[Evaluation of Body Temperature during Pancreaticoduodenectomy for Pancreatic Cancer in Elderly Patients Aged over 75 Years Old].

BACKGROUND: Body temperatures in elderly patients undergoing a pancreaticoduodenectomy(PD)for treatment of pancreatic cancer have not been fully evaluated. We aimed to compare body temperature during a PD between elderly(75 years old)and non-elderly patients. METHODS: This retrospective study included patients who underwent PD between April 2012 and April 2014 at the Kanasgawa Cancer Center. Patients were categorized into 2 groups: elderly patients(≥75 years of age: group A)and non-elderly patients(<75 years of age: group B). Body temperatures were compared between the groups. RESULTS: We evaluated 58 patients-14 were classified into group A, and 44 into group B. Preoperative clinicopathological outcomes demonstrated no significant differences between patients. A comparison of body temperatures between the groups showed 36.3°C(before surgery)/36.1°C(at 1 hr)/36.3°C(at 2 hr)/36.7°C(at 3 hr)/36.8°C(at 4 hr)/37.1°C(at 5 hr)/37.4°C(at 6 hr)in group A compared to 36.2°C(before surgery)/36.2°C(at 1 hr)/36.4°C(at 2 hr)/36.6°C(at 3 hr)/ 36.9°C(at 4 hr)/37.0°C(at 5 hr)/37.3°C(at 6 hr)in group B. Results did not significantly differ between the groups. CONCLUSIONS: Our study suggests that body temperature is not affected by a patient's age.

Resection of a giant, invasive malignant solitary fibrous tumor of pleura.

Solitary fibrous tumor of pleura (SFTP) is a rare mesenchymal neoplasm that most commonly involves the pleura, is probably derived from fibroblasts, and has no relationship to malignant mesothelioma. Here, we report a case of complete resection of a giant malignant SFTP. A 61-year-old woman developed fever and left flank pain. Computed tomography revealed the tumor to be 13 cm in size and located in the left thoracic cavity, directly invading the left lower lobe of the lung. The patient underwent radical resection and left lower lobectomy. Immunohistochemical examination revealed a dense proliferation of spindle-shaped cells with ovoid nuclei and collagen fibers hyperplasia. The cells were positive for CD34 and vimentin, and were negative for cytokeratin AE1/AE3, calretinin, S-100 and smooth muscle α-actin. SFTPs have malignant potential, as 20-30 % of resected SFTPs reportedly contain malignant components. Careful long-term clinical follow-up is therefore required for all cases of SFTP.

Pleural dissemination of esophageal gastrointestinal stromal tumors after an eight-year interval following the primary surgery.

A 71-year-old man who had undergone surgical resection of esophageal gastrointestinal stromal tumors (GISTs) through a right posterolateral thoracotomy 8 years earlier was referred for treatment of an anterior mediastinal mass discovered on a follow-up chest radiograph in October 2007. Computed tomography findings revealed a tumor, 82 x 49 mm, with calcification, in the anterior mediastinum. When we radically resected the tumor via a median sternectomy, we found that it was actually located in the pleural cavity, and there was a small nodule near the main tumor on other pleura. Microscopically, the tumor was comprised of uniform spindle cells with fibrillary eosinophilic cytoplasm. In addition, immunostaining showed that the tumor was positive for CD117 (c-kit). The diagnosis was pleural dissemination of esophageal GISTs 8 years after primary surgery, making this the first report of pleural dissemination of esophageal GISTs after such a prolonged postsurgical interval.

Accuracy of helical computed tomography for the identification of lymph node metastasis in resectable non-small cell lung cancer.

PURPOSE: The criteria for the diagnosis of lymph node metastasis (LNM) in non-small cell lung cancer were investigated using helical computed tomography (hCT). The conventional criterion (1-cm short axis threshold) is generally accepted; however, this criterion is based on conventional CT. New criteria for LNM were investigated because the resolution of hCT is better than that of conventional CT. METHODS: Ninety-seven NSCLC patients examined with hCT were enrolled. Both the long axis (LA) and short axis (SA) of the nodes were measured using hCT. RESULTS: Based on the receiver operating characteristic curves, the thresholds that gave optimal sensitivity and specificity for LNM were 13 mm for LA and 9 mm for SA. The LNM diagnosis was re-evaluated using the combination of cutoff values. When the LA was > or =13 mm and the SA was > or =9 mm, the sensitivity, specificity, and accuracy were 56.3%, 92.1%, and 88.1%, respectively. When the LA was > or =13 mm or SA was > or =9 mm, sensitivity, specificity, and accuracy were 75.0%, 74.7%, and 74.7%, respectively. These values were not so different from the conventional criterion recalculated from these data. CONCLUSION: The new criteria are considered to be useful for making a LNM diagnosis. The conventional criteria for the LNM diagnosis might therefore be applicable even for hCT.

[A case of survival--excellent response to chemotherapy in long-term postoperative recurrence of non-small cell lung cancer].

A 63-year-old female underwent lobectomy with ND2a lymph node dissection for left lung cancer in April 1999. Histopathological examination revealed moderately-differentiated adenocarcinoma (pT2N2M0, pStage III A). She received one course of a combination of etoposide (ETP) and cisplatin(CDDP)as adjuvant therapy, followed by oral intake of UFT. At 9 months post-operatively, she received radiation therapy for lymph node recurrence, at which time new multiple lung metastases were found. After receiving 3 courses of a combination of vinorelbine (VNR) and CDDP, a complete response (CR) of all metastatic lesions was achieved. Three years after the original surgery, metastatic lesions recurred, and a total of 9 courses of a combination of VNR and carboplatin (CBDCA) and partial resection of the right lung for pulmonary metastasis were performed in succession. Following this therapy, treatment with gefitinib was initiated for about 6 months, and computed tomography (CT) showed progressive disease. For 8 years following the original operation, the patient received oral chemotherapy using S-1 and has maintained CR on CT. We conclude that oral administration of S-1 is useful as palliative chemotherapy without serious adverse events or worsening of quality of life. Patients like this case are thus able to continue chemotherapy for a long time.

Polymorphonuclear leukocytes are activated during atelectasis before lung reexpansion in rat.

Although reexpansion of a collapsed lung often causes pulmonary edema, the pathogenesis of the condition is not yet fully understood. To determine whether inflammatory changes occur in the pulmonary circulation during atelectasis and study the mechanism underlying the development of reexpansion pulmonary edema, we used a rat model in which the left lung was collapsed by bronchial occlusion for 1 h and then reexpanded and ventilated for an additional 1 h. We evaluated the accumulation of polymorphonuclear leukocytes (PMNs) in the lung and the production of reactive oxygen species (ROS) in the pulmonary circulation using a fluorescent imaging technique. We also used confocal laser scanning microscopy and computerized image analysis to evaluate the membrane translocation of p47-phox, one of the nicotinamide adenine dinucleotide phosphate (reduced form) oxidase subunits, in PMNs sequestered in the lung. Polymorphonuclear leukocytes accumulated in the lung during atelectasis, and p47-phox was translocated to the plasma membrane, but no ROS production was observed. Marked PMN ROS production was observed after reexpansion of the collapsed lung with air. Little ROS production was observed when the lung was reexpanded with nitrogen. During atelectasis, PMNs accumulate in the lung, where they are primed for respiratory bursting. After pulmonary reexpansion, oxygen is supplied from the alveoli, and PMN respiratory bursting occurs.

REG1A expression is an independent factor predictive of poor prognosis in patients with non-small cell lung cancer.

UNLABELLED: Regenerating gene I alpha (REG1A) is a known growth factor affecting pancreatic islet beta cells. Although REG1A expression also has been observed in various tumors, the correlation between REG1A expression and the clinicopathological characteristics of non-small cell lung cancer (NSCLC) and patient prognosis has not been evaluated. METHODS: We used real-time semi-quantitative reverse transcription polymerase chain reaction to assess REG1A mRNA expression in tumor samples from 86 NSCLC patients. We then correlated REG1A mRNA expression with known clinicopathological factors. We also used immunohistochemical staining to determine the source of REG1A. RESULTS: Within samples of tumor tissue, the cytosol of tumor cells was stained with anti-REG1A antibody. Cells from normal tissue were not stained. The 5-year over-all survival rate among patients expressing lower levels of REG1A was significantly better than among those expressing higher levels of REG1A (P=0.0031 by log-rank test). Multivariate Cox proportional hazard analyses revealed REG1A (hazard ratio, 2.34; 95% CI, 1.25-5.90; P=0.0055) and pathological stage III (hazard ratio, 3.46; 95% CI, 1.52-14.82; P=0.0012) to be independent factors affecting the 5-year over-all survival rate. CONCLUSION: High levels of REG1A expression by tumor cells are an independent predictor of a poor prognosis in patients with NSCLC.

[A case of thoracic esophageal cancer with invasion of the main bronchus in which long-term survival with high quality of life was achieved through chemoradiotherapy, esophageal bypass and then additional chemotherapy].

We administered chemoradiotherapy consisting of 5-fluorouracil and cisplatin combined with radiation (59.8 Gy) to a patient with locally advanced esophageal cancer (T4 (left main bronchus) N2M0, stage IVa). The cancer disappeared completely after the chemoradiotherapy. However, because an esophagobronchial fistula occurred, an esophageal bypass was performed according to the method of Postlethwait. Thereafter, multiple lung metastases appeared, which we treated with paclitaxel 120-210 mg/body during a total of 23 chemotherapy treatments over more than 2 years. For a lesion that recurred in a cervical paraesophageal lymph node, we administered 60 Gy of radiation. With these combined therapies, this patient survived 50 months as an outpatient with high quality of life. It is difficult to treat patients in whom there is direct invasion of the trachea or main bronchus by esophageal cancer, and we cannot generalize about the best treatment for these patients. This case, however, highlights how to treat such a patient so that he retains a high quality of life.

Subpleural injection of tracer improves detection of mediastinal sentinel lymph nodes in non-small cell lung cancer.

BACKGROUND: The advantages and disadvantages of various tracer injection protocols for sentinel lymph node (SLN) mapping have been extensively discussed in relation to breast and gastric cancer. But no such discussion has taken place in relation to SLN mapping in non-small cell lung cancer. We therefore studied the effect of two tracer injection protocols on SLN mapping in patients with non-small cell lung cancer; of particular interest was the relationship between subpleural tracer injection and identification of mediastinal SLNs. METHODS: A quadrant injection group (n=49) received 1.6 ml of ferucarbotran by peritumoral quadrant injection after thoracotomy. In the subpleural injection group, the same amount of ferucarbotran was injected into the peritumoral quadrants plus the subpleural region (n=27). SLNs were then detected intraoperatively by measuring the magnetic force within lymph nodes using a hand-held magnetometer. After completing the SLN mapping, lobectomy and hilar and mediastinal lymph node dissection was performed. RESULTS: The incidence of mediastinal SLNs was significantly higher in the subpleural injection group (45.4%) than in the quadrant injection group (14.6%) (p=0.007). Moreover, nominal logistic regression analysis revealed subpleural injection to be a significant independent factor contributing to detection of mediastinal SLNs (p=0.024, odds ratio 5.26). In the quadrant injection group, mediastinal lymph node metastasis was detected in two patients thought to have nonmetastatic parenchymal SLNs. By contrast, there were no false-negative cases in the subpleural injection group. CONCLUSION: Subpleural tracer injection significantly improves detection of mediastinal SLNs in non-small cell lung cancer.

Usefulness of circumference difference for estimating the likelihood of malignancy in small solitary pulmonary nodules on CT.

OBJECTIVE: The presence of a small solitary pulmonary nodule (SSPN) is a common finding on chest computed tomography (CT); however, preoperative diagnosis of SSPN is often difficult. We measured the extent of ground-glass opacity (GGO) and our own original method of circumference difference (CD) as an additional approach in classifying SSPN revealed on CT, and evaluated the likelihood of malignancy. METHOD: In total, 214 single SSPN with diameter <15mm were studied. All SSPN were histologically examined with surgical resection; preoperative CT findings and pathological diagnosis were evaluated retrospectively. The extent of the ratio of GGO and CD was evaluated using NIH image, where CD is defined as the ratio of the nodule margin distance to the circumference of the predicted circle with an area equal to that of the nodule. RESULTS: The thresholds for differentiating SSPN are 70% of GGO and 68% of the CD ratio. Differentiation of malignancy from benign tumor using our algorithm had sensitivity of 96.6%, specificity of 86.1%, and positive predictive value of 94.1%. CONCLUSION: Combined with other malignant likelihood parameters such as extent of GGO, CD ratio is a useful additional factor for estimating the likelihood of malignancy of SSPN on CT.

[A clinical study of hepatic arterial infusion chemotherapy with 5-FU and leucovorin for liver metastases].

We followed patients who underwent hepatic arterial infusion chemotherapy (HAI) with 5-FU and Leucovorin for liver metastases. Since CR (complete response) and PR (partial response) were achieved, this therapy seems to be effective. 5-FU metabolized on its first pass through the liver, and the hepatic extraction with rapid HAI is lower than that with slow HAI. It is suggested that control of extrahepatic lesions thought rapid HAI is useful for life prolongation.