A Case of Descending Thoracic and Abdominal Aortic Aneurysm with Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a systemic inflammatory disorder that affects the axial skeleton. It often involves the extra-articular organs. Cardiovascular involvement is one of the extra-articular manifestations, which is mostly represented by aortic root, valvular heart disease, and conduction disturbances. An aortic sclerosing inflammatory process induces aortic root thickening and rigidity. An aortic aneurysmal change is a rare complication that often leads to life threatening conditions. A few cases regarding aortic aneurysm have been reported, but there are no reported cases in Korea. We report the first case of descending thoracic and abdominal aortic aneurysm in a patient with ankylosing spondylitis.

Serum Level of Interleukin-33 and Soluble ST2 and Their Association with Disease Activity in Patients with Behcet's Disease

Interleukin (IL)-33 is an important mediator of innate immunity. Behcet's disease (BD) is an autoinflammatory disorder characterized by hyperactivity of the innate immune response. We measured serum levels of IL-33 and its receptor soluble ST2 (sST2) in patients with BD to investigate their association with disease activity. Serum levels of both IL-33 and sST2 were higher in patients with BD compared with those in normal controls (IL-33: 594.48+/-175.04 pg/mL in BD and 224.23+/-56.64 pg/mL in normal controls [P=0.048], sST2: 99.01+/-15.92 pg/mL in BD and 23.56+/-3.25 pg/mL in normal controls [P<0.001]). IL-33 and sST2 expression in skin tissue, as shown by immunohistochemistry, was higher in patients with BD compared with that in the normal controls. Serum sST2 level correlated significantly with the BD currently active form (BDCAF), Iranian BD dynamic activity measure (IBDDAM), erythrocyte sedimentation rate and C-reactive protein. Multiple linear regression showed that serum sST2 was an independent factor associated with IBBDAM (regression coefficient, 0.374; P=0.004), and BDCAF (regression coefficient, 0.236; P=0.047). These results demonstrate that IL-33 and sST2 are highly expressed in patients with BD and that serum sST2 is an independent factor associated with IBDDAM and BDCAF, suggesting a potential role for sST2 as a surrogate marker of disease activity in patients with BD.

EGFR Polymorphism as a Predictor of Clinical Outcome in Advanced Lung Cancer Patients Treated with EGFR-TKI

PURPOSE: Mutations in the epidermal growth factor receptor (EGFR) have been confirmed as predictors of the efficacy of treatment with EGFR-tyrosine kinase inhibitors (TKIs). We investigated whether polymorphisms of the EGFR gene were associated with clinical outcomes in non-small cell lung cancer (NSCLC) patients treated with EGFR-TKI. MATERIALS AND METHODS: A polymorphic dinucleotide repeat in intron 1 [CA simple sequence repeat in intron 1(CA-SSR1)] in intron 1 and single nucleotide polymorphisms (SNP-216) in the promoter region of the EGFR gene were evaluated in 71 NSCLC patients by restriction fragment length polymorphism and DNA sequencing. The relationship between genetic polymorphisms and clinical outcomes of treatment with EGFR-TKIs was evaluated. RESULTS: SNP-216G/T polymorphisms were associated with the efficacy of EGFR-TKI. The response rate for the SNP-216G/T tended to be higher than that for G/G (62.5% vs. 27.4%, p=0.057). The SNP-216G/T genotype was also associated with longer progression-free survival compared with the GG genotype (16.7 months vs. 5.1 months, p=0.005). However, the length of CA-SSR1 was not associated with the efficacy of EGFR-TKI. CONCLUSION: SNP-216G/T polymorphism was a potential predictor of clinical outcomes in NSCLC patients treated with EGFR-TKI.

Air-leakage syndrome after allogeneic peripheral blood stem cell transplantation from unrelated donor / 대한내과학회지

Bronchiolitis obliterans, a late, non-infectious pulmonary complication of bone marrow transplantation (BMT), is an obstructive airway disease associated with chronic graft-versus-host disease (cGVHD). We report a rare case of air-leakage syndrome including pneumothoraces, pneumomediastinum, and subcutaneous emphysema with bronchiolitis obliterans after allogeneic peripheral blood stem cell transplantation (PBSCT) from an unrelated donor. The pathogenesis of air-leakage syndrome is not fully understood, and its management has not yet been established. This patient was treated with high-concentration oxygen, tube thoracostomy, percutaneous drainage with a pigtail catheter to relieve the tension pneumomediastinum, and mechanical ventilatory support. The patient has now recovered and is being followed on an outpatient basis.

Two Cases of Fatal Hypoxemia after Talc Pleurodesis for Recurrent Malignant Pleural Effusion / 결핵및호흡기질환

Talc pleurodesis is a safe and effective treatment for a recurrent malignant pleural effusion. However, acute hypoxemia, pulmonary edema or acute respiratory failure can develop in a small number of patients. We report 2 patients who developed fatal hypoxemia after talc pleurodesis which was necessary the control recurrent pleural effusion. The first case was an 18-year old male diagnosed with Ewing's sarcoma with bilateral lung metastases and pleural effusion. The performance status was ECOG (Eastern Cooperative Foncology Group) grade 3. Fever along with hypoxemia and leukocytosis developed 10 hours after the second talc pleurodesis on the right side for an uncontrolled pleural effusion, The patient died from respiratory failure after 13 days. The second case was a 66-year old female diagnosed with non-small cell lung cancer with a bone metastasis. Two weeks after systemic chemotherapy, she complained of dyspnea, and a pleural effusion was observed on the right side. Her performance status was ECOG grade 3. Talc pleurodesis was performed for recurrent pleural effusion, but hypoxemia developed 6 days after pleurodesis and she died from respiratory failure 10 days after pleurodesis. In conclusion, talc pleurodesis should be performed very carefully in patients with a poor performance status, in cases with repeated pleurodesis, bilateral pleural effusion, recent chemotherapy, radiotherapy and when there are parenchymal metastatic lesions present.

A Case of Chronic Pneumonitis of Infancy in a 3-Year-Old Boy / 소아알레르기및호흡기학회지

Interstitial lung disease, mostly chronic lung disorder, is usually characterized by diffuse infiltrates and disordered gas exchange, is a very rare disease in children. Chronic pneumonitis of infancy (CPI) is a recently described entity representing a distinct form of interstitial lung disease affecting infants and young children. The histologic findings suggest marked alveolar septal thickening, striking alveolar pneumocyte hyperplasia, and alveolar exudates containing numerous macrophages and foci of eosinophilic debris. A 3-year-old boy visited a local clinic with cough and tachypnea for a duration of 3 weeks. His clinical symptoms were aggravated and he was referred to our hospital. He was diagnosed with chronic pneumonitis of infancy after undergoing open lung biopsy. We herein present the case with review of literature.

Mucoepidermoid Carcinoma in a 12-Year-Old Boy / 소아알레르기및호흡기학회지

Bronchial mucoepidermoid tumors are rare, especially in children. They are commonly misdiagnosed as infections or asthma and treated with bronchodilators without resolution. Based on the available clinical outcome and survival data, it is believed that tracheobronchial mucoepidermoid carcinoma may be successfully managed by surgical intervention alone in children and adolescents. We report a case of a 12-year-old boy with low-grade mucoepidermoid carcinoma in the right intermediate bronchus that caused chronic cough. He underwent sleeve resection of the right bronchus and remained symptom-free without recurrence during the follow-up period of 16 months.

A Case of Video-Assisted Thoracoscopic Pneumonectomy for Unilateral Diffuse Pulmonary Arteriovenous Malformation / 결핵및호흡기질환

Pulmonary arteriovenous malformations (PAVMs) are abnormal direct communications between the pulmonary arteries and veins. PAVMs may occur as either an isolated abnormality or in association with hereditary hemorrhagic telangiectasia, also called Osler-Weber-Rendu disease. The topic of PAVM has recently been extensively reviewed, but little is known about the clinical characteristics and course of patients having a diffuse pattern of the disease. Herein, is reported a case of unilateral diffuse PAVM in an 18 year old female patient, who underwent a right pneumonectomy, under a video-assisted thoracic surgery (VATS) approach, as the diffuse small pulmonary arteriovenous malformation involved the whole right lung.

The Comparison of VATS Ramicotomy and VATS Sympathicotomy for Treating Essential Hyperhidrosis

This study was undertaken to determine if better results could be achieved by comparing the results of a thoracic sympathetic ramicotomy (division of rami communicantes) with a conventional thoracic sympathicotomy (division of sympathetic trunk) for treating essential hyperhidrosis. From August 2001 to February 2002, 29 consecutive patients underwent surgery of the sympathetic nerves in order to treat severe essential hyperhidrosis. Of these patients, a ramicotomy was performed under VATS (VATS-R) in 13 patients, sympathicotomy under VATS (VATS-S) in 13, a unilateral ramicotomy and contralateral sympathicotomy under VATS (VATS-RS) in 2 and a sympathicotomy via a thoracotomy (T-S) in 1. There was no significant difference between the VATS ramicotomy group (VATS-R, n=13) and VATS sympathicotomy group (VATS-S, n=13) in terms of gender, pleural adhesions or comorbidities. However, the age of the VATS-S group at surgery was higher than that of the VATS-R group (p=0.050). The operation times, and hospital stays of the groups were 51.5 and 41.9 minutes, and 2.0 and 2.3 days, respectively. The recurrence rate of the operated sites according to the surgical methods (ramicotomy and sympathicotomy regardless of VATS) was 21.4% (6/28) in the ramicotomy group and 6.7% (2/30) in the sympathicotomy group, but there was no statistical significance (p=0.101). This study compared the dryness of the enervated sites and the severity of compensatory sweating among the ramicotomy (n=11, excluded 2 re-operated cases from 13 VATS-R), sympathicotomy (n=14, VATS-S 13 and T-S 1) and the synchronous or metachronous ramicotomy/sympathicotomy groups (n=4, included 2 reoperated cases of VATS-R). The sympathicotomy group had an over-dryness of the enervated sites (dryness 1.4, from 1 to 3; 1: over-dried, 2: humid, 3: persistent sweating) and complained of severe compensatory sweating (severity 3.5, from 1 to 4; 1: absent, 2: mild, 3: embarrassing, 4: disabling). However, the patients whounderwent a ramicotomy maintained some humidity of the enervated sites (dryness 2.0, p=0.012) and showed milder compensatory sweating (severity 2.7, p=0.056) than those in the sympathicotomy group. Furthermore, the dryness of the ramicotomy side was different from that of the sympathicotomy side in 3 out of 4 ramicotomy / sympathicotomy (R+S) patients (the side of the ramicotomy was humid and that of the sympathicotomy was over-dried). The average dryness and the compensatory sweating at these sites were in the midst of the two groups (dryness and severity 1.6 and 3.0, respectively). A ramicotomy can prevent over-dryness of the enervated area and decrease the severity of compensatory sweating through the selective division of the rami communicantes of the thoracic sympathetic ganglia. Postoperatively, almost all ramicotomy patients had no functional problems in daily life or in their occupational activity, because they could maintain hand humidity. Moreover, they showed no more than a mild degree of compensatory sweating and reported high long-term satisfaction rates. Therefore, a sympathetic ramicotomy rather than a conventional sympathicotomy is recommended as a more selective and physiologic modality for treating essential hyperhidrosis.

The Effect of Visceral Pleura Invasion in the Resected Stage IB Non-Small Cell Lung Cancer Patients

PURPOSE: The purpose of this study was to clarify the prognostic significance of visceral pleura invasion in T2N0M0 non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Between Jan. 1990 and Dec. 2001, 213 consecutive patients with T2N0M0 NSCLC underwent complete surgical resection. The patients were divided into two groups according to the existence of visceral pleural invasion. P1 and P2 defined by Hammar's definition were included in visceral pleural invasion group. The follow-up was carried out completely without missing case. The median follow-up period was 34.4 months, ranging from 0.13 to 156.2 months. RESULTS: Patient ages ranged from 10 to 79 years (mean: 60.1 years, median : 62 years). Visceral invasion was identified in 55 patients (25.8%). The operation included lobectomy in 110, pneumonectomy in 67, bi-lobectomy in 36 patients. Histology was squamous cell carcinoma in 110, adenocarcinoma in 72, large cell carcinoma in 13, others in 18. There were 5 hospital mortality (2.3%) and 71 late mortality (33.3%). 27 (50.94%) and 44 (28.4%) of late mortality were in visceral pleural invasion group (Group I) and visceral pleural non-invasion group (Group II) respectively (p=0.002). Overall 5-year survival rate was 44.8% in Group I and 63.5% in group II (p=0.0017). There were 55 (25.8%) postoperative recurrences, 24(43.6%) in group I, 21 (13.3%) in group II (p<0.0001). There were 60 recurrence sites, 58 (96.7%) of them were distant metastases, 2 (3.3%) were local recurrences. CONCLUSION: Visceral pleural invasion is a significant prognostic factor in stage IB NSCLC in survival time and recurrence. The postoperative adjuvant systemic therapy can be thought in stage IB NSCLC with visceral pleural invasion

Aortic Root Replacement with Valve Preservation in a Patient with Annuloaortic Ectasia / 대한흉부외과학회지

Patients with aortic root disease, frequently seen in Marfan syndrome have progressive dilatation of the aortic sinuses and dilatation and distortion of the aortic annulus, leading to aortic incompetence. They are currently treated with composite graft replacement of the ascending aorta and aortic valve and reimplantation of the coronary arteries. Recently, we experienced an aortic root replacement with aortic valve preservation in a patient with annuloaortic ectasia. The ascending aorta and sinus was excised except the aortic annulus and aortic valve. The aortic valve was reimplanted inside of a collagen-impregnated tubular Dacron graft. The coronary arteries were also reimplanted. The patient was followed up for six months and reevaluated with the echocardiography. Postoperative Doppler echocardiography revealed normal aortic valve function. With this technique, it is possible to preserve the native aortic valve if the aortic leaflets are anatomically normal.

Surgical Resection of Small Cell Lung Cancer ( SCLC ) / 대한흉부외과학회지

Bafckground: Thr role and indication of surgery in the treatment of small cell lung cancer (SCLC) is currently limited and unsettled. MATERIAL AND METHOD: We analyzed the surgical results of 9 patients with SCLC at Yosei Medical Center from January 1990 to December 1996. There were 8 males and 1 female, and their mean age was 57.2 years (range; 35-76). Preoperatively SCLC was confirmed in 5, but the other 4 cases were diagnosed as undifferentiated squamous cell carcinoma. All patients underwent pulmoinary resection (lobectomy;5, lobectomy, segmentectomy and en-bloc resection of rib;1, bilobectomy; 2, pneumonectomy;1) and mediastinal lymph node dissection. RESULTS: There were no operative mortality with two complications (postoperative bleeding;1, arrhythmia;1). All cases were diagnosed as SCLC histologically and their TNM staging were confirmed as follows: T1N0M0;1, T2N0M0;4, T3N0M0;1, T3N1M0;1, T2N2M0; 1, T4N0M0;1. All patients had received postoperative chemotherapy, and radiotherapy was combined in 4 patients. During follow up period (range 1-63 months; mean 33.0months), there was only one metastasis to pelvic bone among 8 patients without lymph node metastasis, and all patients were alive. On the other hand, among 3 patients who had regional and/or mediastinal lymph node metastasis or T4 lesion, all patients had recurrences (local;2, brain;1), and 2 patients died. CONCLUSION: We suggest that the use of TNM staging is beneficial, and surgical resection should be recommended in the patients with early staged SCLC as an important treatment modality.

The Clinical Experiences of Patch Angioplasty in Isolated Critical Left Main Coronary Artery Stenosis / 대한흉부외과학회지

The conventional surgical treatment of isolated critical stenosis of the left main coronary artery restores a less physiologic perfusion of the myocardium, leads to occlusion of the left coronary ostium, and consumes an appreciable length of bypass material. From June 1994 to February 1996, eleven patients, three male and eight female, underwent patch angioplasty and additional bypass graft to left anterior descending artery (10 internal mammary artery, 1 saphenous vein) in isolated critical left main coronary artery stenosis. Their ages ranged from 34 to 62 years, mean 44 years. All had 60% to 90% stenosis of the left main coronary artery and Class III angina. The angiogram showed nine osteal lesion and three main stem stenosis. The operation was performed with conventional cardiopulmonary bypass and cold blood cardioplegia. We approached anteriorly and used bovine pericardium as onlay patch in all patients. There were one leg wound dehiscence, but no operative deaths and infarctions. All patients are free of symptoms after a mean follow-up of 15.5 months. Angiographic restudy at an average 14.4 months was obtained in five patients and showed widely patent left main coronary artery with excellent runoff. But additional graft to left anterior descending coronary artery were stenosed in two patients and showed diminutive flow in others. Our preliminary results suggest that angioplasty of the left main coronary artery can be carried out with low operative risks. But additional bypass graft to left anterior descending coronary artery may be unnecessary. The technique appears to be a promising alternative to conventional coronary artery bypass grafting in isolated left main coronary artery stenosis.

Prediction of Improvement of Hibernating Myocardium after Coronary Artery Bypass Grafting: The role of dobutamine stress echocardiography / 대한흉부외과학회지

BACKGROUND: In patients with coronary artery disease, dysfunctional hypoperfused myocardium at rest may represent either nonviable or viable hibernating myocardium. Two-dimensional echocardiography can detect regional wall motion abnormalities resulting from myocardial ischemia by dobutamine infusion. The purpose of the present study was to identify the prediction of improvement of regional left ventricular (LV) function after surgical revascularization. MATERIALS AND METHODS: Sixteen patients with chronic regional LV dysfunction underwent dobutamine stress echocardiography (DSE) (dobutamine: baseline, 5, 10, 20microgram/kg/min) before coronary artery bypass grafting (CABG) and underwent echocardiography at least 2 months after CABG. RESULTS: All patients were male with mean age of 58 years ranging from 42 to 73 years. The mean LV ejection fraction was 41.8% with a range from 19% to 55%. During DSE, there were no complications, also, there were no operative morbidities or mortalities. Improvement of wall motion within the dysfunctional myocardium was found in 8 (50%) of 16 patients in DSE. Among them, 6 patients (75%) showed functional recovery after CABG. Another 8 patients did not show improvement of wall motion in DSE. But among them, 3 patients (38%) showed functional recovery after CABG. 84 dysfunctional segments were found in 256 segments of 16 patients. Improvement of wall motion was found in 34 of 84 segments in DSE. Among them, 23 segments (74%) showed functional recovery after CABG. Another 53 segments did not show improvement of wall motion in DSE. But among them, 12 segments (23%) showed functional recovery after CABG. The sensitivity and specificity of DSE for the prediction of postoperative improvement of segmental wall motion were 66% and 84%, respectively. The positive and negative predictive value of DSE were 74% and 77%, respectively. In patients with chronic regional LV dysfunction, think that DSE is a good predictor of the improvement of dysfunctional segments after CABG.

The Surgical Results of Stage I Lung Cancer / 대한흉부외과학회지

BACKGROUND: Surgical resection is the standad therapy for the stage I lung cancer. We analysed the risk facturs of stage I lung cancer patent and tryed to establish more effective and aggressive treatment modality. MATERIALS AND METHODS: A detailed analysis was undertaken to evaluate the surgical results and to define the risk factors associated with the recurrence and the survival time in 146 consecutive patients with stage I lung cancer who were diagnosed, and resected at Yonsei Medical Center from January 1990 to December 1996. RESULTS: There were 115 males and 31 females. Their ages ranged from 27 to 79 years (mean age:58.9+/-9.3 years). The histologic types were squamous carcinoma in 72 cases (49.3%) and adenocarcinoma in 45 cases (30.8%). A pulmonary resection and mediastinal lymph node dissection were done in all cases. A lobectomy was performed in 96 cases (65.7%) and a pneumonectomy in 48 cases (32.9%). There were 5 operative mortalities (3.4%) and complications occured in 24 cases (16.5%). The overall 5-year survival was 64.1%, and survival time did not depend on the type of operation or histologic type. Significant predictors of decreased survival were visceral pleural invasion (p=0.0079), T2 lesion (p=0.0462), and tumor size (> or =5 cm) in adenocarcinoma (p=0.0472). The overall incidence of recurrence was 33.3% (47 cases; local or regional 6.4%, distant 26.9%). Almost all recurrences (44cases) occurred in T2 lesions. The distant organs that failed were the contralateral lung in 13 patients, the brain in 12, the bone in 10, and other organs in 3. CONCLUSIONS: even in stage I lung cancer, we suggest that postoperative adjuvant therapy is recommended in patients with poor prognostic factors such as visceral pleural invasion, T2 lesions, and a tumor size (> or =5 cm) in the adenocarcinoma.