Shoji Namikawa

Pulmonary leiomyosarcoma extending into left atrium or pulmonary trunk: complete resection with cardiopulmonary bypass☆☆☆★★★

Primary pulmonary leiomyosarcoma is a rare tumor. Few cases have been treated surgically because of its rapid invasion into the pulmonary trunk or heart and tendency toward massive intrapulmonary metastases. We report the cases of two patients with leiomyosarcoma originating in a pulmonary artery or vein that involved the pulmonary trunk or left atrium, both of whom underwent complete surgical resection with cardiopulmonary bypass (CPB). Since their operations, these patients have shown no evidence of recurrent tumor. PATIENT 1. A 72-year-old woman with persistent cough, chest pain, and hemoptysis was referred to our hospital for evaluation and treatment of presumed pulmonary thromboembolism. An angiogram revealed filling defects in the pulmonary trunk, absence of filling of the left main pulmonary artery, and decreased arterial filling in the left lung. A biopsy specimen was obtained from a tumor in the left main pulmonary artery by means of a suction catheter, and the pathologic diagnosis of sarcoma was made. Computed tomography disclosed a mass occluding the left main pulmonary artery and densely filling pulmonary artery branches. Median sternotomy was performed and CPB was applied. The left pulmonary veins were ligated and the left main pulmonary artery was incised. A large tumor completely filled the left main pulmonary artery. Extension of the incision into the pulmonary trunk disclosed that the tumor invaded its wall laterally on the left. The portion of tumor located in the left main pulmonary artery and pulmonary trunk, including the left main pulmonary artery and the left lateral wall of the trunk, was excised. Direct suture closure of the pulmonary trunk was carried out and CPB was terminated. The left main bronchus was transected and left pneumonectomy was completed. Fig. 1 shows the resected left lung and pulmonary artery. Tumor in the main pulmonary artery extended intraluminally into its branches. The tumor was diagnosed histologically with the aid of immunohistochemical stainFrom the Department of Thoracic and Cardiovascular Surgery, Mie University, School of Medicine, Tsu, Japan.

Rupture of a benign mediastinal teratoma into the right pleural cavity

A 27-year-old woman with a ruptured mediastinal cystic teratoma had high levels of amylase and carcinoembryonic antigen in cystic fluid. The activity of the amylase is thought to be the most likely cause of the rupture. High levels of carcinoembryonic antigen in pleural fluid are not necessarily indicative of a malignant lesion but may suggest the presence of a ruptured teratoma in patients with mediastinal tumors.

Effects of inhaled nitric oxide in rats with chemically induced pulmonary hypertension.

To determine the model animal with pulmonary hypertension in which nitric oxide (NO) inhalation reduces pulmonary arterial pressure (PAP), we examined the inhalation of 20-100 ppm NO gas on normal rats and rats with monocrotaline induced pulmonary hypertension. In the control group, mean PAP showed no change after spontaneous breathing of NO at the concentration of 20 to 100 ppm for 5 min. On the contrary, in both the severe (mean PAP > 40 mmHg) and moderate (mean PAP < 40 mmHg) pulmonary hypertensive groups, NO inhalation produced a prompt reduction of the mean PAP which had been elevated by monocrotaline. 20 ppm NO inhalation reduced mean PAP from 64.4 +/- 3.7 mmHg to 56.2 +/- 4.4 mmHg (mean +/- SEM, P < 0.01) in the severe pulmonary hypertensive group, from 31.0 +/- 2.0 mmHg to 24.2 +/- 0.9 mmHg in the moderate pulmonary hypertensive group (mean +/- SEM, P < 0.05). The onset of the reduction of mean PAP occurred within 30 sec after the start of NO inhalation and maximum reduction occurred within 4 min. 20 ppm NO inhalation significantly reduced mean PAP, and mean PAP was reduced dose-dependently at the concentration of 20 to 60 ppm and reaction to NO was almost constant at the concentrations of over 60 ppm.

The role of surgical resection and the effects of neo-adjuvant therapy in the management of small cell lung cancer

A study was conducted on 58 patients who underwent surgery for small cell lung cancer (SCLC) as resection or exploratory thoracotomy, and 43 patients encountered during the same period who received no surgical treatment. The following conclusions were drawn from our analysis: At stage I, an operation is desirable, regardless of the subtype of SCLC, but chemotherapy should be given first; at stages II and III, by the addition of surgery after neo-adjuvant chemotherapy, “state-of-the-art” results for limited SCLC can be surpassed; in patients with stage II disease on whom curative resection has been performed, particular attention must be paid to the possibility of metastasis to the brain; and finally, exploratory thoractomy did not bring about the early death of patients or reduce the quality of life, but only delayed chemotherapy for about one week, while enabling the staging and histological subtype of SCLC to be clarified.

Fulminant myasthenia gravis manifested after removal of anterior mediastinal tumor

Myasthenia gravis developed in a 35-year-old man after removal of an encapsulated anterior mediastinal tumor that was preoperatively diagnosed as a teratoma based on a computed tomographic image. Postoperative pathologic diagnosis of the excised tumor was thymoma. The patient was in crisis after the initiation of immunosuppressive treatment. The therapy was changed to immunoadsorbent perfusion therapy because of concurrent severe pneumonia and an extremely high serum concentration of anti-acetylcholine receptor antibodies. Respiratory support was necessary for 2 months after reoperation.

The effects of single lung transplantation in rats with monocrotaline-induced pulmonary hypertension.

Abstract Acute haemodynamic change after single lung transplantation for primary pulmonary hypertension was evaluated using a rat transplantation model. Inbred Fisher 344 rats were administered with 40 mg/kg monocrotaline in order to induce pulmonary hypertension. The rats whose mean pulmonary arterial pressure (PAP) was over 30.0 mmHg received a left lung isograft from a normal donor after right heart catheterization. In the control group, PAP increased after single lung transplantation. On the other hand, in the pulmonary hypertensive group, PAP was significantly decreased 60 min after the transplantation, but 3 and 6 h after the transplantation, the PAP significantly increased again. On the day after the operation, it again decreased significantly. Left‐to‐right lung blood flow ratio was significantly increased in rats with pulmonary hypertension compared to rats with normal pulmonary pressure on both the 1st and 3rd postoperative days. The oedema of the grafted lung was more severe in the pulmonary hypertensive group than in the control group in the acute phase. In conclusion, single lung transplantation for pulmonary hypertension shifted pulmonary blood perfusion to the grafted lung and this shift made pulmonary oedema of the grafts more severe in the acute phase. These oedematous changes, which were more pronounced in the grafts in the pulmonary hypertensive rats, might have contributed to the transient rise in PAP in those rats after single lung transplanation.

Clinical Analysis of Mediastinal Tumors Associated with Lung Tumor.

教室では過去17年間に縦隔腫瘍症例を153例経験しており, うち肺腫瘍との合併症例は5例で, これらについて検討を加えた.男性2例, 女性3例, 年齢は35歳から76歳で, 診断は胸腺腫と肺癌症例2例, 縦隔嚢胞性腫瘍と肺癌症例2例, 胸腺腫と肺過誤腫症例1例であった.全例手術症例で, うち合併切除は3例であり, 70歳以上の高齢者2例は手術侵襲を少なくする目的で縦隔腫瘍は良性と判断し切除せず肺腫瘍のみ切除し, 術後, 縦隔腫瘍に変化はみられなかった.開胸方法は縦隔腫瘍と肺腫瘍のどちらの切除を重視するかで違いがあり, 胸骨正中切開法, 前側方切開第4肋間開胸法, 後側方切開第5肋骨床開胸法を施行した.この5例の検討により, 縦隔腫瘍に肺腫瘍を合併した症例では症例の背景因子, 術前診断, 腫瘍部位を考慮して手術術式を決定すべきであると考えられた.