Successful Resection of a Giant Pulmonary Colloid Adenocarcinoma via Median Sternotomy

We report on a giant pulmonary colloid adenocarcinoma successfully resected using a median sternotomy approach. A 69-year-old woman visited our hospital owing to a giant mass detected on chest radiography. A giant cystic mass measuring 115 × 90 mm was detected in the right upper lung using computed tomography. We suspected mucinous adenocarcinoma and performed right upper lobectomy and mediastinal lymph node dissection with median sternotomy. The surgical field of view for the tumor and superior vena cava was satisfactory, and compression but not invasion of the superior vena cava and chest wall by the tumor was observed. The tumor was pathologically diagnosed as a colloid adenocarcinoma of stage IIIA with pT4N0M0. The postoperative course was uneventful, with no signs of recurrence at one and a half years after operation. Thus, this case demonstrates that for giant lung tumor surgery, median sternotomy is useful and safe for improving the surgical field of view.

Metachronous Thin-Walled Cavity Lung Cancers Exhibiting Variable Histopathology

We report a case of metachronous thin-walled cavity lung cancers exhibiting variable histopathology. A 70-year-old man visited our hospital because of a thin-walled cavity located in the right upper lobe, detected by chest computed tomography. Right upper lobectomy was performed and a histological diagnosis of squamous cell carcinoma was made. Computed tomography at 7 years posttreatment detected a new thin-walled cavity in the left lower lobe. Histopathology after video-assisted thoracic surgery left S6 segmentectomy revealed adenocarcinoma. Patients with primary lung carcinoma may present with thin-walled cavities; postoperative screening can aid early the detection of metachronous primary lung cancers of variable origin.

Empyema and pyogenic spondylitis caused by direct Streptococcus gordonii infection after a compression fracture: a case report

Background

Empyema and pyogenic spondylitis are common diseases that are often caused by oral pathogens in direct or hematogenous infection. However, there exists no report describing empyema and pyogenic spondylitis caused by oral pathogens after a compression fracture of the vertebral body. Herein, we report a case of empyema and pyogenic spondylitis caused by direct Streptococcus gordonii infection after a compression fracture of the vertebral body.

Case presentation

A 74-year-old man had back pain while working. At 1 week after experiencing back pain, he underwent periodontal debridement. At 3 weeks after periodontal debridement, he visited our hospital owing to the absence of improvement in back pain. He was admitted on the same day with a diagnosis of compression fracture of the 12th thoracic vertebral body. Magnetic resonance imaging (MRI) revealed a compression fracture of the 12th thoracic vertebral body and a hematoma anterior to the vertebral body. Computed tomography (CT) showed no findings suggestive of infection. After admission, antibiotic therapy was initiated, as the patient developed fever and his blood cultures grew S. gordonii. CT performed after antibiotic therapy revealed a right-sided pleural effusion, and drainage was performed. As the inflammation did not improve after thoracic drainage for empyema, surgical debridement through video-assisted thoracic surgery was performed. Intraoperative pleural effusion cultures also grew S. gordonii. Postoperative MRI showed low T1-weighted signals and high T2-weighted signals in the 12th thoracic vertebral body, and the signals spread to the upper and lower intervertebral disk space; hence, a diagnosis of empyema and pyogenic spondylitis due to direct infection spread was established. Intravenous antibiotic therapy was continued for 6 weeks and then was switched to oral antibiotic treatment. His C-reactive protein level and erythrocyte sedimentation rate gradually decreased and remained within normal limits. Neither empyema nor pyogenic spondylitis had recurred at 12 months after surgery.

Conclusions

Compression fracture with dental procedures possibly results in the thoracic cavity and spinal infection caused by oral pathogens. We emphasize the importance of early imaging examinations, diagnosis, and appropriate treatment for patients with compression fractures who develop a fever.

A solitary fibrous tumor arising from the thymus

Solitary fibrous tumors (SFTs) are localized mesenchymal lesions which most frequently arise in the pleura but have also been observed in many other sites. SFTs arising from the thymus are relatively rare, however, and only a few cases have been reported to date. We report such a case in our current study.

Hepatocyte growth factor prevents pulmonary ischemia-reperfusion injury in mice

BACKGROUND

Ischemia-reperfusion (IR) injury after lung transplantation leads to significant morbidity and mortality in recipients, which remains the major obstacle in clinical lung transplantation. To reduce pulmonary graft dysfunction and improve prognosis after lung transplantation, prevention of IR-induced lung injury in the peri-operative period is required. In the present study, we investigated the effects of recombinant hepatocyte growth factor (HGF) on pulmonary IR injury using a murine model system.

METHODS

To assess the protective effect of HGF against lung injury, mice with pulmonary IR were divided into two groups and injected with 500 microg/kg of human recombinant HGF or the same dose of saline alone as a control.

RESULTS

After pulmonary IR injury, the lung injury score increased in a time-dependent manner up to 24 hours. A significant reduction of lung injury score was observed with the administration of exogenous HGF. Moreover, the ratio of apoptotic cells was significantly reduced in mice treated with HGF. Significantly increased expression of Bcl-xL was observed after IR in mice administered HGF as compared with saline-treated controls. In contrast, expression of Bax was reduced significantly in HGF-treated mice. Serum levels of endogenous murine HGF were increased significantly in HGF-treated mice.

CONCLUSIONS

Our findings indicate that administration of exogenous HGF ameliorates the pulmonary tissue injury induced by IR, which may provide an alternative for prevention of IR-induced lung injury in the peri-operative period in lung transplantation.

Suppression of Acute and Chronic Rejection by Hepatocyte Growth Factor in a Murine Model of Cardiac Transplantation

Background— Although treatment with immunosuppressive agents has contributed to overcoming acute rejection and improving the midterm survival of transplanted hearts, cardiac allograft vasculopathy (CAV) has remained the main cause of primary graft failure. Recent approaches have shown that hepatocyte growth factor (HGF) exhibits cardiotrophic functions. We therefore addressed whether HGF would regulate acute and chronic rejection in cardiac transplantation.

Methods and Results— We used a murine heterotopic cardiac transplantation model between fully incompatible strains and administered 500 μg · kg −1 · d −1 HGF during the initial 14 days after transplantation. The HGF-treated allografts showed significantly prolonged survival (42.3±4.1 days, P <0.001) compared with the controls (11.1±0.6 days), with tolerance induction in 47.4%. Histopathologically, the number of infiltrating cells was significantly decreased and myocardial necrosis was less prominent with a reduction of apoptosis in the allografts by HGF treatment during acute rejection. In the long-term surviving allografts, HGF significantly inhibited the development of CAV and interstitial fibrosis. With respect to intragraft cytokine mRNA expression, HGF treatment reduced the early expression of interferon-γ and enhanced the expression of transforming growth factor-β1 during the acute phase and of interleukin-10 continuously through the acute phase to the chronic phase.

Conclusions— Our findings demonstrate that HGF can prolong the survival of allografts by its cardioprotective and immunomodulative potencies. Thus, HGF administration may constitute a new therapeutic approach to preventing cardiac graft failure that has not been overcome by conventional immunosuppressive agents.

Chest wall myxoma protruding into the thoracic cavity

Myxoma protruding from the chest wall into the thoracic cavity is very rare. We report our experience in treating a 42-year-old man admitted for a painless mass on the anterior chest wall. Magnetic resonance imaging showed a sharply defined 5 x 4 x 4 cm mass protruding from the chest wall into the thoracic cavity, which we excised surgically. Histologically, the tumor proved to be a myxoma.

Recurrence of thymoma: clinicopathological features, re-operation, and outcome

BACKGROUND

Even after complete resection, recurrence of thymoma is not infrequently observed, and treatment of recurrent thymoma remains controversial.

STUDY DESIGN

One hundred and twenty-six patients underwent surgically complete resection for thymoma, and 24 of them had a recurrence. Surgical treatment of recurrent thymoma was attempted in 15 patients for a total of 18 times. In the present study, the relevance of clinicopathological features and the re-operation on the survival rate after the recurrence were determined.

RESULTS

The most frequent recurrent type was pleural dissemination (92%), with local recurrence observed in 5%. Overall 5- and 10-year survivals after recurrence were 37 and 16%, respectively. Disease-free interval after initial operation and complication of myasthenia gravis had no significant effect on postrecurrent survival. The use of postoperative mediastinal irradiation had no effect on reducing the recurrence rate or improving survival after recurrence. Two of 15 patients who underwent re-operation died of major complications after It. pleuropneumonectomy for severe pleural dissemination. In the present study, the re-operation was not significantly effective for prolongation of postrecurrence survival.

CONCLUSION

Our study showed that re-operation should not be attempted for all patients with recurrent thymoma. Because effect of subtotal resection for severe pleural recurrence is disappointing, total resection for minimal pleural dissemination or small local recurrence will be undertaken to improve postrecurrent survival. Careful follow-up for > 10 years will increase the chance of the total resection of the recurrent thymoma.

[Clinical study of operated nine thymic carcinomas]

Nine cases of thymic carcinoma (5 males and 4 females) were operated in our hospital between 1990 and 1998. These cases included 4 squamous cell carcinomas, 2 small cell carcinomas, 2 undifferentiated carcinomas and one adenocarcinoma. Preoperative chemotherapy were performed in 3 cases. All cases underwent median-sternotomy followed by mediastinal irradiation, 4 had total resection of the tumor, 2 had subtotal resection and 3 had exploratory thoracotomy followed by mediastinal irradiation. Adjuvant chemotherapy were administered in 4 cases and re-operation were performed in 2 cases. We applied Masaoka's clinical staging for thymoma, nine cases consisted of 6 stage III cases, 2 stage IV b cases and one stage IV a case. Within 2 years after operation, 3 cases (two complete resection cases and one exploratory thoracotomy case) were died of the carcinoma. However, two cases of squamous cell carcinoma have been alive more than 5 years after surgery followed by chemoradiation. The remaining 4 patients are alive either with or without the carcinoma after 7 to 28 months after operation. Thymic carcinoma is not so common mediastinal tumor but is expected to increase in the future. The treatment of thymic carcinoma remains a controversial matter and the survival is poor compared with invasive thymoma, but multimodal-therapy would contribute to improvement of the results in treatment for thymic carcinoma especially in squamous cell carcinoma.

Hepatectomy of cavernous hemangioma with constitutional indocyanine green excretory defect

The constitutional ICG excretory defect with marked ICG retention in spite of other normal hepatic functions has not been so rare in Japan. However, there is no previous report of hepatectomy in a patient with this disease. We describe a successful case of hepatectomy for cavernous hemangioma with this disease and use of technetium-99m diethylenetriaminepentaacetic acidgalactosyl-human serum albumin (99mTC-GSA) liver scintigraphy as the preoperative assessment of the liver functional reserve. In our case, ICGR15 was more than 55%, however, a modified receptor index obtained from 99mTC-GSA liver scintigraphy was normal. Left lateral segmentectomy of the liver was performed without any perioperative complications. Hepatectomy of patients with the constitutional ICG excretory defect is possible if modified receptor index value obtained from 99mTC-GSA scintigraphy is within the normal range.

[Assessment of the new TNM classification for resected lung cancer]

To evaluate the revised TNM classification, we investigated the prognoses of 552 consecutive patients who had resection of non-small-cell lung cancer between April 1982 and March 1996. According to the new classification, the 5-year survival rate was 76.9% for stage I A, 57.2% for stage I B (I A versus I B, p < 0.0005), 47.7% for stage IIA, 49.8% for stage IIB, 18.6% for stage IIIA (IIB versus IIIA, p = 0.005), 16.7% for stage IIIB, and 7.9% for stage IV (IIIB versus IV, p = 0.02). Especially for patients in stage I A, there was significant difference in survival between patients with the tumor size within 1.5 cm and those with larger than 1.5 cm. The survival rate for T3N0M0 patients was significantly better than that for T3N1-2M0, but there was no significant difference between patients with T3N0M0 disease and those with T2N1M0 disease. Concerning the pm1 patients, the survival rate was significantly better than other stage IIIB patients. Our results supported the revision for dividing stage I and putting T3N0M0 into stage IIB. However, the classification is controversial about dividing stage II and putting pm1 as T4 disease. Furthermore, subgrouping of T1N0M0 disease by tumor size, T3 by tumor invaded organ will be necessary in the next revisions.

Solitary aneurysm of the innominate vein

Two cases of isolated saccular aneurysms of the innominate vein are presented that appeared as mediastinal masses. Contrast-enhanced computed tomography (CT) allowed for accurate diagnosis in one patient, while the second patient had atypical CT findings that led to thoracotomy for proper diagnosis. A diagnosis of innominate vein aneurysm should be considered when a uniform attenuation mediastinal mass is seen on CT so that unnecessary biopsy and surgery can be avoided.

[Metastatic squamous cell carcinoma of hilar lymph node with unknown primary site]

An abnormal shadow was observed on chest X-ray films of a 63-year-old man presenting with cough and sputum. Chest computed tomographic scans disclosed enlargement of the right hilar lymph nodes, but no obvious primary lesion was found in the lung field. Bronchoscopic examination revealed a slightly widened second carina, but no malignant cells were detected by transbronchial aspiration cytology. At surgery, a tumor was found between the truncus superior and the truncus intermedius. The pathologic diagnosis was a metastatic lymph node of poorly differentiated squamous cell carcinoma. Because the tumor severely adhered to the bronchus and pulmonary arteries, we performed a right pneumonectomy with mediastinal node dissection. Pre- and postoperative examinations did not detect the primary lesion, and no recurrence had been observed 76 months after surgery. This was thought to be a very rare case of T0 N1 M0 lung cancer. In general, the prognosis is poor for patients with metastatic carcinoma of unknown primary site. However, patients with T 0 lung cancer, as in this case, might enjoy a better prognosis if complete resection and dissection of metastatic lymph nodes are performed.

[Two cases of the bronchial cyst located in the anterior mediastinum]

Bronchial cysts are common cystic tumors around the tracheobronchial tree in the middle and posterior mediastinum and rarely locate in the anterior mediastinum. We reported two cases of the bronchial cyst located in the anterior mediastinum. One case was a 57 year-old-female. A thymic cyst was suspected and the extended total thymectomy was performed through the mediansternotomy. The microscopic examination showed bronchial epithelium and cartilage in the cystic wall. The another case was 71 year-old-male operated by thoracoscopic surgery for the cystic tumor in the anterior mediastinum. Microscopic examination showed bronchial epithelium and gland in the cystic wall.

[A case of thymic carcinoid with multiple endocrine neoplasm (MEN)-type I]

We presented a case of thymic carcinoid with MEN type I. A 43-year-old woman who followed at MEN type I for 4 years was pointed out an abnormal shadow by chest X-ray. Chest CT levealed the presence of two anterior mediastinal tumors. Extended total thymectomy was performed through the median sternotomy. There were 3 tumors in thymus. Histological examination revealed three tumors in the thymus and all of the tumor were diagnosed carcinoid. Our experience suggests that CT or MRI of the chest should be considered as part of clinical screening in patients with MEN type I.

Arterial ketone body ratio does not correlate with ischemic changes during major hepatectomy

BACKGROUND/AIMS

The arterial ketone body ratio (AKBR) has been proposed as an accurate indicator of hepatic mitochondrial redox potential. However, recent studies of the utility of the AKBR as a biochemical marker have been called into question. It is not clear whether the AKBR is closely related to ischemic changes during major hepatectomy.

METHODOLOGY

Arterial acetoacetate and beta-hydroxybutyrate concentrations were measured in eleven patients who underwent major hepatectomy. The ratio between them (AKBR) was calculated before and after vascular occlusion during the hepatectomy procedure.

RESULTS

The AKBR increased following normothermic arterial or portal venous ischemia as compared to the levels prior to vascular occlusion in 36.4% of the patients who underwent major hepatectomy. An AKBR of less than 0.5 prior to vascular occlusion did not correlate with preoperative hepatocellular function. An AKBR of less than 0.7 throughout surgery was not a consistent risk factor for postoperative complications or liver dysfunction.

CONCLUSIONS

The AKBR does not correlate with ischemic changes or postoperative complications after major hepatectomy.

Surgical outcome in early gastric cancer with lymph node metastasis

BACKGROUND/AIMS

Definitive surgical management of early gastric cancer with lymph node metastasis has not been established. This paper describes the clinico-pathologic characteristics of early gastric cancer with lymph node metastasis.

MATERIALS AND METHODS

A retrospective study of early gastric cancer with lymph node metastasis (32 patients) was performed to compare clinico-pathologic features with patients without lymph node metastasis (283 patients).

RESULTS

All patients with lymph node metastasis had submucosal gastric invasion. The incidence of histologically proven curative resection in patients with lymph node metastasis was significantly lower than in those without metastasis (40.6% versus 93.3%). The 5-year survival rate was poorer in patients with positive nodes than in those with negative nodes (83.8% versus 96.2%). Recurrence was more frequent in patients with involved nodes (12.5% versus 0.4%). Lymph node metastasis was more frequent with the following: submucosal invasion, tumor over 5 cm in size, positive venous involvement, and an advanced growth pattern.

CONCLUSIONS

Pre-operative and intra-operative evaluation for lymph node metastasis is essential for the appropriate surgical treatment of early gastric cancer.