[Coexistence of Schwannomatosis from Vagal Nerve and Intercostal Nerve;Report of a Case].

Schwannomatosis with mediastinal vagal schwannoma is rare. A 71-year-old man presented with multiple mediastinal tumors by a regular check-up. A chest computed tomography showed well-defined round tumors along with the 3rd intercostal nerve and in the left upper mediastinal area. A percutaneous biopsy specimen of the tumor suggested benign tumor, however surgical excision was performed for a definitive diagnosis and treatment. The histological diagnosis was schwannoma. Since the tumor originated from the mediastinal vagal nerve proximal to the recurrent laryngeal nerve and was suggested to be benign, it was not resected to preserve the function of the recurrent laryngeal nerve.

Anterior mediastinal tumor as a solitary lymph node metastasis of occult thyroid carcinoma.

Solitary metastasis of occult thyroid carcinoma to the anterior mediastinum is very rare. A 65-year-old woman was examined for anterior mediastinal tumor based on the FDG accumulation on PET. We resected the tumor by video-assisted thoracic surgery. A pathological examination revealed that the tumor was lymph node metastasis of papillary thyroid carcinoma. The postoperative examination showed that the tumor was a solitary lymph node metastasis of occult thyroid carcinoma. Primary thyroid carcinoma has not appeared in 2 years since the surgery, and careful follow-up has been continued.

Modified risk scoring system for acute exacerbation of interstitial lung disease.

BACKGROUND: Lung cancer patients with interstitial lung disease often develop acute exacerbation of their interstitial lung disease after lung resection. Special care is needed in selection of the surgical procedure to reduce acute exacerbation and provide long-term survival. METHODS: The Japanese Association for Chest Surgery devised a risk scoring system based on 7 risk factors to predict the probability of postoperative acute exacerbation. We excluded surgical procedures and used a modified system categorizing 4 groups: group A (risk score 0-6), group B (risk score 7-10), group C (risk score 11-14), and group D (risk score 15-18). We retrospectively examined 60 lung cancer patients with interstitial lung disease to determine whether the modified risk scoring system is useful for selecting the optimal surgical procedure in anticipation of curability and risk of postoperative acute exacerbation. RESULTS: Eight (13.3%) patients experienced postoperative acute exacerbation. In group A ( n = 20), there was no difference in the incidence of acute exacerbation between wedge (0%) and anatomic resection (6.3%, p = 0.800). In group B ( n = 40), the incidence was significantly higher after anatomic resection (5.0% vs. 30.0%, p = 0.046). Thus group A had high-quality outcomes with anatomic resection, and in group B, the incidence of postoperative acute exacerbation can be reduced if wedge resection is performed. CONCLUSIONS: Our modified risk scoring can be useful for selecting the optimal surgical procedure in anticipation of curability and the risk of acute exacerbation of interstitial lung disease after lung cancer surgery.

Idiopathic spontaneous pulmonary torsion of the lingula: A case report.

INTRODUCTION: Spontaneous pulmonary torsion is an extremely rare event and is known to occur as a complication of thoracic surgery and traumatic injuries. PRESENTATION OF CASE: An 18-year-old man presented to our hospital with pain in the left back region. Clinical examination, computed tomography and bronchoscopy are crucial for diagnosis of pulmonary torsion. During thoracotomy, the lingula segment was observed to be bent on the head side and turned 180° counterclockwise; subsequently, lingulectomy was performed. DISCUSSION: Spontaneous pulmonary torsion may occur in pulmonary conditions such as pneumothorax, atelectasis, infection, pleural effusion, congenital defect, or tumor. Furthermore, it can be speculated that torsion of the segment is possible only in the patients with an accessory fissure or those who have undergone a segmentectomy. CONCLUSION: We have reported an extremely rare case with respect to the fact that the pulmonary torsion occurred spontaneously in an unseparated segment, and that the etiological factor could not be identified.

Immunohistochemical Expression and Serum Levels of CD44 as Prognostic Indicators in Patients with Non-Small Cell Lung Cancer.

BACKGROUND/OBJECTIVES: CD44 is often expressed in various types of tumor cells and involved in a number of biological behaviors of malignancy. The present study focused on the clinical significance of the expression of CD44st and CD44v6 in non-small cell lung cancer (NSCLC). METHODS: The cohort consisted of 261 consecutive patients who had undergone complete resection of NSCLC. CD44 expression was evaluated in surgical specimens by immunohistochemical staining. Serum CD44 levels were determined using a sandwich ELISA (enzyme-linked immunosorbent assay). RESULTS: In the immunohistochemical analysis, significant correlations were observed between CD44 expression and clinicopathological factors such as the T factor, N factor, pathological stage, and histological type. The 5-year survival rates according to CD44v6 expression were 65.8 and 80.6% in the higher and lower expression groups, respectively (p = 0.0053). According to ELISA, the group with higher expression of serum CD44v6 also showed a significantly more unfavorable prognosis than the lower expression group (p = 0.014). According to multivariate analysis using these significant variables, serum CD44v6 level was found to be an independent prognostic factor (p = 0.048). CONCLUSIONS: CD44v6 overexpression and higher serum CD44v6 levels were found to be significantly unfavorable prognostic factors.

The impact of covering the bulla with an absorbable polyglycolic acid (PGA) sheet during pneumothorax surgery.

We herein present the pathological findings of a bulla covered using an absorbable polyglycolic acid sheet applied with fibrin glue. These findings indicated that the membrane of the bulla was reinforced. Covering the bulla with an absorbable polyglycolic acid sheet (Neoveil, Gunze Ltd, Kyoto, Japan) and applying fibrin glue was effective to prevent the recurrence of the pneumothorax. Moreover, this report is the first case report showing the pathological findings of a bulla which was covered with an absorbable polyglycolic acid sheet and fibrin glue.

Primary Pulmonary Angiosarcoma Presenting with Hemoptysis and Ground-Glass Opacity: A Case Report and Literature Review.

Angiosarcoma originates from the vascular endothelium and accounts for only 1-2% of all sarcomatous malignancies. The skin is one of the most common primary sites. However, primary pulmonary angiosarcoma is rare, and only 31 cases of primary pulmonary angiosarcoma have been reported. A 79-year-old Japanese female developed bloody sputum, and chest X-ray and chest computed tomography (CT) showed consolidation with ground-glass opacity (GGO) on the right middle and lower lung fields. The bronchoscopic findings demonstrated bleeding from the right B(4) and B(5), and bronchial arterial embolization was subsequently performed. However, the CT findings demonstrated new pulmonary nodules with GGO in the left lung, and she presented with hemosputum and a progression of anemia. Right hemothorax also occurred, and surgical lung resection was performed to control the bleeding. The pathological analysis of the resected lung revealed the focal growth of atypical alveolar epithelioid-like cells that were positive for CD31 and negative for epithelial membrane antigen, and these atypical cells were replacing the endothelium of the pulmonary artery. Based on these findings, the patient was diagnosed with pulmonary angiosarcoma, which might originate from the endothelium of the pulmonary artery. No abnormal findings were observed except for the pulmonary involvement on systemic CT scanning. However, the patient passed away due to respiratory failure with compression of the brainstem caused by brain metastasis three months after the first visit. Early surgical resection is the important treatment for patients with angiosarcoma. In addition, we review the literature reporting the patients with primary pulmonary angiosarcoma.

Primary Adenoid Cystic Carcinoma of the Peripheral Lungs.

We herein report a very rare case of adenoid cystic carcinoma of the peripheral lungs. A 77-year-old female visited a family physician for aortitis syndrome, diabetes mellitus and hyperlipidemia. A follow-up chest computed tomography scan for aortitis syndrome revealed a nodule in the middle lobe of the right lung. Although a transbronchial lung biopsy was attempted, a definitive diagnosis could not be made. Because the possibility of lung malignancy could not be ruled out, thoracoscopic wedge resection of the middle lobe was performed. The intraoperative pathological diagnosis revealed carcinoma of the lungs and we performed middle lobectomy under complete video-assisted thoracoscopic surgery. A histopathological examination demonstrated an adenoid cystic carcinoma with a characteristic cribriform structure.

Discrepancy between the Clinical Image and Pathological Findings of Non-Small Cell Lung Cancer Harboring an Epidermal Growth Factor Receptor Gene Mutation That Was Surgically Resected after Gefitinib Treatment.

We herein describe a discrepancy between the clinical image and pathological findings in a non-small cell lung cancer patient with an epidermal growth factor receptor (EGFR) mutation who underwent surgical resection after gefitinib treatment. The patient was a 66-year-old female with c-stage IIIA lung adenocarcinoma harboring an EGFR gene mutation; she was surgically treated after receiving gefitinib. The pathological examination revealed adenocarcinoma, and the pathologically therapeutic effect was considered to be slight or of no response. EGFR T790M mutation and MET amplification were not present. The pathologically therapeutic effect is generally well correlated with the response rate after induction therapy. In this case, there was a discrepancy between the clinical image and pathological findings. Our findings, therefore, raise questions about the role of surgery after EGFR-tyrosine kinase inhibitor treatment.

Evaluation of undiagnosed solitary lung nodules according to the probability of malignancy in the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines.

BACKGROUND: This study retrospectively investigated the clinical significance of undiagnosed solitary lung nodules removed by surgical resection. PATIENTS AND METHODS: We retrospectively collected data on the age, smoking, cancer history, nodule size, location and spiculation of 241 patients who had nodules measuring 7 mm to 30 mm and a final diagnosis established by histopathology. We compared the final diagnosis of each patient with the probability of malignancy (POM) which was proposed by the American College of Chest Physicians (ACCP) guidelines. RESULTS: Of the 241 patients, 203 patients were diagnosed to have a malignant lung tumor, while 38 patients were diagnosed with benign disease. There were significant differences in the patients with malignant and benign disease in terms of their age, smoking history, nodule size and spiculation. The mean value and the standard deviation of the POM in patients with malignant tumors were 51.7 + 26.1%, and that of patients with benign lesions was 34.6 + 26.7%. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.67. The best cut-off value provided from the ROC curve was 22.6. When the cut-off value was set at 22.6, the sensitivity was 83%, specificity 52%, positive predictive value 90%, negative predictive value 36% and accuracy 77%, respectively. CONCLUSIONS: The clinical prediction model proposed in the ACCP guidelines showed unsatisfactory results in terms of the differential diagnosis between malignant disease and benign disease of solitary lung nodules in our study, because the specificity, negative predictive value and AUC were relatively low.

Clinical Characteristics of Resected T3 Non-small Cell Lung Cancer Characterized by Parietal Pleural Invasion or Chest Wall Invasion.

This study investigated the clinicopathological characteristics and the surgical outcome in patients with non-small cell carcinoma (NSCLC) with parietal pleura invasion or chest wall invasion (p3/T3). This study clinicopathologically evaluated 760 patients who had undergone a resection for NSCLC between 1999 and 2008. There were 43 (5.7 %) patients with p3/T3 NSCLC. The patients included 37 males and 6 females. The histological types included 23 squamous cell carcinomas, 13 adenocarcinomas, 3 large cell carcinomas, 3 pleomorphic carcinomas, and 1 spindle cell carcinoma. Pneumonectomy was performed in 2 patients, bilobectomy in 1, lobectomy in 31, segmentectomy in 3, and partial resection of the lung in 6. The combined resection regions were parietal pleural in 23, ribs in 16, pericardium in 2, and diaphragm in 2 patients. Major complications included empyema in 1, chylothorax in 1, and postoperative bleeding in 1 patient. The first recurrence sites in 16 patients with recurrent disease were the lung in 5 patients, brain in 3, bone in 2, adrenal gland in 2, skin in 2, liver in 1, mesenterium in 1, mediastinal lymph node in 1, axillary lymph node in 1, and carcinomatous pleuritis in 1. The overall 5-year survival rate after surgery was 50.6 %. An en bloc resection for p3/T3 NSCLC provides a modestly favorable prognosis. Local recurrence was observed in a minority of case, and recurrence by distant metastasis was observed in most cases, suggesting a greater need for postoperative chemotherapy.

Clinical significance of the frequency of regulatory T cells in regional lymph node lymphocytes as a prognostic factor for non-small-cell lung cancer.

BACKGROUND: Regulatory T cells (Tregs) are potent immunosuppressive cells that play a crucial role in tumor immune escape. The purpose of the present study was to evaluate the prognostic significance of the frequency of CD4+CD25+Foxp3+ Tregs in the regional lymph node lymphocytes (RLNL) and peripheral blood lymphocytes (PBL) in patients who underwent surgical resection of non-small cell lung cancer (NSCLC). METHODS: The RLNL and PBL in 158 NSCLC patients who underwent complete surgical resection were collected at the time of surgery. The proportions of CD4+CD25+Foxp3+ cells in the RLNL and PBL were determined by flow cytometry. RESULTS: The average proportions of Tregs in the RLNL and PBL were 1.28% and 0.76%, respectively. The proportion of Tregs in the RLNL was significantly higher than that in the PBL (p < 0.0001). The 5-year overall survival rates of the patients according to the proportion of Tregs in the RLNL were 84.4% and 63.5% in the lower and higher groups, respectively. A significant difference was observed in the survival rate between the higher and lower groups (p = 0.0056). Among the patients with stage I disease, the 5-year survival rate (91.4%) was significantly higher in patients with the lower proportion of Tregs in RLNL that in the higher group (72.1%) (p = 0.0147). CONCLUSIONS: The higher proportion of Tregs in the RLNL was a significant unfavorable prognostic factor, even in patients with node-negative NSCLC. The information about the proportion of Tregs in the RLNL might improve the discriminatory power for assessing the risk of the recurrence of NSCLC.

Clinical significance of expression of cancer/testis antigen and down-regulation of HLA class-I in patients with stage I non-small cell lung cancer.

AIM: The purpose of this study was to investigate the clinical significance of expression of cancer/testis (CT) antigen and down-regulation of HLA class-I in patients with stage I non-small cell lung cancer (NSCLC), which underwent complete surgical resection. PATIENTS AND METHODS: The expression of HLA class-I molecules was evaluated in 136 resected NSCLC specimens by immunohistochemistry. The results were scored as the percentage of stained tumor cells and categorized into two groups: 0-79%, reduced expression; and >80%, normal expression. The expression of CT antigen was performed by reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: The expression of HLA class-I was normal in 49 tumors (36%), and there was reduced expression in 87 tumors (64%). The expression of Melanoma antigen (MAGE)-A3, MAGE-A4, and Kita-Kyushu lung cancer antigen-1 (KK-LC-1) was positive in 34 (25.0%), 22 (16.2%), and 42 (30.9%) patients, respectively. There was no significant difference in the proportion of HLA class-I expression associated with the expression of any of the CT antigens. Among the patients with positive expression of at least one of the CT antigens, the 5-year survival rate of the patients with the normal expression of HLA class-I was 87.5%; however, it was 63.4% in patients with the reduced expression of HLA class-I (p=0.0477). CONCLUSION: Reduced expression of HLA class-I was an unfavorable prognostic factor in patients with positive expression of CT antigen, and represents an important hurdle to antigen-based cancer immunotherapy.

Discriminative features of thin-slice computed tomography for peripheral intrapulmonary lymph nodes.

BACKGROUND: The use of computed tomography (CT) scans has increased the opportunities to detect small nodular shadows in peripheral lung fields. Intrapulmonary lymph nodes (IPLNs) are sometimes identified among these nodular shadows, and a differential diagnosis is often difficult. However, few descriptions of the CT findings of IPLNs, with regard to their potential for the differential diagnosis of lung cancer, have been published. METHODS: From 2006 through 2011, 606 patients underwent thoracic surgery for pulmonary nodules. Nine patients (1.5%) had pathologically diagnosed IPLNs. We retrospectively reviewed the clinicopathological features and thin-section CT findings of the patients with IPLNs. We also compared these IPLN patients with 17 patients having small-sized lung cancer. RESULTS: In six cases, the nodules were round, and linear density extending from the IPLNs was visualized in seven nodules. The nodules in IPLNs were located in the lower lobe, and the nodule borders were clearer than those of lung cancers. Six out of nine nodules were round, and linear densities were more easily visualized for the IPLNs. CONCLUSION: Medical specialists need to be familiar with the discriminative features of thin-slice CT for IPLNs not only to avoid performing unnecessary operations, but also to prevent the mis-staging of lung cancer.

Intrapleural chemotherapy improves the survival of non-small cell lung cancer patients with positive pleural lavage cytology.

PURPOSE: Information regarding the treatment of pleural lavage cytology (PLC)-positive patients is still limited. This study evaluated the efficacy of intrapleural chemotherapy (IPC) in PLC-positive patients. METHODS: Three hundred eighty-six of the 567 lung cancer patients who underwent surgery had undergone PLC after thoracotomy, following by a complete resection were evaluated. IPC was performed after surgery, and cisplatin or adriamycin was injected intrapleurally through the thoracic tube. RESULTS: The pathological diagnosis showed that 17 patients (4.4 %) were positive for (or suspected to have) malignancy in their PLC. The univariate and multivariate analysis showed that only pleural invasion was a significant predictor of a PLC-positive status. The 5-year overall survival in PLC-positive patients was 38 % and that in PLC-negative patients was 84 %. Both the univariate (p < 0.01) and multivariate (p = 0.045) analyses showed that the status of PLC was significantly associated with the overall survival. Eight of the 17 PLC-positive patients underwent IPC. The 2-year OS rate in the patients treated with IPC was 88 % and that of those without IPC was 44 (p = 0.04). CONCLUSION: IPC improved the postoperative survival in PLC-positive NSCLC patients, and a further prospective evaluation regarding this therapy is warranted.

Serum level of osteopontin as a prognostic factor in patients who underwent surgical resection for non-small-cell lung cancer.

BACKGROUND: OPN is a multifunctional glycophosphoprotein originally described as a secreted protein from malignant epithelial cells. This study focused on the clinical significance of preoperative serum level of OPN in NSCLC patients who underwent a complete resection. PATIENTS AND METHODS: The serum OPN level was assayed in 244 patients who underwent a complete resection of NSCLC by commercially available sandwich enzyme-linked immunosorbent assay kits. The patients were considered as a higher group, when the serum OPN levels exceeded 81.3 ng/mL. RESULTS: The patients included 166 male and 78 female subjects. The histologic types included 172 adenocarcinomas, 49 squamous cell carcinomas, and 23 other types of carcinoma. The serum level of OPN in male patients (92.6 ng/mL) was significantly higher than that of female patients (76.9 ng/mL). The OPN level of squamous cell carcinoma was significantly higher than that of adenocarcinoma. The OPN level was significantly elevated in patients with the pleural invasion or microvascular invasion than those without the invasion. The 5-year survival rate after surgery in the lower OPN group (82.0%) was a significant favorable prognosis than that in the higher OPN group (63.7%) (P < .0001). The 5-year survival rates in the lower OPN group at stage I NSCLC (88.1%) was significantly better than that in the higher OPN group (80.5%) (P = .0321). CONCLUSION: The preoperative serum OPN level was a useful predictor of an unfavorable prognosis, and it was found to be an independent prognostic determinant of outcome in patients who underwent surgery for NSCLC.

Prognostic implications of human leukocyte antigen class I expression in patients who underwent surgical resection for non-small-cell lung cancer.

BACKGROUND: The purpose of the present study was to clarify the prognostic significance of human leukocyte antigen (HLA) class I expression in patients with non-small-cell lung cancer who underwent complete surgical resection. PATIENTS AND METHODS: The expression of HLA class I molecules was evaluated in 403 resected NSCLC specimens using immunohistochemistry. The results were scored as the percentage of stained tumor cells and were categorized into three groups: 0%-24% (decreased), 25%-79% (heterogeneous), and 80% or more (normal). RESULTS: The expression of HLA class I was evaluated in 124 tumors in the normal expression group, 181 tumors in the heterogeneous expression group, and 98 tumors in the decreased expression group. The 5-year survival rate of all patients after surgery according to the HLA class I expression in the normal, heterogeneous, and decreased groups was 76.6%, 65.9%, and 76.1%, respectively. The prognosis was significantly better in the normal expression group than in the heterogeneous group. Normal HLA class I expression also correlated with favorable survival in patients with stage I disease. CONCLUSIONS: The normal expression of HLA class I was associated with a favorable prognosis compared with the heterogeneous expression group, but no significant difference was observed between the normal expression and decreased expression groups.

An endobronchial lipoma successfully resected by high-frequency electric snare: a report of 2 cases.

Endobronchial lipoma is a rare, benign disease. When it causes chronic cough and pneumonia due to obstruction of the central airway, appropriate treatment is required. We herein report 2 cases of endobronchial lipoma successfully treated with a high-frequency electric snare through a flexible bronchoscope. Case 1, an 83-year-old man, visited a nearby hospital because of dyspnea on exertion. Chest computerized tomography revealed a tumor in the right main bronchus. He was referred to our hospital for further examination and treatment. Bronchoscopy showed a polypoid lesion in the right main bronchus. The tumor was resected by high-frequency electric snare through a flexible bronchoscope. Case 2 was an 83-year-old man who was diagnosed with pneumonia by a primary care physician on the basis of findings on chest computerized tomography. Bronchoscopy showed a polypoid lesion at the orifice of the right B6 bronchus, which caused segmental obstructive pneumonia. The tumor was bronchoscopically resected using a high-frequency electric snare and an neodymium-yttrium-aluminum-garnet laser. In both cases, the pathologic diagnosis was endobronchial lipoma.

Results of surgical resection for patients with thymoma according to World Health Organization histology and Masaoka staging.

OBJECTIVES: Thymomas are relatively rare tumors. In this study, we investigated the clinical features of patients who underwent surgical resection for thymoma. PATIENTS AND METHODS: This study clinicopathologically evaluated 54 consecutive patients who underwent a surgical resection of thymoma in our department between 1994 and 2006. RESULTS: A complete resection was performed in 52 patients, while two patients underwent an incomplete resection due to pleural dissemination. Combined resection with adjacent organs was performed for the lung (n=6), pericardium (n=5), and large vessels (brachiocephalic vein in three, superior vena cava in two). The concomitant autoimmune diseases were observed in 20 patients (37%), and they included myasthenia gravis in 17 patients, macroglobulinemia in one, pemphigus vulgaris in one, and stiff person syndrome in one patient. The histologic types of the World Health Organization classification diagnosed as type A in four patients, type AB in 14, type B1 in eight, type B2 in 15, and type B3 in 11. There were 27, 17, eight, and two patients with Masaoka stages I, II, III, and IV, respectively. Four patients died, and the causes of death included recurrence of thymoma in two, gastric carcinoma in one, and respiratory failure due to myasthenia gravis in one patient. The overall survival rate at 10 years was 94.6% in patients with stages I and II disease and 77.1% in patients with stages III and IV disease. CONCLUSIONS: Long-term survival can be expected not only for patients at early stages, as well as for patients with stages III and IV disease if surgical resection is completed macroscopically.

Effects of hyaluronic acid and CD44 interaction on the proliferation and invasiveness of malignant pleural mesothelioma.

Hyaluronic acid (HA) has been proposed as a biochemical marker of malignant pleural mesothelioma (MPM). The present study focused on the implications of HA and CD44 interaction in the proliferation and invasiveness of MPM. The proliferation and invasive activity was evaluated in two human mesothelioma cell lines, ACC-MESO-1 and K921MSO, by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and the transwell chamber model. The knockdown of CD44 gene expression was accomplished by transfection of the cells with small interfering RNA. Flow cytometry revealed that both the ACC-MESO-1 and K921MSO cell lines highly expressed CD44. Treatment with HA enhanced the proliferation in both mesothelioma cell lines in comparison to cells without HA treatment. The treatment with HA (25 µg/ml) also significantly upregulated the invasion of both types of cells. The silencing of CD44 significantly abrogated the effect of HA treatment on the proliferation of ACC-MESO-1 cells and significantly suppressed the proliferation of K921MSO cells. HA-CD44 binding is important for the migration and proliferation of mesothelioma cells. Therefore, the HA-CD44 interaction is a potentially useful therapeutic target in MPM.