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A case of synchronous multiple thymomas is reported. The patient was an 81-year-old woman with 2 separate thymomas in the anterior mediastinum. A histological study revealed that both thymomas consisted of dense lymphocyte infiltration in the stroma and a small number of polygonal epithelial tumor cells with clear nuclei and distinct nucleoli. Immunohistochemical staining using the antibodies to 2 antigens, bcl-2, and MIB-1 showed identical staining patterns. In spite of these findings, we considered their origin to be synchronous multicentric development rather than intra-thymic metastasis, based on the non-invasive nature of these tumors.

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From 1989 to 2002, 9 patients with metastatic renal cell carcinoma to lung underwent lung resections for curative removal of metastatic disease in our department. Disease free interval (DFI), number and size of metastases resected (at first metastasectomy), and number of metastasized regional lymph nodes were studied after resection of pulmonary metastases. DFI were 0 to 60 months with mean value of 23 months. At first operation, single metastases accounted for 4 cases and multiple lesions more than 2 metastases accounted for 5 cases with mean value of 2.1. Maximal diameter of metastases was 10 to 50 mm with mean value of 24 mm. Regional lymph nodes metastases were demonstrated only 1 patient in 2 of No. 12 lymph nodes adjacent to metastases. At subsequent relapse, 1 patient had second-stage metastasectomy, 2 patients went on to a third phase. Four patients were lost, 2 are under treatment for newly relapsed lesions, and 3 are now free of metastases. Analysis was performed by Cox proportional hazards model of survival using these factors. Though lacking the statistical significance, only maximal diameter of metastases was prone to have influencing factor on prognosis. Survival was not related to DFI between 0 to 21 months and more than 21 months and numerous lung metastases between single metastasis and with 2 or more. In general, estimated survival rate of these patients according to Kaplan-Meier was 0% at 67 months. Considering the above results, surgical treatment for patients with metastatic renal cell carcinoma to lung should be planned carefully.

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AIM: When multiple synchronous or metachronous lung cancer lesions are identified, discrimination of multicentric lung cancers from intrapulmonary metastases by clinical findings is often difficult. When tissue types have the same pathological features, such as combinations of squamous cell carcinoma (SCC), adenocarcinoma (AD) or bronchiolo-alveolar cell carcinoma (BAC), it is especially difficult to distinguish a 2(nd) primary lung cancer from a metastatic lesion. A new strategy for accurate diagnosis of multiple synchronous or metachronous lung cancer is needed because of the difficulty of histological discrimination. METHODS: Of 363 patients with primary lung cancer for which surgeries were conducted at our hospital, 7 cases were diagnosed as synchronous multiple lung cancer (BAC-BAC in 4 cases and SCC-BAC in 3 cases) and 8 cases (BAC-BAC in 2 cases, AD-BAC in 1 case, AD-AD in 1 case, SCC-AD in 1 case and SCC-SCC in 3 cases) were diagnosed as metachronous multiple lung cancer according to the clinical diagnostic criteria. This study focused on 8 cases with the combinations AD-AD, AD-BAC, or BAC-BAC. For immunohistochemical staining, we used the antibodies to 6 antigens as follows: CK-19, p53, CEA, Hup-1, PE-10, and Ki-67. RESULTS: Of 4 cases diagnosed as synchronous lung cancer according to the clinical diagnostic criteria, differing immunohistochemical stained images of the lesions were observed in 3 cases, while in the 4th case almost identical immunohistochemical stained images were obtained, which indicated the 2 lesions were the primary and metastatic focuses. Of 4 cases diagnosed as metachronous lung cancer according to the clinical diagnostic criteria, almost identical stained images were seen in 3 cases, which indicated the 2 lesions were the primary and metastatic focuses. CONCLUSION: In general, Type A and Type B in Noguchi's BAC classification, tended to be multiple synchronous or metachronous lung cancer lesions, while AD and Type C in Noguchi's BAC classification tended to be the metastatic focus. For the focuses with tissue type of BAC-BAC, the staining using CK-19, PE-10, and Ki-67 was useful in distinguishing multiple primary lung cancer from pulmonary metastasis in cases with a combination of AD and BAC.

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We present 2 surgically treated cases with thymoma classified as Masaoka stage III and IV a (type B 3 thymoma), which showed the border-line pathological aspects between the thymoma and thymic carcinoma. Induction chemotherapy [CAV-PVP (cyclophosphamide, adriamycin, vincristine sulfate, etoposide) therapy in one case and ADOC (adriamycin, cisplatin, vincristine sulfate, cyclophosphamide) therapy in another case] preluded their surgical resection resulted in reduction of the tumor's size moderately or severely. After achievement of induction chemotherapy, these tumors were resected with the midsternotomy approach, along with resection of the right upper lobe and the left brachiocephalic vein replacing the expanded pdytetrafluoroethylene (ePTFE) graft following mediastinal lymphnodes dissection in one case and leaving the tumor tissue around the pulmonary trunk in another case. Postoperative irradiation of 40 Gy in one case and 60 Gy in another case were performed in the mediastinal regions. From pathological aspects especially in second case, though the specimen by preoperative needle biopsy stained positive for bcl-2 and strong immunoreactivity (20%) for MIB-1, specimens excised operatively after induction chemotherapy showed negative staining for bcl-2 and little staining (lower than 5%) for MIB-1. This fact indicates that the induction chemotherapy makes the tumor less malignant, in other words, from the face of thymic carcinoma to the face of thymoma. Induction chemotherapy performed for the purpose of reducing the tumor size was very advantage in these 2 cases with type B 3 thymoma.

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If more than 2 lesions of cancer are observed in the lung, differences in the histology or in situ component is the basic criterion for multicentricity. In addition, remote lung mass with same histology in the absence of both distant metastasis and mediastinal lymphadenopathy is also regarded as multicentricity. We have studied the difference between the clinical diagnostic criteria and the results of immunohistochemical staining. Thirteen patients who were diagnosed as double lung cancers under the clinical of Martini et al or Cortese et al were reviewed. Of them, clinically 6 patients had synchronous double lung cancers and 7 patients had metachronous double lung cancers. Four patients in each group with combination of adenocarcinoma (AD) and bronchiolo-alveolar cell carcinoma (BAC) were studied by immunohistochemical staining. As the result, 3 patients in the former group were defined as the synchronous double lung cancers, however in the latter group, only 1 patients was defined as the metachronous double lung cancers. As for from the histological findings, if either of multiple lung cancer lesion were Noguchi's A or B typed BAC, the patients are prone to have double lung cancers. Subsequently if the histology of the both lesions were the same as AD-AD or Noguchi's C typed BAC-BAC, then the patients are prone to have the metastatic lung cancers.

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Even when gross pathologic specimens are available, evaluation is always complicated due to the difficulty in distinguishing the pathologic diagnosis of an adenocarcinoma as a pulmonary metastasis of the breast or lung. In this paper, we describe the usefulness of a preoperative immunohistochemical study using gross cystic disease fluid protein-15 (GCDFP-15). A 50-year-old woman, who had undergone a right radical mastectomy due to an infiltrating ductal carcinoma 4 years previously, was admitted because of an abnormal shadow on chest roentgenography. A chest CT scan showed a nodule 20 mm in diameter with an irregular margin and vascular involvement in the S3 region of the right lung. Though the specimen from a percutaneous CT guided needle biopsy revealed characteristic pathologic findings of a primary lung adenocarcinoma under H.E. stain, which was recommended for lobar resection, we re-examined that specimen immunohistochemically, which disclosed that the tumor cells were negative for the antibody to pulmonary surfactant apoprotein and were positive for GCDFP-15 antibody. Therefore, the diagnosis of a metastatic breast carcinoma in the lung was established. Upon her request, a wedge resection of the right upper lobe including the tumor was performed under video-assisted thoracoscopic surgery (VATS). Her postoperative course was uneventful.

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A case of paraesophageal omental herniation in a 74-year-old man is reported. Although computed tomography (CT) and magnetic resonance imaging (MRI) depicted a retrocardiac fatty mass that resembled omental herniation, residual concern remained regarding lipomatous tumor. Angiography provided decisive evidence of a mass containing omental vessels passing through the esophageal hiatus, which led to the final diagnosis. The patient underwent a strict course of observation, because he had no symptoms or abnormal physical or laboratory findings. Paraesophageal omental herniation mimics lipomatous tumors, such as lipoma or well-differentiated liposarcoma, extending to both sides of the diaphragm. Correct diagnosis of omental herniation requires the evidence of omental fat accompanied with omental vessels passing through the esophageal hiatus. Since angiography is an invasive diagnostic procedure, we would recommend dynamic MRI or reconstructed 3D MR angiography as alternatives to angiography.

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A 68-year-old woman was admitted because of two abnormal lung shadows, which later proved to be differentiated double cancer. Preoperative hematology tests showed a low platelet count and the result of bone marrow aspiration was compatible with idiopathic thrombocytopenic purpura (ITP). A normal platelet count was once obtained by preoperative percutaneous partial splenic arterial embolization (PSE). However, as there was a tendency for the platelet count to decrease just before surgery, one shot high-dose immunoglobulin (Ig) was administered, which is thought to have a short term effect. The operation was performed successfully. After resection of lung cancer, her platelet count was maintained at around 15x10(4) mm3 without taking drugs for ITP. These findings suggest a relationship between lung cancer and ITP.

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A case of pure red cell aplasia (PRCA), myasthenia gravis (MG) and thymoma is reported. A 70-year-old woman presented with severe anemia. She had been diagnosed as having MG 8 years earlier and her symptoms were adequately controlled with ambenonium chloride. When she visited our hospital, her hematocrit was 13.7% with a hemoglobin concentration of 4.7 g/dl and her reticulocyte counts were persistently abnormal at 0.1%. Although both direct and indirect Coombs' tests were positive, there was no evidence of hemolysis. Routine screening tests for other etiologies of anemia were negative. Serological tests for anti-DNA and anti-acetylcholine receptor antibodies gave positive results. A bone marrow examination revealed severe erythroid hypoplasia. PRCA was diagnosed and the patient was treated with periodic transfusions. A lateral view chest roentgenogram and a computed tomography scan of the thorax showed the presence of an anterior mediastinal mass which was suspected to be thymoma. The patient underwent thymothymectomy and the tumor was diagnosed as a thymoma. Although the patient received no treatment for MG and PRCA after surgery, her hematological test results rapidly improved and she was discharged from the hospital on the 29th postoperative day. At that time, her hematocrit was 33.2%, her hemoglobin concentration was 10.0 g/dl, her peripheral reticulocyte level was 1.8% and her left partial ptosis had improved. She is doing well, 9 months after surgery. For a patient to remain in remission without treatment for PRCA and MG after thymothymectomy is extremely rare.

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A case of lobar torsion after lung surgery is reported here. She developed a right middle lobar torsion diagnosed by postoperative bronchial fiberscopy, suggesting incomplete obstruction of the intermedial bronchus. Re-operation was performed successfully either by fixing the right lower lobe to both the middle lobe and the thoracic wall. Careful postoperative observation with chest radiography, bronchial fiberscopy, are important for precise diagnosis of and therapy for lobar torsion following pulmonary lobectomy.

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A case of sustained lung fistula after lung surgery is reported here. This case of a sustained pulmonary fistula was diagnosed by sustained air leak through the chest drain and a positive culture of the drainage fluid. The third re-operation was performed successfully by omentopexy via median sternotomy. Careful postoperative observation with chest radiography, bronchial fiberscopy, and determining whether infection is present in the drainage fluid are important for precise diagnosis and therapy for complications following pulmonary lobectomy.

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Neutrophil activation and oxygen-derived free radical formation have been implicated in cardiac ischemia-reperfusion injury. To elucidate the mechanism of ischemia-reperfusion injury, we thus determined the effect of the nitric oxide (NO) precursor L-arginine on the free radical injury of cultured cardiomyocytes which were obtained from patients undergoing corrective surgery for tetralogy of Fallot. Free radicals were generated from hypoxanthine via xanthine oxidase, and the cellular changes were determined microscopically. All concentrations of L-arginine (0.5 to 3 mM) prolonged the myocyte survival time compared to the control group, with 0.5 mM L-arginine increasing the survival time to the greatest extent. Cellular susceptibility to free radical injury was the lowest with 0.5 mM L-arginine. Further experiments were performed with 0.5 mM L-arginine plus 100 mM or 1000 mM of the NO synthase (NOS) inhibitor NG-nitro-L-arginine methylester (L-NAME) to determine whether or not the effects of L-arginine are mediated through the NO pathway. The survival time for the cells treated with a concentration of L-NAME was shorter than for the cells treated with 0.5 mM L-arginine alone. These results suggest that L-arginine acts through the NO-dependent pathway. In conclusion, our findings thus confirmed the quenching effects of NO on free radical injury in cultured cardiomyocytes.

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We describe a patient who developed a false aneurysm interposed between bilateral common iliac arterial stumps 6 years after replacement of a bifurcated graft for repair of abdominal aortic aneurysm. The false aneurysm formed a fistula to the contralateral common iliac artery stump. In the light of this patient's history of severe arterial disease, weakness of the arterial wall was thought to be responsible for this anastomotic false aneurysm. Due to significant risk factors, the patient was treated with transcatheter intervention and he recovered without complications.

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The intrathoracic subclavian artery is a rare location for a peripheral arterial atherosclerotic aneurysm when compared with the femoral and popliteal arteries. Resection of the aneurysm and replacement with a prosthetic graft has come to be the most commonly performed procedure for this problem. Because of the tight adherence of surrounding tissues such as the vagal nerve, phrenic nerve, jugular veins, and their branches, we preferred an exclusion method with revascularization to the aneurysmorrhaphy and achieved a good result. We report the clinical aspects of such a case.

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BACKGROUND: Antegrade cardioplegic delivery may be impaired by coronary occlusions, whereas retrograde delivery of cardioplegic solution may be inhomogeneous, leading to an accumulation of lactate and hydrogen ions, the products of anaerobic metabolism. Integrated cardioplegia using continuous retrograde cardioplegia and antegrade infusions into completed vein grafts washes out metabolites accumulated in regions inadequately perfused by retrograde cardioplegia alone. To determine the flow rates required to achieve the greatest washout, we compared a high flow rate (200 ml/min) to a low flow rate (100 ml/min). METHODS: Twenty patients scheduled for isolated coronary bypass surgery were prospectively randomized to compare two flow rates for integrated cardioplegic protection using tepid (29 degrees C) blood cardioplegia. Arterial and coronary sinus blood samples were collected to evaluate myocardial metabolism. After antegrade arrest, cardioplegic solution was delivered by coronary sinus perfusion and simultaneous infusions into each completed vein graft at either high or low flow. RESULTS: Increasing from low to high flow increased the washout of lactate and hydrogen ions during the aortic crossclamp period. Two hours after crossclamp removal, ventricular function was better in the high flow groups. CONCLUSIONS: Tepid retrograde cardioplegia resulted in an accumulation of toxic metabolites. The addition of antegrade vein graft infusions at a flow rate of 100 ml/min resulted in a washout of these metabolites. A flow rate of 200 ml/min further improved this washout and resulted in improved ventricular function. An integrated approach to myocardial protection using a flow rate of 200 ml/min may improve the results of coronary bypass surgery.

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A 54-year-old hypertensive woman was admitted with severe interscapular back pain. A chest radiograph showed marked widening of the mediastinum. Aortography demonstrated a DeBakey type III, a thoracic aortic dissection and an anomalous right subclavian artery which was associated with an isolated left vertebral artery. The patient underwent aortic arch replacement with 5 branches and made an uneventful recovery. As far as we can determine, this is the first reported occurrence of these anomalies together with acquired disease of the aorta.

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During cardiac surgery, ischemia-reperfusion injury (IRI) is thought to be a major factor in intraoperative myocardial damage. Coronary endothelial cells have been thought to play an important role in the pathogenesis of cardiac IRI. Release of nitric oxide (NO) from coronary endothelial cells is impaired following myocardial ischemia, and this may contribute to the vulnerability of the coronary circulation to thrombus-formation and vasospasm. Several experimental studies have found that NO has a cardioprotective effect in myocardial IRI. In this regard, attempts have been made to supplement NO production exogenously during reperfusion, when endogenous NO release from endothelial cells may be diminished. In a blood-reperfused heart model, L-arginine acts cardioprotectively via 2 primary possible mechanisms: (1) by blocking both neutrophil aggregation and neutrophil adherence, and (2) by scavenging oxygen-derived free-radicals. On the other hand, in a non-blood reperfused heart model, the optimal concentration of L-arginine may be low and protection may be due to 2 additional mechanisms: (3) direct coronary vasodilatation and (4) reduced oxygen demand due to vasodilatation-induced hypotension. Other studies have suggested that NO exacerbates IRI and that NO synthase (NOS) inhibitors act cardioprotectively. It has also been suggested that the pharmacological effectiveness of inhibiting NO production may be due to the prevention of peroxinitrite formation from NO and superoxide during reperfusion. This review summarizes the current understanding of the role of NO in IRI.

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The release of nitric oxide (NO) from coronary endothelial cells is impaired following reperfusion; however, several experimental studies have found that it exerts a cardioprotective effect during myocardial ischemia-reperfusion. Thus, attempts have been made to supplement NO production exogenously during reperfusion when endogenous NO release may be diminished. Conversely, other studies suggest that NO exacerbates reperfusion injury by inducing the production of peroxynitrite. NO has also been reported to provide beneficial effects as a selective pulmonary vasodilator to relieve pulmonary hypertension. A loss of NO-mediated relaxation caused by the dysfunction of endothelial cells is characteristic of intimal hyperplasia, and nitrosovasodilators have proven efficient against atherosclerotic coronary heart disease, which may be attributable to their antiplatelet effects as well as to vasodilation. Furthermore, protamine sulfate, which is rich in L-arginine, is thought to augment NO production by supplying exogenous L-arginine, or to act on endothelial cell receptors to stimulate the production of NO. This review summarizes the current role of NO in cardiac surgery.

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We present a case of video-assisted partial resection of the right lower lobe for a pulmonary tumor. A 67 year-old woman was admitted because of an abnormal shadow on a chest roentgenogram. The operation was carried out via a small lateral thoracotomy incision and two surgical ports, by video-assisted thoracotomy with intraoperative ultrasonographic detection of the tumor. Pathologic examination of the specimen revealed a carcinoid tumor and showed no tumor cells remaining in the stump. As the postoperative course was uneventful, we describe the usefulness of video-assisted thoracoscopic surgery combined with intraoperative ultrasonography.

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