Randomised study of adjuvant chemotherapy for completely resected p-stage I-IIIA non-small cell lung cancer.

We evaluated the therapeutic usefulness of adjuvant chemotherapy in patients with completely resected non-small cell lung cancer (NSCLC). We also examined the relation between DNA ploidy pattern and the response to chemotherapy. A total of 267 patients with NSCLC (pathologically documented stage I, II, or IIIA) underwent complete resection, and DNA ploidy pattern was analysed. Patients with stage I disease (n=172) were randomly assigned to receive surgery alone (group A) or surgery followed by adjuvant chemotherapy (UFT (oral anti-cancer drug, a combination of Uracil and Tegaful) 400 mg day-1 for 1 year after surgery; group B). Stage II or IIIA disease patients (n=95) were randomly assigned to surgery alone (group C) or surgery followed by chemotherapy (two 28-day courses of cisplatin 80 mg m-2 on day 1 plus vindesine 3 mg m-2 on days 1 and 8, followed by UFT 400 mg day-1 for at least 1 year; group D). Eight-year overall survival rate in patients with stage I disease was 74.2% (95% confidence interval (CI): 64.4-84.0%) in group B and 57.6% (95% CI: 46.4-68.8%) in group A (P=0.045 by log-rank test). In patients with stage II and IIIA disease, no difference was found between groups C and D. Analysis according to DNA ploidy pattern revealed no difference between the groups. Postoperative chemotherapy with UFT was suggested to be useful in patients with completely resected stage I NSCLC. No difference was seen in relation to DNA pattern in any treatment group.

[Lung cancer with both sarcoid reaction and metastasis in the mediastinal lymph nodes; report of a case].

A 66-year-old man was admitted to our hospital for detailed investigation of an abnormal shadow on his chest X-ray. Chest radiography and computed tomography(CT) of the chest showed mediastinal lymphadenopathy and a tumor shadow in the left upper lobe. Biopsy of the mediastinal lymph nodes by mediastinoscopy showed that sarcoid nodules existed in all the biopsies nodes. Therefore, the lymphadenopathy was thought to be sarcoidosis or sarcoid reaction accompanied with lung cancer. Left upper lobectomy and dissection of hilar and mediastinal lymph nodes were performed. Although sarcoid nodules were seen in all the dissected lymph nodes, the cancer involved #5 and #14 lymph nodes. He died of brain metastasis 10 months after surgery.

[Intrapleural streptokinase-streptodornase in the treatment of empyema and hemothorax].

Fourteen of 15 patients (93%) with retained pleural collections underwent successful enzymatic debridement and tube drainage with streptokinase-streptodornase (SK-SD) injections. No significant adverse reactions occurred. One patient required decortication when SK-SD therapy failed. Intrapleural SK-SD is a safe, effective means of removing retained proteinaceous collections in the pleural space. It may obviate the need for more invasive procedures.

A new technique for two-trocar laparoscopic cholecystectomy.

BACKGROUND: New techniques for laparoscopic cholecystectomy (LC) that reduce the number of trocars or use very thin instruments have been devised with the goal of further minimizing surgical invasiveness. METHODS: We performed two-trocar LC using an original new technique in 70 consecutive patients. A 10-mm trocar and a 5-mm trocar were inserted in the subumbilical and epigastrium positions, respectively. A 2-mm grasper forceps was inserted directly without a trocar below the costal margin. The fundus of the gallbladder was ligated and lifted up with a folded 0 silk string and a 16-gauge vessel cannula. RESULTS: The mean operative time was 73.2 +/- 23.5 min. A third trocar was added in two cases. None of the patients required conversion of the procedure to an open cholecystectomy, and there were no intraoperative complications. CONCLUSION: Based on our experience, we think that this technique is as safe and effective as the classic four-trocar technique; moreover, it has a cost benefit.

[Three cases of pulmonary eosinophilic granuloma].

CASE 1. A 55-year-old man was admitted because of an abnormality in chest radiographs. Chest HRCT showed multiple cystic lesions with thick and thin walls, and nodules; and strongly suggested pulmonary eosinophilic granuloma (EG). Open lung biopsy revealed granuloma formation and a fibrotic area consistent with EG. CASE 2. A 28-year-old woman was admitted because of chest pain and dyspnea. Chest radiography revealed bilateral pneumothorax. Chest HRCT showed multiple cystic lesions with thick walls involving the entire lung. As lung biopsy revealed, proliferative lesions and cavitation containing S-100 protein-positive histiocytes, we diagnosed this case as pulmonary EG in the active stage. CASE 3. A 32-year-old woman was admitted because of dyspnea. Chest CT showed bullous changes in the lung. As an open lung biopsy revealed, honeycomb changes with S-100 protein-positive histiocytes, this case was diagnosed as the regressive phase of EG. It is known that the chest radiography and HRCT findings of EG are characteristic and vary with the stage, so a surgical lung biopsy is necessary for diagnosis of EG. It is considered that the prognosis of the active phase of EG involving the entire lung is poor.

The spectrum of micronodular thymic epithelial tumours with lymphoid B-cell hyperplasia.

AIMS: A rare type of thymoma, micronodular thymoma with lymphoid B-cell hyperplasia, was recently reported by Suster and Moran. Thymic epithelial tumours with a similar pattern but with varied cytological features of the tumour cells are analysed. METHODS AND RESULTS: A total of 11 cases of thymic epithelial tumours characterized by micronodular proliferation of tumour cells separated by abundant lymphoid stroma with prominent germinal centres were reviewed clinicopathologically and examined immunohistochemically. The presence of Epstein-Barr virus (EBV) genome was also examined by in-situ hybridization. Based on the morphology of tumour epithelial cells, cases were subdivided into four groups: group 1 (two cases) having spindle epithelial cells; group 2 (two cases) showing an admixture of spindle and polygonal epithelial cells; group 3 (five cases) having polygonal epithelial cells, with mild to moderate cytological atypia in four cases, and group 4 (two cases) representing lymphoepithelioma-like carcinoma. The degree of cytological atypia and the number of tumour cells positive for MIB-1 and p53 gradually increased towards group 4. The abundant lymphoid stroma in all cases contained many CD20-positive B-cells and CD3 and CD45RO-positive T-cells. CD99-positive immature T-cells were present in all cases of groups 1 and 2 and in most cases of group 3, but not in both cases of group 4 tumours. IgG, IgM and IgD-positive plasma cells and lymphocytes were also present in all cases, more prominent in those of groups 3 and 4. The EBV genome was detected in only a few lymphocytes in five cases. CONCLUSIONS: The tumours in this series belong to a distinct category of thymic epithelial tumours and each of the above groups may constitute a spectrum in the continuum of cytological atypia. The aetiological relationship of EBV with these tumours could not be proved. The lymphoid B-cell hyperplasia may result from a host immune response and may suggest a favourable clinical course of this type of tumour.

Mucin-producing tumor of the pancreas associated with pyothorax: report of a case.

We report herein the case of a 76-year-old man for whom an invasive mucin-producing tumor of the pancreas (MPTP) was successfully treated by surgery. A cystic lesion of the pancreas had been found by computed tomography (CT) 9 years earlier, 2 years following which suction drainage for left pyothorax had been carried out. A pancreatic cyst fistula to the thorax had subsequently been found during decortication for recurrent pyothorax 2 years later. Methicillin-resistant Staphylococcus aureus was detected in the pleural discharge after the thoracotomy, and thoracic fenestration was performed. A CT scan done 4 years later showed enlargement of the pancreatic cysts and a cystography revealed communication to the duodenum via the main pancreatic duct. Endoscopic retrograde cholangiopancreatography (ERCP) showed dilatation of the main pancreatic duct. The pancreatic cyst fistulated to the stomach and to the fenestrated thorax. Since MPTP was suspected from this clinical course, a distal pancreatectomy, partial gastrectomy, and omentopexy to the thorax were performed. The pathological diagnosis was intraductal papillary-mucinous tumor of the pancreas with a megacyst. While MPTP is recognized as a low-grade malignancy, some cases of invasive disease have been reported. To the best of our knowledge, this is the first case of MPTP associated with pyothorax due to fistula formation.

Prognosis of non-small cell lung cancer patients with positive pleural lavage cytology after a thoracotomy: results of the survey conducted by the Japan Clinical Oncology Group.

OBJECTIVE: The purpose of this study was to clarify the prognosis of non-small cell lung cancer patients without pleural effusion whose intrapleural cancer cells were detected by a cytologic examination of pleural lavage fluid obtained immediately after a thoracotomy. METHOD: A questionnaire survey on the survival of the patients with positive pleural lavage cytology from January 1985 to December 1994 was performed by the Japan Clinical Oncology Group. RESULTS: According to the data collected from 15 institutions, 1890 non-small cell lung cancer patients without pleural effusion underwent pleural lavage cytology immediately after thoracotomy and 142 (7.8%) of them were found to have intrapleural cancer cells detected by the cytological analysis. The information of survival on 113 patients was available. This comprised of 64 males and 49 females with a mean age of 64.6 years. The predominant histologic type was adenocarcinoma (74%). Out of these 113 patients, 109 (97%) underwent a surgical resection. The 5-year survival rate was 30% in all patients, 49% in pathological stage I (n=35), 23% in stage II (n=20) and 26% in stage IIIA (n=34). CONCLUSION: Patients with a positive pleural lavage cytology in pathological stage I or II appear to have a poor 5-year survival rate.

Telomerase activity in endoscopically visible lung cancer.

To examine the correlation between telomerase activity and clinical features in patients with lung cancer, we examined 86 patients with endoscopically visible lung cancer including 61 with non-small cell lung cancer (NSCLC) and 25 with small cell lung cancer (SCLC). Telomerase activity was detected by using Telomerase ELISA Kit (Böhringer Manheim, Germany). The median and interquartile ranges of telomerase activity in normal lung, NSCLC and SCLC were 65 and 51-75, 106 and 58-349 and 285 and 117-2214, respectively. Normal lung, NSCLC and SCLC had significantly different telomerase activity (p < or = 0.0001). Between NSCLC and SCLC, SCLC exhibited higher telomerase activity than did NSCLC (p=0.0029). A cut-off level of absorbance [A450nm-A690nm] of 86 derived from 90% specificity in normal lung was used; sensitivity for overall lung cancer, NSCLC and SCLC was 62.8%, 54.1% and 84.0%, respectively. There was no significant difference in telomerase activity between each stage in NSCLC (p=0.9243). In SCLC, however, the median and interquartile range of telomerase activity in extensive disease (2128 and 292-2681) was significantly higher than those in limited disease (207 and 97-252) (p=0.0285).

Surgical results for small cell lung cancer based on the new TNM staging system. Thoracic Surgery Study Group of Osaka University, Osaka, Japan.

BACKGROUND: Operation with combined chemotherapy has been recently recommended for very early stage of small cell lung cancer without lymph node metastasis. METHODS: A retrospective study was undertaken in 91 patients who had undergone pulmonary resection for small cell lung cancer according to the new international staging system. RESULTS: The 5-year overall probability of survival was 37.1%. The 5-year survival rate was 100% for p-stage 0, 56.1% for p-stage IA, 30.0% for p-stage IB, 57.1% for p-stage IIA, and 42.9% for p-stage IIB. In the p-stage IA-IIB patients who underwent a complete resection, the 5-year survival rate of the patients treated by operation with chemotherapy was better than that of patients treated by operation alone. In addition, the 5-year survival rate of the patients who had four or more courses of chemotherapy was 80.0%. CONCLUSIONS: These results suggest that operation should be considered for p-stage IA-IIB patients and more than four courses of combined chemotherapy might be desirable in these resectable cases.

Results of preoperative mediastinoscopy for small cell lung cancer.

BACKGROUND: The significance of mediastinoscopy for small cell lung cancer is unclear owing to the small number of surgical cases. METHODS: To determine the N component of the TNM staging system, computed tomographic findings and the results of mediastinoscopy were compared with the pathologic examination of surgical specimens. RESULTS: Four cases among 37 patients (10.8%) were determined as inoperable by mediastinoscopy because of mediastinal lymph node metastasis. A thoracotomy was performed in 33 patients. Six patients (18.2%) who had been judged to have no metastasis by mediastinoscopy were found to have N2 disease after examination of the surgical specimens. In the identification of all mediastinal metastases, mediastinoscopy was 40.0% sensitive, 100% specific, and 83.8% accurate. When the superior mediastinal, paratracheal, pretracheal, tracheobronchial, and subcarinal lymph nodes were defined as approachable nodes, mediastinoscopy was 66.7% sensitive, 100% specific, and 94.6% accurate in the evaluation of these restricted nodes. Four cases among 8 patients with cN1 lesions resulted in a designation as pN2. CONCLUSIONS: Mediastinoscopy is useful for the diagnosis of an approachable mediastinal lymph node in small cell lung cancer cases. This exploration is necessary for patients with small cell lung cancer who are diagnosed as cN1 before thoracotomy.

Surgery for pulmonary metastases from colorectal carcinoma.

BACKGROUND: This study aims to clarify which patients would benefit by surgery for pulmonary metastases from colorectal carcinoma. METHODS: A retrospective study was undertaken in 25 patients who had undergone complete resection. In all cases, prethoracotomy carcinoembryonic antigen (CEA) level was measured and mediastinal or hilar lymph nodes were histologically examined. RESULTS: Overall 5-year survival was 39.2%. The 5-year survival rate for patients with a normal CEA level was 61.1%, as compared with 19.0% for patients with an elevated CEA level (p = 0.0423). The 5-year survival rate for patients without a lymph node metastasis was 49.5%, as compared with 14.3% for patients with a lymph node metastasis (p = 0.0032). No lymph node metastasis was a predictor of longer survival by univariate and multivariate analyses. The primary site, disease-free interval, and number and size of the metastasis were not significant prognostic factors. CONCLUSIONS: A resection for pulmonary metastasis from colorectal carcinoma is effective in patients with a normal CEA level and without a lymph node metastasis.

Prognostic significance of hTERT expression in non-small cell lung cancer.

To investigate the prognostic role of hTERT expression in non-small cell lung cancer (NSCLC), we examined the expression of hTERT mRNA in tumor specimens from 68 patients with NSCLC using RT-PCR. The expression of hTERT was detected in 34 (50%) of 68 cancer tissues. There were no correlations between hTERT status and any common clinical features except age. Patients with hTERT expression had shorter survival than those without hTERT expression. Multivariate analysis showed that hTERT expression was an independent negative prognostic factor. These results suggest that expression of hTERT may be an independent prognostic factor for NSCLC patients.

[Effect of granisetron in preventing emesis due to anti-cancer drug (CDDP) administration pulmo-mediastinal malignancies--comparison of simultaneous infusion with the conventional method of administration].

For patients with pulmo-mediastinal malignancies, the antimetic effect of granisetron was studied in the following two ways. Firstly in the standard method, 40 micrograms/kg of granisetron was infused for 30 minutes, 30 minutes before CDDP infusion. Secondly, in the simultaneous method, granisetron was mixed with CDDP in a 500 microliters infusion bottle, and then infused over 0.5-3 hours. Over a 24-hour time course, significantly effective rates (nausea less than mild, and vomiting 2 times less) were 72.7% in the simultaneous group (n = 22) and 52.6% in the standard group (n = 19). The non-effective rates were 18.2% and 15.8%, respectively. Although the results were not statistically significant, the simultaneous method is easier to perform and it seems to confer a slightly better clinical outcome than the conventional method.

Prognostic significance of CYFRA 21-1 in non-small cell lung cancer.

Between July 1991 and February 1993, CYFRA 21-1 levels of 149 newly diagnosed patients with histologically proven non-small cell lung cancer (NSCLC) at Osaka Prefectural Habikino Hospital were measured with an enzyme immunoassay method developed by Boeringer Mannheim (Enzymun-Test CYFRA 21-1). NSCLC patients with CYFRA 21-1 serum levels over 3.5 ng/ml had a significantly poorer prognosis than did patients with normal CYFRA 21-1 levels (P < 0.001). Univariate analysis revealed that CYFRA 21-1 levels above 3.5 ng/ml, poor PS, advanced stage and serum LDH over 450 U/l strongly correlated with survival period. In multivariate analysis, however, only CYFRA 21-1 was found to be an independent prognostic factor compatible with Stage and PS (P = 0.0040 for CYFRA 21-1, P < 0.001 for PS, P = 0.0052 for Stage).

Transcutaneous needle biopsy of the lung.

PURPOSE: To evaluate the usefulness of transcutaneous needle biopsy (TCNB). MATERIAL AND METHODS: From May 1988 to December 1994, we performed TCNB under fluoroscopic control in 408 patients with mass lesions of the peripheral lung. The Surecut needle (1.5 mm) was selected mainly because of its ability to obtain specimens large enough for histological examination. Of the 408 patients, 286 had had previous bronchofiberscopic examinations but no definite diagnosis had been reached. RESULTS: A definite diagnosis was obtained by TCNB in 305 (74.7%) of 408 cases (251 malignant neoplasms, 54 benign lesions). In malignant neoplasms, the pathological diagnosis based on cytology and histology together was more reliable than that based on cytology alone. Although the complications of this procedure (such as pneumothorax) were within the range of acceptability, care should be taken to avoid air embolism and the seeding of cancer cells along the needle tract. CONCLUSION: TCNB with the Surecut needle is a useful procedure with relatively low risk.

Prognostic significance of serum p53 antibodies in squamous cell carcinoma of the lung.

BACKGROUND: The prognostic significance of serum p53-Abs positivity for non-small cell lung cancer (NSCLC) is still unknown. PATIENTS AND METHODS: To determine the prognostic value of serum p53-Abs status, we determined serum p53-Abs and immunohistochemistry in 140 patients with stage I-IIIA NSCLC. RESULTS: p53-Abs were detected in 12.1% of all patients and in 17.6% of those with squamous cell carcinoma (SCC). Neither p53-Abs nor p53 overexpression alone was correlated with survival for all patients. When these factors were combined for SCC, seronegative patients with tumors overexpressing p53 survived significantly longer than did those with p53-Abs or p53-nonexpressing tumors. In multivariate analysis, p53-Abs status and p53 overexpression were independent prognostic factors for SCC (p = 0.0337). CONCLUSIONS: These findings suggest that the combination of p53Abs seropositivity and p53 overexpression may be a prognostic factor for SCC.