Establishment of a clinical pathway as an effective tool to reduce hospitalization and charges after video-assisted thoracoscopic pulmonary resection.

OBJECTIVE: The purpose of this study was to assess the effect of establishing a clinical pathway based on the length of hospitalization, hospital charges, and the outcome for video-assisted thoracoscopic pulmonary resection (VATPR). METHODS: We retrospectively analyzed consecutive patients who were diagnosed as having primary lung cancer, metastatic lung cancer, or a nodule that was suspected to be malignant and thus was operated on using VATPR during the 1-year period before (n = 105) and after (n = 113) pathway implementation. RESULTS: The mean economic cost and total hospital stay before and after pathway implementation were about dollars 14439 and dollars 13093 (US), and 29.4 and 18.6 days, respectively. These figures were significantly lower after pathway implementation than before establishment of the pathway. CONCLUSION: A clinical pathway is thus considered useful for reducing the length of total hospital stay and the costs associated with VATPR while maintaining high-quality postoperative care.

Initial experience with video-assisted thoracoscopic surgery for pulmonary metastasis in the prone position.

We performed video-assisted thoracoscopic surgery for pulmonary metastasis with the patient in the prone position because the use of the full lateral decubitus position was not possible owing to a deformity of the upper extremity, which existed because of a previous operation for osteosarcoma. In cases where the lateral decubitus position cannot be used, the prone position is both safe and effective for treating dorsal lesions of the lung by means of video-assisted thoracoscopic surgery.

Intrathoracic omental herniation through the esophageal hiatus in a young patient.

We herein present a case of intrathoracic omental herniation through the esophageal hiatus in a young patient. A 21-year-old obese man was asymptomatic, and his chest X-ray demonstrated a large, sharply defined mass. A computed tomography scan of the thorax indicated a large retrocardial mediastinal mass in which the density indicated the presence of fatty tissue judging from the Hounsfield unit range. A thoracotomy was performed under a diagnosis of either mediastinal lipoma or liposarcoma with an encapsulated fatty mass, measuring 17 x 12 x 8 cm in size. The mass, however, proved to be an omental herniation through the esophageal hiatus. It is generally assumed that the major contributing factors leading an individual to develop an omental herniation through the esophageal hiatus include aging and obesity. This is the first report of omental herniation through the esophageal hiatus in a patient still in his twenties.

Triplet chemotherapy with cisplatin, gemcitabine and vinorelbine for malignant pleural mesothelioma.

BACKGROUND: The incidence of malignant pleural mesothelioma (MPM) is expected to increase due to delayed control of occupational exposure to asbestos in Japan. We investigated the use of triplet combination chemotherapy with cisplatin (CDDP), gemcitabine (GEM) and vinorelbine (VNR) for the treatment of Japanese patients with MPM. METHODS: From December 2000 to August 2003, 12 patients received the following regimen: CDDP 40 mg/m(2), GEM 800 mg/m(2) and VNR 20 mg/m(2) on days 1 and 8 every 4 weeks. Among the 12 patients, six selected patients underwent an extrapleural pneumonectomy (EP) after a median of three cycles of triplet chemotherapy. RESULTS: The overall response rate for all patients and the response rate for chemotherapy-naive cases were 58 and 67%, respectively. The median survival time and survival rate at 2 years for all patients were 11 months and 50%, respectively. The 2-year survival rates for the patients with and without EP were 83.3 and 16.7%, respectively. CONCLUSIONS: Triplet chemotherapy with CDDP, GEM and VNR was thus found to be highly effective for patients with MPM and its toxicity was manageable. A multi-institutional phase II trial is now being planned to establish the effectiveness of this new regimen in chemotherapy-naive patients with MPM.

Serum carcinoembryonic antigen as a predictive marker for sensitivity to gefitinib in advanced non-small cell lung cancer.

Gefitinib is an inhibitor of epidermal growth factor receptor tyrosine kinase, which has a tumour reducing effect in non-small cell lung cancer (NSCLC). In this study, we retrospectively reviewed the clinical data from 105 patients with advanced NSCLC treated with gefitinib at our department between May 2002 and April 2004. The overall response rate was 27.8% and the median survival time was 9.3 months. Pretreatment characteristics suggested that those with no history of smoking or an elevated serum carcinoembryonic antigen (CEA) level were more likely to be sensitive to gefitinib (P = 0.009). A multivariate analysis indicated good PS (P < 0.0001) and elevated serum CEA level (P = 0.0027) to be independent prognostic factors. These data show that the serum CEA level can be a predictive factor for the efficacy of gefitinib treatment while it is also a prognostic factor for advanced NSCLC patients undergoing this treatment.

Long-term survivors in stage IV non-small cell lung cancer.

BACKGROUND AND OBJECTIVES: To determine the prognostic factors for long-term survivors (LTS) with stage IV non-small cell lung cancer (NSCLC) who had undergone various treatments. PATIENTS AND METHODS: From 1990 to 1999, 222 NSCLC patients with stage IV disease, who had been treated in our department, were reviewed. As the initial treatment, 135 patients (48%) were treated with chemotherapy alone, 52 patients with a combination of chemotherapy and radiotherapy, 19 patients underwent an operation with or without any other therapeutic modalities and 16 were received radiotherapy alone. RESULTS: Seventeen (7.7%) patients survived for more than 2 years, and all but one had adenocarcinoma. Among these LTS, eight patients received surgery as the initial therapy, and 16 (94.1%) received some type of local-control therapy, including surgery or radiotherapy, during the course of their disease. Regarding the clinical characteristics between LTS and others (non-LTS), an early N status, a single metastatic site, a good performance status, and surgery for initial therapy were all found to be significantly important factors for LTS. A multivariate analysis using a logistic regression model also showed an early N status and surgical treatment to be significantly associated with LTS. CONCLUSIONS: Selected patients with an early N status may be appropriate candidates for aggressive multimodality treatment including surgery, in order to provide a long-term survival for stage IV NSCLC.

Prognostic value of visceral pleural invasion in resected non-small cell lung cancer diagnosed by using a jet stream of saline solution.

OBJECTIVE: Visceral pleural invasion caused by non-small cell lung cancer is a factor in the poor prognosis of patients with that disease. We investigated the relationship between the diagnosis of visceral pleural invasion by using a jet stream of saline solution, which was previously reported as a new cytologic method to more accurately detect the presence of visceral pleural invasion, and prognosis. METHODS: From January 1992 through December 1998, 143 consecutive patients with peripheral non-small cell lung cancer that appeared to reach the visceral pleura underwent a surgical resection at the Department of Thoracic Oncology, National Kyushu Cancer Center. The surface of the visceral pleura in patients undergoing lung cancer resection was irrigated with a jet stream of saline solution. The diagnosis of visceral pleural invasion was determined by means of either a pathologic examination or by means of a jet stream of saline solution. In addition, a cytologic examination of the pleural lavage fluid obtained immediately after a thoracotomy was evaluated. RESULTS: Forty-nine (34%) resected tumors were identified as having visceral pleural invasion. The diagnosis of visceral pleural invasion in 31, 6, and 12 patients was determined by using a jet stream of saline solution alone, pathologic examination alone, or both, respectively. The visceral pleural invasion and positive findings of intrapleural lavage cytology were linked. Although there was no significant difference between the incidence of distant metastases in the patients with visceral pleural invasion and those without visceral pleural invasion, the incidence of local recurrence, especially regarding carcinomatous pleuritis (malignant pleural effusion, pleural dissemination, or both), in the patients with visceral pleural invasion was significantly higher than in those without visceral pleural invasion. The recurrence-free survival of patients with visceral pleural invasion was significantly shorter than that of patients without visceral pleural invasion (P =.004), even patients with stage I disease (P =.02). There was also a significant difference between the patients with or without visceral pleural invasion in the overall survival (P =.02). Visceral pleural invasion was independently associated with a poor recurrence-free survival on the basis of multivariate analyses (P =.03), as were sex (P =.03), age (P = 002), and the stage of the disease (P <.0001). CONCLUSIONS: This study confirmed that the jet stream of saline solution method in addition to ordinary pathologic examination was useful for detecting visceral pleural invasion, which is considered to be one of the causes of local recurrence, especially in carcinomatous pleuritis.

[A case of successfully treated nifedipine-poisoning].

Calcium antagonists have been prescribed for treatment of hypertension and several other diseases, and the incidence of poisoning involving these agents is increasing. We encountered and successfully treated a case of nifedipine poisoning. The patient was a 52-year-old man who ingested 76 tablets of nifedipine 20 mg while drinking alcohol. He was brought to a clinic and transferred to our emergency department. Since systolic blood pressure on arrival was 110 mmHg, primary care involved gastric lavage, infusion of lactated Ringer solution, and administration of activated charcoal and cathartics. Hypotension subsequently developed and continuous infusion of dobutamine was initiated. Arrhythmia did not appear during the course of treatment, and the patient was discharged after four days.