A case of incomplete Carney's triad.

A 62-year-old woman, who had multiple pulmonary nodules noted 6 years earlier, and surgery for a gastrointestinal stromal tumor 2 years earlier, was found to have enlargement of her pulmonary nodules. Surgery was selected to make a definite diagnosis. Thoracoscopic segmentectomy of right segments 9 and 10 was performed, and pulmonary chondroma was diagnosed. Carney designated the combination of 3 rare soft tissue tumors (gastric leiomyosarcoma, pulmonary chondroma, and extraadrenal paraganglioma) as a syndrome. This patient may have had an incomplete type of Carney's triad with 2 lesions in the stomach and lung.

Intramuscular myxoma in the chest wall.

Intramuscular myxomas are benign soft-tissue tumors that often develop in the thigh. A 66-year-old woman was referred with an abnormal shadow on chest roentgenogram. The tumor was well defined and smooth and originated from the second intercostal space. Positron emission tomography showed no accumulation of 18F-fluorodeoxyglucose in the tumor. The patient attended the outpatient department for follow-up care. Because the mass grew slightly after 52 months, the patient underwent complete removal by video-assisted thoracoscopic surgery. On histopathological examination, the tumor was diagnosed as an intramuscular myxoma in the chest wall. The patient has had no recurrence 3 years after surgery. A case of intramuscular myxoma in the chest wall, completely resected by video-assisted thoracoscopic surgery, is reported. A well-defined, smooth, homogeneous mass in the chest wall may therefore be intramuscular myxoma.

A case of coelomic cysts of the mediastinum.

Coelomic cysts are rare cysts of mesothelial origin. They are generally unilocular and can develop in various sites. We describe a case of a multicystic lesion discovered incidentally in the anterior mediastinum of a 41-year-old man. Immunohistochemistry confirmed multiple coelomic cysts of the mediastinum.

A case of primary solitary pulmonary plasmacytoma.

Most solitary extramedullary plasmacytomas are plasma cell tumors that tend to develop in mucosa-associated lymphoid tissues including the upper respiratory tract. We present a 43-year-old patient who was diagnosed with a solitary plasmacytoma in the lung. Primary plasmacytoma of the lung is exceedingly rare, and the treatment is surgical excision. This malignancy advances to multiple myeloma in a minority of patients. Multiple myeloma is a plasma cell malignancy that typically presents in the bone marrow.

Venous hemangioma of the posterior mediastinum.

Here, we describe our experience in treating a patient with mediastinal hemangioma, a rare neoplasm. An abnormal shadow was noted in the thoracic region of a 54-year-old woman at a health checkup, and she was referred to our hospital. A neurogenic tumor was suspected based on the findings of the chest X-ray and computed tomography scan. Thoracoscopic tumorectomy was performed. The tumor surface was smooth with a reddish-dark reddish color, and capillary blood vessels showed marked growth around the tumor. The tumor was composed of medium or large blood vessels with a relatively thick vascular wall containing smooth muscle. On immunostaining, anti-CD34 antibody and Factor VIII were positive and D2-40 was negative. Based on these findings, the tumor was diagnosed as mediastinal venous hemangioma.

Serum hepatocyte growth factor and interleukin-6 are effective prognostic markers for non-small cell lung cancer.

AIM: We surveyed prognostic biomarkers for resectable non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: We obtained preoperative serum from 109 patients, and measured the levels of hepatocyte growth factor (HGF), interleukin-6 (IL-6), and nicotinamide N-methytransferase (NNMT) in the sera. RESULTS: The median HGF and IL-6 contents were 860 pg/ml and 2.7 pg/ml, respectively. Analysis of survival curves indicated that an HGF or IL-6 level higher than the median was associated with poor overall survival (HGF, p=0.019; IL-6, p=0.002). In addition, we analyzed stage III lung cancer alone. Higher HGF and IL-6 levels were associated with poor overall survival (HGF, p=0.016; IL-6, p=0.013). Disease-free survival was not statistically significantly affected by these cytokine contents. The tumor status (pT factor) and nodal status (pN factor) were not associated with the survival of stage III patients. CONCLUSION: The levels of HGF and IL-6 in serum could be useful prognostic indicators of the survival of patients with stage III NSCLC undergoing surgery and chemotherapy.

Unification of T2a and T2b tumors to T2 tumors in non-small cell lung cancer staging.

INTRODUCTION: We investigated the validation of the seventh edition of the TNM staging (2009) system for lung cancer, retrospectively. METHODS: From January 1990 to March 2004, 1629 patients who underwent lung resection with systemic lymph node dissection for non-small cell lung cancer at Nippon Medical School and Saitama Cancer Center were included. The overall survivals after surgery by each pathological stage according to the 1997 and 2009 systems were statistically analyzed using Kaplan-Meier estimated survival curves, and the significance of the difference was analyzed by the log-rank test. RESULTS: The 2009 system had significant prognostic distinction between each T descriptor except for T2a and T2b, and between each M descriptor. The 2009 system had better prognostic distinction between each pathological stage except for stages IB and IIA, and stages IIIB and IV. In the simulation, we unified T2a and T2b tumors into T2 tumors, and T2bN0M0 and T2bN1M0 were moved to stages IB and IIA, respectively. This proposed system had significant prognostic distinction between the proposed IB, IIA, and IIB stages. CONCLUSIONS: The 2009 system provides better patient selection for surgery and prognostic distinction between each stage except for stages IB and IIA, and stages IIIB and IV, compared with the 1997 system. Unification of T2a and T2b tumors to T2 tumors can improve prognostic distinction between stages IB and IIA.

[Prolonged convulsion after intoxication of alachlor herbicide (Lasso): a case report].

We experienced a case of alachlor herbicide (Lasso) intoxication. A 57-year-old man was transported to our hospital by ambulance after ingesting 450 mL of Lasso. He was unconscious and had difficulty in breathing. Gastric lavage was performed after tracheal intubation and the patient was placed on mechanical ventilation. Activated charcoal and laxative were administrated. Even after admission, disturbance of consciousness persisted. He had liver and kidney disorders but these did not progress to multiple organ failure. He experienced convulsions from day 4 and was administered anticonvulsants. Convulsion was intractable and needed long-term treatment. His general condition improved until discharge. He was weaned from mechanical ventilation and recovered consciousness, but he still displayed tremors. The herbicide (Lasso) is a combination of alachlor and monochlorobenzene. Studies have shown that alachlor is neurotoxic and monochlorobenzene accumulates in the brain. In case of intoxication with the herbicide Lasso, treatment is required for ameliorating neurotoxic effects and intractable convulsion as well as liver and kidney disorders, gastrointestinal mucosal damage, hematopoietic disorder, and acute circulatory failure.

Locally infiltrative glomus tumor of the bronchus: a case report.

We report a glomus tumor of the bronchus that showed invasion of the neural area and extrabronchial extension without significant histological malignancy. The patient was a male in his late 30s with the chief complaint being hemosputum. CT revealed a nodal shadow 15 mm in diameter in the right bronchus intermedius. An irregularly protruding lesion on the tumor surface was observed by bronchoscopy immediately under the second carina in the right truncus intermedius, but could not be diagnosed because of bleeding. Sleeve lobectomy of the right upper lobe was performed, since carcinoid tumor was suspected in open chest biopsy and intraoperative frozen section diagnosis. A solid growth of spherical and cubic uniform cells with a clear eosinophilic cytoplasm and spherical nuclei was observed. Immunohistochemistry was positive for α-smooth muscle actin and type IV collagen, weakly positive for synaptophysin, and negative for keratin, neural cell adhesion molecule, chromogranin A, desmin, CD34, and S100, leading to a diagnosis of glomus tumor. Neuroinvasion and extrabronchial tumor extension were observed, but an atypical cytology, bleeding, or necrosis was found histologically. This is the first description of infiltrative glomus tumor of the bronchus.

Beneficial effect of polymyxin B-immobilized fiber column (PMX) hemoperfusion treatment on acute exacerbation of idiopathic pulmonary fibrosis.

OBJECTIVE: This study was aimed to investigate the effect of polymyxin B-immobilized fiber column (PMX) hemoperfusion treatment on the acute exacerbation of idiopathic pulmonary fibrosis (IPF). PATIENTS AND METHODS: Six patients with a clinical diagnosis of idiopathic pulmonary fibrosis (IPF) who developed acute exacerbation were included in this study. Although five of six patients were treated with high-dose corticosteroid therapy, mechanical ventilation was necessary for all six patients due to severe respiratory failure. Blood endotoxin levels were undetectable in all patients. PMX treatment was performed on these six patients. RESULTS: In four of six patients, alveolar-arterial difference of oxygen (AaDO(2)), serum KL-6 and lactate dehydrogenase (LDH) were improved after PMX treatment. These four patients were successfully weaned from mechanical ventilation and survived more than 30 days after the initial PMX treatment. CONCLUSION: These data suggest a potential beneficial effect of PMX treatment on acute exacerbation of IPF.

[Tuberculoma of the mediastinal lymph nodes with spinal caries].

A 65-year-old male presented with a chief complaint of back pain. Chest computed tomography (CT) demonstrated partially calcified enlargements of the anterior mediastinal lymph nodes and pleural effusion in both lungs. His spondylous lesion rapidly progressed and developed into quadriparesis approximately 2 months after he noticed the back pain. We could not determine whether the lesion was an invasion of the spinal cord by a carcinoma of unknown primary or malignant lymphomas. Therefore, we performed a lymph node biopsy using a thoracoscope for a definitive diagnosis. Histopathology showed tuberculoma with epithelioid cell growth and images of previous scars. However, the staining method for tubercle bacillus did not reveal the presence of tubercle bacillus. As in this case, not all cases of tuberculoma present tubercle bacillus. Therefore, even with poor, suspicious findings for tuberculosis, we should always consider tuberculosis. Old tuberculoma may relapse and rapidly progress. Therefore, we concluded that a biopsy should be performed when tuberculoma is suspected.

Surgical treatment of superior sulcus tumors.

PURPOSE: To access the clinical outcome of patients with superior sulcus tumor. METHODS: We reviewed the records of 16 patients who underwent surgery for a superior sulcus tumor between 1988 and 2003, focusing on the type of surgery. RESULTS: All 16 patients underwent en bloc lung and chest wall resection, which was done as pneumonectomy in 1 patient and lobectomy in 15. Complete resection was achieved in 11 patients, but incomplete resection was done in 5 patients because microscopic examination revealed positive surgical margins. Eight patients underwent partial vertebrectomy and 1 patient had combined resection of the subclavian artery. There was no postoperative mortality. All patients received pre- or postoperative adjuvant therapy, or both. The overall 5-year survival rate was 31.0%. The 5-year survival rate was higher after complete resection than after incomplete resection (59.3% vs 0%, P = 0.08). Patients who underwent complete resection for vertebral invasion and those who did not had 5-year survival rates of 66.7% and 0%, respectively (P = 0.17). Patients who underwent preoperative induction therapy followed by complete resection and those who did not had 5-year survival rates of 80% and 0%, respectively (P = 0.009). CONCLUSION: Although superior sulcus tumors are still complex, preoperative induction therapy followed by complete resection seemed effective for prolonging survival.

Surgical treatment for lung cancer patients with poor pulmonary function.

UNLABELLED: This retrospective study was aimed to review the risk factors of postoperative hospital death in lung cancer patients with poor pulmonary reserves. We performed surgery on 30 lung cancer patients (average age: 71 years) with less than 1.0L of preoperative forced expiratory volume in one second (FEV1.0 < 1.0L) between 1982 and 2003. The preoperative FEV1.0 of these 30 patients was 0.81+/-0.1L on average. Six of 20 patients who underwent surgery between 1982 and 1997 died during their postoperative hospital stay (hospital death group). Between 1998 and 2003, 10 patients underwent surgery with uneventful postoperative courses. The clinical background was evaluated between the hospital death group (n = 6) and the survivor group (n = 24). The single-variable analysis of the preoperative conditions of the postoperative hospital death revealed the presence of two or more preoperative concomitant diseases (p < 0.001) and a performance status of grade 2 or higher (p = 0.005). Peripheral obstructive pneumonia with abscess and chronic pleurisy with adhesion influenced surgery and related to their postoperative hospital death. Whereas, patients with chronic obstructive pulmonary diseases (COPD) tended to show that pulmonary resection resulted in an improvement of pulmonary functions. CONCLUSION: To achieve better results of surgical treatment for patients with preoperative FEV1.0 < 1.0L, patient selection should be required based on precise evaluation of physical conditions and management of infectious diseases. Moreover, we thought that a preoperative performance status of grade 1 or lower, at most one preoperative concomitant disease, and a COPD are desirable for deciding the surgical indication.

Video-assisted thoracic surgery for Ewing's sarcoma of the mediastinum in a 3-year-old girl.

We report of the experience of video-assisted thoracic surgery (VATS) for a Ewing's sarcoma at the posterior mediastinum in a 3 year old girl. The patient developed common cold like symptoms and developed rapid lower limb paraplegia. A chest computed tomography (CT) showed a solid mass adjacent to the vertebrae. This was diagnosed as a Ewing's sarcoma histopathologically by CT-guided needle biopsy (CT-NB). The mass was pressing on a nerve root in the vicinity of a vertebral foramen. As the tumor reduced after induction chemotherapy, with improvement of paraplegia, the patient underwent thoracoscopic examination followed by complete removal of the tumor by VATS. After surgery, the patient underwent postoperative chemo-radiotherapy. Five years has passed after operation without tumor recurrence. VATS could be an option as combined therapy for Ewing's sarcoma when well controlled and localized under induction therapy.

Prognostic significance of the tumor suppressor gene maspin in non-small cell lung cancer.

BACKGROUND: Maspin is a serpin protease inhibitor, which is known to suppress tumor progression in breast cancer and to be regulated by wild-type p53. This study was performed to elucidate the biologic significance of maspin expression in non-small cell lung cancer. METHODS: To investigate whether maspin is involved in progression, clinicopathologic features, and prognosis of non-small cell lung cancer, we performed an immunohistochemical study using antimaspin antibody and identified the presence of maspin messenger ribonucleic acid in cancerous and noncancerous tissues by reverse transcription-polymerase chain reaction analysis. In addition, we evaluated p53 expression immunohistochemically on the serial sections. RESULTS: Most adenocarcinoma and squamous cell carcinoma showed cytoplasmic staining pattern. The cytoplasmic positive rate was 77.8% (42 of 54 specimens) for the stage III group, and 36.2% (21 of 58 specimens) for the stage I group (p < 0.0001). Three-year survival rates after operation were 30.8% for the maspin-positive group and 71.1% for the maspin-negative group (p = 0.007). In multivariate analysis, immunohistochemical maspin expression in patients with non-small cell lung cancer was an independent prognostic factor for overall survival. No correlation between maspin and p53 expression in cancer cells could be observed. There was an average fourfold increase in maspin messenger ribonucleic acid levels in cancerous tissues compared with those of noncancerous tissues, and stage III cases exhibited significantly higher maspin messenger ribonucleic acid levels than stage I cases (p = 0.003). CONCLUSIONS: The results of this study suggest that overexpression of maspin in cytoplasm may be a useful marker of tumor progression and unfavorable prognosis for overall survival in some patients with non-small cell lung cancer. Furthermore, maspin expression in cytoplasm appears to be unaffected by p53.

Primary pulmonary mucosa-associated lymphoid tissue lymphoma combined with idiopathic thrombocytopenic purpura and amyloidoma in the lung.

Three abnormal shadows were detected in the right lung on chest X-ray films and computed tomography in a 75-year-old woman during follow-up for idiopathic thrombocytopenic purpura. Because a definitive diagnosis was not obtained through general examinations, exploratory thoracotomy was performed for diagnosis and treatment. The main lesion in the right middle lobe was diagnosed as mucosa-associated lymphoid tissue (MALT) lymphoma according to histopathological findings, cytogenic studies and reverse transcriptase-polymerase chain reaction analysis, and nodular lesions in S(3) and S(7) were diagnosed with Congo-red staining as local deposition of amyloid. The patient had no recurrence of the MALT lymphoma of the lung or other organs for 4 years after surgery. To our knowledge, this is the first reported case of primary pulmonary MALT lymphoma combined with idiopathic thrombocytopenic purpura/lung amyloidoma.

Surgical treatment of lung cancer with vertebral invasion.

Vertebral body invasion by lung cancer has been problematic due to uncertainty regarding a clear surgical resection margin. Therefore, additional chemoradiotherapy has been performed to assist clearance of the surgical margin. We reviewed our experience of surgical treatment for lung cancer patients with vertebral invasion. Between 1982 and 2003, 1,070 patients underwent lung cancer surgery at the Nippon Medical School Hospital. Eight patients (0.74%) of this group underwent a combined vertebral body and chemoradiotherapy. Seven lobectomies and one pneumonectomy with mediastinal lymphadenectomy were performed. All patients underwent partial vertebrectomy. The percentage with vertebral tumor involvement was 15%. A defect of vertebral cortical bone was reinforced with implantation of rib in one patient. There was no postoperative mortality. Postoperative complications were pneumonia and arrhythmia. The median follow-up period was 19 months (range from 4 to 69.7 months). The overall actuarial survivals at 1-year, 3-year and 5-year were 68.6%, 22.9% and 22.9%. Local recurrence occurred in three patients and distant metastasis was evident in five. Even though the number of patients was small, partial vertebrectomy with chemoradiotherapy offer reduction of severe pain and an improved prognosis. However, a patient with further progressive disease should be treated with a multidisciplinary approach.

Surgical treatment of lung cancer combined with interstitial pneumonia: the effect of surgical approach on postoperative acute exacerbation.

UNLABELLED: Postoperative acute exacerbation of interstitial pneumonia (IP) is known to be a serious complication in the surgical treatment for primary lung cancer combined with IP. This retrospective study was conducted to investigate the influence of three different approaches to the thorax on postoperative acute exacerbation of IP in lung cancer patients. Forty-seven lung cancer patients who developed it underwent pulmonary resection between 1982 and 2003. Among them, approaches to the thorax consisted of posterolateral thoracotomy (PLT) (n=15), muscle-sparing thoracotomy (MST) (n=15), and video-assisted thoracic surgery (VATS) (n=17). Seven of 47 suffered from acute exacerbation of IP. Single variable analysis suggested that exertion dyspnea (Hugh-Jones classification), serum C-reactive protein, serum lactate dehydrogenase and total lung capacity were considered to be preoperative risk factors of acute exacerbation. As for the VATS patient, there was little frequency of postoperative complication in comparison with the other two approaches. However no significant difference was shown in the incidence of acute exacerbation between the three approaches. CONCLUSION: The use of VATS did not prevent acute exacerbation of IP. However, the incidence of postoperative complications in VATS seemed to be low, therefore further trials are required.

Video-assisted lobectomy for a lung cancer patient with chronic obstructive pulmonary disease.

OBJECTIVES: This retrospective study was conducted to see whether a video-assisted lobectomy is beneficial in lung cancer patients with chronic obstructive pulmonary disease regarding preservation of pulmonary function compared to lobectomy by standard thoracotomy. SUBJECTS AND METHODS: Between 1982 and 2002, 67 patients who underwent lobectomy for primary lung cancer showed 55% or less of preoperative forced expiratory volume in one second/vital capacity. Among them, 25 patients were enrolled in this retrospective study. The remaining 42 patients were excluded because of no presence of a postoperative pulmonary function test. Nine of 25 patients underwent a video-assisted lobectomy between 1994 and 2002 and the remaining 16 patients who underwent a lobectomy by standard thoracotomy between 1982 and 1994 were employed as a historical control. Perioperative conditions and changes in pulmonary function were compared between two groups. RESULTS: A parameter of chest wall damage was minor in video-assisted lobectomy compared to that in lobectomy by standard thoracotomy. Changes between pre- and postoperative percent of vital capacity, forced expiratory volume in one second and maximal ventilatory volume showed significantly minor deterioration or even improvement in video-assisted lobectomy patients. Predicted postoperative pulmonary function tended to be underestimated for postoperative values in video-assisted lobectomy patients. CONCLUSIONS: Video-assisted lobectomy seemed to be profitable in preservation of pulmonary function in lung cancer patients with chronic obstructive pulmonary disease. Prediction of postoperative pulmonary function should be revised due to the underestimation for postoperative values in video-assisted lobectomy, which could offer profitable surgical treatment for lung cancer patients with chronic obstructive pulmonary disease.

Immunohistochemical study of the expression of drug-resistant proteins in large cell neuroendocrine carcinoma of the lung.

OBJECTIVES: In 1999, the World Health Organization categorized pulmonary large cell neuroendocrine carcinoma as a variant of large cell carcinoma. However, an optimal treatment for large cell neuroendocrine carcinoma has not been established yet. Recently, multimodality therapy combining both surgery and adjuvant chemotherapy has been reported as a useful treatment for large cell neuroendocrine carcinoma, but the effect of chemotherapy on it has not yet been fully investigated. Thus, we evaluated immunohistochemical data of the expression of drug-resistant proteins in large cell neuroendocrine carcinoma. METHODS: We identified 10 large cell neuroendocrine carcinomas (1.2%) out of 850 primary lung cancers that had been surgically resected. We examined the immunohistochemical staining of three drug-resistant proteins, namely, P-glycoprotein, metallothionein and glutathione S-transferase-pi to compare large cell neuroendocrine carcinoma with other histological types of lung cancer. RESULTS: The mean tumor cell positivity rates for P-glycoprotein, metallothionein and glutathione S-transferase-pi in large cell neuroendocrine carcinoma were 0%, 2.4 +/- 3.6% and 35.0 +/- 37.5%, respectively. The positivity rates for P-glycoprotein and glutathione S-transferase-pi were significantly lower than those in adenocarcinoma (P = 0.0003, P = 0.0009). The positivity rate for glutathione S-transferase-pi was also lower than that in squamous cell carcinoma (P = 0.0387). These drug-resistant proteins showed similar expression pattern in both large cell neuroendocrine carcinoma and small cell carcinoma except glutathione S-transferase-pi. CONCLUSION: Immunohistochemical expression of drug-resistant proteins in large cell neuroendocrine carcinoma was lower than that in adenocarcinoma and squamous cell carcinoma, and differences exist in drug-resistance between large cell neuroendocrine carcinoma and small cell carcinoma.