Yoshihiko Arano

IgG4-related sclerosing mesenteritis : A rare mesenteric disease of unknown etiology

Sclerosing mesenteritis is a rare inflammatory and fibrosing disorder of unknown etiology, while IgG4‐related disease (IgG4‐RD) consists of mass‐forming, fibroinflammatory lesions characterized by high serum IgG4 levels and tissue infiltration of many IgG4‐positive plasma cells; obliterative phlebitis is common. This report describes a case of sclerosing mesenteritis that was considered a manifestation of IgG4‐RD. A 53‐year‐old man underwent right hemicolectomy because of an ileocecal mass that did not improve with conservative therapy. The ill‐defined fibroinflammatory lesion extended in the mesentery with storiform fibrosis, obliterative phlebitis, and infiltration of many IgG4‐positive plasma cells. The ratio of IgG4‐positive/IgG‐positive cells was 64%, and the ratio of forkhead box protein 3 (FOXP3)‐positive/CD4‐positive cells was elevated (13%). It is likely that at least some cases of sclerosing mesenteritis are a manifestation of IgG4‐RD. It is important to investigate this relationship because steroid therapy may benefit such cases.

Comparison of pleuropneumonectomy and limited surgery for lung cancer with pleural dissemination

The role of surgery in the management of lung cancer with pleural dissemination is controversial. We performed a retrospective analysis of our patients with lung cancer and pleural dissemination who were treated surgically. Between 1973 and 1993, 1,206 patients with lung cancer underwent pulmonary resection at Kanazawa University Hospital. Among them, 40 (3.3%) had pleural dissemination without pleural effusion. The 1‐, 3‐, and 5‐year survival rates for 38 patients (except 2 patients undergoing exploratory thoracotomy alone) were 51.5%, 19.4%, and 19.4%, respectively. The 1‐year survival rate in the 10 patients who underwent pleuropneumonectomy was only 20%, and 9 of these patients died within 18 months postoperatively (1 patient has survived for 25 months). In contrast, the 1‐, 3‐, and 5‐year survival rates for the 14 patients who underwent resection of the primary tumor plus parietal pleurectomy were 85.1%, 35.5%, and 35.5%, respectively, a significantly better outcome (P < 0.01). Seven patients are still alive (the longest survival time is 65 months with the disease). The average survival time in the seven fatal cases was 18 months. In patients with lung cancer accompanied by pleural dissemination, it is quite possible that local excision plus pleurectomy will be justified.

Comparative Immunohistochemical Analysis of IMP3, GLUT1, EMA, CD146, and Desmin for Distinguishing Malignant Mesothelioma From Reactive Mesothelial Cells

OBJECTIVES To identify useful biomarkers for differentiating between malignant mesothelioma (MM) and reactive mesothelial cells (RMCs). METHODS Formalin-fixed, paraffin-embedded (FFPE) tissues from 34 MM and 40 RMC samples were analyzed using immunohistochemistry, and the findings were compared. RESULTS Positive markers for MM included insulin-like growth factor 2 messenger RNA binding protein 3 (IMP3), glucose transporter 1 (GLUT1), epithelial membrane antigen (EMA), and CD146, which showed sensitivities of 94%, 85%, 79%, and 71% and specificities of 78%, 100%, 88%, and 98%, respectively. In sarcomatoid MM, EMA had significantly lower expression than did IMP3, GLUT1, and CD146 (P < .001). The areas under receiver operating characteristic curves were the highest for IMP3 (0.95), followed by GLUT1 (0.93). When the optimal cutoff points for IMP3 (30%) and GLUT1 (10%) were used, the sensitivity of IMP3 and GLUT1 for MM was 100%, and the specificity of both for MM was 95%. CONCLUSIONS The combination of IMP3 and GLUT1 is most appropriate for distinguishing MM from RMC using FFPE sections.

Single incision laparoscopic surgery (SILS) using cross hand technique

Abstract Single incision laparoscopic surgery (SILS) was developed as a less invasive surgical procedure, but it remains difficult because of its specific skills and left-right reversal of the instruments. Such a difference makes manipulating endoscopic instruments more challenging and increases the risk. In this study, we introduce the cross hand technique allowing the surgeon to manipulate instruments with intuitive movement.

Clinicopathological study of surgically treated cases of tracheobronchial adenoid cystic carcinoma.

Between 1980 and 2007, five patients were pathologically diagnosed as tracheobronchial adenoid cystic carcinoma (ACC). All five patients were women aged 37–67 years. Four tumors were located in the larger airways, and one tumor was located in the peripheral lung. The following operations were done: bronchoplastic procedures in three (carinal resection with doublebarreled carinoplasty in one, sleeve right pneumonectomy in one, sleeve middle lobectomy in one), left pneumonectomy in one, and left upper lobectomy in one. Three of the five patients have survived for 172, 144, and 10 months after surgery, respectively. The best local treatment for ACC of the major airway is considered to be sleeve resection of the trachea or bronchus in an area where airway reconstruction may not be disturbed and to add postoperative irradiation when there is residual carcinoma at the stump. However, it seems controversial to recommend adjuvant radiotherapy in all patients undergoing resection.

Evaluation of surgical treatment of pyothorax with special reference to the usefulness of the omental pedicle flap method.

The operative results in a series of 17 patients with pyothorax were reviewed. Of these, 10 had chronic empyema (group 1), and 7 had postoperative empyema (group 2). A single-stage operation was performed in eight patients in group 1 (decortication in six, thoracoplasty in one, omental plombage in one) and in all patients in group 2 (omentopexy in five, thoracoplasty in two). Two-stage procedures were performed in two patients in group 1. We obtained favorable postoperative results in eight patients in group 1, and in four patients in group 2. In our series, good results were not obtained by thoracoplasty alone; however, satisfactory results were achieved by short-term management in patients treated with the omental method. We think this series demonstrates the value of the omental pedicle flap method, which prevents loss of function due to a defective organ and offers excellent therapeutic results following an easy operative procedure. Further active application of this method can be expected in the management of thoracic disorders.

Malignant fibrous histiocytoma originating in the mediastinum: Report of a case

Malignant fibrous histiocytoma (MFH) is a tumor which most often develops in the soft tissues of the extremities and retroperitoneum, but very rarely originates in the mediastinum. We report herein the case of a 63-year-old man who underwent surgical resection of a rapidly growing tumor in the right thoracic cavity which was diagnosed as an MFH of mediastinal origin on the basis of histological findings, the definitive diagnosis ultimately being made by specific immunostaining.

A Clinical Analysis of Small-Sized Lung Cancer with Advanced Disease

A clinical analysis of small-sized lung cancers with advanced disease was conducted on a total of 58 patients: 34 diagnosed as T1N2, 6 as T1N3, 9 as T1M1, and 9 as T4 due to pleural dissemination. The cumulative 5-year survival rate after surgery for the 34 patients with a T1N2 lesion was 17.4%. Of these 34 patients, 24 underwent a curative operation resulting in a 5-year survival rate of 23.7%, but the remaining 10 patients, who underwent a non-curative operation, had a 5-year survival rate of 0%. Extended lymph node dissection for N3 disease has only been performed in recent years, so it is not yet clear whether it will affect the survival rate or not. T4 disease due to pleural dissemination and T1M1 disease associated with intrapulmonary metastasis encountered at thoracotomy could be expected to have relatively long-term survival with the combined use of systemic immunochemotherapy after surgery. In cases diagnosed as T4 due to pleural dissemination, we have recently employed resection of the primary lesion with parietal pleurectomy as the standard operative procedure. For cases of T1M1 with intrapulmonary metastasis confined to the same lobe as the primary lesion, a lobectomy is usually performed, while for cases with intrapulmonary metastasis extending to another lobe, a lobectomy with enucleation of metastatic nodules or pneumonectomy is most often performed instead of an exploratory thoracotomy.

Intractable lung abscess successfully treated with cavernostomy and free omental plombage using microvascular surgery

A 68-year-old man, complaining of fever and puriform sputum, was referred to our hospital. A giant abscess was detected in the upper lobe of the right lung. Percutaneous drainage of a lung abscess was carried out. When the pus collected was cultured, Candida was 1+ and Escherichia coli was 2+. Later, it became difficult to control the abscess by drainage, and cavernostomy was selected. The contents of the abscess cavity were removed, and the cavity was opened, followed by exchange of gauze every day. For 14 months after cavernostomy, once-weekly gauze exchange was continued at the outpatient clinic to clean the abscess cavity. Finally, the abscess was filled with a free greater omentum flap, accompanied by microvascular anastomosis. In this way, the intractable lung abscess was successfully cured. Conventionally, surgical treatment, particularly cavernostomy, has been applied only to limited cases when dealing with a lung abscess. Our experience with the present case suggests that surgical treatment, including cavernostomy as one option, should also be considered when dealing with lung abscesses resisting medical treatment and causing compromised respiratory function. To enable maximum utilization of the greater omental flap, which is available in only a limited amount, it seems useful to prepare and graft a free omental flap making use of microvascular surgery.

Modification of the surgical procedure to enable the complete resection of lung cancer with carcinomatous pleuritis.

Carcinomatous pleuritis, accompanied by pleural dissemination or malignant pleural effusion, is listed as one of the factors limiting adequate surgical treatment. It is relatively easy to peel the parietal pleura of the chest wall and mediastinum during a pleuropneumonectomy, but it is quite difficult to peel the parietal pleura of the diaphragm. A pleuropneumonectomy was conducted with the combined resection of the pericardium and all layers of the diaphragm without opening of the peritoneum through a posterolateral subcostal approach. This approach thus made it possible to perform a complete resection of the diaphragm relatively easily in a reliable manner, and also contributed to a more thorough resection of pleural dissemination without a second thoracotomy.