Prognostic significance of persistent mediastinal metastasis following induction therapy in large (> or = 2cm) N2 or N3 non-small cell lung cancer

Objective: It is controversial whether or not surgery is beneficial for patients with non-small cell lung cancer accompanied by persistent lymph node metastasis in the mediastinum following induction therapy. We have therefore conducted a retrospective study to assess this issue Methods: Eligibility criteria were defined as follows: 1) the period of treatment was between January 1991 and April 1998, 2) the clinical stages were IIIA (N2) or IIIB (N3) with large lymph nodes (> or = 2 cm), 3) induction therapy had been administered, 4) tumor was resected completely, 5) at least one mediastinal lymph node had necrosis or scar if the pathological N status was p-N0 or p-N1 and 6) the p-stage was not IV. Dichotomous variables included the radiographic response of the tumor, the T status, and the N status. Results: Thirty-nine patients were eligible. There were 29 males and 10 females aged from 27 to 74 years, and involved 20 cases of adenocarcinoma. The pathological N status was as follows: p-N0 in 18 patients, p-N1 in 3, p-N2 in 16, and p-N3 in the other 2. In overall survival, the median survival time (MST) was 34 months and the actuarial 5-year-survival rate (5-YSR) was 28%. The group of patients with either N0 or N1 (n-21) had a 71-month MST and a 54% 5-YSR, and the group of patients with either N2 or N3 (n=18) had a 13-month MST and a 5-YSR of 0% (p<0.0001). On multivariate analysis, the pathological N factor was confirmed as an independently significant. Conclusions: Our retrospective study found that the survival rate of patients with persistent mediastinal nodal metastasis was very poor. A prospective study is needed to investigate whether or not surgery is beneficial for these patients.     

Effect of Short-term Administration of Prostaglandin E<Subscript>1 </Subscript>on Viability after Ischemia/Reperfusion Injury with Extended Hepatectomy in Cirrhotic Rat Liver

The cytoprotective effect of prostaglandin E₁ (PGE₁) has been demonstrated experimentally and clinically against hepatic ischemia and reperfusion injury and against the effects of partial hepatectomy in both individual and combined models of noncirrhotic livers. Cirrhotic livers are more vulnerable to ischemia/reperfusion injury during hepatectomy than are noncirrhotic livers, and postoperative malfunctioning complicates life with multiple organ failure. Cirrhotic livers with tumors have mostly been treated conservatively because extended hepatectomy with induced ischemia during surgery is impossible. The purpose of our study was to document postoperative surgical adaptation in inoperable cases with improved survival after extended hepatectomy in a rat model of cirrhosis treated by PGE₁. Cirrhosis was induced by intraperitoneal injections of 1% dimethylnitrosamine. The liver was subjected to 15 minutes of total ischemia by occluding the hepatoduodenal ligament. Hepatectomy was performed during ischemia. Pretreatment with PGE₁ (0.4 g/kg/min) (or without it in the controls) was given for 15 minutes by intravenous infusion prior to inducing ischemia and during reperfusion. Portal venous flow (PVF) and liver tissue blood flow (LTBF) were measured during reperfusion. At the end of 60 minutes of reperfusion, venous blood was collected for liver function tests. The animals were followed up regarding survival for 48 hours. The PVF and LTBF were significantly improved in the PGE₁ group. The blood chemical analysis indicated that PGE₁ significantly suppressed posthepatectomy liver dysfunction. Most importantly, PGE₁ treatment markedly improved the survival rate, from 42% in the controls to 75% in the test animals at 24 hours after hepatectomy and from 17% in the controls to 58% in the test animals at 48 hours. We concluded that short-term administration of PGE₁ makes extensive hepatectomy possible under ischemic conditions in cirrhotic livers.     

Oxygen dynamics at paraspinal muscles during exertion using near-infrared spectroscopy in patients with degenerative lumbar scoliosis

 Oxygen dynamics were measured in both sides of the paraspinal muscles of patients with degenerative lumbar scoliosis. The objective was to investigate the extent of stress by measuring the changes in oxygenation and blood flow volume using near-infrared spectroscopy. There were 44 patients with degenerative lumbar scoliosis (7 men, 37 women) and 11 controls with no scoliosis (2 men, 9 women). The measured recovery time for deoxyhemoglobin indicated the recovery from energy deficit after exercise. The average recovery time of the 11 control subjects was 2.4 ± 0.7 s on the right and 2.4 ± 0.8 s on the left. Among the 44 patients the average recovery time was 3.8 ± 1.8 s on the convex side and 2.1 ± 1.1 s on the concave side. There was a significant difference between the two groups. The recovery time on the concave side in patients was faster than that on the convex side. The results of the current study support the theory that stretching the muscles at the convex side results in chronic increases in the intramuscular compartment and reduced muscular blood flow. Received: May 23, 2002 / Accepted: October 29, 2002 Offprint requests to: M. Miyake, Department of Orthopaedic Surgery, Eiko Hospital, 1381 Takuma, Takuma-cho, Mitoyo-gun, Kagawa 769-1101, Japan     

Effects of barium concentration on the radiopacity and biomechanics of bone cement: experimental study

Purpose  This study was undertaken to evaluate the changes in the radiopacity and mechanics of polymethylmethacrylate (PMMA) bone cement with the addition of barium. Materials and methods  Barium sulfate powder was added to a PMMA bone cement with an initial 10% barium concentration. The changes in radiopacity and strength were evaluated by testing cement blocks containing four barium concentrations (10%, 20%, 30%, 40%). Radiopacity was evaluated by measuring the computed tomography (CT) values of the bone cement, and strength was evaluated by compressive, three-point bending, and impact load tests. Results  CT values increased in proportion to the barium concentration. The compressive load test showed that cement with a 40% barium concentration was significantly more fragile than cement with lower barium concentrations. The three-point bending load test showed that the cement became more fragile in proportion to the barium concentration. The impact load test showed that cement with 30% and 40% barium concentrations was significantly more fragile than cement with 10% and 20% barium concentrations. Conclusion  Radiopacity is increased and strength is reduced by adding increasing concentrations of barium powder to bone cement. The results of the present study suggest that adding barium permits the radiopacity and strength of bone cement to be adjusted in clinical practice.     

Analysis of tolerance induction using triple chimeric mice: major histocompatibility complex-disparate thymus, hemopoietic cells, and microenvironment

BACKGROUND: Although bone marrow transplantation (BMT) has become a valuable strategy for the treatment of various intractable diseases in recent years, success rates remain low in elderly patients because of low thymic function. We have previously shown that fetal thymus transplantation (TT) with BMT is effective for elderly recipients in mice. METHODS: We performed fully major histocompatibility complex (MHC)-mismatched fetal TT from B6 (H-2) mice plus allogeneic BMT from C3H/HeN (H-2) mice by intra-bone marrow-BMT (IBM-BMT) using congenitally athymic nude (nu/nu) BALB/c (H-2), or BALB/c adult-thymectomized recipients to obtain triple chimeras. We next carried out the IBM-BMT+TT using senescence-accelerated mouse P1 strain (SAMP1) to examine whether this method would be applicable to aging mice. RESULTS: Triple chimeric mice survived for a long period with sufficient T-cell functions comparable to the mice treated with BMT plus MHC-matched TT, whereas those without TT survived for a short period with insufficient T-cell reconstitution. Almost all the hematolymphoid cells were derived from donor bone marrow cells. Interestingly, they showed tolerance to all three types of MHC determinants with donor-derived thymic dendritic cells in TT. Triple chimeric SAMP1 also survived for long periods with T-cell functions restored in contrast to non-TT SAMP1 recipients. CONCLUSION: These findings suggest that third party combined TT with allogeneic IBM-BMT may be more advantageous for elderly recipients with low thymic function, than IBM-BMT alone (without TT).     

Treatment of bone and soft tissue sarcomas of the hand and wrist

We studied 13 consecutive patients with bone and soft tissue sarcomas of the hand and wrist. Chondrosarcoma, Ewing's sarcoma, synovial sarcoma and epithelioid sarcoma were the most frequent histological diagnoses. Limb-sparing surgery was performed in ten patients but eventually three patients required an amputation. Surgical margins were wide in nine patients and marginal in four. Adjuvant therapy for nine patients consisted of chemotherapy in five and chemotherapy with radiation in four. Local recurrence occurred in two patients with epithelioid sarcoma. There was no significant relationship between surgical margin and local recurrence. Distant metastasis occurred in four patients. The 5-year survival rate was 66%. The mean functional score was 87%. Our study indicates that treatment consisting of resection of these tumours with either a wide margin or a marginal margin followed by adjuvant radiation appeared to be safe and resulted in an acceptable degree of limb function except in the patients with epithelioid sarcoma.     

Diagnosis of esophageal cancer using positron emission tomography

Fluorodeoxyglucose positron emission tomography (FDG-PET) is more accurate than computed tomography (CT) for evaluating lymph node metastases and for N staging, but less accurate than combined CT and endoscopic ultrasonography (EUS). Lymph nodes located adjacent to the primary lesion tend to be false negatives. We consider that combined FDG-PET and EUS is the most accurate for the detection of lymph node metastasis in esophageal cancer. FDG-PET is also more accurate than CT for detecting distant metastases and improves the detection of stage IV disease compared with the conventional staging modalities. For the diagnosis of recurrence except for perianastomotic recurrence, FDG-PET provides additional information and is more sensitive than conventional work-ups. FDGPET is a valuable tool for the noninvasive assessment of tumor response after neoadjuvant therapy. 11C-methionine (MET) is another tracer for PET that can be used to assess the metabolism of amino acids, since MET accumulates in esophageal malignant tumors. Choline-PET is more accurate than FDG-PET for the detection of mediastinal lymph node metastases.     

A minute small-cell lung cancer showing a latent phase early in growth.

A minute small-cell lung cancer measuring 8 x 5 mm was detected and serially imaged by computed tomography for about a year preceding resection. Although this solid nodule showed a short overall doubling time (76 days), the growth curve included an early phase without apparent growth prior to the phase of rapid growth. Accordingly, lung cancer cannot be ruled out when a small nodule (<10 mm) does not enlarge in the first several months of computed tomographic follow-up.     

Repair of an Abdominal Aortic Aneurysm with a Remarkably Dilated Meandering Artery: Report of a Case

A 73-year-old man on dialysis for chronic renal dysfunction was referred to our hospital for surgical treatment of an abdominal aortic aneurysm (AAA). Preoperative angiography showed a remarkably developed meandering artery branching from the inferior mesenteric artery (IMA). The superior mesenteric and celiac arteries were occluded at the origin, and all blood flow to the abdominal organs was apparently supplied by collateral circulation from the IMA. Considering the risk of mesenteric ischemia after aortic clamping in conjunction during surgery, we used a perfusion catheter with a 12-F balloon to create a shunt to the IMA from the subclavian artery. The operation was successful and the patient recovered uneventfully. We describe this surgical procedure for its effectiveness in preventing postoperative mesenteric ischemia in a rare case of an AAA with complex branching lesions.     

Carpal tunnel syndrome grading system in rheumatoid arthritis

The grading system of Hashizume and Hirooka for carpal tunnel syndrome (CTS) was modified to refine the system for surgical treatment selection for specific subsets of CTS in patients with rheumatoid arthritis (RA). The grading system uses clinical signs and symptoms of CTS, including pain indications, to identify surgical subsets of patients to facilitate treatment selection. Retrospective analysis of the system included radiographic and electromyographic findings. Twenty-nine hands of 21 adult patients with CTS in RA were graded in the current study. Eight hands with mild synovitis received conservative treatment only. Endoscopic carpal tunnel release (ECTR), using Okutsu's universal subcutaneous endoscopic system with a clear cannula, was performed in 11 hands with moderate synovitis. Open carpal tunnel release (OCTR) combined with flexor tenosynovectomy was performed in 9 hands with severe synovitis. One more hand required OCTR after ECTR when malignant RA was diagnosed. Clinical results, evaluated using Kelly's criteria, were: excellent in 19 hands, good in 5, fair in 4, and poor in the 1 patient with malignant RA. Clinical symptoms of CTS improved in all but the latter patient. Although the sample size in the current study is small, the results appear to warrant further study to determine the clinical utility of the grading system. Received: April 2, 2001 / Accepted: November 1, 2001