A Rare Case of Laparoscopic Repair of Simultaneously Occurring Morgagni and Paraesophageal Hernias.

Simultaneously occurring Morgagni hernia and paraesophageal hernia is an extremely rare clinical condition with only six case reports in the English-language literature and only two laparoscopic repair reports. We report a 73-year-old woman with both Morgagni hernia and paraesophageal hernia who underwent successful laparoscopic repair of the hernia defects using transabdominal wall suturing. The laparoscopic operation can provide excellent exposure and repair the hernia defect easily with minimal invasiveness and fewer complications. This case report reported the concurring Morgagni and paraesophageal hernias and validated the feasibility of laparoscopic repair both hernias simultaneously.

Diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration in intrapulmonary lesions.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered to have high value in the staging of mediastinal lymph nodes in lung cancer. The current study was conducted to investigate the diagnostic value of EBUS-TBNA in intrapulmonary lesions located near the central airway. METHODS: From September 2009 to March 2013, 66 patients with pulmonary masses located close to the central airways suspected to be lung cancer were accessed by EBUS-TBNA. Conventional bronchoscopic biopsy before EBUS-TBNA was nondiagnostic in all cases. If EBUS-TBNA did not result in a formal pathological diagnosis of malignancy, patients were subsequently referred for a surgical procedure. RESULTS: Among the 66 cases, 59 were confirmed as pulmonary malignancies by EBUS-TBNA, of which 48 cases were non-small cell lung cancer, nine were small cell lung cancer, and two were metastatic lung tumors. No evidence of malignancy was found by biopsy and histopathological examination in the other seven cases. Thoracoscopy or thoracotomy was subsequently undergone for them. Postoperative pathological examinations confirmed three cases of squamous cell carcinoma of the lung, one case of lymphoma, two cases of sclerosing hemangioma, and one case of pulmonary tuberculoma. The definitive diagnosis rate of EBUS-TBNA for intrapulmonary lesions near the central airway was 89.4%. The sensitivity, specificity, and accuracy of EBUS-TBNA in distinguishing benign from malignant intrapulmonary lesions were 93.7%, 100.0%, and 93.9%, respectively. The positive and negative predictive values were 100.0% and 42.9%, respectively. The EBUS-TBNA procedures were well-tolerated by all patients. No associated complications were observed. CONCLUSIONS: For intrapulmonary lesions near the central airway highly suspected of cancer, EBUS-TBNA has satisfactory diagnostic value. However, the negative predictive value of this technique is low, so negative results obtained by EBUS-TBNA should be confirmed by other methods.

Diagnostic value of endobronchial ultrasound guided transbronchial needle aspiration in superior vena cava syndrome.

BACKGROUND: The pathological diagnosis is of critical importance to the subsequent treatment for the pathients with superior vena cava syndrome (SVCS). The aim of this study is to report our experience in the diagnosis of SVCS by endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). METHODS: The data of 520 patients who underwent EBUS-TBNA from September 2009 to May 2012 at our institution were reviewed. Of these, there were 14 males and 6 females (mean age of 59.1 years) with SVCS who received EBUS-TBNA that were included in the analysis. RESULTS: The mean short axis diameter of the paratracheal lesions was (3.32 ± 1.79) cm (range, 1.69 to 9.50 cm) and 6 cases also had subcarinal lymph node enlargement with a mean short axis diameter of (2.14 ± 0.49) cm (range, 1.73 to 3.01 cm). An average of 4.3 punctures was performed per lesion. Malignancy was confirmed in 16 cases (10 small cell carcinomas, 4 adenocarcinomas, 1 squamous cell carcinoma and 1 Hodgkin lymphoma). In two patients, pathological examination of tissue revealed no evidence of malignancy and for 13 to 24 months of follow-up. One patient from whom adequate tissue was not obtained refused further surgical biopsy since he had undergone endovascular stenting of the SVC. One patient in whom a diagnosis was not obtained by EBUS-TBNA underwent thoracoscopic biopsy and the final diagnosis was B cell non-Hodgkin's lymphoma. The diagnosis accuracy of EBUS-TBNA in SVCS was 18/20 patients. CONCLUSION: EBUS-TBNA is a highly effective and safe procedure for the diagnosis of SVCS.

Change of CMTM7 expression, a potential tumor suppressor, is associated with poor clinical outcome in human non-small cell lung cancer.

BACKGROUND: CKLF-like MARVEL transmembrane domain-containing 7 (CMTM7) located at 3p22.3, is a frequent deletion site and a tumor suppressor gene (TSG) locus in many cancer, which suggests CMTM7 may be a potential TSG. The aim of this study was to investigate the correlations of CMTM7 expression and survival rate in patients with non-smallcell lung cancer (NSCLC). METHODS: Surgical specimens of 180 cases with pathologically confirmed NSCLC were grouped into 18 tissue microarray slides. CMTM7 expression in these specimens were detected by immunohistochemistry staining and representative cases were confirmed by Western blotting. Univariate and multivariate analyses were performed to identify the association of CMTM7 expression with pathological features and survival of patients with NSCLC. RESULTS: A total of 78.9% of the 180 patients had variations of CMTM7 protein expression, either up-regulated or down-regulated. Univariate analysis showed that the patients' survival rate after surgery was highly correlated with CMTM7 expression (P = 0.0091). In addition, prognostic factors were examined by multivariate Cox regression analysis, and results suggested that CMTM7 expression was a unique prognostic factor in NSCLC survival. CONCLUSIONS: The CMTM7 expression may be related to survival of patients with NSCLC and a unique prognostic factor. CMTM7 may play an important role in NSCLC development.

Completely thoracoscopic lobectomy for the surgical management of bronchiectasis.

BACKGROUND: The feasibility of completing a lobectomy by completely video-assisted thoracoscopic surgery (cVATS) in the management of bronchiectasis is unclear. By retrospectively comparing the outcomes from the lobectomies that used thoracotomy vs. cVATS, we determined the appropriateness of the minimally invasive cVATS approach in the management of bronchiectasis. METHODS: Between June 2001 and October 2010, 60 patients with bronchiectasis underwent surgery, of which 56 lobectomies were performed. All lobectomies were carried out by either thoracotomy or cVATS approach. Pulmonary vessels and bronchi were manipulated by ligation or stapler in the thoracotomy group, while they were dissected by endo-cutters in the cVATS group. RESULTS: There were 21 patients in the thoracotomy group and 35 patients in the cVATS group. Two cVATS patients (5.7%) converted. The difference in operation time, chest tube duration, lengths of hospitalization, and morbidity were not significantly different between the two groups (P > 0.05). The blood loss was less in the cVATS group (P = 0.015). A total of 52.4% and 62.9% of patients were postoperatively asymptomatic in the thoracotomy and cVATS groups respectively, and symptomatic improvement was obtained in 38.1% patients by thoracotomy vs. 31.4% patients by cVATS. CONCLUSION: cVATS lobectomy is safe and effective for the management of bronchiectasis, especially for the patients with localized lesions.

[Application of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of isolated mediastinal lesions].

OBJECTIVE: To evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of isolated mediastinal lesions. METHODS: A retrospective study was conducted of 73 consecutive patients with isolated mediastinal lesions of unknown origin without parenchymal lung abnormalities, who underwent EBUS-TBNA from September 2009 to April 2011. The patients who were nondiagnostic with EBUS-TBNA subsequently underwent surgical biopsies and a minimum of 6 months'clinical and radiologic follow-up. RESULTS: EBUS-TBNA achieved definitive diagnoses in 60 patients of the 73 patients (82.2%, 60/73). Malignancies were diagnosed in 23 patients and benignancies in 37. The sensitivity, specificity, and accuracy of EBUS-TBNA in distinguishing malignant mediastinal lesions were 95.8%(23/24), 100%(49/49) and 98.6%(72/73), respectively. EBUS was well tolerated by all of the patients with no complications. CONCLUSION: EBUS-TBNA of isolated mediastinal lesions is a minimally invasive and safe diagnostic technique with high yield.

[Preliminary comparison research of thoracoscopy and thoracotomy lobectomy for clinical N0 and post-operatively pathological N2 non-small cell lung cancer].

OBJECTIVE: To evaluate the safty, thoroughness and efficacy of the video-assisted thoracoscopic surgery compared with open thoracotomy, in treatment of patients with the preoperative staging of lymph node negative and postoperative pathological mediastinal lymph node positive (cN0-pN2) locally advanced non-small cell lung cancer(NSCLC). METHODS: We performed a retrospective review of 616 patients who underwent either VATS lobectomy or open thoracotomy from July 2000 to December 2009. Of which 386 patients were diagnosed with preoperative staging of lymph node negative(cN0) non-small cell lung cancer. Of the 386 patients 76 were diagnosed with postoperative pathological mediastinal lymph node positive (pN2). Twenty-nine patients were operated by video-assisted thoracoscopic surgery (VATS group), 47 patients were operated by open thoracotomy(T group).The patients' preoperative and intraoperative conditions, postoperative survival and recurrence, etc. were compared. RESULTS: The two groups were similar in age, gender distribution, pulmonary function, preoperative complications and the preoperative clinical stage. VATS group was slightly lower than T group in operation time, and blood loss. The station number of mediastinal lymph nodes dissection was (3.3±1.1) vs. (3.3±1.3), P=0.959; the number of lymph nodes dissected (12.7±8.9) vs. (10.5±7.2),P=0.260; positive lymph nodes / lymph nodes dissection 28.7% vs. 32.5%, P=0.592; the postoperative proportion of single-station N2 55.2% vs. 66.0%(P=0.189) in VATS group and T group, respectively. One, three-year disease-free survival rates after operation in VATS and T group were 82.6% vs.69.2%(P=0.088) and 49.3% vs. 51.3% respectively(P=0.996); one, three-year overall survival rates were 84.9% vs. 71.2%(P=0.149) and 64.0% vs. 42.7% (P=0.121). Both groups had the similar pattern of recurrence, most of which were distant metastases. CONCLUSION: With respect to the safety,thoroughness and recent effect, VATS is not inferior to open thoracotomy in the treatment of cN0-pN2 non-small cell lung cancer.

[Establishment of a mathematical prediction model to evaluate the probability of malignancy or benign in patients with solitary pulmonary nodules].

OBJECTIVE: To evaluate the clinical factors affecting the definite pathological diagnosis of solitary pulmonary nodules (SPN) with multivariate Logistic regression analysis, and to build the clinical prediction model to estimate the probability of malignancy. METHODS: A retrospective cohort study in our institution included 371 patients (197 males and 174 females) with definite pathological diagnosis of solitary pulmonary nodules from Jan 2000 to Sep 2009 (group A). Clinical data included age, gender, course of disease, symptoms, history and quantity of smoking history, history of tumor, family history of tumor, site, diameter, calcification, speculation, border, lobulation, traction of pleural, vascular convergence sign, and cavity. The independent predictors of malignancy were estimated with multivariate analysis, then the clinical prediction model was built. Other 62 SPN patients (group B) with definite pathological diagnosis in our institute from Oct 2009 to Mar 2010, were used to validate value of this clinical prediction model. RESULTS: 53.1% of the nodules were malignant, and 46.9% were benign in goup A. Logistic regression analysis showed that seven clinical characteristics [age of patient (OR: 1.073), diameter (OR: 1.966), border (OR: 0.245), calcification (OR: 0.199), spiculation (OR: 2.088) and the family history of tumor (OR: 3.550)] were independent predictors of malignancy in patients with SPN (P<0.05). The cut-off value was 0.463. The sensitivity in group B was 92.5%, specificity 81.8%, positive predictive value 90.2%, and negative predictive value 85.7%. The area under the ROC curve for our model was 0.888±0.054. CONCLUSION: Age of patient, diameter, border, calcification, spiculation and the family history of tumor are independent predictors of malignancy in patients with SPN. Our prediction model is accurate and sufficient to estimate the malignancy of patients with SPN.

Application of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal lesions.

BACKGROUND: Mediastinal lesions are often difficult to diagnose in clinical practice because of the unique anatomical position of the mediastinum, which makes performance of biopsy difficult. The value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer and mediastinal lymph node staging has been widely accepted. However, few studies have been conducted on the value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and differential diagnosis of mediastinal lesions. The current study was conducted to investigate the value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and differential diagnosis of isolated mediastinal lesions without lung abnormalities. METHODS: We retrospectively analyzed the data of patients with isolated mediastinal lesions without lung abnormalities for whom endobronchial ultrasound-guided transbronchial needle aspiration examination was performed at the Department of Thoracic Surgery of Peking University People's Hospital, between September 2009 and December 2010. For patients who could not be diagnosed with endobronchial ultrasound-guided transbronchial needle aspiration, surgical biopsy or more than 6 months of clinical and imaging follow-up was carried out. RESULTS: Endobronchial ultrasound-guided transbronchial needle aspiration was performed for 60 patients with isolated mediastinal lesions. Correct diagnosis was made in 48 cases. Nineteen cases were malignant, and 29 were benign. The rate of correct diagnosis was 80%. The sensitivity, specificity, and accuracy of endobronchial ultrasound-guided transbronchial needle aspiration in distinguishing benign from malignant mediastinal lesions were 95%, 100%, and 98%, respectively. The examination was tolerable for all patients. No associated complications were observed. CONCLUSION: Endobronchial ultrasound-guided transbronchial needle aspiration is a safe and effective method of diagnosing mediastinal lesions.

Comparison of the autofluorescence bronchoscope and the white light bronchoscope in airway examination.

BACKGROUND AND OBJECTIVE: The sensitivity and accuracy of white light bronchoscopy (WLB) in airway examination are low. Autofluorescence bronchoscope (AFB) can determine early lesions in bronchial mucosa more sensitively, but it has seldom performed in China. To assess the clinical value of the AFB in airway examination, we compared the sensitivity and specificity of the AFB and WLB in detecting cancer of the airway mucosa. METHODS: Between September 2009 and May 2010, bronchoscope examinations using both the AFB and WLB were performed on 136 patients, 95 men and 41 women with a median age of 61.5 years (ranged from 25 to 84 years). There were 46 lesions located in the central airway, 84 in the peripheral lung parenchyma, and 6 in the mediastinal region. All patients received local and general anesthesia and were subsequently examined with the WLB and AFB in tandem. All procedures were completed safely. Abnormal visual findings were recorded, and biopsies of the affected regions were collected for pathologic examination. RESULTS: Of 241 regions sampled for biopsy, 76 sites contained malignant lesions, whereas 165 sites contained benign lesions. The AFB detected 72 of the 76 malignant lesions, but the WLB detected only 50. The sensitivities of the AFB and WLB were 94.7% and 65.8%, respectively, and the specificities were 57.0% and 83.6%, respectively. The negative predictive values of the AFB and WLB were 95.9% and 84.1%, respectively. CONCLUSIONS: The AFB is more sensitive than the WLB in detecting cancerous lesions in the mucosa, and is an effective airway examination.

[Clinical analysis of thoracoscopic lobectomy: a report of 40 cases].

OBJECTIVE: To review the technology of completely thoracoscopic lobectomy procedures. METHODS: From September 2006 to July 2007, 40 patients (23 male and 17 female) underwent completely thoracoscopic lobectomy. The median age was 59.5-years-old, with a range from 24 to 79-years-old. The lobectomy was completed through 3 incision in the 5th, 8th and 7th intercostal space. The procedures were similar with conventional open lobectomy. RESULTS: All procedure were carried out safely, including lung cancer (n = 34), lymphoma(n = 1), pulmonary cyst (n = 1), middle lobe syndrome (n = 1) , bronchiectasis (n = 2) and renal carcinoma metastasis to lung (n = 1). There were no operative mortality or serious complications. There was one patient opposed to open thoracotomy because of the mediastinal lymph nodes metastasis. The average surgical duration was 206 min (range from 60 to 300 min). The average blood loss was 221 ml (range from 100 to 400 ml) with no blood transfusion required. The average length of stay was 8.9 d. No recurrence and metastasis was observed in a follow-up range from 1 to 10 months except one patient with adenocarcinoma occurred metastasis of tumor 3 months postoperation. CONCLUSION: The completely thoracoscopic lobectomy is a safe and feasible surgical procedure compared with conventional open lobectomy for selected patients.

[Epidermal growth factor receptor and phosphorylated Akt protein expression in non-small-cell lung cancer].

OBJECTIVE: To evaluate the expressions of epidermal growth factor receptor (EGFR) and phosphorylated Akt (p-Akt) in non-small-cell lung cancer (NSCLC). METHODS: 189 NSCLC samples were made into tissue microarray and immunohistochemistry was used to detect the expression of EGFR and p-Akt proteins. The association of the expressions of EGFR and p-Akt protein with the survival time was evaluated. RESULTS: The EGFR and p-Akt protein positive rates were 54.5% and 51.3% respectively. Univariate analysis showed that the EGFR expression was associated with gender (chi2 = 4.267, P = 0.039), histology (chi2 = 14.749, P = 0.002), differentiation (chi2 = 6.295, P = 0.043), and pathological stage (chi2 = 9.318, P = 0.025). Logistic multivariate analysis showed that only the pathological type was associated with EGFR expression (P = 0.047). The p-Akt expression was not related with the above clinicopathological features (P > 0.05) Kaplan-Meire survival analysis showed that neither of the two proteins had an impact on the patients' survival (P = 0.972 and P = 0.903 respectively). CONCLUSION: Protein expressions of IEGFR and p-Akt have no impact on NSCLC patients' survival, thus so far they can not serve as molecular staging or prognostic indicators.

[Study of growth inhibition of lung cancer cells by siRNA targeting mutant K-ras gene in vitro and in vivo].

OBJECTIVE: To study the inhibitory effect of mutant K-ras gene depletion by small interfering RNA on the growth of lung cancer cell line-H441 cells in vitro and in vivo. METHODS: One pair of 63 bp reverse repeated sequence targeting mutant K-ras(V12) mRNA spaced by 9 bp nucleotide were synthesized and inserted into plasmid pSilencer3.1 eukaryotic expression vector. After transient and stable transfection into H441 cells, the mutant K-ras mRNA and protein level were measured by RT-PCR and Western blotting, and the H441 cells proliferation was measured by MTT method, and the apoptosis rate was detected by flow-cytometry. H441 cells treated with pSilencer3.1-K-ras(V12) were transplanted subcutaneously in nude mice and their tumorigenesis ability was observed. RESULTS: The recombinant plasmid pSilencer3.1-K-ras(V12) was successfully constructed by sequencing. The introduction of pSilencer3.1-K-ras(V12) was showed to efficiently and specifically inhibit the expression of K-ras(V12) gene according to the results of RT-PCR and Western blotting (P < 0.01, as compared with controls). The inhibitory effect on cell proliferation was confirmed by MTT test (P < 0.05, as compared with controls). Apoptosis rate of H441 cells treated with pSilencer3.1-K-ras(V12) was significantly higher than that of the control cells (P < 0.01). The test in vivo showed that downregulation of K-ras(V12) expression in H441 cells apparently affected their ability to form tumors in nude mice. CONCLUSIONS: siRNA targeting mutant K-ras mRNA can specifically suppress the expression of mutant K-ras gene in H441 cells, and therefore has a substantially inhibitory effect on cell proliferation in vitro and in vivo, it provides a new method and material to the gene therapy of lung cancer.

[Craniofacial hyperhidrosis treated by video-assisted thoracoscopic sympathectomy].

OBJECTIVE: To investigate the feasibility, safety and prospect application value of video-assisted thoracoscopic sympathectomy utilized in the treatment of craniofacial hyperhidrosis. METHODS: Eighteen patients with craniofacial hyperhidrosis underwent sympathectomy from January 2003 to December 2004, including 10 cases combined with palmar hyperhidrosis. There were 17 males and 1 females with a mean age of 36.5 years (ranges, 25-42). Sympathetic chain was transected just below the stellate ganglion in pure craniofacial hyperhidrosis. Additional T(3) sympathectomy was performed in those patients combined with palmar hyperhidrosis. RESULTS: There were no surgical complication or surgical mortality cases. Seventeen patients achieved improvement of craniofacial hyperhidrosis without recurrent symptoms, but one had partial remission due to thoracic adhesion and false location of the ganglions. The effective rate was 97% (35/36). No recurrent symptoms occurred after a mean of 8.3 months of follow-up. No relapse occurred. Fifteen patients (83%) developed compensatory sweating of the trunk and lower limbs. Six patients (33%) presented palmar dry (severe hypohidrosis) and they all can tolerate the condition. All patients were satisfied with the outcomes of their operations. CONCLUSION: The initial results show that thoracoscopic sympathectomy is a safe and effective method for the treatment of craniofacial hyperhidrosis.