[Techniques and arts of mediastinal lymph nodes dissection for lung cancer].

The outcomes ofhe operations for the lung cancer depends on the quality of the hilar and mediastinal lymph nodes dissection. Especially in the mediastinal lymph nodes dissection, techniques and arts are indispensable for reliable and promising results in the lung cancer surgery. The essence of procedures of mediastinal lymph nodes dissection are as follows, ( ystematic and sharp lymph nodes dissection as a group, precise and perfect removal of lymph nodes with adjacent fatty tissues based on the anatomical structures, retrograde lymph nodes dissection from the view point of prevention of lymph node metastasis and consequent distant metastasis. Satisfactory and confidential lymph nodes dissection requires attentive assistance of the coworker-surgeons providing good fields of vision. Nowadays minimally invasive approaches by means of thoracoscopic techniques are considered to be smart and welcomed widely in the current thoracic surgery. However, essential for the lung cancer surgery is trying to choose between the operability of radical operation and the degree of minimal invasion. According to a standard rule of ND2a lymph nodes dissection, procedures of upper and middle mediastinal lymph nodes dissection under postero-lateral thoracotomy are summarized.

[Median approach for the right upper lobe lung cancer patient with impaired pulmonary function].

We report the usefulness of a median approach to the right upper lobe lung cancer with impaired pulmonary function. Patient was a 68-year-old man with chronic obstructive pulmonary disease and primary right upper lobe (S1) lung cancer with suspected anterior mediastinal invasion (cT4N0M0). Thoracoscopy excluded mediastinal invasion, but a median sternal incision was made to avoid injuring respiratory muscles and postoperative respiratory complications. We successfully performed systematic mediastinal lymph node dissection (ND2a) after right upper lobectomy. The patient was discharged on the 10th postoperative day without any events. He eventually underwent additional chemotherapy because of the liver metastasis confirmed at 8 months after the operation. In right upper lobe lung cancer patients with impaired pulmonary function, a median approach seems useful for intraoperative respiratory management and the sparing of respiratory muscles which will reduce the possibility of postoperative respiratory complications.

[Surgical approach for histopathological determination of anterior mediastinal malignant lymphoma].

In a retrospective review of all patients who admitted our hospital between January 1992 and December 2006, we identified 9 with anterior mediastinal malignant lymphoma. They represented 6.8% of the 133 patients with mediastinal tumor. Histology revealed 3 cases of primary mediastinal large B-cell lymphoma, 2 of Hodgkin lymphoma, 2 of precursor T-lymphoblastic lymphoma and 2 of thymic extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma. Careful attention should be paid to the relatively high incidence of malignant lymphoma in the anterior mediastinal tumors. It is highly important to differentiate of malignant lymphoma from other diseases that shape anterior mediastinal tumor to avoid unnecessary operation. Early and accurate diagnosis of these tumors is also important because some of these patients require immediate treatment by hematology specialists.

[Congenital bronchoesophageal fistula in an adult; an undiscribed mechanism of symptom tolerance].

We present a case of a congenital bronchoesophageal fistula in a 61-year-old woman. She was referred to hospital because of postprandial heart burn. Three-dimensional (3D) computed tomography (CT) demonstrated an anastomosis between her right intermediate bronchus and esophagus. In spite of direct communication between her bronchus and esophagus, she has never suffered severe infection. We visualized the orifice of fistula closed with mucosal flap in swallowing by means of a bronchofiberscope. The delay of a diagnosis was explained by symptom tolerance. Some theories as to the symptom tolerance are found in literatures, but we supposed to find an undiscribed mechanism; closure of the orifice in swallowing. The fistula was surgically closed.

[Pulmonary staple granuloma mimicking lung cancer; report of a case].

A 67-year-old man was referred to our hospital with chief complaints of bloody sputum and an abnormal chest shadow. He had a history of chronic renal failure and surgery for right pneumothorax. During dialysis treatment 2 years ago, an examination revealed a mass shadow with spiculation in the apex of the right lung. Subsequently, he noted bloody sputum, and the shadow became larger. Serum Progastrin-releasing-peptide (GRP) levels remained within the range of 70-80 pg/ml at the previous clinic, but were elevated to 109 pg/ml on admission to our hospital. These findings suggested lung cancer developing around the scar due to pneumothorax surgery, and we performed an operation. The resected tumor was a granuloma formed around a staple with a polytetra-fluoroethylene (PTFE) sheet, showing no evidence of malignancy. The patient's postoperative course was uneventful, and the serum Pro-GRP level fell to 60 pg/ml.

[Pulmonary actinomycosis developing diffuse phregmone after pneumonectomy].

The patient was a 75-year-old male who consulted the department of respiratory tract internal medicine in our hospital for left chest pain occurring from the beginning of December 2003. Chest X-ray indicated a tumorous shadow in the left lower lung field. A chest CT also revealed an irregularly shaped mass shadow in the left lower lobe. Since bronchoscopy failed to establish a definitive diagnosis, the patient was referred to our department for surgery to undertake thoracotomy. After left pneumonectomy being performed based on a suspicion of lung abscess, pathological examination of specimen from the resected left lung showed sulfur granules which led to the diagnosis of pulmonary actinomycosis. Because of the diffuse phregmone developing around the surgical wound, benzylpenicillin potassium administration was started, and was continued for a further 6 months on an outpatient basis. Pulmonary actinomycosis is a relatively rare chronic pulmonary infection. It is often difficult to distinguish pulmonary actinomycosis from other pulmonary disease such as lung cancer because of the similarity of their appearance on X-ray or CT, and almost all cases of pulmonary actinomycosis are diagnosed by thoracotomy.

[Large cell carcinoma with chest wall infiltration combined with contralateral giant bulla].

A 48-year-old male consulted the department of respiratory medicine for right precordial pain occurring from the beginning of May 2004. Chest X-ray indicated a tumorous shadow in the right upper lung field and a large left lung cyst. Although chest wall infiltration was suspected based on computed tomography (CT) demonstrating a mass lesion in the right S2, there was no significant swelling of the mediastinal lymph node. On the left side, the lung was markedly compressed by a large cyst in the left upper lobe. Since bronchoscopy failed to establish a definitive diagnosis, the patient was referred to our department for surgery based on a suspicion of malignant pulmonary tumor. Considering both the risk of perioperative complications due to the left cystic lesion at surgery for right lung lesion and the improvement of respiratory function by removing cystic lesion of the left lung, the left side operation was preceded by the right side. Although postoperative examinations of respiratory function did not demonstrate any particular improvement, the results of selective right pulmonary artery obstruction test supported the possibility of pulmonary lobectomy. Therefore, the right upper lobectomy and ND 2a mediastinal dissection combined with chest wall resection was subsequently performed. Postoperative pathological diagnosis revealed that the tumor was a stage IIB large cell carcinoma of pT3N0M0 with costal infiltration.

[Diplopia and blepharoptosis associated with orbital emphysema following thoracotomy with lung cancer; report of a case].

BACKGROUND: Orbital emphysema is a common complication of trauma and fracture of orbital bones. However, subcutaneous emphysema also can rarely lead to orbital emphysema. We reported the clinical and radiological findings in a patient with diplopia and blepharoptosis following thoracotomy for lung cancer. CASE: A 76-year-old man had undergone left inferior lobectomy and ND 2 a in October 2002, based on the clinical diagnosis of stage IB lung squamous cell carcinoma. He presented with diplopia and blepharoptosis several days following thoracotomy. Chest X-ray demonstrated extensive subcutaneous emphysema, and physical examination also revealed diffuse subcutaneous emphysema including face and palpebrae. Head computed tomography (CT) revealed subcutaneous emphysema in the infratemporal fossa bilaterally. His diplopia and blepharoptosis gradually resolved, and he was discharged with no visual complaints on the fourteenth postoperative day. CONCLUSIONS: Subcutaneous emphysema can lead to diplopia and orbital emphysema in the absence of orbital trauma. Early surgical intervention for air leakage is highly recommended to avoid both the orbital emphysema and the visual complications in the event that subcutaneous emphysema should get to including face or palpebrae.

[Conservative therapy for recurrent bronchial stump fistula occurred after surgery for lung cancer with cerebrovascular disease].

BACKGROUND: Although pyrothorax caused by bronchial stump fistula is 1 of the most severe respiratory complications frequently encountered after surgery for lung cancers, it is very difficult to prevent the development of pyrothorax. However, conservative treatment for bronchial stump fistula occurred after surgery for lung cancer was successfully performed in 1 of our elderly lung cancer patients with a history of cerebrovascular events. CASE: Patient was a 74-year-old man who developed cerebral infarction in October 2000, and was continuously undergoing rehabilitation for left hemiplegia. Chest computed tomography (CT) demonstrated a tumorous lesion in the right S6. Clinical diagnosis of stage IA squamous cell carcinoma was made. His performance status (PS) was degree IV, and he required complete assistance. In addition, since several abnormal florae were detected by preoperative examinations of sputum, the development of postoperative respiratory complications was suspected. In April 2001, thoracoscopy-assisted right inferior lobectomy and nodal dissection 1 (ND 1) were performed. Although the patient developed bronchial stump fistula on the 6th hospital day, it was successfully treated by conservative procedures after second surgery. CONCLUSION: Conservative therapy under nutritional management mainly consisting of central venous nutrition may be useful for some surgically treated lung cancer patients with bronchial stump fistula when they have mild inflammation and the reduction of pyrothorax cavity can be expected by re-expansion of the residual lobes of the lung.

The chemotactic effect of a dermal papilla cell-derived factor on outer root sheath cells.

The effect of cultured normal human dermal papilla cells (DPCs) and conditioned medium prepared with cultured DPCs on chemotactic migration of human hair outer root sheath cells (ORSCs) was examined quantitatively. ORSCs showed significantly increased migration toward both cultured DPCs and the conditioned medium suggesting that DPCs produce and secrete a paracrine factor(s), which attracts hair follicle epithelial cells. Some soluble factors, which are reportedly produced by DPCs, such as insulin-like growth factor-I (IGF-I), hepatocyte growth factor (HGF), vascular endothelial cell growth factor (VEGF), and transforming growth factor-beta1 (TGF-beta1), were also examined. ORSCs showed dramatically increased migration toward IGF-I and HGF at concentrations of 1-10 ng/ml. On the other hand, neither VEGF nor TGF-beta1 showed any effect on the chemotaxis of ORSCs. It is interesting that all factors involving mitogenic activity did not always have chemotactic activity for ORSCs. This is the first report to establish that IGF-I and HGF have not only a growth stimulatory but also a chemotactic effect on ORSCs. In addition, the method presented here may help to simplify chemotaxis assays of any type of epithelial keratinocytes with poor mobility.

Wall correction factors for calibration of plane-parallel ionization chambers with high-energy photon beams.

Most dosimetry protocols recommend that calibration of plane-parallel ionization chambers be performed in an electron beam of sufficiently high energy by comparison with cylindrical chambers. For various plane-parallel chambers, the 1997 IAEA TRS-381 protocol includes an overall perturbation factor pQ for electron beams, a wall correction factor p(wall) for a 60Co beam and the product of two wall corrections k(att)k(m) for 60Co in-air calibration. The recommended values of p(wall) for plane-parallel chambers, however, are limited to certain phantom materials and a 60Co beam, and are not given for other phantom materials and x-ray beams. In this work, the p(wall) values of the commercially available NACP, PTW/Markus and PTW/Roos plane-parallel chambers in a solid water phantom have been determined with 60Co and 4 and 10 MV photon beams. The k(att)k(m) values for the NACP and PTW/Markus chambers have also been obtained. The wall correction factors p(wall) and k(att)k(m) have been determined by intercomparison with a calibrated Farmer chamber. The average value of p(wall) for these plane-parallel chambers was 1.005 +/- 0.1% (1 SD) for 60Co beams and 1.007 +/- 0.2% (1 SD) for both 4 MV and 10 MV photons. The k(att)k(m) values for the NACP and PTW/Markus chambers were about 1.5% lower than other published data.

Cerebriform intradermal nevus: a case of scalp expansion on the galea.

We report here a 7-year-old Japanese girl with cerebriform intradermal nevus (CIN). By placement of expanders on the galea, her scalp was expanded more easily with less discomfort than is expected when the expanders are placed under the galea. An immunohistochemical study on the expression of proliferating cell nuclear antigen suggested higher proliferative activity of nevus cells from the CIN lesion than that of cells from congenital or acquired intradermal nevi. The high proliferative activity appeared to be associated with a growth spurt of the lesion.

Sintered bone implantation for the treatment of benign bone tumours in the hand.

We report the results of treatment of benign bone tumours in the hand with curettage and sintered bone implantation using bovine sintered bone (True Bone Ceramics). There were 22 patients who underwent sintered bone implantation in our department in 1984 or later. The follow-up survey period varied from 9 months to 11 years and 2 months (mean, 5.8 years). Recurrence of tumours and complications such as infection or fracture were not observed, and there were no clinical symptoms. X-rays revealed new bone formation connecting the implanted blocks to bone. Sintered bone was not absorbed, and lucent zones around the implants or other abnormal findings were not observed. Bone union was achieved in all patients who had pathological fractures before surgery.

[Clinical evaluation of kampo medication, mainly with wen-pi-tang, on the progression of chronic renal failure].

Previous studies have shown that Kampo (traditional Chinese) prescriptions, mainly Wen-Pi-Tang (Onpi-to, [symbol see: text]), have a useful effect in patients with chronic renal failure (CRF). We aimed to examine the long-term effect of Kampo prescriptions on serum creatinine (Cr) among patients with CRF. Patients with serum Cr levels of 2 mg/dl more were enrolled if they had at least 4 recordings of serum Cr in the previous 6 months or more, and were followed-up until the start of dialysis. Eight patients aged 24-59 years with serum Cr 4.5 mg/dl were enrolled in the study for 40 to 402 weeks (mean; 228.1 +/- 118.8 weeks). The cause of CRF was chronic glomerulonephritis in 7 patients and systemic lupus erythematosus in 1 patient. The end points of the study were the slope of the reciprocal of the serum Cr concentration plot against time using Mitch's method, and the predicted period of pre-dialysis. The predicted pre-dialysis period was defined as an increase in serum Cr by 10 mg/dl. As a result, the individual slopes were improved in 6 of 8 cases, in particular, in 4 of 5 Wen-Pi Tang-treated cases. The average slope was improved significantly (p < 0.01) in Wen-Pi-Tang-treated cases, although it showed only a tendency to improve in all 8 cases. The predicted pre-dialysis period was prolonged from 79.2 +/- 74.8 weeks to 389.5 +/- 355.4 weeks and 55.6 +/- 37.0 weeks to 262.4 +/- 145.8 weeks in all 8 cases and Wen-Pi-Tang-treated cases, respectively. The observed pre-dialysis period was 228.1 +/- 118.8 weeks, which showed that Kampo prescriptions prolonged the predicted period for 186 additional weeks. In conclusion, this study demonstrated that the Kampo prescriptions, consisting mainly of Wen-Pi-Tang, retarded the progression of CRF.

Changes in the extracellular matrix on the surface of sintered bovine bone implanted in the femur of a rabbit: an immunohistochemical study.

The interface of implanted True Bone Ceramics (TBC; sintered bovine bone; Koken, Tokyo, Japan) was examined. In the primary experiment, TBC was implanted into the bone marrow of a rabbit's femur. The extracellular matrices (types I, II, and III collagens and fibronectin) of decalcified specimens collected 1-48 weeks postoperatively were immunohistochemically examined. Undecalcified sections collected 6 weeks postoperatively were used for line analyses of calcium and phosphorus, by a scanning electron microscope-electron probe microanalysis (SEM-EPMA) method. In a secondary experiment, TBC was implanted into an osteochondral defect of a femoral condyle, harvested 1-12 weeks postoperatively, and decalcified to examine the extracellular matrices at the interface. In the bone marrow in the early phase, TBC had absorbed quantities of fibronectin. Immature bone (containing both types I and III collagens) in direct apposition to the ceramic surface had matured (containing type I collagen alone) in the TBC pores. SEM-EPMA revealed the continuity of high levels of calcium and phosphorus at the TBC-bone interface. In the secondary experiment, enchondral ossification or fibrous tissue formation was observed near the articular surface. However, in the subchondral layer, direct bone formation was observed in the TBC pores. It was concluded that TBC has excellent bioactivity for inducing maturation of new bone matrix on porous surfaces.

Immunohistochemical localization of thyroid hormone nuclear receptors in human hair follicles and in vitro effect of L-triiodothyronine on cultured cells of hair follicles and skin.

To investigate the cellular basis of the action of thyroid hormone on hair follicles, we studied the immunohistochemical localization of thyroid hormone receptors (TRs) in human scalp skin using a mouse monoclonal antibody, TR alpha 1 (C4) against TRs. Immunoreactive TRs were detected in the nuclei of the outer root sheath cells (ORSCs), dermal papilla cells (DPCs), fibrous sheath cells of hair follicles, hair arrector pili muscle cells and sebaceous gland cells. However, nuclei of hair matrix cells were not clearly stained with TR alpha 1 (C4). The epidermis showed positive nuclear staining by the antibody. Ductal and secretory portions of eccrine sweat glands were also stained with the antibody as we had expected. In the dermis, almost all the cell components including fibroblasts, vascular endothelial and smooth muscle cells, and Schwann cells were positively stained. Immunofluorescence also showed TRs expression in cultured ORSCs, DPCs, epidermal keratinocytes and dermal fibroblasts. L-triiodothyronine stimulated the proliferation and/or metabolism of all these four types of cells significantly, although there was variation at the rate of stimulation. Whereas, structurally similar, but metabolically inactive analog, reverse T3 had no effect. These results demonstrate the presence of thyroid hormone nuclear receptors in human hair follicles. Furthermore, the presence of TRs in different cell types in the skin suggests numerous direct effects of thyroid hormone on this target tissue.

Proof that green tea tannin suppresses the increase in the blood methylguanidine level associated with renal failure.

The effects of a green tea tannin mixture and its individual tannin components on methylguanidine were examined in rats with renal failure. The green tea tannin mixture caused a dose-dependent decrease in methylguanidine, a substance which accumulates in the blood with the progression of renal failure. Among individual tannin components, the effect was most conspicuous with (-)-epigallocatechin 3-O-gallate and (-)-epicatechin 3-O-gallate, while other components not linked to gallic acid showed only weak effects. Thus, the effect on methylguanidine was found to vary among different types of tannin.