[Long-Term Survival Following Multidisciplinary Therapy for Pancreatic Head Cancer with Liver Metastasis].

A 71-year-old female was referred to our hospital for liver dysfunction. After careful examination, she was diagnosed with resectable pancreatic head cancer. Pancreatoduodenectomy was scheduled. In the laparotomy, 2 nodules on the liver were found. A frozen section examination of the liver nodule revealed adenocarcinoma. S-1 chemotherapy was administered for about 17 months to treat the unresectable pancreatic cancer. After chemotherapy, computed tomography(CT) revealed that the pancreatic tumor remained unchanged, and there was no distant metastasis. Positron emission tomography( PET)-CT revealed no significant uptake in the pancreatic tumor and no distant metastasis. The patient was then observed for about 10 months without chemotherapy. After that, CT showed that the size of the pancreatic tumor had increased, but there were no signs of distant metastases. Therefore, pancreatoduodenectomy was performed. Histopathological examination revealed invasive ductal adenocarcinoma in the pancreas head. The patient underwent adjuvant chemotherapy with S-1 for 5 months. So far, she has survived without any recurrence for 57 months after the initial surgery.

Difficult intubation due to unknown congenital tracheal stenosis in the adult: a case report and literature review.

Congenital tracheal stenosis (CTS) is a rare disorder almost always diagnosed in infancy due to respiratory failure and other cardiopulmonary abnormalities. We experienced a 42-year-old female undiagnosed with CTS until difficult intubation upon surgery. Chest X-ray and computed tomography (CT) images revealed bronchial narrowing, which could already be seen prior to intubation, but was left unnoticed. Difficult airway management is a potentially lethal airway emergency. This life-threatening situation is preventable with the appropriate awareness. We report this clinically valuable case for the safety of future patient care. In English and Japanese literature, there are only 12 reported cases of CTS diagnosed in the adult. Ours and six previous cases were discovered with difficult intubation, a preventable life-threatening airway emergency. Pre-intubation images should be examined carefully for the possibility of CTS, as its frequency may be underestimated. Moreover, in treatment resistant recurrent asthmatic episodes, CTS should be kept in mind.

Intraoperative mechanical and chemical pleurodesis with 50 % glucose solution for secondary spontaneous pneumothorax in patients with pulmonary emphysema.

PURPOSE: Secondary spontaneous pneumothorax is life-threatening for patients with pulmonary emphysema. To prevent recurrence, intraoperative pleurodesis is performed in addition to bullectomy. We report the therapeutic process and effectiveness of adding mechanical plus chemical pleurodesis, with a 50 % glucose solution, to bullectomy, for patients with pulmonary emphysema-related pneumothorax. METHODS: The subjects were 20 patients (19 men and 1 woman; mean age 68 years) with pulmonary emphysema-related pneumothorax. After bullectomy was completed, 500 mL of a 50 % glucose solution was injected into the pleural cavity, followed by mechanical pleurodesis performed via ablation of the parietal pleura. RESULTS: The volume of pleural effusion decreased on postoperative day (POD) 1, and the temperature decreased on POD 2. The blood sugar levels increased on the day of surgery but decreased on POD 1. The mean postoperative follow-up period was 521 days. One patient died of pneumonia on POD 24. All other patients survived without pneumothorax recurrence. CONCLUSIONS: These results demonstrated the effectiveness of our treatment process for pulmonary emphysema-related pneumothorax. The fact that no patient experienced pneumothorax recurrence suggests that mechanical and chemical pleurodesis with 50 % glucose solution might be effective prophylaxis.

Pleurodesis with a 50% glucose solution in patients with spontaneous pneumothorax in whom an operation is contraindicated.

PURPOSE: Pleurodesis continues to play a central role in the management of pneumothorax. In our institute, a 50% glucose solution is used for pleurodesis. We retrospectively analysed the treatment effects of pleurodesis in patients with spontaneous pneumothorax in whom an operation was contraindicated because of underlying disease. METHODS: 13 patients (18 cases) with spontaneous pneumothorax were treated with pleurodesis with a 50% glucose solution. After local anesthesia of parietal pleura, 200 to500 mL of a 50% glucose solution was instilled into the pleural space. Pleurodesis was repeated two or three times, until the air leakage stopped. RESULTS: Air leakage stopped in all cases and there were no treatment-related deaths.Overall survival rates at 1, 2, and 3 years after treatment were 83%, 74%, and 49%, respectively. Post-treatment recurrence was observed in six cases. Four cases of recurrence were treated with pleurodesis with a 50% glucose solution. All cases of recurrence occurred within 3 months after pleurodesis. CONCLUSION: Pleurodesis with a 50% glucose solution is effective and safe in patients with pneumothorax. This procedure can be performed in patients with recurrent pneumothorax as well as patients with a first episode of pneumothorax in whom prolonged air leakage is predicted.

Role of pulmonary resection in the diagnosis and treatment of limited-stage small cell lung cancer: revision of clinical diagnosis based on findings of resected specimen and its influence on survival.

PURPOSE: Our aims were to evaluate (1) the result of surgical treatment of limited-stage small cell lung cancer (SCLC) by examining long-term survival and prognostic factors, (2) the diagnostic role of surgery by comparing clinical and histopathological diagnoses and staging, and (3) the impact of preoperative diagnostic accuracy on survival. METHODS: We retrospectively reviewed the clinical profiles of 37 patients treated at our institution between January 1990 and December 2007 for SCLC diagnosed using surgical specimens. RESULTS: The median follow-up period was 41.2 months, and the 5-year survival rate was 57.5%. Lobectomy or wider resection was performed alone in 33 cases and with mediastinal dissection in 29 cases. Fifteen patients did not receive chemotherapy. SCLC was diagnosed preoperatively or intraoperatively in 75% and non-SCLC in 25%. Clinical stage 1 disease was diagnosed in 29 patients; however, pathological stage 1 was seen in only 20. Patients at pathological stage 1 disease showed better survival than those at stage 2, but a similar result was not obtained in the case of clinical stage of the disease. Tumor size and nodal stage were the only significant factors influencing survival in a multivariate analysis. The adequacy of preoperative clinical diagnosis of tumor extensiveness, nodal involvement, and clinical stage did not significantly influence survival. CONCLUSION: Surgery for limited-stage SCLC was associated with a favorable survival rate and provided important pathological information that can help predict survival. Accuracy of preoperative diagnoses showed no apparent impact on survival for surgically treated SCLC patients.

Biphasic clinical characteristics of mild to moderate chest trauma according to age.

PURPOSE: Mild to moderate chest trauma is a common disease, although its clinical characteristics are not well known. We investigated the clinical profiles and the early and long-term outcome of hospitalized patients with chest trauma, focusing particularly on elderly patients. METHODS: The clinical records of patients who were hospitalized in Higashisumiyoshi Morimoto Hospital for chest trauma between January 2001 and December 2004 were retrospectively reviewed. The clinical profiles, treatment methods, and outcomes were investigated. The primary endpoint was a repeat visit to the hospital for another traumatic condition after discharge, and the secondary endpoint was death. The patients were divided into two groups with respect to the age of 60 years, and differences were compared statistically. RESULTS: In all, 53 patients (34 men) were hospitalized for chest trauma in our hospital between January 2001 and December 2004. The mean age was 54.9 years (17-85 years). The distribution of age showed biphasic peaks-in the tens to twenties, and sixties to seventies. Injuries were significantly more likely to be caused by a fall in elderly patients than in younger patients (P < 0.05). The elderly patients revisited our hospital with another trauma more frequently than did the younger patients (P < 0.05). CONCLUSION: Elderly patients were likely to suffer both falls and a further traumatic condition. This probably reflects the general deterioration of physical abilities, such as lowered cognitive and somatic performances.

Lung cancer surgery in nonagenarians.

We report two cases of lung cancer in nonagenarians successfully treated by pulmonary resection and assess the feasibility of surgical treatment in such an old population. Case 1. An asymptomatic 93-year-old man was diagnosed as having non-small cell lung cancer with clinical T1N0M0 stage IA disease, and a right upper lobectomy was performed via video-assisted thoracoscopic surgery. Mediastinal dissection was omitted. He was discharged on postoperative day 16, and he remains well without recurrence 6 months after the operation. Case 2. A 92-year-old man was diagnosed as having non-small cell lung cancer with clinical T2N0M0 stage IB disease and diminished pulmonary function. A right lower lobectomy with complicated partial resection of the diaphragm was performed via axillary thoracotomy with thoracoscopic support. He was discharged on postoperative day 28 and is well 42 months after the surgery. Although the feasibility of pulmonary resection in a nonagenarian could not be confirmed from only these two cases, pulmonary resection is a possible treatment option for lung cancer in selected nonagenarians.

Contralateral pneumothorax after lung cancer surgery: report of two cases.

Due to recent increases in numbers of patients who underwent surgical treatments for lung cancer, numbers of complications of contralateral pneumothorax after lung surgery are suggested to increase. Moreover, recent spread of surgical indication to elderly people and patients with severely damaged pulmonary function may lead postoperative complication of contralateral pneumothorax more lethal. We herein describe 2 cases of contralateral pneumothorax following lung cancer surgery with a review of recent literatures. Case 1 underwent left lower lobectomy with combined partial resection of the chest wall for lung cancer. Five months later, he suffered from contralateral pneumothorax and respiratory failure. Immediate chest drainage followed by bullectomy and pleurodesis were performed. Case 2 was surgically treated for left lung cancer. Preoperative computed tomography incidentally demonstrated contralateral pneumothorax. Chest drainage was started immediately, followed by left lower lobectomy. Contralateral bullectomy and pleurodesis were performed 6 days after lobectomy. Both patients have been well without recurrence of pneumothorax or lung cancer.

Pulmonary resection for non-small cell lung cancer in patients with hepatocellular carcinoma.

BACKGROUND: This study was designed to determine the clinical characteristics and verify the results of surgical treatment for non-small cell lung cancer (NSCLC) in patients with hepatocellular carcinoma (HCC), from the results of retrospective analysis of the cases. METHODS: We retrospectively reviewed our database of 751 patients who underwent curative surgical intervention for NSCLC from January 1993 to December 2006 and found 11 patients with NSCLC with coexisting or previously treated HCC at a perioperative period of lung cancer surgery. Postoperative complications and long-term outcome were analyzed. RESULTS: All cases had coexisting liver cirrhosis. The overall morbidity was 27.2% (n = 3). All complications were considered to be the result of liver cirrhosis-related conditions, such as liver failure (n = 2), postoperative bleeding from the thoracic tube (n = 2), and gastrointestinal bleeding (n = 1). There was no operative mortality. The 1-, 3-, and 5-year survival rates of patients with lung cancer were 88.9%, 74.1%, and 74.1%, respectively. The 1-, 3-, and 5-year survival rates for death from hepatic causes were 79.5%, 79.5%, and 39.8%, respectively. Overall survival rates were 70.7%, 58.9%, and 29.5%, respectively. Preoperative indicators of liver function, such as serum values of total bilirubin (P < 0.01), choline esterase (P < 0.05), prothrombin test (P < 0.01), and platelet count (P < 0.05), were significantly correlated with long-term survival, whereas local extensiveness and nodal stage of lung cancer were not. DISCUSSION: We conclude that postoperative complications and factors that influence long-term survival are correlated with the severity of impaired liver function, whereas early and mid term death are the result of lung cancer. Standard operation is encouraged for NSCLC when the patient is expected to live more than 3 years with impaired liver function, even if coexisting with HCC.

Acute nonbacterial pleuritis caused by spontaneous rupture of metastatic pulmonary adenocarcinoma.

Nonbacterial pleuritis caused by rupture of a metastatic adenocarcinoma is extremely rare and has not yet been reported. A 59-year-old man with a history of rectal cancer surgery 6 years earlier presented with a solitary lung mass in the periphery of the right lower lobe on computed tomography. Transbronchial biopsy disclosed a suspected metastatic adenocarcinoma, and he was admitted for pulmonary metastasectomy. He had been asymptomatic, but 4 weeks after the diagnostic bronchoscopy, the patient suddenly complained of a right back pain and dyspnea at rest; shortly after that, he developed a fever of 39 degrees C. A chest X-ray showed right pleural effusion, collapse of the right lower lobe, and elevation of the right diaphragmatic dome, but without pneumothorax. Emergent video-assisted thoracoscopy revealed a perforated tumor in the collapsed lower lobe, and a right lower lobectomy was carried out. The postoperative course was uneventful, and he was well without recurrent disease 2 years after pulmonary resection.

Extended resection of primary lung cancer directly invading the liver.

A 61-year-old woman presented with chest pain. Chest CT revealed a mass of 6 cm diameter in the right lower lobe. Bronchoscopic biopsy showed squamous cell carcinoma. Video-assisted thoracotomy revealed that the main tumour was directly invading the liver through the diaphragm. To alleviate local symptoms and for possible cure with adjuvant chemotherapy and radiotherapy, standard right lower lobectomy and mediastinal dissection were carried out, followed by combined resection of the diaphragm and posterior superior segmentectomy of the liver. Eleven months postoperatively, the patient was alive but had a metastatic lesion in the other lobe of the liver which reduced in size following chemotherapy.

Functional large parathyroid carcinoma extending into the superior mediastinum.

Mediastinal parathyroid carcinoma is very rare regardless of whether it is functioning, and it is sometimes problematic in both diagnosis and treatment. We herein report a case of primary hyperparathyroidism (PHP) associated with large parathyroid carcinoma extending into the superior mediastinum successfully removed by a transcervical approach, with a review of recent literature. A 61-year-old male with a six-year history of PHP and urinary stone disease presented with an abnormal mediastinal mass in a chest X-ray. His serum level of intact parathyroid hormone (PTH) was markedly elevated to 1,220.0 pg/mL (normal range: 10.0-65.0 pg/mL), though calcium and phosphorus levels were within normal limits. Chest computed tomography demonstrated a large mass in the superior mediastinum, displacing the trachea to the right and reaching the aortic arch, posteriorly adjacent to the thoracic vertebra. Transcervical extirpation of the tumor was performed. The resected specimen measured 50x85x38 mm and weighed 56.8 g. Histopathological examination revealed a capsular invasion of the tumor cells, and a diagnosis of parathyroid carcinoma was made. On the 8th postoperative day, the patient was discharged uneventfully with a decreased serum level of PTH (59.0 pg/mL), and no recurrent disease or exacerbation of hyperthyroidism was observed 36 months after surgery.

Synthesis and properties of DNA complexes containing 2,2,6,6-tetramethyl-1-piperidinoxy (TEMPO) moieties as organic radical battery materials.

We report here the first example of organic radical battery with DNA. Though there is a growing interest in DNA/cationic-lipid complexes as promising gene delivery vehicles, few efforts have been focused on the use of such complexes as advanced materials for organic optoelectronic applications. The present article describes how substitution of the sodium counter cation of DNA with cationic amphiphilic lipid(1-4) provided novel DNA-lipid complexes that contain TEMPO radicals, in which the actual mole ratio of phosphate to lipid was 1:0.84 to 1:0.16. All the TEMPO-containing DNA-lipid complexes displayed reversible two-stage charge/discharge processes, the discharge capacities of which were 40.5-60.0 A h kg(-1). In particular, the capacity of a DNA-lipid(3)-based cell reached 60.0 A h kg(-1), which corresponds to 192 % relative to its theoretical value for the single-electron one-stage process, indicating a two-electron process.

Pulmonary metastasis from colorectal carcinoma with hepatic metastasis.

OBJECTIVE: Although some beneficial effects of surgical treatments for pulmonary or hepatic metastases from colorectal carcinoma have been reported, identifying candidates for these aggressive surgical procedures is controversial. In this study, patients with pulmonary metastases from colorectal carcinoma, particularly those with pulmonary and hepatic metastases, were retrospectively analyzed. METHODS: Forty-six patients who had undergone complete resection for pulmonary metastases from colorectal carcinoma were retrospectively analyzed. RESULTS: The median follow-up period after pulmonary resection was 26 months, and the 5-year postoperative survival rate was 34%. The 5- and 10-year survival rates of patients with pulmonary metastasis alone, metachronous pulmonary metastasis after liver metastasis, and synchronous metastasis to the liver and lung were 75%, 75%, and 25% and 25%, 38%, and 0%, respectively, when calculated from the time of primary colorectal resection (P < 0.01). Patients with synchronous metastases had a poorer prognosis than did the patients in the other two groups. CONCLUSIONS: Surgical treatments for patients with pulmonary metastasis alone or metachronous metastasis can provide a beneficial outcome. Patients with synchronous metastasis have a poor prognosis, and effective pre- and postoperative systemic treatments should be considered to prolong their survival.

Long-term outcome of surgical treatment for non-small cell lung cancer with comorbid liver cirrhosis.

BACKGROUND: Long-term outcome of surgery for non-small cell lung cancer with comorbid liver cirrhosis is not well known. We aimed to establish the factors influencing survival in such cases. METHODS: We retrospectively reviewed 33 patients who had undergone surgery for non-small cell lung cancer with comorbid liver cirrhosis. Clinical features, early outcome, survival time, and cause of death were investigated. Factors influencing survival were estimated by univariate and multivariate analyses. RESULTS: There were 2 in-hospital deaths (6.5%). Five-year survival rate for lung cancer death (n = 9) was 59.7%, whereas for hepatic death (n = 6), it was 62.9%. Factors influencing lung cancer death were nodal stage and limited resection (p < 0.05 for each). Factors influencing hepatic death were serum total bilirubin (p < 0.0001) and cholinesterase (p < 0.05), platelet count (p < 0.05), and alpha-fetoprotein (p < 0.05). Lung disease factors such as local extensiveness of the tumor and pathologic stage, and surgical factors such as performance of mediastinal dissection and limited surgery, also influenced survival from hepatic death (p < 0.05 for each). CONCLUSIONS: Although pulmonary resection invasiveness may have some impact on long-term liver function, the life expectancy of patients with cirrhosis does not seem to be severely affected by pulmonary resection itself. Curative surgery should be performed if possible, even in patients with cirrhosis.

[Resection of cancer of the cardia enabled by combined treatment with S-1 and paclitaxel after esophageal stenting for impaired patency complicating stage IV gastric cancer - a case report].

The patient was a 47-year-old man who was discovered to have Borrmann type 4 cancer of the cardiac region of the stomach associated with esophageal invasion during upper GI endoscopy and was histopathologically diagnosed with poorly-differentiated adenocarcinoma. Invasion of the aorta was suspected based on a CT examination, and resection was judged to be impossible. Since the tumor was associated with impaired patency, after first inserting a metallic stent, the patient was treated with 4 cycles of S-1 100 mg/body for 2 weeks and paclitaxel (PTX) 120 mg/body by intravenous drip infusion on days 1 and 15 for 2 weeks followed by a 2-week rest period. The tumor regressed considerably, and total gastrectomy and lower esophagectomy with D1+ a lymph node resection through a left thoracolaparotomy became possible. A bypass operation or palliative resection is sometimes performed when complicated by impaired patency. In our patient, after achieving an improvement in QOL by stenting, resection became possible as a result of a response to chemotherapy with S-1. However, when considering resection after chemotherapy it seemed necessary to be careful to insert the stent as close as possible to the proximal margin of the tumor so as not to broaden the extent of the esophageal resection.

Pulmonary inverted Schneiderian papilloma causing high serum levels of carcinoembryonic antigen and squamous cell carcinoma-associated antigen: report of a case.

We report a rare case of inverted Schneiderian papilloma causing exceedingly high serum levels of carcinoembryonic antigen (CEA) and squamous cell carcinoma-associated antigen (SCC). A 74-year-old man presented with a 6-month history of a productive cough, bloody sputa, and dyspnea. Chest computed tomography showed massive infiltration in the lower lobe with multiple focal soft tissue densities. Blood biochemical analysis revealed a serum CEA level of 107.0 ng/ml (normal <5.0 ng/ml), and an SCC level of 373.0 ng/ml (normal <1.5 ng/ml). Squamous papilloma was diagnosed by histological examination of a bronchoscopic biopsy specimen. To alleviate the patient's symptoms and refine the diagnosis, we performed a right lower lobectomy. The lower lobe of the lung was filled with mucinous sputa and very fragile papillary tumors of various sizes. Microscopic examination revealed papillary growth of stratified epithelial cells with massive mucin production. No nuclear abnormality or invasion of the basal membrane of the tumor cells was observed. Postoperatively, the patient's symptoms resolved quickly, and the serum levels of CEA and SCC decreased to 6.4 ng/ml and 1.7 ng/ml, respectively, within 3 months.

Early recurrence of completely resected N2-positive non-small-cell lung cancer.

OBJECTIVE: Postoperative early recurrence, defined as recurrence within 1 year postoperatively, is often experienced with completely resected N2 disease. In this study, we evaluated the risk factors for early recurrence with completely resected N2 disease. METHODS: . Potential risk factors for postoperative early recurrence were evaluated in 75 patients with N2 disease who underwent complete resection without any preoperative therapy. Prognostic significance was determined by univariate and multivariate analyses. RESULTS: The median follow-up period was 24 months, and the 5-year survival rate was 23%. Thirty-nine patients developed postoperative early recurrence. The 1-, 3-, and 5-year survival rates of patients with early recurrence were 64%, 10%, and 5%, respectively, and 100%, 51%, and 34%, respectively (p < 0.001). Multistation N1 metastasis was a risk factor for postoperative early recurrence by univariate analysis and an independent risk factor by multivariate analysis. CONCLUSIONS: Early recurrence is a significant poor prognostic factor for completely resected N2 disease. It is suggested that the number of N1 stations with metastasis is a risk factor for early recurrence and a poor prognostic factor in N2 disease.

Thymolipoma associated with myasthenia gravis.

A 51-year-old woman with a 3-year history of diplopia was admitted to our hospital. Repetitive stimulation of the right median nerve revealed decreasing hand muscle responses. Edrophonium chloride administration alleviated the symptoms. The serum antiacetylcholine receptor antibody level was 3.3 nmol/l; thus, myasthenia gravis was diagnosed. A chest roentgenogram revealed a left inferior mediastinal mass, and a chest computed tomographic scan revealed a fat density mass partly containing soft tissue areas in the left side of the anterior mediastinum. Median sternotomy and extended thymectomy were performed. The pathology examination of the tumor revealed mature adipose tissue including islands of thymic tissue containing Hassall's corpuscles, without germinal centers. The tumor was a thymolipoma of the anterior mediastinum. Her postoperative course was good, and she is doing well at 1 year postoperatively.

Thymic tuberculosis preoperatively evaluated with thallium-201 SPECT: two resected cases.

We present 2 resected cases of thymic tuberculosis, which had been preoperatively diagnosed as invasive thymoma, using a thallium-201 ((201)Tl) single photon emission computed tomography ((201)Tl SPECT). [Patient 1] A 74-old-male with a 32-year history of steroid therapy for rheumatic arthritis was diagnosed with an anterior mediastinal tumor by routine chest CT scans after onset of myocardial infarction. [Patient 2] A 56-old-female with a 28-year history of diabetes mellitus presented with a dry cough. A chest CT demonstrated an anterior mediastinal tumor. Neither patient showed pulmonary infiltrations on chest x-ray. (201)Tl SPECT was undertaken for each patient. Abnormal findings could not be detected on a planar image of the scintigraphy; however, on SPECT images accumulations of (201)Tl were clearly detected in the anterior mediastinal mass and a thymoma was thus suspected in each case. Total thymectomy was carried out in each case and the mass then diagnosed as caseous granuloma in the thymus. Both patients are well without recurrence after operation. In patients with a (201)Tl SPECT positive anterior mediastinal tumor associated with an immunologically deficient status, and with negative findings in planar images on thallium scintigraphy, the possibility of thymic tuberculosis should be considered.