[Primary lung cancer protruding into right main bronchus, successfully treated with endoscopic neodymium yttrium aluminum garnet (Nd-YAG) laser].

Endoscopic neodymium yttrium aluminum garnet (Nd-YAG) laser treatment for endobronchial obstruction originating from the tumor provides a favorable outcome. A 67-year-old male patient with a chief complaint of cough and sputum had a primary lung cancer (squamous cell carcinoma) in the upper lobe of the right lung. The tumor projected into the right main bronchus through the upper lobe bronchus, which completely occluded the lumen of right main bronchus. Middle and lower lobes showed an obstructive pneumonia caused by its obstruction. Firstly, endoscopic Nd-YAG laser treatment for patency of right main bronchus was preoperatively performed with an aim to early improvement of obstructive pneumonia Since the inflammatory findings showed markedly improvement, a right upper sleeve lobectomy could safely be performed. The resected specimen of the tumor in the right upper lobe proved to be a case of complete resection with pathological stage IIIA (T3N1M0). When preoperative lung cancer patient has an obstructive pneumonia causing by the protruding tumor into the central airway, a patency treatment of bronchial airway using endoscopic Nd-YAG laser may lead to decrease a perioperative risk.

Bacteriological characteristics of Staphylococcus aureus isolates from humans and bulk milk.

The aim of this study was to clarify the epidemiological association and bacteriological characteristics of human and animal Staphylococcus aureus isolates. Pulsed-field gel electrophoresis showed that pulsotypes (PT) of isolates from bulk milk differed from PT from human isolates, suggesting that there is no epidemiological association between isolates from these 2 sources. The absence of a common PT could result from the lack of contact between the sources. Methicillin-resistant S. aureus from human secretions and S. aureus from bulk milk in Japan consisted of 1 and 2 dominant clusters, respectively, whereas methicillin-susceptible S. aureus from humans consisted of assorted clusters. Isolates belonging to the dominant clusters showed the coagulase serotype, the capsule serotype, detection of exotoxin genes, and antimicrobial susceptibility. Isolates from bulk milk did not show the penicillin-binding protein 2a gene, and 252 of 275 isolates belonging to the 2 dominant clusters of bulk milk were susceptible to ampicillin, cefazolin, erythromycin, chloramphenicol, oxacillin, and vancomycin. Moreover, the LukM/LukF'-PV leukotoxin gene was detected in 233 of 275 isolates belonging to the dominant clusters in bulk milk isolates. These results support the hypothesis that a number of factors play a role in the adaptation of S. aureus isolates to specific hosts.

[Surgical treatment for clinical stage II and III small cell lung cancer patients].

To evaluate a surgical resection in multidisciplinary treatment for clinical stage (c-stage) II and III small cell lung cancer (SCLC) patients, we examined the postoperative prognosis concerning in 18 patients who underwent complete surgical resection. Five-year survival rate of 8 c-stage II and 10 c-stage III patients showed 62.5% and 46.7%, respectively. Of these, 7 patients underwent preoperative induction chemotherapy resulting in down-staging to c-stage 0-I, and their survival rate at 5 years after sugery was as good as 68.6%. However, in 4 (57.1%) of 7 patients, tumor cells proved to be alive by pathological assessment of lymph nodes. As a consequence, it was suggested that surgery for c-stage II and III SCLC patients is a meaningful treatment considering their prognoses. In particular, even though the patients show a favorable response of preoperative chemotherapy, to completely eliminate remnant tumor cells, a surgical resection may be necessary.

[A case of idiopathic subglottic stenosis successfully treated with endoscopic laser treatment].

A 24-year-old woman presented with an abnormal sound in her neck. She had no history of previous surgery, endotracheal intubation or neck trauma. She had been aware of this abnormal sound since she was 12 years old, but paid no attention to it. She had been recommended to visit a hospital for a neck examination. Stridor was heared in the neck ["coming from the throat"?]. Peak flow was markedly suppressed in pulmonary function tests, and the flow volume loop indicated upper airway stenosis. Bronchoscopy revealed subglottic tracheal stenosis, and magnetic resonance imaging showed that the cricoid cartilage was normal. Nd-YAG laser treatment was performed in Mitsui Memorial Hospital and her symptoms were improved. Biopsy of the stenotic area of the trachea showed dense fibrous tissue proliferation in the submucosa. Neither granuloma nor vasculitis was found in the biopsy specimen. No systemic disease capable of inducing tracheal stenosis was found on systemic examination. From these clinical and pathological findings, we diagnosed idiopathic subglottic stenosis.

Activation of cyclin D1-related kinase in human lung adenocarcinoma.

Cyclin D1 gene amplification is an important event in many cancers, but it is rarely found in non-small-cell lung cancer (NSCLC). This study was conducted in an attempt to clarify any other mechanisms related to cyclin D1 involvement in the malignant transformation of NSCLC, and we clearly showed for the first time that cyclin D1-related kinases are activated in NSCLC, especially in adenocarcinoma but not in squamous cell carcinoma. The results of this study strongly suggest that enhanced cyclin D1-related kinase activity could contribute to a progression of adenocarcinoma in NSCLC.

[Investigation of factors affecting psychological depression in child-rearing mothers].

Child-rearing mothers (n = 1,459) were surveyed by questionnaire in regard to their feeling psychologically depressed and for prevalence of some conditions in their life frequently referred to as affecting factors that may be rated to the depression. A working scale of depression for this research was developed through a Multi Dimensional Scaling Procedure. Crobach's alpha of this scale was as large as 0.77 and correlational coefficients of this scale between each question were greater than 0.46 and less than 0.70. This scale was considered sufficient for the purpose of this research to obtain depressive scores. Coefficients in multiple regression analysis predictive for depressive score were obtained. Correlations were also calculated between depressive score and the factors stratifying by mothers' demographic factors. Out of a total 21.6 coefficients only 14 were greater than 0.30 and no factor showed coefficients greater than 0.80 through all the stratifications. None of the factors analyzed in this study appear to satisfactorily explain psychological depression. Therefore further search for real factors that affect the psychological depression in child-rearing mothers is required.

[Surgical treatment of N2 involved non-small cell lung cancer--the systematic extended lymph node dissection based on the regional lymphatic drainage].

From the study on regional lymphtic drainage, we have decided the extent of lymphadenectomy as follows; a) For the left lung cancer and the right upper lobe primary, systematic bilateral mediastinal dissection (R3 alpha) through a median sternotomy, b) For the cases with the highest mediastinal node involvement, lower half of radical neck dissection (R3 gamma) through a cervical collar incision in addition to a). The cN diagnosis by CT interpretation and pN diagnosis were compared. The under estimated rates of N were 32% of 137 patients with the left lung primary. 46 patients with pN2(+) included 14 patients (31%) with pN3 disease. As for the right upper lobe primary, 17 patients with pN2(+) included 13 patients (76%) with pN3 disease. Postoperative survival rates calculated with Kaplan-Meiermethod; 1) The five-year survival rates were 43% of 46 patients with pT1-3 N2-3 of the left lung primary. 2) As for the right upper lobe primary, the two-year survival rates were 51% of 17 patients with pT1-4 N2-3. 3) The three-year survival rates of 26 patients with pN3 gamma diagnosed as cN0-3 alpha preoperatively were 41%. These systematic extended dissection (R3 alpha, R3 gamma) would bring better prognosis in the patients with pN2-3 disease.

Metastatic cervical carcinoma mimicking kidney abscess.

A 26-year-old female, who had been treated for cervical carcinoma, presented with high fever and right flank pain. A right renal abscess was initially suspected from the clinical symptoms and diagnostic imaging. However, pathologic findings for the right kidney revealed squamous cell carcinoma, which was consistent in type with the original cervical carcinoma. Demonstration of human papillomavirus 16 in tissues from both the renal tumor and the cervical carcinoma confirmed that the right kidney carcinoma was a metastasis from the cervical carcinoma. The role of interleukin-6 in occurrence of the unexplained fever is discussed.

[Prospective study on evaluation of the ischemic heart disease for preoperative patients with lung cancer].

One hundred twenty-four patients with lung cancer undergoing operation in our hospital were prospectively studied on evaluation of the ischemic heart disease before operation. They performed master double electrocardiogram and exercised T1 scintigram before operation. The patient with positive master double electrocardiogram and/or exercised T1 scintigram was taken into high risk group. All patients in high risk group performed coronary angiography. This high risk group consisted of 37 patients (29.8%), including 6 single vessel disease (4.8%), 2 double vessel disease (1.6%), and 1 triple vessel disease (0.8%). Preoperative revascularization was done 8 patients (6.5%). These revascularization patients had uneventful course during and after lung operation. However 2 cases of vasospastic angina (VSA) occurred in non-risk group during operation. It was impossible to anticipate VSA before lung operation in our series. Therefore our preoperative evaluation and care of organic ischemic heart disease was effective in preventing cardiac complications.

[Pleural adenosine deaminase levels in tuberculous pleurisy--its diagnostic performance under the different prevalences in the different age of population].

In the diagnosis of pleural effusion, tuberculous pleurisy should always be considered because the prevalence of tuberculosis in Japan remains high. The measurement of adenosine deaminase (ADA) levels in pleural fluid is useful for the diagnosis of the tuberculous pleurisy because of its high sensitivity and specificity. However, no studies have addressed the post-test probability (= positive predictive value; PPV) of the test. Since the PPV depends on the pre-test probability (= prevalence) of the tuberculous pleurisy that varies with age, we have retrospectively evaluated the PPV in the different age population; the young (-35 years of age), the middle (36-65 years), and the old (66-years). A total of 208 data sets were collected; the tuberculosis (n = 52), malignancy (n = 34), non-specific infection (n = 31), transudates (n = 45), the others (n = 36), and unknown causes (n = 10). It was found that 1) the prevalence of tuberculous pleurisy was decreased with age, (70% in the young, 28.7% in the middle, and 8.5% in the old), 2) the PPV was the lowest in the old (53.8%), while the highest in the young (95.0%), and 3) no significant correlation was found between age and the ADA activity in pleural effusion.

[Prognosis and prognostic factor after extended lymphadenectomy in lung cancer].

From 1984 to 1994, 418 patients were received surgery for the lung cancer in our center. Of them, 178 patients were underwent extended lymphadenectomy. Fifty six of the 178 were histologically proven N2 of N3 alpha disease after surgery. Extended lymphadenectomy means R2b lymphadenectomy including the left tracheobronchial node dissection for the right lung cancer and R3 (bilateral mediastinal lymphadenectomy through a median sternotomy) for the left. In the 56 patients, we examined the location and frequency of metastases to the mediastinal lymph nodes and the relationship between some clinical factors (pT, number of metastatic station, clinical staging of the lymph node (CN), histological type, contralateral mediastinal lymph nodes metastases) and prognosis. Most of the pN2 patients of the right lung cancer showed ipsilateral mediastinal lymph nodes metastases and 25 percent of the patients showed the spread to N2b mediastinal modes. The patients of the left lung cancer showed higher incidence of contralateral mediastinal lymph nodes metastases than the patients of the right lung cancer. The five years survival rate of all pN2 patients (N = 39) was 48%, and T1 or T2-N2 patients (N = 22) was 67%. On the other hand, all T4 N2 patients (N-9) died within 3 years after operation. There was no significant difference in postoperative survival between the patients with single station metastasis (N = 20) and multistation metastases (N = 30, including 11 cases with N3 alpha). The five years survival rate of all the patients with multistation metastases was 45%, and that of T1 or T2 multilevel (N = 20) was 65%. There was significant difference in postoperative survival between the patients with CN0-pN2 and CN2-pN2 (p < 0.05). The five years survival of CN0-pN2 patients (N = 14) was 85% and four years survival rate of CN2 pN2 patients (N = 19) was 30%. Among the patients with T1 or T2 tumor, however, there was no significant differences in postoperative survival between CN0-pN2 patients and CN2 pN2 patients. There was no difference in postoperative survival between adenocarcinoma and squamous cell carcinoma (5 years survival: 56%, 43%). In conclusion, extended lymphadenectomy has brought a good prognosis in the patient with T1 or T2 in spite of presence of CN2 or multistation N2. The patients with contralated mediastinal metastases (N3 alpha) showed good prognosis after R3 (5 years survival: 100%) in the patients with the left lung cancer (N = 6). But the N3 alpha patients of right lung cancer showed poorer prognosis (3 years survival: 30%) after R3 (N = 5) than the left. It suggested that R3 lymphadenectomy was significant and beneficial for the left lung cancer patients with N3 alpha but controversial for the right.

[Investigation into mediastinal lymph node metastasis of lung cancer and rationale for decision of the extent of mediastinal dissection].

UNLABELLED: From the study on the regional lymphatic drainage and investigation into mediastinal lymph node metastasis of lung cancer, we have decided the extent of mediastinal dissection as follows; 1) For right lung cancer, as the routine procedure, extended systematic ipsilateral mediastinal dissection including the left tracheobronchial region, the anterior and the posterior ipsilateral mediastinum through a conventional thoracotomy. 2) For left lung cancer, as the routine procedure, systematic bilateral mediastinal dissection through a median sternotomy. 3) For the patients with advanced lymph node metastasis (the highest mediastinal or the cervical node involvement) or direct extension into the upper mediastinum of cancer in any side of the lungs, the lower half of modified radical neck dissection combined with systematic bilateral mediastinal dissection through a cervical collar incision and median sternotomy. RESULTS: 1. The noteworthy location and incidences of mediastinal lymph node involvement were as follows; 1) Among 34 patients of right lung cancer with pN2-3 M0 disease, in 5 patients the anterior mediastinal node involvement and in 6 patients (18%) the contralateral tracheobronchial node involvement were found by the pathological investigation at surgery. 2) The incidences of contralateral mediastinal node involvement at median sternotomies were 20% of 15 patients of the left upper lobe primary and 57% of 7 patients of the left lower lobe primary. 2. Postoperative survival rates calculated with Kaplan-Meier method; 1) The five-year survival rates were 67% in 22 patients with pT1-2N2M0; 72% in 20 patients with pT1-2N2-3 alpha (one level) M0 and 65% in 13 patients with pT1-2N2-3 alpha (multi level) M0. 2) The five-year survival rate of 8 patients with N3 gamma whose cancer were diagnosed as cN0-3 alpha preoperatively and resected completely was 60%. In conclusion, these results encourage us to continue this study because we can believe that our systematic mediastinal dissection beyond the anatomical difficulties would bring better prognoses in the patients with pN2-3 disease.

[Sleeve pulmonary arterial resection for bronchogenic carcinoma].

Two cases of bronchogenic carcinoma undergone left upper lobectomy (R 3) with bronchoplasty and sleeve pulmonary arterial resection via mid-sternotomy were reported. Both cases were squamous cell carcinoma originated in the orifice of the left upper lobe. Case 1 was stage IIIB (T2N3M0) bronchogenic carcinoma, its postoperative course was uneventful and died of distant lymphatic metastasis thirty-three months after operation. Case 2 was stage II (T2N1M0) bronchogenic carcinoma and its postoperative management was laborious because of hard expectoration of the sputum but is doing well fifteen months after operation. In order to preserve adequate pulmonary function and to maintain reasonable quality of life (QOL) for the patients with impaired pulmonary function, this angioplastic procedure seems to be acceptable. It is still under discussion to perform this procedure for the patients who would be able to withstand undergoing pneumonectomy, therefore we adopt this method only for every patient for whom it is difficult to maintain desirable QOL after pneumonectomy. Namely, for the patient whose predicted one second forced expiratory volume (FEV1.0) after pneumonectomy is less than 900 ml/m2, we'll be likely to try this angioplastic procedure at first.

[Evaluation of neck lymph node dissection and extended lymphadenectomy through a collar incision and median sternotomy for lung cancer].

Since 1983, 421 patients have been treated for lung cancer at this institute. Since 1988, neck lymph node dissection (11 cases) and new extended lymphadenectomy through a collar incision and median sternotomy (22 cases) have been conducted. Indications for this new radical operation are scalene, supraclavicular or highest mediastinal node involvement, or superior pulmonary sulcus carcinoma, in patients aged 70 or less without distant metastasis and NSCLC. No major complications and operative mortality were encountered in this study. Patients with scalene or supraclavicular node involvement showed poor prognosis. Postsurgical local recurrence was frequent. Whether resection in N3 disease should be conducted or not, remains a point of controversy. The authors consider that lymphadenectomy should be conducted more extensively. A significant better survival of N2 disease and satisfactory prognosis of patients without metastasis of cervical lymph nodes demonstrates the effectiveness of neck lymph node dissection in the present superradical operation for lung cancer.

[Combination therapy with arbekacin and fosfomycin against postoperative severe mixed-pneumonia of MRSA in primary lung cancer patients].

We experienced successful treatment of postoperative severe pneumonia of Methicillin-resistant Staphylococcus aureus (MRSA) with combination therapy of Arbekacin (ABK) and Fosfomycin (FOM) in three lung cancer patients. Case 1 was a advanced age of seventy-nine man who had had right upper lobectomy. Case 2 was a 61-year-old man who had had left lower lobectomy and extended bilateral mediastinal lymph-node dissection through the median sternotomy. And case 3 was a 59-year-old man who had suffered from pulmonary embolism after right pneumonectomy and partial resection of left atrium and superior vena cava. All cases were immuno-compromised patients and super-infected with Gram-negative rods, and Pseudomonas aeruginosa in case 1 and case 3. Clinical symptoms were improved after the start of administration of ABK and FOM inspite of ineffectiveness of prior treatment with other antibiotics. We added staggered chemotherapy of Sulbactam/Cefoperazone (SBT/CPZ) and Ceftazidime (CAZ) for case 1 and case 3 respectively. Thus, the combination therapy of ABK and FOM might be useful for severe pneumonia of MRSA in the immunocompromised patients, and the combined staggered chemotherapy of beta-lactum agents and above would be the first choice in the treatment for the case involving Pseudomonas aeruginosa.

[A case of diffuse malignant mesothelioma diagnosed by thoracoscopic biopsy].

We report a case of diffuse malignant mesothelioma discovered by thoracoscopic examination undertaken while formulating a preoperative diagnosis. A 61-year-old male complained of coughing and sputum production, and was admitted because his chest roentgenogram indicated an abnormal shadow. Chest CT scanning demonstrated right pleural effusion and multiple nodules sited on the diaphragm. Because aspiration biopsy of such nodules was difficult, we performed a thoracoscopic examination. The thoracoscopic findings demonstrated bloody pleural effusion in the right thoracic cavity and multiple nodules on the diaphragm, parietal and pulmonary pleura. They were white and 0.5 to 2 cm in size. By excisional biopsy, these were diagnosed as epithelial-type diffuse malignant mesothelioma. We therefore performed panpleuropneumonectomy. Even though we completely resected the canal of thoracoscope and drainage tube, microscopic findings showed invasion of mesothelioma cells into this thoracoscopic canal. Although we suggest that, in preoperative diagnosis of pleural tumor, thoracoscopy is efficient to perform a pathological examination and confirm the extension of tumor, in the actual operation, we believe that the thoracoscopic canal should be resected.

[A case report of intralobar sequestration associated with lung aspergillus].

A 21-year-old woman with fever and dyspnea was admitted to our hospital. X-ray examination of this patient showed abscess forming in the right lower lobe of the lung. Aspergillus fumigatus was detected by percutaneous lung biopsy. She had repeated pneumonia since her childhood, so congenital lung disease was suspected. Aortic angiography showed the flow of an aberrant artery originated from the right inferior phrenic artery into the right lower lobe. Preoperative diagnosis of the patient was lung sequestration associated with aspergillosis. The operative procedure included right lower lobectomy with ligation of the aberrant artery. Postoperative diagnosis was intralobar sequestration of Pryce III type which was infected with aspergillus. Intralobar sequestration associated with aspergillosis is very rare, perhaps this is the third case in the literature of Japan.

[Application of the polyglycolic acid (PGA) pledgets or sheet for pulmonary fistulas and defects of the pleura].

A felt-like bioabsorbable prosthesis (Polyglycolic Acid (PGA) pledget and sheet; Medifit feft) was used for pulmonary fistula in a total of 10 patients. "Fibrin glue A" was absorbed into the PGA prosthesis previously. And next, the part of pulmonary fistula was coated with "Fibrin glue B", and then covered with the fibrin-absorbed PGA prosthesis. The prosthesis adhered to the diseased part of pulmonary pleura immediately, and therefore, in all these 10 patients, the post-operative air-leakage was stopped up to 4 days and neither side effect nor complication was observed.

[Factors affecting health behavior of the people aged forties--a test of the health belief model].

The health behavior of 1120 persons, aged in their forties, living in a city, a mountain village and a fishing village were analyzed according to the Health Belief Model. Women practiced more health behaviors than men. People living in the city and mountain village practiced more than people in fishing village. Company employees, farmers and housewives practiced more than self-employeds and fishermen. Education level had no significant influence in the practice of health behavior. As predicted, people who believed in the effectiveness of health behavior practiced more health behaviors. On the other hand, people who perceived barriers to health behavior practiced less. Paradoxically, people who perceived vulnerability to hypertension, cerebrovascular disease or cancer, and the seriousness of these diseases, practiced less health behaviors. Stepwise multiple regression analysis revealed that health beliefs, social supports and information from mass media could account for 33.0% of the Health Behavior Score variation. Perceived barriers to health behavior was the strongest determinant for practice of health behavior. Perceived barriers may account for gender and occupational differences in health behavior.

[Extended extrapleural pneumonectomy by median approach for advanced malignant mesothelioma with right supraclavicular lymph node metastasis--a case report].

A 52-year-old woman of diffuse malignant mesothelioma of the right pleura with metastasis to right supraclavicular lymph nodes underwent extended extrapleural right pneumonectomy and neck dissection. For this resection we selected the new approach: median sternotomy with hemi-collar incision. Through this approach systematical dissection of the cervical-mediastinal lymph nodes was performed together with resection of the right lung, parietal pleura, the pericardium and the diaphragm. As a result of this en bloc resection, she is alive without recurrence for one year after the operation.