[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.

Obstructive Shock Due to a Crushed Left Atrium and Pulmonary Vein by Pulmonary Artery Intimal Sarcoma Successfully Treated with Pulmonary Vein Stenting.

A 46-year-old patient who had undergone right pneumonectomy for pulmonary artery intimal sarcoma presented with hypoxemia. The recurrent sarcoma in the mediastinum revealed external compression to the left pulmonary veins (PVs), leading to obstructive shock and cardiac arrest. Venous artery extracorporeal membrane oxygenation (VA-ECMO) was initiated; however, withdrawal was difficult, and the patient's survival seemed hopeless. However, the patient's condition improved with stenting for the compressed PV; therefore, VA-ECMO was discontinued, and he was discharged on foot. This is the first case report of obstructive shock due to critical PV stenosis caused by compression of a malignant tumor that responded to PV stenting.

[Clinical significance of micrometastases in the lymph nodes of patients with resectable lung cancer].

Clinical evaluation of micrometastases in the lymph nodes of lung cancer patients is not currently recommended in guidelines because of several different results concerning their prevalence and prognostic implications. However, a recent large, prospective, multicenter clinical study has shown a significant prognostic impact of micrometasteses in the lymph nodes of patients with resectable lung cancer; therefore, the clinical significance of micrometastases as predictive markers of recurrence and prognosis has begun to be clarified. From the viewpoint of surgery for lung cancer, sentinel node navigation surgery, segmentectomy, and individualized therapies such as adjuvant chemotherapy are expected to be developed. In the near future, standardization and improvement of the efficiency of diagnostic procedures will be necessary in common clinical practice. Recently, minimal residual cancer cell research, such as circulating tumor cells in the peripheral blood and disseminated tumor cells in the bone marrow, has made good progress. As research in this field continues, it is expected that the mechanism of metastasis and novel therapeutic strategies targeting minimal residual cancer cells will become better understood.

Thoracoscopic and laparoscopic approach for pleuroperitoneal communication under peritoneal dialysis: a report of four cases.

BACKGROUND: Pleuroperitoneal communication (PPC) is a rare complication of continuous ambulatory peritoneal dialysis (CAPD) and often forces patients to switch to hemodialysis. Some efficiencies of video-assisted thoracic surgery (VATS) for PPC have been reported recently; however, there is no standard approach for these complications. In this case series, we present a combined thoracoscopic and laparoscopic approach for PPC in four patients to better assess its feasibility and efficiency. CASE PRESENTATION: Clinical characteristics, perioperative findings, surgical procedures, and clinical outcomes were retrospectively analyzed. We combined VATS with a laparoscopic approach to detect and repair the diaphragmatic lesions responsible for PPC. We first performed pneumoperitoneum in all patients following thoracoscopic exploration. In two cases, we found bubbles gushing out of a small pore in the central tendon of the diaphragm. The lesions were closed with 4-0 non-absorbable monofilament sutures, covered with a sheet of absorbable polyglycolic acid (PGA) felt, and sprayed with fibrin glue. In the other two cases without bubbles, a laparoscope was inserted, and we observed the diaphragm from the abdominal side. In one of the two cases, two pores were detected on the abdominal side. The lesions were closed using sutures and reinforced using the same procedure. In one case, we failed to detect a pore using VATS combined with the laparoscopic approach. Therefore, we covered the diaphragm with only a sheet of PGA felt and fibrin glue. There was no recurrence of PPC, and CAPD was resumed at an average of 11.3 days. CONCLUSIONS: The combined thoracoscopic and laparoscopic approach is an effective treatment for detecting and repairing the lesions responsible for PPC.

A Case of Intractable Lung Abscess Following Dropped Gallstone-Induced Subphrenic Abscess: A Rare Postoperative Complication Caused by Dropped Gallstone During Laparoscopic Cholecystectomy.

Dropped gallstones into the abdominal cavity due to perforation of the gallbladder occasionally occur during laparoscopic cholecystectomy. Abscess formation caused by residual gallstones is one of the late postoperative complications after laparoscopic cholecystectomy. Most of them are intra-abdominal abscesses; however formation of intra-thoracic abscesses, in particular, lung abscess, is less described, and surgery for an intra-thoracic abscess is rarely performed. We describe a case of intractable lung abscess following dropped gallstone-induced subphrenic abscess caused by a residual gallstone after laparoscopic cholecystectomy.

A case of pleuroperitoneal communication in which establishing a laparoscopic pneumoperitoneum was useful for the detection of a fistula.

BACKGROUND: Pleuroperitoneal communication (PPC) is rarely observed, accounting for 1.6% of all patients who undergo continuous ambulatory peritoneal dialysis (CAPD). Although there have been several reports concerning the management of this condition, we have encountered several cases in which control failed. We herein report a valuable case of PPC in which laparoscopic pneumoperitoneum with video-assisted thoracic surgery (VATS) was useful for supporting the diagnosis and treatment. CASE PRESENTATION: The patient was a 58-year-old woman with chronic renal failure due to chronic renal inflammation who was referred to a nephrologist in our hospital to undergo an operation for the induction of CAPD. Post-operatively, she had respiratory failure, and chest X-ray and computed tomography (CT) showed right-sided hydrothorax that decreased when the injection of peritoneal dialysate was interrupted. Therefore, PPC was suspected, and she was referred to our department for surgical repair. We planned surgical treatment via video-assisted thoracic surgery. During the surgery, we failed to detect any lesions with thoracoscopy alone; we therefore added a laparoscopic port at her right-sided abdomen near the navel and infused CO2 gas into the abdominal cavity. On thoracoscopy, bubbles were observed emanating from a small pore at the central tendon of the diaphragm, which was considered to be the lesion responsible for the PPC. We closed it by suturing directly. CONCLUSIONS: VATS with laparoscopic pneumoperitoneum should be considered as an effective method for inspecting tiny pores of the diaphragm, especially when the lesions responsible for PPC are difficult to detect.

[Plasmacytoma of chest wall].

We report a 70-year-old man who suffered from right anterior chest wall tumor. Physical examination revealed an elastic hard mass at the right 4th rib measured 6 cm in diameter. Chest X-ray and computed tomography (CT) revealed enhanced mass and destruction of the 4th rib. As needle aspiration cytology did not define the diagnosis, we performed a chest wall resection and reconstruction. Histological diagnosis of the tumor was plasmacytoma (IgG lambda type). Five months after the operation, the tumor recurred at the right anterior chest wall. Radiotherapy was performed with dose of 50 Gy. Fourteen months after the operation, the tumor recurred at the lower sternum, and the chemotherapy was performed using ranimustine, vincristine, melpharan and dexamethasone. He is doing well 2 years and 9 months after surgery without signs of progressive disease or conversion to myeloma

Cardiac herniation after extrapleural pneumonectomy.

Cardiac herniation is a fatal complication in patients undergoing pneumonectomy with pericardial resection. A 53-year-old man underwent right-sided extrapleural pneumonectomy for malignant pleural mesothelioma. He underwent right-sided pericardial resection and reconstruction with an expanded polytetrafluoroethylene sheet. Routine chest radiography performed 18 h postoperatively revealed cardiac herniation into the right-sided thoracic cavity. The patient was immediately transferred to the operating room, and the defect was repaired. He died of tumor progression. However, cardiac herniation did not recur over 2 years postoperatively.

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.

Management of Airway Obstruction due to Diffuse Idiopathic Skeletal Hyperostosis in the Cervical Spine: A Case Report and Literature Review.

Diffuse idiopathic skeletal hyperostosis (DISH) is a relatively common progressive noninflammatory entheses disease. Patients are often asymptomatic or are undiagnosed due to minor chronic symptoms. We herein report a rare case in which the primary symptom was sudden-onset upper airway obstruction due to exuberant osteophytosis in the cervical spine. Treatment was successful with careful airway management and surgical osteophyectomy. Most DISH cases in the literature with airway obstruction have been managed with tracheotomy. However, the safety and necessity of this approach remain questionable. We herein discuss the possibility of conservative management as a choice of airway control. Airway obstruction due to DISH may be underrecognized. This highlights the importance of including DISH in the differential diagnosis of airway obstruction. In addition, a detailed evaluation and personalized care for each individual case is essential.

Expression of cytochrome P450 in non-small cell lung cancer.

Lung cancer accounts for most of cancer-related deaths in both men and women. Lung cancer is also associated with cigarette smoking that exposes the individual to carcinogenic chemicals. Normally, CYP enzymes (cytochrome P450s) metabolize carcinogens to inactive derivatives, however, occasionally the action of CYP enzymes leads to development of more potent carcinogens. In addition to the metabolism of carcinogenic compounds, CYP enzymes are also involved in the activation and/or inactivation of agents, which are used in the treatment of lung cancer. Therefore, the local level of CYP enzymes in lung cancer and surrounding tissues could be an important determinant in the efficacy of anticancer drugs. Furthermore, the expression of CYP19 (aromatase), estrogen synthesis P450, was found in more than 80 percent of non-small cell lung cancers. Lung cancer was also found to frequently express CYP24A1 that converts 1 alpha, 25-dihydroxyvitamin D3 to its inactive 24-hydroxylated derivatives. The understanding of the local expression of CYP enzymes in tumor tissues is important in the development of better treatment for lung cancer and a standardized treatment, tailor-made, for individual patients.

Thoracic empyema and lung abscess resulting from gastropulmonary fistula as a complication of esophagectomy.

A benign fistula between the gastric tube and the airway resulting from esophagectomy is a rare complication, but it is a potentially life-threatening status. We present a 59-year-old man with thoracic empyema and lung abscess resulting from a benign gastric tube-to-pulmonary fistula caused by a penetration of the peptic ulcer in the gastric tube four years after an esophagectomy for esophageal cancer. After a thorough conservative management of infection and nutrition, the fistula was successfully repaired surgically with direct closure. The postoperative course was uneventful. Two years and nine months later, the patient retains satisfactory oral feeding status and is in good general condition.

Results of surgical treatment for lung cancer in young adults.

In this study, we evaluated the results of surgical treatment in young adults and compared the clinico-pathological features between young and elderly patients. We reviewed the clinical records of 1185 lung cancer patients who underwent surgery in our department. A total of 20 (1.7%) primary lung cancer patients (14 men and 6 women) < or =40 years of age were retrieved. The age range was from 26 to 40 years. Histological type included 10 adenocarcinomas (50%), 3 large cell carcinomas (15%), 3 carcinoids (15%), 2 squamous cell carcinomas (10%), and 2 others. The surgical procedure included 7 (35%) pneumonectomies, 11 (55.0%) lobectomies, and 1 (5%) partial resection. The proportion of pneumonectomies was significantly higher than among elderly patients. Clinical stage was underestimated in 7 of 20 patients, and among these, mediastinal lymph node metastases were revealed by pathological examination in 6 patients. Postoperative 5-year survival rates were 50.2%, 50.4%, and 43.8% in patients < or =40, 41-70, and > or =71 years old, respectively. There were no significant differences in survival rates between younger group and elderly groups. This study suggests that surgical resection is also recommended as the first-line treatment for younger patients with lung cancer.

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.

Prognostic impact of micrometastatic tumor cells in the lymph nodes and bone marrow of patients with completely resected stage I non-small-cell lung cancer.

PURPOSE: This study was designed to substantiate the prognostic impact of occult micrometastatic tumor cells in the lymph nodes (LNs) and bone marrow (BM) in stage I non-small-cell lung cancer (NSCLC) patients using cytokeratin (CK) as a micrometastatic marker and the relationship between the micrometastases in the LNs and BM. PATIENTS AND METHODS: A total of 2,432 hilar and mediastinal LNs were removed during surgery from 115 patients with completely resected stage I NSCLC. The LNs were analyzed for micrometastasis using immunohistochemistry with the biclonal anti-CK antibody AE1/AE3. BM aspirates from 115 patients were immunocytochemically stained with the monoclonal anti-CK antibody CK2. RESULTS: CK-positive (CK+) cells were detected in 42 (1.7%) of 2,432 LNs, in 32 (27.8%) of 115 patients, and in 32 (27.8%) of 115 BM aspirates. There was no relationship between the frequencies of CK+ cells in the LNs and in the BM. The patients with CK+ cells in the LNs had a poor prognosis by both univariate (P =.008) and multivariate analyses (P =.01), whereas the presence of CK+ cells in the BM did not allow prediction of survival (P =.32). The prognostic impact of LNs micrometastasis was independent even after adjusting for the status of BM micrometastasis. CONCLUSION: The detection of lymph nodal micrometastatic tumor cells provides an accurate assessment of tumor staging and has powerful prognostic implications for completely resected stage I NSCLC patients.

Molecular genetic tumor markers in non-small cell lung cancer.

Not only serum tumor markers, such as carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC) and carbohydrate antigen (CA) 125, but also serum growth factors have been examined to evaluate tumor stages and to predict the recurrence and metastasis in patients with non-small cell lung cancer (NSCLC) (1-5). In recent years, the analysis of the genome and proteome has advanced remarkably. An array of molecular genetic tumor markers (MGTMs) have been identified based on the biological characterization of tumors, such as tumor development, growth, invasion and metastasis. Molecular genetic tumor marker research has also entered a new era, since comprehensive gene profile analysis using cDNA microarrays and comprehensive protein expression analysis using proteomics technology have been developed. On the other hand, the frequency of lung cancer patients with which various tumor markers are associated is increasing in Japan (6-8). This paper reviews MGTMs characteristic of lung cancer and clarifies the clinical usefulness and applications of MGTM for cancer treatment.

Establishment of 15 cancer cell lines from patients with lung cancer and the potential tools for immunotherapy.

BACKGROUND: Since lung cancer is the major cause of death not only in Japan but in many other industrialized countries, the development of new therapeutic modalities is quite important. In patients with melanoma, immunotherapy with some tumor antigens has been shown to result in tumor regression. However, little is known about specific immune responses and tumor antigens in lung cancer, due to difficulty in establishing appropriate lung cancer cell lines. In order to resolve these difficulties, we tried to establish and characterize lung cancer cell lines as useful tools for the analysis of tumor-specific immune responses in patients with lung cancer. MATERIALS AND METHODS: We tried to establish lung cancer cell lines from 549 patients with resectable lung cancer and from 21 patients with pleural and pericardial effusions or lymph node metastasis. We characterized the established cell lines after the induction of tumor-specific cytotoxic T lymphocytes (CTLs), and analyzed both the major histocompatibility complex (MHC) class I and class II molecules on their surfaces. RESULTS: We succeeded in establishing 15 lung cancer cell lines from 570 specimens (2.6%). The success rate of the establishment of lung cancer cell lines was significantly higher in patients at such advanced stages as MHC III and IV than in those at MHC stages I and II (p = 0.004). MHC class I molecules were expressed in 12 of 15 cell lines (80%), while MHC class II molecules were found in 3 of 15 cell lines (20%) on their cell surfaces by flow cytometry. A haplotype loss of MHC class I antigens was found in 6 of 15 cell lines (40%). Although CTLs were induced in only two of eight cell lines tried by stimulation with nontransduced autologous tumor cell lines, CTLs were successfully induced in all of eight cell lines tested by stimulation with CD80-transfected autologous tumor cells. CONCLUSIONS: These results suggested that the tumor antigens recognized by CTLs could thus exist in the tumor cells derived from many lung cancer patients. It is, therefore, possible that antigen-specific immunotherapies may be potentially effective for patients with lung cancer by adoptive transfer of CTLs, as well as by vaccine therapy using tumor-specific antigens.

Survival and characteristics of lymph node involvement in patients with N1 non-small cell lung cancer.

N1 non-small cell lung cancer (NSCLC) encompasses a heterogeneous subgroup with differential lymph node involvement. Among 738 patients with NSCLC who underwent surgical resection, including 579 patients (78.5%) with systematic hilar and mediastinal lymph nodal dissection, from 1992 to 2001, 82 patients were pathologically defined as having N1 disease. We retrospectively analyzed the factors influencing survival, including the characteristics of lymph node involvement; the location of involved stations, the number of involved stations, the number of involved nodes, and the status of nodal involvement (microscopic N1, nodal involvement first defined by postoperative histological examination; or macroscopic N1, nodal involvement obviously recognized by preoperative examinations or surgical explorations). The overall 5-year survival rate of the 82 patients with N1 disease was 50.9%. No significant differences in the overall survival were found with regard to gender, age, histologic type, type of resection, or adjuvant therapies. Pathologic T status significantly influenced the overall survival (T1 versus T2 disease, P=0.008). According to the characteristics of lymph node involvement, the prognosis of patients with multiple-node N1 involvement was significantly poorer than that of those with single-node N1 involvement (5-year survival: 29.6% versus 61.5%, p=0.003). The prognosis of patients with macroscopic N1 disease was significantly poorer than that of those with microscopic N1 disease (5-year survival: 43.0% versus 65.0%, P=0.046). By comparison with the survival of patients who underwent surgical resection during the same period for pathologic N0 (pN0) and pathologic N2 (pN2) diseases, no survival differences were observed between microscopic N1/single-node N1 and pN0, or between multiple-node N1 and pN2 diseases. In patients with pathologic N1 disease, microscopic N1 and single-node N1 diseases may be an early stage, whereas multiple-node N1 disease behaves like an advanced stage.

Visceral pleural involvement in nonsmall cell lung cancer: prognostic significance.

BACKGROUND: A tumor of any size that invades the visceral pleura is classified in the T2 category; however, the definition of the visceral pleural involvement has remained somewhat ambiguous. It is unclear whether the T2 category includes the p2 status alone or incorporates the extent of the p1 status. METHODS: We retrospectively analyzed the survival of 474 patients with T1 and T2 nonsmall cell lung cancer to evaluate the influence of the degree of visceral pleural involvement (p0, p1, and p2) on the prognosis and to clarify the definition of the visceral pleural involvement. RESULTS: The 5-year survival rates according to the degree of visceral pleural involvement were 68.0% in p0 (n = 345), 43.9% in p1 (n = 110), and 54.9% in p2 (n = 19; p0 versus p1, p = 0.0004; p0 versus p2, p = 0.013; and p1 versus p2, p = 0.61). The degree of visceral pleural involvement (p0 versus p1/p2) was a significant independent prognostic factor from tumor size and lymph node involvement, by multivariate analysis (relative risk = 1.47, p = 0.033). The prognosis of pN0 patients with p1 and tumor size 3 cm or less was significantly poorer than that of those with p0 and tumor size 3 cm or less (p = 0.0004), and the prognosis of patients with p1 and tumor size more than 3 cm was significantly poorer than that of those with p0 and tumor size more than 3 cm (p = 0.024). CONCLUSIONS: The degree of visceral pleural involvement (p0 versus p1/p2) is an important component of the lung cancer staging system. Tumors with p1 and p2 status should be regarded as representing visceral pleural involvement and T2 disease.