Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in the surgical treatment of lung cancer: Report of a case

A 63-year-old man was referred to our institute for the treatment of squamous cell carcinoma of the upper lobe of his right lung. A right upper lobectomy of the lung was performed with a mediastinal lymph node dissection. The postoperative pathological examination of the dissected specimens revealed one of the superior mediastinal lymph nodes to be morbid with micrometastasis of occult thyroid cancer, while no node involvement was seen due to lung cancer. A right lobectomy of the thyroid gland with a modified radical neck dissection was done 4 years later after the confirmation of the absence of any recurrent sign of lung cancer. In the resected specimen, papillary thyroid microcarcinoma was observed with several intraglandular metastases and right regional lymph node involvement. Eight months later, a new primary lung cancer developed in the left lung, and a left upper lobectomy of the lung with a mediastinal lymph node dissection was performed. At that time, the absence of mediastinal lymph node metastasis from lung cancer or thyroid cancer was confirmed. Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in surgical treatment for lung cancer is rare, but it is important to be aware of the possibility of incidentally detecting occult thyroid cancer in surgical dissections in this area for lung cancer. The appropriate surgical treatment should be determined while carefully considering the prognosis of the lung cancer as well as that of any coexisting malignancy.     

Protective effect of nisoldipine on myocardial ischemia during coronary bypass surgery.

BACKGROUND: Nisoldipine, a calcium antagonist, was assessed for myocardial protection and the prevention of reperfusion injury in patients undergoing CABG. METHODS: Of the 34 subjects undergoing CABG in this study, 20 were given nisoldipine orally at 10 mg/day for 2 weeks before surgery (N group) and the other 14 untreated controls (C group). Myocardial protection was conducted via ante-grade cold blood cardioplegia at 20-minute intervals. RESULTS: Myocardial blood flow was significantly higher in the N group (67.8 +/- 21.8 ml/100 g vs. 47.2 +/- 14.4 ml/100 g, p < 0.05) after cardiopulmonary bypass. Serum interleukin-6 levels were significantly lower in the N group 1 hour after reperfusion (116 +/- 58 vs. 409 +/- 362 pg/ml, p < 0.05), as were serum lactate dehydrogenase levels immediately after surgery (888 +/- 268 vs. 1350 +/- 486 IU/L, p < 0.05). The N Group showed a better left ventricle stroke work index 6 hours after surgery (43 +/- 8 vs. 36 +/- 9 g.m/m2). Dopamine dosage in the N group on postoperative day 1 was lower than in controls (5.3 +/- 1.9 vs. 3.0 +/- 2.4 micrograms/kg/min). CONCLUSIONS: Preoperative nisoldipine treatment increased blood flow in the postischemic myocardium and prevented myocardial damage and reperfusion injury to some extent.     

Surgical Treatment of Bone Metastasis Followed by a Primary Lung Cancer Lesion: Report of a Case

In August 1997, a 68-year-old man presented with right pelvic pain. Pelvic computed tomography (CT) and bone scintigraphy showed a huge tumor of the right iliac bone. No other lesion was detected, in spite of a high serum carcinoembryonic antigen level (CEA, 963ng/ml). In October 1997, the iliac bone tumor was widely resected, and thereafter was diagnosed to be a metastatic adenocarcinoma of unknown origin. After a resection, the serum CEA level dropped as low as 6.4ng/ml, but gradually went up to 80ng/ml in October 1999. Next, a lung tumor in the left upper lobe was detected by routine chest CT. In January 2000, a left upper lobectomy was performed, and based on not only the pathological findings but also on an immunohistochemical analysis for napsin A expression, the tumor was diagnosed to be lung adenocarcinoma. The histological and immunohistochemical findings in the previously resected bone lesion were completely compatible with those in the pulmonary tumor, which was finally regarded as M1 lung cancer. In October 2002, the patient was alive without any symptoms, although the serum CEA level was elevated again. We consider this case worthy of presentation because of its unique clinical course as well as the successful long-term survival after surgical treatment alone, for both the primary and metastatic lesions.     

A case of delayed shock due to dissection of the hyperplastic coronary artery after balloon angioplasty and stenting

A 42-year-old obese woman with a history of liver cirrhosis and diabetes mellitus was admitted because of chest pain. Coronary balloon angioplasty and stenting were performed on the left anterior descending artery (LAD), which was 90% stenotic. She developed moderate shock about 6h later, and about 15 h after the procedure, she died from excessive bleeding from the right femoral artery because of removal of the catheter sheath by herself. Autopsy disclosed haemorrhagic cardiac tamponade and extensive haemorrhage into the epicardial adipose tissue, however, neither coronary perforation nor myocardial rupture was recognized. Histological examination of the dilated coronary segment revealed extensive dissection with an eccentric intimal thickening and the disruption of the adventitia. It was thought to be the origin of the haemorrhage. Although coronary dissection is a well-known complication during cardiac catheterization procedures, this report describes a rare fatal case with delayed onset of shock due to coronary dissection caused by balloon angioplasty and stenting in the presence of eccentric hyperplasia of the vessel wall.     

Cerebellar Contribution to Pattern Separation of Human Hippocampal Memory Circuits

The cerebellum is a crucial structure for cognitive function as well as motor control. Benign brain tumors such as schwannomas, meningiomas, and epidermoids tend to occur in the cerebellopontine angle cisterns and may cause compression of the posterior lateral cerebellum near the superior posterior fissure, where the eloquent area for cognitive function was recently identified. The present study examined cognitive impairment in patients with benign cerebellar tumors before and after surgical intervention in order to clarify the functional implications of this region in humans. Patients with cerebellar tumors showed deficits in psychomotor speed and working memory compared with healthy controls. Moreover, these impairments were more pronounced in patients with right cerebellar tumors. Functional magnetic resonance imaging during performance of a lure task also demonstrated that cerebellar tumors affected pattern separation or the ability to distinguish similar experiences of episodic memory or events with discrete, non-overlapping representations, which is one of the important cognitive functions related to the hippocampus. The present findings indicate that compression of the human posterior lateral cerebellum affects hippocampal memory function.     

Adjacent segment disease after anterior cervical interbody fusion

BACKGROUND CONTEXT: There have been many follow-up studies on anterior interbody fusion for cervical nerve root and spinal cord compression, and excellent neurological outcomes have been reported. However, postoperative degenerative changes at adjacent discs may lead to the development of new radiculopathy or myelopathy. In the previous reports, the incidence of symptomatic adjacent segment disease has ranged from 7% to 15%. PURPOSE: The present study was undertaken to investigate the incidence of symptomatic adjacent segment disease after anterior cervical interbody fusion (ACIF) and to identify the factors that are related to the development of this disease. STUDY DESIGN/SETTING: This is a retrospective cohort study. PATIENT SAMPLE: A total of 112 patients were followed up clinically and radiologically for more than 2 years. OUTCOME MEASURES: Follow-up evaluation was primarily by means of clinical visits. The postoperative course of any symptoms, the findings of neurological examination and serial follow-up radiographs were performed in all patients. METHODS: The diagnosis of symptomatic adjacent segment disease was based on the presence of new radiculopathy or myelopathy symptoms referable to an adjacent level, and the presence of a compressive lesion at an adjacent level by magnetic resonance imaging or myelography. We evaluated the correlation between the incidence of symptomatic adjacent segment disease and the following clinical parameters (age at operation, sex, number of the levels fused) and radiological parameters (preoperative cervical spine alignment, preoperative range of motion of C2-C7 cervical spine, anteroposterior spinal canal diameter, preoperative existence of an adjacent segment degeneration on plain radiograph, myelography and magnetic resonance imaging [MRI]). RESULTS: Symptomatic adjacent segment disease developed in 19 of 112 patients (19%) followed. A Kaplan-Meier survival analysis was performed in order to follow the disease-free survival of the entire series of patients. The disease-free survival rates were 89% at 5 years, 84% at 10 years and 67% at 17 years. The incidences of indentation of dura matter on preoperative myelography or disc protrusion on MRI at the adjacent level were significantly higher in disease cases (p=.0087, .0299, respectively; chi-squared test). However, the other parameters did not show a statistically significant difference. There were seven cases (37%) who had failure of nonoperative treatment and additional operations were performed. CONCLUSIONS: The incidence of symptomatic adjacent segment disease after ACIF was higher when preoperative myelography or MRI revealed asymptomatic disc degeneration at that level regardless of the number of the levels fused, preoperative alignment, spinal canal diameter or fusion alignment.     

Antegrade selective cerebral perfusion with mild hypothermic systemic circulatory arrest during thoracic aortic surgery

Objective Antegrade selective cerebral perfusion (ASCP) and retrograde cerebral perfusion (RCP) have proven to be reliable methods of brain protection during aortic surgery. These techniques are usually accompanied by systemic circulatory arrest with moderate hypothermia (24–28°C) or deep hypothermia (18–24°C). However, hypothermia can lead to various problems. The present study therefore reports results for thoracic aorta replacement using ASCP with mild hypothermic systemic arrest (28–32°C).

Design Between 1995 and 2003, 68 consecutive patients underwent repair of the ascending aorta and/or aortic arch. Mild hypothermic ASCP was utilized in 31 cases, moderate hypothermic ASCP in 20, and deep hypothermic RCP in 17. Various parameters were compared between the mild hypothermic ASCP, moderate hypothermic ASCP, and RCP.

Results Hospital mortality was 10.3%, with no significant differences observed between any groups. Permanent neurological dysfunction was 8.8%, and no significant differences were observed between any groups. Mild hypothermic ASCP displayed significantly decreased transfusion volume, intubation time, and ICU stay.

Conclusions Use of ASCP with mild hypothermic systemic circulatory arrest during aortic surgery resulted in acceptable hospital mortality and neurological outcomes. ASCP with mild hypothermic arrest allows decreased transfusion volume and reduced duration of intubation and ICU stay.     

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy

Background

Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped.

Objective

Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors.

Design, setting, and participants

A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n = 22) or without anatomic VMD (group 2; n = 22) performed by a single surgeon from April 2010 to January 2011.

Intervention

Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary.

Measurements

Baseline, perioperative, and postoperative data were collected prospectively.

Results and limitations

Group 1 tumors were larger (4.3 vs 2.6 cm; p = 0.011), were more often hilar (41% vs 9%; p = 0.09), were medial (59% and 23%; p = 0.017), were closer to the hilum (1.46 vs 3.26 cm; p = 0.0002), and had a lower C index score (2.1 vs 3.9; p = 0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p = 0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1 h), median blood loss (200 and 100 ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3 mg/dl). The study was limited by the relatively small sample size.

Conclusions

Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.     

Three-dimensional reconstruction of renovascular-tumor anatomy to facilitate zero-ischemia partial nephrectomy

Zero-ischemia robotic and laparoscopic partial nephrectomy, a novel concept, eliminates ischemia to the tumor-free normal kidney. Anatomic microdissection of tertiary/higher-order tumor-specific arteries is performed to selectively devascularize only the tumor, maintaining normal perfusion of the remaining kidney. A thorough understanding of renovascular tumor anatomy is essential. Based on 0.5-mm-slice thickness computed tomography scans, we developed a novel three-dimensional (3D) reconstruction technique that fuses three key anatomic aspects: surface-rendered tumor, semitransparent kidney, and extra- and intrarenal arterial anatomy. Four central completely intrarenal hilar masses underwent 3D reconstruction for surgical navigation during zero-ischemia partial nephrectomy. Negative surgical margins were obtained in all four cases, with no intraoperative complications or transfusions. For these challenging laparoscopically invisible masses, 3D image navigation precisely identified tumor-specific arterial branches, thus facilitating zero-ischemia partial nephrectomy without hilar cross clamping.     

Adult transmesenteric hernia: report of two cases

Transmesenteric hernia is a rare cause of bowel obstruction in adults. We herein describe two cases that occurred in adult women, ages 27 and 19. Both cases presented with abdominal pain without muscular defense signs. Computed tomography of both cases showed features of small bowel obstruction by an internal hernia. A laparotomy showed mesenteric defects of the mesentery of the ileum in the former case and the mesentery of the transverse colon in the latter case, with a herniating ileum. The involved small bowel was viable in both cases, and the bowel was pulled out of the mesenteric defect without resection. The mesenteric defects were then successfully repaired.