Patients with End-stage Interstitial Lung Disease may have More Problems with Dyspnea than End-stage Lung Cancer Patients.

INTRODUCTION: Patients with end-stage interstitial  lung disease (ILD) do not appear to receive adequate palliative care despite apparent suffering before death. The aim of this study was to evaluate their signs, symptoms, and treatment received before death. METHODS: Patients with ILD and lung cancer (LC) who were hospitalized and died in our hospital were enrolled retrospectively. Signs and symptoms and treatments at 7 days, 3 days, and 1 day before death were evaluated and compared between the two groups of patients. RESULTS: A total of 23 patients with ILD and 59 patients with LC group were eligible for participation. Significantly more LC patients had loss of consciousness than ILD patients on 7 days (ILD: LC = 1 [5.6%]:24 [41%], P = 0.013), 3 days (1 [5.6%]:33 [56%], P < 0.001). Significantly more ILD patients had dyspnea than LC patients on 3 days (16 [89%]:38 [64%], P = 0.047) 1 day before death (21 [91%]:33 [56%], P = 0.001). On 1 day before death, significantly more LC patients received morphine than ILD patients (2 [8.7%]: 14 [24%], P = 0.015). More ILD patients received sedation (11 [48%]: 11 [19%], P = 0.007). CONCLUSIONS: End-stage ILD patients may experience dyspnea more frequently than terminal LC patients, and they need sedation. Morphine should be administered to ILD patients who have dyspnea. Additional prospective studies are needed.

Efficacy of multi-slice computed tomography cholangiography before laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury is one of the serious surgical complications of laparoscopic cholecystectomy (LC). Clear biliary tract imaging to detect the anomaly of the bile ducts before operation is thought to be useful to prevent this complication. The objective of this study was to investigate the preoperative feasibility of using multi-slice computed tomography scanning after drip infusion cholangiography-computed tomography (DIC-CT) for LC. METHODS: Laparoscopic cholecystectomies were carried out in 33 patients and DIC-CT and magnetic resonance cholangiography (MRC) were also carried out in all of these patients. We evaluated the recognition of the junction of the cystic duct and detection of anomalies of the extrahepatic bile ducts using the latter two methods. RESULTS: In 33 patients, DIC-CT showed the junction of the cystic duct in 31 (94%) and MRC in 25 (76%) patients, respectively. Anomalies of the extrahepatic bile ducts or the cystic duct were detected in four (12%) patients by DIC-CT, but MRC could show only one of these lesions. There were no major adverse reactions in either examination. CONCLUSION: DIC-CT is an efficacious preoperative technique as compared with MRC for the biliary tract imaging. DIC-CT may be of benefit for both patients scheduled to undergo LC and their surgeons.

[A case of transverse colon cancer with left supraclavicular lymph node metastasis and paraaortic lymph node metastases responding to TS-1].

A 61-year-old man was seen at our hospital because he noticed a mass on the left side of his neck. After examinations, he was diagnosed as transverse colon cancer with the left supraclavicular lymph node metastasis and paraaortic lymph node metastases. Rt. hemicolectomy was performed for the transverse colon cancer. At 15 days after operation, TS-1 chemotherapy was started (each treatment course consisted of daily oral administration of 100 mg TS-1 for 4 weeks followed by 2 drug-free weeks). After the first course, the left supraclavicular lymph node had shrunk markedly in physical findings. After the second course, both the left supraclavicular lymph node metastasis and paraaortic lymph node metastases had disappeared in CT findings. A complete remission was observed after the second course, and was maintained thereafter. The serum level of CA 19-9 decreased from 62 U/ml under the normal value after the second course, and was kept under this normal value. Leukopenia and eruption (grade 2) were the only observed adverse effects. This patient continues to undergo outpatient treatment with good QOL.

Left upper division sleeve segmentectomy for early stage squamous cell carcinoma of the segmental bronchus: report of two cases.

Early hilar lung cancer is rare. It is usually curable if properly diagnosed and treated. We recently encountered two cases of early stage squamous cell carcinoma of the left upper division bronchus, which responded well to left upper division sleeve segmentectomy. Case 1 was a 74-year-old man, a heavy smoker, who was referred to our hospital after sputum cytology had resulted in a positive diagnosis while receiving inpatient care for heart failure at another hospital. Bronchoscopy revealed a thickened tumor at the spur between left B(1+2) and B(3). Squamous cell carcinoma was diagnosed by forceps biopsy via bronchoscopy. Left upper division sleeve segmentectomy with lymph node dissection was performed. Since the bronchi to be anastomosed to each other were greatly different in diameter, telescoped anastomosis was used. His postoperative course was uneventful, and he continues to show good respiratory condition, without any evidence of recurrence 25 months after surgery. Case 2 was a 60-year-old man, a heavy smoker, who was identified by sputum cytology as needing detailed examination during a mass screening of high-risk groups for early detection of lung carcinoma. Bronchoscopy revealed a nodular tumor at the orifice of the left upper division bronchus. Squamous cell carcinoma was diagnosed by forceps biopsy via bronchoscopy. Left upper division sleeve segmentectomy with lymph node dissection was performed. During surgery for this case, the lingular bronchus was dissected obliquely to make its cross-section wide enough to match the diameter of the left upper lobe bronchus to which the former was anastomosed. His postoperative course was uneventful, and he shows good respiratory condition, without any evidence of recurrence five months after surgery. The pathological stage was TisN0M0 (stage 0) in both patients, and their tumors were confirmed as early hilar lung cancer. Sleeve segmentectomy, aimed at radical resection of cancer while preserving lung function, can serve as a standard procedure for surgical treatment of cases of early hilar lung cancer confined to the segmental bronchi.

Cardiac herniation following intrapericardial pneumonectomy with partial pericardiectomy for advanced lung cancer.

We present in this paper a case of cardiac herniation following right intrapericardial pneumonectomy after induction chemotherapy. A 52-year-old man with advanced squamous cell carcinoma of the lung was admitted to our hospital suffering from a dry cough and chest pain. An intrapericardial pneumonectomy with partial pericardiectomy (4 x 4 cm) was performed. The pericardial defect was left open. Just prior to removal of the tracheal tube, cardiac herniation occurred with hypotension, arrhythmia and cardiac arrest. A chest X-ray revealed cardiac herniation into the right hemithorax. Re-thoracotomy was performed and the heart was returned to its normal position and the pericardial defect was immediately repaired with an expanded polytetrafluoroethylene (EPTFE) patch. The patient's postoperative course was uneventful. Unless prompt diagnosis and surgical treatment can be accomplished, cardiac herniation can be a fatal complication. We recommend that when pneumonectomy is performed, pericardial defects should be closed with a prosthetic patch, regardless of the defect's size.

Gastric cancer occurred after coronary artery bypass grafting using the right gastroepiploic artery.

We recently encountered a rare case where gastric cancer developed in the long-term postoperative stage after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) and distal partial gastrectomy was performed to treat the cancer. The patient was a 64-year-old man. In November 2001, he underwent three-vessel CABG, involving bypassing between the right coronary artery (RCA) and the RGEA, to treat an old myocardial infarction. In May 2003, he was admitted to our hospital because of exacerbation of diabetes mellitus and anemia. Gastric endoscopy revealed gastric cancer affecting the pylorus. Preoperative abdominal angiography showed the RGEA graft remained well patent. In June 2003, he underwent distal partial gastrectomy and regional lymph node dissection. Because the RGEA had been freed adequately to the point of bifurcation of the gastroduodenal artery during the previous CABG, the RGEA graft was preserved during distal partial gastrectomy. When the RGEA is used for CABG, it seems advisable to free the RGEA adequately to a point of bifurcation of the gastroduodenal artery. If done so, regional lymph node dissection around the RGEA is easier to perform when gastric cancer has occurred in these cases, eventually reducing the risk for injury of the graft. Following CABG with the RGEA, it seems essential to perform periodical checks for gastric cancer to facilitate early detection of gastric cancer. The necessity of close follow-up of these cases is endorsed by the fact that healing of gastric cancer by endoscopic mucosal resection (EMR) is highly probable if the cancer is detected at early stages.

Advanced lung cancer invading the left atrium wall treated with pneumonectomy and combined resection of the left atrium using stapling devices: report of two cases.

In chest surgery, stapling devices are primarily used to close bronchi. However, they are also used for dissection and suturing between lung lobes, resection and plication of lung tissue (including bullae), combined resection of the superior vena cava, closure of the pulmonary great vessels, closure of the left atrium following combined resection of the left atrium, and so on. We recently treated two cases of advanced lung cancer, which had invaded the left atrial wall, with pneumonectomy and combined resection of the left atrium using stapling devices, and obtained favorable results. For combined resection of the left atrium, it is safer to use stapling devices than vascular clamps, since the latter involve the risk of dislocation during use. Furthermore, since stapling devices require no margin for suturing, the left atrium can be resected at a point sufficiently distant from the cancer, thus allowing for highly radical resection. Stapling devices are also useful because they can be manipulated even within narrow operative fields. When dealing with lung cancer requiring combined resection of the left atrium, pneumonectomy is needed in most cases. When performing surgery for these cases, it is essential to first close and divide the bronchi and pulmonary arteries and veins as far as possible so that adequate adherence around the left atrium can be developed and the entire lung can be lifted up, followed by resection of the left atrium with a stapling device applied to the left atrium without any tension.

Use of a silicone T-tube for management of a tracheal injury in a patient with cervical blunt trauma.

A 71-year-old woman fell forward hitting the anterior part of her neck against a table. Bronchoscopy revealed deformation of the cartilage crescent in the cervical trachea (suggestive of cartilage contusion) and a longitudinal tear in the membranous region. Because subcutaneous emphysema and dyspnea developed and progressed, we made a tracheostomy and inserted a silicone T-tube through the stoma to relieve intraluminal pressure. This then served as a stent for the airway after the patient had progressed through the acute stage. The subcutaneous emphysema and pneumomediastinum abated gradually during the 7 days after insertion of the T-tube, which remained in the cervical trachea as a tracheal stent for 2 months thereafter. The T-tube is easy to manage and can be inserted through the stoma without major surgery. As an alternative to tracheotomy, the T-tube is nonirritating, allows speech, aspiration of sputum, and respiration through the nasopharynx, and in general requires little if any special maintenance or cleaning. Furthermore, a relatively long T-tube can be used, and so the stent can occupy a longer section of the trachea than can a tracheostomy tube. We recommend the placement of a T-tube to provide a useful stent for cervical tracheal injury.

[A case of paraaortic lymph nodes metastases responding to TS-1 following surgery for gastric cancer].

A 58-year-old man underwent distal gastrectomy with a D2 lymph adenectomy for advanced gastric cancer (pStage IIIB). Seven months later, abdominal CT revealed multiple paraaortic lymph nodes metastases. Radiation therapy was not effective, so TS-1 chemotherapy was started (each treatment course consisted of daily oral administration of 100 mg TS-1 for 4 weeks followed by 2 drug-free weeks). The CT findings revealed that the metastatic lesion had shrunk markedly after the first course. A complete response was observed after the fifth course, and was maintained thereafter. The serum level of CEA decreased from 337 to 2.7 ng/ml after the third course, but gradually rose again and stayed between 30 and 50 ng/ml. Although the re-elevation of serum CEA level suggested the existence of a recurrent lesion, no sign of recurrence was found by radiographical or endoscopic examinations. Leukocytopenia and anemia (grade 2) were the only observed adverse effects. This patient continues to undergo outpatient treatment with good QOL.

Prognostic factors in patients with terminal stage lung cancer.

BACKGROUND: Lung cancer is the leading cause of cancer-related death.(1) Accurate prediction of survival in the terminal stage is important, because it may help patients make a rational decision. Although several prognostic scores have been described as effective indicators of outcome, these scores were intended for patients with other types of cancers. There is no prognostic score for patients with terminal-stage lung cancer. OBJECTIVE: The aim of this study was to determine prognostic factors for patients with terminal-stage lung cancer. SETTING/SUBJECTS: Patients in our palliative care unit (PCU) were selected retrospectively and divided into two independent groups, training and testing. Univariate and multivariate analyses were performed on data from the training group to detect independent prognostic factors, while data from patients in the testing group were analyzed to validate whether these prognostic factors predicted near-term death. RESULTS: Ninety-three patients (69 in the training group and 24 in the testing group) were included in the analyses. Multivariate analysis showed that fatigue, anorexia, desaturation, hyponatremia, and hypoalbuminemia were independent prognostic factors in the training group. Mean survival time in patients who had more than three of these five factors was 9.2±2.6 days (p=0.012). In the testing group, the presence of more than three of these five factors predicted death within two weeks, with a sensitivity of 100% and specificity of 75%. CONCLUSIONS: This study revealed that fatigue, anorexia, desaturation, hyponatremia, and hypoalbuminemia may be short-term prognostic factors in terminally ill lung cancer patients. In particular, the presence of more than three of these factors predicted death within two weeks.

Tissue oxygen saturation during colorectal surgery measured by near-infrared spectroscopy: pilot study to predict anastomotic complications.

INTRODUCTION: We investigated the relation between tissue oxygen saturation measured by near-infrared spectroscopy (NIRS) and anastomotic complications associated with colorectal surgery. METHODS: A series of 20 patients with colorectal cancer underwent radical surgery with enteric anastomosis. Measurements of tissue oxygen saturation (StO2) were performed at both the proximal and distal portions of the anastomotic site; in cases of anterior resection, we measured StO2 only in the proximal portion. RESULTS: Two anastomotic complications (one leakage, one stenosis) occurred in the 20 cases. The StO2 in patients with anastomotic complications was 58.0%, and that in patients without complications was 71.0%. Altogether, 18 patients had StO2 values > 66%, and none of them had anastomotic complications. In contrast, 2 patients had StO2 values < 60%, and both had anastomotic complications. CONCLUSIONS: The StO2 of the anastomotic site can be safely and reliably measured by NIRS during colorectal surgery. Low StO2 on both sides of the anastomosis may indicate an increased risk of anastomotic complications. Further study is needed to determine the cutoff value for StO2 required to prevent serious complications.

Duct-narrowing chronic pancreatitis without immunoserologic abnormality: comparison with duct-narrowing chronic pancreatitis with positive serological evidence and its clinical management.

We reviewed the clinical features and clinical course of patients with duct-narrowing chronic pancreatitis who were negative for immunoserologic test results (n = 16) in comparison with the findings for serological test-positive patients (n = 20) in order to determine an adequate treatment for those who had typical morphology of autoimmune pancreatitis in the absence of immunoserologic abnormality. No significant differences were found between the two groups of patients in clinical profiles including associated autoimmune-related diseases, pancreatic histology, and response to steroid therapy. Of the seronegative patients, eight who showed an improvement in narrowing of the main pancreatic duct with steroid therapy and three who did no show an improvement or who relapsed after surgical resection without this therapy had stenosis of the common bile duct with increased levels of serum hepatobiliary enzymes, except for two patients with affected sites limited to the body or tail of the gland. For the remaining five patients, who showed an improvement in pancreatic duct changes or long-term remission after surgery without steroid administration, normal biochemistry test results for liver functions were obtained, with no abnormal cholangiographic findings in the three patients examined. Duct-narrowing chronic pancreatitis without immunoserologic abnormality overlaps in clinical features with that fulfilling the immunoserologic criteria for a diagnosis of autoimmune pancreatitis. In particular, the disease with bile duct involvement should be treated clinically as autoimmune pancreatitis, for which steroid therapy is recommended, even if an autoimmune mechanism is not demonstrated serologically.

Long-term prognosis of duct-narrowing chronic pancreatitis: strategy for steroid treatment.

OBJECTIVES: The purpose of this study was to assess the long-term prognosis in patients with duct-narrowing chronic pancreatitis (DNCP) and determine the indications for steroid therapy. METHODS: We evaluated clinical and imaging outcomes in patients with DNCP classified into 3 groups (A, B, and C) according to the treatment given. Group A included 6 patients who underwent surgical resection. Groups B and C included 21 and 10 patients treated medically with and without steroid therapy, respectively. RESULTS: In group A, 2 patients relapsed in the remnant pancreas. In group B, pancreatic swelling was resolved in all the patients, and moreover, both the irregular narrowing of the main pancreatic duct (MPD) and the strictures of the common bile duct (CBD) improved after initiation of corticosteroid therapy in all but 1 of the patients, including 5 without immunoserologic abnormality. However, clinical recurrences occurred in 4 patients (19%) during or after the maintenance therapy. In group C, all the patients showed an improvement in swelling of the gland, while only 5 showed improvement of pancreatic duct involvement. Four of these 5 patients did not show any serologic data suggesting autoimmune abnormality or CBD involvement. In all the other 5 patients in whom MPD irregularities did not improve, bile duct strictures or positive immunoserologic test results were noted. CONCLUSIONS: Steroid therapy is effective for improving pancreatic duct and bile duct lesions in patients with DNCP and is indicated particularly in those with CBD strictures or immunoserologic abnormality, although some patients have recurrences.

Clinical and imaging features of autoimmune pancreatitis with focal pancreatic swelling or mass formation: comparison with so-called tumor-forming pancreatitis and pancreatic carcinoma.

OBJECTIVES: Autoimmune pancreatitis (AIP) with a mass formation or swollen pancreas located in one or two segments of the gland (focal type AIP) has been reported. The aims of this study were to elucidate the relationship of the disease entity between this focal variant and so-called tumor-forming pancreatitis (TFP) and to describe the clinical and imaging features discriminating focal AIP from pancreatic carcinoma (Pca). METHODS: The clinical, radiologic, and pathologic profiles of nine patients with focal AIP were reviewed retrospectively and compared with those of 11 patients with alcohol-induced TFP and 80 patients with Pca. RESULTS: The patients with focal AIP were predominantly older (mean age 64.7 +/- 13.6 yr, range 28-78 yr), male, and presenting with obstructive jaundice or focal pancreatic enlargement accompanied by mild abdominal symptoms. In comparison, the patients with alcohol-induced TFP who were mostly middle-aged (mean age 50.1 +/- 7.95 yr, range 39-62 yr), male, and often had attacks of pancreatitis associated with findings of CT scans showing pseudocysts or peripancreatic effusion. Focal AIP usually demonstrated no abnormalities on pancreatograms downstream from the stricture or obstruction and often presented few contrast-filled side branches in the area of main pancreatic duct (MPD) stenosis. These characteristics were similar to the imaging features of Pca. Significant factors differentiating focal AIP from Pca were lower serum levels of CA19-9, homogeneous delayed enhancement evident in dynamic CT scans, and ERCP findings exhibiting a longer stenosed MPD and a thinner MPD upstream from the stricture. CONCLUSIONS: Focal AIP is associated with clinical and radiologic features that are different from those of alcohol-induced TFP. In TFP there are two causative factors, namely, AIP and alcohol-induced chronic pancreatitis. Differential diagnosis of focal AIP from Pca seems to be possible in many cases by evaluating imaging findings such as dynamic CT and ERCP, although focal AIP sometimes shows clinical and radiologic features similar to those of Pca.

Clinical study of chronic pancreatitis with focal irregular narrowing of the main pancreatic duct and mass formation: comparison with chronic pancreatitis showing diffuse irregular narrowing of the main pancreatic duct.

INTRODUCTION: Main pancreatic duct (MPD)-narrowed chronic pancreatitis (CP) may be an autoimmune abnormality. It also has been called autoimmune pancreatitis and sclerosing pancreatitis. It is unclear whether cases with focal pancreatographic changes are part of the same clinical entity as cases with diffuse MPD changes. AIM AND METHODOLOGY: We reviewed seven cases of chronic pancreatitis (CP) with focal narrowing of the main pancreatic duct (MPD), evidenced by endoscopic retrograde cholangiopancreatography (ERCP), and swelling of one or two segments of the pancreas, evidenced by ultrasonography (US) /computed tomography (CT), and indicated the clinicopathologic features of focal-type MPD-narrowed CP. RESULTS: The patient group comprised six men and one woman, and their age range was 28-75 years, with a mean of 63.7 years. Affected sites were in the head in two patients, the body in one patient, the tail in one patient, and the body and tail in three patients; ERP showed narrowing in six patients and obstruction in one. Stricture of the lower portion of the common bile duct (CBD) that caused obstructive jaundice was shown by ERC in two cases in which the pancreas head was affected. In all six patients, a dynamic study by CT or MRI homogeneously showed delayed enhancement of involved segments of the pancreas. Serum levels of pancreatic enzyme were elevated in five patients, but only one subject had pancreatitis-like epigastric pain. Serological evidence suggestive of autoimmune abnormality was detected in only three patients with hypergammaglobulinemia (> or =2.0 g/dL) or positive titers of antinuclear antibody (ANA; > or =80). Histological assessment was available for five patients, who characteristically had dense lymphocytic or plasmocytic infiltration with severe fibrosis that caused luminal narrowing. The clinical, serologic, and histologic findings as described above were comparable to those for 12 CP patients with diffuse narrowing of the MPD, diagnosed during the same period. Surgical resection was performed in 5 patients, in 2 of whom a similar inflammatory process recurred in the remnant head of the pancreas, whereas pancreatitis no longer developed in the other 3 patients. One patient was initially treated with steroids, with clinical remission, although there was neither hypergammaglobulinemia nor positive ANA. CONCLUSION: These results indicate that CP with focal narrowing of the MPD is part of the same clinical spectrum as CP with diffuse narrowing of the MPD, and whether the distribution is diffuse or focal seems to be related to the stage or the extent of the disease. It is therefore important to recognize the possible existence of this focal variant to avoid unnecessary surgery.

Salvage surgery for primary non-Hodgkin's lymphoma of the thyroid gland with histopathological complete response to radio-chemotherapy: report of a case.

A 74-year-old woman was admitted to a local hospital for investigation of a rapidly growing mass in her neck, and exertional dyspnea. An open biopsy confirmed a diagnosis of non-Hodgkin's lymphoma of the thyroid (NHLT), of a diffuse large cell type. The patient was referred to our department for radio-chemotherapy for stage I E NHLT. She was given radiotherapy in the form of 40 Gy radiation directed at her neck and superior mediastinum, with one course of chemotherapy using cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP). After radio-chemotherapy, the tumor was obviously smaller. Because the patient refused further chemotherapy, she underwent salvage surgery, after being sufficiently advised, and with her informed consent. Histological examination of the removed thyroid tissue showed that the radio-chemotherapy had produced a complete response. Thus, we believe that an open biopsy should be performed early to confirm the diagnosis of lymphoma histologically and to determine the degree of malignancy. We also stress the fact that NHLT is presently most effectively treated by radiotherapy combined with several courses of CHOP chemotherapy. The role of surgery in the treatment of NHLT is diminishing.