Shizuka Kaseda

Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy

BACKGROUND Data regarding pulmonary function and prognosis after video-assisted thoracic surgery lobectomy are limited. METHODS From September 1992 to April 2000, 204 video-assisted thoracic surgery lobectomies were performed, and their preoperative and postoperative pulmonary function test results and prognoses were evaluated. RESULTS The postoperative to preoperative ratio of pulmonary function tests (vital capacity and forced expiratory volume in 1 s) were better in video-assisted thoracic surgery lobectomy than in open thoracotomy (p < 0.0001). Furthermore, the 5-year survival rate of pathologic stage I lung cancers after video-assisted thoracic surgery was 97.0%, whereas that after open thoracotomy was 78.5% (p = 0.0173; Mantel-Cox). CONCLUSIONS Pulmonary function and prognosis were far better after video-assisted thoracic surgery lobectomy than after open thoracotomy.

Evaluation of the Malignant Grade of Thymoma by Morphometric Analysis

To determine the histologic grade of malignancy of thymoma, the nuclear areas of epithelial cells of 42 thymomas, 14 thymic hyperplasias, and ten normal thymuses were measured by morphometry and the results were compared with the extent of disease, association with myasthenia gravis (MG), and histologic subtypes of the thymomas. The nuclei of epithelial cells of thymomas were significantly larger than those of both of thymic hyperplasias and normal thymuses (P < 0.01). The nuclei of epithelial cells of invasive thymomas were significantly larger than those of noninvasive ones (P < 0.001). In the noninvasive group, the nuclei of epithelial cells of thymomas associated with MG were significantly larger than those without MG (P < 0.02), and were similar to those of invasive thymomas. These results confirm that invasive thymomas are morphometrically malignant tumors, and suggest that noninvasive thymomas associated with MG might have malignant potential.

Cell-cycle analysis detecting endogenous nuclear antigens: Comparison with BrdU-in vivo labeling and an application to lung tumors

The versatility of non‐radioactive cell‐cycle analysis in detecting endogenous nuclear antigens of the proliferating cells was evaluated. Optimal conditions for immunostaining varied in fixation and pretreatment procedures among antigens, bromodeoxyuridine (BrdU), Ki‐67 epitope, DNA polymerase α and PCNA. A significant correlation between BrdU labeling index (LI) was observed in each positive ratio (PR, positive/total neoplastic cells) for nuclear antigens in tumor‐sections which had been labeled in vivo with BrdU. The best correlation was observed in Ki‐67 PR (y = 1.26x+ 2.5; y= Ki‐67 PR; x= BrdU LI; r= 0.97). To determine its prognostic value, Ki‐67 analysis was applied to the surgically resected lung tumors. Ki‐67 PR were different according to the histologic types of the tumors: 47.8 ± 3.4% in small cell carcinoma; 29.5 ± 3.5% in squamous cell carcinoma; 28.3 ± 4.7% in large cell carcinoma; 15.2 ± 1.8% in adenocarcinoma and 0.1 ± 0.1% in mature carcinoid tumor. When the mean value was used to divide each type to a higher or lower proliferative activity (15% Ki‐67 PR for adenocarcinoma and 30% for squamous cell carcinoma), the group with the lower Ki‐67 PR showed a significantly more favorable prognosis than that of a higher ratio. Ki‐67 PR was not correlated with other pathologic factors such as size, lymph node metastasis or pleural involvement. Non‐radioactive cell‐cycle analysis was feasible and useful for detecting endogenous nuclear antigens even in the lung tumors, particularly when the analysis was coupled with histologic typing.

Techniques for Treating Aberrant Arteries During Resection of Pulmonary Sequestration by Video-Assisted Thoracic Surgery: Report of Two Cases

Abstract.We describe the techniques we used for treating aberrant arteries during resection of pulmonary sequestration by video-assisted thoracic surgery (VATS) in two patients. In patient 1, the aberrant artery was transected after securing six rows of staples with a knifeless vascular endostapler. In patient 2, the aberrant artery was cut after ligation with special forceps that designed by one of us (S.K.) to push a knot, tied outside the body, into the thoracic cavity, then ligate the suture. Left lower lobectomy and right basal segmentectomy were both successfully performed by these methods. These two cases are reported to show that VATS lobectomy is a feasible and minimally invasive technique of treating pulmonary sequestration and other diseases of the lung.

Skin rash by gefitinib is a sign of favorable outcomes for patients of advanced lung adenocarcinoma in Japanese patients

Skin rash is one of the notorious adverse events of gefitinib as well as other epidermal growth factor receptor tyrosine kinase inhibitors. The differences of response rate and frequency of adverse events between ethnic groups are well known. Some reports demonstrated the correlation between development of rash and efficacy in Caucasian patients treated with erlotinib, gefitinib or cetuximab. We analyzed clinical course of Japanese patients of lung adenocarcinoma in order to assess the relation between adverse events and efficacy of gefitinib. Between January 2008 and June 2012, 24 Japanese patients administered gefitinib 250 mg daily. The adverse events were evaluated in accordance with Common Terminology Criteria For Adverse Events v4.0 (CTCAE). Objective response to gefitinib was evaluated with using computed tomography every 1–2 months. The relationship between each adverse event and objective response was examined by chi-square test. The Log-rank Test was used to assess the relationship between the presence of skin rash and overall survival. Twenty four patients with a median age of 67 years (range 55–89) entered were 16 female and 8 male patients; the pathological diagnosis of all patients was adenocarcinoma. Skin rash in CTCAE occurred in 10. The objective response and overall survival among the patients with skin rash was significantly superior to the patients without skin rash. Skin rash by gefitinib correlates with improved clinical outcomes among advanced lung adenocarcinoma patients.

Gefitinib frequently induces liver damage in patients with lung adenocarcinoma previously treated by chemotherapy

BACKGROUND Gefitinib is known as one of the agents for treating patients with both advanced lung cancer and an epidermal growth-factor receptor mutation. In the epidermal growth-factor receptor-mutant advanced non-small-cell lung cancer population, gefitinib therapy has been associated with increased response rate, longer progression-free survival, and better quality of life compared to other anticancer drugs. However, gefitinib has to be discontinued for patients in whom adverse events occur, even if it is still effective. Here, we retrospectively assessed the clinical course of patients receiving gefitinib therapy, with a particular focus on liver damage. PATIENTS AND METHODS Of 24 Asian patients treated with 250 mg gefitinib daily at Kanagawa National Hospital, Japan, between January 2008 and June 2012, grade 3 liver damage (Common Terminology Criteria for Adverse Events, version 4.0) occurred in nine and were eligible for our assessment. The regimen was subsequently changed to alternate-day administration. The relationships between liver damage and each clinical factor were retrospectively examined using Fishers exact test. RESULTS Of the nine patients with liver damage, seven had previous exposure to another anticancer drug. There was a significant relationship between the incidence of liver damage and previous chemotherapy (P = 0.009). The objective response rates of patients treated with daily gefitinib 250 mg and alternate-day gefitinib following liver damage were 66.7% and 46.7%, respectively; these were not significantly different (P = 0.597). CONCLUSION Gefitinib for advanced adenocarcinoma patients who have previously undergone chemotherapy should be used cautiously and liver function monitored closely, because it frequently induces significant liver damage. The alternate-day administration of gefitinib may be a suitable option for patients in whom daily gefitinib therapy induces liver damage.

Surgery for lung adenocarcinoma with smokers’ polycythemia: a case report

BackgroundSmoking is a cause of cancer and polycythemia. Therefore, surgeons who treat patients with cancer may also encounter patients with polycythemia. However, few cases of surgical patients with polycythemia have been reported; in particular, a surgical case involving smokers’ polycythemia has never been reported. We herein report a patient with lung cancer and smokers’ polycythemia who successfully underwent lobectomy with control of hematocrit based on a modified formula in the perioperative period.Case presentationA 67-year-old man underwent abdominoperineal resection for rectal carcinoma in June 2008. A ground glass opacity had been identified in the upper lobe of the right lung and was gradually enlarging. In March 2012, bronchoscopic cytology for investigation of the mass revealed non-small cell lung cancer, suggesting primary lung non-small cell carcinoma (T1bN0M0, Stage IA). When he was referred to our hospital for surgery, his complete blood count showed a red blood cell level of 6.50×106/μL, hemoglobin of 21.0 g/dL, and hematocrit of 60.1%. The hematologists’ diagnosis was secondary polycythemia due to heavy smoking (smokers’ polycythemia) because the white blood cell and platelet counts were within normal limits and the erythropoietin was not increased. We calculated the appropriate phlebotomy and infusion volumes based on a formula that we modified. After 550 g of blood was phlebotomized to reduce the hematocrit to approximately 55%, video-assisted right lung upper lobectomy with lymph node dissection was performed in April 2012. The hematocrit was maintained at <50% postoperatively, and the patient was uneventfully discharged on postoperative day 7. The predictive hematocrit and measured hematocrit were very closely approximated in this case.ConclusionWe experienced a patient with smokers’ polycythemia who underwent right upper lobectomy for adenocarcinoma. The findings in this case report are meaningful for surgeons treating cancer patients because there are few reports discussing the perioperative care of surgical patients with polycythemia.

Laparoscopic Repair of Bochdalek Hernia Into Contralateral Thoracic Cavity

Introduction: Bochdalek hernias in adults rarely become symptomatic. However, once the abdominal organs become incarcerated in Bochdalek hernia, surgery is required to reduce them from the thoracic cavity. Case Description: We present the case of a 71-year-old woman with continuous chest discomfort and spontaneous epigastralgia. Computed tomography demonstrated that the colon and omentum were herniated into the right thoracic cavity through the posterior mediastinum from a left diaphragm defect. We suspected Bochdalek hernia because upper gastrointestinal series radiography showed that the esophageal hiatus was intact. At first, the hernia was unsuccessfully reduced by colonoscopy. Then laparoscopic repair was performed because the abdominal organs were herniated in the thoracic cavity opposite to the hernial orifice. We succeeded in laparoscopic repair and closure of the orifice by direct suturing and diagnosed this diaphragm hernia as Bochdalek hernia. Discussion: Surgical repair should be performed immediately after diagnosis to prevent strangulation or perforation. To the best of our knowledge, this is the first report of adult Bochdalek hernia in which abdominal organs were herniated into the opposite side of the hernial orifice.

Ritodrine for intractable uterine pain due to extrapelvic malignant tumor metastases: a case report.

Background:Effective pain management is an essential component of cancer treatment as approximately 75% of all cancer patients experience excruciating nociceptive pain even at maximum safe doses of nonsteroidal anti-inflammatory drugs and/or opioids. We report a case where ritodrine hydrochloride effectively controlled refractory pain due to uterine metastases from thymic carcinoma. Case presentation:A 40-year-old woman presented at our hospital with chest discomfort, severe right femoral pain, and intermittent hypogastralgia. Computed tomography, magnetic resonance imaging, and positron emission tomography revealed a large mass in the anterior mediastinum, multiple nodules in the lungs, and multiple metastases on the uterus, lumbar vertebrae, and pelvic bones. Needle biopsies of the mediastinal and uterine cervical tumors revealed undifferentiated carcinoma of the thymus metastasizing to the uterus. Oxycodone and nonsteroidal anti-inflammatory drugs relieved the right femoral pain but not the hypogastralgia. We speculated that hypogastralgia did not result from somatalgia but from splanchnodynia. Ritodrine was administered in an effort to inhibit uterine contractions and to reduced the refractory pain and improved her quality of life. Conclusion:Ritodrine relieved the pain caused by uterine contraction due to metastases and enhanced the quality of life.

Change in ratio of histological types of lung cancer in the past 13 years.

過去13年間の肺癌における組織型の比率の変遷について検討を行った. 対象は1976年～1988年の13年間に当院で病理組織学的に診断の確定した肺癌患者, 955名 (男711名, 女224名) で, 腺癌患者が45%, 扁平上皮癌患者が33%であった. 肺癌患者は増加しており, その組織型においては, 扁平上皮癌比率の減少と腺癌比率の増加がみられ, その傾向は特に1981年以降, 扁平上皮癌と腺癌の比率逆転という事態になった. この変遷は, 性別や年齢構成の変化によるものではなかった. 1983年までの日本TNM肺癌委貝会の患者登録からみても全国的に腺癌の比率が増加していることが推察される. 従来, 扁平上皮癌が腺癌より多いと言われていたが, 近年では, 腺癌の方が多くなっている可能性が示唆された.