Impact of residual induction number of non-pulmonary vein foci on the 2-year outcomes in patients with paroxysmal atrial fibrillation.

BACKGROUND: Residual non-pulmonary vein (PV) foci are significantly associated with atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). However, we previously reported among patients with non-PV foci induced only once, none experienced AF recurrence. Thus, we aimed to investigate the correlation between the residual induction number of non-PV foci and ablation outcome in paroxysmal AF patients. METHODS AND RESULTS: We investigated 55 paroxysmal AF patients with residual non-PV foci after PVI and ablation of non-PV-foci. Study patients were classified into the residual one-time induction of non-PV foci (residual OTI-nPVF) group (n = 23) and residual repeatedly induced non-PV foci (residual RI-nPVF) group (n = 32). Furthermore, the residual RI-nPVF group was divided into the low inducibility group (n = 10) and high inducibility group (n = 22) according to the presence or absence of non-PV foci provoked by two sets of drug induction tests (non-PV foci inducibility). In addition, the latter was divided into the ablation group (n = 14) or observation group (n = 8). The 2-year AF recurrence-free rate in the residual RI-nPVF group was significantly lower compared to the residual OTI-nPVF group (53% vs. 90%, p = 0.018). There was no significant difference of the 2-year AF recurrence-free rates in the inducibility of non-PV foci (p = 0.913) and the presence or absence of ablation (p = 0.812) in the residual RI-nPVF group. CONCLUSIONS: Among paroxysmal AF patients, the presence of residual RI-nPVF was associated with higher AF recurrence compared to residual OTI-nPVF. Furthermore, within residual RI-nPVF subgroup, non-PV foci inducibility or ablation of some residual RI-nPVF did not affect ablation outcome.

Clinical Impact of Perfusion Balloon for ST-Segment Elevated Myocardial Infarction: RYUSEI Study.

Drug-eluting stents have significantly contributed to reducing mortality in patients with ST-segment elevation myocardial infarctions (STEMIs), but slow-flow/no-reflow phenomenon (SFNR) and in-stent restenosis are still clinical problems. In contrast, perfusion balloons (PBs) can compress thrombi and ruptured plaque for long inflation without ischemia and can be used as a delivery device for infusion of nitroprusside to distal risk area during ballooning. We conducted a Reduction of risk bY perfUsion balloon for ST-segment Elevated myocardial Infarction (RYUSEI) study to evaluate whether PBs before stenting are more effective than conventional stenting for STEMIs. We divided consecutive patients with STEMIs who underwent optical coherence tomography (OCT)-guided percutaneous coronary intervention into PB group who were treated with PBs (Ryusei; Kaneka Medix Corporation, Osaka, Japan) before stenting and the conventional percutaneous coronary intervention (CP) group. We compared clinical results including SFNR, OCT findings, and clinical events between the 2 groups. We finally analyzed 34 patients in PB group and 90 in CP group. After propensity score-matching, PB and CP groups consisted of 23 patients, respectively. In the propensity score-matched cohort, SFNR and maximum protrusion area detected by OCT were significantly lower (p = 0.047 and p = 0.019), and thrombolysis in myocardial infarction flow grade 3 was higher (p = 0.022) in the PB group than CP group. Kaplan-Meier analysis revealed a significantly better clinical outcome in PB group than CP group (p = 0.038). In conclusion, the RYUSEI study revealed a pre-stent lesion modification in addition to nitroprusside infusion using PB is useful to achieve better clinical courses in STEMI patients.

Prognostic Comparison of Octogenarian vs. Non-Octogenarian With Acute Decompensated Heart Failure　- AURORA Study.

BACKGROUND: Acute decompensated heart failure (ADHF) is the main cause of hospitalization and death of octogenarians, but no data on the 1-year post-discharge mortality rate. We evaluated the clinical status and predictors of 1-year mortality in octogenarians with ADHF.Methods and Results: From the AURORA (Acute Heart Failure Registry in Osaka Rosai Hospital) study, we examined 1,246 hospitalized ADHF patients. We compared the in-hospital mortality rate and the proportion of heart failure (HF) with preserved ejection fraction (HFpEF) between octogenarians and non-octogenarians. After discharge we compared the 1-year mortality rate between these groups, and we also evaluated the predictors of death in both groups. The proportion of HFpEF among the in-hospital deaths of octogenarians was significantly higher than in non-octogenarians (46.2% vs. 15.0%, P=0.031). The 1-year mortality rate after discharge was significantly higher in the octogenarians than non-octogenarians (P=0.014). Multivariable Cox regression analysis revealed that albumin ≤3.0 g/dL and antiplatelet agents were useful predictors of 1-year death after discharge of octogenarians whereas chronic kidney disease was a predictor in the non-octogenarians. CONCLUSIONS: The proportion of HFpEF among in-hospital deaths of octogenarians with ADHF was high as compared with non-octogenarians. When octogenarians with ADHF have severe hypoalbuminemia and antiplatelet agents, early nutritional and medical interventions after discharge may be important to improve the 1-year prognosis.

Bilateral video-assisted thoracic surgery for esophageal cancer with left inferior pulmonary vein invasion following chemoradiation therapy.

BACKGROUND: The surgical strategy for thoracic esophageal cancer that invades the lungs is controversial. In particular, invasion of the pulmonary vein is often regarded unresectable. We successfully applied bilateral video-assisted thoracic surgery (VATS) in esophagectomy for esophageal cancer with left inferior pulmonary vein invasion following induction chemoradiotherapy (CRT), with a favorable response. CASE PRESENTATION: A 64-year-old woman was diagnosed with squamous cell carcinoma of the lower third of the esophagus. Computed tomography (CT) revealed that the tumor was suspected to be invading the main trunk of the left lower pulmonary vein and left lower lung. We initiated induction CRT comprising 5-fluorouracil, cisplatin, and concurrent radiotherapy at 50.4 Gy/28Fr. CT revealed shrinkage of the tumor, and the main trunk of the left inferior pulmonary vein was released from the tumor invasion. We considered the tumor to be completely resectable. VATS esophagectomy is usually performed using a right-sided approach. However, the right-sided approach is inappropriate for evaluating tumors around the left inferior pulmonary vein. We started with left-sided VATS to determine tumor resectability and dissected between the esophagus and the main trunk of the left inferior pulmonary vein. We only needed to perform partial resection of the left lower lobe. We then performed a right-sided VATS esophagectomy and lymphadenectomy with partial en bloc resection of the left lower lobe. Following this, we performed hand-assisted laparoscopic proximal gastrectomy and reconstruction using the gastric remnant. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Histopathological examination of the surgical specimen revealed a complete pathological response without any remnant tumor or lymph node metastasis. There were no signs of recurrence or metastasis at the 1-year follow-up. CONCLUSIONS: Curative resection for thoracic esophageal cancer that invades the pulmonary vein could be possible via the bilateral VATS approach following induction CRT with a favorable response.

[A Case of Sister Mary Joseph's Nodule after Radiation Therapy for Cervical Cancer].

An umbilical metastasis from an internal malignancy is called Sister Mary Joseph's nodule(SMJN)and has a poor prognosis. Herein, we report a case of umbilical metastasis of cervical cancer. A woman in her eighties underwent radiation therapy for cervical cancer(cT3bN0M0, cStage ⅢB). Primary tumor shrank after treatment, suggesting that radiation therapy induced complete response. Two years and 9 months after treatment, the patient presented with umbilical pain. A CT scan showed an umbilical mass near the umbilical hernia. PET-CT demonstrated high accumulation of FDG at the mass, which led to suspicion of umbilical metastasis(SMJN). Although she underwent radical surgery, she died from cancer 8 months after surgery.

Detection of sentinel lymph node with a novel near-infrared fluorescence spectrum system and indocyanine green fluorescence in patients with early breast cancer: First clinical experience.

BACKGROUND: Sentinel lymph node biopsy (SLNB) for early breast cancer is common, and many studies have reported its usefulness with indocyanine green (ICG). However, in the case of sentinel lymph node (SNs) identification using ICG, it is difficult to accurately identify the fluorescence signal of SNs through the skin because of the weakening of the signal due to the intervening tissue thickness. In this study, we examined whether fluorescence spectroscopy can detect weaker fluorescence signals and accurately identify SNs that have accumulated ICG. METHODS: Six women with early breast cancer and clinically confirmed negative axillae were recruited. The periareolar region was subcutaneously injected with ICG (1 ml, 5 mg/mL). The identification rate of SNs in the skin was studied using the novel fluorescence spectroscopy (Lumifinder™, ADVANTEST, Tokyo, Japan). RESULTS: Lumifinder™ was able to identify 100% of SNs in the skin (6/6 patients). In addition, for SNs identification in deeper axillary areas, pressing the probe tip against the body surface allows clearer fluorescence observation. CONCLUSION: Novel fluorescence spectroscopy (Lumifinder™) may overcome the problem of SLNB using ICG for breast cancer.

Thoracic stent-graft herniation through the aortic wall in a case of lung cancer.

A 67-year-old man had left upper lung cancer with invasion into the descending aorta. He underwent pre-emptive thoracic endovascular aortic repair using a Valiant Navion followed by left lung upper lobectomy with resection of the aortic wall. Because of continuous bleeding, he underwent re-thoracotomy. Since the surgically resected aortic wall was largely cleaved, bleeding around the stent-graft that herniated into the left pleural cavity was observed. Re-thoracic endovascular aortic repair using a GORE TAG was immediately performed to prevent further stent-graft herniation and impending lethal haemorrhage. It may be necessary to consider reinforcement of the resected aortic wall to prevent thoracic endovascular aortic repair-related complications.

[A Case of Hormone Receptor‒Positive HER2‒Negative Advanced/Recurrent Breast Cancer with 1.5 Years Withdrawal Period of Palbociclib Showed a Good Response Treated by Abemaciclib and Fulvestrant].

A 58‒year‒post‒menoposal woman was presented with left chest pain and shortness of breath because her breast cancer metastasized to the skin, lung, and pleural dissemination. In late‒line treatment for hormone receptor‒positive HER2‒negative advanced/recurrent breast cancer, we experienced a patient with tumor shrinkage leading to pain relief who was treated with a second combination of a CDK4/6 inhibitor and fulvestrant. Due to her poor performance status, she was treated with combined therapy to avoid severe adverse events. The CDK4/6 inhibitor was reintroduced after 1.5 years withdrawal period of endocrine therapy during anticancer drugs and radiation treatment. It has also been reported that withdrawal of CDK4/6 inhibitors might restore susceptibility related to the inhibitory signal. Rather than sequentially administering combined endocrine therapy with a CDK4/6 inhibitor, the withdrawal strategy of endocrine therapy continuing to administer anticancer drugs should be considered in case of reintroduction of CDK4/6 inhibitor.

Alternative Treatment for Residual Aortobronchial Fistula After Thoracic Endovascular Aortic Repair.

A patient with an aortobronchial fistula secondary to a thoracic endovascular aortic repair was successfully treated with a re-thoracic endovascular aortic repair with debranching technique. Five months postoperatively, the aneurysm had shrunk; however, computed tomography revealed air in the thrombo-excluded aortic aneurysmal sac without signs of infection. Because of worsening air finding at the eighth month, we performed a resection of the residual fistula and wrapped the stent graft in a pedicled muscle flap.

Adenoid cystic carcinoma of the lower trachea treated by resection of 11 of 18 rings of the total length: report of a case.

We report the case of a 63-year-old woman with adenoid cystic carcinoma of the lower trachea treated by resection of 11 of the 18 cartilaginous rings (61%) of the total length. The little remaining membranous portion of the carina was sewn up to create a margin for anastomosis. The anastomotic sites could be approximated by the mobilization of the cervical trachea and the left main bronchus, pulling across the traction sutures, and anteflexion of the neck. The patient's postoperative course was uneventful without any complications associated with anastomosis. Because both the proximal and distal margins showed microscopic tumors, radiation therapy was performed with 50 Gy 2 months after surgery. The patient has a good social life without recurrence 20 months after surgery.

Diffusion-weighted magnetic resonance imaging in preoperative assessment of non-small cell lung cancer.

BACKGROUND: Diffusion-weighted magnetic resonance imaging (DWI) frequently shows heterogeneity of signal intensity (SI) in non-small cell lung cancer (NSCLC). The purpose of our study was to examine the association of SI and DWI patterns with histology, tumor invasiveness, lymph node metastasis, and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) uptake in NSCLC. METHODS: One hundred forty-five patients with NSCLC underwent preoperative DWI and FDG-PET. DWI patterns were visually classified as homogenous (HOM) (n = 81) or heterogeneous (HET) (n = 64). The former was further classified as faint (faint-HOM) (n = 27) or dark (dark-HOM) (n = 54) according to a cutoff value of SI. Associations of SI and DWI patterns with tumor histology, lymphatic or vascular invasion, pleural invasion, lymph node metastasis, and FDG uptake were evaluated. RESULTS: All faint-HOM tumors were well-differentiated adenocarcinoma, whereas dark-HOM and HET tumors were less-differentiated adenocarcinoma or non adenocarcinoma. Although the dark areas in HET tumors showed a dense aggregation of tumor cells, their faint areas showed abundant fibrovascular stroma or necrosis, or a well-differentiated part of adenocarcinoma. Tumor size and the frequencies of lymphatic or vascular invasion, pleural invasion, and nodal metastasis were highest in HET tumors, followed by dark-HOM and faint-HOM (P = .1-P < .001) tumors. Sixty-five tumors having at least 1 of the invasions or metastasis showed significantly higher SI than the 81 tumors without (P < .001). HET tumors had the highest FDG uptake, followed by dark-HOM and faint-HOM tumors; differences between the groups were significant (P < .01 to P < .001). CONCLUSIONS: The SI and heterogeneity of DWI reflect the histologic heterogeneity, tumor aggressiveness, and FDG-PET uptake in NSCLC.

Twenty-five years' experience with a trap-door thoracotomy modified with disconnection of the first rib for tumors invading the anterior superior sulcus.

BACKGROUND: A procedure of modified trap-door thoracotomy and our 25 years' experience in 33 patients with tumors invading the anterior superior sulcus are presented. METHODS: The modified portion of the original trap-door thoracotomy is the disconnection of the first rib from inside the thorax. Tumors consisted of lung cancer in 13 patients, thyroid cancer in 10, thymic tumor in 5, neurogenic tumor in 3, germ cell tumor in 1, and metastatic tumor in 1. Of the 33, 16 patients underwent a combined resection of the invaded organs, which included the brachiocephalic and subclavian veins in 4 patients, brachiocephalic vein in 3, thoracic wall in 6, trachea in 2, and trachea and brachiocephalic artery in 1. Combined resections of the trachea in the total 3 patients were treated with a sleeve resection and reconstruction, and those of the brachiocephalic and subclavian veins in 2 patients and brachiocephalic artery in 1 were reconstructed by a vessel graft. RESULTS: Compared with the original trap-door thoracotomy, the additional disconnection of the first rib from inside the thorax provided a more adequate opening in the chest wall and more extensive exposure of the entire superior sulcus region, which enabled the complete resection of the tumors in all patients. A postoperative complication occurred in 1 patient, who had chylothorax. CONCLUSIONS: A trap-door thoracotomy modified with a disconnection of the first rib enabled a sufficient approach for resection of tumors invading the anterior superior sulcus.

Triple-layer sealing with absorptive mesh and fibrin glue is effective in preventing air leakage after segmentectomy: results from experiments and clinical study.

OBJECTIVES: Fibrin glue in combination with polyglycolic acid (PGA) mesh is effective in preventing air leakage after segmentectomy, but we frequently experienced air leakage with single-layer application. To investigate improved usage, we compared the sealing effect among single-, double- and triple-layer PGA mesh and fibrin glue in both experimental and clinical segmentectomy. METHODS: Ex vivo pig lungs were used for experiments. As a model of segmentectomy, the lateral segment of the left lung was removed using electrocautery. As a model of peripheral lung defect, peripheral lung tissue was resected with scissors. The inter-segmental plane and the peripheral lung defect were sealed using one of the following four methods: (i) fibrin glue alone (Group 1, n = 8), (ii) single-layer with PGA mesh and fibrin glue (Group 2, n = 8), (iii) double-layer (Group 3, n = 8) and (iv) triple-layer (Group 4, n = 8). The seal-breaking pressures among them were compared. In clinical segmentectomy, the periods of chest-tube drainage were compared retrospectively between 17 patients treated by the single-layer and 17 treated by the triple-layer method. RESULTS: In experimental segmentectomy, the seal-breaking pressure in the triple-layer (100 ± 25 cmH2O) was significantly higher than those in the other methods (26 ± 17, 48 ± 12 and 69 ± 19 cmH2O in the Groups 1, 2 and 3, respectively, P < 0.001-0.05), while there were no significant differences among other methods. For peripheral lung defect, the seal-breaking pressures did not differ among the methods. In clinical segmentectomy, the mean chest-drainage period with the triple-layer was 2 ± 0.9 days, which was significantly shorter than 3.6 ± 2.8 days with the single-layer (P = 0.009). CONCLUSIONS: Stronger sealants are required to prevent air leakage from inter-segmental planes than from peripheral lung. To prevent air leakage after segmentectomy, triple-layer PGA mesh and fibrin glue is recommended.

Giant solitary fibrous tumor of the pleura causing respiratory insufficiency: report of 3 cases.

We present 3 cases of solitary fibrous tumors (SFTs) occupying entire hemithorax and resulting in respiratory insufficiency. All patients were treated by complete resection, resulting in immediate re-expansion of the lungs and recovery from respiratory insufficiency. Although, two patients remain alive without recurrence, one patient had pleural recurrences three times over a 20-year period, all of which were treated by surgical resection. All of the primary tumors exhibited areas of hypercellularity, hemorrhage, or necrosis. All of the recurrent tumors in the recurrent case displayed large areas of hypercellularity, similar to the part of primary tumor. Although, the MIB-1 index in primary tumors was less than 5%, the index of the recurrent tumors increased up to 11% with repeated recurrence. Giant SFTs usually display hypercellularity, hemorrhage, or necrosis. Tumors with hypercellularity could recur. MIB-1 index could display malignant characteristics of recurrent tumors. Long-term follow-up for more than 10 years after surgery is necessary, particularly for tumors with areas of hypercellularity.

Small bowel metastasis of uterine cervical adenocarcinoma.

A few cases of small bowel metastasis from uterine cervical cancer have been previously reported. All reported cases were connected to squamous cell carcinoma, while none were associated with cervical adenocarcinoma. This report is of a rare case of cervical adenocarcinoma that haematogenously metastasised to the small intestine, and which caused a perforation and small bowel obstruction metachronously. An 84-year-old woman was admitted to our hospital with vaginal bleeding. She was diagnosed with FIGO stage III cervical adenocarcinoma by imaging and pathohistological examinations. Three months after receiving radiation therapy to control the bleeding, surgery was performed twice; the first operation for small bowel perforation and the second for small bowel obstruction. She was then diagnosed with haematogenous metastasis of cervical adenocarcinoma to the ileum according to the operative, histopathological and immunopathological findings.

Sedation With Meperidine for Endobronchial Ultrasound-guided Transbronchial Needle Aspiration.

BACKGROUND: Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become increasingly available and more widely used for the diagnosis of mediastinal lymph node lesions, there are few reports regarding methods of anesthesia. We conducted a retrospective study assessing the efficacy of meperidine (MP) for EBUS-TBNA. METHODS: Sixty cases that underwent EBUS-TBNA between January 2006 and December 2009 at the Kameda Medical Center were retrospectively analyzed. We classified them into 2 groups: cases that were performed under sedation with intravenous MP cases (n=31) and cases with general anesthesia (GA cases: n=29). Furthermore, we also classified the MP cases into 2 groups: patients above 65 years of age (elderly patients) and the others (young patients) to assess the safety of MP for the elderly. RESULTS: MP of 35 mg was administered just before EBUS-TBNA. Mean age, weight, physical status (American Society of Anesthesiologists grade), the size of the lesions, and examination time were not different between the MP and GA cases. Although the mean number of centesis for the MP cases was less than that of the GA cases (2.7 vs. 3.2 times; P<0.05), accurate diagnostic rates and sensitivity and specificity of each disorder were not different. Although the lowest saturation of peripheral oxygen during examination of the MP cases was lower than that of the GA cases (93.6% vs. 97.6%; P<0.05), GA cases required more vasopressor for a decline in the blood pressure than MP cases. Finally, none of the cases had any complications during or after the examination. In comparison between the elderly and young patients, the physical status, examination time, and the frequency or degree of complications were not different either. CONCLUSIONS: EBUS-TBNA under the intravenous sedation by MP was as feasible and safe as that under GA. It has a possibility to be one of the effective drugs for sedation during EBUS-TBNA regardless of age, and we should analyze its safety and efficacy in prospective studies henceforth.

Case with bromine exposure leading to respiratory insufficiency.

A 21-year-old male had a chemical burn on the right forearm when he inadvertently spilled bromine during an experiment. Since he inhaled vaporized bromine and had dyspnea and pharyngalgia, he arrived at our hospital in an ambulance as an emergency patient. On arrival, he kept a clear consciousness with a pulse rate of 98, body temperature of 36.8 degrees C, blood pressure of 132/80 mmHg, respiratory rate of 25, and oxygen saturation of 100%. (10 L/min of oxygen were administered.) He had marked dry coughs. His clothes had a foreign odor with mucosal irritation. Arterial blood gas analysis and blood biochemistry were normal. Based on these findings, he was diagnosed with chemical airway damage and bulbar conjunctiva from the exposure to bromine and a chemical burn on the right forearm. His respiratory condition became worse after admission, resulting in pulmonary edema. He was endotracheally intubated and controlled with an artificial ventilator on Day 3 after his injury. He was continuously treated with steroids and sivelestat sodium hydrate, which gradually improved his respiration. He was released from the artificial ventilator and extubated on Day 7. Although dyspnea associated with body movement and hoarseness persisted after extubation, the symptoms decreased and he was discharged on Day 41. This rare case is worth attention because serious respiratory insufficiency requiring artificial ventilation due to pulmonary edema from bromine exposure has not been reported in Japan.

Endoscopic hemostasis using fibrin adhesive to treat hemorrhage in the upper digestive system.

PURPOSE: There are several methods of achieving endoscopic hemostasis of hemorrhage in the upper digestive system. We compared the therapeutic results and advantages of using a local injection of fibrin adhesive for endoscopic hemostasis, which we have found more effective than other hemostatic methods. METHODS: Between October 2000 and April 2002, 16 patients with hemorrhage in the upper digestive system underwent endoscopic hemostasis using fibrin adhesive. The hemorrhage was caused by a hemorrhagic tendency from liver disease, anticoagulant therapy, or failed hemostasis with clipping or local ethanol injection. The fibrin adhesive was injected through a standard 21-gauge endoscopic needle using the so-called sandwich method. RESULTS: Hemostasis was successfully achieved by a single local injection of fibrin adhesive, in all except one patient who had been on anticoagulant therapy for a long time and needed an additional local injection of fibrin adhesive. CONCLUSION: Fibrin adhesive does not cause any tissue injury, and a sufficient amount can be injected endoscopically even in patients with liver dysfunction and those on anticoagulant therapy. Thus, we think that endoscopic hemostasis with fibrin adhesive is safe and effective.