[Intrapulmonary Solitary Fibrous Tumor].

We report a case of intrapulmonary solitary fibrous tumor( SFT). A 34-year-old woman was referred to our hospital due to an abnormal shadow on a chest roentgenogram without symptom. Computed tomography showed a circumscribed intrapulmonary tumor with mild uptake on fluorodeoxyglucose (FDG)-positron emission tomography( PET) in the left lower lobe( S6). Frozen examination revealed a mesenchymal tumor. Based on the pathological and immunohistochemical findings, the tumor was diagnosed as intrapulmonary SFT.

[Heparin-induced thrombocytopenia developed during the acute phase after left upper lobectomy for lung cancer].

Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin administration. This must not be rarely encountered but is not often reported in Japan compared to Western countries. A 68-year-old woman underwent left upper lobectomy for lung cancer. Low-dose unfractionated heparin was administrated to prevent thromboembolism after the operation. Two days later, sudden dyspnea appeared and ultracardiosonography showing an extensive thromboembolus from the main trunk to both main branches of pulmonary artery indicated pulmonary embolization. After the establishment of percutaneous cardiopulmonary support (PCPS) support, the embolus was removed by emergent open heart surgery. However, despite further unfractionated heparin administration following embolization surgery, other thrombus was identified in both the bi-lateral internal jagular veins and inferior vena cava by ultrasonography and contrast computed tomography( CT). Her platelet count was decreased gradually despite platelet transfusion. Plate factor 4( PF4) antibody against heparin in her blood examination was found, and HIT II was diagnosed. Discontinuation of unfractionated heparin and administration of antithrombin agent improved platelet count, and no additional embolization was identified.

[Primary malignant peripheral nerve sheath tumor of the lung; report of a case].

We report a patient with primary malignant peripheral nerve sheath tumor (MPNST) of the lung. A 84-year-old man was referred to our hospital because of an abnormal shadow on chest X-ray. The computed tomography( CT) of the chest revealed a 6 cm tumor close to the posterior chest wall in the left thorax. He was followed-up because a benign tumor from posterior mediastinum was suspected. But the CT after 17 months showed the tumor enlargement. We performed complete resection under video-assisted thoracic surgery. It arose from the left lower lobe and was diagnosed as primary MPNST of the lung by immuno-histopathological examination. MPNSTs have a poor prognosis with tendency to recur. Although there is no sign of recurrence a year after surgery, we should follow-up carefully.

[Empyema that was diagnosed as primary ciliary dyskinesia by electron microscopical image of nasal mucosa].

A patient was 17-year-old. She had a history of repeated pneumonia and sinusitis. She was admitted to our hospital with the diagnosis of pneumonia. Although she was prescribed a course of antibiotics, chest roentgenogram and computed tomography showed increased and capselized pleural effusion, suggesting the development of acute empyema. Capsulized effusion and pus in thorax were removed by surgery. A part of lingular segment was raptured necessitating the partial resection of lingular segment. Her postoperative course was well. Her history of repeated pneumonia and sinusitis indicated the existence of primary ciliary dyskinesia, and the biopsy of nasal mucosa was done. The electron microscopical image of nasal mucosa showed defect of inner dynein arm. We made a diagnosis of primary ciliary dyskinesia based on her previous history and electron microscopical image.

[Long-term survival with complete response by gefitinib treatment followed by noncurative operation for lung cancer].

A 54-year-old man was referred to our hospital because of an abnormal shadow on chest X-ray. A computed tomography( CT) scan of the chest revealed a 6.5 cm tumor in the right upper lobe suspected of superior vena cava (SVC) infiltration. He was diagnosed as lung cancer(adenocarcinoma), and the right upper lobectomy with partial resection of SVC was performed. But the pathology confirmed the surgery to be non-curative. Nine months after operation, carcinomatous pleuritis was detected on chest X-ray. Since deoxyribonucleic acid (DNA)analysis revealed a mutation of epidermal growth factor receptor (EGFR) gene in exon 21, gefitinib treatment was started. Nine months later, pleural effusion regressed and his cerum carcinoembrionic antigen( CEA) level was normalized. 4 years later, gefitinib was discontinued by patient's request, however, he is alive without any signs of relapse 9 years after the operation.

[Typical bronchial carcinoid with repeated recurrence observed for 17 years after radical operation].

A 68-years-old male patient had been diagnosed as having bronchial carcinoid in B2 and right upper lobectomy with systematic hiler and mediastinal lymphadenectomy had been performed in 1996. Pathological diagnosis was a typical carcinoid (pT1aN0M0, stage I A). In 2004, 4 tumors were found in the trachea, right bronchial stump, right main bronchi and right B6 orfice. These were diagnosed as typical carcinoids by pathology. In 2005 argon plasma coagration was performed.In 2013, a localized recurrence was found in the right S6 by chest computed tomography (CT). The segmentectomy of the right S6 was performed. Even after radical operation for typical carcinoids, we should conduct long-term observation.

[Resected thymic hyperplasia with myasthenia gravis and Lambert-Eaton myasthenic syndrome].

A 61-year-old male who noticed muscular weakness of his extremities, diplopia and slur his words was found to have a thymic tumor on computed tomography. The immunological examination showed incremental of anti Acetylcholine receptor antibody titer and anti P/Q-type voltage-gated calcium channels antibody titer. Electromyography showed decremental response to low frequency stimulations, and incremental response to high frequency stimulations. So he was diagnosed with thymic tumor combined with myasthenia gravis and Lambert-Eaton myasthenic syndrome. He treated with extended thymomectomy resulting in the improvement of his neurological symptoms. Five years after operation, the patient is well without any malignant diseases.

[The influence of difference of surgical procedure for the young spontaneous pneumothorax to the recurrence rate after surgery].

INTRODUCTION: In spontaneous pneumothorax (SP) in patients under the age of 30, we studied the postoperative recurrence rate due to differences in the surgical procedures and the patient's age. MATERIALS AND METHODS: Between October 2003 and September 2012, 351 operations were performed for the young(30 years or younger)SP in our hospital. The recurrence rate was calculated in 2 age groups( under 20 or older) with different surgical procedures which were classified into 5 groups on the basis of the combination of the covering site with the polyglycol acid (PGA) seat and the presence or absence of ligation at both ends of staple-line. RESULTS: The mean age of all patients was 21.0±4.4, 320 were male. The recurrence rate of all was 8.8%.The group 20 years or younger in comparison with the group 21 years or older had significantly high recurrence rate after surgery(11.9% v.s. 5.1%;p=0.034).However, covering the staple-line with ligation of both ends and covering the staple-line and the bullae common site were both significantly lower recurrence rate compared with the group with covering only to the staple-line in 20 years or younger group(0% v.s. 23.8%;p=0.041, 4.9% v.s. 23.8%;p=0.041). CONCLUSION: The results suggest that we need to choose the appropriate procedure of the surgery for SP considering the patient's age. The recurrence rate in the patient 20 years or younger can be reduced by covering the bullae common site and/or the ligating both ends of staple-line in addition to covering the staple-line.

[Primary pulmonary malignant melanoma].

The patients was 63-year-old man. He had a chest abnormally shadow pointed out in examination of March, 2012 and referred to our hospital for a close inspection. The chest computed tomography(CT)revealed a mass shadow of 60 mm in left lung. Bronchoscopic examination was done and it was diagnosed as non-small-cell lung cancer by cytology. The clinical stage was cT2bN1M0 and video-assistedthoracic surgery (VATS) left pneumonectomy with mediastinal lymph node dissection was performed. A lot of neoplastic cells which contained melanin in cytoplasm were recognized by pathology and the diagnosis of malignant melanoma was comfirmed. Lymph node metastasis were recognized in #10, #11, #12 and the pathological stage of a disease was pT2bN1M0, pStage IIB. Further examination to find another lesion after surgery was in vain suggesting primary site to be left lung. A adjuvant chemotherapy has not been done. Surgical resection of primary pulmonary malignant melanoma is reported with reference to literatures.

[Mixed squamous and glandular papilloma].

The patient was a 64-year-old man. He had a smoking history for 43 years (20 cigarettes per day). Being pointed out a mass shadow in the left lower lung field on chest X-ray in a regular checkup, he was referred to our hospital. The chest computed tomography (CT) revealed a tumor shadow of 30 mm diameter in the left S8. Blood tests showed that carcinoembryonic antigen (CEA) and squamous cell carcinoma-related antigen (SCC) were elevated. Accumulation of standardized uptake value (SUV) max 9.78/15.17 match the tumor shadow in fluorodeoxyglucose positron emission tomography (FDGPET),suspected of malignancy. As a result of bronchoscopy, squamous cell carcinoma was suspected by cytology, and he was introduced to us for surgery. Video-assisted thoracic surgery (VATS)-left lower lobectomy and lymph node dissection was performed. By pathology, the tumor showed papillary growth in peripheral bronchus, with squamous cell and high columnar epithelial cell components. The tumor was diagnosed as mixed squamous and glandulas papilloma. In addition, a part of the squamous cells was considered to be atypical, indicating squamous cell carcinoma in situ in a mixed epithelial and glandular papilloma.

[Re-operation for recurrent pulmonary metastases].

Fifty two patients with metastatic lung tumors were treated surgically in our hospital. Second pulmonary resections were performed in 6 patients. They consist of 1 male and 5 females, their age ranged from 59 to 80 years old( average 66 years old). Tumors originate from laryngeal cancer, colorectal cancer in 2 cases respectively, lung cancer and hepatic cancer in 1 case respectively. Three-year and 5-year survival was seen in 75% and 75% of patients, respectively.

[Treament using a free omental flap for pulmonary Aspergillosis with chronic methicillin-resistant Staphylococcus aureus( MRSA) empyema after fenestration].

A case is 48-year-old man who had a history of Blalock-Taussig shunt and the radical operation for Fallot's tetralogy, had been performed cavernostomy and fenestration operation for aspergilloma of left upper lobe in the previous hospital due to control blood spitting. Although the contents of the abscess cavity were removed, the opened cavity was again infected by methicillin-resistant Staphylococcus aureus (MRSA) and he was referred to our hospital. The plombage of free omental flap with vascular anastomosis was performed. He has been well without any symptoms or recurrence of empyema for 6 years after surgery.

[Examination using multivariate analysis of the risk factors by surgical approach in elderly intractable pneumothorax].

PURPOSE: In this study, we evaluated the risk factors for postoperative complications in elderly patients with intractable pneumothorax and constructed a risk assessment model. MATERIALS AND METHODS: Between January 2004 and December 2011, 83 elderly patients( age, 75 years or older) underwent an operation at our hospital for intractable pneumothorax. Preoperative factors of these cases were assessed to clarify which is contributory to the development of postoperative complications by using univariate analysis and multivariate logistic regression analysis. RESULTS: Thirty-five patients (42.2%) developed postoperative complications. In univariate analysis, total protein, albumin level, blood urea nitrogen, creatinine level, Paco2, body mass index, performance status, and preoperative respiratory complications showed statistically significant associations with the occurrence of postoperative complications. In the multivariate analysis, the performance status showed a statistically significant association( 95% confidence interval, 1.17〜4.44;odds ratio, 2.28;p=0.0157). CONCLUSION: The results suggested that the preoperative examinations were useful in predicting postoperative complications in the elderly patients with intractable pneumothorax. Poor performance status, low nutrition, respiratory failure, and preoperative respiratory complications are risk factors for postoperative complications in elderly patients with intractable pneumothorax.

Effect of postoperative adjuvant chemotherapy with tegafur-uracil on survival in patients with stage IA non-small cell lung cancer: an exploratory analysis from a meta-analysis of six randomized controlled trials.

BACKGROUND: The Seventh Edition of the Tumor, Node, Metastasis Classification of Malignant Tumors in non-small cell lung cancer (NSCLC) proposes a more detailed classification of primary tumor diameter. Stage IA T1 disease is subdivided into two groups: T1a disease (tumor diameter, < or = 2 cm) and T1b disease (tumor diameter, >2 to < or = 3 cm). Tegafur-uracil (UFT) improves survival in patients with stage I NSCLC. However, whether it is effective in patients with T1 disease (stage IA) remains controversial. METHODS: Data from a 2005 meta-analysis of UFT were reanalyzed to evaluate the effectiveness of UFT according to T1a and T1b tumors as proposed by the new tumor, node, metastasis classification in patients who had T1 tumors with no lymph-node metastasis. RESULTS: Data from 1269 patients were analyzed: 670 (52.8%) had T1a tumors and 599 (47.2%) had T1b tumors. In the surgery-alone group, survival rates at 5 years were 85% in patients with T1a tumors and 82% in those with T1b tumors after surgery alone and 87% in patients with T1a tumors and 88% in those with T1b tumors after surgery followed by adjuvant treatment with UFT. In patients with T1b tumors, the survival rate was significantly higher in the UFT group than in the surgery-alone group (hazard ratio = 0.62; 95% confidence interval, 0.42-0.90; log-rank p = 0.011). The hazard ratio for death in the UFT group when compared with the surgery-alone group was 0.84 for those with T1a disease (95% confidence interval, 0.58-1.23). The results of a test for interaction between treatment response and T1 subgroup were not significant (p = 0.30). CONCLUSIONS: UFT significantly improves survival in patients with stage IA T1b NSCLC compared with surgery alone.

Four years experience of the survey on quality control of lung cancer screening system in Japan.

Although quality control is essential in mass screening system for early detection of cancer, no global method for quality control has not been established, because the mass screening system in each country is quite different from each other. At present, we have to find appropriate method for each cancer and for each country. In 2000, The Lung Cancer Screening Division (LCSD) of the Miyagi Prefectural Committee for Management of the Cancer Screening System (Miyagi PCMCSS) decided to evaluate annually whether the local governments had appropriate information to evaluate the quality of lung cancer screening systems, announcing that the results would be informed to residents. On the basis of the manual developed by the Ministry of Health, Labor and Welfare, 45 items were selected as indicators for the survey, which could be obtained easily when the screening had been conducted according to the standard method. LCSD of Miyagi PCMCSS sent a questionnaire including the 45 items to the municipalities. According to the reply to the questionnaire, LCSD rated each municipality using a 5-rank classification depend on the number of insufficient items: A: 0; B: 1-4; C: 5-8; D: 9 or more; E: no reply. As the results, 58, 3, 6, 3, and 0 municipalities were categorized in 2002 as A, B, C, D, and E, respectively. In 2003, the number of municipalities changed to 60, 7, 2, 1, and 0. In 2005, the distribution improved more, such as 68, 2, 0, 0, and 0. The detection rate of lung cancer also improved. It is possible for PCMCSS to annually conduct surveys to determine whether the local government has appropriate information to evaluate the quality of lung cancer screening systems. Such surveys improve the distribution of response to better direction.

Meta-analysis of postoperative adjuvant chemotherapy with tegafur-uracil in non-small-cell lung cancer.

PURPOSE: Recent clinical trials have shown the efficacy of platinum-based adjuvant chemotherapy for completely resected non-small-cell lung cancer (NSCLC). In Japan, many clinical trials of adjuvant chemotherapy with tegafur-uracil (UFT) have been conducted, and some trials showed positive results while others showed negative results. Thus, we performed a meta-analysis to assess the efficacy of postoperative adjuvant chemotherapy with UFT in NSCLC. METHODS: Among nine trials of postoperative adjuvant UFT-containing chemotherapy, six trials comparing surgery alone with surgery plus UFT were identified. Of six trials, two were three-arm trials including cisplatin-based chemotherapy followed by UFT, and data from that arm were not included in the meta-analysis. RESULTS: Of 2,003 eligible patients, most (98.8%) had squamous cell carcinoma or adenocarcinoma, and most had stage I disease; the tumor classification was T1 in 1,308 (65.3%), T2 in 674 (33.6%), and the nodal status was N0 in 1,923 (96.0%). The two treatment groups did not differ significantly in major prognostic factors. The median duration of follow-up was 6.44 years. The survival rates at 5 and 7 years were significantly higher in the surgery plus UFT group (81.5% and 76.5%, respectively) than in the surgery alone group (77.2% and 69.5%, respectively; P = .011 and .001, respectively). The overall pooled hazard ratio was 0.74, and its 95% CI was 0.61 to 0.88 (P = .001). CONCLUSION: This meta-analysis showed that postoperative adjuvant chemotherapy with UFT was associated with improved 5- and 7-year survival in a Japanese patient population composed primarily of stage I adenocarcinoma patients.

Surgical treatment of stage I non-small cell lung carcinoma.

In stage I non-small cell lung cancer (NSCLC), the cancer is localized to the lung. For this early stage NSCLC, therefore, surgery is considered to be the treatment of choice. In this report, we reviewed the surgical treatment approaches for stage I NSCLC, placing emphasis on limited resection and video-assisted thoracic surgery (VATS). In regard to limited resection, sublobar resection (wedge resection and segmentectomy) may yield a good long-term outcome in selected cases, as does lobectomy. No strong evidence to recommend this procedure has, however, been published. On the other hand, many descriptive studies have indicated that VATS may be useful for the treatment of NSCLC, although the results have not shown any statistically significant differences from those of resection by conventional open thoracotomy. In addition to the low invasiveness, the curability of NSCLC using the VATS approach has been recognized to be similar to that of the standard thoracotomic approaches in clinical practice. Well-controlled studies with strong statistical results are needed to provide strong supportive evidence for the use of VATS for NSCLC. (Ann Thorac Cardiovasc Surg 2003; 9: 283-9)

The efficacy of lung cancer screening conducted in 1990s: four case-control studies in Japan.

The efficacy of lung cancer screening is still controversial. In order to evaluate efficacy of mass screening for lung cancer in 1990s, the Japanese Ministry of Health and Welfare planned to conduct four independent case-control studies in four different regions; Miyagi, Gunma, Niigata, and Okayama Prefecture. The study design of all the four studies was a matched case-control study in which the decedents from lung cancer were defined as cases. In Gunma Prefecture, a screening examination is annual miniature chest X-ray only, whereas sputum cytology is added for high-risk screenees in others. Matching conditions were gender, year of birth, smoking histories (except Okayama), and municipality. Smoking adjusted odds ratio (OR) of dying from lung cancer for those screened within 12 months before case diagnosis compared with those not screened ranged 0.40-0.68. Three of four studies revealed statistically significant reduction of the risk for lung cancer death. OR of pooled analysis, where all sets were combined and analyzed, was 0.56 (95% confidence interval: 0.48-0.65). Recent mass screening program for lung cancer in Japan could reduce the risk for lung cancer death. However, the possibility exists that some confounding factors affected the results. In order to elucidate whether the results can be applied to Western countries, further studies will be required.

A randomized trial of postoperative UFT therapy in p stage I, II non-small cell lung cancer: North-east Japan Study Group for Lung Cancer Surgery.

OBJECTIVE: A prospective randomized trial was performed to investigate the prognostic advantage of postoperative adjuvant chemotherapy in patients with resected stage I-II non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: From March 1992 to December 1994, 221 patients with completely resected stage I-II primary NSCLC were enrolled and randomly assigned to two groups, as follows: 2-year oral administration of Uracil plus Tegafur (UFT) (adjuvant group, 109 patients), and surgical treatment alone (control group, 110 patients). RESULTS: The overall 5-year survival rates were 79% for the adjuvant group and 75% for the control group, and there was no statistical significance. The 5-year disease-free survival rates were 78% for the adjuvant group and 71% for the control group, and there was also no statistical significance. There have been seen no severe complications in the adjuvant group. The mean total dosages of UFT were about 75% of maximum basic amount. CONCLUSIONS: The UFT regimen was feasible. However, we have not observed any survival benefit in the adjuvant group. Larger trials are needed to confirm the effect of UFT to patients with resected NSCLC.