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Aberrant hypermethylation of specific genes is present in esophageal squamous cell carcinomas (ESCCs). Such hypermethylation is also present in normal-appearing esophageal mucosae of ESCC patients and is considered to contribute to the formation of a field for cancerization. On the other hand, the presence of global hypomethylation in ESCCs or in their background esophageal mucosae is unknown. We collected 184 samples of esophageal mucosae (95 normal mucosae from healthy subjects, and 89 non-cancerous background mucosae from ESCC patients) and 93 samples of ESCCs. Methylation levels of repetitive elements (Alu, LINE1) and cancer/testis antigen genes (NY-ESO-1, MAGE-C1) were measured by bisulfite pyrosequencing and quantitative methylation-specific PCR, respectively. Methylation levels of Alu, LINE1, NY-ESO-1, and MAGE-C1 were significantly lower in ESCCs than in their background and normal mucosae. Also, in the background mucosae, a significant decrease of the Alu methylation level compared with the normal mucosae was present. In ESCCs, methylation levels of the two repetitive elements and the two cancer/testis antigen genes were correlated with each other. This is the first study to show the presence of global hypomethylation in ESCCs, and even in their non-cancerous background mucosae. Alu hypomethylation might reflect the severity of an epigenetic field for cancerization.

Massive bleeding from large vessels is a serious and life-threatening complication after radical esophagectomy. Here, we present the rare case of patient survival following two episodes of massive bleeding from a tracheo-brachiocephalic artery fistula after salvage surgery for cervical esophageal cancer following definitive chemoradiation. During the first episode of bleeding, the damaged part of the brachiocephalic artery was transected with an extra-anatomical arterial bypass (right femoro-axillo artery bypass graft) to maintain the arterial blood flow to the brain and the free jejunal graft. During the second bleeding, the distal stump of the brachiocephalic artery was reclosed. During both episodes of bleeding, the musculocutaneous flap was effectively employed to seal the stumps of the brachiocephalic artery and fill the dead space. Finally, the patient was discharged 351 days after the first surgery. (132/150).

Reactive oxygen species stimulate lymphatic metastasis by accelerating epithelial-to-mesenchymal transition and lymphangiogenesis in the tumor microenvironment. Hence, systemic oxidative stress level may correlate with nodal involvement in patients with a malignant tumor. We examined 46 patients with clinical stage I lung adenocarcinoma who had undergone pulmonary resection with mediastinal lymph node dissection. Serum reactive oxygen metabolite (ROM) level was measured as an indicator of systemic oxidative stress. We investigated the association between nodal involvement and clinicopathological factors. Preoperative serum carcinoembryonic antigen (CEA; P = 0.045), cytokeratin 19 fragment (CYFRA21–1; P = 0.038), and ROM (P = 0.007) levels were significantly higher in patients with nodal involvement than in those without nodal involvement. A receiver operating characteristic curve was constructed to determine whether patients with and without nodal involvement could be differentiated on the basis of their serum ROM levels. The area under curve was 0.763 and the prognostic cut-off value was set at 318 Carratelli units. In univariate analysis, clinical stage IB (odds ratio [OR] = 4.55; P = 0.033), CEA-positive (OR = 5.56, P = 0.018), and ROM-positive (OR = 10.46, P = 0.006) were significant predictive factors for nodal involvement. In multivariate analysis, ROM-positive was an independent predictive factor for nodal involvement (OR = 6.22, P = 0.045). Preoperative serum ROM level was an independent significant predictive factor for nodal involvement in patients with clinical stage I lung adenocarcinoma. Hence, serum ROM level may be a useful biomarker for staging of lung adenocarcinoma.

A 58-year-old man underwent surgery for the treatment of lung adenocarcinoma at our hospital. He had a history of spinal caries at the age of 3 and frequent recurrent asthma-like symptoms thereafter. Chest plain radiography revealed an irregularly shaped mass in the left hilum and a thoracic cage severely deformed by kyphosis. A pulmonary function test demonstrated a severe restrictive ventilation pattern. He underwent a left upper lobectomy without mediastinal dissection. His asthma-like symptoms were exacerbated by difficulty in expectoration of sputum for several days after surgery, but the symptoms disappeared without any medical care. Dyspnea, hemoptysis, and intrathoracic hemorrhage were observed on the 8th postoperative day. Computed tomography revealed torsion of the residual left lower lobe, but the symptoms spontaneously disappeared in a week. The patient had complained of frequent coughing and mild dyspnea on exertion for years, but his quality of life was unchanged after the lobectomy. Bone metastasis was detected 3 years after the surgery, and the patient then underwent chemotherapy. However, he died of the disease 4 years 2 months after the surgery.

Poststernotomy mediastinitis (PSM) following cardiovascular surgery remains an intractable complication associated with considerable mortality. It is therefore necessary to assess the risk factors associated with hospital mortality and evaluate the surgical treatment options for PSM.We identified 59 (2.2%) patients who developed PSM after cardiovascular surgery between January 1991 and January 2010. PSM was defined as deep sternal wound infection requiring surgical treatment. In all, 31 patients were infected with methicillin-resistant Staphylococcus aureus (MRSA); and 14 patients died in hospital from PSM. A total of 51 patients were treated by simple closure or tissue flap reconstruction after débridement (traditional treatment), and 8 underwent closure or reconstruction after negative-pressure wound therapy (NPWT). The risk factors for in-hospital mortality due to PSM were analyzed by comparing the characteristics of survivors and nonsurvivors. The available surgical treatments for mediastinitis were also assessed.Univariate analysis identified age, sex, pulmonary disease, MRSA infection, prolonged mechanical ventilation and prolonged intensive care unit stay as risk factors for in-hospital mortality (P0.05). Multiple logistic regression analysis identified MRSA infection (odds ratio 20.263, 95% confidence interval 1.580-259.814; P = 0.0208) as an independent risk factor for hospital mortality. NPWT was associated with significantly less surgical failure than traditional treatment (P = 0.0204). There were no deaths as a result of PSM in patients who underwent NPWT irrespective of the presence of MRSA infection.MRSA infection was an independent risk factor for PSM-related in-hospital mortality. NPWT may improve the prognosis for patients with MRSA mediastinitis.

A 38-year-old man had Stanford type B chronic aortic dissection. Blood pressure was diffi cult to control, and further examination revealed primary aldosteronism. Magnetic resonance images showed a 1-cm nodule in the left adrenal gland. Graft replacement for aortic dissection under extracorporeal circulation and resection of the left adrenal gland were undertaken simultaneously. The postoperative course was uneventful, and blood pressure was controlled without antihypertensive drugs.

Di-(2-ethylhexyl)phthalate (DEHP), an excellent plasticizer for poly(vinyl chloride) (PVC), is a known endocrine-disrupting chemical. This study was designed to investigate whether a new non-DEHP bilayer tube reduced the release of DEHP, suppressed inflammatory cytokines, and altered coagulation-fibrinolysis systems. Sixteen patients undergoing coronary artery bypass grafting (CABG) were randomly assigned to the non-DEHP bilayer group (group B, n = 8), or the noncoated PVC group (group N, n = 8). The level of DEHP in the blood was measured before and after cardiopulmonary bypass (CPB). The levels of interleukin-6 (IL-6), D-dimer, and thrombin-antithrombin complex (TAT) were also measured at six points during and after CPB. DEHP was significantly lower in group B (472 +/- 141 ng/ml) after CPB compared with group N (2094 +/- 1046 ng/ml). The IL-6 level was significantly lower in group B (151 +/- 131 pg/ml) than group N (206 +/- 224 pg/ml) 180 min after protamine administration. The D-dimer level was significantly lower in group B 60 min after protamine administration (6.2 +/- 2.4 microg/ml in group B vs 10.4 +/- 4.5 microg/ml in group N) and 180 min after protamine administration (4.4 +/- 0.7 microg/ml in group B vs 7.3 +/- 2.7 microg/ml in group N). Group B had a tendency toward reduced postoperative bleeding compared with group N at any time. The bilayer tube was superior to the noncoated tube in terms of the inhibition of DEHP release, inflammatory cytokines, and the fibrinolysis system.

This study was designed to determine the clinical characteristics and verify the results of surgical treatment for non-small cell lung cancer (NSCLC) in patients with hepatocellular carcinoma (HCC), from the results of retrospective analysis of the cases. We retrospectively reviewed our database of 751 patients who underwent curative surgical intervention for NSCLC from January 1993 to December 2006 and found 11 patients with NSCLC with coexisting or previously treated HCC at a perioperative period of lung cancer surgery. Postoperative complications and long-term outcome were analyzed. All cases had coexisting liver cirrhosis. The overall morbidity was 27.2% (n = 3). All complications were considered to be the result of liver cirrhosis-related conditions, such as liver failure (n = 2), postoperative bleeding from the thoracic tube (n = 2), and gastrointestinal bleeding (n = 1). There was no operative mortality. The 1-, 3-, and 5-year survival rates of patients with lung cancer were 88.9%, 74.1%, and 74.1%, respectively. The 1-, 3-, and 5-year survival rates for death from hepatic causes were 79.5%, 79.5%, and 39.8%, respectively. Overall survival rates were 70.7%, 58.9%, and 29.5%, respectively. Preoperative indicators of liver function, such as serum values of total bilirubin (P

Nonbacterial pleuritis caused by rupture of a metastatic adenocarcinoma is extremely rare and has not yet been reported. A 59-year-old man with a history of rectal cancer surgery 6 years earlier presented with a solitary lung mass in the periphery of the right lower lobe on computed tomography. Transbronchial biopsy disclosed a suspected metastatic adenocarcinoma, and he was admitted for pulmonary metastasectomy. He had been asymptomatic, but 4 weeks after the diagnostic bronchoscopy, the patient suddenly complained of a right back pain and dyspnea at rest; shortly after that, he developed a fever of 39 degrees C. A chest X-ray showed right pleural effusion, collapse of the right lower lobe, and elevation of the right diaphragmatic dome, but without pneumothorax. Emergent video-assisted thoracoscopy revealed a perforated tumor in the collapsed lower lobe, and a right lower lobectomy was carried out. The postoperative course was uneventful, and he was well without recurrent disease 2 years after pulmonary resection.

We report a rare case of inverted Schneiderian papilloma causing exceedingly high serum levels of carcinoembryonic antigen (CEA) and squamous cell carcinoma-associated antigen (SCC). A 74-year-old man presented with a 6-month history of a productive cough, bloody sputa, and dyspnea. Chest computed tomography showed massive infiltration in the lower lobe with multiple focal soft tissue densities. Blood biochemical analysis revealed a serum CEA level of 107.0 ng/ml (normal

Sorin Bicarbon (SB) and Edwards Mira (EM) valves have an identical mechanical design but different sewing cuffs. The purpose of this retrospective study was to analyze the long-term clinical and echocardiographic outcomes after mitral valve replacement with these two valves in a combined population of patients.We retrospectively reviewed records of 73 patients who underwent mitral valve replacement using SB (n = 19) or EM (n = 54) valves. Preoperatively, 49 patients (68.1%) were in New York Heart Association (NYHA) functional class III or IV. Concomitant procedures were performed in 52 patients (71.2%). Early and late postoperative echocardiography was performed in 69 and 57 patients, respectively.Operative mortality was 4.1%, and early morbidity was 9.6%. Overall patient survival at 9 years was 85.1% +/- 4.8%. Actuarial freedom from valve-related death was 95.4% +/- 2.6% at 9 years. As shown by Doppler echocardiography, the early and late mean transprosthetic pressure gradients were 3.4 +/- 1.4 mmHg and 3.8 +/- 2.1 mmHg, respectively. At the end of follow-up, 98.4% of survivors were in NYHA class I or II.The Sorin Bicarbon and, Edwards Mira mechanical valves in the mitral position provide satisfactory long-term clinical and echocardiographic performance.

A 41-year-old man was shot three times with a custom-made handgun. There were six small round wounds on the surface from two bullets that went into the body and one bullet found in a wall behind the victim at the scene. The gunshot wound in the left supraclavicular region bled massively. He was transferred to our hospital and soon fell into shock. A chest radiogram showed right hemothorax. Resuscitation and blood transfusion were started, and right thoracic drainage was immediately undertaken. The left subclavicular region was incised, and bleeding from the left subclavian vein stopped. Right thoracotomy was done, and bleeding from the lung was controlled. Laparotomy was needed to look for the missing trajectory. Speculation regarding trajectories of bullets in patients with multiple thoracoabdominal gunshot wounds is difficult, and an emergent operation is often needed to control bleeding or to evaluate possible organ injury.

A 29-year-old female was admitted to our hospital complaining of severe dry cough and low-grade fever. A chest roentgenogram and a chest computed tomographic scan revealed a huge tumor and massive pleural effusion in the left pleural cavity. Pathological examination revealed spindle shaped malignant cells. SYT-SSX fusion gene transcripts were detected, so we diagnosed the tumor as a synovial sarcoma in the pleural cavity. After neoadjuvant chemotherapy we resected the tumor completely. A synovial sarcoma in the pleural cavity is extremely rare. To the best of our knowledge, this is the thirteenth case, and the first case to undergo neoadjuvant chemotherapy and complete resection. Because a synovial sarcoma in the pleural cavity has a poor prognosis and is characterized by a high incidence of recurrence, we must carefully follow up this patient.

We examined the expression of mucin core protein 1 (MUC1) immunohistochemically in 186 surgical specimens of histopathologically nonmucinous hepatocellular carcinoma (HCC) and compared the clinicopathological features in patients with MUC1-positive HCC (MUC1-positive group) with those in patients with MUC1-negative HCC (MUC1-negative group).MUC1 immunoreactively was present in 85 of the 186 HCCs. Of the clinicopathological variables examined, the serum concentration of alpha-fetoprotein, tumor differentiation, bile duct invasion, lymph node metastasis, and cytokeratin 19 expression exhibited significant associations with MUC1 expression. Although cumulative and tumor-free survival rates were not different between the two groups, the percentage of patients with first recurrence of HCC in distant organs (distant metastasis) within 2 years after surgery was significantly higher in the MUC1-positive group than in the MUC1-negative group (P = 0.0104). The risk ratio of MUC1 positivity for this type of distant metastasis was 3.156 (95% confidence interval, 1.064-9.358).In patients with MUC1-positive HCC, careful follow-up is necessary, not only for intrahepatic recurrence but also for distant metastasis, after the resection of primary HCC.

The purpose of this study was to analyze the clinical significance of serum Sialyl Lewisx (SLX) concentrations as a predictor of N2 disease in patients with non–small-cell lung cancer. The study included 272 patients with non–small-cell lung cancer who underwent pulmonary resection in our institution between January 1998 and December 2003. Of 272 patients, the serum concentrations of SLX were measured by using a commercially available radioimmunoassay kit. The 5-year survival rates of patients with concentrations of SLX > 38 U/mL and those with lower concentrations were 32% and 69%, respectively (P < .0001). The median serum concentration of SLX in patients with multilevel N2 or N3, single-level N2, and N0/1 disease were 44, 30, and 27 U/mL, respectively. The concentrations of serum SLX in patients with multilevel N2 disease were significantly higher than those in patients with single-level N2 or those with N0/1 disease (Mann-Whitney U-test; P < .0001). Although the sensitivity of SLX for identifying patients with non–small-cell lung cancer was only 24% in all patients, the sensitivity of SLX increased as the N-factor increased; the sensitivity of N0/1 disease was 15%, that of single-level N2 disease was 22%, and that of multilevel N2 or N3 disease was 71%. High serum concentrations of SLX predicted multilevel N2 disease and the associated poor outcome. Although the sensitivity of serum SLX is not acceptable for use as a screening tumor marker, we suggest that the serum concentration of SLX is useful as a staging marker to determine the strategy of treatment.

We describe an unusual case of a thoracic aortic aneurysm caused by Aspergillus. A 70-year-old man underwent prednisolone and Ara-C treatments for a myelodysplastic syndrome. Blood examination revealed pancytopenia. Under these treatments, an aneurysm presented at the distal aortic arch. He underwent resection of the aneurysm with a graft repair covered by a pedicled omentum flap, followed by prolonged administration of micafungin and itraconazole for a mycotic aneurysm. The postoperative course was favorable without complications. Serum C-reactive protein became negative and he was discharged 2 months after the surgery. However, 4 months after the surgery, he died from worsening of the myelodysplastic syndrome. The prognosis for patients with mycotic aneurysms is poor due to their immunocompetent condition arising from underlying diseases. Therefore, in addition to prompt treatment with antifungal agents combined with surgical debridement, control of the underlying disease is essential for improving the outcome.

Self-expandable metallic stent (EMS) placement has been the first choice for dysphagia because of the certainty over its safety, low invasiveness, and immediate efficacy. However, there still remain some problems in relation to the EMS placement site and anticancer therapies before and after EMS placement. Methods: Consecutive 78 patients in whom EMS was placed due to the unresectable malignant stricture in the esophagus or cardia from July 1995 to August 2003 in our department were studied. Results: Gastroesophageal reflux was found in 5 of 8 patients after placement of conventional EMS for the stricture in the gastroesophageal junction. Meanwhile, acid and bile reflux into the esophagus were not detected by pH and bilirubin monitoring, respectively, in 6 patients after placement of the EMS with an anti-reflux mechanism for the stricture in the gastroesophageal junction. The median survival period of all patients after EMS placement was 123 days. The median survival period of 7 patients with radiotherapy only after EMS placement was 138 days and that of 17 patients with radiotherapy before EMS placement was 60 days, which was shorter than that of the former (p

The failure of the vascular anastmoses is a devastating complication in free jejunum transplantation. We used color Doppler sonography to estimate blood flow in free jejunal grafts in 21 patients who underwent radical pharyngoesophagectomy. Fast Fourier transform (FFT) analysis of blood flow, the pulsatility index (PI) as a measure of peripheral vascular resistance, and thickening of the graft wall were evaluated for predictive value. The arterial wave patterns were classified into three types based on systolic–diastolic differences and magnitude of flow. Type I was physiologic flow, type III overtly pathologic, and type II intermediate. The three patients who required vascular reanastomoses intraoperatively had a type II pattern that degenerated to type III within 15 minutes. The PI increased to 3.5 to 4.5 over 1 hour. In the one patient who required retransplantation, the wave pattern became type III by 18 hours and had disappeared by 24 hours, at which point the PI could not be measured. Jejunal thickening increased from 1.0 mm to 5.0 mm after 24 hours, even in healthy grafts. Monitoring blood flow during the 24 hours after surgery is critical. A type III wave pattern or a PI >2.5 is an indication for reexploration. Doppler sonography offers a noninvasive way to measure blood flow in jejunal grafts semiquantitatively and can predict free jejunal graft failure.

A 63-year-old woman successfully underwent a graft replacement of the retrohepatic inferior vena cava with a ringed polytetrafluoroethylene graft for primary leiomyosarcoma of the inferior vena cava (IVC). Although anticoagulant had been administered, a thrombus was found in the IVC just cranial of the downstream anastomosis 67 months after the operation. The patient remained free of symptoms, and she had no evidence of any tumor recurrence. She underwent a complete resection with a prosthetic reconstruction for leiomyosarcoma of the IVC and has since been able to enjoy a reasonably long-term survival. The occurrence of thrombosis must be kept in mind in the long-term follow-up of such cases.

Objective: Radial artery suitability in coronary artery bypass grafting was assessed using duplex ultrasonography.Subjects and Methods: The vascular condition along the entire radial artery was scanned in 55 patients, measuring the internal diameter and mean flow velocity at the wrist (distally), after ulnar artery branching (proximally), and midway between these 2 points (medially). Distally along the radial and ulnar arteries, the mean flow velocity was determined before and after radial artery occlusion.Results: Atherosclerotic changes were detected in 4 patients. The internal diameter was 3.1 ± 0.4 mm proximally, 2.7 ± 0.3 mm medially, 2.4 ± 0.4 mm distally. The distal flow velocity was 0, and a reverse flow (peak velocity: 11.3 ± 6.0 cm/s) was observed after the occlusion test in patients with an intact palmar arch, their mean flow velocity, 21.1 ± 8.9 cm/s, and flow distally along the ulnar artery 58.0 ± 23.4 ml/min, were higher after the occlusion test than before it 14.7 ± 6.7 cm/s mean flow and 38.1 ± 15.9 ml/min distally. This was not observed in patients with an interrupted palmar arch. In 15 patients, radial arteries could not be used because of their small internal diameter, lack of a radial artery, poor vascular condition, or an interrupted palmar arch evaluated using duplex scanning.Conclusion: Reliable noninvasive assessment of radial artery anatomy and palmar arch continuity is thus possible using duplex ultrasonography.

It is well known that activation of proteases in the lysosomes and cytosol is one of the mechanisms of ischemic injury. It might thus be beneficial to determine whether the addition of several clinically available protease inhibitors to a cardioplegic solution can improve its protective ability. Using an isolated working rat heart preparation, the effects of several protease inhibitors (serine protease inhibitors; nafamostat mesilate and gabexate mesilate, a thiol-protease inhibitor; NCO-700; and a urinary trypsin inhibitor, urinastatin) on the postischemic recovery of function and enzyme leakage were investigated in this study. These protease inhibitors were added to either the cardioplegic solution or reperfusion solution. The addition of each of the protease inhibitors, except urinastatin, to the cardioplegic solution improved the postischemic recovery of function and reduced enzyme leakage. The dose-response characteristics of these three protease inhibitors were bell shaped, and the optimal concentrations of nafamostat mesilate, gabexate mesilate, and NCO-700 were 5 µM, 100 µM, and 20 µM, respectively. In contrast to the results of the preischemic treatment study, the addition of any of the protease inhibitors to the perfusion medium during Langendorff reperfusion failed to improve the postischemic recovery of function and to reduce enzyme leakage. Surprisingly, the addition of NCO-700 to the reperfusion solution at a concentration of 5 µM or higher had rather harmful effects on both functional recovery and enzyme leakage. These findings suggest that serine and thiol proteases may play an important role in myocardial injury during ischemia, but not necessarily during reperfusion.