Favorable Response of Advanced Superior Sulcus Non-Small Cell Lung Carcinoma to Gefitinib for 11 years complicated by Interval Development of Small Cell Carcinoma of the Lung.

Gefitinib is a medication that was originally developed as an epidermal growth factor receptor (EGFR) blocker. It has been used to treat non-small cell lung cancer with varying success. We describe a patient who presented with Pancoasts syndrome and after being deemed surgically unresectable had limited success with chemotherapy and radiation but had an excellent response to the medication Gefitinib. The patient was disease free for several years and after 11 years of follow up with CT scans, a PET CT showed an isolated area of FDG avidity which on biopsy was small cell carcinoma of the lung. The patient had been maintained continually on Iressa for 11 years. Gefitinib treatment and continuing EGFR blockade invariably result in resistance to the medication and ultimate relapse. However in the present case, presumed sensitivity of the original tumor was noted for a prolonged time period, with development of either a new, small cell lung cancer, or histologic transformation. Similar cases have described this phenomenon of epithelial cancers treated with tyrosine kinase inhibitor blockade and development of small cell lung cancer however our case is unusual in that this transformation is observed over an eleven year time horizon

Angiosarcoma of the Lower Extremity presenting as Bilateral Pneumothoraces

Abstract Spontaneous pneumothorax usually presents as unilateral disease. Bilateral spontaneous pneumothoraces are less common and are more likely to be secondary than primary. We describe a case of bilateral spontaneous pneumothoraces that were resistant to conventional treatment, and found ultimately to be secondary to angiosarcoma of the lower extremity. A previously well 49 year old white female was referred to our institution in London with bilateral pneumothoraces. A left video assisted thoracoscopic procedure was undertaken, and the wedge resection of the lung specimen contained an area of metastatic tumor. Talc was placed into the left pleural cavity; talc was also placed at the bedside into the right pleural cavity which was slow to heal, and required a second chest tube and Heimlich valve. The pneumonthoraces were eventually found to be secondary to metastatic angiosarcoma of the thigh. A groin mass was biopsied and found to be the source of the metastatic deposits. This was not present on initial examination. The patient was referred for chemotherapy to a specialized sarcoma unit. Spontaneous pneumothorax may be the first and only evidence for pulmonary metastases. This report highlights the importance of considering an underlying pathology in patients presenting with spontaneous bilateral pneumothoraces

Management of co-existing lung cancer and endobronchal hamartomas

Abstract: The coexistence of lung cancer with an endobronchial hamartoma is infrequent, and requires accurate oncologic evaluation of the endobronchial lesion prior to potential surgical treatment of the lung cancer. We describe a patient who presented with an undiagnosed endobronchial mass and and a biopsy-proven lung cancer which were successfully managed by a staged approach using initial bronchoscopic resection of the endobronchial lesion and subsequent lobectomy for squamous cell lung cancer

The Proposed U.S.-South Korea Free Trade Agreement (KORUS FTA): Provisions and Implications

[Excerpt] On June 30, 2007, U.S. and South Korean trade officials signed the proposed U.S.-South Korean Free Trade Agreement (KORUS FTA) for their respective countries. If approved, the KORUS FTA would be the second-largest FTA that South Korea has signed to date, after the agreement with the European Union (EU). It would be the second-largest (next to North American Free Trade Agreement, NAFTA) in which the United States participates. South Korea is the seventhlargest trading partner of the United States and the United States is South Korea’s third-largest trading partner. Various studies conclude that the agreement would increase bilateral trade and investment flows. The final text of the proposed KORUS FTA covers a wide range of trade and investment issues and, therefore, could have substantial economic implications for both the United States and South Korea. The agreement will not enter into force unless Congress approves implementation legislation. The negotiations were conducted under the trade promotion authority (TPA), also called fast-track trade authority, that Congress granted the President under the Bipartisan Trade Promotion Act of 2002 (P.L. 107-210). Under TPA the President has the discretion on when to submit the implementing legislation to Congress. President Bush did not submit the legislation because of differences with the Democratic leadership over treatment of autos and beef, among other issues. Early in his Administration, President Obama indicated the need to resolve those issues before he would submit the implementing legislation. On December 3, 2010, after a series of arduous negotiations and missed deadlines, President Obama and President Lee announced that their negotiators reached agreement on modifications in the KORUS FTA, and that they were prepared to move ahead to getting the agreement approved by the respective legislatures. The White House is expected to send implementing legislation to the 112th Congress and that it would like to see Congress approve the agreement by July 1 of this year. The modifications are in the form of changes in phase-out periods for tariffs on autos, a new safeguard provision on autos, and concessions by South Korea on allowing a larger number of U.S. cars into South Korea under U.S. safety standards than was the case under the original KORUS FTA provisions. The issue of full U.S. beef access was not resolved because of the political sensitivity of the issue in South Korea. In 2008, when President Lee reached a separate agreement with the United States to lift South Korea’s ban on U.S. beef imports, massive anti-South Korean government protests forced the two governments to renegotiate its terms. The U.S. beef sector has largely supported the KORUS FTA. A broad swath of the U.S. business community supports the KORUS FTA . With the modifications in the agreement reached in December, this group also includes the three Detroit-based auto manufacturers and the United Auto Workers (UAW) union. It still faces opposition from some labor unions and other groups, including Public Citizen. Many U.S. supporters view passage of the KORUS FTA as important to secure new opportunities in the South Korean market, while opponents claim that the KORUS FTA does not go far enough to break down South Korean trade barriers or that the agreement will encourage U.S. companies to move their production offshore at the expense of U.S. workers. Other observers have suggested the outcome of the KORUS FTA could have implications for the U.S.-South Korean alliance as a whole, as well as on U.S. Asia policy and U.S. trade policy, particularly in light of an FTA signed in by South Korea and the EU that is expected to go into effect on July 1, 2011

The EU-South Korea Free Trade Agreement and Its Implications for the United States

[Excerpt] On October 6,2010, the 27 member European Union (EU) and South Korea signed a bilateral free trade agreement (FTA). The agreement is expected to go into effect on July 1, 2011, pending approval by the European Parliament and the South Korean National Assembly. If enacted, the South Korea-EU FTA (KOREU FTA) would be the largest FTA in terms of market size that South Korea has entered into. The KOREU FTA reflects the EU and South Korean trade strategies to use FTAs to strengthen economic ties outside their home regions. It also builds upon the surge in trade and investment flows between South Korea and the EU over the past decade. This agreement has possible implications for U.S. trade with South Korea and congressional action on the proposed U.S.-South Korea FTA (KORUS FTA). The proposed KOREU FTA is very comprehensive. It would reduce and eliminate tariffs and other trade barriers in manufactured goods, agricultural products and services and would also cover such trade-related activities as government procurement, intellectual property rights, labor rights and environmental issues. Most studies done on the potential impact of the KOREU FTA estimate that the agreement will have a small but positive effect on the economies of the EU and South Korea as a whole and that the larger relative impact would be on the South Korean economy. The greatest economic impact of the KOREU FTA would be on specific sectors in each economy. EU services providers would be expected to experience gains from the agreement, especially in the areas of retail and wholesale trade, transportation services, financial services, and business services. In terms of trade in goods, EU exporters of pharmaceuticals, auto parts, industrial machinery, electronics parts, and some agricultural goods and processed foods would be expected to gain from the KOREU FTA\u27s implementation. At the same time, South Korean manufacturers of cars, ships, wireless telecommunications devices, chemical products, and imaging equipment would be expected to increase their exports to the EU market. The KOREU FTA is similar to the proposed KORUS FTA in many respects. Both agreements are comprehensive and both would eliminate tariffs on most trade in goods soon after they enter into force. However, they differ in other respects. Phase-out periods for tariffs on some manufactured goods differ. In addition, the KOREU FTA does not cover foreign direct investment. Unlike the KORUS FTA, the KOREU FTA would not allow trade sanctions to be applied where violations of the workers\u27 rights, and environment provisions have been deemed to occur. In addition, the KORUS FTA would cover a broader range of trade in services than would the KOREU FTA. It is not clear whether these differences in the structures of the FTAs would result in appreciable differences in outcomes in terms of economic gains and losses. U.S. and European firms are close competitors in a number of sectors and industries, particularly autos. Some business representatives argue that enactment of the KOREU FTA before enactment of the KORUS FTA would give European competitors commercial first mover advantages, since EU firms, such as those in the auto industry or the services sector, could gain greater market opportunities in South Korea not afforded to US. firms. On the other hand, other factors could also mitigate such advantages. For example, U.S. multinational firms operating in the EU could benefit from the KOREU FTA. Nevertheless, the content and fate of the KOREU FTA could influence the pace and tone of any debate in the United States on the KORUS FTA in the 112th Congress

The Proposed U.S.-South Korea Free Trade Agreement (KORUS FTA): Provisions and Implications

On June 30, 2007, United States Trade Representative Susan Schwab and South Korean Foreign Trade Minister Kim Hyung-chong signed the proposed U.S.-South Korean Free Trade Agreement (KORUS FTA) for their respective countries. If approved, the KORUS FTA would be the largest FTA that South Korea has signed to date and would be the second largest (next to North American Free Trade Agreement NAFTA) in which the United States participates. South Korea is the seventh-largest trading partner of the United States and the United States is South Korea’s third largest trading partner. Various studies conclude that the agreement would increase bilateral trade and investment flows. The final text of the proposed KORUS FTA covers a wide range of trade and investment issues and, therefore, could have wide economic implications for both the United States and South Korea. The KORUS FTA includes issues on which the two countries achieved early agreement, such as the elimination on tariffs on trade in most manufactured goods and the partial liberalization in services trade. The agreement also includes provisions on a number of very sensitive issues, such as autos, agriculture, and trade remedies, on which agreement was reached only during the final hours of negotiations. If the agreement is to enter into force, Congress will have to approve implementation legislation. The negotiations were conducted under the trade promotion authority (TPA), also called fast-track trade authority, that the Congress granted the President under the Bipartisan Trade Promotion Act of 2002 (P.L. 107-210). The authority allows the President to enter into trade agreements that receive expedited congressional consideration (no amendments and limited debate). The White House has not indicated when it will send the draft implementing legislation to Congress. (The TPA sets no deadline for the President to do this.) While a broad swath of the U.S. business community supports the agreement, the KORUS FTA faces opposition from some groups, including some auto and steel manufacturers and labor unions. In addition, the agricultural community and some Members of Congress have withheld support for the agreement until South Korea lifts its restrictions on imports of U.S. beef. Some U.S. supporters view passage of the KORUS FTA as important to secure new opportunities in the South Korea market. Opponents claim that the KORUS FTA does not go far enough in opening up the South Korean market and is a lost opportunity to resolve long running concerns about South Korean barriers. Other observers have suggested the outcome of the KORUS FTA could have implications for the U.S.-South Korean alliance as a whole. Differences between the White House and the Democratic leadership in the Congress over the implications of the KORUS FTA have made the timing and even the likelihood of the President’s submission and the Congress’s subsequent consideration of implementing legislation uncertain. This report will be updated as events warrant

Successful Surgical Outcome after Traumatic Diaphragmatic Intra-Pericardial Herniation from Blunt Abdominal Injury

Intrapericardial diaphragmatic hernia (IPDH) is a rare manifestation of non-hiatal diaphragmatic hernias (NHDH). Intrapericardial diaphragmatic hernia is defined as the prolapse of the abdominal viscera into the pericardium through the diaphragm. Their incidence has increased over the last 50-60 years, secondary to high-speed transport, and constitutes 5% of major thoracic and abdominal trauma today. These injuries can present during the initial workup or months after the initiating injury. These hernias can be caused by both blunt and penetrating trauma with concomitant central tendon rupture and pericardial laceration. We report an interesting case of intrapericardial diaphragmatic hernia with delayed presentation that was successfully reduced via open surgical repair after a laparoscopic repair attempt failed. We present a 77-year-old female admitted to the hospital after a motor vehicle crash. On hospital day 9, the patient developed shortness of breath, which prompted a chest x-ray. The chest x-ray revealed bowel in the patient’s chest. The patient was taken to the operating room, where they underwent an attempted laparoscopic diaphragmatic hernia repair and, ultimately, open repair of the diaphragmatic hernia. The patient did well after surgery and was discharged on post-injury day 22

Enhancement of thrust reverser cascade performance using aerodynamic and structural integration

This paper focuses on the design of a cascade within a cold stream thrust reverser during the early, conceptual stage of the product development process. A reliable procedure is developed for the exchange of geometric and load data between a two dimensional aerodynamic model and a three dimensional structural model. Aerodynamic and structural simulations are carried out using realistic operating conditions, for three different design configurations with a view to minimising weight for equivalent or improved aerodynamic and structural performance. For normal operational conditions the simulations show that total reverse thrust is unaffected when the performance of the deformed vanes is compared to the un-deformed case. This shows that for the conditions tested, the minimal deformation of the cascade vanes has no significant affect on aerodynamic efficiency and that there is scope for reducing the weight of the cascade. The pressure distribution through a two dimensional thrust reverser section is determined for two additional cascade vane configurations and it is shown that with a small decrease in total reverse thrust, it is possible to reduce weight and eliminate supersonic flow regimes through the nacelle section. By increasing vane sections in high pressure areas and decreasing sections in low pressure areas the structural performance of the cascade vanes in the weight reduced designs, is improved with significantly reduced levels of vane displacement and stress

Spontaneous Pneumothorax: A Rare Complication of Neurofibromatosis Type 1 Associated Diffuse Lung Disease

The visually striking neurocutaneous findings of neurofibromatosis type 1 (NF1) are well recognized and have been well documented throughout scientific literature. While not uncommon, the pulmonary manifestations of NF1 are unknown to many physicians. Complications of NF1 associated diffuse lung disease (NF-DLD) include pulmonary hypertension, pulmonary artery stenosis, subpleural cysts, and spontaneous pneumothorax. We present a case of a 34-year-old male with NF-DLD found incidentally in adolescence with previous apical bleb repair, presenting nearly twenty years later with spontaneous pneumothorax. In NF1 patients with pulmonary complaints, NF-DLD should be assessed with computed tomography (CT) and physicians should be familiar with associated complications

Recurrent Spontaneous Pneumothorax During Pregnancy; A Case Report

Spontaneous pneumothorax is a rare but potentially life-threatening condition during pregnancy. We discuss a case of recurrent spontaneous pneumothorax during a single pregnancy. The pneumothorax occurred twice during the pregnancy, first in the second trimester and again in the third trimester with both times being managed conservatively. Due to the low prevalence of this condition management guidelines are few. We report our management of recurrent spontaneous pneumothorax during pregnancy to support the literature and current guidelines