[Port-access lobectomy for lung cancer: experience in the single institute].

We reviewed the data on 171 patients who underwent thoracoscopic lobectomy for lung cancer via 5 access ports at our institution between April 2005 and May 2008. Port-access lobectomy was completed in 153 patients and conversions to open thoracotomy were required in 18 patients. Among the above 153 patients, mean operative time was 145 minutes and the mean blood loss was 159 ml. Morbidity rate was 12% and mortality rate was 0.7%. Pathologic study demonstrated stage I in 106 patients (69%), stage II in 16 patients (11%), and stage III in 31 patients (20%). At mean follow-up of 635 days after surgery, the overall 3-year survival rates of the patients with non-small cell lung cancer at stage I, stage II, and stage III were 88%, 80%, and 79%, respectively. Port-access lobectomy with mediastinal lymph nodes dissection for lung cancer is feasible with low morbidity and mortality rates. Long-term outcomes should be reviewed in the near feature.

[Video-assisted thoracoscopic removal for mediastinal mature teratoma following extraction of cystic components].

Video-assisted thoracoscopic resection for mediastinal mature teratoma is sometimes converted to open thoracotomy. Because it has rich components including pancreatic tissue and dense adhesion, even when it is asymptomatic. Prior to thoracoscopic resection, extraction of the cystic components with the aid of a 20 Fr tube can provide a wide thoracoscopic view leading to easier complete removal. Between October 1998 and June 2008, 6 patients (1 man and 5 women) with benign mediastinal mature teratoma underwent the thoracoscopic operations. The average age was 36.3 (range, 24-54). The mean diameter was 9.0 cm (range, 5-11 cm). The mean operation time was 143 minutes and the mean blood loss was 103 ml. Neither complications nor tumor recurrences developed during the mean follow-up period of 3.4 years. The presented thoracoscopic surgery for benign mature teratoma is a feasible procedure.

[Mucinous bronchiolo-alveolar cell carcinoma with marked serum elevation of CA19-9: report of a case].

An 83-year-old woman was referred to our hospital to examine for an infiltration shadow in the right lower lobe with progressive bronchorea Computed tomography showed an infiltration lesion with the longest diameter of 10 cm in the right lower lobe and a tumor with the longest diameter of 3 cm in the middle lobe. Serum level of carbohydrate antigen (CA) 19-9 markedly increased to 37,670 U/ml over a period of 3 months. The pathologic study obtained by a transbronchial tumor biopsy revealed a mucinous adenocarcinoma The patient underwent video-assisted thoracoscopic right middle and lower bi-lobectomies with nodal sampling. Postoperative course was uneventful Pathologic study revealed an adenocarcinoma with mixed subtypes, predominantly composed of mucinous bronchiolo-alveolar cell carcinoma (BAC). Immunohistochemical study showed CA19-9 positivity in the apical surface of some tumor cells and diffuse patterns of other tumor cells. Postoperative course was uneventful and serum CA19-9 levels decreased within the normal range. Clinico-pathologic features of the lung cancer patients with serum elevation of CA19-9 and CA19-9 positivity in the cancer cells was discussed. CA19-9 can be an useful tumor marker in the selected patients with mucinous BAC.

[Complete thoracoscopic lobectomy with systematic nodal dissection via 5 ports for lung cancer].

We herein report a procedure for thoracoscopic lobectomy with mediastinal dissection for primary lung cancer using 5 access ports. A thoracoscope is inserted through an access port on the mid-axillary line in the 6th intercostal space. The availability of 4 instruments through 4 ports makes it easy to divide bronchus and pulmonary vessels and to dissect mediastinal lymph nodes. Between April 2005 and March 2007, 88 patients with clinical stage I/II primary lung cancer underwent this thoracoscopic procedure. Mean (+/- SD) operation time was 148 +/- 42 minutes and mean (+/- SD) blood loss was 166 +/- 148 ml. No local recurrence was found in patients with pathologic stage I/II diseases, whereas ipsilateral mediastinal lymphadenopathy occurred in 2 with pathologic stage III A disease during the mean post-opetrative period of 518 +/- 200 days. The thoracoscopic surgery for lung cancer presented here was seen to be a feasible procedure and has the advantage of reducing operative time.

[Massive hemoptysis due to traction bronchiectasis caused by thoracic radiotherapy 23 years earlier].

We reported a 72-year-old woman who had a massive hemoptysis due to traction bronchiectasis in the left upper lobe. The patient underwent left radical mastectomy followed by thoracic radiotherapy for left breast cancer. The chest computed tomography showed traction bronchiectasis in the atrophic left upper lobe and the bronchial angiography showed hypervascularization of bronchial and internal thoracic arteries to the left upper lobe. Left upper lobectomy was performed after bronchial embolization for recurrent massive hemoptysis. Postoperative course was uneventful. Pathologic findings showed non-anatomical but clearly-bordered traction bronchiectasis with hypervascularized bronchial artery in the left upper lobe. These lesions were consistent with the field of the previous radiotherapy. Traction bronchiectasis causing massive hemoptysis should be considered as one of pulmonary sequelae after thoracic radiotherapy.

[Combined thoracoscopic and open chest approach of lobectomy with inferior chest wall resection for advanced lung cancer].

Patients with advanced non-small cell lung cancer invading a chest wall are surgical candidates if complete resection is possible. When a primary tumor locating the lower lobe invades an inferior chest wall, either a wide skin incision or double skin incisions to secure surgical views both for dissection of hilum and mediastinum and for inferior chest wall resection is necessary. Wider incision causes higher rate of wound necrosis and infection. We describe a combined approach of thoracoscopic and open chest surgery for lobectomy and inferior chest wall resection, respectively. Patient was a 68-year-old man with an advanced non-small cell lung cancer. Video-assisted thoracoscopic middle and lower lobectomies and mediastinal nodal dissection was completed via 5 ports. Chest wall resection including the posterior portion of the 9th and 10th ribs and the transverse process followed inferior postero-lateral thoracotomy. Postoperative course was uneventful. The present surgical approach can avoid a wide thoracotomy for an advanced lung cancer invading an inferior chest wall.

[Video-assisted thoracoscopic left upper lobectomy for lung cancer patients: bronchial dissection technique prior to pulmonary artery dissection].

BACKGROUND: Dissection of anterior segmental artery anatomically crossing over apico-posterior segmental bronchus during left upper lobectomy may sometime cause life-threatening vascular injury. PATIENTS AND TECHNIQUE: Between August 2006 and July 2007, 12 patients with clinical stage IA-lung cancer underwent the video-assisted thoracoscopic left upper lobectomy with bronchial dissection prior to anterior and apico-posterior pulmonary artery dissections following dissection of lingular segmental artery. RESULTS: Operation time ranged from 75 minutes to 190 minutes (average 132 +/- 39 minutes). Operative blood loss ranged from 10 ml to 400 ml (124 +/- 112 ml). Postoperative course was uneventful except 1 patient who had left recurrent nerve palsy. CONCLUSIONS: Bronchial dissection prior to the upper segmental pulmonary artery dissections can produce better surgical field around left main pulmonary artery, leading to safe pulmonary arterial dissection during video-assisted thoracoscopic left upper lobectomy.

[Surgical treatment of an endobronchial inflammatory pseudotumor].

A 62-year old man with an abnormal chest radiograph was referred to our hospital for further evaluation. Chest computed tomography (CT) revealed a 3.0 cm tumor on the hilum of the right S3 segment. Bronchofiberscopic findings showed a polypoid tumor arising from right B3. Brushing cytology under bronchofiberscopy couldnot diagnose the tumor. The tentative preoperative diagnosis was primary lung cancer or a metastatic lung tumor. To confirm the histopathological diagnosis, a right upper lobectomy was performed. Intraoperative histopathological examination showed a pulmonary inflammatory pseudotumor.

[Hemoptysis one year after video-assisted thoracoscopic bullectomy for spontaneous pneumothorax: report of a case].

A 63-year-old man who had underwent video-assisted thoracoscopic bullectomy for left spontaneous pneumothorax 1 year before developed recurrent hemoptysis. Chest computed tomography showed previous stapling of the subsegmental bronchus in the left apico-posterior segment Bronchial arteriography showed hypervascularization of bronchial artery in the left upper segment and pooling of contrast medium along the staple-suture line. Video-assisted thoracoscopic apico-posterior segmentectomy was performed successfully. Pathological examination revieled hemosiderin lining along the surgical stump of B(1+2)cii, neither with infection nor infarction. These findings suggest that mechanical stapling of B(1+2)cii induced ischemia in the peripheral lung parenchyma causing bronchial hypervascularization. Late onset hemoptysis should be kept in mind as a complication after bullectomy with a mechanical stapler.

[Surgical outcome of tracheobronchial reconstruction for lung cancer].

We retrospectively evaluated the surgical outcome after sleeve lobectomy and pneumonectomy with tracheobronchial reconstruction for lung cancer. From 1993 to 2008, 46 patients with primary lung cancer underwent these surgical procedures. Seventeen patients (37%) received induction therapy, 15 received chemotherapy, while chemoradiotherapy or radiotherapy alone were received by one patient each. Sleeve lobectomy without carinal resection was performed in 41 patients. Carinal resection with 2 sleeve pneumonectomies was performed in 5 patients. There were no operative deaths. Bronchopleural fistula occurred in one patient, who required completion pneumonectomy. One patient presented local mucosal necrosis in the anastomotic site and was managed conservatively. Two patients had bronchial strictures as late complications and successfully dilated by a balloon using bronchoscopy. Overall 5-year and 10-year survival rates were 54% and 48%, respectively. No recurrence developed at any anastomotic site. The results showed that sleeve lobectomy and pneumonectomy with tracheobronchial reconstruction can be performed with low mortality and bronchial anastomotic complication rates. As well, local control of the tumor was satisfactory.

[Atypical pulmonary carcinoid tumor with abnormal elevation of serum gastrin-releasing peptide precursor: report of a case].

We report a rare case of atypical pulmonary carcinoid tumor accompanied by elevation of serum gastrin-releasing peptide precursor (ProGRP). A 55-year-old male presented to our hospital with a history of bloody sputum. The level of serum ProGRP was elevated to 781 pg/ml (normal < 46 pg/ml). Chest computed tomography (CT) revealed a solitary pulmonary tumor in the left lower lobe with sub-carinal lymph node enlargement. Transbronchial lung biopsy showed a pulmonary carcinoid, therefore left lower lobectomy with mediastinal lymph node dissection was performed. ProGRP decreased to normal level 1 month after operation. Histopathological diagnosis showed an atypical pulmonary carcinoid tumor.

Hyaluronan activates cell motility of v-Src-transformed cells via Ras-mitogen-activated protein kinase and phosphoinositide 3-kinase-Akt in a tumor-specific manner.

We investigated the production of hyaluronan (HA) and its effect on cell motility in cells expressing the v-src mutants. Transformation of 3Y1 by v-src virtually activated HA secretion, whereas G2A v-src, a nonmyristoylated form of v-src defective in cell transformation, had no effect. In cells expressing the temperature-sensitive mutant of v-Src, HA secretion was temperature dependent. In addition, HA as small as 1 nM, on the other side, activated cell motility in a tumor-specific manner. HA treatment strongly activated the motility of v-Src-transformed 3Y1, whereas it showed no effect on 3Y1- and 3Y1-expressing G2A v-src. HA-dependent cell locomotion was strongly blocked by either expression of dominant-negative Ras or treatment with a Ras farnesyltransferase inhibitor. Similarly, both the MEK1 inhibitor and the kinase inhibitor clearly inhibited HA-dependent cell locomotion. In contrast, cells transformed with an active MEK1 did not respond to the HA. Finally, an anti-CD44-neutralizing antibody could block the activation of cell motility by HA as well as the HA-dependent phosphorylation of mitogen-activated protein kinase and Akt. Taken together, these results suggest that simultaneous activation of the Ras-mitogen-activated protein kinase pathway and the phosphoinositide 3-kinase pathway by the HA-CD44 interaction is required for the activation of HA-dependent cell locomotion in v-Src-transformed cells.

[Localized pleural adenocarcinoma].

We report a 58-year-old male with localized pleural adenocarcinoma, the origin of which was not identified. The disk-shaped pleural tumor was 8 x 6 x 2 cm in size and involved the left upper chest wall including the ribs. A fine needle biopsy showed adenocarcinoma, but whole body survey revealed no neoplasm other than the chest wall tumor. The left chest wall resection was followed by the left pleuropneumonectomy, because a few disseminations were identified in the visceral pleura. Pathological examinations showed no primary tumor in the lung. Immunohistochemical examinations suggested that micro-adenocarcinoma originating the subpleural lung invaded chest wall. It may be possibly a subtype of pseudomesotheliomatous adenocarcinoma. The patient has no recurrent tumor 1 year after the operation.

[Prognosis of patients after resection for lung cancer with intrapulmonary metastasis in different lobes].

BACKGROUND: The prognosis of lung cancer patients with intrapulmonary metastasis in different lobes (pm2) is poor. However, some patients achieve long-term survival. We retrospectively investigated the prognosis of resected primary lung cancer patients with pm2. METHOD: Among 845 patients with primary lung cancer who underwent complete resection from 1984 to 2003, 14 cases that had lung cancer with pm2 were evaluated about prognostic factors. RESULTS: The overall 5-year survival rate was 9.5%. The analysis of survival curve based on clinicopathological factors (surgical procedure, histology, tumor size, lymph nodal metastasis, pleural invasion, pleural dissemination and number of pm2) revealed that bronchioloalveolar carcinoma (BAC), the absence of pleural invasion and the absence of pleural dissemination are better prognostic factors. CONCLUSION: Lung cancer patients with pm2 whose lesions show BAC histology, the absence of pleural invasion or pleural dissemination may achieve long-term survival and could be candidates for surgical treatment.

A role for FAK in the Concanavalin A-dependent secretion of matrix metalloproteinase-2 and -9.

To study the signaling pathway critical for the secretion of matrix metalloproteinases (MMPs), we examined the role of focal adhesion kinase (FAK) in Concanavalin A (Con A)-stimulated cells. We established a cell line in which FAK gene was conditionally inducible by use of FAK-null fibroblasts and the tetracycline repression system. In this cell line, FAK expression was undetectable in the presence of tetracycline but induced within 1 day by the removal of the drug. We found that FAK expression augmented the Con A-dependent secretion of MMP-9 and MMP-2. In contrast, proteolytic activation of MMP-2 by Con A-treatment did not require FAK expression. In addition, activation of MMP-secretion and tyrosine phosphorylation of FAK by Con A, but not the proteolytic activation of MMP-2, required attachment of the cells to the extracellular matrix. Taken together, our results suggest that the FAK signaling pathway play a pivotal role in the secretion of MMPs.

[Non-tuberculous mycobacterial infection along the staple-suture line after segmentectomy for small peripheral lung cancer; report of a case].

A 60-year-old non-immunocompromised man who had undergone right upper lobectomy and subsequent left superior segmentectomy for small peripheral lung cancers (stage I well-differentiated adenocarcinomas) 2 years earlier, was referred to us for further investigation of an asymptomatic abnormal shadow observed on a chest radiograph. Chest computed radiography showed air-space consolidation along the staple-suture line associated with the left superior segmentectomy, the abnormality was 4 x 5 x 5 cm. Completion lower lobectomy was performed because transbronchial biopsy did not provide for a definite diagnosis. Pathological examination revealed a large granuloma infected by Mycobacterium intercellulare. The lung parenchyma may be exposed along the staple-suture line and somewhat vulnerable to infection in cases of partial pulmonary resection. We should be aware of this possibility after lesser pulmonary resection for small peripheral lung cancer.

Role of red blood cells in the coronary microcirculation during cold blood cardioplegia.

The role of red blood cells during cold blood cardioplegia was studied using an intravital microscope in 13 isolated canine hearts perfused with diluted blood containing potassium chloride. The coronary microcirculation on the left ventricular epicardial surface was observed while the perfusate temperature was varied between 37 degrees C and 10 degrees C. Considerable sludging of red blood cells occurred during hypothermia. The percentage of capillaries perfused by red blood cells (percentage change) significantly decreased as perfusate temperature was reduced (100, 56, and 31% at 37, 20, and 10 degrees C respectively). This was caused by occlusion of microvessels due to sludging and by functional closure due to hypothermia. There was incomplete recovery of perfusion of capillaries at the end of rewarming (60%). The diameters of venules were reduced to 76% of control value at 10 degrees C because of the decrease in the numbers of feeding capillaries, but this value returned to 91% at the end of rewarming. Coronary vascular resistance (mmHg.ml-1.min-1 (kPa.s.litre-1] significantly decreased from 2.0(0.2) at 37 degrees C to 1.2(0.12) at 10 degrees C, but it increased to 2.4(0.24) at the end of rewarming. The finding in this study that sludging occurred which was slow to clear is a definite disadvantage of perfusion with red blood cells during hypothermia.

Pulmonary gangliocytic paraganglioma: case report and comparative immunohistochemical study of related neuroendocrine neoplasms.

The authors report a case of gangliocytic paraganglioma of the lung, which has not yet been described in a pulmonary neoplasm. A 75-year-old man underwent right middle and lower lobe lobectomy. A slightly yellowish mass was located at the bifurcation between the lower and middle lobe bronchus, protruding into the truncus intermedius. The neoplastic cells were composed of three cellular elements: uniform endocrine cells in a Zellballen arrangement, large ganglion-like cells within the nests of endocrine cells, and spindle-shaped cells arranged in streams to surround the nests. Each component exhibited the characteristic immunohistochemical properties, which were similar to those of the corresponding neuroendocrine neoplasms: Endocrine cells were positive for CAM 5.2, chromogranin A, and synaptophysin, like carcinoid tumor; ganglion-like cells were positive only for neurofilament, like ganglioneuroma; and spindle-shaped cells were positive for neurofilament and S-100 protein, like paraganglioma. These results agreed with those in gangliocytic paraganglioma of the duodenum. Pulmonary gangliocytic paraganglioma is similar to that in the duodenum, and is a hamartomatous proliferation of epithelial endocrine and neuronal cells of the bronchus.

Computed tomography analysis of the anterior mediastinal fat after left upper lobectomy.

RATIONALE AND OBJECTIVES: The authors evaluate changes in the anterior mediastinal fat (AMF) after left upper lobectomy. METHODS: In 36 carcinoma patients undergoing left upper lobectomy, the area and volume of AMF were measured using computed tomography before and after surgery, and their relations to postoperative mediastinal deviation were examined. RESULTS: The postoperative AMF distribution was changed distinctly, showing marked increase from the aortic arch to the main pulmonary arterial level, with converse decrease at upper and lower slices, but no significant postoperative change was noted in total AMF volume. There was a close correlation between changes in AMF area and mediastinal deviation after lobectomy. In two patients, a pseudotumor composed of AMF was depicted on frontal radiograph postoperatively, pseudotumor was thought to appear when the postoperative mediastinal deviation was marked but unaccompanied by marginal fluid or fibrosis. CONCLUSIONS: The AMF distribution is distinctly changed postoperatively, the displaced AMF redistribution is considered to be the main cause of seemingly increased fat or pseudotumor.

Symptomatic accessory cardiac bronchus.

Symptomatic accessory cardiac bronchus is rare. A 52-year-old woman with an accessory bronchus, who had had frequent episodes of hemosputum for 6 years, suffered from empyema complicated by a right lower lung abscess infected with Pseudomonas aeruginosa. Resection of the anomalous cardiac bronchus after open drainage of the pleural cavity was successful.