[Outcomes of bronchoplasty procedures for lung cancer].

A sleeve lobectomy is an established general thoracic surgical procedure. To improve clinical outcomes following the procedure, we reviewed the records of 60 patients who underwent a bronchoplasty procedure in our department from 1992 to 2007. Induction chemotherapy was performed for 20, of whom 10 underwent radiotherapy as well. For all subjects, the postoperative mortality and morbidity rates were 1.7% and 33.3%, respectively. Induction therapy did not significantly affect those rates, though complications related to bronchial anastomoses occurred exclusively in subjects who received that therapy. The overall 5-year survival rate was 51.0%, while subjects with pN0 (67.9%) and pN1 (60.0%) disease, and those in stage I (79.1%) and stage II (59.9%) had better survival as compared with patients with pN2 (16.9%) disease, and those in stage III (21.8%) and stage IV (0%). Furthermore, the survival rate of yp-stage I and II patients was significantly greater than that of those in yp-stage III and IV (59.9% vs. 14.3%, p = 0.0158). We concluded that patients in stages I, II or with pN0-1 disease are good candidates for a bronchoplasty procedure, though induction therapy should be considered thereafter. In addition, due diligence for postoperative complications is necessary.

Fine-needle aspiration cytologic technique for lung cancer has a high potential of malignant cell spread through the tract.

BACKGROUND: Fine-needle aspiration cytologic technique (FNAC), a method to detect malignancy for undetermined pulmonary nodules, may have a high potential to spread malignant cells from the tumor to the pleural cavity. OBJECTIVE: The authors assessed malignant cell spread through the needle tract following FNAC for peripheral lung carcinoma. MATERIALS AND METHODS: Lung lobes resected from 20 patients during the treatment of lung carcinoma were examined. The visceral pleura over the lung carcinoma was irrigated by heparinized saline solution to clean the surface, and then irrigated before FNAC and irrigated following FNAC to collect cells on the visceral pleura. FNAC was performed once for each tumor. Papanicolau's method was employed for cytologic examination. RESULTS: There were 15 specimens of adenocarcinoma, 4 specimens of squamous cell carcinoma, and 1 specimen of atypical carcinoid. The maximum diameter of the specimens ranged from 10 to 60 mm (median, 25 mm). Pleural indentation was observed in 15 samples. All results of FNAC were positive and matched the histologic diagnosis. Pre-FNAC specimens revealed a positive malignancy rate of 10% (2 of 20), but post-FNAC specimens had a rate of 60% (12 of 20; p = 0.002) CONCLUSION: FNAC has the potential to spread malignant cells to the pleural space. Further study is needed to determine the clinical significance of the spread of malignant cells in the pleural space.

Operable non-small cell lung cancer diagnosed by transpleural techniques : do they affect relapse and prognosis?

STUDY OBJECTIVE: We assessed whether transpleural methods for diagnosing peripheral lung cancer, such as needle aspiration or tumor excision, affect relapse and prognosis, because these techniques have potential to spread malignant cells from the tumor. DESIGN: A retrospective study. SETTING: National referral hospital. PATIENTS: We reviewed 239 patients who underwent surgery between 1990 and 1998 and for whom non-small cell lung cancer (NSCLC) of < 3 cm in maximum diameter was completely resected. The duration of postoperative follow-up ranged from 12 to 105 months, with a median period of 45 months. INTERVENTIONS: We defined the transbronchial method as using a bronchoscope, and the transpleural method as using needle aspiration cytology or tumor excision. Dichotomous variables included gender, histologic type of squamous cell carcinoma or other type of carcinoma, pathologic stage, and whether the diagnostic method was the transbronchial type only (first-line method) or the transpleural type (second-line method). RESULTS: NSCLC was diagnosed in 45 patients by the transpleural technique and in 194 patients by the transbronchial technique. There were no significant statistical differences in age of patients, gender, histologic type, pathologic stage, and tumor size. There were 42 relapses, 7 in the transpleural technique group and 35 in the transbronchial technique group (p = 0.90). Of the 7 patients in the transpleural group, there were 4 distant metastasis and 3 local relapses; of the 35 patients in the transbronchial group, there were 20 distant metastasis and 15 local relapses (p = 0.99). Pleural carcinomatosis occurred in none of the 45 patients in the transpleural group and in 1 case (0.5%) in the 194 patients in the transbronchial group (p = 0.99). Patients in the transpleural group had a statistically better 5-year survival rate than patients in the transbronchial group (79.4% vs 60.3%, p = 0.04). This is also confirmed as an independent prognostic factor in a multivariate analysis. CONCLUSIONS: Transpleural methods seem to be an advisable way to diagnose operable lung cancer that is difficult to diagnose using bronchoscopy, because these methods did not affect relapse and prognosis in the patients in our study.

Protection against lipid peroxidation induced during preservation of lungs for transplantation.

The questions of whether oxygen-derived free radicals are induced during preservation of lungs and, if so, how such radicals might relate to reperfusion injury were investigated by means of an isolated canine lung model. Lungs were obtained from 16 mongrel dogs and divided into groups 1 (n = 6), 2 (n = 5), and 3 (n = 5). The lungs of groups 1, 2, and 3 were flushed through the pulmonary artery with Euro-Collins solution alone, the solution with superoxide dismutase (120,000 U/L), and the solution with allopurinol (1 mmol/L), respectively, at 4 degrees C and then stored for 4 hours in the respective solutions at 4 degrees C with clamped bronchi. They were then reperfused for 2 hours by means of an isolated lung model. Lung lipid peroxidation was sequentially determined. The lung functional status was assessed by systolic pulmonary arterial pressure and end-inspiratory airway pressure. The lung edema was assessed by lung wet/dry weight ratio. Lipid peroxidation was induced after 1 hour of preservation and the first 30 minutes of the reperfusion in group 1 and only 2 hours of the reperfusion in group 2, whereas no induction was observed in group 3. Values for systolic pulmonary arterial pressure and end-inspiratory pressure in group 1 were significantly higher than those in group 3 (p < 0.05). The lung wet/dry weight ratio in group 1 was significantly higher than that in groups 2 and 3 (p < 0.05). The present results indicate that the administration of free radical scavengers in the preservation may effectively improve conditions for lung transplantation.

In vitro comparison between Argon Beam Coagulator and Nd:YAG laser in lung contraction therapy.

BACKGROUND: The Argon Beam Coagulator (ABC) and neodymium:yttrium-aluminum garnet (Nd:YAG) laser are used for lung tissue contraction. Assessing the damage of treated lung tissue is helpful in choosing devices for pulmonary volume reduction by pneumoplastic procedures. METHODS: We assessed the damage of in vitro lung lobes resected at operation for pulmonary carcinoma. Samples were irradiated with noncontact Nd:YAG laser and ABC. One hundred forty-four samples obtained from 24 lobes were examined by light microscopy. The lung tissue showing destructive degeneration at the pleura and slight coagulation at the residual parenchyma was defined as showing "air leak pattern" based on a previously reported experiment of the air inflation test. RESULTS: At the power of clinical use (Nd:YAG, 15 W; ABC, 80 W), most of the visceral pleura treated with the Nd:YAG laser was classified as presenting amorphous degeneration, and that treated with ABC showed destructive degeneration. Air leak pattern occurred in all samples treated with ABC. At the power of 40 W, ten (42%) of 24 visceral pleuras irradiated with the Nd:YAG laser were classified as presenting destructive degeneration, and of those irradiated with the ABC, 18 (75%) showed destructive degeneration (p < 0.05). Air leak patterns were found in 3 (13%) of the samples treated with the Nd:YAG laser and in 16 (63%) of those treated with the ABC (p < 0.05). CONCLUSIONS: The ABC had more potential to damage the pleura and less potential to produce underlying parenchymal coagulation in the lung tissue than did the Nd:YAG laser. This information may be useful in the selection of devices for pulmonary volume reduction by pneumoplastic procedures.

In vitro study of ablated lung tissue in Nd:YAG laser irradiation.

BACKGROUND: Neodymium:yttrium-aluminum garnet lasers are used to reduce lung volume. An assessment of the relationship between the histologic and gross findings in the lung irradiated by a laser would be helpful in laser-assisted pneumoplastic procedures. METHODS: In vitro lung lobes surgically resected for pulmonary carcinomas were irradiated with a neodymium:yttrium-aluminum garnet laser at three energy levels in three modes: contact rubbing, contact pointing, and noncontact. Pleural degeneration in 216 samples from 24 lobes was classified as coagulative, amorphous, or destructive. At all energy levels, the laser was applied for 1.5 seconds. RESULTS: Noncontact mode at 7.5 W or 15 W and contact rubbing at 5 W caused coagulative or amorphous degeneration but no destructive degeneration. The energy level correlated with the color of the degenerated pleura. The incidence of destructive pleural degeneration, which led to air leaks as revealed by an air inflation test, was 0% in pink and white samples, 59% in brown samples, and 100% in black samples (p < 0.0001, white versus brown samples). CONCLUSIONS: In neodymium:yttrium-aluminum garnet laser ablation of lung tissue, the color of the degenerated pleura correlates with the intensity of the applied laser energy and the degree of pleural degeneration.

Angiographic demonstration of no-flow anatomical patency of internal thoracic-coronary artery bypass grafts.

To clarify the no-flow situation of the stringlike internal thoracic artery graft, we angiographically examined such grafts by temporarily occluding the recipient coronary artery with a percutaneous transluminal coronary angioplasty balloon and were able to reveal anatomical patency of the internal thoracic artery graft in 2 patients 1 year and 3 years after the operations. Thus, there is a possibility that internal thoracic artery grafts may continuously maintain anatomical patency even under no-flow situations just like nonfunctioning collateral vessels and may function properly later as a graft when the native coronary flow decreases. Also, this angiographic technique can be a new method for detecting anatomical patency of no-flow and functionally closed internal thoracic artery grafts.

Tracheal replacement with cryopreserved tracheal allograft: experiment in dogs.

BACKGROUND: It has been difficult to perform tracheal allotransplantation without immunosuppression. To determine whether cryopreserved trachea can be used in tracheal replacement, we evaluated the viability of cryopreserved tracheal allografts in a canine model of immunosuppressant-free transplantation. METHODS: Cryopreserved tracheal allografts, which had been frozen to -80 degrees C in a programmed freezer and then stored in liquid nitrogen (-196 degrees C) (group 1, n = 6), fresh tracheal autografts (group 2, n = 5), and fresh tracheal allografts (group 3, n = 4) were transplanted into the thoracic segment of the trachea using an omental flap without immunosuppressive agents. RESULTS: All dogs in groups 1 and 2 survived, but in group 3, all 4 died of airway obstruction between 1 month and 2 months after operation. Histologically, the cryopreserved allografts displayed normal epithelium and cartilage, but the fresh allografts showed chronic inflammatory changes, no epithelium, and no cartilage. CONCLUSIONS: Cryopreserved tracheal allografts maintain their structural integrity after transplantation. The cryopreservation process seems to reduce the allogenic response of the trachea in canine models. Therefore, we believe the cryopreserved tracheal allograft is an excellent choice for tracheal replacement.

Safe pleural contraction employing a new tip for electrosurgical units. An ex vivo experiment.

BACKGROUND: Certain pulmonary lesions are treated by lung tissue contraction induced by heat administered by laser or electrosurgical unit (ES). ESs are comparatively less expensive, less complicated and more ubiquitous than a lasers but with their conventional tip carries the a risk of damaging the pleura. We developed a large ball tip (M-tip) for ES and evaluated its effect on the pleura in comparison with that of Nd:YAG laser in ex vivo lung. METHOD: We employed lobes obtained through surgical resection. Using the Nd:YAG laser, the lung was irradiated for 2 seconds at levels of 5, 10 and 20 watts (10, 20 and 40 Joules). Using the M-tip ES, the pleura received treatment at levels of 10, 20 and 40 watts for 2 seconds (20, 40 and 80 Joules) in spray coagulation mode. Upon completion of these procedures, 144 tissue specimens obtained from 24 lobes were examined under light microscopy. RESULTS: Upon the application of Nd:YAG at 20 Joules, 22 (92%) of 24 visceral pleura demonstrated amorphous degeneration. With the application of ES at 40 Joules watts, 24 (100%) samples examined demonstrated amorphous degeneration (P = 0.47). Of the samples where pleural destruction was evident (Nd:YAG; 40 Joules, ES; 80 Joules), an accompanying air leak pattern (pleural destruction associated with slight parenchymal contraction) was observed in 5 (21%) of the samples treated with Nd:YAG and in 10 (42%) of those treated with the M-tip ES (p = 0.12). CONCLUSION: The M-tip ES induced proper contraction of the pleura with relatively little destructive damage to the pleura at 40 Joules. Accordingly, it may be possible to induce pleural contraction using this new device with the same degree of safely that the Nd:YAG laser provides.

Which type of diffuse emphysema is adequately contracted by the Nd:YAG laser. An ex-vivo experiment.

Diffusely emphysematous lungs are not always effectively contracted by laser therapy; however, which type of diffuse emphysema that responds to laser therapy remains unclear. We macroscopically and histopathologically examined human lung tissue, which was resected from patients with carcinoma, after irradiation with an Nd:YAG laser. Forty-six lung lobes were irradiated with a non-contact mode Nd:YAG laser at a power setting 15 watts. Macroscopically, twenty samples of normal lungs revealed moderate contraction, fourteen samples of predominantly centrilobular diffuse emphysema showed significant contraction, and eight samples of predominantly panlobular diffuse emphysema with a slight elastic network showed slight contraction. Histopathologically, the normal lungs showed amorphous change of the collagen and severely contracted elastic fibers (amorphous degeneration) at the pleura and some parenchymal coagulation; the predominantly centrilobular diffuse emphysema showed contraction of elastic fibers and collagen (coagulative degeneration) in the pleura and adequate contraction of the elastic fibers in the parenchyma and the predominantly panlobular diffuse emphysema showed only slight coagulation of the visceral pleura and very little coagulation of the parenchyma. On ex-vivo lung, panlobular emphysema was inadequately contracted by laser therapy, due to elastic recoil. Centrilobular emphysema responded to laser treatment, due to the severe contraction of the elastic fibers.

Are superficial bullae with broad bases suitable for ablation?

Superficial bullae with broad bases are not suitable for resection, because the residual lung is too deformed to re-expand adequately when we resect them. Therefore, we believe superficial bullae with broad bases are suitable for ablation. It is not clear, however, whether ablated superficial bullae with broad bases remain contracted after treatment or not. We examined the morphologic changes of ablated superficial bullae with broad bases on chest computed tomographs. Ten patients with superficial bullae with broad bases that could be identified on computed tomograph underwent ablation using an electrocoagulator. These bullae were examined by chest computed tomograph preoperatively and again one, three and 12 months after surgery. There were no intra-operative complications. Postoperatively, the only complication was prolonged air leak (more than 7 days) in 1 (10%) patient. Pneumothorax after the operation presented in 1 (10%) patient. Morphologically, a disappearance of air space associated with bulla-wall thickness was observed in 9 (90%) of the 10 heat-ablated lesions and air space decreased in 1 (10%) lesion. Heat ablation proved to be effective in patients with SBBs. Lesions remained contracted for at least one year after the operation.

Thoracoscopic lung volume reduction surgery for emphysema. Evaluation using ventilation-perfusion scintigraphy.

Thoracoscopic lung volume reduction surgery was conducted in 28 consecutive patients (bilateral 21, unilateral 7). The bilateral procedure was conducted simultaneously in 16 and as a planned staged approach in 5, using stapler resection with Nd:YAG laser ablation. Perfusion and ventilation scintigraphy were used to evaluate status before and after surgery. One operative death (3.6%) due to pneumonia occurred after a simultaneous bilateral procedure. Three to 6 months after surgery, the forced expiratory volume in 1 second (FEV1.0) had improved an average of 44% after the bilateral procedure and 17% after unilateral. Improved ventilation and perfusion distribution in the lower lung field correlated significantly with improved dyspnea scale (p < 0.01). Mean transit time was shortened significantly in each lung field (p < 0.01). Improved mean transit time correlated significantly with improved FEV1.0 and maximum oxygen consumption (VO2max) (p < 0.05). In conclusion, we found that bilateral thoracoscopic lung volume reduction surgery produces short-term functional outcomes superior to those of the unilateral procedure, and should be considered the procedure of choice for most patients. Ventilation and perfusion scintigraphy are useful both in determining target areas for resection and in evaluating lung volume reduction surgery effects.

[The role of surgery for chronic empyema of the advanced ages].

Chronic empyema, a sequelae of pulmonary tuberculosis, is now a only tuberculosis-related disease which was remained to be treated surgically. The candidates who have basically poor respiratory function are now attained advanced age. Over a 15 years period (1980-95), 22 patients 70 years of age or older underwent surgical intervention for chronic empyema at our hospital. There were 17 men and 5 women, ranging from 70 to 80 years of age (median age 75.0). They were 15.3% of all 145 surgically treated patients during same period. The empyema continued latent from 25 to 58 years (average 39.8 years). On admission they complained of productive cough (9), fever (9), hemosputam (5) and mass on the chest wall. Their Hugh-Johnes classification for dyspnea was I.: 4, II.: 6, III.: 11, IV.: 1 respectively. Their %VC ranged from 31.5 to 79.0 (average 54.8). In fifteen patients, tubercle bacilli (5), aspergillus (3) and other bacteria (9) were discovered in the empyema space. Surgical procedures consisted of 1 pneumonectomy (4.5%), 12 decortication or curettage of empyema wall (54.5%), 4 extraperiosteal air plombage (18%) and 5 other procedures (muscle or omental plombage, thoracoplasty, fenestration and others) (22.7%). There were no operative death and no lethal postoperative complication. In contrast, lethal postoperative complications such as GVIID, MOF and gastrointestinal bleeding occurred in the younger group. There were 2 cases of late respiratory failure in 70 years or older and 6 cases in younger group. Seventy-four years man who, preoperative %VC 33.0, underwent pneumonectomy died of asphyxia 6 month postoperatively. Another 74 years man who, preoperative %VC 76.1, developed respiratory failure after relapse of pulmonary tuberculosis. Four patients of younger group who developed late respiratory failure had all received thoracoplasty as a second operation. Other 2 patients, preoperative %VC 33.0 and 27.4 respectively, had undergone pneumonectomy. The risk of lethal postoperative complication or late respiratory failure were dependent mainly on preoperative respiratory function or surgical procedure selected rather than the age of patients.

[A clinical study of resected bronchopulmonary carcinoids].

19 surgically treated cases with bronchopulmonary carcinoid in our hospital were studied clinically, and we discussed the criteria of limited operation for typical carcinoid. 11 cases had typical carcinoid and 8 had atypical. All patients of typical type were alive with no recurrence. No lymph node metastasis was revealed in all cases of typical type. On the contrary, in cases of atypical type, 1 had n 2 disease and 1 had distant metastasis. The five survival rates of patients with typical carcinoid was 100%, and significantly better than that of patients with atypical, 27%. Therefore, patients with typical carcinoid can be cured by limited operation, but radical operation should be indicated for atypical carcinoid.

[Adhesion or organization during surgery due to mediastinoscopy before induction therapy for non-small cell lung cancer].

We conducted a retrospective study to investigate amounts of adhesion or organization during surgery due to mediastinoscopy before induction therapy for non-small cell lung cancer (NSCLC). A case series of 13 patients (c-stage IIIA in 11 and IIIB in 2) with right-side NSCLC who underwent induction therapy were assessed. They were between 39 and 71 years old and 8 males and 5 females. Induction therapy was chemotherapy alone in 4 cases and chemo-radiotherapy in 9 cases. The mediastinocopy was used in 4 cases. Mediastinal lymph node resection was incomplete in 3 of the 4 (75%) cases among the mediastinoscopy group but the no-mediastioscopy group had no incomplete resection (p = 0.01), though 2 of the 9 (22%) cases among the chemo-radiation group and 1 of the 4 (25%) among the chemo alone group (p > 0.9). Severe adhesion or organization can occur after the mediastinoscopy and induction therapy, which might be a course of incomplete mediastinal lymph node resection.

[Two cases of metastasizing benign leiomyomatosis from myoma uteri].

Case 1. A 50-year-old woman was referred to our hospital because of multiple bilateral small round lesion on chest radiography. She had undergone total hysterectomy for myoma uteri at the age of 33. She underwent thoracoscopic tumor excision at left lung. The lesion was proved benign. Right side lesions were laterly excised using thoracotomy. Case 2. A 49-year-old woman was referred to us because of two ovoid lesion at left lung area of chest radiography. She also had undergone total hysterectomy for myoma uteri at the age of 37. She underwent tumor extirpation using thoracotomy. All samples of two patients revealed, pathologically, lesions were consisted of benign spindle-like calls similar to those of myoma uteri. Therefore, we consider these lesions were pulmonary metastasis of myoma uteri. Myoma uteri has certain potential of metastasizing to the lung, in spite of benign disease.

[Stump curettage cytologic examination of excised tumor is more sensitive than histologic examination].

Some malignant lung tumors relapse on the cutting line in spite of a negative histologic stump. Histologic examination is limited to only few sites of excised sample. Conversely, stump curettage cytologic examination is useful to examine the whole area. We conducted a simultaneous histological and cytological study to assess the value of stump curettage cytologic examination. Forty-two staple-excised peripheral small lesions (< 3 cm in diameter) from 35 patients, aged 50 to 82 years, were assessed. Ten were subject to VATS and 32 to thoracotomy. Preoperative diagnoses were: 15 undiagnosed lesions (lung cancer: 8, benign lesion: 7), 18 lung cancers and 9 metastatic cancer. The whole area of the excised stump was curetted before observing the cross section to prevent malignant cell contamination. After that, the sample was cut vertically to staple line and pathologically examined. Thirty-eight percent (11/29) of histologically negative stumps were cytologically positive. Twenty-seven malignant lesions underwent only excision and 6 stumps were finally cytologically positive. Two of 6 cytological positive lesions relapsed at the staple site were excised at the second operation. Stump curettage cytological examination was more sensitive than histological examination to detect malignant cell contamination.

Spread of malignant cells in the surgical margin with stapled excision of lung cancer: comparison of aggressive clump and less traumatic jaw closure type staplers.

BACKGROUND: During stapled excision of lung cancer tissue, malignant cells can spread in the surgical margin. Stapling methods can be classified as aggressive clumping (AC) and less traumatic jaw closing (LTJC) types, thus the ratio of malignant margins may differ between stapler types. METHODS: The malignant status of the stapled margin was retrospectively investigated in 112 cases using a cytology technique. Stapler type, maximum tumor diameter, distance from surgical margin, thoracotomy type, and tumor location were used as variables. In addition, clinical results of excision cases were assessed. RESULTS: The ratio of malignant margins was 22/54 (41 %) in the AC group and 11/58 (19 %) in the LTJC group ( P = 0.01). Multivariate analysis revealed that the stapling method and tumor location were an independently significant factor. Surgical margin recurrence occurred only in 4 (57 %) of 7 cases with malignant margin. CONCLUSIONS: The AC type method showed a greater potential to spread malignant cells, thus there seems to be a higher possibility of regional relapse with that technique.