Feasibility of a novel diagnostic chart of intramedullary spinal cord tumors in magnetic resonance imaging.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Each type of intramedullary spinal cord tumor (IMSCT) has specific anatomical and pathological features visible on magnetic resonance (MR) imaging. The purpose of this study was to investigate the accuracy of preoperative IMSCT diagnosis using our diagnostic chart of tumor-specific MR imaging findings. SETTING: Hamamatsu, Japan. METHODS: From 2009 to 2013, 28 consecutive patients with IMSCT who underwent surgery in our university hospital were included in this study. There were 17 men and 11 women with an average age of 49 years (12-81). The pathological diagnoses were hemangioblastoma (12), ependymoma (11), astrocytoma (4) and squamous cell carcinoma (1). Tumor-specific MR imaging findings were as follows: ependymoma ((a) spinal cord swelling, (b) contrast effect with necrosis, (c) tumor in the center of the spinal cord), hemangioblastoma ((a) spinal cord swelling, (b) homogeneous contrast effect) and astrocytoma ((a) spinal cord swelling, (b) contrast effect is either, (c) eccentric tumor). Based on these features, we generated a diagnostic chart to investigate the MR imaging diagnosis accuracy for IMSCTs. RESULTS: The accuracy of preoperative diagnosis was 89% (25/28 cases). Correct diagnoses were made in 100% of hemangioblastomas (12/12 cases), 90% of ependymomas (9/11 cases) and 100% of astrocytomas (4/4 cases). CONCLUSIONS: Different types of IMSCTs exhibit unique MR imaging characteristics. These features can be used to preoperatively diagnose IMSCTs with high accuracy.

[Single-stage operation for synchronous bilateral multiple lung cancer through median sternotomy].

An asymptomatic 65-year-old woman was incidentally found to have abnormal shadows on a chest X-ray during a medical examination. A chest computed tomography (CT) scan showed a pulmonary nodule in both right and left lung. Those were diagnosed as synchronous cStage IA bilateral lung cancer, and right upper lobectomy and segmentectomy of the left lung with lymphoadenectomy were sequentially performed through median sternotomy. The patient showed a favorable course after surgery, and was discharged on postoperative day 12. The pathological diagnosis was synchronous lung cancer and both were adenocarcinoma. The pathological stage was IA on the right side and IB on the left. A single-stage operation through median sternotomy was a useful surgical procedure for treating this case of synchronous bilateral lung cancer.

[Bronchoplastic procedures for lung cancer].

Bronchoplastic procedures for patients with lung cancer are designed to achieve radical cure with preservation of functioning lung parenchyma. The operative results of 139 cases of lung cancer who underwent bronchoplasty between 1963 through 2007 were reviewed. The mean age of the patients was 62.5 years (range, 20 to 78 years). Sleeve lobectomy (SL) was performed in 119 cases, wedge lobectomy (WL) in 10 cases, sleeve segmentectomy (SS) in 5 cases, wedge segmentectomy (WS) in 2 cases, sleeve resection (SR) in 2 cases, and wedge resection (WR) in 1 case. Squamous cell carcinoma was the most frequently encountered histological type of disease (78%), followed by adenocarcinoma (12%) and other histological types (10%). The tumor was central in 125 patients (90%) and peripheral with nodal involvement in 14 patients (10%). Vascular resection and reconstruction was performed in 16 patients. Early major bronchial anastomotic complications occurred in 6 patients (4.3%). The 5-year survival rate in the patients with squamous cell carcinoma was 63.2%, and in patients with adenocarcinoma was 26.3%. SS for patients with early-stage squamous cell carcinoma of the segmental bronchus is a curative operation with preservation of the pulmonary function. Bronchoplasty without lung resection (SR, WR) is a reliable method for patients with low-grade malignant polypoid tumors arising from the bronchus. Patients with adenocarcinoma, N2 disease or major bronchial anastomotic complication show a worse prognosis.

CT-guided agar marking for localization of nonpalpable peripheral pulmonary lesions.

BACKGROUND: Small pulmonary lesions with ground-glass opacity (GGO) are increasingly detected by CT; however, intraoperative localization of such lesions is difficult because these lesions are often invisible and nonpalpable. STUDY OBJECTIVES: To localize and resect nonpalpable and invisible small pulmonary lesions, a new marking technique that we call "agar marking" was developed. METHODS AND PATIENTS: Powdered agar was dissolved in distilled water at a concentration of 5% and kept at > 50 degrees C to maintain its liquid form. Agar was injected through an 18-gauge needle and placed near the target lesion with CT. After animal experiments, agar marking was applied to the nine patients who had lesions < 20 mm in diameter and lesions with GGO. The mean diameter of these lesions was 11 mm, with a mean depth of 19 mm from the pleural surface on CT. RESULTS: Agar could be detected as a hard nodule by manual palpation, and the lesion was resected during thoracotomy in all cases. There were no complications associated with the agar injection, aside from one case of slight pneumothorax. CONCLUSIONS: Agar marking may represent a feasible alternative technique for localizing nonpalpable occult lesions located away from the pleural surface.

Prognosis of resected non-small cell lung cancer patients with carcinomatous pleuritis of minimal disease.

OBJECTIVE: The purpose of this study was to clarify the prognosis of resected non-small cell lung cancer (NSCLC) patients with carcinomatous pleuritis of minimal disease which might be considered as the next advanced stage of positive pleural lavage cytology. METHOD: The data were collected from a questionnaire survey on the survival of the patients with carcinomatous pleuritis found at thoracotomy from 1985 to December 1994 which was conducted by the Japan Clinical Oncology Group (JCOG). RESULTS: Out of 227 patients with carcinomatous pleuritis found at thoracotomy who had available information on a survival, 100 patients who underwent a resection of the primary tumor had carcinomatous pleuritis of minimal disease defined based on the criteria of the Japan Lung Cancer Society. The mean malignant fluid volume (+/-S.E.) was 37.1 (6.3) ml and the mean number of pleural disseminated nodules was 5.6 (0.9). A lobectomy was performed in 79 patients, a pneumonectomy in 11 and a limited resection in ten. The 3- and 5-year survival rates were 31.8 and 22.8%, respectively. CONCLUSIONS: The prognosis of resected NSCLC patients with carcinomatous pleuritis of minimal disease was unexpectedly good. This indicates that no fine line may exist between positive pleural lavage cytology findings and the aforementioned lesion.

Prognosis of non-small cell lung cancer patients with positive pleural lavage cytology after a thoracotomy: results of the survey conducted by the Japan Clinical Oncology Group.

OBJECTIVE: The purpose of this study was to clarify the prognosis of non-small cell lung cancer patients without pleural effusion whose intrapleural cancer cells were detected by a cytologic examination of pleural lavage fluid obtained immediately after a thoracotomy. METHOD: A questionnaire survey on the survival of the patients with positive pleural lavage cytology from January 1985 to December 1994 was performed by the Japan Clinical Oncology Group. RESULTS: According to the data collected from 15 institutions, 1890 non-small cell lung cancer patients without pleural effusion underwent pleural lavage cytology immediately after thoracotomy and 142 (7.8%) of them were found to have intrapleural cancer cells detected by the cytological analysis. The information of survival on 113 patients was available. This comprised of 64 males and 49 females with a mean age of 64.6 years. The predominant histologic type was adenocarcinoma (74%). Out of these 113 patients, 109 (97%) underwent a surgical resection. The 5-year survival rate was 30% in all patients, 49% in pathological stage I (n=35), 23% in stage II (n=20) and 26% in stage IIIA (n=34). CONCLUSION: Patients with a positive pleural lavage cytology in pathological stage I or II appear to have a poor 5-year survival rate.

Changes in graft flow pattern from the descending aorta due to intraaortic balloon pump.

During surgery for lung cancer in a patient who had undergone coronary artery bypass grafting through the descending aorta by left thoracotomy, we measured graft bypass blood flow from the descending aorta under intraaortic balloon pump (IABP) assistance. Under IABP assistance, the diastolic waveform changed to a spiky pattern with a sharp drop in blood flow of approximately 16% compared to that without IABP assistance. We report changes in graft flow pattern during IABP assistance when the graft is placed from the descending aorta.

Preoperative use of erythropoietin for cardiovascular operations in anemia.

Erythropoietin was used in 10 patients undergoing elective cardiovascular operations who were compromised with anemia. Initially, their blood hemoglobin levels were less than 10 g/dL (range, 7.5 to 9.9 g/dL). Erythropoietin (600 to 700 units/kg per week) was administered intravenously or subcutaneously for about 2 to 12 weeks. Blood hemoglobin levels increased in each patient (11.0 to 14.5 g/dL) until the day operation, and during this course autologous blood donations (400 to 1,200 mL) were obtained from 8 patients. As a result, homologous blood transfusions were needed in only 1 patient in whom erythropoietin treatment was interrupted for other reasons. All these patients were discharged without event, and no adverse effects due to erythropoietin were found. Although the causes of anemia were not specified in some of these patients, it was noteworthy that erythropoietin was effective even in a patient with hypoplastic bone marrow. Subcutaneous use was assumed to be especially favorable in managing anemic patients, in whom preoperative erythropoietin treatment could be continued for up to 82 days. We conclude that erythropoietin would be beneficial for the anemic population to secure homologous-blood-free operations.

Complications associated with pulmonary resection in lung cancer patients on dialysis.

BACKGROUND: There are few studies available investigating the perioperative problems experienced by lung cancer patients on dialysis undergoing pulmonary resection. METHODS: A retrospective review of 7 patients on dialysis undergoing pulmonary resection for lung cancer was performed. RESULTS: The patient population consisted of 7 men, with a mean age of 59.9 years. The underlying kidney disease was glomerulonephritis in 5 patients and nephrosclerosis in 2. The mean levels of blood urea nitrogen and serum creatinine were 70.7 mg/dL and 9.4 mg/dL, respectively. Histologic diagnoses were adenocarcinoma in 2 patients and squamous cell carcinoma in 5. Standard lobectomy with lymph node dissection was performed in all cases. There was one operation related death due to pulmonary edema and subsequent development of pneumonia. There were two cases of sputum retention and four of hyperkalemia. One patient died of cerebral bleeding that occurred during dialysis 2 months postoperatively. CONCLUSIONS: In patients on dialysis who undergo pulmonary resection, there is a high incidence of pulmonary complications, in addition to hyperkalemia, hemodynamic instability, and a tendency for postoperative dialysis-associated bleeding.

Early results of a prospective study of limited resection for bronchioloalveolar adenocarcinoma of the lung.

BACKGROUND: We reported that bronchioloalveolar adenocarcinoma (BAC) without active fibroblastic proliferation of the lung had no lymph node and pulmonary metastasis and had a favorable prognosis. However, there has been no prospective trial regarding limited pulmonary resection for this type of BAC. The purpose of this study is to confirm the effectiveness of limited resection for histologically confirmed BAC without active fibroblastic proliferation. METHODS: From 1996 through 1999, 42 patients who had small peripheral lung tumors (< or = 20 mm), suspected of being BAC, were enrolled in this trial. The patient population consisted of 24 men and 18 women with a mean age of 58.4 years. Limited resection was completed when BAC, without both active fibroblastic proliferation and lymph node metastasis, was confirmed histologically by intraoperative pathologic examination. RESULTS: Limited resection was completed in 36 patients, wedge resection in 34, and segmentectomy in 2 patients. In 6 patients, the procedure was converted into lobectomy because of pathologic invasive sign in 3, active fibroblastic proliferation in 1, and for other reasons in 2 patients. All patients have been followed for a median follow-up period of 30 months and are alive without sign of recurrence. CONCLUSIONS: Our early results indicate that limited resection may be an acceptable alternative to lobectomy for histologically confirmed BAC without active fibroblastic proliferation.

Efficacy and safety of extended thymectomy for elderly patients with myasthenia gravis.

BACKGROUND: The number of elderly patients who are diagnosed as myasthenia gravis (MG) is increasing in Japan. Although several factors affecting thymectomy have been well documented, few studies have focused on the efficacy and safety of thymectomy for elderly patients older than 60 years. METHODS: We evaluated 94 patients with MG who underwent extended thymectomy, and divided them into two groups: patients younger than 59 years and patients older than 60 years. Preoperative patient data, pathology of the thymus, complications, and clinical outcome were evaluated. RESULTS: In 69 young patients and 25 elderly patients, we observed no significant differences between the two groups with regard to preoperative data. Thymic hyperplasia was present in 45% of the young group and 16% of the elderly group. Remission and improvement rate were 40% and 57% in the young group and 8% and 75% in the elderly group, respectively. There were no serious complications, except one early death due to gastrointestinal bleeding in the elderly group. CONCLUSIONS: We conclude that thymectomy is a safe and effective alternative for elderly patients with MG.

Simultaneous detection of colorectal carcinoma liver and lung metastases does not warrant resection.

BACKGROUND: Recent evidence suggests that metastasectomy is efficacious for selected patients with hepatic and pulmonary metastases from a colorectal primary. The aim of this study was to identify a subgroup of patients who best benefit from hepatic and pulmonary metastasectomy among those with colorectal carcinoma metastases. STUDY DESIGN: We analyzed retrospectively a total of 136 patients who underwent resection of hepatic or pulmonary metastases of colorectal origin at Niigata University Medical Hospital between 1982 and 2000. The median follow-up period was 94 months. Eighty-four patients underwent hepatectomy alone, 25 underwent pulmonary resection alone, and 27 underwent both hepatic and pulmonary resection. The 27 patients undergoing hepatic and pulmonary resection were divided into two groups: 17 patients with sequentially detected hepatic and pulmonary metastases and 10 patients with simultaneously detected metastases. Survival time was determined from the date of initial metastasectomy. Differences in cumulative survival were evaluated using the log-rank test. Sixteen factors were assessed for their influence on the survival of the 27 patients undergoing resection of hepatic and pulmonary metastases; univariate and multivariate analyses were used in this evaluation. RESULTS: Patient survival after hepatic and pulmonary resection was comparable with that after hepatectomy alone (p = 0.536) and that after pulmonary resection alone (p = 0.294). Among the 27 patients undergoing hepatic and pulmonary resection, the outcomes after resection were significantly better in patients with sequentially detected metastases (cumulative 5-year survival of 44%) than in those with simultaneously detected ones (cumulative 5-year survival of 0%) (p < 0.001). On multivariate analysis sequential detection of hepatic and pulmonary metastases was the strongest independent favorable prognostic factor (p <0.001). CONCLUSIONS: Patients with sequentially detected hepatic and pulmonary metastases from a colorectal primary are good candidates for aggressive metastasectomy. Simultaneous detection of these metastases does not warrant resection.

A novel enzyme system for the reduction of 3-oxo bile acids in human red blood cells.

7 alpha,12 alpha-Dihydroxy-3-oxo- and 3,7,12-trioxo-5 beta-cholanoic acids labeled with 18O atoms were incubated with human red blood cells, and the biotransformation products were separated and characterized by gas chromatography-mass spectrometry as the pentafluorobenzyl ester-trimethylsilyl and -dimethylethylsilyl ether derivatives with the negative ion chemical ionization mode. The reduced products, 3 beta,7 alpha,12 alpha-trihydroxy-5 beta-cholanoic acid for the former, and 3 alpha-hydroxylated dioxo bile acid together with 3 beta-hydroxylated 7,12-dioxo-5 beta-cholanoic acid for the latter, were identified as metabolites. When 3-oxo bile acid was incubated with human blood denatured at 70 degrees C for 2 min, no metabolites were formed. The enzymic reduction activity has been localized in the red blood cell fraction.

Successful tracheal transplantation using cryopreserved allografts in a rat model.

OBJECTIVES: The purpose of this study was to determine the appropriate cryopreservation period of tracheal allografts based on morphological and immunological findings and to test the possibility of tracheal transplantation in rats using cryopreserved allografts without immunosuppression. METHODS: Morphological and immunological studies were performed to compare the differences between non-cryopreserved grafts and cryopreserved grafts. Orthotopic tracheal transplantation using cryopreserved allografts, non-cryopreserved allografts, and non-cryopreserved autografts was performed and the rejection score of each group was evaluated. RESULTS: Epithelial cells were lost when the grafts were cryopreserved for more than 20 days. Immunohistochemical staining of the trachea revealed that the MHC classII antigen was expressed on normal epithelium. These findings suggest that cryopreservation for more than 20 days decreased the antigeneicity of allografts because of epithelial desquamation. All rats that received allografts cryopreserved for more than 20 days survived until the scheduled sacrifice day. Microscopically, cryopreserved allografts that had been preserved for more than 20 days had a significantly lower rejection score than that of non-cryopreserved allografts (P < 0.05). CONCLUSIONS: We conclude that the appropriate period for cryopreservation of allografts would be 20 days or more, because cryopreservation for more than 20 days depleted epithelium, which possessed the MHC classII antigen. Therefore, a longer period of cryopreservation decreases the antigeneicity of allografts. Rat tracheal transplantations using cryopreserved allografts is possible without immunosuppression when the grafts have been cryopreserved for more than 20 days.

Pulmonary complications after surgical treatment of lung cancer in octogenarians.

OBJECTIVE: The purpose of this study was to analyze the risks associated with pulmonary resection for primary non-small cell lung cancer in octogenarians to help better management in these patients. METHODS: We reviewed the outcome in our 35 patients aged 80 years and older who underwent pulmonary resection between 1981 and 1998. RESULTS: The 5-year survival rate was 39.8%. The operative mortality rate was 0% and the morbidity 60%. There were ten major pulmonary complications, including respiratory insufficiency following bacterial pneumonia and sputum retention. Preoperative arterial pO(2) was significantly lower, A-aDO(2) was significantly higher, and operation time were significantly longer in patients with pulmonary complications after surgical treatment than in patients without complications (P<0.05). CONCLUSIONS: Surgical treatment was not contraindicated for octogenarians with lung cancer. However, a relatively preoperative low arterial pO(2), high A-aDO(2), and long operation time may be risk factors for postoperative pulmonary complications in such patients. Surgeons must assess the preoperative data prudently to determine appropriate surgical strategy.

Mediastinal yolk sac tumor in a young girl: case report and review of the literature.

The authors report a rare case of a female infant who underwent successful treatment of a mediastinal yolk sac tumor. Therapy included four cycles of preoperative PVB (cisplatinum, vinblastine, bleomycin), complete surgical resection of the tumor, and one postoperative cycle of PVB and four cycles of VAC (vincristine, actinomycine, cyclophosphamide) chemotherapy. The successful treatment of this tumor depends on preoperative chemotherapy to reduce the size, followed by complete surgical excision with subsequent postoperative chemotherapy. Recent improvements in the treatment of mediastinal yolk sac tumors are discussed.

A rare case of lung cancer associated with renal cell cancer and benign histiocytoma of bone.

Lung cancer often metastasizes to organs outside the thorax, and consequently radiological evaluation of distant metastasis has become standard procedure prior to surgery. Although positive radiological findings generally suggest distant metastasis, the possibility of the co-existence of a benign tumor and primary malignancies must be considered. Herein we report a case of surgical resection of histologically confirmed lung cancer associated with renal cell cancer and benign histiocytoma of the humerus.

Segmental bronchial atresia of the left upper lobe treated with segmental resection under video-assisted thoracic surgery.

We report our experience of segmental bronchial atresia managed with segmental resection under video-assisted thoracic surgery. A 23-year-old woman reporting a cough, dyspnea, and back pain underwent segmental resection in which a stapling device was used under video-assisted thoracic surgery. Her postoperative course was uneventful with minimal pain and a disappearance of preoperative symptoms after surgery. Once an accurate preoperative diagnosis can be established, video-assisted thoracic segmentectomy together with the use of a stapling device is considered to be feasible.

Placental transport of bile acids: analysis of bile acids in maternal serum and urine, umbilical cord blood, and amniotic fluid.

To investigate the role of placental transport of bile acids in fetal bile acid metabolism, such as with regard to synthesis of the unusual bile acids (1 beta- and 6 alpha-hydroxylated and unsaturated bile acids), we measured the concentrations of bile acids in umbilical cord blood, amniotic fluid, maternal serum and maternal urine at delivery by means of gas chromatography-mass spectrometry. Serum and urine from healthy nonpregnant women were used as controls. We detected large amounts of unusual bile acids, especially hyocholic acid and 3 beta-hydroxy-delta 5 bile acids, in amniotic fluid and umbilical cord blood. The concentration of total bile acids in maternal serum was less than that of control serum and umbilical cord blood, and the concentration of total bile acids in maternal urine was higher than that of control urine and amniotic fluid. In conclusion, the fetus synthesized large amounts of unusual bile acids, and these compounds were transported from fetus to mother by placental transfer. We suggest that pregnant women may excrete large amounts of bile acids into the urine to control serum concentration of bile acids in fetus.

Recurrent thymic carcinoid tumor in the pleural cavity. 2 cases of long-term survivors.

Thymic carcinoid is a rare malignant tumor having a high incidence of local recurrence and distant metastasis. To date, few reports have described the reoperative management of recurrent thymic carcinoid appearing as a pleural tumor. Here we report 2 such cases in long-term survivors. Long-term follow-up is recommended for patients with thymic carcinoid even after curative surgery. Aggressive treatment including surgical resection may prolong survival in these patients.