Intrathoracic Space Research Articles

COVID-19 infection with serial bilateral pneumothoraces

Background: Coronavirus disease 2019 (COVID-19) is most frequently associated with a mild presentation of fever, cough, and shortness of breath. Typical radiographic findings in severe COVID-19 infection are bilateral ground-glass opacities on computed tomography (CT) scans. Bilateral pneumothorax is a rare complication of COVID-19. Among observational studies, the incidence of pneumothorax is low at 0.3% in hospitalized COVID-19 patients. However, the incidence of pneumothorax increases to 12.8-23.8% in patients requiring invasive mechanical ventilation. Case: This case report describes a previously healthy 52-year-old man who had recurrent pneumothoraces. He had five separate episodes of bilateral pneumothoraces during a two-month infection with SARS-CoV-2 during which he required mechanical ventilation. Chest x-rays revealed pneumothoraces, and bilateral chest tubes were inserted into the intrathoracic space for drainage five times. This case highlights the potential atypical clinical course in a COVID-19 infection and is the first reported case, to our knowledge, that features five bilateral spontaneous recurring pneumothoraces. Conclusion: COVID-19-related pneumothorax is likely a sequela of COVID-19 disease progression due to the inflammatory insult from COVID-19 infection and the increased respiratory effort needed to maintain gas exchange. COVID-19- related pneumothoraces are associated with mechanical ventilation and resolved in prolonged hospitalization. The treatment of COVID-19 and its long-term consequences represents a relatively new challenge for clinicians and health care providers. A multidisciplinary approach during the posthospitalization management of COVID-19 survivors is strongly advised. Keywords: SARS-CoV-2 infection, COVID-19 lung complications, pneumothorax

Impact of fetal treatments for congenital diaphragmatic hernia on lung development.

The extent of lung hypoplasia impacts the survival and severity of morbidities associated with congenital diaphragmatic hernia (CDH). The alveoli of CDH infants and in experimental models of CDH have thickened septa with fewer type II pneumocytes and capillaries. Fetal treatments of CDH-risk preterm birth. Therefore, treatments must aim to balance the need for increased gas exchange surface area with the restoration of pulmonary epithelial type II cells and the long-term respiratory and neurodevelopmental consequences of prematurity. Achievement of sufficient lung development in utero for successful postnatal transition requires adequate intra-thoracic space for lung growth, maintenance of sufficient volume and appropriate composition of fetal lung fluid, regular fetal breathing movements, appropriate gas exchange area, and ample surfactant production. The review aims to examine the rationale for current and future therapeutic strategies to improve postnatal outcomes of infants with CDH.

Case Report Effectiveness of Using Antibiotics as Infection Prevention in Open Pneumothorax: Post Chest Tube

BACKGROUND: Open pneumothorax is an injury caused by sharp trauma or blunt, causing the thoracic cavity to open and air can enter from the outside. Open pneumothorax is a potentially lethal illness that requires cautious early management and the mortality rate was found to be 33%. In general, a chest tube is used to establish the negative pressure in the thorax cavity and facilitate redevelopment of the pulmo to assist remove air from the intrathoracic space. Antibiotics are usually given to prevent infection in the patient. We will report a case related to the effectiveness of using antibiotics as infection prevention in open pneumothorax post chest tube.
 CASE REPORT: We report a case of a 20-year-old man that was presented to our emergency department after got a traffic accident. The patient complained of chest pain, shortness of breath, and no other complaints. The patient was found to have an open wound on the right chest, measuring 5 x 3 cm with a lung wound base, and active bleeding. The patient's chest was found to be hyper resonant, decreased vesicular breath sounds, and asymmetry in physical examination. The patient was diagnosed with open pneumothorax and further instruction was surgical disposition. There were no radiological abnormalities on the chest x-ray of this patient. The main therapy, in this case, was the administration of antibiotics and the installation of a chest tube. The patient experienced postoperative pain after the insertion of a chest tube. Complete blood counts showed relatively normal results after three days and the patient stated that his complaints had decreased after four days. Two weeks later, the patient's previous complaints had not been felt. This condition indicates that there is no infection in the patient that can be associated with the administration of antibiotics. The therapy process is continued with chest physiotherapy until ten weeks later.
 CONCLUSION: The administration of antibiotics to this patient with open pneumothorax post chest tube indicated an effective result. Further research is needed to support the existing literature sources regarding open pneumothorax.

Effect of Instructional Package on Knowledge and Practices Regarding Care of the Patients with Intercoastal Drainage among Staff Nurses in Selected Hospitals

Introduction: Lungs are the vital organs for respiration. The lungs are covered by a double-layered serous membrane called pleura. The space between the pleura contains pleural fluid which helps in lubrication and prevents friction between the lungs and chest wall. Intercostal drain is a flexible plastic tube that is inserted through the chest wall into the pleural space. It is used to remove air, fluid, and pus from the intrathoracic space. Apatient may require an intercoastal drainage system at any time when the negative pressure in the pleural cavity is disrupted, resulting in respiratory distress. Aims: The aim of the study was to assess the effect of instructional package on knowledge and practices regarding care of the patients with intercoastal drainage among staff nurses in selected hospitals. Materials and Methods: A descriptive evaluatory research approach with one group pre-test post-test research design was used for the study. The sample comprised 50 staff nurses who fulfilled the inclusion criteria, using non-probability convenient sampling technique. Data were analyzed using descriptive and inferential statistics. Results: We observed that knowledge and practices measured after instructional package was significant (P < 0.05). There were association of knowledge with age, department, and qualification and for practices association found with age and qualification, respectively. Conclusion: Instructional package was effective measured to improve knowledge and practices regarding care of the patients with intercoastal drainage among staff nurses in selected hospitals.

Re-expansion pulmonary edema following a pneumothorax drainage in a patient with COVID-19

BackgroundRe-expansion pulmonary edema is an uncommon complication following drainage of a pneumothorax or pleural effusion. While pneumothorax is noted to complicate COVID-19 patients, no case of COVID-19 developing re-expansion pulmonary edema has been reported.Case representationA man in his early 40 s without a smoking history and underlying pulmonary diseases suddenly complained of left chest pain with dyspnea 1 day after being diagnosed with COVID-19. Chest X-ray revealed pneumothorax in the left lung field, and a chest tube was inserted into the intrathoracic space without negative pressure 9 h after the onset of chest pain, resulting in the disappearance of respiratory symptoms; however, 2 h thereafter, dyspnea recurred with lower oxygenation status. Chest X-ray revealed improvement of collapse but extensive infiltration in the expanded lung. Therefore, the patient was diagnosed with re-expansion pulmonary edema, and his dyspnea and oxygenation status gradually improved without any intervention, such as steroid administration. Abnormal lung images also gradually improved within several days.ConclusionsThis case highlights the rare presentation of re-expansion pulmonary edema following pneumothorax drainage in a patient with COVID-19, which recovered without requiring treatment for viral pneumonia. Differentiating re-expansion pulmonary edema from viral pneumonia is crucial to prevent unnecessary medication for COVID-19 pneumonia and pneumothorax.

Impact of the Axillary Approach on Epicardial Pacing Lead Durability in Children

BackgroundTo avoid lead failure and pocket infection in neonates and infants requiring pacemakers, we used the axillary approach of placing the generator in the axilla and the leads in the intrathoracic space. We describe the technical details of the axillary approach and evaluate the efficacy of this method. MethodsWe assessed 21 patients (7 male) weighing 8 kg or less who underwent epicardial pacemaker implantation with the axillary approach between 2004 and 2018. The axillary approach entails (1) positioning the pacemaker generator in the axilla to avoid local skin and pocket complications due to tissue compression by the generator, and (2) making a double loop in the pleural space to reduce stress on the pacemaker leads caused by somatic growth. This approach can be combined with median sternotomy for simultaneous intracardiac repair. ResultsThe patients' median age at pacemaker implantation was 6 months; 16 patients (76%) were aged less than 12 months. The median body weight was 4.5 kg (interquartile range, 3 to 7). In all 5 patients requiring simultaneous cardiac repair, a median sternotomy was performed to access the heart. Sixteen patients required only pacemaker implantation: left thoracotomy was performed in 10 patients, right thoracotomy in 5, and subxiphoid approach in 1. The 5-year and 10-year freedom from pacemaker-related adverse events was 89.4% and 79.5%, respectively. ConclusionsThe axillary approach using intrathoracic double-loop routing of leads to position the generator in the axilla for pacemaker implantation can be a valuable alternative for neonates/infants weighing 8 kg or less with or without complex congenital heart disease.

Transabdominal fetal reduction: a report of 124 cases

To prevent fetal loss, preterm delivery, and perinatal morbidity of multifetal pregnancies (MPs), fetal reduction (FR) is offered to some patients. We retrospectively analysed the data of 124 MPs that underwent transabdominal FR to twin (n = 63) and singleton (n = 61) pregnancies at a mean gestational age of 12 + 6 weeks between December 2006 and January 2018. FR was performed transabdominally with the injection of potassium chloride into the intracardiac or intrathoracic space of the fetus or fetuses after ultrasound screening for nuchal translucency and anatomical defects. The initial number of embryos were 48 twins, 63 triplets, 11 quadruplets, and 2 quintuplets. The procedure-related pregnancy loss rate was 0.8% (1/124), the overall pregnancy loss rate was 2.4% (3/124), the fetal loss rate was 1.6% (2/124), and the neonatal death rate was 0.8% (1/124). The baby take-home rates were 96% for twin pregnancies and 96.7% for singletons. This study shows that transabdominal FR is an effective and safe procedure with a pregnancy loss rate of 2.4%. Impact statement What is already known on this subject? The incidence of multifetal pregnancies has increased over the years. Because multifetal pregnancies increase perinatal morbidity and mortality due to prematurity, fetal reduction is offed to some patients. What the results of this study add? The results of this study add to the growing body of research on fetal reduction. The study showed that transabdominal fetal reduction is a safe procedure with a pregnancy loss rate of 2.4%. What the implications are of these findings for clinical practice and/or further research? The results of this study can be used in counselling couples with multifetal pregnancies who are considering fetal reduction. Further research is needed to confirm the current findings.

Inflow or Outflow Obstruction Requiring Surgical Corrections Late after HeartMate 3 Left Ventricular Assist Device Insertion

Inflow or outflow obstruction is a rare, but critical complication after HeartMate 3 (HM3) LVAD implantation. We report our single center experience of outflow or inflow obstruction requiring surgical intervention after HM3 implant. We retrospectively reviewed 166 patients who underwent primary HM3 implantation at Columbia University Irving Medical Center between November, 2014 and July, 2019. Seven cases (4.2%) of inflow or outflow obstruction were identified (Table 1). Median age was 59 years (IQR 44-71), and all but one were men. There were 3 cases of inflow occlusion, 2 outflow graft twists, 1 outflow graft compression by thrombus, and 1 bend relief disconnect. The duration from device implantation to reintervention was 162-804 days. All patients underwent HM 3 implantation via median sternotomy and the pump was placed either in the intrapericardial (n=6) or intrathoracic (n=1) space. Of note, both patients who developed outflow graft twist, had the initial implant prior to introduction of the outflow graft clip. Presence of low flow alarm was the most common presenting sign. CT angiogram identified a problem in 6 out of 7 cases. Surgical approach used for correction is presented in Table 1. Clinical symptoms and/or alarms resolved after surgery in all cases and all patients remain alive on support with median follow-up of 528 days (IQR 49-834). HM3 inflow or outflow obstruction is a rare but significant complication of device therapy. CT angiogram is a useful diagnostic modality that should be considered in all patients with persistent low flow alarms. Prompt diagnosis and surgical correction results in good outcomes.

Robotic-assisted computed tomography-guided 18F-FDG PET/computed tomography-directed biopsy for diagnosis of intra thoracic lesions: An experience from a tertiary care centre in North India.

The aim of this study was to assess the diagnostic yield of robotic-assisted computed tomography (CT)-guided F-FDG PET/CT-directed biopsy for the evaluation of intrathoracic space occupying lesions. Twenty-four patients being evaluated for intrathoracic masses were included in the study. The indications were patients with unknown/likely primary detected from PET-CT, suspicious lesions identified from PET-CT in a known primary disease and fine needle aspiration cytology/CT-guided biopsy negative lesions with a high index of suspicion for malignancy. Biopsies were carried out with the help of automated radiology arm (ROBIO-EX) which is essentially a needle positioning and holding device. A two-day protocol was followed in which PET-CT scan was done on the first day, biopsy procedure was done on the next scheduled day. PET images were refused with the CT images done on the second day in the console by using manual alignment and then a biopsy was carried out with the help of a robotic arm. Primary outcome was histopathological yield from the obtained specimens. Tissue yield was 100% (n = 24) and histopathological diagnosis rate was 96% (n = 23). Out of the 24 lesions biopsied 30% (n = 8) were benign and 70% (n = 16) turned out to be malignant. The complication rates were pneumothorax 4% (n = 1) and haemothorax 4% (n = 1). Robotic-assisted CT-guided F-FDG PET/CT-directed biopsy is a useful and accurate technique for diagnostic evaluation of intrathoracic neoplasms with minimal complications rates as compared with conventional imaging techniques.

Commentary: Mus uni non fidit antro…use of the modified Nuss to facilitate transplant in patients with pectus excavatum

In this issue of the Journal, Nasirov and colleagues1 steal a line from the Roman playwright Plautus to treat a young patient with Marfan syndrome with severe pectus excavatum suffering from end-stage cardiac disease. The Latin proverb Mus uni non fidit antro, or a mouse does not rely on just one hole, aptly describes the authors' creative ability to increase a very sick patient's chance of successfully receiving a lifesaving operation by simultaneously performing a modified Nuss procedure at the time of heart transplant to augment and increase intrathoracic space.

Chest wall replacement

The optimal surgical reconstruction of chest wall defects especially in the context of posttraumatic, oncological and congenital etiologies has alarge impact on the recovery of the patients. Regardless of the etiology, various complications, such as agenerally impaired respiratory physiology in an unstable thorax or decreased pulmonary clearance associated with acute and chronic pulmonary infections, may impair the recovery of affected patients. The postoperative occurrence of an intrathoracic dead space may lead to adifficult to treat empyema. Each thoracic wall defect must be accurately assessed and treated according to size, depth and location on the chest. The complexity of this condition and the resulting complications require the highest degree of surgical care which should be interdisciplinary both preoperatively and postoperatively.

Heart–Lung Interaction

AbstractMechanical interplay between respiratory and cardiac systems was first recognized about 300 years ago when an English physiologist Stephen Hales observed that the level of the blood column in a glass tube inserted into the carotid artery of a horse varied cyclically with respiration.Heart and lung share the same intrathoracic space, and mechanically this configuration is akin to pump within a pump. As a result, intrathoracic pressure (ITP) and volume changes during respiratory cycle affect the performance of heart. Besides direct mechanical effects, lung and heart interplay also involves certain neurally and humorally mediated phenomena. Taken together, these dynamics constitute heart–lung interaction. Knowledge of heart–lung interaction is especially useful while dealing with critically sick patients on ventilator, because not only are such patients more vulnerable to hemodynamic instability induced by ventilator, but it also forms the basis of functional hemodynamic monitoring.

Laparoscopic repair of an incarcerated diaphragmatic hernia after right hepatectomy for hepatic injury: a case report

BackgroundDiaphragmatic hernias (DH) are generally classified as either congenital or acquired. Acquired DH are generally of traumatic cause, being a rare complication after hepatectomy. Although repair of a DH can be performed via laparotomy, laparoscopy, or thoracoscopy, the use of laparoscopy is rare after hepatectomy owing to the formation of scar tissue. In this case, we describe our successful attempt at laparoscopic repair of a recurrent DH after hepatectomy.Case presentationA 30-year-old man underwent right hepatectomy for trauma and thoracotomy via the eighth intercostal space, with direct closure of the diaphragm by suturing. The patient subsequently developed a right DH, with strangulation ileus of the small intestine. He underwent laparotomy 3 months after the initial surgery. The defect was observed to be clearly separate from the previously sutured area of the diaphragm. Five years after treatment, the patient developed abdominal pain and vomiting due to incarceration of the transverse colon in the right intrathoracic space (detected via abdominal computed tomography and radiography). The patient was again diagnosed with DH and underwent laparoscopic repair of the hernia with direct closure. The patient was discharged 11 days after surgery without further complication.ConclusionsA laparoscopic approach was feasibly and safely used to repair a recurrent DH after hepatectomy. The surgical approach will need to be decided in a patient-specific manner.

NEPHRO-PLEURAL ABSCESS SECONDARY TO MRSA

SESSION TITLE: Chest Infections 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: It is not uncommon to have pleural effusions secondary to subdiaphragmatic pathology due to an intrabdominal process. However, pleural suppurative infections caused by direct communication between intraabdominal abscesses and the thoracic cavity is extremely rare. We present a unique case of a female diagnosed with a perinephric abscess extending into the pleural space causing an empyema. CASE PRESENTATION: A 45-year-old female with known history of Moya Moya and intravenous drug use presented with left flank pain and shortness of breath of three weeks duration. On presentation she was notable for fever, tachycardia, tachypnea, and hypoxia requiring supplemental oxygenation. Her physical examination revealed diminished breath sounds on the left and left flank tenderness. Her laboratory tests were significant for a leukocytosis with a neutrophil predominance and were otherwise within normal limits. Her urinalysis was negative for white blood cells, nitrites, and bacteria. Blood and urine cultures were also negative. Chest x-ray revealed a left sided effusion, and a subsequent computed tomography of the abdomen and pelvis revealed a left 5x4x3 suprarenal abscess that extended superiorly into the intrathoracic space. She was empirically treated with vancomycin and piperacillin-tazobactam. A thoracentesis was performed and pleural fluid studies demonstrated an exudative effusion with a pH of 7.13. A chest tube was inserted for management of the empyema and was further treated with consecutive doses of tPA and Dornase. Antibiotics were tailored to linezolid once pleural fluid cultures were positive for MRSA. The patient continued to clinically improve, and the chest tube was removed as the effusion diminished and drainage decreased. The patient was discharged home with a six week course of linezolid and close follow up. Repeat abdominal imaging noted improvement of the pleural effusion and decrease in abscess size. DISCUSSION: The majority of nephro-pleural fistulas are formed in patients with nephrolithiasis. An empyema formed secondary to an intrabdominal abscess, such as this case, is extremely rare and is likely secondary to a fistula formation. Due to our patient's delayed presentation and history of drug abuse she suffered from a MRSA abscess complicated by a potential fistulous track leading to a concomitant empyema. CONCLUSIONS: The significance of this case is to increase awareness that chronic untreated intrabdominal abscesses may develop into an intrathoracic infection. Management typically consists of evacuation and a prolonged course of antibiotics. Reference #1: Jones GH, Kalaher HR, Misra N, Curtis J, Parker RJ. Empyema and Respiratory Failure Secondary to Nephropleural fistula Caused by Urinary Tract Infection: A Case Report. Case Reports in Pulmonology. 2012; 1-5. https://doi.org/10.1155/2012/595402. DISCLOSURES: No relevant relationships by Said Chaaban, source=Web Response No relevant relationships by Rachel Goodwin, source=Web Response No relevant relationships by Melissa Jordan, source=Web Response

MTE15.01 Identifying High Risk Patients: What Makes a Patient Too High Risk for Surgery and Who Decides?

MTE15.01 Identifying High Risk Patients: What Makes a Patient Too High Risk for Surgery and Who Decides?

A tertiary centre experience of thoracic CT and cardiac MRI scanning in the presence of a reveal LINQ insertable cardiac monitoring system: a case series review of artefact, patient safety and data preservation.

At our tertiary cardiothoracic centre, cardiac MRI and thoracic CT scans are performed in patients with implanted LINQ devices. The degree of foreign body artefact associated with the LINQ device, and its clinical importance, has not previously been assessed. A case series review was therefore performed with a simultaneous review of patient safety and data loss events, secondary to the MRI environment. A local database search identified LINQ device patients who underwent thoracic CT or cardiac MRI scans between March 2014 and December 2016. Images were reviewed by two radiologists, recording the presence of subcutaneous and intrathoracic artefact, and its clinical significance. Furthermore a specialist in cardiac rhythm management reviewed all LINQ data downloads undertaken before and after MRI scanning, and a search of the trust incident reporting system was performed. Minor subcutaneous artefact was present on all scans. Intrathoracic artefact was observed in 25.6% of thoracic CT scans and 33.3% of cardiac MRIs; however no clinically significant artefact was observed. Device downloads were only performed by 53.8% of patients prior to their MRI scan and 56.5% after their MRI scan. No adverse patient safety or data loss events were noted. The LINQ device does not produce clinically significant artefact, even when artefact extends into the intrathoracic space, which occurs in a third of MRIs and a quarter of CTs. MRI scanning of the LINQ device is safe with no evidence of inappropriate data loss. Advances in knowledge: This is the first published case series of CT and MRI scanning in LINQ patients and the first performed quantification of artefact related to the LINQ device.

Laparoscopic repair of parahiatal hernia after esophagectomy: a case report

BackgroundDiaphragmatic hernia is a potential complication of esophagectomy, which usually occurs as a hiatal hernia and more frequently after minimally invasive esophagectomy. Parahiatal hernia is a rare form of diaphragmatic hernia, and to the best of our knowledge, parahiatal hernia after esophagectomy has not been previously reported. Here, we report a case of parahiatal hernia after esophagectomy that was successfully managed laparoscopically.Case presentationA 73-year-old man underwent thoracoscopic esophagectomy for esophageal cancer with gastric tube reconstruction via the posterior mediastinum. Postoperative morbidity was ileus, which required conservative treatment, and intestinal obstruction for which operation with laparotomy was necessary. He was admitted with abdominal pain and vomiting at 15 months after esophagectomy. Abdominal X-ray revealed colon gas in the intrathoracic space. A barium enema examination showed a transverse colon incarcerated in the intrathoracic space. The patient was preoperatively diagnosed with hiatal hernia after esophagectomy, and laparoscopic hernia repair was performed. During the surgery, the hiatus was found to be intact, and the defect was clearly separated from the left crus of the diaphragm. Parahiatal hernia was the operative diagnosis. The incarcerated colon was repositioned in the abdominal cavity, and the defect was repaired using a composite mesh.ConclusionsLaparoscopic surgery was found to be effective for the diagnosis and repair of parahiatal hernia.

Abstract 4133: Amrubicin is effective for synovial sarcoma

Abstract Background: Synovial sarcoma (SS) is representative sarcoma types, which is account for 6% of sarcomas. Although the gold-standard of treatment is surgery, SS is often diagnosed in an advanced clinical stage. Chemotherapy is the primary treatment modality. Amrubicin (AMR), an anthracycline agent, is converted in the body to amrubicinol (AMRol) by reduction of the 13-position ketone, which has a higher antitumor activity than the parentmolecule. In this study, we evaluate the effectiveness in vitro and in vivo. Materials and Methods: Cell lines and reagent. The SS cell lines, SW982, HSSYII and SS1. Cell viability assay. WST-1 mixture was used. Cell-cycle analysis. To evaluate the cell cycle, FITC BrdU Kit Flow Kit was used. HSSY-II, SW982 were treated with AMRol for 4 hours and analyzed by flow cytometry using BD FACSVerseTM. Animal experiments. Severe Combined Immuno-Deficiency mice were used. SS cells were injected subcutaneously or into right intrathoracic space. These mice were assigned randomly to AMR group and normal saline group (NS). Micro-computed tomography (μCT). The R-mCT system was used to measure the diameter of tumor in intrathoracic space. Statistical analysis: All of the results are expressed as meanSEM. The Kaplan-Meier method was used to estimate survival. Treatment groups were compared using a two-sided log-rank test. Results: Cell viability assay. AMR was highly metabolized into AMRol in tumor tissue and AMRol was more toxic than AMR. AMRol was used to in vitro assay. AMRol was equivalent to, or even more toxic than DXR in this experiments. Cell-cycle analysis. After AMRol treatment, more cells were found in S-phase compared with no treatment control. Subcutaneous SS model. AMR showed cytostatic effect compared with normal saline (NS) in each of HSSYII and SW982. Intrathoracic space SS model. SS-1 was established from primary pleural SS patient. In preliminary experiments, location of tumor was confirmed on μCT. Tumor growth was suppressed in AMR group compared with in NS group and AMR showed cytostatic effect. In survival analysis, it was shown that AMR group was tend to survive longer than NS group. Discussion: It was shown that AMR is effective for SS in vitro and in vivo. Our results suggest an alternative treatment of SS patients, including primary pleural SS. The effectiveness and safety should be addressed in future studies. Citation Format: Shinnosuke Takemoto, Hiroshi Gyotoku, Hiroaki Senjuu, Takayuki Suyama, Noritaka Honda, Kosuke Mizoguchi, Takaya Ikeda, Hiroyuki Yamaguchi, Katsumi Nakatomi, Yoichi Nakamura, Minoru Fukuda, Hiroshi Mukae. Amrubicin is effective for synovial sarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4133. doi:10.1158/1538-7445.AM2017-4133

Lung development requires an active ERK/MAPK pathway in the lung mesenchyme.

Reciprocal epithelial-mesenchymal communications are critical throughout lung development, dictating branching morphogenesis and cell specification. Numerous signaling molecules are involved in these interactions, but the way epithelial-mesenchymal crosstalk is coordinated remains unclear. The ERK/MAPK pathway transduces several important signals in lung formation. Epithelial inactivation of both Mek genes, encoding ERK/MAPK kinases, causes lung agenesis and death. Conversely, Mek mutation in mesenchyme results in lung hypoplasia, trachea cartilage malformations, kyphosis, omphalocele, and death. Considering the negative impact of kyphosis and omphalocele on intrathoracic space and, consequently, on lung growth, the exact role of ERK/MAPK pathway in lung mesenchyme remains unresolved. To address the role of the ERK/MAPK pathway in lung mesenchyme in absence of kyphosis and omphalocele, we used the Tbx4Cre deleter mouse line, which acts specifically in lung mesenchyme. These Mek mutants did not develop kyphosis and omphalocele but they presented lung hypoplasia, tracheal defects, and neonatal death. Tracheal cartilage anomalies suggested a role for the ERK/MAPK pathway in the control of chondrocyte hypertrophy. Moreover, expression data indicated potential interactions between the ERK/MAPK and canonical Wnt pathways during lung formation. Lung development necessitates a functional ERK/MAPK pathway in the lung mesenchymal layer in order to coordinate efficient epithelial-mesenchymal interactions. Developmental Dynamics 246:72-82, 2017. © 2016 Wiley Periodicals, Inc.

Modified Thoracoscopic Hepatectomy For Segment VIII

Although previous studies have reported the use of total thoracoscopic hepatectomy (TH) for malignant liver tumors, it is technically impossible to perform intraoperative ultrasonography (IUSO) to exclude intrahepatic metastasis for the whole liver via a thoracic approach. Therefore, total TH may be inappropriate for these patients. We here report the first case of modified TH for a malignant liver tumor in China.The patient was a 26-year-old man with a 10-year HBV infection. Preoperative CT showed a 1.2 cm × 0.9 cm mass located in segment VIII. His alpha-fetal protein level was 444 ng/mL. Child-Pugh was Grade (A, 6), whereas an ICG-15 test yielded 2.7%. HCC was diagnosed preoperatively. The indications for TH were difficult tumor location, HCC, and a young patient with good resilience.The modified TH included 2 steps: (1) the patient was placed in a supine position. IUSO was used to locate the tumor in segment VIII and determine that intrahepatic metastasis had not occurred. The hepatoduodenal ligament was hanged over using a Pringle maneuver; (2) patient was then placed in the left-lateral position with single-lung ventilation. Three trocars were placed into the right thoracic cavity. The intra-thoracic space was observed using a regular 10-mm rigid scope. The diaphragm was transected and retracted. IUSO was used again to confirm the tumor location. Under the Pringle maneuver (once every 10 min), the superficial portion of the liver was transected by ultrasonic shears, whereas the deeper tissue was transected by LigaSure. Bipolar was used for hemostasis. The specimen was put into a retrieval bag and removed from the abdominal trocar. The diaphragm was repaired by running suturing. The operation time was 260 minutes and estimated blood loss was 30 mL. The patient was discharged on postoperative day 5 with normal liver function. No complications arose.Total TH may be inappropriate for malignant liver tumors due to the limitation of IUSO for the whole liver. The 2-step modified TH is technically feasible and suitable for malignant liver tumors located in segments VII or VIII.Video abstract: http://links.lww.com/MD/B6.