Endobronchial Topical Amphotericin B Instillation for Pulmonary Chromomycosis After Lung Transplantation: A Case Report.

We report a very rare case of pulmonary chromomycosis caused by Scedosporium prolificans that developed after lung transplantation and was successfully treated with endobronchial topical amphotericin B instillation. The subject was a woman in her 50s with a history of bilateral lobar lung transplantation from living donors for idiopathic pulmonary hypertension. Eight years after the lung transplantation, chest radiography X-ray and computed tomography showed an abnormal shadow in the right lung. Bronchoscopic findings showed obstruction by a fungal component at the laterobasal bronchus B9. She was diagnosed with pulmonary chromomycosis after S. prolificans was detected in the bronchial aspirate. Systemic antifungal treatment with itraconazole was ineffective. Therefore, we administered topical amphotericin B weekly via endobronchial instillation and replaced oral itraconazole with voriconazole. The endobronchial procedure was safe and tolerable. Bronchial obstruction improved after three 3 instillations. We continued topical amphotericin B instillation once every 3 months for 2 years, and the abnormal shadow nearly disappeared. This case report describes infection by S. prolificans, which rarely becomes an etiologic agent in lung transplant patients, and shows that endobronchial topical amphotericin B instillation is a therapeutic option when systemic antifungal treatment is ineffective.

[Emergency anterior approach for decortication with right pneumonectomy in a patient with chronic expanding hematoma].

The patient was a 68 year-old woman who had a history of treatment of pulmonary tuberculosis 35 years ago. She has experienced dyspnea and hemosputa since several years ago and has been followed up as having chronic empyema. She was admitted to our hospital due to recent exacerbation of symptoms. X-ray films and computed tomography scans of the chest showed the right thoracic cavity to be totally filled with a mass and the shift of mediastinum to the left side. After several days from admission, she needed mechanical ventilation support due to dyspnea exacerbation. Emergency decortication with right pneumonectomy through median sternotomy with anterolateral incision was performed. Postoperative course was uneventful. Pathlogical diagnosis was chronic expanding hematoma.

[Management of surgical approach for intractable secondary spontaneous pneumothorax].

Secondary spontaneous pneumothorax (SSP) such as lymphangioleiomyomatosis (LAM), bronchiolitis obliterans (BO) is intractable or repeated the recurrence of pneumothorax. The most effective chemical pleurodesis for intractable pneumothorax is talc poudrage and so on that is associated with a reduction in the rate of pneumothorax recurrence. However, severe and broad pleural adhesion due to the pleural interventional procedures sometimes cause serious bleeding when the patients undergo lung transplantation. We must be considered for new approaches to these intractable secondary pneumothoraces which replaced traditional conservative and surgical approaches. We had proposed new 2 approaches of total pleural covering (TPC) and awake surgical intervention (ASI) for intractable pneumothorax. We applied the TPC modified with coverage of air leak points with polyglycolic acid (PGA) sheet to 5 patients with intractable bilateral pneumothorax to reduce the risk of excessive bleeding by chemical pleurodesis in lung transplantation. The bilateral pneumothorax was well controlled, and no recurrence has been observed. TPC is reliable procedure for management intractable bilateral SSP. For 12 high-risk patients with other underling pulmonary diseases on general poor conditions, a surgical intervention was performed in awake condition. The air leaks were stopped in 11 cases except for 1 case. The recurrence of pneumothorax after surgery was 2 cases. ASI for intractable secondary pneumothorax can be applicable to selected patients with deteriorated general condition.

[Recurrence patterns and prognosis in lung cancer patients with positive pleural lavage cytology at surgery].

Recurrence patterns and prognosis in lung cancer patients with positive pleural lavage cytology (PLC) at surgery have not been completely understood. From January 2001 to October 2007, we performed PLC on 195 patients undergoing thoracotomy for lung cancer. Fourteen (7.2%) of 195 patients had positive PLC findings. Twenty seven patients who underwent limited surgery due to complication were excluded from the further investigation. Some form of recurrence was observed in 33 (21.2%) of 156 patients with negative PLC, and in 8 (66.7%) of 12 patients with positive PLC (p < 0.05). The local recurrence was observed in 13 (39.4%) of 33 patients who have recurrence with negative PLC and was observed in 4 (25%) of 8 patients who have recurrence with positive PLC (p = 0.45). The survival rate of patients with positive PLC was significantly worse than that of patients with negative PLC (p < 0.05), and was as low as that of patients with macroscopic malignant effusion. The multivariate analysis demonstrated PLC was independent prognostic factor. PLC is an easy procedure and is an important prognostic factor, and should be routinely performed in the lung cancer operation.

[Sternal resection and chest wall reconstruction for primitive neuroectodermal tumor of the sternum].

Primitive neuroectodermal tumor of the sternum is rare. A 59-year-old woman referred to our department with anterior chest pain and a tumor in the sternum. The patient was diagnosed as primitive neuroectodermal tumor of the sternum by core biopsy of the lesion. She received 2 cycles of preoperative chemotherapy with vincristine, doxorubicin, cyclophosphamide, ifosfamide, etoposide. She underwent a total sternectomy with resection of adjacent bilateral costal cartilages and sternal ends of the clavicles. The skeletal defect of chest wall was reconstructed by polypropylene mesh-resin sandwich. The myocutaneus defect was reconstructed by the pedicled latissimus dorsi myocutaneus flap and the bilateral breast flaps. The postoperative course was uneventful and adjuvant radiotherapy was started 6 weeks after the operation. She died of distant metastases 3 months after the operation, although this patient was free from local recurrence.

[Problems in donor lung evaluation for transplantation with regard to airway infection].

The shortage of donor organs has been 1 of the major obstacles to solid organ transplantation. Typical lung donor criteria include clear lung field on chest radiograph, adequate oxygenation, acceptable lung compliance, and satisfactory bronchoscopic findings. To extend usage of available donors, liberalization of donor lung selection criteria has been facilitated, however, marginal donor lungs must be used with discretion, because donor lung injury, especially that related to infection, has a potential leading to early post-operative death of the recipient. From March 2000 to December 2006, we evaluated 15 braindead donors and at least 1 of the lungs from 9 donors was judged suitable for transplantation. One of 9 recipients developed severe pneumonia cased by carbapenems-resistant Pseudomonas aeruginosa possibly originating from the donor lungs, eventually leading to death. The chest radiograph and oxygenation of the donor had been satisfactory, however, a moderate amount of mucopurulent secretions was observed by bronchoscopic inspection and the donor had been given a cefozopran for 9 days before the procurement operation. Remaining 8 recipients were free from air-way infection in the early postoperative period. We discuss the status and problems of donor lung evaluation for transplantation with regard to donor lung infection.

Lipid-mediated transbronchial human interleukin-10 gene transfer decreases acute inflammation associated with allograft rejection in a rat model of lung transplantation.

BACKGROUND: Transferring genes with immunoregulatory capacity to transplanted organs has the potential to modify allograft rejection (AR). We examined the effect of ex vivo lipid-mediated transbronchial human interleukin-10 (hIL-10) gene transfer on acute AR in a rat model of lung transplantation. METHODS: Left single lung transplantations were performed between a highly histoincompatible rat combination: Brown Norway to Lewis. The extracted donor left lung was intrabronchially instilled with a plasmid encoding hIL-10 or Escherichia coli beta-galactosidase (control), mixed with a cationic lipid. On day 6 posttransplantation, the degree of AR was graded histologically (stages 1-4) based upon pathological categories of inflammation: perivascular, peribronchial, and peribronchiolar lymphocytic infiltrates, edema, intraalveolar hemorrhage, and necrosis. RESULTS: The stage of AR in the IL-10 group (3.1 +/- 0.4) was significantly lower than the control group (3.8 +/- 0.4). Pathological scores for edema, intraalveolar hemorrhage, and necrosis in the IL-10 group (2.3 +/- 0.8, 0.3 +/- 0.5, and 0.3 +/- 0.5, respectively) were also significantly decreased compared with those in the control group (3.2 +/- 0.4, 2.2 +/- 0.8, and 1.2 +/- 0.4, respectively). CONCLUSION: Ex vivo lipid-mediated transbronchial hIL-10 gene transfer attenuated acute inflammation associated with AR in a rat model of lung transplantation.

The DNA mismatch repair gene hMSH2 is a potent coactivator of oestrogen receptor alpha.

The DNA mismatch repair gene is a key regulator in the elimination of base-base mismatches and insertion/deletion loops (IDLs). Human MutS homologue 2 (hMSH2), originally identified as a human homologue of the bacterial MutS, is a tumour suppressor gene frequently mutated in hereditary non-polyposis colorectal cancer. Hereditary non-polyposis colorectal cancer is characterised by the early onset of colorectal cancer and the development of extracolonic cancers such as endometrial, ovarian, and urological cancers. Oestrogen receptor (ER) alpha and beta are members of a nuclear receptor (NR) superfamily. Ligand-dependent transcription of ER is regulated by the p160 steroid receptor coactivator family, the thyroid hormone receptor-associated proteins/the vitamin D receptor-interacting proteins (TRAP/DRIP) mediator complex, and the TATA box-binding protein (TBP)-free TBP associated factor complex (TFTC) type histone acetyltransferase complex. Here, we report the interaction between ER alpha/beta and hMSH2. Immunoprecipitation and glutathione-S-transferase pull-down assay revealed that ER alpha and hMSH2 interacted in a ligand-dependent manner, whereas ER beta and hMSH2 interacted in a ligand-independent manner. Oestrogen receptor alpha/beta bound to hMSH2 through the hMSH3/hMSH6 interaction domain of hMSH2. In a transient expression assay, hMSH2 potentiated the transactivation function of liganded ER alpha, but not that of ER beta. These results suggest that hMSH2 may play an important role as a putative coactivator in ER alpha dependent gene expression.

[Anterior cervical approach for resection of brachial plexus schwannoma expanding into the thoracic apex].

Primary tumors of the brachial plexus are unusual. We describe 2 patients with schwannomas of the brachial plexus that had the radiologic appearance of apical lung masses. We used anterior cervical approach for both of the patients. Our technique permitted safe and complete resection of the tumors of this complex area. Both tumors were arising from the Th1 component of brachial plexus. Histopathological findings revealed that both of the tumors were benign schwannomas. This approach is quick and safe, allowing much better control of the important vascular and neural structures of the thoracic apex. Tumors at the area are inaccessible by using posterolateral thoracotomy or video-assisted thoracic surgery. We suggest that the anterior cervical approach would be applied for the resection of other kind of tumors in the thoracic apex.

A nonsurgical technique to create an esophagostomy for difficult cases of percutaneous endoscopic gastrostomy.

BACKGROUND: We developed a minimally invasive technique of esophagostomy called percutaneous transesophageal gastrotubing (PTEG) using a rupture-free balloon (RFB) for enteral nutrition and drainage as well as percutaneous endoscopic gastrostomy (PEG). PTEG using RFB allows surgeons to create a nonsurgical esophagostomy even in difficult cases of PEG (i.e., total gastrectomized patients and massive ascites). METHODS: To create the PTEG, a RFB is inserted into the esophagus through the nose and inflated. The RFB is punctured with a needle at the left neck under ultrasonographic vision. A guidewire is inserted through the needle, followed by dilatation of the punctured site using a dilator with sheath. Finally, the tube is inserted into the gastrointestinal tract and the sheath is peeled off. RESULTS: From January 1998 to June 2002, we treated 115 patients using PTEG with a RFB and there were no major complications. Therapeutic results are as good as those for PEG and it took approximately 15 min to perform. CONCLUSIONS: PTEG with RFB is as safe as PEG and is simple and less invasive. It can be used in some cases for which PEG is contraindicated.

[Resected cases with primary lung cancer after preoperative high dose irradiation].

After greater than 60 gray (Gy) irradiation, we performed the pulmonary resection in the 18 primary lung cancer cases. The mean irradiation dose to the tumor was 68.2 (range 60-101) Gy, and the mean irradiation dose to the bronchial stump was 47.1 (range 0-82) Gy. Median time from end of irradiation to surgical resection was 136 (range 20-894) days. One partial resection, 9 single lobectomies, 3 double lobectomies, and 5 pneumonectomies were done. Mainly, we closed the bronchial stump by the automatic stapling device and additional hand suturing. The bronchial stump was covered in the 12 cases by the owner stalk thymus, the intercostals muscular flap, the omentum flap, and et al. The major postoperative complications due to preoperative irradiation were not seen. Bronchopleural fistulas did not occur. Pathologically, the wall of the submucosal capillary vessels were getting thick in the patients operated more than 3 months later after irradiation. In such cases with the decrease of the blood flow, the bronchial stump should be covered. The pulmonary resection after the high dose irradiation was considered to be tolerable.

[Percutaneous trans-esophageal gastro-tubing (PTEG): experience of home care with a long-term PTEG].

PURPOSE: Percutaneous trans-esophageal gastro-tubing (PTEG) was developed as a new method of esophagostomy for drainage and feeding. It is especially easy to create a PTEG for patients in whom it is difficult to perform a percutaneous endoscopic gastrostomy (PEG). Here we report a satisfactory experience with a patient with dysphagia for whom we improved the patient's QOL with PTEG. The patient suffered from terrible dysphagia due to Parkinson's disease and was in the postoperative recovery status after undergoing a gastrectomy for gastric cancer. PTEG allowed the patient to receive further long-term medical care at home. CASE: The patient was a 74-year-old man with severe dysphagia due to Parkinson's disease and had a residual stomach as a consequence of a gastrectomy. He had to continue receiving long-term enteral nutrition at home, however it was difficult to create a PEG. We therefore decided to use a PTEG. MATERIALS/METHOD: For the PTEG, a rupture-free balloon (RFB) catheter for enteral nutrition was used. First, an RFB was inserted through the nose into the esophagus and inflated. The RFB was punctured percutaneously aided by ultrasonography and conventional fluoroscopy. Then, a guide wire followed by a dilator with a sheath were inserted. Finally, an indwelling catheter was inserted into the digestive tract through the sheath. REMARK: PTEG using an RFB catheter was a safe, simple and less invasive method; it enabled the patient to continue receiving further medical treatment at home without major complications for a long term.

A retrospective analysis of 88 patients with pancreaticogastrostomy after pancreaticoduodenectomy.

BACKGROUND/AIMS: Recently, pancreaticogastrostomy after pancreaticoduodenectomy has been reintroduced as a useful procedure with a low incidence of pancreatic leakage. We decided to retrospectively analyze the early postoperative and late follow-up complications in a large number of patients who had undergone our improved pancreaticogastrostomy. METHODOLOGY: Between August 1993 and November 1998, we performed pancreaticogastrostomy following pancreaticoduodenectomy in 88 consecutive patients including pylorus preservation in 14. Our pancreaticogastrostomy used a two-layer implantation method using a pancreatic duct stent with an anterior gastrotomy. RESULTS: The morbidity and mortality rates were 5.7% and 0%, respectively. There were no cases of pancreatic leakage and no postoperative complications directly related to the pancreaticogastrostomy. As for gastric emptying, the average time until resumption feeding was 12 days, with no significant difference between pancreaticogastrostomy and pylorus-preserving pancreaticogastrostomy. As to late follow-up complications, diabetes developed postoperatively in 6.5% (4/62) patients, and of 14 patients who were shown by magnetic resonance cholangiopancreatography, 5 (35.7%) developed pancreatic ductal dilatation after surgery. CONCLUSIONS: These results from a relatively large group conclusively prove the safety of pancreaticogastrostomy and indicate that the follow-up quality of life is good under the circumstances.

Long-term natural history of hemorrhagic moyamoya disease in 42 patients.

OBJECT: The purpose of this study was to delineate the long-term natural history of hemorrhagic moyamoya disease (MMD). METHODS: A retrospective review was conducted among 42 patients suffering from hemorrhagic MMD who had been treated conservatively without bypass surgery. The group included four patients who had undergone indirect bypass surgery after an episode of rebleeding. The follow-up period averaged 80.6 months. The clinical features of the first bleeding episode and repeated bleeding episodes were analyzed to determine the risk factors of rebleeding and poor outcome. Intraventricular hemorrhage with or without intracerebral hemorrhage was a dominant finding on computerized tomography scans during the first bleeding episode in 29 cases (69%). During the follow-up period, 14 patients experienced a second episode of bleeding, which occurred 10 years or longer after the original hemorrhage in five cases (35.7%). The annual rebleeding rate was 7.09%/person/year. The second bleeding episode was characterized by a change in which hemisphere bleeding occurred in three cases (21.4%) and by the type of bleeding in seven cases (50%). After rebleeding the rate of good recovery fell from 45.5% to 21.4% and the mortality rate rose from 6.8% to 28.6%. Rebleeding and patient age were statistically significant risk factors of poor outcome. All four patients in whom there was indirect revascularization after the second bleeding episode experienced a repeated bleeding episode within 8 years. CONCLUSIONS: The occurrence of rebleeding a long time after the first hemorrhagic episode was not uncommon. Furthermore, the change in which hemisphere and the type of bleeding that occurred after the first episode suggested the difficulty encountered in the prevention of repeated hemorrhage.

Malignant schwannoma metastasizing to the parenchyma of the brain--case report.

A 48-year-old male presented with a very rare case of malignant schwannoma metastasizing to the parenchyma of the brain. He had undergone previous radical surgical resection of an abdominal wall tumor that was histologically confirmed as a malignant schwannoma. Five years later, the patient presented with metastases to the parenchyma of the brain and lung. A large mass at the left frontoparietal region was totally resected immediately after intratumoral hemorrhage. He recovered well and the lung metastasis was also removed, but he later developed further multiple metastases in the lung and brain.

[A case of spontaneous cervical carotid artery dissection managed by using primary stent placement].

The authors report the case of a 35-year-old male who underwent stenting for spontaneous cervical carotid dissection. He presented with sudden onset of hemicrania and left facial palsy followed by left hemiparesis and dysarthria. On admission, carotid angiography revealed postsinus tapering occlusion of the right internal carotid artery. Initially, he was managed with conservative treatment, but his neurological status deteriorated. Findings of brain CT, MRI and IMP-SPECT suggested hypoperfusion of the right cerebrum. A Palmaz stent, 39 mm in length, was successfully placed over the site of the dissection to restore normal patency through the dissected carotid artery. Following stent implantation, his neurological signs improved gradually but completely. Since the procedure, with oral administration of antiplatelet medication, he has suffered no cerebral ischemic events. Follow-up carotid angiography one year after stent implantation showed good patency of the stented segment. The present case emphasizes the usefulness of stenting for spontaneous cervical carotid dissection.

Retrospective analysis of type of hepatic resection for hepatocellular carcinoma.

BACKGROUND: Hepatic resection for hepatocellular carcinoma is now considered a relatively safe procedure, owing to refined surgical techniques and management. METHODS: Three hundred different types of hepatic resection performed in one hospital were reviewed retrospectively. The operative morbidity and mortality rates and long-term survival were assessed. RESULTS: Tumours were extirpated by lobectomy or extended lobectomy in 48 patients, by segmentectomy in 53, by subsegmentectomy in 94 and by partial resection in 105. The overall hospital mortality rate was 4 per cent (13 of 300). No operative death occurred after lobectomy or extended lobectomy. Segmentectomy and subsegmentectomy were associated with high postoperative complication and hospital mortality rates. There was a significant difference in survival rate between patients with and without a cancer-free surgical margin of more than 1.0 cm. The overall 5- and 9-year survival rates were 51 and 9 per cent respectively. Rates were 56 and 24 per cent for lobectomy or extended lobectomy. CONCLUSION: For tumours of 2.1 cm or more in size lobectomy appears to carry the least risk of postoperative complications and death in hospital and best achieves a cancer-free surgical margin.

Isolated metastases of adenocarcinoma in the bilateral internal auditory meatuses mimicking neurofibromatosis type 2--case report.

A 56-year-old male with a history of lung cancer presented with isolated metastases of adenocarcinoma in the bilateral internal auditory meatuses (IAMs), mimicking the bilateral acoustic schwannomas of neurofibromatosis type 2, and manifesting as rapidly worsening tinnitus and bilateral hearing loss. Magnetic resonance imaging showed small tumors in both IAMs with no sign of leptomeningeal metastasis. The preoperative diagnosis was neurofibromatosis type 2. Both tumors were removed and the histological diagnoses were adenocarcinoma. Neuroimaging differentiation of a solitary metastatic IAM tumor from a benign tumor is difficult, although rapidly progressive eighth cranial nerve dysfunction suggests a malignant process. Metastases should be considered as a rare diagnostic possibility in a patient with small tumors in both IAMs.

Outcomes of surgical treatment for cervical myelopathy in patients more than 75 years of age.

STUDY DESIGN: Retrospective study on the results of surgical treatment of compressive cervical myelopathy in patients more than 75 years of age. OBJECTIVES: To investigate clinical features and surgical outcomes of compressive cervical myelopathy in aged patients and to discuss the role of surgical treatment. SUMMARY OF BACKGROUND DATA: There are few data focused on the outcomes of surgery in patients with cervical myelopathy who are more than 75 years of age. METHODS: Seventeen patients with compressive cervical myelopathy who underwent surgery were reviewed. The average age at the time of surgery was 77.2 years. Posterior decompression in 15 patients and anterior decompression in 2 patients were performed. Neurologic deficits before and after surgery were assessed using a scoring system proposed by the Japanese Orthopaedic Association (JOA score). Independence of daily living was evaluated. Radiologic features were examined with radiographs and magnetic resonance imaging. Clinical results were compared with those of patients less than 65 years old as a control. RESULTS: The preoperative mean JOA score was 6.1, the postoperative maximum JOA scores averaged 11.4, and the recovery rate was 48.4%. These were significantly inferior to scores in those less than 65 years of age. All seven of the patients who could not walk even with aids before surgery became independent in daily activities after surgery. At the final follow-up, the mean JOA score had decreased to 10.7 and the recovery rate to 39.1%. Five of nine patients whose follow-up periods were more than 5 years showed decreases in JOA score, although all patients were still ambulatory. CONCLUSIONS: Surgical decompression for cervical myelopathy appears to be beneficial, even in patients more than 75 years of age, in improving neurologic function and ability to engage in activities of daily living.

An Interlaboratory Validation Study of the Improved Transformation Assay Employing Balb/c 3T3 Cells: Results of a Collaborative Study on the Two-stage Cell Transformation Assay by the Non-genotoxic Carcinogen Study Group.

The Non-genotoxic Carcinogen Study Group of the Environmental Mutagen Society of Japan organised the first step of an interlaboratory validation study on an improved cell transformation assay employing Balb/c 3T3 A31-1-1 cells. Nineteen laboratories participated in this study. The modified transformation assay was evaluated for its responsiveness, its interlaboratory reproducibility and its transferability. In this study, a mixture of Dulbecco's modified Eagle's medium and nutrient mixture F12, supplemented with insulin-transferrin-ethanolamine-sodium selenite and 2% fetal bovine serum (FBS) was used during the period of expression of transformed foci, intead of the usual minimum essential medium with 10% FBS. 20-Methylcholanthrene (MCA) and 12-O-tetradecanoylphorbol-13-acetate (TPA) were selected as a prototype initiator and a tumour promoter, respectively. Two series of experiments were conducted. In the first series, the transformation activity of MCA was examined at various concentrations. In the absence of the promoting treatment with TPA, exposure to MCA only weakly induced transformed foci. In the presence of 0.1µg/ml TPA, all laboratories observed significant dose-dependent increases in the number of transformed foci with increasing MCA concentrations. In the second series of experiments, various concentrations of TPA were tested. In the absence of initiating treatment with MCA, exposure to TPA weakly induced transformed foci in about half of the laboratories. In the presence of 0.2µg/ml MCA, all the laboratories observed significant dose-dependent increases in the number of transformed foci with increasing TPA concentrations. The results from this study support the usefulness of this modified two-stage transformation assay with Balb/c 3T3 cells.