Tsuneo Ishihara

Surgical treatment for both pulmonary and hepatic metastases from colorectal cancer

OBJECTIVE The role of surgery in the treatment of patients with pulmonary and hepatic metastases from colorectal cancer has not been delineated. METHODS Of the 351 patients enrolled in the Metastatic Lung Tumor Study Group of Japan between June 1988 and June 1996 who underwent thoracotomy for pulmonary metastases from colorectal cancer, 47 also underwent hepatic resection for metastatic tumors. The records of these patients were studied. RESULTS The 47 patients who underwent pulmonary and hepatic resection had a 3-year survival of 36% +/- 8%, a 5-year survival of 31% +/- 8%, and an 8-year survival of 23% +/- 9%. The longest survival was 98 months. This patient was alive without recurrence. There was a significant difference in the cumulative survival of the patients with a solitary pulmonary metastasis and the patients with multiple pulmonary metastases (P =.04). Neither age, sex, location of the primary tumor, maximum diameter of the pulmonary metastases, method of pulmonary resection, number of hepatic metastases, nor method of hepatic resection was correlated with survival. However, 9 of 10 patients who survived 3 years or more after the initial thoracotomy had only one or two hepatic metastases. CONCLUSION Surgical treatment of a solitary pulmonary metastasis concurrent with or after resection of hepatic metastases from colorectal cancer may be appropriate if the hepatic metastases are resectable for cure. Patients with a solitary pulmonary metastasis and a small number of hepatic metastases are good candidates for resection. Long-term survival can be expected.

Resection of the trachea infiltrated by thyroid carcinoma.

Twenty-four thyroid carcinoma patients with infiltration of the trachea were treated surgically. The histological diagnosis in these cases included papillary adenocarcinoma in 22 different patients, medullary carcinoma in one patient, and undifferentiated carcinoma in one patient. In 19 of the patients hemoptysis was noted, and dyspnea was present in ten patients. In 14 of the 24 patients the carcinoma was diagnosed by radiographs of the neck, while in seven patients it was demonstrated bronchoscopically. In three patients tracheal infiltration by thyroid carcinoma was diagnosed by biopsy of the tracheal wall at operation. When the tracheal wall was infiltrated by thyroid carcinoma, treatment consisted of circumferential resection of the involved segment of the trachea followed by an end-to-end anastomosis. Of the 24 patients, 17 survived and six died. In the 17 patients who survived, 13 were disease free. Of this number, six survived more than five years after the initial tracheal resection.

Tracheal reconstruction by esophageal interposition : an experimental study

The purpose of this study was to assess the possibility of reconstructing a circumferential tracheal defect with autogenous esophagus. In 6 mongrel dogs, a circumferential defect involving seven rings of the cervical trachea was reconstructed by interposing pedicled esophagus. A silicone T tube was used as a stent. The vertical limb of the T tube (usually referred to as the horizontal limb when used in humans) was cut shorter after the cervical wound had healed well, and it eventually was buried subcutaneously. Two dogs died 36 days after operation, and 1 died 28 weeks after operation. In no dog was the cause of death related to the operation or to a respiratory tract complication. Two dogs were put to death 4 weeks and 32 weeks after operation. They were well until then, and all the anastomoses between the trachea and the esophagus had healed fully without formation of granulation tissue. One dog is alive and well 14 months after operation. The vertical limb of the T tube retracted into the subcutaneous space, and there is no open cervical wound. Esophageal interposition might be a feasible technique for tracheal replacement in select groups of patients.

Resection of thyroid carcinoma infiltrating the trachea.

We have treated surgically 11 patients with thyroid carcinoma that had infiltrated into the trachea. Three patients had primary tumours, and eight had recurrent tumours after previous operations. Sleeve resection of trachea was performed where thyroid carcinoma had proliferated; the trachea was reconstructed by end-to-end anastomosis. In two patients 10 rings of the trachea were resected. In three patients the anterior half of the cricoid cartilage was resected along with the cervical trachea. In one patient tracheoplasty was performed using partial extracorporeal circulation because severe tracheal stenosis prevented endotracheal intubation. Two of the 11 patients died from the surgery and one from disseminated metastases. One patient who had undergone tracheal resection for thyroid carcinoma three years and five months previously had a recurrence of the tumour in the trachea adjacent to the anastomosis, and a second tracheal resection was performed. In three patients postoperative laryngeal stenosis occurred. Five patients are alive and well two years and one month to four years and seven months after their operations. The histological pattern of the tumour was papillary adenocarcinoma in all 11 patients.

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.

Malignant grading of cortical and medullary differentiated thymoma by morphometric analysis.

Forty‐seven thymomas were histologically classified into cortical, mixed, and medullary types, and the malignant grade of each subtype was evaluated by measuring the nuclear areas of epithelial cells. Fourteen normal thymuses and 23 thymic hyperplasias were used as controls. The cortical thymomas were more frequently invasive and associated with myasthenia gravis than the medullary type (P < 0.01 and 0.05, respectively). Cortical thymomas had larger epithelial cell nuclei than the medullary type (P < 0.001). Cortical and medullary thymomas had larger epithelial cell nuclei than the thymic cortex and medulla (P < 0.001 and 0.01, respectively). The thymic cortex had larger epithelial cell nuclei than the medulla (P < 0.001). These results confirm that the epithelial cell nuclei of cortical and medullary thymomas correspond morphometrically to the thymic cortex and medulla, respectively, and that most cortical thymomas have a higher malignant grade than the medullary type.

Primary osteogenic sarcoma of the mediastinum.

Ikeda, T., Ishihara, T., Yoshimatsu, H., Kikuchi, K., Murakami, M., Kobayashi, K., Inoue, H., and Kasahara, M. (1974). Thorax, 582-588. Primary osteogenic sarcoma of the mediastinum. A 22-year-old man with primary osteogenic sarcoma of the superior mediastinum is reported. This case is the second instance of primary osteogenic sarcoma of the mediastinum and the first case of superior mediastinal origin to be reported. The patient had local recurrence one year after the first operation. After resection of the recurrent tumour with left upper lobectomy and partial pericardectomy followed by radiation, he has been well for more than five years without recurrence. Extraosseous osteogenic sarcoma of soft tissue is very rare and has been reported in 103 patients. The five-year survival of patients with extraosseous osteogenic sarcoma is 22·4%. The distribution and prognosis of this tumour are similar to those of rhabdomyosarcoma in soft tissue. Primary amputation or wide excision is the treatment of choice.

Improved technique for inserting a T tube in patients with subglottic stenosis.

An improved method for inserting a silicone T tube through a tracheostomy stoma in patients with subglottic stenosis is presented. A silicone T tube is pulled into the trachea with a catheter that is inserted into the tracheostomy stoma, advanced through the stenotic subglottic space, and pulled out the mouth. A cone-shaped dilator is placed beforehand at the proximal end of the vertical limb of the T tube to facilitate the passage of that end through the stenotic subglottic space. This method was used in 4 patients with good results. We suggest this technique be tried when attempts to insert a T tube by the usual method fail, as it can be performed under local anesthesia without special instruments and is technically easy.

Assay for type III collagenolytic activity in lung cancer tissue

We developed a method for measuring the activity of type III collagenolytic enzyme in lung cancer tissue, using as substrate, type III collagen purified from human placenta. In this method [3H]propionate is used for labeling type III collagen, with bacterial collagenase used for making the standard curve. It, therefore, becomes possible to compare type III collagenolytic activity with those of other collagen subtypes (types I and IV). As this method is a fibril assay it is not susceptible to trypsin or other proteases. The average type III collagenolytic enzyme activity was higher in squamous cell carcinoma than in adenocarcinoma, while that of lung cancer tissue exceeded that of normal lung tissue. The activity of type III collagenase increased with the progression from one disease stage to the next.