 9.02 (2.99). There was no correlation between DNA indices and RNA indices. The patients with DNA diploidy had a better prognosis than those with DNA aneuploidy, but the differences were not significant. The patients with a high RNA index of more than 4.0 had a significantly poorer prognosis than those with an index of less than 4.0. Those results suggest that RNA contents, and DNA contents are independent prognostic factors, and especially RNA contents may be a good prognostic factor in long-term survival in breast cancer.

Treatment of pulmonary hypertension with the continuous infusion of a prostacyclin analogue, iloprost

OBJECTIVE

To compare prostacyclin with an analogue, iloprost, in treatment of severe pulmonary hypertension.

PATIENTS

Eight patients with severe pulmonary hypertension: primary in five, thromboembolic pulmonary hypertension in three.

METHODS

All patients underwent right heart catheterisation. Mean (SEM) right atrial pressure was 9.9 (2.2) mm Hg, mean pulmonary artery pressure 67.4 (3.0) mm Hg, cardiac index 1.75 (0.13) l/min/m2 and mixed venous oxygen saturation 59.1(3.1)%. Continuous intravenous epoprostenol (prostacyclin, PGI2) or iloprost was given for phase I (three to six weeks); the patients were then crossed over to receive the alternate drug in an equivalent phase II.

MAIN OUTCOME MEASURES

Exercise tolerance was measured at baseline and at the end of phase I and II with a 12 minute walk; distance covered, rest period, percentage drop in arterial oxygen saturation (delta Sao2%) and percentage rise in heart rate (delta HR%).

RESULTS

Walking distance covered rose from (mean (SEM)) 407.5 (73) to 591 (46) m with PGI2 (p = 0.004) and to 602.5 (60) m while on iloprost (p = 0.008). Rest period decreased from 192 (73) seconds at baseline to 16 (16) seconds with PGI2 (p = 0.01) and to 58 (34) seconds with iloprost (p = 0.008). Delta HR% was 37.5(6)% at baseline, 35(3)% on PGI2, and 24(6)% on iloprost (p = 0.04).

CONCLUSIONS

Both intravenous PGI2 and iloprost caused significant improvement in exercise tolerance. Iloprost offers an alternative to PGI2 treatment of severe pulmonary hypertension.

[Basilar artery aneurysm associated with agenesis of unilateral internal carotid artery: two case reports]

Two patients presented with a basilar artery aneurysm associated with agenesis of the right internal carotid artery. In both cases, the right middle cerebral artery was supplied by the basilar artery via the enlarged right posterior communicating artery, and the right anterior cerebral artery was supplied by the left internal carotid artery via the anterior communicating artery. The first patient was a 65-year-old woman who suffered from a subarachnoid hemorrhage due to rupture of a basilar bifurcation aneurysm, which was demonstrated as a "de novo" aneurysm 13 years after successful clipping of the anterior communicating artery aneurysm. Delayed surgery was planned, but she died due to recurrent hemorrhage. The second patient was a 67-year-old woman who had had a history of progressive left sided weakness over the previous few years. Conventional angiography and 3 dimensional CT angiography showed a large aneurysm of the basilar artery trunk with a wide neck. Endovascular embolization was performed with mechanically detachable coils, and the aneurysm was incompletely occluded. The patient regained complete strength in the left arm after the treatment, but the follow-up angiography at 5 months disclosed recanalization of the treated aneurysm, associated with shift of the packed coils. Hemodynamic stress resulting from unique collateral circulation with agenesis of the internal carotid artery may cause a predisposition to "de novo" aneurysm formation or recanalization of an occluded aneurysm with coils.

Inhaled nitric oxide and arterial oxygen tension in patients with chronic obstructive pulmonary disease and severe pulmonary hypertension

BACKGROUND

Inhaled nitric oxide (NO) is a selective pulmonary vasodilator which can improve gas exchange in acute lung injury. However, it is uncertain that this effect on arterial oxygenation can be generalised to all lung diseases.

METHODS

The effects of inhaled NO on gas exchange were studied in nine patients with chronic obstructive pulmonary disease (COPD), 11 patients with severe pulmonary hypertension, and 14 healthy volunteers. A randomized sequence of 40 ppm of NO or air was inhaled for 20 minutes through an orofacial mask.

RESULTS

Inhaled NO reduced mean (SE) transcutaneous arterial oxygen tension (TcPO2) from 9.6 (0.3) to 8.9 (0.4) kPa in healthy volunteers and from 7.4 (0.6) to 7.0 (0.5) kPa in patients with COPD. There was no change in TcPO2 in patients with severe pulmonary hypertension. During inhalation of NO and air no change occurred in transcutaneous arterial carbon dioxide tension (TcPCO2), arterial oxygen saturation (SaO2) measured by pulse oximeter, or cardiac output determined by the transthoracic impedance method.

CONCLUSIONS

Inhaled NO does not improve TcPO2 nor increase cardiac output in normal subjects and patients with COPD, suggesting that inhaled NO worsens gas exchange. This could represent inhaled NO overriding hypoxic pulmonary vasoconstriction in COPD. The finding that TcPO2 also fell when normal subjects inhaled NO suggests that a similar mechanism normally contributes to optimal gas exchange. Whilst inhaled NO can improve oxygenation, this effect should not be considered to be a general response but is dependent on the type of lung disease.

Graft damage after a single lung transplantation for pulmonary hypertension in a rat model

The hemodynamic effect and degree of damage in grafts of single lung transplants for pulmonary hypertension were studied in rats with monocrotaline-induced pulmonary hypertension. Inbred male Lewis rats (weight 200-230 g) were divided into two groups. Group 1 (control group, n = 16) underwent isogenic left lung transplantation, while group 2 (n = 15) received an intravenous administration of monocrotaline (80 mg/kg i.v.) and underwent isogenic left single lung transplantation 3 week later. Hemodynamic evaluations were performed prior to transplantation, at 1 h postoperatively, and on days 3 and 7 after transplantation. Mean pulmonary arterial pressure (mPAP) rapidly declined after transplantation in group 2, from 39.3 +/- 8.7 mmHg to 18.5 +/- 3.0 mmHg 1 h after transplantation, and remained stable on day 7 after transplantation. No significant difference in the mPAP between the two groups was observed after transplantation. The extravascular lung water volume (ELWV: dry/wet ratio) in the right lung of group 2 significantly increased on day 3 (0.86 +/- 0.02) (P < 0.01), and subsequently decreased to control levels on day 7 (0.83 +/- 0.02). There was no significant difference in the ELWV in the grafted lungs between the two groups (0.84 +/- 0.03 vs 0.86 +/- 0.04), but there was tendency toward an increase in ELWV in group 2 on days 3 and 7. These data thus demonstrated that a hemodynamic improvement was obtained by single lung transplantation; however the degree of graft damage was remarkable in the pulmonary hypertension group.

Bronchoscopic evaluation of bronchial healing after carinal reconstruction

Bronchoscopic evaluation of the anastomoses created by carinal reconstruction was carried out over a period of 7 weeks in 6 patients who had undergone carinal and lobar resections for lung cancer, and 4 who had undergone carinal resection without pulmonary resection for carinal tumors. The techniques of reconstruction included end-to-end and end-to-side tracheobronchial anastomoses with omental, fat, or pleural wrapping. Bronchial healing at the anastomosis was evaluated using a bronchial healing score (BHS) based on the bronchoscopic findings. The degree of healing was scored on a 0 to 4 scale, with 0 indicating normal mucosa; 1, edema or reddening; 2, mucosal color changes; 3, ulceration; and 4, diffuse ulceration. One postoperative death occurred as a result of anastomotic leakage. The remaining nine patients were divided into three groups according to the bronchoscopic findings on postoperative day (POD) 7: group A (n = 3) had mild ischemia at the anastomosis, group B (n = 3) had moderate ischemia at the anastomosis, and group C (n = 3) had severe ischemia at the anastomosis. Bronchial healing of the anastomosis improved over a 7-week period in groups A and B, but was delayed in group C. These findings led to the conclusion that wound healing of the anastomosis following carinal reconstruction requires more than 7 weeks due to the consequent devascularization resulting from the extended bronchial resection and lymph node dissection.

[Suspension of ventilation during extracorporeal membrane oxygenation with veno-venous by pass in dogs]

We studied whether extracorporeal membrane oxygenation with a veno-venous bypass would allow withdrawal of mechanical ventilation. Three mongrel dogs were anesthetized with intravenous pentobarbital. A Swan-Ganz catheter was placed via the left jugular vein into the main pulmonary artery, and an extra-long total volume catheter was placed in the right femoral artery. The animals were placed in the lateral position, and cannulas (15 Fr.) were placed in the inferior vena cava and the superior vena cava via the right jugular vein and the right femoral vein. These cannulas were connected to a pump and a membrane oxygenator. When the pump flow was almost the same as the previous cardiac output, the partial pressure of oxygen in the pulmonary artery, was high enough to allow ventilation to be suspended. All dogs survived. This suggests that extracorporeal membrane oxygenation with a veno-venous bypass can allow mechanical ventilation to be suspended during tracheocarinal operations such as tracheocarcinal resection.

Successful utilization of a video-assisted thoracic approach to repair Morgagni's hernia: report of a case

We describe herein the successful utilization of a video-assisted thoracic surgical approach to repair Morgagni's hernia. The patient was a 62-year-old woman in whom a routine chest X-ray had revealed an asymptomatic mass, which was presumed to be a pericardial lipoma or Morgagni's hernia. The video-assisted thoracic surgical approach was combined with a right submammary minithoracotomy to successfully repair the hernia without performing a laparotomy. The patient's postoperative course was uneventful and she was discharged 14 days after surgery. Thus, we believe that video-assisted thoracic surgery may be a useful and effective method for repairing Morgagni's hernia.

[Surgical treatment for acute pulmonary thromboembolism occurring 9 months after an operation for lung cancer]

Successful surgery for pulmonary thromboembolism is reported, with emphasis on the indication and the necessity of cardiopulmonary bypass. Surgical treatment is indicated for patients with localized large thromboemboli not amenable to medical management. Surgery is also an option for patients in whom medical treatment is not effective. In the present case, the etiology was unknown and there was no history of deep vein thrombophlebitis of the legs, which suggested that the cause was an embolus from a lung tumor that had already been treated surgically. Histological examination revealed a fresh blood thrombus, 9 months after pulmonary resection. This patient had syncope at the onset of the pulmonary thromboembolism (major vessel type) without circulatory collapse.

Results of carinal resection for bronchogenic carcinoma

Fifteen patients underwent carinal resection for lung cancer during the years of 1957 through 1993. All were males with ages ranging from 40 to 81 (mean 60.1) years old. Cell Types of the cancer were squamous cell carcinoma in 12 cases, adenocarcinoma in 2 and small cell carcinoma in one. In 14 of 15 cases there was cancerous invasion into the tracheal carina (T4) and one had no involvement of the carina (T3). Four patients had no lymph node metastasis (N0), 2 had hilar node metastasis (N1), 8 had ipsilateral mediastinal node metastasis (N2) and one had contralateral mediastinal node metastasis (N3). Operative procedures for carino-plasty were sleeve pneumonectomy in 3 cases, pneumonectomy with wedge resection of the carina in 3, sleeve resection of the carina followed by reconstruction of the carina (Montage type) in 8, and carinal resection with reconstruction of the one-stoma type in one. Two patients died within one month due to pneumonia or renal failure (13.3%). Postoperative complications occurred in 14 cases and bronchorrhea (n = 8), anastomotic stenosis (n = 5) and pneumonia (n = 4) were frequent. Excluding 2 operative deaths, 8 cases died from 2 to 37 months after operation (mean 13.1 months) and 5 are alive from 10 to 24 months without recurrences. Patients with squamous cell carcinoma with N0 or N1 had better prognosis.

Anal metastasis from carcinoma of the lung: report of a case

We report herein the case of a 75-year-old man who developed anal canal metastasis from squamous cell carcinoma of the lung. Initially, he underwent a right middle and lower lobectomy combined with left atrial wall resection under cardiopulmonary bypass. He presented 3 months later with an anal polyp which had prolapsed and bled, for which he underwent a transanal polypectomy. Histologically, the polyp was classified as squamous cell carcinoma and considered to be a metastasis from the primary lung cancer. He is presently well with no signs of recurrence 9 months after his initial operation. To our knowledge, there has been no other case of anal metastasis from lung cancer ever reported.

Bronchoplastic procedures for lung cancer: clinical study in 136 patients

Between 1969 and 1991 a total of 136 patients (119 men, 17 women) underwent bronchoplastic procedures for lung cancer. A bronchoplastic procedure with angioplasty was performed in 37 patients. Ages ranged from 30 to 79 years (mean 62 years). The histologic type of cancer was squamous cell carcinoma in 97 patients (70.0%). The 30-day mortality was 5.1% (7 patients), and morbidity was 30.1% (41 patients). The most common complications were bronchopleural fistula in nine (6.6%), stricture or stenosis in eight (5.9%) and atelectasis in eight patients. Local recurrence occurred in nine (6.6%) patients. The overall 5-year survival for patients undergoing bronchoplastic procedures was 37.1%: 60.1% for patients with stage I disease (n = 41), 31.7% for stage II (n = 17), and 29.7% for stage IIIA (n = 66). We conclude that bronchoplastic procedures are effective therapy for selected patients with lung cancer.

DNA stemline heterogeneity of non-small cell lung carcinomas and differences in DNA ploidy between carcinomas and metastatic nodes

Nuclear DNA contents were measured using a flow cytometry technique in non-small cell lung carcinomas and differences in ploidy patterns were compared between primary lung carcinomas and metastatic lymph nodes. Negative node lung cancer revealed diploidy in 82.6% of the 224 non-small cell lung cancers, in contrast with 19.5% in positive node lung cancer. In multi-stemline cells, a high incidence of nodal involvement was seen when compared with single stemline cells. The more the DNA indices increased, the more the lymph nodes were seen to be extensively involved. Furthermore, intratumoral heterogeneity was evaluated in terms of n-categories. In conclusion, it is suggested that nodal metastasis may be caused by tumor cells with high DNA indices in lung carcinomas, in particular for multi-stemline cells.

Monitoring canine lung allograft rejection using Ia antigen expression by bronchoalveolar lymphocytes

The expression of Ia antigens by lymphocytes in bronchoalveolar lavage (BAL) was evaluated after canine lung allotransplantation with immunosuppression using FK-506. The expression of Ia antigens labeled using an OKIa-1 monoclonal antibody from Ortho Diagnostic Systems was measured by flow cytometry. Twenty-three adult mongrel dogs underwent left lung allotransplantation and were treated with FK-506 at a dose of 0.1 mg/kg/day intramuscularly until death. Allograft rejection was evaluated microscopically. The percentage of OKIa-1-positive cells among the BAL lymphocytes was 34.8% +/- 8.9% (mean +/- SD) from the allografted lungs showing no rejection, whereas it was 68.8% +/- 16.2% from the allografted lungs which showed rejection (P < 0.01). When a diagnosis of rejection was made prior to pathologic examination by an OKIa-1-positive lymphocyte percentage of 42% or more, the sensitivity, specificity, and accuracy of diagnosis were 100%, 87.5%, and 94.1%, respectively. Subsequently, pulse steroid therapy was attempted in those dogs with a high rate of OKIa-1-positive lymphocytes in the BAL. In 3 of 4 dogs showing histological signs of rejection, a decrease in the rate of OKIa-1-positive cells among the BAL lymphocytes corresponded to an improvement in pathologic diagnosis. In two dogs with bacterial pneumonia and pulmonary vein thrombosis, densities indistinguishable from those of rejection were seen on chest roentgenograms, but in these dogs the rate of OKIa-1-positive BAL lymphocytes was 42% or less. In conclusion, Ia antigen expression by BAL lymphocytes could be useful for monitoring rejection in lung allotransplantation.

[Segmentectomy and bronchoplasty for early stage squamous cell carcinoma of the segmental bronchus]

Five cases with hilar type early stage squamous cell carcinoma of the segmental bronchi underwent segmentectomy and bronchoplasty. All were males and the ages with sixties. Locations of early stage lung cancer were the apical bronchus of the right lower lobe (B6) in one patient, the intermediate-lower lobe bronchus in one, the anterior bronchus of the left upper lobe (B3) in two and the lower division bronchus (B4+5) in one. All were diagnosed as early stage squamous cell carcinoma by preoperative bronchoscopic examination. The segments resected were the right S6 in two, left S1+2+3 in one, left S4+5 in one and left S3 in one. There was no postoperative complications related to bronchial anastomosis. One patient died of secondary primary lung cancer 3 years after operation. While, four patients are alive and well one, 6, 12 and 46 months after surgery. Sleeve segmentectomy for the patients with early stage squamous cell carcinoma of the segmental bronchus is a curative operation with preserving pulmonary function.

Management of anastomotic complications after sleeve lobectomy for lung cancer

One hundred twelve patients (102 male and 10 female) underwent sleeve lobectomy for lung cancer from January 1969 to December 1991. Bronchopleural fistula occurred in 6 (5.6%), bronchovascular fistula in 2 (1.8%), pulmonary arterial occlusion in 2 (1.9%), anastomotic stricture or stenosis in 7 (6.3%), and local recurrence in 7 patients (6.3%). Early repair of bronchopleural fistula combined with an omentopexy achieved permanent closure of the fistula. Two patients who underwent a completion pneumonectomy for a pulmonary arterial occlusion died of respiratory failure. Two patients experienced uncontrollable bleeding into the bronchial tree through a bronchovascular fistula and sudden death. Completion pneumonectomy is indicated for a stricture due to scar formation. If pneumonectomy is precluded by poor pulmonary reserve, endoscopic excision using biopsy forceps is an alternative. Endoscopic resection is the treatment of choice for suture granulomas. Complications associated with bronchial or vascular anastomoses are serious and frequently fatal.

[Evaluation of hilar and mediastinal lymph node metastases in resected cases of bronchogenic carcinoma]

To establish a reasonable regional lymph node dissection as curative operation for lung cancer, hilar and mediastinal lymph node metastases were analyzed. From 1982 to December, 1990, 404 patients underwent pulmonary resection with complete mediastinal node dissection. There were 194 adenocarcinomas, 175 squamous cell carcinomas, 14 large cell carcinomas, 13 small cell carcinomas and 8 others. The rates of hilar (N1) and mediastinal lymph node (N2) metastasis were 12.4% and 28.9% in adenocarcinoma, 12.6% and 30.3% in squamous cell carcinoma, 14.2% and 28.6% in large cell carcinoma and 15.4% and 30.8% in small cell carcinoma. In cases with adenocarcinoma, there was a close relationship between mediastinal metastasis and grade. No lymph node metastasis was seen in cases with tumor less than one cm in diameter. However, mediastinal node metastasis was found in cases with one cm or more in diameter of primary lesion and rates of metastasis were increased in proportion to tumor size. Because considerable metastases are found in the mediastinal lymph nodes and exact diagnosis of node metastasis before and during operation is difficult, complete mediastinal node dissection is still standard as curative resection for resectable lung cancer except lesion less than one cm in diameter or early hilar type squamous cell carcinoma.

The RNA content of alveolar macrophages in canine lung allografts

To evaluate the utility of RNA synthesis by alveolar macrophages (AM) in lung allografts as a marker of acute rejection, we performed canine left lung allotransplantation and measured the AM RNA content during immunosuppressive therapy with azathioprine (AZ), cyclosporine A (CsA), or CsA combined with AZ and prednisolone (Pr). We determined the RNA content by determining the RNA index (RI) (peak channel number of AM/peak RNA channel number of peripheral blood lymphocytes) by flow cytometry. The dogs were classified into one of five treatment groups: Group 1 (n = 18), control (no surgery) dogs; Group 2 (n = 11), allotransplanted dogs without pre- or postoperative immunosuppressive therapy; Group 3 (n = 14), received AZ at dose of 5 mg/kg/day orally; Group 4 (n = 17), received CsA at dose of 20 mg/kg/day orally; Group 5 (n = 15), CsA combined with AZ (5 mg/kg/day) and Pr (0.5 mg/kg/day). The RI of normal lungs was 2.14 +/- 0.20 (mean +/- SD) (n = 18). The RI of rejected lungs was significantly higher than the RI of normal lungs in Group 2 (2.51 +/- 0.21, n = 8, P < 0.05) or Group 3 (2.76 +/- 0.36, n = 7, P < 0.05), but did not differ significantly from that in Group 4 (2.19 +/- 0.20, n = 7) or Group 5 (2.05 +/- 0.45, n = 8). The RI of rejected lungs was higher than the RI of nonrejected lungs in Group 2 (vs 2.18 +/- 0.12, n = 3, P < 0.05) or in Group 3 (vs 2.18 +/- 0.22, n = 7, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Combined transection of the trachea and esophagus following cervical blunt trauma

The successful management of a patient with combined transection of the cervical trachea and esophagus following blunt trauma is reported. This type of injury was rare in the past, but is gradually increasing at the present time because of the increased use of motorcycles. Immediate primary closure of the transected trachea and esophagus offers the best chance for a good result.