Feasibility and Early Outcomes of Intensivist-Led Critical Care after Major Trauma in the Korean ICU

PURPOSE: Substantial evidence supports the benefits of an intensivist model of critical care delivery. However, currently, this mode of critical care delivery has not been widely adopted in Korea. We hypothesized that intensivist-led critical care is feasible and would improve ICU mortality after major trauma. MATERIALS AND METHODS: A trauma registry from May 2009 to April 2011 was reviewed retrospectively. We evaluated the relationship between modes of ICU care (open vs. intensivist) and in-hospital mortality following severe injury [Injury Severity Score (ISS) >15]. An intensivist-model was defined as ICU care delivered by a board-certified physician who had no other clinical responsibilities outside the ICU and who is primarily available to the critically ill or injured patients. ISS and Revised Trauma Score were used as measure of injury severity. The Trauma and Injury Severity Score methodology was used to calculate each individual patient's probability of survival. RESULTS: Of the 251 patients, 57 patients were treated by an intensivist [intensivist group (IG)] while 194 patients were not [non-intensivist group (NIG)]. The ISS of IG was significantly higher than that for NIG (26.5 vs. 22.3, p=0.023). The hospital mortality rate for IG was significantly lower than that for NIG (15.8% and 27.8%, p<0.001). CONCLUSION: The intensivist model of critical care is feasible, and there is room for improvement in the care of major trauma patients. Although trauma systems take time to mature, future studies are needed to evaluate the best model of critical care delivery for severely injured patients in Korea.

Thoracoscopic Diaphragmatic Plication Using Three 5 mm Ports / 대한흉부외과학회지

BACKGROUND: Diaphragmatic plication through a thoracoscopic approach has been an effective modality to treat diaphragmatic enventration. However, the conventional technique for thoracoscopic plication has some disadvantages. We have developed an improved and simplified technique with utilizing the head up position, CO2 insufflation and figure-of-eight sutures. MATERIAL AND METHOD: Between October 2005 and September 2009, 9 patients with diaphragmatic paralysis underwent repair using our modified technique. The mean patient age was 38.5+/-53.0 years (range: 2~76 years). RESULT: The mean operation time was 46.7+/-15.9 min (range: 30~85 min). None of the patients died due to this procedure, but there was one case of prolonged air leakage, and a case of re-expansion pulmonary edema, which required 3 days of ventilator support after the procedure. The mean hospital stay was 6.22+/-2.04 days (range: 4~11 days). The mean follow-up duration was 27.2+/-11.6 months (range: 2~43 months). All the patients had their symptoms relieved and there was no recurrence of eventration except for one patient who developed more than 2 cm elevation of the diaphragm compared to the immediate post-operation status. CONCLUSION: With our technique, thoracoscopic diaphragmatic plication was feasible via using only three 5 mm ports and without a working window and the midterm results were favorable. Therefore, we advocate thoracoscopic diaphragmatic plication as a preferred technique to the conventional open plication technique.

The Prognostic Significance of Multiple Station N2 in Patients with Surgically Resected Stage IIIA N2 Non-small Cell Lung Cancer

Mediastinal (N2) lymph node involvement is heterogenous with huge variation in the extent and grouped together under stage IIIA. However, they showed a different survival even in the same stage. We tried to determine the prognostic implication of the multiple station N2 lymph node metastasis in stage IIIA N2 non-small cell lung cancer (NSCLC). The survival of stage IIIA N2 was analyzed according to the number of N2 station and their survival was compared with that of stage IIIB. In stage IIIA N2 NSCLC, multivariate analysis indicated that multiple station N2 was one of the independent prognostic factors for poor survival. The 5-yr survival of multiple station N2 IIIA (20.4%) was lower than that of single station N2 IIIA (33.8%) significantly (p=0.016). but when it was compared with that of stage IIIB (15.5%), there was no difference. Therefore, we suggest that multiple station N2 should be considered similar to stage IIIB disease with regard to predicting survival and accordingly should receive a new position in the TNM staging system.

Impact of Postoperative Oral Administration of UFT for Completely Resected pT2N0 Non-Small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Recent studies have suggested that UFT may be an effective adjuvant therapy for completely resected IB (pT2N0) non-small cell lung cancer (NSCLC). We designed this study to clarify the feasibility of performing adjuvant chemotherapy with UFT for completely resected IB non-small cell lung cancer. MATERIAL AND METHOD: We randomly assigned patients suffering with completely resected IB non-small cell lung cancer to receive either UFT 3g for 2 year or they received no treatment. All patients had to be followed until death or the cut-off date (December 31 2006). RESULT: From June 2002 through December 2004, 64 patients were enrolled. Thirty five patients were assigned to receive UFT(the UFT group) and 29 patients were assigned to observation (the control group). A follow-up survey on the 3 year survival rate was successfully completed for all the patients. The median follow-up time for all the patients was 32.8 months. In the UFT group, the median time of administration was 98 weeks (range: 2~129 weeks). The rate of compliance was 88.2% at 6 months, 87.5% at 12 months, 80.6% at 18 month and 66.7% at 24 months. Seven recurrences (24.1%) occurred in the control group and six (17.1%) occurred in the UFT group (p=0.489). The three-year disease free survival rate was 71.3% for the control group and 82.0% for the UFT group (p=0.331). On the subgroup analysis, the three-year disease free survival rate for the patients with adenocacinoma was 45.0% for the control group and 75.2% for the UFT group (p=0.121). The three-year disease free survival rate for the patients with non-adenocarcinoma was 88.1% for the control group and 88.9% for the UFT group (p=0.964). CONCLUSION: Postoperative oral administration of UFT was well-tolerated. Adjuvant chemotherapy with UFT for completely resected pT2N0 adenocarcinoma of the lung could be expected to improve the disease free survival, but this failed to achieve statistical significance. A prospective randomized study for a large number of patients will be necessary.

Repair of Morgagni Hernia through the Abdominal Approach: A case report / 대한흉부외과학회지

Morgagni's hernia constitutes about 3% of all the congenital diaphragm hernias. It is usually asymptomatic and it is frequently found coincidentally during routine diagnostic testing in adulthood. It is usually diagnosed by simple chest X-ray, but when this condition is without intestinal herniation, then chest CT or other modalities are necessary. Operative repair is desirable when there is the risk of strangulation of the intestine. The trans-thoracic or trans-abdominal approaches are possible to treat this malady. We report here on one case for which we successfully used a laparoscopic approach to treat this problem.

A Case of Mixed Germ Cell Tumor of the Mediastinum / 결핵및호흡기질환

The Mixed germ cell tumors of the mediastinum are very quite rare. The Prognosis is generally dominated by the most aggressive component, which is represented by a choriocarcinoma, an endodermal sinus tumor, an embryonal carcinoma, and a seminoma, in descending order of in the degree of malignancy. We experienced one a case of a mixed germ cell tumor at the anterior mediastinum. The patient was 27-year-old male, who complained of hemoptysis and cough. The Chest X-ray showed a well-defined lobulated mediastinal mass in the left upper lung field. The operation was done and The mass was excised surgically. A Biopsy showed elements of mature tissues, immature neuronal components, and seminoma components.

Prognostic Factors of Thymic Carcinoma / 대한흉부외과학회지

BACKGROUND: Thymic carcinoma is a rare malignant disease with sparse data for treatment and prognosis. We intended to investigate the prognostic factors of thymic carcinoma. MATERIAL AND METHOD: Data of 42 patients, who were diagnosed and treated for thymic carcinoma from January of 1986 to August of 2003 were reviewed retrospectively. Influences of characteristics of patients, Masaoka stage, histologic grade, completeness of resection and adjuvant treatment on survival were evaluated. RESULT: There were 30 male and 12 female patients and their mean age was 52.0+/-15.7 years old. There were 28 patients with low-grade histology and 13 patients with high- grade histology. Clinical stage according to Masaoka stage were I in 2, II in 2, III in 15 (35.7%), IVa in 10 (23.8%), and IVb in 13 (31%) patients. Surgical resection was done in 22 patients. Complete resection was possible in 13 patients and incomplete resection was done in 9 patients. Among 20 patients without resection, 8 patients received chemotherapy, 7 patients received radiotherapy and 5 patients received combined therapy. Median survival time was 31.7+/-6.1 months and 5 year survival rate was 28.6%. High grade histology (hazard ratio=3.009, 95% confidence interval=1.178~7.685, p=0.021) and incompleteness of resection (hazard ratio=3.605, 95% confidence interval=1.154~11.580, p=0.023) were the prognostic factors of thymic carcinoma. CONCLUSION: In thymic carcinoma, low grade histology is a good prognostic factor and complete resection can prolong the survival of patients.

Risk Factors for Recurrence in Completely Resected pT1/2N1 Non-small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Complete surgical resection is the most effective treatment for pT1/2N1 non-small cell lung cancer, however 5 year survival rate of these patients is about 40% and the major cause of death is recurrent disease. We intended to clarify the risk factors of recurrence in completely resected pT1/2N1 non-small cell lung cancer. MATERIAL NAD METHOD: From Jan. 1990 to Jul. 2003, total of 117 patients were operated for pT1/2N1 non-small cell lung cancer. The risk of recurrence according to patients characteristics, histopathologic findings, type of resection, pattern of lymph node metastasis, postoperative adjuvant treatment were evaluated retrospectively. RESULT: Mean age of patients was 59.3 years. There were 14 patients with T1N1 and 103 patients with T2N1 disease. Median follow-up time was 27.5 months and overall 5 year survival rate was 41.3%. 5 year freedom-from recurrence rate was 54.1%. Recurrence was observed in 44 (37.6%) patients and distant recurrence developed in 40 patients. 5 year survival rate of patients with recurence was 3.3%, which was significantly lower than patients without recurrence (61.3%, p=0.000). In multi-variate analysis of risk factors for freedom-from recurrence rate, multi-station N1 (hazard ratio=1.997, p=0.047) was a poor prognostic factor. CONCLUSION: Multi-station N1 is the risk factor for recurrence in completely resected pT1/2N1 non-small cell lung cancer.

Change in Pulmonary Function Following Empyemectomy and Decortication in Tuberculous and Non-Tuberculous Chronic Empyema Thoracis

Chronic empyema thoracis results from various etiologies. Improvement in pulmonary function after empyemectomy and decortication has proved difficult to predict when the etiology of chronic empyema thoracis is tuberculosis. The purpose of this study was to confirm the changes in pulmonary function according to the etiology after an operation. Sixty-five patients were classified into two groups according to their etiology: Group A (tuberculous) and Group B (non-tuberculous), and they were retrospectively evaluated with regard to their forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), percentage of predicted normal value of FEV1 (% FEV1) and FVC (%FVC). Empyemectomy and decortication was performed for all the patients and the two groups were similar in age, gender and preoperative spirometric parameters. In Group A (n=41), the pre- and postoperative mean values were 2.31L and 2.88L in FEV1, 65.8% and 80.5% in %FEV1, 2.62L and 2.55 L in VC, 61.9% and 71.8% in %VC, respectively. In Group B (n=24), the pre- and postoperative mean values were 2.13L and 2.49L in FEV1, 66.4% and 73.8% in %FEV1, 2.55L and 2.95 L in FVC, 64.9% and 71.8% in %FVC, respectively. All the spirometric parameters improved significantly in both groups compared to their preoperative values. However, no significance was shown in the rate of increase of the spirometric parameters between the two groups. In conclusion, improvement of lung function is expected after empyemectomy and decortication, regardless of the etiology of the chronic empyema thoracis.

Diagnosis and Treatment of Primary Mediastinal Tumors and Cysts: Forty-two years report in a University Hospital / 결핵

BACKGROUND: The diagnostic and therapeutic approaches to mediastinal tumors and cysts have changed over the past three decades. This report summarizes our forty-two years of experience with these tumors. METHODS: This study retrospectively reviewed 479 patients with primary mediastinal tumors and cysts that were diagnosed and managed over the past 17-year period (1985~2002) and compared them to the report of the previous 25-year result (1960~1985) in Yonsei University College of Medicine, Severance Hospital in Seoul, Korea. RESULTS: During the 17 years, there were 479 cases of pathologically proven mediastinal tumors and cysts. Thymoma (38.2%) was the most common mediastinal tumor and has increased noticeably during recent years. The gender ratio showed a male predominance (1.3:1) and the age distributions were even over all the age groups. The most common sites of the tumor and the proportion(28.6%) of malignant tumors were the same as that previously reported. A diagnosis of a tumor in asymptomatic patients was possible in 174 cases (36.3%), which was higher that reported previously. The diagnostic yield of a fine needle aspiration biopsy was 68.6% in the total tumors and 80.9% in the malignant tumors. A surgical resection was the most frequently chosen treatment modality and was performed in 405 cases (84.6%). The complete resection rate was 91.1%, which is higher than the previous result of 78.8%. CONCLUSION: These results showed that the prevalence of mediastinal tumors and cysts, particularly thymoma, increased. A fine needle aspiration biopsy was a valuable preoperative differential diagnostic method for malignant tumors. The surgical and complete resection rate increased remarkably possibly due to the better applicable chest CT scans, the more frequent health check-up provided by the regular health promotion program for all people as a health insurance policy, and the improved diagnostic techniques in the pathologic, radiological, and clinical fields.

Two Cases of Bronchial Leiomyoma Initially Misdiagnosed as Bronchial Asthma / 결핵

Leiomyoma of the bronchus is a very rare benign tumor of the lung. Leiomyoma is usually found in the young and the middle age. The symptom depends on the location of the tumor, it's size, and changes in the lung distal to the lesion. Obstructive symptoms due to leiomyoma could be similar to those of asthma and bronchitis, and therefore delayed diagnosis is common. The treatment of leiomyoma is conservative since there have been no reports of recurrence after limited resection. Recently bronchoscopic tumor resection has been applied to selected cases. We experienced two cases of bronchial leiomyoma initially misdiagnosed as bronchial asthma which were successfully excisedby resection, end-to-end anastomosis and bronchoplasty. To prevent destructive changes of lung distal to obstruction and to preserve the pulmonary function, early diagnosis and appropriate treatment are important points of consideration.

The Comparison of VATS Ramicotomy and VATS Sympathicotomy for Treating Essential Hyperhidrosis

This study was undertaken to determine if better results could be achieved by comparing the results of a thoracic sympathetic ramicotomy (division of rami communicantes) with a conventional thoracic sympathicotomy (division of sympathetic trunk) for treating essential hyperhidrosis. From August 2001 to February 2002, 29 consecutive patients underwent surgery of the sympathetic nerves in order to treat severe essential hyperhidrosis. Of these patients, a ramicotomy was performed under VATS (VATS-R) in 13 patients, sympathicotomy under VATS (VATS-S) in 13, a unilateral ramicotomy and contralateral sympathicotomy under VATS (VATS-RS) in 2 and a sympathicotomy via a thoracotomy (T-S) in 1. There was no significant difference between the VATS ramicotomy group (VATS-R, n=13) and VATS sympathicotomy group (VATS-S, n=13) in terms of gender, pleural adhesions or comorbidities. However, the age of the VATS-S group at surgery was higher than that of the VATS-R group (p=0.050). The operation times, and hospital stays of the groups were 51.5 and 41.9 minutes, and 2.0 and 2.3 days, respectively. The recurrence rate of the operated sites according to the surgical methods (ramicotomy and sympathicotomy regardless of VATS) was 21.4% (6/28) in the ramicotomy group and 6.7% (2/30) in the sympathicotomy group, but there was no statistical significance (p=0.101). This study compared the dryness of the enervated sites and the severity of compensatory sweating among the ramicotomy (n=11, excluded 2 re-operated cases from 13 VATS-R), sympathicotomy (n=14, VATS-S 13 and T-S 1) and the synchronous or metachronous ramicotomy/sympathicotomy groups (n=4, included 2 reoperated cases of VATS-R). The sympathicotomy group had an over-dryness of the enervated sites (dryness 1.4, from 1 to 3; 1: over-dried, 2: humid, 3: persistent sweating) and complained of severe compensatory sweating (severity 3.5, from 1 to 4; 1: absent, 2: mild, 3: embarrassing, 4: disabling). However, the patients whounderwent a ramicotomy maintained some humidity of the enervated sites (dryness 2.0, p=0.012) and showed milder compensatory sweating (severity 2.7, p=0.056) than those in the sympathicotomy group. Furthermore, the dryness of the ramicotomy side was different from that of the sympathicotomy side in 3 out of 4 ramicotomy / sympathicotomy (R+S) patients (the side of the ramicotomy was humid and that of the sympathicotomy was over-dried). The average dryness and the compensatory sweating at these sites were in the midst of the two groups (dryness and severity 1.6 and 3.0, respectively). A ramicotomy can prevent over-dryness of the enervated area and decrease the severity of compensatory sweating through the selective division of the rami communicantes of the thoracic sympathetic ganglia. Postoperatively, almost all ramicotomy patients had no functional problems in daily life or in their occupational activity, because they could maintain hand humidity. Moreover, they showed no more than a mild degree of compensatory sweating and reported high long-term satisfaction rates. Therefore, a sympathetic ramicotomy rather than a conventional sympathicotomy is recommended as a more selective and physiologic modality for treating essential hyperhidrosis.

Clinicopathological Correlation of Intralobar Pulmonary Sequestration / 대한흉부외과학회지

BACKGROUND: Intralobar and extralobar pulmonary sequestrations have been considered as congenital lesions that occur at different stages of embryonic life. However, most cases of intralobar pulmonary sequestration (IPS) seem to have an acquired origin, as they are absent in infants and associated anomalies are relatively uncommon among them. MATERIAL AND METHOD: The cases of 25 patients who were diagnosed as IPS after surgical resection from December, 1985 to July, 2002 were included in this study. The medical records were retrospectively reviewed and the clinical characteristics were age at operation; gender; symptoms at presentation; presence of congenital anomalies; combined diseases; preoperative studies and diagnosis; location of the lesion; method of surgical resection; origin, size and numbers of aberrant artery; histopathological findings; and postoperative complications. RESULT: There were 17 (68%) female patients and 8 (32%) male patients, their ages ranged from 1 to 57 and mean value was 23 years old. Though 14 patients (56%) complained of respiratory symptoms such as pneumonia and recurrent respiratory infections, a large number of patients (44%) were asymptomatic or had chest pain only when the lesion was discovered. Only 8 patients (32%) were diagnosed as pulmonary sequestration preoperatively and 8 (32%) were suspected as mediastinal or lung tumor, 5 (20%) were congenital or acquired cystic lung disease, and 4 (16%) were lung abscess or bronchiectasis, respectively. The majority of aberrant arteries (86.4%) confirmed during the operation were originated from thoracic aorta and 2 were thoracic and abdominal aorta, 1 was abdominal aorta, respectively. The younger patients (less than 10 years old) had more other congenital anomalies (30% vs 6.7%) but the proportion of congenital IPS was not signifi cantly different (10% vs 6.7%, p>0.05) compared with elder patients. Histopathologically, almost all lesions showed chronic inflammation, cystic changes and similar pleural adhesions regardless of age. CONCLUSION: The large portion of the patients with IPS (44%) was clinically asymptomatic or presented non-respiratory symptoms at diagnosis and likely to be diagnosed as mediastinal or lung tumor especially in elder patients. Though the younger patients had more other congenital anomalies, most cases of IPS proved to be acquired lesions in terms of the histopathlogical findings and the proportion of congenital evidences.

Clinical Features of Pulmonary Large Cell Neuroendocrine Carcinoma / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study was performed to investigate the clinical features of large cell neuroendocrine carcinomas (LCNEC). MATERIALS AND METHODS: We retrospectively reviewed the histopathology and clinical information of 37 patients with LCNEC, diagnosed between June 1992 and May 2002 at the Severance Hospital, and performed immunohistochemical (IHC) staining. RESULTS: The prevalence of LCNEC among primary lung cancers was 0.3%, 37 out of 13, 012 cases over a 10 year period. The mean age was 61+/-12 years old, with 34 (92%) males and 3 (8%) females. 30 patients smoked, with an average of 42 packs per year. A cough was the most frequent symptom. The tumor was located at the periphery of the lung in 24 cases (65%). Among the 30 cases that underwent surgery, 4 were diagnosed pathological stage IA, 11 IB, 1 IIB, 13 IIIA and 1 IIIB. The 7 clinically non-operable cases were IIIB in 3, and IV in 4. The positive rates of CD56, thyroid transcription factor-1 (TTF-1), chromogranin A, synaptophysin and 34betaE12 for tumor cells were 88.9, 55.6, 42.1, 31.6 and 21.1%, respectively, from the IHC staining. The median survival time and 5 year-survival rate were 24 months and 27%, respectively. The group that underwent surgery had a better prognosis than those that did not. CONCLUSION: The positive rates for the tumor markers varied, but those of the CD56 and TFT-1 were the highest. The possibility of LCNEC needs to be evaluated for the following situations: small cell carcinomas located at the periphery and not responding chemotherapy, small cell carcinomas diagnosed by percutaneous needle aspiration, poorly differentiated non-mall cell carcinomas, with uncertain histologic type, and unclassified neuroendocrine tumor, etc.

The Effect of Visceral Pleura Invasion in the Resected Stage IB Non-Small Cell Lung Cancer Patients

PURPOSE: The purpose of this study was to clarify the prognostic significance of visceral pleura invasion in T2N0M0 non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Between Jan. 1990 and Dec. 2001, 213 consecutive patients with T2N0M0 NSCLC underwent complete surgical resection. The patients were divided into two groups according to the existence of visceral pleural invasion. P1 and P2 defined by Hammar's definition were included in visceral pleural invasion group. The follow-up was carried out completely without missing case. The median follow-up period was 34.4 months, ranging from 0.13 to 156.2 months. RESULTS: Patient ages ranged from 10 to 79 years (mean: 60.1 years, median : 62 years). Visceral invasion was identified in 55 patients (25.8%). The operation included lobectomy in 110, pneumonectomy in 67, bi-lobectomy in 36 patients. Histology was squamous cell carcinoma in 110, adenocarcinoma in 72, large cell carcinoma in 13, others in 18. There were 5 hospital mortality (2.3%) and 71 late mortality (33.3%). 27 (50.94%) and 44 (28.4%) of late mortality were in visceral pleural invasion group (Group I) and visceral pleural non-invasion group (Group II) respectively (p=0.002). Overall 5-year survival rate was 44.8% in Group I and 63.5% in group II (p=0.0017). There were 55 (25.8%) postoperative recurrences, 24(43.6%) in group I, 21 (13.3%) in group II (p<0.0001). There were 60 recurrence sites, 58 (96.7%) of them were distant metastases, 2 (3.3%) were local recurrences. CONCLUSION: Visceral pleural invasion is a significant prognostic factor in stage IB NSCLC in survival time and recurrence. The postoperative adjuvant systemic therapy can be thought in stage IB NSCLC with visceral pleural invasion

A Case of Lung Metastasis of Mesoblastic Nephroma in Adulthood / 결핵

Mesoblastic nephroma is a neoplasm of the kidney which is characterized by interlacing bundles of spindle mesenchymal cells. It is usually diagnosed during the first six months of life and is mostly benign. Incidence in adults is exceedingly rare. In most cases, only total excision is required without postoperative adjuvant therapy, and the rare cases of local recurrence have usually been related to incomplete removal. However, mesoblastic nephroma may behave aggressively, in contrast to a congenital mesoblastic nephroma. Several cases of metastatic mesoblastic nephroma have been previously described. We report herein a case of a 42-year-old woman with mesoblastic nephroma which recurred as a large metastatic lung mass seven years after the nephrectomy. The patient presented with chest wall discomfort for four days. Seven years previously, total nephrectomy had been performed because of a right renal tumor which had been diagnosed as a mesoblastic nephroma. There had been no evidence of recurrence for five years, after which she discontinued follow-up. On readmission two years later, chest X-ray and CT scan revealed a large lung mass in the left upper lobe. It was completely excised and the pathologic examination was identical with that of the original renal tumor. Synovial sarcoma was excluded because the fusion transcripts of the SYT-SSX fusion gene associated with the t(X;18) translocation were negative. The final diagnosis was a lung metastasis of mesoblastic nephroma and the patient remained free of disease for 7 months postoperatively.

The Effect of ZD 1839 (Iressa(R)) in the Treatment of Refractory Non Small Cell Lung Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The aim of this study was to evaluate the efficacy and the safety of ZD 1839 (Iressa(R)) as a 3rd or 4th line chemotherapy regimen in NSCLC patients who are refractory to a previous chemotherapy regimen. MATERIALS AND METHODS: Twenty-five patients who were refractory to previous chemotherapy were selected for this study. The eligible patients had an ECOG performance status of 0 to 2, and an appropriate end organ function. ZD 1839 (Iressa(R))250 mg/d was orally administered until the patients experienced disease progression or unacceptable toxicity. RESULTS: Twenty-five patients were analyzed. The median age of the patients was 57 years. The response rate was 12.0% with partial responses in 3 patients. Fourteen patients (56%) remained in the stable disease state and 8 patients progressed. The median overall survival was 9.0 months (95% CI 6.7~11.2). The median progression free survival was 3 months (95% CI 2.2~3.8). Hematological toxicities of grade 3 or 4 neutropenia, anemia and thrombocytopenia were absent. Non-hematological toxicities were grade 2 or 3 skin rashes in 10 (40.0%) patients and 1 (4.0%) patient and grade 3 nausea in 3 (12.0%) patients. No patient failed to continue chemotherapy due to any drug-related adverse events. CONCLUSION: The results suggest that ZD 1839 (Iressa(R)) monotherapy is effective and tolerable as a 3rd or 4th line salvage treatment for NSCLC patients refractory to previous chemotherapy regimens.

Clinical Significance of the Aortic Node in Non-small Cell Lung Cancer of the Left Upper Lobe / 대한흉부외과학회지

BACKGROUND: To clarify the clinical significance of the aortic nodes in resected non-small cell lung cancer of the left upper lobe. MATERIAL AND METHOD: One hundred fifty six patients with resected non-small cell lung cancer of the left upper lobe were studied. Patients who received preoperative induction therapy, non-curative operation or defined as operative mortality were excluded from this study. RESULT: In N2 left upper lobe tumors, aortic nodes comprised 52.7% of the metastatic mediastinal lymph nodes. In single station N2 disease, a frequently metastasized station was aortic node (64.3%). 5-year actuarial survival according to the N status was 65.0% in N0, 30.4% in N1, and 17.9% in N2. There was no statistically significant difference in survival between N1 and N2 diseases (p=0.06). The patients with metastasis to aortic node alone had a comparatively good prognosis (5-year survival: 35.6%) than other N2 diseases (5-year survival: 4.6%) (p=0.01) and had a similar survival outcome as N1 diseases (p=0.97). Considering the aortic node as N1 node, 5-year survival according to the N status was 65.0% in N0, 31.2% in N1, 4.6% in N2 and significant survival difference was observed between N1 and N2 disease (p=0.00). In multivariate analysis, the male sex (hazard ratio 6.892, p=0.011) and the involvement to the aortic node alone (hazards ratio 2.799, p=0.009) were the significant factors affecting postoperative survival. CONCLUSION: According to the our data, involvement to the aortic node alone in left upper lobe tumors should be grouped with N1 disease because this combined category reflects the surgical outcome more accurately.

Nodal Station as a Prognostic Factor in Resected Stage IIIA N2 Non-Small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: To clarify the prognostic implication of the location and number of the metastatic mediastinal nodes in resected stage IIIA N2 non-small cell lung cancer. MATERIAL AND METHOD: One hundred and seventy-four patients with resected non-small cell lung cancer who eventually proved to have pathologic stage IIIA N2 disease were studied. Patients who received preoperative induction therapy, non-curative operation or defined as operative mortality were excluded from this study. RESULT: In upper lobe tumors, there was no difference in 5-year survival according to the involvement of lower mediastinal nodes (32.3% vs 25.6%, p=0.86). In lower lobe tumors, no differencee was found in 5-year survival according to the involvement of upper mediastinal nodes (25.1% vs 14.1%, p=0.33). There was no significant difference in 5-year survival between patients with or without metastatic subcarinal node (20.9% vs 25.6%, p=0.364). In terms of the number of metastatic mediastinal nodes, 5-year survival was better in single station group (26.3%) than multiple station group (18.3%) (p=0.048). In multiple station N2 group, the patients who received postoperative chemotherapy and radiation therapy had better 5-year survival (34.2%) (p=0.01). Cox's proportional hazards model revealed that the age > or =60 (O.R: 1.682, p=.006), multiple station N2 (O.R: 1.503. p=0.021), pneumonectomy (O.R: 1.562, p=0.018), postoperative chemotherapy and radiation therapy (O.R: 0.625, p=0.012) were the factors affecting the postoperative survival. CONCLUSION: Multiple station N2 disease was the important prognostic factor for postoperative survival in resected stage IIIA N2 non-small cell lung cancer. Postoperative chemotherapy and radiotherapy were thought to improve the survival in case of multiple station N2 disease.

Anatomical Variations in the Communicating Rami of the Upper Thoracic Sympathetic Ganglia Related to the Essential Palmar Hyperhidrosis / 대한흉부외과학회지

BACKGROUND: Although ramicotomy (division of the rami communicantes of the thoracic sympathetic ganglia) is a selective and physiological surgical method for essential hyperhidrosis, it has some problems such as higher recurrence rates and the different surgical results among the patients and between left and right sides in the same individual. As one of the factors that are related to the differences in surgical result and recurrences, we investigated the anatomical variations of the rami communicantes. The purpose of this study is to help develop new surgical methods to decrease surgical differences among the patients or between the left and right sides of the same individual and recurrence rates in the clinical application of ramicotomy. MATERIAL AND METHOD: We dissected 118 thoracic sympathetic chains in 59 adult Korean cadavers (male: 33, female: 26) to examine the anatomical variations of the rami communicantes from the second to the fourth thoracic sympathetic ganglia that have major components innervating to the hands. After the dissection of bilateral thoracic sympathetic chains, we compared the anatomy of left and right sides and examined the anatomical variations of rami communicantes. RESULT: The number and variation of communicating rami connecting the spinal nerves and the second sympathetic thoracic ganglion were much larger than lower levels. There was considerably less variability in the anatomy of the rami communicantes at successive levels. Among the 59 cadavers dissected, only 14.3% (9/59) had similar anatomy of thoracic sympathetic chains at both sides. As the components related to the essential palmar hyperhidrosis, intrathoracic nerve of Kuntz from the second thoracic sympathetic ganglion to the first intercostal nerve or brachial plexus were observed in 55.9% (66/118). The incidence of descending rami communicates from the second thoracic sympathetic ganglion to the third intercostal nerve and from the third thoracic sympathetic ganglion to the fourth intercostal nerve were 49.2% (58/118) and 28.0% (33/118). And the incidence of ascending rami communicates from the third thoracic sympathetic ganglion to the second intercostal nerve and from the fourth thoracic sympathetic ganglion to the third intercostal nerve were 6.8% (8/118) and 3.4% (4/118), respectively. CONCLUSION: Based on the various anatomical evidences of the rami communicantes from this study, only the ramicotomy at the third sympathetic ganglion level is insufficient for the treatment of the essential palmar hyperhidrosis to decrease the difference of surgical results and recurrences. When one is planning to perform the ramicotomy for the essential palmar hyperhidrosis, it is advantageous to divide the intrathoracic nerve of Kuntz on the second rib and the descending or ascending rami communicantes on the third and the fourth ribs as well as all the communicating rami from the third sympathetic ganglion.