[A pulmonary tumorlet with caseous granuloma associated with atypical mycobacterium].

We encountered a case of pulmonary tumorlet with caseous granuloma associated with atypical mycobacterium. A 73-year-old woman was admitted to the hospital because a chest x-ray film showed enlargement of an abnormal shadow in the middle lobe of the right lung. Primary lung cancer was suspected and right middle lobectomy was performed. Acid-fast bacilli (Gaffky 1) were found in a caseous lesion and examination of intraoperatively obtained frozen specimens showed caseous granulomas. The bacilli were later identified as Mycobacterium avium complex. The permanent specimen showed a minute lesion consisting of small clusters of epithelial cells resembling carcinoid tumor in contact with granulomatous tissue. Histopathological examination revealed argyrophilia on Grimelius stain and immunoreactivity to chromogranin-A in the clusters of epithelial cells. Although these results are consistent with small cell carcinoma or peripheral carcinoid tumor, pulmonary tumorlet was diagnosed because of the lesion's small and minimal cytologic atypia, and because of chronic pulmonary damage around the lesion. Pulmonary tumorlets are minute, usually microscopic, tumor-like lesions mostly found in damaged lung tissue obtained at autopsy or during surgery. Morphological diagnosis is sometimes very difficult, but recently these lesions have been regarded as hyperplastic lesions arising in pulmonary neuroendocrine cells (Kultschitzky cells) and caused by chronic pulmonary damage, such as hypoxia and inflammation. Pulmonary tumorlets must be considered in the differential diagnosis of minute lesions suspected to be small cell carcinoma or peripheral carcinoid tumor.

Elimination of CO from the body: an experimental study on the rabbit.

Rabbits were exposed to gases containing CO with concentrations ranging from 2.0 to 2.9% for 40 sec, 1 min, or 5 min, and the time course of the change in the arterial blood COHb concentration was followed from immediately after the end of exposure up to 180 min. All rabbits survived. Hypercapnia was not observed. The COHb concentration at the end of the 5-min exposure ranged from 68.8-82.0%. The pattern of the elimination of CO was not linear; the decreasing rate of COHb concentration became slower with the lapse of time. The COHb concentration plotted against the post-exposure time on a semi-logarithmic graph showed three phases. In the first 10 min, the rate of decrease was the fastest. The second phase was followed by the third phase at about 90 min after exposure. In the shorter exposure groups too, the initial phase was observed. The initial phase was considered to be a stage in which CO was distributed throughout the body. The appearance of the third phase is probably explained by the contribution of CO produced endogeneously. The existing equations for predicting COHb concentrations failed to explain the initial and third phases.

[Flow cytometric analysis of the DNA content of resected non-small cell lung cancer with reference to long-term follow-up].

We measured the cellular DNA content of paraffin-embedded tumor specimens by flow cytometry from 340 cases of resected non-small cell lung cancer, and investigated the correlation of DNA content and prognosis of these cases with long-term follow-up. These 340 cases were divided into some populations according to pathological stage, histologic type, surgical curativity and N factor, and we compared the prognosis of DNA diploidy cases and DNA aneuploidy cases in each population. DNA aneuploidy cases had a significantly less favorable prognosis than DNA diploidy cases in population of stage I adenocarcinoma, stage IIIA non-small cell lung cancer and N2 cases among stage IIIA non-small cell lung cancer, all after curative operation. But in other populations, there was no significant difference in prognosis between DNA diploidy cases and DNA aneuploidy cases. In conclusion, DNA ploidy pattern is a prognostic factor for survival in patients with stage I adenocarcinoma and N2 cases of stage IIIA non-small cell lung cancer.

[T cell lymphoma presenting as recurrent bilateral pulmonary infiltrates over five years].

A 52-year-old man presented with BOOP-like recurrent bilateral pulmonary infiltrates. In 1989 a chest X-ray film showed an infiltrative shadow in the right S6 region which disappeared after administration of prednisolone. Thereafter, bilateral patchy infiltrates recurred many times, and each time they resolved rapidly with steroid therapy. Skin eruptions on the face recurred. In October 1994 the patient underwent an open-lung biopsy of the infiltrate in the left S6 region. The pathological findings were consistent with BOOP, except for the moderate-to marked infiltration of lymphocytes. A lymphoproliferative disorder was suspected, and Southern blot analysis of the specimen revealed a rearrangement of the TCR-beta gene, which led to the diagnosis of T cell lymphoma. Ten months after the diagnosis, no recurrence of the lymphoma had been detected. In this case a gene analysis of the biopsy specimen was very useful for the diagnosis of T cell lymphoma.

[Chest wall reconstruction using polyester mesh].

From January 1987 through December 1994, we performed chest wall reconstruction using the polyester mesh in 15 patients with lung cancer, 11 with empyema after open drainage, 8 with chest wall tumor and 1 with radiation dermatitis and costal chondritis. Twenty five patients were resected 3 or more ribs. Chest wall defects were reconstructed with the polyester mesh covered with Gore-Tex soft tissue patch. Twenty two cases passed more than a year without signs of infection and follow-up averaged 27.6 months. Polyester mesh was removed due to bronchial fistula (3 cases), deformities (3 cases) and abscess formation (1 case). In these cases, polyester mesh was well incorporated and had no foreign body change. In conclusion, the polyester mesh seems to be a dependable prosthetic material for chest wall reconstruction.

[Positive expression of c-myc and p53 products in two cases of pulmonary sclerosing hemangioma].

The c-myc and p53 genes are thought to be an oncogene and a tumor suppressor gene, respectively. These genes' products are characteristic of malignant tumors. We quantitatively analyzed the c-myc and p53 products by flow cytometry in two cases of pulmonary sclerosing hemangioma. In case 1, 32.3% of the tumor cells were found to have the c-myc product, and 8.9% were found to have the p53 product. In case 2, 6.7% of the tumor cells were found to have the c-myc product and 15.5% were found to have the p53 product. The percentages in both cases were twice as high as those in a negative control lymphocytes stained with c-myc and p53 products. Therefore, these two cases showed positive expression of the c-myc and p53 products. In addition DNA from six other patients with sclerosing hemangioma was analyzed with paraffin-embedded sections. All six had DNA diploidy, with DNA indexes ranging from 0.91 to 1.03 and coefficients of variation ranging from 3.0 to 5.5. We suggest that pulmonary sclerosing hemangioma is a very weakly malignant tumor.

[Detection of loss of heterozygosity by microsatellite probe and DNA content analysis].

We examined replication error (RER) and loss of heterozygosity (LOH) in the region of microsatellites in 60 cases of resected lung cancer. We used microsatellite probes for the short arm of the 2nd chromosome (D2S123, D2S136), the short arm of the 3rd chromosome (D3S1067), and the short arm of the 17th chromosome (TP53). According to stage, the frequency of LOH was 25% in stage I, 33% in stage II, 44% in stage IIIA, 11% in stage III B, and 63% in stage IV. According to histological classification, the frequency of LOH was 41% for squamous cell carcinoma, 24% for adenocarcinoma, and 100% for small cell carcinoma. According to microsatellite probe results, the frequency of LOH was 6.7% for D2S123, 5.0% for D2S136, 16.7% for D3S1067, and 18.3% for TP53. Two of the 60 cases showed RER. One case was stage I squamous cell carcinoma, and the other was stage IV adenocarcinoma. Except for stage III B,LOH in the microsatellite region increases with the stage. LOH is often detected in the order of small cell carcinoma, squamous cell carcinoma, and adenocarcinoma. According to the chromosome number, LOH is detected more often in the 3rd and 17th chromosomes than in the 2nd chromosome. In 20 cases with LOH, only two showed DNA diploidy. Compared to LOH of the microsatellite region, DNA content analysis by flow cytometry has accuracy problems.

[DNA content analysis and detection of c-myc and p53 products using flow cytometry in resected lung cancer cases].

We quantitatively analyzed the c-myc and p53 products using flow cytometry in 28 cases of resected lung cancer and one case each of chorio-carcinoma, plasmacytoma, malignant mesothelioma and sclerosing hemangioma. In the lung cancer cases, c-myc and p53 products were detected in 10 cases (35%) and 7 cases (21%), respectively. These rates are higher than the DNA abnormal expression rates of the c-myc and p53 genes (15% and 12%, respectively) in our own data. In the adenocarcinoma of lung cancer cases, c-myc and p53 products were detected in 9 cases (53%) and 5 cases (29%), respectively. Among the squamous cell carcinoma cases, there were one case (11%) of c-myc expression and one case (11%) of p53 expression. DNA content analysis of the lung cancer patients revealed 7 cases of DNA diploidy and 21 cases of DNA aneuploidy. All 10 c-myc-positive cases showed DNA aneuploidy; thus the positive rate for c-myc products in the DNA aneuploidy cases was significantly different compared with the DNA diploidy cases (p < 0.05). In the sclerosing hemangioma case, we detected both c-myc and p53 products. Sclerosing hemangioma has been thought to be a benign tumor, but it may be a malignant tumor.

[Preoperative staging in T1 and T2 lung cancers by mediastinoscopy and mediastinal lymph node dissection].

Between 1975 and 1992, mediastinoscopy and thoracotomy were performed on 184 T1 and 271 T2 lung cancer cases consisting of adenocarcinoma and squamous cell carcinoma. Mediastinoscopy gave true negative findings in 90.8% of the T1 patients, true positive findings in 7.6% and false negative findings in 1.6%. The comparable rates were 76.7%, 17.0% and 6.3% in T2 patients. The 5-year survival rate was 91.3% for T1N0M0 patients (n = 64) who underwent non-radical dissection (= NRD), and 69.4% for those (n = 70) who underwent radical dissection (= RD). The rate with NRD was significantly better (p < 0.006). The 5-year survival rate was 63.2% for T2N0M0 patients (n = 62) undergoing NRD, and 49.8% for those (n = 72) undergoing RD, but the difference was not significantly. Distant metastasis was a common cause of death, whereas there were no deaths due to local recurrence in the T1N0M0 patients, whether NRD or RD was performed. These results support our opinions that preoperative mediastinoscopy and intraoperative node staging are sufficient for assessment of the N factor in T1 and T2 lung cancer, and that mediastinal node dissection should not be performed in T1N0M0 patients.

Can death at a low COHb concentration frequently observed in fire victims be explained by hypoxic hypoxia?

Fire deaths at low COHb (carboxyhemoglobin) concentrations are frequently observed, but it is difficult to determine the causative factors. Participation of hypoxic hypoxia was examined using rats and rabbits exposed to various low-O2 and CO gas mixtures. The ranges of O2 and CO concentration were 3.0-22.2% and 0.3-2.9%, respectively. The concentration of CO2 was fixed at about 5%. Rats were individually exposed to the test gas in a plastic chamber. Rabbits inhaled the test gas through a tracheal cannula. The survival time of rats ranged from 3.9-7.7 min, and that of rabbits was 8.0-22.5 min. Rats exposed to the most hypoxic gas mixture (O2 3%-CO 0.3%) died with COHb values below 40%. Rabbits also died with a low COHb concentration under this condition, but the COHb concentration was not below 50%. Rabbits were considered to be more resistant to hypoxic hypoxia than rats. From the literature on the relationship between the grade of burns and the concentration of COHb, as well as the findings obtained in the present experiment, hypoxic hypoxia did not appear to be a main factor causing death at low COHb concentrations. In the rabbit the COHb concentration increased exponentially and reached plateau levels within 10 min in many groups. The time required to reach a plateau COHb level was shorter when the concentration of CO was high and that of O2 was low.

[3 fatalities after communal use of methamphetamine]. / 3 Todesfälle nach gemeinschaftlichem Konsum von Methamphetamin.

Two young men and a 17-year-old girl gathered in order to take methamphetamine, the quantity of which remained unknown. After a short time one of the men died on the scene; the other man, who was alcoholized in addition to having taken methamphetamine, fell over a railing from a height of several metres and suffered severe injuries before dying. The girl, who left for home by taxi, collapsed and died in a hospital about 2 hours later. Methamphetamine was detected in the blood of all three people. The autopsy results and the toxicological findings are reported and discussed with reference to the literature data.

[A case of multiple pulmonary arteriovenous fistulae associated with splenic abscess].

A 51-year-old female was admitted with high grade fever, cyanosis and hypoxemia. The chest X-ray showed nodular shadows on bilateral lung fields. Beta-streptococci were found on culture from the blood, and the fever fell after administration of both antibiotics and corticosteroid. Pulmonary angiography revealed four arteriovenous fistulae on bilateral lung fields. On abdominal ultrasonography and CT scan, a hypoechoic lesion with an irregular wall and varying internal echogenicity was detected within the spleen. This lesion changed in size and shape during the clinical course and diminished with improvement in the patient's condition. These findings were compatible with splenic abscess. Splenic abscess with pulmonary arteriovenous fistulae is rare.

[A case of malignant mesothelioma of the pleura].

An operative case of malignant localized mesothelioma of the pleura, a 63-year-old male, came to our clinic with the chief complaint of hemosputa. On suspicion of lung tumor, right upper lobectomy and lymph node cleaning were performed. The tumor was embedded in the lung; there was no infiltration into the chest wall. After the operation, radiotherapy was added but tumor recurrence occurred in the 5th month, and the patient died 7 months after surgery. From the form of the recurrence it was considered a diffuse-type transition case. The prognosis of this disease is known to be poor, but since there have also been cases of long survival, cases of resection are studied in Japan. Based on macroscopic tumor findings, cases of occurrence in the visceral pleura have poor prognosis if embedded in the lung, while cases of occurrence in the parietal pleura have varied prognoses, but the differentiation line is yet unclear. Among six cases of diffuse-type transition, including this case, five cases were of the histological type which included the epithelial component. Further study of these cases is necessary in the near future.