Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study.

BACKGROUND AND STUDY AIMS: The frequency of stricture after endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma with a mucosal defect involving more than three-quarters of the circumference is 70% - 90%. Stricture decreases quality of life and requires multiple endoscopic balloon dilation (EBD) sessions. We investigated the efficacy and safety of a single session of intralesional steroid injections to prevent post-ESD stricture. PATIENTS AND METHODS: We conducted a prospective study on 30 patients with esophageal squamous cell carcinoma treated by ESD, who had a more than three-quarter but less than whole circumferential defect. A single session of intralesional steroid injections was undertaken immediately after ESD. Esophagogastroduodenoscopy was performed whenever patients reported dysphagia and 2 months after ESD in patients without dysphagia. Results were compared with a historical control group of 29 patients who underwent ESD without intralesional steroid injection. The primary endpoint was the post-ESD stricture rate. Secondary endpoints were the number of EBD sessions and the complication rate. RESULTS: Compared with the historical control group, the study group had a significantly lower stricture rate (10%, 3/30 patients vs. 66%, 19/29 patients; P < 0.0001) and a lower number of EBD sessions (median 0, range 0 - 2 vs. median 2, range 0 - 15; P < 0.0001). The study group had a complication rate of 7 % (2 /30 patients), comprising a submucosal tear in one patient and bleeding in another, which were not a direct result of EBD. CONCLUSIONS: A single session of intralesional steroid injections showed promising results for the prevention of stricture after ESD for esophageal cancer.

Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer.

Perforation is a major complication of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). However, there have been no reports on delayed perforation after ESD for EGC. We aimed to elucidate the incidence and outcomes of delayed perforation after ESD. Clinical courses in 1159 consecutive patients with 1329 EGCs who underwent ESD were investigated. Delayed perforation occurred in six patients (0.45 %). All these patients had complete en bloc resection without intraoperative perforation during ESD. Five of six perforations were located in the upper third of the stomach, while one lesion was found in the middle third. Symptoms of peritoneal irritation with rebound tenderness presented within 24 h after ESD in all cases. One patient did not require surgery because the symptoms were localized, and recovered with conservative antibiotic therapy by nasogastric tube placement. The remaining five patients required emergency surgery. There was no mortality in this case series.

Mixed-histologic-type submucosal invasive gastric cancer as a risk factor for lymph node metastasis: feasibility of endoscopic submucosal dissection.

BACKGROUND AND STUDY AIMS: The clinicopathologic features of gastric cancers containing a mixture of differentiated-type and undifferentiated-type components remain uninvestigated. We evaluated the risk of lymph node metastasis and the feasibility of endoscopic submucosal dissection (ESD) for the treatment of mixed-histologic-type gastric cancers. PATIENT AND METHODS: We histologically classified 376 cases of gastric cancer with submucosal invasion into four types (differentiated type, differentiated-type-predominant mixed type, undifferentiated-type-predominant mixed type, and undifferentiated type) and studied the clinicopathologic relations of each type to lymph node metastasis. Lymphatic invasion was evaluated by D2-40 immunostaining. RESULTS: The overall prevalence of lymph node metastasis in gastric cancer with submucosal invasion was 16.5% (62/376). The prevalence of lymph node metastasis was 36.5% (23/63) in undifferentiated-type-predominant mixed type, which was significantly higher than those in the other three types (P < 0.001 vs. differentiated type, P = 0.013 vs. differentiated-type-predominant mixed type, and P = 0.003 vs. undifferentiated type). Lymphatic invasion, a depth of invasion of 500 microm or more from the lower margin of the muscularis mucosae (SM2), tumor size above 30 mm, and undifferentiated-type-predominant mixed histologic type were independent risk factors for lymph node metastasis. Submucosal cancers without these four risk factors were free of lymph node metastasis (0/41; 95 % confidence interval 0%-8.6%). CONCLUSIONS: Undifferentiated-type-predominant mixed-type gastric cancer with submucosal invasion carries a high risk of lymph node metastasis. ESD can be indicated for gastric cancer with submucosal invasion provided that the following conditions indicating a low risk of metastasis are met: a depth of invasion of no more than 500 microm or more from the lower margin of the muscularis mucosae (SM1), no lymphatic invasion, a tumor size of no more than 30 mm, and a proportion of undifferentiated components below 50%.

[The use of 19 Fr silicone drains in chest surgery].

We evaluated a single 19 Fr Blake drain after chest surgery retrospectively. 50 patients underwent drainage of their pleural cavity using Blake drains. Blake drain was found to be effective in drainage of both air and fluid. In addition, this soft silicone drain seemed to improve the comfort of the patients. One single Blake drain is considered to be an option for chest drainage in most of general thoracic surgery.

Recurrent lymphangioleiomyomatosis after living-donor lobar lung transplantation.

Living-donor lobar lung transplantation (LDLLT) has been applied to patients with various end-stage lung diseases. The recurrence of pulmonary lymphangioleiomyomatosis (LAM) after lung transplantation has been rarely reported. Herein, we report a case of recurrent pulmonary LAM after LDLLT. A 24-year-old woman presented with pneumothorax and infiltrates in the left lung 1 year after bilateral LDLLT for LAM. These symptoms and radiologic findings occurred repeatedly and then improved quickly. Thereafter, computed tomography of the chest revealed a tiny emphysematous change of the subpleural region in the left lung, which was exacerbated gradually and was finally diagnosed as LAM recurrence by transbronchial lung biopsy. In previous reports of LAM recurrence, the diagnosis was made at the time of autopsy. This is also the first reported case diagnosed early, that is, when the patient was alive and her allograft had not deteriorated badly.

Evaluation of angiogenesis in non-small cell lung cancer: comparison between anti-CD34 antibody and anti-CD105 antibody.

PURPOSE: Angiogenesis is an essential process in the progression of malignant tumors. Whereas pan-endothelial markers, such as CD34, are generally used in evaluation of angiogenesis, pan-endothelial antibodies react with not only "newly forming" vessels but also normal vessels just trapped within tumor tissues. It has been recently reported that anti-CD105 antibody preferentially reacts with "activated" endothelial cells in angiogenic tissues. Thus, the superiority of anti-CD105 monoclonal antibody (mAb) in evaluation of angiogenesis of non-small cell lung cancer (NSCLC) was assessed. EXPERIMENTAL DESIGN: A total of 236 patients with resected NSCLC were retrospectively reviewed. Intratumoral microvessel density (IMVD) was determined with an anti-CD34 mAb (CD34-IMVD) and with an anti-CD105 mAb (CD105-IMVD). RESULTS: The mean CD34-IMVD and CD105-IMVD were 179.9 and 41.6, respectively. Whereas CD34-IMVD was significantly correlated with the expression of vascular endothelial growth factor (P = 0.003), CD105-IMVD was more closely correlated with vascular endothelial growth factor expression (P < 0.001). The 5-year survival rate of the lower CD105-IMVD patients was 74.9%, significantly higher than that of the higher CD105-IMD patients (60.4%, P = 0.018). Whereas the 5-year survival rate of the lower CD34-IMVD patients seemed higher than that of the higher CD34-IMVD patients (63.7%), the difference did not reach a statistical significance (P = 0.137). Multivariate analysis confirmed that higher CD105-IMVD was a significant factor to predict poor prognosis (P = 0.029), whereas CD34-IMVD was not (P = 0.070). CONCLUSIONS: Anti-CD105 mAb proved to be superior to anti-CD34 mAb in evaluation of angiogenesis in NSCLC.

Optimal alveolar oxygen concentration for cold storage of the lung.

BACKGROUND: Ischemia of the lung is different from that of solid organs because the lung contains gas in the alveoli. However, the optimal gas composition in the alveoli during cold storage remains uncertain. We investigated the relationship between the alveolar oxygen concentration and reperfusion injury. METHODS: The lungs inflated with 0% O2, 5% O2, room air, 50% O2, or 100% O2 were reperfused after 8 hR storage at 4 degrees C and pulmonary functions were measured for 120 min using an ex vivo rat lung model. The levels of high-energy phosphate and lipid peroxidation of the lung were analyzed after a PA flush, preservation, and reperfusion. Additionally, respiration of the mitochondria in the lungs was measured after preservation. RESULTS: The pulmonary functions were significantly superior in the 5% O2 group than those in the 0% O2, 50% O2, and 100% O2 groups. Pulmonary edema developed in the 0% O2, 50% O2, and 100% O2 groups, but not in the 5% O2 group. After preservation, the energy level in the lungs decreased only in the 0% O2 group. Although lipid peroxidation of the lungs did not increase in any group after preservation, significant increases were observed in the room air, 50% O2 and 100% O2 groups after reperfusion. State 3 and 4 ratios of the mitochondrial respiration significantly decreased in the lungs of the room air, 50% O2 and 100% O2 groups. CONCLUSIONS: Although the cold-preserved lungs require oxygen, hyperoxygenation induced mitochondrial dysfunction and increased lipid peroxidation and led to deleterious lung function after reperfusion. Therefore, hypoxic conditions that can maintain the energy level of the lung during cold storage would be optimal.

Mediastinal thoracic duct cyst.

A healthy 34-year-old man had a mediastinal cyst on the imaging study. Surgical treatment was performed. The cyst was diagnosed as a thoracic duct cyst from its anatomic location and contents. Pathologic examination found it to be consistent with thoracic duct cyst. Endothelial cells on its luminal surface were identified by an immunohistologic stain with the factor VIII-related antigen. Twenty-six cases of thoracic duct cysts have been reported. We report an additional case and review the previously reported cases. We found that the ligation of the inferior pedicle of the cyst is essential to prevent postoperative chylothorax.

A selective transthyretin-adsorption column for the treatment of patients with familial amyloid polyneuropathy.

A transthyretin (TTR)-adsorption column has been developed for the removal of variant TTR from the plasma of patients with familial amyloid polyneuropathy (FAP). The adsorbent is an ion-exchange resin made of porous beads of polyvinyl alcohol gel covalently bound with dimethylaminoethanol. This column was used for three patients with type I FAP. It reduced the concentrations of both normal and variant TTR in the plasma to about half of their pre-adsorption levels. Except for thyroxine, retinol-binding protein and IgM, other proteins in serum were not significantly decreased and there were no adverse effects in long term clinical usage of this TTR-adsorption column. In this trial, we did not obtain concrete evidence that TTR-adsorption therapy can stop or delay the progression of the disease in a FAP patient. However, if we are able to apply this technique more frequently and effectively, TTR-adsorption therapy using our column might be useful for the treatment of FAP patients.

Inflammatory endobronchial stenosis.

We encountered a 71-year-old woman with inoperable bronchial stenosis of the right main bronchus, which was caused by inflammatory granulation infected with Pseudomonas aeruginosa in posttuberculous bronchiectasis. Two months after placement of self-expanding nitinol stents, fiberoptic bronchoscopic examination to investigate hemosputum revealed endobronchial granuloma formation. Endobronchial granulation has disappeared with long-term oral administration of tranilast.

A novel frameshift mutation in the McLeod syndrome gene in a Japanese family.

We report a novel mutation in the XK gene (XK) in a Japanese patient with McLeod syndrome. A 50-year-old man showed progressive muscular atrophy, choreic movement, elevated level of serum creatinine kinase, and acanthocytosis. The expression level of all the Kell antigens in erythrocyte was decreased and molecular analysis revealed a single-base (T) deletion at the nucleotide position 1095 in XK. This deletion caused a frameshift in translation, leading to a premature stop codon at the amino acid position 408. We conclude this single-base deletion causes defective Kx protein, which is responsible for the McLeod phenotype in this patient.

Chemiluminescence: a sensitive and versatile method for analyte detection.

The generation of light from the oxidation of oxalic esters with hydrogen peroxide has been applied to the detection of luminescent materials. In order to improve the efficiency of this method, which is less than 0.1%, and to enhance the selectivity for target analytes, an in-depth investigation of the oxalate ester-hydrogen peroxide reaction has been conducted. A kinetic model has been developed based on the effects of catalysts, reagents and reaction conditions for maximum light production. Application of the model to liquid chromatography through the "time-dependent emission window" concept affords a predictable maximum sensitivity for selected analytes. Application to the detection and quantitation of met- and leu-enkephalins which have been labelled with naphthalene-2,3-dicarboxyaldehyde/cyanide provides support for this methodology. Other bioanalytical applications are presented.

Effective application of ET-Kyoto solution for clinical lung transplantation.

The shortage of lung donors and ischemia-reperfusion injury following transplantation have been grave problems in lung transplantation (LTx). One of the most important strategies to solve these problems is the development of effective and highly reliable methods for lung preservation. Therefore, we developed a new organ preservation solution, namely, the extracellular-type trehalose-containing Kyoto (ET-Kyoto) solution. Here we report the first experience of clinical application of ET-Kyoto solution for cadaveric LTx. The recipient was a 38-year-old man with pulmonary emphysema. The donor was a 51-year-old male current smoker with a smoking history of 62 pack-years. The ventilated donor's PaO(2) was 340 Torr (FiO(2) = 1.0). The pulmonary vasculature was flushed with ET-Kyoto solution supplemented with nitroglycerine and dibutyryl cAMP. The recipient underwent bilateral sequential LTx on cardiopulmonary bypass. The ischemic time was 544 and 613 minutes for the left and right lung, respectively. PaO(2) (FiO(2) = 1.0) was 385 Torr immediately after reperfusion. The donor lung was so large that bilateral partial resections were performed at 413 minutes (right) and 348 minutes (left) after reperfusion. On histopathologic examination of the resected transplanted lungs the structure was almost normal. Postoperatively, PaO(2) (FiO(2) = 1.0) was over 400 Torr with or maximum of 526 Torr. The clinical course was almost uneventful. In conclusion, ET-Kyoto solution may be safely applied in clinical cadaveric LTx with extended donor lungs and relatively long ischemic times. Functional and histopathological efficiency of ET-Kyoto solution was confirmed. Longer preservation times with preserved quality using ET-Kyoto solution would increase the donor pool and enable semielective LTx.

[Steroid therapy and plasmapheresis in chronic inflammatory demyelinating polyradiculoneuropathy: a long-term follow-up study].

We report eight patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), paying special attention to the therapeutic effects of steroid and plasmapheresis. Each patient underwent 4 to 51 plasmapheresis sessions in addition to prednisolone therapy. Plasmapheresis was more effective in patients with motor neuropathy (6 patients) than in those with sensory neuropathy (2 patients). Concomitant steroid therapy enhanced the short-term efficacy of plasmapheresis. During a long-term follow-up, the patients who showed deteriorating clinical symptoms such as limb weakness, sensory disorder, decreased deep tendon reflexes and increased CSF proteins underwent plasmapheresis once or twice a month. This intermittent plasmapheresis could reduce the use of prednisolone or eventually discontinue the drug completely. We were not able to determine whether immunoadsorption plasmapheresis or double-filtration plasmapheresis was more effective for the patients with CIDP. CIDP is characterized by frequent recurrences of a chronic progressive course, and peripheral neuropathy and some patients with this disease are resistant to many therapeutic approaches. The present study strongly suggests that plasmapheresis with concomitant steroid therapy is very useful for both short- and long-term treatment of CIDP patients.

[A case of penetrating chest injury with tension hemothorax by gunshot].

The patient, a 36-year-old male, was admitted with massive hemoptysis. He had two gunshot wounds in the right lateral abdomen and supraclavicular fossa. His chest X-ray showed right tension hemothorax. Emergency thoracotomy and laparotomy were performed. Massive bleeding from the right pulmonary artery (A4+5), lacerations in the diaphragm and injuries of the liver were found. We performed right middle lobectomy, S3 segmentectomy and plication of the diaphragm and liver. He was discharged uneventfully.

Right ventricular outflow tract obstruction after bilateral lung transplantation.

We report here on the successful treatment for right ventricular outflow tract obstruction after bilateral lung transplantation in a patient with primary pulmonary hypertension. A 31-year-old female patient with primary pulmonary hypertension underwent successful bilateral lung transplantation. She had a pressure gradient of 30 mmHg through the right ventricular outflow tract one week after transplantation, but was successfully treated with atelenol and disopyramide. Long-term follow-up cardiac catheterization did not show any significant right ventricular outflow tract obstruction. The actual cause of the right ventricular outflow tract obstruction remained unknown, but longstanding pulmonary hypertension might have induced significant structural changes in the heart, such as right ventricular hypertrophy and enlargement.

The dual PI3 kinase/mTOR inhibitor PI-103 prevents p53 induction by Mdm2 inhibition but enhances p53-mediated mitochondrial apoptosis in p53 wild-type AML.

Activation of the phosphatidylinositol-3 kinase/Akt/mammalian target of the rapamycin (PI3K/Akt/mTOR) pathway and inactivation of wild-type p53 by murine double minute 2 homologue (Mdm2) overexpression are frequent molecular events in acute myeloid leukemia (AML). We investigated the interaction of PI3K/Akt/mTOR and p53 pathways after their simultaneous blockade using the dual PI3K/mTOR inhibitor PI-103 and the Mdm2 inhibitor Nutlin-3. We found that PI-103, which itself has modest apoptogenic activity, acts synergistically with Nutlin-3 to induce apoptosis in a wild-type p53-dependent fashion. PI-103 synergized with Nutlin-3 to induce Bax conformational change and caspase-3 activation, despite its inhibitory effect on p53 induction. The PI-103/Nutlin-3 combination caused profound dephosphorylation of 4E-BP1 and decreased expression of many proteins including Mdm2, p21, Noxa, Bcl-2 and survivin, which can affect mitochondrial stability. We suggest that PI-103 actively enhances downstream p53 signaling and that a combination strategy aimed at inhibiting PI3K/Akt/mTOR signaling and activating p53 signaling is potentially effective in AML, where TP53 mutations are rare and downstream p53 signaling is intact.

Living-donor lobar lung transplantation for pulmonary and abdominopelvic lymphangioleiomyomatosis.

We performed emergency living-donor lobar lung transplantation (LLTx) successfully in a 24-year-old woman with end-stage pulmonary and massive abdominopelvic lymphangioleiomyomatosis (LAM). Preoperatively, her respiratory condition was critical, but abdominopelvic lesions had been well controlled with medication. No LAM patients with massive abdominopelvic lesions as in the present case have been reportedly treated by LLTx previously. The present case demonstrates that LLTx can be a therapeutic option for end-stage pulmonary LAM with massive abdominopelvic involvement.