Jinwook Hwang

The effects of sonic hedgehog signaling pathway components on non-small-cell lung cancer progression and clinical outcome

BackgroundResearchers in recent studies have reported that the sonic hedgehog (Shh) signaling pathway plays a crucial role during tumorigenesis, angiogenesis and cellular differentiation. We investigated the clinical and pathological significances of the Shh pathway and of its lymphangiogenic components in non-small-cell lung cancer (NSCLC), namely, Shh, glioma-associated oncogene homolog zinc finger protein 1 (Gli1), lymphatic vessel endothelial hyaluronan receptor 1 (LYVE-1) and vascular endothelial growth factor D (VEGF-D).MethodsThe expression of Shh, Gli1, LYVE-1 and VEGF-D in primary NSCLC tissue from 40 patients was examined using immunohistochemical assays, and relationships between expression and clinicopathological data, such as age, gender, histology, tumor size, nodal stage, visceral pleural invasion, lymphatic thromboembolism, recurrence and overall survival were investigated.ResultsOf the 40 specimens examined, 25 (62.5%), 20 (50.0%), 11 (27.5%) and 20 (50.0%) were positive for Shh, Gli1, LYVE-1 or VEGF-D expression, respectively. The expression of Gli1 and LYVE-1 were significantly associated (P = 0.011), and Shh and LYVE-1 expression was related to visceral pleural invasion and lymphatic thromboembolism, respectively (P < 0.05). Shh expression levels compared on survival curves were statistically significant in univariate logrank analysis (P = 0.020). However, other clinicopathological factors did not reveal any statistical significance in univariate and multivariate analyses.ConclusionsTo our knowledge, this the first report of the relationship between components of the Shh signaling pathway and prognosis in NSCLC. The expression of Shh, Gli1 and LYVE-1 was found to be associated with clinicopathological factors and survival. Thus, the overexpression of the Shh signaling pathway could serve as a predictor of malignant behavior, including lymphangiogenesis, in NSCLC.

Non-intubated single port thoracoscopic procedure under local anesthesia with sedation for a 5-year-old girl

Medical thoracoscopy is a feasible procedure for the diagnosis or treatment of thoracic diseases, and it can be performed under local anesthesia without tracheal intubation in cooperative adult patients. However, for younger than school aged patients, even simple procedures require general anesthesia with tracheal intubation. In this case report, we demonstrated the safe performance of a single port thoracoscopic procedure without tracheal intubation in a 5-year-old girl under local anesthesia and sedation. Local anesthesia around the site of a previous chest tube and sedation with intravenous (IV) dexmedetomidine and ketamine were applied. In the aspect of not only minimal injection of local anesthetics but also enhanced visualization of the thoracic structures, the non-intubated single port thoracoscopic surgery under local anesthesia with sedation was a good option for performing a simple thoracoscopic procedure in this 5-year-old patient.

Non-intubated thoracoscopic bullectomy under sedation is safe and comfortable in the perioperative period

Background Non-intubated thoracoscopic surgery can be performed under sedation using adjuvant regional anesthesia, however, the benefits of non-intubated thoracoscopic surgery under sedation have not yet been completely verified. In this study, we compare the perioperative safety and pain complaints of sedation without intubation in thoracoscopic bullectomy with that of conventional general anesthesia with double-lumen intubation and mechanical ventilation. Methods Forty-one patients with primary spontaneous pneumothorax who were scheduled for thoracoscopic bullectomy were enrolled in this study. Twenty-one patients were under sedation anesthesia (SA group) and 20 patients were under general anesthesia (GA group). In SA group, sedation was done with dexmedetomidine (a loading dose of 1 µg/kg for 10 min and then maintained in dosages of 0.3-1 µg/kg/h) and ketamine (2-4 mg/kg/h intraoperatively). Meanwhile, in GA group, induction with propofol and rocuronium, intubation with double lumen endotracheal tube and maintenance with 1.0-2.5% sevoflurane was done. In both groups, thoracoscopic bullectomy was performed in the same manner and all operations were conducted by single surgeon. Time for anesthesia [including emergence time and post-anesthesia care unit (PACU) recovery time] and operation, postoperative pain, sore throat, hoarseness, adverse events (nausea, vomiting, hypotension and bradycardia), dose of rescue analgesic drug used for 24 hours post-operatively and perioperative arterial blood gas analysis were recorded. Results The times for anesthesia, operation and emergence were significantly shorter in SA than GA. Incidence of sore throat were significantly lower in SA. The difference of other adverse events in the two groups was not significant. Conclusions Our study demonstrated that compared to double-lumen intubation with general anesthesia, non-intubation with sedation for bullectomy for primary spontaneous pneumothorax was safe and efficient to reduce perioperative time.

Bronchopulmonary foregut malformation presenting as extralobar pulmonary sequestration associated with a bronchogenic cyst: an unusual clinical and radiological feature in an adolescent patient

We present a case of symptomatic complex bronchopulmonary foregut malformation (BPFM), including extralobar pulmonary sequestration and a bronchogenic cyst, in the left anterior mediastinum of a 15-year-old boy. Preoperative computed tomography showed a cystic mass with heterogeneous enhancement of adjacent soft tissue components and pleural effusion. We suggested the infected bronchogenic cyst as the first impression. However, pathological examination after surgical resection revealed extralobar pulmonary sequestration and a bronchogenic cyst with unusual manifestation, which was located in the left upper hemithorax and supplied by the pulmonary artery. In patients presenting with a cystic mass with features of inflammation or infection and collateral vasculature, the possibility of a complex bronchopulmonary foregut malformation should be considered in the differential diagnosis.

Video-assisted thoracoscopic surgery for intrathoracic first rib resection in thoracic outlet syndrome

BACKGROUND First rib resection is a surgical treatment for decompressing the neurovascular structures in thoracic outlet syndrome (TOS). Historically, extrathoracic approaches have used a posterior, supraclavicular, or transaxillary incision to remove the first rib. In this report, we demonstrate video-assisted thoracoscopic surgery for intrathoracic first rib resection (VATS-IFRR). METHODS Between 2009 and 2014, eight patients underwent VATS-IFRR for TOS. Surgery was performed through two 5-mm ports and one 10-mm port. Endoscopic graspers, a hook-type electrocautery probe, a long peapod intervertebral disc rongeur, and Kerrison punches were used. The types of disease, operative times, chest tube indwelling days, lengths of hospital stay after operation, perioperative complications, postoperative pain scale ratings, and postoperative symptom recurrence rates at provocation tests were reviewed. The surgical outcomes were compared to published outcomes of extrathoracic approaches and other VATS approaches. RESULTS The eight patients (3 right ribs, 5 left ribs) exhibited neurogenic (1 patient), combined type (2 patients), arterial (4 patients), and venous type (1 patient) TOS. The mean operative time was 190 (range 155-310) minutes. No mortalities or major complications occurred. The mean chest tube indwelling duration was 6 (range 3-10) days, and the mean postoperative hospital stay was 9 (range 4-21) days. The mean immediate postoperative pain numeric rating scale (NRS) score was 2.7/10 (range 2-4). No recurrence was observed during follow-up (median 25.5 months, range 10-64 months) in any patient. CONCLUSIONS VATS-IFRR was safe and had several advantages. Thus, VATS-IFRR is a minimally invasive surgical option suitable for treating selective cases of TOS.

A Case Report of Primary Pericardial Malignant Mesothelioma Treated with Pemetrexed and Cisplatin

Primary pericardial malignant mesothelioma (PPM) is a very rare malignancy, with an incidence of less than 0.002% and represents less than 5% of all mesotheliomas. The cause of pericardial mesothelioma is uncertain that differ from pleural mesothelioma which is associated with asbestos exposure. This malignancy is terribly aggressive and has very poor prognosis with less than six months of overall survival. We present a case of a 71-year-old woman who was diagnosed with cardiac tamponade caused by PPM and received chemotherapy with pemetrexed and cisplatin for six months. During two years she was alive without disease progression. To better understand the clinical, pathologic features and treatment outcome of this entity, we reviewed 23 cases described in the English literature from 2009, together with our case, provided a total of 24 cases. Based on this review, we suggest that PPM must be considered in patients who have unexplained massive pericardial effusion and recommend chemotherapy with pemetrexed and cisplatin for the better outcome of PPM.

Radiologic factors related to double-bar insertion in minimal invasive repair of pectus excavatum

BackgroundPectus excavatum is the most common congenital chest wall deformity, with a high incidence in live births. This study aimed to evaluate the measured factors on CT images related to the number of pectus bars for surgical correction.MethodsA total of 497 patients who had undergone minimally invasive repair between April 2007 and July 2011 were classified into single-bar (n=358) and double-bar (n=139) insertion groups. We measured eight distinct distances and one angle on CT scans to reflect quantitative assessment. Univariate analysis and multivariate logistic regression analysis were performed to detect statistically significant association between radiologic measurements and the pectus bars required.ResultsAfter adjusting for age and gender, the transverse distance (T), the transverse distance of the depression area (A), the inclined distance of the depression area (B), the AP distance of the depression area (C), the depression angle (G), and the eccentric distance of deformity (E) were significantly correlated with double-bar insertion. The regression model showed that age (P<0.0001), gender (P<0.0001), depression angle (G) (P<0.0001), direction of the depression (DD) (P<0.0001) and depression depth (D) (P<0.0001) were significantly associated with double-bar insertion.ConclusionCT scan provides useful factors which can be of assistance in predicting the number of pectus bars for the surgical correction of pectus excavatum.