[Evaluation of Anesthesia Method to Minimize Intraoperative Body Movement and Respiratory Depression for Dilatation and Curettage A Retrospective Study].

BACKGROUND: The optimal level of anesthesia and the dose of the agent to procure the least intraoperative body movement and respiratory depression have not been evaluated in dilatation of the cervix and curettage of the uterus (D & C). METHODS: Sixty-eight patients were divided to one of the three groups. Group S: the use of sevoflurane (1-2%) [n=22]. Group 2.5 K: high dose (1.6-2.5 mg · kg(-1) of ketamine with fentanyl (50-100 µg) and midazolam (2 mg) [n=23]. Group 1.5 K: the standard dosage of ketamine (0.5-1.5 mg · kg(-1) with fentanyl (50-100 µg) and midazolam (2 mg) [n=23]. Patient's intraoperative body movement and the necessity of jaw-lift and assisted manual ventilation were evaluated. RESULTS: Intraoperative body movement was significantly higher in Group 1.5 than in Groups S or 2.5 K (P<0.05). Necessity of jaw-lift and assisted manual ventilation was significantly higher in Group S than in Groups 1.5 K or 2.5 K (P<0.05). CONCLUSIONS: Intravenous anesthesia using increasing doses of ketamine (1.6-2.5 mg · kg(-1) with fentanyl (50-100 µg) and midazolam (2 mg) reduces the intraoperative body movement without exacerbating respiratory depression during D&C.

Chronic lung injury by constitutive expression of activation-induced cytidine deaminase leads to focal mucous cell metaplasia and cancer.

Activation-induced cytidine deaminase (AID) is an enzyme required for antibody diversification, and it causes DNA mutations and strand breaks. Constitutive AID expression in mice invariably caused lung lesions morphologically similar to human atypical adenomatous hyperplasia (AAH), which can be a precursor of bronchioloalveolar carcinoma. Similar to AAH, mouse AAH-like lesion (MALL) exhibited signs of alveolar differentiation, judging from the expression of alveolar type II (AT2) cell marker surfactant protein C (SP-C). However, electron microscopy indicated that MALL, which possessed certain features of a mucous cell, is distinct from an AAH or AT2 cell. Although MALL developed in all individuals within 30 weeks after birth, lung tumors occurred in only 10%; this suggests that the vast majority of MALLs fail to grow into visible tumors. MALL expressed several recently described markers of lung alveolar regeneration such as p63, keratin 5, keratin 14, leucine-rich repeat containing G protein-coupled receptor 5 (Lgr5), and Lgr6. Increased cell death was observed in the lungs of AID transgenic mice compared with wild-type mice. Based on these observations, we speculate that MALL is a regenerating tissue compensating for cellular loss caused by AID cytotoxicity. AID expression in such regenerating tissue should predispose cells to malignant transformation via its mutagenic activity.

[Evaluation of perioperative blood loss and transfusion in total knee arthroplasty].

BACKGROUND: Total knee arthroplasty (TKA) is generally associated with considerable blood loss and frequent blood transfusion, which are affected by various factors. We evaluated them retrospectively. METHODS: Fifty-five patients underwent TKA at our facility between January 2008 and December 2011. We investigated retrospectively their perioperative blood loss and transfusion by using medical and anesthetic records. RESULTS: Perioperative amounts of blood loss and allogenic transfusion rates were 424 g and 9 percent (average RCC 2.4 units), respectively. All patients who had donated preoperative autologous blood were able to avoid allogenic transfusion. On the other hand, 24% of entire autologous bloods were discarded. CONCLUSIONS: There is considerable perioperative blood loss in TKA. And such factors as hemostasis, anesthetization and anticoagulation can affect it It may be possible to avoid allogenic transfusion by using preoperative autologous blood donation. However, much attention should be paid to appropriate collection of autologous bloods, because of the possibility of a high discard rate of these.

Lung squamous cell carcinoma in a young female never smoker: a case report.

A lung squamous cell carcinoma complicated by lung abscess was found in a 38-year-old female never smoker. After a transbronchial lung biopsy, she complained of chest pain and had a persistent fever. A right middle lobectomy was performed to alleviate her symptoms and complete surgical resection was achieved. She reported no exposure to factors that increase the likelihood of lung cancer. Unknown factors or the patient's lung cancer susceptibility might cause the disease. Survival time is generally shorter in young patients than old patients, but careful observation and aggressive treatment can improve prognoses. A case such as this is rare in the extant literature.

[Anesthetic management for laparoscopic pheochromocytoma resection in a patient with cardiac dysfunction under dynamic monitoring].

A 51-year-old women with cardiac dysfunction due to catecholamine-induced cardiomyopathy underwent laparoscopic adrenalectomy for pheochromocytoma. Her preoperative cardiac status was New York Heart Association (NYHA) class IIand left ventricular ejection fraction (LVEF) was 45%. In her anesthetic management, we used FloTrac® system and monitored arterial pressure-based cardiac output (APCO) and stroke volume variation (SVV) continuously as the indicator of intraoperative hemodynamics. Although her hemodynamics fluctuated highly during manipulation of the tumor and after ligation of adrenal vein intraoperatively, we could manage them rapidly by adjusting administration of vasodilator or pressor agents and appropriate volume expansion under monitoring APCO and SVV. The operation was completed successfully and postoperative course was almost uneventful. As laparoscopic pheochromocytoma resection is accomplished in a brief period with less surgical invasion compared with laparotomy, it may be possible to manage hemodynamics of the patient with cardiac dysfunction properly under dynamic monitoring using FloTrac® system.

[Successful anesthetic management of laparoscopic rectopexy using rocuronium and sugammadex in a patient with Becker muscular dystrophy].

A 70-year-old man with Becker muscular dystrophy (BMD) underwent laparoscopic rectopexy under general anesthesia. For anesthetic induction, we administered total 0.6 mg · kg-1 of rocuronium with titration. Eight minutes later, train-of-four (TOF) count reached to 0 and the patient was intubated smoothly. One hundred and five minutes later, TOF ratio recovered to 100% and we administered rocuronium 10 mg additionally. Surgery was finished without any problems 95 minutes after thereafter. TOF ratio was 45% and we administered sugammadex 3 mg · kg-1, reversing neuromuscular blockade to TOF ratio 100% within 1.5 minute. The patient awoke clearly and respiratory condition was good. He was extubated without remaining neuromuscular blockade. Postoperative course was stable and there was no serious adverse effect on his muscular function intra- and post-operatively. In conclusion, rocuronium and sugammadex can be used safely and effectively in general anesthetic management for patients with muscular dystrophy. However, as the onset times and durations of these agents can be longer, we should administer these agents with titration carefully under periodic neuromuscular monitoring.

[Perioperative management of the elderly patients undergoing hip fracture surgical repair under spinal anesthesia--a comparison between bipolar hip prosthesis and open reduction and internal fixation].

BACKGROUND: We investigated the perioperative courses of 129 elderly patients with hip fracture with different types of surgical repair under spinal anesthesia. METHODS: All patients above 80 years of age were divided into the following two groups: bipolar hip prosthesis group (BH group, n = 54) and open reduction and internal fixation group (OR group, n = 75). We examined their perioperative courses retrospectively using medical and anesthetic records. RESULTS: No significant differences were observed between two groups in pre- and postoperative complications; hemodynamics, oxygenation and amount of bleeding during surgery; perioperative blood transfusion and postoperative 1-month morbidity. Only the final morbidity of OR group was significantly higher than that of BH group (10.7% vs. 0%). However, perioperative course was almost stable in both groups. CONCLUSIONS: Although the elderly patients with hip fracture have several pre- and postoperative complications, it is likely that they can fare well during perioperative period under spinal anesthesia regardless of the type of surgical repair.

Snail expression is associated with a poor prognosis in malignant pleural mesotheliomas.

BACKGROUND: Malignant pleural mesotheliomas (MPMs) are aggressive tumors with a poor prognosis. We aimed to clarify the mechanisms of epithelial-to-mesenchymal transition (EMT) in MPMs by analyzing the expressions of EMT-associated transcription factors and E-cadherin in relation to tumor proliferation rates and patient survival. METHODS: One hundred nine patients with MPMs were investigated. Among these patients, there were 61 epithelioid tumors, 21 sarcomatoid tumors, 20 biphasic tumors, and 7 desmoplastic tumors. Immunohistochemical analyses were performed to evaluate the expressions of Snail, ZEB1, Twist, E-cadherin, and the Ki-67 proliferation index. RESULTS: The expressions of Snail and ZEB1 were significantly higher in the nonepithelioid tumors than in the epithelioid tumors (p<0.0001 and p=0.0051, respectively). Furthermore, the E-cadherin expression was significantly lower in the Snail-high tumors than in the Snail-low tumors (p=0.0423). The E-cadherin expression was significantly lower in the nonepithelioid tumors than in the epithelioid tumors (p=0.0126). The Ki-67 proliferation index was significantly higher in the nonepithelioid tumors than in the epithelioid tumors (p=0.025). Patient survival was significantly lower in patients with Snail-high MPMs than in those with Snail-low MPMs (p=0.0016), especially in patients with nonepithelioid tumors (p=0.0089). The multivariate analysis also demonstrated that nuclear Snail expression was a significant predictor of poor prognosis in patients with MPMs (p=0.0142). CONCLUSIONS: The Snail expression is associated with EMT and a poor prognosis in MPMs. Snail could be a potential molecular target for the treatment of patients with MPMs.

[A case of ventilation disorder and poor oxygenation after changing position from prone to supine].

A 68-year-old obese woman (BMI 35) underwent posterior lumbar interbody fusion in prone position. Immediately after changing position postoperatively from prone to supine, severe ventilation disorder and poor oxygenation occured. Chest X-ray showed severe atelectasis. Poor oxygenation was suspected to be the result of the atelectasis by the pressure of massive abdominal fatty tissue to the diaphragm. Ventilation disorder was suspected of the bronchospasm associated with inadequate anesthesia. We ventilated her manually with a bag in Fowler position for twenty minutes, and then mechanically by pressure controlled ventilation. She recovered gradually. It is concluded that in obese patients undergoing operation in prone position, changing position should be done very carefully during adequate anesthesia, understanding respiratory physiology in positioning and considering the effect of the abdominal fatty tissue to the diaphragm.

Higher expression of receptor tyrosine kinase Axl, and differential expression of its ligand, Gas6, predict poor survival in lung adenocarcinoma patients.

BACKGROUND: Downstream activation through receptor tyrosine kinases (RTKs) plays important roles in carcinogenesis. In this study, we assessed the clinical involvement of Axl, an RTK, and its ligand, Gas6, in surgically treated lung adenocarcinoma. METHODS: Axl and Gas6 mRNA and protein expression levels were quantified using quantitative real-time polymerase chain reaction and immunohistochemistry, respectively, in completely resected lung adenocarcinoma tissues (n = 88) and were evaluated for correlation with clinicopathologic features and patient survival. RESULTS: Higher expressions of Axl mRNA/protein and Gas6 protein were significantly related to worse clinicopathological features and prognosis (5-year overall survival rates: Axl mRNA low: 72.3 %, high: 49.7 %, P = 0.047; Axl protein low: 77.5 %, high: 38.6 %, P < 0.001; and Gas6 protein low: 70.5 %, high: 48 %, P = 0.042). On the contrary, higher Gas6 mRNA expression was related to better clinicopathological features and prognosis (5-year overall survival rates: Gas6 mRNA low: 59.2 %, high: 81.8 %, P = 0.054). Multivariate analysis suggests that high Axl mRNA expression may be an independent factor for poor patient prognosis (P = 0.04). CONCLUSIONS: In lung adenocarcinoma, Axl and Gas6 expression levels were associated with tumor advancement and patient survival, thus rendering them as reliable biomarkers and potential targets for treatment of lung adenocarcinoma.

Intratumoral Wnt2B expression affects tumor proliferation and survival in malignant pleural mesothelioma patients.

Malignant pleural mesothelioma (MPM) is an aggressive thoracic tumor with a poor prognosis. We performed a comprehensive clinical study on the intratumoral expression of Wnt1, Wnt2B and Wnt5A in MPM. One hundred and seven MPM patients were investigated. Immunohistochemistry was performed to evaluate the intratumoral expression of Wnt1, Wnt2B, Wnt5A, survivin and c-Myc, and the Ki-67 proliferation index. The apoptotic index was evaluated by the TUNEL method. Among the 107 MPMs, 23 MPMs (21.5%) were Wnt1-high tumors, 72 MPMs (67.3%) were Wnt2B-high tumors and 54 MPMs (50.5%) were Wnt5A-high tumors. There was no correlation among the levels of Wnt expression. The percentage of Wnt2B-positive tumors was significantly higher compared to that of the other Wnts (p<0.0001). Furthermore, intratumoral Wnt2B expression significantly correlated with the expression of survivin (p<0.001) and c-Myc (p<0.001). Regarding tumor biology, the Ki-67 proliferation index was significantly higher in the Wnt2B-high tumors than in the Wnt2B-low tumors (p=0.0438). In addition, the overall survival was significantly lower in patients with Wnt2B-high tumors than in those with Wnt2B-low tumors (p=0.0238). A Cox multivariate analysis also demonstrated the Wnt2B status to be a significant prognostic factor in MPM patients (p=0.0042). Intratumoral Wnt2B expression was associated with the expression of survivin and c-Myc, tumor proliferation and patient survival in MPM. Wnt2B is a potential molecular target for the treatment of Wnt2B-overexpressing MPMs.

[Evaluation of motor block of the lower legs in continuous lumbar epidural infusion of ropivacaine].

BACKGROUND: Continuous epidural infusion of ropivacaine is commonly used for postoperative analgesia because of its motor-sparing properties. But there are a few patients whose motor block of the lower legs is prolonged. The aim of this study is to investigate the effect of low density ropivacaine regarding motor block of the lower legs when administered continuously into the lumbar epidural space. METHODS: All patients were randomly divided into following three groups. Ropivacaine 0.2% was administered after spinal anesthesia (0.2%S group, n=24). Ropivacaine 0.2% was administered after epidural anesthesia (0.2%E group, n=37). Ropivacaine 0.1% was administered after epidural anesthesia (0.1%E group, n=20). We measured the effect of motor block of the lower legs by Bromage scale after postoperative 7 and 19 hours. RESULTS: The motor block was significantly stronger and the duration was more prolonged in order of 0.2%S group, 0.2%E group, and 0.1%E group. CONCLUSIONS: For avoiding prolongation of motor block of the lower legs in continuous lumbar epidural infusion for postoperative analgesia, 0.1% ropivacaine would be better than 0.2%. We should pay attention to the fact that the use of ropivacaine after spinal anesthesia prolongs and increases motor block of the lower legs.

[Case in which massive hydroxyethylated starch (HES) infusion was useful for massive hemorrhage in spite of progressive hemodilution].

A 72-year-old man with no internal complication underwent total prostatectomy. During operation, massive hemorrhage occurred. Because of delay in transfusion, hemodilution progressed until minimum hemoglobin concentration of 1.6 g x dl(-1): minimum hematocrit of 4.8%. In spite of this extreme hemodilution, we could stabilize his hemodynamics and he recovered without any apparent damage in major organs. For management of hemodynamics a massive dose of hydroxyethylated starch (HES) was infused to maintain the intravascular volume. For massive hemorrhage, HES infusion may be useful to keep hemodynamics in spite of progressive hemodilution.

Higher expression of EphA2 and ephrin-A1 is related to favorable clinicopathological features in pathological stage I non-small cell lung carcinoma.

BACKGROUND: The overexpression of receptor tyrosine kinase EphA2 has been reported in various cancers. In non-small cell lung cancer (NSCLC), a positive correlation has been reported between high EphA2 immunohistochemical staining level and poor prognosis. However, its ligand, ephrin-A1, is supposed to act as a tumor suppressor via the kinase activity of EphA2. Thus, the biphasic roles of this system are not fully elucidated. We retrospectively evaluated the expression levels of EphA2 and ephrin-A1 in surgically treated pathological (p-) stage I NSCLC tumor samples, and their relation to clinicopathologic features or postoperative prognoses. METHODS: The levels of EphA2 and ephrin-A1 mRNA expression were quantified by real-time reverse-transcription polymerase chain reaction in tissue samples from p-stage I NSCLC patients who had undergone complete resection in our facility (n=195). They were divided into two (EphA2/ephrin-A1-Low and -High) groups based on the median expression level, and their respective clinicopathologic features and prognoses were analyzed. Furthermore, samples were stained immunohistochemically and classified into four groups according to their staining levels, and their prognoses analyzed. RESULTS: Marked demographic differences were found between EphA2/ephrin-A1-Low and -High groups. Both EphA2-High and ephrin-A1-High groups had more females, no smoking history, adenocarcinoma histology, well-differentiated carcinomas, p-stage IA patients, and patients with EGFR gene mutations. Five-year overall survival rates of the EphA2-Low and the EphA2-High patient groups were 68.9% and 86.1%, respectively (P=0.017), and five-year disease-free survival rates were 69.9% and 83.2%, respectively (P=0.035). There were no statistical differences between ephrin-A1-Low and ephrin-A1-High groups concerning postoperative survival. Although showing smaller differences, the findings from the immunohistochemical analyses supported the above results. CONCLUSIONS: Higher expression of EphA2 and ephrin-A1 was more related to the female sex, reduced smoking status, adenocarcinoma, well differentiated carcinomas, p-stage IA, and EGFR gene mutations. Higher EphA2 mRNA expression in p-stage I NSCLC patients was positively related to improved prognoses. These results may reflect a tumor suppressive role for the EphA2/ephrin-A1 system in a population of patients restricted to p-stage I NSCLC.

Expression of IGF1R is associated with tumor differentiation and survival in patients with lung adenocarcinoma.

PURPOSE: The insulin-like growth factor 1 receptor (IGF1R) is widely expressed in normal tissues and many malignancies in humans. We investigated the clinical significance of the expression of the IGF1R gene in human lung adenocarcinoma. METHODS: A total of 238 patients with lung adenocarcinoma were investigated. Quantitative real-time reverse-transcription polymerase chain reaction (RT-PCR) assays were performed to evaluate the gene expression of IGF1R, and immunohistochemical staining was done to evaluate the protein expression of IGF1R. RESULTS: Among the 238 patients with lung adenocarcinoma, 107 tumors (45.0%) were IGF1R-low and 131 tumors (55.0%) were IGF1R-high. The IGF1R gene expression ratio was significantly lower in moderately to poorly differentiated adenocarcinomas than in well-differentiated adenocarcinomas (P = 0.0388). Gene expression of IGF1R was significantly correlated with protein expression of IGF1R (r = 0.7163, P < 0.0001). Regarding patient survival, overall survival was significantly lower in patients with IGF1R-low tumors than in those with IGF1R-high tumors (63.2% versus 76.1% 5-year survival, P = 0.0188). Multivariate analysis using a Cox proportional-hazards model demonstrated that IGF1R gene status was a significant prognostic factor predicting overall survival of patients with lung adenocarcinoma (hazard ratio 1.800; P = 0.0321). Moreover, the disease-free survival rate was significantly lower in patients with IGF1R-low tumors than in those with IGF1R-high tumors (49.2% versus 64.6% 5-year survival, P = 0.0084). CONCLUSION: The present study suggests the level of IGF1R expression to be a useful prognostic marker for patients with dedifferentiated lung adenocarcinoma.

Malignant melanoma of the lung: report of two cases.

Malignant melanoma (MM) is the most fatal cutaneous neoplasm. Primary MM of the lung is quite rare, and late recurrence of MM is also uncommon. We report 2 cases of pulmonary MM, the first involving primary MM of the lung and the second involving late recurrence 8 years after the initial surgery. Bronchoscopic punch biopsy identified MM in both cases. In the first case, work-up of the patient did not reveal any anomalies other than those in the primary site. In the second case, the patient had a history of thumb amputation for MM 8 years ago. For pulmonary MM, extrapulmonary origin of the tumor must be excluded by detailed examination because melanomas involving the lung are almost always metastatic. Whether the diagnosis is primary or metastatic disease, the potential for recurrence should be considered even in patients with a long disease-free survival.