Exercise capacity of thoracotomy patients in the early postoperative period.

OBJECTIVE: We investigated the mechanism involved with the initial drop and subsequent recovery of exercise capacity in the early postoperative period of thoracotomy patients. METHODS: Sixteen patients (13 who had undergone lobectomy, 3 who had undergone pneumonectomy) underwent a routine pulmonary function test (PFT) and a cardiopulmonary exercise test preoperatively, within 14 postoperative days (POD; post-1; mean +/- SD, 9 +/- 2 POD), and after 14 POD (post-2; mean, 26 +/- 12 POD). RESULTS: After surgery on post-1, PFT results of FVC, FEV(1), and maximum ventilatory volume (MVV) significantly decreased. Oxygen uptake (VO(2)) at a venous blood lactate level of 2.2 mmol/L (La-2. 2), which was adopted as the empirical anaerobic threshold, and maximum V O(2) (VO(2)max) decreased significantly to 88.2 +/- 7.9% and 73.1 +/- 15.4% of the preoperative values, respectively. La-2.2 min ventilation (VE)/ MVV and maximum VEmax)/MVV increased significantly from 0.36 +/- 0.08 to 0. 66 +/- 0.20 and from 0.58 +/- 0.14 to 0.80 +/- 0.09, respectively. On post-2, though La-2.2 VO(2) did not change, VO(2)max improved significantly to 81.5 +/- 19.7% of the preoperative values, in association with significant increases in maximal tidal volume and VEmax, which were produced by significant increases in the PFT results. La-2.2 VE/MVV also decreased significantly to 0.49 +/- 0.13, which indicated a sufficient recovery of respiratory reserve at submaximal exercise. CONCLUSIONS: The initial drop of exercise capacity after lung resection seems to be derived from both circulatory and ventilatory limitations. Further, the subsequent recovery within 1 month seems to be produced by an improvement in ventilatory limitation, which was caused by the surgical injury to the chest wall.

[Histoculture drug response assay on non-small cell lung cancer].

We examined the chemosensitivity of non-small cell lung cancer (NSCLC) tissues to CDDP, 5-FU, ADM, MMC, ETP and SN38 using histoculture drug response assay (HDRA). One-hundred and thirty surgical specimens from NSCLC patients who were not given preoperative chemotherapy were used. The inhibition indexes of CDDP, 5-FU, MMC, ADM, ETP and SN38 were 39.1 +/- 18.2%, 48.0 +/- 19.7%, 63.3 +/- 17.7%, 47.6 +/- 22.0%, 36.9 +/- 21.1%, and 37.9 +/- 25.2%, respectively. Inhibition indexes were above the cutoff level, i.e., 'judged sensitive,' in 40 cases (31.3%) for CDDP, 34 cases (27.4%) for 5-FU, 54 cases (44.3%) for MMC, 36 cases (33.0%) for ADM, 29 cases (29.8%) for ETP, and 34 cases (37.4%) for SN38, respectively. In almost one-third of patients, the inhibition indexes of all drugs were under cutoff levels. Correlations between in vitro chemosensitivity data and patient responses to chemotherapy were obtained from 16 evaluable patients, and a 44.4% true positive rate and a 100% true negative rate were observed. Our results with HDRA for NSCLC showed a high incidence of intrinsic multidrug resistance. HDRA may help doctors to avoid non-effective chemotherapy for NSCLC patients.

Intrapleural administration of a large amount of diluted fibrin glue for intractable pneumothorax.

OBJECTIVE: Pleurodesis using chemical agents has been applied to high-risk patients with pneumothorax. This treatment, however, is sometimes unsuccessful in patients with intractable pneumothorax or intrapleural dead space. We developed a technique for the intrapleural administration of diluted fibrin glue as a treatment for such patients. METHODS: Fibrin glue was diluted fourfold with saline solution and/or contrast medium. Pleurodesis with a large amount of the diluted fibrin glue was performed in 40 high-risk patients with intractable pneumothorax and in 13 postthoracotomy patients with persistent air leakage associated with an intrapleural dead space. RESULTS: The air leaks were stopped by administration of the glue in all patients of both groups. During the follow-up period, a recurrence rate of 12.5% was observed in the former group. These recurrent pneumothoraces also were successfully treated by glue administration with no further recurrence. In the 13 postthoracotomy patients, there was no recurrence after the initial treatment. Pyrexia (12.5%) and chest discomfort (4.1%) were observed as side effects, but there were no findings of severe chest pain or thoracic empyema. CONCLUSIONS: These results suggest that intrapleural administration of a large amount of diluted fibrin glue is a useful treatment for intractable pneumothoraces in high-risk or postthoracotomy patients who have an intrapleural dead space.

Disappearance curves for tumor markers after resection of intrathoracic malignancies.

Determination of the standard elimination kinetics of tumor markers will be helpful in the diagnosis of malignancies. We analyzed the disappearance curves for serum tumor marker levels after resection of intrathoracic malignancies. Serum levels of CEA, SLX, AFP, CA 19-9, SCC, TPA and CYFRA were measured several times after surgery in a total of 40 patients. To obtain precise biological half-lives, we applied non-linear least square analysis, taking into consideration the possibility of residual tumor cells. Disappearance curves were monophasic for CEA, SCC, TPA, CYFRA and SLX and biphasic for CA 19-9 and AFP. Temporary elevation of serum levels after surgery was observed for SCC, TPA and CYFRA. The average half-lives of CEA, SLX, SCC, TPA and CYFRA were 1.5 days, 2.7 days, 2.2 hours, 2.5 hours and 1.5 hours, respectively. The average half-life of CA 19-9 was 0.5 days in the first compartment and 4.3 days in the second compartment, while that of AFP was 1.0 days and 6.3 days, respectively. These values will be helpful in the interpretation of serum tumor marker levels after surgery.

[Surgical treatment of lung cancer with chest wall invasion].

From January 1986 to May 1998, 45 lung cancer patients with chest wall invasion (P3) underwent resection (40 male, 5 female), (median age 63.2 yrs (30-79)). Histological types were squamous cell carcinoma in 20, adenocarcinoma in 14, large cell carcinoma in 7, adenosquamous cell carcinoma in 2, and unknown in 2. Operative methods of lung resection were total pneumonectomy in 2, bilobectomy in 3, lobectomy in 38, and partial lung resection in 2. Resection was regarded as complete in 35 and incomplete in 10 patients. Thirty one patients had negative lymph nodes (N0), 9 had peribronchial or hilar lymph node metastases (N1), and 5 had mediastinal lymph node metastases (N2). The extent of tumor invasion to chest wall was P3a (invasion within parietal pleura) in 11, P3b-c (invasion to intercostal muscle) in 16, P3d (invasion to rib) in 18, patients. 5-year survival rate was totally 19.7%. Cisplatin based chemotherapy and concurrent thoracic radiation following surgery (CCRT) was performed in latest nine P3d cases. Partial response was observed in 5 of 9 cases (response rate 56%) and viable tumor cell in the primary site was not seen histologically in 5 of 9 cases. Three year survival rate was 46.9% for CCRT(+) 11.1% for CCRT(-). Acturial 5-year survival rate in P3a-d was 19.76%. P3d cases had poor survival, but CCRT improved prognosis of P3d cases.

[Induction chemotherapy based on histoculture drug response assay for a patient with advanced thymic cancer--a case report].

Histoculture drug response assay (HDRA) was applied to a biopsy specimen of advanced thymic cancer from a 68 years-old male patient. HDRA revealed that the tumor was not sensitive to CDDP but highly sensitive to 5-FU, ADM and MMC, which were administered as induction chemotherapy. The tumor regressed to 14% of the pretreatment size and was able to be completely resected with right and left brachiocephalic veins, superior vena cava, pericardium, right phrenic nerve and a part of right lung. Histologically, only a few small cancer nests remained in the fibrous tissue. The patient is alive and disease free 32 months after surgery. This result suggests that HDRA is useful to select anticancer agents which are sensitive to a rare kind of carcinoma such as thymic cancer.

Analysis of the early postoperative serum carcinoembryonic antigen time-course as a prognostic tool for bronchogenic carcinoma.

BACKGROUND: The serum kinetics of carcinoembryonic antigen (CEA) after resection of lung carcinoma are not well characterized. Its prognostic implications remain unclear. This study was designed to clarify the correlation between postoperative CEA time-course and patient prognosis. METHODS: The authors analyzed early postoperative CEA time-course in 31 lung carcinoma patients using nonlinear least square analysis with the following three equations: Equation 1: C(t) = C(0); Equation 2: C(t) = C(0)exp(-kt); and Equation 3: C(t) (C(0)PLAT)exp(-kt) + PLAT, in which t: postoperative day; C(t): postoperative CEA; PLAT: postoperative CEA at plateau; C(0): CEA at postoperative Day zero; and k: rate constant of elimination. The equation that yielded the least Akaike's information criterion was adopted as the best fitting regression equation for each patient. When Equation 3 was adopted, postoperative CEA production (PROD) was calculated as PLAT multiplied by k. RESULTS: Equations 1, 2, and 3 were adopted for 16 (Group 1), 0, and 15 (Group 2) patients, respectively. In Group 1, no decrease in serum CEA level after surgery was detected and CEA production appears to have been little or none. In Group 2, biologic CEA half-life was 1.1 +/- 0.7 days and was not useful for predicting patient prognosis. Tumor recurrences were observed in 9 of the Group 2 patients 19 +/- 9 months postoperatively and there was no significant difference in PLAT or PROD between patients with and without recurrence. Early recurrence within 6 months after surgery was recognized in 5 (early-REC) of the 15 Group 2 patients, in whom there was a tendency for PLAT to be higher than in the other 10 patients without recurrence (early-NON) (early-REC: 3.8 +/- 4.9 ng/mL; early-NON: 1.5 +/- 1.1 ng/mL; P = 0.08). PROD was significantly higher in early-REC than in early-NON (early-REC: 3.5 +/- 4.2 ng/mL/day; early-NON: 0.8 +/- 0.4 ng/mL/day; P < 0.05). CONCLUSIONS: Although PROD is more sensitive than PLAT, both parameters appear to be useful as prognostic tools for predicting early recurrence after resection of lung carcinoma. This is probably because they represent the number of residual tumor cells immediately after surgery.

[Double primary lung cancers producing alpha-fetoprotein].

A 81-year-old male with a high serum alpha-fetoprotein (AFP) level of 2644 ng/ml underwent left pneumonectomy for squamous cell carcinoma in the lower lobe and large cell carcinoma in the upper lobe. Both tumors were classified as pathological T2N0M0 and stage I. The AFP level was normalized to be 19 ng/ml in 49th postoperative day. Immunohistochemical staining using anti-AFP antibody demonstrated AFP granules only in the large cell carcinoma. The study of lectin affinity against the serum AFP revealed that the concanavalin A (Con-A) non-reactive fraction rate was 14%, the lentil agglutinin (LCA) non-reactive and strongly reactive subfractions were 16.7 and 83%, respectively and P2, P4 and P5 subfractions of the erythroaggultinating phytohemagglutinin (E-PHA) were 58.6, 24.9 and 16.5%, respectively. According to the analysis of 21 cases reported in the Japanese literature including our case, the AFP did not demonstrate a common affinity pattern against the Con-A but the common pattern resembling hepatocellular carcinoma against LCA and E-PHA.

[A case of bilateral pneumothorax in the patient with Marfan syndrome].

A case of bilateral pneumothorax in the patient with Marfan Syndrome was reported 13-year-old male was admitted to our hospital with diagnosis of left pneumothorax. He was tall and thin with long tapered extremities and echography revealed annulo-aortic-ectasia. A diagnosis of Marfan Syndrome was established by these characteristic of skeletal and cardiovascular findings. Air leakage continued inspite of the drainage of left chest cavity. Therefore, the resection of bullae was surgically undertaken. Post-operative course was uneventful and he discharged on 18th post-operative day. The pneumothorax of the right side occurred six months after first operation. After chest drainage, the surgical treatment was performed. However, he had recurrence of right pneumothorax six months after second operation. He was treated successfully with drainage tube and minocycline injection into the right pleural cavity. He should be carefully followed up, because the patient of Marfan Syndrome often dies due to cardiovascular abnormalities.

Evaluation of effect of lung resection on lobar ventilation and perfusion using intrabronchial capnography.

Intrabronchial capnography was applied in 11 lung cancer patients to investigate the effects of lobectomy on regional lung function. Spirometry and intrabronchial capnography were performed before surgery (PRE), and during the early (POST1,19 +/- 5 POD) and late (POST2, 184 +/- 98 POD) postoperative periods. End-tidal carbon dioxide concentration (EtCO2) and Smidt's velocity profile index (V-index) were calculated from each lobar capnogram obtained bronchoscopically. The V-index of lobes without cancer on the operated-on side increased after surgery (PRE, 10.7 +/- 5.0%; POST1, 14.3 +/- 9.4%, NS; POST2, 16.8 +/- 8.6%, p < 0.05), while the V-index on the unoperated-on side decreased after surgery (PRE, 10.5 +/- 5.3%; POST1, 7.9 +/- 3.5%, p < 0.05; POST2, 7.2 +/- 2.9%, p < 0.05). EtCO2 after surgery was lower on the operated-on side (POST1, 5.1 +/- 1.1%; POST2, 4.6 +/- 1.1%) than on the unoperated-on side (POST1, 5.4 +/- 0.9%, p < 0.05; POST2, 5.0 +/- 0.9%, p < 0.01). Since the V-index and EtCO2 are compatible with the expiratory flow rate and the perfusion/ventilation ratio, respectively, we concluded that the air flow decreased on the operated-on side and increased on the unoperated-on side postoperatively and that perfusion on the operated-on side was more severely reduced than ventilation. These findings suggest that intrabronchial capnography is useful for assessing the ventilation and perfusion of the individual lobes as single units.

[Surgical resection of pulmonary metastases from colorectal cancer].

Fourteen patients with known primary colorectal adenocarcinoma underwent pulmonary resection for its pulmonary metasoasis. The cumurative survival rate at five years was 25.7% in all patients and 37.5% in 9 patients with a solitary metastasis. One of two patients with both pulmonary and hepatic metastases survived 33 months with no evidence of recurrence after pulmonary and hepatic resection. Although none of seven patients with tumor smaller than 3.5 cm in diameter had regional lymph node metastasis, two of three patients with tumors larger than 3.6 cm in diameter had hilar lymph node metastases. Lobectomy and mediastinal lymph node dissection may be recommended for the patient with large tumor.

[Thoracoscopic partial resection of the lung for peripheral lung tumor].

We report a thoracoscopic partial resection of the lung for the peripheral lung tumor in a 66-year-old woman. Her chest roentgenogram and computed tomographic scan showed a single tumor 1.9 cm in diameter within the periphery of the right lower lobe. A solitary metastatic lung tumor of colon cancer, which was resected one year ago, was suspected. Partial resection of the lung involving this tumor was performed using the MULTIFIRE ENDO GIA 30 disposable surgical stapler under thoracoscopy. There was neither air leak nor bleeding at the resection line. Pathological examination of the tumor revealed benign localized pleural mesothelioma. Her postoperative course was uneventful and she was discharged from the hospital on the eighth postoperative day. Thoracoscopic pulmonary resection using EndoGIA is a safe technique for a peripheral lung tumor.

Malignant schwannoma of the intrathoracic vagus nerve: report of a case.

We report herein the case of a 48-year-old man with malignant schwannoma of the intrathoracic vagus nerve associated with von Recklinghausen's disease. Malignant intrathoracic vagal tumors are extremely rare and to our knowledge, only four other cases have been documented in the literature, none of which were associated with von Recklinghausen's disease.

[A case of giant thymolipoma in a child].

A case report of a giant thymolipoma in 6-year-old boy is reported. Following school screening, an abnormal shadow in the left chest was found on the chest X-ray. CT scan and MRI suggested the mediastinal tumor containing a fatty mass. The tumor was resected on bloc through the median sternotomy and left antero-lateral thoracotomy. The tumor was 85 X 210 X 140 mm in size and 1380 g in weight. The postoperative histological examination revealed the thymolipoma. We were able to find only 19 other reported cases of thymolipoma in Japanese literature. Of 19 cases, this thymolipoma is the largest one in proportion to the patient's body weight.

[A case of mediastinal cavernous hemangioma].

A 6-year-old boy had an abnormal shadow on the chest X-ray film. It showed a tumor shadow with calcification on the right hilum. The plain CT scan showed an anterior mediastinal mass and its density was similar to that of large vessels. On the angio CT scan the lesion displayed a much lower enhancement than large vessels. The tumor was resected completely by median sternotomy. It was 5.6 X 3.6 X 3.0 cm in size and contained a phlebolith 5 mm in diameter. The histological diagnosis was cavernous hemangioma.

[Clinical evaluation of surgical treatment of lung cancer involving the chest wall].

Twenty-four patients with primary lung cancer involving chest wall underwent pulmonary and chest wall resections. All patients were males ranging from 38 to 74 years of age. Pain was the most frequent symptom. Twenty-three lobectomies and one pneumonectomy were performed. Resections of parietal pleura were performed in 4 patients and en block resections of chest wall were performed in 20 patients. After operation, postsurgical stage was pT3N0M0 in 16 patients, pT3N1M0 in 4 patients and pT3N2M0 in four. Operative mortality was 4.2%. Actuarial survival of 23 patients surviving operation was 45.7% at 1 year, 28.7% at 2 year and 17.2% at 3 and 5 year. Three patients who had no lymphnode metastases and no rib invasion survived more than 5 years. We concluded that long term survival can be expected in pN0 patients without invasion to the ribs.

[Gastroesophageal reflux after esophageal surgery--evaluations based on esophageal transit scintigram].

By means of esophageal transit scintigram using 99mTc-DTPA, 15 patients (13 esophageal carcinomas and 2 cardia carcinomas) were studied, in whom esophagogastric anastomosis was done according to the posterior invagination anastomosis technique we had devised. In all 8 patients with anastomosis at cervical region, gastroesophageal reflux was not seen on both scintigrams before and after meals, and the average pressure gradient of high pressure zone at anastomosis was 39.8 cmH2O. In 2 of 7 patients with intrathoracic anastomosis, the scintigram before meals showed severe reflex, and the endoscopic findings showed diffuse and moderate erosion in the esophageal mucosa. The average pressure gradient across the anastomosis was 6.5 cmH2O. In these 2 patients, the new fornix with a sharp angle of His was not formed. In the remaining 5 patients with intrathoracic anastomosis, reflux was not seen on the scintigram before meals. However, in 2 of them, the scintigram after meal and endoscopic examination revealed mild reflux and mild esophagitis respectively. Furthermore in one patient very mild reflux was observed only on the scintigram after meals but the endoscopic findings showed the normal esophageal mucosa. In these 5 patients, the average pressure gradient across the anastomosis was 17.0 cmH2O, which was significantly higher (p less than 0.01) than that in 2 patients with severe reflux and was significantly lower (p less than 0.01) than the mean value of high pressure zone in 8 patients with cervical anastomosis. In conclusion, it is presumed that the formation of a large fornix enough to store food and a sharp angle of His are important factors in maintaining an anti-reflux mechanism. The esophageal transit scintigram was proved to be an excellent technique in detecting and evaluating quantitatively gastroesophageal reflux.

[Adjuvant BCG immunotherapy for breast cancer (T1N0M0, T2N0M0)].

The present study was performed to evaluate the effect of BCG immunotherapy for breast cancer (T1n0M0, T2n0M0) in nonrandomized series. During a 5-year follow-up study, patients in the BCG-treated group suffered neither recurrence nor death, while the historical control group had 6 cases of recurrence and 5 cases of disease death. As seen in our series, we concluded that breast cancer patients should be advised to accept adjuvant BCG immunotherapy after mastectomy.