Localized mediastinal lymph node amyloidosis showing an unusual unsynchronized pattern of enlargement and calcification on serial CT.

Amyloidosis is an unusual cause of mediastinal lymphadenopathy. A localized form of amyloidosis manifesting solely in the intrathoracic lymphnode is extremely rare. We describe a case of intrathoracic lymphadenopathy caused by a localized form of amyloidosis. Calcification has been reported in amyloidosis; however, it has been considered as non-specific. In our case, serial CT carried out over a period of 3 years and 3 months showed an unusual and unsynchronized pattern of enlargement and calcification.

[Extrapleural pneumonectomy for thoracic malignancies].

Extrapleural pneumonectomy has been used by thoracic surgeons in the treatment of malignant pleural mesothelioma as well as other pleural diseases, such as tuberculous empyema. Recently, this operative procedure has been also sporadically applied for the treatment of carcinomatous pleuritis of lung cancer and/or invasive thymoma in some institutions. We performed this operation in 24 patients with thoracic malignancy: 15 patients with carcinomatous pleuritis of primary lung adenocarcinoma (6 patients with T4N0 disease, 2 with T4N1, and 7 with T4N2), 3 patients with stage IV a thymoma, and 6 patients with malignant pleural mesothelioma (2 patients with stage II disease, 3 with stage III, and 1 with stage IV). All patients survived the operation and were discharged from the hospital. Major complications were intrathoracic hemorrhage and empyema in 2 patients each. The median survival time and 5-year survival rate of lung cancer patients were 34 months and 45.5%, respectively. All patients with thymoma are alive now without disease 9 to 133 months after operation. All patients with malignant pleural mesothelioma except 1, who lately underwent this treatment, died of disease from 15 to 27 months after surgery. Our results indicate that carefully selected patients with carcinomatous pleuritis of lung cancer and thymoma may be candidates for extrapleural pneumonectomy for cure. Nevertheless, the ultimate value of this surgical treatment should be ascertained in a prospective study with a large number of patients.

[Synchronous tumors consisted of bronchial carcinoid and adenocarcinoma of the lung].

We report a case of synchronous tumors consisted of bronchial carcinoid and adenocarcinoma of the lung. A 58-year-old female was referred to our hospital after screening, because an abnormal shadow was noted in the right lung on her computed tomography (CT) of the chest. CT scans showed a peripheral pulmonary mass in the right middle lobe and a nodule around the right lower lobe bronchus. The nodular lesion like swollen lymph node was diagnosed as bronchial carcinoid originated in B6 by bronchoscopy. The pulmonary mass was diagnosed as adenocarcinoma by using core needle biopsy during operation. Right middle and lower bilobectomy and mediastinal lymph node dissection were performed. Coincidence of a bronchial carcinoid and an adenocarcinoma of the same side of the lung is a rare occurrence.

Detection of brain metastasis in potentially operable non-small cell lung cancer: a comparison of CT and MRI.

STUDY OBJECTIVE: To compare the usefulness of MRI and CT in the detection of brain metastases during preoperative evaluation and postoperative follow-up. DESIGN: A prospective and sequential comparison. PATIENTS AND METHODS: Of 332 patients with potentially operable non-small cell lung cancer who were free of neurologic signs and symptoms, brain CT was performed preoperatively on 155 patients (CT group) and brain MRI on 177 patients (MRI group). Patient characteristics in both groups were comparable. In 279 patients with complete resection of the primary lung tumor, intensive follow-up with CT and MRI was performed in the respective groups. The preoperative detection of brain metastases, postoperative intracranial recurrence rates, and characteristics of detected brain tumors were compared between the two groups. The survival of patients with brain metastases was also compared. RESULTS: From the first evaluation to 12 months after surgery for primary lung cancer, brain metastases were observed in 11 patients (7.1%) from the CT group and 12 patients (6.8%) from the MRI group. MRI detected brain metastases preoperatively in 6 of the 12 patients (3.4% of the total MRI group), whereas CT detected brain metastases preoperatively in 1 of the 11 patients (0.6% of the total CT group). MRI showed a tendency toward a higher preoperative detection rate of brain metastases than CT (p = 0.069). Furthermore, the mean (+/- SD) maximal diameter of the brain metastases was significantly smaller in the MRI group (12.8+/-9.1 mm) than in the CT group (20.3+/-7.0 mm) (p = 0.041). However, the median survival time and 2-year survival rate after treatment of detected brain metastases, respectively, were 10 months and 27% in the CT group and 17 months and 28% in the MRI group. There was no significant difference between the groups in survival time. CONCLUSIONS: Preoperative evaluation and intensive follow-up with MRI could facilitate early detection of brain metastases in patients with potentially operable lung cancer. However, further studies on detection and treatment of the metastatic tumors are considered necessary.

Endobronchial brachytherapy for recurrent thymoma showing endobronchial polypoid growth.

The authors report a case of recurrent thymoma displaying endobronchial polypoid growth. Initially, the patient had invasive thymoma with intracaval growth into the right atrium. He was treated with multimodality therapy consisting of chemotherapy, surgical resection, and radiotherapy (50.4 Gy). Both 3 years and 6 years after the initial treatment, the tumor recurred outside the reconstructed superior vena cava. The patient was treated with repeated radiotherapy (50.4 Gy and 40 Gy), and remission was achieved. Eight years after the first therapy, an endobronchial polypoid lesion was detected in the right upper lobe bronchus and was histologically found to be thymoma. Endobronchial high-dose rate brachytherapy (20 Gy at 3 mm/5 fractions) was carried out for palliation because the recurrent tumor occurred outside of the superior vena cava area, which had been reirradiated. After the treatment, the endobronchial tumor shrunk remarkably in size without adverse effects. No tumor regrowth has been noted after a follow-up of 10 months.

[Cystic thymoma without solid mass lesions on diagnostic imaging--a case report].

A 68-year-old man was referred to our hospital because of an abnormal shadow on a chest X-ray film. A chest CT scan and MRI demonstrated a cystic mass without solid lesions on the anterior mediastinum. The CT scan also showed that it was a well-defined and homogenous mass without contrast enhancement effect. 67Ga and 201T1 scintigrams showed no uptake in the mass. Needle aspiration cytology was performed, and there was no evidence of neoplasms. A thymic cyst was diagnosed, and then an operation was performed. At the operation, the cystic tumor was removed along with thymic tissues by a median sternotomy. On the cut section of the resected specimen, the tumor was found to be a cyst with small solid nodules on the wall. Pathologic examination revealed that the tumor was a cystic thymoma. We consider that patients with cystic tumors on the anterior mediastinum should obtain histopathologic diagnosis because of the difficulty in excluding neoplasms such as thymoma.

[Huge localized mesothelioma of the diaphragm in a 17-year-old female--a case report with calculated tumor volume doubling time].

An operative case of localized mesothelioma of the pleura developed in a 17-year-old female was reported. She was admitted to our hospital complaining of right chest pain. A chest X-ray film showed a huge mass in the right lower field of the lung. After the embolization of the right inferior phrenic artery, which was the main feeder to the tumor, it was then successfully resected combined with the right diaphragm and the right lower lobe of the lung. Histologically, the tumor was diagnosed as benign localized mesothelioma (solitary fibrous tumor of the pleura). Further histological and immunohistochemical study revealed that it had developed from the connective tissue under the parietal mesothelium of the diaphragm. As chest roentgenograms had been undertaken during past two years, the tumor volume doubling time was calculated at 153 days. Despite the short tumor volume doubling time as like primary lung cancer, she is alive without recurrence 5 years after the operation.

[Intralobar pulmonary sequestration with three aberrant arteries: a case report and review of the Japanese literature].

A case of intralobar pulmonary sequestration with three aberrant arteries was reported. The patient was a 26-year-old man. His chest film showed an abnormal shadow suspected of a pulmonary sequestration in the left lower lobe of the lung. Computed tomography of the chest revealed that the aberrant arteries originated from the descending aorta and circulated the emphysematous area of the left lung. Angiography clearly demonstrated three aberrant arteries and three veins draining into the hemiazygos and lower pulmonary veins. Pulmonary sequestration was diagnosed and then resected. Microscopically, the resected lung had emphysematous change, multiple cysts and winded vessels. Aberrant arteries were the elastic type of vessels and accompanied with atherosclerosis. According to the review of 139 Japanese cases of intralobar pulmonary sequestration, 7% of all patients had more than two aberrant arteries. Moreover, only 3% of patients had veins draining into the systemic vessels. In many cases the thin aberrant arteries were clearly demonstrated by angiography and the draining veins were detected. We consider that angiography is necessary to show definitely the aberrant arteries and drainage veins.

Epithelioid hemangioendothelioma presenting as a chest wall tumor.

We report a case of epithelioid hemangioendothelioma presenting as a chest wall tumor. The patient had invasive bladder carcinoma and a soft-density mass protruding into the left thoracic cavity from the lateral chest wall on a computed tomographic scan. Percutaneous needle biopsy was performed to obtain a definite diagnosis of the chest wall tumor. Because of an intrathoracic hemorrhage after the procedure, the patient underwent an emergency thoracotomy and excision of the mass with adjacent structures. Pathologic examination demonstrated the mass to be a subpleural epithelioid hemangioendothelioma. This rare tumor has never been reported previously as arising from the chest wall.