BACKGROUNDPrevious studies showed the prognostic impact of inflammatory markers such as the neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP), in resected non-small cell lung cancer (NSCLC). However, there are no studies that examined both of these markers simultaneously.PATIENTS AND METHODSThree hundred and one consecutive cases of resected NSCLC with a follow-up period of more than 5 years were reviewed retrospectively.RESULTSA significant association was only observed between NLR and patients' survival (p<0.0001). High CRP also led to a higher 5-year survival rate than low CRP (38.71% vs. 70.71%, p<0.0001). We evaluated the prognostic significance of the use of NLR and CRP combined. The 5-year survival of patients with both low NLR and low CRP was 74.18%. On the other hand, that of patients with both of these at a low level was significantly poor (20.00%, p<0.0001). Univariate and multivariate analyses of the clinicopathological factors affecting survival revealed that the combined use of preoperative NLR and CRP was an independent prognostic determinant.CONCLUSIONThe combined use of preoperative NLR and CRP might be useful to predict the prognosis of patients with NSCLC.

For complete resection of anterior apical invasive lung cancer, it is of clinical significance to select the appropriate surgical approaches based on the anatomic location of the tumor and extent of invasion of adjacent anatomic structures. However, patients with anterior apical lung cancer without vessel invasion are occasionally burdened with unnecessarily excessive surgical invasion. We present 2 cases of anterior apical lung cancer invading the 1st rib but not subclavian vein, who underwent complete resection through the parasternal approach. We also discuss the feasibility of this approach.

There are few case reports of cardiovascular surgery with multiple myeloma. We report 3 cases of cardiovascular surgery with multiple myeloma. CASE 1: A 73-year-old male hemodialytic patient with multiple myeloma was performed off-pump coronary artery bypass grafting (OPCAB) for angina. He was dead on the 72th postoperative day because of sepsis. CASE 2: A 68-year-old female patient with multiple myeloma was performed mitral valve replacement for mitral regurgitation. The postoperative course was uneventful. CASE 3: A 78-year-old male patient, the aorta was replaced with a artificial graft for impending rupture of thoracoabdominal aortic aneurysm. He was diagnosed with multiple myeloma after surgery. He was dead on the 99th postoperative day because of sepsis. One of the affecting prognosis factors is infection and it is intractable.

A 85-year-old female with two lesions in left upper lobe (S1+2: 4.7 cm and S3: 1.5 cm) was diagnosed with pulmonary adenocarcinoma. Preoperatively, a mutation analysis of epidermal growth factor receptor (EGFR) gene resulted in negative one. A computed tomographic scan pointed out a contralateral small nodule (right S8: 1 cm) with bilateral multicentric ground glass opacities. Even though a very-elderly but a healthy IV-staged advanced lung cancer, she desired for receiving a multimodality therapy. Left upper lobectomy with mediastinal nodal dissection was preceded. Eventually, the postoperative pathology disclosed lung cancer with multiple pulmonary metastasis in the contralateral lobe (T3N2M1a, stage IV). An another detection method of EGFR gene mutation revealed a positive result of the resected specimen. A first-line adjuvant oral administration of erlotinib treatment had diminished the unresected multicentric lesions, which stable status have been maintained for more than 12 months. The first-line erlotinib therapy showed a dramatic response for the elderly patient with EGFR gene mutation-positive. A reliability and accuracy of the detection method should be important to select an appropriate treatment. In clinical practice of the selected population of advanced lung cancer with EGFR mutation-positive, combination therapy of aggressive surgical resection and erlotinib therapy might take advantage of extending the progression-free survival, in case of her no enough time in the rest life because of her very-elderly age.

Objective— The mechanisms underlying abdominal aortic aneurysm development remain unknown. We hypothesized that acceleration of glucose metabolism with the upregulation of glucose transporters is associated with abdominal aortic aneurysm development. Methods and Results— Enhanced accumulation of the modified glucose analogue 18 fluoro-deoxyglucose by positron emission tomography imaging in the human abdominal aortic aneurysm was associated with protein expressions of glucose transporters-1 and -3, assessed by Western blot. The magnitude of glucose transporter-3 expression was correlated with zymographic matrix metalloproteinase-9 activity. Intraperitoneal administration of glycolysis inhibitor with 2-deoxyglucose significantly attenuated the dilatation of abdominal aorta induced by periaortic application of CaCl 2 in C57BL/6J male mice or reduced the aneurysmal formation in angiotensin II-infused apolipoprotein E knockout male mice. In monocytic cell line induced by phorbol 12-myristate 13-acetate or ex vivo culture obtained from human aneurysmal tissues, 2-deoxyglucose abrogated the matrix metalloproteinase-9 activity and interleukin-6 expression in these cells/tissues. Moreover, 2-deoxyglucose attenuated the survival/proliferation of monocytes and the adherence of them to vascular endothelial cells. Conclusion— This study suggests that the enhanced glycolytic activity in aortic wall contributes to the pathogenesis of aneurysm development. In addition, pharmacological intervention in glycolytic activity might be a potential therapeutic target for the disorder.

A smoker, 55-year-old male with a small nodule in left S5 on computed tomographic (CT) scanning of chest was diagnosed with pulmonary adenocarcinoma (cT1N0M0, c-stage IA). However, the CT scanning revealed that several small nodules on pleural surface might suspect a pleural dissemination, that is, IV-staged advanced lung cancer. The patient desired for receiving an aggressive multimodality containing of surgery, immunotherapy, and gefitinib treatment. After thoracotomy, the small pleural nodules were intraoperatively diagnosed with pleural dissemination by pathological examination. However, there was no malignant pleural effusion and intraoperative cytological examination of intrathoracic lavage resulted in a negative finding. Because of clinical N2-negative disease without malignant pleural effusion, left upper lobectomy with mediastinal lymph nodes dissection was preceded. The postoperative pathological examination disclosed pulmonary adnocarcinoma with mixed subtypes (pT1N2M1a, p-stage IV) and with micropapillary pattern. A detection test of epidermal growth factor receptor (EGFR) gene mutation revealed a positive result (L858R). As a systemic therapy, a combination chemotherapy of gemcitabine and carboplatin was performed in 2 cycles for the remained pleural dissemination. The patient received combination therapy of gefitinib and interleukin-2 lymphokine-activated killer cell immunotherapy in 6 cycles. A CT scanning of chest displayed disappearances of the remained pleural dissemination. There had been uneventful for 25 months. On the third postoperative year, a stereotactic radiotherapy surgery was performed for small three brain metastases. He had been healthy and received the gefitinib treatment for 45 months without any regrowing of the irradiated cerebral metastases and the treated pleural dissemination. The combination therapy of gefitinib and immunotherapy in the postoperative early phase would take advantage of extending the patient's progression-free survival, and also in case of the selected population of the advanced lung cancer harboring a EGFR mutation-positive.

A 62-year-old female with a productive sputum was pointed out of a mass of 2.5 cm in diameter in left S4 with lymphadenopathy of station 10, 4, and 3 on computed tomographic scan, which were heterogeneously enhanced by radiocontrast agent. She was diagnosed with pulmonary adenocarcinoma and clinical stage IIIA (T1N2M0, N2-multistation). First-line induction therapy of cisplatin plus paclitaxel had been performed but failed to respond to the chemotherapy. Second-line induction therapy of gefitinib for 6 months had showed the shrinkage of the tumor and resulted in a down-stage (T1N0M0, IA). Positron emission topography revealed no abnormal accumulations of the primary tumor and the mediastinal lymph nodes. As salvage surgery, left upper lobectomy was performed and the pathology revealed negative findings of metastasis in lymph nodal station 4, 5, 6, 7, and 11 but in a positive in station 10. The viable cells in the tumor had been residual (Ef.2) and diagnosed with stage IIA (pT1N1M0). Detection test of epidermal growth factor receptor gene mutation showed a negative result. The patient obtained 5-year's long-term survival without metastasis and recurrence. The combination therapy of gefitinib-induction therapy followed by surgery for advanced lung cancer with N2-multistation would have an advantage of good outcome for such patient in the limited gefitinib-responded population as tailor-made therapies.

AIMS:The relationship between the maximum standardized uptake values (SUVmax) on positron emission tomography (PET) and serum carcinoembryonic antigen (CEA) level in non-small cell lung cancer (NSCLC) patients was investigated.METHODS:Consecutively, 197 surgically resected NSCLC patients with preoperative staging including serum CEA and PET were reviewed retrospectively.RESULTS:When patients were subdivided into two groups based on the median value of the SUVmax (6.6), the 5-year survival of patients with a high SUVmax was 63.20%, which was significantly worse than patients with a low SUVmax (87.29%, P = 0.0004). The 5-year survival of patients with normal and high serum CEA level was 82.70 and 51.08%, respectively (P < 0.0001). Univariate and multivariate analyses indicated the independent prognostic impact of the SUVmax and serum CEA level. Patients with both low SUVmax and normal serum CEA level had favorable prognosis, whereas those with both high SUVmax and high serum CEA level had poor prognosis.CONCLUSION:Preoperative SUVmax and serum CEA level are independent prognostic factors for survival in NSCLC. The combined use of preoperative SUVmax and serum CEA level might be a better prognostic indicator.

PURPOSE The purpose of this study was to clarify the most suitable method to measure the aortic annulus diameter. PATIENTS AND METHODS Fifty-five patients, who had undergone aortic valve replacement at Miyazaki University Hospital between April 2008 and May 2011, were included in this study. The maximum diameter of the sizing tool that could be inserted into the left ventricle through the annulus had been predicted, based on the diameter measured by each modality. Agreement with surgery and each imaging modality, namely transthoracic echocardiography, multidetector computed tomography and contrast angiography, were compared using Bland-Altman analysis. RESULTS The predicted aortic annulus diameter, based on the diameter measured by transthoracic echocardiography, multidetector computed tomography and contrast angiography, was 20.3 ± 2.50, 23.9 ± 3.19, and 23.5 ± 3.55 mm, respectively, whereas, the diameter measured at surgery was 23.7 ± 2.99 mm. Predicted aortic annulus diameter measured by multidetector computed tomography best agreed with that measured at surgery. CONCLUSION We conclude that the aortic annulus diameter, measured by multidetector computed tomography, is the best modality to measure the aortic annulus diameter.

A 59-year-old man, who had been treated using the infarction exclusion technique for inferior post-infarction ventricular septal rupture (VSR) 4 months previously, was readmitted because of deterioration of mitral valve regurgitation, residual shunt, and progression of pulmonary hypertension. We performed mitral valve replacement via the transseptal approach, patch closure of the defect via the transtricuspid approach, and tricuspid valve annuloplasty. The post-operative course was uneventful. The transtricuspid approach is useful in redo surgery for post-infarction VSR.

It is established that the segment of saphenous vein (SV) that is widely used as a conduit vessel in coronary artery bypass graft (CABG) surgery is distended with high pressure to check for leaks and to increase the patency before implantation into coronary arterial circulation. The aim of the present study was to elucidate the relative contributions of 5-hydroxytryptamine (5-HT) receptor subtypes responsible for 5-HT-induced vasoconstriction of the distended human SV. Whereas about half of the 5-HT-induced vasoconstriction still remained in the presence of supramaximum concentration of sarpogrelate or of SB224289 (5-HT2A and 5-HT1B receptor antagonists, respectively), simultaneous treatment with sarpogrelate and SB224289 almost completely inhibited the 5-HT-induced vasoconstriction. Immunopositive staining for 5-HT2A and 5-HT1B receptors was detected in smooth muscle cells of the distended human SV and there was no significant difference between the immunopositive areas of 5-HT2A and 5-HT1B receptors. These results demonstrate that 5-HT2A and 5-HT1B receptors similarly contribute to 5-HT-induced vasoconstriction in human distended SV. Thus, when the SV is used as a CABG conduit, a combination of 5-HT2A and 5-HT1B receptor antagonists would appear to be most useful to prevent 5-HT-induced spasm.

Completion pneumonectomy (CP) is one of the most difficult procedures and known to be associated with a high morbidity and mortality. A 74-year-old male underwent a left upper lobectomy for pulmonary adenocarcinoma (T3N0M0); six days later after the surgery, he had a sudden postoperative intrathoracic excessive hemorrhage with shock. Emergent redo thoracotomy was performed to treat the bleeding from the ablated interlobar pulmonary artery by suturing with prolene. However, 3 days later after the second operation, he had the second intrathoracic bleeding. Emergent CP was performed with cardiopulmonary bypass by anterior transpericarsial approach via a median sternotomy. The hemorrhage was caused by a rupture of the proximal fragile and infected pulmonary artery. We performed omentopexy for the infected intrathoracic cavity and for covering of the divided main bronchial stump. We had a rare experience of two times of postoperative life-threatening hemorrhage from rupture of the infected pulmonary artery after left upper lobectomy. Emergent CP as salvage surgery should have an advantage in control of infected proximal pulmonary arterial hemorrhage. We should take care of tearing off of adventitia of pulmonary artery in lobectomy because of a possibility of postoperative hemorrhage under a fragility of the injured pulmonary artery with infection.

Background: The previous study of ours showed the prognostic impact of preoperative neutrophil to lymphocyte ratio (NLR) in resected non-small cell lung cancer (NSCLC) patients.Methods: In the present study, the relationship between postoperative NLR and patients' prognosis was examined in NSCLC patients with preoperative high NLR. Consecutive 85 resected NSCLC patients with preoperative high NLR (≥2.5) were reviewed retrospectively. In this study, patients with a follow-up period less than 5 years were omitted.Results: Among these 85 patients, the postoperative NLR in 46 patients were persistently higher than 2.5. The 5-year survival of the patients with postoperative NLR≥2.5 was significantly worse than that of the patients with postoperative NLR<2.5 (34.78% vs. 61.54%, p=0.0067). Univariate and multivariate analyses of the clinicopathological factors affecting survival revealed that postoperative high NLR was an independent prognostic determinant.Conclusion: NSCLC patients with preoperative high NLR, patients with a persistently high NLR after surgery had poor prognosis.

OBJECTIVES:The present study was undertaken to identify risk factors for permanent neurological dysfunction (PND) and in-hospital mortality after total aortic arch replacement (TAR) with separate arch vessel grafting using selective cerebral perfusion (SCP) and hypothermic circulatory arrest.METHODS:Between 1998 and 2008, we preformed a TAR on 143 consecutive patients in two centers by identical methods. Of these, 19 (13.3%) were emergency operations, and 46 (32.2%) were open stent-graft placements. Statistical analysis was performed to determine risk factors for PND and mortality, and furthermore, the survival rate was analyzed.RESULTS:The in-hospital mortality rate was 4.9%, with chronic renal failure (p = 0.0013, odds ratio 10.0) as a significant risk factor. Nine patients (6.3%) had PND, with significant risk factors identified as (1) the presence of an old cerebral or silent lacunar infarction on preoperative imaging methods (p = 0.0458, odds ratio 8.0) and (2) duration of SCP (p = 0.0026, odds ratio 1.036). Long-term survival was the same in patients with or without PND.CONCLUSION:The enhanced vulnerability of the brain in patients with a pre-existing old cerebral infarction or silent lacunar infarction is reflected by a high incidence of PND. Chronic renal failure had an impact on in-hospital mortality.

BACKGROUND The prognostic impact of neutrophil to lymphocyte ratio (NLR) in non-small cell lung cancer (NSCLC) was examined using patients with a follow-up period more than 5 years. PATIENTS AND METHODS Two hundred and eighty four consecutive resected NSCLC patients were reviewed retrospectively. In this study, patients who were treated with a follow-up period less than 5 years were omitted, RESULTS The mean value of NLR was 2.44±2.22 (range: 0.56-29.44). The 5-year survival of the patients with a high NLR (≥2.5) was significantly worse than that of the patients with a low NLR (47.06% vs. 67.84%, p<0.0001). Univariate analysis of the clinicopathological factors affecting survival revealed that age, gender, histology, pT status, pN status, high serum CEA level, positive findings of pleural lavage cytology and high NLR were significant risk factors for reduced survival. On multivariate analysis, a high NLR was an independent risk factor for reduced survival. CONCLUSION A high preoperative NLR may be a convenient biomarker to identify patients with a poor prognosis after resection for NSCLC.

当院における周術期VTE防止対策について，外科，心臓血管外科，整形外科（骨盤以下），産婦人科において施行された待機的手術症例連続342症例を対象に検討した．術前および術後7日目に採血を行い，D-dimer値を測定して基準値以上の場合には下肢静脈エコーを施行した．VTE早期診断のために，診断感度を落とすことなく，より効率的にスクリーニングする基準として，術前においては「DD値2.0 μg/ml以上」，術後においては「術後7日目におけるDD値10.0 μg/ml以上かつ3日間以上の術後安静」が，静脈エコーを施行するための最も良好な判断指標となる可能性が示唆された．また，安静期間と術後7日目のDD値から類推して，術後，より早期でのDVT検索を行う必要がある可能性が示唆された．

We report a case of a 60-year-old man who presented with severe productive cough caused by an endobronchial foreign body, which was due to the migration of a staple-line reinforcement material (Seamguard, W.L.Gore & Associates, Inc., Flagstaff, AZ). This material was placed over 5 years ago during a right upper lobe lobectomy for a poorly differentiated adenocarcinoma, (T1N0M0). We were able to remove the entire staple line by performing 2 separate flexible bronchoscopic interventions during a 1-year period without any consequences, thereby preventing an open thoracotomy. Our technique involved trimming the projecting reinforcement material with endoscopic scissors and removing it by pulling or pushing the staple line with a grasping forceps. Three-dimensional computed tomographic scanning was useful to detect the exact anatomic location and relation of the bronchial airway, great vessels, and pulmonary tissue to the foreign body. The use of absorbable staple-line reinforcement could avoid such a complication.

A novel method for closure of the lower membranous trachea after right pneumonectomy using a flap derived from the cartilaginous portion of the right main bronchus is described in this study. This technique was used successfully in patients with tracheal stenosis due to a giant posterior mediastinal tumor known as schwannoma. Because of the severe tracheobronchial stenosis and destroyed right lung, tumor resection combined with resection of the lower membranous trachea and right pneumonectomy was carried out. We closed the defect in the membranous lower trachea with the flap derived from the right main bronchus. The clinical course was uneventful. (Ann Thorac Surg 2011;91:935-7) (C) 2011 by The Society of Thoracic Surgeons