[Ectopic Adrenocorticotropic Hormone-Producing Pulmonary Carcinoid Presenting as Cushing's Syndrome after Intrapleural Hyperthermic Chemotherapy].

The patient was a woman in her 70's was referred to our hospital because of an abnormal shadow on chest roentgenogram at an annual medical checkup. Since preoperative examinations suggested lung cancer in the right middle lobe, thoracoscopic right middle lobectomy was planned. However, pleural dissemination was detected at surgery and we changed the treatment plan to the intrapleural hyperthermic chemotherapy. During the postoperative course, facial edema, hypokalemia, and hyperglycemia developed, and the diagnosis of Cushing's syndrome was suggested based on an increase in serum level of adrenocorticotropic hormone (ACTH) and cortisol, and was confirmed by a dexamethasone suppression test. Intrapleural hyperthermic chemotherapy was likely to collapse the ACTH-producing tumor leading Cushing's syndrome.

Postoperative Lung Torsion With Retained Viability: The Presentation and Surgical Indications.

BACKGROUND: We review our experience with postoperative lung torsion with retained viability. METHODS: A total of 2165 patients underwent pulmonary resection (lobectomy or segmentectomy) at our institution between 1 January, 1986, and 31 March, 2017. Eight (0.3%, six males and two females: median age, 68 years) had lung torsion with retained viability. RESULTS: The right upper lobe was resected in seven patients, while the left upper segment was resected in one patient. The lung torsion with retained viability was the right middle lobe in seven patients and the left lingular segment in one patient. A bronchoscopic examination was performed in four patients to diagnose the pulmonary torsion; however, it demonstrated no specific findings. Subsequently, computed tomography (CT) was performed in all the patients, and lung torsion was diagnosed in all the patients based on the CT findings. None of the patients showed any symptoms when lung torsion was diagnosed in them. The diagnosis of pulmonary torsion was made at a median of 4 days (range, 1-22 days) after the initial surgery. Six patients underwent detorsion of the affected lung, while one patient had a lobectomy, and one patient received conservative management. The lungs of all patients in which detorsion was performed adequately re-expanded. Frequent pneumonia in the viable torsed lung was diagnosed as a cause of death in the one patient who received conservative management. CONCLUSION: The timely decision to follow a surgical approach for lung torsion with retained viability can lead to a satisfactory outcome.

Thirteen cases of pulmonary dirofilariasis in a single institution in Okinawa Island.

Pulmonary dirofilariasis is an infection caused by Dirofilaria immitis, which is an endemic parasite in Japan. We experienced 13 surgical cases of pulmonary dirofilariasis in our hospital. Of the 13 patients, 61.5% were men. The responsible lesions were located in the right lung in all cases, and 76.9% of them were in the lower lobe. Histologically, 12 cases showed necrotic nodules with peripheral granuloma with worms inside the pulmonary artery. One case did not show a necrotic nodule but showed only thickening and hyalinization of the pulmonary artery wall with a degenerated worm inside. Eosinophils were found histologically in all cases. Thirteen cases of dirofilariasis in one institution seem to be the largest number in Japan, based on previous reports. One reason for this increased prevalence may be the hot and humid climate of our prefecture considering the ecology of the mosquito as a vector. Elastic staining and eosinophils in peripheral granulomatous areas can contribute to the diagnosis when the worms are degenerated.

Expression of mismatch repair proteins, hMLH1/hMSH2, in non-small cell lung cancer tissues and its clinical significance.

BACKGROUND: hMLH1 and hMSH2 have been implicated to be involved in the DNA mismatch repair (MMR) system. The purpose of this study is to investigate the expression of hMLH1 and hMSH2 DNA MMR proteins in non-small cell lung cancer (NSCLC) tissue and to elucidate their clinical significance. METHODS: The hMLH1 and hMSH2 protein expression was evaluated by immunohistochemistry for a consecutive series of 113 NSCLC patients. The expressions of each protein were examined for an association with the clinicopathological variables, including genetic alterations analyzed by high resolution fluorescent microsatellite analysis. RESULTS: Regarding the hMLH1 expression, the MSI-positive patients showed significantly lower scores than the MSI-negative patients. For hMSH2 expression, the patients with a 20 or higher pack-year index (PYI) showed significantly higher scores than the patients with a PYI less than 20. The expression status of proteins did not affect both the disease free and overall survival of the patients. No significant correlation was observed among the scores for the proteins. CONCLUSIONS: The expressions of hMLH1 and hMSH2 are independently regulated and play different roles in NSCLC. The genetic instability is possibly due to the reduced expression of hMLH1 protein, and hMSH2 expression is associated with smoking status.

[A case of long-term survival of postoperative brain metastasis of small cell lung cancer effectively treated with chemotherapy, whole brain radiotherapy and stereotactic radiosurgery].

A 63-year-old woman underwent right upper lobectomy for small cell carcinoma. She received a total of 2 courses of carboplatin and etoposide infusion as adjuvant therapy. One year after the operation, because of elevated serum Pro GRP levels and a metastatic brain tumor revealed by CT, 4 courses of IP therapy (irinotecan 60 mg/m(2), day 1, 8, 15 and cisplatin 60 mg/m(2), day 1, every 4 weeks) and whole brain radiotherapy (2 Gy f, 5 f/week, total 40 Gy) were given. A complete response was obtained, but a tumor relapse occurred ten months after the last chemotherapy. We then performed a stereotactic radiosurgery (marginal dose: 22 Gy, maximum dose 44 Gy), and one month later MRI showed the tumor had shrunk markedly. FDG-PET showed no intensive uptake, suggesting that there was no remaining viable tumor. No severe side effects were observed during these treatments. Currently, the patient has been alive with good performance status and no signs of relapse.

Comparison of GLUT-1, SGLT-1, and SGLT-2 expression in false-negative and true-positive lymph nodes during the 18F-FDG PET/CT mediastinal nodal staging of non-small cell lung cancer.

INTRODUCTION: Although positron emission tomography (PET) with 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography (CT), (18F-FDG PET/CT), has recently improved the mediastinal nodal staging of non-small cell lung cancer (NSCLC), this method can show false negativity. We immunohistochemically investigated the expression of glucose transporters (GLUT-1, SGLT-1, and SGLT-2) in false negative and true positive mediastinal nodes via 18F-FDG PET/CT. METHODS: We investigated patients with clinically-diagnosed N0/pathological N2 diseases and patients with clinically-diagnosed N2/pathological N2 disease. The patients who were included in this study were evaluated using 18F-FDG PET/CT followed by surgical resection between January 2004 and December 2015. The expression of GLUT-1, SGLT-1, and SGLT-2 in the metastatic mediastinal lymph nodes, and clinicopathological variables such as primary tumor size, lymph node size, histological type, and SUVmax of the primary lesion, were compared between false negative nodes and true positive nodes. RESULTS: The total number of PET false negative metastatic mediastinal lymph nodes was 22 in the 17 patients who were clinical N0/pathological N2, and the number of PET true positives was 15 in the 11 patients who were clinical N2/pathological N2. GLUT-1 expression was positive in five false negative nodes and 10 true positive nodes. SGLT-2 expression was positive in 12 false negative nodes and one true positive node, whereas both false negative and true positive nodes showed no SGLT-1 staining. Univariate analysis showed that the reduced expression of GLUT-1 (P = 0.015), and overexpression of SGLT-2 (P = 0.004) were the significant causative factors for false negative nodes. Multivariate analysis also showed that the reduced expression of GLUT-1 (P = 0.012) and overexpression of SGLT-2 (P = 0.006) were the significant causative factors for false negative nodes. CONCLUSION: It suggests that the reduced expression of GLUT-1 and overexpression of SGLT-2 are associated with false-negative lymph node metastases in NSCLC.

Clinically predictive factors of pathologic upstaging in patients with peripherally located clinical stage IA non-small cell lung cancer.

OBJECTIVE: Post-surgical pathologic examination often reveals a more advanced state than clinically defined in non-small cell lung cancer (NSCLC), posing the need for careful consideration of a lesser resection. We investigated the predictive factors for the pathologic upstaging in clinical stage IA NSCLC. METHODS: The clinical features of 253 consecutive patients with peripherally located T1N0M0 NSCLC who underwent complete resection between 1991 and 2004 were investigated in relation to pathologic T- and N-factors. RESULTS: Of the 253 patients, 46 (18.2%) were upstaged after surgery, due to T-factor in 12 patients, N-factor in 32, M-factor in 2 and both T- and N-factors in 1. Among the clinical parameters, a higher level of serum CEA (p=0.0378) and larger tumor size (p=0.0276) were observed in the upstaged patients. Multivariable analysis revealed that tumor size and positive serum CEA were independently associated with pathologic upstaging. When tumor size was greater than 10mm, patients with positive serum CEA (>2.0 ng/ml) showed a significantly higher incidence of pathologic upstaging (29.2%) than the rest (15.5%, p=0.0461). CONCLUSION: Clinically defined peripheral stage IA NSCLC should be carefully indicated for a lesser resection when positive serum CEA and/or tumors greater than 10mm in size are observed.

Relationship between the loss of heterozygosity and tobacco smoking in pulmonary adenocarcinoma.

A loss of heterozygosity (LOH) is a major cause of lung carcinogenesis, and it is considered to be related to tobacco smoking in central type lung cancer. We investigated the relationship between LOH in lung adenocarcinoma and tobacco smoking. In a consecutive series of 50 patients with lung adenocarcinoma who underwent a surgical resection, cancer tissue specimens and corresponding normal peripheral lung and central bronchial tissue specimens were analyzed for LOH at the regions of D3S1234 (FHIT), D3S1300 (FHIT), D9S171 (CDKN2), and D17S796 (p53) by polymerase chain reaction using four fluorescence-labeled dinucleotide markers. To examine how cells are influenced by smoking, the A549 cell line was exposed to benzo[a]pyrene (B[a]P) for 24 weeks and then was subjected to the above analysis. The LOH in cancer tissue was thus detected in four (17%) patients at D3S1234, six (14%) at D3S1300, and seven (18%) at D17S796, but no LOH was detected in any normal tissue specimens. The incidence of LOHs in cancer tissue specimens from active smokers was 21% at D3S1234, 11% at D3S1300, and 19% at D17S796, whereas that of LOHs from nonactive smokers was 0% at D3S1234, 19% at D3S1300, and 14% at D17S796. Analyzing the relationship between the pack-year index and the presence of LOH, a significant difference was found among the active smokers. Besides, in the A549 cell line exposed to B[a]P, LOH was de novo detected in one (D2S123) of the nine regions examined. The incidence of LOH could be influenced by tobacco smoking in lung adenocarcinoma, thus suggesting the presence of an important event in the carcinogenesis of this disease.

Use of small-bore silastic drains in general thoracic surgery.

STUDY OBJECTIVE: To evaluate the safety and efficacy of small-bore, silastic drains for patients undergoing general thoracic surgery. PATIENTS AND METHODS: Twenty-five patients who received soft, small-bore, silastic drains were compared with 17 patients who received semi-rigid double lumen (DL) tubes retrospectively. RESULTS: The pain score was significantly lower in patients who received the silastic tubes in video-assisted thoracoscopic surgery (VATS) cases on postoperative days 5 and 6 , after continuous epidural analgesia had finished (P=0.018). No specific morbidity was seen in the patients who received silastic tubes. CONCLUSION: We considered that soft, small-bore silastic drains were just as effective as traditional DL tubes, but caused less pain especially in VATS cases.

A rare case of congenital bronchoesophageal fistula in an adult.

INTRODUCTION: When congenital bronchoesophageal fistulas exist without atresia of the esophagus, the diagnosis can be delayed, although symptoms may occur early following fistula development. Therefore, while they are usually found in infants, they can be extremely rarely found in adults. We herein report a rare case of bronchoesophageal fistula without atresia in an adult. CASE: An 69-year-old male presented to the outpatient clinic with a decades-long history of cough with expectoration immediately after taking food, especially liquids. Computed tomograph, esophagoscopy, and esophagography revealed the fistulous communication between the mid-esophagus and right lower lobe bronchus, with consolidation in the right lower lobe. We performed right lower lobectomy with the closure and excision of the fistula. The histopathology of the fistula revealed the mucosa to be lined by stratified squamous epithelium. There was no evidence of inflammation, granuloma, or carcinoma. CONCLUSION: In conclusion, despite the benign nature of this malformation, if left untreated, it can cause long-term debilitating respiratory symptoms associated with the fistula. Therefore, the diagnosis should be considered in the evaluation of recurrent lung infection.

The long-term prognosis of induction chemotherapy followed by surgery for N2 non-small cell lung cancer: A retrospective case series study.

INTRODUCTION: The long-term prognosis of induction chemotherapy followed by surgery for N2 non-small lung cell cancer (NSCLC) remains controversial. PATIENTS AND METHODS: We retrospectively reviewed the data and assessed the prognosis of 31 N2-NSCLC patients who underwent induction chemotherapy followed by surgery at our institution between January 1999 and December 2013. Potential prognostic factors, such as age, gender, tumor histology, tumor marker levels, tumor size, the number of N2 lymph nodes, the time from the last induction chemotherapy to the date of surgery, induction chemotherapy, RECIST response, downstaging status, pathological stage, adjuvant chemotherapy, and EF, were analyzed. RESULTS: The chemotherapy regimens of 30 of the 31 patients included a platinum agent. Complete resection was performed in 96.7% of the cases. Pathological downstaging was induced in 9 (29%) of the 31 patients. The median follow-up period was 7.89 years. The median DFI was 13.9 months. The recurrence rate was 74.2%. The 5-year OS was 56.9%. Univariate analyses revealed that none of the factors significantly affected OS, while the tumor histology had a significant effect on the DFI. CONCLUSION: Although the recurrence rate in our study was similar to previous studies, our survival data were much better than those of past reports. Although the tumor histology was the only factor that had a significant association with DFI in the current study, the possibility of bias exists.

Partial Anomalous Pulmonary Venous Connection Coexisting with Lung Cancer: A Case Report and Review of Relevant Cases from the Literature.

A 45-year-old man had an abnormal shadow in the right lung field on an annual screening chest X-ray. He was diagnosed with Stage IA (cT1bN0M0) lung cancer. Initially, we did not notice an anomalous vein on non-contrast computed tomography. However, we found that the right upper lobe bronchus branched from the lateral wall of the right main bronchial orifice, above the level of the common right upper lobe bronchus. Therefore, the bronchus was thought to be a tracheal bronchus. We carefully reevaluated the patient using three-dimensional computed tomography angiography. This technique showed that the anomalous right superior pulmonary vein drained into the azygos vein along the superior vena cava. These findings confirmed a partial anomalous pulmonary venous connection of the right upper lobe. We performed video-assisted thoracoscopic right upper lobectomy and mediastinal lymph node dissection for definitive treatment for lung cancer and partial anomalous pulmonary venous connection. No hemodynamic problems occurred in the postoperative course.

Lingular segment torsion following a left upper division segmentectomy.

INTRODUCTION: Numerous publications regarding lung torsion have reported lobar torsion after lobectomy. On the other hand, torsion of the remaining segment after segmentectomy is extremely rare. We herein report a rare case of lingular segment torsion following a left upper division segmentectomy. CASE: A 68-year old female underwent thoracoscopic segmentectomy of the left upper division. She underwent chest radiography immediately after the initial surgery, which revealed complete expansion on the operated side. Routine chest radiograph findings on postoperative day 1 demonstrated atelectasis on the operated side, although she did not have any symptoms. Chest computed tomography was conducted because a follow-up chest radiograph on postoperative day 5 showed no improvement, and she was diagnosed with torsion of the lingular segment. We performed an exploratory thoracotomy. Based on intraoperative findings, the lingular segment was found to have a 90° clockwise torsion along the pedicle axis, although the segment was viable. We straightened the kinked lingular segment and affixed the lingular segment to the left lower lobe. The postoperative course was uneventful. CONCLUSION: Although lobectomy is the most common cause of lung torsion, physicians should check for lung segment torsion when performing segmentectomy.

Giant pedunclated lipoma of the esophagus: A case report.

INTRODUCTION: Although Esophageal lipoma is extremely rare and pathologically benign, surgical excision of the lipoma is recommended when symptomatic or uncertain biological behavior. In general, some of the esophageal lipoma has a stalk. The pedunclated non-invasive tumor can be removed by stalk ligation, which is either endoscopic or surgical approache. Therefore, the preoperative evaluation is essential. We herein present a case of a huge esophageal lipoma. CASE REPORT: A 82-year-old man, with a wet cough and dyspnea for 6 months, who had the huge mass that almost completely occupied the esophageal lumen, was referred to our institution for the treatment.We diagnosed the mass as non-invasive tumor that has a stalk at the close to the esophageal orifice, by the CT image using air injection into esophageal lumen. We performed excision of the pedunclated huge mobile mass by esophagotomy via right thoracic approach with use of endoloop. Pathological examination showed a lipoma. CONCLUSION: In conclusion, an adequate preoperative evaluation to identify the correct origin of the stalk is mandatory for a successful treatment. In order to do the adequate preoperative evaluation and successful surgery, our diagnostic method of CT image can be effective.

Analysis of gastrointestinal metastasis of primary lung cancer: Clinical characteristics and prognosis.

The prevalence of gastrointestinal metastasis of lung cancer is low. The aim of the present study was to analyze the frequency and clinical characteristics of metastases to the gastrointestinal tract by retrospectively assessing the clinical records of 2,066 patients with lung cancer. A total of 7 patients (0.33%) were diagnosed with gastrointestinal metastasis, including 4 patients with adenocarcinoma, 1 patient with large cell carcinoma and 2 patients with pleomorphic carcinoma. Furthermore, 3 of the patients presented with small bowel metastases, 2 with gastric metastases, 1 with large bowel metastasis and 1 with metastasis of the appendix. The mean time between the diagnosis of the lung tumors and the identification of gastrointestinal metastasis was 13.5 months (range, 3-49 months). The mean time between the identification of the gastrointestinal metastasis and mortality was 100.6 days (range, 21-145 days). In conclusion, the prognosis of patients with recurrence in distant organs, including the gastrointestinal tract, may be worse than patients with recurrence in distant organs, excluding the gastrointestinal tract, particularly those with symptomatic gastrointestinal metastasis. Therefore, the presence of clinical gastrointestinal metastasis may be life threatening; comprehensive evaluations are required to detect and monitor gastrointestinal metastasis during follow-up.

Extension of liver tissue into the thorax following a right extrapleural pneumonectomy for malignant pleural mesothelioma.

A 56-year-old male underwent a right extrapleural pneumonectomy for malignant pleural mesothelioma. Two years after the operation, an intrathoracic mass was suspected of recurrence by imaging, however, biopsy revealed that the mass was actively proliferating liver tissues. We discussed this condition in terms of ectopic liver proliferation.

Lung Cancer Detected 5 Years after Resection of Cancer of Unknown Primary in a Mediastinal Lymph Node: A Case Report and Review of Relevant Cases from the Literature.

We report the rare and interesting case of a primary lung cancer detected 5 years after cancer of unknown primary (CUP) of a mediastinal lymph node (LN) was resected. A 40-year-old male was diagnosed with adenocarcinoma of unknown primary in a mediastinal lymph node after resection of the mediastinal tumor. Five years after resection of the CUP in mediastinal LN, a small, abnormal nodular shadow in left upper lobe was detected by chest CT. This pulmonary tumor was diagnosed as a lung adenocarcinoma. The pathological and immunohistological findings of the resected pulmonary tumor resembled those of the LN resected 5 years before. We speculated that the pulmonary lesion represented primary lung cancer that enlarged later than the metastatic mediastinal LN. This case illustrates the importance of careful observation and long-term follow-up in patients treated for CUP of a thoracic LN.

Loss of heterozygosity (LOH) in non-small cell lung cancer: difference between adenocarcinoma and squamous cell carcinoma.

BACKGROUND: In non-small cell lung cancer, a loss of heterozygosity (LOH) is frequently observed; however, few studies have investigated the differences in the LOH status between adenocarcinoma and squamous cell carcinoma. PATIENTS AND METHODS: In a consecutive series of 49 patients with adenocarcinomas and 22 patients with squamous cell carcinomas, the LOH in tumors was analyzed using polymerase chain reaction employing 5 fluorescence-labeled dinucleotide markers (D2S123, D5S107, D10S197, D11SS904, D13S175) and an autosequencer. RESULTS: LOH was more frequently observed in squamous cell carcinoma (20 of 22, 90%) than in adenocarcinomas (33 of 49, 67%) (P=0.0348), and the number of LOH per patient was also higher in the patients with squamous cell carcinoma (2.2+/-1.4) than in those with adenocarcinoma (1.5+/-1.2, P=0.037). In adenocarcinomas, the number of LOH per patients correlated significantly with the pack-year index, whereas the pathological stage significantly affected the number of LOH in squamous cell carcinomas. CONCLUSION: The presence of LOH is relatively uncommon in adenocarcinoma of the lung; however, the incidence of LOH tends to be associated with the smoking status.

Novel approach for a pulmonary bronchogenic cyst: a report of a case.

We present a case of a bronchogenic pulmonary cyst in a 48-year-old patient. We performed [corrected] mucoclasis using argon laser photocoagulation following resection of mucosa, closure of some drainage bronchus, and covering of the inner surface by the intrapulmonary bronchogenic cyst with an [corrected] absorbable vicryl mesh. At [corrected] 4-year [corrected] follow-up, the patient had no signs of recurrence.

Repeated Localized Treatment for Endobronchial Metastasis of Thymic Carcinoma.

BACKGROUND: Endobronchial metastases derived from nonpulmonary tumors are uncommon, although a variety of malignant tumors have been reported to be associated with endobronchial metastasis. We herein report a case of repeated bronchoscopic resection of endobronchial metastasis of a thymic carcinoma. CASE REPORT: A 59-year-old woman was diagnosed with primary thymic carcinoma, Masaoka stage IVA, in May 2009. In June 2013, she developed dyspnea. A chest CT scan revealed left upper lobe atelectasis, and a polypoid lesion was noted in the left upper bronchus on bronchoscopy. A pathological examination of the lesion revealed metastatic thymic carcinoma, and bronchoscopic resection was performed for symptom relief. However, the lesion was partially resected, based on the operative findings, which showed the peripheral part of B3 to be the origin of the polypoid lesion and bronchoscopy could not be used to reach this site. Although the patient underwent repeated partial bronchoscopic resection of the polypoid lesion due to the symptoms of dyspnea caused by regrowth of the polypoid metastatic thymic cancer in the left upper bronchus, she remains alive with an excellent performance status and no evidence of widespread or other metastases for more than 5 years after the initial diagnosis. CONCLUSIONS: We speculate that this case was successfully managed with repeated partial bronchoscopic resection because thymic cancer tends to be a slow-growing tumor. Therefore, it is worth resecting endobronchial metastatic thymic carcinoma repeatedly in such cases, even if the resection is partial.