Only surgical resection can identify the second primary lung cancer out of the metastasis after gastric cancer surgery.

OBJECTIVE: Solitary pulmonary lesions (SPLs) in patients with a history of malignancy require not only the distinction between benign and malignant, but also that between metastatic and primary lesions. We aim to establish the clinical strategy for the treatment of a solitary pulmonary lesion that is detected during the postoperative surveillance for gastric cancer. METHODS: We retrospectively examined the clinical records of the patients who underwent curative resection for gastric cancer between January 1999 and December 2009. Patients who were diagnosed with solitary pulmonary lesion during the postoperative surveillance underwent pulmonary resection, and were reviewed with regard to their histological diagnosis and prognosis. RESULTS: Out of a total of 1017 patients who underwent gastric resections during this period, 13 patients with solitary pulmonary lesion underwent pulmonary resection. These tumors were shown to be eight primary lung cancers, four metastatic tumors (three from gastric cancer) and one benign nodule. Of the eight patients with primary lung cancer, seven remained alive after pulmonary resection, including one liver metastasis case, and the other died without recurrence. In contrast, the other three patients with metastasis from gastric cancer died with distant metastasis, despite undergoing curative pulmonary resection. One of these three metastatic patients was misdiagnosed as primary lung cancer by transbronchial biopsy before surgery. CONCLUSIONS: Solitary pulmonary lesions detected during postoperative gastric cancer surveillance should undergo surgical resection to distinguish between primary and metastatic disease because of the quite different prognosis of these two entities.

An evaluation of the surgical morbidity of polyglycolic acid felt in pulmonary resections.

PURPOSE: Several methods using various materials have so far been reported to repair pulmonary air leaks, which is an essential problem in general thoracic surgery. Although the efficacy of these materials has been often discussed, the safety has only rarely been examined. This study evaluated the safety of polyglycolic acid (PGA) felt, one of the most commonly materials employed at this institute. METHODS: A total of 1026 patients who underwent a pulmonary resection from January 2000 to December 2007 were enrolled in this study. The status of PGA use, type of surgery, and incidence and type of surgical site infection (SSI) were reviewed retrospectively from the clinical records. RESULTS: Three hundred and forty-four patients were treated with PGA. Although two patients in the PGA group underwent a reoperation, PGA itself was not causative. In one case, the PGA felt strictly adhered to both the parietal and visceral pleura. CONCLUSION: Polyglycolic acid felt can be used safely in general thoracic surgery and did not influence the incidence or type of SSI. Surgeons should be aware of the possibility of adhesion around the material at the time of re-operation, and the criteria of PGA use should be strictly discussed.

[A case of primary pulmonary nocardiosis with multiple pulmonary nodules successfully treated with moxifloxacin].

A 18-year-old man was admitted with fever. His chest radiograph and CT scan showed consolidation shadow in the right middle lobe and multiple nodules in both lungs. He was treated with meropenem and minocycline. After this antibiotic therapy, the consolidation shadow disappeared and the multiple nodules were slightly reduced in their size. Since filamentous bacteria suspicious of Nocardia grew transiently in the initial sputum culture, we started to treat him with oral sulfametoxazole-trimethoprim. However, because agranulocytosis was caused by sulfametoxazole-trimethoprim therapy, we had to change the anti-bacterial therapy to minocycline. Minocycline was not effective, and the nodules enlarged. For accurate diagnosis, we employed video-assisted thoracic surgery (VATS) to investigate the histological and bacterial analyses of the pulmonary nodules. Histological findings of the pulmonary nodule obtained by VATS revealed granuloma with central necrosis associated with neutrophilic micro-abscess. Filamentous gram-positive bacteria in pulmonary nodule tissue was stained positively with both Grocott and Ziehl-Neelsen staining. Taking these findings together, we diagnosed primary pulmonary nocardiosis. Three months after initiating moxifloxacin, the size of the multiple pulmonary nodules was markedly reduced. Our experience with this case suggests that moxifloxacin can be recommended for the treatment of pulmonary nocardiosis.

Metachronous multiple thymoma with different clinical behavior and pathological findings.

A 70-year-old woman presented with a nodule in the left hilum on a chest radiograph 3 years before. Another mass emerged caudal to the initial nodule and was diagnosed as thymoma. A surgical specimen revealed two components: an encapsulated rostral nodule and a caudal mass invading the left lung. Histological findings showed that the rostral nodule was a stage 1 type B2 thymoma, whereas the caudal mass was a stage 3 type B3 thymoma. Based on the differences in biological behavior and histological findings, we concluded that these tumors derived from multicentric origin.

Simultaneous pulmonary metastases from colon and prostate cancer to the same lobe.

Simultaneous pulmonary metastases from different primary tumors to the same lobe are extremely rare, and we herein report the case. Surgical specimen of the pulmonary metastasis from colon cancer contained two additional nodules that were confirmed as metastases from prostate cancer. Pulmonary metastasis from prostate cancer rarely forms nodules, and there is a discrepancy in the incidence of pulmonary metastases between autopsy and clinical findings. This case suggests that different malignant tumors could simultaneously metastasize to the same pulmonary lobe, and more pulmonary metastases from prostate cancer might exist than expected.

[A case of solitary nodular pulmonary amyloidosis].

A 64-year-old man without respiratory symptoms was introduced to our hospital because of a nodule of 20 mm in diameter found in the left lung in a periodic health examination. The chest radiograph and CT scan showed a well-defined nodule in the middle of the left lung field, and enlarged mediastinal lymph nodes. Lung cancer was suspected, and transbronchial and CT guided biopsies were performed, but did not lead to a definitive diagnosis. Since the patient refused further examinations, we carefully followed up the nodule in the chest radiograph. After a year and a half, the nodule and the lymph nodes became enlarged, and the patient was admitted to the hospital for a surgical biopsy. Video-assisted thoracoscopic surgery followed by thoracotomy was performed for both a biopsy and nodule resection. Histologically, the nodule tissue was rich in amorphous substances positively stained with Congo Red, which was consistent with amyloidosis. No findings of systemic amyloidosis or secondary amyloidosis were demonstrated.

Multiple granulomatous lung lesions in a patient with Epstein-Barr-virus-induced mononucleosis and new-onset systemic lupus erythematosus: a case report.

INTRODUCTION: Granulomatous lesions are commonly encountered abnormalities in pulmonary pathology, and often pose a diagnostic challenge. We report an unusual case of granulomatous lung disease with uncommon characteristics, which developed following Epstein-Barr-virus-induced mononucleosis and new-onset systemic lupus erythematosus. We aim to highlight a diagnostic approach for the condition and to raise awareness of the possibility of it being related to the immunological reaction caused by Epstein-Barr virus infection. CASE PRESENTATION: A 36-year-old Japanese man, who had been diagnosed with Epstein-Barr-virus-induced infectious mononucleosis, new-onset systemic lupus erythematosus, and secondary Sjögren's syndrome three weeks previously, presented to our facility with fever and diffuse pulmonary infiltrates. A computed tomography scan of the chest revealed multiple small nodules in both lungs. Fiberoptic bronchoscopy with bronchoalveolar lavage revealed lymphocytosis with predominance of T lymphocytes. A histological examination of a lung biopsy taken during video-assisted thoracic surgery showed randomly distributed tiny granulomatous lesions with infiltration of eosinophils. The differential diagnoses included hypersensitivity pneumonitis, sarcoidosis, and pulmonary involvement of Crohn's disease, systemic lupus erythematosus, and Sjögren's syndrome, but the clinical and pathological findings were not consistent with any of these. Our patient's condition did not improve; therefore, prednisolone therapy was started because of the possibility of specific immunological reactions associated with Epstein-Barr virus infection. After steroid treatment, our patient showed radiological and clinical improvement. CONCLUSIONS: To the best of our knowledge, this is the first case of a patient developing randomly distributed multiple granulomatous lung lesions with eosinophilic infiltrates after Epstein-Barr virus infection and systemic lupus erythematosus. On the basis of our data, we hypothesize that Epstein-Barr virus infection altered the immune response of our predisposed patient and contributed to the pathogenesis of the lung lesions. Our patient's clinical response to steroid treatment was excellent.

A case of IgG4-related lung disease associated with multicentric Castleman's disease and lung cancer.

A 67-year-old man with submaxillary lymphadenopathy diagnosed as reactive follicular hyperplasia of the lymph node was referred to us for pulmonary evaluation. Pathological findings of the lung and hilar lymph node biopsies showed the histological feature of Castleman's disease (CD). Interestingly, infiltrated plasma cells had strong immunoreactivity for IgG4. In addition, this patient had coexisting lung cancer. We believe this is the first described case of IgG4-related lung disease associated with multicentric CD (MCD) and lung cancer. To establish a therapeutic strategy for IgG4-related lung disease, the association between IgG4-related disease and MCD needs to be clarified.

Feasibility study of adjuvant chemotherapy with gemcitabine and split-dose cisplatin for completely resected non-small-cell lung cancer.

INTRODUCTION: Recent clinical trials have shown significant survival benefits from postoperative adjuvant chemotherapy for resected non-small-cell lung cancer (NSCLC). However, due to the comparatively low compliance in recent clinical trials, this study investigated the feasibility of adjuvant chemotherapy with gemcitabine plus split-dose cisplatin for completely resected NSCLC. METHODS: Gemcitabine at a dose of 1000 mg m(-2) and cisplatin at 40 mg m(-2) were given intravenously on days 1 and 8 every 4 weeks for a maximum of four cycles. According to Simon's minimax two-stage design, if the regimen was judged to be safe and tolerable in five or more of the seven patients in the first stage, then enrollment would increase to a total of 20 patients. The feasibility of this regimen was proven if four cycles of chemotherapy were completed in more than 14 patients. The primary endpoint was the compliance to this regimen in the adjuvant setting, while the secondary endpoints were safety and toxicity. RESULTS: The regimen was judged to be safe and tolerable in the first stage, and therefore 21 patients were accrued as planned. Twenty patients (95%) received four cycles of chemotherapy; therefore chemotherapy compliance in the four cycles was 95%. The relative dose intensity was 97% for both gemcitabine and cisplatin. Grade 3/4 toxicities of neutropenia occurred in 33% and thrombocytopenia in 20%. Nonhematological adverse effects were extremely rare. CONCLUSION: Adjuvant chemotherapy with gemcitabine and split-dose cisplatin showed a favorable feasibility and acceptable toxicity in Japanese NSCLC patients.

The common trunk of the left pulmonary vein injured incidentally during lung cancer surgery.

We report a case in which the common trunk of the left pulmonary vein was injured incidentally due to a misunderstanding of the anatomy. After cutting the trunk, we recognized that the vessel included not only the superior but also the inferior component of the pulmonary vein. The cut end of the trunk and the left atrium were successfully anastomosed without any surgical morbidity. Although we retrospectively determined that the common trunk was visualized on preoperative computed tomography, we missed this finding during the preoperative evaluation. Furthermore, because we used the endostapler to cut the vessel, exposure of the pulmonary hilum was too short to identify the anomaly correctly. In the era of the endoscopic devices, exposure of the anatomical structures at surgery has become more limited, resulting in a tendency to misunderstand the anatomy during surgery. Because the common trunk of the left pulmonary vein occurs in 14% of patients demonstrating anatomical variations, thoracic surgeons should be aware of this type of anomaly not only before but also during surgery, and meticulous intraoperative confirmation of the vascular anatomy is required when using endoscopic devices.

Prognostic significance and possibility in guiding adjuvant therapy of the pleural lavage cytology in patients with non-small cell lung cancer.

Pleural lavage cytology (PLC) has been reported to be a significant prognostic factor in patients with operable non-small cell lung cancer (NSCLC). PLC may detect micro metastasis in patients without apparent pleural effusion or dissemination. Although many studies have reported PLC as a good predictor of postoperative recurrence, its role in the staging of NSCLC and in determining adjuvant therapy is still controversial. From June 1999 through December 2006, PLC immediately after thoracotomy was performed in 284 NSCLC patients without effusion or dissemination. Cases with exploratory thoracotomy were excluded from this study. Results of PLC were evaluated with other clinicopathological factors, and the difference in survival according to PLC status was investigated. Thirteen patients with positive PLC showed a poorer disease-free survival (P<0.0001) compared to those with negative PLC. The difference in survival rate between patients with positive and negative PLC, was significant in stage I disease, but not in stage II and III disease. PLC is a useful predictive marker for postoperative recurrence and should be routinely evaluated in lung cancer surgery, especially, in stage I disease. PLC might also assist in guiding adjuvant therapy.

A small, incidentally detected pancreatic somatostatinoma: report of a case.

We report an asymptomatic 72-year-old woman with a small, incidentally detected, pancreatic somatostatinoma. The tumor, measuring 1 cm in diameter, showed a hypervascular pattern of contrast enhancement on computed tomography, and was found angiographically to receive a blood supply from the posterior superior pancreaticoduodenal artery. The results of preoperative hormonal assays all were normal. No assay for somatostatin was performed. No abnormality in either the pituitary or parathyroid was found. We thus considered the tumor to be a sporadic, nonfunctioning endocrine cell tumor, and enucleation was carried out. As some tumor cells in the resected specimen showed immunoreactivity for somatostatin, a diagnosis of somatostatinoma was made. Therefore, the possibility of somatostatinoma should be kept in mind when making a differential diagnosis of pancreatic endocrine tumors in cases where even a small hypervascular tumor is detected on enhanced computed tomography.