[Outcomes of the Critical Pathway for Cooperative Follow-up on Patients with Postoperative Lung Cancer].

OBJECTIVES: We introduced the critical pathway (CP) for follow-up on patients with postoperative lung cancer to the staff of the Hyogo Prefectural Awaji Medical Center and regional medical institutions in Japan, in 2010. METHODS AND RESULTS: We raised awareness within our hospital and collaborating medical institutes and trained our staff on the CP before introducing it. From May 2013 through October 2023, lung cancer surgery was performed on 460 patients. Our CP was applied to 71.7% of these patients. Reasons for non-application included the high risk of recurrence due to advanced cancer stages( 39.2%) and the treatment for other types of cancer was needed in our hospital (26.2%). We reviewed the outcome of our CP. CONCLUSION: The high application rate was facilitated by preparatory actions, including training our hospital staff and collaborating medical institutions. An even higher application rate can be achieved by continuing to raise awareness and strengthening cooperation between concerned medical institutions that treat advanced lung cancer.

[Solitary Pulmonary Metastasis of Pancreatic Cancer Seven Years after Pancreatoduodenectomy That Needed to Differentiate from Primary Lung Cancer].

The indications for resection of pulmonary metastases of pancreatic cancer are controversial even now. We report a 63-year-old woman who was found a pulmonary nodule in the apical area of the left lung by chest computed tomography (CT) seven years after pancreatoduodenectomy for pancreatic cancer. Since the nodule was located adjacent to the left subclavian artery, we performed surgery for diagnosis and treatment without biopsy. The final pathological diagnosis was pulmonary metastasis of pancreatic cancer. The patient received adjuvant chemotherapy after lung resection and has remained relapse-free for 12 months.

[Ectopic Cervical Thymoma that was Difficult to Differentiate from Thyroid Tumor:Report of a Case].

We report a case of ectopic cervical thymoma that was difficult to differentiate from thyroid tumor. A 69-year-old woman was referred to our hospital with a tumor on the left side of the neck. Fine-needle aspiration cytology could not establish the diagnosis and the surgery was then performed for diagnosis and treatment. Since the intraoperative pathological diagnosis was also inconclusive, thymectomy was performed because of the macroscopic finding suggesting close relation to the thymus. The final pathological diagnosis was type AB thymoma.

[Experience with Pleural Metastasis from Hepatocellular Carcinoma;Report of a Case].

A 69-year-old man with a ruptured hepatocellular carcinoma(HC) was treated by hepatic transcatheter embolization (TAE) followed by upper segmentectomy of the liver. He developed postoperative intrahepatic recurrence and was treated with transcatheter arterial chemoembolization (TACE) at 6 months and 12 months postoperatively. Furthermore, chest computed tomography (CT) revealed a nodule suspected to be pleural metastasis 12 months postoperatively. Pathological assessment of a CT-guided biopsy of the nodule confirmed pleural metastasis of HC. Surgical resection of the metastatic tumor and adjuvant chemotherapy was performed. Despite developing lung metastasis, the patient has survived for more than 20 months. Early detection and treatment of pleural metastasis of HC might help to prolong survival.

Successful management of threatened aortic rupture late after rib fracture caused by blunt chest trauma.

A 62-year-old man was crushed in a car accident and diagnosed with a fractured left ninth rib, pulmonary and heart contusion, hemopneumothorax, and descending aortic injury based on a computed tomography scan. He underwent chest tube drainage and was intubated for mechanical ventilation because a bone fragment of the ninth rib threatened to penetrate the descending aorta. On the second posttrauma day, computed tomography showed the bone fragment of the ninth rib approaching the descending aorta. He underwent graft replacement of the injured portion of the descending thoracic aorta, and we removed the fractured left ninth rib.

Pulmonary sequestration with high levels of tumor markers tending to be misdiagnosed as lung cancer.

A 62-year-old man with hemoptysis and an abnormal shadow on chest roentgenogram was diagnosed as having anomalous systemic arterial supply to the normal basal segment of the left lower lobe. The preoperative serum carbohydrate antigen 19-9 and carcinoembryonic antigen levels were 73.8 units/ml and 10.8 ng/ml, respectively. Histopathological examination confirmed that the lesion was an intralobar pulmonary sequestration without air connection. There was no malignant finding in the resected specimen. The serum values of tumor markers returned to their approximate normal ranges after lower lobectomy.

Functional advantage after radical segmentectomy versus lobectomy for lung cancer.

BACKGROUND: Although several reports have recently demonstrated that segmentectomy for small-sized N0 lung cancer leads to recurrence and survival rates equivalent to those associated with lobectomy, controversy regarding the postoperative functional advantage in the former over the latter still persists. The purpose of this study was to evaluate the degree of postoperative functional loss in patients undergoing segmentectomy or lobectomy for lung cancer. METHODS: We analyzed patients able to tolerate lobectomy, who underwent radical segmentectomy (n = 38) or lobectomy (n = 45) for non-small-cell lung cancer. Functional testing included forced vital capacity, forced expiratory volume in 1 second, and anaerobic threshold measured preoperatively and at 2 and 6 months after surgery. RESULTS: Preoperative function tests showed no differences between segmentectomy and lobectomy patients. A positive and significant correlation was found between the number of resected segments versus loss of forced vital capacity (r = 0.518, p < 0.0001 at 2 months; r = 0.604, p < 0.0001 at 6 months) and loss of forced expiratory volume in 1 second (r = 0.492, p < 0.0001 at 2 months; r = 0.512, p < 0.0001 at 6 months). The postoperative reduction of forced vital capacity (p = 0.0006) and forced expiratory volume in 1 second (p = 0.0007) was significantly less in the segmentectomy group; however, a marginally significant benefit was observed in this group for anaerobic threshold (p = 0.0616). CONCLUSIONS: The extent of removed lung parenchyma directly affected that of postoperative functional loss even at 6 months after surgery, and segmentectomy offered significantly better functional preservation compared with lobectomy. These results indicate the importance of segmentectomy for early staged lung cancer.

Suppression of laser-induced choroidal neovascularization by oral administration of SA3443 in mice.

The effect of a synthetic cyclic disulfide compound, SA3443, on neovascularization was investigated. In vitro, enzyme-linked immunosorbent assay and RT-PCR demonstrated that SA3443 suppressed the expression of the hypoxia-induced vascular endothelial growth factor (VEGF) at both protein and mRNA levels in ARPE-19 cells. In vivo, the administration of SA3443 to mice with laser-induced choroidal neovascularization (CNV) suppressed the leakage from the lesions and reduced their size. Furthermore, the expression level of VEGF protein was significantly reduced by the administration of SA3443. Taken together, our results demonstrate that SA3443 suppresses VEGF production and reduces vascular leakage and the growth of mouse experimental CNV.

Technique for using the St. Jude aortic connector in anastomosis with a composite graft of saphenous vein and radial artery.

We presented a technique for using the St. Jude Aortic Connector System in anastomosis with a composite graft of saphenous vein and radial artery. This technique has not been reported in the previous literature. Our technique could improve some disadvantages of the St. Jude Aortic Connector and allow this device to be used in off-pump coronary artery bypass grafting (OPCAB).

Complications and outcomes after pulmonary resection for cancer in patients 80 to 89 years of age.

OBJECTIVE: Patients 80 years or older often present with potentially resectable cases of non-small cell lung cancer. Whether such patients should undergo surgical treatment is becoming increasingly important in this rapidly aging society. METHODS: From April 1997 through March 2004, 40 consecutive patients with non-small cell lung cancer who were 80-88 years of age underwent complete resection of their tumors, as confirmed pathologically. We reviewed preoperative data including gender, age, history of smoking, pulmonary function, co-morbidity, and induction/adjuvant therapy. Perioperative data consisted of surgical procedure, operative morbidity and mortality, histopathologic type, pathologic stage, and outcome. RESULTS: The procedures comprised 16 lobectomies (40%), 12 segmentectomies (30%), and 12 wedge resections (30%). The histopathologic diagnosis was adenocarcinoma in 22 patients, squamous cell carcinomas in 11, large cell carcinomas in 4, adenosquamous cell carcinomas in 2, and neuro-endocrine cell carcinoma in 1. The disease stage was IA in 21 patients, IB in 14, IIB in 3, and IIIA in 2. There was no perioperative mortality. Eight patients had non-lethal complications (20%), including five with cardiopulmonary complications (parenchymal air leaks persisting for more than 7 days in two patients, interstitial pneumonia in one, bacterial pneumonia in one, and moderate arrhythmias in one) and three with minor complications (depression or confusion). The actuarial survival rates of the 40 patients, including deaths from all causes, were 92.4, 71.6, and 56.9% at 1, 3, and 5 years, respectively. In patients with stage I disease, the respective survival rates were 94.3, 74.3, and 57.3%. CONCLUSIONS: Advanced age is not a contraindication to curative resection in patients 80-89 years of age with stage I non-small cell lung cancer.

Primary pulmonary myxoma.

We report a case of a primary pulmonary myxoma. The patient was a 69-year-old previously healthy human. Computed tomographic scan demonstrated a well-circumscribed tumor with a diameter of approximately 13 mm in the right upper lobe. We performed a right upper lobectomy under video-assisted thoracoscopy. Microscopic examination of the tumor disclosed elongated and stellate cells in a myxoid stroma, typical of myxoma.

Resection of chest wall invasion in patients with non-small cell lung cancer.

OBJECTIVE: The treatment of patients with non-small cell lung cancer invading the parietal pleura or chest wall is still debated. It is unsolved whether the depth of chest wall involvement or the type of resection (extrapleural or en bloc) affects long-term survival. METHODS: design, retrospective analysis; setting, Hyogo Medical Center for Adults, patients: the 97 patients who underwent surgical resection for non-small cell lung cancer involving the parietal pleura or chest wall between 1985 and 1997 were reviewed. RESULTS: Of the 97 patients, 76 had apparently complete resection, 21 had incomplete resection. The overall 5-year survival of completely resected patients was 34.2%, and that of incompletely resected patients was 14.3% (P=0.0489). In complete resection cases, the chest wall involvement was limited to the parietal pleura in 40, extended into the subpleural soft tissues in 10, and extended into the ribs in 26. The 5-year survivals were 32.5, 30.0 and 38.5%, respectively (no significant difference). The 5-year survival of completely resected patients with T3 N0 M0 disease was 44.2%, T3 N1 M0 disease 40.0%, and T3N2 M0 disease 6.2% (P=0.0019). The 5-year survival of completely resected patients with extrapleural resections was 30.0%, that of en bloc resections 38.9% (no significant difference). CONCLUSIONS: Survival of patients with lung cancer invading the chest wall or parietal pleura after resection is highly dependent on the completeness of resection and the extent of nodal involvement, but not so much on the depth of chest wall invasion or type of resection.

Prediction of morbidity after lung resection with risk factors using treadmill exercise test.

OBJECTIVE: To predict accurate morbidity after lung resection using treadmill exercise test. METHODS: A total of 130 patients (108 men and 22 women, with mean age 67.1+/-11.4 years (range, 34-78 years)) of 1129 patients underwent standard lobectomy were performed both treadmill exercise test and spirometry preoperatively. We measured maximum oxygen uptake/body weight (VO2max/BW) and change in arterial blood oxygen pressure from rest to symptom-limited maximum loading (delta aPaO2) and calculated exercise-induced hypoxemia (delta PaO2/delta VO2/BW), and retrospectively compared these parameters for patients with and without complications. RESULTS: There were five patients with severe postoperative complications, including three requiring use of a respirator, two with home oxygen therapy. %Vital capacity, VC (%, 80.2+/-13.2 vs. 92.5+/-20.9, P=0.026), delta PaO2 (Torr, -29.3+/-4.3 vs. -13.2+/-10.8, P=0.0004), VO2max/BW (ml/min/kg, 16.5+/-2.9 vs. 20.6+/-5.1, P=0.018) and delta PaO2/delta VO2/BW (Torr/ml/min/kg, -1.98+/-0.26 vs. -0.57+/-0.47) were significantly associated with worse outcome. All the five patients with complications had delta PaO2/delta VO2/BW<-1.7. CONCLUSIONS: Treadmill exercise testing is a good method for assessment of cardiopulmonary reserve. Limited resection must be performed if delta PaO2/delta VO2/BW is under -1.7.

Division of the pulmonary ligament after upper lobectomy is less effective for the obliteration of dead space than leaving it intact.

PURPOSE: To investigate whether division of the pulmonary ligament after upper lobectomy obliterates dead space. METHODS: Thirty-five patients scheduled to undergo upper lobectomy (23 right, 12 left) were randomly assigned to two groups, according to whether the inferior pulmonary ligament was divided (11 right, 12 left) or preserved (6 right, 6 left). To assess upward movement of the nonoperated lobes, plain chest X-ray films (posterior-anterior) were done at end-inspiration preoperatively and 1 month postoperatively, and the ratio of dead space in the longitudinal axis was measured. To assess the change in the angle of the main bronchus, chest X-ray tomography films were done preoperatively and 1 month postoperatively. The angles formed by the main bronchus and the truncus intermedius on the right side, and by the main bronchus and the lower bronchus on the left side, were measured, and the postoperative changes were calculated. RESULTS: The dead space ratio did not differ significantly between the divided group and the preserved group (3.5% vs 5.5%) or between sides. The change in the angle of the main bronchus did not differ significantly between the two groups on either the right (36.4 degrees vs 36.3 degrees) or the left side (72.5 degrees vs 60.0 degrees). CONCLUSION: Division of the pulmonary ligament after upper lobectomy is less effective for the obliteration of dead space than leaving it intact.

Selective segmental jet injection to distinguish the intersegmental plane using jet ventilation.

We used the selective jet injection method under bronchofiberscopy to distinguish the intersegmental plane. This method can reveal the intersegmental line clearly, quickly and easily with a good operative view even through a miniature utility thoracotomy or a thoracoscope, since only the burdened segment and not the entire lobe is inflated.

Subconjunctival administration of bucillamine suppresses choroidal neovascularization in rat.

PURPOSE: Bucillamine is an antirheumatic drug with antiangiogenic properties that is currently used in clinical practice. Because bucillamine inhibits the production of VEGF, it is possible that this drug may inhibit choroidal neovascularization (CNV). Thus, the effect of bucillamine on the eyes of rats with experimental CNV was investigated in vivo by subconjunctival injection or oral intake. METHODS: CNV was induced in rat eyes by diode laser photocoagulation. The intensity of fluorescein leakage from the photocoagulated lesions was studied 7 and 14 days after photocoagulation. The areas of CNV lesions were measured histologically and studied immunohistochemically at days 4, 7, and 14. In addition, the concentration of the drug in ocular tissue and blood was measured by high-performance liquid chromatography-tandem mass spectrometry after the drug was delivered orally or subconjunctivally. RESULTS: After subconjunctival injection, fluorescein leakage from the CNV lesions decreased significantly compared with the control eyes throughout the study period. Histologic and immunohistochemical analyses 4, 7, and 14 days after photocoagulation demonstrated that the average size of the CNV lesions was reduced in the bucillamine-treated eyes compared with the control eyes. Subconjunctival injection maximized the ocular drug concentration while minimizing the blood concentration of the drug compared with oral intake. CONCLUSIONS: Subconjunctival injection of bucillamine significantly reduced the leakage and size of experimental CNV. These results suggest that bucillamine may be beneficial in treating CNV and that further studies can be considered to evaluate this possibility.

Inhibitory effect of bucillamine on laser-induced choroidal neovascularization in rats.

PURPOSE: We investigated the inhibitory effects of bucillamine on formation of laser-induced choroidal neovascularization (CNV) in a rat model. METHODS: Bucillamine administration (approximately 150 mg/kg/day) was started 1 week before photocoagulation and continued to the end of the study. Control groups received drinking water. Two weeks after photocoagulation, choroidal neovascularization development was evaluated using simultaneous fluorescein and indocyanine green angiography, and the maximal thickness of the lesions was measured histologically. RESULTS: The incidence of CNV formation was 99.5 +/- 0.2% [mean +/- standard deviation (SD)] in control rats and 64.3 +/- 15.1% with bucillamine (P < 0.01). Histological study showed that the thickness of the CNV lesions was 23.4 +/- 6.5 microm (mean +/- SD) in the bucillamine-treated rats, which was significantly decreased compared to that in controls (60.8 +/- 9.2 microm) (P < 0.01). CONCLUSIONS: Our results suggest that bucillamine may inhibit the development of laser-induced CNV in rats.

Empyema necessitatis into the retroperitoneal space.

Empyema necessitatis is a rare complication of tuberculous empyema. We present a very rare case of empyema necessitatis into the retroperitoneal space through the diaphragm. The fistula between the thoracic empyema cavity and the retroperitoneal abscess was clearly identified by magnetic resonance imaging.

Mediastinal angioleiomyoma.

We report a case of a mediastinal angioleiomyoma. The patient was a 64-year-old previously healthy man. Computed tomographic scan revealed a well-circumscribed tumor with a diameter of approximately 2 cm in the right anterior mediastinum. We removed the tumor through a midline sternotomy. Microscopic examination revealed a highly vascular mesenchymal tumor without cellular dysplasia or mitotic figures.

Efficacy of a pedicled pericardial fat pad fixed with fibrin glue on postoperative alveolar air leakage.

The purpose of this randomized trial was to investigate the effect of using a pedicled pericardial fat pad fixed with fibrin glue on postoperative alveolar air leakage. Thirty consecutive patients with lung cancer, who had moderate alveolar air leaks after pulmonary resection, were randomized into two groups: in group A fibrin glue was applied onto the surface of the leaking raw lung and in group B, after applying fibrin glue in the same manner as in group A, a pedicled pericardial fat pad was immediately fixed to the leaking lung surface with fibrin glue. The duration of the postoperative air leakage and chest tube drainage was recorded. In 6 of 15 patients in group B the air leakage ceased within the first 24h after pulmonary resection, while in group A only 1 of 15 patients showed a cessation of the air leakage, and a significant difference was noticed between the two groups (P = 0.0309). The duration of the postoperative air leakage was 4.8+/-4.6 days in group A and 3.6+/-3.4 days in group B. The pedicled pericardial fat pad fixed onto the surface of the leaking raw lung using fibrin glue was found to reduce alveolar air leakage after pulmonary resection.