Localization of macrophages and dendritic cells in human thoracic lymph nodes: An immunohistochemical study using surgically obtained specimens.

Both dendritic cells (DCs) and macrophages are bone marrow-derived cells that perform antigen presentation. The distribution of DCs and CD68-positive macrophages were immunohistochemically examined in 103 thoracic nodes obtained from 23 lung cancer patients (50-84 years old) without metastasis. Among three antibodies tested initially-CD209/DCsign, fascin, and CD83-DCsign was chosen as the DC marker. For comparison, 137 nodes from 12 patients with cancer metastasis were also examined histologically. In patients without metastasis, DCs were found as (1) clusters along the subcapsular sinus and in a border area between the medullary sinus and cortex (mean sectional area of multiple nodes at one site, 8.4%) and, (2) rosette-like structures in the cortex (mean number in multiple nodes at one site, 20.5). Notably, DC clusters and rosettes contained no or few macrophages and were surrounded by smooth muscle actin (SMA)-positive, endothelium-like cells. The subcapsular linear cluster corresponded to 5%-85% (mean, 34.0%) of the nodal circumferential length and was shorter in older patients (p = 0.009). DC rosettes, solitary, or communicating with a cluster, were usually connected to a paracortical lymph sinus. Few differences were found between nodes with or without metastasis, but DC cluster sometimes contained abundant macrophages in cancer metastasis patients. The subcapsular DC cluster is not known in the rodent model, in which the subcapsular sinus is filled with macrophages. This quite different, even complementary, distribution suggests no, or less, cooperation between DCs and macrophages in humans.

Approach to Functions of BHLHE41/DEC2 in Non-Small Lung Cancer Development.

The circadian rhythm-related genes BHLHE40/DEC1 and BHLHE41/DEC2 have various functions under different cell and tissue conditions. BHLHE41/DEC2 has been reported to be both a cancer-suppressive and an oncogenic gene during cancer development. The effects of BHLHE41/DEC2 on differentiation have been examined using Bhlhe41/Dec2 knockout mice and/or in vitro differentiation models, and research has been conducted using genetic analysis of tumor cells, in vitro analysis of cancer cell lines, and immunohistochemical studies of the clinical samples. We summarize some of these studies, detail several problems, and consider possible reasons for contradictory results and the needs for further research.

A prospective observational study of postoperative adjuvant chemotherapy for non-small cell lung cancer in elderly patients (≥ 75 years).

BACKGROUND: To examine the effects of postoperative adjuvant chemotherapy for elderly (≥ 75 years of age) patients with completely resected non-small cell lung cancer (NSCLC), we conducted a multi-institutional and prospective observational study. METHODS: Patients were recruited between January 2014 and December 2017, and assigned to two cohort groups based on the patients' choice either to receive postoperative adjuvant chemotherapy (Cohort B) or not (Cohort A). All the patients were observed for 2 years after enrollment. The primary endpoint was the postoperative change of Karnofsky Performance Status (KPS) at 2 years. The secondary endpoints were postoperative recurrence-free survival (RFS) and overall survival (OS) at 2 years, and the completion rate of the adjuvant chemotherapy. RESULTS: Two hundred and seventy-two patients were enrolled (Cohort A, n = 225; Cohort B, n = 47). At any time point after surgery, no marked difference of KPS was observed between Cohort B and Cohort A. The RFS at 2 years was 70.8% (95% confidence interval [CI], 64.3-76.4) in Cohort A and 76.0% (95% CI 60.8-85.9) in Cohort B. The OS at 2 years was 85.9% (95% CI 80.4-89.9) in Cohort A and 89.1% (95% CI 75.8-95.3) in Cohort B. The completion rate of planned chemotherapy was 49.9% (95% CI 34.1-63.9%). CONCLUSIONS: The elderly patients were not likely to choose to receive postoperative adjuvant chemotherapy; however, no significant adverse effect on postoperative KPS was identified. TRIAL REGISTRATION: Clinical Trial Registration ID: UMIN000020736.

First reported case of Lachnoanaerobaculum gingivalis bacteremia in an acute myeloid leukemia patient with oral mucositis during high dose chemotherapy.

CASE DESCRIPTION: Lachnoanaerobaculum gingivalis is an obligate anaerobe identified in a human dental plaque in 2019. Here, we report the first case of L. gingivalis bacteremia in a patient with oral mucositis during chemotherapy. L. gingivalis was confirmed by 16S rRNA gene analysis but not by MALDI-TOF-MS. CONCLUSION: During chemotherapy in patients with oral mucositis, we should consider the possibility of L. gingivalis bacteremia.

BHLHE41/DEC2 Expression Induces Autophagic Cell Death in Lung Cancer Cells and Is Associated with Favorable Prognosis for Patients with Lung Adenocarcinoma.

Lung cancer constitutes a threat to human health. BHLHE41 plays important roles in circadian rhythm and cell differentiation as a negative regulatory transcription factor. This study investigates the role of BHLHE41 in lung cancer progression. We analyzed BHLHE41 function via in silico and immunohistochemical studies of 177 surgically resected non-small cell lung cancer (NSCLC) samples and 18 early lung squamous cell carcinoma (LUSC) cases. We also examined doxycycline (DOX)-inducible BHLHE41-expressing A549 and H2030 adenocarcinoma cells. BHLHE41 expression was higher in normal lung than in lung adenocarcinoma (LUAD) tissues and was associated with better prognosis for the overall survival (OS) of patients. In total, 15 of 132 LUAD tissues expressed BHLHE41 in normal lung epithelial cells. Staining was mainly observed in adenocarcinoma in situ and the lepidic growth part of invasive cancer tissue. BHLHE41 expression constituted a favorable prognostic factor for OS (p = 0.049) and cause-specific survival (p = 0.042) in patients with LUAD. During early LUSC, 7 of 18 cases expressed BHLHE41, and this expression was inversely correlated with the depth of invasion. DOX suppressed cell proliferation and increased the autophagy protein LC3, while chloroquine enhanced LC3 accumulation and suppressed cell death. In a xenograft model, DOX suppressed tumor growth. Our results indicate that BHLHE41 expression prevents early lung tumor malignant progression by inducing autophagic cell death in NSCLC.

The clinical value of texture analysis of dual-time-point 18F-FDG-PET/CT imaging to differentiate between 18F-FDG-avid benign and malignant pulmonary lesions.

OBJECTIVES: To examine whether the texture analysis of dual-time-point (DTP) F-18-fluorodeoxyglucose (18F-FDG)-PET/CT imaging can differentiate between 18F-FDG-avid benign and malignant pulmonary lesions. METHODS: We compared standardized uptake value (SUV)-related (SUVmax [g/ml] and SUVmean [g/ml]), volumetric (metabolic tumor volume [MTV] [cm3] and total lesion glycolysis [TLG] [g]), and texture (entropy, homogeneity, dissimilarity, intensity variability [IV], size-zone variability [SZV], and zone percentage [ZP]) (MTV ≥ 5.0 cm3 and SUV ≥ 2.5 g/ml) parameters between 13 benign and 46 malignant lesions using the Mann-Whitney U test. Diagnostic performance was evaluated by receiver operating characteristic (ROC) analysis. Stepwise logistic regression analysis was performed to identify and use the independent variables that correctly differentiate between benign and malignant lesions. RESULTS: Malignant pulmonary lesions showed significantly higher SUVmax, SUVmean, MTV, TLG, entropy, dissimilarity, IV, and SZV and significantly lower homogeneity and ZP than benign pulmonary lesions (all p < 0.05) in both early and delayed images. Their areas under the ROC curves (AUCs) ranged between 0.69 and 0.94, and diagnostic accuracies between 64.4% and 93.2%. Entropy-early (p = 0.014), SUVmean-delay (p = 0.039), and dissimilarity-delay (p = 0.027) were independent parameters, and combined use of them yielded the highest AUC (0.98) with 100% sensitivity (46/46), 84.6% specificity (11/13), and 96.7% (57/59) accuracy for distinguishing between benign and malignant lesions. CONCLUSIONS: The individual early and delayed SUV-related, volumetric, and texture parameters showed a wide range of accuracy. Combined use of independent parameters extracted from DTP imaging might yield a high diagnostic accuracy with balanced sensitivity and specificity to differentiate between benign and malignant 18F-FDG-avid pulmonary lesions. KEY POINTS: • Malignant pulmonary lesions showed significantly higher SUV-related (SUVmax and SUVmean) and volumetric (MTV and TLG) parameters than benign pulmonary lesions in both early and delayed images. • Malignant pulmonary lesions showed significantly more heterogeneous18F-FDG uptake than benign pulmonary lesions in both early and delayed images. • Combined use of independent parameters extracted from DTP imaging might yield a high diagnostic accuracy to differentiate between benign and malignant18F-FDG-avid pulmonary lesions.

Current status of surgery for clinical stage IA lung cancer in Japan: analysis of the national clinical database.

PURPOSE: As the number of cases of early lung cancer in Japan grows, an analysis of the present status of surgical treatments for clinical stage IA lung cancer using a nationwide database with web-based data entry is warranted. METHODS: The operative and perioperative data from 47,921 patients who underwent surgery for clinical stage IA lung cancer in 2014 and 2015 were obtained from the National Clinical Database (NCD) of Japan. Clinicopathological characteristics, surgical procedure, mortality, and morbidity were analyzed, and thoracotomy and video-assisted thoracic surgery (VATS) were compared. RESULTS: The patients comprised 27,208 men (56.8%) and 20,713 women (43.2%); mean age, 69.3 years. Lobectomy was performed in 64.8%, segmentectomy in 15.2%, and wedge resection in 19.8%. The surgical procedures were thoracotomy in 12,194 patients (25.4%) and a minimally invasive approach (MIA) in 35,727 patients (74.6%). MIA was divided into VATS + mini-thoracotomy (n = 13,422, 28.0%) and complete VATS (n = 22,305, 46.5%). The overall postoperative mortality rate was 0.4%, being significantly lower in the MIA group than in the thoracotomy group (0.3% vs 0.8%, P < 0.001). CONCLUSIONS: Our analysis of data from the NCD indicates that MIA has become the new standard treatment for clinical stage IA lung cancer.

Current status of site-specific cancer registry system for the clinical researches: aiming for future contribution by the assessment of present medical care.

BACKGROUND: The current status of site-specific cancer registry has not been elucidated, but sufficient system is found in some societies. The purpose of this study was to clear the present condition of site-specific cancer registries in Japan and to suggest for the improvement. METHODS: The questionnaire was conducted by the study group of the Ministry of Health, Labor, and Welfare. It consisted of 38 questions, conflicts of interest, clinical research method, informed consent and funding for registry. We distributed this questionnaire to 28 academic societies, which had published the clinical practice guideline(s) assessed under Medical Information Network Distribution Service (MINDS). RESULTS: The concept of the importance in assessment for medical quality by the data of the site-specific cancer registry was in good consensus. But the number of the society with the mature registry was limited. The whole-year registry with the scientific researches in the National Clinical Database (NCD) and in the Translational Research Informatics Center (TRI) might seem to be in success, because assured enhancement may be estimated. Now, academic societies have the structural factors, i.e., the financial limitation in the registry maintenance and the data analysis, and in the difficulty of employment of the researchers with skill and talent. CONCLUSIONS: To manage the site-specific cancer registry effectively, the scientific registry system will be essentially important. Each academic society had much experienced highly qualified clinical researches in past. Accordingly, the scientific suggestion and co-operation should be of great importance for the improvement.

Detection of alternative subpleural lymph flow pathways using indocyanine green fluorescence.

PURPOSE: Pulmonary lymphatic fluid predominately flows along the bronchi. However, there are reports suggesting that an alternative lymphatic pathway exist, which may result in skip metastases. The aim of this study was to evaluate the subpleural lymph flow in vivo using indocyanine green (ICG) fluorescence. METHODS: One hundred cases were enrolled. ICG was injected into the macroscopically healthy subpleural space. Intraoperative fluorescence images were then observed in real time. RESULTS: ICG fluorescence was observed moving through subpleural channels in 58/100 cases. ICG flowed into adjacent lobes over interlobar lines in 18 cases and flowed from the visceral pleura directly into the mediastinum in 5 cases. The frequency of mediastinal detection without hilar lymph node detection was significantly higher in the left lung compared to the right (p < 0.05). The subpleural lymph flow detection rates were significantly lower in patients with smoking pack-years ≥ 40 than those with < 40 (p < 0.05). CONCLUSIONS: The flow of lymphatic fluid directly into the mediastinum suggests one mechanism of skip metastasis. In addition, the reduction of the subpleural lymph flows in smokers with ≥ 40 pack-years suggests that smoking might modify lymph flow patterns. These findings may assist in selecting the optimal therapy for patients with possible skip metastasis.

Napsin A levels in epithelial lining fluid as a diagnostic biomarker of primary lung adenocarcinoma.

BACKGROUND: It is crucial to develop novel diagnostic approaches for determining if peripheral lung nodules are malignant, as such nodules are frequently detected due to the increased use of chest computed tomography scans. To this end, we evaluated levels of napsin A in epithelial lining fluid (ELF), since napsin A has been reported to be an immunohistochemical biomarker for histological diagnosis of primary lung adenocarcinoma. METHODS: In consecutive patients with indeterminate peripheral lung nodules, ELF samples were obtained using a bronchoscopic microsampling (BMS) technique. The levels of napsin A and carcinoembryonic antigen (CEA) in ELF at the nodule site were compared with those at the contralateral site. A final diagnosis of primary lung adenocarcinoma was established by surgical resection. RESULTS: We performed BMS in 43 consecutive patients. Among patients with primary lung adenocarcinoma, the napsin A levels in ELF at the nodule site were markedly higher than those at the contralateral site, while there were no significant differences in CEA levels. Furthermore, in 18 patients who were undiagnosed by bronchoscopy and finally diagnosed by surgery, the napsin A levels in ELF at the nodule site were identically significantly higher than those at the contralateral site. In patients with non-adenocarcinoma, there were no differences in napsin A levels in ELF. The area under the receiver operator characteristic curve for identifying primary lung adenocarcinoma was 0.840 for napsin A and 0.542 for CEA. CONCLUSION: Evaluation of napsin A levels in ELF may be useful for distinguishing primary lung adenocarcinoma.

Dexamethasone Suppression FDG PET/CT for Differentiating between True- and False-Positive Pulmonary and Mediastinal Lymph Node Metastases in Non-Small Cell Lung Cancer: A Pilot Study of FDG PET/CT after Oral Administration of Dexamethasone.

PURPOSE: To examine whether dexamethasone suppression can reduce fluorine 18 fluorodeoxyglucose (FDG) uptake in false-positive (FP) findings in pulmonary and mediastinal lymph nodes in non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Institutional ethics review board approved this prospective study with written informed consent. The study population was composed of 17 patients with NSCLC who underwent both baseline and dexamethasone suppression (24 hours after oral administration of 8 mg dexamethasone) FDG positron emission tomography/computed tomography and surgery. FDG uptake was evaluated by using a five-point visual scoring system (negative findings, score of 0-1; positive findings, score of 2-4) and maximum standardized uptake value (SUVmax). The Mann-Whitney U, Wilcoxon signed-rank, Kruskal-Wallis, or Spearman rank correlation tests were used as necessary for statistical evaluations. RESULTS: In 17 primary lesions, no significant difference was noted in visual score between baseline (mean, 3.4 ± 1.2) and dexamethasone suppression scans (mean, 3.3 ± 1.2; P = .16), although SUVmax was significantly lower on dexamethasone suppression scans (mean, 7.1 ± 5.2) than on baseline scans (mean, 8.6 ± 6.6; P = .005). In eight nodes with true-positive (TP) findings, there were no significant differences in visual score (mean for both, 3.8 ± 0.5) and SUVmax (mean, 5.3 ± 2.3 vs 5.5 ± 2.5, respectively; P = .81) between baseline and dexamethasone suppression scans. In 19 nodes with FP findings at baseline, dexamethasone suppression resulted in significantly lowered visual score (mean, 3.4 ± 0.6 vs 2.4 ± 0.8, respectively; P < .001) and SUVmax (mean, 3.5 ± 0.8 vs 2.7 ± 0.7, respectively; P < .001), and four nodes with FP findings were rated as true-negative findings on dexamethasone suppression scans, which resulted in a significant difference in SUVmax between nodal lesions with TP and FP findings (P = .014). CONCLUSION: Oral dexamethasone has the potential to reduce FDG uptake in pulmonary and mediastinal nodes with FP findings in NSCLC.

Comparison of general anesthesia and monitored anesthesia care in patients undergoing breast cancer surgery using a combination of ultrasound-guided thoracic paravertebral block and local infiltration anesthesia: a retrospective study.

PURPOSE: The aim of this study was to compare post-anesthesia recovery time and the incidence of hypotension episodes during anesthesia in breast cancer surgery between general anesthesia (GA) and monitored anesthesia care (MAC) retrospectively. Both techniques were combined with ultrasound-guided paravertebral block (US-PVB) and local infiltration anesthesia (LIA). METHODS: We reviewed the medical records of patients who received US-PVB for breast cancer surgery retrospectively and divided them into two groups based on the method of anesthetic management. In the GA group, anesthesia was induced using propofol and maintained by sevoflurane inhalation via a laryngeal mask airway after US-PVB was performed under sedation with midazolam. In the MAC group, US-PVB and surgery were carried out under sedation with propofol and remifentanil and supplemental oxygen through a facemask. All patients in both groups breathed spontaneously and received US-PVB and LIA with 0.5 % ropivacaine and diclofenac suppository for pain relief. RESULTS: Times from post-anesthesia care unit admission to fluid intake (mean ± SD; 79 ± 34 vs. 99 ± 33 min, P = 0.034) and gait (77 ± 45 vs. 109 ± 45 min, P = 0.013) were significantly shorter in the MAC group (n = 29) than in the GA group (n = 29). Average systolic blood pressure (SBP) was significantly lower (89 ± 11 vs. 99 ± 16 mmHg, P = 0.011) and the incidence of hypotension (SBP < 70 mmHg) was higher (52 vs. 21 %, P = 0.014) in the GA group than in the MAC group during anesthesia. CONCLUSION: MAC with US-PVB and LIA exhibited faster post-anesthesia recovery and a lower incidence of hypotension episodes during anesthesia than GA with US-PVB and LIA in breast cancer surgery.

[Esophageal Injury Treated with a Covered Expandable Metallic Stent].

We report a case of iatrogenic esophageal injury treated with a covered expandable metallic stent after thoracoscopic chest drainage. A 70-year-old man who had stricture of the esophagus after endoscopic submucosal dissection underwent balloon dilation. Chest computed tomography revealed esophageal rupture. Initially, continuous intra-esophageal drainage was carried out, however, due to the development of mediastinitis with enlarged abscess around the descending aorta and the left pneumothorax, thoracoscopic chest drainage was performed. Since direct closure was thought to be in appropriate, an intra-esophageal approach was chosen and a covered expandable metallic stent was mounted under fluorography on the next day. After the treatment, the patient was able to eat, and was able to discharge 42 days later. Intra-esophageal covered expandable metallic stent can be an alternative treatment for esophageal rupture.

[Metastatic Lung Tumor Diagnosed as Primary Lung Cancer due to its Accompanying Lesion Mimicking Atypical Adenomatous Hyperplasia by Intraoperative Needle Biopsy Findings;Report of a Case].

We reported a case of metastatic lung tumor, which was suspected as being a primary lung cancer because of its accompanying lesion mimicking atypical adenomatous hyperplasia(AAH) based on intraoperative needle biopsy findings. AAH is a preinvasive lesion or marginal lesion of primary lung cancer that is not accompanied by metastatic tumor. However, it needs to be distinguished pathologically from secondary changes of inflammation or fibrosis. In our case, the needle biopsy revealed AAH-like pathological findings, which indicates a primary lung cancer, and the standard lobectomy with lymph node dissection was performed, however, the final diagnosis turned out to be metastatic tumor. The rapidly enlarging tumor led to surrounding obstructive pneumonitis, which may have caused pathological changes mimicking AAH findings. In the case of obstructive pneumonitis, we must be careful to diagnose AAH, in addition to decisions about the surgical procedure especially when based on frozen section diagnosis.

Animal Experiments of the Helical Flow Total Artificial Heart.

Severe cardiac failure patients require a total artificial heart (TAH) to save life. To realize a TAH that can fit a body of small stature and has high performance, high durability, good anatomical fitting, good blood compatibility, and physiological control, we have been developing the helical flow TAH (HFTAH) with two helical flow pumps with hydrodynamic levitation impeller. Animal experiments of the HFTAH were conducted to perform in vivo studies. The HFTAH was implanted in 13 adult female goats weighing 45.0-64.0 kg. After surgery, neither anti-coagulant nor anti-platelet medication was given systemically. The HFTAH was usually driven with a quasi-pulsatile mode. The 1/R control or ΔP control was applied to control the circulation. The ΔP control is a new method using simplified equation of the 1/R control. The HFTAH could be implanted in all goats with good anatomical fitting. Two goats survived for a long time (100 and 68 days). Major causes of termination were device failure and surgical complications. In the device failure, trouble with hydrodynamic bearing was conspicuous. In the two long-term survived goats, experiments were terminated with bearing instability that was probably caused by the suction effect. In these goats, hemolysis occurred on postoperative day 88 and 44, which was considered to be relevant to the bearing trouble. Thrombus was found at the broken right bearing of the 100-day survived goat. However, antithrombogenicity of the pump is expected to be good unless bearing trouble occurs. In two long-term survived goats, the 1/R control or ΔP control worked appropriately to prevent the elevation of right atrial pressure. In both goats, hemodynamic parameters changed with the condition of the animals, liver and kidney functions remained almost normal except when recovering from surgery and during hemolysis, and total protein recovered 2 weeks after surgery. Although instability of the hydrodynamic bearing should be improved, performance of the HFTAH with physiological control could be demonstrated.

Hydrodynamic characteristics of the helical flow pump.

The helical flow pump (HFP) was invented to be an ideal pump for developing the TAH and the helical flow TAH (HFTAH) using two HFPs has been developed. However, since the HFP is quite a new pump, hydrodynamic characteristics inside the pump are not clarified. To analyze hydrodynamic characteristics of the HFP, flow visualization study using the particle image velocimetry and computational fluid dynamics analysis were performed. The experimental and computational models were developed to simulate the left HFP of the HFTAH and distributions of flow velocity vectors, shear stress and pressure inside the pump were examined. In distribution of flow velocity vectors, the vortexes in the vane were observed, which indicated that the HFP has a novel and quite unique working principle in which centrifugal force rotates the fluid in the helical volutes and the fluid is transferred from the inlet to the outlet helical volutes according to the helical structure. In distribution of shear stress, the highest shear stress that was considered to be occurred by the shunt flow across the impeller was found around the entrance of the inlet helical volute. However, it was not so high to cause hemolysis. This shunt flow is thought to be improved by redesigning the inlet and outlet helical volutes. In distribution of pressure, negative pressure was found near the entrance of the inlet helical volute. However, it was not high. Negative pressure is thought to be reduced with an improvement in the design of the impeller or the vane shape.

[Transient Femoral Nerve Palsy after Ilioinguinal-Iliohypogastric Nerve Block: Comparison of Ultrasound-guided and Landmark-based Techniques in Adult Inguinal Hernia Surgery].

BACKGROUND: Transient femoral nerve palsy (TFNP) is a well-known complication associated with ilioinguinal-iliohypogastric nerve block (IINB). We compared the incidence of TFNP after ultrasound-guided IINB and that after anatomical landmark-based IINB. METHODS: We reviewed medical records of adult patients (ASA-PS 1-3, Age 21-87) who had received inguinal hernia surgery under general anesthesia and LINB retrospectively. IINB was performed using 0.5% ropivacaine either by ultrasound-guidance (US group, n = 16) or by landmark-based technique (LM group, n =17). TFNP was defined as sensory loss in the anterior aspect of the thigh or weakness of quadriceps femoris muscle in the nerve-blocked side. RESULTS: The frequency of TFNP in US group (6%) was lower than that in LM group (41%) in the post-anesthesia care unit (P = 0.019). TFNP symptom was resolved completely on the morning after surgery. The incidence of severe-intermediate postoperative pain and analgesic requirement were not different between the two groups. CONCLUSIONS: This study revealed that ultrasound-guided technique is effective to lower the incidence of TFNP after IINB in adult inguinal hernia surgery.

Concept of left atrial pressure estimation using its pulsatile amplitude in the helical flow total artificial heart.

The total artificial heart (TAH) requires physiological control to respond to the metabolic demand of the body. To date, 1/R control is a single physiological control method that can control venous pressure. To realize an implantable 1/R control system, we are developing a new pressure measuring method using absolute pressure sensor. To find a method for absolute pressure sensor, which went well without calibration, concept of left atrial pressure (LAP) estimation using its pulsatile amplitude was proposed. Its possibility was investigated with two long-term survived goats whose hearts were replaced with the helical flow TAHs. In manual control condition, there existed a positive relation between mean LAP (mLAP) and normalized pulsatile amplitude (NPA). Percent systole revealed not to affect the relationship between mLAP and NPA. Dispersion was observed between different pulse rates. As for cardiac output difference (QLD) that is the difference of flow rate between systolic and diastolic phases, similar results were obtained except in low QLDs. In the 1/R control condition, relatively high correlation between mLAP and NPA could be obtained. In estimation of mLAP using the correlating function of individual goat, fairly good correlation was obtained between measured mLAP and estimated mLAP. Despite that further studies are necessary, it was demonstrated that the concept of the LAP estimation could be possible.

[Diagnostic bronchoscopy].

Endoscopic technology has developed markedly with endobronchial ultrasonography (EBUS) having become dramatically widespread over the past 10 years. EBUS-guided transbronchial needle aspiration (EBUS-TBNA) has become an important modality for the mediastinal staging of lung cancer as well as mediastinoscopy. The combination of EBUS with a guide sheath( EBUS-GS) and virtual navigation systems, such as Bf-NAVI, LungPoint, superDimension/Bronchus system, is useful for diagnosis of small peripheral pulmonary lesions. Moreover, the ability to observe lesions has increased using picture enhancement developed by new methods such as autofluorescence imaging( AFI), narrow band imaging (NBI), and FUJI intelligent color enhancement( FICE). However, these modalities have limited value in detection of lung cancer and preneoplastic lesions. In recent years, the indications for AFI have widened and it can be now used for evaluation of tumor extension. Knowledge of these new technologies is certainly useful to allow their routine clinical use by respiratory surgeons. We will review these new technologies in this paper.

[Completion pneumonectomy].

Completion pneumonectomy (CP)is the complete removal of lung tissue remaining after an initial ipsilateral partial pulmonary resection and is one of the most invasive operations in the field of general thoracic surgery. Mortality and morbidity rates are higher after CP than standard pneumonectomy. CP is a highly demanding procedure, usually due to major pleural and sometimes pericardial dense adhesions from previous surgery or infection. Intra-pericardial control of the pulmonary artery and veins is recommended to avoid vessel injury. This operative intervention should, therefore, be performed only by experienced thoracic surgeons on carefully selected patients in order to improve ostoperative outcomes. Preoperative pulmonary and cardiac functions are decreased by the previous procedure. In addition, the rate of complications, such as residual respiratory and cardiac failure, is high because of excessive operative invasiveness and added transfusion load. Therefore, preoperative assessment, surgical indication, low invasive surgical technique, and good postoperative management are very important elements when CP is performed. This article reviews these operative strategies.