Immunohistochemical findings in the lungs of COVID-19 subjects: evidence of surfactant dysregulation.

OBJECTIVE: Acute respiratory distress syndrome (ARDS) is characterized by quantitative and qualitative changes in surfactant composition, leading to surfactant dysregulation with alveolar collapse and acute respiratory hypoxic failure. Recently, surfactant has been hypothesized to play a relevant role in COVID-19, representing a strong defender against SARS-CoV-2 infection. The aim of our work was the study of immunohistochemical surfactant expression in the lungs of patients died following SARS-CoV-2 ARDS, in order to shed light on a possible therapeutic surfactant administration. PATIENTS AND METHODS: We investigated four patients who died due to ARDS following SARS-COV-2 infection and four patients submitted to lung biopsy, in the absence of SARS-CoV-2 infection. In all 8 cases, lung specimens were immunostained with anti-surfactant protein A (SP-A) and B (SP-B). RESULTS: In control subjects, reactivity for SP-B was restricted to type II alveolar cells. Immunostaining for SP-A was observed on the surface of alveolar spaces. In the COVID-19 positive lungs, immunoreactivity for SP-B was similar to that observed in control lungs; SP-A was strongly expressed along the alveolar wall. Moreover, dense aggregates of SP-A positive material were observed in the alveolar spaces. CONCLUSIONS: Our immunohistochemical data show the dysregulation of surfactant production in COVID-19 patients, particularly regarding SP-A expression. The increased presence of SP-A in condensed masses inside alveolar spaces could invalidate the therapeutic efficacy of the treatment with exogenous surfactant.

Changes in lung surfactant proteins in rats with lipopolysaccharide-induced fever.

The study was designed to prove the hypothesis that lipopolysaccharide (LPS)-induced fever elicits the changes in surfactant specific proteins, potentially related to thermal tachypnea. In adult rats fever was induced by intraperitoneal administration of LPS at a dose 100 microg/kg of body weight; control group received saline. Respiratory parameters, arterial blood gases and pH and colonic body temperature (BT) were recorded. Five hours later, surfactant proteins (SP) A, B, C and D were evaluated in bronchoalveolar lavage fluid (BALF) and lung tissue (LT). LPS evoked monophasic thermic response (at 300 min 38.7+/-0.2 vs. 36.4+/-0.3 °C, P 0.05) and an increase in minute ventilation due to changes in breathing rate and tidal volume. LPS-instilled animals had higher levels of SP-A and SP-D in LT (P 0.05 and 0.01), and higher SP-D in BALF (P 0.01) than controls. SP-B increased in LT and SP-C in BALF of animals with LPS (both P 0.05 vs. controls). The changes in all surfactant specific proteins are present in LPS-induced fever. Alterations of proteins related to local immune mechanisms (SP-A, SP-D) are probably a part of general inflammatory response to pyrogen. Changes in proteins related to surface activity (SP-B and SP-C) might reflect the effort of the body to stabilize the lungs in thermal challenge.

[Study of the lung surfactant maturity by biochemical and biophysical analyses of gasral aspirates from newborn infants].

The aim of the present study was to estimate the lung surfactant maturity by analyses of gastral aspirates (GA) from prematurely born and full-term infants. A biochemical analysis of the protein and lipid content in GA from the children groups tested was made. By thin-layer chromatography the individual phospholipids components in GA samples from prematurely born and full-term children were detected. In addition, by using the pending drop method the surface characteristics (equilibrium, maximal and minimal surface tension values) were determined. Our results showed an increase in the phospholipid and the protein concentrations in GA during pregnancy progress as well as significant differences in the individual phospholipids profile of the aspirates from prematurely born and full-term children. In case of surface characteristics a highest difference was observed for the minimal surface tension values (gammamin, m/Nm); while in the full-term children a lower surface tension was determined, in the prematurely born children significant higher values were reached, which define gammamin as the most informative from the parameters studied. Our results could find application into the clinical practice for fast surfactant maturity diagnostics in prematurely born children regarding lifesaving therapy with exogenous surfactants administration.

Detection of surfactant proteins A, B, C, and D in human gingiva and saliva.

BACKGROUND: The oral cavity along with the teeth and the surrounding gingival epithelium is open to the oral environment and is thus exposed to multiple microbiological and pathogenic influences. To prevent permanent inflammatory processes such as gingivitis or parodontitis, an efficient defense system is necessary to sustain the physiological function of the oral cavity. Surfactant proteins (SPs), originally known from pulmonary tissue, are important players of the immune system and, beyond this, support the stability and rheology of gas or fluid interphases. METHODS: Here we evaluate the expression and presence of SPs (SP-A, SP-B, SP-C, and SP-D) in human gingiva and saliva. Messenger RNA expression of SP-A, SP-B, SP-C, and SP-D was analyzed by reverse transcriptase-polymerase chain reaction in healthy gingiva. The distribution of all four SPs was further determined with monoclonal antibodies using Western blot analyses and immunohistochemistry in healthy and pathologically changed tissues samples obtained during biopsies and in saliva of volunteers. RESULTS: Our results indicate that SP-A, SP-B, SP-C, and SP-D are peptides produced by healthy gingiva that reveal a changed expression pattern in cases of gingival disease. CONCLUSION: Based on the known direct and indirect antimicrobial effects, SP-A and SP-D appear to be involved in immune defense within the oral cavity especially in direct proximity of teeth. Gingiva affected by bacterial inflammation (gingivitis) seems to increase expression of SPs. As a result, the rheology of saliva may be changed especially at the crest of the gingival epithelium to support the function of antimicrobial substances present in saliva. Furthermore, SPs could assist in pellicle formation on teeth, which needs to be determined in further experiments.

Characterization of VAMP-2 in the lung: implication in lung surfactant secretion.

Lung surfactant is crucial for reducing the surface tension of alveolar space, thus preventing the alveoli from collapse. Lung surfactant is synthesized in alveolar epithelial type II cells and stored in lamellar bodies before being released via the fusion of lamellar bodies with the apical plasma membrane. SNAREs (soluble N-ethylmaleimide-sensitive fusion protein-attachment protein receptors) play an essential role in membrane fusion. We have previously demonstrated the requirement of t-SNARE (target SNARE) proteins, syntaxin 2 and SNAP-23 (N-ethylmaleimide-sensitive factor-attachment protein 23), in regulated surfactant secretion. Here, we characterized the distribution of VAMPs (vesicle-associated membrane proteins) in rat lung and alveolar type II cells. VAMP-2, -3 and -8 are shown in type II cells at both mRNA and protein levels. VAMP-2 and -8 were enriched in LB (lamellar body) fraction. Immunochemistry studies indicated that VAMP-2 was co-localized with the LB marker protein, LB-180. Functionally, the cytoplasmic domain of VAMP-2, but not VAMP-8 inhibited surfactant secretion in type II cells. We suggest that VAMP-2 is the v-SNARE (vesicle SNARE) involved in regulated surfactant secretion.

Analysis of bronchoalveolar lavage fluid adhering to lung surfactant. Experiment on intratracheal instillation of nickel oxide with different diameters.

Nickel oxide with two different particle sizes, micron size (NiO) and submicron size (nNiOm), as well as crystalline silica as a positive control and titanium dioxide as a negative control, were intratracheally instilled in rats and the phospholipid concentration and the protein concentration and surface tension of bronchoalveolar lavage fluid (BALF), which are used in surfactant assessment, were measured to see if they could be effective biomarkers in toxicity assessment. The results showed that the NiO instilled group showed no significant difference compared to the control group throughout the observation period. In contrast, a significant difference was found in the nNiOm instilled group compared to the control group throughout the observation period. Moreover, a significant difference was found in the crystalline silica instilled group for each measurement compared to the control group while for the titanium dioxide group, almost no significant difference was found. These results indicate that submicronsized particles of nickel oxide with smaller median diameters potentially have a stronger biological effect than micron size particles. They also indicate that screening can be done by measuring the phospholipid concentration and the protein concentration and surface tension of BALF.

Therapeutic role of terbutaline in a rat whole-lung lavage model.

Whole-lung lavage (WLL) is the preferred therapy for patients with pulmonary alveolar proteinosis (PAP). However, WLL can cause fluid retention, surfactant lost, and hypoxia. Terbutaline has been shown to accelerate the rate of alveolar fluid clearance and augment surfactant secretion. The present study aimed at investigating effects of terbutaline and oxygen ventilation in rats with WLL. Forty rats were randomly divided into control, ventilation, NS (normal saline) + ventilation, LT (terbutaline in low concentration, 10(-4) M) + ventilation, and HT (terbutaline in high concentration, 10(-3) M) + ventilation groups. The left thoracic cavity was opened and a cannula was inserted into the left bronchus. The left lung was ventilated, while the right lung was lavaged. Arterial blood gas, electrocardiogram, histological changes, and wet/dry ratio of lung tissues were examined. The concentrations of total protein (TP), total phospholipids (TPL), and disaturated phosphatidylcholine (DSPC) in recovery fluid were measured. For the in vitro study, alveolar type II (ATII) cells were isolated from healthy male rats, incubated for 24 hours, and divided into control, LT, and HT groups and exposed to different concentration of terbutaline (10(-4) and 10(-3) M) for 2 hours, followed by measuring sodium-potassium adenosine triphosphatase (Na(+),K(+)-ATPase) activity. Oxygen ventilation significantly increased Pao(2)/Fio(2) after lavage in the ventilation group, as compared to control group (249.4 ± 7.9 vs 210.6 ± 9.4; P = .001). Compared with NS + venlitation group, a higher concentration of terbutaline decreased the wet/dry ratio of lung tissues (5.0 ± 0.1 vs 5.6 ± 0.1; P = .007), increased the concentrations of TPL (175.9 ± 14.0 vs 162.0 ± 6.8 mg/L; P = .031) and DSPC (93.2 ± 6.9 vs 70.9 ± 6.2 mg/L, P = .0001) in the recovery fluid, and alleviated hypoxia significantly. Terbutaline in both low and high doses increased Na(+),K(+)-ATPase activity in ATII cells (62.5 ± 2.4 and 62.6 ± 2.8 vs 32.2 ± 2.1 mmol/h/mg protein; P < .01). Theses results show that the administration of terbutaline facilitates alveolar fluid absorption and increases surfactant secretion during lung lavage, the former is partly driven by increasing Na(+),K(+)-ATPase activity. The modified lavage method, with the use of terbutaline and oxygen ventilation, is one of potential therapies for patients with PAP.

Allometry of the mammalian intracellular pulmonary surfactant system.

Alveolar epithelial (AE) surface area is closely correlated with body mass (BM) in mammals. The AE is covered by a surfactant layer produced by alveolar epithelial type II (AE2) cells. We hypothesized that the total number of AE2 cells and the volume of intracellular surfactant-storing lamellar bodies (Lb) are correlated with BM with a similar slope as AE surface area. We used light and electron microscopic stereology to estimate the number and mean volume of AE2 cells and the total volume of Lb in 12 mammalian species ranging from 2 to 3 g (Etruscan shrew) to 400-500 kg (horse) BM. The mean size of Lb was evaluated using the volume-weighted mean volume and the volume-to-surface ratio of Lb. The mean volume of AE2 cells was 500-600 µm(3) in most species, but was higher in Etruscan shrew, guinea pig, and human lung. The mean volume of Lb per AE2 cell was 80-100 µm(3) in most species, with the same exceptions as above. However, the total number of AE2 cells and the total volume of Lb were closely correlated with BM and exhibited an allometric relationship similar to the slope of AE surface area. The mean size of Lb was similar in all investigated species. In conclusion, the mean volume of AE2 cells and their Lb are independent of BM but show some interspecific variations. The adaptation of the intracellular surfactant pool size to BM is obtained by the variation of the number of AE2 cells in the lung.

The closer we look the more we see? Quantitative microscopic analysis of the pulmonary surfactant system.

The surfactant system of the lung has essential biophysical and immunomodulatory functions. Only at the electron microscopic level does surfactant reveal its morphological complexity--and beauty. Therefore, morphological tools are indispensible to characterize the surfactant system in health and disease. Stereology provides the gold standard for obtaining quantitative (morphometric) data in microscopy. The combination of microscopy and stereology allows for qualitative and quantitative analysis of the intraalveolar as well as the intracellular surfactant pool, both in its preserved microorganization and localization within the lung. Surfactant-producing alveolar epithelial type II cells can be counted and sampled for size estimation with physical disectors at a high magnification light microscopic level. The number of their surfactant storing lamellar bodies can be estimated using physical disectors at the electron microscopic level. Electron tomography allows for high resolution 3D visualization of lamellar body fusion pores. Intraalveolar surfactant subtypes can be quantitated in situ, thus reflecting the functional state of the intraalveolar surfactant pool. By immunoelectron microscopy, surfactant protein distribution can be analyzed. These methods allow for a comprehensive quantitative analysis of surfactant (ultra-)structure. Here, we give an overview on the analysis of the normal and disordered surfactant system by electron microscopy and stereology.

Pulmonary surfactant: an immunological perspective.

Pulmonary surfactant has two crucial roles in respiratory function; first, as a biophysical entity it reduces surface tension at the air water interface, facilitating gas exchange and alveolar stability during breathing, and, second, as an innate component of the lung's immune system it helps maintain sterility and balance immune reactions in the distal airways. Pulmonary surfactant consists of 90% lipids and 10% protein. There are four surfactant proteins named SP-A, SP-B, SP-C, and SP-D; their distinct interactions with surfactant phospholipids are necessary for the ultra-structural organization, stability, metabolism, and lowering of surface tension. In addition, SP-A and SP-D bind pathogens, inflict damage to microbial membranes, and regulate microbial phagocytosis and activation or deactivation of inflammatory responses by alveolar macrophages. SP-A and SP-D, also known as pulmonary collectins, mediate microbial phagocytosis via SP-A and SP-D receptors and the coordinated induction of other innate receptors. Several receptors (SP-R210, CD91/calreticulin, SIRPalpha, and toll-like receptors) mediate the immunological functions of SP-A and SP-D. However, accumulating evidence indicate that SP-B and SP-C and one or more lipid constituents of surfactant share similar immuno-regulatory properties as SP-A and SP-D. The present review discusses current knowledge on the interaction of surfactant with lung innate host defense.

Metastatic uterine cervical cancer originating in the lung: a case report.

We report a case of primary pulmonary adenocarcinoma which metastasized to the uterine cervix. A 69-year-old postmenopausal Japanese female was admitted to our hospital because of general fatigue and atypical genital bleeding. Four years before, she had undergone video-assisted thoracoscopic right upper lobectomy, for primary lung cancer (adenocarcinoma), stage IIIb, pT3N1M0. Gynecologic investigation showed a cauliflower-like tumor in the uterine cervix and parametrial invasion towards the bilateral pelvic wall. Metastasis of extragenital carcinoma to the cervix uteri is rare. Most such reported cases originated in the breast and gastrointestinal tract. In this case, cervical biopsy specimens were revealed to be adenocarcinomatous, similar in pathological features to the previously resected lung cancer. Immunohistochemical staining was positive for thyroid transcription factor-1 and pulmonary surfactant apoprotein A and negative for CA125 and thyroglobulin. Although rare, the respiratory tract should be considered as a possible primary site of uterine cervical metastatic carcinoma.

Synthetic surfactants: where are we? Evidence from randomized, controlled clinical trials.

The benefits of exogenous synthetic or animal-derived surfactants for prevention or treatment of respiratory distress syndrome (RDS) are well established. Data from head-to-head trials comparing animal-derived surfactants primarily with the synthetic surfactant colfosceril suggest that the major clinical advantages afforded by the presence of surfactant protein (SP)-B and SP-C in animal-derived preparations relate to faster onset of action, a reduction in the incidence of RDS when used prophylactically, and a lower incidence of air leaks and RDS-related deaths. However, no benefits in terms of overall mortality or BPD have been shown in these head-to-head comparisons. Findings from trials of a new-generation synthetic surfactant containing a peptide that mimics SP-B, as well as their follow-up study suggest that its administration improves short-term clinical outcomes compared with colfosceril and results in survival through 1 year of age, which is at least comparable, if not perhaps superior, to that seen with animal-derived surfactants.

Role of vagal innervation on pulmonary surfactant system during fetal development.

Vagally mediated afferent feedback and compliant lungs (surfactant system) play vital roles in the establishment of adequate alveolar ventilation and pulmonary gas exchange at birth. Although the significance of vagal innervation in the establishment of normal breathing patterns is well recognized, the precise role of lung innervation in the maturation of the surfactant system remains unclear. The specific aim of the present study was to investigate whether vagal denervation compromises the surfactant system during fetal development. Experiments were performed on 12 time-dated fetal sheep: 8 underwent cervical vagal denervation, and 4 were sham operated. Vagal denervation was performed at 110-113 days gestation. Fetal lambs were instrumented in utero to record arterial pH and blood-gas tensions. The animals were delivered by cesarean section under general anesthesia between 130 and 133 days gestation (term approximately 147 days). Lung samples were collected for wet-to-dry ratios, light and electron microscopy, and overall lung morphology. In addition, total proteins, total phospholipids, and surfactant proteins A and B were analyzed in both lung tissue and bronchoalveolar lavage fluid. Vagal denervation had no effect on alveolar architecture, including type II cells or the morphology of lamellar bodies within them. Furthermore, surfactant proteins A and B and total phospholipids were similar in lung tissue and bronchoalveolar lavage fluid between the two groups. A significant correlation was observed between circulating cortisol concentrations and surfactant proteins in the bronchoalveolar lavage fluid and lung tissue. We provide definitive evidence that vagal innervation at midgestation is not required for maturation of the pulmonary surfactant system during fetal development.

Hypobaric hypoxia-related impairment of pulmonary surfactant proteins A and D did not favour Pneumocystis carinii Frenkel 1999 growth in non-immunocompromised rats.

It has been suggested that patients with pulmonary surfactant impairment are more susceptible to Pneumocystis infection than healthy controls. Owing the fact that most patients with pulmonary surfactant impairment also suffer from hypoxia, we explored the effect of intermittent hypobaric hypoxia conditions on the ability of non-immunocompromised rats infected by endotracheal route with P. carinii to clear the infection from their lungs. Control rats, inoculated or not with P. carinii, were maintained in normobaric normoxic conditions, and were submitted or not to dexamethasone administration. It was found that even if hypobaric hypoxia weakened host immune mechanisms and impaired significantly the surfactant composition, mainly of surfactant proteins A and D, these changes were not enough to favour the Pneumocystis growth or to inhibit the clearing of Pneumocystis organisms from the lungs of non-immunocompromised rats. The potential influence of surfactant protein changes on Pneumocystis infection is discussed.

Betamethasone for lung maturation: testing dose and formulation in fetal sheep.

OBJECTIVE: We evaluated lung maturation responses to the mixture of betamethasone phosphate (Beta-PO4) + betamethasone acetate (Beta-Ac) in comparison to Beta-PO4 or Beta-Ac in fetal sheep. STUDY DESIGN: Ewes carrying singleton pregnancies at 122 days of gestation were randomized to single doses of 0.5 mg/kg Beta-PO4 + Beta-Ac, 0.25 mg/kg Beta-PO4, 0.5 mg/kg Beta-PO4, or 0.25 mg/kg Beta-Ac given 48 hours before delivery. These treatments were compared with saline placebo and 2 doses of 0.5 mg/kg Beta-PO4 + Beta-Ac that were given 48 and 24 hours before delivery. Fetal lung maturation was evaluated. RESULTS: The 2 doses of the Beta-PO4 + Beta-Ac mixture gave the best lung maturation. Single doses of the Beta-PO4 + Beta-Ac mixture and Beta-Ac alone also induced lung maturation. There were no consistent responses to either dose of Beta-PO4. CONCLUSION: Beta-PO4 alone is ineffective with the dosing schedule used; Beta-Ac can induce lung maturation. However, the best responses result from the mixture of Beta-PO4 + Beta-Ac.

Relationship between pulmonary surfactant protein and lipid peroxidation in lung injury due to paraquat intoxication in rats.

BACKGROUND: Pulmonary damage resulting from lipid peroxidation is a principal effect of paraquat intoxication. The host-defense functions of surfactant are known to be mediated by the surfactant proteins A and D (SP-A and SP-D, respectively). The primary objective of this study was to evaluate the variations over time in levels of surfactant protein and lipid peroxidation (LPO) in lung tissue following free-radical-induced injury. METHODS: 42 adult, male, Sprague-Dawley rats were administered intraperitoneal injections of paraquat (35 mg/kg body weight). SP-A and SP-D levels were determined via Western blot. LPO in the left lung homogenate was measured via analyses of the levels of thiobarbituric acid-reactive substances. RESULTS: LPO levels peaked at 6 hours, with no associated histological changes. SP-D levels increased until hour 12 and declined until hour 48; SP-D levels subsequently began to increase again, peaking at hour 72. SP-A levels peaked at hour 6, declining thereafter. CONCLUSIONS: We suggest that in the early phase of paraquat injury, SP-D levels reflect alveolar damage and that de novo synthesis of SP-D takes 72 hours. Levels of SP-A, on the other hand, reflect abnormalities in the surfactant system in the late stage of paraquat intoxication. Surfactant proteins may play a role in protecting the lungs from reactive oxygen injury. A time-dependent variation has been observed in the levels of surfactant proteins A and D following paraquat injury, and it has been suggested that these proteins play a role in the protection of lung tissue against ROS-induced injuries.

Lung mechanics in the TIMP3 null mouse and its response to mechanical ventilation.

Tissue inhibitor of metalloproteinase-3 (TIMP3) null mice develop emphysema-like airspace enlargement due to an enzymatic imbalance. This study investigates how these abnormalities alter lung mechanics and the response to 2 different mechanical ventilation strategies. Phenotypically, TIMP3 null mice had increased compliance, and decreased resistance, tissue damping, and tissue elastance over wild-type controls. Decreased compliance and increased resistance were observed following the injurious ventilation strategy; however, the TIMP3 null response to both ventilation strategies was similar to wild-type mice. In conclusion, TIMP3 null mice have significant alterations in lung mechanics; however, this does not affect their response to ventilation.

Lung surfactant function and composition in neonatal foals and adult horses.

BACKGROUND: Lung surfactant function and composition are varied and adapted to the specific respiratory physiology of all mammalian species. HYPOTHESIS: Lung surfactant function and composition are different in neonatal foals as compared to adult horses. ANIMALS: Six adult horses, 7 term foals (<24 hours old), and 4 premature foals were used. Animals were part of the Auburn University teaching herd except for 3 client-owned premature foals. METHODS: Bronchoalveolar lavage fluid (BALF) was obtained from all animals. Ultracentrifugation of cell-free BALF separated surfactant into crude surfactant pellets (CSP) and supernatant. Both fractions were analyzed for phospholipid and protein content with the Bartlett and bicinchoninic acid method, respectively. Phospholipid composition of the CSP was determined by using high-performance liquid chromatography with an evaporative light scatter detector. Surface tension of the CSP was measured with a pulsating bubble surfactometer. Results from term foals (<24 hours old) were compared statistically to those from adult horses. Values of P < .05 were considered significant. RESULTS: BALF phospholipid content was similar between adult horses and term foals, but BALF protein content was significantly decreased in term foals. Phosphatidylglycerol was significantly decreased, phosphatidylinositol was significantly increased, and the minimum surface tension was significantly increased in the CSP from term foals compared to adult horses. CONCLUSIONS AND CLINICAL IMPORTANCE: Surface tension and phospholipid composition of surfactant in neonatal foals are significantly different compared to adult horses. These changes may influence biophysical and immunologic functions of surfactant.

Leptin enhances lung maturity in the fetal rat.

Pulmonary alveolar type II cells synthesize and secrete phospholipids and surfactant proteins. In most mammalian species, the synthesis of phospholipids and proteins of lung surfactant increases with fetal lung maturation, which occurs late in gestation. Factors that may promote lung maturation and surfactant production include the placental hormone, leptin, whose expression increases with advancing gestational age. We demonstrate that physiologic concentrations of leptin (1 and 10 ng/mL) increase the levels of surfactant proteins (SP) A, B, and C mRNA as well as SP-A and SP-B protein in d-17 fetal rat lung explants in vitro. To determine whether leptin exerts similar effects in vivo, we administered leptin antenatally to pregnant rats and compared its effects to that of dexamethasone, a known mediator of fetal lung development. Antenatal treatment with leptin for 2 d significantly increased the average weight of the fetal lungs in relation to their body weight. Histologic analysis revealed that the increase in fetal lung weight was accompanied by an increase in the number and maturation of type II alveolar cells and the expression of surfactant proteins B and C in these cells. Collectively, these results suggest that leptin is a cytokine regulator of rat fetal lung maturity.

Long-term survival after incomplete resection of immunohistochemically diagnosed T0N1 lung cancer: report of a case.

A 63-year-old man who had undergone resection of colon cancer 15 years previously was found to have a right hilar mass on chest X-ray, and an elevated serum carcinoembryonic antigen level. The hilar lymph nodes were resected with the right upper lobe, and the initial diagnosis was colon cancer metastasis to the right hilar lymph nodes. Although the resection was incomplete, and no additional treatment was given, the patient remained free of recurrence for 10 years. This prompted us to reconsider our diagnosis using immunohistochemistry. The resected lymph nodes were found to be positive for thyroid transcription factor 1 (TTF-1) and cytokeratin 7, and negative for surfactant apoprotein (SAP), cytokeratin 20, and napsin A. The neuroendocrine markers and thyroglobulin were also negative. These findings led us to diagnose T0N1 lung cancer. There are reports of patients with clinical T0N1,2 lung cancer having exceptionally good prognoses despite noncurative treatment; however, to our knowledge, this is the first case of a patient with T0N1 lung cancer diagnosed by immunohistochemistry, with a good prognosis despite incomplete resection. In this case, TTF-1 and cytokeratin staining was particularly helpful in the differential diagnosis.