Hatched "egg" of thymoma with sarcoidosis.

BACKGROUND: While calcification of thymoma is common, "eggshell" calcification is rare. We report a case of an eggshell calcified thymoma that "hatched" after 4 years of follow-up. Pathologically, it revealed that sarcoidosis accompanied this case of thymoma, which might cause in calcification. CASE PRESENTATION: The patient was a 68-year-old female. A 20-mm anterior mediastinal nodule completely covered with calcification was noted in an annual health check-up. However, as the nodule did not change during 6 months of follow-up, she discontinued regular examinations. Four years later, an abnormality in her chest X-ray was noted again. The tumor grew outside the calcification to reach 63 mm. She underwent resection of this anterior mediastinal tumor. Pathologically, the tumor was diagnosed as thymoma of type B1 in the WHO classification. The histology of the tumor inside and outside of the calcification was not different, suggesting that the tumor grew from the inside of the calcification. The calcification was located within the fibrotic capsule of thymoma. Sarcoidosis also presented in her lung and mediastinal lymph nodes. CONCLUSIONS: Although the mechanism of calcification of the capsule was not clear, sarcoidosis might be related to this case because macrophage accumulation and altered lipid metabolism in sarcoidosis present with similar dystrophic calcification.

[Benefit of Adjuvant Chemotherapy after Curative Resection of Liver and Lung Metastases in Colorectal Cancer].

The survival benefit of adjuvant chemotherapy after resection of liver and pulmonary metastases in colorectal cancer(CRC) remains controversial. We enrolled9 0 CRC patients who underwent hepatic metastasectomy and2 5 CRC patients who underwent pulmonary metastasectomy between April 2005 and March 2017 to clarify the efficacy of adjuvant chemotherapy after hepatic andpulmonary metastasectomy. Forty-two patients receivedad juvant chemotherapy after hepatic metastasectomy, and1 0 patients receivedad juvant chemotherapy after pulmonary metastasectomy. Patients who underwent hepatic metastasectomy andreceivedad juvant chemotherapy hadlonger overall survival(OS)(p=0.043)andrelapse -free survival (RFS)(p=0.043)than those who underwent surgery alone. There were no significant differences in OS(p=0.84)andRFS (p=0.87)between patients receiving adjuvant chemotherapy after pulmonary metastasectomy and those receiving surgery alone. On multivariate analysis, adjuvant chemotherapy was independently associated with favorable OS in patients who underwent hepatic metastasectomy(hazardratio: 0.473, 95% confidence interval: 0.23-0.97, p=0.04). No prognostic factor associatedwith OS andRFS was identifiedin patients undergoing pulmonary metastasectomy. These results suggest that patients who undergo hepatic metastasectomy couldhave an OS andRFS benefit from adjuvant chemotherapy, but those who undergo pulmonary metastasectomy would not.

[Palliative Care Interactive Network in KAWAGOE: PINK for regional alliances].

The Cancer Control Act has come into effect in 2007. As an important idea of the act, a regional based hospital for cancer treatment and care should respect cancer patient's autonomy and improve his/her quality of life. We have organized PINK (Palliative Care Interactive Network in Kawagoe)in order to fulfill the idea in practical palliative care. Our activities are: Annual conference, Civic forum on Relay for Life in Kawagoe , Patients' association, and Case study examination using our mailing list. This network was built based on our activities to realize an important idea of the Cancer Control Act.

A desmoplastic fibroblastoma that developed in the anterior mediastinum: a case report.

BACKGROUND: Desmoplastic fibroblastoma (also known as collagenous fibroma) is a benign, slowly growing soft-tissue tumor. Most desmoplastic fibroblastomas develop in the limbs, neck, or trunk. A mediastinal origin is quite rare. CASE PRESENTATION: A 32-year-old Asian female was referred to us for the diagnosis and treatment of an anterior mediastinal tumor. The tumor was 80 mm in the largest diameter and was located on the pericardium. No invasion was evident. She underwent resection of the tumor via video-assisted thoracoscopic resection. The tumor was totally encapsulated, and its pedicle was on the pericardium. The resected specimen was very rigid, making it difficult to remove from the intercostal space. Histologically, the tumor was composed of a paucicellular dense collagenous tissue. Mitosis was rarely observed, and cellular atypia was not evident, suggesting that the tumor was benign. We diagnosed the tumor as a desmoplastic fibroblastoma by morphology and immunohistochemistry. CONCLUSIONS: Desmoplastic fibroblastoma of the mediastinum is an extremely rare disease. Preoperative diagnosis is difficult. Early surgical resection is suitable for diagnosis and treatment planning.

[Successful management of a patient with pain and dyspnea from bone metastasis and lymphangitis carcinomatosa after surgery for non-small cell lung cancer (NSCLC) in whom optimal dosages of transdermal fentanyl were determined by titration with fentanyl injection, and oxycodone hydrochloride].

With recent progress in disease-modifying treatments for cancer, patients who have recurrences during a period of several years before entering the terminal stage are encountered frequently. Despite improved life expectancy with cancer therapy, for patients this means prolongation of the period in which various symptoms such as cancer pain and adverse reactions are undergone. In these conditions, although the recognition is not yet sufficient, the importance of palliative care along with disease-modifying treatment is recognized in Japan. We treated a 50s female with pain and dyspnea from bone metastasis and lymphangitis carcinomatosa after surgery for NSCLC in whom the optimal dosages of transdermal fentanyl (Durotep Patch) were determined by titration with fentanyl injection, and oxycodone hydrochloride (OxyContin) in a short period. The dosages after titration were transdermal fentanyl 35 mg, oxycodone hydrochloride 60 mg, and betamethasone 4 mg. Before her death, she was able to stay at home with her family for 3 days without severe symptoms. In the present study we describe the clinical course of this case, the difference of characteristics in these opioids, and the titration method with fentanyl injection.

Metastatic thymic tumor arising from spermatic cord leiomyosarcoma.

We report the first known case of a metastatic thymic tumor arising from spermatic cord leiomyosarcoma, occurring in a 35-year-old man. He had undergone an orchiectomy 24 months previously and a surgical excision of a subcutaneous metastasis 4 months prior to his current presentation. Computed tomography revealed a 1.5-cm, round-shaped anterior mediastinal mass. A thymectomy was performed and the diagnosis of metastatic leiomyosarcoma was made.

[Prognosis of patients undergoing resection of both hepatic and pulmonary metastases from colorectal cancer].

This retrospective study evaluated the prognosis of patients undergoing resection of both hepatic and pulmonary metastases from colorectal cancer. The subjects were 14 patients who underwent resection of both hepatic and pulmonary metastases from colorectal cancer between January 1991 and January 2008. The range of patient age at first metastatectomy was 48- 73-years-old (median 59). The ratio of males to females was 4 to 3. Hepatic metastatectomy proceeded to pulmonary metastatectomy in 10 cases, while pulmonary metastatectomy was performed first in 4 cases. The median duration of relapse-free survival and overall survival after the second metastatectomy was 11.2 months and 20.4 months, respectively. The overall survival after the second metastatectomy tended to correlate with the relapse-free survival after the first metastatectomy (rs=0.55, p=0.08). In conclusion, relapse-free survival after the first metastatectomy should be considered when a second metastatectomy is scheduled in patients with both hepatic and pulmonary metastases from colorectal cancer.

[Problems involved in the resection of pulmonary metastasis from colorectal cancer in the era of new anticancer drugs].

BACKGROUND AND PURPOSE: Surgical resection has been the standard treatment recommended for respectable pulmonary metastasis from colorectal cancer. However, we should evaluate again the indication of bilateral thoracotomy and repeat resection of pulmonary metastatic lesions, because these surgical interventions may deteriorate the patients' quality of life. This retrospective study was performed to address this issue. PATIENTS AND METHODS: The subjects were 39 patients who underwent pulmonary metastatectomy of colorectal cancer between May 1990 and January 2007. The prognosis was evaluated according to the types of thoracotomy, bilateral thoracotomy (n=5), repeat pulmonectomy (n=6), and single thoracotomy (n=28). In addition, the impact of new anticancer drugs (5-fluorouracil+Leucovorin, S-1, irinotecan, and oxaliplatin) on survival after thoracotomy was examined. RESULTS: The patients undergoing bilateral thoracotomy showed a significantly shorter survival after the last thoracotomy than those in other groups (p=0.03). The survival time after the initial thoracotomy was not different between patients who received new anticancer drugs (n=11) and those without (n=28, p=0.58). CONCLUSIONS: Bilateral pulmonary metastatectomy from colorectal cancer appears to have little benefit on survival, while a repeat metastatectomy may cause a long-term survival. A further collection of cases is needed to conclude whether the new anticancer drugs would be useful for prolonging the patients' survival after pulmonary metastatectomy.

Clinical evaluation of chemosensitivity testing for patients with unresectable non-small cell lung cancer (NSCLC) using collagen gel droplet embedded culture drug sensitivity test (CD-DST).

PURPOSE: In the present study, we prospectively evaluated the clinical feasibility and efficacy of collagen gel droplet embedded culture drug sensitivity test (CD-DST) in unresectable non-small cell lung cancer (NSCLC) without previous treatment. EXPERIMENTAL DESIGN: Eighty patients with unresectable NSCLC, aged less than 81 years old, PS 0-1, and with evaluable tumor lesions, entered the study. If the patient had CD-DST active drugs, more than three cycles of chemotherapy containing these drugs were administered. If the patient did not have CD-DST active drugs, the patient could choose any treatment including best supportive care. RESULTS: Of the 80 patients in this study, CD-DST yielded results successfully in 49 patients (61.3%). CD-DST active drugs were present in 22 patients, and significantly more female patients had in vitro active anticancer agents than male (P=0.0008). All of the patients with CD-DST active agents received chemotherapy including these agents. In these patients, the response rate was 72.7%, and median survival was 15.0 months. In the patients without CD-DST active agents, 11 patients received standard, empirical chemotherapy. In these patients, response rate was 0%, and median survival was 6.0 months. CONCLUSIONS: The results show that CD-DST is capable of selecting the responders and the respective optimal regimens, and also delineating the patients less likely benefit from treatment.

Hemostatic efficacy of a recombinant thrombin-coated polyglycolic acid sheet coupled with liquid fibrinogen, evaluated in a canine model of pulmonary arterial hemorrhage.

BACKGROUND: In thoracic surgery, although infrequent, we encounter unexpected damage to the pulmonary artery (PA). In the present study, we evaluated the hemostatic efficacy of a newly developed fibrin-based sheet material, thrombin sheet, coupled with liquid fibrinogen (TSF), in an experimental model of PA hemorrhage. METHODS: Female beagles (n = 8) were used for the study. Left thoracotomy was performed under general anesthesia. PA injury (approximately 4 x 2 mm) was created, and repaired by TSF (TSF group) or TachoComb (TC group). The animals were allowed to survive, and the repaired site was evaluated 4 weeks after the experiment. RESULTS: The number of sheet application and compression procedures required for hemostasis was increased in the TC group compared with in the TSF group (TC vs. TSF, 4 +/- 1 vs. 1 +/- 0.5, p = 0.01, unpaired t test). The time required to achieve hemostasis was increased in the TC group compared with in the TSF group (TC vs. TSF, 7 +/- 3 vs. 1 +/- 0.5 minutes, p = 0.01, unpaired t test). The amount of bleeding during the hemostasis procedure was increased in the TC group compared with in the TSF group (TC vs. TSF, 48 +/- 22 vs. 3 +/- 3 g, p = 0.01, unpaired t test). At 4 weeks, rethoracotomy revealed no apparent indication of delayed bleeding, such as intrathoracic hematoma formation or excessive adhesion formation in the vicinity of PA, in either group. Histologically, the vessel lumen was well sustained in both groups, with no apparent stenosis or thrombus formation. CONCLUSION: The hemostatic efficacy of TSF was superior to TC in this particular experiment. Single application of TSF was sufficient to achieve hemostasis in all but one animal. Compression time of approximately 1 minute was also very short albeit that the bleeding was from the PA and not an artery. These results were presumably because the adhesion was stronger, faster, and the sheet was more pliable in TSF compared with TC.

Total absence of the pericardium incidentally found during surgery for spontaneous pneumothorax.

Congenital absence of the pericardium is a rare malformation which is often found incidentally. We report a case of pericardial absence which was found during surgery for spontaneous pneumothorax. Image analyses suggested that the pericardial absence was bilateral and total. These findings were overlooked on CT, preoperatively. Although rare, the possibility of asymptomatic pericardial absence should be kept in mind when observing the chest images before performing thoracic interventions.

Bcl-2 overexpression enhances in vitro sensitivity against docetaxel in non-small cell lung cancer.

Taxanes (docetaxel and paclitaxel) as well as cisplatin (CDDP) are key chemotherapeutic agents in the treatment of non-small cell lung cancer (NSCLC). Although some indicators of taxane resistance, such as beta-tubulin mutations, P-glycoprotein (P-gp) and Bcl-2, have been reported in malignant cells, the mechanisms of taxane resistance in NSCLCs have yet to be fully elucidated. We evaluated in vitro chemosensitivity to docetaxel (DOC) and CDDP in 87 surgically-resected specimens of NSCLC by collagen gel-droplet embedded culture drug sensitivity test (CD-DST). Bcl-2 and P-gp expression in these specimens were also investigated by immunohistochemistry. We examined the association between Bcl-2 and P-gp expression and in vitro chemosensitivity to DOC and CDDP. Out of the 87 NSCLCs that were examined, Bcl-2 and P-gp were expressed in 32 (36.8%) and 28 (32.2%) of the tumors, respectively. Positive Bcl-2 expression was significantly associated with enhanced DOC sensitivity in NSCLCs (p=0.007) while no apparent association was observed between DOC sensitivity and P-gp expression. Interestingly, although DOC, but not CDDP has been reported to be a substrate of P-gp, P-gp expression was significantly inversely correlated with CDDP sensitivity in pulmonary adenocarcinomas (p=0.03). Positive Bcl-2 expression may be a promising indicator in determining in vitro taxane sensitivity in NSCLCs. On the other hand, positive P-gp expression may be an indicator of enhanced in vitro resistance to CDDP in pulmonary adenocarcinomas.

The sealing effect of fibrin glue against alveolar air leakage evaluated up to 48 h; comparison between different methods of application.

OBJECTIVE: There is little experimental evidence to show how much positive airway pressure fibrin sealants can actually withstand, and in particular, how this effect changes over time. In the present study, we experimentally evaluated the sealing effect of fibrin glue against alveolar air leakage up to 48 h after application. METHODS: Beagles were used (n = 48). Under thoracotomy, approximately 5 x 10 mm defects (2 mm depth) were made on the lung surface. Fibrin glue sealants were applied to this defect in three ways. In rubbing and spray method, fibrinogen was rubbed, followed by spraying of both fibrinogen and thrombin solutions. In double layer method, fibrinogen was dripped, followed by thrombin. Collagen fleece, coated with fibrinogen and thrombin (TachoComb) was also tested. The minimum positive airway pressure which produced air leakage was measured for each sealed defect (seal breaking pressure, cmH2O) at 0, 3, 6, 12, 24, and 48 h after application (n = 6 at each time point). RESULTS: The seal-breaking pressure increased over time in all of the application methods. At 6 h, differences between methods were not significant but three defects in RS reached 70 cmH2O, the maximum pressure tested, compared with none in other two methods. At 12h, the seal-breaking pressure was significantly higher in RS compared with the other two methods (rubbing and spray method vs TachoComb; 66+/-3 vs 47+/-17, P = 0.047, rubbing and spray method vs double layer method; 66+/-3 vs 42+/-18, P = 0.024). Beyond 24 h, sealing pressure reached close to 70 cmH2O in all the methods. CONCLUSIONS: The results show that the sealing effect of fibrin glue is relatively unstable up to 12h after its application. Rubbing and spray method may help the fibrin seal to reach its full strength faster compared with the other two methods.

G-protein inwardly rectifying potassium channel 1 (GIRK 1) gene expression correlates with tumor progression in non-small cell lung cancer.

BACKGROUND: G-protein inwardly rectifying potassium channel 1 (GIRK1) is thought to play a role in cell proliferation in cancer, and GIRK1 gene expression level may define a more aggressive phenotype. We detected GIRK1 expression in tissue specimens from patients with non-small cell lung cancers (NSCLCs) and assessed their clinical characteristics. METHODS: Using reverse transcription-polymerase chain reaction (RT-PCR) analyses, we quantified the expression of GIRK1 in 72 patients with NSCLCs to investigate the relationship between GIRK1 expression and clinicopathologic factors and prognosis. RESULTS: In 72 NSCLC patients, 50 (69%) samples were evaluated as having high GIRK1 gene expression, and 22 (31%) were evaluated as having low GIRK1 gene expression. GIRK1 gene expression was significantly associated with lymph node metastasis, stage (p = 0.0194 for lymph node metastasis; p = 0.0207 for stage). The overall and stage I survival rates for patients with high GIRK1 gene expressed tumors was significantly worse than for those individuals whose tumors had low GIRK1 expression (p = 0.0004 for the overall group; p = 0.0376 for stage I). CONCLUSIONS: These data indicate that GIRK1 may contribute to tumor progression and GIRK1 gene expression can serve as a useful prognostic marker in the overall and stage I NSCLCs.

Successful management of a patient with stage IIIA non-small cell lung cancer using sensitivity-based induction chemotherapy--report of a case.

To select the most appropriate drug treatment for different patients with lung cancer, we have been measuring the chemosensitivity of lung cancer tissues to various drugs using the collagen gel droplet embedded culture drug sensitivity test (CD-DST). A 57-year-old Japanese male with stage IIA squamous cell carcinoma of the lung received sensitivity-based induction chemotherapy consisting of docetaxel (70 mg/m2) given on days 1, 22, and 43. He was treated as an outpatient, and no serious side effects were observed. After the chemotherapy, the left upper bronchus was reopened by the reduction of the tumor, and a left pneumonectomy with simultaneous partial resection of the pericardium was performed. After discharge, the patient received 2 cycles of adjuvant chemotherapy, consisting of weekly docetaxel doses (35 mg/m2) for 3 consecutive weeks, followed by one week without treatment. Although the 3-year survival rate of stage IIIA NSCLC patients is under 30%, three years after administration of the chemotherapy no other recurrence site has been detected, and the patient is in good health. Using CD-DST, sensitivity-based induction chemotherapy with docetaxel was successful in the patient reported here.

A case of pulmonary sarcoma with significant extension into the right lung.

A female patient in her 30s was referred to us with a mass approximately 8 centimeters in diameter in right lung segment 6. Bronchoscopy was done, and a tumorous lesion obstructing right B6 was found. Biopsy of this lesion supported suspicions of sarcoma or spindle cell carcinoma. Contrast-enhanced CT showed that the mass extended to and obstructed the right main pulmonary artery. A skip lesion was also suspected in the periphery of pulmonary artery trunk. The tumor was removed by right pneumonectomy accompanied by resection of the main and left pulmonary arteries under cardiopulmonary bypass. The pulmonary artery trunk and the left pulmonary artery were reconstructed with a vascular graft. Collectively, intimal sarcoma originating from the right main pulmonary artery with extension into the right lung was diagnosed. Significant extension of pulmonary artery sarcoma into the lung, as was observed in the present case, is considered to be rare, and to our knowledge this is the first report in which the primary lesion was biopsied by bronchoscopy.

Granulation tissue formation at the bronchial stump is reduced after stapler closure in comparison to suture closure in dogs.

The aim of this study was to compare the morphology of the bronchial stump after lobectomy between mechanical stapler closure and manual suture closure. The effect of fibrin glue application on each method of closure was also observed. Right upper lobectomy was performed in beagles (n=31) using staplers (ST group) or sutures (SU group). In a separate experiment, fibrin glue was sprayed onto the stump after each respective method of closure. After one week, the stump region was examined macroscopically, and also by histology. chi(2)-Test and Mann-Whitney test were used for comparative analysis. The incidence of adhesion formation between the surrounding tissues was significantly reduced in the ST group in comparison to the SU group (22 vs. 80%, P=0.04). The thickness of granulation tissue over the stump was significantly reduced in the ST group in comparison to the SU group (0.8+/-0.2 vs. 2.5+/-0.3 mm, P<0.0001). Vessel density in the granulation tissue was also significantly reduced in the ST group in comparison to the SU group (6+/-2 vs. 16+/-2, P=0.003). Fibrin glue application after stapler closure significantly increased the incidence of adhesion formation, granulation tissue thickness, and vessel density in the granulation tissue over the stump.

ATP7B expression is associated with in vitro sensitivity to cisplatin in non-small cell lung cancer.

Copper-transporting P-type adenosine triphosphatase (ATP7B) is reportedly associated with platinum drug resistance in various solid tumors. However, the impact of ATP7B on platinum drug resistance in non-small cell lung cancer (NSCLC) remains unclear. We investigated in vitro cisplatin (CDDP) sensitivity using the collagen gel-droplet embedded culture drug sensitivity test. The ATP7B mRNA expression level in each specimen was also examined using real-time polymerase chain reaction. The relationship between ATP7B expression and in vitro CDDP sensitivity was then evaluated. The ATP7B mRNA expression levels in CDDP-resistant tumors were significantly higher than those in the CDDP-sensitive group (p=0.015; Mann-Whitney U test). Our results suggested that ATP7B expression is a promising chemoresistance marker for cisplatin.

Association of ATP7A expression and in vitro sensitivity to cisplatin in non-small cell lung cancer.

Expression of copper-transporting P-type adenosine triphosphatase A (ATP7A) is reportedly associated with platinum drug resistance in various types of solid tumors. However, the impact of ATP7A expression on platinum drug resistance in non-small cell lung cancer (NSCLC) has yet to be adequately elucidated. In vitro cisplatin (CDDP) sensitivity was investigated using the collagen gel-droplet embedded culture drug sensitivity test, and the ATP7A mRNA expression levels were assessed by real-time polymerase chain reaction in surgically resected specimens of NSCLC. The relationship between the ATP7A expression levels and the in vitro CDDP sensitivity was then evaluated. The ATP7A mRNA expression levels in the CDDP-resistant tumors were significantly higher than those in the CDDP-sensitive tumors (p=0.0167, Mann-Whitney U test). In conclusion, the results suggest that evaluation of ATP7A expression is useful as a marker for cisplatin chemoresistance.

Migration of a Kirschner wire from the clavicle into the intrathoracic trachea.

We report a 70-year-old man who had a rare complication related to the insertion of Kirschner wires for fixation of a right clavicle fracture. Eight months after the placement of the Kirschner wires, he presented with cough and hemosputum. Chest roentgenograms, chest computed tomographic scans, and bronchoscopy revealed that one of the Kirschner wires had migrated through the lung and into the intrathoracic trachea. Immediate thoracotomy was performed to remove the wire. His postoperative course was uneventful.