Takehiko Hiramoto

Significance of pulmonary artery pressure in emphysema patients with mild-to-moderate hypoxemia

The guidelines of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) do not recommend the measurement of pulmonary artery pressure in patients with chronic obstructive pulmonary disease (COPD). This is on the basis that the mean pulmonary artery pressure (mPAP) does not provide more clinical information than measurement of the oxygen tension in arterial blood (PaO2). The mPAP correlates well with PaO2 in emphysema patients with severe hypoxemia (PaO2 < or = 7.3 kPa (55 mmHg)). However, the occurrence and significance of mPAP is unclear in patients without severe hypoxemia (PaO2 > 7.3 kPa (55 mmHg)). In order to evaluate the usefulness of measurement of mPAP in emphysema patients without severe hypoxemia, we performed right heart catheterization and investigated the pulmonary hemodynamics of 53 patients without severe hypoxemia. In addition, we identified long-term prognostic factors with a mean follow-up term of 77 months after right heart catheterization. Seventeen of 27 patients with mild-to-moderate hypoxemia exhibited pulmonary hypertension (mPAP > or = 2.7 kPa (20 mmHg)) and the classification according to severity in GOLD exhibited a greater correlation to mPAP than PaO2. Moreover, only mPAP was found to be a significant prognostic factor according to multivariate proportional hazards analysis (P = 0.01). We conclude that mPAP is more informative about the severity of emphysema than PaO2 in patients with mild-to-moderate hypoxemia.

Almitrine enhances in low dose the reactivity of pulmonary vessels to hypoxia

Almitrine bismesylate (Alm) has been shown to increase arterial oxygen tension in patients with chronic obstructive pulmonary disease. This effect is though to be attributable to the enhancement of hypoxic pulmonary vasoconstriction (HPV). We evaluated the effect of various doses of Alm on HPV in terms of blood flow diversion associated with anoxic challenge to the left lower lobe (LLL) in dogs with the LLL and the rest of the lung separately ventilated. The stimulus-response curve shifted to the right with increasing rate of Alm infusion, suggesting that Alm enhances the reactivity of the pulmonary vessels to hypoxia. Low doses of Alm enhanced HPV, while higher doses attenuated it. This suggests that the degree of vasoconstriction in hypoxic and non-hypoxic regions depends on the dose of Alm. The same effects of Alm were also observed in peripheral chemoreceptor denervated dogs. It is supposed that the vasoconstriction induced by Alm may be attributable to a direct effect on pulmonary vessels rather than to a nervous reflex effect.

Assessing the Site of Maximal Obstruction in the Trachea Using Lateral Pressure Measurement during Bronchoscopy

RATIONALE Lateral airway pressure can provide valuable physiological information during bronchoscopy. OBJECTIVES To evaluate tracheal obstruction during intervention. METHODS To prospectively measure lateral airway pressure during bronchoscopy using a double-lumen catheter in 15 healthy subjects and 30 patients with tracheal obstruction. Pressure difference was used to evaluate the site of maximal obstruction. The angle between pressure recordings on either side of the stenosis was measured simultaneously (pressure-pressure curves) to assess the degree of tracheal obstruction. MEASUREMENTS AND MAIN RESULTS In the experimental study, the angle of the pressure-pressure curve was unaffected by breathing maneuvers whereas the pressure difference was affected. In healthy subjects, no pressure difference between the carina and trachea was observed during tidal breathing, and the angle was close to 45°. In patients with tracheal obstruction, the dyspnea scale, pressure difference, and angle changed significantly beyond 50% obstruction (P<0.0001). After stenting, the pressure difference disappeared and the angle was close to 45°. The degree of tracheal obstruction was significantly correlated with the pressure difference (r=0.83, P<0.0001) and angle (r=-0.84, P<0.0001). The cross-sectional area, dyspnea scale, pulmonary function tests, pressure difference, and the angle significantly improved after procedures (P<0.0001). Responder rates on the modified Medical Research Council Scale were 84.6% for obstructions above 80%, and 58.8% for obstructions between 50 and 80%. CONCLUSIONS The direct measurement of pressure difference and the angle of the pressure-pressure curve represent a new assessment modality for the success of interventional bronchoscopy. Measuring lateral airway pressure could estimate the need for additional procedures better than bronchoscopy alone.

Reversal of oleic acid-induced respiratory distress by prostacycllin (PGI2)

The effects of Prostacyclin (PGI2) on gas exchange were investigated in 13 adult mongrel dogs with acute pulmonary edema induced by oleic acid (0.09 ml/kg). The time course of changes in gas exchange was measured during spontaneous ventilation with room air. In the Control group, with oleic acid induced respiratory distress, there were marked decreases in arterial PO2 and PCO2, and marked increases in respiratory frequency, expired minute volume, alveolar (end tidal)-arterial PO2 difference, arterial-alveolar (end tidal) PCO2 difference and physiological dead space to tidal volume ratio. In the Test group, respiratory distress was also induced by the oleic acid injection, however, subsequent infusion of PGI2 (200 ng/kg/min) reversed the values of these parameters, which were significantly different from those in the Control group. The results suggest that PGI2 has a protective action against impairment of gas exchange in the presence of increased pulmonary vascular permeability.

Assessment of Bronchial Obstruction Using Lateral Pressure Measurement during Bronchoscopy

Background: In patients with bronchial obstruction estimating the location of the maximal obstruction is crucial for guiding interventional bronchoscopy. However, flow-volume curves cannot discriminate between the right and left lungs. Objectives: The aim of this study was to physiologically evaluate bronchial obstruction during interventional bronchoscopy. Methods: We prospectively measured lateral airway pressure (Plat) at either side of the obstruction using a double-lumen catheter (pressure-pressure [P-P] curve) simultaneously to assess the degree of bronchial obstruction in 22 patients. The shape of the P-P curve was assessed to confirm the site of maximal obstruction. Results: In the experimental study, Plat was uniform between both bronchi in the normal model. For the unilateral and bilateral obstruction models, a phase shift was only seen for the more obstructed side. In healthy subjects, the angle of the P-P curve was close to 45° and linear in shape. In patients with bronchial obstruction, the angle was much smaller but approached 45° after the bronchoscopic procedure. The degree of bronchial obstruction was significantly correlated with the angle of the P-P curve (r = –0.51, p < 0.01). Dyspnea significantly increased when the airway lumen was obstructed by more than 60% (p < 0.0001), and when the P-P curve appeared loop-shaped (p < 0.01). Conclusions: The shape of the P-P curve could be used to detect the site of maximal obstruction for the optimal positioning of the stent and assess the need for additional procedures in real time in patients with bronchial obstruction.

Two Cases of Malignant Pleural Mesothelioma Treated With Chemotherapy Plus Concurrent High-dose Hemithoracic Radiation After Extrapleural Pneumonectomy

背景.悪性胸膜中皮腫の根治治療として局所制御を狙った集学的治療が試みられているが, 依然として局所再発による腫瘍死が多い. 著者らは悪性胸膜中皮腫2例に対し胸膜肺全摘出術後に同時放射線化学療法を追加する集学的治療を行ったので報告する. 症例. 50歳と60歳の男性で, いずれも悪性胸膜中皮腫の上皮型で臨床病期Stage Iであった. 胸膜肺全摘術を行い2カ月後に, 片側胸郭に50Gyの放射線照射とシスプラチン6mg/m2 (連日) +ビンデシン3mg/m2 (週1回) との同時併用を追加した. Grade 3以上の毒性は2例とも好中球減少だけであり, 治療は遅延なく完遂できた. 2例とも切除断端の一部に腫瘍細胞を認めたが, 照射野内には再発しなかった. いずれも照射野外に再発したが1例は術後22カ月間生存中であり, 他方1例は術後10カ月で細菌性肺炎のため死亡した. 結論. 悪性胸膜中皮腫に対する胸膜肺全摘出術と同時放射線化学療法は, 耐用可能で局所制御を改善できる集学的治療と考える.

A Case of Malignant Fibrous Histiocytoma of the Lung.

-Background. Malignant fibrous histiocytoma (MFH) originating in the lung is a rare tumor. We report a surgically resected case. Case. A 76-year-old man had a complaint of cough for six months. A chest X-ray revealed an abnormal shadow in the left lung. A computed tomography of the lung showed a tumor 6cm in diameter in the superior segment of his left lower lobe. At first, preoperative cytological examination of the curetted specimen through fiberoptic bronchoscope revealed squamous cell carcinoma. Left lower lobectomy with systematic lymph node dissection was performed. The tumor was 10•~6.5•~5.5cm in size. Postoperative histopathological findings revealed MFH of the lung. Lymph node metastasis was not recognized. Adjunctive chemotherapy was intended but so far not done because of prolonged postoperative elevation of fever and his age. Six months after the operation, right adrenal metastasis was pointed out, so right adrenectomy was done. He is doing well without any sign of recurrence one year since then. Conclusion. We found only 54 cases of MFH originating in the lung in the Japanese literature, but recently the number of reported cases has been increasing. The prognosis of MFH of the lung is said to be poor. Effectiveness of chemotherapy or radiation therapy has not been established, so only curative surgical resection is effective. (JJLC. 2002; 42: 631-635) KEY WORDS-Malignant fibrous histiocytoma, Lung tumor, Adrenal metastasis 国立病 院呉 医療セ ンター1呼 吸 器外 科,2呼 吸器科,3検 査 科;4現 大阪大学大学 院医学系研究科臓器制御外科学;5現 国 立療養所愛媛病院呼吸器外科;6現 大阪府立羽曳野病院外科. 別刷請求先:遠 藤俊治,大 阪大学大学院医学系研究科臓器制御 外科学,〒565-0871大 阪府吹田市 山田丘2-2 E1. Department of 1 General Thoracic Surgery, 2 Pulmonology, 3Pathology, National Hospital Kure Medical Center, Japan; 4 Dr Endo is now with Department of Surgery, Osaka University Graduate School of Medicine, Japan; 5 Dr Nakamura is now with Department of Chest Surgery, Ehime National Hospital for Chest Disease, Japan; 6 Dr Sakaguchi is now with Department of Surgery, Osaka Prefectural Habikino Hospital, Japan. Reprints: Shunji Endo, Department of Surgery, Osaka University Graduate School of Medicine, E1, 2-2, Yamadaoka, Suita-shi, Osaka 565-0871, Japan. Received December 10, 2001; accepted August 26, 2002

Concurrent high-dose thoracic irradiation plus daily low-dose cisplatin and vindesine in locally advanced unresectable stage III non-small cell lung cancer.

Patients with unresectable non small-cell lung cancer were treated to evaluate the toxicity and efficacy of high-dose thoracic irradiation (RT) combined with concurrent daily cisplatin plus vindesine. Fourteen evaluable patients with unresectable stage III non small-cell lung cancer treated with continuous-course RT (70 Gy in 35 fractions of 2 Gy once daily) and concurrent daily intravenous cisplatin (6 mg/m2) plus vindesine (3 mg/m2 on day 1 and day 8). The objective response rate was 86%, and two patients achieved a radiographic complete response. Leukocytopenia was the severe toxicity, but there were no episodes of discontinuation of treatment. Only one patient had grade 3 acute radiation esophagitis. Ten patients experienced late radiation pneumonitis and nine of those had grade 1 or grade 2. There was only one life-threatening case of toxicity (grade 5 pneumonitis). We concluded that the regimen of high-dose thoracic RT combined with concurrent daily cisplatin plus vindesine obtained a high response rate. Further testing on late toxicities and survival time is required.

A Case of Primary B Cell Lymphoma of the Lung.

症例は50歳の男性.検診にて右下肺野のair bronchogramを伴う腫瘤状陰影を指摘された.気管支鏡下肺生検標本の組織像にて異型性の少ない小型リンパ球の密な増殖を認め, 悪性リンパ腫が否定できないことから右下葉切除術を施行された.切除標本の免疫染色像ではIgMλのみが陽性となり, また, flow cytometoryでは表面マーカーのCD19と20が著増しており, 表面免疫グロブリンのlgMλが著増していた.この結果, 肺原発の非ポジキンリンパ腫 (diffuse, small cell type) と診断した.Southern blot法による切除標本の遺伝子解析では免疫グロブリンのみに明らかな遺伝子再構成が認められ, 免疫染色の診断を裏付ける結果を得た.術後は後療法を行わず経過観察中であるが, 3年を経過した現在, 再発は認めていない.本疾患の診断には免疫組織染色に加え, 遺伝子再構成の確認が重要であると考えられる.