Moderate Hypothermic Circulatory Arrest with Antegrade Cerebral Perfusion for Rapid Total Arch Replacement in Acute Type A Aortic Dissection.

BACKGROUND: The optimal hypothermic level during circulatory arrest is controversial. The aim of our study was to comprehensively assess the impact of moderate hypothermic circulatory arrest with antegrade cerebral perfusion (ACP) on total aortic arch replacement. METHODS: From 2010 to 2013, data were collected from 99 consecutive patients with acute type A aortic dissection. All patients underwent total arch replacement plus frozen elephant trunk procedure. There were 51 patients in the deep hypothermia circulatory arrest (DHCA) group and 47 in the moderate hypothermia circulatory arrest (MHCA) group. Either unilateral or bilateral ACP was applied for cerebral protection. Perioperative data and measured outcomes were compared. RESULTS: Overall mean circulatory arrest time was 29.9 ± 6.0 minutes. Temporary neurologic dysfunction incidence was lower in the MHCA group compared with the DHCA group (21.3 vs. 40.4%, p = 0.041). The total 30-day mortality was 17.2% (14.9 vs. 19.2%, p = 0.568) and permanent neurologic dysfunction morbidity was 3.0% overall. In MHCA, less blood products were used than in DHCA. Moderate hypothermia was a protective factor for the composite outcome of temporary and permanent neurologic dysfunctions (odds ratio = 0.385; 95% confidence interval = 0.162-0.919). Hypothermic level did not significantly affect the perioperative alanine aminotransferase and serum creatinine levels. CONCLUSION: Within a short circulatory arrest time, MHCA combined with ACP seemed to be a safe and effective method to protect cerebral and visceral organs during total aortic arch replacement.

Tongxinluo Prevents Endothelial Dysfunction Induced by Homocysteine Thiolactone In Vivo via Suppression of Oxidative Stress.

Aim. To explore whether Chinese traditional medicine, tongxinluo (TXL), exerts beneficial effects on endothelial dysfunction induced by homocysteine thiolactone (HTL) and to investigate the potential mechanisms. Methods and Results. Incubation of cultured human umbilical vein endothelial cells with HTL (1 mM) for 24 hours significantly reduced cell viabilities assayed by MTT, and enhanced productions of reactive oxygen species. Pretreatment of cells with TXL (100, 200, and 400 µg/mL) for 1 hour reversed these effects induced by HTL. Further, coincubation with GW9662 (0.01, 0.1 mM) abolished the protective effects of TXL on HTL-treated cells. In ex vivo experiments, exposure of isolated aortic rings from rats to HTL (1 mM) for 1 hour dramatically impaired acetylcholine-induced endothelium-dependent relaxation, reduced SOD activity, and increased malondialdehyde content in aortic tissues. Preincubation of aortic rings with TXL (100, 200, and 400 µg/mL) normalized the disorders induced by HTL. Importantly, all effects induced by TXL were reversed by GW9662. In vivo analysis indicated that the administration of TXL (1.0 g/kg/d) remarkably suppressed oxidative stress and prevented endothelial dysfunction in rats fed with HTL (50 mg/kg/d) for 8 weeks. Conclusions. TXL improves endothelial functions in rats fed with HTL, which is related to PPARγ-dependent suppression of oxidative stress.

Androgen receptor promotes esophageal cancer cell migration and proliferation via matrix metalloproteinase 2.

Esophageal squamous cell carcinoma (ESCC) is one of the most common malignancies worldwide. Androgen receptor (AR) plays an important role in many kinds of cancers. However, the molecular mechanisms of AR in ESCC are poorly characterized. In the present study, Western blot analysis and real-time quantitative PCR were performed to identify differentially expressed AR in 40 ESCC tissue samples, which revealed that the messenger RNA (mRNA) and protein expression of AR is upregulated in the ESCC tissue samples. AR overexpression induced increases in ESCC cell invasion and proliferation in vitro. Silencing of AR inhibited the proliferation of KYSE450 cells which have a relatively high level of AR, and the invasion of KYSE450 cells was distinctly suppressed. Furthermore, AR knockdown led to substantial reductions in matrix metalloproteinase 2 (MMP2) and p-AKT levels in ESCC cell lines, but no significant change in AKT and MMP9 expression. These results suggest that AR is involved in tumor progression, and thus, AR could represent selective targets for the molecularly targeted treatments of ESCC.

Minimally invasive esophagectomy with right bronchial occlusion under artificial pneumothorax.

AIMS: To assess the safety and feasibility of minimally invasive esophagectomy and selected three-field lymphadenectomy with the right bronchial occlusion in left semi-prone position under artificial pneumothorax. METHODS: Thoracoscopic-laparoscopic subtotal esophagectomy and selected three-field lymphadenectomy were performed in 166 patients with esophageal carcinoma by the right bronchial occlusion in left semi-prone position under artificial pneumothorax. RESULTS: 109 patients received two-field lymphadenectomy and 57 received three-field lymphadenectomy. The average operative time was 202.5 ± 21.3 min; the average thoracoscopic operative time was 98.4 ± 15.5 min. The average blood loss was 39.6 ± 4.2 ml, and no blood transfusion was needed during the surgery. The mean lymph node harvest was 28.4 ± 5.2 nodes. Hospital stay ranged from 7 to 95 days and the average was 11.3 days. The postoperative complication rate was 29.5%, and the mortality rate was 1.2%. CONCLUSIONS: It is feasible and safe to perform thoracoscopic-laparoscopic subtotal esophagectomy and selected three-field lymphadenectomy with the right bronchial occlusion in left semi-prone position under artificial pneumothorax for esophageal carcinoma. The procedure shows advantages in improved visibility and accessibility of the surgical field, and better subsequent surgical outcomes.

Resistance to cetuximab in EGFR-overexpressing esophageal squamous cell carcinoma xenografts due to FGFR2 amplification and overexpression.

Esophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Despite improvements in surgical techniques and perioperative management and surgery combined with chemotherapy and/or radiotherapy, the prognosis of esophageal squamous cell carcinoma (ESCC) at an advanced stage remains poor. ESCC shows a relatively high incidence of EGFR (50% - 70%), and the humanized monoclonal antibody (mAb) cetuximab against EGFR has been undergoing clinical development. However, all responding patients eventually developed acquired resistance to cetuximab. In the current study, we described a cetuximab-sensitive ESCC xeongraft model that developed resistance to cetuximab as a result of FGFR2 gene amplification and overexpression. Inhibition of FGFR2 signaling in this xenograft model restored its sensitivity to cetuximab. The antitumor effect may be induced by inhibition of AKT phosphorylation. These findings suggest that combination therapyincluding cetuximab and FGFR2 inhibition may be a promising strategy to treat ESCC.

Nicotine upregulates microRNA-21 and promotes TGF-ß-dependent epithelial-mesenchymal transition of esophageal cancer cells.

A consistent positive association between cigarette smoking and the human esophageal cancer has been confirmed all over the world. However, details in the association need to be more focused on and be identified. Recently, aberrantly expressed microRNAs (miRNAs) have been shown to be promising biomarkers for understanding the tumorigenesis of a wide array of human cancers, including the esophageal cancer, and the deregulation on the epithelial to mesenchymal transition (EMT) by miRNAs is involved in the tumorigenesis. In present study, we were going to identify the role of nicotine-induced miR-21 in the EMT of esophageal cells. We found that there was an overexpression of miR-21 in esophageal specimens, having an association with cigarette smoking, and the upregulation of miR-21 was also induced by nicotine in esophageal carcinoma cell line, EC9706. Moreover, the upregulated miR-21 by nicotine promoted EMT transforming growth factor beta (TGF-ß) dependently. Thus, the present study reveals a novel oncogenic role of nicotine in human esophageal cancer.

Neuropilin 1 expression in human aortas, coronaries and the main bypass grafts.

OBJECTIVES: Development of intimal hyperplasia (IH) is the main pathology underlying graft failure following coronary artery bypass graft surgeries for ischaemic heart diseases, especially for great saphenous vein grafts which have a lower patency rate than internal mammary arteries. Neuropilin 1 (NRP1), which is a co-receptor for vascular endothelial growth factor found in vascular endothelial and smooth muscle cells, affects the development of IH. We examined the difference in NRP1 expression and distribution in human coronaries, aortas, mammary arteries and saphenous veins to detect a possible relation to their susceptibility to IH. METHODS: Ninety-five human vascular segments obtained from 40 patients were used for the comparison of NRP1 expression between different groups of blood vessels by western blot and real-time PCR. Additionally, staining scores were generated by computerized analysis of the microscopic images obtained after immunofluorescence and immunohistochemical staining to compare NRP1 expression patterns in endothelium, smooth muscles and adventitia in each vessel type. RESULTS: NRP1 expression in the aorta (2.03 ± 1.44) was more than twice as high as mammary artery expression (0.85 ± 0.75; n = 16, P = 0.0004); NRP1 of the latter (0.99 ± 0.91) was more than 30% greater than that of the corresponding saphenous vein (0.73 ± 0.69; n = 20, P = 0.0085). In adventitia, NRP1 receptor staining of the saphenous vein was higher (22.96 ± 8.73) than in the mammary artery (15.83 ± 7.13; n = 7, P = 0.049). Variations in NRP1 protein levels were accompanied by parallel variations in its mRNA levels (n = 15, P = 0.34). CONCLUSIONS: Autologous saphenous vein grafts, unlike internal mammary artery grafts, have lower NRP1 expression and abundant adventitial distribution of NRP1 within their walls; this may correlate with higher susceptibility to IH development.

A completely resected paraganglioma arising from the right atrioventricular groove.

We report a case of completely resected right atrioventricular groove paraganglioma. Primary cardiac paragangliomas are extremely rare. Only about 60 cases have been reported in the literature, and most of these tumors originated from the left atrium or the base of the aortic root and pulmonary artery; 5 cases originated from the right atrium. In our patient, the paraganglioma was largely located in the right atrioventricular groove and protruded into the right atrial wall. To our knowledge, there has been no paraganglioma reported in the right atrioventricular groove. We successfully carried out complete tumor resection. Most of these tumors are locally invasive, and complete resection is often difficult.

Focal organizing pneumonia mimicking lung cancer: a surgeon's view.

Focal organizing pneumonia is a unique form of organizing pneumonia. Little is known regarding its clinical and radiological feature, diagnosis, management, and outcome. Twenty patients with focal organizing pneumonia were investigated and compared with 40 patients with bronchogenic carcinoma. There were 38 men (63.3%) and 22 women (36.7%). The mean age was 55 ± 9.9 years. No specific feature in clinical and radiological manifestation was found to distinguish between focal organizing pneumonia and bronchogenic carcinoma. In patients with focal organizing pneumonia, wedge resection was performed in 12 cases and lobectomy in eight cases. Follow-up was complete with a median period of 26 months (range, 6 to 104 months). All patients were free from recurrence of organizing pneumonia. Clinical and radiologic findings of focal organizing pneumonia are nonspecific, and this unique form of organizing pneumonia is difficult to differentiate from lung cancer. Surgical resection allows both diagnosis and cure. However, considering the benign nature of this disease, major pulmonary resections should be avoided.

Multimodality FDG PET/CT appearance of pulmonary tuberculoma mimicking lung cancer and pathologic correlation in a tuberculosis-endemic country.

OBJECTIVES: Differentiation between pulmonary tuberculoma and malignancy by preoperative diagnostic imaging sometimes proves difficult. The purpose of this study is to investigate variable manifestations of pulmonary tuberculoma mimicking lung cancer on fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) image and pathologic correlation. PATIENTS AND METHODS: Twenty-five patients with a high suspicion of malignancy and histopathologically diagnosed as pulmonary tuberculoma were included. Their FDG PET/CT images, clinical data, and pathologic findings were investigated. RESULTS: There were 18 men and seven women. The mean age was 52 ± 8.8 years. The maximal diameter of pulmonary tuberculoma ranged from 1.7 to 4.2 cm. CT scan revealed that abnormal signs associated with malignancy such as spicular radiation, notching, and pleural indentation also frequently manifested in tuberculoma. During early imaging, positive FDG uptake was identified in 21 patients (84%), intermediate uptake in 3 patients (12%) and negative uptake in 1 patient (4%). During delayed imaging, 16 patients (64%) showed persistent elevated FDG accumulation and 8 patients (32%) experienced a slight drop of FDG accumulation. Pathologically active tuberculoma showed significantly higher FDG radioactivity during both early and delayed imaging than inactive lesion (P < 0.05). Lymphadenopathy with positive FDG uptake was identified in nine patients (36%). CONCLUSION: Pulmonary tuberculomas mimicking lung cancer, most of which were pathologically active lesions, commonly displayed abnormal appearances in CT scan and an increase in FDG uptake, similar to changes seen on malignancy. Coexistent lymphadenopathy made differential diagnosis even more complicated. These results suggested that positive FDG PET/CT findings should be interpreted with caution in tuberculosis-endemic regions.

Congenital left circumflex artery fistula drainage into left ventricle.

Congenital communication between left coronary artery to left ventricle is a rare anomaly. A 52-year-old male patient visited our institution complaining of paroxysmal palpitation and echocardiography revealed a large fistula draining into the left ventricle. Coronary angiography and computed tomography (CT) scanning confirmed the fistula located between the left circumflex coronary artery (LCX) and left ventricle (LV). A simple fistula ligation was performed, and postoperative three-dimensional coronary CT scanning confirmed the patient got a complete cure.

Successful correction of congenital giant right coronary artery aneurysm with fistula to left ventricle.

A 26-year-old male presented with radiographical evidence of enlargement of the right side of the heart. Echocardiography and computed tomography-scan revealed a diffuse, hugely enlarged right coronary artery (RCA) aneurysm, with the distal portion flowing directly into the left ventricle (LV). A radical correction operation was performed successfully. The RCA was reconstructed with an autograft of a greater saphenous vein after the aneurysm was removed and the RCA-to-LV fistula was closed. The postoperative course was uneventful and the patient was discharged on 12th day after operation.

Congenital right pulmonary artery-to-left atrial fistula.

A 23-year-old man presented with cyanosis since birth. Precordial echocardiography failed to detect any structural heart abnormality except for enlarged left atrium. Pulmonary angiography revealed a type I right pulmonary artery-to-left atrial fistula. Simple ligation of the fistula without cardiopulmonary bypass was performed successfully, and the cyanosis disappeared postoperatively.

Bilateral giant pulmonary bronchogenic cysts.

Bilateral giant tension bronchogenic cysts were detected by computed tomography in a 13-year-old girl who presented with fever and severe cough. One was located in the right upper lobe, the other in the left lower lobe. The cysts, both measuring 10 cm in diameter, were removed in 2 operations 2 months apart.