Showing papers in "Journal of Thoracic Disease in 2012"

Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial

Abstract: Although, minimally invasive oesophagectomy was first described in the early 1990s, there is a paucity of high quality data on the relative merits of minimally-invasive versus open oesophagectomy (1,2) This is contrast to colorectal surgery where a number of randomised control trials have conclusively demonstrated the efficacy of laparoscopic colorectal resections (3) The reason for this disparity in evidence base lies in the relative rarity of oesophageal cancers combined with the variety of potential surgical approaches for resection oesophageal cancers (eg, transhiatal, 2 stage, 3 stage and hybrid laparoscopic approaches) The paper by Beire et al (4) is therefore very significant addition to the literature on the topic of minimally invasive oesophagectomies

Excessive daytime sleepiness in sleep disorders

Abstract: Excessive daytime sleepiness is a significant public health problem, with prevalence in the community estimated to be as high as 18%. Sleepiness is caused by abnormal sleep quantity or sleep quality. Amongst others, multiple neurological, psychological, cardiac and pulmonary disorders may contribute. Risk factors for excessive sleepiness include obesity, depression, extremes of age and insufficient sleep. In the clinical setting, two of the most commonly encountered causes are obstructive sleep apnoea and periodic limb movement disorder. There is continuing discussion of the mechanisms by which these disorders cause daytime symptoms, with intermittent nocturnal hypoxia, sleep fragmentation and autonomic dysregulation identified as important factors. The increased prevalence of obstructive sleep apnoea in obese subjects does not fully account for the increased rates of daytime sleepiness in this population and there is evidence to suggest that it is caused by metabolic factors and chronic inflammation in obese individuals. Sleepiness is also more common in those reporting symptoms of depression or anxiety disorders and significantly impacts their quality of life. Clinicians should be aware of factors which put their patients at high risk of daytime sleepiness, as it is a debilitating and potentially dangerous symptom with medico-legal implications. Treatment option should address underlying contributors and promote sleep quantity and sleep quality by ensuring good sleep hygiene. However, stimulant medication may be indicated in some cases to allow for more normal daytime functioning.

Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution.

Abstract: Objective: Tracheal intubation with one-lung ventilation is considered mandatory for thoracoscopic surgery. This study reported the experience of thoracoscopic lung resection without endotracheal intubation in a single institution. Methods: From August 2009 through July 2012, 285 consecutive patients were treated by nonintubated thoracoscopic surgery using epidural anesthesia, intrathoracic vagal blockade, and sedation for lobectomy, segmentectomy, or wedge resection in a tertiary medical center. The feasibility and safety of this technique were evaluated. Results: The final diagnosis for surgery were primary lung cancer in 159 patients (55.8%), metastatic lung cancer in 17 (6.0%), benign lung tumor in 104 (36.5%), and pneumothorax in 5 (1.8%). The operative methods consisted of conventional (83.2 %) and needlescopic (16.8%) thoracoscopic surgery. The operative procedures included lobectomy in 137 patients (48.1%), wedge resection in 132 (46.3%), and segmentectomy in 16 (5.6%). Collapse of the operative lung and inhibition of coughing were satisfactory in most of the patients. Fourteen (4.9%) patients required conversion to tracheal intubation because of significant mediastinal movement [5], persistent hypoxemia [2], dense pleural adhesions [2], ineffective epidural anesthesia [2], bleeding [2], and tachypnea [1]. One patient (0.4%) was converted to thoracotomy because of bleeding. No mortality was noted in our patients. Conclusions: Nonintubated thoracoscopic lung resection is technically feasible and safe in selected patients. It can be a valid alternative in managing patients with pulmonary lesions.

Photodynamic therapy for the treatment of non-small cell lung cancer.

Abstract: Photodynamic therapy is increasingly being utilized to treat thoracic malignancies. For patients with early-stage non-small cell lung cancer, photodynamic therapy is primarily employed as an endobronchial therapy to definitely treat endobronchial, roentgenographically occult, or synchronous primary carcinomas. As definitive monotherapy, photodynamic therapy is most effective in treating bronchoscopically visible lung cancers ≤1 cm with no extracartilaginous invasion. For patients with advanced-stage non-small cell lung cancer, photodynamic therapy can be used to palliate obstructing endobronchial lesions, as a component of definitive multi-modality therapy, or to increase operability or reduce the extent of operation required. A review of the available medical literature detailing all published studies utilizing photodynamic therapy to treat at least 10 patients with non-small cell lung cancer is performed, and treatment recommendations and summaries for photodynamic therapy applications are described.

Electromagnetic navigation bronchoscopy: A descriptive analysis

Abstract: Electromagnetic navigation bronchoscopy (ENB) is an exciting new bronchoscopic technique that promises accurate navigation to peripheral pulmonary target lesions, using technology similar to a car global positioning system (GPS) unit. Potential uses for ENB include biopsy of peripheral lung lesions, pleural dye marking of nodules for surgical wedge resection, placement of fiducial markers for stereotactic radiotherapy, and therapeutic insertion of brachytherapy catheters into malignant tissue. This article will describe the ENB procedure, review the published literature, compare ENB to existing biopsy techniques, and outline the challenges for widespread implementation of this new technology.

Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature

Abstract: Objective: Spontaneous recurrent pneumothorax during menstruation is reported as catamenial pneumothorax. It is encountered in 3-6% of spontaneous pneumothorax cases among menstruating women. The percentage among women referred for surgery is significantly higher (25-30%). Although it usually involves the right-side (85-95%) it can be left-sided or bilateral. It is associated with diaphragmatic perforations and/or thoracic endometriosis. There is pelvic endometriosis in up to 30-51% of cases. The lesions that are not always found may present as small or larger holes at the central tendon of the diaphragm, as red, blueberry, brown spots or larger nodules at the diaphragm, the visceral or parietal pleura. Lesion histology may reveal endometriosis. We present 5 cases of catamenial pneumothorax treated surgically during the last 6 years. Patients and methods: Five women, with a mean age of 34+/-9.9 years (median 38, range, 19-45 years) presented with right-sided recurrent catamenial pneumothorax. In 3 patients diaphragmatic perforation(s) were found; perforation suturing (n=1), and diaphragmatic plication reinforced with bovine pericardial patch (n=1) were performed. All patients underwent atypical resection of upper and/or middle lobe segments of lung parenchyma that appeared abnormal (haemorrhagic/ emphysematous or blebs). Four patients underwent pleurodesis and 1 patient underwent pleurectomy. Four interventions were performed through video assisted thoracoscopic surgery, while diaphragmatic plication was performed through a video assisted mini-thoracotomy. Histology did not reveal endometriosis tissue. Results: The postoperative course was uneventful. The patients were extubated in theatre and were discharged home at a mean of 7+/-4 days (median 6 days, range, 4-14 days). Two of them received hormonal therapy [Gonadotropin Releasing Hormone (GnRH) analogue] postoperatively. At a follow-up of 14.16 patient-years (mean 2.83+/-1.08 years, range, 1.33- 3.83 years) there was recurrence, 6.5 months postoperatively, in one patient that had not undergone closure of a tiny diaphragmatic hole and had not received hormonal treatment postoperatively. She was treated medically (amenorrhea for 6 months with GnRH analogue) and had no further recurrences (in 3.3 years). Conclusions: Surgery is the treatment of choice of catamenial pneumothorax. It should aim to complete management of all lesions. The most common complication is recurrence. Early diagnosis and multidisciplinary treatment including hormonal therapy may be beneficial in high risk patients.

COPD in India: Iceberg or volcano?

Abstract: The purpose of this article is to provide an overview of the epidemiology of COPD in India which is one of the most affected countries in the world and contributes significantly to the mortality and morbidity of this disease; to provide insights into the etiological determinants of COPD in India; comment on treatment aspects including drug treatment, adherence to guidelines, treatment of exacerbations and to try to comment on whether it differs significantly from rest of the world.The article reviews published literature on COPD in India; provides insight into comparative methodologies involved; comments on gaps in knowledge and suggests areas of further research such as Prescription Audit. India contributes very significantly to mortality from COPD 102.3/100,000 and 6,740,000 DALYs out of world total of 27,756,000 DALYs; thus significantly affecting health related Quality of Life in the country. COPD is surpassing Malaria, TB even today and the gap would get wider with time in near future. The lack of robust real time nation-wide data does plague India as well, however multiple studies from 1994 to 2010 show increasing trends of COPD morbidity and mortality. Since most inhalational drugs are available in the country there is no reason why mortality should not be comparable to rest of the world but there is poor adherence to treatment guidelines, both national and international. Urban centers in India are comparable to their global counterparts in terms of service quality and facilities and this is also work in progress. However, the rural hinterland is poorly serviced; national GDP spending on health is remarkably low. Some innovation is emerging and that could be the harbinger of a new future if properly nurtured. The article is an overview of COPD in India with emphasis on understanding the multi-dimensional nature of the problem and an attempt of providing insight into possible de-bottlenecking to reduce the pain and suffering of millions of COPD patients in India in future.

Anesthesia with nontracheal intubation in thoracic surgery

Abstract: Objective: To study one-lung respiration during VATS wedge resection of bullae and pulmonary nodules with nontracheal intubation, and to explore the changes of vital signs when patients return to two-lung ventilation. Methods: Twenty-two patients with normal cardiopulmonary function and absence of contraindications to epidural anesthesia were included in this study. VATS wedge resection of bullae or pulmonary nodules was performed. 0.5% Ropivacain was administrated for epidural anesthesia (T8-9), and 2 mL of 2% lidocaine was used for local anesthetic block of the intrathoracic vagus nerves. The BIS value was maintained between 50 and 70 by target-controlled infusion of propofol and remifentanil. Electrocardiogram (ECG), heart rate (HR), blood pressure (Bp), pulse oxygen saturation (SpO 2 ), respiratory rate (RR), bispectral index (BIS) and urine volume were monitored. Results: None patients were converted to endotracheal intubation during anesthesia. MAP and SpO 2 after wound disclosure were stable (P>0.05), level of CVP significantly elevated, HR and RR increased (P<0.05), PaCO 2 increased gradually while PaO 2 remained stable. Fifteen minutes after wound closure, MAP, RR and SpO 2 returned to their preanesthesia levels, PH value gradually recovered, PaCO 2 tended to decrease and returned to normal one hour after wound closure. Physical agitation occurred in one case due to inadequate epidural anesthesia during skin incision. Cough before intrathoracic vagal blockade was noted in two cases (9.1%) because of lobe traction. Conclusions: Nontracheal intubation is feasible in VATS wedge resection of bullae and pulmonary nodules. The patients are with stable intraoperative vital signs and none experiences hypoxemia; intraoperative hypercapnia is tolerable and transient, which can be improved quickly when bilateral lungs resume spontaneous respiration.

Hydration with magnesium and mannitol without furosemide prevents the nephrotoxicity induced by cisplatin and pemetrexed in patients with advanced non-small cell lung cancer

Abstract: Background: The aim of this study was to examine the effect of hydration with magnesium and mannitol without furosemide on the nephrotoxocity accompanying combination chemotherapy using cisplatin and pemetrexed in patients with advanced non-small cell lung cancer (NSCLC). Methods: Fifty patients with NSCLC who received cisplatin plus pemetrexed, using either old hydration protocol including normal saline with mannitol and furosemide, or a new one including normal saline with magnesium and mannitol without furosemide were retrospectively analyzed. Nephrotoxicity was compared between patients treated using the old protocol and those treated with the new protocol. Univariate and multivariate analyses were performed to identify the independent factors associated with protection against nephrotoxicity in patients with NSCLC who received cisplatin plus pemetrexed. Results: Thirty patients received the old hydration protocol, while 20 patients were treated using the new hydration protocol. The patients treated using the new hydration protocol showed a significantly greater increase in creatinine clearance (P=0.0004) and a decrease in the serum creatinine level (P=0.0148) after one course of chemotherapy compared with those treated using the old hydration protocol. There were no differences in the chemotherapeutic response or overall survival between the groups (P=0.572). The new hydration protocol with supplemented magnesium with mannitol without furosemide was an independent factor for the protection against nephrotoxicity induced by cisplatin and pemetrexed in patients with advanced NSCLC [HR 0.232 (95% CI: 0.055-0.986), P=0.039]. Conclusions: These results demonstrate that the new hydration protocol comprising supplementation with magnesium without furosemide could prevent the nephrotoxicity induced by cisplatin and pemetrexed without affecting the treatment outcome.

Clinicopathologic analysis of cardiac myxomas: Seven years’ experience with 61 patients

Abstract: Objective: Cardiac myxomas are the most common primary neoplasms of heart. The present study was performed on the 61 cases of patients with cardiac myxoma, in order to investigate the tumors’ clinical and pathological features, and to identify the relationship between the pathological characteristics and clinical behaviors. Methods: A total of 61 cardiac myxoma cases were analyzed and reviewed retrospectively, including the clinical presentations, physical examinations, and echocardiography, electrocardiography, and pathology documents. Results: The total patient cohort was made up of 37 women and 24 men. The average age at diagnosis was 48.8 years in males and 51.9 years in females. The most common complaint was dyspnea (37 cases, 60.7%) and the most common sign was systolic murmur (30 cases, 49.2%). Two surface structures and three tumor cell arrangement patterns were observed, and statistical analysis revealed the surface structure was related to the cell arrangement pattern. However, neither the cell arrangement pattern nor the tumor surface structure showed a significant correlation with the clinical presentation. Conclusions: The present study showed the pathological profiles of cardiac myxomas were not related to the clinical presentations. The results of our study indicate morphologic classifications of cardiac myxomas may not be significant for clinical practice.

Pleural infection-current diagnosis and management.

Abstract: Pleural infection is a common and increasing clinical problem in thoracic medicine, resulting in significant morbidity and mortality. In recent years there has been a marked increase in interests and publications relating to evolving interventions and management options for pleural infection and empyema. Recently published research data as well as guidelines have suggested better approaches of radiological assessment, updated management algorithms for pleural infection, intrapleural adjunct therapies and re-examined the roles of biomarkers, pleural drainage techniques, and the role of surgery. This review highlights some of the recent advances and recommendations relevant to clinical care of pleural infection.

Management of complex benign post-tracheostomy tracheal stenosis with bronchoscopic insertion of silicon tracheal stents, in patients with failed or contraindicated surgical reconstruction of trachea

Abstract: Tracheal stenosis is a potentially life-threatening condition. Tracheostomy and endotracheal intubation remain the commonest causes of benign stenosis, despite improvements in design and management of tubes. Post-tracheostomy stenosis is more frequently encountered due to earlier performance of tracheostomy in the intensive care units, while the incidence of postintubation stenosis has decreased with application of high-volume, low-pressure cuffs. In symptomatic benign tracheal stenosis the gold standard is surgical reconstruction (often after interventional bronchoscopy). Stenting is reserved for symptomatic tracheal narrowing deemed inoperable, due to local or general reasons: long strictures, inflammation, poor respiratory, cardiac or neurological status. When stenting is decided, silicone stent insertion is considered the treatment of choice in the presence of inflammation and/or when removal is desirable. We inserted tracheal silicone stents (Dumon) under general anaesthesia through rigid bronchoscopy in two patients with benign post-tracheostomy stenosis: a 39-year old woman with failed initial operation, and continuous relapses with proliferation after multiple bronchscopic interventions, and a 20-year old man in a poor neurological status, with a long tracheal stricture involving the subglottic larynx (lower posterior part), and inflamed tracheostomy site tissues (positive for methicillin resistant staphylococcus aureus). The airway was immediately re-establish, without complications. At 15- and 10-month follow-up (respectively) there was no stent migration, luminal patency was maintained without: adjacent structure erosion, secretion adherence inside the stents, granulation at the ends. Tracheostomy tissue inflammation was resolved (2nd patient), new infection was not noted. The patients maintain good respiratory function and will be evaluated for scheduled stent removal. Silicone stents are removable, resistant to microbial colonization and are associated with minimal granulation. In benign post-tracheostomy stenosis silicone stenting appeared safe and effective in restenosis after surgery and multiple bronchoscopic interventions, and in long stenosis, involving the lower posterior subglottic larynx in the presence on inflammation and poor neurological status.

Detection methods of circulating tumor cells.

Abstract: Early during the formation and growth of a primary epithelial tumor, cells disseminate through the bloodstream to distant organs These circulating tumor cells (CTCs) can be enriched and detected via different technologies and CTC analyses are considered as a real-time “liquid biopsy” in cancer patients This biopsy allows the characterization of specific sub-populations of CTCs and may revolutionize cancer detection and management This editorial highlights the current strategies used for enrichment and detection of CTCs

Cryosurgery for lung cancer.

Abstract: Cryosurgery is suited for patients with lung cancer who are not considered for lung resection because of the advanced stage of the disease or the patient’s poor general condition or poor respiratory function and with tumor recurrence following radiotherapy, chemotherapy or lung resection, and those patients who have localized lung cancer but refuse to receive operative therapy. Procedures of cryosurgery for lung cancer can be performed through endobronchial, direct intrathoracic (at exploratory thoracotomy) or percutaneous routes depending upon location and size of tumor. Six hundred and twentyfive patients with Non-small cell lung cancer (NSCLC) received percutaneous cryoablation in Fuda Cancer Hospital Guangzhou, China. One hundred and fifty patients were followed-up for 12 to 38 months. Results showed that 1-, 2-, and 3-year survival rates were 64%, 45% and 32%, respectively. The adverse effects after cryosurgery of lung cancer include haemoptysis, pneumothorax, bloody thorax, pleural effusion and pulmonary infection which are generally mild, transient, and recovery with symptomatic management. In vitro studies have shown cryotherapy of lung cancer cells can improve the immune system to trigger the specific anti-tumor response. In the future, comparative studies between this modality and other therapies should be conducted for the treatment of lung cancer. In addition, more attention needs to be put on the immunomodulators that enhance the cryoimmunology.

Revisiting signs, strengths and weaknesses of Standard Chest Radiography in patients of Acute Dyspnea in the Emergency Department

Abstract: Dyspnoea, defined as an uncomfortable awareness of breathing, together with thoracic pain are two of the most frequent symptoms of presentation of thoracic diseases in the Emergency Department (ED). Causes of dyspnoea are various and involve not only cardiovascular and respiratory systems. In the emergency setting, thoracic imaging by standard chest X-ray (CXR) plays a crucial role in the diagnostic process, because it is of fast execution and relatively not expensive. Although radiologists are responsible for the final reading of chest radiographs, very often the clinicians, and in particular the emergency physicians, are alone in the emergency room facing this task. In literature many studies have demonstrated how important and essential is an accurate direct interpretation by the clinician without the need of an immediate reading by the radiologist. Moreover, the sensitivity of CXR is much impaired when the study is performed at bedside by portable machines, particularly in the diagnosis of some important causes of acute dyspnoea, such as pulmonary embolism, pneumothorax, and pulmonary edema. In these cases, a high inter-observer variability of bedside CXR reading limits the diagnostic usefulness of the methodology and complicates the differential diagnosis. The aim of this review is to analyze the radiologic signs and the correct use of CXR in the most important conditions that cause cardiac and pulmonary dyspnoea, as acute exacerbation of chronic obstructive pulmonary disease, acute pulmonary oedema, acute pulmonary trombo-embolism, pneumothorax and pleural effusion, and to focus indications and limitations of this diagnostic tool.

Theoretical models of carcinogenic particle deposition and clearance in children’s lungs

Abstract: Introduction: Deposition and clearance of carcinogenic particles in the lungs of subjects belonging to four different age groups (infants, children, adolescents, and adults) were theoretically investigated. The study is thought to contribute to the improvement of our knowledge concerning the behaviour of inhaled particles in lungs that may be attributed to different stages of development. Methods: Particle deposition and clearance were simulated by using a well established stochastic lung model, allowing the generation of nearly realistic scenarios. For the computation of particle deposition all main deposition forces were considered. Additionally, any influences on particle behaviour due to particle geometry were covered by using the aerodynamic diameter concept. Particle clearance was simulated by defining both a fast mucociliary clearance phase and a slow bronchial/alveolar clearance phase, the latter of which is based on previously published models and suggestions. Results: As clearly provided by the modelling computations, lung deposition of particles with aerodynamic diameters ranging from 1 nm to 10 μm may significantly differ between the studied age groups. Whilst in infants and children most particles are accumulated in the extrathoracic region and in the upper bronchi, in adolescents and adults high percentages of inhaled particular substances may also reach the lower bronchi and alveoli. Although mucus velocities are significantly lower in young subjects compared to the older ones, fast clearance is more efficient in small lungs due to the shorter clearance paths that have to be passed. Slow clearance is commonly characterized by insignificant discrepancies between the age groups. Conclusions: From the study presented here it may be concluded that particle behaviour in infants’ and children’s lungs has to be regarded in a different light with respect to that in adolescents and adults. Although young subjects possess natural mechanisms of protecting their lungs from hazardous aerosols (e.g., expressed by breathing behaviour and lung size), they are much more sensitive to any particle exposure, since particle concentrations per lung tissue area may reach alarming values within a short period of inhalation.

OSA and atherosclerosis

Abstract: Untreated obstructive sleep apnea (OSA) is increasingly recognized as a risk factor contributing to cardiovascular morbidity and mortality. Research in recent decades has uncovered many components of the complex pathological events leading to the atherosclerotic vascular diseases in OSA, which involve heightened oxidative stress as a result of intermittent hypoxia, vascular inflammation, activation of platelet and coagulation cascades, endothelial dysfunction and ultimately the formation of atherosclerotic plagues. The close association of OSA and conventional cardiovascular risk factors including hypertension, diabetes mellitus, dyslipidemia and obesity adds to the adverse cardiovascular sequelae. Further studies are required to clarify further on the pathophysiological processes, and the effect size of OSA therapy, and other potential preventive strategies.

Whole genome sequencing for lung cancer

Abstract: Lung cancer is a leading cause of cancer related morbidity and mortality globally, and carries a dismal prognosis. Improved understanding of the biology of cancer is required to improve patient outcomes. Next-generation sequencing (NGS) is a powerful tool for whole genome characterisation, enabling comprehensive examination of somatic mutations that drive oncogenesis. Most NGS methods are based on polymerase chain reaction (PCR) amplification of platform-specific DNA fragment libraries, which are then sequenced. These techniques are well suited to high-throughput sequencing and are able to detect the full spectrum of genomic changes present in cancer. However, they require considerable investments in time, laboratory infrastructure, computational analysis and bioinformatic support. Next-generation sequencing has been applied to studies of the whole genome, exome, transcriptome and epigenome, and is changing the paradigm of lung cancer research and patient care. The results of this new technology will transform current knowledge of oncogenic pathways and provide molecular targets of use in the diagnosis and treatment of cancer. Somatic mutations in lung cancer have already been identified by NGS, and large scale genomic studies are underway. Personalised treatment strategies will improve care for those likely to benefit from available therapies, while sparing others the expense and morbidity of futile intervention. Organisational, computational and bioinformatic challenges of NGS are driving technological advances as well as raising ethical issues relating to informed consent and data release. Differentiation between driver and passenger mutations requires careful interpretation of sequencing data. Challenges in the interpretation of results arise from the types of specimens used for DNA extraction, sample processing techniques and tumour content. Tumour heterogeneity can reduce power to detect mutations implicated in oncogenesis. Next-generation sequencing will facilitate investigation of the biological and clinical implications of such variation. These techniques can now be applied to single cells and free circulating DNA, and possibly in the future to DNA obtained from body fluids and from subpopulations of tumour. As costs reduce, and speed and processing accuracy increase, NGS technology will become increasingly accessible to researchers and clinicians, with the ultimate goal of improving the care of patients with lung cancer.

Chinese guidelines on the diagnosis and treatment of primary lung cancer (2011).

Abstract: Primary lung cancer (PLC) is one of the most common malignant tumors in China. According to the Health Statistics Yearbook 2010, PLC was the first leading cause of cancer death nationwide in 2005.

Pulmonary rehabilitation program including respiratory conditioning for chronic obstructive pulmonary disease (COPD): Improved hyperinflation and expiratory flow during tidal breathing

Abstract: Background: Pulmonary rehabilitation has generally relieved symptoms, strengthened exercise endurance and improved health-related quality of life (QOL) in patients with COPD, but recovery of pulmonary function remains questionable. This analysis of our innovative rehabilitation program is directed at documenting changes in patients’ expiratory airflow limitation, pulmonary symptoms and QOL. This program is designed to provide “respiratory conditioning”, a physical therapist-assisted intensive flexibility training that focuses on stretching and rib cage mobilization. Methods: Thirty-one patients with COPD who attended rehabilitation sessions at Juntendo University Hospital from 1999 to 2006 were analyzed. Pulmonary function, expiratory flow limitation during tidal breathing, six minute walk distance (6MWD), respiratory muscle strength, and St. George Respiratory Questionnaire (SGRQ) were measured before and after pulmonary rehabilitation. Results: In participants ages 68±7 years, the FEV 1 % predicted was 39.3±15.7%. 6MWD, SGRQ and respiratory muscle strength were significantly improved after pulmonary rehabilitation. Although neither FEV 1 % predicted nor FEV 1 /FVC was affected to a significant extent, indicating little effect on airflow limitation, expiratory flow limitation in supine as well as seated during tidal breathing improved significantly. Moreover, rehabilitation significantly diminished TLC% predicted, FRC% predicted, RV% predicted and RV/TLC values, thus indicating a reduction of hyperinflation of the lungs at rest. Conclusion: The present results suggest that our rehabilitation program with respiratory conditioning significantly lowered the hyperinflation of lungs at rest as well as the expiratory flow limitation during tidal breathing. In patients with COPD, overall pulmonary function improved, exercise endurance increased and health-related QOL was enhanced.

Involvement of Rho kinase (ROCK) in sepsis-induced acute lung injury.

Abstract: Indirect acute lung injury is associated with high morbidity and mortality. We investigated the link between Rho kinase (ROCK) activation and apoptotic cell death in sepsis induced acute lung injury. This hypothesis was tested by administering a specific, selective inhibitor of ROCK (Y-27632) to rats subjected to cecal ligation and puncture (CLP). Rats were randomly divided into 4 groups as; sham-operated, sham + Y-27632, CLP and CLP + Y-27632. Twenty-four hours later, each experiment was terminated and lungs analyzed. Histopathology was assessed by hematoxylin-eosin staining and the presence of apoptosis was evaluated through the TUNEL assay. Pulmonary activity of caspase 3 and ROCK 1 & 2 were measured by western blot. Interstitial edema, severely damaged pulmonary architecture with massive infiltration of the inflammatory cells and an increase in lung tissue TBARS levels as well as 3-NT to total tyrosine ratios were observed in untreated CLP animals. Pretreatment of animals with Y-27632, reduced lung injury in the CLP induced septic rats in each of these parameters of lung injury (p<0.05). Western immunoblot revealed active caspase cleavage and increased expression of active fragment of ROCK 1 & 2 in the CLP group. TUNEL assay showed an increase in percentage of apoptotic cells when comparing the CLP group with the CLP + Y-27632 group. These results suggest an important role of Rho kinase in sepsis induced lung injury by a mechanism that might be related to oxidative and/or nitrosative stress mediated caspase cleavage leading to apoptosis.

Five-year update on the mouse model of orthotopic lung transplantation: Scientific uses, tricks of the trade, and tips for success.

Abstract: It has been 5 years since our team reported the first successful model of orthotopic single lung transplantation in the mouse. There has been great demand for this technique due to the obvious experimental advantages the mouse offers over other large and small animal models of lung transplantation. These include the availability of mouse-specific reagents as well as knockout and transgenic technology. Our laboratory has utilized this mouse model to study both immunological and non-immunological mechanisms of lung transplant physiology while others have focused on models of chronic rejection. It is surprising that despite our initial publication in 2007 only few other laboratories have published data using this model. This is likely due to the technical complexity of the surgical technique and perioperative complications, which can limit recipient survival. As two of the authors (XL and WL) have a combined experience of over 2500 left and right single lung transplants, this review will summarize their experience and delineate tips and tricks necessary for successful transplantation. We will also describe technical advances made since the original description of the model.

Severe amiodarone induced pulmonary toxicity

Abstract: A known complication of Amiodarone therapy is Amiodarone induced Pulmonary Toxicity (APT). Several features of this adverse effect make it difficult to diagnosis and treat. The case of a 63-year-old male with classic radiographic and histologic findings of APT is discussed. Clinical presentation, pathophysiology, diagnostic findings, and treatment strategies are reviewed. The patient was successfully managed with pulse high dose steroid therapy.

A pilot study of nimotuzumab combined with cisplatin and 5-FU in patients with advanced esophageal squamous cell carcinoma.

Abstract: Objective: To observe the short-term effect and adverse reaction of Nimotuzumab in combination with chemotherapy on advanced esophageal squamous cell carcinoma (ESCC). Method: 19 patients were treated with the following protocol: Nimotuzumab 400mg/time/week in the 1 st week, 200mg/time/week from the 2 nd to 8 th week, intravenous drip (IVD); Cisplatin 80 mg/m 2 , IVD, 4 weeks a cycle and repeated again; 5-FU 750 mg/m2continuous 24-hours pump-in × 5 days, 4 weeks a cycle and repeated again. Result: 16 of all 19 patients can be evaluated. After treatment, RP is 42.1% (95% CI, 19.9-64.3%) and DCR is 68.4%; the main side effects include arrest of bone marrow, gastrointestinal reactions, asthenia, etc. Conclusion: Nimotuzumab in combination with cisplatin/5-FU regimens in patients with advanced ESCC is safe and effective, which deserves a further expanded sample research.

Quantified smoking status and non-small cell lung cancer stage at presentation: Analysis of a North Indian cohort and a systematic review of literature

Abstract: Background: There are variable observations in published literature regarding smoking status and stage of lung cancer (LC) with positive, negative and no associations being reported. In particular, data regarding the association of quantified smoking status (QSS) with non-small cell lung cancer (NSCLC) stage at the time of diagnosis is limited. In India, bidi - the hand rolled form of tobacco wrapped in the dried tendu leaf - is the most common smoking product. The current study was conducted to assess stage differences, if any, based upon QSS, among newly diagnosed LC patients. Methods: A systematic review of English literature was performed for previous publications that had assessed NSCLC stage differences in relation to QSS. Collected data on demographic and disease characteristics of 654 LC patients presenting to the authors’ institute was also analyzed. Smoking index (SI) was used for QSS and was defined as number of bidis and cigarettes smoked per day multiplied by years smoked. Patients were categorized as never-smokers [Group I, n=151]; light/moderate smokers (SI=1-300) [Group II, n=202] and heavy smokers (SI ≥301) [Group III, n=301]. Multivariate logistic regression analysis (LRA) was performed to derive adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results: Among the 520 NSCLC patients, mean [standard deviation (SD)] age in groups I, II and III was 54.5 (12.5), 58.6 (9.9) and 61.2 (9.4) years respectively (P<0.001). Percentage of males in the three groups was 48.1%, 88.0%, and 97.9% (P<0.001). Age and gender differences between groups I, II and III were also significant among 134 small cell lung cancer patients with mean (SD) ages of 44.0 (10.6), 55.7 (10.3) and 58.9 (9.3) years (P<0.001) and percentage of males being 50.0%, 90.4% and 95.5% respectively (P<0.001). Among NSCLC patients, distribution in groups I, II and III respectively of squamous (28.1%, 50.0% and 57.9%) and non-squamous histologies (59.3%, 37.3% and 27.2%) differed significantly (P<0.001). Stage distribution observed for NSCLC patients in groups I, II and III respectively was as follows: stages I-IIIA (8.1%, 19.3 and 18.7%), stage IIIB (24.4%, 34.7% and 42.1%) and stage IV (67.4%, 46.0% and 39.1%). The difference was statistically significant (P<0.001). Differences remained significant (P<0.001) for presence of extrathoracic disease [ETD] (41.5%, 28.0% and 16.6%). On multivariate LRA, SI ≥301 was the only variable that was independently associated with both advanced stage (IIIB-IV) [OR=0.25 (95% CI=0.11-0.61)] and ETD [OR=0.29 (95% CI=0.16-0.53)] at presentation. Conclusions: Among newly diagnosed NSCLC patients in North India, significant differences exist, based upon SI, for disease stage. Heavy smoking was independently associated with lower odds of having advanced stage as well as with lower odds of having ETD at the time of diagnosis. This observation of the current study however requires confirmation by larger prospective studies.

The evolution of the role of surgery in the management of breast cancer lung metastasis.

Abstract: Breast cancer is the second leading cause of cancer death among women in the United States. Patients with metastatic disease have a median survival of 12 to 24 months and most present with disseminated disease; however, some present with isolated pulmonary metastases which may benefit from surgical resection. Although the initial experience with resection of pulmonary metastases in the late 19th and early 20th centuries produced some encouraging results, patient selection criteria for resection were strict until the mid-1960’s when a significant improvement in survival resulted from aggressive management of pulmonary metastasis in osteosarcoma patients. The application of this approach to breast cancer patients similarly produced encouraging results, with five year survival rates in select patients ranging from 36-54%, but this was not without controversy. In this review, we discuss the evaluation of the breast cancer patient with a pulmonary nodule, the historical evolution of the role of surgery in the management of pulmonary metastasis, as well as the latest evidence to guide patient selection and management.

Establishment of an orthotopic lung cancer model in nude mice and its evaluation by spiral CT.

Abstract: Objective: To establish a simple and highly efficient orthotopic animal model of lung cancer cell line A549 and evaluate the growth pattern of intrathoracic tumors by spiral CT. Methods: A549 cells (5×10 6 mL -1 ) were suspended and inoculated into the right lung of BALB/c nude mice via intrathoracic injection. Nude mice were scanned three times each week by spiral CT after inoculation of lung cancer cell line A549. The survival time and body weight of nude mice as well as tumor invasion and metastasis were examined. Tissue was collected for subsequent histological assay after autopsia of mice. Results: The tumor-forming rate of the orthotopic lung cancer model was 90%. The median survival time was 30.7 (range, 20-41) days. The incidence of tumor metastasis was 100%. The mean tumor diameter and the average CT value gradually increased in a time-dependent manner. Conclusion: The method of establishing the orthotopic lung cancer model through transplanting A549 cells into the lung of nude mice is simple and highly successful. Spiral CT can be used to evaluate intrathoracic tumor growth in nude mice vividly and dynamically.

Surgical treatment of esophageal leiomyoma larger than 5 cm in diameter: A case report and review of the literature

Abstract: Although leiomyoma is the most common benign esophageal neoplasm, it is a rare condition. Resection of the tumor is recommended in symptomatic patients, and observation is recommended in asymptomatic patients with small lesions. We discussed here a patient admitted to our hospital for dyspepsia in whom a calcified mediastinal neoplasm was diagnosised preoperatively and esophageal leiomyoma was diagnosised postoperatively. Enucleation of a leiomyoma of the esophagus is recommended and the optimal approaches should be tailored based on the location and size of the tumor.

Combination of cryosurgery and Iodine-125 seeds brachytherapy for lung cancer

Abstract: It has been proven that radioactive seeds such as Iodine-125 seeds implantation is a highly effective treatment for patients with localized cancer, such as lung cancer. It may increase the effectiveness of cryosurgery for lung cancer with the combination of Iodine-125 seed implantation into edge of the cryoablation zone. Percutaneous cryosurgery and Iodine-125 seed implantation are mutual complementation; both have been proved to be safe and effective modality for unresectable lung cancer, especially for centrally located lung cancer. Well-designed, randomized and control study both in the laboratory and in the clinical about this option are needed before the conclusive evidence submits.

High-resolution CT findings of patients with pulmonary nocardiosis.

Abstract: Background: Opportunistic pulmonary infection with Nocardia species is rare in humans, and only a few studies have radiologically analyzed patients with pulmonary nocardiosis using high-resolution computed tomography (HRCT). Methods: We retrospectively reviewed the medical records of patients with pulmonary nocardiosis at our hospital between April 2006 and December 2011 to assess HRCT and clinical findings. We also searched the medical literature for pulmonary nocardiosis reported in Japan between 2002 and 2011 for comparison. Results: We identified seven patients at our institution and 33 reported infections in Japan. Four of our patients were immunocompetent, whereas the other three had impaired cellular immunity due to type 2 diabetes mellitus or having been inappropriately treated with steroid. Thoracic HRCT revealed no zonal predominance, but tropism for distribution from the middle to the peripheral area, and radiological findings of nodules, cavitation, mass, consolidations, bronchial wall thickening, septal line thickening and ground glass opacity (GGO) were evident. The main HRCT finding in our study comprised nodules (n=5, 71.4%) <30 mm and four patients had multiple nodules as described in other reports. Furthermore, we discovered a crazy paving appearance (CPA) around nodules, cavities, masses or consolidations in five patients (71.4%). Conclusions: Multiple nodules distributed from the middle to the peripheral area on HRCT might reflect pulmonary nocardiosis, and CPA seemed to be a worth paying attention to the diagnosis.