Modified blowhole skin incision using negative pressure wound therapy in the treatment of ventilator-related severe subcutaneous emphysema.

OBJECTIVES: A 2-3-cm blowhole incision in the supraclavicular or infraclavicular area is widely used to eliminate the presence of subcutaneous air in cases of life-threatening subcutaneous emphysema (SE). However, when the patient is supported by mechanical ventilation, it is difficult to eliminate completely such air because mechanical ventilation leads consistently to the formation of large amounts of air. To overcome this, we applied negative pressure wound therapy (NPWT) along with blowhole incisions for the treatment of severe SE. METHODS: To evaluate the feasibility of NPWT, we retrospectively analysed the clinical outcomes of 10 patients who developed severe SE during ventilator care and were treated with a modified blowhole incision using NPWT from January 2009 to November 2013. RESULTS: All patients showed immediate improvement in SE after NPWT, and no symptom aggravation occurred after NPWT. The mean duration of NPWT was 7.5 ± 5.1 (range, 3-14) days, and the mean number of dressing changes was 1.5 ± 0.7 (range, 1-2). There were no blowhole-incision-related wound infections or any other complications. CONCLUSIONS: While it is not necessary to apply a blowhole incision with NPWT in all cases of SE, this therapy can be helpful for patients with severe SE associated with mechanical ventilation requiring rapid decompression.

The use of neutrophil elastase inhibitor in the treatment of acute lung injury after pneumonectomy.

BACKGROUND: The prognosis of acute lung injury (ALI) after pneumonectomy is poor, with reported mortality rates of 30-100%. Neutrophil elastase inhibitor (NEI) is known to prevent lung injury caused by neutrophil elastase and improve lung function in ALI. We evaluated the effect of NEI on ALI after pneumonectomy. METHODS: We analyzed nine patients who required ventilator care due to ALI after pneumonectomy. Five of these patients underwent conventional ventilator care (group I), and four patients underwent ventilator care and were administrated NEI (group II). We retrospectively analyzed the lung injury score (LIS) for 10 days after intubation. RESULTS: The LIS before intubation satisfied the diagnostic criteria of ALI or acute respiratory distress syndrome (ARDS) in all patients. After intubation, the LIS improved in both groups. But, as times went on, the mean value of the LIS in group II was lower compared to group I. In group I, only one patient underwent extubation. In group II, extubation was possible in three patients. Mortality rates were 80% in group I and 25% in group II. CONCLUSIONS: We conclude that NEI may improve the lung function, shorten the duration of mechanical ventilation, and reduce mortality in patients with ALI after pneumonectomy.

Feasibility and early outcomes of intensivist-led critical care after major trauma in the Korean ICU.

PURPOSE: Substantial evidence supports the benefits of an intensivist model of critical care delivery. However, currently, this mode of critical care delivery has not been widely adopted in Korea. We hypothesized that intensivist-led critical care is feasible and would improve ICU mortality after major trauma. MATERIALS AND METHODS: A trauma registry from May 2009 to April 2011 was reviewed retrospectively. We evaluated the relationship between modes of ICU care (open vs. intensivist) and in-hospital mortality following severe injury [Injury Severity Score (ISS)>15]. An intensivist-model was defined as ICU care delivered by a board-certified physician who had no other clinical responsibilities outside the ICU and who is primarily available to the critically ill or injured patients. ISS and Revised Trauma Score were used as measure of injury severity. The Trauma and Injury Severity Score methodology was used to calculate each individual patient's probability of survival. RESULTS: Of the 251 patients, 57 patients were treated by an intensivist [intensivist group (IG)] while 194 patients were not [non-intensivist group (NIG)]. The ISS of IG was significantly higher than that for NIG (26.5 vs. 22.3, p=0.023). The hospital mortality rate for IG was significantly lower than that for NIG (15.8% and 27.8%, p<0.001). CONCLUSION: The intensivist model of critical care is feasible, and there is room for improvement in the care of major trauma patients. Although trauma systems take time to mature, future studies are needed to evaluate the best model of critical care delivery for severely injured patients in Korea.

Silibinin regulates gene expression, production and secretion of mucin from cultured airway epithelial cells.

We investigated whether silibinin significantly affects gene expression, production and secretion of mucin from cultured airway epithelial cells. Confluent NCI-H292 cells were pretreated with silibinin for 30 min and then stimulated with epidermal growth factor (EGF), phorbol 12-myristate 13-acetate (PMA) or TNF-α for 24 h. The MUC5AC mucin gene expression and mucin protein production were measured by reverse transcription-polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). The effect of silibinin on TNF-α-induced activation of NF-κB p65 was also examined. Confluent primary rat tracheal surface epithelial (RTSE) cells were pretreated with adenosine triphosphate (ATP) for 5 min and then treated for 30 min in the presence of silibinin to assess the effect on mucin secretion using ELISA. The results were as follows: (i) silibinin inhibited the expression of the MUC5AC mucin gene induced by EGF, PMA or TNF-α from NCI-H292 cells; (ii) silibinin also inhibited the production of MUC5AC mucin protein induced by the same inducers from NCI-H292 cells; (iii) silibinin inhibited the activation of NF-κB p65 by TNF-α in NCI-H292 cells; (iv) silibinin significantly decreased ATP-induced mucin secretion from cultured RTSE cells. This result suggests that silibinin can regulate gene expression, production and secretion of mucin by directly acting on airway epithelial cells.

Altered expression of phosphatase of regenerating liver gene family in non-small cell lung cancer.

Protein tyrosine phophatases (PTPs) are implicated in the tumorigenesis and metastasis of human cancer. The phosphatase of regenerating liver (PRL) gene family, a subgroup of PTPs is also linked to these processes. In many solid cancers, high levels of PRL-3 expression are related with metastasis and poor prognosis. However, the expression patterns of PRL-1 and -2 have not been explored in lung cancer yet. Thus, we investigated the expression levels of PRL-1, -2 and -3 in the tissues of primary lung cancer patients. The protein expression levels of PRL-2, but not PRL-1 and -3 were increased in cancer tissues. However, there was no correlation between mRNA and protein expression levels of the PRLs. Reporter assays showed that PRLs suppressed the activity of the p21 promoter but promoted AP-1 activity. Furthermore, transfection of PRLs showed significantly increased cell proliferation. Therefore, these results suggest that PRL-2 plays an important role in lung cancer and can be a biomarker of lung cancer, substituting for the function of other PRLs.

Validity of International Association for the Study Of Lung Cancer proposals for the revision of N descriptors in lung cancer.

OBJECTIVE: This study was conducted to assess the validity of the pending suggestions for N descriptors by the International Association for the Study of Lung Cancer. METHODS: Medical records from 1032 patients with non-small cell lung cancer who had pulmonary resection and proven stage I-III were retrospectively reviewed. Lymph node stations were grouped together into six "zones": peripheral or hilar for N1 and upper or lower mediastinal, aortopulmonary, and subcarinal for N2. Survival was analyzed according to the proposed subdividing N descriptors: single-zone N1 (N1a), multizone N1 (N1b), single-zone N2 (N2a), and multizone N2 (N2b). RESULTS: The 5-year survival rate was 63.8% for N0, 42.3% for N1a, 36.5% for N1b, 35.8% for N2a, and 17.4% for N2b. There were three distinct prognostic groups for N1 and N2 nodes: N1a, N1b or N2a, and N2b disease. In multivariate analysis, age, sex, type of surgery, T stage, and node status were independent prognostic factors. Hazard ratios versus N0 for N1a, N1b or N2b, N2b, and N3 were 1.577, 2.164, 3.291, and 5.897, respectively. CONCLUSION: Amalgamating lymph node stations into zones and subdividing N descriptors described a significant stepwise deterioration of disease status. Although more studies are needed, the lymph node zone and subdivided N descriptors could be one of step for desirable approach of forthcoming tumor, node, metastasis classification in non-small cell lung cancer.

The prognostic significance of multiple station N2 in patients with surgically resected stage IIIA N2 non-small cell lung cancer.

Mediastinal (N2) lymph node involvement is heterogeneous with huge variation in the extent and grouped together under stage IIIA. However, they showed a different survival even in the same stage. We tried to determine the prognostic implication of the multiple station N2 lymph node metastasis in stage IIIA N2 non-small cell lung cancer (NSCLC). The survival of stage IIIA N2 was analyzed according to the number of N2 station and their survival was compared with that of stage IIIB. In stage IIIA N2 NSCLC, multivariate analysis indicated that multiple station N2 was one of the independent prognostic factors for poor survival. The 5-yr survival of multiple station N2 IIIA (20.4%) was lower than that of single station N2 IIIA (33.8%) significantly (p=0.016). but when it was compared with that of stage IIIB (15.5%), there was no difference. Therefore, we suggest that multiple station N2 should be considered similar to stage IIIB disease with regard to predicting survival and accordingly should receive a new position in the TNM staging system.

Topographical considerations under video-scope guidance in the T3,4 levels sympathetic surgery.

INTRODUCTION: Anatomical variation of the sympathetic nervous system is known to be one of the main causes of failure and dissatisfaction after sympathetic surgery. However, there are only few reports on the descriptive analysis of sympathetic nerve variants. The purpose of this study is to investigate the anatomical variations of the sympathetic trunk at the levels of T3 and T4 ganglia considered in a topographic approach for sympathetic procedures and to further improve the postoperative outcome. MATERIALS AND METHODS: From June 2003 to January 2004, 44 patients with palmar hyperhidrosis underwent bilateral T3,4 ramicotomy via video-assisted thoracoscopic surgery. The anatomy of T3 and T4 sympathetic ganglia, pathway of sympathetic trunk, and rami-communicantes were recorded on video and still cut images for descriptive analysis. RESULTS: The thoracic sympathetic trunks were mostly lying against the heads of the ribs, but there were variants of sympathetic trunk running along the medial side of the rib heads of 3rd, 4th and 5th ribs, respectively in 9.0%, 18.0% and 37.5% of the cases. There were also variants running along the lateral side of rib heads near the neck portion in 12.5%, 10.2% and 8.0% of the cases. The 3rd ganglion was located within the intercostal space (59.1%) or at the level of the upper border of the 4th rib (36.4%) or upon the 4th rib (4.5%). The location of the 4th ganglion was in the intercostal space (18.2%), the upper border of the 5th rib (44.3%) or upon the 5th rib (37.5%). The ascending rami were found at the level of the 3rd ganglion in 48.8% and the 4th ganglion in 45.5% of the cases. The descending rami were located at the level of 3rd and the 4th ganglion in 8.0% and 6.8%, respectively. And the middle rami were found in all cases except one. CONCLUSIONS: It may be difficult to localize the sympathetic trunk in some cases of severe obesity; a careful inspection has to be performed from the medial side of the rib heads to the neck portion. The obvious 'downward shift of ganglion' in the position shown as the thoracic sympathetic trunk descends is to be deliberated in T4 sympathetic surgery. Many ascending and descending accessory pathways of sympathetic nerve were observed; therefore, a lateral extension of electrocoagulation at the level of upper and lower rib border is necessary to impose a complete blockage of sympathetic nerve stimulus.

Number of metastatic lymph nodes in resected non-small cell lung cancer predicts patient survival.

BACKGROUND: This study was conducted to evaluate the prognostic significance of the number of lymph node metastases compared with the pathologic nodal stage (pN category) based on the anatomic extent of lymph node metastases in TNM classification of non-small cell lung cancer. METHODS: We reviewed 1,081 patients who underwent major pulmonary resection and were proven to be pathologic stage I through IIIA between 1990 and 2006. Patients were divided into four subgroups (nN category) according to the number of metastatic lymph nodes: those without nodal metastases were nN0, those with 1 to 3 metastatic lymph nodes were nN1-3, those with 4 to 14 were nN4-14, and those with 15 or more were nN > or = 15. RESULTS: The nN category followed a significant stepwise deterioration. The 5-year survival rate was 69.0% for nN0, 42.9% for nN1-3, 30.0% for nN4-14, and 11.5% for nN > or = 15 (p < 0.001). Multivariate analysis showed that the nN category was a significant prognostic indicator similar to the pN category. Hazard ratios versus pN0 for pN1 and pN2 were 1.639 and 2.639, respectively, and 1.860, 2.029, and 4.758 for nN1-3, nN4-14, and nN > or = 15, respectively. The nN category showed excellent agreement with the pN category (kappa = 0.723; p < 0.001). CONCLUSIONS: We can predict patient prognosis after surgery for non-small cell lung cancer according to the number of lymph nodes instead of the anatomic extent of lymph node metastases. At minimum, the number of metastatic lymph nodes adds more information to the pN category of the current TNM classification system.

Thoracoscopic diaphragmatic plication using three 5 mm ports.

Thoracoscopic plication is the most effective treatment for diaphragmatic enventration. However, the conventional thoracoscopic plication procedure introduced by Mouroux in 1996 has some disadvantages. We improved and simplified the Mouroux technique with the patient in the head up position, CO(2) insufflations and figure-of-eight sutures. These were possible to perform by pure thoracoscopic surgery using three 5 mm ports without the requirement for open thoracotomy.

Prognostic factors for disease-free survival in pT2N0 non-small cell lung cancer.

To clarify the prognostic factors for disease-free survival in completely resected pT2N0 non-small cell lung cancer, 81 consecutive patients who were treated between 1998 and 2001 were retrospectively reviewed. Follow-up was complete for all patients and the median follow-up time was 37.5 months. The overall 5-year survival rate was 68.6%, and the 5-year disease-free survival rate was 62.5%. Four factors (age, sex, visceral pleural invasion, and administration of tegafur and uracil) were proposed as prognostic factors for disease-free survival by univariate analysis. In multivariate analysis, visceral pleural invasion by the tumor (hazard ratio = 2.709, 95% confidence interval: 1.085 to 6.765, p = 0.033) and administration of tegafur and uracil (hazard ratio = 0.327, 95% confidence interval: 0.147 to 0.730, p = 0.006) were significant factors. Visceral pleural invasion was a prognostic factor for reduced disease-free survival in completely resected pT2N0 non-small cell lung cancer, and postoperative treatment with tegafur and uracil significantly improved disease-free survival.

Prognostic and clinical relevance of the World Health Organization schema for the classification of thymic epithelial tumors: a clinicopathologic study of 108 patients and literature review.

STUDY OBJECTIVES: Controversy has ensued about the prognostic relevance of the new World Health Organization (WHO) schema for the classification of thymoma. In this study, we present the clinical and histologic features of 108 thymomas and evaluate the usefulness of this histologic schema in view of the prognosis. DESIGN: Retrospective, clinicopathologic analysis of our experience and a review of recent literature. SETTING: Department of Thoracic and Cardiovascular Surgery of a university hospital. METHODS: A series of 108 thymomas were reviewed and classified by the new WHO schema. The clinical characteristics and the survival outcome were investigated in reference to the WHO subtypes. The Cox proportional hazards model was applied to determine the factors affecting the tumor-related survival. Recent literature on the prognostic relevance of the WHO schema was reviewed. RESULTS: There were 7 type A tumors, 25 type AB tumors, 12 type B1 tumors, 32 type B2 tumors, 20 type B3 tumors, and 12 type C tumors. The histologic subtype closely correlated with the Masaoka stage (p = 0.00). The tumor-related survivals at 5 years and 10 years were 88.0% and 77.9%, respectively. Stage III and IV tumors had a significantly worse prognosis than stage I or II tumors (p < 0.05). Type B3 tumors had an intermediate prognostic ranking in comparison with the carcinomas and with the other groups. On multivariate analysis, the WHO subtype (A-B2 vs B3 vs C) could predict the tumor-related survival, but the Masaoka stage was the most important prognostic factor affecting the postoperative survival (p = 0.026). CONCLUSION: The Masaoka stage is the most important determinant of survival in surgically resected cases of thymoma. To clarify the prognostic relevance and clinical usefulness of the WHO schema, consistent parameters reflecting the surgical outcome and development of the diagnostic tools that could improve the interobserver agreement within type B are needed.

Change in pulmonary function following empyemectomy and decortication in tuberculous and non-tuberculous chronic empyema thoracis.

Chronic empyema thoracis results from various etiologies. Improvement in pulmonary function after empyemectomy and decortication has proved difficult to predict when the etiology of chronic empyema thoracis is tuberculosis. The purpose of this study was to confirm the changes in pulmonary function according to the etiology after an operation. Sixty-five patients were classified into two groups according to their etiology: Group A (tuberculous) and Group B (non-tuberculous), and they were retrospectively evaluated with regard to their forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), percentage of predicted normal value of FEV1 (% FEV1) and FVC (%FVC). Empyemectomy and decortication was performed for all the patients and the two groups were similar in age, gender and preoperative spirometric parameters. In Group A (n=41), the pre- and postoperative mean values were 2.31 L and 2.8 L in FEV1, 65.8% and 80.5% in %FEV1, 2.62 L and 2.55 L in VC, 61.9% and 71.8% in %VC, respectively. In Group B (n=24), the pre- and postoperative mean values were 2.13 L and 2.49 L in FEV1, 66.4% and 73.8% in %FEV1, 2.55 L and 2.95 L in FVC, 64.9% and 71.8% in %FVC, respectively. All the spirometric parameters improved significantly in both groups compared to their preoperative values. However, no significance was shown in the rate of increase of the spirometric parameters between the two groups. In conclusion, improvement of lung function is expected after empyemectomy and decortication, regardless of the etiology of the chronic empyema thoracis.

Prognosis of thymic epithelial tumors according to the new World Health Organization histologic classification.

BACKGROUND: The aim of this study was to document the prognosis of thymic epithelial tumors (TETs) according to new the World Health Organization (WHO) classification. METHODS: We retrospectively reviewed 150 patients with TETs that were confirmed pathologically during 11 years (from 1992 to 2002) in Severance Hospital, Seoul, Korea. RESULTS: TETs were classified as type A, AB, B1, B2, B3, or C, tumors and these represented 7 (4.7%), 26 (17.3%), 13 (8.7%), 45 (30.0%), 26 (17.3%), and 33 (22.0%) cases, and the 5-year survival rates were 100%, 93%, 89%, 82%, 71%, and 23%, respectively. Their Masaoka stages were I, II, III, IVa, and IVb, with 53 (35.3%), 39 (26.0%), 20 (13.3%), 22 (14.7%), and 16 (10.7%) cases. Tumor invasiveness, recurrence, completeness of resection, and tumor-related death were more frequent in types AB, B2, B3, and C than in types A and B1. Multivariate analysis showed that Masaoka stage (p < 0.001) and the WHO classification (p = 0.019) were significant independent prognostic factors. CONCLUSIONS: The WHO classification is associated with tumor invasiveness, recurrence, completeness of resection, and tumor-related death, and has good correlation with Masaoka stage. The WHO histologic subtypes are an independently significant prognostic factor with respect to survival in our multivariate analysis. Types AB, B2, B3, and C showed invasive behaviors and R1 or R2 resections were frequently performed. Postoperative adjuvant radiotherapy was effective, but long-term follow-up is recommended because of decreased survival after 5 years following operation. The WHO classification may be helpful in clinical practice for the assessment and treatment of TET patients.

Basaloid carcinoma of the lung: a really dismal histologic variant?

BACKGROUND: Basaloid carcinoma of the lung has been reported as an uncommon and highly aggressive form of nonsmall cell lung cancers. Even in stage I and II of basaloid carcinoma, a 5-year survival rate of only 15% has been reported and it has been suggested that different treatment modalities for basaloid carcinoma should be considered. The aim of this study was to determine the prognostic implications of a basaloid carcinoma of the lung. METHODS: This study included a series of 291 surgically resected lung tumors, which were originally diagnosed as a poorly or undifferentiated carcinoma, a small cell carcinoma, or an atypical carcinoid. Of these, 35 basaloid carcinoma patients were identified and compared with 167 poorly differentiated squamous cell carcinoma (PDSC) patients in terms of the preoperative clinical data, the procedure performed, and the survival outcome. RESULTS: The overall incidence of basaloid carcinoma was 4.8%. The actuarial 5-year survival rate was 40.6% in patients with PDSC and 36.5% in those with basaloid carcinoma (p = 0.86). In stage I and II patients, the actuarial 5-year survival rate was 53.9% in the PDSC group and 57.2% in the basaloid group (p = 0.97). There were no differences in the recurrence rate and the relapse pattern (p = 0.584). Cox's proportional hazards model revealed that an age equal to 60 years old (hazard ratio 2.179, p = 0.000) and an advanced stage (hazard ratio 2.264, p = 0.000) were the risk factors for postoperative survival in both groups. CONCLUSIONS: Basaloid carcinoma of the lung does not have a worse prognosis than the other nonsmall cell lung cancers. Although it is obvious that a basaloid carcinoma is a unique histologic entity, it does not require a different treatment modality due to the similar clinical behavior with other nonsmall cell lung cancers.

Prognostic value of visceral pleura invasion in non-small cell lung cancer.

OBJECTIVES: The purpose of this study was to clarify the prognostic significance of visceral pleura invasion in T2 non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Between 1990 and 2001, 439 consecutive patients with T2 NSCLC underwent curative surgical resection. The subjects included 234 patients with stage IB, 95 with stage IIB, and 110 with stage IIIA and B disease. The patients were divided into two groups according to the existence of visceral pleura invasion (group I without, group II with). Both groups were compared with regard to tumor size, histology, associated mediastinal lymph node involvement, and survival rates. RESULTS: Visceral pleura invasion (group II) was identified in 114 patients (26%), and was present in 22% of patients with NSCLC with a tumor size of 3 cm or less and in 27% of those with a tumor larger than 3 cm (P=0.37). Visceral pleura invasion was associated with a higher frequency of mediastinal lymph node involvement (group I=22%, group II=34%, P=0.009). Five- and 10-year survival rates were 50 and 45% in group I, and 36 and 22% in group II (P=0.0006). In stage IB, visceral pleura invasion was identified in 53 patients (23%), and 5- and 10-year survival rates were 63 and 60% in the visceral pleura non-invasion group, and 44 and 28% in visceral pleura invasion group (P=0.0018). By multivariate Cox model analysis, age at intervention (relative risk=1.03, P=0.0017), N status (relative risk=1.53, P<0.0001), tumor size (relative risk=1.83, P=0.0452) and visceral pleura invasion (relative risk=1.42, P=0.0291) were independent predictors of poor prognosis. CONCLUSIONS: We were able to demonstrate that visceral pleura invasion was a factor of poor prognosis in T2 NSCLC. It was found to correlate with more extensive mediastinal lymph node involvement and a decreased survival rates. Therefore, the patients with visceral pleura invasion should be closely followed up especially.

Clinical Features of Pulmonary Large Cell Neuroendocrine Carcinoma.

PURPOSE: This study was performed to investigate the clinical features of large cell neuroendocrine carcinomas (LCNEC). MATERIALS AND METHODS: We retrospectively reviewed the histopathology and clinical information of 37 patients with LCNEC, diagnosed between June 1992 and May 2002 at the Severance Hospital, and performed immunohistochemical (IHC) staining. RESULTS: The prevalence of LCNEC among primary lung cancers was 0.3%, 37 out of 13, 012 cases over a 10 year period. The mean age was 61+/-12 years old, with 34 (92%) males and 3 (8%) females. 30 patients smoked, with an average of 42 packs per year. A cough was the most frequent symptom. The tumor was located at the periphery of the lung in 24 cases (65%). Among the 30 cases that underwent surgery, 4 were diagnosed pathological stage IA, 11 IB, 1 IIB, 13 IIIA and 1 IIIB. The 7 clinically non-operable cases were IIIB in 3, and IV in 4. The positive rates of CD56, thyroid transcription factor-1 (TTF-1), chromogranin A, synaptophysin and 34betaE12 for tumor cells were 88.9, 55.6, 42.1, 31.6 and 21.1%, respectively, from the IHC staining. The median survival time and 5 year-survival rate were 24 months and 27%, respectively. The group that underwent surgery had a better prognosis than those that did not. CONCLUSION: The positive rates for the tumor markers varied, but those of the CD56 and TFT-1 were the highest. The possibility of LCNEC needs to be evaluated for the following situations: small cell carcinomas located at the periphery and not responding chemotherapy, small cell carcinomas diagnosed by percutaneous needle aspiration, poorly differentiated non-mall cell carcinomas, with uncertain histologic type, and unclassified neuroendocrine tumor, etc.