Maximum SUV on positron emission tomography and serum CEA level as prognostic factors after curative resection for non-small cell lung cancer.

AIMS: The relationship between the maximum standardized uptake values (SUVmax) on positron emission tomography (PET) and serum carcinoembryonic antigen (CEA) level in non-small cell lung cancer (NSCLC) patients was investigated. METHODS: Consecutively, 197 surgically resected NSCLC patients with preoperative staging including serum CEA and PET were reviewed retrospectively. RESULTS: When patients were subdivided into two groups based on the median value of the SUVmax (6.6), the 5-year survival of patients with a high SUVmax was 63.20%, which was significantly worse than patients with a low SUVmax (87.29%, P = 0.0004). The 5-year survival of patients with normal and high serum CEA level was 82.70 and 51.08%, respectively (P < 0.0001). Univariate and multivariate analyses indicated the independent prognostic impact of the SUVmax and serum CEA level. Patients with both low SUVmax and normal serum CEA level had favorable prognosis, whereas those with both high SUVmax and high serum CEA level had poor prognosis. CONCLUSION: Preoperative SUVmax and serum CEA level are independent prognostic factors for survival in NSCLC. The combined use of preoperative SUVmax and serum CEA level might be a better prognostic indicator.

[Parasternal approach for anterior apical lung cancer with invasion of the first rib].

For complete resection of anterior apical invasive lung cancer, it is of clinical significance to select the appropriate surgical approaches based on the anatomic location of the tumor and extent of invasion of adjacent anatomic structures. However, patients with anterior apical lung cancer without vessel invasion are occasionally burdened with unnecessarily excessive surgical invasion. We present 2 cases of anterior apical lung cancer invading the 1st rib but not subclavian vein, who underwent complete resection through the parasternal approach. We also discuss the feasibility of this approach.

Elevated preoperative inflammatory markers based on neutrophil-to-lymphocyte ratio and C-reactive protein predict poor survival in resected non-small cell lung cancer.

BACKGROUND: Previous studies showed the prognostic impact of inflammatory markers such as the neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP), in resected non-small cell lung cancer (NSCLC). However, there are no studies that examined both of these markers simultaneously. PATIENTS AND METHODS: Three hundred and one consecutive cases of resected NSCLC with a follow-up period of more than 5 years were reviewed retrospectively. RESULTS: A significant association was only observed between NLR and patients' survival (p<0.0001). High CRP also led to a higher 5-year survival rate than low CRP (38.71% vs. 70.71%, p<0.0001). We evaluated the prognostic significance of the use of NLR and CRP combined. The 5-year survival of patients with both low NLR and low CRP was 74.18%. On the other hand, that of patients with both of these at a low level was significantly poor (20.00%, p<0.0001). Univariate and multivariate analyses of the clinicopathological factors affecting survival revealed that the combined use of preoperative NLR and CRP was an independent prognostic determinant. CONCLUSION: The combined use of preoperative NLR and CRP might be useful to predict the prognosis of patients with NSCLC.

Transtricuspid approach in redo surgery for post-infarction ventricular septal rupture.

A 59-year-old man, who had been treated using the infarction exclusion technique for inferior post-infarction ventricular septal rupture (VSR) 4 months previously, was readmitted because of deterioration of mitral valve regurgitation, residual shunt, and progression of pulmonary hypertension. We performed mitral valve replacement via the transseptal approach, patch closure of the defect via the transtricuspid approach, and tricuspid valve annuloplasty. The post-operative course was uneventful. The transtricuspid approach is useful in redo surgery for post-infarction VSR.

Inhibition of development of abdominal aortic aneurysm by glycolysis restriction.

OBJECTIVE: The mechanisms underlying abdominal aortic aneurysm development remain unknown. We hypothesized that acceleration of glucose metabolism with the upregulation of glucose transporters is associated with abdominal aortic aneurysm development. METHODS AND RESULTS: Enhanced accumulation of the modified glucose analogue 18 fluoro-deoxyglucose by positron emission tomography imaging in the human abdominal aortic aneurysm was associated with protein expressions of glucose transporters-1 and -3, assessed by Western blot. The magnitude of glucose transporter-3 expression was correlated with zymographic matrix metalloproteinase-9 activity. Intraperitoneal administration of glycolysis inhibitor with 2-deoxyglucose significantly attenuated the dilatation of abdominal aorta induced by periaortic application of CaCl(2) in C57BL/6J male mice or reduced the aneurysmal formation in angiotensin II-infused apolipoprotein E knockout male mice. In monocytic cell line induced by phorbol 12-myristate 13-acetate or ex vivo culture obtained from human aneurysmal tissues, 2-deoxyglucose abrogated the matrix metalloproteinase-9 activity and interleukin-6 expression in these cells/tissues. Moreover, 2-deoxyglucose attenuated the survival/proliferation of monocytes and the adherence of them to vascular endothelial cells. CONCLUSIONS: This study suggests that the enhanced glycolytic activity in aortic wall contributes to the pathogenesis of aneurysm development. In addition, pharmacological intervention in glycolytic activity might be a potential therapeutic target for the disorder.

Aortic annulus diameter measurement: what is the best modality?

PURPOSE: The purpose of this study was to clarify the most suitable method to measure the aortic annulus diameter. PATIENTS AND METHODS: Fifty-five patients, who had undergone aortic valve replacement at Miyazaki University Hospital between April 2008 and May 2011, were included in this study. The maximum diameter of the sizing tool that could be inserted into the left ventricle through the annulus had been predicted, based on the diameter measured by each modality. Agreement with surgery and each imaging modality, namely transthoracic echocardiography, multidetector computed tomography and contrast angiography, were compared using Bland-Altman analysis. RESULTS: The predicted aortic annulus diameter, based on the diameter measured by transthoracic echocardiography, multidetector computed tomography and contrast angiography, was 20.3 ± 2.50, 23.9 ± 3.19, and 23.5 ± 3.55 mm, respectively, whereas, the diameter measured at surgery was 23.7 ± 2.99 mm. Predicted aortic annulus diameter measured by multidetector computed tomography best agreed with that measured at surgery. CONCLUSION: We conclude that the aortic annulus diameter, measured by multidetector computed tomography, is the best modality to measure the aortic annulus diameter.

Preoperative neutrophil to lymphocyte ratio as a prognostic predictor after curative resection for non-small cell lung cancer.

BACKGROUND: The prognostic impact of neutrophil to lymphocyte ratio (NLR) in non-small cell lung cancer (NSCLC) was examined using patients with a follow-up period more than 5 years. PATIENTS AND METHODS: Two hundred and eighty four consecutive resected NSCLC patients were reviewed retrospectively. In this study, patients who were treated with a follow-up period less than 5 years were omitted, RESULTS: The mean value of NLR was 2.44±2.22 (range: 0.56-29.44). The 5-year survival of the patients with a high NLR (≥2.5) was significantly worse than that of the patients with a low NLR (47.06% vs. 67.84%, p<0.0001). Univariate analysis of the clinicopathological factors affecting survival revealed that age, gender, histology, pT status, pN status, high serum CEA level, positive findings of pleural lavage cytology and high NLR were significant risk factors for reduced survival. On multivariate analysis, a high NLR was an independent risk factor for reduced survival. CONCLUSION: A high preoperative NLR may be a convenient biomarker to identify patients with a poor prognosis after resection for NSCLC.

Factors influencing permanent neurologic dysfunction and mortality after total arch replacement with separate arch vessel grafting using selective cerebral perfusion.

OBJECTIVES: The present study was undertaken to identify risk factors for permanent neurological dysfunction (PND) and in-hospital mortality after total aortic arch replacement (TAR) with separate arch vessel grafting using selective cerebral perfusion (SCP) and hypothermic circulatory arrest. METHODS: Between 1998 and 2008, we preformed a TAR on 143 consecutive patients in two centers by identical methods. Of these, 19 (13.3%) were emergency operations, and 46 (32.2%) were open stent-graft placements. Statistical analysis was performed to determine risk factors for PND and mortality, and furthermore, the survival rate was analyzed. RESULTS: The in-hospital mortality rate was 4.9%, with chronic renal failure (p = 0.0013, odds ratio 10.0) as a significant risk factor. Nine patients (6.3%) had PND, with significant risk factors identified as (1) the presence of an old cerebral or silent lacunar infarction on preoperative imaging methods (p = 0.0458, odds ratio 8.0) and (2) duration of SCP (p = 0.0026, odds ratio 1.036). Long-term survival was the same in patients with or without PND. CONCLUSION: The enhanced vulnerability of the brain in patients with a pre-existing old cerebral infarction or silent lacunar infarction is reflected by a high incidence of PND. Chronic renal failure had an impact on in-hospital mortality.

Bronchial flap closure of the lower membranous trachea.

A novel method for closure of the lower membranous trachea after right pneumonectomy using a flap derived from the cartilaginous portion of the right main bronchus is described in this study. This technique was used successfully in patients with tracheal stenosis due to a giant posterior mediastinal tumor known as schwannoma. Because of the severe tracheobronchial stenosis and destroyed right lung, tumor resection combined with resection of the lower membranous trachea and right pneumonectomy was carried out. We closed the defect in the membranous lower trachea with the flap derived from the right main bronchus. The clinical course was uneventful.

Relative contributions of 5-hydroxytryptamine (5-HT) receptor subtypes in 5-HT-induced vasoconstriction of the distended human saphenous vein as a coronary artery bypass graft.

It is established that the segment of saphenous vein (SV) that is widely used as a conduit vessel in coronary artery bypass graft (CABG) surgery is distended with high pressure to check for leaks and to increase the patency before implantation into coronary arterial circulation. The aim of the present study was to elucidate the relative contributions of 5-hydroxytryptamine (5-HT) receptor subtypes responsible for 5-HT-induced vasoconstriction of the distended human SV. Whereas about half of the 5-HT-induced vasoconstriction still remained in the presence of supramaximum concentration of sarpogrelate or of SB224289 (5-HT(2A) and 5-HT(1B) receptor antagonists, respectively), simultaneous treatment with sarpogrelate and SB224289 almost completely inhibited the 5-HT-induced vasoconstriction. Immunopositive staining for 5-HT(2A) and 5-HT(1B) receptors was detected in smooth muscle cells of the distended human SV and there was no significant difference between the immunopositive areas of 5-HT(2A) and 5-HT(1B) receptors. These results demonstrate that 5-HT(2A) and 5-HT(1B) receptors similarly contribute to 5-HT-induced vasoconstriction in human distended SV. Thus, when the SV is used as a CABG conduit, a combination of 5-HT(2A) and 5-HT(1B) receptor antagonists would appear to be most useful to prevent 5-HT-induced spasm.

Bronchoscopic removal of staple-line reinforcement material.

We report a case of a 60-year-old man who presented with severe productive cough caused by an endobronchial foreign body, which was due to the migration of a staple-line reinforcement material (Seamguard, W.L.Gore & Associates, Inc., Flagstaff, AZ). This material was placed over 5 years ago during a right upper lobe lobectomy for a poorly differentiated adenocarcinoma, (T1N0M0). We were able to remove the entire staple line by performing 2 separate flexible bronchoscopic interventions during a 1-year period without any consequences, thereby preventing an open thoracotomy. Our technique involved trimming the projecting reinforcement material with endoscopic scissors and removing it by pulling or pushing the staple line with a grasping forceps. Three-dimensional computed tomographic scanning was useful to detect the exact anatomic location and relation of the bronchial airway, great vessels, and pulmonary tissue to the foreign body. The use of absorbable staple-line reinforcement could avoid such a complication.

Emergent completion pneumonectomy for postoperative hemorrhage from rupture of the infected pulmonary artery in lung cancer surgery.

Completion pneumonectomy (CP) is one of the most difficult procedures and known to be associated with a high morbidity and mortality. A 74-year-old male underwent a left upper lobectomy for pulmonary adenocarcinoma (T3N0M0); six days later after the surgery, he had a sudden postoperative intrathoracic excessive hemorrhage with shock. Emergent redo thoracotomy was performed to treat the bleeding from the ablated interlobar pulmonary artery by suturing with prolene. However, 3 days later after the second operation, he had the second intrathoracic bleeding. Emergent CP was performed with cardiopulmonary bypass by anterior transpericarsial approach via a median sternotomy. The hemorrhage was caused by a rupture of the proximal fragile and infected pulmonary artery. We performed omentopexy for the infected intrathoracic cavity and for covering of the divided main bronchial stump. We had a rare experience of two times of postoperative life-threatening hemorrhage from rupture of the infected pulmonary artery after left upper lobectomy. Emergent CP as salvage surgery should have an advantage in control of infected proximal pulmonary arterial hemorrhage. We should take care of tearing off of adventitia of pulmonary artery in lobectomy because of a possibility of postoperative hemorrhage under a fragility of the injured pulmonary artery with infection.

[Acute massive pulmonary thromboembolism treated with percutaneous cardiopulmonary support perioperatively].

A 57-year-old female was transferred to our hospital because of sudden dyspnea. She was hypotensive and hypoxic. Acute massive pulmonary thromboembolism was detected by echocardiography and computed tomography (CT). Before the operation, she fell into severe shock and needed cardiopulmonary resuscitation. We applied percutaneous cardiopulmonary support (PCPS), and performed emergency open embolectomy under total cardiopulmonary bypass. Because of the right ventricular failure, she could not be weaned from total cardiopulmonary bypass. PCPS was required again and used continuously during postoperative management. Her cardiopulmonary state improved gradually. PCPS was stopped at 6 days after surgery, and she was extubated at 14 days after surgery. PCPS was very useful for resuscitation and stabilization of the cardiopulmonary function for acute massive pulmonary thromboembolism perioperatively.

Prognostic significance of the combined use of preoperative platelet count and serum carcinoembryonic antigen level in non-small-cell lung cancer.

PURPOSE: The prognostic significance of the combined use of preoperative platelet count and serum carcinoembryonic antigen (CEA) level in non-small-cell lung cancer patients was investigated. METHODS: Consecutive 289 non-small-cell lung cancer patients were reviewed retrospectively. Thrombocytosis was defined as a platelet count of at least 40 × 10(4)/mm(3). RESULTS: The frequency of preoperative thrombocytosis was 4.5% (13/289). The 5-year survival of patients with thrombocytosis was 30.77%, which was significantly poorer than that of patients with normal counts (68.65%, P = 0.0010). The 5-year survivals of patients with a normal CEA level and those with an elevated serum CEA level were 74.18% and 55.78%, respectively (P = 0.0019). Patients with both a normal platelet count and a normal serum CEA level had a favorable prognosis, whereas those with both thrombocytosis and elevated serum CEA level had a poor prognosis. The prognostic impact of the combined use of the platelet count and the serum CEA level was more significant than that of the platelet count or the serum CEA level alone. Both univariate and multivariate analyses indicated an independent prognostic impact of the combined use of platelet count and serum CEA levels. CONCLUSION: The combined use of preoperative platelet count and serum CEA levels might be useful for predicting the prognosis of non-small-cell lung cancer patients.

Postoperative serum C-reactive protein levels in non-small cell lung cancer patients.

PURPOSE: The significance of the postoperative serum C-reactive protein (CRP) level as a prognosis indicator was evaluated in patients with non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: A total of 276 patients who had undergone a curative resection of NSCLC were retrospectively reviewed. RESULTS: The overall and disease-specific survival rates in the postoperative CRP/high group (≥ 0.5 mg/dL at 30 days postoperation: n = 130) were significantly lower than those in the postoperative CRP/low group (< 0.5 mg/dL at 30 days postoperation: n = 146). However, based on a multivariate analysis, the postoperative CRP level was not among the unfavorable indicators regarding survival. The patients were divided into two groups, namely, the preoperative CRP/low group (n = 231) and the CRP/high group (n = 45). The proportion of the postoperative CRP/low group (60.2%) in the preoperative CRP/low group was significantly lower than that in the preoperative CRP/low group (15.6%; p <0.0001). No significant difference was observed in the disease-specific survival rates in the postoperative CRP/high group and the postoperative CRP/low group in either the preoperative high/group or low/group. CONCLUSIONS: The overall and disease-specific survival rates in the postoperative CRP/high group were significantly lower than that in the postoperative CRP/low group. This difference may be associated with the relationship between the pre- and postoperative CRP levels.

Prognostic significance of tumour marker index based on preoperative CEA and CYFRA 21-1 in non-small cell lung cancer.

BACKGROUND: Prognostic impact of tumour marker index (TMI) based on preoperative serum carcinoembryonic antigen (CEA) and CYFRA 21-1 in non-small cell lung cancer (NSCLC) was examined using patients with a follow-up period more than 5 years. PATIENTS AND METHODS: Two hundred and ninety-three consecutive NSCLC patients were reviewed retrospectively, and any patients with follow-up periods less than 5 years were omitted. RESULTS: The 5-year survival of the patients with normal and high serum CEA levels was 71.52% and 48.41%, respectively (p<0.0001). The 5-year survival of the patients with a high serum CYFRA 21-1 level was 39.66%, which was significantly poorer compared with that of the patients with a normal serum CYFRA 21-1 level (66.95%, p<0.0001). There was a 5-year-survival rate of 72.28% in patients with a TMI less than or equal to 1.0 compared to only 37.08% in patients with a TMI greater than 1.0 (p<0.0001). Both univariate and multivariate analyses indicated the independent prognostic impact of TMI. CONCLUSIONS: TMI may be useful for predicting the prognosis of NSCLC patients.

Combination of adoptive cell transfer and antibody injection can eradicate established tumors in mice--an in vivo study using anti-OX40mAb, anti-CD25mAb and anti-CTLA4mAb-.

Boosting an effective immune response against established tumors remains a difficult challenge. This study shows the combination of 1) adoptive cell transfer using CD25 depleted splenocytes co-cultured with irradiated tumor cells, and 2) antibody injection therapy using CTLA4 blockade, the elimination of Treg and OX40, which together could eradicate an established MethA tumor in over 50% of the BALB/c mice. Each element of the protocol was shown to be necessary, as elimination of any factor except anti-CD25 antibody injection failed to eradicate the tumor.

Pulmonary metastasis from renal cell carcinoma 17 years after nephrectomy: report of two cases.

We herein report two cases of pulmonary metastasis from renal cell carcinoma with 17-year disease-free intervals. Despite long disease-free intervals, their clinical course after pulmonary resection was different. An 82-year-old man (case 1) and a 73-year-old man (case 2), with histories of having undergone left nephrectomy for clear-cell-type renal cell carcinoma 17 years ago, were found to have right pulmonary nodules, which were detected incidentally by chest roentgenograms. A chest computed tomography revealed the presence of nodules in the right lung. They underwent surgical pulmonary resection 17 years after nephrectomy. These tumors were diagnosed as metastatic renal cell carcinoma. Currently, the case 1 patient is doing well with no signs of recurrence 42 months after pulmonary metastasectomy; however, the case 2 patient was found to have multiple tumor recurrences 11 months after metastasectomy. Their clinical courses indicate that a longer disease-free interval does not always imply a favorable prognosis.

Preoperative leukocytosis, anemia and thrombocytosis are associated with poor survival in non-small cell lung cancer.

BACKGROUND: Previous studies have reported any prognostic impact of preoperative leukocytosis, anemia and thrombocytosis in non-small cell lung cancer (NSCLC). The significance of the combined use of these 3 abnormal blood cell counts was investigated. PATIENTS AND METHODS: Two hundred and eighty-nine consecutive NSCLC patients were reviewed retrospectively. RESULTS: The patients with leukocytosis, anemia and thrombocytosis had significantly worse prognosis. The 5-year survival of the patients with all three of these abnormal blood cell counts was 25.0%, which was significantly poorer compared with that of the patients without any of these abnormal cell counts (78.23%). The 5-year survival of the patients with 1 or 2 out of the three abnormal blood cell counts was an intermediate value. Both univariate and multivariate analyses indicated the independent prognostic impact of the use of these three abnormal blood cell counts combined. CONCLUSION: The use of leukocytosis, anemia and thrombocytosis combined might be useful for predicting the prognosis of NSCLC patients.

Serum carcinoembryonic antigen level in non-small-cell lung cancer patients with preoperative normal serum level.

OBJECTIVE: The prognostic significance of serum carcinoembryonic antigen (CEA) levels in non-small-cell lung cancer (NSCLC) patients with a normal serum CEA level (<5.0 ng/ml) was examined. METHODS: A total of 220 consecutive NSCLC patients with preoperative normal serum CEA levels were included. Patients were subdivided into two groups: preoperative serum CEA level >/=2.5 and <2.5 ng/ml. RESULTS: The 5-year survival of patients with preoperative serum CEA level less and more than 2.5 ng/ml were 79.62% and 62.0%, respectively (P = 0.0036). Multivariate analysis indicated that a preoperative serum CEA level of >/=2.5 ng/ml was an independent prognostic factor. Similar results were found in patients with adenocarcinoma but not found in others. CONCLUSION: NSCLC patients with a high serum CEA level, especially adenocarcinoma patients, had poorer prognosis even if their serum CEA levels were within the normal upper limit.